Outcome in early-onset schizophrenia revisited: findings from the Early Psychosis Prevention and Intervention Centre long-term follow-up study

Effect of onset age on the long-term outcome of early-onset psychoses and other mental disorders: a register-based Northern Finland Birth Cohort 1986 study

Psychiatric illnesses can affect the social transitions of adolescence and young adulthood, such as completing education and entering working life and relationships. However, associations between earlier onset age and long-term outcomes among those with early-onset psychoses (EOP) are unclear, as are the long-term outcomes of EOP compared to non-psychotic disorders. We used national register data of the Northern Finland Birth Cohort 1986 to detect persons with EOP and other early-onset psychiatric disorders. The long-term clinical and work-family outcomes of persons with onset age before 18 years (n = 41 psychoses, n = 495 non-psychoses) or between 18-22 years (n = 61 psychoses, n = 377 non-psychoses) were compared. Individuals with the onset of psychosis between 18-22 years had significantly more unfavourable long-term outcomes when compared to those with psychosis onset before 18 years. Persons with psychosis onset before the age of 18 years had similar outcomes to those with non-psychotic psychiatric disorder onset before 18 years regarding educational level, marital status, having children, and substance use disorders. Individuals with EOP were more often on a disability pension compared to those with other early-onset mental disorders. Adjusting for sex, educational level and substance use only slightly diluted these results. Unexpectedly, later onset age of EOP was associated with worse outcomes. Those with psychosis onset between 18-22 years of age are in a critical period, which underlines the importance of investing on interventions in this age group. Further studies on the effect of the onset age on later outcomes in EOP are needed.

Measures of Social and Occupational Function in Early Psychosis: A Systematic Review and Meta-analysis

Deficits in social and occupational function are widely reported in psychosis, yet no one measure of function is currently agreed upon as a gold standard in psychosis research. The aim of this study was to carry out a systematic review and meta-analysis of functioning measures to determine what measures were associated with largest effect sizes when measuring between-group differences, changes over time, or response to treatment. Literature searches were conducted based on PsycINFO and PubMed to identify studies for inclusion. Cross-sectional and longitudinal observational and intervention studies of early psychosis (≤5 years since diagnosis) that included social and occupational functioning as an outcome measure were considered. A series of meta-analyses were conducted to determine effect size differences for between-group differences, changes over time, or response to treatment. Subgroup analyses and meta-regression were carried out to account for variability in study and participant characteristics. One hundred and sixteen studies were included, 46 studies provided data (N = 13 261) relevant to our meta-analysis. Smallest effect sizes for changes in function over time and in response to treatment were observed for global measures, while more specific measures of social and occupational function showed the largest effect sizes. Differences in effect sizes between functioning measures remained significant after variability in study and participant characteristics were accounted for. Findings suggest that more specific measures of social function are better able to detect changes in function over time and in response to treatment.

The relationship between sex and functional outcome in first-episode schizophrenia: the role of premorbid adjustment and insight

BACKGROUND

Studies that examined sex differences in first-episode patients consistently show that males compared to females have poor premorbid adjustment, earlier age of onset, worse clinical characteristics, and poorer outcomes. However, little is known about potential mediators that could explain these sex differences.

METHODS

Our sample consisted of 137 individuals with first episode schizophrenia (males, n = 105; 77%) with a mean age of 22.1(s.d. = 4.1) years and mean education of 12.5(s.d. = 1.7) years. At entry, patients were within 2 years of their first psychotic episode onset. Baseline assessments were conducted for premorbid adjustment, symptoms, cognitive functioning, insight, and at 6-months for role and social functioning.

RESULTS

Males as compared to females had poorer premorbid adjustment across several key developmental periods (p < 0.01), an earlier age of onset [M = 20.3(3.3) v. 22.8(5.6), p = 0.002], more negative symptoms (p = 0.044), poorer insight (p = 0.031), and poorer baseline and 6-month role (p = 0.002) and social functioning (p = 0.034). Several of these variables in which males showed impairment were significant predictors of 6-month role and social functioning. Premorbid adjustment and insight mediated the relationship between sex and role and social functioning at 6-months, but not negative symptoms.

DISCUSSION

Males compared to females were at lower levels across several key premorbid and clinical domains which are strongly associated with functional outcome supporting the hypothesis that males might have a more disabling form of schizophrenia. The relationship between sex with role and social functioning was mediated through premorbid adjustment and insight suggesting pathways for understanding why females might have a less disabling form of schizophrenia.

Longitudinal change in neurocognitive functioning in children and adolescents at clinical high risk for psychosis: a systematic review

Clinical high risk of psychosis (CHR-P) population has become an attractive area of interest in preventing transitions to psychosis. The consequences of developing a psychotic disorder may be worse in cases of early onset. Thus, childhood and adolescence represent a critical developmental window, where opportunities to gain social and adaptive abilities depend on the individuals' neurocognitive performance. There have been previous syntheses of the evidence regarding neurocognitive functioning in CHR-P individuals and its longitudinal changes. However, there has been less focus on children and adolescents at CHR-P. A multistep literature search was performed from database inception until July 15th, 2022. PRIMSA/MOOSE compliant systematic review and PROSPERO protocol were used to identify studies reporting on longitudinal changes in neurocognitive functioning in children and adolescents (mean age of sample ≤ 18 years) at CHR-P and matched healthy control (HC) group. A systematic review of identified studies was then undertaken. Three articles were included, resulting in a total sample size of 151 CHR-P patients [mean (SD) age, 16.48 (2.41) years; 32.45% female] and 64 HC individuals [mean (SD) age, 16.79 (2.38) years; 42.18% female]. CHR-P individuals had worse outcomes in verbal learning, sustained attention and executive functioning domains compared to HC. Individuals taking antidepressants had better outcomes in verbal learning in contrast with those taking antipsychotics. In children and adolescents, neurocognition may be already impaired before the psychosis onset, and remains stable during the transition to psychosis. Further study should be performed to obtain more robust evidence.

Schizophrenia among young people first admitted to psychiatric inpatient care during early and middle adolescence

OBJECTIVE

This study explored the incidence and stability of schizophrenia in a large national register data of all adolescents first admitted to psychiatric inpatient care at ages 13-17 in Finland 1980-2010.

METHODS

The study population (N 17,112) comprised all Finnish citizens aged 13-17 receiving their first ever psychiatric inpatient treatment between 1980 and 2010 in Finland. To explore incidence and stability of schizophrenia, the diagnostic information on inpatient care or disability pension was obtained from the appropriate registers.

RESULTS

The incidence of schizophrenia disorders (F20 + F25) during adolescence was higher in the study population for those admitted to psychiatric inpatient care 1980-1989 than in other decades examined. Overall, psychiatric inpatient care during adolescence was a risk factor for subsequent schizophrenia, especially if a diagnosis of F20-29 was set although a considerable share of those with psychotic disorders other than schizophrenia diagnosis did not subsequently convert to schizophrenia. The stability of adolescent onset schizophrenia diagnosis was high.

CONCLUSION

Adolescents requiring psychiatric inpatient care have a higher later rate of schizophrenia diagnosis than prevalence at community level. Whereas adolescent onset schizophrenia diagnosis is a fairly stable diagnosis, there are other adolescent psychotic disorders which are more transient in nature.

A Scoping and Systematic Review of Employment Processes and Outcomes for Young Adults Experiencing Psychosis

Young adults who experience psychosis want to work but are less likely to be employed than their peers. Sixty two studies relating to young adults with psychosis and employment were reviewed following a systematic search of five databases: CINAHL, PsycINFO, MEDLINE, SCOPUS and EMBASE. Publication date ranged from 1973 to 2019 with > 70% between 2010 and 2019. Intervention was considered in 29 papers; critical appraisal revealed 90% of these had moderate to good methodological quality with only three RCTs. Of 11 intervention types "Early Intervention" and "Individual Placement and Support" were most common; both demonstrating positive impact on obtaining employment. The review identified minimal participant perspectives and great variability in: terminology used; the reporting of participant attributes; intervention characteristics and ways employment outcomes were measured. Employment processes identified were preparing for, seeking, obtaining, keeping and re-obtaining employment, with current research efforts focused on obtaining work. More focus is required on keeping and re-obtaining employment.

Diagnosed Incidence of Non-Affective Psychotic Disorders Amongst Adolescents in British Columbia and Sociodemographic Risk Factors: A Retrospective Cohort Study

OBJECTIVES

To estimate the diagnosed incidence of non-affective psychotic disorder between the ages of 13 and 19 years in South-Western British Columbia (BC) and to examine variation in risk by sex, family and neighbourhood income, family migration background, parent mental health contact and birth year.

