Suffolk County Mental Health Project Research Articles

Long-Term Course of Remission and Recovery in Psychotic Disorders.

Understanding prognosis is critical to anticipating public health needs and providing care to individuals with psychotic disorders. However, the long-term course of remission and recovery remains unclear. In this study, the most common trajectories of illness course are described for a cohort of individuals followed for 25 years since first admission for psychosis. Participants are from the Suffolk County Mental Health Project, an epidemiological study of first-admission psychosis. Data for the present study was collected from six follow-ups, with 311 individuals assessed at the 25-year follow-up. Common patterns of remission and recovery were assessed in the baseline cohort of 591 individuals and the subsample from the 25-year follow up. In the baseline cohort and the 25-year subsample, the most common trajectory for individuals with schizophrenia spectrum disorders was no remission and no recovery. Among individuals with other psychotic disorders, in both the baseline and 25-year cohorts, the modal pattern was one of intermittent remission and recovery. Individuals with other psychotic disorders were more likely to experience stable remission (15.1%) and stable recovery (21.1%), outcomes that were rare among individuals with schizophrenia spectrum disorders (0% and 0.6%, respectively). The modal longitudinal pattern for individuals with other psychoses is one of multiple transitions into and out of symptomatic and functional recovery. Engagement in a long-term health care plan may help individuals detect and respond to these changes. Sustained remission and recovery are rare among people with schizophrenia spectrum disorders. Efforts should be directed toward developing more effective treatments for this population.

The Course of General Cognitive Ability in Individuals With Psychotic Disorders

Schizophrenia is associated with major cognitive deficits and has been conceptualized as both a neurodevelopmental and a neurodegenerative disorder. However, when deficits develop and how they change over the course of illness is uncertain. To trace cognition from elementary school to old age to test neurodevelopmental and neurodegenerative theories of psychotic disorders. Data were taken from the Suffolk County Mental Health Project, a first-admission longitudinal cohort study of individuals with psychotic disorders. Participants were recruited from all 12 inpatient psychiatric facilities in Suffolk County, New York. This analysis concerns the 428 participants with at least 2 estimates of general cognitive ability. Data were collected between September 1989 and October 2019, and data were analyzed from January 2020 to October 2021. Psychiatric hospitalization for psychosis. Preadmission cognitive scores were extracted from school and medical records. Postonset cognitive scores were based on neuropsychological testing at 6-month, 24-month, 20-year, and 25-year follow-ups. Of the 428 included individuals (212 with schizophrenia and 216 with other psychotic disorders), 254 (59.6%) were male, and the mean (SD) age at psychosis onset was 27 (9) years. Three phases of cognitive change were observed: normative, declining, and deteriorating. In the first phase, cognition was stable. Fourteen years before psychosis onset, those with schizophrenia began to experience cognitive decline at a rate of 0.35 intelligence quotient (IQ) points per year (95% CI, 0.29-0.42; P < .001), a significantly faster decline than those with other psychotic disorders (0.15 IQ points per year; 95% CI, 0.08-0.22, P < .001). At 22 years after onset, both groups declined at a rate of 0.59 IQ points per year (95% CI, 0.25-0.94; P < .001). In this cohort study, cognitive trajectories in schizophrenia were consistent with both a neurodevelopmental and neurodegenerative pattern, resulting in a loss of 16 IQ points over the period of observation. Cognitive decline began long prior to psychosis onset, suggesting the window for primary prevention is earlier than previously thought. A window for secondary prevention emerges in the third decade of illness, when cognitive declines accelerate in individuals with schizophrenia and other psychotic disorders.

A comparison of cognitive performance in the Suffolk County cohort and their unaffected siblings

People diagnosed with schizophrenia and other psychoses demonstrate impaired neuropsychological performance. Their unaffected siblings exhibit mild impairments relative to unrelated controls, suggesting genetic and shared environmental risk for psychosis account for some portion of cognitive impairments observed in cases. However, most sibling studies were conducted early in illness course. Studying cases and unaffected siblings later in life is valuable because diagnostic misclassification is common early in illness, possibly leading to spurious conclusions. This study compared neuropsychological performance of individuals with psychotic disorders (schizophrenia and other psychoses), their unaffected siblings, and controls. Assessments were conducted 20 years after case enrollment in the Suffolk County Mental Health Project, when siblings and controls were added to the protocol. Results showed individuals with schizophrenia and other psychoses performed worse than their matched siblings across domains. Relative to controls, siblings of participants with schizophrenia showed mild deficits in executive function and processing speed, while no significant differences were observed between siblings of those with other psychoses and controls. These findings suggest pre- and post-onset factors impact cognitive deficits in psychosis, but pre-onset factors are more salient in schizophrenia. Additionally, schizophrenia and other psychoses exist on a neurodevelopmental continuum, with schizophrenia being a more severe manifestation.

