The Time is Ripe for a Consensus Definition of Clinical Recovery in First-episode Psychosis: Suggestions Based on a 10-Year Follow-up Study

Taking what you get or Getting what you Need: A Qualitative Study on Experiences with Mental Health and Welfare Services in Long-Term Recovery in First-Episode Psychosis

How people in long-term recovery (clinical and personal) in first-episode psychosis (schizophrenia and bipolar spectrum disorders) experience the mental health and welfare services they interact with is not frequently studied but has significant implications. We therefore aimed to explore which aspects of these services people with FEP evaluate as important for their long-term recovery. Twenty participants in clinical and/or personal recovery from two Norwegian long-term follow-up studies after FEP (TOP 10-year and TIPS 20-year) were sampled for this interview-based qualitative study. The research-team included service user experience. A deductive analysis based on personal accounts of recovery generated five service aspects. Few specific types of interventions were reported to promote recovery although medications, psychotherapy and employment support were mentioned. Participants valued services based in collaboration and that focused on their resources rather than limitations. The importance of long-term follow-up with a consistent aim was highlighted, as was the inclusion of caregivers and peers. Welfare services contributed to recovery by supporting basic needs and safety, but some experienced social exclusion when not participating in the labor market. This study is unique in exploring the role of services, including welfare, in long-term FEP recovery from service user perspectives. Participants evaluated that services played a more indirect role in long-term recovery by supporting their personal resources, although what they needed from services had frequently not been offered. Their expertise by experience contributes valuable knowledge. Better service coordination and consistent implementation of this knowledge are crucial to support recovery in FEP.

Long-term clinical recovery and treatment resistance in first-episode psychosis: a 10-year follow-up study

Illness trajectories in people with first-episode psychosis (FEP) vary significantly over time. Identifying early-course parameters predicting outcomes is essential, but long-term data still needs to be provided. We conducted a 10-year follow-up study of a comprehensive first-episode psychosis (FEP) cohort investigating the prevalence of clinical recovery (CR) and treatment resistance (TR) after ten years, as well as clinical, demographic, and pre-illness predictors of long-term outcomes. 102 participants with FEP DSM-IV Schizophrenia spectrum disorders were recruited within their first year of treatment. The Treatment Response and Resistance in Psychosis Working Group (TRRIP) and the Remission in Schizophrenia Working Group (RSWG) criteria were used to define TR and CR, respectively. At 10-year follow-up, 29 (29%) of the participants were classified as in CR, while 32 (31%) were classified as TR. We also identified a larger middle group (n = 41, 40%) consisting of participants in partial recovery. 7% of all participants had tried Clozapine at the 10-year follow-up. Logistic regression analyses identified insidious onset (OR = 4.16) and baseline disorganized symptoms (OR = 2.96) as significantly associated with an increased risk of developing TR. Good premorbid academic adjustment (OR = 1.60) and acute onset (OR = 3.40) were associated with an increased chance of CR. We identified three long-term outcome groups by using recent consensus definitions. We also identified the potential importance of assessing baseline disorganized symptoms and monitoring patients with insidious onset more closely. Further, the findings suggest that clinicians should pay close attention to early-course parameters and provide adequate treatment to improve long-term outcomes of FEP.

A good life with psychosis: rate of positive outcomes in first-episode psychosis at 10-year follow-up

BACKGROUND

More knowledge about positive outcomes for people with first-episode psychosis (FEP) is needed. An FEP 10-year follow-up study investigated the rate of personal recovery, emotional wellbeing, and clinical recovery in the total sample and between psychotic bipolar spectrum disorders (BD) and schizophrenia spectrum disorders (SZ); and how these positive outcomes overlap.

METHODS

FEP participants (n = 128) were re-assessed with structured clinical interviews at 10-year follow-up. Personal recovery was self-rated with the Questionnaire about the Process of Recovery-15-item scale (total score ⩾45). Emotional wellbeing was self-rated with the Life Satisfaction Scale (score ⩾5) and the Temporal Experience of Pleasure Scale (total score ⩾72). Clinical recovery was clinician-rated symptom-remission and adequate functioning (duration minimum 1 year).

RESULTS

In FEP, rates of personal recovery (50.8%), life satisfaction (60.9%), and pleasure (57.5%) were higher than clinical recovery (33.6%). Despite lower rates of clinical recovery in SZ compared to BD, they had equal rates of personal recovery and emotional wellbeing. Personal recovery overlapped more with emotional wellbeing than with clinical recovery (χ2). Each participant was assigned to one of eight possible outcome groups depending on the combination of positive outcomes fulfilled. The eight groups collapsed into three equal-sized main outcome groups: 33.6% clinical recovery with personal recovery and/or emotional wellbeing; 34.4% personal recovery and/or emotional wellbeing only; and 32.0% none.

CONCLUSIONS

In FEP, 68% had minimum one positive outcome after 10 years, suggesting a good life with psychosis. This knowledge must be shared to instill hope and underlines that subjective and objective positive outcomes must be assessed and targeted in treatment.

