Rationale for the study of early intervention

The Impact of Prolonged Duration of Untreated Illness on Clinical Correlates in Chronic Schizophrenia: Exploring the Relationship With Suicide Risk

OBJECTIVE

Studies on duration of untreated psychosis are common in patients with schizophrenia, but few studies have investigated the relationship between duration of untreated illness (DUI) and suicide, especially in patients with chronic schizophrenia. Therefore, we intended to investigate the relationship between DUI and suicide and clinical correlates in patients with chronic schizophrenia.

METHODS

A total of 1,555 Chinese patients with chronic schizophrenia were enrolled in this study. DUI was measured in years, reflecting the prolonged untreated periods observed in this population. Clinical correlates were assessed, including symptoms, cognitive functioning, and body mass index. Suicidal ideation and attempts were also examined. Statistical analyses, including multivariate models, were employed to investigate the associations between DUI and clinical correlates while controlling for potential confounders.

RESULTS

The study revealed a significant proportion (23.3%) of patients with chronic schizophrenia in China received their first treatment after a 4-year delay, with the longest untreated duration reaching 39 years. Patients with longer DUI exhibited more severe negative symptoms, lower immediate memory scores, a higher likelihood of being overweight, and surprisingly, a reduced likelihood of suicidal ideation and attempts. Each additional year of untreated illness was associated with a 3% decrease in the risk of suicidal ideation and attempts.

CONCLUSION

The findings underscore the prevalence of extended untreated periods in Chinese patients with chronic schizophrenia and highlight the impact of DUI on negative symptoms, cognitive function, and body weight. Intriguingly, a longer DUI was associated with a lower risk of suicidal ideation and attempts.

Duration of untreated illness and clinical correlates in first-episode and drug-naïve patients with major depressive disorder

BACKGROUNDS

The notion that a prolonged duration of untreated illness (DUI) leads to poorer outcomes has contributed to extensive changes in mental health services worldwide. However, most studies on DUI have focused on schizophrenia and related psychosis. This study aimed to assess the possible relationship between DUI and certain clinical correlates in first-episode and drug-naïve patients with major depressive disorder (MDD).

METHODS

This cross-sectional study recruited 1718 first-episode and drug-naïve MDD outpatients. All participants were scored on the Hamilton Depression Rating Scale, Hamilton Anxiety Rating Scale, Positive and Negative Syndrome Scale, and thyroid hormone and metabolic parameters were measured. We used the Structure Clinical Interview for DSM-IV for clinical diagnosis and investigated suicide attempts through face-to-face interviews.

RESULTS

A total of 171 (10%) of MDD patients had co-morbid psychiatric symptoms. Participants who were older, with lower education level, and married were less likely to seek a timely treatment compared to the counterparts. One-month longer untreated duration was associated with 2% to 9% higher odds of being with most of the investigated clinical conditions. For those with the longest DUI, the risk was increased for most of the investigated clinical conditions, with absolute risk differences ranging from 5.19% to 29.48%.

CONCLUSIONS

These findings suggest that longer DUI may be negatively associated with clinical correlates in MDD. Further long-term follow-up studies are warranted to confirm these preliminary results.

Evidence base for early intervention in psychosis services in rural areas: A critical review

AIM

Early Intervention in Psychosis teams (EITs) are a growing entity internationally, yet they remain under-researched given challenges facing their delivery. Model adaptations include stand-alone services, a hub-and-spoke model with various bases and integrating specialist staff into existing mental health teams. The present critical review focuses on reviewing the evidence base for the delivery of EITs in rural areas, first pertaining to evidence for model adherence and second to clinically outcomes.

METHOD

A systematic literature search was undertaken, finding 53 papers of interest. Nine papers met the inclusion criteria. A critical appraisal tool was used to consider the quality of the evidence and a narrative review of their findings is presented.

RESULTS

The five studies reporting clinical outcomes of rural EITs demonstrate positive outcomes of a hub-and-spoke and stand-alone EIT on reducing hospital admissions, psychotic symptoms and improving quality of life. One study directly comparing hub-and-spoke to stand-alone EIT found that hub-and-spoke EIT had more positive outcomes than a stand-alone service. Of the studies attempting to promote adherence to EIT model in rural areas, services show low overall adherence and report issues pertaining to funding and managerial support for practical barriers to implementation.

CONCLUSIONS

EIT services in rural areas may show similar positive outcomes to urban areas and adaptations to suit rural populations appear acceptable, such as using a hub-and-spoke model, though further research is required. Adherence to EIT service models in rural areas may be limited and training programmes to promote adherence benefit from managerial and financial support.

Review of Early Intervention Programmes in Psychosis: Implementation Proposal for Peru

A delay in receiving an antipsychotic treatment is associated with unfavourable clinical and functional outcomes in patients with a first episode of psychosis. In recent years, early psychosis intervention programmes have been implemented that seek the early detection and treatment of patients who begin to describe psychotic symptoms. These programmes have shown to be more effective than standard care in improving the symptoms of the disorder and recovering the patient's functionality, in turn proving to be more cost-effective. The benefits of these programmes have led to their implementation in high-income countries. However, implementation in medium- and low-income countries has been slower. Peru, a Latin American country with an upper middle income, is undergoing a mental health reform that prioritises health care based on the prevention, treatment and psychosocial recovery of patients from a comprehensive and community approach. The present manuscript describes the characteristics and structure of the pioneering and more developed programmes for early psychosis intervention, and discusses the benefits and challenges of implementing an early psychosis intervention programme in Peru in the current context of mental health reform.

The case for improved care and provision of treatment for people with first-episode mania

The care of people with first-episode mania has been overlooked in comparison with the care of patients with other non-affective psychoses, despite evidence suggesting targeted treatments might be of benefit for this patient group. In this Personal View, we outline the general epidemiology of first-episode mania in the context of bipolar disorder, the natural history of mania (with an emphasis on its recurrent nature), current evidence for pharmacological, psychological, and service-level interventions, current guidelines for the treatment of first-episode mania, and provide a patient's point of view of the care pathway (appendix). We note the paucity of high-quality evidence for interventions in first-episode mania and the lack of agreement among treatment guidelines in relation to treatment, especially maintenance treatment. We suggest that, based on high morbidity and clinical need, research evidence to inform guideline development is necessary, and in the interim, clearer guidance on treatment and diagnosis should be given; specifically, we have suggested that patients should be cared for within a first-episode psychosis service, when such a service exists.

The Translational Potential of Neuroimaging Genomic Analyses To Diagnosis And Treatment In The Mental Disorders

Imaging genomics focuses on characterizing genomic influence on the variation of neurobiological traits, holding promise for illuminating the pathogenesis, reforming the diagnostic system, and precision medicine of mental disorders. This paper aims to provide an overall picture of the current status of neuroimaging-genomic analyses in mental disorders, and how we can increase their translational potential into clinical practice. The review is organized around three perspectives. (a) Towards reliability, generalizability and interpretability, where we summarize the multivariate models and discuss the considerations and trade-offs of using these methods and how reliable findings may be reached, to serve as ground for further delineation. (b) Towards improved diagnosis, where we outline the advantages and challenges of constructing a dimensional transdiagnostic model and how imaging genomic analyses map into this framework to aid in deconstructing heterogeneity and achieving an optimal stratification of patients that better inform treatment planning. (c) Towards improved treatment. Here we highlight recent efforts and progress in elucidating the functional annotations that bridge between genomic risk and neurobiological abnormalities, in detecting genomic predisposition and prodromal neurodevelopmental changes, as well as in identifying imaging genomic biomarkers for predicting treatment response. Providing an overview of the challenges and promises, this review hopefully motivates imaging genomic studies with multivariate, dimensional and transdiagnostic designs for generalizable and interpretable findings that facilitate development of personalized treatment.

