Is early intervention in psychosis effective?

A whole-brain neuromark resting-state fMRI analysis of first-episode and early psychosis: Evidence of aberrant cortical-subcortical-cerebellar functional circuitry

Psychosis (including symptoms of delusions, hallucinations, and disorganized conduct/speech) is a main feature of schizophrenia and is frequently present in other major psychiatric illnesses. Studies in individuals with first-episode (FEP) and early psychosis (EP) have the potential to interpret aberrant connectivity associated with psychosis during a period with minimal influence from medication and other confounds. The current study uses a data-driven whole-brain approach to examine patterns of aberrant functional network connectivity (FNC) in a multi-site dataset comprising resting-state functional magnetic resonance images (rs-fMRI) from 117 individuals with FEP or EP and 130 individuals without a psychiatric disorder, as controls. Accounting for age, sex, race, head motion, and multiple imaging sites, differences in FNC were identified between psychosis and control participants in cortical (namely the inferior frontal gyrus, superior medial frontal gyrus, postcentral gyrus, supplementary motor area, posterior cingulate cortex, and superior and middle temporal gyri), subcortical (the caudate, thalamus, subthalamus, and hippocampus), and cerebellar regions. The prominent pattern of reduced cerebellar connectivity in psychosis is especially noteworthy, as most studies focus on cortical and subcortical regions, neglecting the cerebellum. The dysconnectivity reported here may indicate disruptions in cortical-subcortical-cerebellar circuitry involved in rudimentary cognitive functions which may serve as reliable correlates of psychosis.

Service evaluation of an embedded Early Intervention in Psychosis programme

BACKGROUND

An average of 1300 adults develop First Episode Psychosis (FEP) in Ireland each year. Early Intervention in Psychosis (EIP) is now widely accepted as best practice in the treatment of conditions such as schizophrenia. A local EIP programme was established in the Dublin South Central Mental Health Service in 2012.

METHODS

This is a cross-sectional study of service users presenting to the Dublin South Central Mental Health Service with FEP from 2016 to 2022 following the introduction of the EIP programme. We compared this to a previously published retrospective study of treatment as usual from 2002 to 2012.

RESULTS

Most service users in this study were male, single, unemployed and living with their partner or spouse across both time periods. Cognitive Behavioural Therapy for psychosis was provided to 12% (n = 8) of service users pre-EIP as compared to 52% (n = 30) post-programme introduction (p < 0.001), and 3% (n = 2) of service users engaged with behavioural family therapy pre-EIP as opposed to 15% (n = 9) after (p < 0.01). Rates of composite baseline physical healthcare monitoring improved significantly (p < 0.001).

CONCLUSION

Exclusive allocation of multidisciplinary team staff to EIP leads to improved compliance with recommended guidelines, particularly CBT-p, formal family therapy and physical health monitoring.

First-episode psychosis intervention programme versus standard care for the clinical management of early phases of psychosis: cost analysis

BACKGROUND

Early intervention programmes (EIPs) in psychosis have gained attention as specialised interventions to improve health-related and societal impacts for people with psychotic disorders. Previous studies have presented evidence in favour of EIPs over the first year of intervention, despite none considering the critical period before psychosis onset (5 years).

AIMS

To compare the associated costs of the First Episode Psychosis Intervention Program (CRUPEP) and treatment as usual (TAU) in a real-world cohort in a non-specialised psychiatric community setting.

METHOD

Direct and indirect mental health-related costs were calculated over 1 year and up to 7 years. Healthcare and societal costs were calculated from economic data related to the consumption of all healthcare resources, including emergency department attendances, hospital admissions, psychotropic medication prescriptions and societal costs.

RESULTS

From a healthcare perspective, the intervention (CRUPEP) group initially showed a marginally higher cost per patient than the TAU group (€7621 TAU group v. €11 904 CRUPEP group) over the first year of follow-up. However, this difference was reversed between the groups on considering the entire follow-up, with the TAU group showing considerably higher associated costs per patient (€77 026 TAU v. €25 247 CRUPEP).

