Depressive symptoms in first episode schizophrenia spectrum disorder

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Abstract

Background

Depressive symptoms in ‘non-affective’ first episode schizophrenia spectrum disorders (FES) are common, but poorly understood, resulting in a range of conceptual and clinical management issues. This study had three aims: (i) to determine the prevalence of moderate to severe depressive symptoms (defined as a Clinical Global Impressions Scale-Bipolar Disorder (CGI-BP depression) score > 3) in a large representative sample of FES patients; (ii) to compare the clinical and functional characteristics of FES patients with and without these depressive symptoms at service entry; and (iii) to compare the characteristics of FES patients with and without persistent depressive symptoms.

Methods

Medical file audit methodology was employed to collect information on 405 patients with FES treated at the Early Psychosis Prevention and Intervention Centre (EPPIC), Melbourne, Australia.

Results

26.2% (n = 106) of the patients had moderate to severe depression at service entry. At service entry and at discharge, those with depressive symptoms had greater insight into their illness but did not differ from those without depressive symptoms in terms of severity of overall psychopathology. Substance use was significantly less common in those with depressive symptoms at service entry and at discharge. Of those who were depressed at baseline, 14.2% (n = 15) continued to have moderate to severe depressive symptoms at discharge.

Discussion

Depressive symptoms are common in patients with FES. Understanding the nature and characteristics of depression in FES has important clinical implications for both early intervention and treatment.

Introduction

Within the traditional Kraepelinian framework, schizophrenia is considered a ‘non-affective’ psychosis (Upthegrove et al., 2010). Depressive symptoms, however, are common in ‘non-affective’ first episode schizophrenia spectrum disorders (FES) (Koreen et al., 1993, Addington et al., 1998, Siris, 2000). Indeed, Bleuler was the first to describe depressive symptoms as being characteristic of schizophrenia, with hallucinations and delusions considered secondary manifestations of the disorder (Bleuler, 1924). Others have supported this view (Johnson, 1981, Hirsch, 1982, Koreen et al., 1993, Zisook et al., 1999, Birchwood et al., 2000, Siris, 2000, an der Heiden et al., 2005). Some authorities have argued that “depressive symptoms are quantitatively and qualitatively amongst the most important characteristics of schizophrenia” (an der Heiden et al., 2005) (p.174). Consequently, there has been much research interest in the nature and trajectory of depressive symptoms in schizophrenia (Hirsch, 1982, DeLisi, 1990, Siris, 2000).

Depressive symptoms usually appear either in prodrome (Koreen et al., 1993, Hafner et al., 1999, Schultze-Lutter et al., 2007) or during the first psychotic episode (Birchwood et al., 2000), and follow the course of positive psychotic symptoms (Koreen et al., 1993, Lançon et al., 2001, Oosthuizen et al., 2006). They are less common between acute psychotic episodes compared to earlier stages of illness (Lançon et al., 2001) and rarely occur de novo in recovery after the first psychotic episode (Upthegrove et al., 2010). Co-occurring depression increases the risks of suicide attempt (Fenton, 2000) and of future relapse (Subotnik and Nuechterlein, 1988).

Previous research into depressive symptoms in schizophrenia and FES has a number of methodological limitations including the use of cross-sectional designs involving small unrepresentative samples. The inclusion of chronically ill patients, who experience multiple episodes and life stressors, and are not neuroleptic naive (Koreen et al., 1993, Zisook et al., 1999), may also confound the already complex relationship between depressive symptoms and illness course.

Depressive symptoms tend to be neglected in FES, due to the emphasis on treating positive and negative symptoms and to the uncertainties surrounding their aetiology, nosological status and impact on outcome (Birchwood et al., 2000, Birchwood et al., 2009, Peralta and Cuesta, 2009). Much of the research has been focused on post-psychotic depression or elevated levels of depression during the interval between psychotic episodes (MacGlashan and Carpenter, 1976); however, it is unclear what percentage of cases with FES is present with depressive symptoms at service entry. Information is also limited regarding whether depressive symptoms influence the treatment response and discharge outcomes of those patients treated at specialised early psychosis intervention services. These issues are address in this paper.

The current study stems from the First Episode Psychosis Outcome Study (FEPOS). FEPOS involved a medical file audit of a large epidemiologically representative cohort of FEP patients treated at the Early Psychosis Prevention and Intervention Centre (EPPIC). There were three aims of this paper: (i) to determine the prevalence of moderate to severe depressive symptoms in patients with FES from the FEPOS cohort who present to an early intervention service; (ii) to compare the clinical and functional characteristics of FES patient with and without moderate to severe depressive symptoms at service entry; and (iii) to determine if there are differences in the clinical and functional characteristics of FES patients with and without persistent severe depressive symptoms during 18 months of early intervention treatment.

Section snippets

Sample and setting

EPPIC is a comprehensive program for young people aged 15–29 years experiencing their first episode of psychosis (McGorry et al., 1996). EPPIC's catchment area covers the northwestern regions of Melbourne, Australia.

FEPOS comprised a file audit of all 786 first episode psychosis (FEP) patients treated at EPPIC between January 1998 and December 2000 (Lambert et al., 2005, Schimmelmann et al., 2005, Schimmelmann et al., 2006, Conus et al., 2007, Schimmelmann et al., 2007, Schimmelmann et al., 2008

Results

Four hundred and five out of 407 patients had a CGI-BP depression score at service entry, of these 26.2% (n = 106) had moderate to severe depression.

Prevalence of depressive symptoms

Moderate to severe depressive symptoms were prevalent in our cohort, with 26.2% demonstrating such symptoms during their first psychotic episode. These rates are similar to those reported by Siris (2000) and support the notion that clinically significant depressive symptoms are common during the early phase of illness (Koreen et al., 1993, Addington et al., 1998, Siris, 2000). Interestingly, only 29.2% of those with depressive symptoms had a co-morbid clinical diagnosis of MDD at service entry.

Role of funding source

The First Episode Outcome Study (FEPOS) was supported by a grant to Prof. Martin Lambert from Eli Lilly Company Australia, and a grant to Prof. Philippe Conus from the Leenaards Foundation, Switzerland. Eli Lilly Australia funded the assessment of files on a subgroup of this cohort treated with olanzapine and risperidone. Associate Prof. Sue Cotton is supported by the Ronald Phillip Griffith Fellowship, Faculty of Medicine, Dentistry, and Health Sciences, The University of Melbourne.

Contributors

Prof. Lambert, Prof. Conus, and Prof. McGorry designed the First Episode Outcome Study (FEPOS). Prof. Lambert and Prof. Conus collected the data and also provided feedback on drafts of the manuscript. A/Prof. Cotton analysed and interpreted the data and wrote the first draft of this manuscript. Prof. McGorry, Prof. Schimmelmann, Prof. Mackinnon, Prof. Gleeson, Prof. Berk, Dr. Hides, and Dr. Chanen all provided feedback and comments on the various versions of the manuscript. All authors have

Conflict of interest

Prof. Lambert, Prof. Conus, Prof. Schimmelmann, and Prof. McGorry have served on the speakers' board of Eli Lily. There are no other relevant disclosures.

Acknowledgements

Thanks to Ms. Felicity Butselaar for reading a draft of the manuscript.

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