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Mayer SF, Corcoran C, Kennedy L, Leucht S, Bighelli I. Cognitive behavioural therapy added to standard care for first-episode and recent-onset psychosis. Cochrane Database Syst Rev 2024; 3:CD015331. [PMID: 38470162 PMCID: PMC10929366 DOI: 10.1002/14651858.cd015331.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/13/2024]
Abstract
BACKGROUND Cognitive behavioural therapy (CBT) can be effective in the general population of people with schizophrenia. It is still unclear whether CBT can be effectively used in the population of people with a first-episode or recent-onset psychosis. OBJECTIVES To assess the effects of adding cognitive behavioural therapy to standard care for people with a first-episode or recent-onset psychosis. SEARCH METHODS We conducted a systematic search on 6 March 2022 in the Cochrane Schizophrenia Group's Study-Based Register of Trials, which is based on CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, PubMed, ClinicalTrials.gov, ISRCTN, and WHO ICTRP. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing CBT added to standard care vs standard care in first-episode or recent-onset psychosis, in patients of any age. DATA COLLECTION AND ANALYSIS Two review authors (amongst SFM, CC, LK and IB) independently screened references for inclusion, extracted data from eligible studies and assessed the risk of bias using RoB2. Study authors were contacted for missing data and additional information. Our primary outcome was general mental state measured on a validated rating scale. Secondary outcomes included other specific measures of mental state, global state, relapse, admission to hospital, functioning, leaving the study early, cognition, quality of life, satisfaction with care, self-injurious or aggressive behaviour, adverse events, and mortality. MAIN RESULTS We included 28 studies, of which 26 provided data on 2407 participants (average age 24 years). The mean sample size in the included studies was 92 participants (ranging from 19 to 444) and duration ranged between 26 and 52 weeks. When looking at the results at combined time points (mainly up to one year after start of the intervention), CBT added to standard care was associated with a greater reduction in overall symptoms of schizophrenia (standardised mean difference (SMD) -0.27, 95% confidence interval (CI) -0.47 to -0.08, 20 RCTs, n = 1508, I2 = 68%, substantial heterogeneity, low certainty of the evidence), and also with a greater reduction in positive (SMD -0.22, 95% CI -0.38 to -0.06, 22 RCTs, n = 1565, I² = 52%, moderate heterogeneity), negative (SMD -0.20, 95% CI -0.30 to -0.11, 22 RCTs, n = 1651, I² = 0%) and depressive symptoms (SMD -0.13, 95% CI -0.24 to -0.01, 18 RCTs, n = 1182, I² = 0%) than control. CBT added to standard care was also associated with a greater improvement in the global state (SMD -0.34, 95% CI -0.67 to -0.01, 4 RCTs, n = 329, I² = 47%, moderate heterogeneity) and in functioning (SMD -0.23, 95% CI -0.42 to -0.05, 18 RCTs, n = 1241, I² = 53%, moderate heterogeneity, moderate certainty of the evidence) than control. We did not find a difference between CBT added to standard care and control in terms of number of participants with relapse (relative risk (RR) 0.82, 95% CI 0.57 to 1.18, 7 RCTs, n = 693, I² = 48%, low certainty of the evidence), leaving the study early for any reason (RR 0.87, 95% CI 0.72 to 1.05, 25 RCTs, n = 2242, I² = 12%, moderate certainty of the evidence), adverse events (RR 1.29, 95% CI 0.85 to 1.97, 1 RCT, n = 43, very low certainty of the evidence) and the other investigated outcomes. AUTHORS' CONCLUSIONS This review synthesised the latest evidence on CBT added to standard care for people with a first-episode or recent-onset psychosis. The evidence identified by this review suggests that people with a first-episode or recent-onset psychosis may benefit from CBT additionally to standard care for multiple outcomes (overall, positive, negative and depressive symptoms of schizophrenia, global state and functioning). Future studies should better define this population, for which often heterogeneous definitions are used.
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Affiliation(s)
- Susanna Franziska Mayer
- Section for Evidence-Based Medicine in Psychiatry and Psychotherapy, TUM School of Medicine and Health, Technical University of Munich, München, Germany
| | | | - Liam Kennedy
- Department of Old Age Psychiatry, Carew House, St Vincent's Hospital, Dublin, Ireland
| | - Stefan Leucht
- Section for Evidence-Based Medicine in Psychiatry and Psychotherapy, TUM School of Medicine and Health, Technical University of Munich, München, Germany
- German Center for Mental Health (DZPG), Munich, Germany
| | - Irene Bighelli
- Section for Evidence-Based Medicine in Psychiatry and Psychotherapy, TUM School of Medicine and Health, Technical University of Munich, München, Germany
- German Center for Mental Health (DZPG), Munich, Germany
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Griffiths SL, Bogatsu T, Longhi M, Butler E, Alexander B, Bandawar M, Everard L, Jones PB, Fowler D, Hodgekins J, Amos T, Freemantle N, McCrone P, Singh SP, Birchwood M, Upthegrove R. Five-year illness trajectories across racial groups in the UK following a first episode psychosis. Soc Psychiatry Psychiatr Epidemiol 2023; 58:569-579. [PMID: 36717434 PMCID: PMC10066114 DOI: 10.1007/s00127-023-02428-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 01/12/2023] [Indexed: 02/01/2023]
Abstract
PURPOSE Psychosis disproportionally affects ethnic minority groups in high-income countries, yet evidence of disparities in outcomes following intensive early intervention service (EIS) for First Episode Psychosis (FEP) is less conclusive. We investigated 5-year clinical and social outcomes of young people with FEP from different racial groups following EIS care. METHOD Data were analysed from the UK-wide NIHR SUPEREDEN study. The sample at baseline (n = 978) included White (n = 750), Black (n = 71), and Asian (n = 157) individuals, assessed during the 3 years of EIS, and up to 2 years post-discharge (n = 296; Black [n = 23]; Asian [n = 52] and White [n = 221]). Outcome trajectories were modelled for psychosis symptoms (positive, negative, and general), functioning, and depression, using linear mixed effect models (with random intercept and slopes), whilst controlling for social deprivation. Discharge service was also explored across racial groups, 2 years following EIS. RESULTS Variation in linear growth over time was accounted for by racial group status for psychosis symptoms-positive (95% CI [0.679, 1.235]), negative (95% CI [0.315, 0.783]), and general (95% CI [1.961, 3.428])-as well as for functioning (95% CI [11.212, 17.677]) and depressive symptoms (95% CI [0.261, 0.648]). Social deprivation contributed to this variance. Black individuals experienced greater levels of deprivation (p < 0.001, 95% CI [0.187, 0.624]). Finally, there was a greater likelihood for Asian (OR = 3.04; 95% CI [2.050, 4.498]) and Black individuals (OR = 2.47; 95% CI [1.354, 4.520]) to remain in secondary care by follow-up. CONCLUSION Findings suggest variations in long-term clinical and social outcomes following EIS across racial groups; social deprivation contributed to this variance. Black and Asian individuals appear to make less improvement in long-term recovery and are less likely to be discharged from mental health services. Replication is needed in large, complete data, to fully understand disparities and blind spots to care.
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Affiliation(s)
- Siân Lowri Griffiths
- Institute for Mental Health, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK.
| | - Tumelo Bogatsu
- Institute for Mental Health, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Mia Longhi
- Institute for Mental Health, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Emily Butler
- Institute for Mental Health, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Beel Alexander
- Institute for Mental Health, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Mrunal Bandawar
- Institute for Mental Health, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Linda Everard
- Birmingham and Solihull Mental Health Foundation Trust, Birmingham, UK
| | - Peter B Jones
- Department of Psychiatry, University of Cambridge and CAMEO, Cambridge and Peterborough NHS Foundation Trust, Fulbourn, UK
| | - David Fowler
- Department of Psychology, University of Sussex, Brighton, UK
| | | | - Tim Amos
- Academic Unit of Psychiatry, University of Bristol, Bristol, UK
| | - Nick Freemantle
- Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Paul McCrone
- Institute for Life Course Development, University of Greenwich, London, UK
| | - Swaran P Singh
- Mental Health and Wellbeing Warwick Medical School, University of Warwick, Coventry, UK
| | - Max Birchwood
- Mental Health and Wellbeing Warwick Medical School, University of Warwick, Coventry, UK
| | - Rachel Upthegrove
- Institute for Mental Health, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
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Weiss A, Steadman S, Mercier HD, Hansel TC, Chaudhry S, Clark I. Pathways to Care: How Help-Seeking Behaviors Relate to Duration of Untreated Psychosis and Treatment Engagement. Psychiatr Q 2022; 93:473-482. [PMID: 34669120 DOI: 10.1007/s11126-021-09960-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/23/2021] [Indexed: 01/20/2023]
Abstract
While much research has focused on the relationship between duration of untreated psychosis (DUP) and clinical outcomes in the first episode psychosis (FEP) patient population, little is known about the individual help-seeking episodes (HSE) that patients undergo before receiving appropriate care. The purpose of this project is to better understand how early referral to FEP-specific care and support system differences affect patients' DUP and engagement with treatment. Data from 50 patients was analyzed at the Early Psychosis Intervention Clinic of New Orleans (EPIC-NOLA) using a modified version of the Pathways to Care Assessments and data captured during clinical care. Patients with their first HSE leading to a referral to EPIC-NOLA (M = 13.3, SD = 11.17) had shorter DUP compared to patients referred after two or more HSEs (M = 29.7, SD = 36. 7), t (38.6) = 2.31, p = .026, 95%CI = 2.0-30.7. One chi-square test revealed a significantly greater proportion of patients referred after one HSE stayed in treatment for 12 months or more. Cluster analysis and independent t-test analyses revealed that patients with hospital pathways (M = 35.00, SD = 39.36) had significantly longer DUP compared to those with self, other and hospital (M = 15.21, SD = 19.07) care pathways. This study supports existing literature that suggest early FEP treatment leads to shortened DUP and longer treatment engagement. Additionally, patients with support systems (people or services) assisting them with help-seeking reach EPIC-NOLA faster, have shorter DUP, and have better treatment engagement.
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Affiliation(s)
- Ashley Weiss
- Department of Psychiatry and Behavioral Services, Tulane University School of Medicine, New Orleans, LA, USA.
| | - Spencer Steadman
- Department of Psychiatry and Behavioral Services, Tulane University School of Medicine, New Orleans, LA, USA
| | - Hannah D Mercier
- Department of Psychiatry and Behavioral Services, Tulane University School of Medicine, New Orleans, LA, USA
| | | | - Serena Chaudhry
- Department of Psychiatry and Behavioral Services, Tulane University School of Medicine, New Orleans, LA, USA
| | - Isabel Clark
- Department of Psychiatry and Behavioral Services, Tulane University School of Medicine, New Orleans, LA, USA
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Abstract
This invited commentary provides a conceptual history of modern early intervention services, briefly reviews the accomplishments of an international clinical and research community, and offers proposals for how such services might participate in the next generation of progress. In keeping with the theme of this column, we make the argument that such services should orient around bi-directional knowledge translation across basic, clinical and policy domains.
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Affiliation(s)
- Vinod H Srihari
- Department of Psychiatry, Yale University, New Haven, CT, USA
- Program for Specialized Treatment Early in Psychosis (STEP), Connecticut Mental Health Center, New Haven, CT, USA
| | - Matcheri S Keshavan
- Department of Psychiatry, Harvard Medical School at Beth Israel Deaconess Medical Center, Boston, MA, USA
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Griffiths SL, Leighton SP, Mallikarjun PK, Blake G, Everard L, Jones PB, Fowler D, Hodgekins J, Amos T, Freemantle N, Sharma V, Marshall M, McCrone P, Singh SP, Birchwood M, Upthegrove R. Structure and stability of symptoms in first episode psychosis: a longitudinal network approach. Transl Psychiatry 2021; 11:567. [PMID: 34743179 PMCID: PMC8572227 DOI: 10.1038/s41398-021-01687-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 09/21/2021] [Accepted: 10/20/2021] [Indexed: 12/13/2022] Open
Abstract
Early psychosis is characterised by heterogeneity in illness trajectories, where outcomes remain poor for many. Understanding psychosis symptoms and their relation to illness outcomes, from a novel network perspective, may help to delineate psychopathology within early psychosis and identify pivotal targets for intervention. Using network modelling in first episode psychosis (FEP), this study aimed to identify: (a) key central and bridge symptoms most influential in symptom networks, and (b) examine the structure and stability of the networks at baseline and 12-month follow-up. Data on 1027 participants with FEP were taken from the National EDEN longitudinal study and used to create regularised partial correlation networks using the 'EBICglasso' algorithm for positive, negative, and depressive symptoms at baseline and at 12-months. Centrality and bridge estimations were computed using a permutation-based network comparison test. Depression featured as a central symptom in both the baseline and 12-month networks. Conceptual disorganisation, stereotyped thinking, along with hallucinations and suspiciousness featured as key bridge symptoms across the networks. The network comparison test revealed that the strength and bridge centralities did not differ significantly between the two networks (C = 0.096153; p = 0.22297). However, the network structure and connectedness differed significantly from baseline to follow-up (M = 0.16405, p = <0.0001; S = 0.74536, p = 0.02), with several associations between psychosis and depressive items differing significantly by 12 months. Depressive symptoms, in addition to symptoms of thought disturbance (e.g. conceptual disorganisation and stereotyped thinking), may be examples of important, under-recognized treatment targets in early psychosis, which may have the potential to lead to global symptom improvements and better recovery.
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Affiliation(s)
| | - Samuel P Leighton
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | | | - Georgina Blake
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Linda Everard
- Birmingham and Solihull Mental Health Foundation Trust, Birmingham, UK
| | - Peter B Jones
- Department of Psychiatry, University of Cambridge and CAMEO, Cambridge and Peterborough NHS Foundation Trust, Cambridge, UK
| | - David Fowler
- Department of Psychology, University of Sussex, Brighton, UK
| | | | - Tim Amos
- Academic Unit of Psychiatry, University of Bristol, Bristol, UK
| | - Nick Freemantle
- Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Vimal Sharma
- Early Intervention Service, Cheshire and Wirral NHS Foundation Trust, Liverpool, UK
| | - Max Marshall
- Lancashire Care NHS Foundation Trust, Preston, UK
| | - Paul McCrone
- Institute for Life Course Development, University of Greenwich, London, UK
| | - Swaran P Singh
- Mental Health and Wellbeing Warwick Medical School, University of Warwick, Coventry, UK
| | - Max Birchwood
- Mental Health and Wellbeing Warwick Medical School, University of Warwick, Coventry, UK
| | - Rachel Upthegrove
- Institute for Mental Health, University of Birmingham, Birmingham, UK
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
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Marwaha S, Hett D, Johnson S, Fowler D, Hodgekins J, Freemantle N, McCrone P, Everard L, Jones P, Amos T, Singh S, Sharma V, Birchwood M. The impact of manic symptoms in first-episode psychosis: Findings from the UK National EDEN study. Acta Psychiatr Scand 2021; 144:358-367. [PMID: 33864251 DOI: 10.1111/acps.13307] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 04/12/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The extant literature is inconsistent over whether manic symptoms in first-episode psychosis (FEP) impact on its development and trajectory. This study addressed the following: (1) Does Duration of Untreated Illness (DUI) and Duration of Untreated Psychosis (DUP) differ between FEP patients with and without manic symptoms? (2) Do manic symptoms in FEP have an impact on time to remission over 1 year? METHODS We used data from the National EDEN study, a longitudinal cohort of patients with FEP accessing early intervention services (EIS) in England, which measured manic, positive and negative psychotic symptoms, depression and functioning at service entry and 1 year. Data from 913 patients with FEP (639 without manic symptoms, 237 with manic symptoms) were analysed using both general linear modelling and survival analysis. RESULTS Compared to FEP patients without manic symptoms, those with manic symptoms had a significantly longer DUI, though no difference in DUP. At baseline, people with manic symptoms had higher levels of positive and negative psychotic symptoms, depression and worse functioning. At 12 months, people with manic symptoms had significantly poorer functioning and more positive psychotic symptoms. The presence of manic symptoms delayed time to remission over 1 year. There was a 19% reduced rate of remission for people with manic symptoms compared to those without. CONCLUSIONS Manic symptoms in FEP are associated with delays to treatment. This poorer trajectory persists over 1 year. They appear to be a vulnerable and under-recognised group for poor outcome and need more focussed early intervention treatment.
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Affiliation(s)
- Steven Marwaha
- Institute for Mental Health, University of Birmingham, Birmingham, UK.,National Centre for Mental Health, Birmingham and Solihull Mental Health Trust, Birmingham, UK
| | - Danielle Hett
- Institute for Mental Health, University of Birmingham, Birmingham, UK.,National Centre for Mental Health, Birmingham and Solihull Mental Health Trust, Birmingham, UK
| | - Sonia Johnson
- Division of Psychiatry, University College London, London, UK
| | - David Fowler
- School of Psychology, University of Sussex, Brighton, UK
| | | | | | - Paul McCrone
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Linda Everard
- National Centre for Mental Health, Birmingham and Solihull Mental Health Trust, Birmingham, UK
| | | | - Tim Amos
- Avon and Wiltshire Mental Health Partnership NHS Trust, Bath, UK
| | - Swaran Singh
- Mental Health and Well-being, University of Warwick Medical School, Warwick University, Coventry, UK
| | | | - Max Birchwood
- Mental Health and Well-being, University of Warwick Medical School, Warwick University, Coventry, UK
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Singh SP, Mohan M, Iyer SN, Meyer C, Currie G, Shah J, Madan J, Birchwood M, Sood M, Ramachandran P, Chadda RK, Lilford RJ, Rangaswamy T, Furtado V. Warwick-India-Canada (WIC) global mental health group: rationale, design and protocol. BMJ Open 2021; 11:e046362. [PMID: 34117045 PMCID: PMC8202113 DOI: 10.1136/bmjopen-2020-046362] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
INTRODUCTION The primary aim of the National Institute of Health Research-funded global health research group, Warwick-India-Canada (WIC), is to reduce the burden of psychotic disorders in India. India has a large pool of undetected and untreated patients with psychosis and a treatment gap exceeding 75%. Evidence-based packages of care have been piloted, but delivery of treatments still remains a challenge. Even when patients access treatment, there is minimal to no continuity of care. The overarching ambition of WIC programme is to improve patient outcomes through (1) developing culturally tailored clinical interventions, (2) early identification and timely treatment of individuals with mental illness and (3) improving access to care by exploiting the potential of digital technologies. METHODS AND ANALYSIS This multicentre, multicomponent research programme, comprising five work packages and two cross-cutting themes, is being conducted at two sites in India: Schizophrenia Research Foundation, Chennai (South India) and All India Institute of Medical Sciences, New Delhi (North India). WIC will (1) develop and evaluate evidence-informed interventions for early and first-episode psychosis; (2) determine pathways of care for early psychosis; (3) investigate the efficacy and cost-effectiveness of community care models, including digital and mobile technologies; (4) develop strategies to reduce the burden of mental illnesses among youth; (5) assess the economic burden of psychosis on patients and their carers; and (6) determine the feasibility of an early intervention in psychosis programme in India. ETHICS AND DISSEMINATION This study was approved by the University of Warwick's Biomedical and Scientific Research Ethics Committee (reference: REGO-2018-2208), Coventry, UK and research ethics committees of all participating organisations. Research findings will be disseminated through peer-reviewed scientific publications, presentations at learnt societies and visual media.
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Affiliation(s)
- Swaran P Singh
- Division of Mental Health & Wellbeing, Warwick Medical School, University of Warwick, Coventry, UK
- Coventry and Warwickshire Partnership Trust, Coventry, UK
| | - Mohapradeep Mohan
- Division of Mental Health & Wellbeing, Warwick Medical School, University of Warwick, Coventry, UK
| | - Srividya N Iyer
- Prevention and Early Intervention Program for Psychosis (PEPP-Montréal), Douglas Mental Health University Institute, Verdun, Quebec, Canada
- Department of Psychiatry, McGill University, Montreal, Québec, Canada
| | - Caroline Meyer
- WMG and Warwick Medical School, University of Warwick, Coventry, UK
| | - Graeme Currie
- Warwick Business School, University of Warwick, Coventry, UK
| | - Jai Shah
- Prevention and Early Intervention Program for Psychosis (PEPP-Montréal), Douglas Mental Health University Institute, Verdun, Quebec, Canada
- Department of Psychiatry, McGill University, Montreal, Québec, Canada
| | - Jason Madan
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Max Birchwood
- Division of Mental Health & Wellbeing, Warwick Medical School, University of Warwick, Coventry, UK
| | - Mamta Sood
- Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | | | - Rakesh K Chadda
- Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Richard J Lilford
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | | | - Vivek Furtado
- Division of Mental Health & Wellbeing, Warwick Medical School, University of Warwick, Coventry, UK
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8
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Crespo-Facorro B, Such P, Nylander AG, Madera J, Resemann HK, Worthington E, O'Connor M, Drane E, Steeves S, Newton R. The burden of disease in early schizophrenia - a systematic literature review. Curr Med Res Opin 2021; 37:109-121. [PMID: 33095689 DOI: 10.1080/03007995.2020.1841618] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Schizophrenia is a heterogeneous disorder with a burden that can vary greatly depending on the severity and the duration. Previous research has suggested that patients in the earlier stages of schizophrenia (typically first-episode schizophrenia) benefit from effective early treatment, however, a comprehensive review of the burden specifically in this population has not been undertaken. A systematic literature review was therefore conducted to characterize the clinical, economic, and humanistic burden, as reported in naturalistic studies of schizophrenia populations specifically at an early stage of disease in comparison with healthy controls, patients with chronic schizophrenia, and patients with other psychiatric disorders. METHODS AND MATERIALS Searches were conducted in MEDLINE, MEDLINE In-Process, Embase, PsycINFO, and EconLit databases for records published between January 2005 and April 2019, and of relevant conference abstracts published between January 2014 and May 2019. Data were extracted from relevant publications and subjected to qualitative evaluation. RESULTS Fifty-two publications were identified for inclusion and revealed a considerable burden for early schizophrenia with regards to mortality, psychiatric comorbidities such as substance abuse and depression, poor social functioning, and unemployment. Comparisons with chronic schizophrenia suggested a greater burden with longer disease duration, while comparisons with other psychiatric disorders were inconclusive. This review uncovered various gaps in the available literature, including limited or no data on incarcerations, caregiver burden, and costs associated with early schizophrenia. CONCLUSIONS Overall, the burden of schizophrenia is apparent even in the early stages of the disease, although further research is required to quantify the burden with chronic schizophrenia and other psychiatric disorders.
