A systematic review of long-term outcomes of patients with psychosis who received early intervention services

Intervention Programmes for First-Episode Psychosis: A Scoping Review

The aim of this scoping review was to map intervention programmes for first-episode psychosis by identifying their characteristics, participants, and specific contexts of implementation. It seems reasonable to suggest that early intervention may be beneficial in improving recovery outcomes and reducing the duration of untreated psychosis (DUP). Despite the expansion of these programmes, there are still some significant variations and barriers to access that need to be addressed. In line with the Joanna Briggs Institute (JBI) methodology and the Participants, Concept, and Context (PCC) framework, this review encompasses studies focusing on individuals grappling with early-stage psychosis and their caregivers across a range of settings, including hospital and community environments. The review identified 47 studies from 2002 to 2023, which revealed a great deal of diversity in programme characteristics and implementation contexts. This reflects a global perspective. The results showed that there is a great deal of variety in the characteristics of the programmes, with interventions ranging from single-component strategies, such as cognitive-behavioural therapy (CBT) and cognitive remediation therapy (CRT), to multicomponent programmes that integrate a number of different approaches, including psychosocial, pharmacological, and family-focused strategies. The objectives included attempts to improve cognitive functioning; enhance coping skills; reduce caregiver burden; and address symptoms such as anxiety, depression, and hallucinations. It is notable that there was considerable variation in the frequency, duration, and follow-up periods of the interventions, with some lasting just three sessions over one month and others spanning five years and 48 sessions. The majority of the programmes were delivered in community or outpatient settings, although there were also examples of hospital- and home-based interventions. These findings highlight the value of early interventions and provide a useful resource for adapting programmes to different social and cultural contexts. It would be beneficial for future research to explore how these interventions can be tailored to diverse settings.

Self-Harm and Suicide Rates Before and After an Early Intervention Program for Patients With First-Episode Schizophrenia

Importance

Evidence on the association of early intervention services (EISs) with self-harm and suicide among patients with first-episode schizophrenia (FES) at older than 25 years is lacking.

Objective

To examine changes in self-harm and suicide rates among patients with FES before and after the implementation of an EIS program.

Design, Setting, and Participants

This population-based cohort study conducted among 37 040 patients aged 15 to 64 years with FES between January 1, 2001, and March 31, 2020, used electronic medical records from the Hong Kong Clinical Data Analysis and Reporting System. All patients were followed up from the first diagnosis of schizophrenia (the index date) until the date of their death or the end of the study period (March 31, 2021), whichever came first. Statistical analysis was performed from July to November 2023.

Exposure

The EIS extended the Early Assessment Service for Young People With Early Psychosis (EASY) program from patients aged 15 to 25 years to those aged 15 to 64 years (EASY Plus). The exposure was the implementation of the EASY Plus program in April 2011. The exposure period was defined as between April 2012 and March 2021 for the 1-year-time-lag analysis.

Main Outcomes and Measures

The outcomes were monthly rates of self-harm and suicide among patients with FES before and after the implementation of the EASY Plus program. Interrupted time series analysis was used for the main analysis.

Results

This study included 37 040 patients with FES (mean [SD] age at onset, 39 [12] years; 82.6% older than 25 years; 53.0% female patients). The 1-year-time-lag analysis found an immediate decrease in self-harm rates among patients aged 26 to 44 years (rate ratio [RR], 0.77 [95% CI, 0.59-1.00]) and 45 to 64 years (RR, 0.70 [95% CI, 0.49-1.00]) and among male patients (RR, 0.71 [95% CI, 0.56-0.91]). A significant long-term decrease in self-harm rates was found for all patients with FES (patients aged 15-25 years: RR, 0.98 [95% CI, 0.97-1.00]; patients aged 26-44 years: RR, 0.98 [95% CI, 0.97-0.99]; patients aged 45-64 years: RR, 0.97 [95% CI, 0.96-0.98]). Suicide rates decreased immediately after the implementation of the EASY Plus program among patients aged 15 to 25 years (RR, 0.33 [95% CI, 0.14-0.77]) and 26 to 44 years (RR, 0.38 [95% CI, 0.20-0.73]). Compared with the counterfactual scenario, the EASY Plus program might have led to 6302 fewer self-harm episodes among patients aged 26 to 44 years.

