Early intervention in psychosis: concepts, evidence and future directions

Disturbances of the Basic Self and Prodromal Symptoms Among Young Adolescents From the Community: A Pilot Population-Based Study

BACKGROUND AND GOAL

Recent findings have provided preliminary support for the notion that basic self-disturbances (SD) are related to prodromal symptoms among nonpsychotic help-seeking adolescents. As a sizable proportion of adolescents who are at risk do not seek help, this study attempts to assess the extent to which these findings can be generalized to the entire population of adolescents who are at risk for psychosis.

METHOD

The concurrent relationship between SD and prodromal symptoms was explored in a sample of 100 non-help-seeking adolescents (age 13-15) from the community. SD were assessed with the Examination of Anomalous Self-Experience (EASE); prodromal symptoms and syndromes were assessed with the Structured Interview for Prodromal Syndromes (SIPS); psychosocial functioning was assessed with the "Social and Role Global Functioning Scales"; and level of distress with the Mood and Anxiety States Questionnaire (MASQ).

RESULTS

SD significantly correlated with sub-clinical psychotic symptoms (r = .70, P < .0001). This correlation was significantly stronger than those of SD with mood symptoms and social functioning. Finally, SD was the single best concurrent predictor of prodromal symptoms and syndromes.

CONCLUSIONS

These results provide preliminary support for the generalizability of the association between SD and prodromal symptoms for the entire population of adolescents who are clinically at high risk for psychosis. In addition, they further support the notion that this association is both specific and unique.

Disrupted latent inhibition in individuals at ultra high-risk for developing psychosis

The addition of off-the-shelf cognitive measures to established prodromal criteria has resulted in limited improvement in the prediction of conversion to psychosis. Tests that assess cognitive processes central to schizophrenia might better identify those at highest risk. The latent inhibition paradigm assesses a subject's tendency to ignore irrelevant stimuli, a process integral to healthy perceptual and cognitive function that has been hypothesized to be a key deficit underlying the development of schizophrenia. In this study, 142 young people at ultra high-risk for developing psychosis and 105 controls were tested on a within-subject latent inhibition paradigm. Additionally, we later inquired about the strategy that each subject employed to complete the test, and further investigated the relationship between reported strategy and the extent of latent inhibition exhibited. Unlike controls, ultra high-risk subjects did not demonstrate a significant latent inhibition effect. This difference between groups became greater when controlling for strategy. The lack of latent inhibition effect in our ultra high-risk sample suggests that individuals at ultra high-risk for psychosis are impaired in their allocation of attentional resources based on past predictive value of repeated stimuli. This fundamental deficit in the allocation of attention may contribute to the broader array of cognitive impairments and clinical symptoms displayed by individuals at ultra high-risk for psychosis.

Childhood adversity and psychosis: generalised or specific effects?

BACKGROUND

This study examines relationships between childhood adversity and the presence of characteristic symptoms of schizophrenia. It was hypothesised that total adversity exposures would be significantly higher in individuals exhibiting these symptoms relative to patients without. Recent proposals that differential associations exist between specific psychotic symptoms and specific adversities was also tested, namely: sexual abuse and hallucinations, physical abuse and delusions, and fostering/adoption and delusions.

METHOD

Data were collected through auditing 251 randomly selected medical records, drawn from adult patients in New Zealand community mental health centres. Information was extracted on presence and subtype of psychotic symptoms and exposure to ten types of childhood adversity, including five types of abuse and neglect.

RESULTS

Adversity exposure was significantly higher in patients experiencing hallucinations in general, voice hearing, command hallucinations, visions, delusions in general, paranoid delusions and negative symptoms than in patients without these symptoms. There was no difference in adversity exposure in patients with and without tactile/olfactory hallucinations, grandiose delusions or thought disorder. Indication of a dose-response relationship was detected, in that total number of adversities significantly predicted total number of psychotic symptoms. Although fostering/adoption was associated with paranoid delusions, the hypothesised specificity between sexual abuse and hallucinations, and physical abuse and delusions, was not found. The two adversities showing the largest number of associations with psychotic symptoms were poverty and being fostered/adopted.

CONCLUSIONS

The current data are consistent with a model of global and cumulative adversity, in which multiple exposures may intensify psychosis risk beyond the impact of single events. Implications for clinical intervention are discussed.

Adherence to Antipsychotic Medication in Bipolar Disorder and Schizophrenic Patients: A Systematic Review

Antipsychotics are the drugs prescribed to treat psychotic disorders; however, patients often fail to adhere to their treatment, and this has a severe negative effect on prognosis in these kinds of illnesses. Among the wide range of risk factors for treatment nonadherence, this systematic review covers those that are most important from the point of view of clinicians and patients and proposes guidelines for addressing them. Analyzing 38 studies conducted in a total of 51,796 patients, including patients with schizophrenia spectrum disorders and bipolar disorder, we found that younger age, substance abuse, poor insight, cognitive impairments, low level of education, minority ethnicity, poor therapeutic alliance, experience of barriers to care, high intensity of delusional symptoms and suspiciousness, and low socioeconomic status are the main risk factors for medication nonadherence in both types of disorder. In the future, prospective studies should be conducted on the use of personalized patient-tailored treatments, taking into account risk factors that may affect each individual, to assess the ability of such approaches to improve adherence and hence prognosis in these patients.

Course of auditory vocal hallucinations in childhood: 11-year follow-up study

OBJECTIVE

Childhood auditory vocal hallucinations (AVH) are mostly transient but may predict clinical outcomes. Little is known about their course over time and associations with risk factors, and how this may inform early intervention. Our objective was to assess the 11-year course of AVH, associated psychopathology and risk factors.

METHOD

A 5-year (T1) and 11-year (T2) follow-up of a baseline case-control sample (n = 694, of whom 347 with AVH). At T2, online assessment of AVH, other psychotic experiences, psychopathology, trauma and cannabis use was completed by 293 adolescents aged 18-19 years.

RESULTS

The AVH 6-year (T1-T2) persistence rate was 18.2%, and the AVH 11-year (T0-T2) persistence rate was 6.2%. AVH at T2 were associated with higher levels of T2 other psychotic experiences, T2 psychopathology and T2 traumatic events, but not with T2 stress or T2 cannabis use. Persistence of AVH (i.e. AVH reported two or three times from T0) was associated with T2 traumatic events and higher risk for post-traumatic stress disorder.

CONCLUSION

Auditory vocal hallucinations in early childhood are mostly transitory. AVH in adolescence, especially when persistent, are associated with affective symptoms and environmental risk, particularly traumatic events.

