Department of Psychiatry and Psychotherapy, Martin Luther University, Halle-Wittenberg, Halle, Germany
Correspondence: Dr Frank Pillmann, Klinik und Poliklinik für Psychiatrie und Psychotherapie, Martin-Luther-Universität Halle-Wittenberg, 06097 Halle, Germany. Tel: +49 345 557 4560; fax: +49 345 557 3500; e-mail: frank.pillmann{at}medizin.uni-halle.de
Funding detailed in Acknowledgement.
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ABSTRACT |
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INTRODUCTION |
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METHOD |
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The majority (79%) of participants were female; 19 of those with acute and transient psychotic disorders (45%) and 26 of those with positive schizophrenia (62%) had had earlier episodes (P=0.126). The mean age at first episode was 35.8 years (s.d.=11.1) for those with acute and transient psychotic disorders and 35.3 years (s.d.=13.9) for those with positive schizophrenia (P=0.867). Age at index admission was 41.2 years (s.d.=12.5) and 41.1 years (s.d.=12.4) (P=0.968).
Follow-up investigations took place at predetermined times 2.5 (s.d.=1.3), 4.9 (s.d.=1.4) and 7.0 (s.d.=1.5) years after the index episode, or 8.6 (s.d.=7.8), 10.5 (s.d.=7.3) and 12.4 (s.d.=7.3) years after the first episode. Three patients died before the first follow-up and four declined follow-up examinations throughout. Data from at least one point of follow-up were obtained from 39 patients with acute and transient psychotic disorders and 38 with positive schizophrenia (92% of the original participants). At the third follow-up, 66 (79%) of the original participants, or 88% of those surviving (n=75), were examined.
For the evaluation of socio-demographic features we used a semi-structured interview as in earlier studies (Marneros et al, 1991). The level of general functioning during the previous week was assessed using the Global Assessment Scale (GAS; Endicott et al, 1976). Relapse was defined as the occurrence of a major affective syndrome or of psychotic symptoms leading either to hospitalisation or to out-patient treatment, including psychiatric medication and a disruption of daily activities. ICD10 diagnoses were assessed with the Schedules for Clinical Assessment in Neuropsychiatry (SCAN; van Gulick-Bailer et al, 1995).
For the calculation of interrater reliability, 15 interviews were independently coded by two raters; one conducted the interview with the other present (interviewer observer method). Kappa values for categorical items exceeded 0.80 for all items. The intraclass correlation coefficient for GAS was excellent (0.86).
As the conditions of normality and equal variances were not generally met,
the non-parametric Wilcoxon test for paired samples and the MannWhitney
U-test were used. In addition, 2 tests or
Fishers exact test were performed, as applicable. P<0.05
was considered statistically significant.
All participants provided written informed consent. The study protocol was approved by the local ethics committee.
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RESULTS |
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Relapses during the follow-up period were frequent and occurred in 31 out of 39 individuals with acute and transient psychotic disorders (79%) and 30 out of 38 with positive schizophrenia (79%; P=0.953). There was no difference in the median time to the first relapse between the two groups (1.04 and 1.57 years, respectively; KaplanMeier method, P=0.548).
In order to delineate a core group in longitudinally stable remission without medication, we set three criteria to be met at the last follow-up: no medication and no relapse for at least 2 years, and a GAS>70 at the last follow-up (Mason et al, 1995). Out of the 39 individuals with acute and transient psychotic disorder, 12 (31%) fulfilled all three conditions but none of the 38 with positive schizophrenia met the criteria (P<0.001).
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DISCUSSION |
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Strengths of the present study include the use of standardised instruments, multiple points of follow-up and a low attrition rate. Important limitations are the small sample size, which affects the analysis of subgroups with acute and transient psychotic disorders, the absence of baseline data on GAS and the failure to mask the raters to the index diagnosis. Because of the case control design of the study, the control group had a female preponderance and a relatively late onset, probably skewing the sample towards a somewhat better prognosis (Harrison et al, 1996). This bias precludes generalisation to unselected samples of individuals with schizophrenia, but makes differences between the two groups even more noteworthy.
The control group with positive schizophrenia had a slight deterioration in the long-term course of their illness. The effect is of questionable clinical significance but confirms other similar, if controversial, findings (Eaton et al, 1995; Stirling et al, 2003). Deterioration was not observed in those with acute and transient psychotic disorders. As we have reported elsewhere (Marneros & Pillmann, 2004), this stability does not preclude syndromic change during long-term follow-up which affected more than half of the patients with acute and transient psychotic disorder in the present study.. study Although acute and transient psychotic disorders might represent a mild variant of the schizophrenia spectrum, characteristics such as the lack of deterioration, polymorphic features and affective syndromes during the long-term course suggest different pathogenetic mechanisms (Marneros & Pillmann, 2004).
At the end of the prospective follow-up, 31% of those with acute and transient psychotic disorders, but none of those with positive schizophrenia, could be regarded as being in longitudinally stable remission without medication. If in this subgroup the disorder is self-limiting, maintenance medication may be less often necessary than in schizophrenia. However, 31% may be an overestimation because of the possibility of later relapse. Only longer follow-up times and randomised controlled trials can resolve this matter.
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ACKNOWLEDGMENTS |
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REFERENCES |
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Endicott, J., Spitzer, R. L., Fleiss, J. L., et al (1976) The global assessment scale. A procedure for measuring overall severity of psychiatric disturbance. Archives of General Psychiatry, 33, 766 -771.[Abstract]
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Received for publication October 4, 2004. Revision received February 14, 2005. Accepted for publication February 18, 2005.
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