Conclusions and Relevance

This cohort study of the EASY Plus program suggests that the extended EIS was associated with reduced self-harm and suicide rates among all patients with FES, including those older than 25 years. These findings emphasize the importance of developing tailored interventions for patients across all age ranges to maximize the benefits of EISs.

Cost-effectiveness of early intervention in psychosis in low- and middle-income countries: economic evaluation from São Paulo, Brazil

AIMS

The effectiveness and cost-effectiveness of early intervention for psychosis (EIP) services are well established in high-income countries but not in low- and middle-income countries (LMICs). Despite the scarcity of local evidence, several EIP services have been implemented in LMICs. Local evaluations are warranted before adopting speciality models of care in LMICs. We aimed to estimate the cost-effectiveness of implementing EIP services in Brazil.

METHODS

A model-based economic evaluation of EIP services was conducted from the Brazilian healthcare system perspective. A Markov model was developed using a cohort study conducted in São Paulo. Cost data were retrieved from local sources. The outcome of interest was the incremental cost-effectiveness ratio (ICER) measured as the incremental costs over the incremental quality-adjusted life-years (QALYs). Sensitivity analyses were performed to test the robustness of the results.

RESULTS

The study included 357 participants (38% female), with a mean (SD) age of 26 (7.38) years. According to the model, implementing EIP services in Brazil would result in a mean incremental cost of 4,478 Brazilian reals (R$) and a mean incremental benefit of 0.29 QALYs. The resulting ICER of R$ 15,495 (US dollar [USD] 7,640 adjusted for purchase power parity [PPP]) per QALY can be considered cost-effective at a willingness-to-pay threshold of 1 Gross domestic product (GDP) per capita (R$ 18,254; USD 9,000 PPP adjusted). The model results were robust to sensitivity analyses.

CONCLUSIONS

This study supports the economic advantages of implementing EIP services in Brazil. Although cultural adaptations are required, these data suggest EIP services might be cost-effective even in less-resourced countries.

The schizophrenia syndrome, circa 2024: What we know and how that informs its nature

With new data about different aspects of schizophrenia being continually generated, it becomes necessary to periodically revisit exactly what we know. Along with a need to review what we currently know about schizophrenia, there is an equal imperative to evaluate the construct itself. With these objectives, we undertook an iterative, multi-phase process involving fifty international experts in the field, with each step building on learnings from the prior one. This review assembles currently established findings about schizophrenia (construct, etiology, pathophysiology, clinical expression, treatment) and posits what they reveal about its nature. Schizophrenia is a heritable, complex, multi-dimensional syndrome with varying degrees of psychotic, negative, cognitive, mood, and motor manifestations. The illness exhibits a remitting and relapsing course, with varying degrees of recovery among affected individuals with most experiencing significant social and functional impairment. Genetic risk factors likely include thousands of common genetic variants that each have a small impact on an individual's risk and a plethora of rare gene variants that have a larger individual impact on risk. Their biological effects are concentrated in the brain and many of the same variants also increase the risk of other psychiatric disorders such as bipolar disorder, autism, and other neurodevelopmental conditions. Environmental risk factors include but are not limited to urban residence in childhood, migration, older paternal age at birth, cannabis use, childhood trauma, antenatal maternal infection, and perinatal hypoxia. Structural, functional, and neurochemical brain alterations implicate multiple regions and functional circuits. Dopamine D-2 receptor antagonists and partial agonists improve psychotic symptoms and reduce risk of relapse. Certain psychological and psychosocial interventions are beneficial. Early intervention can reduce treatment delay and improve outcomes. Schizophrenia is increasingly considered to be a heterogeneous syndrome and not a singular disease entity. There is no necessary or sufficient etiology, pathology, set of clinical features, or treatment that fully circumscribes this syndrome. A single, common pathophysiological pathway appears unlikely. The boundaries of schizophrenia remain fuzzy, suggesting the absence of a categorical fit and need to reconceptualize it as a broader, multi-dimensional and/or spectrum construct.

More smoke and mirrors: Fifteen further reasons to doubt the effectiveness of headspace

OBJECTIVE

Commentary on the debate concerning the effectiveness of headspace, including the most recent independent evaluation of its services.

