Association of an Early Intervention Service for Psychosis With Suicide Rate Among Patients With First-Episode Schizophrenia-Spectrum Disorders

Trajectories of suicidality during a 2-year early-intervention program for first-episode psychosis: A longitudinal study

Little is known about the individual course of suicidal ideations and attempts (i.e., suicidality) after treatment initiation. We examined the trajectories of suicidality and associated risk factors over a 2-year early intervention program for first-episode psychosis in 450 patients (age range 18-35 years at admission) consecutively admitted from 2003 to 2017. Suicidality was assessed via systematic file review, while sociodemographic and clinical variables were assessed at admission. Latent class growth modelling identified three trajectories: low (69.6 %), initially high (22.9 %), and persistently high (7.6 %) suicidality. Patients who were younger, lived alone and were diagnosed with affective psychosis were significantly more likely to follow the initially high trajectory. Patients who attempted suicide up to 3 months before admission, lived alone and presented lower levels of the PANSS excited factor were significantly more likely to follow the persistently high trajectory. Attempting suicide up to 3 months before admission distinguished persistently high and initially high suicidality trajectories. Suicide risk during early intervention program for first-episode psychosis is heterogenous, with acute and enduring suicidal risk, suggesting the need to adapt suicide prevention strategies to these different risk profiles.

Self-Harm and Suicide Rates Before and After an Early Intervention Program for Patients With First-Episode Schizophrenia

Importance

Evidence on the association of early intervention services (EISs) with self-harm and suicide among patients with first-episode schizophrenia (FES) at older than 25 years is lacking.

Objective

To examine changes in self-harm and suicide rates among patients with FES before and after the implementation of an EIS program.

Design, Setting, and Participants

This population-based cohort study conducted among 37 040 patients aged 15 to 64 years with FES between January 1, 2001, and March 31, 2020, used electronic medical records from the Hong Kong Clinical Data Analysis and Reporting System. All patients were followed up from the first diagnosis of schizophrenia (the index date) until the date of their death or the end of the study period (March 31, 2021), whichever came first. Statistical analysis was performed from July to November 2023.

Exposure

The EIS extended the Early Assessment Service for Young People With Early Psychosis (EASY) program from patients aged 15 to 25 years to those aged 15 to 64 years (EASY Plus). The exposure was the implementation of the EASY Plus program in April 2011. The exposure period was defined as between April 2012 and March 2021 for the 1-year-time-lag analysis.

Main Outcomes and Measures

The outcomes were monthly rates of self-harm and suicide among patients with FES before and after the implementation of the EASY Plus program. Interrupted time series analysis was used for the main analysis.

Results

This study included 37 040 patients with FES (mean [SD] age at onset, 39 [12] years; 82.6% older than 25 years; 53.0% female patients). The 1-year-time-lag analysis found an immediate decrease in self-harm rates among patients aged 26 to 44 years (rate ratio [RR], 0.77 [95% CI, 0.59-1.00]) and 45 to 64 years (RR, 0.70 [95% CI, 0.49-1.00]) and among male patients (RR, 0.71 [95% CI, 0.56-0.91]). A significant long-term decrease in self-harm rates was found for all patients with FES (patients aged 15-25 years: RR, 0.98 [95% CI, 0.97-1.00]; patients aged 26-44 years: RR, 0.98 [95% CI, 0.97-0.99]; patients aged 45-64 years: RR, 0.97 [95% CI, 0.96-0.98]). Suicide rates decreased immediately after the implementation of the EASY Plus program among patients aged 15 to 25 years (RR, 0.33 [95% CI, 0.14-0.77]) and 26 to 44 years (RR, 0.38 [95% CI, 0.20-0.73]). Compared with the counterfactual scenario, the EASY Plus program might have led to 6302 fewer self-harm episodes among patients aged 26 to 44 years.

Conclusions and Relevance

This cohort study of the EASY Plus program suggests that the extended EIS was associated with reduced self-harm and suicide rates among all patients with FES, including those older than 25 years. These findings emphasize the importance of developing tailored interventions for patients across all age ranges to maximize the benefits of EISs.

Duration of Untreated Psychosis and Outcomes in First-Episode Psychosis: Systematic Review and Meta-analysis of Early Detection and Intervention Strategies

BACKGROUND

The role of duration of untreated psychosis (DUP) as an early detection and intervention target to improve outcomes for individuals with first-episode psychosis is unknown.

STUDY DESIGN

PRISMA/MOOSE-compliant systematic review to identify studies until February 1, 2023, with an intervention and a control group, reporting DUP in both groups. Random effects meta-analysis to evaluate (1) differences in DUP in early detection/intervention services vs the control group, (2) the efficacy of early detection strategies regarding eight real-world outcomes at baseline (service entry), and (3) the efficacy of early intervention strategies on ten real-world outcomes at follow-up. We conducted quality assessment, heterogeneity, publication bias, and meta-regression analyses (PROSPERO: CRD42020163640).

STUDY RESULTS

From 6229 citations, 33 intervention studies were retrieved. The intervention group achieved a small DUP reduction (Hedges' g = 0.168, 95% CI = 0.055-0.283) vs the control group. The early detection group had better functioning levels (g = 0.281, 95% CI = 0.073-0.488) at baseline. Both groups did not differ regarding total psychopathology, admission rates, quality of life, positive/negative/depressive symptoms, and employment rates (P > .05). Early interventions improved quality of life (g = 0.600, 95% CI = 0.408-0.791), employment rates (g = 0.427, 95% CI = 0.135-0.718), negative symptoms (g = 0.417, 95% CI = 0.153-0.682), relapse rates (g = 0.364, 95% CI = 0.117-0.612), admissions rates (g = 0.335, 95% CI = 0.198-0.468), total psychopathology (g = 0.298, 95% CI = 0.014-0.582), depressive symptoms (g = 0.268, 95% CI = 0.008-0.528), and functioning (g = 0.180, 95% CI = 0.065-0.295) at follow-up but not positive symptoms or remission (P > .05).

CONCLUSIONS

Comparing interventions targeting DUP and control groups, the impact of early detection strategies on DUP and other correlates is limited. However, the impact of early intervention was significant regarding relevant outcomes, underscoring the importance of supporting early intervention services worldwide.

Neural stem/progenitor cells from olfactory neuroepithelium collected by nasal brushing as a cell model reflecting molecular and cellular dysfunctions in schizophrenia

OBJECTIVES

Neural stem/progenitor cells derived from olfactory neuroepithelium (hereafter olfactory neural stem/progenitor cells, ONSPCs) are emerging as a potential tool in the exploration of psychiatric disorders. The present study intended to assess whether ONSPCs could help discern individuals with schizophrenia (SZ) from non-schizophrenic (NS) subjects by exploring specific cellular and molecular features.

METHODS

ONSPCs were collected from 19 in-patients diagnosed with SZ and 31 NS individuals and propagated in basal medium. Mitochondrial ATP production, expression of β-catenin and cell proliferation, which are described to be altered in SZ, were examined in freshly isolated or newly thawed ONSPCs after a few culture passages.

RESULTS

SZ-ONSPCs exhibited a lower mitochondrial ATP production and insensitivity to agents capable of positively or negatively affecting β-catenin expression with respect to NS-ONSPCs. As to proliferation, it declined in SZ-ONSPCs as the number of culture passages increased compared to a steady level of growth shown by NS-ONSPCs.

CONCLUSIONS

The ease and safety of sample collection as well as the differences observed between NS- and SZ-ONSPCs, may lay the groundwork for a new approach to obtain biological material from a large number of living individuals and gain a better understanding of the mechanisms underlying SZ pathophysiology.

Assessing the generalisability of the psychosis metabolic risk calculator (PsyMetRiC) for young people with first-episode psychosis with validation in a Hong Kong Chinese Han population: a 4-year follow-up study

Background

Metabolic syndrome (MetS) is common following first-episode psychosis (FEP), contributing to substantial morbidity and mortality. The Psychosis Metabolic Risk Calculator (PsyMetRiC), a risk prediction algorithm for MetS following a FEP diagnosis, was developed in the United Kingdom and has been validated in other European populations. However, the predictive accuracy of PsyMetRiC in Chinese populations is unknown.

Methods

FEP patients aged 15-35 y, first presented to the Early Assessment Service for Young People with Early Psychosis (EASY) Programme in Hong Kong (HK) between 2012 and 2021 were included. A binary MetS outcome was determined based on the latest available follow-up clinical information between 1 and 12 years after baseline assessment. The PsyMetRiC Full and Partial algorithms were assessed for discrimination, calibration and clinical utility in the HK sample, and logistic calibration was conducted to account for population differences. Sensitivity analysis was performed in patients aged >35 years and using Chinese MetS criteria.

Findings

The main analysis included 416 FEP patients (mean age = 23.8 y, male sex = 40.4%, 22.4% MetS prevalence at follow-up). PsyMetRiC showed adequate discriminative performance (full-model C = 0.76, 95% C.I. = 0.69-0.81; partial-model: C = 0.73, 95% C.I. = 0.65-0.8). Systematic risk underestimation in both models was corrected using logistic calibration to refine PsyMetRiC for HK Chinese FEP population (PsyMetRiC-HK). PsyMetRiC-HK provided a greater net benefit than competing strategies. Results remained robust with a Chinese MetS definition, but worse for the older age group.