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Affiliation(s)
- Benedicto Crespo-Facorro
- Department of Medicine & Psychiatry, University Hospital Virgen del Rocio, IBiS, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Sevilla, Spain
| | | | | | - Jessica Madera
- Global Medical Affairs, Otsuka Pharmaceutical Development & Commercialization, Inc, Princeton, NJ, USA
| | | | | | | | - Emma Drane
- Costello Medical Consulting Ltd, Cambridge, UK
| | | | - Richard Newton
- Peninsula Health, Monash University, Frankston, Victoria, Australia
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Puntis S, Minichino A, De Crescenzo F, Cipriani A, Lennox B, Harrison R. Specialised early intervention teams (extended time) for recent-onset psychosis. Cochrane Database Syst Rev 2020; 11:CD013287. [PMID: 33135812 PMCID: PMC8094422 DOI: 10.1002/14651858.cd013287.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Psychosis is an illness characterised by the presence of hallucinations and delusions that can cause distress or a marked change in an individual's behaviour (e.g. social withdrawal, flat or blunted effect). A first episode of psychosis (FEP) is the first time someone experiences these symptoms that can occur at any age, but the condition is most common in late adolescence and early adulthood. This review is concerned with FEP and the early stages of a psychosis, referred to throughout this review as 'recent-onset psychosis.' Specialised early intervention (SEI) teams are community mental health teams that specifically treat people who are experiencing, or have experienced, a recent-onset psychosis. SEI teams provide a range of treatments including medication, psychotherapy, psychoeducation, educational and employment support, augmented by assertive contact with the service user and small caseloads. Treatment is time limited, usually offered for two to three years, after which service users are either discharged to primary care or transferred to a standard adult community mental health team. Evidence suggests that once SEI treatment ends, improvements may not be sustained, bringing uncertainty about the optimal duration of SEI to ensure the best long-term outcomes. Extending SEI has been proposed as a way of providing continued intensive treatment and continuity of care, of usually up to five years, in order to a) sustain the positive initial outcomes of SEI; and b) improve the long-term trajectory of the illness. OBJECTIVES To compare extended SEI teams with treatment as usual (TAU) for people with recent-onset psychosis. To compare extended SEI teams with standard SEI teams followed by TAU (standard SEI + TAU) for people with recent-onset psychosis. SEARCH METHODS On 3 October 2018 and 22 October 2019, we searched Cochrane Schizophrenia's study-based register of trials, including registries of clinical trials. SELECTION CRITERIA We selected all randomised controlled trials (RCTs) comparing extended SEI with TAU for people with recent-onset psychosis and all RCTs comparing extended SEI with standard SEI + TAU for people with recent-onset psychosis. We entered trials meeting these criteria and reporting usable data as included studies. DATA COLLECTION AND ANALYSIS We independently inspected citations, selected studies, extracted data and appraised study quality. For binary outcomes we calculated the risk ratios (RRs) and their 95% confidence intervals (CIs). For continuous outcomes we calculated the mean difference (MD) and their 95% CIs, or if assessment measures differed for the same construct, we calculated the standardised mean difference (SMD) with 95% CIs. We assessed risk of bias for included studies and created a 'Summary of findings' table using the GRADE approach. MAIN RESULTS We included three RCTs, with a total 780 participants, aged 16 to 35 years. All participants met the criteria for schizophrenia spectrum disorders or affective psychoses. No trials compared extended SEI with TAU. All three trials randomly allocated people approximately two years into standard SEI to either extended SEI or standard SEI + TAU. The certainty of evidence for outcomes varied from low to very low. Our primary outcomes were recovery and disengagement from mental health services. No trials reported on recovery, and we used remission as a proxy. Three trials reported on remission, with the point estimate suggesting a 13% increase in remission in favour of extended SEI, but this included wide confidence intervals (CIs) and a very uncertain estimate of no benefit (RR 1.13, 95% CI 0.97 to 1.31; 3 trials, 780 participants; very low-certainty evidence). Two trials provided data on disengagement from services with evidence that extended SEI care may result in fewer disengagements from mental health treatment (15%) in comparison to standard SEI + TAU (34%) (RR 0.45, 95% CI 0.27 to 0.75; 2 trials, 380 participants; low-certainty evidence). There may be no evidence of a difference in rates of psychiatric hospital admission (RR 1.55, 95% CI 0.68 to 3.52; 1 trial, 160 participants; low-certainty evidence), or the number of days spent in a psychiatric hospital (MD -2.70, 95% CI -8.30 to 2.90; 1 trial, 400 participants; low-certainty evidence). One trial found uncertain evidence regarding lower global psychotic symptoms in extended SEI in comparison to standard SEI + TAU (MD -1.90, 95% CI -3.28 to -0.52; 1 trial, 156 participants; very low-certainty evidence). It was uncertain whether the use of extended SEI over standard SEI + TAU resulted in fewer deaths due to all-cause mortality, as so few deaths were recorded in trials (RR 0.38, 95% CI 0.09 to 1.64; 3 trials, 780 participants; low-certainty evidence). Very uncertain evidence suggests that using extended SEI instead of standard SEI + TAU may not improve global functioning (SMD 0.23, 95% CI -0.29 to 0.76; 2 trials, 560 participants; very low-certainty evidence). There was low risk of bias in all three trials for random sequence generation, allocation concealment and other biases. All three trials had high risk of bias for blinding of participants and personnel due to the nature of the intervention. For the risk of bias for blinding of outcome assessments and incomplete outcome data there was at least one trial with high or unclear risk of bias. AUTHORS' CONCLUSIONS There may be preliminary evidence of benefit from extending SEI team care for treating people experiencing psychosis, with fewer people disengaging from mental health services. Evidence regarding other outcomes was uncertain. The certainty of evidence for the measured outcomes was low or very low. Further, suitably powered studies that use a consistent approach to outcome selection are needed, but with only one further ongoing trial, there is unlikely to be any definitive conclusion for the effectiveness of extended SEI for at least the next few years.
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Affiliation(s)
- Stephen Puntis
- Department of Psychiatry, University of Oxford, Oxford, UK
| | | | | | | | - Belinda Lennox
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - Rachael Harrison
- Oxford University Medical School, Medical Sciences Divisional Office, Oxford, UK
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Puntis S, Minichino A, De Crescenzo F, Cipriani A, Lennox B, Harrison R. Specialised early intervention teams for recent-onset psychosis. Cochrane Database Syst Rev 2020; 11:CD013288. [PMID: 33135811 PMCID: PMC8092671 DOI: 10.1002/14651858.cd013288.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Psychosis is an illness characterised by the presence of hallucinations and delusions that can cause distress or a marked change in an individual's behaviour (e.g. social withdrawal, flat or blunted effect). A first episode of psychosis (FEP) is the first time someone experiences these symptoms that can occur at any age, but the condition is most common in late adolescence and early adulthood. This review is concerned with first episode psychosis (FEP) and the early stages of a psychosis, referred to throughout this review as 'recent-onset psychosis.' Specialised early intervention (SEI) teams are community mental health teams that specifically treat people who are experiencing, or have experienced a recent-onset psychosis. The purpose of SEI teams is to intensively treat people with psychosis early in the course of the illness with the goal of increasing the likelihood of recovery and reducing the need for longer-term mental health treatment. SEI teams provide a range of treatments including medication, psychotherapy, psychoeducation, and occupational, educational and employment support, augmented by assertive contact with the service user and small caseloads. Treatment is time limited, usually offered for two to three years, after which service users are either discharged to primary care or transferred to a standard adult community mental health team. A previous Cochrane Review of SEI found preliminary evidence that SEI may be superior to standard community mental health care (described as 'treatment as usual (TAU)' in this review) but these recommendations were based on data from only one trial. This review updates the evidence for the use of SEI services. OBJECTIVES To compare specialised early intervention (SEI) teams to treatment as usual (TAU) for people with recent-onset psychosis. SEARCH METHODS On 3 October 2018 and 22 October 2019, we searched Cochrane Schizophrenia's study-based register of trials, including registries of clinical trials. SELECTION CRITERIA We selected all randomised controlled trials (RCTs) comparing SEI with TAU for people with recent-onset psychosis. We entered trials meeting these criteria and reporting useable data as included studies. DATA COLLECTION AND ANALYSIS We independently inspected citations, selected studies, extracted data and appraised study quality. For binary outcomes we calculated the risk ratios (RRs) and their 95% confidence intervals (CIs). For continuous outcomes we calculated the mean difference (MD) and their 95% CIs, or if assessment measures differed for the same construct, we calculated the standardised mean difference (SMD) with 95% CIs. We assessed risk of bias for included studies and created a 'Summary of findings' table using the GRADE approach. MAIN RESULTS We included three RCTs and one cluster-RCT with a total of 1145 participants. The mean age in the trials was between 23.1 years (RAISE) and 26.6 years (OPUS). The included participants were 405 females (35.4%) and 740 males (64.6%). All trials took place in community mental healthcare settings. Two trials reported on recovery from psychosis at the end of treatment, with evidence that SEI team care may result in more participants in recovery than TAU at the end of treatment (73% versus 52%; RR 1.41, 95% CI 1.01 to 1.97; 2 studies, 194 participants; low-certainty evidence). Three trials provided data on disengagement from services at the end of treatment, with fewer participants probably being disengaged from mental health services in SEI (8%) in comparison to TAU (15%) (RR 0.50, 95% CI 0.31 to 0.79; 3 studies, 630 participants; moderate-certainty evidence). There was low-certainty evidence that SEI may result in fewer admissions to psychiatric hospital than TAU at the end of treatment (52% versus 57%; RR 0.91, 95% CI 0.82 to 1.00; 4 studies, 1145 participants) and low-certainty evidence that SEI may result in fewer psychiatric hospital days (MD -27.00 days, 95% CI -53.68 to -0.32; 1 study, 547 participants). Two trials reported on general psychotic symptoms at the end of treatment, with no evidence of a difference between SEI and TAU, although this evidence is very uncertain (SMD -0.41, 95% CI -4.58 to 3.75; 2 studies, 304 participants; very low-certainty evidence). A different pattern was observed in assessment of general functioning with an end of trial difference that may favour SEI (SMD 0.37, 95% CI 0.07 to 0.66; 2 studies, 467 participants; low-certainty evidence). It was uncertain whether the use of SEI resulted in fewer deaths due to all-cause mortality at end of treatment (RR 0.21, 95% CI 0.04 to 1.20; 3 studies, 741 participants; low-certainty evidence). There was low risk of bias for random sequence generation and allocation concealment in three of the four included trials; the remaining trial had unclear risk of bias. Due to the nature of the intervention, we considered all trials at high risk of bias for blinding of participants and personnel. Two trials had low risk of bias and two trials had high risk of bias for blinding of outcomes assessments. Three trials had low risk of bias for incomplete outcome data, while one trial had high risk of bias. Two trials had low risk of bias, one trial had high risk of bias, and one had unclear risk of bias for selective reporting. AUTHORS' CONCLUSIONS There is evidence that SEI may provide benefits to service users during treatment compared to TAU. These benefits probably include fewer disengagements from mental health services (moderate-certainty evidence), and may include small reductions in psychiatric hospitalisation (low-certainty evidence), and a small increase in global functioning (low-certainty evidence) and increased service satisfaction (moderate-certainty evidence). The evidence regarding the effect of SEI over TAU after treatment has ended is uncertain. Further evidence investigating the longer-term outcomes of SEI is needed. Furthermore, all the eligible trials included in this review were conducted in high-income countries, and it is unclear whether these findings would translate to low- and middle-income countries, where both the intervention and the comparison conditions may be different.
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Affiliation(s)
- Stephen Puntis
- Department of Psychiatry, University of Oxford, Oxford, UK
| | | | | | | | - Belinda Lennox
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - Rachael Harrison
- Oxford University Medical School, Medical Sciences Divisional Office, Oxford, UK
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Stokes I, Griffiths SL, Jones R, Everard L, Jones PB, Fowler D, Hodgekins J, Amos T, Freemantle N, Sharma V, Marshall M, Singh SP, Birchwood M, Upthegrove R. Prevalence of treatment resistance and clozapine use in early intervention services. BJPsych Open 2020; 6:e107. [PMID: 32938513 PMCID: PMC7576650 DOI: 10.1192/bjo.2020.89] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Treatment resistance causes significant burden in psychosis. Clozapine is the only evidence-based pharmacologic intervention available for people with treatment-resistant schizophrenia; current guidelines recommend commencement after two unsuccessful trials of standard antipsychotics. AIMS This paper aims to explore the prevalence of treatment resistance and pathways to commencement of clozapine in UK early intervention in psychosis (EIP) services. METHOD Data were taken from the National Evaluation of the Development and Impact of Early Intervention Services study (N = 1027) and included demographics, medication history and psychosis symptoms measured by the Positive and Negative Syndrome Scale (PANSS) at baseline, 6 months and 12 months. Prescribing patterns and pathways to clozapine were examined. We adopted a strict criterion for treatment resistance, defined as persistent elevated positive symptoms (a PANSS positive score ≥16, equating to at least two items of at least moderate severity), across three time points. RESULTS A total of 143 (18.1%) participants met the definition of treatment resistance of having continuous positive symptoms over 12 months, despite treatment in EIP services. Sixty-one (7.7%) participants were treatment resistant and eligible for clozapine, having had two trials of standard antipsychotics; however, only 25 (2.4%) were prescribed clozapine over the 12-month study period. Treatment-resistant participants were more likely to be prescribed additional antipsychotic medication and polypharmacy, instead of clozapine. CONCLUSIONS Prevalent treatment resistance was observed in UK EIP services, but prescription of polypharmacy was much more common than clozapine. Significant delays in the commencement of clozapine may reflect a missed opportunity to promote recovery in this critical period.
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Affiliation(s)
- Imogen Stokes
- Birmingham Medical School, College of Medical and Dental Sciences, University of Birmingham, UK
| | | | - Rowena Jones
- School of Psychology, Institute for Mental Health, University of Birmingham; and Research and Innovation, Birmingham and Solihull Mental Health Foundation Trust, UK
| | - Linda Everard
- Research and Innovation, Birmingham and Solihull Mental Health Foundation Trust, UK
| | | | - David Fowler
- Department of Psychology, University of Sussex, UK
| | | | | | - Nick Freemantle
- Institute of Clinical Trials & Methodology, University College London, UK
| | - Vimal Sharma
- Faculty of Health and Social Care, University of Chester, UK
| | | | - Swaran P Singh
- Birmingham Early Intervention Service, Birmingham Women's and Children's NHS Trust, UK
| | | | - Rachel Upthegrove
- Birmingham Medical School, College of Medical and Dental Sciences, University of Birmingham; School of Psychology, Institute for Mental Health, University of Birmingham; Birmingham Early Intervention Service, Birmingham Women's and Children's NHS Trust, UK
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12
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Lamsma J, Cahn W, Fazel S. Use of illicit substances and violent behaviour in psychotic disorders: two nationwide case-control studies and meta-analyses. Psychol Med 2020; 50:2028-2033. [PMID: 31462346 PMCID: PMC7525769 DOI: 10.1017/s0033291719002125] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 07/22/2019] [Accepted: 07/30/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Substance use disorder explains much of the excess risk of violent behaviour in psychotic disorders. However, it is unclear to what extent the pharmacological properties and subthreshold use of illicit substances are associated with violence. METHODS Individuals with psychotic disorders were recruited for two nationwide projects: GROUP (N = 871) in the Netherlands and NEDEN (N = 921) in the United Kingdom. Substance use and violent behaviour were assessed with standardized instruments and multiple sources of information. First, we used logistic regression models to estimate the associations of daily and nondaily use with violence for cannabis, stimulants, depressants and hallucinogens in the GROUP and NEDEN samples separately. Adjustments were made for age, sex and educational level. We then combined the results in random-effects meta-analyses. RESULTS Daily use, compared with nondaily or no use, and nondaily use, compared with no use, increased the pooled odds of violence in people with psychotic disorders for all substance categories. The increases were significant for daily use of cannabis [pooled odds ratio (pOR) 1.6, 95% confidence interval (CI) 1.2-2.0), stimulants (pOR 2.8, 95% CI 1.7-4.5) and depressants (pOR 2.2, 95% CI 1.1-4.5), and nondaily use of stimulants (pOR 1.6, 95% CI 1.2-2.0) and hallucinogens (pOR 1.5, 95% CI 1.1-2.1). Daily use of hallucinogens, which could only be analysed in the NEDEN sample, significantly increased the risk of violence (adjusted odds ratio 3.3, 95% CI 1.2-9.3). CONCLUSIONS Strategies to prevent violent behaviour in psychotic disorders should target any substance use.
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Affiliation(s)
- Jelle Lamsma
- Department of Psychiatry, University of Oxford, Oxford, UK
- Department of Psychiatry, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Wiepke Cahn
- Department of Psychiatry, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Seena Fazel
- Department of Psychiatry, University of Oxford, Oxford, UK
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Drake RJ, Husain N, Marshall M, Lewis SW, Tomenson B, Chaudhry IB, Everard L, Singh S, Freemantle N, Fowler D, Jones PB, Amos T, Sharma V, Green CD, Fisher H, Murray RM, Wykes T, Buchan I, Birchwood M. Effect of delaying treatment of first-episode psychosis on symptoms and social outcomes: a longitudinal analysis and modelling study. Lancet Psychiatry 2020; 7:602-610. [PMID: 32563307 PMCID: PMC7606908 DOI: 10.1016/s2215-0366(20)30147-4] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 03/31/2020] [Accepted: 04/01/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND Delayed treatment for first episodes of psychosis predicts worse outcomes. We hypothesised that delaying treatment makes all symptoms more refractory, with harm worsening first quickly, then more slowly. We also hypothesised that although delay impairs treatment response, worse symptoms hasten treatment, which at presentation mitigates the detrimental effect of treatment delay on symptoms. METHODS In this longitudinal analysis and modelling study, we included two longitudinal cohorts of patients with first-episode psychosis presenting to English early intervention services from defined catchments: NEDEN (recruiting 1003 patients aged 14-35 years from 14 services between Aug 1, 2005, and April 1, 2009) and Outlook (recruiting 399 patients aged 16-35 years from 11 services between April 1, 2006, and Feb 28, 2009). Patients were assessed at baseline, 6 months, and 12 months with the Positive and Negative Symptom Scale (PANSS), Calgary Depression Scale for Schizophrenia, Mania Rating Scale, Insight Scale, and Social and Occupational Functioning Assessment Scale. Regression was used to compare different models of the relationship between duration of untreated psychosis (DUP) and total symptoms at 6 months. Growth curve models of symptom subscales tested predictions arising from our hypotheses. FINDINGS We included 948 patients from the NEDEN study and 332 patients from the Outlook study who completed baseline assessments and were prescribed dopamine antagonist antipsychotics. For both cohorts, the best-fitting models were logarithmic, describing a curvilinear relationship of DUP to symptom severity: longer DUP predicted reduced treatment response, but response worsened more slowly as DUP lengthened. Increasing DUP by ten times predicted reduced improvement in total symptoms (ie, PANSS total) by 7·339 (95% CI 5·762 to 8·916; p<0·0001) in NEDEN data and 3·846 (1·689 to 6·003; p=0·0005) in Outlook data. This was true of treatment response for all symptom types. Nevertheless, longer DUP was not associated with worse presentation for any symptoms except depression in NEDEN (coefficients 0·099 [95% CI 0·033 to 0·164]; p=0·0028 in NEDEN and 0·007 [-0·081 to 0·095]; p=0·88 in Outlook). INTERPRETATION Long DUP was associated with reduced treatment response across subscales, consistent with a harmful process upstream of individual symptoms' mechanisms; response appeared to worsen quickly at first, then more slowly. These associations underscore the importance of rapid access to a comprehensive range of treatments, especially in the first weeks after psychosis onset. FUNDING UK Department of Health, National Institute of Health Research, and Medical Research Council.
