First Episode Is the Best Episode: Lessons and Limitations in Duration of Untreated Psychosis (DUP) and Outcome in Schizophrenia

Background: Early intervention in psychosis is an opportunity. Research ahs shown that if any thing community members can do to prevent psychosis is to report early. This has opened newer vistas for understanding the complexity of brain and behaviour in schizophrenia. At the same time it has raised the bar of expectations regarding its correlation to outcome. It finally narrows down to meaningful public campaign for awareness, which will decide success of research to clinics in schizophrenia management. Duration of untreated psychosis (DUP) has emerged as a reliable predictor of outcome and provides credence to development of early intervention services. It is not quite clear if DUP works in isolation and what other factors along with DUP would determine outcome long-term outcome of schizophrenia is multifactorial in nature. The present study examines effect of DUP on outcome of schizophrenia Method: we conducted a ten years follow up study of first episode hospitalized DSM III-R schizophrenia and correlated multiple outcome criteria with DUP at Mumbai. We carefully determined onset of psychosis using criteria for appearance of positive symptoms, negative symptoms or significant social decline. Data was analyzed using SAS. Results: we analyzed 101 patients available at ten years. We found that mean DUP was higher for group, which showed Clinical recovery on GCIS [14.0(SD=8.0) months for recovered & 10.8 (SD=5.7) months in nonrecovered group p=0.091]. There is a significant difference in favour of DUP≤6 months in terms of subscales of PANSS; However DUP was not found to be significantly associated with the end point parameters of good clinical or social outcome. Conclusion: We find that DUP is just one factor in determinants of outcome. Several other psychopathological & phenomenological factors collectively play a role in determining outcome. Future research needs to be directed towards combination of determinants of outcome in early intervention of psychosis

Predictors and Characteristics of Response and Nonresponse: A Ten Year Follow-Up of First Episode Schizophrenia in Mumbai

▪ It is not clearly known what predicts good long-term outcome in first episode schizophrenia and what the characteristics are that differentiate patients who do and do not show good response ▪ We attempted to find the characteristics and predictors of good out-come for patients who presented with severe psychopathology and were hospitalized in their first episode psychosis in a tertiary psychiatric hospital in the city of Mumbai ▪ 101 patients of first episode schizophrenia were assessed at hospitalization, and reassessed at ten years ▪ The data was analyzed on 13 outcome parameters for predictors and characteristics of good outcome, using the SAS system of statistical analysis ▪ 61 of 101 patients showed good outcome on the CGIS after ten years ▪ Predictors of good recovery were high baseline positive symptoms and low negative symptoms, higher anxiety-depressive symptoms, lower level of depressive symptoms, lower level of aggression, higher work performance and ability to live independently. ▪ Characteristics of non-recovered patients showed higher extra pyramidal symptoms, severe aggressive symptoms, higher frequency of disorganization symptoms at baseline and higher level of family burden at the end of the term ▪ Our study shows reasonably good outcome [61.7%] in first episode-hospitalized patients ▪ Good outcome correlated with severity of positive symptoms, level of work function and ability to live independently at baselin

Do Atypical Antipsychotics Differ in Determining Long-term Outcome of First Episode Schizophrenia? A Naturalistic Outcome Study in India

Antipsychotic medications form the mainstream of treatment in schizophrenia. These drugs have several short term as well long term advantage. It is not known if atypical antipsychotics have the long-term effect in improving outcome and meeting expectations (1,2,3). The present study examined usage and association of antipsychotics drugs with clinical outcome a long-term naturalistic study

The abilities of improved schizophrenia patients to work and live independently in the community: a 10-year long-term outcome study from Mumbai, India

Background: The outcome of schizophrenia has several determinants. Socioecological factors, particularly living conditions, migration, community and culture, not only affect the level of risk but also the outcome. Mega cities around the world show a unique socioecological condition that has several challenges for mental health. The present study reports on the long-term status of patients with schizophrenia in such a mega city: Mumbai, India. Aim This study aims to reveal the long-term outcome of patients suffering from schizophrenia with special reference to clinical symptoms and social functioning. Methods: The cohort for this study was drawn from a 10-year follow-up of first episode schizophrenia. Patients having completed 10 years of consistent treatment after first hospitalisation were assessed on psychopathological and recovery criteria. Clinical as well as social parameters of recovery were evaluated. Descriptive statistics with 95% confidence intervals are provided. Results: Of 200 patients recruited at the beginning of this study, 122 patients (61%) were present in the city of Mumbai at the end of 10-year follow-up study period. Among 122 available patients, 101 patients (50.5%) were included in the assessment at the end of 10-year follow-up study period, 6 patients (3.0%) were excluded from the study due to changed diagnosis, and 15 patients (7.5%) were excluded due to admission into long-term care facilities. This indicates that 107 out of 122 available patients (87.7%) were living in the community with their families. Out of 101 (50.5%) patients assessed at the end of 10 years, 61 patients (30.5%) showed improved recovery on the Clinical Global Impression Scale, 40 patients (20%) revealed no improvement in the recovery, 43 patients (72.9%) were able to live independently, and 24 patients (40%) were able to find employment. Conclusions: With 10 years of treatment, the recovery rate among schizophrenia patients in Mumbai was 30.5%. Among the patients, 87.7% of patients lived in the community, 72.9% of patients lived independently, and 40% of patients obtained employment. However, 60% of patients were unable to return to work, which highlights the need for continued monitoring and support to prevent the deterioration of health in these patients. It is likely that socioecological factors have played a role in this outcome