Interpretation

With good predictive performance for incident MetS, PsyMetRiC-HK presents a step forward for personalized preventative strategies of cardiometabolic morbidity and mortality in young Hong Kong Chinese FEP patients.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Emotional distress and dysregulation as treatment targets to reduce suicide in psychosis: a scoping review

There is a pressing need for effective treatments that address the high rate of suicide observed among people with psychosis. In this scoping review we highlight two suicidogenic treatment targets that have been relatively neglected in people with psychotic disorders: emotional distress and emotion dysregulation. We review the research on these constructs in psychosis and their relationship to suicide in this population, and then make clinical recommendations based on research findings. Emotional distress and emotional dysregulation may be promising treatment targets for suicide among people with psychosis.

Modeling the effects of treatment resistance and anticholinergic burden on cognitive function domains in patients with schizophrenia

The contribution of anticholinergic burden to cognitive function in patients with treatment resistant schizophrenia (TRS) is uncertain. This case-control study aims to comprehensively examine the association between treatment resistance and cognitive functions and the contribution of anticholinergic burden in patients with schizophrenia. Anticholinergic burden of all patients was calculated using the Anticholinergic Cognitive Burden scale. Exploratory Factor Analysis of 11 cognitive assessments identified four cognitive domains: verbal memory, attention and general cognitive functions, visual memory and processing speed, and executive function. Two structural equation models (SEM) examined the relationship of TRS and these cognitive functions with, and without considering anticholinergic burden. A total of 288 participants were included (TRS N=111, non-TRS N=177). Patients with TRS performed poorer than the non-TRS group only in the executive function domain. Anticholinergic burden contributed significantly to the attention and general cognitive functions, visual memory and processing speed, and executive function. The impact of TRS on executive function was no longer significant after adding anticholinergic burden to the SEM. Results suggested that anticholinergic burden contributes to a wide range of cognitive function impairment in patients with schizophrenia and is likely to be part of the apparent differences of cognitive function between TRS and non-TRS.

What is the duration of untreated psychosis worldwide? - A meta-analysis of pooled mean and median time and regional trends and other correlates across 369 studies

Duration of untreated psychosis (DUP) has been associated with poor mental health outcomes. We aimed to meta-analytically estimate the mean and median DUP worldwide, evaluating also the influence of several moderating factors. This PRISMA/MOOSE-compliant meta-analysis searched for non-overlapping individual studies from inception until 9/12/2022, reporting mean ± s.d. or median DUP in patients with first episode psychosis (FEP), without language restrictions. We conducted random-effect meta-analyses, stratified analyses, heterogeneity analyses, meta-regression analyses, and quality assessment (PROSPERO:CRD42020163640). From 12 461 citations, 369 studies were included. The mean DUP was 42.6 weeks (95% confidence interval (CI) 40.6-44.6, k = 283, n = 41 320), varying significantly across continents (p < 0.001). DUP was (in descending order) 70.0 weeks (95% CI 51.6-88.4, k = 11, n = 1508) in Africa; 48.8 weeks (95% CI 43.8-53.9, k = 73, n = 12 223) in Asia; 48.7 weeks (95% CI 43.0-54.4, k = 36, n = 5838) in North America; 38.6 weeks (95% CI 36.0-41.3, k = 145, n = 19 389) in Europe; 34.9 weeks (95% CI 23.0-46.9, k = 11, n = 1159) in South America and 28.0 weeks (95% CI 20.9-35.0, k = 6, n = 1203) in Australasia. There were differences depending on the income of countries: DUP was 48.4 weeks (95% CI 43.0-48.4, k = 58, n = 5635) in middle-low income countries and 41.2 weeks (95% CI 39.0-43.4, k = 222, n = 35 685) in high income countries. Longer DUP was significantly associated with older age (β = 0.836, p < 0.001), older publication year (β = 0.404, p = 0.038) and higher proportion of non-White FEP patients (β = 0.232, p < 0.001). Median DUP was 14 weeks (Interquartile range = 8.8-28.0, k = 206, n = 37 215). In conclusion, DUP is high throughout the world, with marked variation. Efforts to identify and intervene sooner in patients with FEP, and to promote global mental health and access to early intervention services (EIS) are critical, especially in developing countries.

Carepath for overcoming psychosis early (COPE): first 5 years of clinical operation and prospective research in the Cavan-Monaghan early intervention service

OBJECTIVES

As Ireland confronts the many challenges of broadening the introduction of early intervention services (EIS) for first episode psychosis (FEP) as national policy, this article describes Carepath for Overcoming Psychosis Early (COPE), the EIS of Cavan-Monaghan Mental Health Service, and presents prospective research findings during its first 5 years of operation.

METHODS

COPE was launched as a rural EIS with an embedded research protocol in early 2012, following an education programme for general practitioners (GPs). Here, operational activities are documented and research findings presented through to late 2016.

RESULTS

During this period, 115 instances of FEP were incepted into COPE, 70.4% via their GP and 29.6% via the Emergency Department. The annual rate of inception was 24.8/100,000 of population aged > 15 years and was 2.1-fold more common among men than women. Mean duration of untreated psychosis was 5.7 months and median time from first psychotic presentation to initiation of antipsychotic treatment was zero days. Assessments of psychopathology, neuropsychology, neurology, premorbid functioning, quality of life, insight, and functionality compared across 10 DSM-IV psychotic diagnoses made at six months following presentation indicated minimal differences between them, other than more prominent negative symptoms in schizophrenia and more prominent mania in bipolar disorder.

CONCLUSIONS

COPE illustrates the actuality of introducing and the challenges of operating a rural EIS for FEP. Prospective follow-up studies of the 5-year COPE cohort should inform on the effectiveness of this EIS model in relation to long-term outcome in psychotic illness across what appear to be arbitrary diagnostic boundaries at FEP.

Mortality and suicidality in veterans health administration patients with newly-identified early episode psychosis

Within the Veterans Affairs (VA), management of self-harm is a major clinical priority. However, there is limited information on risks for self-harm among VA patients with emerging psychotic disorders relative to VA patients with other emerging mental health conditions. Using information from fiscal years 2010 through 2018, a national cohort of VA patients 30 or younger was classified based on mental health diagnoses into three groups: 1) early episode psychosis (EEP), 2) non-early episode psychosis mental health (non-EEP MH), or 3) no mental health (no MH). Analyses focused on cohort members' risk for all-cause mortality, suicide mortality, and non-fatal suicide attempts (NFSA) during the year following initial diagnosis of mental health conditions (or first year of VA care, for the no MH group). In unadjusted analyses, the EEP group had elevated rates of all-cause mortality, suicide mortality, and NFSA relative to the non-EEP MH and no MH groups and the non-EEP MH had elevated rates of all-cause mortality, suicide mortality, and NFSA relative to the no MH group. After adjusting for demographics and care receipt, EEP status was unrelated to all-cause mortality but associated with increased suicide mortality risk and NFSA. Non-EEP MH status was associated with reduced risk of all-cause mortality but increased risk for NFSA. In the year following first diagnosis, VA patients with EEP are at increased risk for suicide mortality and self-harm even after accounting for other risk factors. Clinical services targeting this crucial time can help promote safety for this vulnerable group.

Development of an individualized risk calculator of treatment resistance in patients with first-episode psychosis (TRipCal) using automated machine learning: a 12-year follow-up study with clozapine prescription as a proxy indicator

About 15-40% of patients with schizophrenia are treatment resistance (TR) and require clozapine. Identifying individuals who have higher risk of development of TR early in the course of illness is important to provide personalized intervention. A total of 1400 patients with FEP enrolled in the early intervention for psychosis service or receiving the standard psychiatric service between July 1, 1998, and June 30, 2003, for the first time were included. Clozapine prescriptions until June 2015, as a proxy of TR, were obtained. Premorbid information, baseline characteristics, and monthly clinical information were retrieved systematically from the electronic clinical management system (CMS). Training and testing samples were established with random subsampling. An automated machine learning (autoML) approach was used to optimize the ML algorithm and hyperparameters selection to establish four probabilistic classification models (baseline, 12-month, 24-month, and 36-month information) of TR development. This study found 191 FEP patients (13.7%) who had ever been prescribed clozapine over the follow-up periods. The ML pipelines identified with autoML had an area under the receiver operating characteristic curve ranging from 0.676 (baseline information) to 0.774 (36-month information) in predicting future TR. Features of baseline information, including schizophrenia diagnosis and age of onset, and longitudinal clinical information including symptoms variability, relapse, and use of antipsychotics and anticholinergic medications were important predictors and were included in the risk calculator. The risk calculator for future TR development in FEP patients (TRipCal) developed in this study could support the continuous development of data-driven clinical tools to assist personalized interventions to prevent or postpone TR development in the early course of illness and reduce delay in clozapine initiation.

Life expectancy and years of potential life lost in people with mental disorders: a systematic review and meta-analysis

Background

Mental disorders are associated with premature mortality. There is increasing research examining life expectancy and years-of-potential-life-lost (YPLL) to quantify the disease impact on survival in people with mental disorders. We aimed to systematically synthesize studies to estimate life expectancy and YPLL in people with any and specific mental disorders across a broad spectrum of diagnoses.

