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PAPERS: Diana Perkins, Jeffrey Lieberman, Hongbin Gu, Mauricio Tohen, Joseph McEvoy, Alan Green, Robert Zipursky, Stephen Strakowski, Tonmoy Sharma, René Kahn, Raquel Gur, and Gary Tollefson Predictors of antipsychotic treatment response in patients with first-episode schizophrenia, schizoaffective and schizophreniform disorders The British Journal of Psychiatry 2004; 185: 18-24 [Abstract] [Full text] [PDF]

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Use of the PAS in first episode schizophrenia studies

Gerardo Florez   (28 July 2004)

Use of the PAS in first episode schizophrenia studies 28 July 2004
Gerardo Florez, psychiatrist Send letter to journal: Re: Use of the PAS in first episode schizophrenia studies gerardof{at}mundo-r.com Gerardo Florez	During the last decade, many first-episode schizophrenia studies have been published. Like in the study by Perkins et al., one, if not the most important aim, is to examine the relationship between DUP (Duration of Untreated Illness) and outcome. If DUP is independently associated with better outcome, then early intervention programmes on first episode psychosis are clearly justified; but if DUP is a merely statistically artefact, consequence of the type of onset (acute versus insidious), we can wonder if it is really worthy to invest so much money in these programmes. Many studies have evaluated if DUP is independently related to outcome, or if this influence dissapears when premorbid function is added in the ecuation. Premorbid function has been clearly associated with outcome and type of onset (good premorbid adjustment = acute onset; bad premorbid adjustment = insidious onset ) (1). To measure premorbid function many studies, including the Perkins et al. one, have used the Premorbid Adjustment Scale (PAS). This scale, that divides the premorbid period in four stages ( childhood, early and late adolescence and adulthood ) considers that the premorbid period lasts from birth until six months before the first contact with psychiatric service or before the first psychotic symptom appears. When the scale was developed, in the early eighties, there wasn´t much knowledge about the prodromes in schizophrenia, that´s why the PAS authors arbitrarly established the six month period in order to clearly distinguish the premorbid psychosocial deterioration from the deterioration that appears at the psychotic early stages. But nowadays we have robust data about the existence of a schizophrenic prodromal phase and its duration ( mean duration two years with a one year median (2)); so we can say that if we don´t measure the duration of the prodromal phase and adjust the PAS to it, we will be mixing up two different stages of the illness. As new studies about the relationship between the prodromal phase and the outcome appear, this confusion becomes more relevant(3). That´s why when using the PAS or any other premorbid scale we must firts assess the duration of the DUP and the prodromal phase (also called Duration of Untreated Illness, DUI), and then adjust the premorbid scale to the period of time that goes from birth to the onset of the prodomal phase, a method that has been pointed out by several authors(4). REFERENCES 1. Harrison G. et al. Recovery from psychotic illness: a 15- and 25- year international follow-up study. Br J Psychiatry 2001 ;178: 506-517. 2. Häfner H. Nowotny B. Epidemiology of early – onset schizophrenia. Eur Arch Psychiatry Clin Nuerosci 1995; 245: 80-92. 3. Keshavan MS, Haas G, Miewald J, Montrose DM, Reddy R, Schooler NR, Sweeney JA. Prolonged untreated illness duration from prodromal onset predicts outcome in first episode psychoses. Schizophr Bull. 2003;29(4):757-69. 4. Larsen TK, McGlashan TH, Moe LC. First- Episode Schizophrenia: I. Early Course Parameters. Schizophrenia Bulletin 1996. 22(2): 241-256.