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Classification and Epidemiology of Psychosis Chris Gale Otago Registrar Training Group Feb 2011.

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Presentation on theme: "Classification and Epidemiology of Psychosis Chris Gale Otago Registrar Training Group Feb 2011."— Presentation transcript:

1 Classification and Epidemiology of Psychosis Chris Gale Otago Registrar Training Group Feb 2011.

2 Classification. “DSM-IV is the most incompatible diagnostic variation of ICD-10 that exists” Norman Sartorius, WPA Florence, 2009.

3 Proposed structure DSM5 B 00 Schizophrenia B 01 Schizotypal Personality Disorder B 02 Schizophreniform Disorder B 03 Brief Psychotic Disorder B 04 Delusional Disorder B 05 Schizoaffective Disorder B 06 Attenuated Psychosis Syndrome B Substance-Induced Psychotic Disorder B 15 Psychotic Disorder Associated with a Known General Medical Condition B 16 Catatonic Disorder Associated with a Known General Medical Condition B 17 Other Specified Psychotic Disorder B 18 Unspecified Psychotic Disorder B 19 Unspecified Catatonic Disorder

4 ICD 10 structure (no changes confirmed ICD 11 as yet) Schizophrenia Paranoid schizophrenia Hebephrenic schizophrenia Catatonic schizophrenia Undifferentiated schizophrenia Post- schizophrenic depression Residual schizophrenia Simple schizophrenia Other schizophrenia Schizophrenia, unspecified Schizophreniform disorder Schizotypal disorder Schizoaffective disorders Schizoaffective disorder, manic type Schizoaffective disorder, depressive type Schizoaffective disorder, mixed type Other schizoaffective disorders Schizoaffective disorder, unspecified Acute and transient psychotic disorders Acute polymorphic psychotic disorder without symptoms of schizophrenia Acute polymorphic psychotic disorder with symptoms of schizophrenia Acute schizophrenia- like psychotic disorder Other acute predominantly delusional psychotic disorders Other acute and transient psychotic disorders Acute and transient psychotic disorder, unspecified Delusional disorders Brief delusional disorder Persistent delusional disorder Shared delusional disorder Other persistent delusional disorders Persistent delusional disorder, unspecified

5 Relationship of the psychosis symptoms. Dutta, Schizophr Bull July; 33(4): 868–876

6 Simplified outline of Gene- enivironment interaction. DuttaSchizophr Bull July; 33(4): 868–876

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9 Methodologies used. Population surveys. General population. High risk populations. Screener and re-interview. Case records (raw or capture | release). Comprehensive national records Insurance and prescribing Admission and outpatient Complications of psychosis.

10 Prevalence of psychosis? TypePer Reference Contact Early Psychosis 5 CAMEO Study (Cheng, in press) Contact (non maori) 7.6 Wellington data, MOH (cited by Kake) Contact (capture | recapture): non maori. 35 Wellington clinical data set (Kake, 2008). Latent class analysis fully structured interview (lifetime). 20 NZMHS, Gale CIDI screen with clinician recoding, 150 USA NCS-R, Kessler month, clinician reinterview. 14 USA NCS-R. Kessler 2005 Lifetime, clinician reinterview 31 USA NCS-R. Kessler 2005

11 Early intervention surveys: CAMEO study. (Cheng, in press) Urban and rural Cambridgeshire. Number of people referred to early psychosis. Early psychosi defined by Melbourne Criteria. 1 week psychotic symptoms Less than six months treatment. PANSS score & clinician consensus diagnosis. The rate seems to be dependant on age and gender. This may be an artifact of second criteria (no treatment)

12 CAMEO Results. Highly variable crude rates around England. However, when corrected for age and gender, prevalence of early psychosis around 5 per

13 Contact prevelance and capture- recapture

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15 Fully structured interviews I: clinician reinterview

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17 Comorbidity 87.9% of respondents with lifetime NAP met criteria for at least one other lifetime disorder 74.2% of respondents with 12- month NAP met criteria for at least one other 12-month disorder. The highest lifetime odds-ratios are: bipolar disorder (11.4) OCD (26.0) The highest 12-month odds- ratios are: panic disorder (14.7) drug dependence (15.8) Variation in the ORs across disorders is not reliable due to the very wide confidence intervals. The ORs with having high comorbidity: three or more hierarchy-free diagnoses in addition to NAP  30.4 lifetime  month larger than those associated with any individual disorder.

18 Disability Clinical Interview. Two to four times greater risk of impaired. Basic Functioning Cognition Days out of role Social function Work function.

19 Average disability score in different DAS-M dimensions, 15 years after index admission. (Bottlender, 2010)

20 Clinician reinterview... Estimated rate non affective psychosis 15/1000 from structured interview → 3/1000 with structured clinical interview. Non significant correlation of clinician reassignment of screening question text with reinterview results. Delusions and Halluncinations most highly correlated with psychosis. BUT SCID modified to have first question same as screener in CIDI. Very expensive project, not replicated.

