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Abstract: Introduction: Around 20% of patients who suffer from psychotic disorders will only experience one psychotic episode, but little research has been dedicated to identifying this subgroup of patients. Several key premorbid characteristics have been identified as predictors of outcome in first episode schizophrenia patients. Predictors that appear to have a relatively consistent relationship to poor outcome in FEP include: longer duration of untreated psychosis (DUP), poor premorbid level of adjustment, earlier onset age, male gender, higher initial negative symptoms, and lower levels of baseline cognitive functioning. Objectives: The main objective of this study was to determine whether factors such as gender, age at the onset of psychosis, duration of untreated psychosis, pre-morbid adjustment and clinical profile at the onset of psychosis will influence risk of relapse in the first 5 year of treatment and follow-up. The secondary objectives of this study are to contrast the profiles of patients with and without relapse after a first psychotic episode and to evaluate the impact of psychosis on socio-economic status of the patients. Method: The present paper is based on a naturalistic follow-up study of patients treated for FEP and followed up for 5 years in the Psychiatric Hospital Bistrita. Results: Out of 86 FEP patients 72 (83.7%) had at least one relapse over the 5 year period. 12 patients dont have any relapse and 2 patients were lost from the study. Conclusions: Gender, baseline symptoms, occupational status at onset were not significantly related to relapse after FEP. DUP, duration of first hospitalization, marital status at onset were significantly related to relapse after FEP. A shorter DUP and first hospitalization, having a partner are predictors for a better remission.
Introduction: Large follow-up studies have challenged the notion that the long-term course of schizophrenia is necessarily chronic and deteriorating (Mason et al., 1995, Sartorius et al., 1996). Patients with first episode schizophrenia usually respond well to treatment, but the relapse rate is high during the first years of the illness, and may be associated with clinical deterioration. Relapse rate at the end of one-year follow-up has been reported to be 3.5% to 41% (Gaebel et al. 2004; Novak-Grubic and Tavcar 2002). Around 20% of patients who suffer from psychotic disorders will only experience one psychotic episode (Linszen et al., 2001, Wirsma et al., 1998), but little research has been dedicated to identifying this subgroup of patients. The identification of a separate group of patients who achieve clinical remission with a non-relapsing course of illness is important and may enable more benign treatment approaches tailored to this subgroup's particular needs, minimizing side effects associated with prolonged exposure to antipsychotic medication (Alvarez-Jimnez et al., 2009). Several key premorbid characteristics have been identified as predictors of outcome in first episode schizophrenia patients. Predictors that appear to have a relatively consistent relationship to poor outcome in FEP include: longer duration of untreated psychosis (DUP), poor premorbid level of adjustment, earlier onset age, male gender, higher initial negative symptoms, and lower levels of baseline cognitive functioning. (Malla and Payne, 2005). Clinical attributes during first episode were also studied as potential predictors for relapse. The presence of subjective depressive feelings during the first admission was associated with earlier relapse while the presence of depressive delusions and higher educational attainment protected against early relapse (Geddes et al. 1994). Poor premorbid adjustment was significantly related to earlier first relapse following response from a first episode of schizophrenia or schizoaffective disorder (Robinson et al. 1999), lower levels of remission (Malla et al. 2002) and higher the Positive and Negative Syndrome Scale (PANSS) negative and general symptoms as well as a lower the Global Assessment of Functioning (GAF) score (Larsen et al. 2000) at one year follow-up.
