Division of Psychiatry, University of Nottingham
Division of Psychiatry, University of Bristol
![]() |
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Correspondence: Dr Swaran P. Singh, Department of Psychiatry, B Floor, South Block, University Hospital, Nottingham NG7 2UH
![]() |
ABSTRACT |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Aims To assess the three-year outcome of an inception cohort of first-episode psychoses treated in a modern, community-oriented service; to compare outcomes with an earlier cohort treated in hospital-based care; and to examine the predictive validity of ICD10 diagnostic criteria.
Method Three-year follow-up (1995-1997) of an inception cohort of first-episode psychoses and comparison with two-year follow-up (1980-1982) of the Determinants of Outcome of Severe Mental Disorders (DOSMED) Nottingham cohort.
Results On most outcome measures, non-affective psychoses had a worse outcome than affective psychoses. Affective psychoses had better outcome than previously reported. Substance-related psychoses had very poor occupational outcome. Similar proportions of the current and DOSMED cohort were in remission but the former were rated as having greater disability.
Conclusions In a modern community service, 30-60% of patients with first-episode psychoses experience a good three-year outcome. The ICD10 criteria have good predictive validity.
![]() |
INTRODUCTION |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
![]() |
METHODOLOGY |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
![]() |
FOLLOW-UP STUDY (1995-1997) |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Follow-up assessment
The follow-up assessment included interviews with subjects, family members
and the treating psychiatric teams, and perusal of psychiatric case notes,
general medical notes, community mental health team notes and GP records.
In addition the following instruments were used:
Mode of onset was defined as the period between the first reported symptom or noticeable behavioural change and the emergence of psychotic symptoms. The OPCRIT mode of onset categories were summarised as: onset less than one week; one week to one month; and more than one month. Ethnicity was categorised according to ethnic family origins. The main categories were White (both parents born in the UK), Indo-Asian (one or both parents born in the Indian sub-continent) and African-Caribbean (one or both parents born in the Caribbean). The rationale for recording and analysing data on ethnicity and the findings have been reported previously (Harrison et al, 1999).
Reliability exercise
Both S.A. and S.P.S. carried out an inter-rater reliability exercise before
the study began by concurrently rating ten subjects with psychotic illness who
were not included in the sample. The OPCRIT reliability was calculated by the
completion of ten case vignettes. Intra-class correlation coefficients (ICCs)
were calculated for SCAN profile scores, SANS sub-scale scores,
Strauss-Carpenter global rating, McGlashan global rating, GAF scores and
OPCRIT subsection scores. Kappa values were calculated for the Bleuler
severity rating, DAS global rating and SCAN-generated CATEGO diagnoses.
Reliability was considered satisfactory if the ICC or kappa value was 0.7 or
greater.
The ICC values were as follows: for SCAN profile scores, 0.67-1.0; for SANS sub-scale scores, 0.75-0.88; for McGlashan global rating, 0.92; for Strauss-Carpenter global rating, 0.86; for GAFs, 0.97; for GAFd, 0.98; and for OPCRIT sub-scale scores, 0.85-1.0. Kappa values were as follows: for Bleuler severity rating, 0.84; for DAS global rating, 0.88; for SCAN-generated CATEGO diagnoses, 0.75.
In some cases, the absence of any ratings led to a spuriously perfect agreement (ICC or kappa=1.0). This occurred in the following: SCAN profile scores for Autistic Speech and Behaviour, Appetite Problems, Cognitive Impairment and Somatic and Dissociative Symptoms; and OPCRIT Substance Abuse or Dependence sub-scale (items 78-83).
Classification and description of outcomes
Both longitudinal and cross-sectional outcomes were measured in the domains
of symptoms, employment, social activity, hospitalisation, compulsory
detentions, course type and global functioning. Outcomes are reported for the
entire cohort of first-episode psychoses and for four diagnostic groups:
non-affective psychoses (all non-affective, non-substance-related psychoses:
ICD10 categories F20-29); affective psychoses (ICD10 F30-33);
schizophrenia (ICD10 F20); and substance-related psychoses
(ICD10 F1x). We compared three characteristics of outcome with
the two-year DOSMED follow-up. These were the proportion of patients in
remission, the proportion currently in hospital and disability as measured by
the DAS.
