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Background: People in a putatively late prodromal state not only have an enhanced risk for psychosis but already suffer from mental and functional disturbances., Aims: To evaluate the acute effects of a combined supportive and antipsychotic treatment on prodromal symptoms., Method: Putatively prodromal individuals were randomly assigned to a needs-focused intervention without (n=59) or with amisulpride (n=65). Outcome measures at 12-weeks effects were prodromal symptoms, global functioning and extrapyramidal side-effects., Results: Amisulpride plus the needs-focused intervention produced superior effects on attenuated and full-blown psychotic symptoms, basic, depressive and negative symptoms, and global functioning. Main side-effects were prolactin associated., Conclusions: Coadministration of amisulpride yielded a marked symptomatic benefit. Effects require confirmation by a placebo-controlled study.

Efforts to achieve early detection of and timely intervention in incipient psychotic conditions are characteristic of an extremely innovative area of schizophrenia research over the last ten years or more. Within the Competency Network on Schizophrenia, the Early Recognition Inventory, ERIraos was developed and tested with the aim of identifying persons at an elevated risk of developing a psychosis, and providing them with timely treatment. In this study, the early diagnostic work-up and intervention were performed at the early intervention centers located in Bonn, Düsseldorf, Cologne and Munich. The initial results regarding transition to a psychosis based on 1 year follow-up data are now available.The outcomes of these analyses form the basis for the revision of the Early Recognition Inventory, with the aim of bringing it into line with the requirements met with in practice.

Both Kraepelin and E. Bleuler reported that nonspecific symptoms are frequently present before the first psychotic symptoms manifest. In the ABC schizophrenia study, we were able to show that, in three-quarters of the cases, initial psychotic symptoms are preceded by a prodromal phase of several years standing that begins with non-specific signs such as negative and depressive symptoms. These early symptoms lead to social disabilities that--already before the onset of acute psychotic symptoms--have an adverse effect on the life situation of those who subsequently go on to develop schizophrenia. With the aim of preventing these early social consequences, patients at risk of developing schizophrenia should be identified in good time, and referred to early detection/intervention centers for a diagnostic work-up. In addition to the initial, non-specific symptoms that mark the beginning of the prodromal phase, basic disturbances also need to be considered, since they have considerable prognostic importance for the transition to psychosis. Other factors of importance are retarded development and behavioral anomalies in childhood and familial load, since premorbid risk factors are indicative of a congenital psychotic risk.

Objective: To characterize the epidemiology of schizophrenia., Method: Narrative literature review., Results: Each year 1 in 10,000 adults (12 to 60 years of age) develops schizophrenia. Based on a restrictive and precise definition of the diagnosis and using standardized assessment methods and large, representative populations, the incidence rates appear stable across countries and cultures and over time, at least for the last 50 years. Schizophrenic patients are not born into ecological and social disadvantage. The uneven distribution of prevalence rates is a result of social selection: an early onset leads to social stagnation, a late onset to descent from a higher social status. The main age range of risk for schizophrenia is 20 to 35 years. It is still unclear whether schizophrenia-like late-onset psychoses (for example, late paraphrenia) after age 60 should be classified as schizophrenia either psychopathologically or etiologically. In 75% of cases, first admission is preceded by a prodromal phase with a mean length of 5 years and a psychotic prephase of one year's duration. On average, women fall ill 3 to 4 years later than men and show a second peak of onset around menopause. Consequently, late-onset schizophrenias are more frequent and more severe in women than in men. The sex difference in age of onset is smaller in cases with a high genetic load and greater in cases with a low genetic load. Type of onset and core symptoms do not differ between the sexes. The most pronounced sex difference is the socially negative illness behaviour of young men., Conclusions: Among the factors determining social course and outcome are level of social development at onset, the disorder itself (for example, genetic liability, severity of symptoms, and functional deficits), general biological factors (for example, estrogen), and sex- and age-specific illness behaviour.

Depressive syndromes in schizophrenia are reported in the prodromal stage of the early course, during the first or later psychotic episodes, but also after the fading out of an acute episode and as a precursor of relapse. According to these multiple conditions several explanations also exist as to how to understand depression in schizophrenia. Some authors interpret it as an elementary part of the schizophrenic symptomatology, which is only masked by positive symptoms (revealed depression). However, it can also be understood as a reactive depression or as caused by neuroleptic treatment, as part of the negative syndrome or as co-morbidity. In the ABC-Schizophrenia-Study, depression in the early course was analysed for patients in their first psychotic episode at index admission and an ICD-9 diagnosis of schizophrenia (ICD 295). In 81% of this sample depression was observed, beginning on average 4.3 years prior to index admission. In 42% of the patients depression began in the prepsychotic phase. In 18% the positive and the depressive syndrome developed within one month, and in 21% depression started after the first positive symptom occurred. We could only observe a clear sequence of depressive, negative and positive symptoms in the subgroup characterised by prepsychotic depression. A clear order of negative and positive symptoms was not observed in the other groups. Patients without depression in the early course have lower symptom levels at index admission. They present less positive symptoms (CATEGO-subscore DAH), fewer behavioural disturbances (subscore BSO) and also lower scores of non-specific symptoms (subscores SNR and NSN). More than 80% of the patients with depression in the early course also had a simple depression (as defined by the CATEGO-syndrome SD). Contrary to this, only 20% of the patient group without depression in the early course have positive SD values. Comparable percentages of males and females have depression in the early course, but in females depression begins more frequently in the prepsychotic phase, whereas in the male subgroup it more often starts postpsychotically, i.e. after the onset of the first psychotic symptom.