Predicting Long-Term Outcomes in First-Admission Psychosis: Does the Hierarchical Taxonomy of Psychopathology Aid DSM in Prognostication?

The Hierarchical Taxonomy of Psychopathology (HiTOP) is an empirical, dimensional model of psychological symptoms and functioning. Its goals are to augment the use and address the limitations of traditional diagnoses, such as arbitrary thresholds of severity, within-disorder heterogeneity, and low reliability. HiTOP has made inroads to addressing these problems, but its prognostic validity is uncertain. The present study sought to test the prediction of long-term outcomes in psychotic disorders was improved when the HiTOP dimensional approach was considered along with traditional (ie, DSM) diagnoses. We analyzed data from the Suffolk County Mental Health Project (N = 316), an epidemiologic study of a first-admission psychosis cohort followed for 20 years. We compared 5 diagnostic groups (schizophrenia/schizoaffective, bipolar disorder with psychosis, major depressive disorder with psychosis, substance-induced psychosis, and other psychoses) and 5 dimensions derived from the HiTOP thought disorder spectrum (reality distortion, disorganization, inexpressivity, avolition, and functional impairment). Both nosologies predicted a significant amount of variance in most outcomes. However, except for cognitive functioning, HiTOP showed consistently greater predictive power across outcomes-it explained 1.7-fold more variance than diagnoses in psychiatric and physical health outcomes, 2.1-fold more variance in community functioning, and 3.4-fold more variance in neural responses. Even when controlling for diagnosis, HiTOP dimensions incrementally predicted almost all outcomes. These findings support a shift away from the exclusive use of categorical diagnoses and toward the incorporation of HiTOP dimensions for better prognostication and linkage with neurobiology.

S121. OPUS 20, 20 YEAR FOLLOW-UP ON THE OPUS TRIAL

BackgroundSince the first OPUS trial 20 years ago, structured clinical assessments have been collected from a cohort of first episode psychosis patients at 2, 5 and 10 years follow-up. They found that the symptomatology of patients clustered in distinct groups, and they were able to determine stable long-term trajectories of positive and negative symptoms. The Suffolk County Medical health project has followed patients after a first episode psychosis for 20 years. They also found a stable course of trajectories but with an overall significant worsening of symptom severity over time. The 20 year OPUS follow-up will give us the first opportunity to assess the long term outcome in a large representative cohort treated within modern mental health services with treatment available for all.MethodsFrom 1998 to 2000 578 participants were randomized to OPUS or TAU. Baseline characteristics of the cohort were as follows: mean age 26.6 years, 59% were males, 66% had a diagnosis of schizophrenia and 27% had a secondary diagnosis of alcohol or substance abuseAt the 20 year follow-up the investigators will be blinded to the original treatment allocation. The patients who wish to participate will be assessed using SAPS, SANS, SCAN, PSP and GAF. Socio-demographic factors and suicidal ideation will be register via self report. Cognitive function will be tested using BACS and all participants will be asked to fill out a number of self-rating questioners including WHO quality of life-BREF, self-perceived health, strengths and difficulties, the parenting scale and self-perceived negative symptoms.Using national Danish registers we can collect information on all former participants regarding the use of psychiatric and general healthcare services, medication, supported housing or homelessness, employment status, substance abuse and mortality.ResultsThe OPUS 20 study started collecting data in Jan 2018. We are attempting to contact as many patients as possible from the 578 participants in the original OPUS cohort. At the time of writing we had included data and attempted contact to 322 participants. Overall 104 people (31,7%) have agreed to participate in the interviews. In the follow-up 10 years ago, the participation-rate was 60% so this is a big drop in participation rate. 41 (14%) have died, 31 (9,5%) were lost due to emigration, homelessness or hidden identity and/or disempowerment. 70 (21,3%) didn’t wish to participate and 76 (23,2%) never responded.DiscussionPsychotic disorders and schizophrenia in particular are associated with progressive worsening of symptoms and profound social impairment, and as such are still very stigmatized. Results from the 10 year OPUS follow-up found stable trajectories of positive and negative symptoms over time, with a tendency of reduction and stabilization of positive symptoms but less variation of negative symptoms. They found poor but stable social functioning with a mean GAF score of 55 after 10 years. The Suffolk County mental health project also found stable trajectories of psychopathology measured with SAPS and SANS. They however found progressive worsening of GAF scores declining form 49 points at the beginning to 36 after 20 years.So far we have seen stable GAF scores and SAPS and SANS scores compared to OPUS 10. This gives rise to some optimism about the prognosis for schizophrenia compared to the findings of the Suffolk study.In our study the extensive interviews combined with the data collected form Danish registers give us a unique opportunity to look at the long term course of illness after FEP. The ability to test if previous findings are robust over time will be essential to the development of targeted interventions, differentiated to the needs of different patient groups.