METHODS

Linked individual-level administrative data were used to construct a cohort of individuals born in 1990-1998 and residing in South-Western BC (n = 193,400). Cases were identified by either one hospitalization or two outpatient physician visits within 2 years with a primary diagnosis of a non-affective psychotic disorder (ICD-10: F20-29, ICD-9: 295, 297, 298). We estimated cumulative incidence, annual cumulative incidence and incidence rate between the ages of 13 and 19 years, and conducted Cox proportional hazards regression to estimate associations between sociodemographic factors and risk over the study period.

RESULTS

We found that 0.64% of females and 0.88% of males were diagnosed with a non-affective psychotic disorder between the ages of 13 and 19 years, with increasing risk observed over the age range, especially amongst males. Incidence rate over the entire study period was 106 per 100,000 person-years for females and 145 per 100,000 person-years for males. Risk of diagnosis was elevated amongst those in low-income families and neighbourhoods, those with a parent who had a health service contact for a mental disorder, and more recent birth cohorts. Risk was reduced amongst children of immigrants compared to children of non-migrants.

CONCLUSIONS

Findings from this study provide important information for health service planning in South-Western BC. Future work should examine whether variations in diagnosed incidence is driven by differences in health service engagement or reflect genuine differences in risk.

Improving screening methods for psychosis in an adolescent help-seeking population using the Child Behavior Checklist (CBCL) and the Youth Self Report (YSR) versus the Prodromal Questionnaire -16 items version (PQ-16)

BACKGROUND

Screening methods for detecting Ultra High Risk status (UHR) or psychosis should be improved, especially in adolescent samples. We therefore tested whether the Child Behavior Checklist (CBCL) and the Youth Self Report (YSR) add value to the Prodromal Questionnaire-16 items version (PQ-16) for detecting UHR status or psychosis.

METHODS

We included help-seeking adolescents who had completed the PQ-16, YSR, CBCL, and a Comprehensive Assessment of an At Risk Mental States (CAARMS) interview, and used independent samples t-tests and binary logistic regression analyses to determine the scales contributing to the prediction of UHR status or of having reached the psychosis threshold (PT). Cutoff scores were determined using ROC analyses.

RESULTS

Our sample comprised 270 help-seeking adolescents (mean age 14.67; SD 1.56, range 12-17); 67.8% were girls and 66.3% were of Dutch origin. The Thought Problems syndrome scales of both the YSR and the CBCL best predicted UHR or PT, and had screening values comparable to the PQ-16. Other syndrome scales did not improve screening values. Although combining measures reduced the number of false negatives, it also increased the number of adolescents to be interviewed. The best choice was to combine the YSR Thought Problems scale and the PQ-16 as a first-step screener.

CONCLUSIONS

Combining measures improves the detection of UHR or PT in help-seeking adolescents. The Thought Problems subscales of the YSR and CBCL can both be used as a first-step screener in the detection of UHR and/or psychosis. Trial registration Permission was asked according to the rules of the Ethics Committee at Leiden. This study is registered as NL.44180.058.13.

Associations of Neurocognition and Social Cognition With Brain Structure and Function in Early-Onset Schizophrenia

BACKGROUND

Cognitive impairment is a core feature of schizophrenia that is more serious in patients with early-onset schizophrenia (EOS). However, the neuroimaging basis of cognitive functions, including neurocognition and social cognition, remains unclear in patients with EOS.

METHODS

Forty-three patients with EOS underwent structural and resting state functional magnetic resonance imaging scans. Brain structure and function were evaluated through the analysis of brain gray matter volume (GMV) and amplitude of low-frequency fluctuations (ALFF). They underwent comprehensive assessments for neurocognition (verbal memory, verbal expression, attention, and executive function) and social cognition (theory of mind and attributional bias). Correlation analyses were conducted to detect the potential link between cognitive function indices and brain imaging parameters.

RESULTS

First, neurocognition was linked to brain structure characterized by higher immediate recall scores associated with increased GMV in the left temporal pole, higher verbal fluency scores associated with increased GMV in the left temporal pole: middle temporal gyrus, and higher Stroop-word scores associated with increased GMV in the right middle frontal gyrus. Second, social cognition was related to brain function characterized by lower sense of reality scores associated with increased ALFF in the left precentral gyrus, higher scores of accidental hostility bias associated with increased ALFF in the right middle temporal gyrus, and higher scores of accidental aggression bias associated with increased ALFF in the left precentral gyrus.

CONCLUSION

These findings may add to the existing knowledge about the cognitive function-brain relationship. They may have clinical significance for studying the mechanism of neurocognitive and social cognitive impairment in patients with EOS and providing potential neural targets for their treatment and intervention.

Patterns of Care for Adolescent With Schizophrenia: A Delphi-Based Consensus Study

BACKGROUND

The current conceptualization of schizophrenia as neurodevelopmental disorder should lead to innovative public health policies in terms of a reorganization of the mental health care systems, particularly in the transition from adolescence to adulthood, to reduce personal, familiar, and social costs and burdens. The purpose of the project was to perform a survey among a panel of Italian schizophrenia experts, to share evidence-based information on adolescent schizophrenia and explore the degree of consensus among professionals in the following four macro-areas: early diagnosis; pharmacological treatment; health care system organization and transition process from adolescent to adulthood; and psychosocial interventions.

METHODS

The consensus process consisted of a two-step web-based Delphi method, which took place between June and November 2021. The survey was developed by a panel of four psychiatrists and four child neuropsychiatrists, identified as key opinion leaders (KOLs). The KOLs identified 21 statements involving a total of 70 items with a major need of clarification on early-onset schizophrenia (EOS). The survey was distributed to 86 specialists in psychiatry and child neuropsychiatry.

RESULTS

The results revealed a large agreement among the expert group on all the investigated areas of adolescent schizophrenia patterns of care and management. Consensus was ultimately reached for 67 items of the Delphi survey (95.7%), while negative consensus was reached for 2 items and no consensus was reached for 1 item.

CONCLUSIONS

Overall, results showed a significant gap between the acquired scientific knowledge and clinical practice. In this scenario, it should be necessary to plan specific initiatives at a multiple level, to edit recommendations on clinical decision-making, as well as to prompt changes at the political and organizational levels, also involving scientific societies, patients, and family associations, to overcome the barriers that delay the implementation process.

Implementation of first episode psychosis intervention in India - A case study in a low-and middle-income country

First Episode Psychosis (FEP) is a serious mental illness affecting adolescents and young persons. While many effective interventions are available, there has not been much research to understand the implementation of such interventions in India and other low- and middle-income countries (LMIC). We studied the implementation of an FEP intervention program in a specialist mental health facility in Chennai, India, using a well-established framework for doing so, the Consolidated Framework for Implementation Research (CFIR). We conducted 27 in-depth interviews with the service users (15 persons with FEP and 12 family caregivers of persons with FEP). We also conducted a focus group discussion with 8 service providers and in-depth interviews with 7 other service providers including those in the service management. A thematic analysis approach was used to identify emerging themes. First, we found CFIR effectively accommodated implementation challenges evident in LMICs; that is, it is transferable to LMIC settings. Second, we highlight barriers to implementation that include cost, limited human resources, cultural and professional hierarchy, divergence from evidence-based guidelines, and lack of awareness and stigma in the wider community. Third, we highlight facilitators for implementation such as, leadership engagement, the need for change that was recognized within the service, cosmopolitan perspectives derived from clinicians’ local and international collaborative experiences and expertise, compatibility of the intervention with the existing systems within the organization, accommodating the needs of the service users, and rapport developed by the service with the service users. Fourth, we propose a model of service delivery incorporating a task-sharing approach for first episode psychosis in resource restricted settings based on the feedback from the stakeholders.

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Implementation of interventions for First Episode Psychosis in India is explored systematically.

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Resource constraints, cultural factors, lack of awareness, and stigma are the main barriers to the implementation.

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Buy-in from the service providers, accommodating the needs and developing rapport with the service users are the facilitators.