CONCLUSIONS

The EIP (CRUPEP) showed clinical benefits and minimised the direct and indirect health-related costs of the management of psychosis. Although the CRUPEP intervention initially reported increased costs over 1 year, TAU surpassed the global costs over the entire follow-up.

Psychosis Risk and Development: What Do We Know From Population-Based Studies?

Recent years have seen an advent in population-based studies in children, adolescents, and adults that examine the prevalence, etiology, and developmental trajectories of diverse subclinical psychopathological symptoms that pose a risk for the later development of severe mental illnesses. It is increasingly recognized that most categorically defined psychiatric disorders occur on a spectrum or continuum, show high heterogeneity and symptom overlap, and share genetic and environmental risk factors. We discuss neurodevelopmental underpinnings of psychosis spectrum symptoms and review brain morphometric and functional alterations as well as genetic liability for psychosis in individuals experiencing psychotic symptoms (PSs) in the general population. With regard to brain structure and function, findings of qualitatively similar alterations in individuals experiencing subthreshold PSs and individuals with overt psychotic disorders support the notion of a psychosis continuum. However, genetic and epidemiological studies have emphasized the overlap of PSs and other psychiatric illnesses. In particular, PSs during adolescence appear to be a nonspecific precursor of different psychopathological outcomes. Given the evidence presented in this review, we argue that findings from population-based studies are appropriate to guide policy-making to further emphasize public health efforts. Broadly accessible mental health programs are promising to make a difference in the field of adolescent mental health. However, the specific efficacy of these programs warrants further study, and caution is advised to not overpathologize potentially transient occurrence of mental health problems.

Polish individuals with an at-risk mental state: demographic and clinical characteristics

AIM

The aim of this study is to present sociodemographic and clinical characteristics of Polish individuals with an at-risk mental state (ARMS).

METHODS

A group of 99 individuals meeting the ARMS criteria were assessed in terms of sociodemographic data, psychopathological symptoms, psychosocial functioning and comorbidity.

RESULTS

The sample (mean age 19 years) was 54.55% women. At baseline, nearly 73% of the sample was educated, and 20.20% were employed. Approximately 87.88% of the participants lived with their families. Nearly 77% of the sample presented attenuated psychotic symptoms (APS), 17.17% demonstrated APS with accompanying vulnerability traits and 19.19% showed vulnerability features only. The mean Social and Occupational Functioning Assessment Scale score was 49.55 (±7.70). No effect of age, gender or level of functioning on psychopathological symptoms was observed. The most common comorbid diagnoses were depressive (44.44%) and anxiety disorders (19.19%), which coexisted in 5.05% of the individuals. Approximately 28.28% of the diagnoses met the criteria for personality disorders. The dropout rate from the study was 19.09%, with stigma as the most common reason.

CONCLUSIONS

Polish ARMS individuals are help-seeking young people most commonly presenting APS or vulnerability features. Despite a high level of psychosocial dysfunction, these individuals remain educationally active. Most individuals showed comorbid diagnoses (commonly depressive or anxiety disorders). Despite some differences resulting from the socioeconomic situation of the country or the specificity of the mental health services, the characteristics of the sample remain consistent with descriptions of ARMS populations worldwide. This study reaffirms the need for organizing early intervention services in non-stigmatizing settings.

The CBCL 1.5-5 and the identification of preschoolers with autism in Italy

AIMS

To study the potential use of child behaviour checklist (CBCL) 1.5-5 scales for the early identification of preschoolers at risk of autism.

METHODS

CBCL scores of three groups of preschoolers were compared: (1) an experimental group of 101 preschoolers with autism spectrum disorder (ASD); (2) a control group of 95 preschoolers with other psychiatric disorders (OPD); (3) a control group of 117 preschoolers with typical development (TD). One-way analysis of variance (ANOVA), logistic regression with odds ratio (OR) and receiver operating characteristic (ROC) analyses were performed.

