Early intervention in psychosis: concepts, evidence and future directions

Unmet needs in the management of schizophrenia

Studies on unmet needs during the last decades have played a significant role in the development and dissemination of evidence-based community practices for persistent schizophrenia and other severe mental disorders. This review has thoroughly considered several blocks of unmet needs, which are frequently related to schizophrenic disorders. Those related to health have been the first block to be considered, in which authors have examined the frequent complications and comorbidities found in schizophrenia, such as substance abuse and dual diagnosis. A second block has been devoted to psychosocial and economic needs, especially within the field of recovery of the persistently mentally ill. Within this block, the effects of the current economic difficulties shown in recent literature have been considered as well. Because no patient is static, a third block has reviewed evolving needs according to the clinical staging model. The fourth block has been dedicated to integrated evidence-based interventions to improve the quality of life of persons with schizophrenia. Consideration of community care for those reluctant to maintain contact with mental health services has constituted the fifth block. Finally, authors have aggregated their own reflections regarding future trends. The number of psychosocial unmet needs is extensive. Vast research efforts will be needed to find appropriate ways to meet them, particularly regarding so-called existential needs, but many needs could be met only by applying existing evidence-based interventions. Reinforcing research on the implementation strategies and capacity building of professionals working in community settings might address this problem. The final aim should be based on the collaborative model of care, which rests on the performance of a case manager responsible for monitoring patient progress, providing assertive follow-up, teaching self-help strategies, and facilitating communication among the patient, family doctor, mental health specialist, and other specialists.

Recording of severe mental illness in United Kingdom primary care, 2000-2010

Background

There is increasing emphasis on primary care services for individuals with severe mental illnesses (SMI), including schizophrenia, bipolar disorder, and other non-organic psychotic disorders. However we lack information on how many people receive these different diagnoses in primary care. Primary care databases offer an opportunity to explore the recording of new SMI diagnoses in representative general practices.

Methods

We used data from The UK Health Improvement Network (THIN) primary care database including longitudinal patient records for individuals aged over 16 years from 437 general practices. We determined the annual GP recorded rate of first diagnosis of SMI by age, gender, social deprivation and urbanicity between 2000 and 2010.

Results

We identified 10,520 individuals with a first record of schizophrenia, bipolar disorder or other non-organic psychosis among 4,164,794 patients. This corresponded to a rate of first diagnosis of 46.4 per 100,000 person years at risk (PYAR) (95% CI 45.4 to 47.4) in the 16–65 age group. The rate of first record of schizophrenia was 9.2 per 100,000 PYAR (95% CI 8.7 to 9.6) in this age group, bipolar disorder was 15.0 per 100,000 PYAR (95% CI 14.4 to 15.5) and other non-organic psychotic disorder was 22.3 per 100,000 PYAR (95% CI 21.6 to 23.0).

Conclusions

The rates of GP recorded SMI in primary care records were broadly comparable to incidence rates from previous epidemiological studies of SMI and show similar patterns by socio-demographic characteristics. However there were some differences by specific diagnoses. GPs may be recording rates that are higher than those used to commission services.

Multimodal neuroimaging of frontal white matter microstructure in early phase schizophrenia: the impact of early adolescent cannabis use

BACKGROUND

A disturbance in connectivity between different brain regions, rather than abnormalities within the separate regions themselves, could be responsible for the clinical symptoms and cognitive dysfunctions observed in schizophrenia. White matter, which comprises axons and their myelin sheaths, provides the physical foundation for functional connectivity in the brain. Myelin sheaths are located around the axons and provide insulation through the lipid membranes of oligodendrocytes. Empirical data suggests oligodendroglial dysfunction in schizophrenia, based on findings of abnormal myelin maintenance and repair in regions of deep white matter. The aim of this in vivo neuroimaging project is to assess the impact of early adolescent onset of regular cannabis use on brain white matter tissue integrity, and to differentiate this impact from the white matter abnormalities associated with schizophrenia. The ultimate goal is to determine the liability of early adolescent use of cannabis on brain white matter, in a vulnerable brain.

METHODS/DESIGN

Young adults with schizophrenia at the early stage of the illness (less than 5 years since diagnosis) will be the focus of this project. Four magnetic resonance imaging measurements will be used to assess different cellular aspects of white matter: a) diffusion tensor imaging, b) localized proton magnetic resonance spectroscopy with a focus on the neurochemical N-acetylaspartate, c) the transverse relaxation time constants of regional tissue water, d) and of N-acetylaspartate. These four neuroimaging indices will be assessed within the same brain region of interest, that is, a large white matter fibre bundle located in the frontal region, the left superior longitudinal fasciculus.

DISCUSSION

We will expand our knowledge regarding current theoretical models of schizophrenia with a more comprehensive multimodal neuroimaging approach to studying the underlying cellular abnormalities of white matter, while taking into consideration the important confounding variable of early adolescent onset of regular cannabis use.

Community rehabilitation and psychosocial interventions for psychotic disorders in youth

During recovery, young people with psychosis need attention paid not only to their psychotic symptoms but also to the areas of functioning that restrict their capacity to live a fulfilled life in the community. Despite improvements in medications and psychological therapies, people with psychosis still have poor outcomes in functional domains such as vocation, physical health, housing, and imprisonment. This article reviews 2 of these areas: vocational functioning and physical health. It examines the extent of each of these issues, provides guidance as to what evidence there exists on which to base interventions, and describes such evidence.

Development of a computerized adaptive test for Schizotypy assessment

BACKGROUND

Schizotypal traits in adolescents from the general population represent the behavioral expression of liability for psychotic disorders. Schizotypy assessment in this sector of population has advanced considerably in the last few years; however, it is necessary to incorporate recent advances in psychological and educational measurement.

OBJECTIVE

The main goal of this study was to develop a Computerized Adaptive Test (CAT) to evaluate schizotypy through "The Oviedo Questionnaire for Schizotypy Assessment" (ESQUIZO-Q), in non-clinical adolescents.

METHODS

The final sample consisted of 3,056 participants, 1,469 males, with a mean age of 15.9 years (SD=1.2).

RESULTS

The results indicated that the ESQUIZO-Q scores presented adequate psychometric properties under both Classical Test Theory and Item Response Theory. The Information Function estimated using the Gradual Response Model indicated that the item pool effectively assesses schizotypy at the high end of the latent trait. The correlation between the CAT total scores and the paper-and-pencil test was 0.92. The mean number of presented items in the CAT with the standard error fixed at ≤ 0.30 was of 34 items.

CONCLUSION

The CAT showed adequate psychometric properties for schizotypy assessment in the general adolescent population. The ESQUIZO-Q adaptive version could be used as a screening method for the detection of adolescents at risk for psychosis in both educational and mental health settings.

Integrated treatment vs. treatment-as-usual for recent onset schizophrenia; 12 year follow-up on a randomized controlled trial

BACKGROUND

The aim of this study is to compare the 12-year follow-up effects on in- and outpatient services of 2 years of integrated treatment for recent-onset schizophrenia versus treatment as usual in a randomized controlled trial.

METHODS

50 patients aged 18-35 years were randomized to Integrated Treatment (IT) (N = 30) or Treatment-as-Usual (TAU) (N = 20) for two years. TAU comprised optimal pharmacotherapy and outreach assertive treatment, while IT also included cognitive-behavioural family treatment, skills training, strategies for residual psychotic and non-psychotic problems and home-based crisis management.