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Affiliation(s)
- Richard J Drake
- Division of Psychology & Mental Health, University of Manchester, Manchester, UK; Manchester Academic Health Science Centre, Manchester, UK; Greater Manchester Mental Health NHS Foundation Trust, Prestwich, Manchester, UK.
| | - Nusrat Husain
- Division of Psychology & Mental Health, University of Manchester, Manchester, UK; Manchester Academic Health Science Centre, Manchester, UK; Lancashire Care & South Cumbria NHS Foundation Trust, Preston, Lancashire, UK
| | - Max Marshall
- Lancashire Care & South Cumbria NHS Foundation Trust, Preston, Lancashire, UK
| | - Shôn W Lewis
- Division of Psychology & Mental Health, University of Manchester, Manchester, UK; Manchester Academic Health Science Centre, Manchester, UK; Greater Manchester Mental Health NHS Foundation Trust, Prestwich, Manchester, UK
| | - Barbara Tomenson
- Division of Population Health, Health Services Research & Primary Care, University of Manchester, Manchester, UK; Manchester Academic Health Science Centre, Manchester, UK
| | - Imran B Chaudhry
- Division of Neuroscience & Experimental Psychology, University of Manchester, Manchester, UK; Manchester Academic Health Science Centre, Manchester, UK; Department of Psychiatry, Ziauddin University, Karachi, Pakistan
| | - Linda Everard
- Birmingham and Solihull NHS, Mental Health Foundation, Trust, Birmingham, UK
| | - Swaran Singh
- Department of Mental Health & Wellbeing, University of Warwick, Warwick, UK
| | - Nick Freemantle
- Institute for Clinical Trials, University College London, London, UK
| | - David Fowler
- School of Psychology, University of Sussex, Brighton, UK; Sussex Partnership NHS Foundation Trust, Worthing, UK
| | - Peter B Jones
- Department of Psychiatry, School of Clinical Medicine, University of Cambridge, Cambridge, UK; NIHR Collaboration for Leadership in Applied Health Research & Care East of England, Cambridge, UK
| | - Tim Amos
- School of Clinical Sciences, University of Bristol, Bristol, UK; Avon & Wiltshire Mental Health Partnership NHS Trust, Chippenham, UK
| | - Vimal Sharma
- Chester Medical School, University of Chester, Chester, UK; Cheshire & Wirral Partnership NHS Foundation Trust, Chester, UK
| | - Chloe D Green
- Manchester Academic Health Science Centre, Manchester, UK; Greater Manchester Mental Health NHS Foundation Trust, Prestwich, Manchester, UK
| | - Helen Fisher
- MRC Centre for Social, Genetic & Developmental Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Robin M Murray
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK; NIHR Maudsley Biomedical Research Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Til Wykes
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK; NIHR Maudsley Biomedical Research Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Iain Buchan
- Division of Informatics, Imaging & Data Sciences, University of Manchester, Manchester, UK; Manchester Academic Health Science Centre, Manchester, UK; Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK; Salford Royal NHS Foundation Trust, Salford, UK; Institute of Population Health Sciences, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - Max Birchwood
- Department of Mental Health & Wellbeing, University of Warwick, Warwick, UK
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Hutsebaut J, Debbané M, Sharp C. Designing a range of mentalizing interventions for young people using a clinical staging approach to borderline pathology. Borderline Personal Disord Emot Dysregul 2020; 7:6. [PMID: 32190330 PMCID: PMC7068993 DOI: 10.1186/s40479-020-0121-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 02/11/2020] [Indexed: 12/21/2022] Open
Abstract
Borderline personality disorder (BPD) can have a long-lasting impact on social and professional functioning, even when core symptoms of BPD are in remission. Adolescence may be a critical developmental period to change the potential long-term functional outcome of BPD. This paper presents a range of mentalizing interventions to alter the course and outcome of BPD, based upon a model of clinical staging. Mentalizing interventions have in common a focus on strengthening self-regulatory and interpersonal capacities, aiming to improve adaptive social learning. This paper argues that these interventions should be dosed and organized according to the stage of progression of BPD, which is illustrated by discussing different specific formats for mentalization-based interventions, including an early-intervention program for BPD and a standard program for full BPD.
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Affiliation(s)
- Joost Hutsebaut
- 1Viersprong Institute for Studies on Personality Disorders, Halsteren, the Netherlands.,Centre of Expertise on Personality Disorders, Utrecht, the Netherlands
| | - Martin Debbané
- 3Developmental Clinical Psychology Research Unit, Faculty of Psychology and Educational Sciences, University of Geneva, Geneva, Switzerland.,4Research Department of Clinical, Educational and Health Psychology, University College London, London, UK
| | - Carla Sharp
- 5Department of Psychology, University of Houston, Houston, Texas USA.,6University of the Free State, Bloemfontein, South Africa
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Leighton SP, Upthegrove R, Krishnadas R, Benros ME, Broome MR, Gkoutos GV, Liddle PF, Singh SP, Everard L, Jones PB, Fowler D, Sharma V, Freemantle N, Christensen RHB, Albert N, Nordentoft M, Schwannauer M, Cavanagh J, Gumley AI, Birchwood M, Mallikarjun PK. Development and validation of multivariable prediction models of remission, recovery, and quality of life outcomes in people with first episode psychosis: a machine learning approach. Lancet Digit Health 2019; 1:e261-e270. [PMID: 33323250 DOI: 10.1016/s2589-7500(19)30121-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 08/12/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Outcomes for people with first-episode psychosis are highly heterogeneous. Few reliable validated methods are available to predict the outcome for individual patients in the first clinical contact. In this study, we aimed to build multivariable prediction models of 1-year remission and recovery outcomes using baseline clinical variables in people with first-episode psychosis. METHODS In this machine learning approach, we applied supervised machine learning, using regularised regression and nested leave-one-site-out cross-validation, to baseline clinical data from the English Evaluating the Development and Impact of Early Intervention Services (EDEN) study (n=1027), to develop and internally validate prediction models at 1-year follow-up. We assessed four binary outcomes that were recorded at 1 year: symptom remission, social recovery, vocational recovery, and quality of life (QoL). We externally validated the prediction models by selecting from the top predictor variables identified in the internal validation models the variables shared with the external validation datasets comprised of two Scottish longitudinal cohort studies (n=162) and the OPUS trial, a randomised controlled trial of specialised assertive intervention versus standard treatment (n=578). FINDINGS The performance of prediction models was robust for the four 1-year outcomes of symptom remission (area under the receiver operating characteristic curve [AUC] 0·703, 95% CI 0·664-0·742), social recovery (0·731, 0·697-0·765), vocational recovery (0·736, 0·702-0·771), and QoL (0·704, 0·667-0·742; p<0·0001 for all outcomes), on internal validation. We externally validated the outcomes of symptom remission (AUC 0·680, 95% CI 0·587-0·773), vocational recovery (0·867, 0·805-0·930), and QoL (0·679, 0·522-0·836) in the Scottish datasets, and symptom remission (0·616, 0·553-0·679), social recovery (0·573, 0·504-0·643), vocational recovery (0·660, 0·610-0·710), and QoL (0·556, 0·481-0·631) in the OPUS dataset. INTERPRETATION In our machine learning analysis, we showed that prediction models can reliably and prospectively identify poor remission and recovery outcomes at 1 year for patients with first-episode psychosis using baseline clinical variables at first clinical contact. FUNDING Lundbeck Foundation.
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Affiliation(s)
- Samuel P Leighton
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Rachel Upthegrove
- Institute for Mental Health, University of Birmingham, Birmingham, UK
| | - Rajeev Krishnadas
- Institute of Neuroscience and Psychology, University of Glasgow, Glasgow, UK
| | - Michael E Benros
- Copenhagen Research Center for Mental Health, Mental Health Centre Copenhagen, Copenhagen University Hospital, Copenhagen, Denmark
| | - Matthew R Broome
- Institute for Mental Health, University of Birmingham, Birmingham, UK
| | - Georgios V Gkoutos
- Institute of Cancer and Genomics, University of Birmingham, Birmingham, UK; Institute of Translational Medicine, University of Birmingham, Birmingham, UK; Health Data Research UK Midlands, UK; University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Peter F Liddle
- Institute of Mental Health, University of Nottingham, Nottingham, UK
| | - Swaran P Singh
- Mental Health and Wellbeing, Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Peter B Jones
- Wolfson College, University of Cambridge, Cambridge, UK
| | - David Fowler
- School of Psychology, University of Sussex, Brighton, UK
| | - Vimal Sharma
- Department of Health and Social Care, University of Chester, Chester, UK
| | | | - Rune H B Christensen
- Copenhagen Research Center for Mental Health, Mental Health Centre Copenhagen, Copenhagen University Hospital, Copenhagen, Denmark
| | - Nikolai Albert
- Copenhagen Research Center for Mental Health, Mental Health Centre Copenhagen, Copenhagen University Hospital, Copenhagen, Denmark
| | - Merete Nordentoft
- Copenhagen Research Center for Mental Health, Mental Health Centre Copenhagen, Copenhagen University Hospital, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Matthias Schwannauer
- School of Health in Social Science, Clinical Psychology, University of Edinburgh, Edinburgh, UK
| | - Jonathan Cavanagh
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Andrew I Gumley
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Max Birchwood
- Mental Health and Wellbeing, Warwick Medical School, University of Warwick, Coventry, UK
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16
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Sullivan SA, Carroll R, Peters TJ, Amos T, Jones PB, Marshall M, Birchwood M, Fowler D, Johnson S, Fisher HL, Major B, Rahaman N, Joyce J, Chamberlain-Kent N, Lawrence J, Moran P, Tilling K. Duration of untreated psychosis and clinical outcomes of first episode psychosis: An observational and an instrumental variables analysis. Early Interv Psychiatry 2019; 13:841-847. [PMID: 29696781 DOI: 10.1111/eip.12676] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 02/19/2018] [Accepted: 03/13/2018] [Indexed: 12/01/2022]
Abstract
AIM Duration of untreated psychosis (DUP) is considered as a key prognostic variable in psychosis. Yet, it is unclear whether a longer DUP causes worse outcomes or whether reported associations have alternative explanations. METHODS Data from 2 cohorts of patients with first episode psychosis were used (n = 2134). Measures of DUP were assessed at baseline and outcomes at 12 months. Regression models were used to investigate the associations between DUP and outcomes. We also investigated whether any associations were replicated using instrumental variables (IV) analysis to reduce the effect of residual confounding and measurement bias. RESULTS There were associations between DUP per 1-year increase and positive psychotic symptoms (7.0% in symptom score increase 95% confidence interval (CI) 4.0%, 10.0%, P < .001), worse recovery (risk difference [RD] 0.78, 95%, CI 0.68, 0.83, P < .001) and worse global functioning (0.62 decrease in functioning score 95% CI -1.19, -0.04, P = .035). There was no evidence of an association with negative psychotic symptoms (1.0%, 95%, CI -2.0%, 5.0%, P = .455). The IV analysis showed weaker evidence of associations in the same direction between DUP per 1-year increase and positive psychotic symptoms, recovery and global functioning. However, there was evidence of an inverse association with negative psychotic symptoms (decrease of 15.0% in symptom score 95% CI -26.0%, -3.0%, P = .016). CONCLUSIONS We have confirmed previous findings of a positive association between positive psychotic symptoms, global functioning and recovery and DUP using regression analysis. IV analysis shows some support for these findings. Future investigation using IV analysis should be repeated in large data sets.
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Affiliation(s)
- Sarah A Sullivan
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.,NIHR CLAHRC West, Bristol, UK
| | - Robert Carroll
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Tim J Peters
- NIHR CLAHRC West, Bristol, UK.,School of Clinical Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Tim Amos
- Avon & Wiltshire Mental Health Partnership NHS Trust, Chippenham, UK
| | - Peter B Jones
- Department of Psychiatry, University of Cambridge, Cambridge, UK
| | | | - Max Birchwood
- Mental Health and Wellbeing, Warwick Medical School, University of Warwick
| | - David Fowler
- School of Psychology, University of Sussex, Brighton, UK
| | - Sonia Johnson
- Division of Psychiatry, University College London, London, UK.,Camden and Islington NHS Foundation Trust, London, UK
| | - Helen L Fisher
- King's College London, Social, Genetic & Developmental Psychiatry Centre, Institute of Psychiatry, Psychology & Neuroscience, London, UK
| | - Barnaby Major
- EQUIP, Hackney, East London NHS Foundation Trust, London, UK.,Herefordshire Early Intervention Service, 2gether NHS Foundation Trust, Gloucester, UK
| | - Nikola Rahaman
- Kensington, Chelsea, Westminster and Brent Early Intervention Service, Central & North West London NHS Foundation Trust, London, UK
| | - John Joyce
- Lewisham Early Intervention Service, South London and Maudsley NHS Foundation Trust, London, UK
| | - Nick Chamberlain-Kent
- Wandsworth Early Intervention Service, South West London & St Georges' Mental Health NHS Trust, London, UK
| | - Jo Lawrence
- STEP, Southwark, South London and Maudsley NHS Foundation Trust, London, UK
| | - Paul Moran
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Kate Tilling
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.,NIHR CLAHRC West, Bristol, UK
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17
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Gee B, Hodgekins J, Lavis A, Notley C, Birchwood M, Everard L, Freemantle N, Jones PB, Singh SP, Amos T, Marshall M, Sharma V, Smith J, Fowler D. Lived experiences of negative symptoms in first-episode psychosis: A qualitative secondary analysis. Early Interv Psychiatry 2019; 13:773-779. [PMID: 29573562 DOI: 10.1111/eip.12558] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2017] [Revised: 12/08/2017] [Accepted: 02/04/2018] [Indexed: 11/27/2022]
Abstract
AIM Exploring how negative symptoms are experienced and understood by individuals with lived experience of psychosis has the potential to offer insights into the complex psychosocial processes underlying negative symptom presentations. The aim of the current study was to investigate lived experiences of negative symptoms through secondary analysis of interviews conducted with individuals recovering from first-episode psychosis. METHOD Transcripts of in-depth interviews with participants (n = 24) recruited from Early Intervention in Psychosis services were analysed thematically with a focus on participants' experiences and personal understandings of features corresponding to the negative symptoms construct. RESULTS Descriptions of reductions in expression, motivation and sociability were common features of participants' accounts. Several participants described the experience of having difficulty interacting as like being a "zombie". Some participants experienced diminished capacity for emotion, thought or drive as underlying these experiences. However, participants typically attributed reductions in expression, motivation and sociability to medication side-effects, lack of confidence or active avoidance intended to protect them from rejection or ridicule, sometimes linked to internalized stigma. CONCLUSIONS Personal accounts of experiences of reduced expression, motivation and sociability during first-episode psychosis highlight the personal meaningfulness and role of agency in these features, challenging the framing of negative symptoms as passive manifestations of diminished capacity.
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Affiliation(s)
- Brioney Gee
- Norwich Medical School, University of East Anglia, Norwich, UK.,Norfolk and Suffolk NHS Foundation Trust, Norwich, UK
| | - Jo Hodgekins
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Anna Lavis
- University of Birmingham, Institute of Applied Health Research, Edgbastongh, Birmingham, UK
| | - Caitlin Notley
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Max Birchwood
- University of Warwick, Warwick Medical School, Coventry, UK
| | - Linda Everard
- Birmingham and Solihull Mental Health NHS Foundation Trust, Birmingham, UK
| | - Nick Freemantle
- University College London, Department of Primary Care and Population Health, London, UK
| | - Peter B Jones
- University of Cambridge, Department of Psychiatry, Cambridge, UK.,Cambridgeshire and Peterborough NHS Foundation Trust, Cambridgeshire, UK
| | - Swaran P Singh
- University of Warwick, Warwick Medical School, Coventry, UK
| | - Tim Amos
- University of Bristol, Bristol Medical School, Bristol, UK
| | - Max Marshall
- University of Manchester, School of Health Sciences, Manchester, UK
| | - Vimal Sharma
- University of Chester, Faculty of Health and Social Care, Chester, UK.,Cheshire and Wirral Partnership NHS Foundation Trust, UK
| | - Jo Smith
- University of Worcester, Institute of Health and Society, Worcester, UK
| | - David Fowler
- University of Sussex, School of Psychology, Brighton, UK
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18
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Lennox B, Yeeles K, Jones PB, Zandi M, Joyce E, Yu LM, Tomei G, Pollard R, Vincent SA, Shimazaki M, Cairns I, Dowling F, Kabir T, Barnes TRE, Lingford Hughes A, Hosseini AA, Harrower T, Buckley C, Coles A. Intravenous immunoglobulin and rituximab versus placebo treatment of antibody-associated psychosis: study protocol of a randomised phase IIa double-blinded placebo-controlled trial (SINAPPS2). Trials 2019; 20:331. [PMID: 31174586 PMCID: PMC6555751 DOI: 10.1186/s13063-019-3336-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 03/28/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Evidence is conflicting about a causal role of inflammation in psychosis and, specifically, regarding antibodies binding to neuronal membrane targets, especially N-methyl-D-aspartate receptors. NMDAR, LGI1 and GABA-A antibodies were found more prevalent in people with psychosis than in healthy controls. We aim to test whether these antibodies are pathogenic and may cause isolated psychosis. The SINAPPS2 phase IIa double-blinded randomised controlled trial will test the efficacy and safety of immunoglobulin and rituximab treatment versus placebo for patients with acute psychosis symptoms as added to psychiatric standard of care. METHODS We will screen approximately 2500 adult patients with acute psychosis to identify 160 with antibody-positive psychosis without co-existing neurological disease and recruit about 80 eligible participants to the trial in the period from September 2017 to September 2021 across the UK. Eligible patients will be randomised 1:1 either to intravenous immunoglobulin (IVIG) followed by rituximab or to placebo infusions of 1% albumin followed by 0.9% sodium chloride, respectively. To detect a time-to-symptomatic-recovery hazard ratio of 0.322 with a power of 80%, 56 participants are needed to complete the trial, allowing for up to 12 participants to drop out of each group. Eligible patients will be randomised and assessed at baseline within 4 weeks of their eligibility confirmation. The treatment will start with IVIG or 1% albumin placebo infusions over 2-4 consecutive days no later than 7 days from baseline. It will continue 4-5 weeks later with a rituximab or sodium chloride placebo infusion and will end 2-3 weeks after this with another rituximab or placebo infusion. The primary outcome is the time to symptomatic recovery defined as symptomatic remission sustained for at least 6 months on the following Positive and Negative Syndrome Scale items: P1, P2, P3, N1, N4, N6, G5 and G9. Participants will be followed for 12 months from the first day of treatment or, where sustained remission begins after the first 6 months, for an additional minimum of 6 months to assess later response. DISCUSSION The SINAPPS2 trial aims to test whether immunotherapy is efficacious and safe in psychosis associated with anti-neuronal membrane antibodies. TRIAL REGISTRATION ISRCTN, 11177045. Registered on 2 May 2017. EudraCT, 2016-000118-31. Registered on 22 November 2016. ClinicalTrials.gov, NCT03194815. Registered on 21 June 2017.
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Affiliation(s)
- Belinda Lennox
- Department of Psychiatry, University of Oxford and Oxford Health NHS Foundation Trust, Warneford Hospital, Warneford Lane, Oxford, OX3 7JX UK
| | - Ksenija Yeeles
- Department of Psychiatry, University of Oxford and Oxford Health NHS Foundation Trust, Warneford Hospital, Warneford Lane, Oxford, OX3 7JX UK
| | - Peter B. Jones
- School of Clinical Medicine and Department of Psychiatry, University of Cambridge, Box 189, Addenbrooke’s Hospital, Cambridge, CB2 2QQ UK
| | - Michael Zandi
- Department of Neuromuscular Diseases, University College London Queen Square Institute of Neurology, and National Hospital for Neurology and Neurosurgery, Queen Square, London, WC1N 3BG UK
| | - Eileen Joyce
- University College London Institute of Neurology, The National Hospital for Neurology and Neurosurgery, Box 19, Queen Square, London, WC1N 3BG UK
| | - Ly-Mee Yu
- Primary Care Clinical Trials Unit, Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG UK
| | - Giuliano Tomei
- Department of Psychiatry, University of Oxford and Oxford Health NHS Foundation Trust, Warneford Hospital, Warneford Lane, Oxford, OX3 7JX UK
| | - Rebecca Pollard
- Department of Psychiatry, University of Oxford and Oxford Health NHS Foundation Trust, Warneford Hospital, Warneford Lane, Oxford, OX3 7JX UK
| | - Sally-Anne Vincent
- Department of Psychiatry, University of Oxford and Oxford Health NHS Foundation Trust, Warneford Hospital, Warneford Lane, Oxford, OX3 7JX UK
| | - Mio Shimazaki
- Department of Psychiatry, University of Oxford and Oxford Health NHS Foundation Trust, Warneford Hospital, Warneford Lane, Oxford, OX3 7JX UK
| | - Iona Cairns
- Research and Development, Devon Partnerships NHS Foundation Trust, Wonford House, Dryden Road, Exeter, EX2 5AF UK
| | - Francis Dowling
- Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke’s Hospital, Coton House Level 6, Flat 61, Box 40, Hills Road, Cambridge, CB2 0QQ UK
| | - Thomas Kabir
- The McPin Foundation, 7–14 Great Dover Street, London, SE1 4YR UK
| | - Thomas R. E. Barnes
- Department of Medicine, The Centre for Psychiatry, Imperial College London, 7th Floor Commonwealth Building, Du Cane Road, London, W12 0NN UK
| | - Anne Lingford Hughes
- Centre for Psychiatry, Imperial College London, Burlington Danes, Hammersmith Campus Imperial College, London, UK
| | - Akram A. Hosseini
- Department of Neurology, Queen’s Medical Centre, Nottingham University Hospitals NHS Trust, Derby Road, Nottingham, NG7 2UH UK
| | - Timothy Harrower
- Royal Devon and Exeter Hospital, Royal Devon and Exeter NHS Foundation Trust, Wonford, Barrack Road, Exeter, EX2 5DW UK
| | - Camilla Buckley
- Nuffield Department of Clinical Neurosciences, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, West Wing, Headley Way, Oxford, OX3 9DU UK
| | - Alasdair Coles
- Department of Clinical Neurosciences, University of Cambridge, Box 165, Addenbrooke’s Hospital, Cambridge, CB2 2QQ UK
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19
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Melau M, Albert N, Nordentoft M. Development of a fidelity scale for Danish specialized early interventions service. Early Interv Psychiatry 2019; 13:568-573. [PMID: 29193743 DOI: 10.1111/eip.12523] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 04/11/2017] [Accepted: 09/30/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND The efficacy of the Specialized Early Intervention (SEI) treatment in Denmark, the OPUS treatment, has in a randomized clinical trial proved to be very effective compared to treatment as usual, and the dissemination of SEI services is increasing in Denmark. A prerequisite for upholding positive effects along with creating new teams and preserving critical components is to ensure fidelity to the model. Currently there is no Danish fidelity scale for SEI services. AIM To establish a fidelity scale for SEI teams, in a brief and easily manageable form, for the use of evaluating and assessing the critical components in Danish SEI services. METHOD We identified essential evidence-based components of SEI services internationally and interviewed experts from five Danish SEI teams, using an adapted version of the Delphi Consensus method. RESULTS An 18-point fidelity scale was constructed. The scale was divided into two dimensions: one relating to the structure of the SEI team and one relating to the character and content of the SEI treatment. Each component can be rated either 1 or 0 (1 point = fulfilling the requirements for the components; and 0 point = the requirements were not met). The maximum score was a total of 18 points with 5 of the components being mandatory. CONCLUSION The development of the fidelity scale is an important tool for securing the quality of SEI treatment in Denmark.