CONCLUSIONS

The available evaluations indicate that headspace does not deliver therapy of adequate duration that results in clinically significant improvement. Most evaluations have used either short-term process measures or uncontrolled satisfaction surveys, and where there have been data on outcomes using standardised instruments, findings have been disappointing. Costs are poorly quantified and probably underestimated. Even so, headspace as a primary care intervention costs twice as much as a mental health consultation by a general practitioner and, depending on the assumptions, may not be cost effective.

The associations between cognitive functions and TSNAX genetic variations in patients with schizophrenia

BACKGROUND

The translin-associated factor X (TSNAX) gene, located adjacent to the DISC1 gene, has been implicated in schizophrenia. While cognitive impairment determines long-term the functional outcome of schizophrenia, the role of TSNAX in cognitive dysfunction of schizophrenia patients remains elusive. This study aimed to explore the genetic effect of TSNAX on cognitive functions of schizophrenia.

METHODS

We recruited 286 chronic schizophrenia patients who had been stabilized with antipsychotics for at least 2 months and genotyped three TSNAX SNPs (rs1630250, rs766288, rs6662926). Clinical symptoms and seven cognitive domains were assessed. The score of cognitive tests was standardized to T score.

RESULTS

Clinical symptoms were similar among genotypes of all the three SNPs. The GLM analysis demonstrated that TSNAX genetic polymorphisms influenced cognitive function of schizophrenia patients after adjustment for gender, age, and education. The patients with the rs1630250 C/G genotype performed better than the G/G homozygotes in the Trail Making A (p = 0.034). Those with the rs766288 G/T genotype also performed better than the G/G homozygotes in the Trail Making A (p = 0.012). The patients with the G/G genotype of rs6662926 also performed better than the C/C homozygotes in verbal learning and memory test (p = 0.044).

CONCLUSIONS

This study suggests that the TSNAX gene variation may influence the cognitive functions of the patients with schizophrenia.

Neuronal oscillations: early biomarkers of psychiatric disease?

Our understanding of the environmental and genetic factors contributing to the wide spectrum of neuropsychiatric disorders has significantly increased in recent years. Impairment of neuronal network activity during early development has been suggested as a contributor to the emergence of neuropsychiatric pathologies later in life. Still, the neurobiological substrates underlying these disorders remain yet to be fully understood and the lack of biomarkers for early diagnosis has impeded research into curative treatment options. Here, we briefly review current knowledge on potential biomarkers for emerging neuropsychiatric disease. Moreover, we summarize recent findings on aberrant activity patterns in the context of psychiatric disease, with a particular focus on their potential as early biomarkers of neuropathologies, an essential step towards pre-symptomatic diagnosis and, thus, early intervention.

A randomized controlled trial of a peer-facilitated self-management program for people with recent-onset psychosis

Early patient-centered interventions can improve mental health and prevent psychotic relapse in people with recent-onset psychosis (ROP). However, limited effective peer-facilitated early interventions are found worldwide. We aimed to test the effects of a four-month peer-facilitated self-management intervention (PFSMI) for Chinese patients with ROP compared with a psychoeducation group (PEG) and treatment-as-usual (TAU) group. A randomized controlled trial was conducted at six Integrated Community Centers for Mental Wellness in Hong Kong. The primary outcome was level of recovery. Secondary outcomes were improvement of problem-solving ability, insight into illness/treatment, and functioning, and reducing psychotic symptoms and re-hospitalization rates. Overall, 180 ROP patients were randomly selected, and after collecting baseline data, randomly assigned to the PFSMI, PEG or TAU (60 per group). Their outcomes were measured at 1-week and 6-month post-intervention. One hundred and sixty-one patients (89.4 %) completed their interventions, with an overall attrition rate of 7.8 % (n = 14). Based on intention-to-treat principle, results of generalized estimating equation test indicated that the PFSMI group reported significantly greater improvements in levels of recovery, functioning and insight into illness/treatment and reductions in psychotic symptoms and duration of re-hospitalizations (p = 0.0007-0.02, with moderate to large effect sizes) than the TAU group at 1-week post-intervention, and both the TAU and PEG at 6-month post-intervention. Significantly fewer PFSMI participants were hospitalized than the TAU and PEG over 6-month follow-up (p = 0.003). The findings support that PFSMI can produce medium-term positive effects on the mental health and functioning of patients with ROP.