Pathways from performance monitoring to negative symptoms and functional outcomes in psychotic disorders.

Performance monitoring entails rapid error detection to maintain task performance. Impaired performance monitoring is a candidate pathophysiological process in psychotic disorders, which may explain the broader deficit in executive function and its known associations with negative symptoms and poor functioning. The current study models cross-sectional pathways bridging neurophysiological measures of performance monitoring with executive function, symptoms, and functioning. Data were from the 20-year assessment of the Suffolk County Mental Health Project. Individuals with psychotic disorders (N = 181) were originally recruited from inpatient psychiatric facilities. Data were also collected from a geographically and demographically matched group with no psychosis history (N = 242). Neural measures were the error-related negativity (ERN) and error positivity (Pe). Structural equation modeling tested mediation pathways. Blunted ERN and Pe in the clinical cohort related to impaired executive function (r = 0.26-0.35), negative symptom severity (r = 0.17-0.25), and poor real-world functioning (r = 0.17-0.19). Associations with executive function were consistent across groups. Multiple potential pathways were identified in the clinical cohort: reduced ERN to inexpressivity was mediated by executive function (β = 0.10); reduced Pe to global functioning was mediated by executive function and avolition (β = 0.10). This supports a transdiagnostic model of psychotic disorders by which poor performance monitoring contributes to impaired executive function, which contributes to negative symptoms and poor real-world functioning. If supported by future longitudinal research, these pathways could inform the development of targeted interventions to address cognitive and functional deficits that are central to psychotic disorders.

Lead-Time Bias Confounds Association Between Duration of Untreated Psychosis and Illness Course in Schizophrenia.

At first hospitalization, a long duration of untreated psychosis (DUP) predicts illness severity and worse treatment outcomes. The mechanism of this association, however, remains unclear. It has been hypothesized that lengthy untreated psychosis is toxic or that it reflects a more severe form of schizophrenia. Alternatively, the association may be an artifact of lead-time bias. These hypotheses are tested in a longitudinal study of schizophrenia with 2,137 observations spanning from childhood to 20 years after first admission. Data were from the Suffolk County Mental Health Project. The cohort included 287 individuals with schizophrenia or schizoaffective disorder. DUP was defined as days from first psychotic symptom to first psychiatric hospitalization. Psychosocial function was assessed using the Premorbid Adjustment Scale and the Global Assessment of Functioning Scale. Psychosocial function trajectories were estimated using multilevel spline regression models adjusted for gender, occupational status, race, and antipsychotic medication. Both long- and short-DUP patients experienced similar declines in psychosocial function, but declines occurred at different times relative to first admission. Long-DUP patients experienced most of these declines prior to first admission, while short-DUP patients experienced declines after first admission. When psychosocial function was analyzed relative to psychosis onset, DUP did not predict illness course. The association between DUP and psychosocial function may be an artifact of early detection, creating the illusion that early intervention is associated with improved outcomes. In other words, DUP may be better understood as an indicator of illness stage than a predictor of course.

Long-term Changes in Cognitive Functioning in Individuals With Psychotic Disorders

