McLean OnTrack: a transdiagnostic program for early intervention in first-episode psychosis

Factors associated with improved outcomes in the first psychotic episode at a specialized outpatient clinic in northeastern Brazil

OBJECTIVES

The present study aimed to evaluate data from patients admitted to the first-episode psychotic (FEP) outpatient clinic at the Hospital of Clinics of the Federal University of Pernambuco from July 2018 to July 2021, seeking to identify factors related to better clinical outcomes.

METHODS

This study was conducted using a convenience sample, including all patients between 15 and 65 years of age who were admitted to the FEP outpatient clinic from July 2018 to July 2021. Descriptive statistical analysis was performed using mean and standard deviation or median and interquartile range for continuous quantitative variables, and absolute number/percentage for qualitative variables. Paired T-test, a parametric test, was used to compare PANSS scores upon admission and after 6 months. Spearman's correlation test was employed to assess the correlation between duration of untreated psychosis (DUP) and treatment response with other variables.

RESULTS

The sample consisted of 85.3% male individuals, with 50% of patients aged between 19 and 30 years, and 82% residing in the metropolitan area of Recife. Seventy percent of patients responded to the treatment implemented by the outpatient clinic, and only 30% required psychiatric hospitalization within 6 months of follow-up. The majority of patients had a history of psychoactive substance use (82.4%); however, the use of these substances did not impact the prognosis within the analysed sample. The median DUP was 4 weeks, and a shorter DUP was associated with a lower probability of psychiatric hospitalization and a greater treatment response (reduction >50% in PANSS).

CONCLUSION

A shorter DUP was associated with a lower likelihood of psychiatric hospitalization and a greater treatment response. Furthermore, the specialized early psychosis outpatient clinic itself appears to yield positive outcomes, as 70% of the treated patients exhibited a positive treatment response.

Macro- and Micro-Structural Alterations in the Midbrain in Early Psychosis

Introduction

Early psychosis (EP) is a critical period in the course of psychotic disorders during which the brain is thought to undergo rapid and significant functional and structural changes 1 . Growing evidence suggests that the advent of psychotic disorders is early alterations in the brain's functional connectivity and structure, leading to aberrant neural network organization. The Human Connectome Project (HCP) is a global effort to map the human brain's connectivity in healthy and disease populations; within HCP, there is a specific dataset that focuses on the EP subjects (i.e., those within five years of the initial psychotic episode) (HCP-EP), which is the focus of our study. Given the critically important role of the midbrain function and structure in psychotic disorders (cite), and EP in particular (cite), we specifically focused on the midbrain macro- and micro-structural alterations and their association with clinical outcomes in HCP-EP.

Methods

We examined macro- and micro-structural brain alterations in the HCP-EP sample (n=179: EP, n=123, Controls, n=56) as well as their associations with behavioral measures (i.e., symptoms severity) using a stepwise approach, incorporating a multimodal MRI analysis procedure. First, Deformation Based Morphometry (DBM) was carried out on the whole brain 3 Tesla T1w images to examine gross brain anatomy (i.e., seed-based and voxel-based volumes). Second, we extracted Fractional Anisotropy (FA), Axial Diffusivity (AD), and Mean Diffusivity (MD) indices from the Diffusion Tensor Imaging (DTI) data; a midbrain mask was created based on FreeSurfer v.6.0 atlas. Third, we employed Tract-Based Spatial Statistics (TBSS) to determine microstructural alterations in white matter tracts within the midbrain and broader regions. Finally, we conducted correlation analyses to examine associations between the DBM-, DTI- and TBSS-based outcomes and the Positive and Negative Syndrome Scale (PANSS) scores.

Results

DBM analysis showed alterations in the hippocampus, midbrain, and caudate/putamen. A DTI voxel-based analysis shows midbrain reductions in FA and AD and increases in MD; meanwhile, the hippocampus shows an increase in FA and a decrease in AD and MD. Several key brain regions also show alterations in DTI indices (e.g., insula, caudate, prefrontal cortex). A seed-based analysis centered around a midbrain region of interest obtained from freesurfer segmentation confirms the voxel-based analysis of DTI indices. TBSS successfully captured structural differences within the midbrain and complementary alterations in other main white matter tracts, such as the corticospinal tract and cingulum, suggesting early altered brain connectivity in EP. Correlations between these quantities in the EP group and behavioral scores (i.e., PANSS and CAINS tests) were explored. It was found that midbrain volume noticeably correlates with the Cognitive score of PA and all DTI metrics. FA correlates with the several dimensions of the PANSS, while AD and MD do not show many associations with PANSS or CAINS.