Aberrant default mode connectivity in adolescents with early-onset psychosis: A resting state fMRI study

Abnormal default mode network (DMN) connectivity has been found in schizophrenia and other psychotic disorders. However, there are limited studies on early onset psychosis (EOP), and their results show lack of agreement. Here, we investigated within-network DMN connectivity in EOP compared to healthy controls (HC), and its relationship to clinical characteristics. A sample of 68 adolescent patients with EOP (mean age 16.53 ± 1.12 [SD] years, females 66%) and 95 HC (mean age 16.24 ± 1.50 [SD], females 60%) from two Scandinavian cohorts underwent resting state functional magnetic resonance imaging (rsfMRI). A group independent component analysis (ICA) was performed to identify the DMN across all participants. Dual regression was used to estimate spatial maps reflecting each participant's DMN network, which were compared between EOP and HC using voxel-wise general linear models and permutation-based analyses. Subgroup analyses were performed within the patient group, to explore associations between diagnostic subcategories and current use of psychotropic medication in relation to connectivity strength. The analysis revealed significantly reduced DMN connectivity in EOP compared to HC in the posterior cingulate cortex, precuneus, fusiform cortex, putamen, pallidum, amygdala, and insula. The subgroup analysis in the EOP group showed strongest deviations for affective psychosis, followed by other psychotic disorders and schizophrenia. There was no association between DMN connectivity strength and the current use of psychotropic medication. In conclusion, the findings demonstrate weaker DMN connectivity in adolescent patients with EOP compared to healthy peers, and differential effects across diagnostic subcategories, which may inform our understanding of underlying disease mechanisms in EOP.

Relationship between cognition and age at onset of first-episode psychosis: comparative study between adolescents, young adults, and adults

Psychotic disorders typically manifest from late adolescence to early adulthood, and an earlier onset might be associated with greater symptom severity and a worse long-term prognosis. This study aimed to compare the cognitive characteristics of patients with first-episode psychosis (FEP) by their age at onset. We included 298 patients diagnosed with FEP and classified them as having an early onset (EOS), youth onset (YOS), or adult onset (AOS) based on age limits of ≤ 18 years (N = 61), 19-24 years (N = 121), and ≥ 25 years (N = 116), respectively. Socio-demographic and clinical variables included age at baseline, gender, socio-economic status, antipsychotic medication, DSM-IV diagnoses assessed by clinical semi-structured interview, psychotic symptom severity, and age at onset. Neuropsychological assessment included six cognitive domains: premorbid intelligence, working memory, processing speed, verbal memory, sustained attention, and executive functioning. The EOS group had lower scores than the YOS or AOS groups in global cognition, executive functioning, and sustained attention. Although the scores in the YOS group were intermediate to those in the EOS and AOS groups for most cognitive factors, no statistically significant differences were detected between the YOS and AOS groups. Age at onset results in specific patterns of cognitive interference. Of note, impairment appears to be greater with EOS samples than with either YOS or AOS samples. A longitudinal study with a larger sample size is needed to confirm our findings.

Prevalence, incidence and economic burden of schizophrenia among Medicaid beneficiaries

OBJECTIVE

To estimate the prevalence, incidence and economic burden of schizophrenia among Medicaid beneficiaries.

METHODS

Annual prevalence and incidence of schizophrenia among adult Medicaid beneficiaries were estimated during 2012-2017, by state and across six states (IA, KS, MS, MO, NJ and WI). The pooled estimate of the economic burden of schizophrenia was obtained during 1998Q1-2018Q1 across six states; adults with ≥2 diagnoses of schizophrenia were matched 1:1 to schizophrenia-free controls. The last observed schizophrenia diagnosis (schizophrenia cohort) or the last service claim (control cohort) with ≥12 months of continuous Medicaid enrollment before/after it defined the index date. Healthcare resource utilization (HRU) and costs ($2018 USD) incurred 12 months post-index were compared between cohorts. The economic burden of schizophrenia was also evaluated among young adults (18-34 years).

RESULTS

Annual prevalence of schizophrenia ranged between 2.30% and 2.71% and annual incidence between 0.31% and 0.39% during 2012-2016. In 2017, only states with the highest incidence and prevalence rates (KS, MS, MO) had data, resulting in higher prevalence (4.01%) and incidence (0.52%). For the economic burden, adults with schizophrenia (N = 158,763) had higher HRU and incurred $14,087 higher healthcare costs versus controls (mean: $28,644 vs. $14,557), driven by $4677 higher long-term care costs (all p < .001). Young adults with schizophrenia incurred $14,945 higher healthcare costs versus controls, driven by $3473 higher inpatient costs (p < 0.001).

CONCLUSIONS

Annual prevalence and incidence of schizophrenia varied by state but remained stable over time. Adults with schizophrenia incurred greater HRU and costs relative to adults without schizophrenia; the burden appeared comparable among young adults.

Employment and relationship outcomes in first-episode psychosis: A systematic review and meta-analysis of longitudinal studies

As employment and relationship status are important long-term outcomes in individuals with a diagnosis of first episode psychosis (FEP) disorders, there is a need to elucidate more accurately the extent of these social deficits in people with FEP. This in turn can aid treatment planning and policy development ultimately ensuring more complete and sustainable recoveries. We carried out a systematic review and meta-analysis of longitudinal studies in FEP reporting on employment and relationship status during the illness course. Random effects meta-analyses and meta-regression analyses were employed. Seventy-four studies were included with a sample totalling 15,272 (range = 20-1724) FEP cases with an average follow-up duration of 8.3 years (SD = 7.2). 32.5% (95%CI = 28.5-36.9) of people with a diagnosis of FEP disorders were employed and 21.3% (95%CI = 16.5-27.1) were in a relationship at the end of follow-up. Studies from high-income countries and Europe had a higher proportion of people in employment at the end of follow-up compared to middle-income nations and non-European countries. The inverse was found for relationship status. The proportion of people with a diagnosis of FEP in employment decreased significantly with longer follow-up. Living with family, being in a relationship at first contact and Black and White ethnicities were identified as significant moderators of these outcomes. These findings highlight marked functional recovery deficits for people with FEP, although cultural factors need to be considered. They support the need for interventions to improve employment opportunities, and social functioning, both in early psychosis and during the longitudinal illness course.

Caring for Patients with Psychosis: Mental Health Professionals' Views on Informal Caregivers' Needs

The aim of this study was to explore the views of mental health professionals regarding the needs of the informal caregivers of patients with chronic psychotic syndrome. A qualitative research design was used. The sample consisted of 12 mental health professionals selected by a purposive sampling strategy. Data were collected through semistructured, face to face interviews. Framework analysis was used to analyze qualitative data and establish main themes and subthemes. Three main themes emerged namely, (i) impact of caring on caregivers’ lives, (ii) caregivers’ needs, and (iii) recommendations for better care. Informal caregivers’ needs were conceptualized into subthemes within the main themes. Caregivers’ increased responsibilities of caring for their relatives, the impact on their mental and physical health status and the restrictions in their social and professional life were revealed. Targeted health interventions and social policy planning are recommended for supporting informal caregivers and improving patient care.

Time to Clinical Response in the Treatment of Early Onset Schizophrenia Spectrum Disorders Study

Objectives: We investigated the time course of clinical response in the Treatment of Early Onset Schizophrenia Spectrum Disorders Study (TEOSS). Methods: TEOSS randomized 119 predominantly outpatient youth ages 8-19 years with schizophrenia or schizoaffective disorder to 8 weeks of treatment with molindone, risperidone, or olanzapine. We used proportional hazards regression to determine whether these three antipsychotics differed in the time until clinical response, defined as the time from treatment initiation to the point of achieving a Clinical Global Impressions-Improvement (CGI-I) scale score of 1 ("very much improved") or 2 ("much improved") that was maintained until week 8. Results: Of the 116 youth who initiated treatment, 56 (48%) achieved clinical response. Among clinical responders, the median (±interquartile range) time until clinical response was 4.0 (±4.0) weeks for olanzapine, 4.5 (±4.0) weeks for risperidone, and 6.0 (±4.0) weeks for molindone. There were no significant differences in time course for clinical response between medications (p = 0.84). Youth without symptom improvement (CGI-I ≥ 4) after 3 weeks were more likely to be clinical nonresponders at week 8 (relative risk ratio = 1.98, 95% confidence interval 1.29-3.05), compared with youth with at-least-minimal symptom improvement after 3 weeks when looking at all antipsychotics combined. Conclusion: To our knowledge, our study is the first to investigate medication differences in treatment response timing in early onset schizophrenia spectrum disorders. Clinical response times for molindone, risperidone, and olanzapine were not significantly different. Furthermore, while lack of early improvement predicted clinical nonresponse, whether or not to continue antipsychotic treatment after 3 or more weeks without symptom improvement should be based on clinical judgment after weighing potential risks, benefits, and alternatives. ClinicalTrials.gov Identifier: NCT00053703.