Beyond Clinical Remission in First Episode Psychosis: Thoughts on Antipsychotic Maintenance vs. Guided Discontinuation in the Functional Recovery Era

Treatment guidelines for first episode psychosis (FEP) recommend at least 1 year of antipsychotic treatment following remission; however, in light of some recent research and the preference of some individuals to discontinue their medication sooner, this recommendation can be questioned. The aim of this article is to appraise the current discontinuation studies given our views on how this field should progress. We conducted a review of randomized controlled trials investigating dose-reduction/medication discontinuation compared with treatment maintenance in clinically remitted FEP patients. Seven trials were identified, and these reported a higher rate of relapse in the dose reduction or discontinuation groups. Relapse rates were higher when a lower threshold for relapse was utilized. However, only three studies specified that concurrent psychosocial interventions were also provided, despite an evidence base for these interventions in reducing symptom severity and relapse. Length of follow-up may also be important, as the study with the longest follow-up (7 years), albeit with some methodological shortcomings, found greater functional recovery in the dose-reduction group and that relapse rates between the two groups (dose-reduction vs. maintenance) were equal after 3 years. Finally, in addition to discontinuation or dose reduction, a diagnosis of schizophrenia, a longer duration of illness, and poor premorbid functioning were associated with a greater risk of relapse. Further trials are needed in this area to establish the long-term risk-benefit ratio of antipsychotic medication in FEP. Meanwhile, young people with FEP who do not fulfil criteria for a diagnosis of a schizophrenia disorder, achieve clinical remission for at least 3 months, attain early functional recovery, and have good social support may be possible candidates for discontinuation of antipsychotic medication bolstered by effective psychosocial interventions provided in the context of a specialized FEP service.

Reliability and validity of an instrument for the assessment of bradykinesia

Bradykinesia is associated with reduced quality of life and medication non-compliance, and it may be a prodrome for schizophrenia. Therefore, screening/monitoring for subtle bradykinesia is of clinical and scientific importance. This study investigated the validity and reliability of such an instrument. Included were 70 patients with psychotic disorders. Inertial sensors captured mean cycle duration, amplitude and velocity of four movement tasks: walking, elbow flexion/extension, forearm pronation/supination and leg agility. The concurrent validity with the Unified Parkinson's Disease Rating Scale (UPDRS) bradykinesia subscale was determined using regression analysis. Reliability was investigated with the intra-class correlation coefficient. The duration, amplitude and velocities of the four tasks measured by the instrument explained 67% of the variance on the UPDRS bradykinesia subscale. The instrument test-retest reliability was high. The instrument investigated in this study is a valid and reliable alternative to observer-rated scales. It is an ideal tool for monitoring bradykinesia as it requires little training and experience to achieve reliable results.

Pathway model of parental help seeking for adolescents experiencing first-episode psychosis

AIM

Parents and caregivers are confronted with many challenges when caring for adolescents experiencing first-episode psychosis (FEP). Understanding and support for parental help-seeking process is essential for adolescents' timely access to treatment. The study aimed to develop a pathway model of parental help seeking for adolescents experiencing FEP and identify crucial time points for intervention.

METHODS

Directed content analysis was conducted on semi-structured qualitative interviews of 16 parents whose children had experienced FEP and focused on parents' experiences prior to and during FEP until first hospitalization.

RESULTS

The resultant parental help seeking for FEP model included two stages and six phases. The contemplation stage is composed of phases of initial awareness, recognizing severity and considering options. The action stage entailed help-seeking intention, securing help and service appraisal. All parents promptly began help seeking after recognizing severe symptoms and sought advice from professional and community supports, although parents' lack of initial awareness was common. Further analysis on individual parents' help-seeking trajectories showed that among the 50% parents who reported pre-existing childhood conditions, 87.5% did not report initial awareness of psychotic symptoms.

CONCLUSIONS

Findings recommend intervention at three specific periods of help seeking. First, psychoeducation is needed when parents first engage with health care for their children's disabling conditions. Professionals treating childhood conditions need training to vigilantly monitor the overall mental health of the children over time. Second, it is important to enhance the roles of formal and informal community resources in facilitating parental help seeking. Finally, family-focused interventions are essential in supporting the family for securing needed treatment.

From early intervention in psychosis to youth mental health reform: a review of the evolution and transformation of mental health services for young people

PURPOSE

The objective of this review is to report on recent developments in youth mental health incorporating all levels of severity of mental disorders encouraged by progress in the field of early intervention in psychotic disorders, research in deficiencies in the current system and social advocacy.

METHODS

The authors have briefly reviewed the relevant current state of knowledge, challenges and the service and research response across four countries (Australia, Ireland, the UK and Canada) currently active in the youth mental health field.

RESULTS

Here we present information on response to principal challenges associated with improving youth mental services in each country. Australia has developed a model comprised of a distinct front-line youth mental health service (Headspace) to be implemented across the country and initially stimulated by success in early intervention in psychosis; in Ireland, Headstrong has been driven primarily through advocacy and philanthropy resulting in front-line services (Jigsaw) which are being implemented across different jurisdictions; in the UK, a limited regional response has addressed mostly problems with transition from child-adolescent to adult mental health services; and in Canada, a national multi-site research initiative involving transformation of youth mental health services has been launched with public and philanthropic funding, with the expectation that results of this study will inform implementation of a transformed model of service across the country including indigenous peoples.

CONCLUSIONS

There is evidence that several countries are now engaged in transformation of youth mental health services and in evaluation of these initiatives.

The Experience of Childhood Trauma and Its Influence on the Course of Illness in First-Episode Psychosis: A Qualitative Study

Persons with schizophrenia spectrum disorders often report high levels of childhood trauma, which often exacerbates symptoms and impede the process of recovery. However, little is known about how these traumas are experienced by service users and how they are integrated in their life stories. To examine this, we conducted in-depth interviews with 15 service users with a diagnosis of a first-episode nonaffective psychosis who had reported 1 or more childhood traumas in self-report measures. There was an unexpected discrepancy between the number of traumas reported in self-report measures and in semistructured interviews, and many of the traumas did not seem integrated in their personal narratives. The analyses further revealed that although participants often described complicated and traumatic childhood environments, they still felt supported by their families; they reported a range of ways in which they tried to cope with and gain control of their psychotic disorder, and they described a general optimistic view of the future.

Anomalous self-experiences and their relationship with symptoms, neuro-cognition, and functioning in at-risk adolescents and young adults

Empirical and theoretical studies support the notion that anomalous self-experience (ASE) may constitute a phenotypic aspect of vulnerability to schizophrenia, but there are no studies examining the relationship of ASE with other clinical risk factors in a sample of ultra-high risk (UHR) subjects. The aim of the present study was to explore the relationship between ASE, prodromal symptoms, neurocognition, and global functioning in a sample of 45 UHR adolescents and young adults (age range 15-25years) at first contact with Public Mental Health Services. Prodromal symptoms and global functioning were assessed through the SIPS interview. ASE was evaluated through the Examination of Anomalous Self-Experience (EASE); for neurocognition, we utilized a battery of tests examining seven cognitive domains as recommended by the Measurement And Treatment Research to Improve Cognition in Schizophrenia. In the UHR group, higher levels in two domains of the EASE (stream of consciousness and self-awareness) were found in comparison with help-seeking subjects. Correlational analysis corrected for possible confounding variables showed a strong association (p>0.001) between higher EASE scores and global functioning. A principal factor analysis with Varimax rotation yielded a two-factor solution, jointly accounting for 70.58% of the total variance in the UHR sample. The first factor was comprised of SOPS domains, while the second was comprised of EASE-total, EASE-10, and GAF variables. Our findings provide support for the notion that disorders of self-experience are present early in schizophrenia and are related to global functioning. As such, they may constitute a potential marker of risk supplementing the UHR approach.

Confirming mental health care in acute psychiatric wards, as narrated by persons experiencing psychotic illness: an interview study

Background

It is important that mental health nurses meet the safety, security and care needs of persons suffering from psychotic illness to enhance these persons’ likelihood of feeling better during their time in acute psychiatric wards. Certain persons in care describe nurses’ mental health care as positive, whereas others report negative experiences and express a desire for improvements. There is limited research on how persons with psychotic illness experience nurses’ mental health care acts and how such acts help these persons feel better. Therefore, the aim of this study was to explore, describe and understand how the mental health nurses in acute psychiatric wards provide care that helps persons who experienced psychotic illness to feel better, as narrated by these persons.

