Early intervention in psychosis: a new evidence based paradigm

Cross-cultural adaptation and inter-rater reliability of the Schizophrenia proneness instrument adult version (SPI-A) in the Indonesian context

This study aims to adapt the Schizophrenia Proneness Instrument, Adult Version (SPI-A) for the assessment of basic symptoms to the Indonesian context (culturally and linguistically) and analyze the inter-rater reliability of the translated version. Following a specific methodology for cultural adaptation, direct and back-translations were conducted together with cognitive interviews to analyze the comprehensibility of the translated version. A linguistic expert analyzes the resulting version to determine its grammatical and linguistic adequacy. Finally, the interclass correlation (ICC) of the three expert ratings of the samples (N = 9) was analyzed. The direct and back-translation phases showed good conceptual equivalence to the original version. The cognitive interviews revealed items that were challenging to understand and required revision. The final version also considered the judgments of a linguistic expert for grammatical and conceptual improvements. Inter-rater reliability analysis showed an excellent degree of agreement (ICC value: 0.984; 95% CI: 0.950-0.996). The translated SPI-A fits the Indonesian context and can be used in clinical settings to assess basic symptoms in help-seeking individuals in Indonesia.

Early intervention in psychosis services: A systematic review and narrative synthesis of barriers and facilitators to seeking access

BACKGROUND

The duration of untreated psychosis (DUP) continues to be a global priority. Early intervention services were established to reduce treatment delays but have had limited impact. This systematic review examines barriers and facilitators to seeking access to these services, to identify targets for service level change.

METHODS

We conducted a systematic review of relevant databases (PsychINFO, MEDLINE, CINAHL, and PsychARTICLES) using pre-defined search terms for psychosis, early intervention, and barriers and facilitators. Given the majority of qualitative studies, a thematic synthesis rather than meta-analysis was indicated.

RESULTS

The search yielded 10 studies. Mental health stigma and discrimination predict DUP, compounded by structural barriers which limit the impact of early intervention services on timely access to recommended treatments. Synthesis of the qualitative studies generated three themes: knowledge, relationships, and stigma. Lack of knowledge, absence of supportive relationships (social and professional), and self-stigma constitute significant barriers to seeking access to early intervention services.

CONCLUSIONS

This is the first review of the barriers and facilitators to seeking access to early intervention services. The findings highlight public health and secondary care service targets to expedite access to recommended treatments and thereby reduce the DUP.

The impact of early intervention for first episode psychosis on cognitive functioning

IMPORTANCE

Impaired cognitive functioning is a core characteristic of schizophrenia, present from the onset of the illness and relatively stable thereafter. Despite evidence supporting the impact of early intervention services (EIS) on improving symptoms and functioning in first episode psychosis (FEP), controlled research has not examined its impact on cognitive functioning.

OBJECTIVE

To evaluate the longitudinal course of cognitive functioning in FEP patients participating in a large, controlled study comparing EIS with usual services.

METHODS

A total of 404 persons ages 15-40 years old with non-affective FEP participated in the Recovery After Initial Schizophrenia-Early Treatment Program. A cluster randomized controlled trial was conducted with 34 community mental health treatment centers across the U.S. randomized to provide either an EIS program (NAVIGATE) or usual Community Care (CC) to FEP patients for 2 years. Cognitive functioning was assessed with the Brief Assessment of Cognition in Schizophrenia (BACS) at baseline and 1- and 2-years later.

RESULTS

Older participants (≥20 years old) in both treatment groups improved on all BACS tests. Younger participants (15-19) in NAVIGATE improved significantly more on Digit Sequencing (working memory) than those in CC, whereas both groups improved on most of the other BACS tests. Improvements in cognitive functioning occurred mostly over the first year and were correlated with reductions in symptom severity.

DISCUSSION

EIS do not improve cognitive functioning more than usual care for older FEP patients but may improve working memory in younger FEP patients. Interventions targeting cognition may be required to enhance cognitive functioning in most FEP patients.

Safety Planning in Context: A Case Study Integrating DBT Techniques and ACT for Overlapping Suicide and Psychosis Risk

Suicide risk is markedly higher for clients at clinical high risk for psychosis (CHR-p) compared to the general population. Dialectical behavior therapy (DBT) has a strong evidence base supporting its utility for managing suicide risk. Meanwhile, acceptance and commitment therapy (ACT) has been shown to effectively treat individuals with psychosis symptoms, as well as comorbid anxiety and mood disorders in CHR-p clients. Despite the robust evidence for each of these modalities in addressing concerns around suicidality and psychosis risk independently, there is a paucity of literature on how to support clients experiencing co-occurring suicide and psychosis risk. Such overlapping risk is often central to presenting concerns in CHR-p clients. Our manuscript presents a case example of an integrated DBT-ACT approach to managing risk surrounding both suicide and psychosis symptoms in an outpatient setting. We highlight how an integrated approach may help outpatient providers to implement and modify effective treatment that promotes continued outpatient care focused on goals beyond immediate risk management of both suicide and emerging psychosis. We provide specific examples of DBT techniques and ACT interventions used by a supervised doctoral-level student clinician in treatment with a CHR-p client and discuss implications for future clinical research.

Treatment outcomes for young people at clinical high risk for psychosis: Data from a specialized clinic

AIM

Treatment for youth exhibiting signs of clinical high risk for psychosis (CHR-P) has been emphasized in recent years, but there is need for a greater understanding of the course of symptoms and functioning across treatment. The aim of this study is to describe 10 years of naturalistic treatment outcomes in a real-world, specialized CHR-P outpatient clinic, the Center for Early Detection, Assessment, and Response to Risk (CEDAR) Clinic.

METHODS

The CEDAR Clinic routinely collects client outcomes data for the purposes of program development, monitoring treatment effectiveness, and characterizing the clinic population. Clients are assessed at baseline, every 6 months (for up to 2 years depending on duration of treatment), and at the end of treatment. A series of mixed-effects models were performed to analyse change over time in outcomes (symptoms and functioning) between baseline and follow-up time points.