Adolescent Neurodevelopment and Vulnerability to Psychosis

Adolescence is characterized by significant changes in several domains, including brain structure and function, puberty, and social and environmental factors. Some of these changes serve to increase the likelihood of psychosis onset during this period, while others may buffer this risk. This review characterizes our current knowledge regarding the unique aspects of adolescence that may serve as risk factors for schizophrenia spectrum disorders. In addition, we provide potential future directions for research into adolescent-specific developmental mechanisms that impart vulnerability to psychosis and the possibility of interventions that capitalize on adolescents' unique characteristics. Specifically, we explore the ways in which gray and white matter develop throughout adolescence in typically developing youth as well as in those with psychosis spectrum disorders. We also discuss current views on the function that social support and demands, as well as role expectations, play in risk for psychosis. We further highlight the importance of considering biological factors such as puberty and hormonal changes as areas of unique vulnerability for adolescents. Finally, we discuss cannabis use as a factor that may have a unique impact during adolescent neurodevelopment, and subsequently potentially impact psychosis onset. Throughout, we include discussion of resilience factors that may provide unique opportunities for intervention during this dynamic life stage.

Psychological intervention, antipsychotic medication or a combined treatment for adolescents with a first episode of psychosis: the MAPS feasibility three-arm RCT

BACKGROUND

When psychosis emerges in young people there is a risk of poorer outcomes, and access to evidence-based treatments is paramount. The current evidence base is limited. Antipsychotic medications show only a small benefit over placebo, but young people experience more side effects than adults. There is sparse evidence for psychological intervention. Research is needed to determine the clinical effectiveness and cost-effectiveness of psychological intervention versus antipsychotic medication versus a combined treatment for adolescents with psychosis.

OBJECTIVES

The objective of Managing Adolescent first-episode Psychosis: a feasibility Study (MAPS) was to determine the feasibility of conducting a definitive trial to answer the question of clinical effectiveness and cost-effectiveness of these three treatment options.

DESIGN

This was a prospective, randomised, open-blinded, evaluation feasibility trial with a single blind. Participants were allocated 1 : 1 : 1 to receive antipsychotic medication, psychological intervention or a combination of both. A thematic qualitative study explored the acceptability and feasibility of the trial.

SETTING

Early intervention in psychosis services and child and adolescent mental health services in Manchester, Oxford, Lancashire, Sussex, Birmingham, Norfolk and Suffolk, and Northumberland, Tyne and Wear.

PARTICIPANTS

People aged 14-18 years experiencing a first episode of psychosis either with an International Classification of Diseases, Tenth Revision, schizophrenia spectrum diagnosis or meeting the entry criteria for early intervention in psychosis who had not received antipsychotic medication or psychological intervention within the last 3 months.

INTERVENTIONS

Psychological intervention involved up to 26 hours of cognitive-behavioural therapy and six family intervention sessions over 6 months, with up to four booster sessions. Antipsychotic medication was prescribed by the participant's psychiatrist in line with usual practice. Combined treatment was a combination of psychological intervention and antipsychotic medication.

MAIN OUTCOME MEASURES

The primary outcome was feasibility (recruitment, treatment adherence and retention). We used a three-stage progression criterion to determine feasibility. Secondary outcomes were psychosis symptoms, recovery, anxiety and depression, social and educational/occupational functioning, drug and alcohol use, health economics, adverse/metabolic side effects and adverse/serious adverse events.

RESULTS

We recruited 61 out of 90 (67.8%; amber zone) potential participants (psychological intervention, n = 18; antipsychotic medication, n = 22; combined treatment, n = 21). Retention to follow-up was 51 out of 61 participants (83.6%; green zone). In the psychological intervention arm and the combined treatment arm, 32 out of 39 (82.1%) participants received six or more sessions of cognitive-behavioural therapy (green zone). In the combined treatment arm and the antipsychotic medication arm, 28 out of 43 (65.1%) participants received antipsychotic medication for 6 consecutive weeks (amber zone). There were no serious adverse events related to the trial and one related adverse event. Overall, the number of completed secondary outcome measures, including health economics, was small.

LIMITATIONS

Medication adherence was determined by clinician report, which can be biased. The response to secondary outcomes was low, including health economics. The small sample size obtained means that the study lacked statistical power and there will be considerable uncertainty regarding estimates of treatment effects.

CONCLUSIONS

It is feasible to conduct a trial comparing psychological intervention with antipsychotic medication and a combination treatment in young people with psychosis with some adaptations to the design, including adaptations to collection of health economic data to determine cost-effectiveness.

FUTURE WORK

An adequately powered definitive trial is required to provide robust evidence.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN80567433.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 4. See the NIHR Journals Library website for further project information.

Prepared for transition? A cross-sectional descriptive study of the gains attained in early psychosis programs

AIM

To examine the degree to which youth identified as ready for discharge from three Canadian early psychosis intervention (EPI) programs had achieved optimal outcomes (ie, symptom remission, quality of life, self-esteem and functioning).

METHODS

This cross-sectional descriptive study is part of a larger study assessing the effectiveness of an evidence-based intervention to sustain the gains acquired in EPI programs in two Canadian provinces (Ontario and Nova Scotia), as youth transition from EPI services to community-based care. Baseline data collected from 39 participants receiving usual treatment in these three EPI programs comprised the comparison group. Participants completed measures to assess symptoms, quality of life, self-esteem and functional level just prior to discharge.

RESULTS

Participants demonstrated lower levels of symptoms, greater quality of life, greater self-esteem and greater levels of functioning, following EPI treatment when compared to similar youth described in the literature. These findings suggest that study participants had achieved optimal outcomes following EPI treatment.

CONCLUSION

The study findings have laid the ground work for the current Canadian Institutes of Health Research partnership study in which our research group is assessing the effectiveness of an evidence-based transitional intervention in order to address critical psychosocial issues of identity, stigma, effective relationships and meaningful life goals, along with the development of an individualized 'passport for transition'. It is anticipated that implementing an evidence-based transitional intervention will support participants to maintain the gains made in EPI programs once they transition to community-based care and will inform future research addressing this challenging issue.

Cognitive behavioral therapy in adolescents with early-onset psychosis: a randomized controlled pilot study

Cognitive behavioral therapy for psychosis (CBT) is an effective treatment in adult patients with schizophrenia. However, no randomized controlled and blinded trial in adolescents with early-onset psychosis (EOP) has been conducted. Therefore, the present pilot study explores the acceptance, tolerability, feasibility, and safety of a modified CBT in adolescents with EOP. Twenty-five adolescents with EOP were randomized to either 9 months (20 sessions) of CBT + treatment as usual (TAU) or TAU alone. The primary endpoint was the PANSS-positive subscale (P1-7). Secondary endpoints included psychopathology, global functioning, and quality of life (QoL). Acceptance, tolerability, feasibility, and safety were assessed. Blinded assessments took place by the end of the treatment (9 months) and at 24-month follow-up. Despite improvements in both groups and lack of statistical significance between CBT + TAU and TAU regarding the primary endpoint, we observed between-group effect sizes of at least d = 0.39 in favor of CBT + TAU at post-treatment for delusions, negative symptoms, functioning and QoL after the intervention and effect sizes of at least d = 0.35 after 24 months. CBT in EOP was highly acceptable (73.5% agreed to randomization), well-tolerated (83.1% attendance rate, no drop-outs), and safe (one serious adverse event (SAE) in CBT + TAU in comparison with six SAEs in TAU). These findings suggest that CBT adapted to the needs of adolescents with EOP is a promising approach regarding negative symptoms, functioning, and QoL. CBT is a safe and tolerable treatment. However, due to the small sample size and the pilot character of the study, these conclusions are limited, and should be tested in a larger, adequately powered randomized controlled trial.

Long-term outcome of early-onset compared to adult-onset schizophrenia: A nationwide Danish register study

OBJECTIVE

Early-onset schizophrenia (EOS) may have worse outcomes than adult-onset schizophrenia (AOS), but data are scarce. We compared outcomes of EOS vs. AOS.

METHODS

Longitudinal, register-based study of patients diagnosed with schizophrenia in Denmark between 1996 and 2012, with follow-up until 12/2014. Co-primary outcomes were psychiatric inpatient days during the initial two years after schizophrenia diagnosis and mean number of annual inpatient days for the remaining follow-up.

RESULTS

Altogether, 16,337 patients with schizophrenia were included (EOS = 1223, AOS = 15,114, mean follow-up = 9.5 ± 5.0 years). EOS were hospitalized longer during the first two years than AOS (180.9 ± 171.0 vs 163.4 ± 183.1 days, p < 0.005; IRR = 1.27, 95% CI = 1.19-1.35, p < 0.001), but duration and annual rates thereafter did not differ (EOS = 26.8 ± 57.1 days, AOS = 26.6 ± 56.2 days, p = 0.95; IRR = 1.07, 95% CI = 0.94-1.23, p = 0.30). Fewer EOS patients were never psychiatrically hospitalized (EOS = 17.2%, AOS = 20.1%, p < 0.001), but with no difference in re-admissions in patients diagnosed during hospitalization (EOS = 77.1% vs AOS = 78.1%, p = 0.56). More EOS patients were admitted involuntarily (41% vs. 36%, p < 0.02). AOS patients had more often comorbid substance use disorders during follow-up than EOS (EOS = 21.7%, AOS = 34.2%, p < 0.001). Substance use disorders and out-of-home placement were significantly associated with more inpatient days during both short- and long-term follow-up.