Methods

In this systematic review and meta-analysis, we searched Embase, MEDLINE, PsychINFO, WOS from inception to July 31, 2023, for published studies reporting life expectancy and/or YPLL for mental disorders. Criteria for study inclusion were: patients of all ages with any mental disorders; reported data on life expectancy and/or YPLL of a mental-disorder cohort relative to the general population or a comparison group without mental disorders; and cohort studies. We excluded non-cohort studies, publications containing non-peer-reviewed data or those restricted to population subgroups. Survival estimates, i.e., life expectancy and YPLL, were pooled (based on summary data extracted from the included studies) using random-effects models. Subgroup analyses and random-effects meta-regression analyses were performed to explore sources of heterogeneity. Risk-of-bias assessment was evaluated using the Newcastle-Ottawa Scale. This study is registered with PROSPERO (CRD42022321190).

Findings

Of 35,865 studies identified in our research, 109 studies from 24 countries or regions including 12,171,909 patients with mental disorders were eligible for analysis (54 for life expectancy and 109 for YPLL). Pooled life expectancy for mental disorders was 63.85 years (95% CI 62.63-65.06; I2 = 100.0%), and pooled YPLL was 14.66 years (95% CI 13.88-15.98; I2 = 100.0%). Disorder-stratified analyses revealed that substance-use disorders had the shortest life expectancy (57.07 years [95% CI 54.47-59.67]), while neurotic disorders had the longest lifespan (69.51 years [95% CI 67.26-71.76]). Substance-use disorders exhibited the greatest YPLL (20.38 years [95% CI 18.65-22.11]), followed by eating disorders (16.64 years [95% CI 7.45-25.82]), schizophrenia-spectrum disorders (15.37 years [95% CI 14.18-16.55]), and personality disorders (15.35 years [95% CI 12.80-17.89]). YPLLs attributable to natural and unnatural deaths in mental disorders were 4.38 years (95% CI 3.15-5.61) and 8.11 years (95% CI 6.10-10.13; suicide: 8.31 years [95% CI 6.43-10.19]), respectively. Stratified analyses by study period suggested that the longevity gap persisted over time. Significant cross-study heterogeneity was observed.

Interpretation

Mental disorders are associated with substantially reduced life expectancy, which is transdiagnostic in nature, encompassing a wide range of diagnoses. Implementation of comprehensive and multilevel intervention approaches is urgently needed to rectify lifespan inequalities for people with mental disorders.

Funding

None.

The relationship between sleep and suicidality in schizophrenia spectrum and other psychotic disorders: A systematic review

Individuals with Schizophrenia Spectrum Disorders (SSDs) have significantly higher rates of suicidal thoughts, attempts, and death by suicide in comparison to the general population. Sleep disturbances (reduced duration, timing and quality of sleep) are risk factors for suicidality in the general population, with research indicating the relationship is both immediate and accumulative. Sleep disturbances are also considered to be implicated in the onset and exacerbation of psychotic symptoms in SSDs. Reducing the risk of suicidality in SSDs remains an important public health priority, thus exploration of contributing risk factors is warranted. Sleep monitoring may also offer an adjunct risk monitoring method to suicidality assessments in SSDs, and a potential treatment target for psychotic symptoms. This review aimed to explore proximal and longitudinal relationships between self-reported and objectively measured sleep and suicidality in SSDs and other psychotic disorders. A comprehensive search of four databases was conducted. Eleven studies met the inclusion criteria (10 cross sectional and 1 longitudinal). Narrative synthesis indicated that self-reported sleep disturbances and sleep disorders (e.g. insomnia) were associated with increased risk of suicidal ideation and attempt. However, one study employing polysomnography did not find sleep to be associated with suicidality. Methodological limitations of the evidence base include: i) little experimental or longitudinal evidence, (ii) self-report and/or single item assessment of sleep disturbance, (iii) limited use of validated measures of suicidality, (iv) considerable research in long-term schizophrenia but sparse evidence in early psychosis. Future research should explore (i) cross-sectional and longitudinal relationships between specific aspects of suicidality and objective sleep parameters, (ii) use qualitative or mixed-methods designs to disentangle the nuances and bidirectionality in the sleep-suicide relationship, (iii) explore the psychological processes underpinning or mediating the sleep-suicide relationship in SSDs.

Impact of community mental health services on the adult psychiatric admission through the emergency unit: a 20-year population-based study

Background

There is a lack of real-life population-based study examining the effect of community mental health services on psychiatric emergency admission. In Hong Kong, Integrated Community Center for Mental Wellness (ICCMW) and telecare service were introduced in 2009 and 2012, respectively. We examined the real-life impact of these services on psychiatric emergency admissions over 20 years.

Methods

Number of psychiatric emergency admissions between 2001 and 2020 was retrieved from the Hong Kong Clinical Data Analysis & Reporting System. We used an interrupted time series analysis to examine monthly psychiatric admission trend before and after service implementation, considering socioeconomic and environmental covariates.

Findings

A total of 108,492 psychiatric emergency admissions (47.8% males; 64.9% aged 18-44 years) were identified from the study period, of which 56,858, 12,506, 12,295, 11,791, and 15,051 were that for schizophrenia-spectrum disorders, bipolar affective disorders, unipolar mood disorders, neuroses, and substance use disorders. ICCMW introduction has an immediate effect on psychiatric emergency admission (adjusted estimate per 100,000: -10.576; 95% CI, -16.635 to -4.518, p < 0.001), particularly among adults aged 18-44 years (-8.543; 95% CI, -13.209 to -3.877, p < 0.001), females (-5.843; 95% CI, -9.647 to -2.039, p = 0.003), and with neuroses (-3.373; 95% CI, -5.187 to -1.560, p < 0.001), without a significant long-term effect. Unemployment, seasonality, and infectious disease outbreak were significant covariates.

Interpretation

ICCMW reduced psychiatric emergency admission, but no further reduction following full implementation. Community mental health services should be dynamically tailored for different populations and socioeconomic variations over time.

Funding

None.

Clozapine dosing patterns and clinical outcomes in patients with treatment resistant schizophrenia

Clozapine is the only medication found to be effective for patients with treatment resistant schizophrenia-spectrum disorders (TRS) and its prescription patterns may impact on their outcomes. The study aims to explore the impact of clozapine dosing frequency, dose level and presence of pharmacological augmentation on the clinical, social and cognitive outcomes in patients with TRS. Patients with TRS and on clozapine were interviewed. Daily defined dose (DDD) and anticholinergic burden were calculated. Patients were categorized in three ways: the single daily dose (SDD) and multiple daily dose (MDD), ≤300 mg/day (LD) and >300 mg/day (HD) of clozapine, and clozapine monotherapy (MT) and augmentation therapy (AT). The impact of these clozapine prescription patterns and their interaction on patient outcomes were examined with ANOVA. Of 124 patients on clozapine, 98 patients (79%) had SDD, 59 patients (47.6%) received LD, and 58 patients (46.8%) had MT. Patients in the LD group had significantly better cognitive functions. Though no significant effect of clozapine dosing frequency on outcomes, among patients on LD, those on MDD had better processing speed, short-term and visual memory. Patients with MT had better motivation. Among patients on HD, those with MT had better motivation and vocational functioning. These results provide guidance to the clozapine prescription in a naturalistic setting to achieve optimizing outcomes for patients with TRS in social and cognitive functions. Further longitudinal studies are needed to verify the results.

Incidence, prevalence, and trajectories of suicidal ideation among clients enrolled in early intervention services for first episode psychosis in New York State

Knowledge on how suicidal ideation (SI) varies following first episode psychosis (FEP) onset is scarce. We identified 1-year trajectories of SI and baseline predictors of emergent SI among all 1298 clients aged 16-30 years enrolled between October 2013-December 2018 in OnTrackNY, a program providing early intervention services for FEP across New York State. Clinicians recorded baseline clinical and sociodemographic variables and quarterly assessments of SI over a one-year follow-up. We examined baseline correlates of baseline SI and of 1-year SI trajectory. Among clients not reporting baseline SI, we examined predictors of subsequent emergent SI. Baseline SI was reported by 349 (26.9 %) clients and associated with schizoaffective disorder, previous self-injurious behavior, any alcohol or substance use, higher symptom severity, poorer social functioning, and Non-Hispanic White, Asian or Hispanic ethnoracial background. Two hundred and two (15.6 % overall) clients stopped being suicidal within 6 months of follow-up. Persistent SI was reported by 147 (11.3 % overall) clients and, among clients not discharged before one year of follow-up, was associated with schizoaffective disorder, any alcohol use, being female, and being Hispanic or White Non-Hispanic. Among 949 (73.1 %) clients not reporting baseline SI, subsequent emergent SI was reported by 139 (10.7 % overall) and predicted at baseline by schizoaffective disorder, higher symptom severity, recent homelessness, and not being Hispanic. In conclusion, SI is highly prevalent and varies markedly over time among FEP early intervention clients. These results highlight the importance of ongoing assessment for SI among individuals experiencing FEP - even in the absence of baseline SI.