Conclusions

Our findings contribute to understanding the midbrain-focused circuitry involvement in EP and complimentary alteration in EP. Our work provides a path for future investigations to inform specific brain-based biomarkers of EP and their relationships to clinical manifestations of the psychosis course.

The transition to Schizophrenia spectrum disorder from a first psychotic episode that did or did not appear to be induced by substance use

The first years following a first-episode psychosis (FEP) are crucial. This retrospective cohort study investigates the evolution of first-episode psychosis (FEP), including substance-induced psychosis (SIP), and explores factors influencing the diagnostic conversion to Schizophrenia or Schizophrenia Spectrum Disorders (SSD). Diagnoses of patients discharged from Basurto University Hospital's inpatient psychiatry unit between January 2002 and December 2016 were reviewed. Sociodemographic, clinical, and substance use data, including cannabinoids, opioids, amphetamines, cocaine, and alcohol, were collected. The analysis utilized descriptive statistics, Kaplan-Meier survival curves, and Cox regression. Among 341 patients, 64.8% were male, with a mean age of 33.8 years. Psychiatric family history was present in 33.4% of cases, and cannabis was the most commonly used substance (78.9%). Of the patients, 52.8% received subsequent diagnoses of Schizophrenia or SSD, with 86.9% of these cases occurring within the first five years. No significant differences were observed between patients diagnosed with SIP and other diagnoses in terms of sociodemographic, clinical characteristics, or progression to Schizophrenia or SSD. However, use of cannabis (compared to use of another substance or polysubstance use) was associated with a higher risk to conversion (HR 1.96; p = 0.001). These findings underscore the importance of addressing substance use and treatment adherence in FEP.

Pilot development and feasibility of telehealth Community Reinforcement and Family Training (CRAFT) for early psychosis and substance use

Substance use is associated with poor outcomes for individuals with early psychosis. Community Reinforcement and Family Training (CRAFT) is an evidence-based approach that helps families to reduce substance use, engage in treatment, and improve family wellbeing, but it has not yet been studied for psychosis and substance use. The present study aimed to develop and evaluate a telehealth intervention utilizing CRAFT for families experiencing early psychosis and substance use. Twenty family members completed six to eight telehealth sessions of CRAFT adapted for early psychosis (CRAFT-EP). Participants completed an assessment battery at baseline, mid- and post-intervention, a three-month follow-up, surveys after each session, and a focus group to measure mean percentage of sessions completed, mean program satisfaction ratings, telehealth preference, and qualitative feedback. Participants had 100% session completion, and program satisfaction was at or near excellent for 99% of sessions. Half of participants preferred a primarily virtual hybrid program, whereas 45% preferred exclusively virtual visits. Communication was the most helpful topic, and participants requested additional written examples and resources. CRAFT-EP is feasible and acceptable to serve as the active intervention in a pilot randomized controlled trial comparing treatment as usual plus CRAFT-EP to treatment as usual.

WellSpace: Peer-led groups for first-episode psychosis before and during the COVID era

AIM

Coordinated specialty care (CSC) is a collaborative-team based approach that has been shown to be helpful for patients with first-episode psychosis. Peer support is an important component of CSC. Here, we describe the development and implementation of peer-led group programming (McLean WellSpace) that was loosely affiliated with a CSC (McLean OnTrack). We discuss how we adapted this program to the challenges imposed by COVID-19.

METHODS

WellSpace was developed to have minimal barriers to entry other than a self-reported history of recent onset of psychosis. It is free for participants with minimal restrictions about who may attend. WellSpace and WellSpace groups are largely administered by peer specialists who align with the recovery movement. WellSpace has been a virtual program since March 2020.

RESULTS

McLean WellSpace participants include many people who are not patients of McLean OnTrack, suggesting that such programs may have greater reach than standard medical programs. We transitioned to virtual programming and saw average group attendance and unique participants increase during the pandemic.

CONCLUSIONS

Our experience suggests that peer-led group programming for first-episode psychosis is well-accepted by patients, including many who are not engaged with a CSC. This may be related to our efforts to minimize barriers to entry and our peer-led, non-medical orientation.

