Differences of affective and non-affective psychoses in early intervention services from Latin America

Highlights

• Affective and non-affective psychoses may be distinguished at the first episode.

• Males are more likely to have a non-affective psychosis.

• The affective group initially had more severe manic symptoms but also a greater improvement.

• The non-affective group has more negative symptoms and a higher improvement in these symptoms.

Abstract

Background

Psychosis presentation can be affected by genetic and environmental factors. Differentiating between affective and non-affective psychosis (A-FEP and NA-FEP, respectively) may influence treatment decisions and clinical outcomes. The objective of this paper is to examine differences between patients with A-FEP or NA-FEP in a Latin American sample.

Methods

Patients from two cohorts of patients with a FEP recruited from Brazil and Chile. Subjects included were aged between 15 and 30 years, with an A-FEP or NA-FEP (schizophrenia-spectrum disorders) according to DSM-IV-TR. Sociodemographic data, duration of untreated psychosis and psychotic/mood symptoms were assessed. Generalized estimating equation models were used to assess clinical changes between baseline-follow-up according to diagnosis status.

Results

A total of 265 subjects were included. Most of the subjects were male (70.9 %), mean age was 21.36 years. A-FEP and NA-FEP groups were similar in almost all sociodemographic variables, but A-FEP patients had a higher probability of being female. At baseline, the A-FEP group had more manic symptoms and a steeper reduction in manic symptoms scores during the follow- up. The NA-FEP group had more negative symptoms at baseline and a higher improvement during follow-up. All domains of The Positive and Negative Syndrome Scale improved for both groups. No difference for DUP and depression z-scores at baseline and follow-up.

Limitations

The sample was recruited at tertiary hospitals, which may bias the sample towards more severe cases.

Conclusions

This is the largest cohort comparing A-FEP and NA-FEP in Latin America. We found that features in FEP patients could be used to improve diagnosis and support treatment decisions.

Introduction

Psychoses are clinical syndromes characterized by impairment in reality testing, with thought and perception disturbances, leading to symptoms such as delusions and hallucinations (Freudenreich, 2020). Current diagnostic criteria suggest a clear boundary between affective (essentially, major depressive and bipolar disorders), and non-affective psychotic disorders (i.e., schizophrenia and schizophrenia-related disorders). However, many challenges are commonly faced in identifying a definite diagnosis in the first episode of psychosis in clinical practice. The highly polymorphic presentation may justify the diagnostic instability — 10 % of the affective psychotic diagnostics changed to a further diagnosis of a schizophrenia-spectrum disorder (Fusar-Poli et al., 2016).

The initial 1–3 years of psychotic disorders are a critical period for intervention, since most functional impairment occurs at this phase (Birchwood et al., 1998). Therefore, in the last decade, much emphasis was put on reducing the duration of untreated psychosis (DUP), the period between the onset of the disorder and the beginning of adequate treatment. Shorter DUP promotes better short- and long-term outcomes, such as better treatment response, general functioning, and fewer relapses, but also cost reduction to health systems and may reduce neuroprogression (Howes et al., 2021; Mihalopoulos et al., 2009; Murru and Carpiniello, 2018; Penttilä et al., 2014). Pharmacological and psychosocial treatment can differ between affective and non-affective psychotic disorders (Early Psychosis Guidelines Working Group, 2016; Ramain et al., 2021). Hence, making earlier and more accurate diagnoses may be associated with better outcomes. Although biomarkers and big data can be promising tools for precision medicine, clinical decisions still depend on phenomenological presentation for diagnosis and management.

Most studies addressing differences between affective and non-affective psychosis have been conducted in High-Income Countries (HICs), challenging translation to different clinical scenarios, such as low-and-middle-income countries (LMICs). Various studies suggest that risk factors exposures and clinical courses of psychotic disorders may vary between patients from HICs or LMICs. For example, while in HICs pathways to care for patients in the first episode of psychosis are variable and may be different for ethical minorities, traditional health practitioners frequently are first contacted by the patients in LMICs (Lilford et al., 2020; Singh and Grange, 2006). Also, environmental, and individual characteristics play an important role and may have different impacts depending on the region. One example is urbanicity, a well-known risk factor for psychosis in HICs, but it does not seem to play a significant role in LMICs (DeVylder et al., 2018). Clinical courses and prognosis may also vary. Based on classical studies conducted by World Health Organization (WHO), a “better prognosis hypothesis” for schizophrenia was suggested in LMICs compared to rich countries, since patients diagnosed with schizophrenia had better outcomes in LMICs (Harrison et al., 2001; Hawk, 1978; Leff et al., 1992). Although these results are not universally accepted, several environmental, genetic, and cultural reasons can contribute to the observed differences, such as urban-rural patterns of marijuana use, sociodemographic characteristics, ethnicity, and socioeconomic disparities (DeVylder et al., 2018; Jongsma et al., 2018). There is evidence that affective psychoses are more likely in women, with better premorbid functioning and a family history of psychiatric disorders. In addition, they present with a shorter DUP, more manic symptoms, and mood-congruent delusions (especially guild and grandiosity), with a more episodic course and, are more likely to be prescribed with mood stabilizers and antidepressants (Chang et al., 2016; Conus et al., 2007; Kapila et al., 2019; Large et al., 2008; Picardi et al., 2018; Ramain et al., 2022; Schothorst et al., 2006; Torrent et al., 2018). On the other hand, non-affective psychoses are more likely to have an earlier age of onset, present with more continuous negative and positive symptoms and are less likely to develop insight (Henry et al., 2010; Picardi et al., 2018; Ramain et al., 2022; Torrent et al., 2018). Very little data is available regarding differences between affective and non-affective psychotic disorders in LMICs and even less in Latin American countries during the first episode (FEP). In addition, most of the literature consists of cross-sectional studies.

The objective of this paper is to examine differences between patients with affective (A-FEP) and non-affective first-episode psychosis (NA-FEP) in sociodemographic characteristics, clinical features, and short-term clinical outcomes (symptom reduction of mood and psychotic symptoms and rates of responders to treatment at 2–3 months follow-up) in two early intervention centers in Latin America.