Method

This study had a qualitative design; 12 persons participated in qualitative interviews. The interviews were transcribed, content analysed and interpreted using Martin Buber’s concept of confirmation.

Results

The results of this study show three categories of confirming mental health care that describe what helped the participants to feel better step-by-step: first, being confirmed as a person experiencing psychotic illness in need of endurance; second, being confirmed as a person experiencing psychotic illness in need of decreased psychotic symptoms; and third, being confirmed as a person experiencing psychotic illness in need of support in daily life. The underlying meaning of the categories and of subcategories were interpreted and formulated as the theme; confirming mental health care to persons experiencing psychotic illness.

Conclusion

Confirming mental health care acts seem to help persons to feel better in a step-wise manner during psychotic illness. Nurses’ openness and sensitivity to the changing care needs of persons who suffer from psychotic illness create moments of confirmation within caring acts that concretely help the persons to feel better and that may enhance their health. The results show the importance of taking the experiential knowledge of persons who have experienced psychotic illness seriously to develop and increase the quality of mental health care in acute psychiatric wards.

Early psychosis research at Orygen, The National Centre of Excellence in Youth Mental Health

BACKGROUND

Specialised early intervention (SEI) programs have offered individuals with psychotic disorders and their families new hope for improving illness trajectories and outcomes. The Early Psychosis Prevention and Intervention Centre (EPPIC) was one of the first SEI programs developed in the world, providing services for young people experiencing their first episode of psychosis.

METHODS

We conducted a narrative synthesis of controlled and uncontrolled studies that have been conducted at EPPIC.

DISCUSSION

The history of the EPPIC model is first described. This is followed by a discussion of clinical research emerging from EPPIC, including psychopharmacological, psychotherapeutic trials and outcome studies. Neurobiological studies are also described. Issues pertaining to the conduct of clinical research and future research directions are then described. Finally, the impact of the EPPIC model on the Australian environment is discussed.

Essential components of early intervention programs for psychosis: Available intervention services in the United States

Programs providing interventions for early psychosis are becoming commonplace in the United States (U.S.); however, the characteristics of existing services remain undocumented. We examined program characteristics, clinical services, and program eligibility criteria for outpatient early intervention programs across the U.S. using a semi-structured telephone interview. Content analysis was used to identify the presence or absence of program components, based in part on a recent list of essential evidence-based components recommended for early intervention programs (Addington, MacKenzie, Norman, Wang and Bond, 2013) as well as program characteristics, including eligibility criteria. A total of 34 eligible programs were identified; 31 (91.2%) program representatives agreed to be interviewed. Of the examined components, the most prevalent were individual psychoeducation and outcomes tracking; the least prevalent were outreach services and communication with inpatient units. The populations served by US programs were most frequently defined by restrictions on the duration of psychosis and age. This study provides critical feedback on services for the early psychosis population and identifies research to practice gaps and areas for future improvement.

Employment and educational outcomes in early intervention programmes for early psychosis: a systematic review

AIMS

Young adults with early psychosis want to pursue normal roles - education and employment. This paper summarises the empirical literature on the effectiveness of early intervention programmes for employment and education outcomes.

METHODS

We conducted a systematic review of employment/education outcomes for early intervention programmes, distinguishing three programme types: (1) those providing supported employment, (2) those providing unspecified vocational services and (3) those without vocational services. We summarised findings for 28 studies.

RESULTS

Eleven studies evaluated early intervention programmes providing supported employment. In eight studies that reported employment outcomes separately from education outcomes, the employment rate during follow-up for supported employment patients was 49%, compared with 29% for patients receiving usual services. The two groups did not differ on enrolment in education. In four controlled studies, meta-analysis showed that the employment rate for supported employment participants was significantly higher than for control participants, odds ratio = 3.66 [1.93-6.93], p < 0.0001. Five studies (four descriptive and one quasi-experimental) of early intervention programmes evaluating unspecified vocational services were inconclusive. Twelve studies of early intervention programmes without vocational services were methodologically heterogeneous, using diverse methods for evaluating vocational/educational outcomes and precluding a satisfactory meta-analytic synthesis. Among studies with comparison groups, 7 of 11 (64%) reported significant vocational/education outcomes favouring early intervention over usual services.

CONCLUSIONS

In early intervention programmes, supported employment moderately increases employment rates but not rates of enrolment in education. These improvements are in addition to the modest effects early programmes alone have on vocational/educational outcomes compared with usual services.

Epidemiology on demand: population-based approaches to mental health service commissioning

One in three people will experience a mental health problem in their lifetime, but the causes and consequences of psychiatric morbidity are socially patterned. Epidemiological studies can provide aetiological clues about the causes of disorder, and when they can provide robust estimates about risk in different strata of the population these can also be used translationally, to provide commissioners and service planners with detailed information about local service need. This approach is illustrated using a newly developed population-level prediction tool for first-episode psychosis, PsyMaptic. Such public mental health prediction tools could be used to improve allocation of finite resources, by integrating evidence-based healthcare, public health and epidemiology together.

Psychosis Prevention: A Modified Clinical High Risk Perspective From the Recognition and Prevention (RAP) Program

OBJECTIVE

Early intervention and prevention of psychosis remain a major challenge. Prediction would be greatly advanced with improved ability to identify individuals at true risk, which, at present, is moderate at best. The authors tested a modified strategy to improve prediction by selecting a more homogeneous high-risk sample (attenuated positive symptom criteria only, age range of mid-teens to early 20s) than is currently standard, combined with a systematic selection of neurodevelopmental deficits.

METHOD

A sample of 101 treatment-seeking adolescents (mean age, 15.9 years) at clinical high risk for psychosis were followed clinically for up to 5 years (mean follow-up time, 3.0 years, SD=1.6). Adolescents were included only if they exhibited one or more attenuated positive symptoms at moderate to severe, but not psychotic, severity levels. Cox regression was used to derive a risk index.

RESULTS

The overall conversion rate to psychosis was 28.3%. The final predictor model, with a positive predictive validity of 81.8%, consisted of four variables: disorganized communication, suspiciousness, verbal memory deficits, and decline in social functioning during follow-up. Significant effects also suggest narrowing the risk age range to 15-22 years.

CONCLUSIONS

Clinical high risk criteria that emphasize disorganized communication and suspiciousness while also including compromised verbal memory and declining social functioning have the potential to improve predictive accuracy compared with attenuated positive symptoms used alone. On the resulting risk index (a weighted combination of the predictors), low scores were interpreted as signifying minimal risk, with little treatment necessary, high scores as suggesting aggressive intervention, and intermediate scores, although less informative, as supporting psychosocial treatment.

Use of the Theory of Planned Behaviour to assess factors influencing the identification of students at clinical high-risk for psychosis in 16+ Education

BACKGROUND

The longer psychotic disorders are untreated the worse their prognosis. Increasing the awareness of early psychosis by professionals who come into regular contact with young people is one strategy that could reduce treatment delay. As teachers engage with students on a daily basis, their role could be exploited to increase awareness of the early signs of psychosis. This study employed the Theory of Planned Behaviour (TPB) to identify and measure factors that influence identification of students at high-risk (HR) of developing psychosis in 16+ educational institutions.