Research Domain Criteria (RDoC): Progress and Potential

The National Institute of Mental Health (NIMH) addressed in its 2008 Strategic Plan an emerging concern that the current diagnostic system was hampering translational research, as accumulating data suggested that disorder categories constituted heterogeneous syndromes rather than specific diseases. However, established practices in peer review placed high priority on extant disorders in evaluating grant applications for mental illness. To provide guidelines for alternative study designs, NIMH included a goal to develop new ways of studying psychopathology based on dimensions of measurable behavior and related neurobiological measures. The Research Domain Criteria (RDoC) project is the result, intended to build a literature that informs new conceptions of mental illness and future revisions to diagnostic manuals. The framework calls for the study of empirically-derived fundamental dimensions as characterized by related behavioral/psychological and neurobiological data (e.g., reward valuation, working memory). RDoC also emphasizes full-range dimensional approaches (from typical to increasingly abnormal), neurodevelopment and environmental effects, and research designs that integrate data across behavioral, biological, and self-report measures. This commentary provides an overview of the project's first decade and its potential future directions. RDoC remains grounded in experimental psychopathology perspectives, and its progress is strongly linked to psychological measurement and integrative approaches to brain-behavior relationships.

Impact of the COVID-19 Pandemic on the Employment and Educational Outcomes of Individuals in a First-Episode Psychosis Clinic

OBJECTIVE

A central objective of early psychosis therapy is to restore social functioning (e.g., through employment and education). Employment and educational outcomes during the COVID-19 pandemic were examined in a well-defined cohort of patients receiving care in an early psychosis clinic.

METHODS

Data were extracted from the electronic health records of 128 patients receiving care at McLean Hospital's first-episode psychosis (FEP) clinic between January 1 and September 21 in 2019 and 2020. Using a generalized linear model with a Gaussian distribution and robust standard errors, the authors compared the average changes in the weekly employment and education proportions before and after COVID-19 lockdowns with the same changes in 2019.

RESULTS

Employment losses among patients with FEP were greater than among the general population and persisted through the end of follow-up. In 2020, average employment after a stay-at-home order was instituted was 33% lower than before the order compared with the change in employment during the same period in 2019. The effect was stronger among men and those who identified as non-White, were age <21 years, or did not have a college education. Although educational engagement recovered in the fall of 2020, it still remained below the 2019 levels.

CONCLUSIONS

Employment disruptions were major and persistent among the FEP population, which might affect short- and long-term outcomes. Innovative approaches are needed to help patients transition to remote employment, file unemployment claims, and use online hiring platforms to ameliorate the indirect effects of the COVID-19 pandemic.

Exploring the clinical relevance of a dichotomy between affective and non-affective psychosis: Results from a first-episode psychosis cohort study

AIM

Defining diagnosis is complex in early psychosis, which may delay the introduction of an appropriate treatment. The dichotomy of affective and non-affective psychosis is used in clinical setting but remains questioned on a scientific basis. In this study, we explore the clinical relevance of this dichotomy on the basis of clinical variables in a sample of first-episode psychosis patients.

METHOD

We conducted a prospective study in a sample of 330 first-episode psychosis treated at an early intervention program. Affective and non-affective psychosis patients were compared on premorbid history, baseline data, outcomes and course of symptoms over the 3 years of treatment.

RESULTS

Affective psychosis patients (22.42%) were more likely to be female, and had a shorter duration of untreated psychosis. The longitudinal analyses revealed that positive symptoms remained higher over the entire follow-up in the non-affective sub-group. A higher degree of variability of manic symptoms and a significantly better insight after 6 months were observed in the affective sub-group. No difference was observed regarding depressive and negative symptoms. At discharge, only the environmental quality of life and insight recovery were better in affective psychosis.

CONCLUSIONS

Our study suggests that despite marginal differences at baseline presentation, these sub-groups differ regarding outcome, which may require differentiation of treatment and supports the utility of this dichotomy.

Dynamic and progressive changes in thalamic functional connectivity over the first five years of psychosis

The early stage of psychosis (ESP) is a critical period where effective intervention has the most favorable impact on outcomes. Thalamic connectivity abnormalities have been consistently found in psychosis, and are associated with clinical symptoms and cognitive deficits. However, most studies consider ESP patients as a homogeneous population and fail to take the duration of illness into account. In this study, we aimed to capture the progression of thalamic connectivity changes over the first five years of psychosis. Resting-state functional MRI scans were collected from 156 ESP patients (44 with longitudinal data) and 82 healthy controls (24 with longitudinal data). We first performed a case-control analysis comparing thalamic connectivity with 13 networks in the cortex and cerebellum. Next, we modelled the shape (flat, linear, curvilinear) of thalamic connectivity trajectories by comparing flexible non-linear versus linear models. We then tested the significance of the duration of illness and diagnosis in trajectories that changed over time. Connectivity changed over the ESP period between the thalamus and default mode network (DMN) and fronto-parietal network (FPN) nodes in both the cortex and cerebellum. Three models followed a curvilinear trajectory (early increase followed by a subsequent decrease), while thalamo-cerebellar FPN connectivity followed a linear trajectory of steady reductions over time, indicating different rates of change. Finally, diagnosis significantly predicted thalamic connectivity. Thalamo-cortical and thalamo-cerebellar connectivity change in a dynamic fashion during the ESP period. A better understanding of these changes may provide insights into the compensatory and progressive changes in functional connectivity in the early stages of illness.