Additive effects of a family history of schizophrenia spectrum disorders and an environmental risk score for the outcome of patients with non-affective first-episode psychosis

BACKGROUND

First-episode psychotic disorders comprise a heterogeneous phenotype with a complex etiology involving numerous common small-effect genetic variations and a wide range of environmental exposures. We examined whether a family of schizophrenia spectrum disorder (FH-Sz) interacts with an environmental risk score (ERS-Sz) regarding the outcome of patients with non-affective first episode psychosis (NAFEP).

METHODS

We included 288 patients with NAFEP who were evaluated after discharge from an intensive 2-year program. We evaluated three outcome measures: symptomatic remission, psychosocial functioning, and personal recovery. We analyzed the main and joint associations of a FH-Sz and the ERS-Sz on the outcomes by using the relative excess risk due to interaction (RERI) approach.

RESULTS

A FH-Sz showed a significant association with poor symptomatic remission and psychosocial functioning outcomes, although there was no significant interaction between a FH-Sz and the ERS-Sz on these outcomes. The ERS-Sz did not show a significant association with poor symptomatic remission and psychosocial functioning outcomes, even though the magnitude of the interaction between ERS-Sz and FH-Sz with the later outcome was moderate (RERI = 6.89, 95% confidence interval -16.03 to 29.81). There was no association between a FH-Sz and the ERS-Sz and personal recovery.

CONCLUSIONS

Our results provide further empirical support regarding the contribution of FH-Sz to poor symptomatic remission and poor psychosocial functioning outcomes in patients with NAFEP.

Risk and protective factors for recovery at 3-year follow-up after first-episode psychosis onset: a multivariate outcome approach

PURPOSE

Recovery in people with first-episode psychosis (FEP) remains a major issue. When risk factors are studied in relation to the disorder, potential protective factors should also be considered since they can modulate this relationship. This study is aimed at exploring which premorbid and baseline characteristics are associated with a good and poor global recovery in patients with FEP at 3-year follow-up.

METHODS

We categorized patients' outcome by using a Latent Class Analysis (LCA) considering a multimodal set of symptomatic and functional outcomes. A Mixed effects Models Repeated Measures analysis of variance (MMRM) was used to highlight group differences over time on symptomatic and functional outcomes assessed during the 3-year follow-up.

RESULTS

A total of 325 patients with FEP aged between 18 and 35 years were included. Two groups were identified. A total of 187 patients (57.5%) did not achieve recovery, and 138 patients (42.5%) achieved recovery. Recovered patients had generally a better premorbid and baseline profile in comparison with non-recovered patients (as among which shorter duration of untreated psychosis (DUP), higher degree of insight, better functional level and lower illness severity at baseline). The trajectories for the psychopathological and functional outcomes over 36 months differed between the non-recovered and the recovered group of patients.

CONCLUSIONS

Our results pointed to some variables associated with recovery, acting as potential protective factors. These should be considered for early intervention programs to promote psychological resilience specifically in those with a worse prognosis in order to mitigate the effects of the variables that make them more vulnerable to poorer outcome.

ROI-based analysis of diffusion indices in healthy subjects and subjects with deficit or non-deficit syndrome schizophrenia

We analyzed DTI data involving 22 healthy subjects (HC), 15 patients with deficit syndrome schizophrenia (DSZ), and 25 patients with non-deficit syndrome schizophrenia (NDSZ). We used a 1.5-T MRI scanner to collect diffusion-weighted images and T1 images, which were employed to correct distortions and deformations within the diffusion-weighted images. For 156 regions of interest (ROI), we calculated the average fractional anisotropy (FA), mean diffusion (MD), and radial diffusion (RD). Each ROI underwent a group-wise comparison using permutation F-test, followed by post hoc pairwise comparisons with Bonferroni correction. In general, we observed lower FA in both schizophrenia groups compared to HC (i.e., HC>(DSZ=NDSZ)), while MD and RD showed the opposite pattern. Notably, specific ROIs with reduced FA in schizophrenia patients included bilateral nucleus accumbens, left fusiform area, brain stem, anterior corpus callosum, left rostral and caudal anterior cingulate, right posterior cingulate, left thalamus, left hippocampus, left inferior temporal cortex, right superior temporal cortex, left pars triangularis and right lingual gyrus. Significantly, the right cuneus exhibited lower FA in the DSZ group compared to other groups ((HC=NDSZ)>DSZ), without affecting MD and RD. These results indicate that compromised neural integrity in the cuneus may contribute to the pathophysiological distinctions between DSZ and NDSZ.

A ten-year longitudinal repeated assessment study of cognitive improvement in patients with first-episode schizophrenia and healthy controls: The Oslo Schizophrenia Recovery (OSR) study

The mapping of cognitive trajectories after a first episode of schizophrenia has been the aim in several studies, but the longitudinal course of cognitive impairments remains an important question. Due to methodological limitations, it has been challenging to pinpoint specific periods of improvement or stability in cognitive functioning over time. The objective of this study is to further clarify the longitudinal course of cognitive change after a first episode of schizophrenia through frequent repeated measurement. A total of 56 persons participated in the study (28 first episode patients and 28 healthy pairwise matched controls) with 79 % of patients retained at the 10-year follow-up. The Oslo Schizophrenia Recovery study has a repeated measurement design and includes data from nine cognitive assessments over 10 years. Cognition was assessed with the MATRICS Consensus Cognitive Battery, which is well suited for repeated measurements. Data were analyzed with linear multilevel models. The results challenge some of the views about the course of cognitive impairment in first-episode schizophrenia patients. Using quadratic time effects in our analyses and balancing the patient group with regards to the most relevant confounding demographic variables such as age, gender, and education, we showed that cognitive deficits change and improve more than in healthy individuals until year 6, when both groups stabilize. The patient group improved on some of the most important cognitive domains associated with functional outcome with 63.5 % full recovery at 10-year follow-up.