RESULTS

Over time, clients' (N = 123) positive (F = 11.8, p < .001) and negative (F = 4.91, p = .002) symptoms declined relative to their baseline. Social functioning improved over time (F = 2.50, p = .049), as did depression (F = 8.60, p < .001) and hopelessness (F = 4.21, p = .004). Clients' total CEDAR treatment hours ranged across type of treatment service, but the amount of treatment clients received was not associated with any clinical outcomes.

CONCLUSIONS

Over the course of treatment at this real-world, specialized CHR-P program, clients exhibited significant improvement in clinical outcomes and did not significantly decline in any measured outcomes. We discuss this study in the context of current understanding and guidelines for specialized coordinated specialty care treatment for CHR-P.

Impaired self-recognition in individuals with no full-blown psychotic symptoms represented across the continuum of psychosis: a meta-analysis

BACKGROUND

Impairments in self-recognition (i.e. recognition of own thoughts and actions) have been repeatedly shown in individuals with schizophrenia. According to classical clinical characterizations, schizophrenia is included in a continuum encompassing a large range of genetic statuses, psychotic states and symptoms. The current meta-analysis aims to determine whether self-recognition is affected by individuals within the psychosis continuum.

METHOD

Three populations were considered: people with an at-risk mental state for psychosis (ARMS), hallucination-prone individuals and unaffected relatives of patients with schizophrenia. Eleven studies contrasted self-recognition between these three populations (n = 386) and healthy controls (n = 315) and four studies used correlational analysis to estimate comparable effects (n = 629). Eligible studies used experimental paradigms including source-monitoring and self-monitoring.

RESULTS

We observed significantly reduced self-recognition accuracy in these populations [g = -0.44 (-0.71 to -0.17), p = 0.002] compared to controls. No influence of the type of population, experimental paradigm or study design was observed.

CONCLUSION

The present analysis argues for self-recognition deficits in populations with no full-blown psychotic symptoms represented across the continuum of psychosis.

EPA guidance on the early intervention in clinical high risk states of psychoses

This guidance paper from the European Psychiatric Association (EPA) aims to provide evidence-based recommendations on early intervention in clinical high risk (CHR) states of psychosis, assessed according to the EPA guidance on early detection. The recommendations were derived from a meta-analysis of current empirical evidence on the efficacy of psychological and pharmacological interventions in CHR samples. Eligible studies had to investigate conversion rate and/or functioning as a treatment outcome in CHR patients defined by the ultra-high risk and/or basic symptom criteria. Besides analyses on treatment effects on conversion rate and functional outcome, age and type of intervention were examined as potential moderators. Based on data from 15 studies (n = 1394), early intervention generally produced significantly reduced conversion rates at 6- to 48-month follow-up compared to control conditions. However, early intervention failed to achieve significantly greater functional improvements because both early intervention and control conditions produced similar positive effects. With regard to the type of intervention, both psychological and pharmacological interventions produced significant effects on conversion rates, but not on functional outcome relative to the control conditions. Early intervention in youth samples was generally less effective than in predominantly adult samples. Seven evidence-based recommendations for early intervention in CHR samples could have been formulated, although more studies are needed to investigate the specificity of treatment effects and potential age effects in order to tailor interventions to the individual treatment needs and risk status.

Clinical and demographic correlates of stigma in first-episode psychosis: the impact of duration of untreated psychosis

OBJECTIVE

To evaluate the relationships between perceived stigma and duration of untreated psychosis (DUP), demographic characteristics, and clinical and psychosocial functioning in persons with a first episode of psychosis (FEP).

METHOD

A total of 399 participants with FEP presenting for treatment at 34 sites in 21 states throughout the United States were evaluated using standardized instruments to assess diagnosis, symptoms, psychosocial functioning, perceived stigma, wellbeing, and subjective recovery.

RESULTS

Perceived stigma was correlated with a range of demographic and clinical variables, including DUP, symptoms, psychosocial functioning, and subjective experience. After controlling for symptom severity, perceived stigma was related to longer DUP, schizoaffective disorder diagnosis, more severe depression, and lower wellbeing and recovery. The associations between stigma and depression, wellbeing, and recovery were stronger in individuals with long than short DUP, suggesting the effects of stigma on psychological functioning may be cumulative over the period of untreated psychosis.

CONCLUSION

The findings suggest that independent of symptom severity, perceived stigma may contribute to delay in seeking treatment for FEP, and this delay may amplify the deleterious effects of stigma on psychological functioning. The results point to the importance of reducing DUP and validating interventions targeting the psychological effects of stigma in people with FEP.

Key Worker-Mediated Enhancement of Physical Health in First Episode Psychosis: Protocol For a Feasibility Study in Primary Care

BACKGROUND

Studies have demonstrated that, for patients with psychosis, a majority of the decline in health status and functioning emerges during the first few years after the onset of illness. This knowledge led to the development of specialized early intervention services (EISs) targeting patients experiencing their first episode of psychosis. The central component of EISs is often assertive case management delivered by a multidisciplinary team, where an appointed key worker is responsible for coordinating treatment and delivering various psychosocial interventions to service users.

OBJECTIVE

This paper outlines the protocol for a feasibility study examining how key workers may enhance physical health by supporting integration between primary and secondary care.

METHODS

Semistructured interviews were conducted with key stakeholder groups (General Practitioners and health care professionals working in mental health services). The interviews informed the development of the complex intervention involving a longitudinal pre-post intervention in 8 general practices in 2 regions in Ireland (one urban and one rural). Patients with first episode psychosis (FEP) will be identified from clinical records at general practices and mental health services.

RESULTS

Baseline and follow-up data (at 6 months) will be collected, examining measures of feasibility, acceptability, and intervention effect size.

CONCLUSIONS

Study findings will inform future practice by examining feasibility of key workers enhancing physical health through improved interaction between primary and secondary care. By identifying issues involved in enhancing recruitment and retention, as well as the likely effect size, the study will inform a future definitive intervention.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/13115.