Impact of early negative symptom patterns on the long-term outcomes of patients with first-episode schizophrenia-spectrum disorders: A 12-year follow up study

Given the strong prognostic value of early negative symptoms (NS), understanding their associations with long-term outcomes of schizophrenia is essential. The study examined early NS patterns in trajectory, severity and variability and their association with 12-year outcomes. NS in the first 36 months after onset and the symptomatology, cognitive function, and functioning at 12 years were examined in 330 patients with first-episode schizophrenia spectrum disorders. The relationships and pathways between the outcomes at 12 years and the trajectory, severity, and variability of early NS were examined. We found that the prediction of trajectory of early NS to long-term outcomes was limited, whereas variability was negatively associated with the patient's long-term executive function, and severity was positively associated with long-term symptomatology and negatively associated with long-term functioning. Path modelling revealed that the severity and variability of early NS influenced patients' long-term functioning via cognitive function and/or clinical symptom pathways. Our findings support the notion that severity of early NS influences the prognosis of schizophrenia and the closer examination revealed that the severity and variability of early NS are differentially associated with long-term clinical symptoms, executive function, and functional outcomes via distinct pathways.

Neuropsychological functioning and suicidal behaviours in patients with first-episode psychosis: A systematic review

INTRODUCTION

Suicidal behaviour is particularly frequent in patients with psychosis. Therefore, prevention is a key objective of mental health policies. The aim of the current work is to systematically review the association between neurocognitive functioning and suicidal behaviour in patients with first-episode psychosis (FEP).

MATERIAL AND METHODS

Of the 3051 studies reviewed, only 7 met the inclusion criteria. Documents in English from their earliest date of coverage until January 2022 were searched for in the following databases: PubMed, Science Direct, Web of Science, Cochrane Library, PsycINFO (ProQuest), and Springerlink. We used the PICO strategy to collect and categorize the data from each selected manuscript.

RESULTS

Overall, the results showed that the risk of suicidal behaviour is higher for FEP patients in the presence of a number of factors: poorer general neuropsychological functioning (except for working memory), poorer social cognition, more depressive symptoms, longer duration of untreated psychosis, higher awareness of the illness, poorer premorbid adjustment, and more frequent cannabis use.

DISCUSSION

Comprehensive general neuropsychology and assessment of social cognition, together with routine clinical record keeping, may help to identify FEP patients at a greater risk of attempting suicide.

Mortality rates in people with first diagnosis of schizophrenia-spectrum disorders: A 5-year population-based cohort study

OBJECTIVE

Schizophrenia-spectrum disorder (SSD) is associated with increased premature death, with emerging data suggesting early illness course as a high-risk period for excess mortality. This study aimed to examine mortality rate in patients with incident SSD and differential mortality risk between inpatient-diagnosed and outpatient-diagnosed subsamples within 5 years of first diagnosis.

METHOD

This population-based cohort study identified 8826 patients aged 18-39 years receiving first-recorded SSD diagnosis upon service entry, comprising 3877 inpatient-diagnosed and 4949 outpatient-diagnosed patients, between 2006 and 2012 in Hong Kong using a territory-wide medical record database of public health care services. All-cause, natural-cause, and unnatural-cause mortality risks within 5 years after first diagnosis were quantified by standardized mortality ratios (SMRs) relative to the general population. We also directly compared mortality rates between inpatient and outpatient subsamples over 5-year follow-up.

RESULTS

SSD patients exhibited markedly elevated all-cause (SMR: 12.28, 95% confidence interval [CI]: [10.83, 13.88]), natural-cause (SMR: 3.76, 95% CI: [2.77, 4.98]) and unnatural-cause (SMR: 20.64, 95% CI: [17.49, 24.20]) mortality during first 5 years of diagnosis. Increased mortality rate was most pronounced in the first year of treatment, especially for unnatural deaths (SMR 32.2, 95% CI: [24.08, 42.22]). Discharged inpatient-diagnosed patients displayed significantly higher all-cause and unnatural-cause mortality rates than outpatient-diagnosed counterparts within first 3 years of treatment, and differential mortality risks on all-cause (adjusted hazard ratio [aHR]: 7.05, 95% CI: [2.02, 24.64]) and unnatural-cause (aHR: 5.15, 95% CI: [1.38, 19.19]) deaths were the highest in the first month of follow-up.

CONCLUSIONS

Substantial increase in early mortality risk among people with incident SSD, particularly in the first year of diagnosis and the time shortly after discharge, underscores an urgent need of targeted early intervention for effective suicide prevention and physical health improvement to minimize mortality gap.

Cost-Effectiveness of Early Intervention in Psychosis: A Modeling Study

OBJECTIVE

Programs for early intervention in psychosis have shown clinical efficacy. The authors aimed to evaluate the cost-effectiveness of early intervention programs compared with standard care for the treatment of first-episode psychosis in the United States.

METHODS

A decision-analytic model integrating published data on clinical efficacy, costs, and health utilities was developed to evaluate early intervention versus standard care over the lifetime of patients after their first psychotic episode. Model input data were derived from meta-analyses, clinical trials, and U.S. national data. The main outcomes included hospitalizations, employment rate, quality-adjusted life years (QALYs), lifetime health care costs, and incremental cost-effectiveness ratios (ICERs).

RESULTS

Compared with patients receiving standard care, patients in the early intervention strategy had 3.2 fewer hospitalizations and 2.7 more years of employment over the course of their remaining life expectancy. From a health care perspective, early intervention had an ICER of approximately $51,600 per QALY. From a societal perspective, early intervention saved costs (i.e., yielded greater health benefits and had lower costs compared with standard care). Results were sensitive to the effect of early intervention on suicide, cost of standard care, cost of early intervention, and the effect (relative risk) of early intervention on employment. A scenario analysis that excluded the effect (i.e., hazard ratio) of early intervention on suicide yielded an ICER of approximately $197,000 per QALY.

CONCLUSIONS

These results suggest that it is economically beneficial to fund early intervention in psychosis programs in the United States. The findings indicate that early intervention in psychosis saves costs (from the societal perspective) and is cost-effective (health care sector perspective).

Fear of relapse in schizophrenia: a mixed-methods systematic review

INTRODUCTION

Fears of relapse in people diagnosed with schizophrenia have long been recognised as an impediment to recovery and wellbeing. However, the extent of the empirical basis for the fear of relapse concept is unclear. A systematic review is required to collate available evidence and define future research directions.

METHODS

A pre-registered systematic search (PROSPERO CRD42020196964) of four databases (PubMED, MEDLINE-Ovid, PsycINFO-Ovid, and Cochrane Central Register of Controlled Trials) was conducted from their inception to 05/04/2021.

RESULTS

We found nine eligible studies. Five were quantitative (4 descriptive and 1 randomised controlled trial), and four were qualitative. The available quantitative evidence suggests that fear of relapse may have concurrent positive relationships with depression (r = 0.72) and suicide ideation (r = 0.48), and negative relationship with self-esteem (r = 0.67). Qualitative synthesis suggests that fear of relapse is a complex phenomenon with behavioural and emotional components which has both direct and indirect effects on wellbeing.

CONCLUSIONS

Evidence in this area is limited and research with explicit service user and carer involvement is urgently needed to develop new and/or refine existing measurement tools, and to measure wellbeing rather than psychopathology. Nonetheless, clinicians should be aware that fear of relapse exists and appears to be positively associated with depression and suicide ideation, and negatively associated with self-esteem. Fear of relapse can include fears of losing personal autonomy and/or social/occupational functioning. It appears to impact carers as well as those diagnosed with schizophrenia.

Dynamic Patterns of Symptoms and Functioning in Predicting Deliberate Self-harm in Patients with First-Episode Schizophrenia-Spectrum Disorders Over 3 Years

OBJECTIVES

Patients with schizophrenia have a significant risk of self-harm. We aimed to explore the dynamic relationship between symptomatology, functioning and deliberate self-harm (DSH) and evaluate the feasibility of developing a self-harm risk prediction tool for patients with first-episode schizophrenia (FES).

METHODS

Patients with FES (n = 1234) were followed up for 36 months. Symptomatology, functioning, treatment adherence and self-harm information were obtained monthly over the follow-up period. A time-varying vector autoregressive (VAR) model was used to study the contribution of clinical variables to self-harm over the 36th month. Random forest models for self-harm were established to classify the individuals with self-harm and predict future self-harm events.

RESULTS

Over a 36-month period, 187 patients with FES had one or more self-harm events. The depressive symptoms contributed the most to self-harm prediction during the first year, while the importance of positive psychotic symptoms increased from the second year onwards. The random forest model with all static information and symptom instability achieved a good area under the receiver operating characteristic curve (AUROC = 0.77 ± 0.023) for identifying patients with DSH. With a sliding window analysis, the averaged AUROC of predicting a self-event was 0.65 ± 0.102 (ranging from 0.54 to 0.78) with the best model being 6-month predicted future 6-month self-harm for month 11-23 (AUROC = 0.7).

CONCLUSIONS

Results highlight the importance of the dynamic relationship of depressive and positive psychotic symptoms with self-harm and the possibility of self-harm prediction in FES with longitudinal clinical data.