Completing education and obtaining employment are key developmental milestones for young adults and are important for identity and general well-being. The onset of psychotic disorder, signicantly disrupts the educational and vocational pathway of the aficted individual. Consequently, vocational outcomes are signicantly poorer for people with rst-episode psychosis (FEP) relative to the general population (Killackey et all, 2006). Objectives: The main objective of this study was to determine whether factors such as gender, age at the onset of psychosis, duration of untreated psychosis, pre-morbid adjustment and clinical profile at the onset of psychosis will influence risk of relapse in the first 5 year of treatment and follow-up. The secondary objectives of this study are to contrast the profiles of patients with and without relapse after a first psychotic episode and to evaluate the impact of psychosis on socio-economic status of the patients. Method: The present paper is based on a naturalistic follow-up study of patients treated for FEP and followed up for 5 years in the Psychiatric Hospital Bistrita. Consecutive patients admitted for treatment, as in- or out-patients between January 2006 and February 2007, were treated and followed for a period of 5 years, with data collection ending late in 2012. Inclusion Criteria: Patients who were 1850 years old, with symptoms that met criteria for a ICD-10 psychotic disorder and have not received antipsychotic therapy for a period greater than 1 month, were recruited in this prospective evaluation study. Patients signed an informed consent for participation. Exclusion Criteria: Patients who were over 50 years old and have received antipsychotic therapy for more than 1 month. Assessment Positive and negative symptoms of psychosis were assessed with the Scale for Assessment of Positive Symptoms and Negative Symptoms (PANSS) respectively at baseline and repeated after 1 year, 2 year and 5 year. GAF was assessed at the same time. Remission of positive symptoms was defined as the absence of psychosis. Patients were considered to have achieved remission of positive symptoms if they showed either no evidence or a mild level of psychotic symptoms (delusions, hallucinations, thought disorder and bizarre behavior) lasting for at least 1 month. Relapse was defined as
recurrence of symptoms of psychosis (delusions, hallucinations, thought disorganization and bizarre behavior). For the adherence to medication the assessments were based on direct questioning of the patient, review of their prescriptions and the amount consumed and often verified with the patients family. The adherence to medication was rated on a four point scale [1(0-25%), 2 (26-50%), 3 (51-75%) and 4 (76-100%)] taking in consideration the proportion of time a patient was jugged to be taking medication as prescribed. Data analysis Data were analyzed using SPSS 20. Patients who achieved remission, as defined above, were considered at risk for relapse. Rate of relapse was treated as outcome variables. Rate of relapse was calculated for the total period of 5 years. Data were analyzed using a contrast between patients who did or did not relapse. T-test and 2 analyses were performed for those independent variables that are known to influence relapse (gender, age at onset, clinical variable, duration of first hospitalization and duration of untreated psychosis). Results 86 patients who met the diagnosis criteria for were offered treatment and evaluations according for this study. Table I shows a detailed description of the sample characteristics
Table 1: Sample characteristics Age of onset (years) -Mean (SD) DUP- Mean (SD) PANSS positive Mean (SD) PANSS negative Mean (SD) PANSS general Mean (SD) GAF Mean (SD) Duration of first hospitalization (days) Mean (SD) Gender (N, %) Male Female 35 (40.7%) 51 (59.3%) 28.73 (7.87) 156.40 (177.41) 28.24 (6.03) 20.73 (6.44) 38.75 (6.65) 29.52 (6.47) 21.84 (12.11)
Education (N, %) Elementary education High school completed College or university diploma Schizophrenia in the family (N, %) no yes 63 (73.3) 23 (26.7%) 44 (51.2%) 22 (25.6%) 20 (23.2%)
Concerning the adherence issue, 19.8% of the patients were not adherent to medication. 38.4% of the patients were completely adherent to medication. Only 9.3% of the patients presented full insight and respected the medical prescription.
Table 2: Number of relapses Number of relapses ,00 1,00 2,00 3,00 4,00 5,00 6,00 7,00 8,00 9,00 Total Lost from the study Total N 12 18 21 13 8 3 4 2 2 1 84 2 86 % 14.0 20.9 24.4 15.1 9.3 3.5 4.7 2.3 2.3 1.2 97.7 2.3 100.0
Out of 86 FEP patients 72 (83.7%) had at least one relapse over the 5 year period. 12 patients dont have any relapse and 2 patients were lost from the study. Table 3: Clinical characteristics at 5 Years PANSS positive Mean (SD) PANSS negative Mean (SD) PANSS general Mean (SD) 11.91 (5.41) 13.79 (6.86) 22.89.75 (6.63)
63.63 (19.35)
Table 4: The relationship between clinical variables at baseline and relapse relapse yes no yes no yes no yes PANSS general baseline no yes GAF baseline no yes DUP (days) no duration of first hospitalisation PANSS positive baseline PANSS negative baseline Mean 22.75 16.53 28.09 24.38 20.73 17.92 38.69 39.00 28.20 28.00 158.41 49.07 Std. Deviation 12.39 8.39 5.90 6.82 6.75 5.93 6.98 4.94 6.68 5.68 165.62 97.53 t p
The patients in remission had shorter first hospitalization and DUP. Table 5 The relationship between gender and relapse Gender Male Female Relapse Yes No 40.3% 59.7% 38.5% 61.5% 2 .015 DF 1 p >.05
There were not significant differences between the percentage of men and women who had relapses.
2 4.64
DF 1
p <.05
Marital status at onset (being single) was significantly related to relapse after FEP.
Table 7: The relationship between occupational status at onset and relapse Occupational status at onset don't work work Relapse Yes No 36.1 63.9 30.8 69.2 2 .13 DF 1 p >.05
Occupational status at onset was not significantly related to relapse after FEP.