CONCLUSION

Although EOS was associated with more inpatient days in the first two years after diagnosis, results do not seem to support a generally poorer long-term outcome of EOS compared to AOS. Longer initial hospitalization may be driven by different treatment patterns in child and adolescent vs. adult psychiatry. These data suggest that patient characteristics other than age of onset significantly affect outcomes.

Transition of Substance-Induced, Brief, and Atypical Psychoses to Schizophrenia: A Systematic Review and Meta-analysis

Some people who experience substance-induced psychosis later develop an enduring psychotic disorder such as schizophrenia. This study examines the proportion of people with substance-induced psychoses who transition to schizophrenia, compares this to other brief and atypical psychoses, and examines moderators of this risk. A search of MEDLINE, PsychINFO, and Embase identified 50 eligible studies, providing 79 estimates of transition to schizophrenia among 40 783 people, including 25 studies providing 43 substance-specific estimates in 34 244 people. The pooled proportion of transition from substance-induced psychosis to schizophrenia was 25% (95% CI 18%-35%), compared with 36% (95% CI 30%-43%) for brief, atypical and not otherwise specified psychoses. Type of substance was the primary predictor of transition from drug-induced psychosis to schizophrenia, with highest rates associated with cannabis (6 studies, 34%, CI 25%-46%), hallucinogens (3 studies, 26%, CI 14%-43%) and amphetamines (5 studies, 22%, CI 14%-34%). Lower rates were reported for opioid (12%), alcohol (10%) and sedative (9%) induced psychoses. Transition rates were slightly lower in older cohorts but were not affected by sex, country of the study, hospital or community location, urban or rural setting, diagnostic methods, or duration of follow-up. Substance-induced psychoses associated with cannabis, hallucinogens, and amphetamines have a substantial risk of transition to schizophrenia and should be a focus for assertive psychiatric intervention.

Auditory sensory gating in young adolescents with early-onset psychosis: a comparison with attention deficit/hyperactivity disorder

Numerous studies have demonstrated impaired sensory gating in schizophrenia and this impairment has been proposed as a candidate biomarker for the disorder. The typical age of onset for schizophrenia is early adulthood, however a sizable group of patients present with psychotic symptoms before the age of 18, commonly referred to as early-onset psychosis (EOP). How an earlier onset influences sensory gating is currently unknown. Impaired sensory gating may not be specific to psychosis, but rather a shared disturbance of neurodevelopmental disorders, such as attention deficit/hyperactivity disorder (ADHD). Therefore, the current study investigated P50 suppression in young adolescents (12-17 years old) with either EOP (N = 55) or ADHD (N = 28) and age and gender matched healthy controls (HC) (N = 71). In addition to P50 suppression, N100 and P200 suppression data were also analyzed. No significant group differences in either raw mean P50 amplitude or mean P50 gating ratios were observed between EOP, ADHD, and HC. Additionally, we observed no P50 suppression deficit in those EOP patients diagnosed with schizophrenia (N = 39). Similarly, we observed no differences in N100 or P200 between the three groups. Healthy levels of P50 suppression were found in both patient groups. The results are in line with some previous studies showing healthy levels of P50 suppression in the early phases of schizophrenia. Our findings do not support P50 sensory gating as a valid biomarker for EOP or ADHD.

PROFIP: A Portuguese early intervention programme for first-episode psychosis in Lisbon

AIM

There is currently no national plan for early intervention in first-episode psychosis in Portugal. Consequently, there is some heterogeneity in the evaluation and treatment of first-episode psychosis across the country. The aim of this article is to provide a complete description of the early intervention programme Programa de Intervenção nas Fases Iniciais da Psicose (PROFIP) in Lisbon, a pioneering team in Portugal for treating first-episode psychosis (FEP) patients. We also describe the baseline socio-demographic and clinical data obtained from new patients over a 1-year period. PROFIP programme accepts all cases of FEP, taking a transdiagnostic approach.

METHODS

Description of PROFIP programme and baseline socio-demographic and clinical data obtained from new patients over a 1-year period.

RESULTS

The team was constituted to provide early detection, treatment and support to people aged 16 to 35 years with affective and non-affective FEP. Over a 1-year period, 39 patients were included in the PROFIP programme. The majority of patients were young male patients with a diagnosis of non-affective psychosis, and with 56% of patients reporting cannabis use. Patients received pharmacological and psychosocial interventions based on evidence and individual needs.

CONCLUSIONS

Our team allowed young people with early psychosis to receive effective care. We do need improvements, namely in referrals and the education of health professionals. More teams in our country should be constituted, allowing larger numbers of patients with early psychosis to be treated by specialized teams.

Common Data Elements for National Institute of Mental Health-Funded Translational Early Psychosis Research

The National Institutes of Health has established the PhenX Toolkit as a web-based resource containing consensus measures freely available to the research community. The National Institute of Mental Health (NIMH) has introduced the Mental Health Research Core Collection as part of the PhenX Toolkit and recently convened the PhenX Early Psychosis Working Group to generate the PhenX Early Psychosis Specialty Collection. The Working Group consisted of two complementary panels for clinical and translational research. We review the process, deliberations, and products of the translational research panel. The Early Psychosis Specialty Collection rationale for measure selection as well as additional information and protocols for obtaining each measure are available on the PhenX website (https://www.phenxtoolkit.org). The NIMH strongly encourages investigators to use instruments from the PhenX Mental Health Research Collections in NIMH-funded studies and discourages use of alternative measures to collect similar data without justification. We also discuss some of the potential advances that can be achieved by collecting common data elements across large-scale longitudinal studies of early psychosis.

The psychometrics of psychosis - assessing and rating perceptual and ideational disturbance in adolescents

BACKGROUND

The early recognition and management of psychosis spectrum disorders is associated with superior outcomes in affected individuals. However, this can be challenging for numerous reasons. This article provides perspectives on the effective evaluation and rating of potentially psychotic phenomena young people. We compare and contrast two widely used instruments that can support this process.

FINDINGS

The Comprehensive Assessment for At-Risk Mental States (CAARMS) is used to explore potentially psychotic experiences in young people perceived to be at risk of an emerging or imminent psychosis. There is evidence to support its reliability and, to some extent, the predictive validity of the resultant scores. However, relatively low short-medium transition rates to psychosis in 'positive' cases suggest that its use as a screening instrument should be restricted to groups who show some indication of impending risk (e.g. help-seeking, distress, declining functioning, perceptual disturbance, etc.). In contrast, the Positive and Negative Syndrome Scale (PANSS) is calibrated to rate symptoms in those with an established psychosis, especially those with a diagnosis related to the schizophrenia spectrum. Consequently, the PANSS is useful for evaluating the clinical course and outcomes of psychotic illness.

CONCLUSIONS

Although neither instrument is designed specifically for use in those under 18, with care they can be used to effectively support the management of adolescents reporting perceptual and ideational disturbance. However, it is important that any instrument ratings are placed meaningfully in the context of the overall clinical picture and all available information.

Course, outcome and diagnosis stability of early-onset schizophrenia in Yunnan Province, China-a three years follow-up study

The aim of the study was to describe diagnostic stability and psychosocial outcomes of subjects with early-onset schizophrenia (EOS). All the subjects who had been hospitalized in the Department of Psychiatry of the First Affiliated Hospital of Kunming Medical University between January 2011 and July 2015 with the diagnosis of International Classification of Diseases (ICD)-10 defined schizophrenia, and discharged from the hospital for more than 12 months were enrolled to the study. The Mini International Neuropsychiatric Interview was applied for life-time ICD -10 diagnoses, and Personal and Social Performance (PSP) for global function evaluation. Altogether 249 patients were targeted for follow-up, in which 101 were followed up and the dropout rate was 59.4%. After average 37.2 ± 16.2 months, 92 patients (including 1 death) were still met the ICD-10 diagnosis of schizophrenia (F20). In terms of global functioning, 48.5% of patients had good outcome, 43.6% had moderate outcome, and 7.9% had poor outcome. A relatively high diagnostic stability of ICD-10 defined schizophrenia was obtained in the current study .Moreover, our results draw a much more optimistic picture of the outcome for EOS than what has previously been reported from Western counties.

