Autonomic Flexibility and Early Treatment Success: Heart Rate Variability Predicts Remission in First-Episode Psychosis

Background and hypothesis: Heart-rate variability (HRV) is a low-cost marker of autonomic regulation and a potential prognostic biomarker in psychosis. We hypothesized that HRV markers recorded at admission are associated with remission at discharge in patients with suspected first-episode psychosis. Study design: In this retrospective study, 78 inpatients (mean age: 30.8 years; 45% female) admitted to the Psychiatric University Hospital Zurich between 2018 and 2024 underwent a 2-min electrocardiogram on admission. Frequency-domain indices (log-transformed high-frequency [HF] and low-frequency [LF] power) and the linear slope of heart rate over time (beats per minute [BPM] slope) were extracted. Remission status at discharge was determined from clinician-rated scales and clinical evaluation. Binomial logistic regression with 5-fold stratified cross-validation assessed predictive accuracy (area under the receiver operating curve, AUC). Study results: Twenty-six patients (33.3 %) remitted. Sex was not associated with outcome. In the initial model, log HF (P = .011) and BPM slope (P = .014) predicted remission, whereas log LF and mean BPM did not. The final model retaining log HF and BPM slope achieved an AUC of 0.714. Lower log HF and more rapidly declining BPM slope at admission were linked to higher odds of remission. Conclusions: An HRV profile combining low vagally mediated HF power with rapid heart rate decrease predicted short-term remission, supporting the autonomic-flexibility framework. HRV may aid early treatment stratification, but findings require prospective validation with larger samples, respiratory monitoring, and standardized interventions.