Pattern and correlates of inpatient admission during the initial acute phase of first-episode psychosis

Outcomes for first-episode psychosis after entry via an at-risk mental state clinic compared to direct entry to a first episode of psychosis service: A systematic review and meta-analysis

OBJECTIVE

Early intervention for psychosis services have been established worldwide and consist of specialist services for those with the At-Risk Mental State (ARMS) and a first episode of psychosis (FEP). This systematic review identified the literature on the outcomes of people who initially presented via an ARMS clinic and later transitioned to a psychotic disorder (UHR-T), compared to those who presented directly to an EI service with a FEP (FEP-D). The outcomes examined were (i) symptomatic (ii) functional, (iii) morbidity and mortality (including physical health) and (iv) service-usage.

METHOD

A systematic search strategy was employed using three databases: MEDLINE, PsycInfo, and EMBASE. Studies published in English and that compared any of the above outcomes in a cohort of people with a first episode of psychosis who initially presented via an ARMS clinic to those who presented directly to a FEP service were included. Meta-analysis was performed for any outcome data from at least two studies.

RESULTS

A total of 988 unique articles were identified and of these, three studies fulfilled the inclusion criteria and these included a total of 78 UHR-T and 253 FEP-D individuals. In the one study examining remission rates, there was no difference observed after one year in the UHR-T and FEP-D groups. In the one study that examined neurocognition, no differences were observed in any of the neurocognitive domains between groups after one year. Two studies examined psychiatric admission rates within one year and one of these found that UHR-T individuals were less likely to have any psychiatric admission (46% vs 68%) and admissions were less likely to be involuntary (30% vs 74%), while the other study found no difference in admission rates. In the meta-analysis, UHR-T individuals had lower odds for any psychiatric hospital admission within one year compared to FEP-D individuals (OR = 0.54, 95% C.I. 0.32 - 0.94, p = .03). No studies examined functional outcomes or mortality and morbidity between the groups.

CONCLUSION

The limited research indicates similar or superior outcomes for people with a FEP who present initially via an ARMS clinic. The reduced psychiatric admission rate is an important potential benefit of ARMS clinics that requires replication.

Specialized inpatient treatment for young people with early psychosis: acute-treatment and 12-month results

The objective of the study was to investigate the development of clinical outcomes of young people with early psychosis in a specialized inpatient treatment and assess the feasibility of such an intervention in an inpatient setting. The study was a prospective cohort study of patients with early psychosis treated at the specialized inpatient treatment "Fühinterventions-und Therapiezentrum, FRITZ" (early intervention and therapy center) in Berlin, Germany. The primary outcomes were attitudes towards psychiatric medication and patient satisfaction with treatment after 6 weeks. Secondary outcomes were clinical symptoms, functioning, remission, recovery, all-cause treatment discontinuation, and rehospitalisation at 6 and 12 months after inpatient treatment. We recruited 95 inpatients with early psychosis. Attitudes towards psychiatric medication (Δ_6weeks = 3.00, d_6weeks = 0.55; Δ_6mo = 2.15, d_6mo = 0.35; Δ_12mo = 3.03, d_12mo = 0.52) and patient satisfaction (Δ_6weeks = 0.21, d_6weeks = 0.40; Δ_6mo = 0.32, d_6mo = 0.43; Δ_12mo = 0.13, d_12mo = 0.17) changed with medium effect sizes at six weeks up to a 6- and 12-month follow-up. Clinical outcomes changed significantly with medium-to-large-effect sizes over 12 months CGI_Δ12mo = 1.64, d_12mo = -1.12; PANSS total_Δ12mo = 20.10, d_12mo = -0.76; GAF_Δ12mo = 19.58, d_12mo = 1.25). The all-cause treatment discontinuation rate was 13.69% (n = 13) at a 6-month and 35.79% (n = 34) at a 12-month follow-up. The rehospitalization rate was 30.53% (n = 29) at a 6-month and 43.16% (n = 41) at a 12-month follow-up. Patients with specialized inpatient treatment for early psychosis showed improvements in attitude towards psychiatric medication, patient satisfaction, symptoms, and functioning for up to 12 months.Trial registration: DRKS00024351, 2021/02/11 retrospectively registered.

Voltage-gated potassium channel blanket testing in first-episode psychosis: Diagnostic nihilism?

OBJECTIVE

Voltage-gated potassium channel antibodies are implicated in limbic encephalitis and currently included in first-episode psychosis organic screening guidelines. Individuals with high-positive voltage-gated potassium channel titres most commonly present with neurological symptoms as well as sleep, cognitive, behaviour, psychosis and mood disturbance. The significance of low-positive voltage-gated potassium channel antibody titres in psychiatric patients is unclear and has not been previously examined. We aim to describe a statewide cohort of psychiatric patients with low- and high-positive voltage-gated potassium channel titres and explore if this finding influenced clinical management and patient outcomes.