Longitudinal relapse pattern of patients with first-episode schizophrenia-spectrum disorders and its predictors and outcomes: A 10-year follow-up study

OBJECTIVE

This study explored the 10-year pattern of relapse of patients with first-episode schizophrenia-spectrum disorders (FES), predictors and outcomes of early and late relapse.

METHODS

Patients received EIS (N = 148) in Hong Kong between 1 July 2001 and 30 June 2002 were matched with those who entered standard care (N = 148) one year before. Relapse information over 10 years were obtained and 209 patients were interviewed at 10-year follow-up. Predictors of early relapse ([ER] relapse in initial three years) and late relapse group ([LR] relapse in year 4-10) and their differential outcomes were explored.

RESULTS

Fifty-six patients (26.8%) were relapse-free over 10 years with more EIS patients. Among the relapsed patients, 63.6% were ER patients who had the poorest longitudinal outcomes, including higher suicide attempts, violence episodes, more hospitalization and lower employment, whereas the LR patients do not differ much from the no relapse group. Relapse-free patients required less hospitalization in the first episode and lower antipsychotic dosage. The LR patients had less positive symptoms in year one but longer first-episode hospitalization and higher antipsychotic dosage.

CONCLUSIONS

Delaying the first relapse may help to improve the long-term outcomes. Good response to antipsychotic medications was associated with relapse-free over long-term. However, sufficient antipsychotic medications with good symptomatic control during the early stage of the illness is crucial for relapse prevention for other patients. These findings highlight illness heterogeneity and the importance in differential use of antipsychotics in relapse prevention.

Suicidal Thinking and Behavior in First Episode Schizophrenia: Findings from the 24-Month Follow-Up of the "Parma Early Psychosis" Program

Although suicide risk is relevant in First Episode Schizophrenia (FES), little data are reported on suicidal ideation and its longitudinal stability. Aim of this study was: (1) to evaluate incidence rates of suicide attempts, completed suicide and suicidal thinking in FES patients at baseline and along a 24-month follow-up period, (2) to investigate any relevant association of baseline suicidal ideation with psychopathology, and (3) to longitudinally monitor suicidal thinking during the 2-years of follow-up. Participants (n = 149; age = 12-35 years) were assessed with the Brief Psychiatric Rating Scale (BPRS) and the Positive and Negative Syndrome Scale. FES participants showed a 40.8% percentage of baseline suicidal ideation (i.e., BPRS item 4 cutoff score of ≥3) and a 2-year cumulative incidence rate of attempted suicide of 6.1%. One completed suicide (0.7%) was also found during the follow-up. Baseline suicidal ideation was positively correlated with depression and negatively correlated with younger age. These results support a routine monitoring of suicide risk in this young population at the point of entry into early intervention services.

Suicide and Psychosis: Results From a Population-Based Cohort of Suicide Death (N = 4380)

Approximately 5% of individuals with schizophrenia die from suicide. However, suicide in psychosis is still poorly characterized, partly due to a lack of adequate population-based clinical or genetic data on suicide death. The Utah Suicide Genetics Research Study (USGRS) provides a large population-based cohort of suicide deaths with medical record and genome-wide data (N = 4380). Examination of this cohort identified medical and genetic risks associated with type of suicide death and investigated the relative contributions of psychotic and affective symptoms to method of suicide. Key differences in method of suicide (common vs. atypical methods) were tested in relation to lifetime psychosis and genome-wide genetic risk for schizophrenia, major depressive disorder, and neuroticism. Consistent with previous studies, psychosis-spectrum disorders were observed to be common in suicide (15% of the cohort). Individuals with psychosis more frequently died from atypical methods, with rates of atypical suicide increasing across the schizophrenia spectrum. Genetic risk for schizophrenia was also associated with atypical suicide, regardless of clinical diagnosis, though this association weakened when filtering individuals with schizophrenia from the analysis. Follow-up examination indicated that high rates of atypical suicide observed in schizophrenia are not likely accounted for by restricted access to firearms. Overall, better accounting for the increased risk of atypical suicide methods in psychosis could lead to improved prevention strategies in a large portion of the suicide risk population.

Childhood maltreatment increases the suicidal risk in Chinese schizophrenia patients

OBJECTIVES

Childhood trauma might be a modifiable risk factor among adults with serious mental illness. However, the correlation of child trauma and suicide is unclear, which were cited most frequently as the biggest challenge to schizophrenia (SCZ) patients in China. We aim to study relationships between child trauma and suicide in SCZ patients of different disease stages.

METHODS

Ninety-one participants were included and divided into two groups, namely, first-episode group (n = 46), relapsed group (n = 45). The Positive and Negative Syndrome Scale was used to evaluate the severity of psychotic symptoms. The Beck's Suicide Intent Scale and The Nurses' Global Assessment of Suicide Risk were conducted by patient self-report to assess suicide symptom. The childhood trauma questionnaire was used to estimate severity of traumatic stress experienced during childhood.

RESULTS

Childhood trauma and different dimensions of suicide were significantly higher in the relapsed group than first-episode group (P < 0.01, respectively). BMI has a significant positive relationship with recent psychosocial stress (β = 0.473, t = 3.521, P < 0.001) in first-episode group. As in relapsed group, BMI has a positive effect between severe mental illness and suicide ideation (β = 0.672, t = 5.949, P < 0.001; β = 0.909, t = 2.463, P < 0.001), Furthermore, emotional neglect presented positively related to the suicide risk and proneness to suicidal behavior (β = 0.618, t = 5.518, P < 0.001; β = 0.809, t = 5.356, P < 0.001).

CONCLUSION

Relapsed group of patients had significantly more severe childhood trauma, recent psychosocial stress, suicidal risk and proneness to suicidal behavior. BMI and emotional neglect are unique predictors for different dimensions of suicide.

Integration of biological and psychological illness attributional belief in association with medication adherence behaviour: A path analysis

AIM

This study aimed to determine the association of biological (BAB) and psychological illness attributional beliefs (PAB) with medication adherence behaviour in patients with psychosis in Hong Kong.

METHODS

A cross-sectional survey of 301 outpatients with psychosis in Hong Kong was conducted from August to October 2016. The survey included a set of questionnaires examining patient medication adherence behaviours (using five behavioural items from the Medication Adherence Rating Scale), illness attributional belief, insight into the illness, and attitudes towards antipsychotics and medical professionals. The associations between these variables were analysed using path analysis and adjusted for covariates of perceived social support, experience of side-effects, and gender.

RESULTS

The data fit a model in which medication adherence behaviour was associated with illness attributional belief, insight, and attitudes (chi-square = 32.33, p = .26; RMSEA = 0.02; SRMR = 0.04; and CFI = 0.97). BAB was positively and directly associated with medication adherence behaviour. PAB was positively and indirectly associated with medication adherence behaviour through insight into the illness and attitude towards medical professionals. PAB can strengthen the relationship between BAB and insight, and only the high PAB group exhibited a positive relationship between BAB and attitude towards medical professionals.

CONCLUSIONS

An integration of biological and psychological attributional beliefs in patients with psychosis is essential for better medication adherence behaviour. Future interventions should aim to modify patients' illness attributional beliefs by integrating both biological and psychological illness attribution to improve medication adherence.

Individual psychotherapy can reduce suicidal ideation in first episode psychosis: Further findings from the 2-year follow-up of the 'Parma Early Psychosis' programme

INTRODUCTION

Suicidal thinking is relevant in patients with First Episode Psychosis (FEP). However, longitudinal studies specifically examining treatment response for suicidal ideation in FEP are still relatively scarce, especially with long-term design and in real-world clinical settings. The aims of this research were (A) to longitudinally assess suicidal thoughts in people with FEP along a 2-year follow-up period and (B) to overtime investigate any significant association of suicidal ideation levels with the specific treatment components of an 'Early Intervention in Psychosis' (EIP) protocol along the 2 years of follow-up.

METHODS

At entry, 232 FEP participants (aged 12-35 years) completed the Brief Psychiatric Rating Scale (BPRS), including a 'Suicidality' item subscore. Multiple linear regression analysis was then performed.

RESULTS

Across the follow-up, FEP subjects showed a relevant decrease in suicidal thinking levels overtime. This was specifically predicted by the total number of individual psychotherapy sessions offered within the 2-year EIP protocol and antidepressant dose (at least as regards the first year of our intervention).

CONCLUSION

Suicidal ideation is clinically relevant in FEP but seems to improve overtime together with the provision of specific, patient-tailored and integrated EIP treatments, especially individual psychotherapy.

Nutrition, nutritional deficiencies, and schizophrenia: An association worthy of constant reassessment

Schizophrenia is a mental health disorder that occurs worldwide, cutting across cultures, socioeconomic groups, and geographical barriers. Understanding the details of the neurochemical basis of schizophrenia, factors that contribute to it and possible measures for intervention are areas of ongoing research. However, what has become more evident is the fact that in targeting the neurochemical imbalances that may underlie schizophrenia, the type of response seen with currently available phamacotherapeutic agents does not provide all the answers that are needed. Therefore, the possible contribution of non-pharmacological approaches to schizophrenia management is worthy of consideration. In recent times, research is beginning to show nutrition may play a possibly significant role in schizophrenia, affecting its development, progression and management; however, while attempts had been made to examine this possible relationship from different angles, articles addressing it from a holistic point of view are not common. In this review, we examine existing scientific literature dealing with the possible relationship between nutrition and schizophrenia, with a view to elucidating the impact of diet, nutritional deficiencies and excesses on the aetiology, progression, management and outcome of schizophrenia. Secondly, the effect of nutritional supplements in prevention, as sole therapy, or adjuncts in schizophrenia management are examined.

