Impact of early intervention services on duration of untreated psychosis: data from the National EDEN prospective cohort study

First episode psychoses in people over-35 years old: uncovering potential actionable targets for early intervention services

The traditional youth-oriented design of Early Intervention Services (EIS) may lead to the exclusion of patients who have their psychotic onset later in life. A retrospective study was conducted to compare first-episode psychosis (FEP) patients who accessed treatment when aged ≤ 35 years with those ≥36+. A total of 854 patients were identified among 46,222 individuals who had access to community psychiatric services from 1991 to 2021. FEP were aged 18-65, received care between 2012 and 2021 and had a diagnosis of affective or non-affective FEP. Two groups were identified (FEP diagnosed at age ≤ 35 vs ≥ 36) and compared for sociodemographic and clinical characteristics. Most patients were diagnosed when aged ≥ 36+ (61.8%). Compared to the ≤ 35 group, older patients were more likely to be women, married and diagnosed with affective psychosis, and they were less frequently hospitalized. Long-acting injectables antipsychotics (LAI) were less frequently prescribed in the ≥ 36+ group, whereas antidepressants were more frequently prescribed compared to those aged ≤ 35. In both age groups, women were less frequently prescribed LAIs compared to men. These findings highlight the need to reorient EIS to accommodate the needs of older FEP, especially women.

Social disadvantage in early psychosis and its effect on clinical presentation and service access, engagement and use

Incidence of psychosis varies geographically due to factors such as social disadvantage. Whether this influences the clinical presentation and/or engagement of those experiencing psychosis remains relatively understudied. This study analysed data from young people across Australia accessing ultra-high risk (UHR) or first episode psychosis (FEP) services delivered through the headspace Early Psychosis (hEP) program between June 2017 and March 2021. The cohort was categorised into low, middle, and high tertiles of social disadvantage using the Index of Relative Socioeconomic Disadvantage (IRSD). Data from 3089 participants aged 15-25 were included (1515 UHR, 1574 FEP). The low and middle tertiles for both cohorts had greater percentages of those not in education or employment (NEET), with First Nations or culturally and linguistically diverse backgrounds. Clinical presentations to services were similar across all tertiles in both cohorts, however, functioning at presentation varied significantly within the FEP cohort. Significantly lower numbers of direct services were provided in the low tertile of both cohorts, with significantly poorer engagement in the initial three-months also occurring for these young people. This variation in early psychosis service patterns associated with geographical variation in social deprivation demonstrates the need for further research and fine tuning of national early psychosis services.

Five-year illness trajectories across racial groups in the UK following a first episode psychosis

PURPOSE

Psychosis disproportionally affects ethnic minority groups in high-income countries, yet evidence of disparities in outcomes following intensive early intervention service (EIS) for First Episode Psychosis (FEP) is less conclusive. We investigated 5-year clinical and social outcomes of young people with FEP from different racial groups following EIS care.

METHOD

Data were analysed from the UK-wide NIHR SUPEREDEN study. The sample at baseline (n = 978) included White (n = 750), Black (n = 71), and Asian (n = 157) individuals, assessed during the 3 years of EIS, and up to 2 years post-discharge (n = 296; Black [n = 23]; Asian [n = 52] and White [n = 221]). Outcome trajectories were modelled for psychosis symptoms (positive, negative, and general), functioning, and depression, using linear mixed effect models (with random intercept and slopes), whilst controlling for social deprivation. Discharge service was also explored across racial groups, 2 years following EIS.

RESULTS

Variation in linear growth over time was accounted for by racial group status for psychosis symptoms-positive (95% CI [0.679, 1.235]), negative (95% CI [0.315, 0.783]), and general (95% CI [1.961, 3.428])-as well as for functioning (95% CI [11.212, 17.677]) and depressive symptoms (95% CI [0.261, 0.648]). Social deprivation contributed to this variance. Black individuals experienced greater levels of deprivation (p < 0.001, 95% CI [0.187, 0.624]). Finally, there was a greater likelihood for Asian (OR = 3.04; 95% CI [2.050, 4.498]) and Black individuals (OR = 2.47; 95% CI [1.354, 4.520]) to remain in secondary care by follow-up.