METHODS

A retrospective review of all voltage-gated potassium channel antibodies testing performed in public psychiatric services in Queensland, Australia, with comparison of the clinical presentation and long-term outcomes of low- and high-positive voltage-gated potassium channel titre cases. Specific antigen targets (leucine-rich glioma-inactivated protein 1 and contactin-associated protein 2 antibodies) were also assessed.

RESULTS

The overall prevalence of voltage-gated potassium channel antibody positivity in Queensland, public, psychiatric service testing was 0.3% (14/4098), with 12 cases of low-positive voltage-gated potassium channel titre, 2 cases of high-positive (leucine-rich glioma-inactivated protein 1 antibody positive) cases and a voltage-gated potassium channel negative contactin-associated protein 2 antibody positive case. No low-positive case developed neurological abnormalities or had abnormal paraclinical investigations. In comparison, both high-positive voltage-gated potassium channel/leucine-rich glioma-inactivated protein 1 cases and the contactin-associated protein 2 antibody positive case rapidly developed neurological symptoms, had abnormal paraclinical testing and improved only with immunotherapy. There was no later development of encephalitic symptoms in the low-positive cases over an average of 1067 days follow-up.

CONCLUSION

Voltage-gated potassium channel antibody-associated limbic encephalitis was rare, and always associated with high antibody titres. Low-positive titres were not associated with the development of encephalitis over a long period of follow-up. The value of universal voltage-gated potassium channel antibody screening is unclear, and further prospective studies in first-episode psychosis populations are required.

Predictors of Hospitalization of Individuals With First-Episode Psychosis: Data From a 2-Year Follow-Up of the RAISE-ETP

OBJECTIVE

Despite treatment advances in other domains, inpatient psychiatric hospitalization rates for individuals with first-episode psychosis remain high. Even with early intervention services, a third or more of individuals are hospitalized over the first 2 years of treatment. Reducing hospitalization is desirable from the individual's perspective and for public health reasons because hospitalization costs are a major component of treatment costs.

METHODS

Univariate and multivariate baseline and time-varying covariate analyses were conducted to identify predictors of hospitalization in the Recovery After an Initial Schizophrenia Episode-Early Treatment Program (RAISE-ETP) study, a 2-year cluster randomized trial for participants experiencing a first episode of psychosis who were outpatients at study entry. The trial compared an early intervention treatment model (NAVIGATE) with usual community care at 34 clinics across the United States.

RESULTS

RAISE-ETP enrolled 404 participants of whom 382 had one or more postbaseline assessments that included hospitalization data. Thirty-four percent of NAVIGATE and 37% of usual-care participants were hospitalized during the trial. Risk analyses revealed significant predictors of hospitalization to be the number of hospitalizations before study entry; duration of untreated psychosis; and time-varying days of substance misuse, presence of positive symptoms, and beliefs about the value of medication.

CONCLUSIONS

These results indicate that hospital use may be decreased by reducing the duration of untreated psychosis and prior hospitalizations, minimizing residual symptoms, preventing substance misuse, and facilitating adherence to medication taking. Addressing these factors could enhance the impact of first-episode early intervention treatment models and also enhance outcomes of people with first-episode psychosis treated using other models.

Analysis of influencing factors of visual working memory in young adult patients with schizophrenia

BACKGROUND

Patients with schizophrenia have general cognitive impairments, and the impairment of working memory is considered to be the basis of cognitive impairments. The research on visual working memory, one of the subcomponents, is getting more and more attention. However, the influencing factors which cause the deficits of visual working memory in patients with schizophrenia have not been clearly explained. To provide evidence for cognitive impairment interventions, the present study explored the factors influencing the deficits of patients' visual working memory.

AIM

The present study discussed the relevant factors influencing the visual working memory of patients with schizophrenia by measuring the accuracy of the visual working memory of patients with schizophrenia and healthy controls.

METHODS

Colour-recall paradigm was employed to measure the accuracy of the visual working memory of 61 healthy controls and 61 patients who met the International Classification of Diseases, Tenth Revision diagnostic criteria for schizophrenia. The age range of subjects was 18-50. Scale for the Assessment of Positive Symptoms (SAPS) and Scale for the Assessment of Negative Symptoms (SANS) were used to evaluate the patients' clinical symptoms.