RESULTS

There were no differences in number of days in hospital, time to readmission, number of admittances to psychiatric wards, number of involuntarily psychiatric admissions or number of outpatient contacts over a period of 12 years following the initial 2-year treatment trial. Fewer patients in the IT group were, however, involuntary admitted to hospital in the period.

CONCLUSIONS

The intensive two-year psychosocial intervention seemed to have little long-term effects on use of in- and outpatient services.

TRIAL REGISTRATION

Current Controlled Trials: NCT00184509.

Disturbances of basic self and prodromal symptoms among non-psychotic help-seeking adolescents

BACKGROUND

The goal of this study was to explore the notion that anomalies of self-experience (ASE) are a core, 'not-yet-psychotic' clinical phenotype of emerging schizophrenia and its spectrum. Method To accomplish this goal, we examined the relationship between ASE and commonly accepted risk markers in a sample of 87 help-seeking, non-psychotic adolescents (aged 14-18 years). ASE were assessed with the Examination of Anomalous Self-Experience (EASE), subclinical psychotic symptoms were assessed with the Prodromal Questionnaire and the Structured Interview for Prodromal Syndromes, deterioration in psychosocial functioning was assessed with the Social and Role Functioning Scales, and level of distress with the Mood and Anxiety Symptoms Questionnaire.

RESULTS

About 82 participants completed the entire EASE interview. The number of participants who reported ASE at a clinically meaningful level (n = 18, 22%) was smaller than that who met diagnostic criteria for a prodromal syndrome (n = 28, 34%). The degree of overlap between the two conditions was moderate but statistically significant (χ2 (1) = 7.01, p = 0.008). An exploratory factor analysis revealed that ASE load on a different factor than prodromal symptoms and deterioration in functioning, but that there is a moderate correlation between the three factors.

CONCLUSIONS

These results suggest that ASE are prevalent among non-psychotic help-seeking adolescents, yet at a considerably lower rate than prodromal symptoms. In addition, they suggest that ASE and prodromal symptoms constitute distinct but moderately related dimensions of potential risk. Taken together, they provide preliminary support for the clinical usefulness of supplementing and refining the methods of early detection of risk with assessment of ASE.

Neuropsychological and socio-occupational functioning in young psychiatric outpatients: a longitudinal investigation

BACKGROUND

Clinical symptoms and neuropsychological deficits are longitudinally associated with functional outcome in chronic psychiatric cohorts. The current study extended these findings to young and early-course psychiatric outpatients, with the aim of identifying cognitive markers that predict later socio-occupational functioning.

METHODS

At baseline, 183 young psychiatric outpatients were assessed. Ninety-three returned for follow-up (M = 21.6 years old; SD = 4.5) with an average re-assessment interval of 21.6 months (SD = 7.0), and primary diagnoses of major depressive disorder (n = 34), bipolar disorder (n = 29), or psychosis (n = 30). The primary outcome measure was cross-validated with various other functional measures and structural equation modelling was used to map out the interrelationships between predictors and later functional outcome.

RESULTS

Good socio-occupational functioning at follow-up was associated with better quality of life, less disability, current employment and being in a romantic relationship. The final structural equation model explained 47.5% of the variability in functional outcome at follow-up, with baseline neuropsychological functioning (a composite of memory, working memory and attentional switching) the best independent predictor of later functional outcome. Notably, depressive and negative symptoms were only associated with functioning cross-sectionally. Diagnosis at follow-up was not associated with functional outcome.

CONCLUSIONS

Neuropsychological functioning was the single best predictor of later socio-occupational outcome among young psychiatric outpatients. Therefore, framing psychiatric disorders along a neuropsychological continuum is likely to be more useful in predicting functional trajectory than traditional symptom-based classification systems. The current findings also have implications for early intervention utilising cognitive remediation approaches.

A randomized controlled trial of relapse prevention therapy for first-episode psychosis patients: outcome at 30-month follow-up

The effectiveness of a novel 7-month psychosocial treatment designed to prevent the second episode of psychosis was evaluated in a randomized controlled trial at 2 specialist first-episode psychosis (FEP) programs. An individual and family cognitive behavior therapy for relapse prevention was compared with specialist FEP care. Forty-one FEP patients were randomized to the relapse prevention therapy (RPT) and 40 to specialist FEP care. Participants were assessed on an array of measures at baseline, 7- (end of therapy), 12-, 18-, 24-, and 30-month follow-up. At 12-month follow-up, the relapse rate was significantly lower in the therapy condition compared with specialized treatment alone (P = .039), and time to relapse was significantly delayed for those in the relapse therapy condition (P = .038); however, such differences were not maintained. Unexpectedly, psychosocial functioning deteriorated over time in the experimental but not in the control group; these differences were no longer statistically significant when between-group differences in medication adherence were included in the model. Further research is required to ascertain if the initial treatment effect of the RPT can be sustained. Further research is needed to investigate if medication adherence contributes to negative outcomes in functioning in FEP patients who have reached remission, or, alternatively, if a component of RPT is detrimental.

On the HORYZON: moderated online social therapy for long-term recovery in first episode psychosis

BACKGROUND

Early intervention services have demonstrated improved outcomes in first episode psychosis (FEP); however, recent evidence shows that treatment benefits may not be sustainable over time. These findings have resulted in repeated recommendations for the implementation of longer term treatment programs. An Internet-based intervention specifically designed for young people with psychosis may provide a cost-effective alternative to prevent loss of treatment benefits from early intervention.

METHODS

Our multi-disciplinary team has developed a highly novel online intervention (HORYZONS) in regular consultation with stakeholders within a specialist early psychosis program. HORYZONS integrates: i) peer-to-peer social networking, ii) individually tailored interactive psychosocial interventions, and iii) expert interdisciplinary and peer-moderation in a coherent platform designed to improve long-term outcomes in FEP. The acceptability, safety and initial clinical benefits of HORYZONS were examined through a 1-month pilot study with 20 participants with FEP.

RESULTS

There were no dropouts during the pilot study. Seventy per cent of participants utilised the system for at least 3weeks, 95% used the social networking features, and 60% completed at least 3 therapy modules. System usage was high during the study. There were no incidents and the majority of participants reported feeling safe, empowered and more socially connected using HORYZONS. Analysis revealed a significant reduction in depressive symptoms at follow-up.

CONCLUSIONS

Our results indicate that HORYZONS is feasible, engaging and safe and may augment social connectedness and empowerment in FEP. These findings have significant implications for the enhancement of specialist FEP services. The potential of HORYZONS to improve long-term recovery is worthy of further investigation.

The ultra-high risk concept-a review

Attempts to identify people at imminent risk of psychotic disorder have been made during the past 20 years. High-risk criteria have been developed, and despite findings of a recent decline in the rate of onset of psychosis associated with these criteria, people identified still have a significantly greater risk, compared with the general population. Intervention studies in this group indicate that psychological treatments and fish oil appear to be just as effective as antipsychotics. Future research should refine risk factors for psychosis and examine outcomes other than psychosis. Research is also needed into what harms and benefits are associated with making the high-risk criteria into a formal diagnosis.