CONCLUSION

Findings suggest variations in long-term clinical and social outcomes following EIS across racial groups; social deprivation contributed to this variance. Black and Asian individuals appear to make less improvement in long-term recovery and are less likely to be discharged from mental health services. Replication is needed in large, complete data, to fully understand disparities and blind spots to care.

Predictors of full recovery in patients with early stage schizophrenia spectrum disorders

To promote recovery in psychosis, targeting modifiable factors related to recovery is critical. Using more strict definition of full recovery, we examined predictors for recovery in patients with early stage schizophrenia spectrum disorders (SSD) followed up to 6.5 years. The target subjects were 375 patients with early stage SSD who had been over at least 1-year after registration and evaluated. The criteria for full recovery were having the score of the Positive and Negative Syndrome Scale (PANSS) 8-item ≤ 2 and adequate functional recovery for at least 1-year. We performed univariate Cox and stepwise Cox regression in both total and acute patients. In stepwise Cox regression, several independent predictors for recovery, i.e., negative symptoms of the PANSS, duration of untreated psychosis (DUP) and non-professional job were identified in patients with early stage SSD. In acute patients, other factors such as professional job and subjective well-being under neuroleptics were more important. The present study identified independent predictors for recovery modifiable by various psychosocial intervention and early intervention services. Moreover, it highlights the need of providing different treatment strategies depending on clinical status.

Heterogeneity in treatment outcomes and incomplete recovery in first episode psychosis: does one size fit all?

The heterogeneity in recovery outcomes for individuals with First Episode Psychosis (FEP) calls for a strong evidence base to inform practice at an individual level. Between 19-89% of young people with FEP have an incomplete recovery despite gold-standard evidence-based treatments, suggesting current service models, which adopt a 'one-size fits all' approach, may not be addressing the needs of many young people with psychosis. The lack of consistent terminology to define key concepts such as recovery and treatment resistance, the multidimensional nature of these concepts, and common comorbid symptoms are some of the challenges faced by the field in delineating heterogeneity in recovery outcomes. The lack of robust markers for incomplete recovery also results in potential delay in delivering prompt, and effective treatments to individuals at greatest risk. There is a clear need to adopt a stratified approach to care where interventions are targeted at subgroups of patients, and ultimately at the individual level. Novel machine learning, using large, representative data from a range of modalities, may aid in the parsing of heterogeneity, and provide greater precision and sophistication in identifying those on a pathway to incomplete recovery.

Three-year outcomes and predictors for full recovery in patients with early-stage psychosis

In the present study, various outcomes over 3-year period in patients with early stage psychosis including remission, recovery, relapse and medication adherence were investigated. Predictor for full recovery at year 3 was also examined. Three-year follow-up data in 534 patients with schizophrenia spectrum disorders (SSD) and psychotic disorder not otherwise specified (PNOS) were examined for overall outcome trajectories. The data of completers at year 3 (n = 157) were used to identify predictors for recovery using logistic regression. The rates of symptomatic remission and full recovery at 6-, 12-, 24-, and 36-month follow-up were 76.10, 69.20, 79.50, and 79.10%, and 22.80, 26.40, 28.60, and 39.60%, respectively. The rates of drop-out and relapse at 6-, 12-, 24-, and 36-month follow-up were 25.4, 29.5, 38.6, and 51.1%, and 3.7, 8.9, 19.0, and 38.9%, respectively. The rates of good adherence and prescription of Long-Acting Injectable Antipsychotics (LAIA) at 6-, 12-, 24- and 36-month follow-up were 87.8, 88.0, 91.9, and 93.9%, and 18.3, 21.7, 22.0, and 25.5%, respectively. Significant predictors for full recovery were duration of untreated psychosis (DUP), family intimacy and physical activity. We observed similar or better results on remission, recovery, and relapse rates compared to other previous studies. Effective psychosocial intervention should be provided to shorten the gap between remission and recovery rates and to address DUP, family issues, and exercise to enhance recovery.

The clinical and functional outcomes of a large naturalistic cohort of young people accessing national early psychosis services

AIMS

Services for individuals with a first episode of psychosis or at ultra-high risk of psychosis have become a treatment model of choice in mental health care. The longitudinal changes in clinical and functional outcomes as a result of real-world treatment remain under-reported.

