Early intervention service for first episode psychosis in Modena, Northern Italy: The first hundred cases

First episode psychoses in people over-35 years old: uncovering potential actionable targets for early intervention services

The traditional youth-oriented design of Early Intervention Services (EIS) may lead to the exclusion of patients who have their psychotic onset later in life. A retrospective study was conducted to compare first-episode psychosis (FEP) patients who accessed treatment when aged ≤ 35 years with those ≥36+. A total of 854 patients were identified among 46,222 individuals who had access to community psychiatric services from 1991 to 2021. FEP were aged 18-65, received care between 2012 and 2021 and had a diagnosis of affective or non-affective FEP. Two groups were identified (FEP diagnosed at age ≤ 35 vs ≥ 36) and compared for sociodemographic and clinical characteristics. Most patients were diagnosed when aged ≥ 36+ (61.8%). Compared to the ≤ 35 group, older patients were more likely to be women, married and diagnosed with affective psychosis, and they were less frequently hospitalized. Long-acting injectables antipsychotics (LAI) were less frequently prescribed in the ≥ 36+ group, whereas antidepressants were more frequently prescribed compared to those aged ≤ 35. In both age groups, women were less frequently prescribed LAIs compared to men. These findings highlight the need to reorient EIS to accommodate the needs of older FEP, especially women.

The Italian adaptation of the Mini-SIPS, a tool for early detection of individuals at clinical high risk and first episode of psychosis: A preliminary study of implementation in an Italian FEP program

AIMS

The study aims are to present the Italian adaptation of the Abbreviated Clinical Structured Interview for DSM-5 Attenuated Psychosis Syndrome (Mini-SIPS) and illustrate its implementation in a clinical setting.

METHODS

The Mini-SIPS was developed from the original extended version as a tool designed to identify, within the clinical high risk (CHR) framework, the DSM-5 Attenuated Psychosis Syndrome (APS) and to be implemented in clinical settings. The Mini-SIPS was translated in Italian by a Yale-certified SIPS trainer, then back-translated in English by a trained psychologist, then approved by the Mini-SIPS authors. Since September 2021, the adapted Italian version of the Mini-SIPS has been implemented at the First Episode Psychosis (FEP) Program in Ferrara, Italy.

RESULTS

The Italian version of Mini-SIPS was successfully administered to 15 individuals subsequently referred to the First Episode Psychosis service in Ferrara. Within this sample, the tool has proven to be both an effective and efficient tool for the identification of CHR and FEP, and a valid instrument to help with the differential diagnosis. It also performed as a valuable guide for retrieving information about psychiatric history, to date the onset of APS and/or full-blown psychosis, to track the progression from CHR to psychosis or to symptoms resolution and to describe patients' pathways to care.

CONCLUSION

The Mini-SIPS is an efficient and easy-to-use interview to identify the early stages of psychosis and established psychosis in clinical contexts. The Italian adaptation of this interview could be effectively implemented in other Italian FEP Programs as a screening and monitoring tool. Formal validation of the instrument is needed to assessed validity and reliability in the diagnosis of the CHR and FEP.

Establishment of a Public Mental Health Database for Research Purposes in the Ferrara Province: Development and Preliminary Evaluation Study

Background

The immediate use of data exported from electronic health records (EHRs) for research is often limited by the necessity to transform data elements into an actual data set.

Objective

This paper describes the methodology for establishing a data set that originated from an EHR registry that included clinical, health service, and sociodemographic information.

Methods

The Extract, Transform, Load process was applied to raw data collected at the Integrated Department of Mental Health and Pathological Addictions in Ferrara, Italy, from 1925 to February 18, 2021, to build the new, anonymized Ferrara-Psychiatry (FEPSY) database. Information collected before the first EHR was implemented (ie, in 1991) was excluded. An unsupervised cluster analysis was performed to identify patient subgroups to support the proof of concept.

Results

The FEPSY database included 3,861,432 records on 46,222 patients. Since 1991, each year, a median of 1404 (IQR 1117.5-1757.7) patients had newly accessed care, and a median of 7300 (IQR 6109.5-9397.5) patients were actively receiving care. Among 38,022 patients with a mental disorder, 2 clusters were identified; the first predominantly included male patients who were aged 25 to 34 years at first presentation and were living with their parents, and the second predominantly included female patients who were aged 35 to 44 years and were living with their own families.

Conclusions

The process for building the FEPSY database proved to be robust and replicable with similar health care data, even when they were not originally conceived for research purposes. The FEPSY database will enable future in-depth analyses regarding the epidemiology and social determinants of mental disorders, access to mental health care, and resource utilization.