It remains uncertain whether people with psychotic disorders experience progressive cognitive decline or normal cognitive aging after first hospitalization. This information is essential for prognostication in clinical settings, deployment of cognitive remediation, and public health policy. To examine long-term cognitive changes in individuals with psychotic disorders and to compare age-related differences in cognitive performance between people with psychotic disorders and matched control individuals (ie, individuals who had never had psychotic disorders). The Suffolk County Mental Health Project is an inception cohort study of first-admission patients with psychosis. Cognitive functioning was assessed 2 and 20 years later. Patients were recruited from the 12 inpatient facilities of Suffolk County, New York. At year 20, the control group was recruited by random digit dialing and matched to the clinical cohort on zip code and demographics. Data were collected between September 1991 and July 2015. Analysis began January 2016. Change in cognitive functioning in 6 domains: verbal knowledge (Wechsler Adult Intelligence Scale-Revised vocabulary test), verbal declarative memory (Verbal Paired Associates test I and II), visual declarative memory (Visual Reproduction test I and II), attention and processing speed (Symbol Digit Modalities Test-written and oral; Trail Making Test [TMT]-A), abstraction-executive function (Trenerry Stroop Color Word Test; TMT-B), and verbal fluency (Controlled Oral Word Association Test). A total of 705 participants were included in the analyses (mean [SD] age at year 20, 49.4 [10.1] years): 445 individuals (63.1%) had psychotic disorders (211 with schizophrenia spectrum [138 (65%) male]; 164 with affective psychoses [76 (46%) male]; 70 with other psychoses [43 (61%) male]); and 260 individuals (36.9%) in the control group (50.5 [9.0] years; 134 [51.5%] male). Cognition in individuals with a psychotic disorder declined on all but 2 tests (average decline: d = 0.31; range, 0.17-0.54; all P < .001). Cognitive declines were associated with worsening vocational functioning (Visual Reproduction test II: r = 0.20; Symbol Digit Modalities Test-written: r = 0.25; Stroop: r = 0.24; P < .009) and worsening negative symptoms (avolition: Symbol Digit Modalities Test-written: r = -0.24; TMT-A: r = -0.21; Stroop: r = -0.21; all P < .009; inexpressivity: Stroop: r = -0.22; P < .009). Compared with control individuals, people with psychotic disrders showed age-dependent deficits in verbal knowledge, fluency, and abstraction-executive function (vocabulary: β = -0.32; Controlled Oral Word Association Test: β = -0.32; TMT-B: β = 0.23; all P < .05), with the largest gap among participants 50 years or older. In individuals with psychotic disorders, most cognitive functions declined over 2 decades after first hospitalization. Observed declines were clinically significant. Some declines were larger than expected due to normal aging, suggesting that cognitive aging in some domains may be accelerated in this population. If confirmed, these findings would highlight cognition as an important target for research and treatment during later phases of psychotic illness.

Schizophrenia polygenic risk score and 20-year course of illness in psychotic disorders

Understanding whether and how the schizophrenia polygenic risk score (SZ PRS) predicts course of illness could improve diagnosis and prognostication in psychotic disorders. We tested whether the SZ PRS predicts symptoms, cognition, illness severity, and diagnostic changes over the 20 years following first admission. The Suffolk County Mental Health Project is an inception cohort study of first-admission patients with psychosis. Patients were assessed six times over 20 years, and 249 provided DNA. Geographically- and demographically-matched never psychotic adults were recruited at year 20, and 205 provided DNA. Symptoms were rated using the Schedule for the Assessment of Positive Symptoms and Schedule for the Assessment of Negative Symptoms. Cognition was evaluated with a comprehensive neuropsychological battery. Illness severity and diagnosis were determined by consensus of study psychiatrists. SZ PRS was significantly higher in first-admission than never psychotic groups. Within the psychosis cohort, the SZ PRS predicted more severe negative symptoms (β = 0.21), greater illness severity (β = 0.28), and worse cognition (β = −0.35), across the follow-up. The SZ PRS was the strongest predictor of diagnostic shifts from affective to non-affective psychosis over the 20 years (AUC = 0.62). The SZ PRS predicts persistent differences in cognition and negative symptoms. The SZ PRS also predicts who among those who appear to have a mood disorder with psychosis at first admission will ultimately be diagnosed with a schizophrenia spectrum disorder. These findings show potential for the SZ PRS to become a tool for diagnosis and treatment planning.

Physical Functional Limitations in a First-Admission Cohort at Midlife: Findings From the Suffolk County Mental Health Project.