Predictors of negative symptoms in the chronic phase of schizophrenia: A cross-sectional study

This study was designed to investigate the relationship between negative symptoms and key indicators for long-term hospital stays among inpatients with schizophrenia. A further aim was to elucidate the clinical determinants of negative symptoms. The following were used as index factors: age, duration of illness, duration of hospitalization, age at onset, years of education, smoking status, body mass index, concentrations of serum triglycerides, total cholesterol, uric acid, QTc interval duration from electrocardiography, dose equivalents of antipsychotic and anticholinergic agents, neurocognitive function, drug-induced extrapyramidal symptoms, involuntary movements, and psychiatric symptoms. Spearman's rank correlation coefficients were calculated and regression analyses were performed to examine associations between these factors and negative symptoms. Positive symptoms correlated positively with negative symptoms as rated on the Brief Psychiatric Rating Scale. Age at onset correlated negatively with negative symptoms. Multiple regression analysis showed that dose equivalents of atypical antipsychotics and positive symptoms predicted negative symptoms. Increasing our understanding of these predictors as key indicators of the severity of negative symptoms may aid in the reconsideration of therapeutic programs for chronic schizophrenia.

Long-Acting Injectable Second-Generation Antipsychotics Improve Negative Symptoms and Suicidal Ideation in Recent Diagnosed Schizophrenia Patients: A 1-Year Follow-up Pilot Study

Long-acting injectable second-generation antipsychotics (LAI-SGA) are typically used to maintain treatment adherence in patients with chronic schizophrenia. Recent research suggests that they may also provide an effective treatment strategy for patients with early-phase disease. The aim of this study is to evaluate clinical and psychosocial outcomes among recent and long-term diagnosed schizophrenia outpatients treated with LAI-SGA during a follow-up period of 12 months. Stable schizophrenia patients receiving LAI-SGA with 5 or less years of illness duration (n = 10) were compared to those with more than 5 years of illness duration (n = 15). Clinical data was assessed through the Positive and Negative Syndrome Scale (PANSS), the Global Assessment of Functioning (GAF), the Columbia Suicide Severity Rating Scale (C-SSRS), the Recovery Style Questionnaire (RSQ), and the Mayer-Salovey-Caruso Emotional Intelligence Test (MSCEIT) Managing Emotion branch. Recently diagnosed patients showed greater improvement versus patients diagnosed for more than 5 years in adjusted mean GAF score, in PANSS factor score for negative and depressive symptoms, and in severity and intensity of suicidal ideation. Our preliminary findings support the hypothesis that LAI-SGA may influence the course of the illness if administered at the early phase of the illness. However, replicate studies are needed, possibly with larger samples.

Duration of untreated psychosis/illness and brain volume changes in early psychosis

The time period during which patients manifest psychotic or unspecific symptoms prior to treatment (duration of untreated psychosis, DUP, and the duration of untreated illness, DUI) has been found to be moderately associated with poor clinical and social outcome. Equivocal evidence exists of an association between DUP/DUI and structural brain abnormalities, such as reduced hippocampus volume (HV), pituitary volume (PV) and grey matter volume (GMV). Thus, the goal of the present work was to examine if DUP and DUI are associated with abnormalities in HV, PV and GMV. Using a region of interest (ROI) based approach, we present data of 39 patients from the Basel FePsy (Früherkennung von Psychosen, early detection of psychosis) study for which information about DUP, DUI and HV, PV and GMV data could be obtained. Twenty-three of them were first episode psychosis (FEP) and 16 at-risk mental state (ARMS) patients who later made the transition to frank psychosis. In unadjusted analyses, we found a significant positive correlation between DUP and PV in FEP patients. However, when adjusted for covariates, we found no significant correlation between DUP or DUI and HV, PV or GMV anymore. There only was a trend for decreasing GMV with increasing DUI in FEP. Our results do not comprehensively support the hypothesis of a "toxic" effect of the pathogenic mechanism underlying untreated psychosis on brain structure. If there is any effect, it might rather occur very early in the disease process, during which patients experience only unspecific symptoms.

Duration of active psychosis and first-episode psychosis negative symptoms

AIM

Duration of untreated psychosis (DUP) has been associated with negative symptoms in several studies; however, longitudinal findings have been inconsistent. No previous study has accounted for active psychosis after presentation, although this could impact on outcomes in a manner similar to DUP.

METHODS

We measured Scale for the Assessment of Positive Symptoms at frequent intervals during the 12 months after initial presentation to determine the active psychosis duration for 230 individuals with first-episode psychosis. This duration was added to DUP prior to presentation to create a new variable, duration of active psychosis (DAP). Negative symptoms were divided into expressivity and motivation/pleasure domains as measured by Scale for the Assessment of Negative Symptoms (SANS). The relationship of DUP and DAP with negative symptoms at 24-month follow up was determined and confounders controlled for using regression analysis.

RESULTS

When DUP and DAP were compared as binary variables with long and short groups, 25.2% of individuals had differing category membership. DAP had a significant uncorrected association with both expressivity domain and motivation/pleasure domains at 24 months; however, relationship with DUP was not significant. DAP remained a significant predictor of 24-month expressivity domain after controlling for potential confounders.

CONCLUSIONS

Active psychosis after presentation is substantial, which is a limitation of DUP studies if active psychosis is considered as the key factor within DUP. DAP is a better predictor of negative symptoms than DUP at 2-year follow up, which suggests this concept requires further research.

Duration of untreated psychosis in an Egyptian sample: Sociodemographic and clinical variables

BACKGROUND

Duration of untreated psychosis (DUP) has been considered as a poor prognostic factor for psychotic disorder. Several studies have been investigating different predictors of DUP in Western countries, while in Egypt only a few studies have examined various predictors of DUP.

AIMS

To study DUP in Egyptian patients with psychotic disorders and to investigate how certain illnesses, patient, socio-cultural risk factors and help-seeking behaviour are correlated with prolonged DUP.

METHOD

The sample included 100 patients with Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR) diagnosis of psychotic disorder were selected and interviewed to assess DUP. They were interviewed using the Structured Clinical Interview for DSM-IV axis I disorders (SCID-I), Positive and Negative Syndrome Scale (PANSS) and Global Assessment of Functioning (GAF) scale.

RESULTS

Mean (±standard deviation ( SD)) of DUP was found to be 36.93(±45.27) months. DUP was correlated with various sociodemographic and clinical variables. Following log transformation of DUP, correlation with PANSS scores was done and revealed highly significant statistical relation of DUP to PANSS negative and PANSS positive scores. In linear regression analysis, it was found that age of patients, the age of onset, residence, being illiterate, the insidious mode of onset, negative family history of psychiatric disorder and the severity of illness as indicated by PANSS are among DUP predictors.

CONCLUSION

Longer DUP results from multiple patient- and illness-related factors. This has many implications in targeting early intervention with specific consideration to cultural factors.

Are We Really Impacting Duration of Untreated Psychosis and Does It Matter?: Longitudinal Perspectives on Early Intervention from the Irish Public Health Services

Although early intervention in psychosis is clinically intuitive and theoretically feasible, the reality is that over recent decades the evidence base to support it has not advanced as much as might have been anticipated. Material benefits of early intervention in established psychosis have not been universally demonstrated and much uncertainty continues to surround the field of treatment in the prodromal phase. Undoubtedly methodological differences between studies are relevant and better understanding of different treatment models and the effectiveness of their constituent parts may yield the most benefit, particularly from a public health perspective.

Genetic association analysis of N-methyl-D-aspartate receptor subunit gene GRIN2B and clinical response to clozapine

OBJECTIVE

Approximately 30% of patients with schizophrenia fail to respond to antipsychotic therapy and are classified as having treatment-resistant schizophrenia. Clozapine is the most efficacious drug for treatment-resistant schizophrenia and may deliver superior therapeutic effects partly by modulating glutamate neurotransmission. Response to clozapine is highly variable and may depend on genetic factors as indicated by twin studies. We investigated eight polymorphisms in the N-methyl-D-aspartate glutamate receptor subunit gene GRIN2B with response to clozapine.