METHODS

An elicitation phase revealed beliefs underlying teachers' motivations to detect HR students and informed the construction of a preliminary 114-item questionnaire incorporating all constructs outlined in the TPB. To define the determinants of teachers' intention to identify HR students, 75 teachers from secondary and further education institutions in 12 counties surrounding Cambridgeshire completed the questionnaire. A psychometric model of item response theory was used to identify redundant items and produce a reduced questionnaire that would be acceptable to teachers.

RESULTS

The final instrument comprised 73 items and showed acceptable reliability (α  = 0.69-0.81) for all direct measures. Teacher's confidence and control over identification of HR students was low. Although identification of HR students was considered worthwhile, teachers believed that their peers, students and particularly their managers might not approve. Path analysis revealed that direct measures of attitude and PBC significantly predicted intention, but subjective norm did not. PBC was the strongest predictor of intention. Collectively, the direct measures explained 37 % of the variance of intention to identify HR for psychosis.

CONCLUSIONS

This research demonstrated how the TPB can be used to identify and measure factors that influence identification of students at HR of developing psychosis in 16+ educational institutions and confirmed the feasibility, reliability and acceptability of a TPB-based questionnaire for teachers. Consideration of the key determinants of identification in schools will facilitate the design of successful educational intervention strategies with the potential to reduce treatment delays for HR students.

Variability of structurally constrained and unconstrained functional connectivity in schizophrenia

Spatial variation in connectivity is an integral aspect of the brain's architecture. In the absence of this variability, the brain may act as a single homogenous entity without regional specialization. In this study, we investigate the variability in functional links categorized on the basis of the presence of direct structural paths (primary) or indirect paths mediated by one (secondary) or more (tertiary) brain regions ascertained by diffusion tensor imaging. We quantified the variability in functional connectivity using an unbiased estimate of unpredictability (functional connectivity entropy) in a neuropsychiatric disorder where structure‐function relationship is considered to be abnormal; 34 patients with schizophrenia and 32 healthy controls underwent DTI and resting state functional MRI scans. Less than one‐third (27.4% in patients, 27.85% in controls) of functional links between brain regions were regarded as direct primary links on the basis of DTI tractography, while the rest were secondary or tertiary. The most significant changes in the distribution of functional connectivity in schizophrenia occur in indirect tertiary paths with no direct axonal linkage in both early (P = 0.0002, d = 1.46) and late (P = 1 × 10⁻¹⁷, d = 4.66) stages of schizophrenia, and are not altered by the severity of symptoms, suggesting that this is an invariant feature of this illness. Unlike those with early stage illness, patients with chronic illness show some additional reduction in the distribution of connectivity among functional links that have direct structural paths (P = 0.08, d = 0.44). Our findings address a critical gap in the literature linking structure and function in schizophrenia, and demonstrate for the first time that the abnormal state of functional connectivity preferentially affects structurally unconstrained links in schizophrenia. It also raises the question of a continuum of dysconnectivity ranging from less direct (structurally unconstrained) to more direct (structurally constrained) brain pathways underlying the progressive clinical staging and persistence of schizophrenia. Hum Brain Mapp 36:4529–4538, 2015. © 2015 The Authors. Human Brain Mapping Published by Wiley Periodicals, Inc.

Service Engagement in First-Episode Psychosis: Current Issues and Future Directions

It has been reported that up to 50% of patients receiving mental health services disengage from treatment, with adolescents and young adults being particularly at high risk. Even in the context of specialized services in youth mental health, such as early intervention programs for psychosis, disengagement rates remain high. There is a need for extensive and innovative efforts to address the issue of service disengagement in first-episode psychosis (FEP). A multi-dimensional understanding of the phenomenon of engagement can help to inform the development of strategies to address this important clinical issue. In our paper, we propose a conceptual framework for understanding service engagement, provide an overview of the issues pertaining to service engagement in FEP, and suggest future directions for research and practice.

Treatment response, safety, and tolerability of paliperidone extended release treatment in patients recently diagnosed with schizophrenia

OBJECTIVE

This study was designed to explore the efficacy and tolerability of oral paliperidone extended release (ER) in a sample of patients who were switched to flexible doses within the crucial first 5 years after receiving a diagnosis of schizophrenia.

METHODS

Patients were recruited from 23 countries. Adults with nonacute but symptomatic schizophrenia, previously unsuccessfully treated with other oral antipsychotics, were transitioned to paliperidone ER (3-12 mg/day) and prospectively treated for up to 6 months. The primary efficacy outcome for patients switching for the main reason of lack of efficacy with their previous antipsychotic was at least 20% improvement in Positive and Negative Syndrome Scale (PANSS) total scores. For patients switching for other main reasons, such as lack of tolerability, compliance or 'other', the primary outcome was non-inferiority in efficacy compared with the previous oral antipsychotic.

RESULTS

For patients switching for the main reason of lack of efficacy, 63.1% achieved an improvement of at least 20% in PANSS total scores from baseline to endpoint. For each reason for switching other than lack of efficacy, efficacy maintenance after switching to paliperidone ER was confirmed. Statistically significant improvement in patient functioning from baseline to endpoint, as assessed by the Personal and Social Performance scale, was observed (p < 0.0001). Treatment satisfaction with prior antipsychotic treatment at baseline was rated 'good' to 'very good' by 16.8% of patients, and at endpoint by 66.0% of patients treated with paliperidone ER. Paliperidone ER was generally well tolerated, with frequently reported treatment-emergent adverse events being insomnia, anxiety and somnolence.

CONCLUSIONS

Flexibly dosed paliperidone ER was associated with clinically relevant symptomatic and functional improvement in recently diagnosed patients with non-acute schizophrenia previously unsuccessfully treated with other oral antipsychotics.

Perinatal Risks and Childhood Premorbid Indicators of Later Psychosis: Next Steps for Early Psychosocial Interventions

Schizophrenia and affective psychoses are debilitating disorders that together affect 2%-3% of the adult population. Approximately 50%-70% of the offspring of parents with schizophrenia manifest a range of observable difficulties including socioemotional, cognitive, neuromotor, speech-language problems, and psychopathology, and roughly 10% will develop psychosis. Despite the voluminous work on premorbid vulnerabilities to psychosis, especially on schizophrenia, the work on premorbid intervention approaches is scarce. While later interventions during the clinical high-risk (CHR) phase of psychosis, characterized primarily by attenuated positive symptoms, are promising, the CHR period is a relatively late phase of developmental derailment. This article reviews and proposes potential targets for psychosocial interventions during the premorbid period, complementing biological interventions described by others in this Special Theme issue. Beginning with pregnancy, parents with psychoses may benefit from enhanced prenatal care, social support, parenting skills, reduction of symptoms, and programs that are family-centered. For children at risk, we propose preemptive early intervention and cognitive remediation. Empirical research is needed to evaluate these interventions for parents and determine whether interventions for parents and children positively influence the developmental course of the offspring.

New Targets for Prevention of Schizophrenia: Is It Time for Interventions in the Premorbid Phase?

