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Prognostic Factors in First-Episode Schizophrenia: Five-year Outcome of Symptoms, Function and Obesity
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Psychiatry, Ulleråker, University Hospital.
2010 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Our knowledge of prognostic factors and optimal treatment organisation in schizophrenia is incomplete. The disparity of outcome measures used has been a major obstacle for research. Increasing evidence has shown that schizophrenia is associated with increased cardiovascular mortality, development of obesity and autonomic nervous system imbalance. Assertive community treatment (ACT) has been suggested as a promising direction for organising treatment services for first-episode schizophrenia, but its long-term effect has not been evaluated.

One aim of the present thesis was to investigate prognostic factors for 5-year symptomatic and functional outcome and obesity development. A further aim was to evaluate a recently proposed definition of remission and examine the long-term effects of introducing a modified ACT programme (mACT). Thus, we performed a follow-up study of all consecutive first-episode psychosis patients in Uppsala County, Sweden during 1995-2000 (n=144).

In the first study we investigated the changes in a broad 5-year outcome of symptoms and function among patients presenting first time ever to psychiatric health care during 3 years before and during 3 years after the implementation of mACT. This change in the psychiatric service, however, was not followed by any long-term clinical benefits.

In the second study, we examined the association between remission of eight core schizophrenia symptoms and functional outcome. Remission was strongly associated with having good function and having a higher self-rated satisfaction with life.

In the third study, we explored a set of biochemical markers as predictors of weight gain and development of obesity. Haemoglobin, red blood cell count, hematocrit, γ-glutamyltransferase and creatinine were associated with the development of obesity in first-episode schizophrenia.

In the fourth and final study, we tested electrocardiographic measures of autonomic imbalance as predictors of symptomatic remission. Higher heart rate and high ST and T-wave amplitudes were related to symptomatic remission, indicating that cardiac autonomic imbalance at baseline may have a prognostic value in first-episode schizophrenia.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis , 2010. , p. 63
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 521
Keywords [en]
First-episode, psychosis, schizophrenia, community mental health services, remission, functional outcome, biochemistry, obesity, weight-gain, prediction, autonomic balance, electrocardiography
National Category
Psychiatry
Research subject
Psychiatry
Identifiers
URN: urn:nbn:se:uu:diva-113797ISBN: 978-91-554-7719-6 (print)OAI: oai:DiVA.org:uu-113797DiVA, id: diva2:292583
Public defence
2010-03-26, Sal X, Universitetshuset, Övre Slottsgatan, Uppsala, 09:15 (Swedish)
Opponent
Supervisors
Available from: 2010-03-05 Created: 2010-02-04 Last updated: 2010-03-05Bibliographically approved
List of papers
1. Five-year outcome of first-episode psychosis before and after the implementation of a modified assertive community treatment programme
Open this publication in new window or tab >>Five-year outcome of first-episode psychosis before and after the implementation of a modified assertive community treatment programme
Show others...
2010 (English)In: Social Psychiatry and Psychiatric Epidemiology, ISSN 0933-7954, E-ISSN 1433-9285, Vol. 45, no 6, p. 665-674Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE: Assertive community treatment programmes are increasingly common worldwide but without much knowledge of their long-term effect. We investigated whether the implementation of such a programme would improve symptomatic and functional outcome 5 years later. METHODS: Naturalistic cohort study between 1995 and 2000 of all first-episode psychosis patients (n = 144) in Uppsala County, Sweden. We compared a 3-year period before (non-mACT) and after the introduction of a modified assertive community treatment (mACT) programme in 1998. Five-year outcome was assessed for symptoms and functioning and the two co-primary outcome measures were positive and negative symptoms. Regression models were adjusted for a propensity score based on multiple baseline variables and use of antipsychotics at 5-year follow-up. RESULTS: Contrary to our hypothesis, patients in the mACT group, compared to those in the non-mACT group, had a borderline significant increased risk of having a poor 5-year outcome regarding positive psychotic symptoms [adjusted odds ratio (OR) 3.21, 95% confidence interval (CI) 0.97-10.63]. There was no difference at the 5-year follow-up between the mACT and non-mACT group regarding negative symptoms (adjusted OR 1.65, 95% CI 0.48-5.66), or any of the secondary outcome measures: global assessment of functioning, hazardous alcohol use, use of illicit drugs, working or being in education, independent living, subjective satisfaction with life or suicide. Results were similar in subgroup analyses. CONCLUSIONS: The implementation of a modified assertive community treatment was not followed by subsequent improvements of 5-year outcome on a group level for patients with first-episode psychosis.