Comparison of outcome with prior Nottingham cohort
For comparison with the DOSMED cohort, only patients younger than 54 years,
residing in the catchment area of the DOSMED study and not having a
substance-induced psychosis (the inclusion criteria for the DOSMED study) were
included. A total of 54/166 patients from the present cohort were thus
excluded and data from 112 patients were used for direct comparison with the
DOSMED cohort (n=99).
Analysis
Outcomes were compared statistically between non-affective and affective
psychoses. No statistical analysis was done for patients with
substance-related psychoses owing to the small numbers. Discrete/categorical
outcome variables were summarised using percentages and compared using odds
ratios and 95% confidence intervals. Continuous outcome measures were
summarised with means and confidence intervals and compared using the
t-test or one-way ANOVA.
![]() |
RESULTS |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
We traced 164 subjects (99%) to residence, obtained face-to-face interviews with 135 (81%) and another 8 (5%) were interviewed by phone. Two subjects had died, including one by suicide. Of the direct assessments, 97% were done 35-37 months after inclusion in the original cohort, thus ensuring that subjects were homogeneous with respect to time since contact with the services. We collected collateral information (from the treating psychiatry teams, the carers known to the service and GPs) on all cases, including those not interviewed. Follow-up data were therefore available for almost the entire cohort. Over the entire study, from first presentation to follow-up, 33 patients (19.9%) were never admitted to hospital, being treated entirely within the community. At the time of the followup assessment, eight subjects (4.8%) were in-patients or under the care of rehabilitation services.
Table 1 shows the socio-demographic and clinical profile of the cohort according to ICD10 diagnostic categories at onset, made blind to outcome. A re-diagnosis exercise was conducted at three years, blind to onset diagnosis, and is reported elsewhere (Amin et al, 1999). Almost two-thirds of the total sample (103/166) and over three-quarters of the group with substance-related psychoses (10/13) were less than 30 years of age. In comparison with non-affective psychoses, the group with affective psychoses had a significantly greater proportion of women and more often had an acute onset. They were also older at the time of contact and appeared to be of higher socio-economic status in that they were more likely to be employed and a house-owner, but these differences were not statistically significant. The diagnostic groups were comparable on ethnic status, except for the group with substance-related psychoses, which almost exclusively comprised White males.
|
Cross-sectional outcome
Table 2 shows the
cross-sectional outcome of the total cohort, outcomes for the four diagnostic
groups and comparison between non-affective psychoses (ICD10 F20-29)
and affective psychoses (ICD10 F30-33). Numbers in parentheses in the
variable column show the number of subjects for whom data were available for
each outcome variable. More than half of the cohort had experienced no or
minimal symptoms in the preceding month. In the preceding year, 42% had been
in at least weekly social contact with friends or family, three-quarters had
no hospitalisations, one-third had worked part-time or full-time and over half
had no or minimal overall impairment. Schizophrenia (ICD10 F20) had the
worst outcome on almost all indices, with substance-related psychosis
(ICD10 F10-19) having an intermediate outcome between non-affective and
affective psychoses.
|
Figure 1 shows a comparison of non-affective psychoses and affective psychoses on the Strauss-Carpenter outcome categories. As compared to patients with non-affective psychoses, patients with affective psychoses were about three times more likely to be in weekly social contact with friends or relatives, to be employed and to have minimal impairment. The GAF and DAS score data on symptoms and disability also showed significantly better outcome for patients with affective psychoses. The two groups did not differ on the mood and psychotic symptom scores on SCAN, but non-affective psychoses had significantly higher negative symptom ratings.
|
Longitudinal outcome
Table 3 shows longitudinal
outcome over three years for the total cohort, outcomes for the four
diagnostic groups and comparison between non-affective psychoses and affective
psychoses. Within the entire cohort: 60% of the patients had an episodic
course with full inter-episodic remissions; around 40% had good symptomatic
and social outcome; 27% had good occupational outcome; and 40% had good global
functioning. As in cross-sectional outcome, schizophrenia had the worst
outcome on most domains. Patients with substance-related psychosis were
employed for the least proportion of time over the three-year period, despite
having an episodic course with full remissions and good global
functioning.
