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
ICD 10 structure (no changes confirmed ICD 11 as yet)

Schizophrenia





Paranoid
schizophrenia
Hebephrenic
schizophrenia
Catatonic
schizophrenia
Undifferentiated
schizophrenia
Postschizophrenic

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
Relationship of the psychosis
symptoms.
Dutta, Schizophr Bull. 2007 July; 33(4): 868–876
Simplified outline of Geneenivironment 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
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 12month 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)

drug dependence (15.8)
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
0.7
0.6
'Psychotic'
'Hallucinatory'
'Normal'
Probability
0.5
0.4
0.3
0.2
0.1
0
Visions
Voices
Thought
insertion
Thought
control
Telepathy
Persecution
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.
mean
sd
All cause
2.98
1.75
Unnatural
8.6
3.71
accident
suicide
3.3
42.47
2.36
93.11
Natural
2.31
1.18
CVS
CVA
GI
Endocrine
Infective
Respiratory
2.01
0.83
0.87
0.38
5.28
6.94
5.5
5.34
4.56
3.11
4.01
2.56
Sasha, Arch Gen Psych 2007.
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.
References.
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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.