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Affiliation(s)
- Marianne Melau
- Mental Health Centre, Copenhagen University Hospital, Copenhagen, Denmark
| | - Nikolai Albert
- Mental Health Centre, Copenhagen University Hospital, Copenhagen, Denmark
| | - Merete Nordentoft
- Mental Health Centre, Copenhagen University Hospital, Copenhagen, Denmark
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20
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Puntis S, Minichino A, De Crescenzo F, Cipriani A, Lennox B. Specialised early intervention teams (extended time) for first episode psychosis. Cochrane Database Syst Rev 2019; 2019:CD013287. [PMCID: PMC6422232 DOI: 10.1002/14651858.cd013287] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/06/2023]
Abstract
This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: The primary objective is to compare extended early intervention (EEIP) specialised team care to usual community mental health care for the treatment of people with first episode psychosis (FEP). The secondary objective is to compare the effectiveness of EEIP specialised team care to standard early intervention (SEIP) specialised team care (i.e. to test whether there is a dose‐response effect).
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Affiliation(s)
- Stephen Puntis
- University of OxfordDepartment of PsychiatryWarneford HospitalWarneford LaneOxfordUKOX3 7JX
| | - Amedeo Minichino
- University of OxfordDepartment of PsychiatryWarneford HospitalWarneford LaneOxfordUKOX3 7JX
| | - Franco De Crescenzo
- University of OxfordDepartment of PsychiatryWarneford HospitalWarneford LaneOxfordUKOX3 7JX
| | - Andrea Cipriani
- University of OxfordDepartment of PsychiatryWarneford HospitalWarneford LaneOxfordUKOX3 7JX
| | - Belinda Lennox
- University of OxfordDepartment of PsychiatryWarneford HospitalWarneford LaneOxfordUKOX3 7JX
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21
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Rowland T, Birchwood M, Singh S, Freemantle N, Everard L, Jones P, Fowler D, Amos T, Marshall M, Sharma V, Thompson A. Short-term outcome of first episode delusional disorder in an early intervention population. Schizophr Res 2019; 204:72-79. [PMID: 30195583 DOI: 10.1016/j.schres.2018.08.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 08/22/2018] [Accepted: 08/28/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND Previous evidence suggests that delusional disorder has a later onset and better functional outcomes compared to schizophrenia. However, studies have not examined longitudinal outcomes in a first episode population, where confounding factors may be adjusted for. METHODS A nested case control study was designed within the National EDEN study; a cohort of 1027 first episode psychosis patients. Patients with a baseline diagnosis of delusional disorder (n = 48) were compared with schizophrenia (n = 262) at 6 and 12 months with respect to symptomatic and functional outcomes. Regression analysis was used to adjust for possible confounders. RESULTS Delusional disorder patients had a shorter duration of untreated psychosis compared to schizophrenia but were similar in other baseline characteristics. At baseline, delusional disorder patients had lower symptom scores but higher function scores compared to those with schizophrenia. At 12 months the differences persisted for symptoms scores but not overall function scores. After adjusting for baseline score, age and duration of untreated psychosis, differences between the groups remained significant only for Positive and Negative Syndrome Scale (PANNS) negative, general and total scores and recovery rates. There were no differences in changes in outcomes scores. CONCLUSIONS Delusional disorder in a first episode psychosis population presents with less severe symptoms, higher recovery rates and better functioning than schizophrenia, but at 12 months differences are ameliorated when adjusting for baseline differences.
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Affiliation(s)
- Tobias Rowland
- Division of Mental Health and Wellbeing, Warwick Medical School, University of Warwick, Coventry, UK
| | - Maximillian Birchwood
- Division of Mental Health and Wellbeing, Warwick Medical School, University of Warwick, Coventry, UK
| | - Swaran Singh
- Division of Mental Health and Wellbeing, Warwick Medical School, University of Warwick, Coventry, UK; The Early Intervention in Psychosis Service, Birmingham and Solihull Mental Health Foundation Trust, Birmingham, UK
| | - Nicholas Freemantle
- Department of Primary Care and Population Health, UCL Medical School (Royal Free Campus), London, UK
| | - Linda Everard
- The Early Intervention in Psychosis Service, Birmingham and Solihull Mental Health Foundation Trust, Birmingham, UK
| | - Peter Jones
- Department of Psychiatry, University of Cambridge, Cambridge, UK; CAMEO, Cambridge and Peterborough NHS Foundation Trust, Cambridge, UK
| | - David Fowler
- Academic Unit of Psychiatry and Department of Psychology, University of Sussex, Brighton, UK; School of Medicine, University of East Anglia, Norwich, UK
| | - Tim Amos
- Academic Unit of Psychiatry, University of Bristol, Bristol, UK
| | - Max Marshall
- School of Medicine, The University of Manchester, Manchester, UK
| | - Vimal Sharma
- Early Intervention Service, Cherry Bank Resource Centre, Cheshire and Wirral Partnership NHS Foundation Trust, Ellesmere Port, UK
| | - Andrew Thompson
- Division of Mental Health and Wellbeing, Warwick Medical School, University of Warwick, Coventry, UK; North Warwickshire Early Intervention in Psychosis Service, Coventry and Warwickshire Partnership NHS Trust, Coventry, UK.
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22
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Fowler D, Hodgekins J, French P. Social Recovery Therapy in improving activity and social outcomes in early psychosis: Current evidence and longer term outcomes. Schizophr Res 2019; 203:99-104. [PMID: 29070442 PMCID: PMC6336979 DOI: 10.1016/j.schres.2017.10.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Revised: 09/24/2017] [Accepted: 10/06/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Social Recovery Therapy (SRT) is a cognitive behavioural therapy which targets young people with early psychosis who have complex problems associated with severe social disability. This paper provides a narrative overview of current evidence for SRT and reports new data on a 2year follow-up of participants recruited into the Improving Social Recovery in Early Psychosis (ISREP) trial. METHOD In the ISREP study 50 participants (86%) were followed up at 2years, 15months post treatment. The primary outcome was engagement in paid work, assessed using the Time Use Survey. Engagement in education and voluntary work were also assessed. In addition, the Positive and Negative Syndrome Scales (PANSS) and the Beck Hopelessness Scale (BHS) were administered. RESULTS 25% of individuals with non-affective psychosis in the treatment group had engaged in paid work at some point in the year following the end of therapy, compared with none of the control group. Data from the PANSS and BHS suggested no worsening of symptoms and an indication that gains in hope were maintained over the 15month period following the end of therapy. CONCLUSION Social Recovery Therapy is a promising psychological intervention which may improve social recovery in individuals with early psychosis. The new data reported in this paper shows evidence of gains in engagement in paid employment outcomes that persisted 15months beyond the period of active intervention.
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Affiliation(s)
| | - Jo Hodgekins
- Norwich Medical School, University of East Anglia, Norwich NR4 7TJ, UK.
| | - Paul French
- University of Manchester, Oxford Road, Manchester M13 9PL, UK
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23
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Armando M, Hutsebaut J, Debbané M. A Mentalization-Informed Staging Approach to Clinical High Risk for Psychosis. Front Psychiatry 2019; 10:385. [PMID: 31214062 PMCID: PMC6555089 DOI: 10.3389/fpsyt.2019.00385] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 05/15/2019] [Indexed: 12/21/2022] Open
Abstract
The practice of diagnosis is fundamentally designed to orient treatment. In the case of early diagnosis for schizophrenia spectrum disorders (SSP) risk, the empirical base for such a practice is still young, and many clinical questions arise in the everyday clinical application of risk algorithms and ensuing therapeutic options. One of the key questions that we will focus on is the following: in cases of SSP where symptoms are successfully treated, why does residual social functioning impairment remain the most serious obstacle to remission and reinsertion in society? We will present the evidence suggesting that the roots of residual social functioning impairment may, in many cases, come from thwarted or arrested development in the specialization of social cognition during adolescence and early adulthood. We will review the evidence suggesting that both during the premorbid phase and clinical high-risk phase, attenuated psychotic symptoms may impede the maturation of key social cognitive processes, particularly the suite of reflective thinking processes coming under the term of mentalization. From this evidence base, we will adapt the staging model of SSP progression in function of our mentalization-informed model, tailored to provide a coherent framework of care addressing the key clinical needs at every stage of psychosis progression.
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Affiliation(s)
- Marco Armando
- Department of Psychiatry, Developmental Imaging and Psychopathology Lab, University of Geneva, Geneva, Switzerland
| | - Joost Hutsebaut
- Viersprong Institute for Studies on Personality Disorders (VISPD), MBT Netherlands, Amsterdam, Netherlands
| | - Martin Debbané
- Department of Psychiatry, Developmental Imaging and Psychopathology Lab, University of Geneva, Geneva, Switzerland.,Department of Clinical, Educational and Health Psychology, University College London, London, United Kingdom.,Developmental Clinical Psychology Unit, Faculty of Psychology, University of Geneva, Geneva, Switzerland
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24
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Sullivan SA, Hamilton W, Tilling K, Redaniel T, Moran P, Lewis G. Association of Primary Care Consultation Patterns With Early Signs and Symptoms of Psychosis. JAMA Netw Open 2018; 1:e185174. [PMID: 30646393 PMCID: PMC6324409 DOI: 10.1001/jamanetworkopen.2018.5174] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
IMPORTANCE Primary care is an important part of the care pathway for patients with psychosis; therefore, primary care physicians need to be able to accurately identify those at clinical high risk of psychosis. The difficulty of this task is increased because clinical high-risk symptoms are frequently nonspecific to psychosis. OBJECTIVE To determine whether the consultation patterns for a prespecified set of symptoms can be used to identify primary care patients who later developed a psychotic illness. DESIGN, SETTING, AND PARTICIPANTS This nested case-control study used primary care consultation data collected from 530 primary care practices in 13 UK regions from January 1, 2000, through September 30, 2009. Participants included 11 690 adults with a diagnosis of psychosis and 81 793 control participants who did not have a diagnosis of psychosis individually matched by age group, sex, and primary care practice. Data were analyzed from July 1, 2015, through June 2, 2017. EXPOSURES Prespecified symptoms selected from literature included attention-deficit/hyperactivity disorder-like symptoms, bizarre behavior, blunted affect, problems associated with cannabis, depressive symptoms, role functioning problems, social isolation, symptoms of mania, obsessive-compulsive disorder-like symptoms, disordered personal hygiene, sleep disturbance, problems associated with cigarette smoking, and suicidal behavior (including self-harm). MAIN OUTCOMES AND MEASURES Case (diagnosis of psychosis) or control (no diagnosis of psychosis) status. Conditional logistic regression was used to investigate the association between symptoms and case-control status in the 5 years before diagnosis. Positive predictive values (PPVs) were calculated using the Bayes theorem for symptoms stratified by age group and sex. Repeated-measures Poisson regression was used to investigate symptom consultation rate. RESULTS Of the total sample of 93 483 participants, 57.4% were female and 40.0% were older than 60 years (mean [SD] age, 51.34 [21.75] years). Twelve symptoms were associated with a later psychotic diagnosis (all prespecified symptoms except disordered personal hygiene). The strongest association was with suicidal behavior (odds ratio [OR], 19.06; 95% CI, 16.55-21.95). Positive predictive values were heterogeneous across age and sex. The highest PPVs were for suicidal behavior (33.0% in men 24 years or younger [95% CI, 24.2%-43.2%] and 19.6% in women aged 25-34 years [95% CI, 13.7%-27.2%]). Pairs of symptoms were associated with an increase in PPV. Consultation rates were higher in cases and increased 3 months before diagnosis. CONCLUSIONS AND RELEVANCE Most of the preselected nonspecific symptoms were associated with a later psychotic diagnosis, particularly among young men consulting for suicidal behavior, especially if consulting with increasing frequency. These symptoms should alert physicians to patients who may benefit from a further assessment of psychotic symptoms.
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Affiliation(s)
- Sarah A. Sullivan
- Centre for Academic Primary Care, University of Bristol, Bristol, United Kingdom
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West, University Hospitals Bristol National Health Service Foundation Trust, University of Bristol, Bristol, United Kingdom
| | - William Hamilton
- Exeter Medical School, University of Exeter, Exeter, United Kingdom
| | - Kate Tilling
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West, University Hospitals Bristol National Health Service Foundation Trust, University of Bristol, Bristol, United Kingdom
- School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom
| | - Theresa Redaniel
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West, University Hospitals Bristol National Health Service Foundation Trust, University of Bristol, Bristol, United Kingdom
| | - Paul Moran
- Centre for Academic Mental Health, University of Bristol, Bristol, United Kingdom
| | - Glyn Lewis
- Division of Psychiatry, University College London, London, United Kingdom
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25
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Radhakrishnan M, McCrone P, Lafortune L, Everard L, Fowler D, Amos T, Freemantle N, Singh SP, Marshall M, Sharma V, Lavis A, Jones PB, Birchwood M. Cost-effectiveness of early intervention services for psychosis and fidelity to national policy implementation guidance. Early Interv Psychiatry 2018; 12:747-756. [PMID: 28857431 DOI: 10.1111/eip.12481] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Revised: 05/26/2017] [Accepted: 07/11/2017] [Indexed: 11/28/2022]
Abstract
AIM Early intervention services (EIS) for psychosis are being implemented, internationally. It is important to learn from established examples and define the components and intensity of services that provide good value for money. This study aims to assess the cost-effectiveness of EIS according to how closely they adhered to the recommendations of the English Department of Health 2001 Policy Implementation Guide (PIG). METHODS EIS from the National Eden Study were assessed using a measure of fidelity to the PIG that rated the presence or absence of 64 recommended items relating to team structure and practice. EIS were then classified into three groups: those with fidelity of 75-80%, 81-90% and 91-95%. Patient-level resource use and outcomes were measured 1 year following inception into the service; costs were calculated and combined with quality-adjusted life years (QALYs) gained. RESULTS At a threshold of £20 000 per QALY, the 81-90% fidelity group had a 56.3% likelihood of being the most cost-effective option followed by 75-80% fidelity at 35.8% and 91-95% fidelity group (7.9%). CONCLUSIONS The results from England suggest that striving to maximize fidelity may not be warranted, but that dropping below a certain level of fidelity may result in inefficient use of resources.
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Affiliation(s)
| | - Paul McCrone
- King's Health Economics, Institute of Psychiatry, Psychology & Neuroscience, King's College, London, UK
| | - Louise Lafortune
- Institute of Public Health, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Linda Everard
- The Early Intervention Service, Birmingham and Solihull Mental Health NHS Foundation Trust, Birmingham, UK
| | - David Fowler
- Department of Psychology, University of Sussex, Sussex, UK
| | - Tim Amos
- Academic Unit of Psychiatry, University of Bristol, Bristol, UK
| | - Nick Freemantle
- Department of Primary Care and Population Health, University College London, London, UK
| | - Swaran P Singh
- Mental Health and Wellbeing, Warwick Medical School, University of Warwick, Coventry, UK
| | - Max Marshall
- School of Medicine, University of Manchester, Manchester, UK
| | - Vimal Sharma
- Early Intervention Service, Cheshire and Wirral NHS Foundation Trust & University of Chester, UK
| | - Anna Lavis
- Institute of Applied Health Research, University of Birmingham, UK
| | - Peter B Jones
- Department of Psychiatry, University of Cambridge, Cambridge, UK
| | - Max Birchwood
- School of Medicine, University of Manchester, Manchester, UK
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26
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A randomized controlled trial of comprehensive early intervention care in patients with first-episode psychosis in Japan: 1.5-year outcomes from the J-CAP study. J Psychiatr Res 2018; 102:136-141. [PMID: 29653344 DOI: 10.1016/j.jpsychires.2018.04.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Revised: 02/27/2018] [Accepted: 04/06/2018] [Indexed: 11/22/2022]
Abstract
The first episode of psychosis represents a critical period wherein comprehensive early intervention in psychosis (EIP) may alter the course of illness. However, evidence from randomized controlled trials that have examined the impact of comprehensive EIP care on clinical and functional recovery assessed by independent blinded raters is limited. The objective of this study was to conduct a single-blinded multicenter trial comparing comprehensive EIP care and standard care in young patients with first-episode psychosis (FEP) in Japan (J-CAP Study). A total of 77 participants with FEP (aged 15-35 years) were randomized to receive standard care or specialized comprehensive EIP care and were followed up for 1.5 years (trial no.: UMIN000005092). Function (measured with the Global Assessment of Functioning) and clinical remission (defined by internationally standardized criteria proposed by the Remission in Schizophrenia Working Group) were evaluated by independent raters who were blinded to group assignment. Dropout rate and other secondary outcomes were also examined. The specialized EIP care group had a higher clinical remission rate (odds ratio, 6.3; 95% confidence interval, 1.0-37.9) and lower treatment dropout rate (odds ratio, 0.038; 95% confidence interval, 0.002-0.923) than the standard care group, even after adjusting for baseline characteristics. Functional improvement in the specialized EIP care group was slightly higher than that in the standard care group, but this difference was not statistically significant (p = 0.195). From the results, we conclude that comprehensive EIP care may provide advantages over standard care in patients with FEP.
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27
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Allard J, Lancaster S, Clayton S, Amos T, Birchwood M. Carers' and service users' experiences of early intervention in psychosis services: implications for care partnerships. Early Interv Psychiatry 2018; 12:410-416. [PMID: 26758476 DOI: 10.1111/eip.12309] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Accepted: 12/15/2015] [Indexed: 11/29/2022]
Abstract
AIM To explore carers' and service users' experiences of UK Early Intervention Services following referral for first-episode psychosis. METHODS Thirty-two semi-structured interviews (16 interviews with service users and 16 corresponding interviews with their carers) were completed and analysed. RESULTS Carers spoke retrospectively and prospectively by framing their accounts into the periods before and since their engagement with Early Intervention Services. Desperation was evident as emotive experiences were recalled prior to referral. Relief then emerged as carers described support and engagement with key workers. Hope and optimism for the service user's prognosis and life trajectory were also expressed.Service users described similar positive experiences of Early Intervention Services and the support and insight they had gained through their relationships with key workers. They were however less focused on accounts of desperation and relief and more immersed in their current understanding and attempts to normalize their experiences of first-episode psychosis. Prognosis and future trajectories were only discussed tentatively. CONCLUSION Communication and 'partnerships' with service users and carers are essential for effective service engagement, delivery of care and the reduction in relapse following first-episode psychosis. This study highlights how key workers from Early Intervention Services are appropriately valued and situated to develop such relationships. Findings also reveal that service users' and carers' focus and expectations of recovery vary during the early stages of engagement with services. How key workers manage awareness and communication around such differing expectations is a crucial consideration for maintaining the 'partnerships' necessary for effective service provision.