RESULTS

Compared with the healthy control group, the accuracy of visual working memory of patients with schizophrenia was significantly impaired (t=3.062, p=0.003). The accuracy of visual working memory of patients with schizophrenia was not related to age (r=0.023, p=0.860), the age of onset (r=-0.003, p=0.979), the duration of illness (r=-0.038, p=0.769), education level (r=-0.181, p=0.162), continuous working time before illness (r=-0.107, p=0.413) or the daily dose of antipsychotic drugs (r=0.062, p=0.635); however, it was positively related to the number of hospitalisations (r=0.471, p<0.001). The total score of Scale for the Assessment of Positive Symptoms (SAPS) was negatively related to the accuracy of visual working memory (r=-0.388, p=0.005), while the total score of Scale for the Assessment of Negative Symptoms (SANS) (r=0.416, p=0.001), the total score of diminished emotional expressiveness (r=0.352, p=0.005) and the total score of attention disorder (r=0.310, p=0.015) were positively related to the accuracy of visual working memory. Patients using a single drug and those using multiple drugs were compared with each other. They were not significantly different in age (t=0.010, p=0.992), the number of hospitalisations (t=0.656, p=0.514), the duration of illness (t=0.701, p=0.486), the total score of SANS (t=0.078, p=0.938), the total score of SAPS (t=1.815, p=0.079) and the daily dose of antipsychotic drugs (t=1.794, p=0.078). However, in order to explore whether single or combined drug use would affect the accuracy of visual working memory of patients with schizophrenia, the present study also compared these two groups' different S0 values of the accuracy of visual working memory. The results showed that the accuracy of visual working memory of patients with schizophrenia with combined drug use was significantly better than that of patients with single drug use (t=2.515, p=0.015, independent sample t-test).

CONCLUSION

The present study indicates that the visual working memory of young adult patients with schizophrenia is impaired compared with the healthy people within the same age range. The impairment is more obvious in patients who have multiple hospitalisations and suffer from severe negative symptoms. The impairment in patients with more severe positive symptoms is not very obvious. Combined drug use is likely to alleviate the impairment.

Early intervention in psychosis: strengths and limitations of services

Early intervention services were established on the basis of a number of fundamental principles, including the notions that intervening in the early stages of psychosis alters illness trajectory and prognosis, that multicomponent interventions promote psychosocial recovery and reduce iatrogenic damage, and that early targeting of non-responders reduces treatment resistance. There is growing evidence of the benefits of specialised early intervention services. These include improved clinical, social and vocational outcomes, reduced in-patient stays and better engagement. Early intervention services can also significantly reduce the risk of a second episode and are highly valued by service users and carers. Duration of treatment appears to determine long-term outcome and there remains uncertainty about how long such intensive intervention should last and whether all patients need the same length of care. Budgetary constraints are pervasive and are particularly likely to affect prodrome clinics and community awareness programmes.

The traumatic experience of first-episode psychosis: A systematic review and meta-analysis

INTRODUCTION

A psychotic episode may be sufficiently traumatic to induce symptoms of post-traumatic stress disorder (PTSD), which could impact outcomes in first-episode psychosis (FEP). The objectives of this systematic review and meta-analysis were to estimate the prevalence of PTSD symptoms in relation to psychosis in FEP and to identify risk factors for the development of PTSD symptoms.

METHODS

We searched electronic databases and conducted manual searching of reference lists and tables of contents to identify relevant studies. Quantitative studies were included if the population was experiencing FEP and if PTSD was measured in relation to psychosis. Prevalence of PTSD symptoms and diagnoses were meta-analyzed using a random effects model. Potential risk factors for PTSD symptoms were summarized qualitatively.

RESULTS

Thirteen studies were included. Eight studies assessed PTSD symptoms, three studies assessed full PTSD, and two studies assessed both. The pooled prevalence of PTSD symptoms was 42% (95% CI 30%-55%), and the pooled prevalence of a PTSD diagnosis was 30% (95% CI 21%-40%). Exploratory subgroup analyses suggest that prevalence may be higher in affective psychosis and inpatient samples. Evidence from included studies implicate depression and anxiety as potential risk factors for PTSD symptoms.

CONCLUSIONS

Approximately one in two people experience PTSD symptoms and one in three experience full PTSD following a first psychotic episode. Evidence-based interventions to treat PTSD symptoms in the context of FEP are needed to address this burden and improve outcomes after the first psychotic episode. Further studies are needed to clarify the associated risk factors.

The Positive and Negative Experiences of Caregiving for Siblings of Young People with First Episode Psychosis

Background: The impact of first episode psychosis (FEP) upon parents’ experience of caregiving has been well-documented. However, the determinants and nature of this remain poorly understood in siblings. It is hypothesized that siblings of young people with FEP are also impacted by caregiving and burden. This study aimed to characterize the experience of caregiving for siblings of young people with FEP.

Method: Survey methodology was used to explore the experience of 157 siblings in the first 18 months of their brother or sister’s treatment for FEP. Participants reported on their appraisal of the negative and positive aspects of caregiving as measured by the Experience of Caregiving Inventory (ECI). Descriptive statistics were used to establish the results for the total sample as well as for gender and birth order differences. A series of multivariate regression analyses were conducted to determine the relationships between illness characteristics and siblings’ experience of caregiving.

Results: Older brothers reported the lowest scores for negative experiences in caregiving and younger sisters reported the highest. Negative experiences in caregiving resulted in less warmth within the sibling relationship and impacted negatively upon quality of life. When the young person with FEP had attempted suicide and/or been physically violent, siblings experienced more caregiver burden. Multivariate analysis showed that female gender was a significant factor in explaining the impact of illness related variables on the experience of caregiving.

