Neurodevelopmental disorder in the psychoses
Worldwide, the most common form of psychosis, schizophrenia, falls into the top ten disorders causing disability, accounting for between 1.5% and 2.6% of health care expenditure in developed countries. Psychosis is a major source of dependence on disability benefits and of family burden. This is because the course is often chronic, characterised by repeated exacerbations and often by persistent and severe disability. Only a minority have achieved pre-morbid levels of function 15 to 25 years after diagnosis.
Greater understanding of the factors associated with onset, remission, relapse and recovery in psychosis is of huge importance to the NHS, in terms of individual suffering and disability, of burden on families and of the effectiveness of allocated resources. In urban settings particularly, the problems of psychosis are often compounded by comorbid psychiatric conditions, by severe traumatic experience, by substance abuse, by immigration problems, and by lifestyles leading to poor physical health.
No institution involved in mental health research or treatment can fail to take a position on psychosis. Although primarily defined for diagnostic purposes in terms of positive psychotic symptoms, schizophrenia is very frequently found to have neurodevelopmental underpinnings, which may in fact precede the positive symptoms by many years. Psychosis may often represent the manifestation of genetic influences on the developing brain interacting with environmental risk factors such as obstetric complications, ethnic group/immigration status, severe trauma (including sexual abuse), urban upbringing, social deprivation and cannabis use. Following onset, medication may ameliorate psychotic symptoms but does not affect those aspects of the syndrome, negative symptoms and cognitive dysfunction, which contribute most to poor social and occupational outcomes.
Less is known about the other major psychosis, bipolar disorder. There is evidence of overlap with schizophrenia in genetic and psychosocial risk factors as well as in neural abnormalities. Indeed these two disorders may form a spectrum of psychosis rather than discrete conditions. Psychosis so defined would affect about 1.5% of the population.
The focus of research should be a better understanding of the development of psychotic symptoms and cognitive impairment, their neural substrates, and environmental moderators, with a view to delineating risk factors, improving treatments, and facilitating prevention. The most efficient way to advance the development of treatment requires a focus on the most modifiable factors involved in the maintenance of symptoms.
Research on mechanisms includes identification of genes and copy number variants implicated in the aetiology of schizophrenia and research into the genetics of bipolar disorder in our Molecular Psychiatry Laboratory. Novel structural MRI techniques are demonstrating grey and white pathology at psychosis onset and their relationship to cognitive and oculomotor abnormalities. Advances in neuroimaging have improved diagnostic specificity and prediction of onset in neurodevelopmental diseases. The critically important theory of ‘dysconnectivity’ as the neural and cognitive basis of psychosis, yielding both assessment and treatment approaches, is universally accepted. Separate cognitive and emotional pathways have been demonstrated in the origination of paranoia. Cardiovascular mechanisms are being identified to predict the premature mortality of psychoses.
New assessment procedures include a European measure of best practice for people with long-term mental illness in institutional care. In the area of treatment and service evaluation, UCL academics with partner mental health trusts have constructed a unequalled portfolio of controlled trials including REACT which demonstrated specialist teams for assertive outreach to be ineffective and two trials of Crisis Intervention showing that it reduced hospital admission, increased patient satisfaction, and was cost-effective.
The RCPsych/BPS joint Guidelines Group for Schizophrenia carried out three influential meta-analyses of atypical antipsychotics and psychological treatments which were central to NICE Guidelines for Schizophrenia, and have influenced European, Australasian and USA guidelines.
A Service Users Research Forum (SURF) has been established with service users in North London who have an interest or experience in working in mental health research.
Key departments and research groups
Service Users Research Forum
Molecular Psychiatry Laboratory
Wellcome Trust Centre for Neuroimaging (WTCN)