Primary care support for youth mental health: a preliminary evidence base for Ireland's Mid-West

BACKGROUND

Mental and substance use disorders are leading causes of morbidity. Prevention/treatment amongst young people are global health priorities. International data have highlighted primary care and general practice as important in addressing these.

AIMS

Survey of 128 physicians (GPs) in Ireland's Mid-West (Counties Limerick, Clare, North Tipperary) to document the spectrum of youth mental health problems, describe strategies adopted by GPs in dealing with these, identify barriers (perceived by GPs) to effective care of young mental health patients and collate GP proposals for improved care of this cohort.

METHODS

Self-administered questionnaire on physician and practice demographics, case management and barriers to care in youth mental health.

RESULTS

Thirty-nine GPs (31 %) responded. Mental health and family conflict represented the most frequent reasons why young people attended GPs. Depression, anxiety, family conflict, suicidal thoughts/behaviour, and attention deficit hyperactivity disorder (ADHD) were the most common issues followed by substance abuse and antisocial behaviours. GP referral practices for young people with mental/substance use disorders varied, with distinctions between actual and preferred management due to insufficient access to dedicated youth services and training. GPs stated need for improved access to existing services (i.e., Psychiatry, counseling/psychology, social/educational interventions). A number of GPs surveyed were located, or provided care, in Limerick's 'Regeneration Areas'. Young people in these areas predominantly attended GPs due to mental/substance use issues and antenatal care, rather than acute or general medical problems.

CONCLUSIONS

GPs play an important role in meeting youth mental health needs in this region and, in particular, in economically deprived urban areas.

Pharmacotherapy challenges in patients with first-episode psychosis

The first episode of a psychotic disorder typically occurs in late adolescence or young adulthood, a critical time of development with respect to personality, social role, education, and vocation. The first few years of psychosis appear to be a critical period during which intervention needs to be initiated before the consequences of psychosis become more severe. Early intervention is therefore crucial in maximizing outcomes. Although response rates to antipsychotic medication in first-episode psychosis (FEP) are good, there is a relatively high risk of relapse. The greatest challenges that physicians face in treating FEP and preventing relapse are engaging patients in treatment and preventing non-adherence to therapy. Overall rates of non-adherence to antipsychotic medications for FEP patients are estimated to be at or higher than 50% within the first year of treatment, suggesting that malleable factors linked to non-adherence need to be targeted in interventions provided. Factors influencing adherence can be categorized into four groups: (1) environment-related, (2) patient-related, (3) medication-related, and (4) illness-related. This paper will review the factors associated with adherence and discuss solutions to optimize engagement, adherence to medication, and treatment in order to prevent relapse. Factors like social and family support, therapeutic alliance, attitudes and beliefs toward illness and medication, insight, substance use disorders, medication efficacy, tolerability, and accessibility will be discussed. Solutions, such as early psychosis specialized services integrating psychosocial therapies and careful selection of appropriate antipsychotic medication, will be proposed.

Early intervention in schizophrenia in developing countries: focus on duration of untreated psychosis and remission as a treatment goal

Early intervention services are based on the premise that untreated psychosis may have a deleterious effect on outcome, particularly in the early years of illness. The majority of the studies on duration of untreated psychosis have been conducted in developed countries; therefore this review focuses on publications from developing countries. We also review studies from developing countries that have been published following the Remission in Schizophrenia Working Group criteria. The duration of untreated psychosis is longer in developing countries, and is also associated with poor outcome, whereas remission rates following treatment of first-episode schizophrenia in developing countries appear to be higher than in developed countries. These two findings strongly argue for the establishment of early intervention services for schizophrenia in developing countries.

Early intervention services for psychosis and time until application for disability income support: a survival analysis

Ensuring the financial security of individuals recovering from first episode psychosis is imperative, but disability income programs can be powerful disincentives to employment, compromising the social and occupational aspects of recovery. Survival analysis and Cox regression analysis were used to examine the rate at which individuals served by early intervention for psychosis (EIP) services apply for government disability income benefits and factors that predict rate of application. Health records for 558 individuals served by EIP programs were reviewed. Within the first year of receiving services 30% will make application for disability income; 60% will do so by 5 years. Rate of application is predicted by rate of hospital admission, financial status and engagement in productivity roles at the time of entry to EIP service. The findings suggest the need to examine the extent to which the recovery goals of EI services are undermined by early application for government income support. They also suggest the need to develop best practice guidelines related to ensuring the economic security of individuals served.

Prevention of the phencyclidine-induced impairment in novel object recognition in female rats by co-administration of lurasidone or tandospirone, a 5-HT(1A) partial agonist

Hypoglutamatergic function may contribute to cognitive impairment in schizophrenia (CIS). Subchronic treatment with the N-methyl-D-aspartate receptor antagonist, phencyclidine (PCP), induces enduring deficits in novel object recognition (NOR) in rodents. Acute treatment with atypical antipsychotic drugs (APDs), which are serotonin (5-HT)(2A)/dopamine D(2) antagonists, but not typical APDs, eg, haloperidol, reverses the PCP-induced NOR deficit in rats. We have tested the ability of lurasidone, an atypical APD with potent 5-HT(1A) partial agonist properties, tandospirone, a selective 5-HT(1A) partial agonist, haloperidol, a D(2) antagonist, and pimavanserin, a 5-HT(2A) inverse agonist, to prevent the development of the PCP-induced NOR deficit. Rats were administered lurasidone (0.1 or 1 mg/kg), tandospirone (5 mg/kg), pimavanserin (3 mg/kg), or haloperidol (1 mg/kg) b.i.d. 30 min before PCP (2 mg/kg, b.i.d.) for 7 days (day1-7), followed by a 7-day washout (day 8-14). Subchronic treatment with PCP induced an enduring NOR deficit. Lurasidone (1 mg/kg) but not 0.1 mg/kg, which is effective to acutely reverse the deficit due to subchronic PCP, or tandospirone, but not pimavanserin or haloperidol, significantly prevented the PCP-induced NOR deficit on day 15. The ability of lurasidone co-treatment to prevent the PCP-induced NOR deficit was enduring and still present at day 22. The preventive effect of lurasidone was blocked by WAY100635, a selective 5-HT(1A) antagonists, further evidence for the importance of 5-HT(1A) receptor stimulation in the NOR deficit produced by subchronic PCP. Further study is needed to determine whether these results concerning mechanism and dosage can be the basis for prevention of the development of CIS in at risk populations.

Internet-based interventions for psychosis: a sneak-peek into the future

The Internet and mobile technologies are becoming ubiquitous. However, the potential of these technologies to support people with psychosis has been unexplored and the development of innovative e-based interventions is overdue. Research suggests the acceptability and effectiveness of such interventions in psychosis. Internet-based technologies have the potential to transform psychosis treatment by enhancing the accessibility of evidence-based interventions, fostering engagement with mental health services, and maintaining treatment benefits over the long term. This article reviews the current evidence on Internet-based interventions for psychosis, including potential benefits, risks, and future challenges. Recommendations are proposed for developing future online interventions for psychosis.

Can general practice help address youth mental health? A retrospective cross-sectional study in Dublin's south inner city

AIMS

With general practice potentially having an important role in early intervention of mental and substance use disorders among young people, we aim to explore this issue by determining the prevalence of psychological problems and general practice/health service utilization among young people attending general practice.

