Elaboration on premorbid intellectual performance in schizophrenia: Premorbid intellectual decline and risk for schizophrenia

Context: Consistent evidence indicates that some, but not most, patients with schizophrenia have below-average intelligence years before they manifest psychosis. However, it is not clear whether this below-average premorbid intelligence is stable or progressive. Objective: To examine whether increased risk for schizophrenia is associated with declining intellectual performance from childhood through adolescence. Design: Historical cohort study of an entire population using record linkage for psychiatric hospitalization during an 8- to 17-year follow-up period. Setting: Mandatory assessment by the draft board of Israeli conscripts. Participants: Population-based cohort of 555 326 adolescents born in Israel. Data were available on 4 intelligence subtests as well as on reading and spelling abilities and on behavioral and psychosocial variables. A regression-based approach was used to assess the discrepancy between actual IQ at age 17 years and estimated IQ during childhood based on reading and spelling abilities. Main Outcome Measures: Hospitalization for schizophrenia (as per the International Statistical Classification of Diseases, 10th Revision criteria). Results: Lower-than-expected IQ at age 17 years was associated with increased risk for later hospitalization for schizophrenia. Results were held after controlling for potential confounders. For 75% of patients with schizophrenia with low actual IQ (<85) at age 17 years and for 23% of patients with actual IQ within the normal range (≥85), actual IQ was 10 or more points lower than expected. Lower-than-expected IQ was not associated with bipolar disorder or with depression or anxiety disorder. Conclusions: Indirect evidence suggests that intellectual deterioration from childhood through adolescence is associated with increased risk for schizophrenia. Despite within-normal-range premorbid IQ scores, apparently healthy adolescents who will later manifest schizophrenia nevertheless have intellectual decline.