What happens after early intervention in first-episode psychosis? Limitations of existing service models and an agenda for the future

Novel Occupational Therapy Program (Step Up) to Facilitate the Transition from Early Intervention in Psychosis Services

The purpose of this program evaluation was to examine preliminary outcomes associated with a novel stepdown program for clients of early intervention in psychosis services ("Step Up") that featured occupational therapy (OT) as a critical treatment component. Clients participated in Step Up for at least 6 months and were administered pre-post assessments of clinician-rated performance of daily living activities and self-perceived performance and satisfaction with daily occupational functioning. Paired samples Wilcoxon tests were used to compare outcomes across the two time points. Data from 23 participants of Step Up were analyzed. Clinician-rated performance of daily living (especially in the areas of money and time management and leisure engagement) and client-rated performance and satisfaction with daily occupational functioning improved significantly over time. Results demonstrate the promise of programs such as Step Up that capitalize on OT and promote functional outcomes during the transition from early intervention.

Predictors of relapse and engagement in care one year after ending services in an urban safety net coordinated specialty care program for first episode psychosis

OBJECTIVE

This study aimed to identify risk factors for relapse (psychiatric emergency department visits or hospitalization) and lack of follow-up with outpatient psychiatric care in the 12 months after ending services in an urban safety net coordinated specialty care (CSC) program for first episode psychosis (FEP).

METHODS

The study population (n = 143) were individuals with FEP who had any CSC care between 2014 and 2021. To identify risk factors for relapse and follow up after exit, multivariable logistic regression was performed using data from electronic health records and linked insurance claims data.

RESULTS

Individuals with any emergency department visit or hospitalization 12 months prior to ending CSC (aOR = 4.69, 95 % CI 1.78-12.34) and those who were using cannabis at last CSC contact (aOR = 4.06, 95 % CI 1.56-10.56) had a higher risk of relapse after ending CSC services. Cannabis use at last contact was also associated with lower rates of outpatient psychiatric follow-up (aOR = 0.32, 95 % CI 0.12-0.94), while CSC duration in months had a small positive association with post-CSC psychiatric follow-up. There were no differences in relapse or follow-up by race or ethnicity, primary diagnosis, or medication usage.

CONCLUSIONS

Prior relapse during CSC predicted relapse in the 12 months after ending CSC services, but not outpatient follow up. Cannabis use predicted both a higher rate of relapse and a lower rate of follow up after ending services. There were no differences by race or ethnicity in our sample, suggesting that once individuals engaged in FEP care there were no evident disparities in the observed outcomes.

Remission with or without comorbid substance use disorders in early psychosis: long-term outcome in integrated care (ACCESS III study)

Introduction

Schizophrenia-Spectrum-Disorders are associated with poor long-term outcome as well as disability and often severely affect the lives of patients and their families often from symptom onset. Up to 70% of first episode psychosis (FEP) patients suffer from comorbid substance use disorders (SUD). We aimed at studying the course of illness in FEP patients within evidence-based care, with and without comorbid SUD, to examine how decreased, remitted or persistent substance use impacted rates of a combined symptomatic and functional long-term recovery compared with patients without SUD.

Methods

ACCESS III is an integrated care model for FEP or patients in the early phase of non-affective and affective psychotic disorders. Treatment trajectories of patients, who had been in ACCESS care for 1 year, with and without SUD were compared with regard to the course of illness and quality of life using Mixed Model Repeated Measures (MMRM) and recovery rates were compared using binary logistic regression. Change in substance use was coded as either persistent, decreased/remitted or no use.

Results

ACCESS III was a prospective 1-year study (N = 120) in patients aged 12-29 years. Of these, 74 (61.6%) had a comorbid SUD at admission. There were no group differences regarding the course of illness between patients with or without comorbid SUD or between patients with a substance abuse or substance dependence. The only outcome parameter that was affected by SUD was quality of life, with larger improvement found in the group without substance use (p = 0.05) compared to persistent and remitted users. Using LOCF, 44 patients (48.9%) fulfilled recovery criteria at the endpoint; recovery did not differ based on substance use status.

Discussion

SUD and especially substance dependence are common in psychotic disorders even in FEP patients. Evidence-based integrated care led to long-term improvement in patients with comorbid SUD and rate of recovery did not differ for patients with substance use.

Experiences of a Digital Mental Health Intervention from the Perspectives of Young People Recovering from First-Episode Psychosis: A Focus Group Study

Horyzons is a digital health intervention designed to support recovery in young people receiving specialized early intervention services for first-episode psychosis (FEP). Horyzons was developed in Australia and adapted for implementation in Canada based on input from clinicians and patients (Horyzons-Canada Phase 1) and subsequently pilot-tested with 20 young people with FEP (Horyzons-Canada Phase 2).

OBJECTIVE

To understand the experiences of young adults with FEP who participated in the pilot study based on focus group data.

METHODS

Among the twenty individuals that accessed the intervention, nine participated across four focus groups. Three team members were involved in data management and analysis, informed by a thematic analysis approach. A coding framework was created by adapting the Phase 1 framework to current study objectives, then revised iteratively by applying it to the current data. Once the coding framework was finalized, it was systematically applied to the entire dataset.

RESULTS

Four themes were identified: (1) Perceiving Horyzons-Canada as helpful for recovery; (2) Appreciating core intervention components (i.e., peer networking; therapeutic content; moderation) and ease of use; (3) Being unaware of its features; and (4) Expressing concerns, suggestions, and future directions.

CONCLUSIONS

Horyzons-Canada was well received, with participants wanting it to grow in scale, accessibility, and functionality.

Neglecting the care of people with schizophrenia: here we go again

Specialist early intervention teams consider clinician-patient engagement and continuity of care to be a driving philosophy behind the treatment they provide to people who have developed schizophrenia or a related psychotic illness. In almost all countries where this service model has been implemented there is a dearth of available data about what is happening to patients following time-limited treatment. Information on discharge pathways in England indicates that some early intervention specialists are discharging most of their patients from all psychiatric services after only 2 or 3 years of input. Some ex-patients will be living in a state of torment and neglect due to an untreated psychosis. In the UK, general practitioners should refuse to accept these discharge pathways for patients with insight-impairing mental illnesses.