Biology of over-wintering of perennial root nodules and seed development in beach pea (Lathyrus maritimus L.)

Beach pea (Lathyrus maritimus L.) is a potential cold-climate circumpolar legume crop that naturally grows along the shorelines of Newfoundland, Canada. The present study was undertaken to determine the over-wintering (winter survival) strategies of perennial root nodules of beach pea on the sandy beach of Salmon Cove, Newfoundland, with emphasis on oleosomes (lipid bodies). Seasonal changes in other biochemical constituents of nodules such as carbohydrates, proteins and elements were also studied. In addition, attempts were made to screen the suitable rhizobial inoculum for beach pea and also to trace the patterns of seed development, maturation and abortion in beach pea. -- The native rhizobial strain (ACCCRC) isolated from beach pea nodules was found to be the most effective inoculum. It was superior in nitrogen-fixing traits compared to other bacterial strains. Studies on seasonal changes in nodule structure revealed that perennial nodules undergo winter dormancy when the aerial parts of the plant dry out. With the advent of spring, the nodule meristem is activated to regenerate effective nodule tissues that perform normal functions of the nodule in the following summer. A higher number of oleosomes was seen in histological preparations of winter nodules compared to summer nodules. As winter approached, nodules stored higher amounts of lipids, which decreased gradually throughout winter and spring. The degradation of oleosomes could be localized at the electron microscopic level. -- Phospholipids and monoglycerides were identified as the major oleosomic lipids in perennial root nodules. C16:0, C18:0 and C18:1 were the dominant fatty acids. The fatty acid composition and double bond index differed among lipid classes depending upon the season. Overall, the level of many unsaturated fatty acids increased and many saturated fatty acids decreased in oleosomes of winter nodules. Nodules selectively utilized fatty acids depending upon the season to overcome environmental influence. -- Microscopical studies showed that nodule cells accumulated large amounts of amyloplasts with multiple starch grains in summer to be used in winter, and the degraded products could be visualized by electron microscopy. This was confirmed by quantitative data that starch content of nodules increased during the summer and decreased during the winter. Soluble sugars and non-reducing sugars increased in the winter, whereas reducing sugars increased in the fall. These results indicate that perennial nodules act as temporary storage organs. Nodules have large amounts of storage organelles such as oleosomes and amyloplasts during pre-winter months. These storage organelles may be catabolized to protect the nodule tissues from cold temperatures and also mobilized just before the growing season to support re-growth. Accumulation of more sugars in winter may help to maintain high osmolarity of cells that prevents freezing of dormant nodule tissues. Ultrastructural morphology of winter nodules confirms the lack of freezing damage. -- Protein contents of nodules increased as the winter approached. A wide variation was observed in season-specific accumulation of amino acids and elements. Amino acids such as arginine, cystathionine, ethanolamine, histidine, hydroxyproline, ornithine and proline increased in winter nodules, whereas the level of y-aminobutyric acid declined at the same time. Nodules collected in winter contained higher amounts of P, K, Ca, Mn, Cu and Zn, while summer nodules showed more Cl, Na, S, Mg, Al, Si, Mo and Fe. The possible involvement of some amino acids and elements in cold adaptation was discussed. This study shows that perennial nodules of beach pea have complex winter survival strategies that involve modifications of anatomy, physiology and biochemistry of the nodules. -- Generally, beach pea seeds showed almost a sigmoidal pattern of development. The stage 6 (S6) was identified as the physiological maturity stage in both beach pea and grass pea (Lathyrus sativus L.). This study suggests that harvesting of a seed crop when physiologically mature will ensure seeds of the best quality. Beach pea seeds exhibited precocious germination as well as hardseededness at S4. Hard seed coats completely prevented water absorption and germination at S5 and S6. In grass pea, precocious germination started at S3 and increased with seed maturity. There was no hardseededness in grass pea. Studies on seed abortion revealed that cryptic seed abortion was observed early in pod ontogeny in both beach pea and grass pea. Only 68% and 82% of ovules produced mature seeds in beach pea and grass pea, respectively. The patterns of seed abortion and development at different ovule positions within developing pods were random in beach pea and nonrandom in grass pea. Ovules in position 1 and 2 at the basal end of pods showed a greater probability of seed abortion in beach pea. Grass pea pods showed increased seed abortion towards the basal region of the pod