METHODS

GRIN2B variants were genotyped using standard TaqMan procedures in 175 European patients with schizophrenia deemed resistant or intolerant to treatment. Response was assessed using change in Brief Psychiatric Rating Scale scores following six months of clozapine therapy. Categorical and continuous response was assessed using chi-squared test and analysis of covariance, respectively.

RESULTS

No associations were observed between the variants and response to clozapine. A-allele carriers of rs1072388 responded marginally better to clozapine therapy than GG-homozygotes; however, the difference was not statistically significant (p = 0.067, uncorrected).

CONCLUSIONS

Our findings do not support a role for these GRIN2B variants in altering response to clozapine in our sample. Investigation of additional glutamate variants in clozapine response is warranted.

Stages of recovery in early psychosis: Associations with symptoms, function, and narrative development

OBJECTIVES

This study sought to explore the links between recovery stages, symptoms, function, and narrative development among individuals with a recent onset of psychosis.

DESIGN

A qualitative longitudinal study was conducted including quantitative data at baseline.

METHODS

Forty-seven participants were administered the Indiana Psychiatric Illness Interview three times over 9 months and content analysis was performed. Participants also completed the Social Functioning Scale, the Brief Psychiatric Rating Scale--Expanded, the California Verbal Learning Test, and the Trailing Making Test at baseline. Descriptive discriminant analysis was performed.

RESULTS

Results suggested that participants were mostly in the first two stages of recovery (moratorium, awareness) and that being in the awareness, rather than moratorium, stage was associated, to a different extent, with richer narrative development, better levels of psychosocial function, less negative and positive symptoms, and more years of education. Furthermore, recovery appeared to be a stable process over the assessment period.

CONCLUSIONS

Recovery is a complex concept including objective and subjective aspects. In the recovery path of persons recently diagnosed with psychosis, social engagement, narrative development, and occupational functioning seem to be particularly important aspects. This study is a first step, and future research is needed with larger and more diverse participant pools, and assessments conducted over longer periods of time.

PRACTITIONER POINTS

As greater level of social engagement was the most robust predictor of membership in the awareness versus moratorium stage, treatment of early psychosis should include interventions targeting social relations and social skills. As greater narrative development was the second most robust predictor, enhancing it via psychotherapy could be a pertinent clinical goal.

Youth-caregiver agreement on clinical high-risk symptoms of psychosis

Early identification of individuals who will go on to develop schizophrenia is a difficult endeavor. The variety of symptoms experienced by clinical high-risk youth make it difficult to identify who will eventually develop schizophrenia in the future. Efforts are being made, therefore, to more accurately identify at-risk individuals and factors that predict conversion to psychosis. As in most assessments of children and adolescents, however, both youth and parental report of symptomatology and resulting dysfunction are important to assess. The goals of the current study were to assess the extent of cross-informant agreement on the Structured Interview for Prodromal Symptoms (SIPS), a widely-used tool employed to determine clinical high-risk status. A total of 84 youth-caregiver pairs participated. Youth and caregiver raters displayed moderate overall agreement on SIPS-rated symptoms. Both youth and caregiver ratings of youth symptomatology contributed significantly to predicting conversion to psychosis. In addition, youth age and quality of youth-caregiver relationships appear to be related to cross-informant symptom ratings. Despite differences on individual SIPS domains, the majority of dyads agreed on youth clinical high-risk status. Results highlight the potential clinical utility of using caregiver informants to determine youth psychosis risk.

Neuropsychologic functioning and structural MRI of the brain in patients with schizophrenia

The first episode of schizophrenia represents a transition from a premorbid to a morbid state. Studying the first episode of schizophrenia is useful since it is devoid of the confounds of chronicity and long-term medication. It is also likely to direct us to the core deficits of the illness. Studies on first-episode schizophrenia suggest a generalized neuropsychologic impairment, but that memory, attention and executive function are more severely impaired. Support for a neurodevelopmental model of neuropsychologic impairment in schizophrenia is derived from the findings that much of the neuropsychologic impairment is present by illness onset, that neuropsychologic impairment remains stable over time and that there is a weak relation between duration of untreated psychosis and neuropsychologic impairment. However, neuropsychologic impairment is moderated by neuroleptic treatment, with some evidence that atypical antipsychotics may have some beneficial effects over conventional antipsychotics. The causal mechanisms of brain abnormality in the temporal and frontal lobes appear to be different to that of neuropsychologic impairment in schizophrenia. The observation that there is a brain volume decrement over time and that the rate of change is higher during the first 5 years would be consistent with a neurodegenerative model of schizophrenia. At the same time, the basal ganglia are vulnerable to volumetric increase secondary to neuroleptic medication. Understanding the roles of the neurodevelopmental and neurodegenerative models of schizophrenia is important in deciding intervention strategies.

Changing perceptions of illness in the early course of psychosis: psychological pathways to self-determination and self-management of treatment

Treatment early in the course of psychosis can improve prognostic outcomes, facilitate adaptive functioning, and reduce familial and societal burden. However, little is known about the pathway of first episode psychosis (FEP) from the perspective of highly adherent adolescents and young adults. This study sought to understand the pathways in youth self-determination and self-management of treatment by investigating youth and parents' changing perceptions of illness in the early course of psychosis. Twenty-eight (n = 28) interviews were conducted using a semistructured interview guide on 12 adolescents following their FEP hospitalization and 16 parents. Standardized self-report forms and hospital inpatient records were used to collect and confirm demographic and clinical data. On average, three years had passed from initial hospitalization (age 16.2 years, SD = 1.2) to time of interview (age 19.3 years, SD = 2.3), thus allowing for a range of experiences across the early period of illness. Highly adherent adolescents experienced identifiable temporal phases of early psychosis, comprised of emergent and specific themes. Parents described a parallel pathway toward supporting their child's self-determination and self-management of treatments, with some distinct experiential differences. Five dominant themes that emerged across time were symptom recognition, awareness of change, negative appraisals, positive appraisals, and treatment self-management. Examining how these themes evolve over the early course of psychosis can help guide interventions that are compatible with the parent and adolescent's perceptions of illness at that point in time, and can therefore work in concert with the family's existing efforts to understand and manage their emerging condition and progress toward recovery.

Research in young people at ultra-high risk for psychosis: a review of the current evidence

Background

The past 15 years have seen a growing interest in early intervention and detection of psychosis before the onset of the first episode. Recent proposals to include a psychosis risk syndrome (PRS) in DSM 5 have focused attention on the evidence base achieved to date in this field.

Aims

This article aims to (1) review the underlying principles of early identification and intervention during the pre-psychotic phase, (2) summarise the naturalistic follow-up studies conducted to date in this ‘at-risk’ population, (3) discuss the identified clinical risk factors for transition to psychosis, (4) summarise the interventional studies both psychological and pharmacological completed to date and (5) briefly discuss the controversy around the proposed inclusion of the PRS in DSM 5.

Methods

Electronic databases EmBase, MedLine and PsychInfo were searched using the keywords ultra-high risk/at-risk mental state/risk syndrome/pre-psychotic/prodrome/prodromal and psychosis/schizophrenia.

Results

The evidence suggests that it is possible to identify individuals who may be at risk of developing psychosis. Results from intervention studies, mostly involving second-generation antipsychotics and cognitive behavioural therapy, are currently insufficient to make treatment recommendations for this group. The emerging research with regard to possible neuroprotective factors such as omega fatty acids is promising, but will require replication in larger cohorts before it can be recommended.