Headspace early intervention for psychosis in Australia: Is it still a 'best buy'?

OBJECTIVES

Australia is piloting a stand-alone early intervention programme for psychosis, based on the Early Psychosis Prevention and Intervention Centre (EPPIC) model that was developed within mainstream Victorian State Government psychiatric services. The Australian early intervention programme is located in primary care, and badged as 'headspace Early Psychosis Youth Services'. There are currently six metropolitan early intervention services with two further services planned for the 2023 Financial Year. We discuss key findings from an external evaluation of the first six services, released by the Australian Government Department of Health under a Freedom of Information request.

CONCLUSIONS

headspace Early Psychosis Youth Services received high ratings for patient satisfaction and engagement, which was associated with symptomatic improvement and functional recovery. However, governance was complicated, costs were relatively high, and caseload targets were not met. The cost for an additional year of good quality life was estimated at AUD 318,954, which exceeds the usual thresholds for defining a 'good buy'. Integrated models should be investigated, as they seem in principle to offer efficiencies and improved continuity of care.

Implementation of occupational therapy within early intervention in psychosis services: Results from a national survey

AIM

Occupational therapy plays an important role in fostering community participation in areas such as education, employment, leisure, and social relationships, yet its added value within early intervention in psychosis services, especially in the United States, remains poorly understood. The purpose of this research was to conduct a national survey of early intervention in psychosis programs to: (1) understand the role and unique contributions of occupational therapists to early intervention teams, and (2) identify barriers and supports to the implementation of occupational therapy services within these programs.

METHODS

Fifty-one senior leaders from U.S.-based early intervention in psychosis programs participated in the national survey. The survey consisted of a series of closed and open-ended questions related to program staffing, the presence of specific services that fall within the occupational therapy scope of practice, and implementation barriers and supports.

RESULTS

Despite there being strong interest in employing occupational therapists, a small proportion of programs (31%) reported having them on staff. Occupational therapists supported clients across multiple life areas and were significantly more likely than other team members to promote daily living activities (e.g., cooking) and to address sensory processing needs and challenges. Implementation was influenced by environmental/organizational and staff factors; the primary barrier was funding.

CONCLUSIONS

Findings support the role occupational therapists may play in facilitating the community participation of clients of early intervention services, but significant barriers to implementation of occupational therapy services remain. Additional research is needed to further identify the impact of occupational therapy services within the early intervention model.

A protocol for the first episode psychosis outcome study (FEPOS): ≥15 year follow-up after treatment at the Early Psychosis Prevention and Intervention Centre, Melbourne, Australia

BACKGROUND

Specialist early intervention (SEI) service models are designed to treat symptoms, promote social and vocational recovery, prevent relapse, and resource and up-skill patients and their families. The benefits of SEI over the first few years have been demonstrated. While early recovery can be expected to translate to better long-term outcomes by analogy with other illnesses, there is limited evidence to support this from follow-up studies. The current study involves the long-term follow-up of a sub-set of first episode psychosis (FEP) patients, with a range of diagnoses, who were first treated at Orygen's Early Psychosis Prevention and Intervention Centre (EPPIC) between 1998 and 2000. The aim of this paper is to present the methodology for this follow-up study.

METHODS

Between January 1998 and December 2000, 786 patients between the ages of 15-29 years were treated at EPPIC, located in Melbourne, Australia. Our cohort consists of 661 people (82 were transferred/discharged and 43 were not diagnosed with a psychotic disorder at time of discharge). The 18-month treatment characteristics of this cohort have been extensively examined in the First Episode Psychosis Outcome Study (FEPOS). The ≥15 year outcomes of this cohort are being examined in this study, known as FEPOS15.

RESULTS

Participant follow-up is ongoing. In order to extend and assess broader outcomes of the cohort, data linkage with health-related databases will be conducted.

CONCLUSION

This study will provide a comprehensive evaluation of the long-term trajectory of psychotic disorders after treatment for FEP in a SEI service.

Longitudinal relapse pattern of patients with first-episode schizophrenia-spectrum disorders and its predictors and outcomes: A 10-year follow-up study

OBJECTIVE

This study explored the 10-year pattern of relapse of patients with first-episode schizophrenia-spectrum disorders (FES), predictors and outcomes of early and late relapse.