21 Fully structured interviews II: Latent Class analysis

22 Based on Published Meta-analyses of Population-Based Studies Examining the Association Between Migration and Risk of Schizophrenia (Dutta et a; Schizophr Bull. 2007). Migrant GroupRelative Risk95% CI First-generation migrants2.72.3–3.2 Second-generation migrants4.51.5–13.1 Migrants with “black” skin color –6.2 Migrants with “white” skin color –3.1

23 Urban and rural incidence rates and Incidence Risk Ratios (IRRs) for psychotic disorders, stratified by gender in Ireland. (Kelly, 2010) DiagnosisGenderUrban incidence ratea (SE) Rural incidence ratea (SE) IRR b95% confidence interval SchizophreniaMale25.4 (3.2)13.1 (2.2) –2.44 Female12.3 (2.1)9.2 (1.9) –1.80 Affective psychosis Male7.3 (1.7)11.3 (2.0) –0.67 Female6.3 (1.5)9.2 (1.9) –0.83 Overall psychosis Male39.1 (4.0)34.8 (3.6) –1.10 Female24.2 (2.9)36.7 (3.7) –1.16 a. Unadjusted incidence rate per 100,000 population per year. b. Incidence Risk Ratio adjusted for age effects.

24 Natural history Finland. All patients in North Finland with diagnosis psychosis born N = 91  59 with schizophrenia  12 schizophrenia spectrum.  Schizophreniform 3  Schizoaffective 7  Delusional disorder2 Good recovery.  No hospitalisations last two years.  No or low dose medications. Full recovery above and:  CGI less than 2. PANSS less than 36  Able to work.

25 Outcomes 31Full recovery 715Good recovery 17Suicide 110Death, total Schizophrenia spectrum (N=12) Schizophrenia (N=59)

26 Standard Mortality Ratios patients with schizophrenia.

27 Copyright restrictions may apply. Dutta, R. et al. Arch Gen Psychiatry 2010;67: Suicide Rates (per Person-years) and Age- and Calendar Period-Adjusted SMRs by Time Since First Presentation With Psychosis

28 Cardiovascular (Fleishaker, 2008). Leading cause premature death pts SCZ. Prevelance risk factors 1.5 – 3.5 times higher. Diabetes Obesity Smoking High cholesterol Increased dietary fat Sedentary Lifestyle.

29 However: Cardiovascular risk factors do not account for all of increase in cardiac death. Other hypotheses. Genetics of psychosis relate to lipid metabolism. Use antipsychotics can worsen metabolic syndrome. Other disorders, such as depression, also increase risk.

30 Other somatic conditions Increase in all medical conditions Odds Ratios SCZ vs no SCZ Hypothyroidism 2.62 (2.09 –2.32) COPD 1.88 (1.51 – 2.32) Hep C7.54 (3.55 – 16.99) Other disorders associated SCZ HIV, Tb, Hep B

31 Disparity Health Care. Decrease access to primary and secondary services. Poorer quality of care Globally, mental health poorly funded.  Limited access to any free care.  OR care paid by patient: patients with psychosis much more likely to be unemployed or underemployed. Mental health demedicalised.  In South America, care by non medical psychoanalysis for SCZ first option.  Lack access effective treatment.

32 Summary. Schizophrenia and bipolar are probably different. Schizophrenia occurs in about one in a hundred and has an incidence around one in ten thousand. There is an urban predominance It is more common in second generation immigrants and clearly different minorities. It is more frequent, occurs earlier, and is more disabling in men. Schizophrenia in shortens lives, especially by suicide.

33 References. Cheng F, Kirkbride JB, Lennox BR, et al. Administrative incidence of psychosis assessed in an early intervention service in England: first epidemiological evidence from a diverse, rural and urban setting. Psychol Med Dec 23:1-10. [Epub ahead of print] Fleishaker et al. Comorbid Somatic Illnesses in Patients with Severe Mental Disorders: Clinical, Policy and Research Challenges. Journal of Clinical Psychiatry 2008;69:514 – 519. Foley DL, Morley KI. Systematic Review of Early Cardiometabolic Outcomes of the First Treated Episode of Psychosis. Arch Gen Psychiatry Feb 7. [Epub ahead of print Kake TR, Arnold R, Ellis P. Estimating the prevalence of schizophrenia among New Zealand Maori: a capture-recapture approach. Aust N Z J Psychiatry Nov;42(11):941-9 Carpenter WT, Bustillo JR, Thaker GK, van Os J, Krueger RF, Green MJ. The psychoses: cluster 3 of the proposed meta-structure for DSM-V and ICD-11. Psychol Med Dec;39(12): ] Kelly BD, O'Callaghan E, Waddington JL, Feeney L, Browne S, Scully PJ, Clarke M, Quinn JF, McTigue O, Morgan MG, Kinsella A, Larkin C. Schizophrenia and thecity: A review of literature and prospective study of psychosis and urbanicity inIreland. Schizophr Res Jan;116(1):75-89 Bottlendera, R Strauß A Möller H Social disability in schizophrenic, schizoaffective and affective disorders 15 years after first admission. Schizophrenia Research Volume 116, Issue 1, January 2010, Pages 9–16 Sasha S, Chant D, McGrath J. A systematic review of mortality in schizophrenia: is the differential mortality gap worsening over time? Arch Gen Psychiatry Oct;64(10):


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