Predictors of Hospitalization of Individuals With First-Episode Psychosis: Data From a 2-Year Follow-Up of the RAISE-ETP

Exploring Data Collection Priorities of Community Partners in Early Psychosis Care

OBJECTIVE

Learning health care networks can significantly improve the effectiveness, consistency, and cost-effectiveness of care delivery. As part of a data harmonization process, incorporation of the perspectives of community partners to maximize the relevance and utility of the data is critical.

METHODS

A mixed-methods focus group study was conducted with early psychosis program providers, leadership, service users, and family members to explore their priorities regarding data collection in early psychosis care. Focus group transcripts were analyzed through thematic analysis.

RESULTS

Twenty-two focus groups comprising 178 participants were conducted across 10 early psychosis programs. Participants considered functioning, quality of life, recovery, and symptoms of psychosis as key outcomes to assess, although variation by participants' roles was also evident. Participants emphasized the clinical utility of assessing a broad range of predictors of care outcomes, favored a broad conceptualization of the constructs assessed, and indicated a preference for client-reported measures. Participants also emphasized the importance of surveys adopting a recovery-oriented, strengths-based approach.

CONCLUSIONS

Large-scale aggregation of health care data collected as part of routine care offers opportunities for research and may have a positive impact on care delivery and quality improvement activities. However, these benefits are contingent on the data being both relevant and accessible to those who deliver and receive such care. This study highlights an approach that may inform the development of core assessment batteries used, optimizing the utility of such data for all community partners.

Prevalence and predictors of admission at the time of presentation in first episode psychosis

BACKGROUND

Individuals presenting with first episode psychosis (FEP) constitute a population with high admission rates. Across psychiatric services, community based treatment is aimed for where appropriate. Therefore, further knowledge on predictors of admission is required.

PURPOSE

The objectives were to: (i) determine the proportion of individuals with FEP admitted at time of presentation (voluntarily and involuntarily) (ii) identify associated demographic and clinical factors.

METHODS

This study included all young people (aged 15-24) who presented with FEP to the Early Psychosis Prevention and Intervention Centre, Melbourne, Australia from 01.01.11 to 31.12.16. Binary logistic regression was used to determine unadjusted and adjusted odds ratios.

RESULTS

Of 1208 participants, 58.6% were male and the median age was 20 years (I.Q.R.17-22). At time of presentation, 50.2% were admitted. On multivariate analysis, the following factors predicted admission: being a migrant (OR = 1.75, 95% CI [1.17, 2.62]), aggression (OR = 1.42, 95% CI [1.02, 1.99]), and more severe psychotic symptoms. Longer duration of untreated psychosis was associated with lower admission rates. 70.1% of admissions were involuntary (33.7% of the cohort). Risk factors for involuntary admission were consistent with any admission, other than aggression, and with the addition of older age and male sex.

CONCLUSION

There remains a high admission rate for FEP, even in an established early intervention service, with severity of psychopathology being the strongest predictive factor. There is an independent association between migrancy and admission. Potential reasons for these findings are discussed, and initiatives to reduce admission rates including (i) interventions to prevent admission and (ii) alternative care pathways.

Predictors of Readmission in Young Adults with First-Episode Psychosis: A Multicentric Retrospective Study with a 12-Month Follow-Up

BACKGROUND

A significant number of young individuals are readmitted one or more times shortly after their first episode of psychosis. Readmission may represent a marker of psychopathological vulnerability. Our primary aim was to evaluate the impact of clinical and socio-demographic variables on readmission at 12-month follow-up. Secondly, our goal was to determine whether the use of Long-Acting Injection (LAI) antipsychotics provides notable benefits compared to oral medications in preventing subsequent readmissions.

SUBJECTS AND METHODS

80 patients hospitalised for the first time with a diagnosis of psychotic disorder (ICD-10 criteria) were retrospectively assessed through clinical records. The mean age was 21.7 years. Patients were predominantly male (n = 62, 77.5%), and 55 subjects had at least 8 years of education. 50% of the sample was "NEET" (not in education, employment, or training).

RESULTS

35 patients (43.8%) were discharged with a LAI antipsychotic, while 45 (56.2%) recieved oral antipsychotic therapy. Substance use (p = 0.04) and oral antipsychotics at discharge (p = 0.003) were significantly associated with readmission at 1 year. We did not find any significant predictors of being discharged with LAI therapy.