METHODS

A retrospective cross-sectional study of patients attending three general practices in Dublin city.

RESULTS

Among a sample of young people (mostly women, 44% general medical services (GMS) eligible), we observed considerable contact with general practice, both lifetime and for the 2 years of the study. The mean consultation rate was 3.9 consultations in 2 years and psychosocial issues (most commonly stress/anxiety and depression) were documented in 35% of cases. Identification of psychosocial issues was associated with GMS eligibility, three or more doctor consultations, and documentation of smoking and drinking status.

CONCLUSIONS

Psychosocial issues are common among young people attending general practice and more work on their epidemiology and further identification in general practice are advocated.

Frontal delta power associated with negative symptoms in ultra-high risk individuals who transitioned to psychosis

It has recently been shown that treatment with long-chain omega-3 polyunsaturated fatty acids (PUFAs) could decrease the rate of transition to psychosis, and improve psychiatric symptoms and global functioning in people at ultra-high risk (UHR) for psychosis. Previous studies have suggested that resting state brain activity measured with electroencephalography (EEG) may represent an objective biomarker of changes in neural function associated with supplementation with omega-3 PUFAs. It has also been proposed that although resting state EEG cannot, by itself, predict transition to psychosis in UHR individuals, the combination of resting state EEG with negative symptoms may be a valid predictor of transition. The present study investigated whether treatment with omega-3 PUFAs influenced resting state EEG in UHR participants, and whether or not the association of the participants' resting state EEG with their levels of negative symptoms was dependent on their transition status. The brain activity of 73 UHR participants was recorded in the context of a randomized, placebo-controlled trial of the effects of supplementation with omega-3 PUFAs. The UHR participants who subsequently transitioned to psychosis (UHR+) did not differ from those who did not transition (UHR-) in terms of resting state EEG power in any frequency band. However, negative symptom scores were associated with increased delta activity in the frontal region of the UHR+ participants, but not in the UHR- participants. Treatment with omega-3 PUFAs did not induce changes in resting state EEG in either group. The results suggest that decreased frontal delta activity, in combination with high levels of negative symptoms, may be a risk factor for subsequent transition to psychosis in UHR individuals.

Establishing and operating an early intervention service for psychosis in a defined catchment area of northwestern Greece within the context of the local mental health network

AIM

The study aims to present briefly the development of an early intervention service (EIS) for psychosis in a rural catchment area of north-western Greece within the context of the local mental health network, its structure and procedures, and the results of its operation 2 years after its establishment.

METHOD

Established in December 2007, our EIS is the first service in Greece for patients with a first-episode psychosis. The context and the local mental health network are described, and the EIS operation, including clinical, educational, community and research activities, is outlined. Assessment measures are presented to evaluate the EIS progress 2 years after its establishment.

RESULTS

Between December 2007 and December 2009, EIS received 45 referrals, retaining 38 patients in its caseload. The mean duration of untreated psychosis was 26.6 ± 41.0 months (median = 12 months). Thirty-seven patients (82.2%) were hospitalized after their first referral, 14 under a compulsory order (31.1%). The duration of hospitalization ranged from 2 to 69 days, with a median of 13 days. Mean (±SD) duration of the follow-up was 14.8 ± 8.5 months, indicating adequate adherence to EIS, with particularly low relapse rates (20%).

CONCLUSIONS

Our EIS seems to be successfully established within the local mental health network. Our collaboration with the local mobile mental health unit enabled our communication with rural primary healthcare centers. The collaboration of patients' family and the participation of the mobile mental health unit to the continuity of care contributed greatly to the brief duration of hospitalization and the high adherence to follow-up rates.

PDE4 inhibition enhances hippocampal synaptic plasticity in vivo and rescues MK801-induced impairment of long-term potentiation and object recognition memory in an animal model of psychosis

Inhibition of phosphodiesterase type 4 (PDE4) by rolipram (4-(3-(cyclopentyloxy)-4-methoxyphenyl)-pyrrolidin-2-one) has been the focus of many behavioral and molecular studies in the recent years. Rolipram exhibits memory-enhancing effects in rodents. In vitro studies have shown that long-term potentiation (LTP), which may comprise a cellular substrate for learning, is also enhanced by rolipram. However, effects have not been assessed in vivo. Rolipram has antipsychotic properties. Psychosis affects cognition and in animal models of psychosis LTP is impaired. In this study, we investigated if PDE4 inhibition improves LTP in healthy animals in vivo and if PDE4 inhibition rescues impaired LTP and prevents object recognition memory deficits in an animal model of psychosis. Recordings were made from the hippocampus of adult, freely behaving Wistar rats. Thirty minutes after treatment with rolipram or vehicle, a tetanus was applied to the medial perforant path to elicit short-term potentiation (STP) in the dentate gyrus. At this time-point, radioimmunoassay revealed that rolipram significantly elevated cyclic adenosine monophosphate levels in the dorsal hippocampus, in line with reports by others that rolipram mediates decreased PDE4 activity. In healthy animals, both intracerebroventricular and subcutaneous treatment with rolipram facilitated STP into LTP, suggesting that PDE4 inhibition may have a permissive role in plasticity mechanisms that are relevant for learning and memory. One week after a single systemic treatment with the irreversible N-methyl-D-aspartate antagonist, MK801, LTP and object recognition memory were significantly impaired, but could be rescued by PDE4 inhibition. These data suggest that the relief of cognitive disturbances in psychosis models by rolipram may be mediated in part by a rescue of hippocampal LTP.

Effects of risperidone treatment in adolescence on hippocampal neurogenesis, parvalbumin expression, and vascularization following prenatal immune activation in rats

Maternal infection in pregnancy is an environmental risk factor for the development of schizophrenia and related disorders in the offspring, and this association is recapitulated in animal models using gestational infection or immune stimulation. We have recently shown that behavioral abnormalities and altered hippocampal morphology emerging in adult offspring of dams treated with the viral mimic polyriboinosinic-polyribocytidilic acid (poly I:C) are prevented by treatment with the atypical antipsychotic drug risperidone (RIS) in adolescence. Here we used a battery of cellular markers and Nissl stain to morphometrically analyze different hippocampal cell populations in the offspring of poly I:C and saline-treated mothers that received saline or RIS in adolescence, at different time points of postnatal development. We report that impaired neurogenesis, disturbed micro-vascularization and loss of parvalbumin-expressing hippocampal interneurons, are found in the offspring of poly I:C-treated dams. Most, but not all, of these neuropathological changes are not present in poly I:C offspring that had been treated with RIS. These effects may be part of the complex processes underlying the capacity of RIS treatment in adolescence to prevent structural and behavioral abnormalities deficits in the poly I:C offspring.

Treating co-occurring first-episode psychosis and borderline personality: a pilot randomized controlled trial

AIM

First-episode psychosis and borderline personality disorder are severe mental disorders that have their onset in youth. Their co-occurrence is clinically well recognized, is associated with significant risks and is complex to treat. Yet, there is no published specific intervention for this problem. This study reports a pilot randomized controlled trial comparing combined specialist first-episode treatment plus specialist early intervention for borderline personality, entitled Helping Young People Early, with specialist first-episode treatment alone. We aimed to evaluate the safety and feasibility of adding early intervention for borderline personality.