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Affiliation(s)
- Jon Allard
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Susan Lancaster
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Sara Clayton
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Tim Amos
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Max Birchwood
- School of Psychology, University of Birmingham, Birmingham, UK
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28
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Correll CU, Galling B, Pawar A, Krivko A, Bonetto C, Ruggeri M, Craig TJ, Nordentoft M, Srihari VH, Guloksuz S, Hui CLM, Chen EYH, Valencia M, Juarez F, Robinson DG, Schooler NR, Brunette MF, Mueser KT, Rosenheck RA, Marcy P, Addington J, Estroff SE, Robinson J, Penn D, Severe JB, Kane JM. Comparison of Early Intervention Services vs Treatment as Usual for Early-Phase Psychosis: A Systematic Review, Meta-analysis, and Meta-regression. JAMA Psychiatry 2018; 75:555-565. [PMID: 29800949 PMCID: PMC6137532 DOI: 10.1001/jamapsychiatry.2018.0623] [Citation(s) in RCA: 441] [Impact Index Per Article: 73.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
IMPORTANCE The value of early intervention in psychosis and allocation of public resources has long been debated because outcomes in people with schizophrenia spectrum disorders have remained suboptimal. OBJECTIVE To compare early intervention services (EIS) with treatment as usual (TAU) for early-phase psychosis. DATA SOURCES Systematic literature search of PubMed, PsycINFO, EMBASE, and ClinicalTrials.gov without language restrictions through June 6, 2017. STUDY SELECTION Randomized trials comparing EIS vs TAU in first-episode psychosis or early-phase schizophrenia spectrum disorders. DATA EXTRACTION AND SYNTHESIS This systematic review was conducted according to PRISMA guidelines. Three independent investigators extracted data for a random-effects meta-analysis and prespecified subgroup and meta-regression analyses. MAIN OUTCOMES AND MEASURES The coprimary outcomes were all-cause treatment discontinuation and at least 1 psychiatric hospitalization during the treatment period. RESULTS Across 10 randomized clinical trials (mean [SD] trial duration, 16.2 [7.4] months; range, 9-24 months) among 2176 patients (mean [SD] age, 27.5 [4.6] years; 1355 [62.3%] male), EIS was associated with better outcomes than TAU at the end of treatment for all 13 meta-analyzable outcomes. These outcomes included the following: all-cause treatment discontinuation (risk ratio [RR], 0.70; 95% CI, 0.61-0.80; P < .001), at least 1 psychiatric hospitalization (RR, 0.74; 95% CI, 0.61-0.90; P = .003), involvement in school or work (RR, 1.13; 95% CI, 1.03-1.24; P = .01), total symptom severity (standardized mean difference [SMD], -0.32; 95% CI, -0.47 to -0.17; P < .001), positive symptom severity (SMD, -0.22; 95% CI, -0.32 to -0.11; P < .001), and negative symptom severity (SMD, -0.28; 95% CI, -0.42 to -0.14; P < .001). Superiority of EIS regarding all outcomes was evident at 6, 9 to 12, and 18 to 24 months of treatment (except for general symptom severity and depressive symptom severity at 18-24 months). CONCLUSIONS AND RELEVANCE In early-phase psychosis, EIS are superior to TAU across all meta-analyzable outcomes. These results support the need for funding and use of EIS in patients with early-phase psychosis.
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Affiliation(s)
- Christoph U. Correll
- Department of Psychiatry, The Zucker Hillside Hospital, Northwell Health, Glen Oaks, New York,Department of Psychiatry and Molecular Medicine, Hofstra Northwell School of Medicine, Hempstead, New York,The Feinstein Institute for Medical Research, Manhasset, New York,Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin, Berlin, Germany
| | - Britta Galling
- Department of Psychiatry, The Zucker Hillside Hospital, Northwell Health, Glen Oaks, New York,Department of Psychiatry and Molecular Medicine, Hofstra Northwell School of Medicine, Hempstead, New York,Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin, Berlin, Germany
| | - Aditya Pawar
- Department of Psychiatry, The Zucker Hillside Hospital, Northwell Health, Glen Oaks, New York
| | - Anastasia Krivko
- Department of Psychiatry, The Zucker Hillside Hospital, Northwell Health, Glen Oaks, New York
| | - Chiara Bonetto
- Section of Psychiatry, Department of Public Health and Community Medicine, University of Verona, Verona, Italy
| | - Mirella Ruggeri
- Section of Psychiatry, Department of Public Health and Community Medicine, University of Verona, Verona, Italy
| | - Thomas J. Craig
- Institute of Psychiatry, King’s College London, London, England
| | - Merete Nordentoft
- Mental Health Centre Copenhagen, Copenhagen University Hospital, Copenhagen, Denmark,The Lundbeck Foundation Initiative for Integrative Psychiatric Research, Copenhagen, Denmark
| | - Vinod H. Srihari
- Department of Psychiatry, Yale University, New Haven, Connecticut,Specialized Treatment Early in Psychosis (STEP) Program, Connecticut Mental Health Center, New Haven
| | - Sinan Guloksuz
- Department of Psychiatry, Yale University, New Haven, Connecticut,Department of Psychiatry and Psychology, Maastricht University Medical Center, Maastricht, the Netherlands
| | | | - Eric Y. H. Chen
- Department of Psychiatry, University of Hong Kong, Hong Kong, China,State Key Laboratory of Brain and Cognitive Science, The University of Hong Kong, Hong Kong, China
| | - Marcelo Valencia
- Division of Epidemiological and Psychosocial Research, National Institute of Psychiatry, Mexico City, Mexico
| | - Francisco Juarez
- Division of Epidemiological and Psychosocial Research, National Institute of Psychiatry, Mexico City, Mexico
| | - Delbert G. Robinson
- Department of Psychiatry, The Zucker Hillside Hospital, Northwell Health, Glen Oaks, New York,Department of Psychiatry and Molecular Medicine, Hofstra Northwell School of Medicine, Hempstead, New York,The Feinstein Institute for Medical Research, Manhasset, New York
| | - Nina R. Schooler
- Department of Psychiatry, The Zucker Hillside Hospital, Northwell Health, Glen Oaks, New York,Department of Psychiatry, SUNY Downstate Medical Center, New York, New York
| | - Mary F. Brunette
- Department of Psychiatry, Geisel School of Medicine at Dartmouth, Dartmouth, New Hampshire,Bureau of Behavioral Health, College of Health and Human Services (CHHS), Dartmouth, New Hampshire
| | - Kim T. Mueser
- Department of Occupational Therapy, Center for Psychiatric Rehabilitation, Boston University, Boston, Massachusetts,Department of Psychiatry, Center for Psychiatric Rehabilitation, Boston University, Boston, Massachusetts,Department of Psychological and Brain Sciences, Center for Psychiatric Rehabilitation, Boston University, Boston, Massachusetts
| | - Robert A. Rosenheck
- Department of Psychiatry, Yale University, New Haven, Connecticut,Department of Epidemiology, Yale University, New Haven, Connecticut,Department of Public Health, Yale University, New Haven, Connecticut
| | - Patricia Marcy
- Department of Psychiatry, The Zucker Hillside Hospital, Northwell Health, Glen Oaks, New York,The Feinstein Institute for Medical Research, Manhasset, New York
| | - Jean Addington
- The Hotchkiss Brain Institute, Department of Psychiatry, University of Calgary, Calgary, Alberta, Canada
| | - Sue E. Estroff
- Department of Social Medicine, The University of North Carolina at Chapel Hill
| | | | - David Penn
- Department of Psychology, The University of North Carolina at Chapel Hill
| | | | - John M. Kane
- Department of Psychiatry, The Zucker Hillside Hospital, Northwell Health, Glen Oaks, New York,Department of Psychiatry and Molecular Medicine, Hofstra Northwell School of Medicine, Hempstead, New York,The Feinstein Institute for Medical Research, Manhasset, New York
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29
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Kline E, Thomas L. Cultural factors in first episode psychosis treatment engagement. Schizophr Res 2018; 195:74-75. [PMID: 28864280 DOI: 10.1016/j.schres.2017.08.035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Accepted: 08/18/2017] [Indexed: 11/28/2022]
Abstract
Specialized First Episode Psychosis (FEP) services have been conceptualized in part around the issue of engagement. Creating treatment that is easier to access, with more frequent contacts, assertive outreach to clients between appointments, and an explicit youth-oriented culture could make services more attractive to those most in need of care. However, engagement has remained a mostly fuzzy, peripheral construct rather than the object of study in itself. As we recognize the importance of treatment engagement, we must prepare to address it more rigorously within psychosis and schizophrenia research. At the same time, factors enhancing or obstructing treatment engagement are inevitably local, rather than universal. The availability of care, its associated costs and stigmas, individuals' motivations for seeking treatment, and their beliefs and expectations about providers' roles are determined by local and cultural features. There can be no singular "best practice" for engagement - but curiosity about how culture and locale influence clients' willingness to participate in care, and creativity in how we account for and incorporate these variables into study designs, will help to shed light on the critical issue of engagement in FEP treatment.
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Affiliation(s)
- Emily Kline
- Harvard Medical School, Department of Psychiatry, USA; Department of Psychiatry, Beth Israel Deaconess Medical Center, USA.
| | - Latoya Thomas
- Department of Psychiatry, Beth Israel Deaconess Medical Center, USA
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30
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Fowler D, Hodgekins J, French P, Marshall M, Freemantle N, McCrone P, Everard L, Lavis A, Jones PB, Amos T, Singh S, Sharma V, Birchwood M. Social recovery therapy in combination with early intervention services for enhancement of social recovery in patients with first-episode psychosis (SUPEREDEN3): a single-blind, randomised controlled trial. Lancet Psychiatry 2018; 5:41-50. [PMID: 29242000 PMCID: PMC5818038 DOI: 10.1016/s2215-0366(17)30476-5] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 10/30/2017] [Accepted: 11/02/2017] [Indexed: 10/28/2022]
Abstract
BACKGROUND Provision of early intervention services has increased the rate of social recovery in patients with first-episode psychosis; however, many individuals have continuing severe and persistent problems with social functioning. We aimed to assess the efficacy of early intervention services augmented with social recovery therapy in patients with first-episode psychosis. The primary hypothesis was that social recovery therapy plus early intervention services would lead to improvements in social recovery. METHODS We did this single-blind, phase 2, randomised controlled trial (SUPEREDEN3) at four specialist early intervention services in the UK. We included participants who were aged 16-35 years, had non-affective psychosis, had been clients of early intervention services for 12-30 months, and had persistent and severe social disability, defined as engagement in less than 30 h per week of structured activity. Participants were randomly assigned (1:1), via computer-generated randomisation with permuted blocks (sizes of four to six), to receive social recovery therapy plus early intervention services or early intervention services alone. Randomisation was stratified by sex and recruitment centre (Norfolk, Birmingham, Lancashire, and Sussex). By necessity, participants were not masked to group allocation, but allocation was concealed from outcome assessors. The primary outcome was time spent in structured activity at 9 months, as measured by the Time Use Survey. Analysis was by intention to treat. This trial is registered with ISRCTN, number ISRCTN61621571. FINDINGS Between Oct 1, 2012, and June 20, 2014, we randomly assigned 155 participants to receive social recovery therapy plus early intervention services (n=76) or early intervention services alone (n=79); the intention-to-treat population comprised 154 patients. At 9 months, 143 (93%) participants had data for the primary outcome. Social recovery therapy plus early intervention services was associated with an increase in structured activity of 8·1 h (95% CI 2·5-13·6; p=0·0050) compared with early intervention services alone. No adverse events were deemed attributable to study therapy. INTERPRETATION Our findings show a clinically important benefit of enhanced social recovery on structured activity in patients with first-episode psychosis who received social recovery therapy plus early intervention services. Social recovery therapy might be useful in improving functional outcomes in people with first-episode psychosis, particularly in individuals not motivated to engage in existing psychosocial interventions targeting functioning, or who have comorbid difficulties preventing them from doing so. FUNDING National Institute for Health Research.
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Affiliation(s)
- David Fowler
- Psychology Department, University of Sussex, Brighton, UK.
| | - Jo Hodgekins
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Paul French
- Psychosis Research Unit, Greater Manchester Mental Health NHS Trust, Manchester, UK; Institute of Health and Psychology, University of Liverpool, Liverpool, UK
| | - Max Marshall
- Lancashire Care NHS Foundation Trust, Preston, UK
| | | | - Paul McCrone
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Linda Everard
- Birmingham and Solihull NHS Mental Health Foundation Trust, Birmingham, UK
| | - Anna Lavis
- University of Birmingham, Birmingham, UK
| | | | - Tim Amos
- University of Bristol, Bristol, UK
| | | | - Vimal Sharma
- University of Chester, Chester, UK; Cheshire and Wirral Partnership NHS Foundation Trust, Chester, UK
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31
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Hart LC, Maslow G. The Medical Transition from Pediatric to Adult-Oriented Care: Considerations for Child and Adolescent Psychiatrists. Child Adolesc Psychiatr Clin N Am 2018; 27:125-132. [PMID: 29157498 DOI: 10.1016/j.chc.2017.08.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
More adolescents and young adults are surviving previously fatal childhood illness and need support to transition from pediatric care to adult-oriented care. There are many barriers, but guidelines and tools assist providers with emphasis on gradually addressing transition with patients and families. Child and adolescent psychiatrists should be particularly attuned to the needs of adolescents with previously identified mental illness who are at high risk of falling out of regular care during transition. Providers are also uniquely suited to address the needs of adolescents and young adults with intellectual and developmental disabilities.
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Affiliation(s)
- Laura C Hart
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, 725 Martin Luther King Jr. Boulevard, Chapel Hill, NC, 27514, USA
| | - Gary Maslow
- Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA.
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32
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Hodgekins J, Clarke T, Cole H, Markides C, Ugochukwu U, Cairns P, Lower R, Fowler D, Wilson J. Pathways to care of young people accessing a pilot specialist youth mental health service in Norfolk, United Kingdom. Early Interv Psychiatry 2017; 11:436-443. [PMID: 27111275 DOI: 10.1111/eip.12338] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Revised: 10/30/2015] [Accepted: 02/18/2016] [Indexed: 01/19/2023]
Abstract
AIM Pathways to care (PtC) are a means of examining and understanding routes into mental health care. It is important to examine PtC in order to identify ways in which individuals access services, as well as highlighting barriers or delays to appropriate treatment. This study aimed to examine PtC experienced by young people accessing a pilot specialist youth mental health service (SYMHS) for those with non-psychotic, severe and complex mental health conditions in Norfolk, UK. METHODS Data were collected on a subsample of referrals accepted into the pilot SYMHS (n = 94) over a 12-month period. Duration and number of PtC were assessed using a semi-structured interview augmented by health record examination. Measures of premorbid history, symptoms and functioning were also collected. RESULTS The mean length of PtC was 3.74 years, and a mean of 5.53 pathways was experienced before appropriate services were accessed. Individuals were most likely to first seek help from their general practitioner followed by an educational provider. There were no associations between PtC and current symptoms, although individuals with a premorbid history of mental health problems experienced shorter PtC. There was a trend suggesting that individuals with long pathways had poorer functioning compared with those with shorter pathways. CONCLUSIONS Pathways to care are variable in a group of young people presenting to mental health services. A majority of participants experienced 'long pathways', which may negatively impact on outcome. The results indicate the need to improve access to appropriate services by overcoming pathway barriers. Service implications are discussed.
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Affiliation(s)
- Jo Hodgekins
- Department of Clinical Psychology, Norwich Medical School, University of East Anglia, Brighton, UK.,Central Norfolk Youth Service, Brighton, UK
| | | | | | - Constantina Markides
- Great Yarmouth and Waveney Youth Service, Norfolk and Suffolk NHS Foundation Trust, Norwich, UK
| | - Uju Ugochukwu
- Great Yarmouth and Waveney Youth Service, Norfolk and Suffolk NHS Foundation Trust, Norwich, UK
| | - Peter Cairns
- Great Yarmouth and Waveney Youth Service, Norfolk and Suffolk NHS Foundation Trust, Norwich, UK
| | | | - David Fowler
- School of Psychology, University of Sussex, Brighton, UK
| | - Jon Wilson
- Department of Clinical Psychology, Norwich Medical School, University of East Anglia, Brighton, UK.,Central Norfolk Youth Service, Brighton, UK
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Wilson RP, Patel R, Bhattacharyya S. Do fewer males present to clinical high-risk services for psychosis relative to first-episode services? Early Interv Psychiatry 2017; 11:429-435. [PMID: 26818493 DOI: 10.1111/eip.12311] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Accepted: 12/15/2015] [Indexed: 12/16/2022]
Abstract
AIM A decline in the rate of transition to psychosis in patients presenting with clinical high-risk has been reported in the literature. Several hypotheses have been put forward to explain this decline. In this brief report, we aimed to explore whether the demographic group presenting to clinical high-risk services differs from the 'end-point' population who present with first-episode psychosis (FEP), by focusing on gender. METHOD Gender distribution was compared between clinical high-risk (CHR) and FEP using data extracted from published study samples and clinical data from corresponding cohorts within the same catchment area in South London. RESULTS The proportion of males was significantly higher in FEP compared to CHR services in the literature describing Europe, Australia and North America and in the clinical cohort from South London. CONCLUSION Males are under-represented in existing CHR services in Europe, Australia and North America. This could reflect less willingness in males to seek help if experiencing low-level psychological distress and may be related to the declining transition.
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Affiliation(s)
- Robin P Wilson
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Rashmi Patel
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Sagnik Bhattacharyya
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
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34
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Cotter J, Zabel E, French P, Yung AR. Prolonged duration of untreated psychosis: a problem that needs addressing. Early Interv Psychiatry 2017; 11:263-268. [PMID: 26801870 DOI: 10.1111/eip.12308] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2015] [Accepted: 12/15/2015] [Indexed: 12/01/2022]
Abstract
AIM The duration of untreated psychosis (DUP) refers to the period of time between the emergence of psychotic symptoms and the initiation of appropriate clinical treatment. Prolonged DUP is associated with a range of adverse consequences, including more severe illness course, cognitive deficits and poor functioning. Problems with recognition of illness and in seeking help contribute to DUP, but another major cause of prolonged DUP is delays within secondary mental health services. In an attempt to reduce these delays, National Health Service England and the Department of Health have set new targets to improve access to early intervention services which will come into effect in April 2016. Given this background, we aimed to examine the DUP and pathways to care of new patients entering an early intervention service. We also examined whether they were receiving National Institute for Health and Care Excellence (NICE) concordant treatment. This will enable us to establish a baseline so that the impact of the new targets can be determined and to assess the degree of change that will be required to implement these. METHODS De-identified electronic records of 165 patients accepted into the service over a 12-month period were analysed. RESULTS Median DUP was 6 months. There was a median of 2 contacts prior to service entry. Community Mental Health Teams were the largest source of referrals. CONCLUSIONS The majority of patients had a DUP exceeding the international target of 3 months. The findings appear to support previous evidence that this may be partially attributable to significant delays within the mental health care system.
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Affiliation(s)
- Jack Cotter
- Institute of Brain, Behaviour and Mental Health, University of Manchester, Manchester, UK
| | - Elisabeth Zabel
- Greater Manchester West Mental Health NHS Foundation Trust, Manchester, UK
| | - Paul French
- Greater Manchester West Mental Health NHS Foundation Trust, Manchester, UK.,Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
| | - Alison R Yung
- Institute of Brain, Behaviour and Mental Health, University of Manchester, Manchester, UK.,Greater Manchester West Mental Health NHS Foundation Trust, Manchester, UK
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35
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Lee EHM, Ching EYN, Hui CLM, Lin JJX, Chang WC, Chan SKW, Chen EYH. Chinese label for people at risk for psychosis. Early Interv Psychiatry 2017; 11:224-228. [PMID: 25721613 DOI: 10.1111/eip.12232] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Accepted: 01/23/2015] [Indexed: 11/29/2022]
Abstract
AIM With the movement of early detection and intervention for people at risk for psychosis, there is a growing need for a uniform terminology to describe the condition. A diagnostic label that can adapt into local culture and value may have positive effect in minimizing stigma. This study explored the preference of Chinese label for people at risk of psychosis and its associated stigma in Hong Kong. METHODS A total of 149 individuals from the general public and 51 health-care professionals were recruited between March 2013 and May 2014. The condition of at risk for psychosis was described in a vignette. Participants' preference of label and perceived stigma of the condition and their basic demographics were collected by self-administered questionnaires. RESULTS The most preferred Chinese label was 'yun-niang-qi' (developing period, 45%), followed by 'qian-qu-qi' (precursor period, 19%), 'feng-xian-qi' (risky period, 18%), 'zao-xian-qi' (early sign period, 16%) and 'gao-wei-qi' (high risk period, 4%). Gender, age, occupation and previous contact with mental health were not associated with preference of any Chinese label. CONCLUSIONS The process in searching for this potential and locally accepted label for people at risk for psychosis has raised the awareness among the professionals. A proper label may help promote future clinical research and mental health services in Hong Kong.
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Affiliation(s)
- Edwin H M Lee
- Department of Psychiatry, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Elaine Y N Ching
- Department of Psychiatry, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Christy L M Hui
- Department of Psychiatry, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Jessie J X Lin
- Department of Psychiatry, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - W C Chang
- Department of Psychiatry, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Sherry K W Chan
- Department of Psychiatry, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Eric Y H Chen
- Department of Psychiatry, Queen Mary Hospital, The University of Hong Kong, Hong Kong.,State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong, Hong Kong
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Williams R, Malla A, Roy MA, Joober R, Manchanda R, Tibbo P, Banks N, Agid O. What Is the Place of Clozapine in the Treatment of Early Psychosis in Canada? CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2017; 62:109-114. [PMID: 27310245 PMCID: PMC5298522 DOI: 10.1177/0706743716651049] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Research and development of early intervention (EI) services for first-episode psychosis have brought much-needed transformation of service delivery for this serious mental disorder to many jurisdictions. The effectiveness of the EI model of service delivery is contingent on timely access to all evidence-informed treatment interventions, including a rational approach to pharmacotherapy. In this perspective paper, we present a brief review of the well-established effectiveness of clozapine in patients who clearly show lack of response to regular antipsychotic therapy. We concentrate, in particular, on the need to identify eligibility for clozapine therapy very early on following failure of treatment on 2 antipsychotic medications. We suggest that attention to the low use of clozapine in the very early phase of treatment of psychosis may be of particular value, as the response to clozapine at this stage is likely to produce larger benefits in other domains of outcomes because of the greater retention of patients' personal and social agency.