Persisting symptoms in recovered first episode schizophrenia patients

Persisting symptoms in recovered first episode schizophrenia patients Amresh Shrivastavaa,*, Nilesh Shahb, Meghana Thakara, Larry Stittc, Gurusamy Chinnasamyd aMental Health Foundation of India (PRERANA Charitable trust) and Silver Mind Hospital, 209 Shivkripa Complex, Gokhale Road, Thane, Mumbai, Maharashtra, India 400 602 bLTMG Hospital, University of Mumbai, Sion, Mumbai, Maharashtra, India 400 022 cDepartment of Epidemiology & Biostatistics, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada N6A 5C1 dResearch Office, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada N6A 5C1 *Corresponding author. Tel.: +1-519-631-8510; Fax: +1-519-631-2512. E-mail address: [email protected] (A. Shrivastava). Present address: Regional Mental Health Care, 467 Sunset Drive, St. Thomas, Ontario, Canada N5H 3V9. Abstract Our goal was to determine level of remission in clinical symptoms amongst the recovered patients of first episode schizophrenia in a long-term follow up study. We assessed recovered subjects categorized by Clinical Global Impression Scale (CGIS), in a cohort of long-term follow up study, on parameters of positive, negative and disorganized symptoms as well as on parameters of social functioning, in a naturalistic setting using cross sectional design. Subjects were drawn from a prospective outcome study of schizophrenia. Among the patients who showed ‘improved’ and ‘much improved’ state on CGIS, 40 patients (65.6%) had persistent psychopathology scoring \u3e7 on either positive or negative sub scales of positive and negative symptoms scale. 39% showed presence of one or more positive symptoms, 42% showed one or more negative symptoms, and 49% had disorganization symptoms. There was no significant difference on any parameter of social functioning, cognition and other clinical symptoms between those who had persisting symptoms and those who did not. There were only 10 patients (16.4%) who had both persistent positive and negative symptoms. None of the baseline characteristics were found to have any predictive significance for persisting symptoms in long-term, despite adequate treatment with atypical antipsychotic drugs. This study concludes that clinical symptoms do persist despite treatment in low severity and interfere with patients’ socioeconomic status and independence. The findings suggest the need for continued, comprehensive, multidisciplinary treatment for patients of schizophrenia. Keywords: Persisting symptoms, Clinical outcome, Schizophrenia, Social outcom

First Episode Is the Best Episode: Lessons and Limitations in Duration of Untreated Psychosis (DUP) and Outcome in Schizophrenia

Background: Early intervention in psychosis is an opportunity. Research ahs shown that if any thing community members can do to prevent psychosis is to report early. This has opened newer vistas for understanding the complexity of brain and behaviour in schizophrenia. At the same time it has raised the bar of expectations regarding its correlation to outcome. It finally narrows down to meaningful public campaign for awareness, which will decide success of research to clinics in schizophrenia management. Duration of untreated psychosis (DUP) has emerged as a reliable predictor of outcome and provides credence to development of early intervention services. It is not quite clear if DUP works in isolation and what other factors along with DUP would determine outcome long-term outcome of schizophrenia is multifactorial in nature. The present study examines effect of DUP on outcome of schizophrenia Method: we conducted a ten years follow up study of first episode hospitalized DSM III-R schizophrenia and correlated multiple outcome criteria with DUP at Mumbai. We carefully determined onset of psychosis using criteria for appearance of positive symptoms, negative symptoms or significant social decline. Data was analyzed using SAS. Results: we analyzed 101 patients available at ten years. We found that mean DUP was higher for group, which showed Clinical recovery on GCIS [14.0(SD=8.0) months for recovered & 10.8 (SD=5.7) months in nonrecovered group p=0.091]. There is a significant difference in favour of DUP≤6 months in terms of subscales of PANSS; However DUP was not found to be significantly associated with the end point parameters of good clinical or social outcome. Conclusion: We find that DUP is just one factor in determinants of outcome. Several other psychopathological & phenomenological factors collectively play a role in determining outcome. Future research needs to be directed towards combination of determinants of outcome in early intervention of psychosis

The abilities of improved schizophrenia patients to work and live independently in the community: a 10-year long-term outcome study from Mumbai, India