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

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

ADHD: science, stigma and service implications

We are delighted to dedicate an edition of the Irish Journal of Psychological Medicine to the topic of attention-deficit hyperactivity disorder (ADHD). ADHD accounts for the majority of clinical presentations to Child and Adolescent Mental Health Services, both in terms of new assessments and ongoing attendances. Papers presented in this edition reflect on the evolving construct of ADHD, drawing from science, clinical practice and public opinion. Current and evidenced-based assessment and treatment practice guidelines are reviewed. International longitudinal studies allow us to understand the personal and societal cost, which can persist for many years post-diagnosis. Despite continuation to adulthood in many young people, follow on adult services are lacking. It is fitting that submissions, by way of personal reflections and opinion pieces, are also included from adult colleagues as they reflect on their experiences in this area. Given the recent development of a national clinical programme in ADHD in Ireland, coupled with a growing evidence for effective interventions, it is hoped that this special edition will highlight the need for appropriate and accessible ADHD treatments across the lifespan.

Prediction of self-stigma in early psychosis: 3-Year follow-up of the randomized-controlled trial on extended early intervention

BACKGROUND

Self-stigma represents a major barrier to recovery in people with psychotic disorders but is understudied in early illness stage. Longitudinal investigation of prediction for self-stigma is scarce and none is conducted in early psychosis. We aimed to prospectively examine baseline predictors of self-stigma in early psychosis patients in the context of a 3-year follow-up of a randomized-controlled trial (RCT) comparing 1-year extension of early intervention (EI) with step-down psychiatric care for first-episode psychosis (FEP).

METHOD

One hundred sixty Chinese patients were recruited from a specialized EI program for FEP in Hong Kong after they had completed this 2-year EI service, and underwent a 12-month RCT. Participants were followed up and reassessed 3years after inclusion to the trial. Comprehensive evaluation encompassing clinical, functional, subjective quality of life and treatment-related variables were conducted. Data analysis was based on 136 participants who completed self-stigma assessment at 3-year follow-up.

RESULTS

Fifty patients (36.8%) had moderate to high levels of self-stigma at 3-year follow-up. Multivariate regression analysis revealed that female gender, prior psychiatric hospitalization, longer duration of untreated psychosis and greater positive symptom severity at study intake independently predicted self-stigma at the end of 3-year study period.

CONCLUSION

Our results of more than one-third of early psychosis patients experienced significant self-stigma underscore the clinical needs for early identification and intervention of self-stigmatization in the initial years of psychotic illness. Further research is warranted to clarify prediction profile and longitudinal course of self-stigma in the early illness phase.

A comparative study of psychotic and affective symptoms in Rwandan and Kenyan students

AIMS

War and conflict are known to adversely affect mental health, although their effects on risk symptoms for psychosis development in youth in various parts of the world are unclear. The Rwandan genocide of 1994 and Civil War had widespread effects on the population. Despite this, there has been no significant research on psychosis risk in Rwanda. Our goal in the present study was to investigate the potential effects of genocide and war in two ways: by comparing Rwandan youth born before and after the genocide; and by comparing Rwandan and Kenyan adolescents of similar age.

METHODS

A total of 2255 Rwandan students and 2800 Kenyan students were administered the Washington Early Recognition Center Affectivity and Psychosis (WERCAP) Screen. Prevalence, frequency and functional impairment related to affective and psychosis-risk symptoms were compared across groups using univariate and multivariate statistics.

RESULTS

Rwandan students born before the end of the genocide and war in 1994 experienced higher psychotic and affective symptom load (p's < 0.001) with more functional impairment compared with younger Rwandans. 5.35% of older Rwandan students met threshold for clinical high-risk of psychosis by the WERCAP Screen compared with 3.19% of younger Rwandans (χ 2 = 5.36; p = 0.02). Symptom severity comparisons showed significant (p < 0.001) group effects between Rwandan and Kenyan secondary school students on affective and psychotic symptom domains with Rwandans having higher symptom burden compared with Kenyans. Rwandan female students also had higher rates of psychotic symptoms compared with their male counterparts - a unique finding not observed in the Kenyan sample.

CONCLUSIONS

These results suggest extreme conflict and disruption to country from genocide and war can influence the presence and severity of psychopathology in youth decades after initial traumatic events.

Development of a Boston Treatment Program for Youth at Clinical High Risk for Psychosis: Center for Early Detection, Assessment, and Response to Risk (CEDAR)

Over the past two decades, increasing attention has been given to the importance of early intervention for psychosis. This article describes the development of the Center for Early Detection, Assessment and Response to Risk (CEDAR), which focuses on early identification and treatment of youth at clinical high risk for psychosis. There are relatively few models in the United States for such programs, and we present our developmental story, focusing mainly on the CEDAR Clinic, as a case study of how such a program can develop. We describe the rationale, infrastructure, and services provided at the CEDAR Clinic, and present some descriptive data from the CEDAR Clinic through 2016. A case example is provided to illustrate treatment at CEDAR. We hope that the cultural history of our program's development is informative for clinicians and policy makers as one model of how to build an early intervention service. We believe that this article is timely in view of the growing momentum in the United States for developing programs for intervening as early as possible for youth at clinical high risk for psychosis.

Scales for assessment of depression in schizophrenia: Factor analysis of calgary depression rating scale and hamilton depression rating scale

This study aimed to evaluate the factor structure of Calgary depression rating scale (CDSS) and Hamilton Depression Rating Scale (HDRS) among patients with schizophrenia in acute and remission phase of illness by using exploratory factor analysis. For this, 267 patients with schizophrenia were assessed on CDSS and HDRS. Exploratory factor analysis of CDSS yielded 2 factor models for the whole sample, patients in clinical remission and patients not in clinical remission phase of schizophrenia. Factor analysis of HDRS yielded 3 factor models; however, there was significant difference in the factor structure between those in clinical remission and those not in clinical remission phase of schizophrenia. CDSS total score did not correlate with PANSS positive and negative subscale scores. In contrast, HDRS total score correlated positively with PANSS positive subscale score, PANSS negative subscale score and PANSS general psychopathology subscale score. To conclude, present study suggests while CDSS items separate out into 2 factors, which are stable across different stages of illness, whereas HDRS factor structure appears to be less stable across different stages of illness. Correlation analysis suggests that rating on HDRS may be affected by positive and negative symptoms of schizophrenia, whereas CDSS do not correlate with positive and negative symptoms of schizophrenia.