METHODS

Patients received EIS (N = 148) in Hong Kong between 1 July 2001 and 30 June 2002 were matched with those who entered standard care (N = 148) one year before. Relapse information over 10 years were obtained and 209 patients were interviewed at 10-year follow-up. Predictors of early relapse ([ER] relapse in initial three years) and late relapse group ([LR] relapse in year 4-10) and their differential outcomes were explored.

RESULTS

Fifty-six patients (26.8%) were relapse-free over 10 years with more EIS patients. Among the relapsed patients, 63.6% were ER patients who had the poorest longitudinal outcomes, including higher suicide attempts, violence episodes, more hospitalization and lower employment, whereas the LR patients do not differ much from the no relapse group. Relapse-free patients required less hospitalization in the first episode and lower antipsychotic dosage. The LR patients had less positive symptoms in year one but longer first-episode hospitalization and higher antipsychotic dosage.

CONCLUSIONS

Delaying the first relapse may help to improve the long-term outcomes. Good response to antipsychotic medications was associated with relapse-free over long-term. However, sufficient antipsychotic medications with good symptomatic control during the early stage of the illness is crucial for relapse prevention for other patients. These findings highlight illness heterogeneity and the importance in differential use of antipsychotics in relapse prevention.

First-episode psychosis integrative treatment: Estonian experience

PURPOSE

Research on first-episode psychosis early intervention has shown significant positive effects on psychopathological, functional and quality-of-life outcome measures. The effects reported have however been short-term and there is still only limited information about the long-term effects. This article will present the short-term results of an effectiveness study in a Baltic country and the first results of a registry-based long-term follow-up.

METHODS

One hundred and ninety-nine first-episode psychosis patients were included in the early intervention effectiveness study in 2004-2008, and 107 were available for a follow-up after two years. Registry-based ten-year follow-up (n = 116) was conducted with a retrospectively formed control group (n = 114).

RESULTS

Patients who received early intervention had substantial symptomatic improvement (BPRS score reduction > 50%) after 6 months of treatment, the Global Assessment of Functioning (GAF) scores were significantly improved after 6 months, and the quality of life after 12 months was significantly higher than at the beginning of treatment. After 2 years employment increased by 14% (43.9-57.9%). Long-term follow-up revealed that significantly fewer patients in the intervention group had been in supported housing compared to the control group. Patients in the intervention group had spent more time working during the follow-up period and had almost two times larger incomes, suggestive of higher employment/salary level.

CONCLUSIONS

Early intervention with flexible duration has positive long-term effects on the functioning of patients.

Schizophrenia

Schizophrenia, characterised by psychotic symptoms and in many cases social and occupational decline, remains an aetiological and therapeutic challenge. Contrary to popular belief, the disorder is modestly more common in men than in women. Nor is the outcome uniformly poor. A division of symptoms into positive, negative, and disorganisation syndromes is supported by factor analysis. Catatonic symptoms are not specific to schizophrenia and so-called first rank symptoms are no longer considered diagnostically important. Cognitive impairment is now recognised as a further clinical feature of the disorder. Lateral ventricular enlargement and brain volume reductions of around 2% are established findings. Brain functional changes occur in different subregions of the frontal cortex and might ultimately be understandable in terms of disturbed interaction among large-scale brain networks. Neurochemical disturbance, involving dopamine function and glutamatergic N-methyl-D-aspartate receptor function, is supported by indirect and direct evidence. The genetic contribution to schizophrenia is now recognised to be largely polygenic. Birth and early life factors also have an important aetiological role. The mainstay of treatment remains dopamine receptor-blocking drugs; a psychological intervention, cognitive behavioural therapy, has relatively small effects on symptoms. The idea that schizophrenia is better regarded as the extreme end of a continuum of psychotic symptoms is currently influential. Other areas of debate include cannabis and childhood adversity as causative factors, whether there is progressive brain change after onset, and the long-term success of early intervention initiatives.

Return to the labour market in schizophrenia and other psychoses: a register-based Northern Finland Birth Cohort 1966 study

PURPOSE

The prospects and predictors of returning to the labour market after long-term work disability in psychoses are unclear. Our aim was to study the proportion and characteristics of persons with schizophrenia and other psychoses who return to the labour market after receiving a disability pension.