Impact of Substance Use Disorder on Between-Network Brain Connectivity in Early Psychosis

The Triple Network Model of psychopathology identifies the salience network (SN), central executive network (CEN), and default mode network (DMN) as key networks underlying the pathophysiology of psychiatric disorders. In particular, abnormal SN-initiated network switching impacts the engagement and disengagement of the CEN and DMN, and is proposed to lead to the generation of psychosis symptoms. Between-network connectivity has been shown to be abnormal in both substance use disorders (SUD) and psychosis. However, none have studied how SUD affects connectivity between sub-networks of the DMN, SN, and CEN in early stage psychosis (ESP) patients. In this study, we collected data from 113 ESP patients and 50 healthy controls to investigate the effect of SUD on between-network connectivity. In addition, we performed sub-group analysis by exploring whether past SUD vs current SUD co-morbidity, or diagnosis (affective vs non-affective psychosis) had a modulatory effect. Connectivity between four network-pairs, consisting of sub-networks of the SN, CEN, and DMN, was significantly different between ESP patients and controls. Two patterns of connectivity were observed when patients were divided into sub-groups with current vs past SUD. In particular, connectivity between right CEN and the cingulo-opercular salience sub-network (rCEN-CON) showed a gradient effect where the severity of abnormalities increased from no history of SUD to past+ to current+. We also observed diagnosis-specific effects, suggesting non-affective psychosis patients were particularly vulnerable to effects of substance use on rCEN-CON connectivity. Our findings reveal insights into how comorbid SUD affects between-network connectivity and symptom severity in ESP.

Effects of COVID-19 pandemic on mental health outcomes in a cohort of early psychosis patients

AIM

To evaluate the impact of the COVID-19 pandemic on clinical outcomes, we used data from Electronic Health Records from 128 patients receiving care at a First Episode Psychosis clinic.

METHODS

Rates of admission or emergency room (ER) visits from January 2020 to July 2020 were analysed using difference-in-difference regression. We used the same weeks in 2019 to control for seasonality.

RESULTS

We found 17 hospitalizations or ER visits between 1 January 2020 and 13 March 2020 (incidence rate: 71.4 events/1000 person-weeks) and 6 between 14 March 2020 and 20 June 2020 (incidence rate: 18.5 events/1000 person-weeks) for an incidence rate ratio of 0.26. The severity of presentation worsened after transition to telemedicine. No signs of significant interruptions of care were found.

CONCLUSIONS

We report that patients have avoided accessing higher levels of care, except in extreme cases. We argue that this is not a sustainable trajectory and that public health actions are required.

A narrative review of intervention in first-episode affective psychoses

While first-episode schizophrenia has received extensive attention in the literature, few studies have focused on the first episode of affective psychoses. Considering the lack of structured data regarding this diagnostic grouping commonly used in clinical settings, our aim was to scope the literature on first-episode affective psychoses to consolidate current knowledge and to identify areas to be targeted in future studies. We also planned to investigate the relevance of the "affective psychosis" concept regarding diagnostic categories and specific needs of intervention. We conducted a search on the Embase, Medline, PubMed, PsycINFO and Web Of Science databases until October 2020. We selected studies and synthesized the key findings into a narrative review regarding major topics of early intervention research: diagnostic categorization, premorbid factors, intervention, duration of untreated illness, neurobiology and neurocognition. After screening 961 titles and abstracts and 193 full-text papers, we selected 77 studies for inclusion. Our results showed heterogeneity in diagnosis-related grouping under the concept of affective psychoses, especially variability regarding the inclusion of schizoaffective disorder. Nonetheless, this concept still encompasses patients with different psychopathological and neurocognitive profiles from the non-affective patients requiring specialized intervention. This study thus provided support for the relevance of this concept as well as a need for further investigation.