RESULTS

ANOVA revealed that ASD and OPD had significantly higher scores in almost all CBCL scales than TD. ASD presented significantly higher scores than OPD on Withdrawn, Attention Problems and Pervasive Developmental Problems (PDP) scales. Logistic regression analysis demonstrated that these same CBCL scales have validity in predicting the presence of an ASD towards both TD and OPD. ROC analysis indicated high sensitivity and specificity for PDP (0.85 and 0.90) and Withdrawn (0.89 and 0.92) scales when ASD is compared to TD. Specificity (0.60 for PDP and 0.65 for Withdrawn) decreases when comparing ASD and OPD CONCLUSIONS: The PDP and Withdrawn scales have a good predictive validity so that they could be proposed as a first-level tool to identify preschoolers at risk of autism in primary care settings. Problems regarding the lower specificity when comparing ASD v. OPD are discussed.

What are the major drivers of prevalent disability burden in young Australians?

OBJECTIVE

To examine age and sex differences in the leading causes of prevalent disability in young Australians.

DESIGN, SETTING AND PARTICIPANTS

We analysed data from the 2003 Australian Burden of Disease and Injury Study, which estimated the prevalent disability burden attributable to 170 diseases and injuries, for younger adolescents (10-14 years), older adolescents (15-19 years) and young adults (20-24 years).

MAIN OUTCOME MEASURES

The broad categories of disease and injury that are the main contributors to prevalent disability and the 10 leading disease and injury causes of prevalent disability, according to sex and age group.

RESULTS

Total prevalent disability rates are lowest in younger adolescents and highest in young adults. Mental disorders are the largest "contributor" to disability in young Australians, and anxiety and depressive disorders are the leading single cause. In young males, autism and attention deficit hyperactivity disorder cause similar levels of disability as do anxiety and depression. In young females, eating disorders are the second leading cause of mental disorder disability. Alcohol use disorders and schizophrenia make important contributions to disability in young adult males. Asthma is the most prominent cause of physical disability in all three age groups.

CONCLUSIONS

There are substantial changes in both the pattern and level of disability burden across the three age groups that we studied. The increase in total prevalent disability that occurs from early adolescence to young adulthood should focus attention on the delivery of accessible and youth friendly health care as well as the effectiveness of transitions from child health services to adult health services.

Stressful and intrusive life events preceding first episode psychosis

Aim – To test the hypothesis that stressful life events, in particular intrusive events, would cluster before the first onset of psychosis. Method – Forty-one patients with first episode psychosis were interviewed with the Life Events and Difficulties Schedule to assess events in the year before the onset of illness. Events were rated contextually on timing, independence, threat, and intrusiveness. Within-patient group clustering was evaluated, and the patient group was compared with two general population surveys from London. Results – Events were very frequent in the year before the onset of psychosis. Stressful and intrusive events were more common in the three months before onset compared with the previous nine months, although few analyses reached conventional statistical significance. Threatening and intrusive events were much more frequent in patients than in the comparison groups. First episode psychosis patients were strikingly more likely to report an intrusive event in the three months before onset (OR=17.1, 34% v 3%), and also showed an excess between three months and one year before onset (OR=8.1, 11% v 3%). Conclusions – Events may trigger many cases of first episode psychosis. The effect emerges several months before onset, particularly if the events are intrusive. This has both theoretical and clinical implications.

Declaration of Interest: DR was supported by a UK Medical Research Council studentship. The authors have no conflicts of interest in writing this paper.

Pharmacoepidemiology of psychotropic drugs: examples of current research challenges on major public health issues

Background– As a large number of persons are exposed to prescribed psychotropic drugs, their utilisation and impact should be further explored at the population level.Aims– To illustrate the interest of pharmacoepidemiological studies of psychotropic drugs by selected examples of major public health issues.Method– Selective review of the literature. Results – Many questions remain unsolved regarding the behavioural teratogenicity of prenatal exposure to psychotropic drugs, the impact of their increasing use in children, the long-term cognitive consequences of exposure to benzodiazepines, and the risks associated with extension of indications of antipsychotic drugs.Conclusion– Pharmacoepidemiological studies need to be further developed owing to the large number of public health questions raised by the extensive and expanding use of psychotropic drugs.

Factor analysis of the scale of prodromal symptoms: differentiating between negative and depression symptoms

BACKGROUND

This study examines the ability of the Scale of Prodromal Symptoms (SOPS) to differentiate between negative and depression symptoms in a young help-seeking ultrahigh risk (UHR) group.