Conclusion: Suicide attempts and a history of violence resulted in higher caregiving burden for siblings regardless of whether they lived with the young person experiencing FEP or not. Female siblings are at higher risk of negative experiences from caregiving resulting in a reduced quality of life and a changed sibling relationship. Suicide attempts and violence are indicators for intensive case management to improve outcomes for the individual with FEP which may in turn reduce the burden experienced by the sibling. Clinicians can use these findings to identify siblings, assertively intervene and provide increased psychological support, psychoeducation and practical problem solving to reduce the burden. The caregiving role that they already play for their ill brother or sister should be recognized.

Factors Associated with Timely Physician Follow-up after a First Diagnosis of Psychotic Disorder

OBJECTIVE

Physician follow-up after a first diagnosis of psychotic disorder is crucial for improving treatment engagement. We examined the factors associated with physician follow-up within 30 days of a first diagnosis of schizophrenia.

METHOD

We conducted a retrospective cohort study using linked health administrative data to identify incident cases of schizophrenia between 1999 and 2008 among people aged 14 to 35 years in Ontario. We estimated the proportion of patients who had physician follow-up within 30 days of the index diagnosis. We used multilevel logistic regression models to examine the factors associated with any physician follow-up and follow-up by a psychiatrist.

RESULTS

We identified 20,096 people with a first diagnosis of schizophrenia. Approximately 40% of people did not receive any physician follow-up within 30 days, and nearly 60% did not receive follow-up by a psychiatrist. Males had lower odds of receiving any physician follow-up, and the odds of psychiatrist follow-up decreased with increasing age and were lower for those living in rural areas. Both prior contact with a general practitioner for a mental health reason and prior contact with a psychiatrist were strongly associated with higher odds of receiving both types of follow-up.

CONCLUSIONS

Many people do not have any physician contact within 30 days of the first diagnosis of schizophrenia, and patients without prior engagement with mental health services are at highest risk. We need information on the reasons behind this lack of physician follow-up to inform strategies aimed at improving engagement with services during the early stages of psychosis.

Incidence of hospitalization and its associated factors in first-episode psychosis in Hong Kong

AIM

This study examined the incidence of hospitalization and its associated factors in patients with first-episode psychosis in Hong Kong.

METHOD

From 2009 to 2011, 360 patients were recruited consecutively as part of a controlled study of an early psychosis intervention service (the Jockey Club Early Psychosis project) in Hong Kong. Demographic and clinical information were obtained from face-to-face interviews and was reconfirmed using medical records. Factors relating to hospitalization during first episode were explored.

RESULTS

The incidence of hospitalization during first-episode psychosis was 57.2%. Patients who were hospitalized had higher antipsychotics chlorpromazine equivalent dosage, higher positive and negative syndrome scale total score, higher Udvalg for Kliniske Undersøgelser others mean score and were more likely to have an acute mode of onset compared with those who were not hospitalized.

CONCLUSIONS

Hospitalization was common in first-episode psychosis. Future studies are needed to explore possible programmes to prevent hospitalization in patients with first-episode psychosis.

Forgotten family members: the importance of siblings in early psychosis

OBJECTIVE

This paper reviews the evidence on the significance of sibling inclusion in family interventions and support during early psychosis.

METHOD

This narrative review presents the current research related to the importance of family work during early psychosis, the needs and developmental significance of siblings during adolescence and early adulthood, the protective effects of sibling relationships, and the characteristics of early psychosis relevant to the sibling experience. It will also review the evidence of the sibling experience in chronic physical illness and disability, as well as long-term psychotic illness.

CONCLUSIONS

Despite the evidence that working with families is important during early psychosis, siblings have been largely ignored. Siblings are an important reciprocal relationship of long duration. They play an important role in development during adolescence and early adulthood. These relationships may be an underutilized protective factor due to their inherent benefits and social support. Developmental theories imply that early psychosis could negatively impact the sibling relationship and their quality of life, effecting personality development and health outcomes. The evidence shows that adolescent physical illness or disability has a significantly negative impact on the sibling's quality of life and increases the risk for the onset of mental health issues. Long-term psychotic illness also results in negative experiences for siblings. Current evidence shows that siblings in early psychosis experience psychological distress and changes in functional performance. Further research using standard measures is required to understand the impact early psychosis has on the sibling relationship and their quality of life.

Cannabis and stimulant disorders and readmission 2 years after first-episode psychosis

BACKGROUND

Few studies have examined the impact of stimulant use on outcome in early psychosis. Ceasing substance use may lead to positive outcomes in psychosis.

AIMS

To examine whether baseline cannabis or stimulant disorders and ongoing drug use predict readmission within 2 years of a first psychosis admission.