Evolving Concepts of the Schizophrenia Spectrum: A Research Domain Criteria Perspective

Several trends intersecting over the past two decades have generated increasing debate as to how the concepts of schizophrenia, the schizophrenia spectrum, and the psychotic disorders spectrum should be regarded. These trends are reflected in various areas of research such as genomics, neuroimaging, and data-driven computational studies of multiple response systems. Growing evidence suggests that schizophrenia represents a broad and heterogenous syndrome, rather than a specific disease entity, that is part of a multi-faceted psychosis spectrum. Progress in explicating these various developments has been hampered by the dependence upon sets of symptoms and signs for determining a diagnosis, and by the reliance on traditional diagnostic categories in reviewing clinical research grants. To address these concerns, the U.S. National Institute of Mental Health initiated the Research Domain Criteria (RDoC) project, a translational research program that calls for studies designed in terms of empirically-based functions (such as cognitive control or reward learning) rather than diagnostic groups. RDoC is a research framework rather than an alternative diagnostic system, intended to provide data that can inform future nosological manuals. This commentary includes a brief summary of RDoC as it pertains to schizophrenia and psychotic spectra, examples of recent data that highlight the utility of the approach, and conclusions regarding the implications for evolving conceptualizations of serious mental illness.

Implementing Coordinated Specialty Care for First Episode Psychosis: A Review of Barriers and Solutions

Specialized early interventions (SEI) for individuals diagnosed with a first episode of psychosis (FEP) are effective treatment modalities (Azrin et al. in Psychiatr Ann 45(11):548, https://doi.org/10.3928/00485713-20151103-05 , 2015). SEI offered immediately or shortly following a first episode improves functional and clinical outcomes for those individuals with, and at risk for, serious mental illness (SMI; Correll et al. in JAMA Psychiatry 75(6):555-565, https://doi.org/10.1001/jamapsychiatry.2018.0623 , 2018). In the United States, SEI programs referred to as Coordinated Specialty Care (CSC), have been utilized to provide a beneficial, team-based, multi-component method of treating FEP. However, despite the success, CSC programming is still met with considerable challenges. This article reviews existing CSC literature to identify and explore relevant barriers to successful implementation of CSC. Identified barriers include stigma, cultural competence, disengagement, measurement and evaluation, workforce development, implementation in rural areas, and financial stability. The ongoing efforts to address these barriers are described and areas for continued improvements are discussed.

Diagnostic Stability of Primary Psychotic Disorders in a Research Sample

Psychiatric diagnosis is often treated as a stable construct both clinically and in research; however, some evidence suggests that diagnostic change may be common, which may impact research validity and clinical care. In the present study we examined diagnostic stability in individuals with psychosis over time. Participants with a diagnosis of any psychotic disorder (n = 142) were assessed at two timepoints using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders. We found a 25.4% diagnostic change rate across the total sample. People with an initial diagnosis of psychosis not otherwise specified and schizophreniform disorder had the highest rates of change, followed by those with schizophrenia and schizoaffective disorder; people with bipolar disorder had the lowest change rate. Most participants with an unstable initial diagnosis of schizophrenia, schizophreniform disorder, bipolar disorder, or psychosis not otherwise specified converted to a final diagnosis of schizoaffective disorder. Participants with an unstable initial diagnosis of schizoaffective disorder most frequently converted to a diagnosis of schizophrenia. Our findings suggest that diagnostic change is relatively common, occurring in approximately a quarter of patients. People with an initial diagnosis of schizophrenia-spectrum disorder were more likely to have a diagnostic change, suggesting a natural stability of some diagnoses more so than others.

Abnormal Brain Bioenergetics in First-Episode Psychosis

BACKGROUND

Converging evidence indicates impaired brain energy metabolism in schizophrenia and other psychotic disorders. Creatine kinase (CK) is pivotal in providing adenosine triphosphate in the cell and maintaining its levels when energy demand is increased. However, the activity of CK has not been investigated in patients with first-episode schizophrenia spectrum disorders.

METHODS

Using in vivo phosphorus magnetization transfer spectroscopy, we measured CK first-order forward rate constant (k f ) in the frontal lobe, in patients with first-episode psychosis (FEP; n = 16) and healthy controls (n = 34), at rest.

RESULTS

CK k f was significantly reduced in FEP compared to healthy controls. There were no differences in other energy metabolism-related measures, including phosphocreatine (PCr) or ATP, between groups. We also found increase in glycerol-3-phosphorylcholine, a putative membrane breakdown product, in patients.

CONCLUSIONS

The results of this study indicate that brain bioenergetic abnormalities are already present early in the course of schizophrenia spectrum disorders. Future research is needed to identify the relationship of reduced CK k f with psychotic symptoms and to test treatment alternatives targeting this pathway. Increased glycerol-3-phosphorylcholine is consistent with earlier studies in medication-naïve patients and later studies in first-episode schizophrenia, and suggest enhanced synaptic pruning.