Mobile App-Based Intervention for Adolescents With First-Episode Psychosis: Study Protocol for a Pilot Randomized Controlled Trial

Introduction: Previous studies have shown an improvement in the access to treatment for patients with first-episode psychosis (FEP), specifically young patients, through mobile app-based interventions. The aim of this study is to test the effectiveness of a mobile app-based intervention to improve community functioning in adolescents with FEP. Mobile app-based interventions could increase quality of life and disease awareness, which improve adherence to treatment and reduce the frequency of relapses and rehospitalizations in adolescents with FEP. Methods: This article describes a mobile app treatment and the pilot trial protocol for patients with FEP. We will perform a single-blind randomized clinical trial (RCT) including patients with FEP aged 14-19 years recruited from Gregorio Marañón Hospital, Madrid, Spain. Patients will be randomly assigned to an intervention group, which will receive treatment as usual plus five modules of a psychological intervention through the mobile app (psychoeducation, recognition of symptoms and prevention of relapses, problem solving, mindfulness, and contact wall), or to a control group (standard care). The effectiveness of the intervention will be assessed by means of an extensive battery of clinical tests at baseline and at 3 months of follow-up. The primary outcome is reduction in psychotic and depressive symptoms; secondary outcomes comprise adherence, awareness, use of drugs, and quality of life. Data will be analyzed on an intention-to-treat (ITT) basis. Mixed model repeated-measures analysis will be used to explore the following effect: group × time interaction between the control group and the intervention group for clinical and functional variables during the follow-up period. Discussion: This is an innovative study for the assessment of a psychological intervention through a mobile app for patients with FEP during the critical period. This pilot RCT is intended to be a precursor to larger studies, which in turn could facilitate dissemination of mobile app therapy for patients with FEP. Ethics and Dissemination: The local ethics committee approved the study protocol. All participants must sign the informed consent, to participate. After finalizing the study, the results will be published. Trial registration: NCT03161249. NCT clinicaltrials.gov. Date of registration in primary registry 02 May 2017. clinicaltrials.gov.

A meta-analysis of factors associated with quality of life in first episode psychosis

OBJECTIVE

Improving quality of life for people with first episode psychosis is an important aspect of recovery. Our objective was to review the associative factors on quality of life in first episode psychosis. A meta-analysis was conducted on the associations between quality of life, symptom severity, and duration of untreated psychosis.

METHOD

Fifty-one articles were identified (published through 08/29/2016) that provided data on the relationship between quality of life and at least one other outcome measure of interest in first episode psychosis. Of those studies, 21 were included in a meta-analysis (n = 3992) of the relationship between quality of life, severity of psychosis, and duration of untreated psychosis.

RESULTS

Meta-analysis identified significant negative correlations between quality of life and severity of symptoms (total symptom scores: r = -0.32, p < 0.001) and quality of life and duration of untreated psychosis (r = -0.21, p < 0.001). Heinrich's quality of life scale emerged as being more sensitive to the presence of psychotic symptoms than other measures of quality of life.

CONCLUSIONS

Associations were found between certain disease specific variables and quality of life in first episode psychosis, highlighting the relationship between symptom presentation and quality of life and the need for early intervention. Proper assessment of quality of life is important to promote improved quality of life in patients with first episode psychosis. Future research is needed to examine the interacting effects of symptom presentation, duration of untreated psychosis, and other variables, such as neurocognition, on quality of life.

Motor abnormalities in first-episode psychosis patients and long-term psychosocial functioning

Motor abnormalities (MAs) are highly prevalent in patients with first-episode psychosis both before any exposure and after treatment with antipsychotic drugs. However, the extent to which these abnormalities have predictive value for long-term psychosocial functioning is unknown. One hundred antipsychotic-naive first-episode psychosis (FEP) patients underwent extensive motor evaluation including catatonic, parkinsonism, dyskinesia, akathisia and neurological soft signs. Patients were assessed at naïve state and 6months later. Patients were followed-up in their naturalistic treatment and settings and their psychosocial functioning was assessed at 6-month, 1year, 5year and 10years from the FEP by collecting all available information. A set of linear mixed models were built to account for the repeated longitudinal assessment of psychosocial functioning during the follow-up regarding to the five domains of MAs (catatonic, parkinsonism, akathisia, dyskinesia and neurologic soft-signs) at index episode at antipsychotic naïve state and after 6months of FEP. Basic epidemiological variables, schizophrenia diagnosis and average of chlorpromazine equivalent doses of antipsychotic drugs were included as covariates. Catatonic signs and dyskinesia at drug-naïve state were significantly associated with poor long-term psychosocial functioning. Moreover, higher scores on parkinsonism, akathisia, neurological soft signs and catatonic signs at 6-month of FEP but not dyskinesia showed significant associations with poor long-term psychosocial functioning. Our results added empirical evidence to motor abnormalities as core manifestations of psychotic illness before and after antipsychotic treatment with high predictive value for poor long-term psychosocial functioning in FEP patients.

Predictors of functioning in people suffering from first-episode psychosis 1 year into entering early intervention service in Hong Kong

AIM

To explore the changes of functioning in people suffering from first-episode psychosis throughout their first year into an early intervention service, and the baseline predictors of their functioning levels at baseline, 6 and 12 months METHOD: Consecutive subjects presenting to an early intervention service were recruited from 1 February 2013 to 31 May 2015. Information on their socio-demographic status was collected. Structured instruments were used to assess their premorbid functioning, duration of untreated psychosis, psychopathology and insight at baseline. Psychosocial functioning was assessed by Social Occupational Functioning Assessment Scale (SOFAS) and Role Functioning Scale at baseline, 6 and 12 months.

RESULTS

A total of 269 subjects were recruited. The mean baseline scores for SOFAS were 53.1 (standard deviation = 13.6) and 21.5 (standard deviation = 4.0), respectively. Positive and negative psychopathology, insight and mode of onset were significant factors associated with baseline functioning. Functioning by both instruments showed significant improvement after 6 months, and the gains were maintained at 12 months. For SOFAS, baseline insight (P = 0.008), education attainment (P = 0.016) and its own baseline score (P = 0.024) were predictive at 6 months, while for 12 months, only education attainment was predictive (P = 0.008). For Role Functioning Scale, its baseline score (P = 0.034) was predictive at 6 months, while at 12 months, only female gender predicted better role functioning.

CONCLUSION

Factors predictive of functioning levels at the three time points were different. Phase-specific intervention should be offered to enhance functional recovery of people with first-episode psychosis.

What constitutes 'good practice' in early intervention for psychosis? Analysis of clinical guidelines

BACKGROUND

Early Intervention in Psychosis (EIP) services have been implemented with the dual aims of preventing harmful outcomes associated with early-onset psychosis and improving prognosis. However, concerns have been raised regarding the ethical implications of involving young people in EIP services. One way to ensure high ethical standards and promote good practice in EIP delivery is through governance of clinical practice. This study aimed to investigate the normative dimensions of good practice in EIP through examination of clinical guideline documents published in England over the past 15 years.

METHODS

A total of 14 clinical guidelines and relevant policy documents for EIP were retrieved and analysed using a mixed inductive and deductive thematic approach. Themes were derived from the data itself, whereas the development of broader categories was performed through a constant comparison with the scientific literature describing ethical issues in EIP.

RESULTS

Ethical touchpoints of good practice in EIP included both procedural and substantive factors, which were seen to be interdependent and mutually constitutive. These ethical touchpoints were largely implicit in the documents analysed. Procedural requirements of EIP service delivery consisted of norms and rules pertaining to EIP service structure, adherence to codes of ethics, inclusivity, patient and family centredness and appropriate treatment provision. Substantive factors consisted of moral attributes that should be cultivated by healthcare professionals working in EIP: competency, empathy, sensitivity and trustworthiness.

CONCLUSIONS

We argue that, to ensure good practice in EIP, procedural and substantive ethical expectations embedded in EIP guideline documents should be made explicit in EIP service and care delivery. We suggest that the procedural and substantive factors highlighted in this paper contribute useful dimensions for the eventual evaluation of good practice in EIP services across England.

Dilemmas in the treatment of early-onset first-episode psychosis

Early-onset first-episode psychosis (EOP) is a severe mental disorder that can pose a number of challenges to clinicians, young people and their families. Its assessment and differentiation from other neurodevelopmental and mental health conditions may at times be difficult, its treatment may not always lead to optimal outcomes and can be associated with significant side effects, and its long-term course and prognosis seem to be less favourable compared with the adult-onset disorder. In this paper, we discuss some dilemmas associated with the evaluation and management of EOP and propose approaches that can be used in the clinical decision-making process. A detailed and well-informed assessment of psychotic symptoms and comorbidities, a systematic approach to treatment with minimum possible medication doses and close monitoring of its effectiveness and adverse effects, and multidimensional interventions taking into consideration risks and expectations associated with EOP, are paramount in the achievement of the most favourable outcomes for affected children and young people.