METHODS

We analysed data from first episode of psychosis and ultra-high risk services delivered across Australian primary youth mental health care services known as headspace between 19 June 2017 and 30 September 2019. Outcome measures were completed and entered into a minimum dataset every 90 days a participant was receiving treatment and included psychiatric symptomatology (Brief Psychiatric Rating Scale and psychological distress, K10) and psychosocial functioning (Social and Occupational Functioning Assessment Scale and My Life Tracker). Linear mixed-effects models were used to evaluate changes in outcome over time.

RESULTS

Outcome data from a total of 1252 young people were evaluated (643 first episode of psychosis, 609 ultra-high risk). Of those who entered ultra-high risk services, 11.8% transitioned to first episode of psychosis services. Overall, substantial improvement in clinical (Brief Psychiatric Rating Scale, K10) and functional (Social and Occupational Functioning Assessment Scale, My Life Tracker) outcomes were seen across groups and outcomes. Ultra-high risk patients showed a greater reduction in distress symptoms, while first episode of psychosis patients experienced a greater reduction in positive psychosis symptoms. Although clinical outcomes showed a plateau effect after approximately 3 months of care, improvement in functional outcomes (Social and Occupational Functioning Assessment Scale, My Life Tracker) continued later in treatment.

CONCLUSION

These findings support the use of real-time, real-world and low-cost administrative data to rigorously evaluate symptomatic and functional outcomes in early psychosis treatment settings. Findings that functional outcomes improve past the remittance of clinical outcomes also support the functional recovery focus of early psychosis services and remaining high levels of distress suggest the need for ultra-high risk services to extend beyond 6 months of care.

Transdiagnostic Psychopathology in a Help-Seeking Population of an Early Recognition Center for Mental Disorders: Protocol for an Experience Sampling Study

BACKGROUND

Prevention in psychiatry provides a promising way to address the burden of mental illness. However, established approaches focus on specific diagnoses and do not address the heterogeneity and manifold potential outcomes of help-seeking populations that present at early recognition services. Conceptualizing the psychopathology manifested in help-seeking populations from a network perspective of interacting symptoms allows transdiagnostic investigations beyond binary disease categories. Furthermore, modern technologies such as smartphones facilitate the application of the Experience Sampling Method (ESM).

OBJECTIVE

This study is a combination of ESM with network analyses to provide valid insights beyond the established assessment instruments in a help-seeking population.

METHODS

We will examine 75 individuals (aged 18-40 years) of the help-seeking population of the Cologne early recognition center. For a maximally naturalistic sample, only minimal exclusion criteria will be applied. We will collect data for 14 days using a mobile app to assess 10 transdiagnostic symptoms (ie, depressive, anxious, and psychotic symptoms) as well as distress level 5 times a day. With these data, we will generate average group-level symptom networks and personalized symptom networks using a 2-step multilevel vector autoregressive model. Additionally, we will explore associations between symptom networks and sociodemographic, risk, and resilience factors, as well as psychosocial functioning.

RESULTS

The protocol was designed in February 2020 and approved by the Ethics Committee of the University Hospital Cologne in October 2020. The protocol was reviewed and funded by the Köln Fortune program in September 2020. Data collection began in November 2020 and was completed in November 2021. Of the 258 participants who were screened, 93 (36%) fulfilled the inclusion criteria and were willing to participate in the study. Of these 93 participants, 86 (92%) completed the study. The first results are expected to be published in 2022.

CONCLUSIONS

This study will provide insights about the feasibility and utility of the ESM in a help-seeking population of an early recognition center. Providing the first explorative phenotyping of transdiagnostic psychopathology in this population, our study will contribute to the innovation of early recognition in psychiatry. The results will help pave the way for prevention and targeted early intervention in a broader patient group, and thus, enable greater intended effects in alleviating the burden of psychiatric disorders.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/35206.

First-episode psychosis in the Ferrara Mental Health Department: Incidence and clinical course within the first 2 years

AIM

To examine the incidence of with first-episode psychosis (FEP) in the Integrated Department of Mental Health and Pathological Addictions in Ferrara, Italy, and to examine the association between the Duration of Untreated Psychosis (DUP) and the clinical course.