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Affiliation(s)
- Richard Williams
- 1 Department of Psychiatry, University of British Columbia, Victoria, British Columbia
| | - Ashok Malla
- 2 Department of Psychiatry, McGill University, Montréal, Québec.,3 Prevention and Early Intervention Program for the Psychoses, Douglas Mental Health University Institute, Montréal, Québec
| | - Marc-Andre Roy
- 4 Département de Psychiatrie et Neurosciences, Faculté de Médecine de l'Université Laval, Québec, Québec.,5 Clinique Notre-Dame des Victoires, Centre intégré universitaire de la Capitale Nationale, Québec, Québec
| | - Ridha Joober
- 2 Department of Psychiatry, McGill University, Montréal, Québec.,3 Prevention and Early Intervention Program for the Psychoses, Douglas Mental Health University Institute, Montréal, Québec
| | - Rahul Manchanda
- 6 Psychiatry, Western University, London, Ontario.,7 Prevention and Early Intervention Program for Psychoses, London Health Sciences Centre, London, Ontario
| | - Phil Tibbo
- 8 Dalhousie University, Halifax, Nova Scotia.,9 Nova Scotia Early Psychosis Program, Halifax, Nova Scotia
| | - Nicola Banks
- 10 Canadian Consortium for Early Intervention in Psychosis, Hamilton, Ontario
| | - Ofer Agid
- 11 Complex Mental Illness Program/Schizophrenia Division, Centre for Addiction and Mental Health, Toronto, Ontario.,12 Department of Psychiatry, University of Toronto, Toronto, Ontario
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Thompson A, Marwaha S, Winsper C, Everard L, Jones PB, Fowler D, Amos T, Freemantle N, Singh SP, Marshall M, Sharma V, Birchwood M. Short-term outcome of substance-induced psychotic disorder in a large UK first episode psychosis cohort. Acta Psychiatr Scand 2016; 134:321-8. [PMID: 27479903 DOI: 10.1111/acps.12623] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/04/2016] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The incidence and outcome of first-episode substance-induced psychotic disorder (SIPD) are unclear. The study aimed to compare the 1-year outcomes of those given a SIPD diagnosis by clinicians compared to other psychosis diagnoses in a first-episode cohort. METHOD Data were from a large (n = 1027) cohort of first-episode psychosis (FEP) patients admitted to early intervention services in the UK (National EDEN). Diagnosis, including that of SIPD, was made by treating psychiatrists at baseline using ICD10 criteria. Details on symptoms, functioning, quality of life, relapse and recovery were available at baseline and 12 months. RESULTS There were 67 cases of SIPD (6.5% of the cohort). At baseline, SIPD patients were no different to other psychoses on symptoms, functioning and quality of life. At 12 months, there was no difference in SIPD and other psychoses on functioning, quality of life or relapse and recovery rates. Levels of psychotic and general symptomatology were similar but depressive symptoms were higher in the SIPD group. CONCLUSIONS First-episode psychosis patients with a diagnosis of SIPD do not appear to have better outcomes than those with other primary psychotic diagnoses. The higher levels of depressive symptoms may be a specific marker in these patients.
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Affiliation(s)
- A Thompson
- Division of Mental Health and Wellbeing, Warwick Medical School, University of Warwick, Coventry, UK. .,North Warwickshire Early Intervention in Psychosis Service, Coventry and Warwickshire Partnership NHS Trust, Coventry, UK.
| | - S Marwaha
- Division of Mental Health and Wellbeing, Warwick Medical School, University of Warwick, Coventry, UK.,Affective Disorders Service, Tile Hill, Coventry and Warwickshire NHS Partnership Trust, Coventry, UK
| | - C Winsper
- Division of Mental Health and Wellbeing, Warwick Medical School, University of Warwick, Coventry, UK
| | - L Everard
- The Early Intervention in Psychosis Service, Birmingham and Solihull Mental Health Foundation Trust, Birmingham, UK
| | - P B Jones
- Department of Psychiatry, University of Cambridge, Cambridge, UK.,CAMEO, Cambridge and Peterborough NHS Foundation Trust, Cambridge, UK
| | - D Fowler
- School of Medicine, University of East Anglia, Norwich, UK.,Academic Unit of Psychiatry and Department of Psychology, University of Sussex, Brighton, UK
| | - T Amos
- Academic Unit of Psychiatry, University of Bristol, Bristol, UK
| | - N Freemantle
- Department of Primary Care and Population Health, UCL Medical School (Royal Free Campus), London, UK
| | - S P Singh
- Division of Mental Health and Wellbeing, Warwick Medical School, University of Warwick, Coventry, UK.,The Early Intervention in Psychosis Service, Birmingham and Solihull Mental Health Foundation Trust, Birmingham, UK
| | - M Marshall
- School of Medicine, The University of Manchester, Manchester, UK
| | - V Sharma
- Early Intervention Service, Cherry Bank Resource Centre, Cheshire and Wirral Partnership NHS Foundation Trust, Ellesmere Port, UK
| | - M Birchwood
- Division of Mental Health and Wellbeing, Warwick Medical School, University of Warwick, Coventry, UK
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Connor C, Greenfield S, Lester H, Channa S, Palmer C, Barker C, Lavis A, Birchwood M. Seeking help for first-episode psychosis: a family narrative. Early Interv Psychiatry 2016; 10:334-45. [PMID: 25303624 DOI: 10.1111/eip.12177] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Accepted: 06/22/2014] [Indexed: 01/27/2023]
Abstract
AIM Delayed help-seeking can have serious consequences for young people with first-episode psychosis (FEP), in terms of treatment response and outcome. Young people's narratives about help-seeking are important to understand why delays occur; however, as the majority of help-seeking is initiated by family members, through a general practitioner (GP), family narratives are also of interest. The aim of this study was to explore help-seeking for FEP, including first contact with a GP. METHOD A semistructured interview was developed using a topic guide. Framework analysis was used to analyse data and a deductive qualitative method for applied research. The study was set in Birmingham, UK. Participants were interviewed separately by researchers. Joint coding and identification of 14 complete family dyads was then explored for emerging patterns within the family context. RESULTS Family responses to FEP that had an impact on help-seeking behaviour included withdrawal, normalization, stigma, fear and guilt; poor knowledge of availability, and means of access to mental health services was also important. Help-seeking was usually instigated by a family member through a GP, although this was not the case for two of our families, and while contact with GP was generally described as a positive experience for several families, it was hindered by poor communication and lack of engagement. CONCLUSION Families play a key role in facilitating help-seeking for FEP, but attempts are often derailed by complex family responses to illness. Public mental health interventions should focus on increasing community awareness of psychosis and improving access and alternative routes to mental health services. However, improvements will have little impact unless primary care and other help-seeking sources engage in open and easy dialogue with the families and young people trying to access their specialist services.
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Affiliation(s)
- Charlotte Connor
- Birmingham and Solihull Mental Health, NHS Trust Research and Development Unit, Birmingham, UK.,Division of Health and Wellbeing, Warwick Medical School, University of Warwick, Birmingham, UK.,School of Psychology, University of Birmingham, Coventry, UK
| | - Sheila Greenfield
- Primary Care Clinical Sciences, School of Health and Population Sciences, University of Birmingham, Birmingham, UK
| | - Helen Lester
- Primary Care Clinical Sciences, School of Health and Population Sciences, University of Birmingham, Birmingham, UK
| | - Sunita Channa
- Birmingham and Solihull Mental Health, NHS Trust Research and Development Unit, Birmingham, UK
| | - Colin Palmer
- Birmingham and Solihull Mental Health, NHS Trust Research and Development Unit, Birmingham, UK
| | - Clare Barker
- Birmingham and Solihull Mental Health, NHS Trust Research and Development Unit, Birmingham, UK
| | - Anna Lavis
- School of Life and Population Sciences, University of Birmingham, Birmingham, UK
| | - Max Birchwood
- Division of Health and Wellbeing, Warwick Medical School, University of Warwick, Birmingham, UK
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The course of negative symptom in first episode psychosis and the relationship with social recovery. Schizophr Res 2016; 174:165-171. [PMID: 27131912 DOI: 10.1016/j.schres.2016.04.017] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Revised: 04/11/2016] [Accepted: 04/11/2016] [Indexed: 11/23/2022]
Abstract
AIMS To investigate trajectories of negative symptoms during the first 12months of treatment for first episode psychosis (FEP), their predictors and relationship to social recovery. METHOD 1006 participants were followed up for 12months following acceptance into Early Intervention in Psychosis services. Negative symptom trajectories were modelled using latent class growth analysis (LCGA) and predictors of trajectories examined using multinomial regression. Social recovery trajectories - also modelled using LCGA - of members of each negative symptom trajectory were ascertained and the relationship between negative symptom and social recovery trajectories examined. RESULTS Four negative symptom trajectories were identified: Minimal Decreasing (63.9%), Mild Stable (13.5%), High Decreasing (17.1%) and High Stable (5.4%). Male gender and family history of non-affective psychosis predicted stably high negative symptoms. Poor premorbid adolescent adjustment, family history of non-affective psychosis and baseline depression predicted initially high but decreasing negative symptoms. Members of the Mild Stable, High Stable and High Decreasing classes were more likely to experience stably low functioning than the Minimal Decreasing class. CONCLUSIONS Distinct negative symptom trajectories are evident in FEP. Only a small subgroup present with persistently high levels of negative symptoms. A substantial proportion of FEP patients with elevated negative symptoms at baseline will achieve remission of these symptoms within 12months. However, elevated negative symptoms at baseline, whether or not they remit, are associated with poor social recovery, suggesting targeted interventions for service users with elevated baseline negative symptoms may help improve functional outcomes.
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40
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Connor C, Birchwood M, Freemantle N, Palmer C, Channa S, Barker C, Patterson P, Singh S. Don't turn your back on the symptoms of psychosis: the results of a proof-of-principle, quasi-experimental intervention to reduce duration of untreated psychosis. BMC Psychiatry 2016; 16:127. [PMID: 27145865 PMCID: PMC4855493 DOI: 10.1186/s12888-016-0816-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Accepted: 04/13/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND No evidence based approach to reduce duration of untreated psychosis (DUP) has been effective in the UK. Existing interventions have many components and have been difficult to replicate. The majority of DUP in Birmingham, UK is accounted for by delays within mental health services (MHS) followed by help-seeking delay and, we hypothesise, these require explicit targeting. This study examined the feasibility and impact of an intervention to reduce DUP, targeting help-seeking and MHSs delays. METHODS A dual-component intervention, comprising a direct care pathway, for 16-25 year olds, and a community psychosis awareness campaign, using our youth-friendly website as the central hub, was implemented, targeting the primary sources of care pathway delays experienced by those with long DUP. Evaluation, using a quasi-experimental, design compared DUP of cases in two areas of the city receiving early detection vs detection as usual, controlling for baseline DUP in each area. RESULTS DUP in the intervention area was reduced from a median 71 days (mean 285) to 39 days (mean 104) following the intervention, with no change in the control area. Relative risk for the reduction in DUP was 0.74 (95% CI 0.35 to 0.89; p = .004). Delays in MHSs and help-seeking were also reduced. CONCLUSIONS Our targeted approach appears to be successful in reducing DUP and could provide a generalizable methodology applicable in a variety of healthcare contexts with differing sources of delay. More research is needed, however, to establish whether our approach is truly effective. TRIAL REGISTRATION ISRCTN45058713 - 30 December 2012.
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Affiliation(s)
| | | | | | | | | | - Clare Barker
- />Birmingham & Solihull Mental Health NHS Trust, Centre for Mental Health The Barberry Centre, 25 Vincent Drive, Birmingham, B15 2FG UK
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41
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Seddon JL, Birchwood M, Copello A, Everard L, Jones PB, Fowler D, Amos T, Freemantle N, Sharma V, Marshall M, Singh SP. Cannabis Use Is Associated With Increased Psychotic Symptoms and Poorer Psychosocial Functioning in First-Episode Psychosis: A Report From the UK National EDEN Study. Schizophr Bull 2016; 42:619-25. [PMID: 26536902 PMCID: PMC4838086 DOI: 10.1093/schbul/sbv154] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE The use of cannabis during the early stage of psychosis has been linked with increased psychotic symptoms. This study aimed to examine the use of cannabis in the 12 months following a first-episode of psychosis (FEP) and the link with symptomatic course and outcome over 1 year post psychosis onset. DESIGN AND SETTING One thousand twenty-seven FEP patients were recruited upon inception to specialized early intervention services (EIS) for psychosis in the United Kingdom. Participants completed assessments at baseline, 6 and 12 months. RESULTS The results indicate that the use of cannabis was significantly associated with increased severity of psychotic symptoms, mania, depression and poorer psychosocial functioning. Continued use of cannabis following the FEP was associated with poorer outcome at 1 year for Positive and Negative Syndrome Scale total score, negative psychotic symptoms, depression and psychosocial functioning, an effect not explained by age, gender, duration of untreated psychosis, age of psychosis onset, ethnicity or other substance use. CONCLUSION This is the largest cohort study of FEP patients receiving care within EIS. Cannabis use, particularly "continued use," was associated with poorer symptomatic and functional outcome during the FEP. The results highlight the need for effective and early intervention for cannabis use in FEP.
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Affiliation(s)
- Jennifer L. Seddon
- National Drug & Alcohol Research Centre, UNSW, Sydney, Australia;,*To whom correspondence should be addressed; National Drug & Alcohol Research Centre, UNSW, Sydney 2052, Australia; tel: 61-2-9385-0357, fax: 61-2-9385-0222, e-mail:
| | - Max Birchwood
- Mental Health and Wellbeing Warwick Medical School, University of Warwick, Coventry, UK
| | - Alex Copello
- School of Psychology, University of Birmingham, Birmingham, UK;,The Early Intervention Service, Birmingham and Solihull Mental Health NHS Foundation Trust, Birmingham, UK
| | - Linda Everard
- The Early Intervention Service, Birmingham and Solihull Mental Health NHS Foundation Trust, Birmingham, UK
| | - Peter B. Jones
- Department of Psychiatry, University of Cambridge and CAMEO, Cambridge and Peterborough NHS Foundation Trust, Cambridge, UK
| | - David Fowler
- Department of Psychology, University of Sussex, Brighton, UK
| | - Tim Amos
- Academic Unit of Psychiatry, University of Bristol, Bristol, UK
| | - Nick Freemantle
- Department of Primary Care and Population Health, UCL Medical School (Royal Free Campus), London, UK
| | - Vimal Sharma
- Early Intervention Service, Cheshire and Wirral NHS Foundation Trust, Chester, UK;,Faculty of Health and Social Care, University of Chester, Chester, UK
| | - Max Marshall
- School of Medicine, University of Manchester, Manchester, UK
| | - Swaran P. Singh
- Mental Health and Wellbeing Warwick Medical School, University of Warwick, Coventry, UK
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Hodgekins J, Birchwood M, Christopher R, Marshall M, Coker S, Everard L, Lester H, Jones P, Amos T, Singh S, Sharma V, Freemantle N, Fowler D. Investigating trajectories of social recovery in individuals with first-episode psychosis: a latent class growth analysis. Br J Psychiatry 2015; 207:536-43. [PMID: 26294371 PMCID: PMC4664858 DOI: 10.1192/bjp.bp.114.153486] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Accepted: 11/17/2014] [Indexed: 11/23/2022]
Abstract
BACKGROUND Social disability is a hallmark of severe mental illness yet individual differences and factors predicting outcome are largely unknown. AIM To explore trajectories and predictors of social recovery following a first episode of psychosis (FEP). METHOD A sample of 764 individuals with FEP were assessed on entry into early intervention in psychosis (EIP) services and followed up over 12 months. Social recovery profiles were examined using latent class growth analysis. RESULTS Three types of social recovery profile were identified: Low Stable (66%), Moderate-Increasing (27%), and High-Decreasing (7%). Poor social recovery was predicted by male gender, ethnic minority status, younger age at onset of psychosis, increased negative symptoms, and poor premorbid adjustment. CONCLUSIONS Social disability is prevalent in FEP, although distinct recovery profiles are evident. Where social disability is present on entry into EIP services it can remain stable, highlighting a need for targeted intervention.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | - David Fowler
- Jo Hodgekins, BSc, PhD, ClinPsyD, Norwich Medical School, University of East Anglia, Norwich, UK; Max Birchwood, PhD, DSc, University of Warwick, Gibbet Hill Road, Coventry, UK; Rose Christopher, BSc, Norwich Medical School, University of East Anglia, Norwich, UK; Max Marshall, MB BS, MD, University of Manchester, Manchester, UK; Sian Coker, BSc, DPhil, Norwich Medical School, University of East Anglia, Norwich, UK; Linda Everard, BSc, Birmingham and Solihull NHS Mental Health Foundation Trust, Birmingham, UK; Helen Lester, MB, BCH, MD (deceased), previously at the University of Birmingham, Edgbaston, Birmingham, UK; Peter Jones, PhD, FMedSci, University of Cambridge, Cambridge, UK; Tim Amos, MB BS, MRCPsych, University of Bristol, Bristol, UK; Swaran Singh, MBBS, MD, FRCPsych, DM, University of Warwick, Coventry, UK; Vimal Sharma, MD, FRCPsych, PhD, University of Chester, Cheshire and Wirral Partnership NHS Foundation Trust; Nick Freemantle, MA, PhD, University College London, London; David Fowler, MSc, CPsychol, University of Sussex, Brighton, UK
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Fonagy P, Speranza M, Luyten P, Kaess M, Hessels C, Bohus M. ESCAP Expert Article: borderline personality disorder in adolescence: an expert research review with implications for clinical practice. Eur Child Adolesc Psychiatry 2015; 24:1307-20. [PMID: 26271454 DOI: 10.1007/s00787-015-0751-z] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Accepted: 07/17/2015] [Indexed: 12/26/2022]
Abstract
Borderline personality disorder (BPD) has onset in adolescence, but is typically first diagnosed in young adulthood. This paper provides a narrative review of the current evidence on diagnosis, comorbidity, phenomenology and treatment of BPD in adolescence. Instruments available for diagnosis are reviewed and their strengths and limitations discussed. Having confirmed the robustness of the diagnosis and the potential for its reliable clinical assessment, we then explore current understandings of the mechanisms of the disorder and focus on neurobiological underpinnings and research on psychological mechanisms. Findings are accumulating to suggest that adolescent BPD has an underpinning biology that is similar in some ways to adult BPD but differs in some critical features. Evidence for interventions focuses on psychological therapies. Several encouraging research studies suggest that early effective treatment is possible. Treatment development has just begun, and while adolescent-specific interventions are still in the process of evolution, most existing therapies represent adaptations of adult models to this developmental phase. There is also a significant opportunity for prevention, albeit there are few data to date to support such initiatives. This review emphasizes that there can be no justification for failing to make an early diagnosis of this enduring and pervasive problem.
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Affiliation(s)
- Peter Fonagy
- Research Department of Clinical, Educational and Health Psychology, University College London, Gower Street, London, WC1E 6BT, UK.
| | - Mario Speranza
- Department of Child and Adolescent Psychiatry, Versailles General Hospital, Faculty of Health Sciences, Research Unit EA4047, University of Versailles Saint-Quentin-en-Yvelines, 177 rue de Versailles, 78157, Le Chesnay, France
| | - Patrick Luyten
- Research Department of Clinical, Educational and Health Psychology, University College London, Gower Street, London, WC1E 6BT, UK
- Faculty of Psychology and Educational Sciences, University of Leuven, Tiensestraat 102, Box 3722, 3000, Leuven, Belgium
| | - Michael Kaess
- Department of Child and Adolescent Psychiatry, Centre for Psychosocial Medicine, University of Heidelberg, Blumenstrasse 8, 69115, Heidelberg, Germany
| | - Christel Hessels
- Expertise Centre for Personality Disorders, GGz Centraal, PO Box 3051, 3800 DB, Amersfoort, The Netherlands
| | - Martin Bohus
- Department of Psychosomatics and Psychotherapy, Central Institute of Mental Health Mannheim, Heidelberg University, J5, 68159, Mannheim, Germany
- Faculty of Health, University of Antwerp, Antwerp, Belgium
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Abstract
High-quality services for people with psychosis are essential. However, in this debate David Castle questions whether separate early intervention services are the best option and argues instead for an integrated approach. Swaran Singh responds, robustly defending the value of early intervention services.
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Affiliation(s)
- David J Castle
- For: David J. Castle, MD, FRCPsych, FRANZCP, St Vincent's Mental Health Service and The University of Melbourne, PO Box 2900, Fitzroy, Victoria, Australia 3065. ; Against: Swaran P. Singh, MBBS, MD, FRCPsych, DM, Mental Health and Wellbeing, Warwick Medical School University of Warwick, Coventry, and Birmingham and Solihull Mental Health. Foundation Trust, Birmingham, and Equality and Human Rights Commission.
| | - Swaran P Singh
- For: David J. Castle, MD, FRCPsych, FRANZCP, St Vincent's Mental Health Service and The University of Melbourne, PO Box 2900, Fitzroy, Victoria, Australia 3065. ; Against: Swaran P. Singh, MBBS, MD, FRCPsych, DM, Mental Health and Wellbeing, Warwick Medical School University of Warwick, Coventry, and Birmingham and Solihull Mental Health. Foundation Trust, Birmingham, and Equality and Human Rights Commission.