Experiences and perceptions of people living with schizophrenia in Japan: A qualitative study

This descriptive study used a qualitative inductive approach to investigate the subjective experiences and perceptions of people with schizophrenia living in the community during times of difficulty and how they coped. We conducted semi-structured interviews with nine community-dwelling people with schizophrenia and used the KJ method developed by Kawakita Jiro to structure the data obtained. We identified 10 symbols with his method: bewilderment at the onset; helplessness and longing for death; solitude linked to death; precarious daily life; relationships at risk; fear of being stigmatized; pillars of emotional support; will to overcome; hope to never give up; and living with the illness. The results suggest that community mental health nurses should provide support so their patients can continue to have pillars of emotional support and the will to overcome difficulties, as well as continue to use their coping methods, even when experiencing many difficulties. It is important that nurses understand and share in their patients' difficult experiences and hopes when providing support toward their recovery.

Incidence and method of suicide mortality in patients with schizophrenia: a Nationwide Cohort Study

PURPOSE

Suicide is a leading cause of death in patients with schizophrenia. This nationwide cohort study investigated the incidence of each suicide method in patients with schizophrenia compared with the general population.

METHODS

In total, records of 174,039 patients with schizophrenia were obtained from the National Health Insurance Research Database in Taiwan from 2001 to 2016. This schizophrenia cohort was linked with the national mortality database, and 26,926 patients died during this follow-up period. Of the deceased, 3033 had died by suicide. Univariate Cox regression was used to estimate the demographic variables associated with suicide. We estimated the difference in the proportion of each suicide method used in patients with schizophrenia compared with the general population. The incidence and standardized mortality ratio (SMR) of each suicide method were calculated and stratified based on sex.

RESULTS

Patients aged 25-34 years exhibited the highest suicide risk. Compared with the general population, patients with schizophrenia were more likely to commit suicide by jumping and drowning and less likely to use charcoal-burning and hanging. Women showed a higher incidence of suicide by drowning and jumping than did men. Comorbidity with substance use disorders (SUDs) was associated with a high suicide SMR (26.9, 95% confidence interval [CI] = 23.4-28.9), particularly for suicide by jumping (61.2, 95% CI = 48.3-76.3).

CONCLUSIONS

Patients with schizophrenia had higher suicide rates for all methods than did the general population. Suicide method differed based on sex. Patients with SUDs exhibit a high SMR for each suicide method and warrant intensive clinical attention.

Associations between veteran encounters with suicide prevention team and suicide-related outcomes

OBJECTIVE

Suicide rates have been of increasing concern across the United States, particularly among military veterans. The Veterans Health Administration has initiated multiple suicide prevention initiatives, but little research has examined the impact of these programs. The purpose of this study was to test the hypothesis that more frequent contact with suicide prevention clinicians would predict lower odds of suicidal behavior.

METHOD

Retrospective medical record review was performed for 1364 veterans identified as high risk for suicide during 2012-2018. Logistic regression was used to test whether the number of suicide prevention contacts predicted the odds of suicide attempt, any self-directed violence, or reactivation of high-risk status in the next year, accounting for age, sex, length of high-risk episode, and other mental health contacts.

RESULTS

Each additional suicide prevention coordinator contact was associated with 4%-5% lower odds of suicide attempt, suicidal behavior, and reactivation of high-risk status in the next year (ps < 0.05). For suicide attempt and self-directed violence, associations were stronger when considering only initial high-risk episodes (8%-10% lower odds, ps < 0.05).

CONCLUSIONS

Findings suggest ongoing support from suicide prevention clinicians can have a significant protective effect. Additional research is needed to identify mechanisms by which this support reduces risk.

Suicidality and social problem-solving skills among individuals with first-episode psychosis participating in Coordinated Specialty Care

AIM

Although suicidal ideation may decrease over the course of participation in specialized clinical programmes for first-episode psychosis (FEP), it is unclear whether such improvements exceed those that occur during treatment as usual. Clarifying the mechanisms underlying reductions in suicidal ideation and behaviour among individuals with first-episode psychosis may highlight important strategies through which specialized clinical programmes can increase the potency of their services to reduce suicidality among this high-risk population. Thus, the goal of this study is to evaluate the longitudinal relationships between suicidality and social problem-solving skills among individuals with FEP participating in Coordinated Specialty Care.

METHODS

Within-subject mediational and moderational models were applied to explore the interrelationships and longitudinal course of suicidality, social problem-solving and duration of untreated psychosis (DUP).

RESULTS

Over the first 6 months of care, individuals with FEP experienced improvements in social problem-solving skills that were found to mediate concurrent reductions in suicidality. Although longitudinal changes in social problem-solving skills were moderated by DUP, these results should be interpreted cautiously as they may stem in part from a relatively limited number of participants with longer durations of illness.

CONCLUSIONS

Improvements in social problem-solving skills during participation in CSC may facilitate reductions in suicidality. Treatments targeting suicidality among individuals with FEP may thus benefit from working to enhance social problem-solving skills among these individuals. Further research is needed to clarify if and how DUP may influence the magnitude of change in social problem-solving skills during participation in CSC.

Comparison of Long-Acting Injectable Antipsychotics With Oral Antipsychotics and Suicide and All-Cause Mortality in Patients With Newly Diagnosed Schizophrenia

IMPORTANCE

Schizophrenia is generally considered to be among the most severe psychiatric disorders because of the excessive mortality associated with it. Research to find means to reduce this excessive mortality is warranted.

OBJECTIVE

To investigate associations of long-acting injectable antipsychotics (LAIs) with all-cause, natural-cause, and suicide mortality risks as well as the impacts of early use of LAIs in patients with newly diagnosed schizophrenia.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used data from the Taiwan National Health Insurance Research Database to construct a population-based cohort of patients with schizophrenia who received oral antipsychotics (OAPs) from January 1, 2002, to December 31, 2017. Within this cohort, the LAI group was defined as patients who switched to LAIs and were prescribed LAIs at least 4 times within 1 year. The LAI group was propensity matched 1:1 to patients who continued receiving OAPs of the same compounds. All patients were followed up until switching the antipsychotic administration route, death, or the end of the study (December 31, 2018), whichever occurred first. Data analysis was performed from January 2002 to December 2018.

MAIN OUTCOMES AND MEASURES

All-cause mortality, natural-cause mortality, suicide mortality, and suicide attempts.

RESULTS

In total, 2614 patients who switched to LAIs (median [interquartile range] {IQR} age, 30 [23-39] years) and 2614 who received OAPs (median [IQR] age, 30 [23-39] years) were included (1333 male patients [51.0%] in each group). During the 16-year follow-up period (median [IQR] follow-up of 14 [10-17] years), patients who switched to LAIs had lower risks of all-cause mortality (adjusted hazard ratio [aHR], 0.66; 95% CI, 0.54-0.81), natural-cause mortality (aHR, 0.63; 95% CI, 0.52-0.76), and suicide attempts (incidence rate ratio, 0.72; 95% CI, 0.55-0.93) compared with patients who received the corresponding OAPs. A 47% lower suicide mortality risk (aHR, 0.53; 95% CI, 0.30-0.92) was observed in patients who switched to LAIs within the first 2 years of OAP initiation.

CONCLUSIONS AND RELEVANCE

These findings suggest that LAI use in patients with newly diagnosed schizophrenia is associated with decreased all-cause mortality and suicide risk. Furthermore, early treatment with LAIs within the first 2 years of OAP initiation was associated with a decrease in suicide mortality risk. Thus, LAI use in the early stage of treatment should be actively considered for patients with newly diagnosed schizophrenia.

Suicidality Over the First 5 Years of Psychosis: Does Extending Early Intervention Have Benefits?

OBJECTIVE

We aimed to investigate whether individuals with first-episode psychosis (FEP) receiving extended early intervention (EI) were less likely to experience suicidal ideation and behaviors than those transferred to regular care after 2 years of EI. Another objective was to examine the 5-year course of suicidality in FEP.

METHODS

We conducted a secondary analysis of a randomized controlled trial where 220 patients were randomized after 2 years of EI to receive extended EI or regular care for the subsequent 3 years. Suicidality was rated using the Brief Psychiatric Rating Scale. Linear mixed model analysis was used to study time and group effects on suicidality.

RESULTS

Extended EI and regular care groups did not differ on suicidality. There was a small decrease in suicidality over time, F(7, 1038) = 1.84, P = 0.077, with an immediate sharp decline within a month of treatment, followed by stability over the remaining 5 years. Patients who endorsed suicidality at entry (46.6%) had higher baseline positive, negative, and depressive symptoms. The 5-year course fell in 3 groups: never endorsed suicidality (33.9%), endorsed suicidality at low-risk levels (43.1%), and endorsed high-risk levels (23.0%). The high-risk group had a higher proportion of affective versus nonaffective psychosis diagnosis; higher baseline positive and depressive symptoms; higher 5-year mean depression scores, and fewer weeks of positive symptom remission over the 5-year course.