A public early intervention approach to first-episode psychosis: Treated incidence over 7 years in the Emilia-Romagna region

AIM

To estimate the treated incidence of individuals with first-episode psychosis (FEP) who contacted the Emilia-Romagna public mental healthcare system (Italy); to examine the variability of incidence and user characteristics across centres and years.

METHODS

We computed the raw treated incidence in 2013-2019, based on FEP users aged 18-35, seen within or outside the regional program for FEP. We modelled FEP incidence across 10 catchment areas and 7 years using Bayesian Poisson and Negative Binomial Generalized Linear Models of varying complexity. We explored associations between user characteristics, study centre and year comparing variables and socioclinical clusters of subjects.

RESULTS

Thousand three hundred and eighteen individuals were treated for FEP (raw incidence: 25.3 / 100.000 inhabitant year, IQR: 15.3). A Negative Binomial location-scale model with area, population density and year as predictors found that incidence and its variability changed across centres (Bologna: 36.55; 95% CrI: 30.39-43.86; Imola: 3.07; 95% CrI: 1.61-4.99) but did not follow linear temporal trends or density. Centers were associated with different user age, gender, migrant status, occupation, living conditions and cluster distribution. Year was associated negatively with HoNOS score (R = -0.09, p < .001), duration of untreated psychosis (R = -0.12, p < .001) and referral type.

CONCLUSIONS

The Emilia-Romagna region presents a relatively high but variable incidence of FEP across areas, but not in time. More granular information on social, ethnic and cultural factors may increase the level of explanation and prediction of FEP incidence and characteristics, shedding light on social and healthcare factors influencing FEP.

The 'Parma At-Risk mental states' (PARMS) program: General description and process analysis after 5 years of clinical activity

AIM

From January 2016, the Parma Department of Mental Health developed a specialized care protocol - the 'Parma At-Risk Mental States' (PARMS) program - as a diffused service for early intervention in individuals at Clinical High Risk for Psychosis (CHR-P). The aims of this investigation were (1) to describe the PARMS structural organization and (2) to examine specific process indicators during the first 5 years of its clinical activity.

METHODS

All participants were adolescent and young adult help-seekers (aged 12-25 years) at CHR-P in accordance with well-defined psychometric criteria.

RESULTS

At entry, 52 subjects were provided with a dedicated protocol of care and only 14 dropped out during the first year of treatment. The Duration of Untreated Illness (DUI) overall decreased over time. Most of CHR-P participants suffered from 'Attenuated Psychotic Symptoms' and 'Brief, Limited, Intermittent Psychotic Symptoms' in the same percentage (48.1% [n = 25]). The most common DSM-IV-TR diagnosis was schizotypal personality disorder, followed by borderline personality disorder and brief psychotic disorder.

CONCLUSIONS

A specialized, evidence-based care protocol for CHR-P individuals within Italian adult and child/adolescent psychiatric services is feasible, also in adolescents, who have a high risk of falling through the child/adult service gap.

Granular analysis of pathways to care and durations of untreated psychosis: A marginal delay model

OBJECTIVE

An extensive international literature demonstrates that understanding pathways to care (PTC) is essential for efforts to reduce community Duration of Untreated Psychosis (DUP). However, knowledge from these studies is difficult to translate to new settings. We present a novel approach to characterize and analyze PTC and demonstrate its value for the design and implementation of early detection efforts.

METHODS

Type and date of every encounter, or node, along the PTC were encoded for 156 participants enrolled in the clinic for Specialized Treatment Early in Psychosis (STEP), within the context of an early detection campaign. Marginal-delay, or the portion of overall delay attributable to a specific node, was computed as the number of days between the start dates of contiguous nodes on the PTC. Sources of delay within the network of care were quantified and patient characteristic (sex, age, race, income, insurance, living, education, employment, and function) influences on such delays were analyzed via bivariate and mixed model testing.

RESULTS

The period from psychosis onset to antipsychotic prescription was significantly longer (52 vs. 20.5 days, [p = 0.004]), involved more interactions (3 vs. 1 nodes, [p<0.001]), and was predominated by encounters with non-clinical nodes while the period from antipsychotic to STEP enrollment was shorter and predominated by clinical nodes. Outpatient programs were the greatest contributor of marginal delays on both before antipsychotic prescription (median [IQR] of 36.5 [1.3-132.8] days) and (median [IQR] of 56 [15-210.5] days). Sharper functional declines in the year before enrollment correlated significantly with longer DUP (p<0.001), while those with higher functioning moved significantly faster through nodes (p<0.001). No other associations were found with patient characteristics and PTCs.