METHODS

The study investigated the safety of specialist first-episode treatment plus specialist early intervention for borderline personality in relation to deterioration in psychosis, aggression, self-harm and suicidality, and feasibility in relation to the completion of therapy phases. Sixteen patients meeting Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-Text Revision (DSM-IV-TR) criteria for first-episode psychosis and borderline personality (four or more DSM-IV criteria) were randomized either to specialist first-episode treatment alone or specialist first-episode treatment plus specialist early intervention for borderline personality and were followed up at the end of treatment and 6 months later.

RESULTS

The results showed that it was feasible to recruit and assess a high risk and complex group of patients who were agreeable to study participation. Specialist first-episode treatment plus specialist early intervention for borderline personality was an acceptable and safe treatment.

CONCLUSION

A larger-scale randomized controlled trial of early intervention for borderline personality for young first-episode psychosis patients with co-occurring full or subsyndromal borderline personality is warranted.

Gray matter volumetric abnormalities associated with the onset of psychosis

Patients with psychosis display structural brain abnormalities in multiple brain regions. The disorder is characterized by a putative prodromal period called ultra-high-risk (UHR) status, which precedes the onset of full-blown psychotic symptoms. Recent studies on psychosis have focused on this period. Neuroimaging studies of UHR individuals for psychosis have revealed that the structural brain changes observed during the established phases of the disorder are already evident prior to the onset of the illness. Moreover, certain brain regions show extremely dynamic changes during the transition to psychosis. These neurobiological features may be used as prognostic and predictive biomarkers for psychosis. With advances in neuroimaging techniques, neuroimaging studies focusing on gray matter abnormalities provide new insights into the pathophysiology of psychosis, as well as new treatment strategies. Some of these novel approaches involve antioxidants administration, because it is suggested that this treatment may delay the progression of UHR to a full-blown psychosis and prevent progressive structural changes. The present review includes an update on the most recent developments in early intervention strategies for psychosis and potential therapeutic treatments for schizophrenia. First, we provide the basic knowledge of the brain regions associated with structural abnormalities in individuals at UHR. Next, we discuss the feasibility on the use of magnetic resonance imaging (MRI)-biomarkers in clinical practice. Then, we describe potential etiopathological mechanisms underlying structural brain abnormalities in prodromal psychosis. Finally, we discuss the potentials and limitations related to neuroimaging studies in individuals at UHR.

Long-term tolerability of once-monthly injectable paliperidone palmitate in subjects with recently diagnosed schizophrenia

BACKGROUND

A post hoc analysis from a multiphase trial with open-label transition and maintenance phases, a double-blind relapse prevention phase, and an optional open-label extension examined the long-term tolerability with continuous once-monthly injectable paliperidone palmitate 39, 78, 117, or 156 mg (25, 50, 75, or 100 mg equivalents [mg eq] of paliperidone) in subjects with recently diagnosed (≤5 years; n = 216) versus chronic illness (>5 years; n = 429) schizophrenia.

METHODS

Adverse events reported at a ≥2% margin between subgroups were identified. Relative risks (in the recently diagnosed compared with the chronically ill) and 95% confidence intervals (CI) were determined, and CI not including 1 were considered potentially significant.

RESULTS

In both subgroups, the mean monthly dose was 109 mg (69.9 mg eq). Continuous mean exposures were 333.9 ± 271.9 and 308.7 ± 278.3 days in the recently diagnosed and chronic illness subgroups, respectively. Using the criteria outlined in the methods, nasopharyngitis was a potentially significant event reported in more chronically ill than recently diagnosed subjects at months 6, 9, 12, and endpoint (7.2% versus 2.8%; relative risk 0.384; 95% CI 0.163-0.907). Influenza (2.8% versus 0.7%; relative risk 3.9; 95% CI 1.003-15.730) and amenorrhea (3.2% versus 0.9%; relative risk 3.476; 95% CI 1.029-11.744) at endpoint were potentially significant events in more recently diagnosed than chronically ill subjects. Mean weight changes, sedation/somnolence, any extrapyramidal symptom-related or glucose-related events were generally similar between the groups. The mean prolactin level increased in both sexes in both subgroups (changes from baseline of +41.8 ng/mL and +26.5 ng/mL in recently diagnosed and chronic illness females and +12.3 ng/mL and +15.1 ng/mL in recently diagnosed and chronic illness males, respectively), and were higher in females with recently diagnosed illness than in females who were chronically ill (P = 0.0002 at endpoint). Prolactin-related events were reported by 7.9% of recently diagnosed subjects with schizophrenia and 3.5% of those who were chronically ill.

CONCLUSION

The long-term tolerability of paliperidone palmitate was generally similar in recently diagnosed schizophrenia subjects and those with more chronic illness, with the exception of some prolactin-related measures.

Risperidone administered during asymptomatic period of adolescence prevents the emergence of brain structural pathology and behavioral abnormalities in an animal model of schizophrenia

Schizophrenia is a disorder of a neurodevelopmental origin manifested symptomatically after puberty. Structural neuroimaging studies show that neuroanatomical aberrations precede onset of symptoms, raising a question of whether schizophrenia can be prevented. Early treatment with atypical antipsychotics may reduce the risk of transition to psychosis, but it remains unknown whether neuroanatomical abnormalities can be prevented. We have recently shown, using in vivo structural magnetic resonance imaging, that treatment with the atypical antipsychotic clozapine during an asymptomatic period of adolescence prevents the emergence of schizophrenia-like brain structural abnormalities in adult rats exposed to prenatal immune challenge, in parallel to preventing behavioral abnormalities. Here we assessed the preventive efficacy of the atypical antipsychotic risperidone (RIS). Pregnant rats were injected on gestational day 15 with the viral mimic polyriboinosinic-polyribocytidylic acid (poly I:C) or saline. Their male offspring received daily RIS (0.045 or 1.2 mg/kg) or vehicle injection in peri-adolescence (postnatal days [PND] 34-47). Structural brain changes and behavior were assessed at adulthood (from PND 90). Adult offspring of poly I:C-treated dams exhibited hallmark structural abnormalities associated with schizophrenia, enlarged lateral ventricles and smaller hippocampus. Both of these abnormalities were absent in the offspring of poly I:C dams that received RIS at peri-adolescence. This was paralleled by prevention of schizophrenia-like behavioral abnormalities, attentional deficit, and hypersensitivity to amphetamine in these offspring. We conclude that pharmacological intervention during peri-adolescence can prevent the emergence of behavioral abnormalities and brain structural pathology resulting from in utero insult. Furthermore, highly selective 5HT(2A) receptor antagonists may be promising targets for psychosis prevention.

Pathways to psychosis: help-seeking behavior in the prodromal phase

BACKGROUND

Knowledge of pathways to care by help-seeking patients prior to the onset of psychosis may help to improve the identification of at-risk patients. This study explored the history of help-seeking behavior in secondary mental health care services prior to the onset of the first episode of psychosis.

METHOD

The psychiatric case register in The Hague was used to identify a cohort of 1753 people in the age range of 18-35 at first contact who developed a psychotic disorder in the period from 1 January 2005 to 31 December 2009. We retrospectively examined the diagnoses made at first contact with psychiatric services.