Psychosis is a risk factor for aging-related conditions and early mortality. Little is known about the age-specific risk of objectively measured physical functional limitations among individuals with serious mental illness. The Suffolk County Mental Health Project is a prospective study of individuals hospitalized for the first time for psychosis. To assess physical functioning at midlife and to identify emerging risk factors for older-age changes, 101 participants with schizophrenia (mean age = 47.2, SD = 8.0 years; 41.6% female) and 112 participants with other psychoses (mean age = 48.2, SD = 9.5 years; 45.5% female) were assessed for chair-rise and balance limitations 20 years after diagnosis. A never-psychotic comparison group of 237 age/sex/geographically matched community controls was similarly assessed (mean age = 50.3, SD = 8.8 years; 44.7% female). Logistic regression was used to examine group differences in prevalence of poor performance and demographic, medical, and treatment correlates. Chair-rise limitations (45.5% [35.8-55.3]) and balance limitations (17.2% [9.8-24.5]) were common in individuals with schizophrenia. Prevalence of chair-rise limitations was higher in schizophrenia (46.3%) than in other psychotic disorders (31.9%) and never-psychotic group (22.1%), whereas risk of balance limitations was higher in schizophrenia (17.2%) compared with never-psychotic controls (8.1%). Schizophrenia was a significant risk factor for chair-rise (adjusted odds ratio = 3.01 [1.79-5.08], p < .001) and balance limitations (adjusted odds ratio = 2.63, [1.25-5.51], p = .010). Multivariable analysis of symptom severity found avolition was associated with chair-rise limitations, but not balance, independent of diagnosis. Physical limitations are crucial because they identify existing problems with mobility and portend an increased risk of disability and death. Because participants with schizophrenia were at increased risk of physical limitations, assessments of chair-rise and balance limitations may be critical to monitoring individuals with psychosis.

24.3 EIGHTEEN-YEAR COURSE OF COGNITIVE FUNCTIONING IN PSYCHOTIC DISORDERS: FINDINGS FROM THE SUFFOLK COUNTY MENTAL HEALTH LONGITUDINAL STUDY

BackgroundKnowledge about the long-term cognitive course in psychotic disorders is limited. In this 18-year follow-up of participants of the Suffolk County project we report on the longitudinal course of cognitive performance in individuals with schizophrenia spectrum disorders, affective psychoses and other psychoses. We investigate (i) change in functioning in 6 cognitive domains from 2-years to 20-years follow-up after first admission; (ii) 20-year performance and age-related differences in cognitive performance in patients relative to a never psychotic comparison group; and (iii) key predictors of clinically meaningful cognitive decline in patients.MethodsData came from the Suffolk County Mental Health Project, a prospective study of first-admission patients. Cognitive tests were administered 2 years (n = 399; schizophrenia spectrum: 285, affective psychoses: 226, other psychoses: 117) and 20 years (n = 240; 115, 92, and 34, respectively) after first admission, with 195 individuals completing cognitive tests at both time points. A never psychotic comparison group (N=260) was assessed at year 20.ResultsIndividuals with schizophrenia spectrum disorders showed lower cognitive functioning than those with affective and other psychoses. Over time, patients declined in cognitive performance on almost all tests (d = 0.24 (range 0.12- 0.44)) with comparable magnitude across diagnoses. Longer duration of untreated psychosis and low childhood IQ were significantly associated with clinically relevant decline (>0.5SD) in general verbal ability and processing speed, but there were no robust predictors of cognitive decline across tests. Cross-sectional comparisons of patients to controls showed increasing impairments with age for general verbal ability, verbal fluency, and executive functioning.DiscussionOur findings indicate that cognitive functioning in psychotic disorders continues to decline after the illness onset, that this decline is not specific to schizophrenia but present across psychotic disorders, and that, relative to never-psychotic individuals, impairments on some key-cognitive domains worsen with age. These results imply that cognitive treatment should not only include cognitive remediation but also prevention of age-related cognitive stagnation and/or decline.

5. RETHINKING THE TAXONOMY, COURSE, AND OUTCOME OF PSYCHOSES: DIMENSIONAL, LATENT TRAJECTORY, AND TRANSDIAGNOSTIC APPROACHES