Behavioral and neurochemical consequences of cortical oxidative stress on parvalbumin-interneuron maturation in rodent models of schizophrenia

Oxidative stress, in response to the activation of the superoxide-producing enzyme Nox2, has been implicated in the schizophrenia-like behavioral dysfunction that develops in animals that were subject to either neonatal NMDA receptor-antagonist treatment or social isolation. In both of these animal models of schizophrenia, an environmental insult occurring during the period of active maturation of the fast-spiking parvalbumin-positive (PV+) interneuronal circuit leads to a diminished expression of parvalbumin in GABA-inhibitory neurons when animals reach adulthood. The loss of PV+ interneurons in animal models had been tentatively attributed to the death of these neurons. However, present results show that for the perinatal NMDA-R antagonist model these interneurons are still alive when animals are 5-6 weeks of age even though they have lost their phenotype and no longer express parvalbumin. Alterations in parvalbumin expression and sensory-evoked gamma-oscillatory activity, regulated by PV+ interneurons, are consistently observed in schizophrenia. We propose that cortical networks consisting of faulty PV+ interneurons interacting with pyramidal neurons may be responsible for the aberrant oscillatory activity observed in schizophrenia. Thus, oxidative stress during the maturation window for PV+ interneurons by alteration of normal brain development, leads to the emergence of schizophrenia-like behavioral dysfunctions when subjects reach early adulthood.

Early intervention for psychosis

BACKGROUND

Proponents of early intervention have argued that outcomes might be improved if more therapeutic efforts were focused on the early stages of schizophrenia or on people with prodromal symptoms. Early intervention in schizophrenia has two elements that are distinct from standard care: early detection, and phase-specific treatment (phase-specific treatment is a psychological, social or physical treatment developed, or modified, specifically for use with people at an early stage of the illness).Early detection and phase-specific treatment may both be offered as supplements to standard care, or may be provided through a specialised early intervention team. Early intervention is now well established as a therapeutic approach in America, Europe and Australasia.

OBJECTIVES

To evaluate the effects of: (a) early detection; (b) phase-specific treatments; and (c) specialised early intervention teams in the treatment of people with prodromal symptoms or first-episode psychosis.

SEARCH STRATEGY

We searched the Cochrane Schizophrenia Group Trials Register (March 2009), inspected reference lists of all identified trials and reviews and contacted experts in the field.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) designed to prevent progression to psychosis in people showing prodromal symptoms, or to improve outcome for people with first-episode psychosis. Eligible interventions, alone and in combination, included: early detection, phase-specific treatments, and care from specialised early intervention teams. We accepted cluster-randomised trials but excluded non-randomised trials.

DATA COLLECTION AND ANALYSIS

We reliably selected studies, quality rated them and extracted data. For dichotomous data, we estimated relative risks (RR), with the 95% confidence intervals (CI). Where possible, we calculated the number needed to treat/harm statistic (NNT/H) and used intention-to-treat analysis (ITT).

MAIN RESULTS

Studies were diverse, mostly small, undertaken by pioneering researchers and with many methodological limitations (18 RCTs, total n=1808). Mostly, meta-analyses were inappropriate. For the six studies addressing prevention of psychosis for people with prodromal symptoms, olanzapine seemed of little benefit (n=60, 1 RCT, RR conversion to psychosis 0.58 CI 0.3 to 1.2), and cognitive behavioural therapy (CBT) equally so (n=60, 1 RCT, RR conversion to psychosis 0.50 CI 0.2 to 1.7). A risperidone plus CBT plus specialised team did have benefit over specialist team alone at six months (n=59, 1 RCT, RR conversion to psychosis 0.27 CI 0.1 to 0.9, NNT 4 CI 2 to 20), but this was not seen by 12 months (n=59, 1 RCT, RR 0.54 CI 0.2 to 1.3). Omega 3 fatty acids (EPA) had advantage over placebo (n=76, 1 RCT, RR transition to psychosis 0.13 CI 0.02 to 1.0, NNT 6 CI 5 to 96). We know of no replications of this finding.The remaining trials aimed to improve outcome in first-episode psychosis. Phase-specific CBT for suicidality seemed to have little effect, but the single study was small (n=56, 1 RCT, RR suicide 0.81 CI 0.05 to 12.26). Family therapy plus a specialised team in the Netherlands did not clearly affect relapse (n=76, RR 1.05 CI 0.4 to 3.0), but without the specialised team in China it may (n=83, 1 RCT, RR admitted to hospital 0.28 CI 0.1 to 0.6, NNT 3 CI 2 to 6). The largest and highest quality study compared specialised team with standard care. Leaving the study early was reduced (n=547, 1 RCT, RR 0.59 CI 0.4 to 0.8, NNT 9 CI 6 to 18) and compliance with treatment improved (n=507, RR stopped treatment 0.20 CI 0.1 to 0.4, NNT 9 CI 8 to 12). The mean number of days spent in hospital at one year were not significantly different (n=507, WMD, -1.39 CI -2.8 to 0.1), neither were data for 'Not hospitalised' by five years (n=547, RR 1.05 CI 0.90 to 1.2). There were no significant differences in numbers 'not living independently' by one year (n=507, RR 0.55 CI 0.3 to 1.2). At five years significantly fewer participants in the treatment group were 'not living independently' (n=547, RR 0.42 CI 0.21 to 0.8, NNT 19 CI 14 to 62). When phase-specific treatment (CBT) was compared with befriending no significant differences emerged in the number of participants being hospitalised over the 12 months (n=62, 1 RCT, RR 1.08 CI 0.59 to 1.99).Phase-specific treatment E-EPA oils suggested no benefit (n=80, 1 RCT, RR no response 0.90 CI 0.6 to 1.4) as did phase-specific treatment brief intervention (n=106, 1 RCT, RR admission 0.86 CI 0.4 to 1.7). Phase-specific ACE found no benefit but participants given vocational intervention were more likely to be employed (n=41, 1 RCT, RR 0.39 CI 0.21 to 0.7, NNT 2 CI 2 to 4). Phase-specific cannabis and psychosis therapy did not show benefit (n=47, RR cannabis use 1.30 CI 0.8 to 2.2) and crisis assessment did not reduce hospitalisation (n=98, RR 0.85 CI 0.6 to 1.3). Weight was unaffected by early behavioural intervention.

AUTHORS' CONCLUSIONS

There is emerging, but as yet inconclusive evidence, to suggest that people in the prodrome of psychosis can be helped by some interventions. There is some support for specialised early intervention services, but further trials would be desirable, and there is a question of whether gains are maintained. There is some support for phase-specific treatment focused on employment and family therapy, but again, this needs replicating with larger and longer trials.

Is early intervention in psychosis effective?

Aims – Psychosis is a traumatic experience for both sufferers and their families. The morbidity and mortality associated with psychosis may be improved by an assertive, specialised, multidisciplinary approach to care, provided at the earliest opportunity. Early Intervention in Psychosis (EIP) uses such approach to improve the individual's short and long-term symptomatic and functional outcome, as well as quality of life. However, there is still controversy about whether this type of intervention is effective enough to justify its associated costs. Methods – We reviewed evidence from the literature on EIP for schizophrenia spectrum and non-affective psychoses, with particular attention to evidence on its effectiveness in reducing the duration of untreated symptoms, preventing relapses and reducing admission rates, reducing suicide rates, and reducing treatment costs. Results – There is preliminary evidence that EIP may be effective in delaying transition to psychosis, reducing DUP, preventing relapses, reducing admission and suicidal rates, and reducing treatment costs. Discussion – EIP remains a stimulating multidisciplinary approach to psychosis and a demanding commitment for mental health professionals and service developers.

Declaration of Interest: None.

Duration of untreated psychosis is associated with orbital-frontal grey matter volume reductions in first episode psychosis

BACKGROUND

Delay in treatment of psychosis is associated with poor clinical and social outcome and is measured as the duration of untreated psychosis (DUP) prior to treatment of the first episode. It has been suggested that this may be mediated through toxic effects of psychosis on the structure and function of the brain. Equivocal evidence exists regarding association between longer DUP and neuro-anatomical changes such as, reduced grey matter volume in specific regions in the brain and deficits in neurocognitive functions.

OBJECTIVE

To examine if duration of untreated psychosis (DUP) preceding treatment of a first episode of psychosis is associated with structural brain abnormalities and deficits in neurocognitive functions.

METHOD

We investigated the relationship between DUP and grey matter volume using voxel-based morphometry techniques and with multiple domains of cognition. Eighty patients with a first episode of psychosis were separated into two equal sized groups based on a median split (18 weeks) of their DUP.