CONCLUSIONS

The first month of treatment is a critical period for suicide risk in FEP. Although early reductions in suicidality are often maintained, our findings make the case for sustained monitoring for suicide risk management.

Trajectories of suicidal ideation after first-episode psychosis: a growth mixture modeling approach

OBJECTIVE

The period immediately after the onset of first-episode psychosis (FEP) may present with high risk for suicidal ideation (SI) and attempts, although this risk may differ among patients. Thus, we aimed to identify trajectories of SI in a 2-years follow-up FEP cohort and to assess baseline predictors and clinical/functional evolution for each trajectory of SI.

METHODS

We included 334 FEP participants with data on SI. Growth mixture modeling was used to identify trajectories of SI. Putative sociodemographic, clinical, and cognitive predictors of the distinct trajectories were examined using multinomial logistic regression.

RESULTS

We identified three distinct trajectories: Non-SI trajectory (85.53% sample), Improving SI trajectory (9.58%), and Worsening SI trajectory (6.89%). Multinomial logistic regression model revealed that greater baseline pessimistic thoughts, anhedonia, and worse perceived family environment were associated with higher baseline SI followed by an Improving trajectory. Older age, longer duration of untreated psychosis, and reduced sleep predicted Worsening SI trajectory. Regarding clinical/functional evolution, individuals within the Improving SI trajectory displayed moderate depression at baseline which ameliorated during the study period, while the Worsening SI subgroup exhibited persistent mild depressive symptoms and greater functional impairment at follow-up assessments.

CONCLUSION

Our findings delineated three distinct trajectories of SI among participants with FEP, one experiencing no SI, another in which SI might depend on acute depressive symptomatology, and a last subset where SI might be associated with mild but persistent clinical and functional impairments. These data provide insights for the early identification and tailored treatment of suicide in this at-risk population.

The predictive power of expressed emotion and its components in relapse of schizophrenia: a meta-analysis and meta-regression

BACKGROUND

Schizophrenia is a longstanding condition and most patients experience multiple relapse in the course of the condition. High expressed emotion (HEE) has been found to be a predictor of relapse. This meta-analysis and meta-regression examined the association of global EE and relapse specifically focusing on timing of relapse and EE domains.

METHODS

Random-effects model was used to pool the effect estimates. Multiple random-effects meta-regression was used to compute the moderator analysis. Putative effect moderators including culture, EE measurements, age, length of condition and study quality were included.

RESULTS

Thirty-three prospective cohort studies comprising 2284 patients were included in the descriptive review and 30 studies were included for meta-analysis and meta-regression. Findings revealed that global HEE significantly predicted more on early relapse (⩽12 months) [OR 4.87 (95% CI 3.22-7.36)] than that on late relapse (>12 months) [OR 2.13 (95% CI 1.36-3.35)]. Higher level of critical comments (CC) significantly predicted relapse [OR 2.22 (95% CI 1.16-4.26)], whereas higher level of warmth significantly protected patients from relapse [OR 0.35 (95% CI 0.15-0.85)]. None of the moderators included significantly change the results.

CONCLUSIONS

These findings indicate that there is a dynamic interaction between EE-relapse association with time, and CC and warmth are the two important EE domains to influence relapse among patients with schizophrenia. Results also confirmed the foci of family interventions on reducing CC and improving warmth in relationship.

Cariprazine in the management of negative symptoms of schizophrenia: state of the art and future perspectives

In schizophrenia, dopaminergic hyperactivity in the mesolimbic regions, or possibly even selectively so in the dorsal striatum, seems to cause the emergence of psychotic symptoms, whereas dopaminergic hypoactivity in cortical regions underlies the negative symptoms and cognitive deficits. Managing the negative symptoms is a major current challenge in the treatment of schizophrenia with a dearth of novel modalities to address this clinical issue. Cariprazine is a novel second-generation antipsychotic that specifically targets the D3 receptor mainly associated to negative symptoms. The review summarizes the main issues regarding negative symptom management and the role of cariprazine treatment.

Perspective on medication decisions following remission from first-episode psychosis

While antipsychotics (APs) could provide rapid relief of positive symptoms in psychotic disorders, their usage is often associated with side effects, stigma and inconveniences. For these and other reasons, many psychosis patients, particularly those of first-episode psychosis (FEP) in remission, wish to discontinue maintenance treatment. The current review aims to discuss the strategies of AP treatment following remission from FEP, with particular emphasis on the evaluation of outcomes following AP discontinuation. Upon review of relevant literature, three potential strategies are put forth for treatment-responsive, remitted FEP patients: a) life-long maintenance treatment, b) AP discontinuation during second year of treatment, or c) AP discontinuation after three years of treatment. In theory, the first strategy presents the safest option for maximal symptom control. However, a rigorous RCT indicates that if AP discontinuation is to be attempted, the third strategy best prevents poor long-term clinical outcomes. Further data is needed to address the costs and benefits of each treatment strategy, compare AP-free patients with those on different types of APs, as well as explore even longer-term outcomes.

Mortality and suicide in schizophrenia: 21-year follow-up in rural China

BACKGROUND

Little is known about the trend and predictors of 21-year mortality and suicide patterns in persons with schizophrenia.

AIMS

To explore the trend and predictors of 21-year mortality and suicide in persons with schizophrenia in rural China.

METHOD

This longitudinal follow-up study included 510 persons with schizophrenia who were identified in a mental health survey of individuals (≥15 years old) in 1994 in six townships of Xinjin County, Chengdu, China, and followed up in three waves until 2015. Kaplan-Meier survival analysis and Cox hazard regressions were conducted.

RESULTS

Of the 510 participants, 196 died (38.4% mortality) between 1994 and 2015; 13.8% of the deaths (n = 27) were due to suicide. Life expectancy was lower for men than for women (50.6 v. 58.5 years). Males consistently showed higher rates of mortality and suicide than females. Older participants had higher mortality (hazard ratio HR = 1.03, 95% CI 1.01-1.05) but lower suicide rates (HR = 0.95, 95% CI 0.93-0.98) than their younger counterparts. Poor family attitudes were associated with all-cause mortality and death due to other causes; no previous hospital admission and a history of suicide attempts independently predicted death by suicide.

CONCLUSIONS

Our findings suggest there is a high mortality and suicide rate in persons with schizophrenia in rural China, with different predictive factors for mortality and suicide. It is important to develop culture-specific, demographically tailored and community-based mental healthcare and to strengthen family intervention to improve the long-term outcome of persons with schizophrenia.

Predictors of Treatment-Resistant and Clozapine-Resistant Schizophrenia: A 12-Year Follow-up Study of First-Episode Schizophrenia-Spectrum Disorders

Studies on the long-term development and early predictors of treatment-resistant schizophrenia (TRS) and clozapine-resistant TRS (CR-TRS) in patients with first-episode schizophrenia-spectrum disorders (FES) are limited and have not considered the impact of early intervention services (EIS). This study aimed to explore the development of TRS and CR-TRS among patients with FES over 12 years of follow-up. Of the 1234 patients with FES, 15% developed TRS. A total of 450 patients with schizophrenia or schizoaffective disorder were included in a nested case-control study (157 TRS and 293 non-TRS). Younger age of onset, poorer premorbid social adjustment during adulthood, longer duration of first episode, a greater number of relapses, and a higher antipsychotic dose in the first 24 months were associated with earlier TRS. CR-TRS patients, constituting 25% of TRS patients, had a poorer premorbid social adjustment in late adolescence and longer delay before clozapine initiation compared with non-CR-TRS. CR-TRS had poorer clinical and functional outcomes at 12-year follow-up. However, TRS patients on clozapine had a lower mortality rate compared with non-TRS patients. EIS did not have a significant impact on the development of TRS, but patients in the EIS group had a shorter delay of clozapine initiation. Results suggested that neurodevelopmental factors, early clinical characteristics, and requirement for higher antipsychotic dose may be associated with TRS development, highlighting multiple pathways leading to this form of illness. Specific interventions including relapse prevention and early initiation of clozapine during the early course of illness may reduce the rate of TRS and improve patient outcomes.

Excess Mortality and Life-Years Lost in People With Schizophrenia and Other Non-affective Psychoses: An 11-Year Population-Based Cohort Study

Psychotic disorders are associated with premature mortality, but research was primarily based on Western countries and rarely examined non-affective psychoses other than schizophrenia (ONAP). This population-based cohort study investigated excess mortality in 46 896 schizophrenia and 20 651 ONAP patients between January 2006 and December 2016 in Hong Kong (HK), by estimating all-cause and cause-specific standardized mortality ratios (SMRs), and life-years lost (LYLs), a recently developed, more precise reduced life expectancy measure taking into account the illness onset (age at first-recorded diagnosis). Changes in mortality metrics over the study period were assessed. Study data were retrieved from a territory-wide medical-record database of public healthcare services to 7.5 million HK residents. Results showed that schizophrenia and ONAP patients had higher all-cause (schizophrenia: SMR: 2.49 [95% CI: 2.43-2.55]; ONAP: 2.00 [1.92-2.09]), natural-cause (1.80 [1.74-1.85]; 1.47 [1.40-1.54]), and unnatural-cause (6.97 [6.47-7.49]; 8.53 [7.61-9.52]) mortality rates than general population. Respiratory diseases, cardiovascular diseases, and cancers accounted for the majority of deaths in patient cohorts. Men and women with schizophrenia had 9.53 years and 8.07 years of excess LYLs, respectively. For ONAP, excess LYLs was 8.18 years for men and 5.44 years for women. The overall mortality gap remained similar for both patient groups over time despite their improved longevity and declined unnatural-cause mortality rates. Taken together, schizophrenia and ONAP are associated with increased premature mortality and substantially reduced lifespan in a predominantly Chinese population, with excess deaths mainly attributed to a natural cause. Persistent mortality gap highlights an urgent need for targeted interventions to improve the physical health of patients with psychotic disorders.