RESULTS

985 patients (56.2%) had been treated in secondary mental health services prior to the onset of psychosis. The most common disorders were mood and anxiety disorders (N=385 (39.1%)) and substance use disorders (N=211 (21.4%)). Affective psychoses were more often preceded by mood/anxiety disorders, while psychotic disorder NOS was more often preceded by personality disorder or substance abuse. The interval between first contact and first diagnosis of psychosis was approximately 69 months in cases presenting with mood and anxiety disorders and 127 months in cases presenting with personality disorders.

DISCUSSION

This study confirms the hypothesis that the majority of patients with psychotic disorders had been help-seeking for other mental disorders in the secondary mental health care prior to the onset of psychosis.

Self-experience in the early phases of schizophrenia: 5-year follow-up of the Copenhagen Prodromal Study

Despite the avalanche of empirical data on prodromal/"at risk" conditions, the essential aspects of the vulnerability to the schizophrenia spectrum remain largely unaddressed. We report here the results of the Copenhagen Schizophrenia Prodromal Study, a prospective, observational study of first admission patients in putative state of beginning psychosis (N=151) with a follow-up length of 60 months. At follow-up, the rate of conversion to schizophrenia spectrum diagnosis was 37%, whereas the conversion rate from schizotypal disorder to schizophrenia was 25%. High levels of perplexity and self-disorders baseline scores yielded the best prediction of the subsequent development of schizophrenia spectrum disorders. Escalating transitions within the spectrum (i.e., from schizotypal disorder to schizophrenia) were not associated to any candidate psychopathological predictor.

What is the role of general practice in addressing youth mental health? A discussion paper

BACKGROUND

Mental and substance use disorders are a leading cause of morbidity among young people. Policy and clinical services in Ireland are endeavouring to address these twin issues.

AIMS

To review the emerging literature on the role of general practice in addressing youth mental health and to discuss the implications of this literature for further research, education and service delivery.

METHODS

We conducted a review of 'PubMed' and a web search of relevant national/international primary/mental healthcare agencies and professional bodies.

RESULTS

Although general practice has an important role in addressing youth mental health, there are challenges in how young people seek help. Specifically, young people do not engage with healthcare agencies and many factors which act as barriers and enablers in this regard have been identified. The detection and treatment of mental and substance use disorders by GPs can be improved and implementing interventions to improve screening and early intervention are likely to be valuable.

CONCLUSIONS

General practice is a central agency in addressing youth mental health and complex multifaceted interventions (education, clinical guidelines, and promoting awareness) are likely to support its role. Further research exploring this issue is a priority.

The introduction of an early warning signs journal in an adolescent inpatient unit

Early warning signs are considered to be one of the many tools utilized by specialist early intervention practitioners and other mental health professionals to assist young people how to recognize a deterioration in their mental state or if a relapse is indicated. This article focuses on the role that early warning signs recognition has played in a Child and Adolescent inpatient setting in the form of a journal that is used to record a young person's personal journey by recording early warning signs to prevent a future relapse. Feedback on the use of the journal has been positive from the young people who have utilized the journal and it has also been viewed as a useful and practical framework to identify key symptoms that may potentiate a relapse into illness.

Neuroendocrine markers of high risk for psychosis: salivary testosterone in adolescent boys with prodromal symptoms

BACKGROUND

The peak in age of onset of psychotic disorders such as schizophrenia during puberty and early adulthood suggests a relationship between the expression of psychopathology and the changes in the brain and body that take place during this dynamic maturational period, including a dramatic increase in circulating oestrogens and androgens. This study examined levels of salivary testosterone and oestradiol in adolescents with prepsychotic, prodromal symptoms, as this may mediate risk for psychosis by having an impact on brain development.

METHOD

In 21 male adolescents with prodromal symptoms and 21 male non-clinical controls levels of testosterone and oestradiol were measured in saliva. Tanner pubertal stage and prodromal symptoms were also assessed.

RESULTS

Levels of testosterone were significantly lower in adolescents with prodromal symptoms as compared with non-clinical controls. No group differences in oestradiol were found. In the total sample, level of testosterone was significantly correlated with age and Tanner pubertal stage.

CONCLUSIONS

Our observations are in line with current hypotheses stressing the role of neuroendocrine factors during adolescence in the expression of psychotic symptoms. From a developmental perspective, susceptibility to psychotic disorders increases during adolescence. Our data suggest that testosterone might, in part, mediate this increased vulnerability. Further research is needed to assess the mediating, neural, mechanisms through which testosterone may have an impact on the development of psychotic symptoms. In the search for early risk markers for psychosis, studying neuroendocrine factors might increase our understanding of 'at-risk' developmental pathways.

Tolerability of initiation doses of once-monthly paliperidone palmitate in patients with recently diagnosed schizophrenia in an acute treatment trial

OBJECTIVE

To examine the tolerability of the recommended initiation doses for once-monthly injectable paliperidone palmitate in patients who have recently been diagnosed with schizophrenia and for whom high doses may pose tolerability concerns.

METHODS

A post hoc analysis from a 13-week double-blind study of patients with schizophrenia randomized 1:1:1:1 to placebo or paliperidone palmitate at 25, 100, or 150 mg equivalents (mg eq) of paliperidone (corresponding to 39, 156, or 234 mg respectively). This analysis focused on the recently diagnosed subgroup (≤5 years; N = 146) who received the recommended initiation dosage of paliperidone palmitate [150 mg eq on day 1 (n = 109) followed by 100 mg eq on day 8 (n = 39)] or placebo (n = 37). Adverse events (AEs), reported in ≥2% of patients receiving paliperidone palmitate during days 1-7 or ≥5% during days 8-36, and in a higher percentage of patients receiving paliperidone palmitate than placebo, were identified. AE relative risks (RRs) and 95% confidence intervals (CIs) were determined. A RR was considered potentially significant when its 95% CI did not include 1.

RESULTS

Overall, day 1-7 AE rates were 37.6% (41 of 109) and 29.7% (11 of 37) with paliperidone palmitate and placebo respectively; injection site pain (5.5% versus 2.7%, RR 2.0; 95% CI 0.25 to 16.37), agitation (4.6% versus 2.7%; RR 1.7; 95% CI 0.21 to 14.06), and headache (3.7% versus 0.0%; RR 3.1; 95% CI 0.17 to 56.41) met the ≥2% criteria. Day 8-36 AE rates were 41.0% (16 of 39) and 37.8% (14 of 37) with paliperidone palmitate and placebo respectively; anxiety (5.1% versus 0.0%; RR 4.8; 95% CI 0.24 to 95.76) met the ≥5% criteria. Key limitations were that some patients may have been ill for a significant time before formal diagnosis and that the number of patients is low in this subgroup, limiting the ability to detect statistical significance for AE RRs.

CONCLUSIONS

Paliperidone palmitate initiation doses (150 mg eq day 1, 100 mg eq day 8) were tolerated in this subgroup of patients who were recently diagnosed with schizophrenia, with no unexpected findings. Although the same size was small, these data identified AEs that may be encountered during the week and month after initiation dosing. These findings may assist clinicians when paliperidone palmitate is considered an appropriate treatment choice for these patients.