Relationship of depression with cognitive insight and socio-occupational outcome in patients with schizophrenia

AIM

To evaluate the prevalence of depression using different measures in patients with schizophrenia and to study the relationship of depression in schizophrenia with cognitive insight and clinical insight, disability and socio-occupational functioning.

METHODS

A total of 136 patients with schizophrenia were evaluated for depression, cognitive insight and socio-occupational functioning.

RESULTS

Of the 136 patients included in the study, one-fourth ( N = 34; 25%) were found to have depression as per the Mini International Neuropsychiatric Interview (MINI). The prevalence of depression as assessed by Calgary Depression Scale for Schizophrenia (CDSS), Hamilton depression rating scale (HDRS) and Depressive Subscale of Positive and Negative Syndrome Scale (PANSS-D) was 23.5%, 19.9% and 91.9%, respectively. Among the different scales, CDSS has highest concordance with clinician's diagnosis. Sensitivity, specificity, positive predictive value and negative predictive value for CDSS was also higher than that noted for HDRS and PANSS-D. When those with and without depression as per clinician's diagnosis were compared, those with depression were found to have significantly higher scores on Positive and Negative Syndrome Scale (PANSS) positive and general psychopathology subscales, PANSS total score, participation restriction as assessed by P-scale and had lower level of functioning as assessed by Global Assessment of Functioning (GAF). No significant difference was noted on negative symptom subscale of PANSS, clinical insight as assessed on G-12 item of PANSS, disability as assessed by Indian Disability Evaluation and Assessment Scale (IDEAS) and socio-occupational functioning as assessed by Social and Occupational Functioning Assessment Scale (SOFS). In terms of cognitive insight, those with depression had significantly higher score for both the subscales, that is, self-reflective and self-certainty subscales as well as the mean composite index score.

CONCLUSION

Our results suggest that one-fourth of patients with schizophrenia have depression, compared to HDRS and PANSS-D, CDSS has highest concordance with clinician's diagnosis of depression and presence of depression is related to cognitive insight.

Predicting time to emergency department re-visits and inpatient hospitalization among adolescents who visited an emergency department for psychotic symptoms: a retrospective cohort study

BACKGROUND

Adolescents experiencing psychosis may enter the mental health system by a pathway to care that includes or is initiated at the emergency department (ED). However, a better understanding of the pathway to care involving EDs is required to ensure these patients receive the care they require. This study explores physician-based care factors associated with adolescent ED re-visits and inpatient hospitalization following an index ED visit for psychotic symptoms.

METHODS

Using administrative data from Alberta, Canada, we identified a cohort of adolescents aged 13-17 years who were discharged after an ED visit for psychotic symptoms between April 1, 2002 and September 29, 2010. Multivariable models estimated times to ED re-visit and inpatient hospitalization for mental health care in a 90-day period after ED discharge.

RESULTS

The cohort was comprised of 208 adolescents. Reduced times to ED re-visit and inpatient hospitalization were associated with: 1) multiple physician visits after discharge (ED re-visit: hazard ratio [HR] 5.93, 95 % confidence interval [CI] 2.09-16.82; inpatient hospitalization: HR 9.43, 95 % CI 1.24-72.00), and 2) post-ED physician care provided in a hospital-based outpatient clinic (ED re-visit: HR 3.07, 95 % CI 1.77-5.29; inpatient hospitalization: HR 3.48, 95 % CI 1.54-7.88). A follow-up visit to a pediatrician, compared to other physician specialties, was associated with earlier inpatient hospitalization (HR 4.45, 95 % CI 1.43-13.87). There was a significant interaction between sex and First Nations status in both models. Females with First Nations status re-visited the ED sooner (HR 3.19; 95 % CI 1.41-7.22) and were hospitalized sooner (HR 4.18; 95 % CI 1.24-14.06).

CONCLUSIONS

This study identifies predictors of time to care for adolescents with psychotic symptoms that are worthy of additional investigation. To ensure the pathway to care for these adolescents reduces the duration of untreated problems, health care aspects that require urgent investigation include the type assessments and clinical decisions made during post-ED physician visits.

Normative data of the Magical Ideation Scale from childhood to adulthood in an Italian cohort

The assessment of schizotypy allows to identify people at risk to develop psychosis. For this purpose, psychometric tools have been developed, such as the Magical Ideation Scale (MIS). This scale investigates attenuated forms of thought transmission experiences, thought withdrawal and aberrant beliefs, related to positive schizotypy. This study aims at providing an Italian version of the MIS and its normative data in the general population from childhood to adulthood, being the first study evaluating subjects under 17year-old. The Italian MIS version was translated by three independent operators and administered to 1378 non-clinical participants, stratified into four age groups (i.e., 8-13, 14-17, 18-24 and 25-34). The unidimensionality of the scale was supported, and its internal consistency was satisfactory (i.e., ordinal Cronbach's αs ranging from 0.86 to 0.90 in different age groups), as well as test-retest reliability (i.e., 1-month ICC of 0.82 in a retested sub-sample). Normative data for the age groups were provided. Specific gender and age-related differences in MIS score were found, i.e. females scored higher than males in the 25-34 age group, which in general, as a group, scored lower than all the other age groups. This study provided evidence of reliability for the Italian version of the MIS in childhood and adolescence, for the first time, as well as in adulthood, showing specific gender and age effects in the early adult cohort.