METHOD

Predictors of readmission were examined with Cox regression in 7269 people aged 15-29 years with a first psychosis admission.

RESULTS

Baseline cannabis and stimulant disorders did not predict readmission. A stimulant disorder diagnosis prior to index psychosis admission predicted readmission, but a prior cannabis disorder diagnosis did not. Ongoing problem drug use predicted readmission. The lowest rate of readmission occurred in people whose baseline drug problems were discontinued.

CONCLUSIONS

Prior admissions with stimulant disorder may be a negative prognostic sign in first-episode psychosis. Drug use diagnoses at baseline may be a good prognostic sign if they are identified and controlled.

Does substance use disorder affect clinical expression in first-hospitalization patients with schizophrenia? Analysis of a prospective cohort

Although several papers reported a wide range of negative outcomes among patients with both schizophrenia and Substance Use Disorder (SUD), only a few studies evaluated the impact of SUD on psychopathology and thus on the length of first-hospitalization. The aim of the present study was to compare clinical expression of first-episode of schizophrenia between inpatients with and without SUD, giving close attention to the length of stay. One hundred and thirty inpatients at first-episode of schizophrenia were assigned to either SUD or not SUD group depending on SUD diagnosis and were assessed through BPRS at admission, during hospitalization and at discharge. Cross-sectional and longitudinal statistical analysis were performed to investigate differences between groups and also a linear regression was used to evaluate relationship between length of stay and BPRS scores. SUD group showed more disorganization at admission, less marked improvement of symptoms (disorganization, thought disturbance, anergia), and longer hospital stay than not SUD group. Moreover BPRS total score during hospitalization was a significant positive predictor for length of stay. Taken together, these findings suggest that SUD patients have a more severe and drug-resistant expression of schizophrenia, hence, they need longer treatment to achieve the overall symptoms improvement required for discharge.

Differences in associations between cannabis and stimulant disorders in first admission psychosis

BACKGROUND

Substance use in early psychosis is associated with male gender and earlier onset. Evidence about other correlates of substance use is less consistent. Stimulants (e.g. methamphetamine, cocaine) may precipitate psychosis. However the associations of stimulant disorders in early psychosis are difficult to examine because of lower prevalence and overlap with cannabis disorders.

METHODS

Hospital records were used to identify 9919 persons aged 15-29 with a first hospital admission with psychosis in New South Wales (NSW), Australia. Correlates of illicit drug disorders, cannabis disorders and stimulant disorders were examined using univariate and multivariate logistic regression.

RESULTS

Half of first psychosis admissions had comorbid substance diagnoses. Cannabis and stimulant disorders were increased more than ten-fold compared to the age-matched Australian population. Stimulant disorders were equally common in women and men and associated with urban location, social advantage and older age at first admission. Cannabis disorders were associated with male gender, younger age and non-metropolitan location. Diagnoses of drug-induced psychoses were more strongly associated with stimulants than with cannabis. Compared to people with cannabis diagnoses alone, those with both cannabis and stimulant disorders were older, more likely to have a diagnosis of drug-induced psychosis and more likely to have comorbid alcohol disorders.

CONCLUSIONS

Cannabis is the most commonly used substance in psychosis, and the associations of illicit drug use in psychoses are largely those of cannabis disorders. There are significant differences between the personal, socio-economic and diagnostic correlates of cannabis and stimulant disorders in young people with first admission psychosis.

Country of birth and hospital treatment for psychosis in New South Wales

BACKGROUND

Migration has been found to be a risk factor for schizophrenia in several high-income countries.

AIM

To examine whether overseas migrants to New South Wales (NSW) have higher rates of admission to psychiatric hospitals for psychotic disorders, including schizophrenia and mania, compared to people born in Australia.

METHODS

The country of birth of people admitted to public mental health units for the treatment of psychotic illness and for non-psychotic disorders between 2001 and 2010 was compared to the country of birth for the NSW population in the 2006 census. Meta-analysis was used to estimate the odds of being admitted for any psychotic disorder, for a schizophrenia-related psychosis and for mania compared to non-psychotic disorder, for those born in Australia, New Zealand and for nine global regions.

RESULTS

Those born in Oceania (including Melanesia, Fiji, Samoa, Tonga and other Polynesian islands, but excluding Hawaii and New Zealand) had the highest odds of admission for the treatment of psychosis compared to a non-psychotic disorder and had the highest odds of being admitted with a diagnosis of schizophrenia or mania.

CONCLUSIONS

In the years 2001-2010, those born in Oceania were at an increased risk of admission to NSW psychiatric hospitals for the treatment of psychotic illness.

Bed accessibility in a private psychiatric hospital

OBJECTIVE

Access to beds is a major problem in many psychiatric services and increased waiting times can lead to adverse health outcomes. While there has been a considerable amount of research evaluating bed management systems in public psychiatric services, the private sector has received little attention. This project aimed to determine the time to admission for patients referred to an acute private psychiatric hospital, and to identify factors contributing to time intervals between referral and admission.

