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

Clinical Recovery Among Individuals With a First-Episode Schizophrenia an Updated Systematic Review and Meta-Analysis

BACKGROUND AND HYPOTHESIS

Through decades the clinical recovery outcomes among individuals diagnosed with schizophrenia have been highly inconsistent ranging from 13.5% to 57%. The primary objective of this updated examination was to report the pooled estimate and explore various moderators to improve the understanding of the course of schizophrenia.

STUDY DESIGN

A systematic literature search was set up on PubMed, PsycInfo, and EMBASE until January 13th, 2022. Both observational and interventional studies among cohorts of individuals with the first episode of schizophrenia reporting on clinical recovery were included. The PRISMA 2020 statement was used and data was extracted for a random-effects meta-analysis, meta-regression, and sensitivity analyses. Risk of bias was assessed using The Newcastle-Ottawa Scale.

STUDY RESULTS

A 20.8% (95% CI = 17.3 to 24.8) recovery rate was found among 26 unique study samples (mean trial duration, 9.5 years) including 3877 individuals (mean age, 26.4 years). In meta-regression none of the following study characteristics could uncover the diverse reported recovery rates; age at inclusion (P = .84), year of inclusion (P = .93), follow-up time (P = .99), drop-out rate (P = .07), or strictness of the recovery criteria (P = .35). Furthermore, no differences in recovery were found between early intervention services (EIS; 19.5%; 95% CI = 15.0 to 24.8) compared to other interventions (21%; 95% CI = 16.9 to 25.8), P = .65.

CONCLUSIONS

A clinical recovery rate of approximately 21% was found with minimum impact from various moderators. The rate was not different comparing EIS with other interventions implying that new initiatives are needed to improve the rate of recovery.

Central Oxidative Stress and Early Vocational Outcomes in First Episode Psychosis: A 7-Tesla Magnetic Resonance Spectroscopy Study of Glutathione

BACKGROUND AND HYPOTHESIS

Following the first episode of psychosis, some patients develop poor social and occupational outcomes, while others display a pattern of preserved functioning. Evidence from preclinical, genetic, and biochemical studies suggest a role for high oxidative stress in poor functional outcomes among patients. The measurement of intracortical glutathione (GSH) using magnetic resonance spectroscopy (MRS) enables investigating the relationship between central antioxidant tone and functional outcomes at the time of first-episode psychosis (FEP). We hypothesized that patients with higher central antioxidant tone at first presentation will have better functional outcomes in early stages of illness.

STUDY DESIGN

We scanned 57 patients with FEP and 30 matched healthy controls and estimated GSH resonance using 7-Tesla MRS. We minimized the confounding effects of illness chronicity, long-term treatment exposure, and metabolic complications by recruiting patients with <2 weeks of lifetime antipsychotic exposure on average and followed up this cohort for the next 1 year to determine functional outcomes.

STUDY RESULTS

Patients who achieved employment/education or training status (EET) in the first year, had higher GSH at the baseline than healthy controls. Social and occupational functioning assessment scale (SOFAS) scores were also significantly higher in patients with higher GSH levels at the outset, after adjusting for various confounds including baseline SOFAS. Patients who were not in EET did not differ from healthy subjects in their GSH levels.

CONCLUSION

Our observations support a key role for the central antioxidant tone in the functional outcomes of early psychosis.

Is There a Glutathione Centered Redox Dysregulation Subtype of Schizophrenia?

Schizophrenia continues to be an illness with poor outcome. Most mechanistic changes occur many years before the first episode of schizophrenia; these are not reversible after the illness onset. A developmental mechanism that is still modifiable in adult life may center on intracortical glutathione (GSH). A large body of pre-clinical data has suggested the possibility of notable GSH-deficit in a subgroup of patients with schizophrenia. Nevertheless, studies of intracortical GSH are not conclusive in this regard. In this review, we highlight the recent ultra-high field magnetic resonance spectroscopic studies linking GSH to critical outcome measures across various stages of schizophrenia. We discuss the methodological steps required to conclusively establish or refute the persistence of GSH-deficit subtype and clarify the role of the central antioxidant system in disrupting the brain structure and connectivity in the early stages of schizophrenia. We propose in-vivo GSH quantification for patient selection in forthcoming antioxidant trials in psychosis. This review offers directions for a promising non-dopaminergic early intervention approach in schizophrenia.