METHODS

Participants recruited in 2013-2019 were assessed with the Health of the Nation Outcome Scale (HoNOS) every 6 months for 24 months. Hierarchical growth models analysed changes of global severity (HoNOS total scores) and symptom dimensions. Regression modelled factors associated with remission (HoNOS < 8) and clinical improvement (<12).

RESULTS

The incidence of FEP was 21.5 (95%CI: 21.2-21.9) cases per 100 000 person year. Among participants (n = 86, mean age 23, 76% males), baseline HoNOS scores were higher for those with a longer DUP. More than half subjects reached clinical remission (61.6%) or improvement (82.6%), while very few (2.3%) were re-hospitalized. HoNOS total scores decayed with a mixed linear/quadratic trend, with a slower decay among migrants. A longer DUP was associated with reduced improvements of positive symptoms and lower likelihood of clinical improvement (OR: 0.84; 95%CI: 0.73-0.96).

CONCLUSIONS

Patients from the FEP program of Ferrara reached good clinical outcomes. Nonetheless, individuals with a longer DUP may need additional clinical attention. Systematic monitoring of clinical outcomes may be an optimal strategy to improve the outcomes of FEP in the real world.

A Synthetic Literature Review on the Management of Emerging Treatment Resistance in First Episode Psychosis: Can We Move towards Precision Intervention and Individualised Care?

Treatment resistance is prevalent in early intervention in psychosis services, and causes a significant burden for the individual. A wide range of variables are shown to contribute to treatment resistance in first episode psychosis (FEP). Heterogeneity in illness course and the complex, multidimensional nature of the concept of recovery calls for an evidence base to better inform practice at an individual level. Current gold standard treatments, adopting a ‘one-size fits all’ approach, may not be addressing the needs of many individuals. This following review will provide an update and critical appraisal of current clinical practices and methodological approaches for understanding, identifying, and managing early treatment resistance in early psychosis. Potential new treatments along with new avenues for research will be discussed. Finally, we will discuss and critique the application and translation of machine learning approaches to aid progression in this area. The move towards ‘big data’ and machine learning holds some prospect for stratifying intervention-based subgroups of individuals. Moving forward, better recognition of early treatment resistance is needed, along with greater sophistication and precision in predicting outcomes, so that effective evidence-based treatments can be appropriately tailored to the individual. Understanding the antecedents and the early trajectory of one’s illness may also be key to understanding the factors that drive illness course.

Evidence-based guidelines for the pharmacological treatment of schizophrenia: Updated recommendations from the British Association for Psychopharmacology

These updated guidelines from the British Association for Psychopharmacology replace the original version published in 2011. They address the scope and targets of pharmacological treatment for schizophrenia. A consensus meeting was held in 2017, involving experts in schizophrenia and its treatment. They were asked to review key areas and consider the strength of the evidence on the risk-benefit balance of pharmacological interventions and the clinical implications, with an emphasis on meta-analyses, systematic reviews and randomised controlled trials where available, plus updates on current clinical practice. The guidelines cover the pharmacological management and treatment of schizophrenia across the various stages of the illness, including first-episode, relapse prevention, and illness that has proved refractory to standard treatment. It is hoped that the practice recommendations presented will support clinical decision making for practitioners, serve as a source of information for patients and carers, and inform quality improvement.

Individual factors influencing the duration of untreated psychosis

AIM

Duration of untreated psychosis (DUP), or the time between onset of psychosis and treatment initiation, is a prognostic factor of schizophrenia. However, few studies evaluated the relative influence of individual-related factors on this duration. The objective of this study was to evaluate the influence of socio-demographic, clinical and cannabis use on DUP.

METHODS

This study was part of a large prospective study in help-seeking individuals referred to our specialized early detection / intervention clinic in the Service Hospitalo-Universitaire of Sainte-Anne Hospital in Paris (ICAAR study). We explored 33 consecutive patients who crossed the CAARMS' threshold of psychosis. The DUP and cannabis consumption history were explored during the baseline comprehensive assessment using all available sources (direct interviews of patients, parents, practitioners). Correlations between socio-demographic, clinical and cannabis use, and DUP were studied. A multiple linear regression model was used to determine the variables that could significantly predict DUP.