Two-year diagnostic stability in a real-world sample of individuals with early psychosis

OBJECTIVES

Diagnostic shifts in first episode psychosis (FEP) are not uncommon. Many studies examining diagnostic stability use structured diagnostic interviews. Less is known about the stability of FEP diagnoses made clinically.

METHODS

We conducted a retrospective chart review of patients enrolled in a transdiagnostic FEP clinic. For the 96 patients followed clinically at least 2 years, we compared diagnoses at intake and 24 months.

RESULTS

Diagnostic stability was high for bipolar disorder (89%), schizoaffective disorder (89%), and schizophrenia (82%). Psychosis not otherwise specified (13%) was more unstable, with limited baseline differences that would enable clinicians to predict who would convert to a primary psychotic vs affective psychotic disorder.

CONCLUSIONS

Our real-world clinical sample shows that FEP diagnoses, with the exception of unspecified psychosis, are diagnostically stable, even without structured diagnostic interviews.

Heterogeneity of Outcomes and Network Connectivity in Early-Stage Psychosis: A Longitudinal Study

Imaging studies in psychotic disorders typically examine cross-sectional relationships between magnetic resonance imaging (MRI) signals and diagnosis or symptoms. We sought to examine changes in network connectivity identified using resting-state functional MRI (fMRI) corresponding to divergent functional recovery trajectories and relapse in early-stage psychosis (ESP). Prior studies have linked schizophrenia to hyperconnectivity in the default mode network (DMN). Given the correlations between the DMN and behavioral impairments in psychosis, we hypothesized that dynamic changes in DMN connectivity reflect the heterogeneity of outcomes in ESP. Longitudinal data were collected from 66 ESP patients and 20 healthy controls. Longitudinal cluster analysis identified subgroups of patients with similar trajectories in terms of symptom severity and functional outcomes. DMN connectivity was measured in a subset of patients (n = 36) longitudinally over 2 scans separated by a mean of 12 months. We then compared connectivity between patients and controls, and among the different outcome trajectory subgroups. Among ESP participants, 4 subgroups were empirically identified corresponding to: "Poor," "Middle," "Catch-up," and "Good" trajectory outcomes in the complete dataset (n = 36), and an independent replication (n = 30). DMN connectivity changes differed significantly between functional subgroups (F3,32 = 6.06, P-FDR corrected = .01); DMN connectivity increased over time in the "Poor" outcome cluster (β = +0.145) but decreased over time in the "Catch-up" cluster (β = -0.212). DMN connectivity is dynamic and correlates with a change in functional status over time in ESP. This approach identifies a brain-based marker that reflects important neurobiological processes required to sustain functional recovery.

Transition of Substance-Induced, Brief, and Atypical Psychoses to Schizophrenia: A Systematic Review and Meta-analysis

Some people who experience substance-induced psychosis later develop an enduring psychotic disorder such as schizophrenia. This study examines the proportion of people with substance-induced psychoses who transition to schizophrenia, compares this to other brief and atypical psychoses, and examines moderators of this risk. A search of MEDLINE, PsychINFO, and Embase identified 50 eligible studies, providing 79 estimates of transition to schizophrenia among 40 783 people, including 25 studies providing 43 substance-specific estimates in 34 244 people. The pooled proportion of transition from substance-induced psychosis to schizophrenia was 25% (95% CI 18%-35%), compared with 36% (95% CI 30%-43%) for brief, atypical and not otherwise specified psychoses. Type of substance was the primary predictor of transition from drug-induced psychosis to schizophrenia, with highest rates associated with cannabis (6 studies, 34%, CI 25%-46%), hallucinogens (3 studies, 26%, CI 14%-43%) and amphetamines (5 studies, 22%, CI 14%-34%). Lower rates were reported for opioid (12%), alcohol (10%) and sedative (9%) induced psychoses. Transition rates were slightly lower in older cohorts but were not affected by sex, country of the study, hospital or community location, urban or rural setting, diagnostic methods, or duration of follow-up. Substance-induced psychoses associated with cannabis, hallucinogens, and amphetamines have a substantial risk of transition to schizophrenia and should be a focus for assertive psychiatric intervention.