What is the current status of training and practice of early intervention in psychiatry? Results from a survey in 35 countries

AIM

To assess: (i) trainees' educational needs on early intervention in psychiatry; (ii) their satisfaction and competence in early detection and management of patients with severe mental disorders; (iii) characteristics of training on prevention and on early intervention in psychiatry; and (iv) organizational and clinical differences of early intervention programmes and services in different countries.

METHODS

Sixty early career psychiatrists, recruited from the early career psychiatrists' network of the World Psychiatric Association, were invited to participate in the survey. Respondents were asked to provide the collective input of their trainees' association rather than that of any individual officer or member. An online survey was conducted using an ad hoc questionnaire consisting of 18 items.

RESULTS

Thirty-five countries sent back the questionnaire (58.3%). University training in early intervention for mental disorders was provided in 13 countries (38%); 54% of respondents were not satisfied with received training and about half of them did not feel enough confident to provide specialistic interventions to patients at the onset of the disorder. Services for early intervention existed in 22 countries (63%). The most frequently available were those for schizophrenia (75%). Informative campaigns on mental disorders were usually carried out in almost all surveyed countries (85%).

CONCLUSIONS

Although prevention and early intervention represent one of the current paradigms of psychiatric practice and research, efforts are still needed in order to improve training programmes at university sites.

A systematic review of ethnic variations in hospital admission and compulsory detention in first-episode psychosis

BACKGROUND

Marked ethnic variations in incidence, pathways to care and outcomes have been demonstrated in psychosis. Less research has focused specifically on first-episode psychosis (FEP), particularly adverse contacts such as compulsory detention and hospitalization. This is despite international initiatives to promote equity of care and active early intervention.

AIM

Systematically review current evidence for ethnic variations in rates of compulsory admission and hospitalization in FEP.

METHODS

Relevant articles published before December 2012 were identified from PubMed, PSYCInfo, and CINAHL together with manual searching of reference lists. Studies providing quantitative data on compulsory detention rates and/or hospitalization, comparing ethnic groups in FEP, were included and quality rated by independent raters.

RESULTS

All included studies (n = 7) provided data on compulsory detention while fewer (n = 3) focused on admission rates. Three studies reported increased detention in Black and minority ethnic groups, while one reported more hospitalization in White patients. Only two studies covered early intervention services (EIS).

CONCLUSIONS

There is a paucity of high quality, well powered studies addressing this important issue, especially in EIS settings. In order to best inform and evaluate fast-developing services, it will be essential to combine large methodologically robust studies with qualitative analysis of patient, carer, and staff experiences.

EQ-5D as a measure of programme outcome: results from the Singapore early psychosis intervention programme

The current study aimed to establish the Health-Related Quality of Life (HRQoL) among participants with First Episode Psychosis (FEP) in Singapore, to elucidate the sociodemographic and clinical correlates of HRQoL, and ascertain the change after 1-year of treatment. Two hundred and forty one patients accepted into an Early Psychosis Intervention Programme (EPIP) from April 2009 to June 2011 and who had completed baseline EuroQol-5D (EQ-5D) assessments were included in this analysis. The mean (S.D.) EQ-5D index at baseline was 0.788 (0.258). One hundred thirty five (56.0%) patients who completed the EQ-5D assessment at the 12-month follow-up had a significantly higher EQ-5D index as compared to baseline. EQ-5D index was significantly higher among those patients who met criteria for remission at the 12-month interval than those who were not in remission. Our results suggest that the EQ-5D is responsive to improvement as it corresponded well to objective ratings of remission in our patients with FEP.

[Cognitive deficits in first episode psychosis patients and people at risk for psychosis: from diagnosis to treatment]

BACKGROUND

Up to now, studies have not demonstrated significant efficacy of antipsychotics on cognitive impairments in patients with psychotic disorders. These cognitive deficits are of particular interest since they traditionally start early before the diagnosis of psychosis. They are observed during premorbid and prodromal stages, and during the first episode of psychosis. Moreover, cognitive impairments may be detected without any psychotic symptoms (such as positive symptoms) suggesting their development independently of the psychotic symptoms. Cognitive disturbances consist of impairments of episodic and working memories, intellectual functioning, executive functions (planning, inhibition, and cognitive flexibility), selective and sustained attentions and social cognition (emotion, recognition, theory of mind). The altered cognitive functions observed in schizophrenia are the same as in earlier stages but at a lower level of severity.

LITERATURE FINDINGS

Data suggest that cognitive deficits can be considered as vulnerability markers of psychosis since they have been described in healthy relatives of psychotic patients with high genetic risk. Cognitive deficits might also be considered as predictive of the occurrence of the disease after the first episode of psychosis. Indeed, retrospective studies suggest cognitive impairments in patients with schizophrenia during premorbid and prodromal phases but not in bipolar patients. Cognitive assessment might be of particular interest in people at risk for psychosis, in order to differentiate diagnostic outcomes. Cognitive functioning impairs until the diagnosis of first episode psychosis, even though cognitive profiles are quite heterogeneous in these patients. Once the diagnosis of schizophrenia is considered, cognitive deficits may be stable, although the literature is still controversial. Several factors such as symptoms and gender can contribute in diversifying the cognitive profiles. Moreover, age of onset might worsen the prognosis because of a disruption of the cognitive development and the disturbance of scholarship in young individuals.

DISCUSSION

Considering these results, the treatment of cognitive deficits should be initiated as soon as possible, e.g. in people at risk for psychosis in order to reinforce the normal cognitive development, prevent cognitive decline and to preserve the educational, professional and social status. Since antipsychotic medications do not impact on cognitive functioning, alternative therapeutics should be developed such as cognitive remediation. Several studies and meta-analyses have shown that cognitive remediation programs are particularly efficient in patients with schizophrenia or bipolar disorders. Contrary to antipsychotics, these techniques should be used in patients with a first psychotic episode, but also in individuals with subpsychotic symptoms, subthreshold to the diagnosis of schizophrenia.

Group cognitive behavioural therapy for first episode psychosis: who's referred, who attends and who completes it?