RESULTS

When considered individually, none of the socio-demographic and disease characteristic factors was associated with DUP, with the exception of level of education. In the multivariate analysis, age at inclusion, negative symptoms and history of cannabis use significantly influenced DUP.

CONCLUSION

The determinants of DUP are multi-factorial and include individual centred factors, such as age, cannabis and negative symptoms. The identification of factors resulting in delayed access to care may promote the development of effective strategies to reduce DUP in early psychosis and target effective early intervention.

Predictors of remission during acute treatment of first-episode schizophrenia patients involuntarily hospitalized and treated with algorithm-based pharmacotherapy: Secondary analysis of an observational study

AIM

Early clinical response predicts symptomatic remission and recovery in the maintenance treatment phase of first-episode schizophrenia (FES). However, little is known about predictors of symptomatic remission during acute treatment of severely ill patients with FES. Here, we conducted a secondary analysis of our retrospective observational study, which examined response, remission and treatment-resistance rates in seriously ill patients with FES spectrum disorders involuntarily hospitalized and treated with algorithm-based pharmacotherapy.

METHODS

We performed a retrospective chart review of 131 involuntarily admitted patients with schizophrenia or schizoaffective disorder. Our algorithm aimed to delay olanzapine treatment, standardize medications and suggest initiation of clozapine after failure of third-line antipsychotic treatment. The duration of each adequate antipsychotic treatment at an optimal dosage was 4 weeks or more. Remission was defined using the symptom-severity component of consensus remission criteria. A logistic regression model was applied to identify significant predictors of remission at discharge.

RESULTS

Overall, 74 patients (56%) were in remission at discharge. Non-remitters were hampered from becoming remitters mainly by the presence of negative symptoms. There were no differences in first-line antipsychotics, dosage of antipsychotics at time of response and adherence rates to algorithm-based pharmacotherapy between remitters and non-remitters. Shorter duration of untreated psychosis, favourable early response and less negative symptoms at baseline were identified as independent predictors of remission at discharge.

CONCLUSIONS

The importance of early intervention and specific and adequate treatments of negative symptoms is highlighted.

Fidelity scales and performance measures to support implementation and quality assurance for first episode psychosis services

AIM

The purpose of this paper is to review fidelity and outcome measures which can be used to support broad implementation of first episode psychosis services and ensure quality of existing services. First episode psychosis services use a combination of evidence-based practices to improve the outcome of a first episode of psychosis and the early stages of schizophrenia. Now that there is an established international evidence base to show that they are effective, efforts are being made to make such services widely available as a routine part of health care.

METHODS

We provide an overview of the literature from the perspective of an expert task force that was commissioned to report to the board of the International Early Psychosis Association IEPA. First, we examined the evidence-based components that underpin first episode psychosis services and identified common elements. Next, we reviewed the availability of fidelity measures and outcome indicators, finally we reviewed how broadly these services are delivered internationally, and the barriers to ensuring broad access to quality services.

RESULTS

There is a growing consensus about the elements required to deliver effective services. Fidelity scales and performance measures are available to assess quality, access, and outcome. First episode psychosis services are variably offered in high-income countries and rarely with attention to access and quality of services. Several strategies to promote implementation are identified.

CONCLUSIONS

Fidelity scales and outcome measure are valuable resources to support widespread implementation and quality assurance for first episode psychosis services.

Development and preliminary validation of a brief behavioral measure of psychotic propensity

Extensive research demonstrates that the dimensional assessment of psychotic manifestations is a primary strength of the Rorschach inkblot task, which provides an in vivo sample of problem-solving behavior and normative standards concerning the logic and coherence of thought processes and the typicality of perceptual representations. This article presents foundational research for the Thought and Perception Assessment System (TPAS), a Rorschach-based system designed to assess solely for disordered thinking and perceptual aberrations using either the standard 10-card set of inkblots or alternative 3-, 4-, and 5-card short forms. Using data from three patient samples (ns = 61, 93, and 133) and one nonpatient sample (n = 118), we document the equivalence of mean scores across the full and short-form card sets. We also document satisfactory interrater reliability and validity for the full and short forms, as well as strong part-whole reliability coefficients between the short forms and the full form. Consistent with psychometric theory and the principle of aggregation, each type of coefficient decreased as a function of decreasing the number of cards. We discuss implications and future applications in research and clinical assessment.