Overall : Evidence continues to accumulate on heterogeneity in phenomenology, course and outcome of non-affective and affective psychotic disorders. Both DSM and ICD classification systems have evolved to include a large number of categories of psychosis. However, doubt remains about this categorical approach because of high comorbidity, common etiological factors and the absence of zones of relative rarity between categorical diagnoses. Some authors have nevertheless argued that categorical representations of psychosis may still be of clinical utility if used in combination with dimensional indicators.It is now widely accepted that psychotic symptoms partition into several symptom dimensions that would support the heterogeneity of psychotic disorders. However, there is no consensus on the exact number of these dimensions, with previous factor-analytic work pointing towards models with two to twelve specific symptom dimensions. However, recently, there has been evidence for a transdiagnostic dimension underlying affective and non-affective psychotic symptoms in schizophrenia, schizoaffective and bipolar disorder that challenges their classification as distinct diagnostic constructs. There is also considerable heterogeneity in clinical course and outcome of psychotic disorders, but how to best map and model this over time remains to be established. Taken together, this presents significant challenges for the classification of psychotic disorders as separate diagnostic entities.This symposium brings together international researchers at the forefront of research into the phenomenology, course and outcome of psychotic disorders. Roman Kotov will present novel data on symptom dimensions and examines the course of these dimensions in an epidemiologic cohort of 628 first-admission inpatients with psychosis interviewed 6 times over two decades in the Suffolk County Mental Health Project. Craig Morgan will report new findings from the 10-year follow-up of the Aetiology and Ethnicity in Schizophrenia and Other Psychoses (AESOP-10) study, an epidemiological cohort of 552 patients with a first episode psychosis, using a data driven approach to identify latent trajectory classes to account for heterogeneity in patterns of change in psychotic symptoms over time and characterize these trajectories with the WHO classification, baseline demographic characteristics and diagnoses. Ulrich Reininghaus will present novel data from the Bipolar-Schizophrenia Network on Intermediate Phenotypes (B-SNIP) consortium to investigate whether there is a transdiagnostic dimension cutting across symptoms of schizophrenia, schizoaffective disorder and psychotic bipolar I disorder. Diego Quattrone will report recent findings from EU-GEI Functional Enviromics Study on genetic and socio-environmental factors associated with transdiagnostic and specific symptom dimensions of non-affective and affective psychosis. Robin Murray will discuss these findings in the context of new challenges in the field and directions for future research.

Associations of independent living and labor force participation with impairment indicators in schizophrenia and bipolar disorder at 20-year follow-up

BackgroundSince the Iowa 500 study, residential and occupational status have been frequently used as indicators of everyday achievements in research on schizophrenia and bipolar disorder. The relationships of residential and occupational status with impairment in multiple domains including physical health indicators across these two diagnoses, however, have rarely been studied. We examined these relationships at the 20-year follow-up assessment of a first-admission sample. MethodsWe included 146 participants with schizophrenia and 87 with bipolar disorder with psychosis who participated in the 20-year follow-up of the Suffolk County Mental Health Project. In addition to interviewer-based ratings of employment and residential independence, we examined self-reported impairment derived from the WHODAS, standard measures of current psychopathology, indicators of obesity, as well as performance-based measures of physical and cognitive functioning. ResultsParticipants with bipolar disorder were more likely to live independently and be gainfully employed; they also performed significantly better on each indicator of impairment apart from balance ability. In both groups, unemployment, but not residential independence, was associated with greater self-reported disability on the WHODAS. Residential independence, gainful employment, and subjective disability were also associated with better physical functioning. Across the two groups, psychiatric symptoms and physical functioning were the major determinants of subjective disability. DiscussionPeople with psychotic bipolar disorder were more likely to be gainfully employed and living independently than participants with schizophrenia but as a group, much less frequently than population standards. Interventions aimed at physical fitness may have the potential to improve both objective functioning and perceived disability.

Declining Clinical Course of Psychotic Disorders Over the Two Decades Following First Hospitalization: Evidence From the Suffolk County Mental Health Project.

Kraepelin considered declining course a hallmark of schizophrenia, but others have suggested that outcomes usually stabilize or improve after treatment initiation. The authors investigated this question in an epidemiologically defined cohort with psychotic disorders followed for 20 years after first hospitalization. The Suffolk County Mental Health Project recruited first-admission patients with psychosis from all inpatient units of Suffolk County, New York (response rate, 72%). Participants were assessed in person six times over two decades; 373 completed the 20-year follow-up (68% of survivors); 175 had schizophrenia/schizoaffective disorder. Global Assessment of Functioning (GAF), psychotic symptoms, and mood symptoms were rated at each assessment. Month 6, when nearly all participants were discharged from the index hospitalization, was used as a reference. In the schizophrenia group, mean GAF scores declined from 49 at month 6 to 36 at year 20. Negative and positive symptoms also worsened (Cohen's d values, 0.45-0.73). Among participants without schizophrenia, GAF scores were higher initially (a mean of approximately 64) but declined by 9 points over the follow-up period. Worsening began between years 5 and 8. Neither aging nor changes in antipsychotic treatment accounted for the declines. In all disorders, depression improved and manic symptoms remained low across the 20 years. The authors found substantial symptom burden across disorders that increased with time and ultimately may undo initial treatment gains. Previous studies have suggested that better health care delivery models may preempt this decline. In the United States, these care needs are often not met, and addressing them is an urgent priority.