AIM

Most national guidelines recommend psychological therapy for people with first-episode psychosis (FEP) but interventions proven effective in randomized control trials (RCTs) conducted in research settings do not always translate effectively to real-world clinical environments. In a limited health system, it is important to understand the system and patient barriers to participation in effective treatment. We sought to determine what patient characteristics influenced clinicians' decision to refer or not to refer to group cognitive behavioural therapy for FEP and what characteristics were associated with those referred attending/not attending and adhering/not adhering to the programme.

METHODS

Between 2006 and 2008, all cases of confirmed FEP from a defined geographical region were examined using the Structured Clinical Interview for DSM-IV-TR Axis I Disorders for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnoses, the Scale for Assessment of Positive Symptoms, Scale for Assessment of Negative Symptoms, Calgary Depression Scale for Schizophrenia and Birchwood Insight Scale. Duration of untreated psychosis was established using the Beiser Scale.

RESULTS

Of the 124 (77 males, 47 females) people in the final sample, 88 (72%) were referred for cognitive behavioural therapy (CBT), 52 (59%) attended and 12 (23%) did not complete CBT. Those with higher levels of insight into the need for treatment (U = 740.00, z = -2.63, P = 0.008) and higher levels of positive symptoms (t (120) = -3.064, P = 0.003) were more likely to be referred to CBT. Those with higher educational attainment (χ(2) = 9.48, P = 0.03) and fewer negative symptoms, particularly in relation to global attention (t (85) = 2.32, P = 0.03), were more likely to attend and complete CBT.

CONCLUSION

Within an early intervention service for FEP, it appears that individuals with less education, more negative symptoms and less insight experienced significant barriers to successfully completing group CBT. More information for referring clinicians about the benefits of CBT for FEP could help increase referral rates. Assertive outreach for people at risk of disengaging or non-adherence should also be considered.

Treatment of early onset schizophrenia: recent trends, challenges and future considerations

Early onset schizophrenia (onset before adulthood) is a rare, severe, and chronic form of schizophrenia. The clinical presentation of schizophrenia at this unusually early age of onset has been associated with premorbid developmental abnormalities, poor response to neuroleptic treatment, greater admission rates, and poor prognosis. This is a brief, condensed review of current treatment strategies for the early onset population highlighting the need for novel treatment strategies for these generally treatment-refractory cases. Based on the current literature, second-generation antipsychotics remain the mainstay of treatment, although current medications provide suboptimal response at best. Based on the adult literature, combining antipsychotic treatment with psychotherapeutic intervention may be a more comprehensive treatment strategy. Indeed, early detection, identification of relevant biomarkers, coupled with advancing knowledge of the neurochemical and neuroanatomic pathways may help design informed and novel treatment strategies.

Stigma and treatment delay in first-episode psychosis: a grounded theory study

AIM

A longer duration of untreated psychosis (DUP) is associated with greater morbidity in the early course of schizophrenia. This formative, hypothesis-generating study explored the effects of stigma, as perceived by family members, on DUP.

METHODS

Qualitative interviews were conducted with 12 African American family members directly involved in treatment initiation for a relative with first-episode psychosis. Data analysis relied on a grounded theory approach. A testable model informed by constructs of Link's modified labelling theory was developed.

RESULTS

Four main themes were identified, including: (i) society's beliefs about mental illnesses; (ii) families' beliefs about mental illnesses; (iii) fear of the label of a mental illness; and (iv) a raised threshold for the initiation of treatment. A grounded theory model was developed as a schematic representation of the themes and subthemes uncovered in the family members' narratives.

CONCLUSIONS

The findings suggest that due to fear of the official label of a mental illness, certain coping mechanisms may be adopted by families, which may result in a raised threshold for treatment initiation, and ultimately treatment delay. If the relationships within the grounded theory model are confirmed by further qualitative and quantitative research, public educational programs could be developed with the aim of reducing this threshold, ultimately decreasing DUP.

[Personality disorders in adolescence: conceptual issues and treatment approaches]

Objective of this paper is to search for answers for the question if it is justified to use the diagnosis of personality disorder already in adolescence. Recent research data confirm that the stability of basic personality traits is only gradually lower in adolescence compared to adulthood. Using the diagnostic criteria of adults there is not much of a difference concerning prevalence rate and stability in adolescence and adulthood. Meta-analyses reveal that patients with personality disorders can successfully be treated with specalized treatment programs so that personality disorders should not be viewed as life-course persistent. It is argued that an early assessment with standardized procedures can help to identify adolescents with personality disorders so that specialized treatment approaches can be started. In adulthood there is empirical evidence for the use of Dialectical-Behavior Therapy DBT, Transference Focused Psychotherapy TFP, Mentalization-based Therapy MBT and Schema-focused Psychotherapy SFT for the use in patients with personality disorders. These treatment approaches have to be adapted to the special situation of adolescents so that their use can help to prevent these early developing disorders to become chronic.

Tolerability of antipsychotic drugs: does patient perspective deserve consideration?

This contribution initially describes some traditional tools that are commonly used to measure drug tolerability, including measures that take into considerations both clinicians' and patients' views. Subsequently, it highlights a few studies that compared the patient and clinician's perspective in the evaluation of drug tolerability, trying to understand whether health care providers and patients perceive antipsychotic tolerability in different ways, and whether these different ways may have implications in terms of treatment adherence and outcome. Finally, some clinical and research implications are suggested and discussed.

The Italian guidelines for early intervention in schizophrenia: development and conclusions

AIM

The effectiveness of early intervention in schizophrenia is still under discussion. The guidelines described in the present paper were aimed at contributing to the current debate by providing Italian practitioners, families, patients and health managers with evidence-based information on early intervention. They also examined the diagnostic tools that are currently available for assessing different stages of psychotic disorders.

METHODS

A multidisciplinary panel of experts (the Guidelines Development Group) used a set of key-questions to develop an explicit search strategy to conduct a systematic review of the literature published from January 2000 to June 2006. Trained personnel then selected papers from those yielded by the literature search. The Guidelines Development Group's final recommendations were scaled according to the Italian National Guidelines System grading system.