RESULTS

Compared to the short-DUP group (mean DUP 7.9 weeks ± 5.6), the long-DUP group (mean 113.7 weeks ± 170 .4) showed significant grey matter volume reductions in orbital-frontal regions (bilateral medial frontal gyrus and bilateral rectal gyrus, BA 11) and parietal regions (postcentral gyrus and superior parietal lobule) as well as a significant reduction in whole brain grey matter volume (p<0.04). For schizophrenia spectrum cases only these findings were confined to left rectal gyrus. There were no differences in white matter or cerebral spinal fluid volumes or on cognitive functions. Results are controlled for antipsychotic medication exposure.

LIMITATIONS

The inherent difficulty in separating slow and insidious onset from long-DUP may limit the interpretation of our results and there may be an overlap between DUP and duration of illness (including the prodrome).

CONCLUSION

Patients with a longer delay in treatment of psychosis show a significant reduction in overall grey matter volume with specific reductions in the inferior-orbital region. These results provide some support to a possible neurotoxic effect of prolonged untreated psychosis.

Schizophrenia, "just the facts" 5. Treatment and prevention. Past, present, and future

The introduction of second-generation antipsychotics and cognitive therapies for schizophrenia over the past two decades generated considerable optimism about possibilities for recovery. To what extent have these developments resulted in better outcomes for affected individuals? What is the current state of our science and how might we address the many unmet needs in the prevention and treatment of schizophrenia? We trace the evolution of various treatments for schizophrenia and summarize current knowledge about available pharmacological and psychosocial treatments. We consider the widely prevalent efficacy-effectiveness gap in the application of available treatments and note the significant variability in individual treatment response and outcome. We outline an individualized treatment approach which emphasizes careful monitoring and collaborative decision-making in the context of ongoing benefit-risk assessment. We note that the evolution of both pharmacological and psychosocial treatments thus far has been based principally on serendipity and intuition. In view of our improved understanding of the etiology and pathophysiology of schizophrenia, there is an opportunity to develop prevention strategies and treatments based on this enhanced knowledge. In this context, we discuss potential psychopathological treatment targets and enumerate current pharmacological and psychosocial development efforts directed at them. Considering the stages of schizophrenic illness, we review approaches to prevent progression from the pre-symptomatic high-risk to the prodrome to the initial psychotic phase to chronicity. In view of the heterogeneity of risk factors, we summarize approaches towards targeted prevention. We evaluate the potential contribution of pharmacogenomics and other biological markers in optimizing individual treatment and outcome in the future.

Research in people with psychosis risk syndrome: a review of the current evidence and future directions

After decades of research, schizophrenia and related psychotic disorders are still among the most debilitating disorders in medicine. The chronic illness course in most individuals, greater treatment responsiveness during the first episode, progressive gray matter decline during early disease stages, and retrospective accounts of 'prodromal' or early illness signs and symptoms formed the basis for research on the psychosis risk syndrome (PRS), known variably as 'clinical high risk' (CHR), or 'ultra-high risk' (UHR), or 'prodromal'. The pioneering era of research on PRS focused on the development and validation of specific assessment tools and the delineation of high risk criteria. This was followed by the examination of conversion rates in psychosis risk cohorts followed naturalistically, identification of predictors of conversion to psychosis, and investigation of interventions able to abort or delay the development of full psychosis. Despite initially encouraging results concerning the predictive validity of PRS criteria, recent findings of declining conversion rates demonstrate the need for further investigations. Results from intervention studies, mostly involving second-generation antipsychotics and cognitive behavioral therapy, are encouraging, but are currently still insufficient to make treatment recommendations for this early, relatively non-specific illness phase. The next phase of research on PRS, just now beginning, has moved to larger, 'multisite' projects to increase generalizability and to ensure that sufficiently large samples at true risk for psychosis are included. Emphasis in these emerging studies is on: 1) identification of biomarkers for conversion to psychosis; 2) examination of non-antipsychotic, neuroprotective and low-risk pharmacologic and non-pharmacologic interventions; 3) testing of potentially phase-specific interventions; 4) examination of the relationship between treatment response during PRS and prognosis for the course of illness; 5) follow-up of patients who developed schizophrenia despite early interventions and comparison of illness trajectories with patients who did not receive early interventions; 6) characterization of individuals with outcomes other than schizophrenia-spectrum disorders, such as bipolar disorder and remission from PRS, including false positive cases; and 7) assessment of meaningful social and role functioning outcomes. While the research conducted to date has already yielded crucial information, the translation of the concept of a clinically identifiable PRS into clinical practice does not seem justified at this point.

Effects of duration of untreated psychosis on long-term outcome of people hospitalized with first episode schizophrenia

Duration of untreated psychosis (DUP) has emerged as a reliable predictor of outcome but continues to remain under scientific scrutiny. The present study examines the effect of differential periods of DUP on long-term outcome of first episode schizophrenia at Mumbai, India. This research was a prospective, 10-year follow-up naturalistic study. Hospitalized patients of first episode schizophrenia were selected and followed up. Results showed that the mean DUP was higher for a group which showed clinical recovery on Clinical Global Impression Scale [14.0 months (SD=8.0) in recovered and 10.8 months (SD=5.7) in non-recovered group (P=0.091)]. DUP was not found to be significantly associated with any of the end point parameters of good clinical or social outcome. Thus, this study found that DUP alone does not determine outcome status confirming the role of psychopathological heterogeneity.

Risperidone long-acting therapy in stable patients with recently diagnosed schizophrenia

Early and maintained treatment is important for better long-term outcomes in schizophrenia. We hypothesized that treatment with injectable risperidone long-acting therapy (RLAT) would be associated with improved outcomes in recently diagnosed patients compared with those having longer illness duration. Post-hoc analyses were conducted from a 1-year study of stable patients receiving RLAT (25 or 50 mg every 2 weeks) to compare patients diagnosed with schizophrenia in < or ears (recently diagnosed; n=57) with those diagnosed more than 3 years (n=266). Relapse rates were 10.5 and 21.8%, respectively [P=0.053, chi(2)azard ratio 2.2 (95% confidence interval=0.95, 5.13)]. Both groups improved significantly in mean total Positive and Negative Syndrome Scale and Clinical Global Impressions-Severity (CGI-S) scores (P<0.01). Recently diagnosed patients showed greater improvement versus patients diagnosed for more than 3 years in adjusted mean Positive and Negative Syndrome Scale total (-10.2+/-2.0 vs. -3.8+/-0.9; P=0.004) and Clinical Global Impressions-Severity (-0.5+/-0.1 vs. -0.2+/-0.1; P=0.002) scores. The most common adverse events were insomnia (31.6 vs. 26.7%), psychiatric disorders (19.3 vs. 20.7%), headache (15.8 vs. 19.2%), anxiety (12.3 vs. 17.3%), and influenza (10.5 vs. 5.3%). These findings confirm the benefit of RLAT in patients with schizophrenia and suggest that earlier treatment with long-acting preparations is associated with better outcomes.

Early intervention in psychosis: a case study on normal and pathological

Accumulating evidence suggests that delays in receiving treatment are associated with poorer prognosis and longer periods of unneeded suffering. The duration of untreated psychosis (DUP) is considered to be one of the most important determinants of outcome in the first episode of psychosis. However, the focus on decreasing the length of untreated illness tends to overlook the difficult task of making sense of psychotic experiences during a first episode. Using a qualitative analysis of narratives obtained from interviews with an individual and her husband, we examine what delayed her seeking help, how she became convinced that she needed treatment and what this meant for her and her husband. Additionally, we look at the five-year development of both a literal and a figurative space within which both the subject and her husband came to utilize, whether consciously or unconsciously, the 'stories' of her psychotic experiences to construct a shared and even 'safe' and familiar means of spousal connection. The exploration of this shared space reveals the normative and moral values embedded in the concept of DUP and suggests alternative ways of understanding the help-seeking behaviors in early psychosis.