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Kirkbride JB. Epidemiology on demand: population-based approaches to mental health service commissioning. BJPsych Bull 2015; 39:242-7. [PMID: 26755969 PMCID: PMC4706199 DOI: 10.1192/pb.bp.114.047746] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Revised: 07/31/2014] [Accepted: 09/03/2014] [Indexed: 11/23/2022] Open
Abstract
One in three people will experience a mental health problem in their lifetime, but the causes and consequences of psychiatric morbidity are socially patterned. Epidemiological studies can provide aetiological clues about the causes of disorder, and when they can provide robust estimates about risk in different strata of the population these can also be used translationally, to provide commissioners and service planners with detailed information about local service need. This approach is illustrated using a newly developed population-level prediction tool for first-episode psychosis, PsyMaptic. Such public mental health prediction tools could be used to improve allocation of finite resources, by integrating evidence-based healthcare, public health and epidemiology together.
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Lal S, Malla A. Service Engagement in First-Episode Psychosis: Current Issues and Future Directions. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2015; 60:341-5. [PMID: 26454555 PMCID: PMC4542513 DOI: 10.1177/070674371506000802] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Accepted: 07/01/2014] [Indexed: 12/21/2022]
Abstract
It has been reported that up to 50% of patients receiving mental health services disengage from treatment, with adolescents and young adults being particularly at high risk. Even in the context of specialized services in youth mental health, such as early intervention programs for psychosis, disengagement rates remain high. There is a need for extensive and innovative efforts to address the issue of service disengagement in first-episode psychosis (FEP). A multi-dimensional understanding of the phenomenon of engagement can help to inform the development of strategies to address this important clinical issue. In our paper, we propose a conceptual framework for understanding service engagement, provide an overview of the issues pertaining to service engagement in FEP, and suggest future directions for research and practice.
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Affiliation(s)
- Shalini Lal
- Assistant Professor, School of Rehabilitation, Université de Montréal, Montreal, Quebec; Researcher, Centre de Recherche du l'Université de Montréal, Montreal, Quebec; Associate Researcher, Douglas Mental Health University Institute, Montreal, Quebec
| | - Ashok Malla
- Professor and Canada Research Chair in Early Psychosis, Department of Psychiatry, McGill University, Montreal, Quebec; Researcher, Douglas Mental Health University Institute, Montreal, Quebec
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Lavis A, Lester H, Everard L, Freemantle N, Amos T, Fowler D, Hodgekins J, Jones P, Marshall M, Sharma V, Larsen J, McCrone P, Singh S, Smith J, Birchwood M. Layers of listening: qualitative analysis of the impact of early intervention services for first-episode psychosis on carers' experiences. Br J Psychiatry 2015; 207:135-42. [PMID: 25999336 DOI: 10.1192/bjp.bp.114.146415] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Accepted: 12/06/2014] [Indexed: 11/23/2022]
Abstract
BACKGROUND Early intervention services (EIS) comprise low-stigma, youth-friendly mental health teams for young people undergoing first-episode psychosis (FEP). Engaging with the family of the young person is central to EIS policy and practice.AimsBy analysing carers' accounts of their daily lives and affective challenges during a relative's FEP against the background of wider research into EIS, this paper explores relationships between carers' experiences and EIS. METHOD Semi-structured longitudinal interviews with 80 carers of young people with FEP treated through English EIS. RESULTS Our data suggest that EIS successfully aid carers to support their relatives, particularly through the provision of knowledge about psychosis and medications. However, paradoxical ramifications of these user-focused engagements also emerge; they risk leaving carers' emotions unacknowledged and compounding an existing lack of help-seeking. CONCLUSIONS By focusing on EIS's engagements with carers, this paper draws attention to an urgent broader question: as a continuing emphasis on care outside the clinic space places family members at the heart of the care of those with severe mental illness, we ask: who can, and should, support carers, and in what ways?
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Affiliation(s)
- Anna Lavis
- Anna Lavis, MRes, PhD, University of Birmingham, UK; Helen Lester (deceased), MBBCh, MD, previously at the School of Health and Population Sciences, University of Birmingham; Linda Everard, BSc, The Early Intervention Service, Aston, Birmingham; Nicholas Freemantle, PhD, Department of Primary Care and Population Health, UCL Medical School (Royal Free Campus), Rowland Hill; Tim Amos, MBBS, MRCPsych, Academic Unit of Psychiatry, University of Bristol; David Fowler, PhD, University of East Anglia, Norwich; Jo Hodgekins, PhD, DClinPsych, Department of Clinical Psychology, Norwich Medical School, University of East Anglia, Norwich; Peter Jones, MB BS, PhD, Department of Psychiatry, University of Cambridge and CAMEO, Cambridge and Peterborough NHS Foundation Trust; Max Marshall, MB BS, MD, School of Medicine, University of Manchester; Vimal Sharma, MD, FRCPsych, PhD, Faculty of Health and Social Care, University of Chester and Cheshire and Wirral Partnership NHS Foundation Trust; John Larsen, PhD, Evaluation Team, Rethink Mental Illness, London; Paul McCrone, PhD, Centre for the Economics of Mental Health/Section of Community Mental Health, King's College London; Swaran Singh, MBBS, MD, FRCPsych, DM, Health Sciences Research Institute, School of Medicine, University of Warwick; Jo Smith, PhD, Worcestershire EI Service, Worcestershire Health and Care NHS Trust, Worcester; Max Birchwood, PhD, DSc, Mental Health and Wellbeing, University of Warwick, Coventry
| | - Helen Lester
- Anna Lavis, MRes, PhD, University of Birmingham, UK; Helen Lester (deceased), MBBCh, MD, previously at the School of Health and Population Sciences, University of Birmingham; Linda Everard, BSc, The Early Intervention Service, Aston, Birmingham; Nicholas Freemantle, PhD, Department of Primary Care and Population Health, UCL Medical School (Royal Free Campus), Rowland Hill; Tim Amos, MBBS, MRCPsych, Academic Unit of Psychiatry, University of Bristol; David Fowler, PhD, University of East Anglia, Norwich; Jo Hodgekins, PhD, DClinPsych, Department of Clinical Psychology, Norwich Medical School, University of East Anglia, Norwich; Peter Jones, MB BS, PhD, Department of Psychiatry, University of Cambridge and CAMEO, Cambridge and Peterborough NHS Foundation Trust; Max Marshall, MB BS, MD, School of Medicine, University of Manchester; Vimal Sharma, MD, FRCPsych, PhD, Faculty of Health and Social Care, University of Chester and Cheshire and Wirral Partnership NHS Foundation Trust; John Larsen, PhD, Evaluation Team, Rethink Mental Illness, London; Paul McCrone, PhD, Centre for the Economics of Mental Health/Section of Community Mental Health, King's College London; Swaran Singh, MBBS, MD, FRCPsych, DM, Health Sciences Research Institute, School of Medicine, University of Warwick; Jo Smith, PhD, Worcestershire EI Service, Worcestershire Health and Care NHS Trust, Worcester; Max Birchwood, PhD, DSc, Mental Health and Wellbeing, University of Warwick, Coventry
| | - Linda Everard
- Anna Lavis, MRes, PhD, University of Birmingham, UK; Helen Lester (deceased), MBBCh, MD, previously at the School of Health and Population Sciences, University of Birmingham; Linda Everard, BSc, The Early Intervention Service, Aston, Birmingham; Nicholas Freemantle, PhD, Department of Primary Care and Population Health, UCL Medical School (Royal Free Campus), Rowland Hill; Tim Amos, MBBS, MRCPsych, Academic Unit of Psychiatry, University of Bristol; David Fowler, PhD, University of East Anglia, Norwich; Jo Hodgekins, PhD, DClinPsych, Department of Clinical Psychology, Norwich Medical School, University of East Anglia, Norwich; Peter Jones, MB BS, PhD, Department of Psychiatry, University of Cambridge and CAMEO, Cambridge and Peterborough NHS Foundation Trust; Max Marshall, MB BS, MD, School of Medicine, University of Manchester; Vimal Sharma, MD, FRCPsych, PhD, Faculty of Health and Social Care, University of Chester and Cheshire and Wirral Partnership NHS Foundation Trust; John Larsen, PhD, Evaluation Team, Rethink Mental Illness, London; Paul McCrone, PhD, Centre for the Economics of Mental Health/Section of Community Mental Health, King's College London; Swaran Singh, MBBS, MD, FRCPsych, DM, Health Sciences Research Institute, School of Medicine, University of Warwick; Jo Smith, PhD, Worcestershire EI Service, Worcestershire Health and Care NHS Trust, Worcester; Max Birchwood, PhD, DSc, Mental Health and Wellbeing, University of Warwick, Coventry
| | - Nicholas Freemantle
- Anna Lavis, MRes, PhD, University of Birmingham, UK; Helen Lester (deceased), MBBCh, MD, previously at the School of Health and Population Sciences, University of Birmingham; Linda Everard, BSc, The Early Intervention Service, Aston, Birmingham; Nicholas Freemantle, PhD, Department of Primary Care and Population Health, UCL Medical School (Royal Free Campus), Rowland Hill; Tim Amos, MBBS, MRCPsych, Academic Unit of Psychiatry, University of Bristol; David Fowler, PhD, University of East Anglia, Norwich; Jo Hodgekins, PhD, DClinPsych, Department of Clinical Psychology, Norwich Medical School, University of East Anglia, Norwich; Peter Jones, MB BS, PhD, Department of Psychiatry, University of Cambridge and CAMEO, Cambridge and Peterborough NHS Foundation Trust; Max Marshall, MB BS, MD, School of Medicine, University of Manchester; Vimal Sharma, MD, FRCPsych, PhD, Faculty of Health and Social Care, University of Chester and Cheshire and Wirral Partnership NHS Foundation Trust; John Larsen, PhD, Evaluation Team, Rethink Mental Illness, London; Paul McCrone, PhD, Centre for the Economics of Mental Health/Section of Community Mental Health, King's College London; Swaran Singh, MBBS, MD, FRCPsych, DM, Health Sciences Research Institute, School of Medicine, University of Warwick; Jo Smith, PhD, Worcestershire EI Service, Worcestershire Health and Care NHS Trust, Worcester; Max Birchwood, PhD, DSc, Mental Health and Wellbeing, University of Warwick, Coventry
| | - Tim Amos
- Anna Lavis, MRes, PhD, University of Birmingham, UK; Helen Lester (deceased), MBBCh, MD, previously at the School of Health and Population Sciences, University of Birmingham; Linda Everard, BSc, The Early Intervention Service, Aston, Birmingham; Nicholas Freemantle, PhD, Department of Primary Care and Population Health, UCL Medical School (Royal Free Campus), Rowland Hill; Tim Amos, MBBS, MRCPsych, Academic Unit of Psychiatry, University of Bristol; David Fowler, PhD, University of East Anglia, Norwich; Jo Hodgekins, PhD, DClinPsych, Department of Clinical Psychology, Norwich Medical School, University of East Anglia, Norwich; Peter Jones, MB BS, PhD, Department of Psychiatry, University of Cambridge and CAMEO, Cambridge and Peterborough NHS Foundation Trust; Max Marshall, MB BS, MD, School of Medicine, University of Manchester; Vimal Sharma, MD, FRCPsych, PhD, Faculty of Health and Social Care, University of Chester and Cheshire and Wirral Partnership NHS Foundation Trust; John Larsen, PhD, Evaluation Team, Rethink Mental Illness, London; Paul McCrone, PhD, Centre for the Economics of Mental Health/Section of Community Mental Health, King's College London; Swaran Singh, MBBS, MD, FRCPsych, DM, Health Sciences Research Institute, School of Medicine, University of Warwick; Jo Smith, PhD, Worcestershire EI Service, Worcestershire Health and Care NHS Trust, Worcester; Max Birchwood, PhD, DSc, Mental Health and Wellbeing, University of Warwick, Coventry
| | - David Fowler
- Anna Lavis, MRes, PhD, University of Birmingham, UK; Helen Lester (deceased), MBBCh, MD, previously at the School of Health and Population Sciences, University of Birmingham; Linda Everard, BSc, The Early Intervention Service, Aston, Birmingham; Nicholas Freemantle, PhD, Department of Primary Care and Population Health, UCL Medical School (Royal Free Campus), Rowland Hill; Tim Amos, MBBS, MRCPsych, Academic Unit of Psychiatry, University of Bristol; David Fowler, PhD, University of East Anglia, Norwich; Jo Hodgekins, PhD, DClinPsych, Department of Clinical Psychology, Norwich Medical School, University of East Anglia, Norwich; Peter Jones, MB BS, PhD, Department of Psychiatry, University of Cambridge and CAMEO, Cambridge and Peterborough NHS Foundation Trust; Max Marshall, MB BS, MD, School of Medicine, University of Manchester; Vimal Sharma, MD, FRCPsych, PhD, Faculty of Health and Social Care, University of Chester and Cheshire and Wirral Partnership NHS Foundation Trust; John Larsen, PhD, Evaluation Team, Rethink Mental Illness, London; Paul McCrone, PhD, Centre for the Economics of Mental Health/Section of Community Mental Health, King's College London; Swaran Singh, MBBS, MD, FRCPsych, DM, Health Sciences Research Institute, School of Medicine, University of Warwick; Jo Smith, PhD, Worcestershire EI Service, Worcestershire Health and Care NHS Trust, Worcester; Max Birchwood, PhD, DSc, Mental Health and Wellbeing, University of Warwick, Coventry
| | - Jo Hodgekins
- Anna Lavis, MRes, PhD, University of Birmingham, UK; Helen Lester (deceased), MBBCh, MD, previously at the School of Health and Population Sciences, University of Birmingham; Linda Everard, BSc, The Early Intervention Service, Aston, Birmingham; Nicholas Freemantle, PhD, Department of Primary Care and Population Health, UCL Medical School (Royal Free Campus), Rowland Hill; Tim Amos, MBBS, MRCPsych, Academic Unit of Psychiatry, University of Bristol; David Fowler, PhD, University of East Anglia, Norwich; Jo Hodgekins, PhD, DClinPsych, Department of Clinical Psychology, Norwich Medical School, University of East Anglia, Norwich; Peter Jones, MB BS, PhD, Department of Psychiatry, University of Cambridge and CAMEO, Cambridge and Peterborough NHS Foundation Trust; Max Marshall, MB BS, MD, School of Medicine, University of Manchester; Vimal Sharma, MD, FRCPsych, PhD, Faculty of Health and Social Care, University of Chester and Cheshire and Wirral Partnership NHS Foundation Trust; John Larsen, PhD, Evaluation Team, Rethink Mental Illness, London; Paul McCrone, PhD, Centre for the Economics of Mental Health/Section of Community Mental Health, King's College London; Swaran Singh, MBBS, MD, FRCPsych, DM, Health Sciences Research Institute, School of Medicine, University of Warwick; Jo Smith, PhD, Worcestershire EI Service, Worcestershire Health and Care NHS Trust, Worcester; Max Birchwood, PhD, DSc, Mental Health and Wellbeing, University of Warwick, Coventry
| | - Peter Jones
- Anna Lavis, MRes, PhD, University of Birmingham, UK; Helen Lester (deceased), MBBCh, MD, previously at the School of Health and Population Sciences, University of Birmingham; Linda Everard, BSc, The Early Intervention Service, Aston, Birmingham; Nicholas Freemantle, PhD, Department of Primary Care and Population Health, UCL Medical School (Royal Free Campus), Rowland Hill; Tim Amos, MBBS, MRCPsych, Academic Unit of Psychiatry, University of Bristol; David Fowler, PhD, University of East Anglia, Norwich; Jo Hodgekins, PhD, DClinPsych, Department of Clinical Psychology, Norwich Medical School, University of East Anglia, Norwich; Peter Jones, MB BS, PhD, Department of Psychiatry, University of Cambridge and CAMEO, Cambridge and Peterborough NHS Foundation Trust; Max Marshall, MB BS, MD, School of Medicine, University of Manchester; Vimal Sharma, MD, FRCPsych, PhD, Faculty of Health and Social Care, University of Chester and Cheshire and Wirral Partnership NHS Foundation Trust; John Larsen, PhD, Evaluation Team, Rethink Mental Illness, London; Paul McCrone, PhD, Centre for the Economics of Mental Health/Section of Community Mental Health, King's College London; Swaran Singh, MBBS, MD, FRCPsych, DM, Health Sciences Research Institute, School of Medicine, University of Warwick; Jo Smith, PhD, Worcestershire EI Service, Worcestershire Health and Care NHS Trust, Worcester; Max Birchwood, PhD, DSc, Mental Health and Wellbeing, University of Warwick, Coventry
| | - Max Marshall
- Anna Lavis, MRes, PhD, University of Birmingham, UK; Helen Lester (deceased), MBBCh, MD, previously at the School of Health and Population Sciences, University of Birmingham; Linda Everard, BSc, The Early Intervention Service, Aston, Birmingham; Nicholas Freemantle, PhD, Department of Primary Care and Population Health, UCL Medical School (Royal Free Campus), Rowland Hill; Tim Amos, MBBS, MRCPsych, Academic Unit of Psychiatry, University of Bristol; David Fowler, PhD, University of East Anglia, Norwich; Jo Hodgekins, PhD, DClinPsych, Department of Clinical Psychology, Norwich Medical School, University of East Anglia, Norwich; Peter Jones, MB BS, PhD, Department of Psychiatry, University of Cambridge and CAMEO, Cambridge and Peterborough NHS Foundation Trust; Max Marshall, MB BS, MD, School of Medicine, University of Manchester; Vimal Sharma, MD, FRCPsych, PhD, Faculty of Health and Social Care, University of Chester and Cheshire and Wirral Partnership NHS Foundation Trust; John Larsen, PhD, Evaluation Team, Rethink Mental Illness, London; Paul McCrone, PhD, Centre for the Economics of Mental Health/Section of Community Mental Health, King's College London; Swaran Singh, MBBS, MD, FRCPsych, DM, Health Sciences Research Institute, School of Medicine, University of Warwick; Jo Smith, PhD, Worcestershire EI Service, Worcestershire Health and Care NHS Trust, Worcester; Max Birchwood, PhD, DSc, Mental Health and Wellbeing, University of Warwick, Coventry
| | - Vimal Sharma
- Anna Lavis, MRes, PhD, University of Birmingham, UK; Helen Lester (deceased), MBBCh, MD, previously at the School of Health and Population Sciences, University of Birmingham; Linda Everard, BSc, The Early Intervention Service, Aston, Birmingham; Nicholas Freemantle, PhD, Department of Primary Care and Population Health, UCL Medical School (Royal Free Campus), Rowland Hill; Tim Amos, MBBS, MRCPsych, Academic Unit of Psychiatry, University of Bristol; David Fowler, PhD, University of East Anglia, Norwich; Jo Hodgekins, PhD, DClinPsych, Department of Clinical Psychology, Norwich Medical School, University of East Anglia, Norwich; Peter Jones, MB BS, PhD, Department of Psychiatry, University of Cambridge and CAMEO, Cambridge and Peterborough NHS Foundation Trust; Max Marshall, MB BS, MD, School of Medicine, University of Manchester; Vimal Sharma, MD, FRCPsych, PhD, Faculty of Health and Social Care, University of Chester and Cheshire and Wirral Partnership NHS Foundation Trust; John Larsen, PhD, Evaluation Team, Rethink Mental Illness, London; Paul McCrone, PhD, Centre for the Economics of Mental Health/Section of Community Mental Health, King's College London; Swaran Singh, MBBS, MD, FRCPsych, DM, Health Sciences Research Institute, School of Medicine, University of Warwick; Jo Smith, PhD, Worcestershire EI Service, Worcestershire Health and Care NHS Trust, Worcester; Max Birchwood, PhD, DSc, Mental Health and Wellbeing, University of Warwick, Coventry
| | - John Larsen
- Anna Lavis, MRes, PhD, University of Birmingham, UK; Helen Lester (deceased), MBBCh, MD, previously at the School of Health and Population Sciences, University of Birmingham; Linda Everard, BSc, The Early Intervention Service, Aston, Birmingham; Nicholas Freemantle, PhD, Department of Primary Care and Population Health, UCL Medical School (Royal Free Campus), Rowland Hill; Tim Amos, MBBS, MRCPsych, Academic Unit of Psychiatry, University of Bristol; David Fowler, PhD, University of East Anglia, Norwich; Jo Hodgekins, PhD, DClinPsych, Department of Clinical Psychology, Norwich Medical School, University of East Anglia, Norwich; Peter Jones, MB BS, PhD, Department of Psychiatry, University of Cambridge and CAMEO, Cambridge and Peterborough NHS Foundation Trust; Max Marshall, MB BS, MD, School of Medicine, University of Manchester; Vimal Sharma, MD, FRCPsych, PhD, Faculty of Health and Social Care, University of Chester and Cheshire and Wirral Partnership NHS Foundation Trust; John Larsen, PhD, Evaluation Team, Rethink Mental Illness, London; Paul McCrone, PhD, Centre for the Economics of Mental Health/Section of Community Mental Health, King's College London; Swaran Singh, MBBS, MD, FRCPsych, DM, Health Sciences Research Institute, School of Medicine, University of Warwick; Jo Smith, PhD, Worcestershire EI Service, Worcestershire Health and Care NHS Trust, Worcester; Max Birchwood, PhD, DSc, Mental Health and Wellbeing, University of Warwick, Coventry
| | - Paul McCrone