A prospective 2-year study of emergency department patients with early-phase primary psychosis or substance-induced psychosis

OBJECTIVE

The authors examined treatment utilization and outcomes over 2 years among patients admitted to emergency departments with early-phase primary or substance-induced psychosis. The main hypothesis was that patients with substance-induced psychosis would have a more benign course of illness than those with primary psychosis

METHOD

Using a prospective naturalistic cohort study design, the authors compared 217 patients with early-phase primary psychosis plus substance use and 134 patients with early-phase substance-induced psychosis who presented to psychiatric emergency departments at hospitals in Upper Manhattan. Assessments at baseline and at 6, 12, 18, and 24 months included psychiatric diagnoses, service use, and institutional outcomes using the Psychiatric Research Interview for Substance and Mental Disorders; psychiatric symptoms using the Positive and Negative Syndrome Scale; social, vocational, and family functioning using the World Health Organization Psychiatric Disability Assessment Schedule; and life satisfaction using the Quality of Life Interview. Longitudinal analyses were conducted using generalized estimating equations.

RESULTS

Participants with primary psychosis were more likely to receive antipsychotic and mood-stabilizing medications, undergo hospitalizations, and have outpatient psychiatric visits; those with substance-induced psychosis were more likely to receive addiction treatments. Only a minority of each group received minimally adequate treatments. Both groups improved significantly over time on substance dependence, psychotic symptoms, homelessness, and psychosocial outcomes, and few group-by-time interactions emerged.

CONCLUSIONS

Patients presenting to Upper Manhattan emergency departments with either early-phase primary psychosis or substance-induced psychosis improved steadily over 2 years despite minimal use of mental health and substance abuse services.

Tracing the development of psychosis and its prevention: what can be learned from animal models

Schizophrenia (SCZ) is a neurodevelopmental disorder manifested symptomatically after puberty whose pharmacotherapy remains unsatisfactory. In recent years, longitudinal structural neuroimaging studies have revealed that neuroanatomical aberrations occur in this disorder and in fact precede symptom onset, raising the exciting possibility that SCZ can be prevented. There is some evidence that treatment with atypical antipsychotic drugs (APDs) prior to the development of the full clinical phenotype reduces the risk of transition to psychosis, but results remain controversial. It remains unknown whether progressive structural brain aberrations can be halted. Given the diagnostic, ethical, clinical and methodological problems of pharmacological and imaging studies in patients, getting such information remains a major challenge. Animal neurodevelopmental models of SCZ are invaluable for investigating such questions because they capture the notion that the effects of early brain damage are progressive. In recent years, data derived from such models have converged on key neuropathological and behavioral deficits documented in SCZ attesting to their strong validity, and making them ideal tools for evaluating progression of pathology following in-utero insults as well as its prevention. We review here our recent studies that use longitudinal in vivo structural imaging to achieve this aim in the prenatal immune stimulation model that is based on the association of prenatal infection and increased risk for SCZ. Pregnant rats were injected on gestational day 15 with the viral mimic polyriboinosinic-polyribocytidylic acid (poly I:C) or saline. Male and female offspring were imaged and tested behaviorally on postnatal days (PNDs) 35, 46, 56, 70 and 90. In other experiments, offspring of poly I:C- and saline-treated dams received the atypical antipsychotic drugs (APDs) clozapine or risperidone in two developmental windows: PND 34-47 and PND 48-61, and underwent behavioral testing and imaging at adulthood. Prenatal poly I:C-induced interference with fetal brain development led to aberrant postnatal brain development as manifested in structural abnormalities in the hippocampus, the striatum, the prefrontal cortex and lateral ventricles (LV), as seen in SCZ. The specific trajectories were region-, age- and sex-specific, with females having delayed onset of pathology compared to males. Brain pathology was accompanied by development of behavioral abnormalities phenotypic of SCZ, attentional deficit and hypersensitivity to amphetamine, with same sex difference. Hippocampal volume loss and LV volume expansion as well as behavioral abnormalities were prevented in the offspring of poly I:C mothers who received clozapine or risperidone during the asymptomatic period of adolescence (PND 34-47). Administration at a later window, PNDs 48-61, exerted sex-, region- and drug- specific effects. Our data show that prenatal insult leads to progressive postnatal brain pathology, which gradually gives rise to "symptoms"; that treatment with atypical APDs can prevent both brain and behavioral pathology; and that the earlier the intervention, the more pathological outcomes can be prevented.

Core components in the care of immigrants with psychoses: a Delphi survey of patients, families, and health-care staff

The aim of the present study was to identify core components in the care of immigrants with psychosis in Sweden. Experts (n=43) from different perspectives (immigrants, families, and health-care staff) were assembled and used to score the importance of statements regarding components in the care for a person with psychosis in three questionnaire rounds. After each round, the opinions were consolidated and compared to identify whether consensus was reached. Consensus was reached about the importance of being treated on equal terms, regardless of country of birth. Staff interest and respect, shown in different ways of understanding, was valued. Consensus could not be reached on approximately half of the statements, of which four tended to be ranked towards unimportant. Those included that staff should have specific cultural knowledge or that the patient should be allowed to decide whether to be cared for by male or female staff. Nor was it regarded as important to identify a person's religious or ethnic background. The results illustrate the importance of fundamental psychiatric nursing, which should enable nurses to identify and meet the basic needs of all patients, regardless of country of origin. Areas for which consensus was not reached illustrate a future challenge for health-care staff to identify situations when cultural clashes could appear. Staff should have strategies to accomplish cultural negotiations to build an effective treatment alliance with the patient, as well as the family, to meet individual needs.

Preventing the second episode: a systematic review and meta-analysis of psychosocial and pharmacological trials in first-episode psychosis

OBJECTIVE

The majority of first-episode psychosis (FEP) patients reach clinical remission; however, rates of relapse are high. This study sought to undertake a systematic review and meta-analysis of randomized controlled trials (RCTs) to determine the effectiveness of pharmacological and non-pharmacological interventions to prevent relapse in FEP patients.

METHODS

Systematic review and meta-analysis of RCTs.

RESULTS

Of 66 studies retrieved, 18 were eligible for inclusion. Nine studies investigated psychosocial interventions and 9 pharmacological treatments. The analysis of 3 RCTs of psychosocial interventions comparing specialist FEP programs vs treatment as usual involving 679 patients demonstrated the former to be more effective in preventing relapse (odds ratio [OR]=1.80, 95% confidence interval [CI]=1.31-2.48; P<.001; number needed to treat [NNT]=10). While the analysis of 3 different cognitive-behavioral studies not specifically intended at preventing relapse showed no further benefits compared with specialist FEP programs (OR=1.95, 95% CI=0.76-5.00; P=.17), the combination of specific individual and family intervention targeted at relapse prevention may further improve upon these outcomes (OR=4.88, 95% CI=0.97-24.60; P=.06). Only 3 small studies compared first-generation antipsychotics (FGAs) with placebo with no significant differences regarding relapse prevention although all individual estimates favored FGAs (OR=2.82, 95% CI=0.54-14.75; P=.22). Exploratory analysis involving 1055 FEP patients revealed that relapse rates were significantly lower with second-generation antipsychotics (SGAs) compared with FGAs (OR=1.47, 95% CI=1.07-2.01; P<.02; NNT=10).