CONCLUSION

Our findings underlined the importance of identifying patients at risk of readmission in order to prevent future rehospitalization and promote appropriate prevention strategies. LAIs should be considered as a first-choice treatment for patients hospitalised for FEP since they proved to be effective in preventing relapse.

Clinical decision-making before discharge in hospitalized persons with schizophrenia: a Spanish Delphi expert consensus

Introduction

The care of people with schizophrenia (PWS) is usually provided in an outpatient setting by community mental health teams. However, PWS frequently require inpatient treatment because of a wide array of clinical, personal and/or social situations. Unfortunately, to our knowledge, there are no guidelines available to help psychiatrists in the decision-making process on hospital discharge for PWS. The aim of this project was to develop an expert consensus on discharge criteria for PWS after their stay in an acute inpatient psychiatric unit.

Methods

Using a modified Delphi method a group of 42 psychiatrists throughout Spain evaluated four areas of interest regarding this issue: clinical symptomatology, treatment-related factors, follow-up health care units after discharge, and physical health and monitoring.

Results

After two rounds, among the 64 statements, a consensus was reached for 59 (92.2%) statements. In three (17.7%) of the 17 statements on 'clinical symptomatology' and 2 (13.3%) of the 15 statements on 'follow-up health care units after discharge', a consensus was not reached; in contrast, a consensus was reached for all statements concerning 'treatment-related factors' and those concerning 'physical health and monitoring'. The consensus results highlight the importance for discharge of the control of symptoms rather than their suppression during admission and of tolerability in the selection of anantipsychotic.

Discussion

Although there is a lack of relevant data for guiding the discharge of PWS after hospitalization in an acute inpatient psychiatric unit, we expect that this consensus based on expert opinion may help clinicians to take appropriate decisions.

Identification and treatment of individuals with childhood-onset and early-onset schizophrenia

Approximately 8 % of patients with schizophrenia are diagnosed before age 18, and 18 % experience their first symptoms before age 18. This narrative review explores the management of patients with early-onset schizophrenia (EOS) and childhood-onset schizophrenia (COS) from diagnosis to their transition to adult care settings. Early diagnosis of schizophrenia in children and adolescents is essential for improving outcomes, but delays are common due to overlapping of symptoms with developmental phenomena and other psychiatric conditions, including substance use, and lack of clinicians' awareness. Once diagnosed, antipsychotic treatment is key, with specific second-generation agents generally being preferred due to better tolerability and their broader efficacy evidence-base in youth. Dosing should be carefully individualized, considering age-related differences in drug metabolism and side effect liability. Clinicians must be vigilant in detecting early non-response and consider switching or dose escalation when appropriate. Since early age of illness onset is a consistent risk factor for treatment-resistant schizophrenia (TRS), clinicians need to be competent in diagnosing TRS and using clozapine. Since COS and EOS are associated with cognitive deficits and impaired functioning, psychosocial interventions should be considered to improve overall functioning and quality of life. Good long-term outcomes depend on continuous treatment engagement, and successful transitioning from pediatric to adult care requires careful planning, early preparation, and collaboration between pediatric and adult clinicians. Targeting functional outcomes and quality of life in addition to symptom remission can improve overall patient well-being. Comprehensive evaluations, age-specific assessments, and targeted interventions are needed to address the unique challenges of EOS and COS.

Hospitalization and help-seeking among first episode psychosis patients

PURPOSE

To examine hospitalization as part of a complex pathway to care in first episode psychosis (FEP), exploring help-seeking episodes (HSE) and their relationship to hospitalization.

METHODS

Data from 66 patients at the Early Psychosis Intervention Clinic New Orleans (EPIC-NOLA), a coordinated specialty care (CSC) clinic, was obtained from Pathways to Care (PTC) assessments, which documents elements of help seeking. A chart review was performed identifying hospitalizations.

RESULTS

Most patients were hospitalized multiple times (n = 37, M = 2.98, SD = 2.14). On average, patients had more hospitalizations prior to starting treatment at EPIC-NOLA (M = 1.72, SD = 1.35) than after (M = 1.27, SD = 1.79). Patients whose first HSE resulted in intake at EPIC-NOLA were significantly less likely to be hospitalized after intake than patients with multiple HSE (F(1,52.3) = 12.9, p < .001). There was a significant correlation (N = 42) between HSE and hospitalizations after intake (τb = .327 p < .05); patients seeking help more often were more likely to be hospitalized after intake. No significant correlations were found between duration of untreated psychosis (DUP) and hospitalization.

