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

Persistent suicide risk in clinically improved schizophrenia patients: challenge of the suicidal dimension

BACKGROUND: Suicide is a major problem in schizophrenia, estimated to affect 9%-13% of patients. About 25% of schizophrenic patients make at least one suicide attempt in their lifetime. Current outcome measures do not address this problem, even though it affects quality of life and patient safety. The aim of this study was to assess suicidality in long-term clinically improved schizophrenia patients who were treated in a nongovernmental psychiatric treatment centre in Mumbai, India. METHOD: Participants were 61 patients out of 200 consecutive hospitalized first-episode patients with schizophrenia diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders who were much improved on the Clinical Global Impression Scale-Improvement (CGI-I) scale at the endpoint of a 10-year follow-up. Clinical assessment tools included the Positive and Negative Syndrome Scale for Schizophrenia, CGI-I, Global Assessment of Functioning, and suicidality. RESULTS: Many of the patients, although clinically improved, experienced emerging suicidality during the 10-year follow-up period. All of the patients reported significant suicidality (ie, suicide attempts, suicidal crises, or suicidal ideation) at the end of the study, whereas only 83% had reported previous significant suicidality at baseline. No sociodemographic and clinical variables at baseline were predictive of suicidal status at the end of the 10-year follow-up. CONCLUSION: Schizophrenia is a complex neurobehavioral disorder that appears to be closely associated with suicidal behavior. Adequate assessment and management of suicidality needs to be a continual process, even in patients who respond well to treatment

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

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

Cognitive factors in long term outcome of first episode psychosis

Cognitive factors in long term outcome of first episode psychosis Amresh Shrivastava, Megan Johnston, Nilesh Shah , Meghana Thakar , and Larry Stitt a Excecutive Director , Mental Health Foundation of India (PRERANA Charitable trust) and Silver Mind Hospital, 209 Shivkripa Complex, Gokhale Road, Thane, Mumbai, Maharashtra, India 400 602, Currently: Assistant Professor of Psychiatry, The University of western Ontario, & associate Scientist, Lawson Health Research Institute, London, Ontario,Canada, E Mail : [email protected] b Professor of Psychiatry LTMG Hospital, University of Mumbai, Sion, Mumbai, Maharashtra, India 400 022 c Clinical psychologist, Silver Mind Hospital, Mumbai,India d Department of Epidemiology & Biostatistics, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada N6A 5C1 e Research 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. One negative outcome associated with schizophrenia is a deterioration of cognitive functioning. The existing research on cognitive functioning in first-episode schizophrenia suggests that cognitive deficits may be present quite early on in the illness. Less is known about what happens to cognitive abilities in the years following a diagnosis of first-episode schizophrenia. The present study examined the cognitive function of individuals first diagnosed with schizophrenia and then again ten years later to examine changes in cognitive functioning across this time period. Individuals diagnosed with first-episode schizophrenia, who ten years later were classified as recovered, had their cognitive functioning assessed both at the time of diagnosis and at the ten year follow-up. Our results indicate deterioration in some abilities at baseline and a decline of cognitive abilities in the group of clinically recovered patients. Visuo-spatial memory, working memory and executive functioning were shown to decrease in the ten years of treatment following diagnosis and many individuals classified as recovered still demonstrate abnormal cognitive functioning. These findings suggest that cognitive functions should be focused on to a much greater degree in current treatment methods

Duration of untreated psychosis & Long-term outcome of First episode, hospitalized schizophrenia: Search for a missing link in a linear correlation

Duration of untreated psychosis & Long-term outcome of First episode, hospitalized schizophrenia: Search for a missing link in a linear correlation Amresh Shrivastavaa,*, Nilesh Shahb, Meghana Thakarc, Larry Stittd, Gurusamy Chinnasamye a Excecutive Director , Mental Health Foundation of India (PRERANA Charitable trust) and Silver Mind Hospital, 209 Shivkripa Complex, Gokhale Road, Thane, Mumbai, Maharashtra, India 400 602, Currently: Assistant Professor of Psychiatry, The University of western Ontario, & associate Scientist, Lawson Health Research Institute, London, Ontario,Canada, E Mail : [email protected] b Professor of Psychiatry LTMG Hospital, University of Mumbai, Sion, Mumbai, Maharashtra, India 400 022 c Clinical psychologist, Silver Mind Hospital, Mumbai,India d Department of Epidemiology & Biostatistics, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada N6A 5C1 e Research 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. Background: Duration of untreated psychosis (DUP) has emerged as a reliable predictor of outcome and provides credence to development of early intervention services. While long-term outcome of schizophrenia is multifactorial in nature, it is difficult to argue that DUP is an independent determinant of outcome. Most likely several other factors together with short DUP determine a ‘good outcome’. The present study examines effect of differential periods of DUP on clinical and social outcome in ten year’s long-term follow up. 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 between those with DUP≤6 months compared to those with DUP\u3e6 months in terms of subscales of PANSS, positive symptoms (p=.013), negative symptoms (p=.010), and General psychopathology (p=.004) with those with ≤ 6 months DUP having more positive symptoms, more negative symptoms and a lower GP. DUP was not found to be significantly associated with any of the end point parameters of good clinical or social outcome. Conclusion: We find that DUP alone does not indicate and determine outcome status in first episode. Psychopathological heterogeneity in longitudinal course in early phase needs to be considered as one such factor. Further it is also not clear how early should the intervention be done for the benefit of early intervention.. More research is needed in this fiel

Baseline Serum Prolactinin Drug Naïve First Episode Schizophrenia Predicts a Positive Clinical and Social Outcome at Five Years, Post Discharge Follow-up

Serum prolactinis an indicator of tuberoinfundibulardopamine activity. It is reported to increase in wide variety of mental illnesses. It has close relationship with antipsychotic therapy. However, its relationship with psychopathology and outcome is not clear. Serum prolactinlevel was measured in 30 male and 30 female drug naive patients of schizophrenia. Subsequently, these patients were treated with antipsychotics. The severity of psychopathology at the baseline and subsequent improvement at the end of 3 weeks and 6 weeks was assessed on modified brief psychiatric rating scale (mBPRS). Available to follow up at five years 18 males & 22 females patients were reassessed and findings analyzed for predictive significance.Contrary to expectations, prolactinlevels in patients were twice as high before treatment compared to after. However, this difference was found to be statistically significant in males only. Correlations between the prolactin, BPRS, and outcome measurements were not significant for any time point up to six weeks. Significant positive correlations were observed using measures obtained five years follow up only. From the present study it seems that baseline serum prolactinlevel in drug naive patients of schizophrenia may not be a reliable indicator of psychopathology but it may be an indicator of good prognosis in long term. Further research is necessary to arrive at a definite conclusion

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