Health status and mobility limitations are associated with residential and employment status in schizophrenia and bipolar disorder

IntroductionSchizophrenia (SCZ) and bipolar disorder (BP) are linked to multiple impairments in everyday functioning which share cognitive and symptom risk factors. Other risk factors for critical aspects of every day functioning (e.g., gainful employment; residential independence) such as physical health have not been evaluated, despite poor health in SCZ and BP. MethodsWe analyzed 20-year follow-up data from the Suffolk County Mental Health Project cohort of consecutive first admissions with a psychotic disorder to 12 psychiatric facilities in Suffolk County, NY, between September 1989 and December 1995. Both 20-year symptom, health, and cognition data, and the 20-year course of weight gain were included as predictors of employment and residence status. ResultsThe analysis sample consisted of 122 participants with SCZ ad BP, with SCZ participants less likely to work or live independently. Correlational analyses showed symptoms and cognition predicted vocational outcomes in both samples. The effect of diagnosis was significant for both gainful employment and independence in residence. After consideration of diagnosis, mobility and negative symptoms predicted gainful employment in both samples, but there were no additional predictors of residential independence. Prospective analysis of BMI found that baseline BMI, but not changes during the 20-year follow up, predicted labor force participation. DiscussionHealth status limitations were associated with residential and, particularly, employment status independent from other, previously established predictors of everyday outcomes, including cognition and symptoms. The importance of health status limitations for predicting outcome was confirmed in both SCZ and BP, with schizophrenia representing the more impaired group.

Twenty-year progression of body mass index in a county-wide cohort of people with schizophrenia and bipolar disorder identified at their first episode of psychosis.

There is an increased prevalence of obesity in schizophrenia and bipolar disorder, leading to a disproportionate risk of adverse health conditions. Prospective, long-term weight gain data, however, are scarce. We analyzed data from the Suffolk County Mental Health Project cohort of consecutive first admissions with psychosis recruited from September 1989 to December 1995 and subsequently followed for 20years, focusing on people with schizophrenia (n=146) and bipolar disorder (n=87). The time course of weight gain was examined using a 2 (group)×5 (time) mixed-model repeated measures ANOVA, and body mass index (BMI) scores at the first (6months) and second (2years) assessments were compared to examine whether early overweight predicted later obesity. There was a statistically significant effect of time (F(1,210)=68.06, P<.001) and diagnosis (F(1,210)=29.18, P<.001) on BMI, but not the interaction of time×diagnosis (F(1,210)=0.88, P=.48). Most participants had normal BMIs at the first two assessments. Early overweight was a predictor of eventual obesity for both groups. At the 20-year follow-ups, approximately 50% of the bipolar and 62% of the schizophrenia sample were obese, with a greater prevalence of obesity in schizophrenia at each assessment (all P<.02), except for years 4 (P=.12) and 20 (P=.27). Nearly two-thirds of the participants with schizophrenia and over half of those with bipolar disorder were obese 20years after first hospitalization for psychosis, considerably higher than the rate for adults in New York State (27%). Early intervention may be required to prevent long-term consequences of obesity-related morbidity and mortality.

The 20-Year Longitudinal Trajectories of Social Functioning in Individuals With Psychotic Disorders.

Social impairment is a long-recognized core feature of schizophrenia and is common in other psychotic disorders. Still, to date the long-term trajectories of social impairment in psychotic disorders have rarely been studied systematically. Data came from the Suffolk County Mental Health Project, a 20-year prospective study of first-admission patients with psychotic disorders. A never-psychotic comparison group was also assessed. Latent class growth analysis was applied to longitudinal data on social functioning from 485 respondents with schizophrenia spectrum disorders and psychotic mood disorders, and associations of the empirically derived trajectories with premorbid social adjustment, diagnosis, and 20-year outcomes were examined. Four mostly stable trajectories of preserved (N=82; 59th percentile of comparison group sample distribution), moderately impaired (N=148; 17th percentile), severely impaired (N=181; 3rd percentile), and profoundly impaired (N=74; 1st percentile) functioning best described the 20-year course of social functioning across diagnoses. The outcome in the group with preserved functioning did not differ from that of never-psychotic individuals at 20 years, but the other groups functioned significantly worse. Differences among trajectories were already evident in childhood. The two most impaired trajectories started to diverge in early adolescence. Poorer social functioning trajectories were strongly associated with other real-world outcomes at 20 years. Multiple trajectories were represented within each disorder. However, more participants with schizophrenia spectrum disorders had impaired trajectories, and more with mood disorders had better functioning trajectories. The results highlight substantial variability of social outcomes within diagnoses-albeit overall worse social outcomes in schizophrenia spectrum disorders-and show remarkably stable long-term impairments in social functioning after illness onset across all diagnoses.