A number of influences have converged that make this Special Theme Issue timely: "A New Direction: Considering Developmentally Sensitive Targets for Very Early Intervention in Schizophrenia". These factors include: 1. the substantial knowledge about premorbid developmental vulnerabilities to psychosis, especially regarding schizophrenia; 2. the promising results emerging from interventions during the clinical high-risk (CHR) phase of psychosis and; 3. the recognition that the CHR period is a relatively late phase of developmental derailment. These factors have together led to a perspective that even earlier intervention is warranted. This paper briefly summarizes the articles comprising the Special Theme including new data on early neurocognitive development, proposed potential targets for psychosocial and psychopharmacological interventions during the premorbid period as early as pregnancy, and ethical challenges. These thought experiments must be empirically tested, and the ethical challenges overcome as posed by the various interventions, which range from relatively low risk, supportive, psychosocial to higher risk, experimental, pharmacological interventions. All of the interventions proposed require careful study of ethics, safety, potential stigma, feasibility, efficacy and tolerability, and the meaning to the people involved.

Metacognition in Early Phase Psychosis: Toward Understanding Neural Substrates

Individuals in the early phases of psychotic illness have disturbed metacognitive capacity, which has been linked to a number of poor outcomes. Little is known, however, about the neural systems associated with metacognition in this population. The purpose of this study was to elucidate the neuroanatomical correlates of metacognition. We anticipated that higher levels of metacognition may be dependent upon gray matter density (GMD) of regions within the prefrontal cortex. Examining whole-brain structure in 25 individuals with early phase psychosis, we found positive correlations between increased medial prefrontal cortex and ventral striatum GMD and higher metacognition. These findings represent an important step in understanding the path through which the biological correlates of psychotic illness may culminate into poor metacognition and, ultimately, disrupted functioning. Such a path will serve to validate and promote metacognition as a viable treatment target in early phase psychosis.

New developments in diagnosis and treatment update: Schizophrenia/first episode psychosis in children and adolescents

Childhood onset schizophrenia (COS) is diagnosed before the age of 13 years, and early onset schizophrenia (EOS) is diagnosed before the age of 18 years. EOS is considered extremely rare and its prevalence in comparison to the worldwide prevalence of schizophrenia (1%) has not adequately been studied. Patients who experience the first episode of psychosis need to be treated early and optimally to lessen the morbidity and improve the outcome of the illness. Treatment needs to be a combination of both pharmacological and non-pharmacological modalities. Pharmacological intervention is necessary for remission, improvement of positive symptoms and to aid with the efficacy of psychosocial interventions. There is a lack of efficacy and safety data of the use of antipsychotic medication in children, with most of the information available being extrapolations of adult data. An increased use of atypical antipsychotic drugs in the treatment of EOS has been accompanied by growing concern about the appropriate use and associated side effects in children and adolescents. This update highlights new developments, concepts and treatment trends in EOS.

Early intervention in psychosis: obvious, effective, overdue

Early intervention for potentially serious disorder is a fundamental feature of healthcare across the spectrum of physical illness. It has been a major factor in the reductions in morbidity and mortality that have been achieved in some of the non-communicable diseases, notably cancer and cardiovascular disease. Over the past two decades, an international collaborative effort has been mounted to build the evidence and the capacity for early intervention in the psychotic disorders, notably schizophrenia, where for so long deep pessimism had reigned. The origins and rapid development of early intervention in psychosis are described from a personal and Australian perspective. This uniquely evidence-informed, evidence-building and cost-effective reform provides a blueprint and launch pad to radically change the wider landscape of mental health care and dissolve many of the barriers that have constrained progress for so long.

Setting measurable goals with young people: Qualitative feedback from the Goal Attainment Scale in youth mental health

Introduction

Measuring occupational performance is an essential part of clinical practice; however, there is little research on service user perceptions of measures. The aim of this investigation was to explore the acceptability and utility of one occupational performance outcome measure, Goal Attainment Scaling, with young people (12–25 years old) seeking psychological help.

Method

Semi-structured interviews were conducted with ten young people seeking help from a youth mental health clinic. Interviews were audio taped and a field diary kept. Interviews were transcribed verbatim and analysed using content analysis. Results were verified by member checking.

Results

All participants were able to engage in using Goal Attainment Scaling to set goals for therapy, and reported the process to be useful. The participants identified the physical location and ownership of the scale was important to help motivate them to work on their goals.

Conclusion

Young help-seekers see Goal Attainment Scaling as an acceptable tool to facilitate the establishment of functional goals. Young service users were particularly keen to maintain control over the physical location of completed forms.

Body mass, cardiovascular risk and metabolic characteristics of young persons presenting for mental healthcare in Sydney, Australia

OBJECTIVES

To determine the body mass, cardiovascular and metabolic characteristics of young people presenting for mental healthcare.

DESIGN

Cross-sectional assessments of body mass, cardiovascular and metabolic risk factors.

SETTING

Two primary-care based sites in Sydney, Australia for young people in the early stages of mental disorders.

PARTICIPANTS

A clinical sample of young people (12-30 years) with mental health problems.

OUTCOME MEASURES

Daily smoking rates, body mass index (BMI), blood glucose and lipids, blood pressure (BP) and pulse rate.

RESULTS

Of 1005 young people who had their BMI determined (62% female; 19.0±3.5 years), three quarters (739/1005) also had BP recordings and one-third (298/1005) had blood sampling. Clinically, 775 were assigned to one of three diagnostic categories (anxious-depression: n=541; mania-fatigue, n=104; developmental-psychotic n=130). The profile of BMI categories approximated that of the comparable segments of the Australian population. Older age, lower levels of social functioning and higher systolic BP were all associated with high BMI. In a subset (n=129), current use of any psychotropic medication was associated (p<0.05) with increased BMI. Almost one-third of cases were current daily smokers (compared to population rate of 11%). Males had a higher proportion of raised glucose and high-density lipoprotein (HDL) compared to females (9.3% and 34.1% vs 2.1% and 5.9%, respectively). Overall, there was no relationship between BMI and fasting glucose but significant relationships with triglycerides and HDL were noted. Furthermore, there were no significant relationships between diagnostic subgroup and metabolic profiles.

CONCLUSIONS

Daily smoking rates are increased among young people presenting for mental healthcare. However, these young people do not demonstrate adverse cardiometabolic profiles. The high levels of smoking, and association of BMI with adverse social circumstances, suggest that risk factors for chronic disease are already present and likely to be compounded by medication and social disadvantage.

Developing psychosis and its risk states through the lens of schizotypy

Starting from the early descriptions of Kraepelin and Bleuler, the construct of schizotypy was developed from observations of aberrations in nonpsychotic family members of schizophrenia patients. In contemporary diagnostic manuals, the positive symptoms of schizotypal personality disorder were included in the ultra high-risk (UHR) criteria 20 years ago, and nowadays are broadly employed in clinical early detection of psychosis. The schizotypy construct, now dissociated from strict familial risk, also informed research on the liability to develop any psychotic disorder, and in particular schizophrenia-spectrum disorders, even outside clinical settings. Against the historical background of schizotypy it is surprising that evidence from longitudinal studies linking schizotypy, UHR, and conversion to psychosis has only recently emerged; and it still remains unclear how schizotypy may be positioned in high-risk research. Following a comprehensive literature search, we review 18 prospective studies on 15 samples examining the evidence for a link between trait schizotypy and conversion to psychosis in 4 different types of samples: general population, clinical risk samples according to UHR and/or basic symptom criteria, genetic (familial) risk, and clinical samples at-risk for a nonpsychotic schizophrenia-spectrum diagnosis. These prospective studies underline the value of schizotypy in high-risk research, but also point to the lack of evidence needed to better define the position of the construct of schizotypy within a developmental psychopathology perspective of emerging psychosis and schizophrenia-spectrum disorders.