CONCLUSIONS

The conceptual model and analytic approach outlined in this study give first episode services tools to measure, analyze, and inform strategies to reduce untreated psychosis.

First-episode psychosis in the Ferrara Mental Health Department: Incidence and clinical course within the first 2 years

AIM

To examine the incidence of with first-episode psychosis (FEP) in the Integrated Department of Mental Health and Pathological Addictions in Ferrara, Italy, and to examine the association between the Duration of Untreated Psychosis (DUP) and the clinical course.

METHODS

Participants recruited in 2013-2019 were assessed with the Health of the Nation Outcome Scale (HoNOS) every 6 months for 24 months. Hierarchical growth models analysed changes of global severity (HoNOS total scores) and symptom dimensions. Regression modelled factors associated with remission (HoNOS < 8) and clinical improvement (<12).

RESULTS

The incidence of FEP was 21.5 (95%CI: 21.2-21.9) cases per 100 000 person year. Among participants (n = 86, mean age 23, 76% males), baseline HoNOS scores were higher for those with a longer DUP. More than half subjects reached clinical remission (61.6%) or improvement (82.6%), while very few (2.3%) were re-hospitalized. HoNOS total scores decayed with a mixed linear/quadratic trend, with a slower decay among migrants. A longer DUP was associated with reduced improvements of positive symptoms and lower likelihood of clinical improvement (OR: 0.84; 95%CI: 0.73-0.96).

CONCLUSIONS

Patients from the FEP program of Ferrara reached good clinical outcomes. Nonetheless, individuals with a longer DUP may need additional clinical attention. Systematic monitoring of clinical outcomes may be an optimal strategy to improve the outcomes of FEP in the real world.

The 'Parma-Early Psychosis' programme: Characterization of help-seekers with first episode psychosis

AIM

Research on early psychosis paradigm has demonstrated the importance of early intervention (EI) in reducing illness severity and persistence. From January 2013, the Parma Department of Mental Health developed a specific care pathway [the 'Parma-Early Psychosis' (Pr-EP) programme] as a diffused EI infrastructure aimed to offer an evidence-based protocol of care to help-seekers with a first episode psychosis (FEP). Aim of this study was to investigate sources of referral, drop-out rate, sociodemographic and clinical characteristics of patients enrolled in the Pr-EP programme during the first 6 years of activity.

METHODS

Participants (n = 279) were individuals (aged 12-54 years) completing an ad-hoc socio-demographic/clinical schedule.

RESULTS

At baseline, the most frequent diagnoses were schizophreniform disorder (30.5%) and schizophrenia (29.4%). Only 31 (11.1%) subjects dropped out during the first year of treatment. FEP participants were mainly referred by general practitioners (36.9%) and emergency room/general hospital (28.7%). FEP individuals who were referred by emergency room/general hospital showed a higher percentage of current suicidal ideation compared to those entering the Pr-EP protocol through other sources of referrals.

CONCLUSIONS

EI in FEP help-seekers within Italian public mental health services is feasible and desirable, also in adolescence, where the risk of falling through the child-adult service gap is high.

The "Parma-Early Psychosis" program: General description and process analysis after 5 years of clinical activity

AIM

From January 2013, the Parma Department of Mental Health developed a specific protocol of care (the "Parma-Early Psychosis" [Pr-EP] program) as a diffused service for early intervention in psychosis. The aims of the present research are (a) to describe the Pr-EP macroscopic organization and (b) to analyse specific process indicators across the first 5 years from its establishment.

METHODS

All participants were adolescent and adult help-seekers, aged 12-54 years, with a First Episode Psychosis (FEP) or at Ultra-High Risk for developing psychosis, according to well-defined diagnostic criteria.

RESULTS

At baseline, 358 individuals were offered a dedicated protocol of care and only 40 (11.8%) dropped out during the first year of intervention. In particular, an increase of referrals over time was notably found (especially in adolescence). Furthermore, Duration of Untreated Psychosis decreased over time. The baseline prevalence of FEP diagnosis was 61.4%, with schizophrenia as markedly prevalent Diagnostic and Statistical Manual of mental disorders, IV edition, Text Revised (DSM-IV-TR) diagnosis (41%). The vast majority of UHR individuals met criteria for "Attenuated Psychotic Symptoms" (>90%), and major depressive disorder was the most frequent diagnosis (>55%). Finally, we found considerable percentages of current history of substance abuse (>58%) and of comorbidity with DSM-IV-TR personality disorders (60%).

CONCLUSIONS

An "Early Intervention in psychosis" service in Italian child/adolescent and adult mental health services is feasible, also in adolescents, who have a high risk of falling through the child-adult service gap.