An incongruent reality: The N400 in relation to psychosis and recovery

BackgroundCognitive impairments and delusions are hallmarks of schizophrenia, and are thought to be due in part to abnormalities in semantic priming. The N400, a neural measure of semantic processing, is found to be reduced in schizophrenia. However, it is unclear if individuals with other psychoses (e.g., mood disorders or substance abuse with psychotic features) also show this impairment, and whether N400 reduction relates to real-world functioning and recovery. MethodsEighty-nine individuals from the Suffolk County Mental Health Project, a longitudinal study of first-admission psychosis, and 35 healthy adults were assessed using matched, related, and unrelated picture–word pairs to elicit the N400. Patients' real-world functioning, symptomatology, and recovery were tracked since first hospitalization; EEG assessment was completed during year 15 of the study. ResultsParticipants with schizophrenia had slower reaction times and reduced N400 to semantically incongruent stimuli relative to healthy participants. Schizophrenia and other psychoses did not differ on N400, suggesting that N400 abnormalities characterize psychosis broadly. When grouped by recovery status, patients who remained ill had a significantly blunted N400, while those who recovered did not differ from healthy adults. Few patients with schizophrenia achieved recovery; therefore recovery results are limited to the other psychosis group. Furthermore, reduced N400 and increased reaction times correlated with greater psychotic symptoms, worse global assessment of functioning scores, unemployment, and impaired social functioning. ConclusionsAbnormalities in the N400 are not specific to schizophrenia; in addition, the N400 may be a useful neural correlate of recovery and real-world functioning across psychotic disorders.

Perceived Trauma During Hospitalization and Treatment Participation Among Individuals With Psychotic Disorders

OBJECTIVE; This study assessed the association of perceptions of traumatic experiences during psychiatric hospitalizations and treatment participation. Participants (N=395) in the Suffolk County Mental Health Project, who had been admitted for the first time for a psychotic disorder ten years earlier, were interviewed. The authors examined associations of perceived trauma and distressing or coercive experiences during hospitalizations in the past ten years with patient characteristics and treatment participation. Sixty-nine percent of participants reported perceived trauma. Perceived trauma was more common among females versus males and homemakers versus full-time workers. It was not associated with treatment seeking or time in treatment. However, reporting forced medication was associated with reduced time in treatment, especially for persons with schizophrenia spectrum disorders. Although perceptions of trauma during psychiatric hospitalization were common, they may be unrelated to treatment participation. However, there was modest evidence of a link between coercive experiences and reduced treatment time.

Early determinants of four‐year clinical outcomes in bipolar disorder with psychosis

Bipolar disorder with psychosis is common in inpatient settings and is associated with diverse outcomes after hospital discharge, which can range from a return to premorbid functioning with no recurrence, to a chronic or recurring illness. Less is known, however, about factors that can predict a better or worse clinical outcome. The present study sought to assess four-year clinical outcomes and their predictors in patients hospitalized for bipolar I disorder with psychosis. Participants from the Suffolk County Mental Health Project (SCMHP) with a baseline diagnosis of bipolar I disorder with psychotic features (N=126) were reassessed using face-to-face interviews at six months, two years, and four years following their first hospitalization. At each time point, clinical status, role functioning, and treatment were assessed by highly trained interviewers using standardized instruments. The majority of participants (73.2%) returned to their premorbid level of role functioning by the four-year follow-up and the median percentage of time ill during the interval was less than 20%. Nevertheless, almost half of the sample (46.9%) was rehospitalized at least once. Psychotic symptoms at baseline (particularly Schneiderian symptoms), depressive phenomenology, childhood psychopathology, and younger age at first hospitalization predicted worse outcome, whereas mood-incongruent psychotic features and age of mood disorder onset did not. The four-year outcomes of a first-admission cohort with bipolar I disorder with psychosis were generally favorable. Poorer premorbid functioning, Schneiderian delusions, greater depressive symptoms, and a younger age of first hospitalization portend a worse course.