Pathways to functional outcomes following a first episode of psychosis: The roles of premorbid adjustment, verbal memory and symptom remission

OBJECTIVE

Most studies have investigated either the singular or relative contributions of premorbid adjustment, verbal memory and symptom remission to functional outcomes in first-episode psychosis. Fewer studies have examined the pathways of these factors in impacting functioning. Our study addresses this gap. The objective was to determine whether the relationship between premorbid adjustment and functional outcomes was mediated by verbal memory and symptom remission.

METHOD

A total of 334 first-episode psychosis participants (aged 14-35 years) were assessed on premorbid adjustment, verbal memory upon entry, and positive and negative symptom remission and functioning at multiple time points over a 2-year follow-up.

RESULTS

Mediation analyses showed that over the first year, the relationship between premorbid adjustment and functioning was mediated by verbal memory and positive symptom remission (β = -0.18; 95% confidence interval = [-0.51, -0.04]), as well as by verbal memory and negative symptom remission (β = -0.41; 95% confidence interval = [-1.11, -1.03]). Over 2 years, the relationship between premorbid adjustment and functioning was mediated by verbal memory and only negative symptom remission (β = -0.38; 95% confidence interval = [-1.46, -0.02]).

CONCLUSION

Comparatively less malleable factors (premorbid adjustment and verbal memory) may contribute to functional outcomes through more malleable factors (symptoms). Promoting remission may be an important parsimonious means to achieving better functional outcomes.

An examination of components of recovery after five years of treatment in an early intervention program for psychosis

Recovery from psychotic disorders includes both symptomatic and functional components. Progress in understanding recovery requires careful replication and extension of findings using comparable measures. In the current paper, we present a study of five year recovery rates in an early intervention program in London, Canada with the same operational criteria as those used in a previous report from the OPUS cohort in Denmark. Our analysis extends the OPUS reports by including additional potential predictors of overall recovery, such as cognitive functioning, adherence to medication and early social support, and examining rates and predictors of individual components of recovery at five year follow-up. Consistent with reports from OPUS, we found younger age of onset and lower initial severity of negative symptoms to predict greater likelihood of overall recovery. Different patterns of predictors emerge when we examine individual components of recovery. Adherence to medication during the first year was the sole independent predictor of remission of positive symptoms, while early social adjustment and social support were more likely to predict negative symptom and functional aspects of recovery at five years. Cognitive functioning, as represented by IQ, did not predict any aspects of recovery. Our findings suggest the importance of examining the predictors of individual components in the quest to improve overall recovery.

[Cross-sectional data of inpatient residents of a rehabilitation center with schizophrenic psychosis diagnosis]

Cross-sectional data of inpatient residents of a rehabilitation center with schizophrenic psychosis diagnosis Abstract.

OBJECTIVE

The objective of this study is to evaluate the level of neuropsychological functioning, quality of life, content of treatment, abnormal psychology as well as the level of functioning and medication in children and adolescents who suffer from a schizophrenia spectrum disorder, treated as rehabilitation inpatients.

METHODS

Forty-two patients could be examined, therefore, the IRAOS, the WAIS-IV, the TMT-A/-B, the FBB-P (patient's version), the ILK-P, the SANS/SAPS, the BPRS, the BSCL, the GAF, the CGAS, and the CGI were used.

RESULTS

Patients' average age at onset of the disorder was 14.49 years (± 2.90). The total value of IQ was 87.00 (± 15.02), the value of TMT-A was 73.05 (± 14.51), and of the TMT-B 75.62 (± 15.15). The value for the content of treatment in the summary-score of the FBB-P was 3.05 (± 0.49). The value of the total-score in ILK-P was 2.10 (± 0.70). The summary-score of the SANS was 5.00 (± 2.90) and of the SAPS 3.00 (± 2.70). The BPRS-summary-score's value was 30.70 (± 7.80), the BSCL-GSI's value was 0.90 (± 0.50). GAF and CGAS were at 48.30 (± 12.80), respectively 51.00 (± 12.30). Clozapin has been prescribed in 25.0 % of the cases as first or second neuroleptic medication.

CONCLUSION

We investigated patients with VEOS and EOS living in a rehabilitation center. Usually, the course of their illness is much more severe and chronic than it is seen in a common department for child and adolescent psychiatry. Findings indicate a clear impairment in the level of neuropsychological and global functioning in contrast to rather low to moderate burden of positive/negative deficits. Satisfactory results of treatment and quality of life could be evaluated in spite of the aforementioned impairments. Medication did not conform to current guidelines, especially concerning Clozapin. Findings of the subsequent follow-up will show, if the impairment will improve under inpatient rehabilitation conditions.

The CIRCuiTS study (Implementation of cognitive remediation in early intervention services): protocol for a randomised controlled trial

Background

Cognitive problems in people with schizophrenia predict poor functional recovery even with the best possible rehabilitation opportunities and optimal medication. A psychological treatment known as cognitive remediation therapy (CRT) aims to improve cognition in neuropsychiatric disorders, with the ultimate goal of improving functional recovery. Studies suggest that intervening early in the course of the disorder will have the most benefit, so this study will be based in early intervention services, which treat individuals in the first few years following the onset of the disorder. The overall aim is to investigate different methods of CRT.

Methods

This is a multicentre, randomised, single-blinded, controlled trial based in early intervention services in National Health Service Mental Health Trusts in six English research sites. Three different methods of providing CRT (intensive, group, and independent) will be compared with treatment as usual. We will recruit 720 service users aged between 16 and 45 over 3 years who have a research diagnosis of non-affective psychosis and will be at least 3 months from the onset of the first episode of psychosis. The primary outcome measure will be the degree to which participants have achieved their stated goals using the Goal Attainment Scale. Secondary outcome measures will include improvements in cognitive function, social function, self-esteem, and clinical symptoms.

Discussion

It has already been established that cognitive remediation improves cognitive function in people with schizophrenia. Successful implementation in mental health services has the potential to change the recovery trajectory of individuals with schizophrenia-spectrum disorders. However, the best mode of implementation, in terms of efficacy, service user and team preference, and cost-effectiveness is still unclear. The CIRCuiTS trial will provide guidance for a large-scale roll-out of CRT to mental health services where cognitive difficulties impact recovery and resilience.

Trial registration

ISRCTN, ISRCTN14678860, Registered on 6 June 2016.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2553-3) contains supplementary material, which is available to authorized users.

Evolution of metabolic risk factors over a two-year period in a cohort of first episodes of psychosis

Patients with a first episode of psychosis (FEP) display a broad range of metabolic risk factors related to the development of diverse medical comorbidities. Initial stages of these disorders are essential in understanding the increased vulnerability of developing cardiometabolic disturbances, associated with a reduced life expectancy. This study aimed to evaluate the metabolic profile of a cohort of patients with a FEP and its evolution during a two year follow-up, as well as the factors that influence the changes in their metabolic status. 16 participating centers from the PEPs Project recruited 335 subjects with a FEP and 253 matched healthy controls, aged 9-35years. We investigated a set of anthropometric measures, vital signs and laboratory data obtained from each participant over two years in a prospective, naturalistic study. From the beginning of the study the FEP group showed differences in the metabolic profile compared to the control group, together with a progressive worsening in the major part of the analyzed variables during the follow-up period, with higher rates of obesity and metabolic syndrome. Certain risk factors were related to determinate clinical variables such as male gender, the presence of affective symptoms or an early onset or to treatment variables such as the use of antipsychotic polypharmacy, antidepressants or mood stabilizers. Our results highlight the extremely high risk of patients at early phases of schizophrenia and other psychotic disorders of developing cardiovascular comorbidity and the fast worsening of the metabolic profile during the first two years.

Autism spectrum disorder and schizophrenia: boundaries and uncertainties

Autism and schizophrenia were placed in different diagnostic categories in DSM-III, having previously been considered as related diagnostic entities. New evidence suggests that these disorders show clinical and cognitive deficit overlaps and shared neurobiological characteristics. Furthermore, children presenting with both autism spectrum disorder (ASD) and psychotic experiences may represent a subgroup of ASD more closely linked to psychosis. The study of ASD and childhood schizophrenia, and their clinical boundaries and overlapping pathophysiological characteristics, may clarify their relationship and lead to more effective interventions. This article discusses the relationship through a critical review of current and historical dilemmas surrounding the phenomenology and pathophysiology of these disorders. It provides a framework for working with children and young people with mixed clinical presentations, illustrated by three brief fictional case vignettes.