Ten-year employment patterns of patients with first-episode schizophrenia-spectrum disorders: comparison of early intervention and standard care services

BACKGROUND

Little is known about long-term employment outcomes for patients with first-episode schizophrenia-spectrum (FES) disorders who received early intervention services.

AIMS

We compared the 10-year employment trajectory of patients with FES who received early intervention services with those who received standard care. Factors differentiating the employment trajectories were explored.

METHOD

Patients with FES (N = 145) who received early intervention services in Hong Kong between 1 July 2001 and 30 June 2002 were matched with those who entered standard care 1 year previously. We used hierarchical clustering analysis to explore the 10-year employment clusters for both groups. We used the mixed model test to compare cluster memberships and piecewise regression analysis to compare the employment trajectories of the two groups.

RESULTS

There were significantly more patients who received the early intervention service in the good employment cluster (early intervention: N = 98 [67.6%]; standard care: N = 76 [52.4%]; P = 0.009). In the poor employment cluster, there was a significant difference in the longitudinal pattern between early intervention and standard care for years 1-5 (P < 0.0001). The number of relapses during the first 3 years, months of full-time employment during the first year and years of education were significant in differentiating the clusters of the early intervention group.

CONCLUSIONS

Results suggest there was an overall long-term benefit of early intervention services on employment. However, the benefit was not sustained for all patients. Personalisation of the duration of the early intervention service with a focus on relapse prevention and early vocational reintegration should be considered for service enhancement.

Effectiveness of Suicide-Focused Psychosocial Interventions in Psychosis: A Systematic Review and Meta-Analysis

OBJECTIVE

Suicide ideation, plan, attempt, and death are significant and prevalent concerns among individuals with psychosis. Previous studies have focused on risk factors, but few have systematically evaluated the effect of psychosocial interventions on these experiences among individuals with psychosis. This study evaluated the effectiveness of psychosocial interventions in reducing suicide ideation, plan, attempt, and death among individuals with psychotic symptoms.

METHODS

Eight electronic databases were systematically searched from inception until June 30, 2019. Identified studies included both randomized controlled trials and controlled trials without randomization that examined psychosocial interventions for suicide ideation, plan, attempt, and death among individuals with psychotic symptoms. A random-effects model was used to pool the effect sizes for synthesis.

RESULTS

Eleven studies with 14 effect sizes (N=4,829 participants) were analyzed. The average age of participants ranged from 21 to 51, and most participants identified as male and non-Hispanic Caucasian or Chinese and were in an early or first-episode stage of illness. On average, participants who received psychosocial interventions were less likely than their counterparts in the control group to report suicide ideation, plan, and attempt and die by suicide (odds ratio [OR]=0.57, 95% confidence interval [CI]=0.41-0.78). Subgroup analyses further revealed significant reductions in suicide ideation (OR=0.73, 95% CI=0.55-0.97) and suicide death (OR=0.45, 95% CI=0.30-0.68) among intervention participants.

CONCLUSIONS

Preliminary evidence indicated that psychosocial interventions are effective in reducing suicide ideation, plan, attempt, and death among individuals with psychotic symptoms. Intervention characteristics, however, varied across studies, which suggests a lack of consensus on best clinical practices.

Cognitive behavioural family intervention for people diagnosed with severe mental illness and their families: A systematic review and meta-analysis of randomized controlled trials

WHAT IS KNOWN ON THE SUBJECT?: Cognitive behavioural therapy for psychosis (CBTp) and family intervention (FI) for psychosis are effective evidence-based interventions, but they are practically difficult to be implemented in many clinical settings. The CBTp and FI approaches have been integrated to form cognitive behavioural family intervention (CBFI). This brief intervention may be more feasible to implement in clinical practice. A few individual studies reported the effectiveness of CBFI, but no systematic review and meta-analysis have been conducted. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE: CBFI was effective for reducing overall positive and negative symptoms immediately following the intervention. Compared to CBTp, the intervention seems to be more effective to reduce delusions. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The results of this review suggest that the brief CBFI is an effective family-inclusive intervention that could be integrated into clinical practice. Mental health nurses with adequate training and support may implement and develop CBFI to improve the recovery of people diagnosed with SMI and support their families. Abstract Introduction Cognitive behavioural family intervention (CBFI) may be an effective brief psychosocial intervention for people diagnosed with severe mental illness (SMI) and their families. No systematic review has summarized the effectiveness of CBFI. Aim This review aimed to systematically examine the trial evidence of the effectiveness of CBFI versus treatment as usual (TAU) on improving the outcomes of people diagnosed with SMI and their families. Method Eligible randomized controlled trials were identified from nine databases. Three investigators independently took part in selection of articles, data extraction and risk assessment. Pooled treatment effects were computed using random-effects models. Results Four studies consisting of 524 participants were included. The risk of bias was low-unclear in most areas. The pooled CBFI effect on four service user outcomes including overall positive symptoms, delusions, overall negative symptoms and general psychopathology was significantly improved at post-treatment, compared with TAU, whereas effects on hallucinations and insight were equivocal. Discussion The findings reveal that CBFI is superior to TAU in treating positive and negative symptoms immediately following the intervention. Implications for Practice Mental health nurses may practise CBFI to enrich the psychiatric nursing service and promote nurse-led intervention. However, there is currently no substantial evidence that the intervention is effective over the longer term.

Risk of self-harm after the diagnosis of psychiatric disorders in Hong Kong, 2000-10: a nested case-control study

BACKGROUND

Psychiatric disorders are established risk factors for self-harm. However, variation in the risk of self-harm by specific psychiatric disorder and stratified by gender and age is rarely examined in population-representative samples. This study aimed to investigate the risk of self-harm following diagnosis of different psychiatric disorders in an Asian population, through a review of inpatient records retrieved from the Hong Kong Clinical Data Analysis and Reporting System (CDARS).

METHODS

For this nested case-control study, the inpatient data of people admitted for any reason to Hong Kong public hospitals, between Jan 1, 2000, and Dec 31, 2010, were extracted from CDARS. Cases were people aged 10 years or older who had been admitted to inpatient care with a first-listed record of psychiatric disorder during the study period. The seven psychiatric disorders of interest were: depression, alcohol misuse or dependence, personality disorders, bipolar disorders, anxiety disorders, schizophrenia, and substance misuse or dependence. Two control patients were matched per case from a subsample of all individuals with the same gender, age, and admission time (ie, same calendar year and month), who did not have any record of the psychiatric disorders of interest. Any patients with a history of self-harm diagnosis before, or at the same time as, the first diagnosis of psychiatric disorder (cases) or admission (controls), were excluded. For each diagnostic category, a Cox proportional hazard regression model was fitted to estimate the adjusted hazard ratio (HR; plus 95% CIs) of associated self-harm, adjusting for gender, age, control-matched admission time, 20 districts of residence, physical comorbidities established as risk factors for self-harm (diabetes, asthma, migraine, epilepsy, HIV, and cancer), and presence of the six other psychiatric disorders. We repeated this analysis in subgroups stratified by gender (male and female) and by age (adolescent, 10-24 years; young adult, 25-44 years; middle-aged, 45-64 years; and older people, ≥65 years).

FINDINGS

Between 2000 and 2010, we followed up a cohort of 86 353 people with a first-recorded diagnosis of a psychiatric disorder of interest, and 134 857 matched controls. The highest risk of self-harm was observed in patients with substance misuse or dependence (adjusted HR vs matched controls, 9·6 [95% CI 8·4-11·0]), followed by those with personality disorders (3·7 [2·8-4·9]) and alcohol misuse or dependence (3·2 [2·9-3·7]). When stratified by gender and age, the highest risk of self-harm behaviour was found in the substance misuse or dependence group for both genders (for female patients: adjusted HR vs matched controls, 7·7 [6·0-9·8]; and for male patients, 10·5 [8·9-12·4]), and for all age groups (adolescent: 9·6 [7·2-12·7]; young adults: 10·2 [8·4-12·3]; middle-aged: 11·2 [8·0-15·6], and older people: 3·2 [1·7-6·1]).

INTERPRETATION

First-recorded diagnoses of psychiatric disorders were significantly associated with an elevated risk of subsequent self-harm. The associations varied considerably by diagnostic categories across gender and age subgroups. Our findings highlight the need to develop more efficient and targeted preventive measures in psychiatric care management, with specific attention to demographic characteristics linked to increased risk within the same diagnostic category.

FUNDING

None.