Return to College After a First Episode of Psychosis

A first episode of psychosis (FEP) can derail a patient’s educational goals, including attainment of a college education, and this can have lasting ramifications for socioeconomic and health outcomes. Despite this, few studies have examined return to college, which is an important index of real-world educational success after a FEP. In this study, we conducted a longitudinal medical record review of patients in a transdiagnostic outpatient FEP program and performed survival analysis, setting return to college as the endpoint, among the subset of patients whose college education was interrupted. We found that 82% (93/114) of college-enrolled FEP individuals experienced disruptions to their education after FEP, but that return to college also occurred in a substantial proportion (49/88, 56%) among those on leave who had follow-up data. In this sample, the median time to college return was 18 months. When separated by baseline diagnostic category, FEP patients with affective psychotic disorders (FEAP, n = 45) showed faster time to college return than those with primary psychotic disorders (FEPP, n = 43) (median 12 vs 24 mo; P = .024, unadjusted). When adjusted for having no more than 1 psychiatric hospitalization at intake and absence of cannabis use in the 6 months prior to intake (which were also significant predictors), differences by diagnostic category were more significant (hazard ratio 2.66, 95% CI 1.43–4.94, P = .002). Participation in education is an important outcome for stakeholders, and students with FEP can be successful in accomplishing this goal.

Impaired insulin signaling in unaffected siblings and patients with first-episode psychosis

Patients with psychotic disorders are at high risk for type 2 diabetes mellitus, and there is increasing evidence that patients display glucose metabolism abnormalities before significant antipsychotic medication exposure. In the present study, we examined insulin action by quantifying insulin sensitivity in first-episode psychosis (FEP) patients and unaffected siblings, compared to healthy individuals, using a physiological-based model and comprehensive assessment battery. Twenty-two unaffected siblings, 18 FEP patients, and 15 healthy unrelated controls were evaluated using a 2-h oral glucose tolerance test (OGTT), with 7 samples of plasma glucose and serum insulin concentration measurements. Insulin sensitivity was quantified using the oral minimal model method. Lipid, leptin, free fatty acids, and inflammatory marker levels were also measured. Anthropometric, nutrient, and activity assessments were conducted; total body composition and fat distribution were determined using whole-body dual-energy X-ray absorptiometry. Insulin sensitivity significantly differed among groups (F = 6.01 and 0.004), with patients and siblings showing lower insulin sensitivity, compared to controls (P = 0.006 and 0.002, respectively). Body mass index, visceral adipose tissue area (cm²), lipids, leptin, free fatty acids, inflammatory markers, and activity ratings were not significantly different among groups. There was a significant difference in nutrient intake with lower total kilocalories/kilogram body weight in patients, compared to siblings and controls. Overall, the findings suggest that familial abnormal glucose metabolism or a primary insulin signaling pathway abnormality is related to risk for psychosis, independent of disease expression and treatment effects. Future studies should examine underlying biological mechanisms of insulin signaling abnormalities in psychotic disorders.

Transdiagnostic psychiatry: a systematic review

The usefulness of current psychiatric classification, which is based on ICD/DSM categorical diagnoses, remains questionable. A promising alternative has been put forward as the "transdiagnostic" approach. This is expected to cut across existing categorical diagnoses and go beyond them, to improve the way we classify and treat mental disorders. This systematic review explores whether self-defining transdiagnostic research meets such high expectations. A multi-step Web of Science literature search was performed according to an a priori protocol, to identify all studies that used the word "transdiagnostic" in their title, up to May 5, 2018. Empirical variables which indexed core characteristics were extracted, complemented by a bibliometric and conceptual analysis. A total of 111 studies were included. Most studies were investigating interventions, followed by cognition and psychological processes, and neuroscientific topics. Their samples ranged from 15 to 91,199 (median 148) participants, with a mean age from 10 to more than 60 (median 33) years. There were several methodological inconsistencies relating to the definition of the gold standard (DSM/ICD diagnoses), of the outcome measures and of the transdiagnostic approach. The quality of the studies was generally low and only a few findings were externally replicated. The majority of studies tested transdiagnostic features cutting across different diagnoses, and only a few tested new classification systems beyond the existing diagnoses. About one fifth of the studies were not transdiagnostic at all, because they investigated symptoms and not disorders, a single disorder, or because there was no diagnostic information. The bibliometric analysis revealed that transdiagnostic research largely restricted its focus to anxiety and depressive disorders. The conceptual analysis showed that transdiagnostic research is grounded more on rediscoveries than on true innovations, and that it is affected by some conceptual biases. To date, transdiagnostic approaches have not delivered a credible paradigm shift that can impact classification and clinical care. Practical "TRANSD"iagnostic recommendations are proposed here to guide future research in this field.