Schizophrenia, "just the facts" 4. Clinical features and conceptualization

Although dementia praecox or schizophrenia has been considered a unique disease entity for the past century, its definitions and boundaries have continued to vary over this period. At any given time, the changing concept of schizophrenia has been influenced by available diagnostic tools and treatments, related conditions from which it most needs to be distinguished, extant knowledge and scientific paradigms. There is significant heterogeneity in the etiopathology, symptomatology, and course of schizophrenia. It is characterized by an admixture of positive, negative, cognitive, mood, and motor symptoms whose severity varies across patients and through the course of the illness. Positive symptoms usually first begin in adolescence or early adulthood, but are often preceded by varying degrees of negative and cognitive symptomatology. Schizophrenia tends to be a chronic and relapsing disorder with generally incomplete remissions, variable degrees of functional impairment and social disability, frequent comorbid substance abuse, and decreased longevity. Although schizophrenia may not represent a single disease with a unitary etiology or pathogenetic process, alternative approaches have thus far been unsuccessful in better defining this syndrome or its component entities. The symptomatologic, course, and etio-pathological heterogeneity can usefully be addressed by a dimensional approach to psychopathology, a clinical staging approach to illness course, and by elucidating endophenotypes and markers of illness progression, respectively. This will allow an approach to the deconstruction of schizophrenia into its multiple component parts and strategies to reconfigure these components in a more meaningful manner. Possible implications for DSM-V and ICD-11 definitions of schizophrenia are discussed.

EARLY DETECTION AND INTERVENTION FOR PSYCHOSIS: PERSPECTIVES FROM NORTH AMERICA

Clinicians and researchers in Canada and the United States have established a number of early intervention programs and research sites on the early course of psychosis and the prodromal period that commonly precedes psychotic disorders. In Canada, early detection and treatment programs for psychosis have been established in many areas of the country, and typically serve specific catchment areas. Canadian research on early psychosis is often built on to these clinical sites, and covers a broad array of topics including interventions during the prodromal stage of the illness, treatment-seeking behaviors, and development of optimal pharmacological and psychosocial treatment approaches for early psychosis. In the United States, clinical programs for early intervention in psychosis are often located at academic programs with ongoing research on the early course of psychotic disorders. Researchers from sites across the United States offer a plethora of information, including neuroimaging studies, research on treatment response, and the development of standardized rating scales and research instruments. Researchers from sites in both countries have formed a consortium to launch the North American Prodrome Longitudinal Study, a multi-site collaboration to gain a better understanding of the prodromal period of the illness and prediction of conversion from the prodrome to psychosis.

Schizophrenia, "Just the Facts": what we know in 2008 part 1: overview

For every disorder, there is a set of established findings and accepted constructs upon which further understanding is built. The concept of schizophrenia as a disease entity has been with us for a little more than a century, although descriptions resembling this condition predate this conceptualization. In 1988, for the inaugural issue of Schizophrenia Research, at the invitation of the founding editors, a senior researcher, since deceased (RJ Wyatt) published a summary of generally accepted ideas about the disorder, which he termed "the facts" of schizophrenia. Ten years later, in conjunction with two of the authors (MSK, RT), he compiled a more extensive set of "facts" for the purpose of evaluating conceptual models or theoretical constructs developed to understand the nature of schizophrenia. On the 20th anniversary of this journal, we update and substantially expand our effort to periodically summarize the current body of information about schizophrenia. We compile a body of seventy-seven representative major findings and group them in terms of their specific relevance to schizophrenia -- etiologies, pathophysiology, clinical manifestations, and treatments. We rate each such "fact" on a 0-3 scale for measures of reproducibility, whether primary to schizophrenia, and durability over time. We also pose one or more critical questions with reference to each "fact", answers to which might help better elucidate the meaning of that finding for our understanding of schizophrenia. We intend to follow this paper with the submission to the journal of a series of topic-specific articles, critically reviewing the evidence.

Early psychosis in rural areas

Early psychosis (EP), in which the terms first-episode psychosis or first-break psychosis are also considered, is an area of developing research intensity. Although it is apparent that considerable progress has been made in establishing best practice criteria and protocols for EP in general, the particular issues pertaining to rural areas have not received the same attention. The purpose of the present study was to conduct a systematic review of the literature of early psychosis programmes, initiatives and research in rural areas in order to help establish the best available evidence. The authors conducted a systematic search of major electronic databases, based on the NHMRC hierarchy of evidence, an established scale, for identified early psychosis cross-referenced with multiple rural terms, between the years 1995 and 2005. A total of 637 articles met the initial search criteria; 206 were identified as having primary significance; three dealt specifically with rural areas. There is a paucity of research findings or published literature concerning the specific needs or characteristics of early psychosis practice or service delivery in rural areas. A number of inferences and suggestions for further research, investigations and policy directions are put forward for consideration.

Early intervention for psychosis

BACKGROUND

Proponents of early intervention have argued that outcome might be improved if more therapeutic efforts were focused on the early stages of schizophrenia or on people with prodromal symptoms. Early intervention in schizophrenia has two elements that are distinct from standard care: early detection and phase-specific treatment. Both elements may be offered as supplements to standard care, or may be provided through a specialised early intervention team. Early intervention is now well established as a therapeutic approach in America, Europe and Australasia, but it is unclear how far early detection, phase-specific treatments, and the use of early intervention teams are underpinned by evidence of effectiveness.

OBJECTIVES

To evaluate the effects of: (a) early detection; (b) phase-specific treatments; and (c) specialised early intervention teams in the treatment of people with prodromal symptoms or first episode psychosis.

SEARCH STRATEGY

We searched CINAHL (1982-2002), The Cochrane Controlled Trials Register (November 2001), The Cochrane Schizophrenia Group Register (July 2003), EMBASE (1980-2002), MEDLINE (1966-2002), PsycINFO (1967-2002), reference lists and contacted the European First Episode Network (2003). For the 2006 update we searched the Cochrane Schizophrenia Group's register.

SELECTION CRITERIA

We included all randomised controlled trials designed to prevent progression to psychosis in people showing prodromal symptoms, or to improve outcome for people with first episode psychosis. Eligible interventions, alone and in combination, included early detection, phase-specific treatments, and care from specialised early intervention teams. We accepted cluster-randomised trials but excluded non-randomised trials.

DATA COLLECTION AND ANALYSIS

We reliably selected studies, quality rated them and extracted data. For dichotomous data, we estimated relative risks (RR), with the 95% confidence intervals (CI). Where possible, we calculated the number needed to treat/harm statistic (NNT/H) and used intention-to-treat analysis (ITT).

MAIN RESULTS

We included seven studies with a total of 941 participants. Six studies were small with numbers of participants ranging between 56 and 83, and one study randomised 547 people. None of the studies had similar interventions and therefore they were analysed separately. One small Australian trial (n=59) was concerned with a phase-specific intervention (low dose risperidone and cognitive behavioural therapy) for people with prodromal symptoms. This group were significantly less likely to develop psychosis at a six month follow up than people who only received care from a specialised team which did not involve phase-specific treatment (n=59, RR 0.27 CI 0.1 to 0.9, NNT 4 CI 2 to 20). This effect was not significant at 12 month follow up (n=59, 1 RCT, RR 0.54 CI 0.2 to 1.3). A UK-based study (EDIE) randomised 60 people with prodromal symptoms, to cognitive behavioural therapy (CBT) or a monitoring group. Only two outcomes were reported: leaving the study early and transition to psychosis, both sets of data were non-significant. A Chinese trial used a phase-specific intervention (family therapy) plus out patient care trial for people in their first episode of psychosis and found reduced admission rates care compared with those who received only outpatient care (n=83, RR 0.28 CI 0.1 to 0.6, NNT 3 CI 2 to 6). The applicability of this finding was, however, questionable. One Dutch study (n=76) comparing phase-specific intervention (family therapy) plus specialised team with specialised team for people in their first episode of schizophrenia found no difference between intervention and control groups at 12 months for the outcome of relapse (n=76, RR 1.05 CI 0.4 to 3.0). The large Scandinavian study (n=547) allocated people with first episode schizophrenia to integrated treatment (assertive community treatment plus family therapy, social skills training and a modified medication regime) or standard care. Global state outcome GAF significantly favoured integrated treatment (n=419, WMD -3.71 CI -6.7 to -0.7) by one year, but by two years data were non-significant. Rates of attrition were significantly lower (n=547, RR 0.59 CI 0.4 to 0.8, NNT 9 CI 6 to 18) for integrated treatment by one and two year follow-up. PRIME (USA) was the only double blind study and allocated people with prodromal symptoms to olanzapine or placebo. No significant differences were found between olanzapine and placebo in preventing conversion to psychosis by about 12 months (n=60, RR 0.58 CI 0.3 to 1.2). Clinical Global Impression change scores 'severity of illness' were equivocal by 12 months. Scale of Prodromal Symptoms (SOPS) scores were also equivocal and the PANSS, total, positive and negative outcomes were non-significant. There were no significant differences between the olanzapine and placebo group on adverse effects rating scales - SAS, BAS and AIMS scores; Weight gain was significantly higher in the olanzapine group (n=59, WMD 7.63 CI 4.0 to 11.2) by 12 months. Finally one more Australian study included people in their first episode of psychosis who were acutely suicidal and allocated people to phase-specific cognitively orientated therapy or standard care. Outcome data for leaving the study early and suicide were equivocal.

