Preventing EPISODE II: relapse prevention in first-episode psychosis

Antipsychotic treatment failure in patients with psychosis and co-morbid cannabis use: A systematic review

Whilst the effects of cannabis preceding psychosis onset are well established, an effect post-onset is less clear. Emerging evidence suggests that cannabis use is associated with increased relapse outcomes possibly because of determinants, antipsychotic treatment failure and medication adherence, that are not mutually exclusive. Due to the paucity of literature on antipsychotic treatment failure an association with cannabis remains conjectural. This review sought to summarise current evidence regarding the effect of cannabis use on antipsychotic treatment failure among users and non-users with psychosis. Ovid databases (Embase, Journals@Ovid Full Text, OvidMEDLINE® In-Process and Other Non-Indexed Citations and PsycINFO) were searched to identify relevant articles. Seven articles met eligibility criteria. Cannabis use was associated with the following deleterious outcomes increased: odds of non-remission, prescription of unique antipsychotic medications, cumulative prescription of Clozapine and poor treatment trajectories. One study reported similar life-time, but lower past-year, rates of cannabis use in those prescribed Clozapine. Another study reported differences between groups for chlorpromazine equivalent doses for long-term Olanzapine prescription. Improved methodologies are warranted due to a lack of well-designed prospective studies and heterogeneity of key variables. There remains, despite research paucity, the need to encourage early cannabis cessation and higher-quality research to inform clinical practice.

Early psychosis research at Orygen, The National Centre of Excellence in Youth Mental Health

BACKGROUND

Specialised early intervention (SEI) programs have offered individuals with psychotic disorders and their families new hope for improving illness trajectories and outcomes. The Early Psychosis Prevention and Intervention Centre (EPPIC) was one of the first SEI programs developed in the world, providing services for young people experiencing their first episode of psychosis.

METHODS

We conducted a narrative synthesis of controlled and uncontrolled studies that have been conducted at EPPIC.

DISCUSSION

The history of the EPPIC model is first described. This is followed by a discussion of clinical research emerging from EPPIC, including psychopharmacological, psychotherapeutic trials and outcome studies. Neurobiological studies are also described. Issues pertaining to the conduct of clinical research and future research directions are then described. Finally, the impact of the EPPIC model on the Australian environment is discussed.

The evidence for illness progression after relapse in schizophrenia

It has long been suspected that relapse in schizophrenia is associated with disease progression in so far as time to response is longer, negative and other symptoms persist, some patients become treatment refractory and neuroprogression in terms of structural brain changes may occur. This article examines the evidence for illness progression after relapse in patients with schizophrenia. It reports on indirect evidence obtained from retrospective, naturalistic and brain-imaging studies, as well as a few prospective studies examining pre- and post-relapse treatment response. Findings suggest that the treatment response after relapse is variable, with many patients responding rapidly, others exhibiting protracted impairment of response and a subgroup displaying emergent refractoriness. This subgroup comprises about 1 in 6 patients, irrespective of whether it is the first or a subsequent relapse, and even when the delay between onset of first symptoms of relapse and initiation of treatment is brief. While there is a lack of well-designed studies investigating the post-relapse treatment outcome, available evidence gives sufficient cause for concern that, in addition to the considerable psychosocial risks, an additional risk of biological harm may be associated with relapse.

The introduction of an early warning signs journal in an adolescent inpatient unit

Early warning signs are considered to be one of the many tools utilized by specialist early intervention practitioners and other mental health professionals to assist young people how to recognize a deterioration in their mental state or if a relapse is indicated. This article focuses on the role that early warning signs recognition has played in a Child and Adolescent inpatient setting in the form of a journal that is used to record a young person's personal journey by recording early warning signs to prevent a future relapse. Feedback on the use of the journal has been positive from the young people who have utilized the journal and it has also been viewed as a useful and practical framework to identify key symptoms that may potentiate a relapse into illness.

Familial psychopathology in the First Episode Psychosis Outcome Study

OBJECTIVE

The aim of the present study was to characterize the utility of family history data for predicting psychiatric and functional status in first-episode psychosis (FEP) during the pre-treatment phase of illness, at first presentation, and at 18 months follow up.

METHOD

An epidemiological study based upon a consecutive file audit of 661 patients admitted to the Early Psychosis Prevention and Intervention Centre between January 1998 and December 2000 using a standardized questionnaire.

RESULTS

In the total sample of FEP patients family history was not significantly associated with psychiatric or functional status pre-treatment, at first presentation, or at 18 months. Male patients with a family history of psychotic illness had a longer duration of prodrome compared to those with no family history of psychiatric illness (mean=481.4 days, SD=678.0 vs mean=383.5 days, SD=524.7; p=0.03). Family history of non-psychotic illness was associated with comorbidity at first presentation in female patients, both for substance-use related comorbidity (p=0.02) and non-substance-use related comorbidity (p=0.03). There was substantial agreement between clinician reports of family history of psychosis and those obtained using a structured interview instrument (kappa=0.69, 95% confidence interval (CI)=0.41-0.86), but agreement for non-psychotic family history was comparatively low (kappa=0.28, 95%CI:=-0.03 to 0.52).

CONCLUSIONS

There are gender differences in the association between substance use disorder, duration of prodrome and family history. This supports the hypothesis that psychotic illness manifests differently in men and women. In the present sample, reports of family history of non-psychotic illness had lower convergent validity than reports of psychotic illness. The present reported associations with non-psychotic family history should therefore be interpreted with caution. Information on gender and family history of psychiatric illness may assist clinical diagnosis and determination of treatment in FEP patients, especially if specific familial risk factors can be identified.

Early intervention in psychotic disorders: detection and treatment of the first episode and the critical early stages

The two main goals of early intervention in psychotic disorders are to reduce the period of time between the onset of psychosis and the commencement of effective treatment, and to provide consistent and comprehensive care during the critical early years of illness. Effective care during the critical early years involves proactive engagement and initiation of drug and psychosocial treatments, aiming for maximal symptomatic and functional recovery and the prevention of relapse. Over the past 15 years, an increasing number of specialised or streamed treatment delivery systems for early psychosis have been established around the world. There is now evidence that these services can reduce the duration of untreated psychosis and produce better symptomatic and functional recovery. In addition, they are more cost-effective than standard models of mental health care for these patients. Fully fledged, specialised early intervention services should be established, with full integration with local communities, as well as enhanced primary care systems focused on young people.

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.