METHODS

SOPS data of 77 help-seeking patients at UHR for psychosis were analyzed with an exploratory factor analysis. The extracted Depression factor was validated with the Beck Depression Inventory (BDI). The extracted SOPS Negative symptoms factor was validated with the Negative symptoms subscale of the Positive and Negative Syndrome Scale (PANSS).

RESULTS

Four factors were extracted from the SOPS: a negative, depression, disorganized and positive factor. The Negative symptom factor consisted of three items (N1: social anhedonia and withdrawal, N3: decreased expression of emotion; N4: decreased experience of emotions and self), and could be validated with the PANSS Negative symptoms subscale. The Depression factor was also made up of three items (G2: dysphoric mood, G4: impaired tolerance to normal stress, and D4: personal hygiene/social attentiveness), and could be validated with the BDI.

CONCLUSIONS

Our results suggest that 3 items of the Negative symptoms subscale of the SOPS, 2 items of the General and 1 item of the Disorganization subscale differentiate validly between negative and depression symptoms in an UHR population.

Where to position clozapine: re-examining the evidence

OBJECTIVE

To review clozapine's position in treatment algorithms for schizophrenia.

METHOD

Clozapine's status is reviewed in the context of its initial discovery and unique clinical and (or) pharmacological profile, withdrawal and link with hematologic concerns, reintroduction with monitoring guidelines, prototype for atypicality, positioning in treatment algorithms, and current evidence regarding efficacy, effectiveness, and side effects.

RESULTS

The hematologic monitoring implemented with clozapine's reintroduction here in North America has proven successful in preventing clozapine-related deaths secondary to agranulocytosis. While its other side effects are not without concern, present evidence does not link clozapine to increased mortality rates; indeed, it appears better than other antipsychotics in this regard. Moreover, its clinical superiority compared with all other antipsychotics has been confirmed both in efficacy and in effectiveness trials.

CONCLUSIONS

Schizophrenia continues to represent a treatment challenge, with many people demonstrating suboptimal response and poor functional outcome. Clozapine is routinely positioned as a third-line treatment in schizophrenia, but in light of existing evidence this warrants re-examination.

Clozapine for treatment-resistant schizophrenia: National Institute of Clinical Excellence (NICE) guidance in the real world

INTRODUCTION

Clozapine, a poorly tolerated antipsychotic drug, is widely recognized as the only efficacious option in treatment-resistant psychosis. The United Kingdom (U.K.) National Institute of Clinical Excellence (NICE) guidance for its consideration defined a threshold for treatment resistance substantially more liberal than that utilized in seminal studies of efficacy. This study documented adherence to NICE guidance in a patient group likely to be enriched for treatment resistance: 150 consecutive assertive outreach and former rehabilitation inpatients. Evidence of a NICE-compliant treatment trial was adduced from case notes: treatment resistance was determined through discussion with key workers about ongoing clinical problems, including treatment-resistant patients already on clozapine. Reasons for treatment-resistant patients not receiving clozapine were documented. Levels of ongoing clinical problems were compared between treatment-resistant patients on clozapine, treatment-resistant patients not on clozapine, and non-treatment-resistant patients.

RESULTS

Patients' mean age was 41, with illness duration of 16 years. Twelve percent (18 patients) had not had a NICE-compliant trial of treatment, but all 3 treatment-resistant patients in this subgroup were on clozapine already. Forty-five percent of the whole group was treatment resistant: 54% of the treatment-resistant group was treated with clozapine. Of the remaining 46% (i.e., 31 treatment-resistant patients not taking clozapine), 16 refused and 15 could not be treated for medical reasons including the failure of previous trials and neutropenia. Levels of ongoing clinical problems were generally similar between clozapine-treated patients and nontreatment-resistant patients, with significantly greater problems in treatment-resistant patients not taking clozapine. However, positive symptoms remained relatively high in the clozapine group, while substance abuse was actually lower than in the other two groups, and there were no differences between any of the groups in depression and suicide risk.