A five-year randomized parallel and blinded clinical trial of an extended specialized early intervention vs. regular care in the early phase of psychotic disorders: study protocol

BACKGROUND

Specialized Early Intervention services (SEI) for first episode psychosis are shown to be effective for the treatment of positive and negative symptoms, medication adherence, rates of relapse, substance abuse disorders, functional outcome and quality of life at two-year treatment follow up. However, it is also reported that these benefits are not maintained when SEI is not sustained. The objective of this trial is to test the efficacy of a 3-year extension of a SEI service (following 2 years of SEI prior to randomization) for the maintenance and consolidation of therapeutic gains as compared to regular care in the community.

METHODS

Following an initial 2 years of SEI, patients are randomized to receive either 3-years of continued SEI or regular care. SEI provided at three sites within the McGill network of SEI services, using a model of treatment comprised of: modified assertive case management; psycho education for families; multiple family intervention; cognitive behavioural therapy; and substance abuse treatment and monitoring. Blinded research assistants conduct ongoing evaluation of the outcome variables every three months. The primary outcome measure is remission status measured both as the proportion of patients in complete remission and the mean length of remission achieved following randomization during the additional three years of follow up. Based on preliminary data, it is determined that a total of 212 patients are needed to achieve adequate statistical power. Intent to treat with the last observation carried forward will be the primary method of statistical analysis.

DISCUSSION

The "critical period" hypothesis posits that there is a five year window during which the effects of the nascent psychotic illness can be countered and the impact of the disorder on symptomatic and functional outcomes can be offset through active and sustained treatment. Providing SEI throughout this critical period may solidify the benefits of treatment such that gains may be more sustainable over time as compared to intervention delivered for a shorter period. Findings from this study will have implications for service provision in first episode psychosis.

TRIAL REGISTRATION

ISRCTN11889976.

What is the current status of training and practice of early intervention in psychiatry? Results from a survey in 35 countries

AIM

To assess: (i) trainees' educational needs on early intervention in psychiatry; (ii) their satisfaction and competence in early detection and management of patients with severe mental disorders; (iii) characteristics of training on prevention and on early intervention in psychiatry; and (iv) organizational and clinical differences of early intervention programmes and services in different countries.

METHODS

Sixty early career psychiatrists, recruited from the early career psychiatrists' network of the World Psychiatric Association, were invited to participate in the survey. Respondents were asked to provide the collective input of their trainees' association rather than that of any individual officer or member. An online survey was conducted using an ad hoc questionnaire consisting of 18 items.

RESULTS

Thirty-five countries sent back the questionnaire (58.3%). University training in early intervention for mental disorders was provided in 13 countries (38%); 54% of respondents were not satisfied with received training and about half of them did not feel enough confident to provide specialistic interventions to patients at the onset of the disorder. Services for early intervention existed in 22 countries (63%). The most frequently available were those for schizophrenia (75%). Informative campaigns on mental disorders were usually carried out in almost all surveyed countries (85%).

CONCLUSIONS

Although prevention and early intervention represent one of the current paradigms of psychiatric practice and research, efforts are still needed in order to improve training programmes at university sites.

Association between Unmet Needs and Clinical Status in Patients with First Episode of Schizophrenia in Chile

BACKGROUND

Schizophrenia is a severe mental disorder involving needs in several matters that are often not covered. A need is defined as a gap between the ideal state and the current state of a patient about a specific topic.

AIM

To describe needs in patients with first episode of schizophrenia at the start of treatment and to describe associated clinical factors.

METHODS

Observational descriptive cross-sectional design. Patients were over 15 years old, with first episode schizophrenia, and admitted to treatment in the public health system from six districts in two cities of Chile, between 2005 and 2006. Sociodemographic data, clinical evaluations of current psychosis based on the Positive and Negative Syndrome Scale (PANSS), and the time of untreated psychosis were obtained. A clinical interview was carried out followed by the Camberwell Assessment of Need.

RESULTS

Twenty-nine patients were evaluated, 79.3% male, mean age 21.9 years old. The areas with more needs reported were; psychotic symptoms with 65.5% of sample, 21.1% of which reported it unmet; and daytime activities, where 44.8% of patients reported a need, 61.54% of them as unmet. The percentage of unmet needs correlated with PANSS score (r = 0.55; p = 0.003), and with time of positive symptoms prior to diagnosis (r = 0.416; p = 0.03).

DISCUSSION

Needs assessment in schizophrenia is necessary. It may affect its clinical course, be relevant in its management, and help monitor recovery. Defining the main needs in people with first episode schizophrenia and associated factors allows for a better design of treatment strategies in order to obtain better therapeutic results and recovery.

Self-Disorders: Clinical and Conceptual Implications for the Diagnostic Concept of Schizophrenia

The release of DSM-5 and the preparations for the launch of the ICD-11 provoked a series of critiques of psychiatric classification, which continues to depend largely on clinical description. Among the immediate problems are those of arbitrary diagnostic thresholds, tendency to reification, rigid category boundaries, comorbidity, diagnostic 'epidemics' and differential diagnostic dilemmas. We argue that many of those problems stem from the polythetic-operational definitions of psychiatric categories, which thereby come to lack an organizing prototype-directed or gestaltic intelligibility principle. We illustrate these issues by briefly examining the current operational diagnosis of schizophrenia, its demarcation from affective illness and the status of the spectrum concept and the prodrome of schizophrenia. We point out that European research on schizophrenia always allocated an important diagnostic weight to a certain prototypical trait core of the illness, phenomenologically indispensable for its demarcation from other, nonschizophrenic psychotic conditions. We believe that the notion of self-disorder (reflective of the structural alterations of subjectivity), itemized into its various aspects in the Examination of Anomalous Self-Experience scale, is an important step forward in a more precise psychopathological articulation of that core, strengthening its clinical and research utility.

Intensive case management for high-risk patients with first-episode psychosis: service model and outcomes

BACKGROUND

The first episode of psychosis is a crucial period when early intervention can alter the trajectory of the young person's ongoing mental health and general functioning. After an investigation into completed suicides in the Early Psychosis Prevention and Intervention Centre (EPPIC) programme, the intensive case management subprogramme was developed in 2003 to provide assertive outreach to young people having a first episode of psychosis who are at high risk owing to risk to self or others, disengagement, or suboptimal recovery. We report intensive case management model development, characterise the target cohort, and report on outcomes compared with EPPIC treatment as usual.

METHODS

Inclusion criteria, staff support, referral pathways, clinical review processes, models of engagement and care, and risk management protocols are described. We compared 120 consecutive referrals with 50 EPPIC treatment as usual patients (age 15-24 years) in a naturalistic stratified quasi-experimental real-world design. Key performance indicators of service use plus engagement and suicide attempts were compared between EPPIC treatment as usual and intensive case management, and psychosocial and clinical measures were compared between intensive case management referral and discharge.

FINDINGS

Referrals were predominately unemployed males with low levels of functioning and educational attainment. They were characterised by a family history of mental illness, migration and early separation, with substantial trauma, history of violence, and forensic attention. Intensive case management improved psychopathology and psychosocial outcomes in high-risk patients and reduced risk ratings, admissions, bed days, and crisis contacts.