Impulsivity across severe mental disorders: a cross-sectional study of immune markers and psychopharmacotherapy

BACKGROUND

Impulsivity is a transdiagnostic feature linked to severe clinical expression and a potential target for psychopharmacological strategies. Biological underpinnings are largely unknown, but involvement of immune dysregulation has been indicated, and the effects of psychopharmacological agents vary. We investigated if impulsivity was associated with circulating immune marker levels and with a range of psychopharmacological treatment regimens in severe mental disorders.

METHODS

Impulsivity was assessed in a sample (N = 657) of patients with schizophrenia or schizophreniform disorder (SCZ) (N = 116) or bipolar disorder (BD) (N = 159) and healthy participants (N = 382) using the Barratt Impulsiveness Scale (BIS-11) questionnaire. Plasma levels of systemic immune markers (RANTES, IL-1RA, IL-18, IL-18BP, sTNFR-1) were measured by enzyme immunoassays. Patients underwent thorough clinical assessment, including evaluation of psychotropic medication. Associations were assessed using linear regressions.

RESULTS

Impulsivity  was positively associated with SCZ (p < 0.001) and BD (p < 0.001) diagnosis and negatively associated with age (p < 0.05), but not significantly associated with any of the circulating immune markers independently of diagnostic status. Among patients, impulsivity was negatively associated with lithium treatment (p = 0.003) and positively associated with antidepressant treatment (p = 0.011) after controlling for diagnosis, psychotropic co-medications, manic symptoms, and depressive symptoms.

CONCLUSIONS

We report elevated impulsivity across SCZ and BD but no associations to systemic immune dysregulation based on the current immune marker selection. The present study reveals associations between impulsivity in severe mental disorders and treatment with lithium and antidepressants, with opposite directions. Future studies are warranted to determine the causal directionality of the observed associations with psychopharmacotherapy.

Long-term Outcomes of People With DSM Psychotic Disorder NOS

Introduction

The Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV diagnostic category "Psychotic disorder not otherwise specified" (PNOS) is seldom investigated, and we lack knowledge about long-term outcomes. We examined long-term symptom severity, global functioning, remission/recovery rates, and diagnostic stability after the first treatment for PNOS.

Methods

Participants with first-treatment PNOS (n = 32) were reassessed with structured interviews after 7 to 10 years. The sample also included narrow schizophrenia spectrum disorders (SSD, n = 94) and psychotic bipolar disorders (PBD, n = 54). Symptomatic remission was defined based on the Remission in Schizophrenia Working Group criteria. Clinical recovery was defined as meeting the criteria for symptomatic remission and having adequate functioning for the last 12 months.

Results

Participants with baseline PNOS or PBD had lower symptom severity and better global functioning at follow-up than those with SSD. More participants with PNOS and PBD were in symptomatic remission and clinical recovery compared to participants with SSD. Seventeen (53%) PNOS participants retained the diagnosis, while 15 participants were diagnosed with either SSD (22%), affective disorders (19%), or substance-induced psychotic disorders (6%). Those rediagnosed with SSD did not differ from the other PNOS participants regarding baseline clinical characteristics.

Conclusions

Long-term outcomes are more favorable in PNOS and PBD than in SSD. Our findings confirm diagnostic instability but also stability for a subgroup of participants with PNOS. However, it is challenging to predict diagnostic outcomes of PNOS based on clinical characteristics at first treatment.

Heterogeneity in treatment outcomes and incomplete recovery in first episode psychosis: does one size fit all?

The heterogeneity in recovery outcomes for individuals with First Episode Psychosis (FEP) calls for a strong evidence base to inform practice at an individual level. Between 19-89% of young people with FEP have an incomplete recovery despite gold-standard evidence-based treatments, suggesting current service models, which adopt a 'one-size fits all' approach, may not be addressing the needs of many young people with psychosis. The lack of consistent terminology to define key concepts such as recovery and treatment resistance, the multidimensional nature of these concepts, and common comorbid symptoms are some of the challenges faced by the field in delineating heterogeneity in recovery outcomes. The lack of robust markers for incomplete recovery also results in potential delay in delivering prompt, and effective treatments to individuals at greatest risk. There is a clear need to adopt a stratified approach to care where interventions are targeted at subgroups of patients, and ultimately at the individual level. Novel machine learning, using large, representative data from a range of modalities, may aid in the parsing of heterogeneity, and provide greater precision and sophistication in identifying those on a pathway to incomplete recovery.