Diagnostic Shifts During the Decade Following First Admission for Psychosis

Abstract

OBJECTIVE Diagnostic shifts have been prospectively examined in the short-term, but the long-term stability of initial and follow-up diagnoses have rarely been evaluated. METHOD A cohort of 470 first-admission patients with psychotic disorders was systematically assessed at baseline, 6-month, 2-year, and 10-year follow-up. Longitudinal best-estimate consensus diagnoses were formulated after each assessment. RESULTS At baseline, the diagnostic distribution was: schizophrenia spectrum disorders 29.6%, bipolar disorder with psychotic features 21.1%, major depression with psychotic features 17.0%, substance-induced psychosis 2.4%, and other psychoses 27.9%. At year 10, the distribution changed to 49.8%, 24.0%, 11.1%, 7.0%, and 8.1%, respectively. Overall, 50.7% changed diagnoses at some point during the study. Most participants who were initially diagnosed with schizophrenia or bipolar disorder retained the diagnosis at year 10 (89.2% and 77.8%, respectively). However, 32.0% of participants (N=98) originally given a non-schizophrenia diagnosis gradually shifted into schizophrenia at year 10. The second biggest shift was to bipolar disorder (10.7% of those not given this diagnosis at baseline). Changes in the clinical picture explained many diagnostic shifts. In particular, poorer functioning and greater negative and psychotic symptoms predicted a subsequent shift to schizophrenia. Better functioning and lower negative and depressive symptoms predicted the shift to bipolar disorder. CONCLUSIONS First-admission patients run the risk of being misclassified at early stages in the illness course, including more than 2 years after first hospitalization. Diagnosis should be reassessed at all follow-up points.

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