Abstract Background The outcome of first episode schizophrenia has several determinants. Socioecological factors, particularly living conditions, migration, community and culture, not only affect the level of risk but also the outcome. Mega cities around the world show a unique socioecological condition that has several challenges for mental health. The present study reports on the long-term status of patients with schizophrenia in such a mega city: Mumbai, India. Aim This study aims to reveal the long-term outcome of patients suffering from schizophrenia with special reference to clinical symptoms and social functioning. Methods The cohort for this study was drawn from a 10-year follow-up of first episode schizophrenia. Patients having completed 10 years of consistent treatment after first hospitalisation were assessed on psychopathological and recovery criteria. Clinical as well as social parameters of recovery were evaluated. Descriptive statistics with 95% confidence intervals are provided. Results Of 200 patients recruited at the beginning of this study, 122 patients (61%) were present in the city of Mumbai at the end of 10-year follow-up study period. Among 122 available patients, 101 patients (50.5%) were included in the assessment at the end of 10-year follow-up study period, 6 patients (3.0%) were excluded from the study due to changed diagnosis, and 15 patients (7.5%) were excluded due to admission into long-term care facilities. This indicates that 107 out of 122 available patients (87.7%) were living in the community with their families. Out of 101 (50.5%) patients assessed at the end of 10 years, 61 patients (30.5%) showed improved recovery on the Clinical Global Impression Scale, 40 patients (20%) revealed no improvement in the recovery, 43 patients (72.9%) were able to live independently, and 24 patients (40%) were able to find employment. Conclusion With 10 years of treatment, the recovery rate among schizophrenia patients in Mumbai was 30.5%. Among the patients, 87.7% of patients lived in the community, 72.9% of patients lived independently, and 40% of patients obtained employment. However, 60% of patients were unable to return to work, which highlights the need for continued monitoring and support to prevent the deterioration of health in these patients. It is likely that socioecological factors have played a role in this outcome.</p

Improved Schizophrenia Patient’s Ability to Work and Live Independently in the Community: A Ten-year Long-term Outcome Study from Mumbai, India

Background: The outcome of schizophrenia has several determinants. Socio-ecological factors, particularly living conditions, migration, community and culture, not only affect the level of risk but also the outcome. Mega cities around the world show a unique socio-ecological condition which has several challenges for mental health. The present study reports the long-term status of patients with schizophrenia in such a mega city - Mumbai, India. Aim: This study aims to reveal long-term outcome of patients suffering from schizophrenia with special reference to clinical symptoms and social functioning. Methods: The cohort for this study was drawn from a 10-year follow-up of first episode schizophrenia. Patients having completed 10 years of consistent treatment after first hospitalization were assessed on psychopathological and recovery criteria. Clinical as well as social parameters of recovery were evaluated. Descriptive statistics with 95% confidence intervals are provided. Results: Out of 200 patients recruited at the beginning of this study, 122 patients (61%) were present in the city of Mumbai at the end of 10-year follow-up study period. Among 122 available patients, 101 patients (50.5%) were included in the assessment at the end of 10-year follow-up study period, 6 patients (3.0%) were excluded from the study due to changed diagnosis, and 15 patients (7.5%) were excluded due to admission in the long-term care facilities. This indicates that 107 out of 122 available patients (87.7%) were living in the community with their families. Out of 101 (50.5%) patients assessed at the end of 10-year, 61 patients (30.5%) showed improved recovery on the Clinical Global Impression Scale, 40 patients (20%) revealed no improvement in the recovery, 43 patients (72.9%) were able to live independently, and 24 patients (40%) were able to find employment. Conclusions: With 10 years of treatment, the recovery rate among schizophrenia patients in Mumbai was 30.5%. Among the patients, 87.7% patients lived in the community, 72.9% patients lived independently, and 40% patients obtained employment. However, 60% patients were unable to return to work, which highlights the need for continued monitoring and support to prevent the deterioration of health in these patients. It is likely that socio-ecological factors have played a role in this outcome

Effects of duration of untreated psychosis on long-term outcome of people hospitalized with first episode schizophrenia

Duration of untreated psychosis (DUP) has emerged as a reliable predictor of outcome but continues to remain under scientific scrutiny. The present study examines the effect of differential periods of DUP on long-term outcome of first episode schizophrenia at Mumbai, India. This research was a prospective, 10-year follow-up naturalistic study. Hospitalized patients of first episode schizophrenia were selected and followed up. Results showed that the mean DUP was higher for a group which showed clinical recovery on Clinical Global Impression Scale [14.0 months (SD=8.0) in recovered and 10.8 months (SD=5.7) in non-recovered group (P=0.091)]. DUP was not found to be significantly associated with any of the end point parameters of good clinical or social outcome. Thus, this study found that DUP alone does not determine outcome status confirming the role of psychopathological heterogeneity