AUTHORS' CONCLUSIONS

We identified insufficient trials to draw any definitive conclusions. The substantial international interest in early intervention offers an opportunity to make major positive changes in psychiatric practice, but making the most of this opportunity requires a concerted international programme of research to address key unanswered questions.

Prepsychotic phase of schizophrenia and related disorders: recent progress and future opportunities

BACKGROUND

Clinical and research focus has recently shifted from established psychotic disorders to first-episode psychosis and the prepsychotic phase of illness.

AIMS

To describe the principles, progress and dilemmas associated with the prospective detection, engagement and treatment of young people at risk of developing a psychotic disorder.

METHOD

Strategies to identify young people at heightened risk of a psychotic disorder are described. Preventive interventions and results of their evaluation are provided.

RESULTS

Well-validated criteria for identifying young people at heightened risk of psychosis have been developed, evidence of the efficacy of various psychological and pharmacological interventions in preventing progression has accumulated and progress towards the identification of clinical and neurobiological predictors of transition to acute psychosis has been made.

CONCLUSIONS

The detection, monitoring and treatment of young people in the prepsychotic phase is a growth area in psychiatry. The ethical considerations about treatment options, treatment of minors and provision of information about risk status must be treated with sensitivity if the potential benefit to many young people and their families is to be realised.

Patients in the early phases of schizophrenia and schizoaffective disorders effectively treated with risperidone long-acting injectable

The efficacy and safety of risperidone long-acting injectable (RLAI) was investigated in patients in the early phases of schizophrenia and schizoaffective disorders (< or = 3 years). Patients who required a treatment change received RLAI (2-weekly gluteal injections of 25, 37.5 or 50 mg, per clinical judgement), without an oral risperidone run-in phase.A total of 382 patients were included in this 6-month open-label study; 73% of patients completed the study. A total of 84% had schizophrenia with a median duration of 1.0 year since diagnosis. Previous medications were mainly atypical antipsychotics (70%) and depot neuroleptics (24%). The main reasons for treatment change were non-compliance (42%) and insufficient efficacy (31%) of previous medication. The total Positive and Negative Syndrome Scale (PANSS) and all its subscale scores improved significantly (p < or = 0.0001), with 40% of patients showing a 20% improvement on total PANSS. Global Assessment of Functioning, quality of life, patient satisfaction and movement disorders also improved significantly. Tolerability of RLAI was generally good and no unexpected adverse events were reported. The ensured delivery of medication with RLAI resulted in significant symptom improvement in this patient population. Direct initiation of RLAI is well accepted by patients. RLAI might represent a novel option for patients in the early phases of psychosis.

Childhood laterality and adult schizophrenia spectrum disorders: a prospective investigation

Left or mixed-handedness, footedness, and eye dominance are thought to indicate abnormalities in lateralization related to schizophrenia. Increased left or mixed-dominance in schizophrenia suggests possible hemispheric abnormalities associated with the disorder. A related body of research suggests that some indications of lateralization abnormalities may be evident prior to the onset of schizophrenia, suggesting that disruptions in lateralization are inherent to the developmental course of the disorder. We attempted to replicate and extend upon findings indicating differences in lateralization between children who later developed a schizophrenia spectrum disorder (n = 26) and those who did not develop a schizophrenia spectrum disorder (n = 216), among a high-risk and control, longitudinal sample. The rate of left or mixed-footedness, eye dominance, and any anomalous lateralization, but not handedness, discriminated between those who developed schizophrenia spectrum disorders and those who did not. Left or mixed-laterality appears to signal neurological disruption relevant to the development of schizophrenia spectrum disorders.

Does duration of untreated psychosis bias study samples of first-episode psychosis?

OBJECTIVE

While findings are contradictory, many studies report that long Duration of Untreated Psychosis (DUP) correlates with poorer outcome in first episode psychosis. In an outcome study of first-episode psychosis, we compared the patients who refused to participate in a follow-along with those who consented to estimate the importance of this factor in sample recruitment bias. Our questions were: (i) What is the percentage of refusers? (ii) Are there systematic differences between refusers and consenters on DUP and/or other admission variables? (iii) What is the risk of refusal for different values of DUP?

METHOD

In an unselected group of consecutively admitted patients we compared follow-along refusers and consenters on the following admission variables: sex, age, diagnostic group, substance abuse, being in-patient, coming from an early detection site and DUP. We conducted a logistic regression analysis with refusal as the outcome variable.

RESULTS

Ninety-three of 397 patients (23%) were refusers. In univariate analyses the only significant difference was found for DUP. The median DUP for consenters was 10 weeks and for refusers 32 weeks. DUP remained significant when all independent variables were controlled for.

CONCLUSION

DUP was significantly related to risk for refusal. For tests of the impact of DUP on outcome, this may introduce a type II error bias.

Considering schizophrenia from a prevention perspective

Schizophrenia is a serious mental illness that causes major disability and psychosocial impairment. Recent advances in the neurosciences are prompting considerations of schizophrenia from a preventive perspective. An overview of the literature is provided on two important aspects of the development of a prevention orientation in schizophrenia research: elucidation of potential causal risk factors for schizophrenia and research on risk markers. Risk factors for schizophrenia include, but are not limited to, family history, older paternal age, velo-cardio-facial syndrome, maternal infections during pregnancy, pregnancy and delivery complications, and social adjustment difficulties in childhood and adolescence. Potential risk markers include structural brain pathology, minor physical anomalies and dermatoglyphic abnormalities, neurocognitive deficits, eye-tracking dysfunction, certain electrophysiologic findings, and olfactory identification deficits. Several early efforts at indicated preventive interventions targeting individuals at particularly high risk for developing the disorder are discussed. The preventive medicine and public health disciplines may have a role in future research and interventions that apply a preventive perspective to schizophrenia and other mental illnesses. Like any other chronic medical condition, schizophrenia can be considered from a preventive perspective.

Early Intervention for psychosis

BACKGROUND

Proponents of early intervention have argued that outcome might be improved if more therapeutic effort were focused on the early stages of schizophrenia. Early intervention in schizophrenia has two elements that are distinct from standard care: early detection and phase-specific treatment. Both elements may be offered in addition to standard care, or may be provided by a specialised early intervention team. Early intervention is now well established as a therapeutic approach in America, Europe and Australasia, but it is unclear how far early detection, phase-specific treatments, and the use of early intervention teams are underpinned by evidence of effectiveness.

OBJECTIVES

This review aims to evaluate the effects of: i. early detection and treatment of people with prodromal symptoms; ii. the use of early intervention teams for people in their first episode of psychosis; and iii. phase-specific treatments for people in their first episode of psychosis.