METHODS

In this 50-year follow-up study in the Northern Finland Birth Cohort 1966 (NFBC1966), national registers on demographics, care, and disability pensions were used to detect and characterize individuals who had been on a disability pension for psychiatric reasons. We compared individuals with schizophrenia (SZ, n = 223) or other psychoses (OP, n = 200) to those with non-psychotic psychiatric disorders (NP, n = 1815) regarding demographics and end of pension by cross-tabulations and logistic regression.

RESULTS

Of the 170 (74%) persons with SZ who had been on disability pension for a psychiatric reason, 15 (9%) returned to the labour market. Corresponding percentages were 19% for OP and 28% for NP. In SZ, being married, a later onset age of psychosis, and better school performance, and in OP and NP, having children predicted returning to the labour market. In all groups, a shorter length of the latest disability pension associated with returning to the labour market.

CONCLUSION

Although rare, it is possible to return to the labour market after a disability pension due to psychosis. Factors predicting a return to the labour market could be taken into account when planning rehabilitation.

Using epidemiological evidence to forecast population need for early treatment programmes in mental health: a generalisable Bayesian prediction methodology applied to and validated for first-episode psychosis in England

BACKGROUND

Mental health policy makers require evidence-based information to optimise effective care provision based on local need, but tools are unavailable.

AIMS

To develop and validate a population-level prediction model for need for early intervention in psychosis (EIP) care for first-episode psychosis (FEP) in England up to 2025, based on epidemiological evidence and demographic projections.

METHOD

We used Bayesian Poisson regression to model small-area-level variation in FEP incidence for people aged 16-64 years. We compared six candidate models, validated against observed National Health Service FEP data in 2017. Our best-fitting model predicted annual incidence case-loads for EIP services in England up to 2025, for probable FEP, treatment in EIP services, initial assessment by EIP services and referral to EIP services for 'suspected psychosis'. Forecasts were stratified by gender, age and ethnicity, at national and Clinical Commissioning Group levels.

RESULTS

A model with age, gender, ethnicity, small-area-level deprivation, social fragmentation and regional cannabis use provided best fit to observed new FEP cases at national and Clinical Commissioning Group levels in 2017 (predicted 8112, 95% CI 7623-8597; observed 8038, difference of 74 [0.92%]). By 2025, the model forecasted 11 067 new treated cases per annum (95% CI 10383-11740). For every 10 new treated cases, 21 and 23 people would be assessed by and referred to EIP services for suspected psychosis, respectively.

CONCLUSIONS

Our evidence-based methodology provides an accurate, validated tool to inform clinical provision of EIP services about future population need for care, based on local variation of major social determinants of psychosis.

Computational Mechanism for the Effect of Psychosis Community Treatment: A Conceptual Review From Neurobiology to Social Interaction

The computational underpinnings of positive psychotic symptoms have recently received significant attention. Candidate mechanisms include some combination of maladaptive priors and reduced updating of these priors during perception. A potential benefit of models with such mechanisms is their ability to link multiple levels of explanation, from the neurobiological to the social, allowing us to provide an information processing-based account of how specific alterations in self-self and self-environment interactions result in the experience of positive symptoms. This is key to improving how we understand the experience of psychosis. Moreover, it points us toward more comprehensive avenues for therapeutic research by providing a putative mechanism that could allow for the generation of new treatments from first principles. In order to demonstrate this, our conceptual paper will discuss the application of the insights from previous computational models to an important and complex set of evidence-based clinical interventions with strong social elements, such as coordinated specialty care clinics (CSC) in early psychosis and assertive community treatment (ACT). These interventions may include but also go beyond psychopharmacology, providing, we argue, structure and predictability for patients experiencing psychosis. We develop the argument that this structure and predictability directly counteract the relatively low precision afforded to sensory information in psychosis, while also providing the patient more access to external cognitive resources in the form of providers and the structure of the programs themselves. We discuss how computational models explain the resulting reduction in symptoms, as well as the predictions these models make about potential responses of patients to modifications or to different variations of these interventions. We also link, via the framework of computational models, the patient's experiences and response to interventions to putative neurobiology.