Age at onset and the outcomes of schizophrenia: A systematic review and meta-analysis

The aim of this study was to analyse the effect of age at onset on the long-term clinical, social and global outcomes of schizophrenia through a systematic review and a meta-analysis. Original studies were searched from Web of Science, PsycINFO, Pubmed and Scopus, as well as manually. Naturalistic studies with at least a 2-year follow-up were included. Of the 3509 search results, 81 articles fulfilled the inclusion criteria. The meta-analysis was performed in Stata as a random-effect analysis with correlation coefficients between age at onset and the outcomes (categorized into remission, relapse, hospitalization, positive symptoms, negative symptoms, total symptoms, general clinical outcome, employment, social/occupational functioning and global outcome). There was a statistically significant (P < .05) correlation between younger age at onset and more hospitalizations (number of studies, n = 9; correlation, r = 0.17; 95% confidence interval, CI 0.09-0.25), more negative symptoms (n = 7; r = 0.14; 95% CI 0.01-0.27), more relapses (n = 3; r = 0.11; 95% CI 0.02-0.20), poorer social/occupational functioning (n = 12; r = 0.15; 95% CI 0.05-0.25) and poorer global outcome (n = 13; r = 0.14; 95% CI 0.07-0.22). Other relationships were not significant. This was the first systematic review of the effects of age at onset on the long-term outcomes of schizophrenia. The results show that age at onset has a small, but significant impact on some of the outcomes of schizophrenia.

Occupation and first episode psychosis in Northern Italy: better outcomes for migrants

AIMS

Many studies show that migrants have a higher incidence of psychosis compared to natives, but the influence of migration on psychosis outcomes is little investigated. We aimed to evaluate the occupational outcomes of a first episode psychosis (FEP) sample in Bologna (Northern Italy).

METHODS

An incidence cohort of FEP patients presenting at the Bologna West Community Mental Health Centers between 2002 and 2009 was assessed at the baseline and at 12th month follow-up. Return to school or work was used as occupational outcome.

RESULTS

Most of the patients (82.8%) were still in contact at 12 months. Migrants showed significantly higher rate of return to work compared to natives (adjusted OR 4.45, 95% CI 1.55-12.76).

CONCLUSIONS

First generation migrants had better occupational outcomes. Further cross-cultural studies are needed to further explain these findings.

The association between season of birth, age at onset, and clozapine use in schizophrenia

OBJECTIVE

This study aimed to determine whether the rate of clozapine use, an indicator of refractoriness in schizophrenia, is associated with the season of birth and age at onset in patients with schizophrenia based on nationwide data.

METHODS

Patients with schizophrenia (n = 114 749) who received prescriptions for antipsychotic medication between 2008 and 2014 were retrospectively identified from the Korean National Health Insurance Service database. The study population was divided into three groups based on their age at the onset of schizophrenia (early, middle, and late onset). We assessed differences in the month of birth between patients and the general population. In addition, the cumulative clozapine use was calculated.

RESULTS

Compared to the late-onset schizophrenia group, the early- and middle-onset groups showed a higher probability of birth during the winter season. In addition, the early-onset group showed the highest cumulative clozapine use rate. In the middle-onset group, the initiation of clozapine use was significantly earlier for patients born in winter compared to those born in summer.

CONCLUSION

Our results indicate that the age at onset is an important factor in predicting the prognosis of schizophrenia patients. The season of birth also affects the prognosis, but with less robustness. Specifically, it appears that early disease onset and winter birth might be associated with poor outcomes in Korean patients with schizophrenia.

Men and women with psychosis and the impact of illness-duration on sex-differences: The second Australian national survey of psychosis

We aimed to examine and compare sex-differences in people receiving treatment for psychotic illnesses in community settings, based on long or short duration of illness; expecting association between longer illness-duration and worse outcomes in women and men. Clinical, demographic and service-use data from the Survey of High Impact Psychosis were analysed by sex and duration of illness (≤5 years; ≥6 years), using independent t-tests, chi-square tests, one-way ANOVA, and Cramer's V. Of the 1825 participants, 47% had schizophrenia, 17.5% bipolar and 16.1% schizo-affective disorders. More women than men had undertaken post-school education, maintained relationships, and been living in their own homes. Women with a shorter-illness-duration showed social functioning equivalent to non-ill women in the general population. Men tended to have an early illness onset, show premorbid dysfunction, be single, show severe disability, and to use illicit substances. Men with a longer-illness-duration were very socially disadvantaged and isolated, often experiencing homelessness and substance use. Men with a short-illness-duration were most likely to be in paid employment, but two-thirds earned less than $AUD500 per fortnight. Men with longer-illness-duration showed most disability, socially and globally. Interventions should be guided by diagnosis, but also by a person's sex and duration of illness.

Canadian Guidelines for the Pharmacological Treatment of Schizophrenia Spectrum and Other Psychotic Disorders in Children and Youth

OBJECTIVE

Schizophrenia spectrum and other psychotic disorders often have their onset in adolescence. The sequelae of these illnesses can negatively alter the trajectory of emotional, cognitive, and social development in children and youth if left untreated. Early and appropriate interventions can improve outcomes. This article aims to identify best practices in the pharmacotherapy management of children and youth with schizophrenia spectrum disorders.

METHODS

A systematic search was conducted for published guidelines for schizophrenia and schizophrenia spectrum disorders in children and youth (under age 18 years). Recommendations were drawn from the National Institute for Health and Care Excellence guidelines on psychosis and schizophrenia in children and youth (2013 and 2015 updates). Current guidelines were adopted using the ADAPTE process, which includes consensus ratings by a panel of experts.

RESULTS

Recommendations identified covered a range of issues in the pharmacotherapy management of children and youth with schizophrenia spectrum disorders. Further work in this area is warranted as we continue to further understand their presentation in the developing brain.

CONCLUSIONS

Canadian guidelines for the pharmacotherapy management of children and youth with schizophrenia spectrum disorders are essential to assist clinicians in treating this vulnerable population. Ongoing work in this area is recommended.

Early-onset schizophrenia: Symptoms and social class of origin

BACKGROUND

The genesis of schizophrenia is multifactorial, including biological and environmental risk factors. We tested for an interactive effect between early-onset schizophrenia (EOS) and social class of origins (socioeconomic status (SES)). Data were further analyzed for a possible connection to type of schizophrenic symptoms. Sampling/Methods: Data for the study are taken from the medical records of 642 patients from a large state hospital in the northeastern United States. Clinical assessments were divided into positive and negative symptomatology through application of the Scale for the Assessment of Negative Symptoms (SANS), the Scale for the Assessment of Positive Symptoms (SAPS) and the Positive and Negative Syndrome Scale (PANSS). Detailed information about age of onset and SES of origin was obtained through Social Service Assessment interviews.

RESULTS

We uncovered a significant impact of EOS among the poor that elevates risk for negative symptomatology.

CONCLUSION

Poor SES alone does not increase the likelihood of EOS, but it magnifies the deleterious effect of EOS on negative symptoms. Future research on these variables may inform the relative contribution of each.

Oxidative Stress and Inflammation in Early Onset First Episode Psychosis: A Systematic Review and Meta-Analysis

Background

People with schizophrenia and other psychosis show increased proinflammatory and prooxidative status. However, the few studies that have specifically assessed oxidative and inflammatory markers in early onset psychosis (onset before age 18) have shown contradictory results.

Methods

Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines for systematic reviews and meta-analyses were used to conduct a systematic literature search to detect studies comparing inflammatory and oxidative markers in early onset psychosis patients and healthy controls.

Results

Seven studies met criteria for the qualitative analysis. Four studies met criteria for meta-analysis, comprising an overall sample of 261 early onset psychosis patients and 246 healthy controls. Six independent meta-analyses were performed for catalase, glutathione, glutathione peroxidase, superoxide dismutase, total antioxidant status, and cell/DNA oxidative damage. No significant differences were found between early onset psychosis patients and controls in any of the parameters assessed. Heterogeneity among studies was high. Qualitative analysis of individual studies showed an association of inflammatory and oxidative markers with clinical, cognitive, and neurobiological outcomes, especially in longitudinal assessments.

Conclusions

Despite the lack of significant differences between early onset psychosis patients and controls in the oxidative markers assessed in the meta-analyses, results based on individual studies suggest that greater inflammation and oxidative stress might lead to poorer outcomes in patients with first episodes of early onset psychosis.