SEARCH STRATEGY

We searched CINAHL (1982-2002), The Cochrane Controlled Trials Register (November 2001), The Cochrane Schizophrenia Group Register (July 2003), EMBASE (1980-2002), MEDLINE (1966-2002), PsycINFO (1967-2002), reference lists and contacted the European First Episode Network (2003).

SELECTION CRITERIA

Randomised controlled trials designed to prevent progression to psychosis in people showing prodromal symptoms, or improve outcome for people with first episode psychosis. Eligible interventions, alone and in combination, included early detection, phase-specific treatments, and care from specialised early intervention teams. Non-randomised trials would only have been included if they had been studies of the effects of early detection strategies in reducing the duration of untreated psychosis (since this issue cannot be addressed by simple randomisation).

DATA COLLECTION AND ANALYSIS

Data were extracted independently by two reviewers and cross-checked. Relative risks (RR) and 95% confidence intervals (CI) were calculated for dichotomous data. Weighted mean differences (WMD) were calculated for continuous data.

MAIN RESULTS

In theory, seventeen different comparisons are possible, but the review only identified three studies that met inclusion criteria. One small trial (n=59) was concerned with a phase-specific intervention (low dose risperidone and cognitive behavioural therapy) for people with prodromal symptoms. This group were significantly less likely to develop psychosis at 6 month follow up than people who only received care from a specialised team which did not involve phase-specific treatment (n=59, 1 RCT, RR 0.27 CI 0.08 to 0.89, NNT 4 CI 2 to 20). This effect was not significant at 12 month follow up (n=59, 1 RCT, RR 0.54 CI 0.23 to 1.30). Another trial found that people in their first episode receiving a phase-specific intervention (family therapy) plus out patient care did have reduced admission rates care compared with those who received only outpatient care (n=83, 1 RCT, RR 0.28 CI 0.13 to 0.62, NNT 3 CI 2 to 6). The applicability of this finding was, however, questionable.Finally, one last study (n=76), comparing phase-specific intervention (family therapy) plus specialised team with specialised team for people in their first episode of schizophrenia found no difference between intervention and control groups at 12 months for the outcome of relapse but confidence intervals were wide (n=76, RR 1.06 CI 0.31 to 3.65).

REVIEWERS' CONCLUSIONS

We identified insufficient trials to draw any definitive conclusions, although five ongoing trials should report shortly. The substantial international interest in early intervention offers an opportunity to make major positive changes in psychiatric practice, but this opportunity may be missed without a concerted international programme of research to address key unanswered questions.

Early intervention in schizophrenia: three frameworks for guiding ethical inquiry

Psychiatric research is making important strides toward early detection and treatment of schizophrenia. Discovery of genetic markers, identifiable prodromes, and low-risk interventions fuel this vital scientific movement. At the same time, investigators and clinicians are studying the ethical questions that arise whenever the bounds of diagnosis and treatment are evolving rapidly. This ethical analysis generally falls within three dominant frameworks of bioethics: the conceptualization of disease, scientific uncertainty, and risk-factor ethics. These frameworks are explored as potential guides for directing ethical inquiry in early intervention.

Premorbid functioning in early-onset psychotic disorders

OBJECTIVE

To examine the premorbid characteristics of youths with early-onset psychotic disorders.

METHOD

Subjects with early-onset psychotic disorders received an extensive diagnostic evaluation upon entry into the study, including a historic review of premorbid functioning using the Premorbid Adjustment Scale.

RESULTS

Youths with schizophrenia (n = 27), bipolar disorder (n = 22), and psychosis not otherwise specified (NOS) (n = 20) were included. High rates of premorbid behavioral problems and academic difficulties were noted across all subjects. Youths with schizophrenia had higher rates of premorbid social withdrawal and global impairment. They also tended to have fewer friends. The psychosis NOS group had significantly higher rates of abuse histories and posttraumatic stress disorder.

CONCLUSIONS

Premorbid abnormalities are common features of early-onset psychotic disorders. The social withdrawal and peer problems specific to youths with schizophrenia likely represent early manifestations of negative symptoms. The abuse histories in the psychosis NOS group may explain the atypical nature of their reported psychotic symptoms, which in many cases are likely posttraumatic phenomena.

Is earlier better? At the beginning of schizophrenia: timing and opportunities for early intervention

The fundamental tenet is treating psychotic patients as quickly and as effectively as possible. Few would oppose this idea. Increasing community awareness of the services, enhancing accessibility, optimizing the treatment approaches, improving compliance, and addressing substance misuse should hopefully translate into improved outcomes for the patients and their families and are extremely encouraging and welcome developments. However, the field urgently needs properly designed randomized controlled trials to definitively determine their efficacy. If they are shown to be efficacious the emphasis should then shift to randomized controlled trials of prodromal intervention. If prodromal intervention is proven to be successful then earlier might indeed be better and primary prevention within reach.

The prodromal stage of psychotic illness: observation, detection or intervention?

Accurate identification of individuals in the earliest symptomatic stages of psychosis offers perhaps the best hope for more effective treatment strategies. Recently, research clinics have been set up to identify and possibly treat individuals who are seen as being at high risk of a psychotic disorder. However, there have been concerns about beginning treatment at this stage. We need to address these concerns so that individuals who are at risk of psychosis come to no harm, yet the development of potential interventions is not delayed. This article briefly reviews some of the newer developments and concerns in this area of psychosis research.

Essential polyunsaturated fatty acid and lipid peroxide levels in never-medicated and medicated schizophrenia patients

BACKGROUND

Reduced levels of membrane essential polyunsaturated fatty acids (EPUFAs) and increased levels of lipid peroxidation products (thiobarbituric acid reactive substances; TBARS) have been observed in chronic medicated schizophrenics. The relationship of EPUFA and TBARS to psychopathology is unclear, since their levels may be altered differentially by duration of illness and antipsychotic treatment. To minimize these confounds, their levels were compared among never-medicated patients in early illness, medicated patients and control subjects with similar lifestyle and common ethnic background.

METHODS

RBC membrane EPUFAs, plasma TBARS, and various dimensions of psychopathology were measured using established procedures in never-medicated (n = 20) and medicated (n= 32) schizophrenia patients and in control subjects (n= 45).

RESULTS

Reduced levels of EPUFAs, particularly arachidonic acid (AA) and docosahexaenoic acid (DHA), were found in never-medicated compared with control subjects; however, the reductions in levels of both AA and DHA were much smaller in medicated versus never-medicated patients; AA levels were similar to levels in control subjects. Only DHA levels were significantly reduced in medicated patients. Lower membrane AA levels were associated with increased levels of plasma TBARS in never-medicated patients. Lower levels of membrane EPUFAs and higher levels of plasma TBARS were associated with the severe symptoms in never-medicated versus medicated patients.

CONCLUSIONS

Data indicate that reduced EPUFAs and increased TBARS exist in never-medicated patients, and these measures correlate with the severity of psychopathology indicating that the membrane EPUFA status may reflect the outcome of schizophrenia.

Methodological pitfalls in early detection studies - the NAPE Lecture 2002. Nordic Association for Psychiatric Epidemiology

OBJECTIVE

To identify and discuss methodological pitfalls that may help explain why many questions around early detection (ED) and duration of untreated psychosis (DUP) are still unsolved.

METHOD

This paper concentrates on pitfalls in the following areas: sampling, measurement and data analyses.

RESULTS

The main problems seem to be:

SAMPLING

Referral bias, exclusion of patients, patient refusal, and patients lost to follow-up.

MEASUREMENT

Reliability, which is particularly cogent for multisite investigations, and validity, which includes: Start of illness, start of psychosis, diagnoses, start of treatment, the relationship between ED and DUP and choice of outcome measures. Data Analyses: Overlooking threshold effects of DUP, improper control for baseline scores, and lack of control for confounders.

CONCLUSION

Methodological pitfalls may bias ED studies. Several pitfalls are unavoidable, but proper design and quality assurance can reduce their impact. Researchers ought to identify the pitfalls, and to estimate and discuss their influence.