Schizophrenia outcomes in the 21st century: A systematic review

OBJECTIVE

We report a review of outcomes in schizophrenia in the twenty-first century, replicating and extending work undertaken by the late Richard Warner in his seminal book, "Recovery from Schizophrenia: Psychiatry and Political Economy" (1985;2004).

METHOD

Warner's methods were followed as closely as possible. Only observational/naturalistic studies were included. Six scientific databases were searched from 2000 to 2020. 6,640 records were retrieved. 47 met inclusion criteria.

RESULTS

Overall, complete recovery is higher in this study than in Warner's (37.75% cf 20.4%), especially for first episode psychosis (FEP) (57.1% cf 20.7%). Clinical recovery, annualized remission rate (ARR), and employment outcomes were significantly superior for first episode psychosis compared with multiple episode psychosis (MEP). ARR shows a trend toward reduction over time, from 2.2 before the financial crash of 2008 to 1.6 after (t = 1.85 df 40 p = .07). The decline is statistically significant for the MEP group (t = 2.32 df18 p = .03). There were no differences in outcome by region, sample characteristics, outcome measures used, or quality of studies. Heterogeneity of clinical outcome measures across the literature makes evidence synthesis difficult. Weak and inconsistent reporting of functional and employment outcomes mean that findings lack meaning with respect to lived experience.

CONCLUSION

Future research strategies should aim to reduce heterogeneity in clinical outcome measures and to increase the emphasis on capture and reporting of more sophisticated measures of social and functional outcome. Outcome domains should be disaggregated rather than conflated into unitary recovery constructs.

The Association of Social Support and Symptomatic Remission among Community-Dwelling Schizophrenia Patients: A Cross-Sectional Study

Schizophrenia is a mental disease that often leads to chronicity. Social support could reduce the severity of psychotic symptoms; therefore, its influence on remission should be examined. This study investigated the remission rates in community-dwelling schizophrenia patients and examined the association between social support and remission status. A cross-sectional study was conducted in 129 schizophrenia patients in Taiwan. Remission rates were evaluated, and the level of social support, clinical characteristics, sociodemographic variables, and healthy lifestyle status were compared between the remission and nonremission groups. The association between social support and remission was analyzed after adjusting for confounding factors. The mean illness duration is 12.9 years. More than 95% of the participants lived with their families, 63% were unemployed, and 43% achieved remission. Higher social support was observed in the remission group, and a significant correlation was observed between family domain of social support and remission status. Family support was a protective factor of symptomatic remission in community-dwelling schizophrenia patients in Taiwan. The results reflect the effects of a family-centered culture on patients during illness. Consequently, reinforcing family relationships and the capacity of families to manage the symptoms of patients and providing support to families are recommended.

Mediation of the stigma in the influence of negative symptomatology over recovery in psychosis

Background/Objective: The interest in recovery processes in psychotic disorders has boosted the necessity of knowledge about the factors that could influence in such recovery. Negative symptomatology and the stigma have been negatively linked to the recovery process in psychosis. The aim of this investigation is to improve the understanding of how the recovery process is affected by negative symptomatology based on the analysis of the mediating effects of the internalized stigma. Method: The sample was composed of 114 people that had experienced, at some point in their life, at least one clinically relevant psychotic episode. CAPE-42, STORI and ISMI were used for the evaluation. The macro PROCESS for SPSS was used. The indirect effect was calculated using 10.000 samples of bootstrap for the bootstrap confidence intervals (IC) corrected for bias. Results: The results show that the influence of negative symptomatology predicts the stigmatization of the person regarding his disorder. This predicts a negative influence in the recovery process of the psychosis. Conclusions: These results back the importance of adding the reduction of the stigma as a specific strategy to improve the recovery process in psychotic disorders.

Impact of a Family Interventions Module on Students' Knowledge, Skills and Attitudes

Current evidence strongly supports the implementation of family interventions as a recognised approach to working with families. The aim of this study was to evaluate postgraduate students' learning experiences and skills development whilst undertaking a Master of Science module in family interventions. Questionnaires were used to elicit students' learning and experiences in relation to their work with families. Following analysis of students' responses, the key themes that emerged in relation to family interventions included: prior learning and experiences, changes in practice, skills development, supports in practice, and course strengths and challenges. Participants particularly valued the simulated learning and reflective elements of the module. The results of the study suggest that more staff should have access to education and training to enable practitioners to work more effectively with families. However, they will need to have support mechanisms in practice to effectively implement family interventions.