INTERPRETATION

Characterisation of intensive case management patients validated the clinical research focus and identified a first episode of psychosis high-risk subgroup. In a real-world study, implementation of an intensive case management stream within a well-established first episode of psychosis service showed significant improvement in key service outcomes. Further analysis is needed to determine cost savings and effects on psychosocial outcomes. Targeting intensive case management services to high-risk patients with unmet needs should reduce the distress associated with pathways to care for patients, their families, and the community.

FUNDING

National Health & Medical Research Council and the Colonial Foundation.

Development and evaluation of an educational intervention in youth mental health for primary care practitioners

OBJECTIVES

Irish adolescents have one of the highest rates of suicide and self-harm in the European Union. Although primary care has been identified as an opportune environment in which to detect and treat mental health problems in adolescents, lack of training among primary care professionals (PCPs) is a barrier to optimum identification and treatment. We describe the development and evaluation of an educational intervention on youth mental health and substance misuse for PCPs.

METHODS

Thirty general practitioners and other PCPs working in the Mid-West region participated in an educational session on youth-friendly consultations, and identification and treatment of mental ill-health and substance use. Learning objectives were addressed through a presentation, video demonstration, small group discussions, role play, question-and-answer sessions with clinical experts, and an information pack. Following the session, participants completed an evaluation form assessing knowledge gain and usefulness of different components of the session.

RESULTS

A total of 71% of participants were involved in the provision of care to young people and 55% had no previous training in youth mental health or substance abuse. Participants rated knowledge gains as highest with regard to understanding the importance of early intervention, and primary care, in youth mental health. The components rated as most useful were case studies/small group discussion, the 'question-and-answer session' with clinical experts, and peer interaction.

CONCLUSIONS

The educational session outlined in this pilot was feasible and acceptable and may represent an effective way to train professionals to help tackle the current crisis in youth mental health.

Towards a better understanding of caregiver distress in early psychosis: a systematic review of the psychological factors involved

OBJECTIVES

We sought to review empirical studies of psychological factors accounting for distress in caregivers of young people with early psychosis.

METHOD

Following the PRISMA guidelines, we included studies that empirically tested psychological models of caregiver distress in early psychosis by searching the following databases up until March 2014: PsycINFO, EMBASE and Cochrane Central Register of Controlled Trials (CENTRAL). This was followed by additional manual searches of reference lists and relevant journals.

RESULTS

The search identified 15 papers describing 13 studies together comprising 1056 caregivers of persons with early psychosis. The mean age of caregivers was 47.2years (SD=9.8), of whom 71.5% were female and 74.4% were parents. Nine different psychological variables were examined in the included studies, which were categorised in the following non-mutually exclusive groups: coping, appraisal/attribution and interpersonal response. There was considerable data to support the link between distress and psychological factors such as avoidant coping, appraisal and emotional over-involvement. However, the possibilities of drawing conclusions were limited by a number of methodological issues, including cross-sectional data, small sample sizes, confounding variables not being accounted for, and a wide variation in outcome measures.

DISCUSSION

The strengths of the review were the systematic approach, the exclusion of non-empirical papers and the rating of methodological quality by two independent raters. Limitations were that we excluded studies published in languages other than English, that data extraction forms were developed for this study and hence not tested for validity, and that there was a potential publication bias in favour of significant findings.

CONCLUSION AND IMPLICATIONS

A better grasp of the psychological factors accounting for caregiver distress early in the course of illness may help us understand the trajectory of distress. This is an important step in preventing long-term distress in caregivers and supporting recovery in the whole family.

Being in a process of transition to psychosis, as narrated by adults with psychotic illnesses acutely admitted to hospital

To assist in improving early interventions for psychosis, this study explored how adult people narrated their experience of becoming psychotic, and how contact with mental health personnel was established. Narrative interviews were conducted with 12 participants with psychotic illnesses recruited from acute psychiatric wards. The interviews were content analysed. Participants described being in a process of transition to psychosis as follows: experiencing changes as well-known signs of psychosis, experiencing sudden unexpected changes as signs of psychosis and experiencing unidentified changes as signs of illness. Our results show that participants and their close others who knew the signs of psychosis established a dialogue with mental health personnel and were better equipped to prevent and mitigate the psychosis. Our results demonstrate that participants who did not perceive the signs of psychosis and did not have other people to advocate for them were at risk for delayed treatment, poor communication and coercive interventions. Furthermore, participants who did not know the signs of psychosis perceived these changes as deterioration in their health and awareness of illness. We suggest that participants' experiential knowledge of transitioning to psychosis and an awareness of illness can be used to improve the communication during interventions for psychosis.

Effects of multidimensional treatment foster care on psychotic symptoms in girls

OBJECTIVE

Neurodevelopmental theories of psychosis highlight the potential benefits of early intervention, prevention, and/or preemption. How early intervention should take place has not been established, nor whether interventions based on social learning principles can have preemptive effects. The objective was to test whether a comprehensive psychosocial intervention can significantly alter psychotic symptom trajectories during adolescence-a period of heightened risk for a wide range of psychopathology.

METHOD

This study was a randomized controlled trial (RCT) of Multidimensional Treatment Foster Care (MTFC) for delinquent adolescent girls. Assessment of psychotic symptoms took place at baseline and then 6, 12, 18, and 24 months post-baseline using a standardized self-report instrument (Brief Symptom Inventory). A second source of information about psychotic symptoms was obtained at baseline or 12 months, and again at 24 months using a structured diagnostic interview (the Diagnostic Interview Schedule for Children [DISC]).

RESULTS

Significant benefits for MTFC over treatment as usual for psychosis symptoms were observed over a 24-month period. Findings were replicated across both measures. Effects were independent of substance use and initial symptom severity and persisted beyond the initial intervention period.

CONCLUSION

Ameliorating nonclinical psychotic symptoms trajectories beginning in mid-adolescence via a multifaceted psychosocial intervention is possible. Developmental research on nonclinical psychotic symptoms and their prognostic value should be complemented by more psychosocial intervention research aimed at modifying these symptom trajectories early in their natural history. Clinical trial registration information-Juvenile Justice Girls Randomized Control Trial: Young Adult Follow-up; http://clinicaltrials.gov; NCT01341626.

Staging systems in bipolar disorder: an International Society for Bipolar Disorders Task Force Report

OBJECTIVE

We discuss the rationale behind staging systems described specifically for bipolar disorders. Current applications, future directions and research gaps in clinical staging models for bipolar disorders are outlined.

METHOD

We reviewed the literature pertaining to bipolar disorders, focusing on the first episode onwards. We systematically searched data on staging models for bipolar disorders and allied studies that could inform the concept of staging.

RESULTS

We report on several dimensions that are relevant to staging concepts in bipolar disorder. We consider whether staging offers a refinement to current diagnoses by reviewing clinical studies of treatment and functioning and the potential utility of neurocognitive, neuroimaging and peripheral biomarkers.

CONCLUSION

Most studies to date indicate that globally defined late-stage patients have a worse overall prognosis and poorer response to standard treatment, consistent with patterns for end-stage medical disorders. We believe it is possible at this juncture to speak broadly of 'early'- and 'late'-stage bipolar disorder. Next steps require further collaborative efforts to consider the details of preillness onset and intermediary stages, and how many additional stages are optimal.

