Classification and Epidemiology of Psychosis

Chris Gale

Otago Registrar Training Group

Feb 2011.

Classification.

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

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 07-14 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

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

Relationship of the psychosis symptoms.

Dutta, Schizophr Bull. 2007 July; 33(4): 868–876

Simplified outline of Gene-enivironment interaction.

DuttaSchizophr Bull. 2007 July; 33(4): 868–876

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.

Prevalence of psychosis?Type Per 10 000 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. 2011

CIDI screen with clinician recoding,

150 USA NCS-R, Kessler 2005

12-month, clinician reinterview.

14 USA NCS-R. Kessler 2005

Lifetime, clinician reinterview 31 USA NCS-R. Kessler 2005

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)

CAMEO Results.

● Highly variable crude rates around England.

● However, when corrected for age and gender, prevalence of early psychosis around 5 per 10 000.

Contact prevelance and capture-recapture

Fully structured interviews I: clinician reinterview

Fully structured interviews I: clinician reinterview

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

– 17.2 12-month

● larger than those associated with any individual disorder.

Disability Clinical Interview.

● Two to four times greater risk of impaired.● Basic Functioning● Cognition● Days out of role● Social function● Work function.

Average disability score in different DAS-M dimensions, 15 years after index admission.

(Bottlender, 2010)

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.

Fully structured interviews II: Latent Class analysis

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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 Group Relative Risk 95% CI

First-generation migrants 2.7 2.3–3.2

Second-generation migrants 4.5 1.5–13.1

Migrants with “black” skin color

4.8 3.7–6.2

Migrants with “white” skin color

2.3 1.7–3.1

Urban and rural incidence rates and Incidence Risk Ratios (IRRs) for psychotic disorders, stratified by gender in Ireland. (Kelly, 2010)

Diagnosis Gender Urban incidence ratea (SE)

Rural incidence ratea (SE)

IRR b 95% confidence

interval

Schizophrenia Male 25.4 (3.2) 13.1 (2.2) 1.92 1.52–2.44

Female 12.3 (2.1) 9.2 (1.9) 1.34 1.00–1.80

Affective psychosis

Male 7.3 (1.7) 11.3 (2.0) 0.48 0.34–0.67

Female 6.3 (1.5) 9.2 (1.9) 0.6 0.43–0.83

Overall psychosis

Male 39.1 (4.0) 34.8 (3.6) 0.94 0.80–1.10

Female 24.2 (2.9) 36.7 (3.7) 0.96 0.79–1.16

a. Unadjusted incidence rate per 100,000 population per year.

b. Incidence Risk Ratio adjusted for age effects.

Natural history Finland.● All patients in North Finland with diagnosis psychosis born 1966.● N = 91

– 59 with schizophrenia– 12 schizophrenia spectrum.

– Schizophreniform 3– Schizoaffective 7– Delusional disorder 2

● 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.

Outcomes

31Full recovery

715Good recovery

17Suicide

110Death, total

Schizophrenia spectrum (N=12)

Schizophrenia

(N=59)

Standard Mortality Ratios patients with schizophrenia.

meanAll cause 2.98 1.75

Unnatural 8.6 3.71accident 3.3 2.36suicide 42.47 93.11

Natural 2.31 1.18CVS 2.01 0.83CVA 0.87 0.38GI 5.28 6.94Endocrine 5.5 5.34Infective 4.56 3.11Respiratory 4.01 2.56

Sasha, Arch Gen Psych 2007.

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Copyright restrictions may apply.

Dutta, R. et al. Arch Gen Psychiatry 2010;67:1230-1237.

Suicide Rates (per 100000 Person-years) and Age- and Calendar Period-Adjusted SMRs by Time Since First Presentation With Psychosis

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.

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.

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 C 7.54 (3.55 – 16.99)

● Other disorders associated SCZ● HIV, Tb, Hep B

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.

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.

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. 2010 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. 2011 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. 2008 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. 2009 Dec;39(12):2025-42.]

● 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. 2010 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. 2007 Oct;64(10):1123-31.