Table 8: Marital status after 5 years Marital status Single married divorced nonmarried couple Total after 5 years N % 34 40,7 38 45,3 9 10,5 3 84 3,5 100,0 onset N 39 38 % 45,3 44,2
9 86 100,0
10,5
Table 9: Occupational status after 5 years after N without occupation unemployment works in agriculture (with family) works in agriculture (as hired help) unskilled work semi-skilled work skilled work student illness pension Missing data Total 2 % 2,3 N 29 2 6 2 12 16 13 6 onset % 33,7 2,3 7,0 2,3 14,0 18,6 15,1 7,0
30
34,9
52 2
Table 10 The relationship between occupational status and relapse after 5 years Occupational status after 5 years Unemployed or illness pension Work Total Relapse Yes No 54 75,0% 18 25,0% 72 100,0 % 0 0,0% 12 100,0% 12 100,0% 2 25,2 0 DF 1 p ,000
The patients who didn't relapse were able to keep their jobs.
Conclusions: Gender, baseline symptoms, occupational status at onset were not significantly related to relapse after FEP.
DUP, duration of first hospitalization, marital status at onset were significantly related to relapse after FEP. A shorter DUP and first hospitalization, having a partner are predictors for a better remission. Unemployment rate is very high for schizophrenia. The patients may loose their spouses as a result of the disease.
Discussion: 12 patients (13.95%) did not have a psychotic episode during follow-up, the relapse rate is similar with the relapse rate reported in the context of routine psychiatric care (Robinson et al. 1999) but higher then the ones reported in specialized early intervention services. The results show patients with schizophrenia to have considerable social limitations, very few of them are working. References: 1. Alvarez-Jimnez M., Parker A.G., Hetrick S.E., McGorry P.D., Gleeson J.F., 2011, -Preventing the second episode: a systematic review and meta-analysis of psychosocial and pharmacological trials in first-episode psychosis. Schizophr Bull. 37 (3), 619-30. 2. Gaebel W., Mller H.J., Buchkremer G., Ohmann C., Riesbeck M., Wwler W., Wilmsdroff, M., Bottlender R., Klingberg S., 2004, -Pharmacological long-term treatment strategies in first episode schizophrenia. European Arch Psychiatry Clin Neurosci 254, 129140. 3. Geddes J., Mercer G., Frith C.D., MacMillan F., Owens D.G.C., Johnstone EC., 1994, -Prediction of outcome following a first episode of schizophrenia. A follow-up study of Northwick Park first episode study subjects. Br J Psychiatry 165, 664668. 4. Killackey E.J., Jackson H.J., Gleeson J., Hickie I.B., McGorry P.D., 2006, Exciting career opportunity beckons early intervention and vocational rehabilitation in rst-episode psychosis: employing cautious optimism. Aust NZ J Psychiat 40, 951962. 5. Larsen T.K., Moe L.C., Vibe-Hansen L., Johannessen J.O., 2000, -Premorbid functioning versus duration of untreated psychosis in one year outcome in first-
episode psychosis. Schizophr Res 45, 19. 6. Linszen D., Dingemans P, Lenior M. 2001, -Early intervention and
a five year follow up in young adults with a short duration of untreated psychosis: ethical implications. Schizophr Res. 51(1), 55-61. 7. Malla A.K., Norman R.M.G., Machanda R., Ahmed M.R., Scholten D., Harricaran R., Cortese L., Takhar J., 2002, -One year outcome in first episode psychosis: influence of DUP and other predictors. Schizophr Res 54, 231242. 8. Malla, A., Payne, J., 2005, -First-episode psychosis: psychopathology, quality of life, and functional outcome. Schizophrenia Bulletin 31 (3), 650-659. 9. Mason P., Harrison G., Glazebrook C., Medley I., Dalkin T., Croudace T., 1995, Characteristics of outcome in schizophrenia at 13 years. Br J Psychiatry 167: 596603. 10. Novak-Grubic V., Tavcar R. 2002, -Predictors of relapse in males with first episode schizophrenia, schizophreniform and schizoaffective disorder. Eur Psychiatry 17, 148154. 11. Robinson D., Woerner M.G., Alvir J.M.J., Bilder R., Goldman R., Geisler S., Koreen A., Sheitman, S., Chakos M., Mayerhoff D., Lieberman J.A., 1999, Predictors of relapse following response from a first episode of schizophrenia or schizoaffective disorder. Arch Gen Psychiatry 56, 241247. 12. Sartorius N., Gulbinat W., Harrison G., Laska E., Siegel C., 1996; Long-term follow-up of schizophrenia in 16 countries. A description of the International Study of Schizophrenia conducted by the World Health Organization. Soc Psychiatry Psychiatr Epidemiol 31, 249258.