Predictors of Treatment-Resistant and Clozapine-Resistant Schizophrenia: A 12-Year Follow-up Study of First-Episode Schizophrenia-Spectrum Disorders

Studies on the long-term development and early predictors of treatment-resistant schizophrenia (TRS) and clozapine-resistant TRS (CR-TRS) in patients with first-episode schizophrenia-spectrum disorders (FES) are limited and have not considered the impact of early intervention services (EIS). This study aimed to explore the development of TRS and CR-TRS among patients with FES over 12 years of follow-up. Of the 1234 patients with FES, 15% developed TRS. A total of 450 patients with schizophrenia or schizoaffective disorder were included in a nested case-control study (157 TRS and 293 non-TRS). Younger age of onset, poorer premorbid social adjustment during adulthood, longer duration of first episode, a greater number of relapses, and a higher antipsychotic dose in the first 24 months were associated with earlier TRS. CR-TRS patients, constituting 25% of TRS patients, had a poorer premorbid social adjustment in late adolescence and longer delay before clozapine initiation compared with non-CR-TRS. CR-TRS had poorer clinical and functional outcomes at 12-year follow-up. However, TRS patients on clozapine had a lower mortality rate compared with non-TRS patients. EIS did not have a significant impact on the development of TRS, but patients in the EIS group had a shorter delay of clozapine initiation. Results suggested that neurodevelopmental factors, early clinical characteristics, and requirement for higher antipsychotic dose may be associated with TRS development, highlighting multiple pathways leading to this form of illness. Specific interventions including relapse prevention and early initiation of clozapine during the early course of illness may reduce the rate of TRS and improve patient outcomes.

Cognitive Functioning and Schizotypy: A Four-Years Study

Although there is ample evidence from cross-sectional studies indicating cognitive deficits in high schizotypal individuals that resemble the cognitive profile of schizophrenia-spectrum patients, there is still lack of evidence by longitudinal/follow-up studies. The present study included assessments of schizotypal traits and a wide range of cognitive functions at two time points (baseline and 4-years assessments) in order to examine (a) their stability over time, (b) the predictive value of baseline schizotypy on cognition at follow-up and (c) differences in cognition between the two time points in high negative schizotypal and control individuals. Only high negative schizotypal individuals were compared with controls due to the limited number of participants falling in the other schizotypal groups at follow-up. Seventy participants (mean age: 36.17; 70% females) were assessed at baseline and follow-up. Schizotypal traits were evaluated with the Schizotypal Personality Questionnaire. We found that schizotypal traits decreased over time, except in a sub-group of participants ("schizotypy congruent") that includes individuals who consistently meet normative criteria of inclusion in either a schizotypal or control group. In these individuals, negative schizotypy and aspects of cognitive-perceptual and disorganized schizotypy remained stable. The stability of cognitive functioning also varied over time: response inhibition, aspects of cued attention switching, set-shifting and phonemic/semantic verbal fluency improved at follow-up. High negative schizotypy at baseline predicted poorer response inhibition and semantic switching at follow-up while high disorganized schizotypy predicted poorer semantic processing and complex processing speed/set-shifting. The between-group analyses revealed that response inhibition, set-shifting and complex processing speed/set-shifting were poorer in negative schizotypals compared with controls at both time points, while maintaining set and semantic switching were poorer only at follow-up. Taken together, the findings show differential stability of the schizotypal traits over time and indicate that different aspects of schizotypy predict a different pattern of neuropsychological task performance during a 4-years time window. These results are of significant use in the formulation of targeted early-intervention strategies for high-risk populations.

The outcome of early intervention in first episode psychosis

The last 20 years have seen an increased focus on early intervention in psychotic disorders in research and clinical practice. Interventions have typically aimed at either reducing the duration of untreated psychosis (DUP), or developing specialized treatment facilities for patients with first episode psychosis (FEP). This review presents an overview of the most important trials and meta-analytic evidence within this field. The possibilities for reducing DUP and elements included in specialized early intervention treatment are discussed. Further, it examines long-term outcomes of early interventions and results from prolonged early intervention trials. Lastly, it analyses possible interactions between DUP and specialized early intervention treatment. In conclusion, both elements appear necessary in order to develop an integrated service that can provide the optimal treatment for patients with FEP. The aim of this article is to provide an overview over the most important trials and evidence regarding the outcome of early intervention in first episode psychosis.