For the investigation of the early course of schizophrenia starting from onset, the standardised Interview for the Retrospective Assessment of the Onset of Schizophrenia was developed and validated. In a representative sample of 267 first-admitted German schizophrenics of a broad diagnosis from a population of 1.5 million, the age at which different diagnostic and onset definitions were satisfied, the symptoms at the time of the interview, and the accumulation of positive and negative symptoms until first admission were assessed. Comparison between the two sexes and three age groups yielded hardly any differences in the accumulation of symptoms and their course until first admission, except for a slightly shorter period of negative symptoms in young males and a slightly longer one in older women--which contradicts prevailing opinion. At the time of the interview, no significant sex differences were found with respect to the core symptoms of schizophrenia (negative and first-rank symptoms), but clear and substantial differences emerged in disease behaviour. The significantly higher age at first onset in women is explained, on the basis of animal experiments and a clinical study, by the neuromodulatory effect of oestrogen on D2 receptors and by a higher vulnerability threshold in women.

As a part of the ABC Schizophrenia Study, a large-scale investigation of the influences of age and gender on the onset and course of schizophrenia, this study compared retrospective reports about emerging symptomatology during the early course of schizophrenia given by patients and their significant others in a representative first admission sample. The Interview for the Retrospective Assessment of the Onset of Schizophrenia (IRAOS), a comprehensive interview assessing early signs and symptoms, revealed that, in most cases, patients as well as informants perceived negative, depressive, and unspecific symptoms as early signs of the disorder. Pairwise agreement about the presence of certain symptoms was good for a limited number of signs, e.g., substance abuse, suicidal behavior, parental and marital role deficits, and paranoid delusions. These items mainly concern abnormal behaviors that can be observed easily. In contrast, there was little agreement between reports about perceptual and formal thought disorder, i.e., subjective internal phenomena. The results supported a continuity model for the observability of symptoms in schizophrenia.

Since Kraepelin's first description of dementia praecox in 1889 many data and theories have been published on the onset and course of schizophrenia. Until now studies on these topics had to rely on first admission data and on the subsequent course of the disease. However, first hospitalisation is preceded by a wide variety of patterns and duration of the early course. Items taken from the pre-admission phase of the disease are often incorrectly used as premorbid characteristics, understandably preceding the subsequent course and outcome of schizophrenia with high predictive power. In relation to our interest to study the beginning of schizophrenia, systematically, paying special attention to the age and gender distribution of true onset and the symptomatology and pattern of the early and later course, we developed an 'Interview for the Retrospective Assessment of the Onset of Schizophrenia (IRAOS)'. It allows an objective, reliable, and valid assessment of the symptoms, psychological impairments, demographic and social characteristics as well as the referring points in time of the early course of psychosis. The instrument is administered as a semi-structured interview with both the patient and a key informant. The obtained information is extended by a systematic examination of the clinician's case notes. Some results derived from an ongoing study on age and gender differences in onset and patterns of early course are added to demonstrate the use of the instrument.

Objective: This paper tries to show that gender differences in mental diseases are a valuable paradigm for research into the interplay between biological and psychosocial factors - not only regarding pathogenetic mechanisms, but also concerning therapeutic approaches. Method: Based on relevant literature, this topic is highlighted using schizophrenia as an example. Results: Schizophrenic disorders show a later age of onset in women and a slightly better course, especially in young women. As to pathogenesis, there is some evidence that the age difference might be due at least partly to the female sex hormone oestradiol being a protective factor. Differences in course might also have to do with this biological factor, but at the same time with the psychosocial advantages of a higher age of onset and other psychosocial factors. Concerning therapy, these gender differences have important implications for pharmacotherapy, but also psychotherapy and social measures. Conclusion: A gender-sensitive approach in psychiatry improves our understanding of mental illness and our therapeutic strategies and at the same time illustrates that comprehensive psychiatry cannot be practised in artificially separated 'drawers' called 'biological psychiatry', on one hand, and 'social psychiatry' on the other. [ABSTRACT FROM AUTHOR]

Objective: First treatment contact is preceded by a lengthy prodromal and psychotic prephase. We analysed the occurrence of symptoms and disabilities prior to first contact and their consequences for medium-term illness course. Method: A population-based sample of 232 first episodes of schizophrenia was studied retrospectively using the IRAOS and compared with matched peers from the population of origin. Further illness course was studied prospectively at six cross-sections over 5 years from first admission onwards. Results: Three quarters showed a prodromal phase of 5 years (mean) and a 1-year accumulation of psychotic symptoms. First to appear were depressive and negative symptoms and early signs of cognitive and social impairment. Social disability emerged 4 to 2 years before first contact. Further illness course was determined by stage of social development at psychosis onset with the consequence of a significantly poorer course for men than women because of men's earlier illness onset. Symptomatology, type of onset, age and gender influenced social course via stage of social development and, additionally, via young men's socially adverse illness behaviour. Conclusion: Social course is determined by individual stage of social development at illness onset and by early illness course. Therefore, early detection and intervention are needed. [ABSTRACT FROM AUTHOR]