- Anna Lavis, MRes, PhD, University of Birmingham, UK; Helen Lester (deceased), MBBCh, MD, previously at the School of Health and Population Sciences, University of Birmingham; Linda Everard, BSc, The Early Intervention Service, Aston, Birmingham; Nicholas Freemantle, PhD, Department of Primary Care and Population Health, UCL Medical School (Royal Free Campus), Rowland Hill; Tim Amos, MBBS, MRCPsych, Academic Unit of Psychiatry, University of Bristol; David Fowler, PhD, University of East Anglia, Norwich; Jo Hodgekins, PhD, DClinPsych, Department of Clinical Psychology, Norwich Medical School, University of East Anglia, Norwich; Peter Jones, MB BS, PhD, Department of Psychiatry, University of Cambridge and CAMEO, Cambridge and Peterborough NHS Foundation Trust; Max Marshall, MB BS, MD, School of Medicine, University of Manchester; Vimal Sharma, MD, FRCPsych, PhD, Faculty of Health and Social Care, University of Chester and Cheshire and Wirral Partnership NHS Foundation Trust; John Larsen, PhD, Evaluation Team, Rethink Mental Illness, London; Paul McCrone, PhD, Centre for the Economics of Mental Health/Section of Community Mental Health, King's College London; Swaran Singh, MBBS, MD, FRCPsych, DM, Health Sciences Research Institute, School of Medicine, University of Warwick; Jo Smith, PhD, Worcestershire EI Service, Worcestershire Health and Care NHS Trust, Worcester; Max Birchwood, PhD, DSc, Mental Health and Wellbeing, University of Warwick, Coventry
| | - Swaran Singh
- Anna Lavis, MRes, PhD, University of Birmingham, UK; Helen Lester (deceased), MBBCh, MD, previously at the School of Health and Population Sciences, University of Birmingham; Linda Everard, BSc, The Early Intervention Service, Aston, Birmingham; Nicholas Freemantle, PhD, Department of Primary Care and Population Health, UCL Medical School (Royal Free Campus), Rowland Hill; Tim Amos, MBBS, MRCPsych, Academic Unit of Psychiatry, University of Bristol; David Fowler, PhD, University of East Anglia, Norwich; Jo Hodgekins, PhD, DClinPsych, Department of Clinical Psychology, Norwich Medical School, University of East Anglia, Norwich; Peter Jones, MB BS, PhD, Department of Psychiatry, University of Cambridge and CAMEO, Cambridge and Peterborough NHS Foundation Trust; Max Marshall, MB BS, MD, School of Medicine, University of Manchester; Vimal Sharma, MD, FRCPsych, PhD, Faculty of Health and Social Care, University of Chester and Cheshire and Wirral Partnership NHS Foundation Trust; John Larsen, PhD, Evaluation Team, Rethink Mental Illness, London; Paul McCrone, PhD, Centre for the Economics of Mental Health/Section of Community Mental Health, King's College London; Swaran Singh, MBBS, MD, FRCPsych, DM, Health Sciences Research Institute, School of Medicine, University of Warwick; Jo Smith, PhD, Worcestershire EI Service, Worcestershire Health and Care NHS Trust, Worcester; Max Birchwood, PhD, DSc, Mental Health and Wellbeing, University of Warwick, Coventry
| | - Jo Smith
- Anna Lavis, MRes, PhD, University of Birmingham, UK; Helen Lester (deceased), MBBCh, MD, previously at the School of Health and Population Sciences, University of Birmingham; Linda Everard, BSc, The Early Intervention Service, Aston, Birmingham; Nicholas Freemantle, PhD, Department of Primary Care and Population Health, UCL Medical School (Royal Free Campus), Rowland Hill; Tim Amos, MBBS, MRCPsych, Academic Unit of Psychiatry, University of Bristol; David Fowler, PhD, University of East Anglia, Norwich; Jo Hodgekins, PhD, DClinPsych, Department of Clinical Psychology, Norwich Medical School, University of East Anglia, Norwich; Peter Jones, MB BS, PhD, Department of Psychiatry, University of Cambridge and CAMEO, Cambridge and Peterborough NHS Foundation Trust; Max Marshall, MB BS, MD, School of Medicine, University of Manchester; Vimal Sharma, MD, FRCPsych, PhD, Faculty of Health and Social Care, University of Chester and Cheshire and Wirral Partnership NHS Foundation Trust; John Larsen, PhD, Evaluation Team, Rethink Mental Illness, London; Paul McCrone, PhD, Centre for the Economics of Mental Health/Section of Community Mental Health, King's College London; Swaran Singh, MBBS, MD, FRCPsych, DM, Health Sciences Research Institute, School of Medicine, University of Warwick; Jo Smith, PhD, Worcestershire EI Service, Worcestershire Health and Care NHS Trust, Worcester; Max Birchwood, PhD, DSc, Mental Health and Wellbeing, University of Warwick, Coventry
| | - Max Birchwood
- Anna Lavis, MRes, PhD, University of Birmingham, UK; Helen Lester (deceased), MBBCh, MD, previously at the School of Health and Population Sciences, University of Birmingham; Linda Everard, BSc, The Early Intervention Service, Aston, Birmingham; Nicholas Freemantle, PhD, Department of Primary Care and Population Health, UCL Medical School (Royal Free Campus), Rowland Hill; Tim Amos, MBBS, MRCPsych, Academic Unit of Psychiatry, University of Bristol; David Fowler, PhD, University of East Anglia, Norwich; Jo Hodgekins, PhD, DClinPsych, Department of Clinical Psychology, Norwich Medical School, University of East Anglia, Norwich; Peter Jones, MB BS, PhD, Department of Psychiatry, University of Cambridge and CAMEO, Cambridge and Peterborough NHS Foundation Trust; Max Marshall, MB BS, MD, School of Medicine, University of Manchester; Vimal Sharma, MD, FRCPsych, PhD, Faculty of Health and Social Care, University of Chester and Cheshire and Wirral Partnership NHS Foundation Trust; John Larsen, PhD, Evaluation Team, Rethink Mental Illness, London; Paul McCrone, PhD, Centre for the Economics of Mental Health/Section of Community Mental Health, King's College London; Swaran Singh, MBBS, MD, FRCPsych, DM, Health Sciences Research Institute, School of Medicine, University of Warwick; Jo Smith, PhD, Worcestershire EI Service, Worcestershire Health and Care NHS Trust, Worcester; Max Birchwood, PhD, DSc, Mental Health and Wellbeing, University of Warwick, Coventry
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Srihari VH, Tek C, Kucukgoncu S, Phutane VH, Breitborde NJK, Pollard J, Ozkan B, Saksa J, Walsh BC, Woods SW. First-Episode Services for Psychotic Disorders in the U.S. Public Sector: A Pragmatic Randomized Controlled Trial. Psychiatr Serv 2015; 66:705-12. [PMID: 25639994 PMCID: PMC4490067 DOI: 10.1176/appi.ps.201400236] [Citation(s) in RCA: 82] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE This study sought to determine the effectiveness of a comprehensive first-episode service, the clinic for Specialized Treatment Early in Psychosis (STEP), in an urban U.S. community mental health center by comparing it with usual treatment. METHODS This pragmatic randomized controlled trial enrolled 120 patients with first-episode psychosis within five years of illness onset and 12 weeks of antipsychotic exposure. Referrals were mostly from inpatient psychiatric units, and enrollees were randomly allocated to STEP or usual treatment. Main outcomes included hospital utilization (primary); the ability to work or attend age-appropriate schooling-or to actively seek these opportunities (vocational engagement); and general functioning. Analysis was by modified intent to treat (excluding only three who withdrew consent) for hospitalization; for other outcomes, only data for completers were analyzed. RESULTS After one year, STEP participants had less inpatient utilization compared with those in usual treatment: no psychiatric hospitalizations, 77% versus 56% (risk ratio [RR]=1.38, 95% confidence interval [CI]=1.08-1.58); mean hospitalizations, .33±.70 versus .68±.92 (p=.02); and mean bed-days, 5.34±13.53 versus 11.51±15.04 (p=.05). For every five patients allocated to STEP versus usual treatment, one additional patient avoided hospitalization over the first year (number needed to treat=5; CI=2.7-26.5). STEP participants also demonstrated better vocational engagement (91.7% versus 66.7%; RR=1.40, CI=1.18-1.48) and showed salutary trends in global functioning measures. CONCLUSIONS This trial demonstrated the feasibility and effectiveness of a U.S. public-sector model of early intervention for psychotic illnesses. Such services can also support translational research and are a relevant model for other serious mental illnesses.
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Affiliation(s)
- Vinod H Srihari
- Dr. Srihari, Dr. Tek, Dr. Kucukgoncu, Dr. Pollard, Dr Saksa, Dr. Walsh, and Dr. Woods are with the Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut (e-mail: ). Dr. Phutane is with Goulburn Valley Health, Shepparton, Victoria, Australia. Dr. Breitborde is with the Department of Psychiatry, University of Arizona, Tucson. Dr. Ozkan is with the Department of Psychiatry, Koc University, Istanbul, Turkey. Findings of this study were presented at the International Conference on Early Psychosis, San Francisco, October 11-13, 2012. This article is part of a special section on RAISE and other early intervention services. Marcela Horvitz-Lennon, M.D., M.P.H., served as guest editor of the special section
| | - Cenk Tek
- Dr. Srihari, Dr. Tek, Dr. Kucukgoncu, Dr. Pollard, Dr Saksa, Dr. Walsh, and Dr. Woods are with the Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut (e-mail: ). Dr. Phutane is with Goulburn Valley Health, Shepparton, Victoria, Australia. Dr. Breitborde is with the Department of Psychiatry, University of Arizona, Tucson. Dr. Ozkan is with the Department of Psychiatry, Koc University, Istanbul, Turkey. Findings of this study were presented at the International Conference on Early Psychosis, San Francisco, October 11-13, 2012. This article is part of a special section on RAISE and other early intervention services. Marcela Horvitz-Lennon, M.D., M.P.H., served as guest editor of the special section
| | - Suat Kucukgoncu
- Dr. Srihari, Dr. Tek, Dr. Kucukgoncu, Dr. Pollard, Dr Saksa, Dr. Walsh, and Dr. Woods are with the Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut (e-mail: ). Dr. Phutane is with Goulburn Valley Health, Shepparton, Victoria, Australia. Dr. Breitborde is with the Department of Psychiatry, University of Arizona, Tucson. Dr. Ozkan is with the Department of Psychiatry, Koc University, Istanbul, Turkey. Findings of this study were presented at the International Conference on Early Psychosis, San Francisco, October 11-13, 2012. This article is part of a special section on RAISE and other early intervention services. Marcela Horvitz-Lennon, M.D., M.P.H., served as guest editor of the special section
| | - Vivek H Phutane
- Dr. Srihari, Dr. Tek, Dr. Kucukgoncu, Dr. Pollard, Dr Saksa, Dr. Walsh, and Dr. Woods are with the Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut (e-mail: ). Dr. Phutane is with Goulburn Valley Health, Shepparton, Victoria, Australia. Dr. Breitborde is with the Department of Psychiatry, University of Arizona, Tucson. Dr. Ozkan is with the Department of Psychiatry, Koc University, Istanbul, Turkey. Findings of this study were presented at the International Conference on Early Psychosis, San Francisco, October 11-13, 2012. This article is part of a special section on RAISE and other early intervention services. Marcela Horvitz-Lennon, M.D., M.P.H., served as guest editor of the special section
| | - Nicholas J K Breitborde
- Dr. Srihari, Dr. Tek, Dr. Kucukgoncu, Dr. Pollard, Dr Saksa, Dr. Walsh, and Dr. Woods are with the Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut (e-mail: ). Dr. Phutane is with Goulburn Valley Health, Shepparton, Victoria, Australia. Dr. Breitborde is with the Department of Psychiatry, University of Arizona, Tucson. Dr. Ozkan is with the Department of Psychiatry, Koc University, Istanbul, Turkey. Findings of this study were presented at the International Conference on Early Psychosis, San Francisco, October 11-13, 2012. This article is part of a special section on RAISE and other early intervention services. Marcela Horvitz-Lennon, M.D., M.P.H., served as guest editor of the special section
| | - Jessica Pollard
- Dr. Srihari, Dr. Tek, Dr. Kucukgoncu, Dr. Pollard, Dr Saksa, Dr. Walsh, and Dr. Woods are with the Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut (e-mail: ). Dr. Phutane is with Goulburn Valley Health, Shepparton, Victoria, Australia. Dr. Breitborde is with the Department of Psychiatry, University of Arizona, Tucson. Dr. Ozkan is with the Department of Psychiatry, Koc University, Istanbul, Turkey. Findings of this study were presented at the International Conference on Early Psychosis, San Francisco, October 11-13, 2012. This article is part of a special section on RAISE and other early intervention services. Marcela Horvitz-Lennon, M.D., M.P.H., served as guest editor of the special section
| | - Banu Ozkan
- Dr. Srihari, Dr. Tek, Dr. Kucukgoncu, Dr. Pollard, Dr Saksa, Dr. Walsh, and Dr. Woods are with the Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut (e-mail: ). Dr. Phutane is with Goulburn Valley Health, Shepparton, Victoria, Australia. Dr. Breitborde is with the Department of Psychiatry, University of Arizona, Tucson. Dr. Ozkan is with the Department of Psychiatry, Koc University, Istanbul, Turkey. Findings of this study were presented at the International Conference on Early Psychosis, San Francisco, October 11-13, 2012. This article is part of a special section on RAISE and other early intervention services. Marcela Horvitz-Lennon, M.D., M.P.H., served as guest editor of the special section
| | - John Saksa
- Dr. Srihari, Dr. Tek, Dr. Kucukgoncu, Dr. Pollard, Dr Saksa, Dr. Walsh, and Dr. Woods are with the Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut (e-mail: ). Dr. Phutane is with Goulburn Valley Health, Shepparton, Victoria, Australia. Dr. Breitborde is with the Department of Psychiatry, University of Arizona, Tucson. Dr. Ozkan is with the Department of Psychiatry, Koc University, Istanbul, Turkey. Findings of this study were presented at the International Conference on Early Psychosis, San Francisco, October 11-13, 2012. This article is part of a special section on RAISE and other early intervention services. Marcela Horvitz-Lennon, M.D., M.P.H., served as guest editor of the special section
| | - Barbara C Walsh
- Dr. Srihari, Dr. Tek, Dr. Kucukgoncu, Dr. Pollard, Dr Saksa, Dr. Walsh, and Dr. Woods are with the Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut (e-mail: ). Dr. Phutane is with Goulburn Valley Health, Shepparton, Victoria, Australia. Dr. Breitborde is with the Department of Psychiatry, University of Arizona, Tucson. Dr. Ozkan is with the Department of Psychiatry, Koc University, Istanbul, Turkey. Findings of this study were presented at the International Conference on Early Psychosis, San Francisco, October 11-13, 2012. This article is part of a special section on RAISE and other early intervention services. Marcela Horvitz-Lennon, M.D., M.P.H., served as guest editor of the special section
| | - Scott W Woods
- Dr. Srihari, Dr. Tek, Dr. Kucukgoncu, Dr. Pollard, Dr Saksa, Dr. Walsh, and Dr. Woods are with the Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut (e-mail: ). Dr. Phutane is with Goulburn Valley Health, Shepparton, Victoria, Australia. Dr. Breitborde is with the Department of Psychiatry, University of Arizona, Tucson. Dr. Ozkan is with the Department of Psychiatry, Koc University, Istanbul, Turkey. Findings of this study were presented at the International Conference on Early Psychosis, San Francisco, October 11-13, 2012. This article is part of a special section on RAISE and other early intervention services. Marcela Horvitz-Lennon, M.D., M.P.H., served as guest editor of the special section
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Hodgekins J, French P, Birchwood M, Mugford M, Christopher R, Marshall M, Everard L, Lester H, Jones P, Amos T, Singh S, Sharma V, Morrison AP, Fowler D. Comparing time use in individuals at different stages of psychosis and a non-clinical comparison group. Schizophr Res 2015; 161:188-93. [PMID: 25541138 DOI: 10.1016/j.schres.2014.12.011] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Revised: 11/27/2014] [Accepted: 12/06/2014] [Indexed: 11/26/2022]
Abstract
Social functioning difficulties are a common and disabling feature of psychosis and have also been identified in the prodromal phase. However, debate exists about how such difficulties should be defined and measured. Time spent in structured activity has previously been linked to increased psychological wellbeing in non-clinical samples and may provide a useful way of assessing social functioning in clinical settings. The current study compared hours in structured activity, assessed with the Time Use Survey, in three clinical groups at different stages of psychosis: individuals with at-risk mental states (N=199), individuals with first-episode psychosis (N=878), and individuals with delayed social recovery following the remission of psychotic symptoms (N=77). Time use in the three clinical groups was also compared with norms from an age-matched non-clinical group (N=5686) recruited for the Office for National Statistics UK 2000 Time Use Survey. Cutoff scores for defining social disability and recovery were examined. All three clinical groups spent significantly fewer hours per week in structured activity than individuals in the non-clinical group. Reduced activity levels were observed before the onset of psychosis in individuals with at-risk mental states. Additional reductions in activity were observed in the first-episode psychosis and delayed recovery groups compared to the at-risk mental state group. Assessing time spent in structured activity provides a useful way to assess social disability and recovery across the spectrum of psychosis.
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Affiliation(s)
- Jo Hodgekins
- Norwich Medical School, University of East Anglia, Norwich NR4 7TJ, UK.
| | - Paul French
- University of Manchester, Oxford Road, Manchester M13 9PL, UK
| | - Max Birchwood
- University of Warwick, Gibbet Hill Road, Coventry CV4 7AL, UK
| | - Miranda Mugford
- Norwich Medical School, University of East Anglia, Norwich NR4 7TJ, UK
| | - Rose Christopher
- Norwich Medical School, University of East Anglia, Norwich NR4 7TJ, UK
| | - Max Marshall
- University of Manchester, Oxford Road, Manchester M13 9PL, UK
| | - Linda Everard
- Birmingham and Solihull NHS Mental Health Foundation Trust, Birmingham, UK
| | - Helen Lester
- University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
| | - Peter Jones
- University of Cambridge, Cambridge CB2 1TN, UK
| | - Tim Amos
- University of Bristol, Bristol BS8 1TH, UK
| | - Swaran Singh
- University of Warwick, Gibbet Hill Road, Coventry CV4 7AL, UK
| | - Vimal Sharma
- Cheshire and Wirral Partnership NHS Foundation Trust, University of Chester, UK
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Marshall M, Husain N, Bork N, Chaudhry IB, Lester H, Everard L, Singh SP, Freemantle N, Sharma V, Jones PB, Fowler D, Amos T, Tomenson B, Birchwood M. Impact of early intervention services on duration of untreated psychosis: data from the National EDEN prospective cohort study. Schizophr Res 2014; 159:1-6. [PMID: 25107851 DOI: 10.1016/j.schres.2014.07.005] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2013] [Revised: 07/05/2014] [Accepted: 07/10/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE This study aimed to determine if the inception of Early Intervention Services (EISs) is followed by an improvement in the prompt treatment of people with first episode psychosis. METHOD A prospective cohort study of referrals to new and established EISs was conducted at 1, 2, 3, and 4 years after inception of new EIS. The study was conducted with 14 (seven new and seven established) secondary care EIS within geographically defined catchment areas in England between 2005 and 2009. Participants included 1027 consecutive referrals to EIS aged 14-35 with a first episode of psychosis. Duration of untreated psychosis (DUP) and number of participants treated adequately within 6 months of onset were the main outcome measures. RESULTS A significant downward trend across yearly cohorts for DUP for new EIS (F1,549=8.4, p=0.004) but not for established EIS (F1,429=1.7, p=0.19) was observed. There was a significant upward trend across cohorts in the proportion of referrals treated within 6 months for new EIS (X(2)=8.0, df=1, p=0.005), but not for established EIS (X(2)=0.1, df=1, p=0.72). CONCLUSION The introduction of new EIS was followed by a reduction in DUP and an increase in the proportion of patients treated within 6 months of onset. These trends were not present in the catchment areas of established services where DUP was initially lower, suggesting that there was no general tendency for DUP to fall over time. Hence, the introduction of an EIS was followed by an improvement in the prompt and proper treatment of first episode psychosis.
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Affiliation(s)
- Max Marshall
- School of Medicine, University of Manchester, United Kingdom.
| | - Nusrat Husain
- School of Medicine, University of Manchester, United Kingdom
| | - Natalie Bork
- School of Medicine, University of Manchester, United Kingdom
| | | | - Helen Lester
- University of Birmingham, Birmingham, United Kingdom
| | - Linda Everard
- University of Birmingham, Birmingham, United Kingdom
| | - Swaran P Singh
- Health Sciences Research Institute, University of Warwick, Warwick, United Kingdom
| | - Nick Freemantle
- Department of Primary Care and Population Health, University College, London, United Kingdom
| | | | - Peter B Jones
- Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom
| | - David Fowler
- School of Medicine, University of East Anglia, United Kingdom
| | - Tim Amos
- Academic Unit of Psychiatry, University of Bristol, Bristol, United Kingdom
| | | | - Max Birchwood
- University of Birmingham, Birmingham, United Kingdom
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