RESULTS

The evidence available up to the time of the literature search does not allow for recommendation of early intervention targeting prodromal or at-risk patients to prevent progression from the prodromal phase to acute, full-blown psychosis, nor to improve prognosis. Conversely, identification and timely treatment of first-episode psychotic patients through specific early intervention programmes are highly recommended.

CONCLUSIONS

The Italian Guidelines on early intervention in schizophrenia are based on a comprehensive assessment of an updated, large-scale body of literature. They draw specific, evidence-based conclusions to assist clinicians and stakeholders in the planning and implementation of appropriate intervention programmes. Further research is needed to ascertain the effectiveness of early intervention in delaying or preventing the conversion to psychosis and improving prognosis in prodromal or at-risk patients. Further investigation is also required for first-episode and critical period patients.

Early intervention in psychosis: concepts, evidence and future directions

The rise of the early intervention paradigm in psychotic disorders represents a maturing of the therapeutic approach in psychiatry, as it embraces practical preventive strategies which are firmly established in mainstream health care. Early intervention means better access and systematic early delivery of existing and incremental improvements in knowledge rather than necessarily requiring dramatic and elusive breakthroughs. A clinical staging model has proven useful and may have wider utility in psychiatry. The earliest clinical stages of psychotic disorder are non-specific and multidimensional and overlap phenotypically with the initial stages of other disorders. This implies that treatment should proceed in a stepwise fashion depending upon safety, response and progression. Withholding treatment until severe and less reversible symptomatic and functional impairment have become entrenched represents a failure of care. While early intervention in psychosis has developed strongly in recent years, many countries have made no progress at all, and others have achieved only sparse coverage. The reform process has been substantially evidence-based, arguably more so than other system reforms in mental health. However, while evidence is necessary, it is insufficient. It is also a by-product as well as a catalyst of reform. In early psychosis, we have also seen the evidence-based paradigm misused to frustrate overdue reform. Mental disorders are the chronic diseases of the young, with their onset and maximum impact in late adolescence and early adult life. A broader focus for early intervention would solve many of the second order issues raised by the early psychosis reform process, such as diagnostic uncertainty despite a clear-cut need for care, stigma and engagement, and should be more effective in mobilizing community support. Early intervention represents a vital and challenging project for early adopters in global psychiatry to consider.

Integrating primary care and early intervention in psychosis services: a general practitioner perspective

AIMS

Earlier detection and treatment of psychosis is associated with improved health outcomes. While the role of specialist services to facilitate early diagnosis and treatment has been extensively described internationally, little data on their impact on general practice has been reported. A new specialist service for psychosis - the 'Dublin East Treatment and Early Care Team (DETECT)'- has recently been established. This study aimed to describe general practitioners' (GPs) attitudes towards working within the catchment area of an early intervention service.

METHODS

A purposive sample of GPs practising in DETECT's catchment area was identified from the Irish Medical Directory and invited to participate in a semi-structured interview. The sampling parameters were solo/practice and area of practice. Participants were provided with information regarding the new service and a range of educational material. Each interview was reviewed by two researchers who identified dominant themes. The study was approved by the Research Ethics Committee of the Irish College of GPs.

RESULTS

16 GPs were interviewed. The DETECT early intervention model was identified as reducing the challenges of managing psychosis in primary care including the practical difficulties of accessing psychiatric assessment and the pervasive effect of stigma. Participants viewed communication between primary and specialist care as essential to the success of early intervention services.

CONCLUSIONS

General Practice has an important role in early detection of psychosis and accessing timely psychiatric evaluations of suspected psychosis. Increasing awareness among GPs and ensuring the early intervention model is responsive to primary care can support this role.

Early psychosis: where we've been, where we still have to go

Early intervention in psychosis, while not a new concept, has seen great development over the last 15 years. Growth in this time has occurred in a number of areas and has attracted a broad coalition of researchers, consumers, clinicians, carers and policy makers. In this time the concept of early intervention has moved from the fringes to the mainstream of clinical approaches to psychosis in many places, and is doing so in even more. After a decade and a half, this paper reviews some of the key issues that have been addressed and points to areas where further growth and reform is still required. Some issues that have created controversy are examined here including pre-onset intervention and identification, the relationship of duration of untreated psychosis (DUP) to outcome and whether or not early intervention is an effective and economically viable model. Areas that are only now developing or which require further investigation are considered, including the concept of stages of mental illness and concomitant interventions, closing the efficacy-effectiveness gap and an increased focus on functioning as part of the recovery process. Early intervention in psychosis started as a reformist movement, agitating for change from outside the mainstream. Change has occurred and now early intervention is part of the mainstream approach to psychotic illness. In order to continue to develop, while enjoying the benefits of being a mainstream intervention, early intervention must not stray too far from its reformist roots.

Effectiveness of early intervention in psychosis

PURPOSE OF REVIEW

Over 15 years, early intervention in psychosis has grown to become a mainstream funded approach to clinical care. This review examines recent developments in evaluating the effectiveness of early intervention. It considers identification and treatment of those at risk of psychosis, as well as interventions in the post-onset phase of illness.

RECENT FINDINGS

Development of methods identifying those at risk of psychosis continues to evolve. Promising results in the prevention and delay of transition to psychotic disorder from a high-risk state have been found. Psychological and psychosocial interventions are important components of these preventive programmes. Two recent meta-analyses indicate that there is a consistent relationship between duration of untreated psychosis and outcome independent of other factors. Further evidence shows that early intervention reduces the duration of untreated psychosis, produces better outcomes in terms of symptomatic and functional domains, and is cheaper than standard models of care.

SUMMARY

There is evidence that early intervention is effective for early psychosis. Some challenges remain. These include developing a greater focus on functional recovery and prevention of relapse.