Can We Reduce the Duration of Untreated Psychosis? A Systematic Review and Meta-Analysis of Controlled Interventional Studies

Reduction of duration of untreated psychosis (DUP) is the key strategy of early interventions for improving the outcomes of first-episode psychosis. Although several controlled interventional studies have been conducted with the aim of reducing DUP, the results are highly inconsistent and conflicting. The current study systematically searches Web of Science and Ovid for English original articles investigating interventions adopted to reduce DUP, compared to a control intervention, up to April 6, 2017. Sixteen controlled interventional studies were retrieved, including 1964 patients in the intervention arm and 1358 in the control arm. The controlled intervention studies were characterized by standalone first episode psychosis services, standalone clinical high risk services, community interventions, healthcare professional training, and multifocus interventions. Random effects meta-analyses were conducted. There was no summary evidence that available interventions are successful in reducing DUP during the first episode of psychosis (Hedges' g = -0.12, 95% CI = -0.25 to 0.01). Subgroup analyses showed no differences within each subgroup, with the exception of clinical high risk services (Hedges' g = -0.386, 95% CI = -0.726 to -0.045). These negative findings may reflect a parceled research base in the area, lack of prospective randomized controlled trials (only 2 randomized cluster designed studies were present) and small sample sizes. There was substantial heterogeneity (I2 = 66.4%), most of which was accounted by different definitions of DUP onset (R2 = .88). Psychometric standardization of DUP definition, improvement of study design, and implementation of preventative strategies seem the most promising avenues for reducing DUP and improving outcomes of first-episode psychosis.

Longer Duration of Untreated Psychosis Hinders Improvement in Treatment of Chronic Schizophrenia: Community Based Early Intervention is an Evidence Based Option

To determine the effects of community-based mental health services on the quality of life and disease symptoms of chronic schizophrenia patients and to determine the effects of duration of untreated psychosis on outcome. The first year records of schizophrenia patients who had been followed up at Zeytinburnu CMHC for at least 12 months, have been used to asses outcome using initial and 12th month quality of life (QoL), positive and negative symptom scale (PANSS) scores. Highly significant improvements were shown in the QoL and PANSS scores. There were significant differences between the two study groups (duration of untreated psychosis >2 years, versus duration of untreated psychosis <2 years) in terms of improvements in QoL and PANSS scores. Formation of early intervention teams that seek to provide preventive activities (i.e. for schizophrenia) in countries that have changed to community based mental health systems is a sound mental health implementation.

Canadian Guidelines for the Assessment and Diagnosis of Patients with Schizophrenia Spectrum and Other Psychotic Disorders

OBJECTIVE

The objective of this article is to identify best practices in the diagnosis and assessment of patients with schizophrenia spectrum and other psychotic disorders. The diagnosis and assessment may occur in a range of situations from the emergency room to the outpatient clinic and at different stages of the disorder. The focus may be on acute exacerbations of illness, residual symptoms, levels of function, or changes in the response to treatment.

METHODS

A systematic search was conducted for guidelines published in the last 5 years for schizophrenia and schizophrenia spectrum disorders. The guidelines were rated by at least 2 raters, and recommendations adopted on the diagnosis and assessment were primarily drawn from the American Psychiatric Association practice guidelines for the psychiatric evaluation of adults and the National Institute for Health and Care Excellence guideline on psychosis and schizophrenia in adults. A number of de novo recommendations were also developed.

RESULTS

Eleven recommendations were identified that cover a range of assessment situations from diagnosis to the involvement of families in assessments.

CONCLUSIONS

An accurate assessment establishes the baseline for treatment planning based on clinical decision making for both pharmacotherapy and psychosocial treatments.

Effects of Group Cognitive-Behavioral Therapy in Young Patients in the Early Stage of Psychosis

OBJECTIVE

To develop a model of group cognitive-behavioral therapy (CBT) for Korean patients with early psychosis.