Early Recognition of High Risk of Bipolar Disorder and Psychosis: An Overview of the ZInEP "Early Recognition" Study

Early detection of persons with first signs of emerging psychosis is regarded as a promising strategy to reduce the burden of the disease. In recent years, there has been increasing interest in early detection of psychosis and bipolar disorders, with a clear need for sufficient sample sizes in prospective research. The underlying brain network disturbances in individuals at risk or with a prodrome are complex and yet not well known. This paper provides the rationale and design of a prospective longitudinal study focused on at-risk states of psychosis and bipolar disorder. The study is carried out within the context of the Zurich Program for Sustainable Development of Mental Health services (Zürcher Impulsprogramm zur Nachhaltigen Entwicklung der Psychiatrie). Persons at risk for psychosis or bipolar disorder between 13 and 35 years of age are examined by using a multi-level-approach (psychopathology, neuropsychology, genetics, electrophysiology, sociophysiology, magnetic resonance imaging, near-infrared spectroscopy). The included adolescents and young adults have four follow-ups at 6, 12, 24, and 36 months. This approach provides data for a better understanding of the relevant mechanisms involved in the onset of psychosis and bipolar disorder, which can serve as targets for future interventions. But for daily clinical practice a practicable “early recognition” approach is required. The results of this study will be useful to identify the strongest predictors and to delineate a prediction model.

Longitudinal Youth-At-Risk Study (LYRIKS): outreach strategies based on a community-engaged framework

Schizophrenia and psychoses are debilitating disorders often leading to serious functional impairments. Early detection efforts have shifted focus to the prodromal phase and the emphasis is now on individuals at risk of developing psychosis.

AIM

The Longitudinal Youth-At-Risk Study (LYRIKS) seeks to elucidate the biological markers of psychosis. This paper describes the application of a community-engaged framework to the outreach strategies of LYRIKS. It describes the outreach goals, strategies used and their impact, as well as the various challenges faced by the research team and community partners.

METHODS

The target population was defined. Community organizations having close ties with the target population were identified and approached for collaboration. These included educational and healthcare institutions, and government and welfare organizations. Strategies were categorized as active or passive. Active strategies included clinical screening and recruitment, workshops, roadshows and student internships. Passive strategies included utilizing print and social media.

RESULTS

Three thousand three hundred twenty-one youth were approached and 401 called the hotline to find out more about the study. Three thousand five hundred one were pre-screened; 864 were further screened using the Comprehensive Assessment of At Risk Mental State. One hundred seventy-eight and 346 were eventually recruited as subjects and controls, respectively.

CONCLUSIONS

Challenges encountered included differing priorities, maintaining collaborative relationships, stigmatization and inadequate understanding of the profile of at risk youth. Future community-engaged research should be conducted more comprehensively to generate maximum benefits.

Changes in aspects of cognitive functioning in young patients with schizophrenia during group psychodynamic psychotherapy: a preliminary study

BACKGROUND

The "Sveti Ivan" psychiatric hospital in Zagreb, Croatia, offers an outpatient Early Intervention Program for psychotic patients. This program consists of psycho-educational workshops and group psychodynamic psychotherapy. Two important objectives of the program are improving and maintaining adequate cognitive functioning.

AIMS

The current study examined changes in aspects of cognitive functioning in young patients with schizophrenia after 18 months and after 3 years of psychodynamic group psychotherapy.

METHODS

The study included 28 patients who attended the Early Intervention Program for young patients with psychotic disorders; 10 patients had completed only the psycho-educational part of the program (comparative group), and 18 patients continued with group psychodynamic psychotherapy (experimental group). All patients completed the Revised Beta Examination.

RESULTS

We observed a trend in the experimental group to achieve higher scores than the comparative group. The results for both groups tended to increase with time, and this increase was greater in the experimental group.

CONCLUSIONS

While acknowledging the limitations of this preliminary study, we conclude that participating in psychodynamic group psychotherapy is related to increases in the cognitive functioning of patients with schizophrenia, and our results provide a sound basis for future research.

N-acetylcysteine prevents increased amphetamine sensitivity in social isolation-reared mice

Treating individuals at risk to develop schizophrenia may be strategic to delay or prevent transition to psychosis. We verified the effects of N-acetylcysteine (NAC) in a neurodevelopmental model of schizophrenia. C57 mice were reared in isolation or social groups and treated with NAC from postnatal day 42-70; the locomotor response to amphetamine was assessed at postnatal day 81. NAC treatment in isolated mice prevented the hypersensitivity to amphetamine, suggesting neuroprotection relevant to striatal dopamine. Considering its safety and tolerability profile, complementary studies are warranted to further evaluate the usefulness of NAC to prevent conversion to schizophrenia in at-risk individuals.

Antecedents of manic versus other first psychotic episodes in 263 bipolar I disorder patients

OBJECTIVE

As initial episode type can predict later morbidity in bipolar disorder, we tested the hypothesis that clinical antecedents might predict initial episode types.

METHOD

We studied 263 first-episode, adult, DSM-IV-TR type I bipolar disorder (BD-I) subjects within the McLean-Harvard-International First-Episode Project. Based on blinded assessments of antecedents from SCID examinations and clinical records, we compared first lifetime manic vs. other (mixed, depressive, or non-affective) major psychotic episodes.

RESULTS

We identified 32 antecedents arising at early, intermediate or later times, starting 12.3±10.7 years prior to first lifetime major psychotic episodes. Based on multivariate modeling, antecedents associated significantly and independently with other (n=113) more than manic (n=150) first lifetime major psychotic episodes ranked by odds ratio: more early attentional disturbances, more late depression, more early perplexity, more detoxification, more early unstable mixed affects, more antidepressants, more early dysphoria, more intermediate depression, more early impulsivity, more late anhedonia, longer early-to-intermediate intervals, more intermediate substance abuse, more family history of major depression, and younger at earliest antecedents. Antecedents selectively preceding manic more than other first psychotic episodes included more late behavioral problems and more risk of familial BD-I.

CONCLUSION

Clinical antecedents in adult, BD-I patients, beginning a decade before first major episodes and progressing through sequential stages were dissimilar in manic vs. other first psychotic episodes.

Metacognition, social cognition, and symptoms in patients with first episode and prolonged psychoses

While it has been documented that persons with prolonged schizophrenia have deficits in metacognition and social cognition, it is less clear whether these difficulties are already present during a first episode. To explore this issue we assessed and compared metacognition using the Metacognition Assessment Scale-Abbreviated (MAS-A) and social cognition using the Eyes, Hinting and Bell-Lysaker Emotional Recognition Tests (BLERT) in participants with first episode psychosis (FEP; n=26), participants with a prolonged psychosis (n=72), and a psychiatric control group consisting of persons with a substance use disorder and no history of psychosis (n=14). Analyses revealed that both psychosis cohorts scored lower than controls on the MAS-A total and all subscales except metacognitive mastery. Compared to the FEP group, the persons with prolonged psychosis demonstrated greater metacognitive capacities only in those MAS-A domains reflective of the ability to understand the mental state of others and to see that others may have motivations and desires separate from their own. Other domains of metacognition did not differ between psychosis groups. The Eyes, Hinting and BLERT scores of the two psychosis groups did not differ but were poorer than those produced by the control group. Exploratory correlations in the FEP group showed a pattern similar to that previously observed in prolonged psychosis. Taken together, these findings suggest that while certain domains of metacognition could improve with prolonged psychosis, difficulties with global metacognition and social cognition may be stable features of the disorder and perhaps unique to psychosis.