Classification and Epidemiology of Psychosis Chris Gale Otago

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 DSM 5 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

ICD 10 structure (no changes confirmed ICD 11 as yet) Schizoaffective disorders Schizophrenia Paranoid schizophrenia Hebephrenic schizophrenia Catatonic schizophrenia Undifferentiated schizophrenia Postschizophrenic Schizoaffective disorder, manic type Schizoaffective disorder, depressive type Schizoaffective disorder, mixed type Other schizoaffective disorders Schizoaffective disorder, unspecified Acute and transient psychotic disorders

Relationship of the psychosis symptoms. Dutta, Schizophr Bull. 2007 July; 33(4): 868– 876

Simplified outline of Geneenivironment interaction. Dutta. Schizophr 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 Contact Early Psychosis Per 10 000 Reference 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

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 capturerecapture

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 oddsratios are: panic disorder (14. 7)

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

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 Schizophrenia Affective psychosis Overall psychosis Gender Urban incidence ratea (SE) Rural incidence ratea (SE) IRR b 95% confidence interval 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 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 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 Schizoaffective Delusional disorder 3 7 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 Schizophrenia (N=59) Schizophrenia spectrum (N=12) Death, total 10 1 Suicide 7 1 Full recovery 1 3 Good recovery 15 7

Standard Mortality Ratios patients with schizophrenia.

Suicide Rates (per 100000 Person-years) and Age- and Calendar Period-Adjusted SMRs by Time Since First Presentation With Psychosis Dutta, R. et al. Arch Gen Psychiatry 2010; 67: 1230 -1237. Copyright restrictions may apply.

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

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