METHOD

All staff involved in the admission process engaged in an ongoing, interactive data collection process. Accurate data on waiting times for acute patients was obtained and fed back to credentialed admitting psychiatrists.

RESULTS

Determinants of admission were clarified. For urgent admissions, the longest time interval was between the patient being advised that a bed was available and actually presenting themselves at the hospital.

CONCLUSION

The project was effective in clarifying admission flow in a private psychiatric hospital. Some strategies that might reduce time intervals between referral and admission are described.

Predictors of compulsory admission in schizophrenia-spectrum patients: excitement, insight, emotion perception

PURPOSE

We explored socio-demographic and clinical variables associated with compulsory admissions (CA) compared with voluntary admissions in schizophrenia-spectrum patients; moreover, we investigated the ability of excitement, emotion perception, and lack of insight to predict CA.

METHODS

119 consecutive schizophrenia-spectrum patients admitted to the Servizio Psichiatrico di Diagnosi e Cura (SPDC = PES = psychiatric emergency service) of the Department of Neuroscience and Mental Health-San Giovanni Battista Hospital of Turin in the period between December 2007 and December 2009 were enrolled in the study. A backward stepwise logistic regression was used to test factors contributing to CA.

RESULTS

CA rate in our sample was 28.5%. Previous CAs, drop-out, severity of illness, positive symptoms, excitement, emotion perception, and insight were significantly different in CA patients compared to voluntary ones. After backward selection of variables, three variables predicted CA in our sample: excitement, impaired emotion perception and lesser insight. Finally, the effect of excitement on CA status seemed partially mediated by emotion perception, the prediction model accounting for 53.8% of the variance of CA status. Conversely, insight seemed not to be a mediator of excitement on CA.

IMPLICATIONS

Understanding CA patterns in special populations represents a first step towards improving clinical decision-making and developing appropriate interventions and service-provision.

Rate of cannabis use disorders in clinical samples of patients with schizophrenia: a meta-analysis

OBJECTIVE

Our aim was to review recent studies and estimate the rate of cannabis use disorders (CUDs) in schizophrenia, as well as to examine the factors affecting this rate.

METHODS

We conducted an electronic search of 3 literature databases and a manual search of articles from 1996 to 2008. The key words used were "schizophreni*," "psychos*s," "psychotic," "cannabis abuse," "cannabis dependence," "cannabis use disorder," "substance use disorder," "substance abuse," "substance dependence," and "dual diagnosis." Articles that reported diagnoses according to the Diagnostic and Statistical Manual of Mental Disorders or International Classification of Diseases were included. Regression analysis was used to examine how estimated rates of CUDs are affected by various study characteristics such as the classification system, inpatient vs outpatient status, study location, proportion of males, age of the sample, or duration of illness.

RESULTS

Thirty-five studies met our search criteria. The median current rate of CUDs was 16.0% (interquartile range [IQR] = 8.6-28.6, 10 studies), and the median lifetime rate was 27.1% (IQR = 12.2-38.5, 28 studies). The median rate of CUDs was markedly higher in first-episode vs long-term patients (current 28.6%/22.0%, lifetime 44.4%/12.2%, respectively) and in studies where more than two-thirds of the participants were males than in the other studies (33.8%/13.2%). CUDs were also more common in younger samples than in the others (current 38.5%/16.0%, lifetime 45.0%/17.9%).

CONCLUSIONS

Approximately every fourth schizophrenia patient in our sample of studies had a diagnosis of CUDs. CUDs were especially common in younger and first-episode patient samples as well as in samples with a high proportion of males.

Rates of homicide during the first episode of psychosis and after treatment: a systematic review and meta-analysis

The observation that almost half of the homicides committed by people with a psychotic illness occur before initial treatment suggests an increased risk of homicide during the first episode of psychosis. The aim of this study was to estimate the rates of homicide during the first episode of psychosis and after treatment. A systematic search located 10 studies that reported details of all the homicide offenders with a psychotic illness within a known population during a specified period and reported the number of people who had received treatment prior to the offense. Meta-analysis of these studies showed that 38.5% (95% confidence interval [CI] = 31.1%-46.5%) of homicides occurred during the first episode of psychosis, prior to initial treatment. Homicides during first-episode psychosis occurred at a rate of 1.59 homicides per 1000 (95% CI = 1.06-2.40), equivalent to 1 in 629 presentations. The annual rate of homicide after treatment for psychosis was 0.11 homicides per 1000 patients (95% CI = 0.07-0.16), equivalent to 1 homicide in 9090 patients with schizophrenia per year. The rate ratio of homicide in the first episode of psychosis in these studies was 15.5 (95% CI = 11.0-21.7) times the annual rate of homicide after treatment for psychosis. Hence, the rate of homicide in the first episode of psychosis appears to be higher than previously recognized, whereas the annual rate of homicide by patients with schizophrenia after treatment is lower than previous estimates. Earlier treatment of first-episode psychosis might prevent some homicides.