|
Non-affective and affective psychoses did not differ significantly in the rates of compulsory detention and treatment, number of hospital admissions or the overall length of stay. Significantly more patients with non-affective than affective psychoses had a chronic, unremitting course. On the McGlashan outcome categories, patients with affective psychoses were two to three times as likely to have good symptomatic, occupational, social and global outcome as compared to those with non-affective psychoses. There was a statistically non-significant trend towards patients with affective psychoses being more satisfied with the services than patients with non-affective psychoses.
Figure 2 shows a comparison of outcome of the present cohort with the two-year outcome of the Nottingham subset of the DOSMED cohort. Similar proportions of the two cohorts were in remission at the time of follow-up but a higher proportion of the DOSMED cohort was in hospital. The three components of disability average disability, role handicap and social disability were rated higher in the current cohort. In the DOSMED cohort most of the DAS ratings showed mild dysfunction, whereas the current cohort had considerably more variability in the scores, with the majority indicating serious dysfunction (see Table 2). Re-analysing the data after excluding hospitalised patients from both cohorts did not alter these results.
|
![]() |
DISCUSSION |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Cross-sectionally about half and longitudinally between 30 and 40% of the total cohort had good outcome in all domains. These results are broadly comparable with previous outcome reports (Leff et al, 1992; Scottish Schizophrenia Research Group, 1992; Gupta et al, 1997; Strakowski et al, 1998; Vázquez-Barquero et al, 1999). Our rate of 20% of patients treated entirely within the community is the same as reported earlier (Castle et al, 1994). Just over half of the patients expressed satisfaction with the effectiveness of mental health care that they had received. Only one-third of the entire cohort had been employed in any capacity in the year preceding follow-up assessment, despite symptomatic recovery and no hospital admissions, confirming the poor occupational outcome in these patients (Leary et al, 1991; Mason et al, 1995; Gupta et al, 1997). Occupational rehabilitation has been associated with symptom reduction and improvement of insight in psychoses (Bell et al, 1996). The poor occupational outcome in first-episode psychoses suggests that early and assertive efforts should be made at vocational rehabilitation.
Outcome of first-episode affective psychoses
Earlier outcome studies have suggested that affective disorders have a poor
symptomatic, social and occupational outcome even relatively early in the
course of the illness (Coryell et
al, 1993; Gitlin et
al, 1995; Goldberg et
al, 1995). Most of these studies are based on in-patient
samples rather than first-episode affective psychoses. In a one-year follow-up
study of patients with first-hospitalisation affective psychoses, Strakowski
et al (1998) reported
symptomatic recovery (as defined by an eight-week period of minimal
psychiatric symptoms) in 35% of patients and functional recovery (eight weeks
of functioning at premorbid level) in 35% patients. Our corresponding figures
of good outcome (as defined by minimal symptoms and minimal impairment) are
much higher: 70% and 73%, respectively. Strakowski et al had a
follow-up loss of 23% of the original cohort. The better outcome of affective
psychoses in the present study may therefore be due to low attrition of good
outcome cases, thus avoiding a selection bias towards a poorer outcome
group.
Predictive validity of ICD10 diagnostic criteria: comparison
of outcomes between affective and non-affective psychoses
Both cross-sectional and longitudinal outcomes were significantly better
for affective psychoses than for non-affective psychoses, confirming previous
reports (Leff et al,
1992; Harrow et al,
1997). Affective and non-affective psychoses did not differ on
indices of hospitalisation, despite a more benign and remitting course in the
former. A possible explanation for this might be that the style of
working of psychiatrists and other professionals influences this
outcome measure more than any illness characteristic. Our finding that
affective psychoses (F30-33) had a better outcome than non-affective psychoses
(F20-29), with schizophrenia (F20) having the poorest outcome, provides
confirmation that ICD10 criteria for the diagnostic stratification of
non-organic psychoses have good predictive validity.