The Age of Anxiety: Stones, Feathers and Re-institutionalization

Although the value of the Italian psychiatric reform is widely acknowledged and hotly contested, a meticulous comment on its roots and progress is required. This paper attempts to examine the current state of mental health services in Italy and emphasizes Franco Basaglia's writings. The aim of the paper is to: (1) respond to the challenge of providing adequate and human rights-based mental health services, (2) contrast the new Italian tendency of medicalization, which is supported by a law proposal to re-institutionalize the mental health care system. The analysis is based on both current and historical library work and literature review. Since the present policy seems to be proceeding backwards, the direct study of Basaglia's writings assumes significance in not forgetting the past as well as in re-interpreting the present risk of re-institutionalization. The paper then emphasizes the veracity of Basaglia's thought and suggests a re-reading of his work.

Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of schizophrenia and related disorders

BACKGROUND

The Royal Australian and New Zealand College of Psychiatrists is co-ordinating the development of clinical practice guidelines (CPGs) in psychiatry, funded under the National Mental Health Strategy (Australia) and the New Zealand Health Funding Authority. This paper presents CPGs for schizophrenia and related disorders. Over the past decade schizophrenia has become more treatable than ever before. A new generation of drug therapies, a renaissance of psychological and psychosocial interventions and a first generation of reform within the specialist mental health system have combined to create an evidence-based climate of realistic optimism. Progressive neuroscientific advances hold out the strong possibility of more definitive biological treatments in the near future. However, this improved potential for better outcomes and quality of life for people with schizophrenia has not been translated into reality in Australia. The efficacy-effectiveness gap is wider for schizophrenia than any other serious medical disorder. Therapeutic nihilism, under-resourcing of services and a stalling of the service reform process, poor morale within specialist mental health services, a lack of broad-based recovery and life support programs, and a climate of tenacious stigma and consequent lack of concern for people with schizophrenia are the contributory causes for this failure to effectively treat. These guidelines therefore tackle only one element in the endeavour to reduce the impact of schizophrenia. They distil the current evidence-base and make recommendations based on the best available knowledge.

METHOD

A comprehensive literature review (1990-2003) was conducted, including all Cochrane schizophrenia reviews and all relevant meta-analyses, and a number of recent international clinical practice guidelines were consulted. A series of drafts were refined by the expert committee and enhanced through a bi-national consultation process.

TREATMENT RECOMMENDATIONS

This guideline provides evidence-based recommendations for the management of schizophrenia by treatment type and by phase of illness. The essential features of the guidelines are: (i) Early detection and comprehensive treatment of first episode cases is a priority since the psychosocial and possibly the biological impact of illness can be minimized and outcome improved. An optimistic attitude on the part of health professionals is an essential ingredient from the outset and across all phases of illness. (ii) Comprehensive and sustained intervention should be assured during the initial 3-5 years following diagnosis since course of illness is strongly influenced by what occurs in this 'critical period'. Patients should not have to 'prove chronicity' before they gain consistent access and tenure to specialist mental health services. (iii) Antipsychotic medication is the cornerstone of treatment. These medicines have improved in quality and tolerability, yet should be used cautiously and in a more targeted manner than in the past. The treatment of choice for most patients is now the novel antipsychotic medications because of their superior tolerability and, in particular, the reduced risk of tardive dyskinesia. This is particularly so for the first episode patient where, due to superior tolerability, novel agents are the first, second and third line choice. These novel agents are nevertheless associated with potentially serious medium to long-term side-effects of their own for which patients must be carefully monitored. Conventional antipsychotic medications in low dosage may still have a role in a small proportion of patients, where there has been full remission and good tolerability; however, the indications are shrinking progressively. These principles are now accepted in most developed countries. (vi) Clozapine should be used early in the course, as soon as treatment resistance to at least two antipsychotics has been demonstrated. This usually means incomplete remission of positive symptomatology, but clozapine may also be considered where there are pervasive negative symptoms or significant or persistent suicidal risk is present. (v) Comprehensive psychosocial interventions should be routinely available to all patients and their families, and provided by appropriately trained mental health professionals with time to devote to the task. This includes family interventions, cognitive-behaviour therapy, vocational rehabilitation and other forms of therapy, especially for comorbid conditions, such as substance abuse, depression and anxiety. (vi) The social and cultural environment of people with schizophrenia is an essential arena for intervention. Adequate shelter, financial security, access to meaningful social roles and availability of social support are essential components of recovery and quality of life. (vii) Interventions should be carefully tailored to phase and stage of illness, and to gender and cultural background. (viii) Genuine involvement of consumers and relatives in service development and provision should be standard. (ix) Maintenance of good physical health and prevention and early treatment of serious medical illness has been seriously neglected in the management of schizophrenia, and results in premature death and widespread morbidity. Quality of medical care for people with schizophrenia should be equivalent to the general community standard. (x) General practitioners (GPs)s should always be closely involved in the care of people with schizophrenia. However, this should be truly shared care, and sole care by a GP with minimal or no specialist involvement, while very common, is not regarded as an acceptable standard of care. Optimal treatment of schizophrenia requires a multidisciplinary team approach with a consultant psychiatrist centrally involved.

Components of a modern mental health service: a pragmatic balance of community and hospital care: overview of systematic evidence

BACKGROUND

There is controversy about whether mental health services should be provided in community or hospital settings. There is no worldwide consensus on which mental health service models are appropriate in low-, medium- and high-resource areas.

AIMS

To provide an evidence base for this debate, and present a stepped care model.

METHOD

Cochrane systematic reviews and other reviews were summarised.

RESULTS

The evidence supports a balanced approach, including both community and hospital services. Areas with low levels of resources may focus on improving primary care, with specialist back-up. Areas with medium resources may additionally provide out-patient clinics, community mental health teams (CMHTs), acute in-patient care, community residential care and forms of employment and occupation. High-resource areas may provide all the above, together with more specialised services such as specialised out-patient clinics and CMHTs, assertive community treatment teams, early intervention teams, alternatives to acute in-patient care, alternative types of community residential care and alternative occupation and rehabilitation.

CONCLUSIONS

Both community and hospital services are necessary in all areas regardless of their level of resources, according to the additive and sequential stepped care model described here.