First-ever admitted psychiatric inpatients in Italy: clinical characteristics and reasons contributing to admission: findings from a national survey

The aim of this study was to describe the sociodemographic, clinical and treatment-related characteristics of patients admitted to any acute psychiatric inpatient facilities in Italy for the first time in their life, and to identify reasons contributing to admission. Data from the PROGRES-Acute Project, a national survey on facilities admitting acute psychiatric patients in Italy, were used. A cluster analysis was carried out in order to identify patients' groups sharing similar sociodemographic and clinical characteristics. Among patients admitted during the index period, 337 were at their first-ever admission. Median age at admission was 40, and about 46% of patients were not receiving any treatment in the month prior to admission. Social/work functioning problems, social withdrawal and conflict with family members were the most common reasons contributing to admission. Cluster analysis yielded four patient groups: two groups of younger subjects, differentiating each other for frequency of antisocial behaviors, compulsory admissions, treatment at time of admission and family support; two groups of older subjects, with high rates of affective disorders, who showed remarkable differences with regard to their living situation and family support. Our study shows that first-ever admitted patients represent a highly heterogeneous group. Early intervention research should take this sociodemographic and clinical diversity into account, in order to better allocate resources and develop special intervention programs.

Prevalence of alcohol use disorders in schizophrenia--a systematic review and meta-analysis

OBJECTIVE

Our aim was to present recent studies of alcohol use disorders (AUDs) in patients with schizophrenia, estimate overall prevalence and characteristics affecting the prevalence of AUDs.

METHOD

We conducted a search using three literature databases and a manual search on articles published in 1996-2008. Meta-regression was used to study how prevalence is affected by different study characteristics. Articles that reported diagnoses according to DSM or ICD diagnostic systems were included.

RESULTS

Altogether 60 studies met our criteria. The median of current AUD prevalence was 9.4% (inter-quartile range, IQR 4.6-19.0, 18 studies) and median of lifetime AUD prevalence 20.6% (IQR 12.0-34.5, 47 studies). In studies using DSM-III-R median prevalence was higher than that in studies using DSM-IV, ICD-9 or ICD-10 (32/17/11/6%).

CONCLUSION

Approximately every fifth patient with schizophrenia had lifetime AUD diagnosis. When contrasted with the most recent review, there might be a descending trend in AUD prevalence in patients with schizophrenia.

The development of the Recovery and Prevention of Psychosis Service in Melbourne, Australia

AIM

To describe the establishment of a multicomponent, phase-specific, early intervention service for young people experiencing psychosis.

METHODS

The Recovery and Prevention of Psychosis Service commenced streamed clinical service delivery in November 2004, providing comprehensive case management for up to 3 years within Victoria's largest metropolitan health service. It delivers phase-oriented treatment focusing on early detection, recovery and relapse prevention, and minimizing disability and secondary comorbidity. The combined programme covers training and professional development, data collection and evaluation, specialist intervention services, group programme work and community development.

RESULTS

Of the first 151 clients, 70.2% were male, the average age at first presentation was 20.9 years, 15% were under 18 at first contact and 67% required inpatient admission at least once. Mean age at first contact was 20.84 years for those requiring inpatient services and 70% admitted were male. The average length of stay was 25.69 days and 23% were secluded, with an average of 2.1 seclusions. A large percentage of Recovery and Prevention of Psychosis Service clients (81%) required involuntary treatment, a significantly greater proportion of admitted patients were on Community Treatment Orders compared to those never admitted (22.5% cf. 4.1%; P = 0.04) and 92% of those admitted subsequently relapsed compared to 8% of those not admitted (P = 0.02).

CONCLUSIONS

Recovery and Prevention of Psychosis Service is successfully developing a fully integrated first episode service. Recent developments include expanding the period of care up to 5 years for selected patients, the recruitment of a health promotions officer and planning for the development of a youth inpatient unit.

Patterns of admission to acute psychiatric in-patient facilities: a national survey in Italy

BACKGROUND

A proper understanding of patterns of care represents a crucial step in improving clinical decision making and enhancing service provision. Only a few studies, however, have explored global patterns of psychiatric admissions nationwide, and none have been undertaken in Italy.

METHOD

Sociodemographic, clinical and treatment-related information was collected for 1577 patients admitted to 130 public and 36 private in-patient facilities in Italy during an index period in the year 2004. All patients were also rated using the 24-item Brief Psychiatric Rating Scale (BPRS) and the Personal and Social Performance (PSP) rating scales.

