Schizophrenia Research 159 (2014) 253
Contents lists available at ScienceDirect
Schizophrenia Research journal homepage: www.elsevier.com/locate/schres
Letter to the Editor Comment on Lee et al. As we have previously noted in this journal (Yung et al., 2010; Lin et al., 2011), it is important to measure functioning as an outcome in the Clinical/Ultra High Risk group, as this may give a more accurate picture of an individual's level of impairment than transition to psychosis alone. Chronic poor functioning with or without a history of transition to psychosis in this group may also be more closely aligned to deficit schizophrenia than a history of transition but with good functioning. We therefore read the paper of Lee et al. (2014) with interest. This study examined symptomatic and functional remission in a Clinical High Risk group. However it is difficult to see what this study adds to our knowledge. The authors found that positive symptoms, as measured on the Scale of Prodromal Symptoms (SOPS) and poor functioning, as assessed with the Global Assessment of Functioning (GAF) were predictors of nonremission. However this is a circular finding, as both these measures were used to define remission. The only independent predictor of functioning was medication use. A significantly higher proportion of patients in the non-remitted group were prescribed antipsychotics and they had a significantly higher dose of antipsychotics compared to the remitted group. The non-remitted group also had higher anxiolytic use compared to the remitted group. One likely explanation for this is that the patients in the non-remitted group were more unwell than that of the remitted group (by definition), hence the higher use of medication. A further problem with the study is the high use of antipsychotics. Individuals in the Clinical/Ultra High Risk group do not have a psychotic disorder and antipsychotics are not recommended in this group (National Institute of Clinical Excellence NICE, 2002, 2013). Yet over 82% of the non-transitioned cases were prescribed these medications. In addition to clinical concerns, this means that the diagnosis of these patients cannot be determined as the antipsychotics are treating or partially treating any psychotic symptoms. The non-remitted group in particular could be conceptualized as individuals who are partially treated for schizophrenia.
http://dx.doi.org/10.1016/j.schres.2014.08.012 0920-9964/© 2014 Elsevier B.V. All rights reserved.
What is needed is a study of functioning in the at risk group in the absence of antipsychotics with examination of predictors independent of the definition of functioning. Conflict of interest None.
References Lee, T.Y., Kim, S.N., Correll, C.U., Byun, M.S., Kim, E., Jang, J.H., et al., 2014. Symptomatic and functional remission of subjects at clinical high risk for psychosis: a 2-year naturalistic observational study. Schizophr. Res. 156, 266–271. Lin, A., Wood, S.J., Nelson, B., Brewer, W.J., Spiliotacopoulos, D., Bruxner, A., et al., 2011. Neurocognitive predictors of functional outcome two to 13 years after identification as ultra-high risk for psychosis. Schizophr. Res. 132, 1–7. National Institute of Clinical Excellence, 2013. NICE Clinical Guideline 155: Psychosis and Schizophrenia in Children and Young People: Recognition and Management. NICE, London. National Institute of Clinical Excellence NICE, 2002. Clinical Guideline I: Schizophrenia. Core Interventions in the Treatment and Management of Schizophrenia in Primary and Secondary Care. NICE, London. Yung, A.R., Nelson, B., Thompson, A., Wood, S.J., 2010. The psychosis threshold in Ultra High Risk (“prodromal”) research: is it valid? Schizophr. Res. 120, 1–6.
Alison R. Yung University of Manchester, UK Ashleigh Lin University of Western Australia, Australia Jack Cotter University of Manchester, UK Stephen Wood University of Birmingham, UK 30 June 2014
Contents lists available at ScienceDirect
Schizophrenia Research journal homepage: www.elsevier.com/locate/schres
Letter to the Editor Comment on Lee et al. As we have previously noted in this journal (Yung et al., 2010; Lin et al., 2011), it is important to measure functioning as an outcome in the Clinical/Ultra High Risk group, as this may give a more accurate picture of an individual's level of impairment than transition to psychosis alone. Chronic poor functioning with or without a history of transition to psychosis in this group may also be more closely aligned to deficit schizophrenia than a history of transition but with good functioning. We therefore read the paper of Lee et al. (2014) with interest. This study examined symptomatic and functional remission in a Clinical High Risk group. However it is difficult to see what this study adds to our knowledge. The authors found that positive symptoms, as measured on the Scale of Prodromal Symptoms (SOPS) and poor functioning, as assessed with the Global Assessment of Functioning (GAF) were predictors of nonremission. However this is a circular finding, as both these measures were used to define remission. The only independent predictor of functioning was medication use. A significantly higher proportion of patients in the non-remitted group were prescribed antipsychotics and they had a significantly higher dose of antipsychotics compared to the remitted group. The non-remitted group also had higher anxiolytic use compared to the remitted group. One likely explanation for this is that the patients in the non-remitted group were more unwell than that of the remitted group (by definition), hence the higher use of medication. A further problem with the study is the high use of antipsychotics. Individuals in the Clinical/Ultra High Risk group do not have a psychotic disorder and antipsychotics are not recommended in this group (National Institute of Clinical Excellence NICE, 2002, 2013). Yet over 82% of the non-transitioned cases were prescribed these medications. In addition to clinical concerns, this means that the diagnosis of these patients cannot be determined as the antipsychotics are treating or partially treating any psychotic symptoms. The non-remitted group in particular could be conceptualized as individuals who are partially treated for schizophrenia.
http://dx.doi.org/10.1016/j.schres.2014.08.012 0920-9964/© 2014 Elsevier B.V. All rights reserved.
What is needed is a study of functioning in the at risk group in the absence of antipsychotics with examination of predictors independent of the definition of functioning. Conflict of interest None.
References Lee, T.Y., Kim, S.N., Correll, C.U., Byun, M.S., Kim, E., Jang, J.H., et al., 2014. Symptomatic and functional remission of subjects at clinical high risk for psychosis: a 2-year naturalistic observational study. Schizophr. Res. 156, 266–271. Lin, A., Wood, S.J., Nelson, B., Brewer, W.J., Spiliotacopoulos, D., Bruxner, A., et al., 2011. Neurocognitive predictors of functional outcome two to 13 years after identification as ultra-high risk for psychosis. Schizophr. Res. 132, 1–7. National Institute of Clinical Excellence, 2013. NICE Clinical Guideline 155: Psychosis and Schizophrenia in Children and Young People: Recognition and Management. NICE, London. National Institute of Clinical Excellence NICE, 2002. Clinical Guideline I: Schizophrenia. Core Interventions in the Treatment and Management of Schizophrenia in Primary and Secondary Care. NICE, London. Yung, A.R., Nelson, B., Thompson, A., Wood, S.J., 2010. The psychosis threshold in Ultra High Risk (“prodromal”) research: is it valid? Schizophr. Res. 120, 1–6.
Alison R. Yung University of Manchester, UK Ashleigh Lin University of Western Australia, Australia Jack Cotter University of Manchester, UK Stephen Wood University of Birmingham, UK 30 June 2014