Outcome of first-episode substance-related psychoses
The prevalence and pattern of substance misuse in this cohort have been
reported previously (Cantwell et
al, 1999). The diagnosis of substance-related psychosis was
stable in the majority of the cases, and over a period of three years 9/13
subjects retained their original diagnosis. The positive predictive value of
the diagnosis was 69% (Amin et al,
1999). On most domains, these patients had an outcome intermediate
between those for schizophrenia and affective psychoses. However, despite an
episodic course, benign symptomatic outcome and good overall functioning, they
had the worst occupational outcome of the entire cohort. The cultural
lifestyle of drug misuse may militate against work rehabilitation, although
other factors, such as stigma of drug abuse or employers' concerns about
health and safety issues, may also contribute to such poor occupational
outcome.
Outcome of first-episode psychoses: comparison with DOSMED
cohort
Despite a similar three-year clinical outcome to the DOSMED two-year
outcome, the present cohort was rated as having higher levels of disability.
Raters in the present study were blind to this comparison, hence there was no
systematic bias towards a higher disability rating in the present cohort.
However, there were methodological differences in data collection between the
two studies, in addition to the different follow-up period. In the DOSMED
two-year follow-up, raters collected data on DAS alone, and the key carer was
the key informant. In the present study, raters completed the DAS using all
sources of information, including patient interview. This raises the
possibility that a prior comprehensive assessment of clinical, social and
interpersonal functioning might provide a global view of disability and
therefore a higher DAS rating. Patients and their carers may also differ in
how they perceive the type and magnitude of the patient's disability.
These methodological differences may entirely explain the different disability ratings between the cohorts. However, we are left with the possibility that there was a true difference in the magnitude of disability between these two cohorts collected over a decade apart. This would be an important finding, although difficult to confirm, with major implications for service provision.
![]() |
Clinical Implications and Limitations |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
LIMITATIONS
![]() |
ACKNOWLEDGMENTS |
---|
![]() |
REFERENCES |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Andreasen, N. C. (1982) Negative symptoms in schizophrenia. Archives of General Psychiatry, 39, 784-788.[Abstract]
Bell, M., Lysaker, P. & Milstein, R. M. (1996) Clinical benefits of paid work activity in schizophrenia. Schizophrenia Bulletin, 22, 51-67.[Medline]
Brewin, J., Cantwell, R., Dalkin, T., et al (1997) Incidence of schizophrenia in Nottingham. A comparison of two cohorts, 1978-80 and 1992-94. British Journal of Psychiatry, 171, 140-144.[Abstract]
Cantwell, R., Brewin, J., Glazebrook, C., et al (1999) Prevalence of substance misuse in first-episode psychosis. British Journal of Psychiatry, 174, 150-153.[Abstract]
Castle, D. J., Phelan, M., Wessely, S., et al (1994) Which patients with non-affective functional psychoses are not admitted at first psychiatric contact? British Journal of Psychiatry, 165, 101-106.[Abstract]
Cooper, J. E. & Bostock, J. (1988) Relationships between schizophrenia, social disability, symptoms and diagnosis. In Handbook of Social Psychiatry (eds A. S. Henderson & G. D. Burrows), pp. 317-330. Amsterdam: Elsevier Science.
Coryell, W., Scheftner, W., Keller, M., et al (1993) The enduring psychosocial consequences of mania and depression. American Journal of Psychiatry, 150, 720-727.[Abstract]
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]
Gitlin, M. J., Swendsen, J., Heller, T. L., et al (1995) Relapse and impairment in bipolar disorders. American Journal of Psychiatry, 152, 1635-1640.[Abstract]
Goldberg, J. F., Harrow, M. & Grossman, L. S. (1995) Course and outcome in bipolar affective disorder: a longitudinal follow-up study. American Journal of Psychiatry, 152, 379-384.[Abstract]
Gupta, S., Anderson, N. C., Arndt, S., et al (1997) The Iowa longitudinal study of recent onset psychoses: one year follow-up of first episode patients. Schizophrenia Research, 23, 1-13.[CrossRef][Medline]
Harrison, G., Amin, S., Singh, S. P., et al (1999) Outcome of psychosis in people of African-Caribbean family origin. Population-based first-episode study. British Journal of Psychiatry, 175, 43-49.[Abstract]
Harrow, M., Sands, J. R., Silverstein, M. I., et al (1997) Course and outcome for schizophrenia versus other psychotic patients: a longitudinal study. Schizophrenia Bulletin, 23, 287-303.[Medline]
Jablensky, A., Sartorius, N., Ernberg, E., et al (1992) Schizophrenia: manifestations, incidence and course in different cultures. A World Health Organization Ten-Country Study. Psychological Medicine, Monograph Supplement 20.