METHODS

The group CBT utilized in the present study consisted of metacognitive training, cognitive restructuring, and lifestyle managements. The Subjective Well-being Under Neuroleptics (SWN-K), Ambiguous Intentions Hostility Questionnaire (AIHQ), Drug Attitude Inventory (DAI), Beck Depression Inventory (BDI), Perceived Stress Scale (PSS), and Clinical Global Impression (CGI) were administered prior to and after CBT sessions. The participants were categorized into two groups according to the median duration of untreated psychosis (DUP; 4 months).

RESULTS

A total of 34 patients were included in this analysis. From pre- to post-therapy, there were significant increases in the SWN-K and DAI scores and significant decreases in the hostility subscale of the AIHQ, PSS, and CGI scores. Significant time × DUP interaction effects were observed for the SWN-K, DAI, and BDI scores, such that there were significant changes in patients with a short DUP but not in those with a long DUP.

CONCLUSION

The group CBT program had a positive effect on subjective wellbeing, attitude toward treatment, perceived stress, and suspiciousness of young Korean patients with early psychosis. These effects were particularly significant in patients with a short DUP.

Barriers to Seeking Early Psychiatric Treatment amongst First-episode Psychosis Patients: A Qualitative Study

AIMS

The aim of this study was to explore the family members' determinant of the delay in seeking psychiatric care to patients diagnosed with psychosis.

METHODS

Qualitative semi-structured interviews were carried out with twenty-seven family members of patients with psychosis at psychiatric outpatient clinics in Amman, Jordan.

RESULTS

The findings revealed that perceived stigma and fears about being labelled are the main barriers to requesting early psychiatric health care. The participants cited many different reasons linked to finding help led to delay in seeking help in the early stages of the illness including misattribution of the cause and symptoms of mental illness, family and financial factors.

CONCLUSIONS

The study highlights the importance of enhancing knowledge about the schizophrenia-related spectrum to ensure patients seek treatment in a more timely manner.

Predictors of favourable outcome in young people with a first episode psychosis without antipsychotic medication

INTRODUCTION

Data from the literature suggests that some first episode psychosis (FEP) patients may recover without antipsychotic medication. There is however no reliable way to identify them. In a previous paper we found, in a cohort of 584 FEP patients, that those consistently refusing medication had poorer pre-morbid functioning, less insight, higher rate of substance use and poorer outcome. However, some medication refusers, had a favourable outcome. The study aim was to identify predictors of good short term outcome despite non-exposure to medication.

METHODS

The Early Psychosis Prevention and Intervention Centre (EPPIC) admitted 786 FEP patients between 1998 and 2000. Data were collected from patients' files using a standardized questionnaire. Data on medication adherence was available in 584 patients. Among the 17.9% of patients who consistently refused medication over the entire treatment phase we compared patients who had a favourable symptomatic and functional outcome with those who did not.

RESULTS

Among patients who consistently refused medication, 41% achieved symptomatic remission and 33% reached functional recovery. Predictors of symptomatic remission were a better premorbid functioning level, higher education and employment status at baseline. Predictors of functional recovery were a shorter duration of the prodrome phase, less severe psychopathology at baseline and lower cannabis use.

CONCLUSIONS

Despite limitations mainly linked to the fact that non-exposure to antipsychotic medication was based on patient's treatment refusal, this study identified some characteristics which may contribute to the identification of a sub-group of FEP patients who may have good short term outcome without antipsychotic treatment.

Prolonged duration of untreated psychosis: a problem that needs addressing

AIM

The duration of untreated psychosis (DUP) refers to the period of time between the emergence of psychotic symptoms and the initiation of appropriate clinical treatment. Prolonged DUP is associated with a range of adverse consequences, including more severe illness course, cognitive deficits and poor functioning. Problems with recognition of illness and in seeking help contribute to DUP, but another major cause of prolonged DUP is delays within secondary mental health services. In an attempt to reduce these delays, National Health Service England and the Department of Health have set new targets to improve access to early intervention services which will come into effect in April 2016. Given this background, we aimed to examine the DUP and pathways to care of new patients entering an early intervention service. We also examined whether they were receiving National Institute for Health and Care Excellence (NICE) concordant treatment. This will enable us to establish a baseline so that the impact of the new targets can be determined and to assess the degree of change that will be required to implement these.

METHODS

De-identified electronic records of 165 patients accepted into the service over a 12-month period were analysed.