CONCLUSIONS

Tertiary referral assertive outreach and rehabilitation services include a higher proportion of treatment-resistant patients than secondary services, as appropriate. Most patients receive a NICE-compliant trial for the determination of pharmacological treatment resistance, but only just over half of the patients who need clozapine on clinical grounds are taking it. While half of these refuse, the rest encounter insuperable obstacles to treatment. In general, clozapine reduces levels of ongoing clinical problems to those of nontreatment-resistant patients. In view of the difficulties of delivering clozapine to treatment-resistant patients, the development of treatment resistance should be avoided if possible.

Age at onset and latency to treatment (duration of untreated illness) in patients with mood and anxiety disorders: a naturalistic study

This study was designed to investigate and compare demographic and clinical features with specific emphasis on age at onset, age at first treatment and, in particular, on duration of untreated illness (DUI), in patients with different mood and anxiety disorders. Study sample included 729 outpatients with the following diagnoses: major depressive disorder (n=181), bipolar disorder type I (BD I, n=115) and II (BD II, n=186), generalized anxiety disorder (n=100), panic disorder (n=96), and obsessive-compulsive disorder (n=51). Main demographic and clinical variables of the sample were compared among the diagnostic groups using one-way analysis of variance or chi tests. The diagnostic groups showed significant differences in relation to age at onset and age at first pharmacological treatment and in relation to latency to treatment. In particular, patients with major depressive disorder showed the shortest DUI (39.08 months), whereas patient with BD II showed the longest DUI (97.2 months) in comparison with the other groups. Within the group with anxiety disorders (F=7.512, P<0.001), patients with panic disorder showed the shortest DUI (44.35 months), whereas patients with obsessive-compulsive disorder showed the longest DUI (90.57 months). The present findings suggest that patients with different mood and anxiety disorders show significant differences in terms of age at onset, age at first treatment and, consequently, DUI, which potentially reflect different reasons influencing treatment delay.

The basis for improving and reforming long-term care. Part 4: identifying meaningful improvement approaches (segment 1)

While many aspects of nursing home care have improved over time, numerous issues persist. Presently, a potpourri of approaches and a push to "fix" the problem have overshadowed efforts to correctly define the issues and identify their diverse causes. Together, the two segments of this fourth and final article (divided between this month's issue and the next one) in the series identify strategies that should tie reform efforts together. This Segment 1 of Article 4 discusses the need to judge initiatives and proposals by how well they support and/or promote critical elements such as the care delivery process and clinical problem solving and decision making activities. It also covers the need to critically scrutinize and modify the conventional wisdom and to suppress "political correctness" thatcontinues to inhibit vital critical inquiry and dialogue that are needed to define issues correctly and make further progress. Ultimately, relatively uncomplicated and inexpensive strategies have the potential to bring dramatic progress. But there needs to be more willingness to rethink the issues and reconsider current approaches.

A qualitative evaluation of a regional Early Psychosis Service 3 years after its commencement

Objective. To outline the major findings of a qualitative evaluation of an Early Psychosis Service 3 years after its establishment. Design. Data to evaluate the service were collected from team meetings, focus groups, individual interviews and questionnaires administered to clinicians, school staff, patients, carers and families. Setting. Barwon Health; Mental Health, Drug and Alcohol Services provide public mental health care to the Geelong, Victoria, region (population 270 000), which is a mixed urban and rural setting. The Early Psychosis Service model implemented involved the placement of two early psychosis workers into each of five adult geographically based Area Mental Health Teams rather than the establishment of a single Early Psychosis Team. Results. The service was found not to adhere to its original design in several key respects. Caseloads and periods of case management were found to be lower and shorter respectively than was originally planned for, caseworkers often experienced isolation and resentment from their adult service coworkers, the service was perceived to be difficult to access and premises not to be youth friendly and communication and engagement with external agencies and service providers was perceived to be poor. Conclusions. The choice of service model, inadequate consultation with stakeholders and inadequate promotion of the service contributed to its failure to reach early expectations. Because of these and other issues, including difficulties distinguishing between early psychosis and non-psychosis, a decision was made to restructure youth services and a separate youth mental health service, which incorporated the Early Psychosis Service function, was established.