Leary, J., Johnstone, E. C. & Owens, D. G. C. (1991) Disabilities and circumstances of schizophrenic patients a follow-up study. II. Social outcome. British Journal of Psychiatry, 159 (suppl. 13), 13-20.[Medline]
Leff, J., Sartorius, N., Jablensky, A., et al (1992) The international pilot study of schizophrenia: five-year follow-up findings. Psychological Medicine, 22, 31-145.
Lieberman, J., Koreen, A. R., Chakos, M., et al (1996) Factors influencing treatment response and outcome of first-episode schizophrenia: implications for understanding the pathophysiology of schizophrenia. Journal of Clinical Psychiatry, 57 (suppl. 9), 5-9.
McGlashan, T. H. (1984) The Chestnut Lodge follow-up study. II. Long-term outcome of schizophrenia and affective psychoses. Archives of General Psychiatry, 41, 586-601.[Abstract]
McGuffin, P., Farmer, A. & Harvey, I. (1991) A polydiagnostic application of operational criteria in psychiatric illness: development and reliability of the OPCRIT system. Archives of General Psychiatry, 48, 764-770.[CrossRef][Medline]
Mason, P., Harrison, G., Glazebrook, C., et al (1995) Characteristics of outcome in schizophrenia at 13 years. British Journal of Psychiatry, 167, 596-603.[Abstract]
Office of Population Censuses and Surveys (1992) Census 1991. London: HMSO.
Ruggeri, M. & Dall'Agnola, R. (1993) The development and use of the Verona Expectations for Care Scale (VECS) and the Verona Service Satisfaction Scale (VSSS) for measuring expectations and satisfaction with community-based psychiatric services in patients, relatives and professionals. Psychological Medicine, 23, 511-523.[Medline]
Sartorius, N., Gulbinat, W., Harrison, G., et al (1995) Long-term follow-up of schizophrenia in 16 countries. A description of the International Study of Schizophrenia conducted by the World Health Organization. Social Psychiatry and Psychiatric Epidemiology, 31, 249-258.
Scottish Schizophrenia Research Group (1992) The Scottish first episode schizophrenia study. VIII. Five-year follow-up: clinical and psychosocial findings. British Journal of Psychiatry, 161, 496-500.[Abstract]
Strakowski, S. M., Keck, P. E., McElroy, S. I. et al
(1998) Twelve months outcome after a first hospitalisation
for affective psychoses. Archives of General
Psychiatry, 55,
49-55.
Strauss, J. S. & Carpenter, W. T. (1974) The prediction of outcome in schizophrenia: II. Relationship between predictors and outcome variables. Archives of General Psychiatry, 31, 37-42.[CrossRef][Medline]
Tohen, M., Stoll, A. L., Strakowski, S. M., et al (1992) The McLean First-episode Project: six month recovery and recurrence outcome. Schizophrenia Bulletin, 18, 273-282.[Medline]
Vázquez-Barquero, J. L., Cuesta, M. J., Castanedo, S. H., et al (1999) Cantabria First-Episode Schizophrenia Study: three-year follow-up. British Journal of Psychiatry, 174, 141-149.[Abstract]
World Health Organization (1992) Schedules for Assessment in Neuropsychiatry. Geneva: WHO.
World Health Organization (1994) ICD10 Classification of Mental and Behavioural Disorders with Diagnostic Criteria for Research. Geneva: WHO.
Received for publication February 15, 1999. Revision received July 22, 1999. Accepted for publication July 23, 1999.