RESULTS

Median DUP was 6 months. There was a median of 2 contacts prior to service entry. Community Mental Health Teams were the largest source of referrals.

CONCLUSIONS

The majority of patients had a DUP exceeding the international target of 3 months. The findings appear to support previous evidence that this may be partially attributable to significant delays within the mental health care system.

Duration of unspecific prodromal and clinical high risk states, and early help-seeking in first-admission psychosis patients

PURPOSE

Prevention of psychosis requires both presence of clinical high risk (CHR) criteria and early help-seeking. Previous retrospective studies of the duration of untreated illness (i.e. prodrome plus psychosis) did not distinguish between prodromal states with and without CHR symptoms. Therefore, we examined the occurrence of CHR symptoms and first help-seeking, thereby considering effects of age at illness-onset.

METHODS

Adult patients first admitted for psychosis (n = 126) were retrospectively assessed for early course of illness and characteristics of first help-seeking.

RESULTS

One-hundred and nine patients reported a prodrome, 58 with CHR symptoms. In patients with an early illness-onset before age 18 (n = 45), duration of both illness and psychosis were elongated, and CHR symptoms more frequent (68.9 vs. 33.3 %) compared to those with adult illness-onset. Only 29 patients reported help-seeking in the prodrome; this was mainly self-initiated, especially in patients with an early illness-onset. After the onset of first psychotic symptoms, help-seeking was mainly initiated by others. State- and age-independently, mental health professionals were the main first point-of-call (54.0 %).

CONCLUSIONS

Adult first-admission psychosis patients with an early, insidious onset of symptoms before age 18 were more likely to recall CHR symptoms as part of their prodrome. According to current psychosis-risk criteria, these CHR symptoms, in principle, would have allowed the early detection of psychosis. Furthermore, compared to patients with an adult illness-onset, patients with an early illness-onset were also more likely to seek help on their own account. Thus, future awareness strategies to improve CHR detection might be primarily related to young persons and self-perceived subtle symptoms.

Early intervention in psychosis: still the 'best buy'?

High-quality services for people with psychosis are essential. However, in this debate David Castle questions whether separate early intervention services are the best option and argues instead for an integrated approach. Swaran Singh responds, robustly defending the value of early intervention services.

Evaluation of a community awareness programme to reduce delays in referrals to early intervention services and enhance early detection of psychosis

BACKGROUND

Reducing treatment delay and coercive pathways to care are accepted aims for Early Intervention Services (EIS) for people experiencing first episode psychosis but how to achieve this is unclear. A one-year community awareness programme was implemented in a London EIS team, targeting staff in non-health service community organisations. The programme comprised psycho-educational workshops and EIS link workers, and offering direct referral routes to EIS. Its feasibility and its impact on duration of untreated psychosis and pathways to EIS were evaluated.

METHODS

Evaluation comprised: pre and post questionnaires with workshop participants assessing knowledge and attitudes to psychosis and mental health services; and a comparison of new service users' "service DUP"(time from first psychotic symptom to first contact with EIS) and pathways to care in the intervention year and preceding year. Focus groups sought stakeholders' views regarding the benefits and limitations of the programme and what else might promote help-seeking.

RESULTS

41 workshops at 36 community organisations were attended by 367 staff. 19 follow up workshops were conducted and 16 services were allocated an EIS link worker. Participants' knowledge and attitudes to psychosis and attitudes to mental health services improved significantly following workshops. In the year of the intervention, only 6 of 110 new service users reached EIS directly via community organisations. For all new referrals accepted by EIS, in the intervention year compared to the previous year, there was no difference in mean or median service DUP. A clear impact on pathways to care could not be discerned. Stakeholders suggested that barriers to referral remained. These included: uncertainty about the signs of early psychosis, disengagement by young people when becoming unwell, and worries about stigma or coercive treatment from mental health services. More general, youth focused, mental health services were proposed.

CONCLUSIONS

The community awareness programme did not reduce treatment delays for people experiencing first episode psychosis. Further research is needed regarding effective means to reduce duration of untreated psychosis. Although EIS services are guided to promote access through community engagement, this may not be an effective use of their limited resources.

TRIAL REGISTRATION

Current Controlled Trial ISRCTN98260910 Registered 19th May 2010.