RESULTS

Non-affective psychoses (36%) were the most common diagnoses and accounted to a large extent for compulsory admissions. Private facilities were more likely to admit patients with organic mental disorders and substance abuse/dependence and less likely to admit patients with non-affective psychoses. Overall, 77.8% of patients had been receiving treatment by a mental health professional in the month prior to admission. In 54% of cases, the admission was solicited by patients' family members. The main factors preceding admission were impairment in work or social functioning, social withdrawal, and conflict with family members. Agitation, delusions and/or hallucinations, and the presence of multiple problems were associated with compulsory admissions, whereas depressive and anxiety symptoms were associated with voluntary admissions.

CONCLUSIONS

In a mixed, public-private psychiatric care system, like the Italian one, public and private facilities admit patients with widely different clinical characteristics and needs. Family support represents an important resource for most patients, and interventions specifically addressed to relieving family burden are warranted.

Measurement and reporting of the duration of untreated psychosis

AIM

The aim of this study was to investigate the demographic, illness and methodological factors associated with mean and median duration of untreated psychosis (DUP).

METHODS

A systematic review and meta-analysis of the published studies of DUP and an examination of available DUP distributions.

RESULTS

DUP was longer in samples with a higher proportion of patients with schizophrenia and was shorter in samples that included affective psychosis. Sex, age, and the methods of measuring the onset and end-point of DUP and the type of service in which the studies were performed did not contribute to the heterogeneity of the mean or median DUP values. Mean DUP is significantly prolonged by a small number of patients, and the median DUP is a poor indicator of the rate at which patients present.

CONCLUSIONS

The DUP of patients with affective and non-affective psychosis should be examined separately in order to make measures of DUP more meaningful and comparable, and DUP should be reported using more comprehensive measures. We suggest a method of reporting DUP based on the rate of presentation of first-episode psychosis patients rather than the length of DUP.

Mental health laws that require dangerousness for involuntary admission may delay the initial treatment of schizophrenia

INTRODUCTION

A long duration of untreated psychosis (DUP) is associated with a worse prognosis, an increased risk of suicide and may be linked to serious violence. Mental health laws that require patients to be dangerous to themselves or to others before they can receive involuntary psychiatric treatment may make it more difficult to treat patients in their first episode of psychosis.

METHODS

The mean and median DUP reported in studies of schizophrenia related psychoses were examined. A comparison was made between the DUP reported from jurisdictions that had an obligatory dangerousness criterion (ODC) and those with other criteria for involuntary treatment.

RESULTS

The average mean DUP in samples from jurisdictions with an ODC was 79.5 weeks, but was only 55.6 weeks in those jurisdictions that did not have an ODC (P < 0.007).

CONCLUSIONS

Mental health laws that require the patient to be assessed as dangerous before they can receive involuntary treatment are associated with significantly longer DUP. As reducing DUP is an intervention that can improve the prognosis of schizophrenia, this finding suggests that mental health laws should be amended to allow treatment on grounds other than dangerousness, at least in the crucial first episode of psychosis.

Evidence for a relationship between the duration of untreated psychosis and the proportion of psychotic homicides prior to treatment

BACKGROUND

Recent studies of homicide during psychotic illness have shown that the risk of homicide is greatest during the first episode of psychosis. It is also possible that the proportion of patients who commit homicide before they receive effective treatment may be associated with the length of time they were unwell. We aimed to establish whether there was an association between the average duration of untreated psychosis and the proportion of homicides committed during the first episode of psychosis in the same countries.

METHODS

Systematic searches of published studies of homicide in psychosis and the duration of untreated psychosis were conducted. The results were combined to examine the relationship between the reported delay in receiving treatment and the proportion of homicides committed before initial treatment.

RESULTS

We found 16 studies that reported the proportion of psychotic patients who committed homicide prior to treatment. The proportion of first episode patients ranged from 13% to 76%. We were able to match 13 of those studies with DUP studies from the same country. Longer average DUP was associated with a higher proportion of patients who committed homicide prior to receiving treatment.

CONCLUSIONS

The possibility that the proportion of patients who commit homicide before receiving treatment may be related to the average treatment delay in the region that the homicide occurs needs to be examined using a case controlled design. If this finding were confirmed, then any measure that reduced the delay in treating emerging psychosis would save lives.

Therapeutic alliance, illness awareness, and number of hospitalizations for schizophrenia

While persons with multiple hospitalizations for schizophrenia have been found to differ from those with fewer, it remains unclear whether differences exist in illness awareness (personal understanding of psychopathology) or therapeutic alliance with inpatient staff (treatment involvement). This cross-sectional descriptive study therefore examined whether inpatients with more extensive hospitalization history 1) have less illness awareness and therapeutic alliance (perhaps contributing to the recidivism), 2) have more awareness and alliance (possibly because they have learned from experience), or 3) do not differ relative to persons with fewer inpatient stays. Results from staff and patient interviews (N=307) suggest that illness awareness is greater in persons with more hospitalizations, while therapeutic alliance appears to weaken. Individuals with greater recidivism may therefore need less help than others in building a self-knowledge of psychopathology that may already have developed. Instead, enhanced engagement in care may be more important after multiple disappointing relapses.