Decreased peak alpha frequency and impaired visual evoked potentials in first episode psychosis

Abnormal spontaneous and evoked oscillations have been reported in several studies of patients with psychotic disorders. Resting alpha power and peak alpha frequency may be decreased in patients with psychosis. We used high-density EEG (hd-EEG) to record resting-state data and steady-state visual evoked potentials (SSVEPs) in patients with first episode psychosis (FEP) and healthy controls to compare brain resonances across multiple frequencies. We recorded hd-EEG (128 channels) from 22 FEP patients and 22 healthy controls during eyes-closed resting state and eyes-closed photic stimulation at 1 Hz, 4 Hz, 10 Hz, 20 Hz, and 40 Hz. Alpha power, peak alpha frequency, and SSVEP amplitude were analyzed using ANOVA and statistical non-parametric mapping. We found that FEP patients had lower peak alpha frequencies (9.72 Hz vs 10.40 Hz, p = .02, Cohen's d = 0.73) and this decrease was driven by slowing over the central and posterior scalp. There was no difference in alpha power. Alpha waves propagated primarily from anterior to posterior and that propagation was slowed in patients. During SSVEP, patients had smaller increases in EEG power in the stimulation band (F(1,184) = 5.3, p = .02). Patients had attenuated responses to SSVEP stimulation at alpha, beta and gamma frequencies. The gamma response was partially preserved in patients who also had depressive symptoms. We conclude that even in early stages of illness, psychotic disorders are associated with decreased alpha peak frequency and impaired evoked resonances. These findings implicate multiple patterns of dysconnectivity in cortico-cortico and cortico-thalamic networks in FEP.

Abnormalities in High-Energy Phosphate Metabolism in First-Episode Bipolar Disorder Measured Using 31P-Magnetic Resonance Spectroscopy

BACKGROUND

Brain energy metabolism is critical for supporting synaptic function and information processing. A growing body of evidence suggests abnormalities in brain bioenergetics in psychiatric disorders, including both bipolar disorder (BD) and schizophrenia. ³¹P magnetic resonance spectroscopy provides a noninvasive window into these processes in vivo. Using this approach, we previously showed that patients with BD show normal adenosine triphosphate (ATP) and phosphocreatine levels at rest but cannot maintain normal ATP levels in the visual cortex during times of high energy demand (photic stimulation). Because ATP is replenished from phosphocreatine via the creatine kinase reaction, we have now measured the creatine kinase forward reaction rate constant in BD.

METHODS

We studied 20 patients experiencing a first episode of BD and 28 healthy control participants at 4T and quantified creatine kinase forward reaction rate constant using ³¹P magnetization transfer magnetic resonance spectroscopy as described previously.

RESULTS

We found a significant reduction in creatine kinase forward reaction rate constant in the BD group (F = 4.692, p = .036), whereas brain ATP and phosphocreatine concentrations, as well as brain parenchymal pH, were normal.

CONCLUSIONS

These results pinpoint a specific molecular mechanism underlying our previous observation of an inability to replenish brain ATP during times of high energy demand in BD.

Brain bioenergetics and redox state measured by 31P magnetic resonance spectroscopy in unaffected siblings of patients with psychotic disorders

BACKGROUND

Brain bioenergetic anomalies and redox dysregulation have been implicated in the pathophysiology of psychotic disorders. The present study examined brain energy-related metabolites and the balance between nicotinamide adenine dinucleotide metabolites (oxidized NAD+ and reduced NADH) using ³¹P-magnetic resonance spectroscopy (³¹P-MRS) in unaffected siblings, compared to first episode psychosis (FEP) patients and healthy controls.

METHODS

21 unaffected siblings, 32 FEP patients (including schizophrenia spectrum and affective psychoses), and 21 controls underwent ³¹P-MRS in the frontal lobe (6×6×4cm³) on a 4T MR scanner, using custom-designed dual-tuned surface coil with outer volume suppression. Brain parenchymal pH and steady-state metabolite ratios of high energy phosphate compounds were measured. NAD+ and NADH levels were determined using a ³¹P-MRS fitting algorithm. 13 unaffected sibling-patient pairs were related; other patients and siblings were unrelated. ANCOVA analyses were used to examine ³¹P-MRS measures, with age and gender as covariates.

RESULTS

The phosphocreatine/adenosine triphosphate ratio was significantly reduced in both unaffected siblings and FEP patients, compared to controls. NAD+/NADH ratio was significantly reduced in patients compared to siblings and controls, with siblings showing a reduction in NAD+/NADH compared to controls that was not statistically significant. Compared to patients and controls, siblings showed significantly reduced levels of NAD+. Siblings did not differ from patients or controls on brain pH.

DISCUSSION

Our results indicate that unaffected siblings show some, but not all the same abnormalities in brain energy metabolites and redox state as FEP patients. Thus, ³¹P-MRS studies may identify factors related both to risk and expression of psychosis.