Keywords
Schizophrenia, Psychotic disorders, First-episode psychosis, Cohort studies, Community mental health services
National Category
Psychiatry
Identifiers
urn:nbn:se:uu:diva-113782 (URN)10.1007/s00127-009-0108-3 (DOI)000277942500009 ()19652896 (PubMedID)
Available from: 2010-02-04 Created: 2010-02-04 Last updated: 2017-12-12Bibliographically approved
2. Association between symptomatic remission and functional outcome in first-episode schizophrenia
Open this publication in new window or tab >>Association between symptomatic remission and functional outcome in first-episode schizophrenia
2009 (English)In: Schizophrenia Research, ISSN 0920-9964, E-ISSN 1573-2509, Vol. 107, no 2-3, p. 232-237Article in journal (Refereed) Published
Abstract [en]

Although operational criteria for remission in schizophrenia have recently been proposed, the association of this definition with broader functional outcome has not yet been established in first-episode patients. The severity criteria for remission consist of a score of mild or less on eight core symptoms of schizophrenia. We applied the severity criteria for remission to a sample of patients with first-episode schizophrenia (n = 76) in order to explore the association with functional outcome five years after first presentation to mental healthcare. We evaluated whether other factors than those included in the remission definition predicted good function in logistic regression models. The discriminatory capacities for remission and other factors for good function were tested using C-statistics. The proportions of remitters and non-remitters having good function were 73% and 17%, respectively. Furthermore, remitters had a higher level of subjective satisfaction with life. In comparison with non-remission, symptomatic remission was strongly associated with good function: odds ratio 13.2, 95% confidence interval, 4.3 to 40.3. A duration of untreated psychosis of three months or less as compared with a longer duration was associated with having good function at a five-year follow-up independently of remission status. The discriminatory capacity for symptomatic remission between having good function vs. not was acceptable (C-statistic = 0.78), which was significantly improved to an excellent discriminatory capacity by adding duration of untreated psychosis less than three months (C-statistic = 0.83, p = 0.04). In conclusion, core symptoms of schizophrenia have an important limiting effect on functioning and subjective life satisfaction in the early course of the illness.

Keywords
Remission, Functional outcome, First-episode, Schizophrenia
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-88211 (URN)10.1016/j.schres.2008.10.004 (DOI)000263397600019 ()18957275 (PubMedID)
Available from: 2009-01-26 Created: 2009-01-26 Last updated: 2017-12-14Bibliographically approved
3. Biochemical risk factors for development of obesity in first-episode schizophrenia
Open this publication in new window or tab >>Biochemical risk factors for development of obesity in first-episode schizophrenia
2009 (English)In: Schizophrenia Research, ISSN 0920-9964, E-ISSN 1573-2509, Vol. 115, no 2-3, p. 141-145Article in journal (Refereed) Published
Abstract [en]

Obesity is a serious health issue for many patients with schizophrenia. There is a lack of predictors for and understanding of the development of obesity in the early phase of the illness. Therefore we investigated a set of routine biochemistry variables in blood as predictors of the development of obesity and weight gain over 5 years in an observational cohort study of patients with first-episode schizophrenia (n=59). Twelve percent of the patients were obese at baseline and 37% were obese at the 5-year follow-up. The mean body mass index (BMI) change over 5 years was a 4.1 kg/m(2) increase (4.5 SD). Obesity was predicted by baseline hemoglobin levels (odds ratio per standard deviation [OR/SD] 3.3, 95% confidence interval [CI] 1.4 to 7.5), red blood cell count (OR/SD 2.6, 95% CI 1.2 to 5.5), hematocrit (OR/SD 2.8, 95% CI 1.3 to 5.9), gamma-glutamyltransferase (OR/SD 2.8, 95% CI 1.2-6.3) and creatinine (OR/SD 3.1, 95% CI 1.2 to 8.0). After adjustment for baseline BMI, the associations were attenuated for gamma-glutamyltransferase and creatinine. Low baseline BMI was associated with a greater BMI increase. The major conclusion is that easily available routine biochemistry markers can be useful in predicting the development of obesity in first-episode schizophrenia. The mechanisms underlying the observed associations are unknown, but the predictors identified in this study could signify dehydration or insulin resistance. These observations open a new window to future research on the mechanisms underlying the development of obesity in schizophrenia.

Keywords
Schizophrenia, Obesity, First-episode, Biochemistry, Weight gain, Prediction
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-110340 (URN)10.1016/j.schres.2009.09.024 (DOI)000272423500007 ()19846278 (PubMedID)
Available from: 2009-11-11 Created: 2009-11-11 Last updated: 2017-12-12Bibliographically approved
4. Relations of electrocardiographic signs of autonomic balance to 5-year outcome in first-episode schizophrenia
Open this publication in new window or tab >>Relations of electrocardiographic signs of autonomic balance to 5-year outcome in first-episode schizophrenia
(English)Manuscript (preprint) (Other academic)
Keywords
Electrocardiography, First-episode, Psychosis, Remission, Autonomic balance, Prediction
National Category
Psychiatry
Research subject
Psychiatry
Identifiers
urn:nbn:se:uu:diva-113776 (URN)
Available from: 2010-02-04 Created: 2010-02-04 Last updated: 2010-02-08

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