CONCLUSIONS

Specialist FEP programs are effective in preventing relapse. Cognitive-based individual and family interventions may need to specifically target relapse to obtain relapse prevention benefits that extend beyond those provided by specialist FEP programs. Overall, the available data suggest that FGAs and SGAs have the potential to reduce relapse rates. Future trials should examine the effectiveness of placebo vs antipsychotics in combination with intensive psychosocial interventions in preventing relapse in the early course of psychosis. Further studies should identify those patients who may not need antipsychotic medication to be able to recover from psychosis.

The CACNA1C and ANK3 risk alleles impact on affective personality traits and startle reactivity but not on cognition or gating in healthy males

OBJECTIVES

The rs10994336 ANK3 and rs1006737 CACNA1C genetic variants have recently been identified as the most consistent, genome-wide significant risk factors for bipolar disorder, while the CACNA1C variant has also been associated with schizophrenia and major depression. The aim of this study was to examine the phenotypic consequences of the risk CACNA1C and ANK3 alleles in a large homogeneous cohort of healthy young males.

METHODS

We recruited 703 randomly selected, healthy army conscripts (mean age 22.1 ± 3.0 years) from the first wave of the Learning on Genetics of Schizophrenia project in Heraklion, Crete. Of those recruited, 530 subjects entered and completed the study. Subjects were assessed for prepulse inhibition (PPI), startle reactivity, neuropsychology, and personality.

RESULTS

  UNPHASED analysis revealed that the rs1006737 A-allele was associated with lower extraversion and higher harm avoidance, trait anxiety, and paranoid ideation, while the rs10994336 T-allele was associated with lower novelty seeking and behavioral activation scores (p < 0.01). Both alleles were associated with high startle reactivity (p < 0.05). There were no significant associations with any cognitive task performance or PPI.

CONCLUSIONS

The CACNA1C genotype was associated with proneness to anxiety and negative mood, while the ANK3 genotype was associated with proneness to anhedonia. Both risk genotypes were associated with high startle reactivity, suggesting a role of these polymorphisms in threat/stress signal processing, probably in the hippocampus and/or amygdala. None of the risk genotypes affected sensorimotor gating or behavioral performance in an extensive battery of executive function tests in this cohort of healthy males.

Transition to adulthood: the critical period for pre-emptive, disease-modifying care for schizophrenia and related disorders

There is an urgent need and a global opportunity to rethink not only the dominant research paradigms in etiological research but also to invest in less constrained strategies which cut across the existing diagnostic silos to seek out common risk factors, late as well as early neurodevelopmental processes, pathophysiologies, and novel treatment strategies. The high-quality research presented in this special issue of Schizophrenia Bulletin makes a compelling case for such a rethink. While there is still a genuine disconnect between our understanding of the complex and dramatic brain changes that occur during the transition to adulthood and the concurrent surge in incidence of mental ill-health, there is no doubt that a much more serious focus on the perionset stage of clinical disorders in young people with their rapidly evolving brains, social environments, and life trajectories could be extremely productive. Research access to these early stages of illness would be catalyzed by the widespread construction of engaging stigma-free portals and clinical scaffolding appropriate for young people in the 21st century. The latter are urgently required to supersede traditional models of care, which have served both patients and families so poorly, and equally have failed to unlock a deeper understanding of the origins and progression of potentially serious mental disorders.

Initial diagnosis and treatment in first-episode psychosis: can an operationalized diagnostic classification system enhance treating clinicians' diagnosis and the treatment chosen?

AIM

Diagnosis during the initial stages of first-episode psychosis is particularly challenging but crucial in deciding on treatment. This is compounded by important differences in the two major classification systems, International Classification of Diseases, 10th revision (ICD-10) and Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV). We aimed to compare the concordance between an operationalized diagnosis using Operational Criteria Checklist (OPCRIT) and treating clinician-generated diagnosis in first episode psychosis diagnosis and its correlation with treatment prescribed.

METHODS

Operationalized polydiagnostic assessments were conducted on 150 first-episode psychosis patients using OPCRIT. OPCRIT generated ICD-10, DSM-IV and treating clinician diagnoses were compared. The association between these diagnoses and choice of treatment was evaluated.

RESULTS

General agreement between the three classification systems was moderate to good, with kappa values between 0.460 and 0.674. There was a higher frequency of schizophrenia diagnosis in ICD-10 (n = 85) comparing to DSM-IV (n = 45) and similar in clinical diagnosis (n = 76), with moderate to good agreement between classifications (kappa between 0.602 and 0.731). No significant differences were found for ratings of psychotic depressive and manic/bipolar disorders with psychosis, with affective disorders having the higher agreement. Heterogeneous group of 'other disorders' achieved a kappa value from 0.250 (DSM-IV/ICD-10) to 0.566 (DSM-IV/clinical diagnosis).

CONCLUSION

Despite the challenges in first-episode psychosis diagnosis, it is possible to have a good agreement between OPCRIT-generated (DSM-IV and ICD-10) diagnoses and clinician based diagnoses, although some differences exist. The choice of psychopharmacological treatment prescribed matches well with these operationalized diagnoses.

Synergistic pathways to delusions: enduring vulnerabilities, proximal life stressors and maladaptive psychological coping

AIM

We sought to extend findings on the vulnerability to psychosis by investigating multifactorial pathways to delusions. Risk factors assessed spanned across early acquired vulnerabilities (heredity, childhood trauma, early cannabis use), proximal life stressors (life hassles, methamphetamine use) and psychological coping (experiential avoidance).

METHODS

Participants were recruited to a non-clinical sample (n = 133) or a clinical sample of psychosis patients (n = 100).

RESULTS

Path analyses indicated three distinct pathways predicting vulnerability to delusions in the non-clinical sample: (i) childhood emotional trauma combined with subsequent experiences of life hassles; (ii) heredity in combination with experiential avoidance; and (iii) early cannabis use combined with proximal methamphetamine use. The first pathway was partially mediated by experiential avoidance. The model was largely replicated in the clinical sample, with childhood sexual trauma replacing emotional trauma in the model.

CONCLUSION

The study demonstrated that vulnerability to delusions can be usefully predicted by a synergistic model incorporating early-acquired vulnerability factors, proximal day-to-day factors and cognitive styles.

The comprehensive assessment of at-risk mental states: from mapping the onset to mapping the structure

BACKGROUND

Improving the identification of clinical vulnerability to psychosis in help-seeking subjects is crucial for refining risk stratifications and implementing intervention strategies.

AIMS

To define underlying dimensions of subclinical psychopathology in Ultra-High-Risk (UHR) subjects; to test their temporal stability and association with baseline clinical and functional features; and to evaluate their predictive value for subsequent transition to psychosis.

METHOD

223 subjects meeting the Personal Assessment and Crisis Evaluation (PACE) criteria for UHR were assessed with the Comprehensive Assessment of At-Risk Mental States (CAARMS) and monitored for a period of up to three years. Data were analysed via principal component analysis (PCA), Spearman correlation analysis and Cox regression.

RESULTS

PCA of the CAARMS yielded three orthogonal symptom clusters (negative, disorganized and perceptual-affective instability) with substantial temporal stability over a one-month time span. These clusters were strongly related to global functioning, quality of life, baseline major psychopathology and duration of symptoms before referral. The severity of the CAARMS disorganized component was the strongest predictor of transition to frank psychosis at follow-up.

CONCLUSIONS

A dimensional approach to CAARMS-measured symptoms may refine current early identification heuristics and provide an alternative way to characterize UHR profiles complementary to the current categorical one.