CONCLUSION

While results are correlational, several key relationships were noted. Fewer hospitalizations occurred after intake into EPIC-NOLA. Starting treatment after the first HSE was related to fewer future hospitalizations, compared to intake after multiple HSEs. Intake into a CSC clinic after a single HSE may reduce hospitalization. Additionally, increased HSE, not DUP, impacted patients' likelihood of hospitalization. This prompts treatment engagement during a first HSE to reduce hospitalization.

Metabolic disturbances are risk factors for readmission to psychiatric hospitals in non-smokers but not in smokers: results from a Swiss psychiatric cohort and in first-episode psychosis patients

Background

Psychiatric patients are at high risk of readmission, and a high body mass index has previously been shown as a risk factor. We sought to replicate this finding and 1) to prospectively assess the association of metabolic syndrome and its five components with readmission in psychiatric hospitals and 2) to identify other clinical and sociodemographic predictors of readmission.

Methods

Between 2007 and 2019, data on 16727 admissions of 7786 adult and elderly patients admitted to the Department of Psychiatry of the Lausanne University Hospital, were collected. Metabolic syndrome was defined according to the International Diabetes Federation definition. Cox frailty models were used to investigate the associations between readmission and metabolic disturbances.

Results

A total of 2697 (35%) patients were readmitted to our psychiatric hospital. Novel risk factors for readmission in non-smokers were identified, including being overweight (HR=1.26; 95%CI=[1.05; 1.51]) or obese (HR=1.33; 95%CI=[1.08; 1.62]), displaying hypertriglyceridemia (HR=1.21; 95%CI=[1.04; 1.40]) and metabolic syndrome (HR=1.26; 95%CI=[1.02; 1.55]). Central obesity and hyperglycemia increased the risk of readmission when considering the Health of the Nation Outcome Scales variable. In first-episode psychosis patients, obesity (HR=2.23; 95%CI=[1.14; 4.30]) and high-density lipoprotein hypocholesterolemia (HR=1.90; 95%CI=[1.14; 3.20]) doubled the risk of readmission.

Conclusion

The observed interaction between smoking and metabolic variables are compatible with a ceiling effect; metabolic variables increase the risk of readmission in non-smokers but not in smokers who are already at higher risk. Future studies should determine whether better metabolic monitoring and treatment can reduce readmission risk.

EMDR therapy vs. supportive therapy as adjunctive treatment in trauma-exposed bipolar patients: A randomised controlled trial

INTRODUCTION

Patients with bipolar disorder (BD) are frequently exposed to traumatic events which worsen disease course, but this study is the first multicentre randomised controlled trial to test the efficacy of a trauma-focused adjunctive psychotherapy in reducing BD affective relapse rates.

MATERIALS AND METHODS

This multicentre randomised controlled trial included 77 patients with BD and current trauma-related symptoms. Participants were randomised to either 20 sessions of trauma-focused Eye Movement Desensitization and Reprocessing (EMDR) therapy for BD, or 20 sessions of supportive therapy (ST). The primary outcome was relapse rates over 24-months, and secondary outcomes were improvements in affective and trauma symptoms, general functioning, and cognitive impairment, assessed at baseline, post-treatment, and at 12- and 24-month follow-up. The trial was registered prior to starting enrolment in clinical trials (NCT02634372) and carried out in accordance with CONSORT guidelines.

RESULTS

There was no significant difference between treatment conditions in terms of relapse rates either with or without hospitalisation. EMDR was significantly superior to ST at the 12-month follow up in terms of reducing depressive symptoms (p=0.0006, d=0.969), manic symptoms (p=0.027, d=0.513), and improving functioning (p=0.038, d=0.486). There was no significant difference in dropout between treatment arms.

CONCLUSIONS

Although the primary efficacy criterion was not met in the current study, trauma-focused EMDR was superior to ST in reducing of affective symptoms and improvement of functioning, with benefits maintained at six months following the end of treatment. Both EMDR and ST reduced trauma symptoms as compared to baseline, possibly due to a shared benefit of psychotherapy. Importantly, focusing on traumatic events did not increase relapses or dropouts, suggesting psychological trauma can safely be addressed in a BD population using this protocol.

Brexpiprazole in patients with schizophrenia with or without substance use disorder: an observational study

Background

Partial dopamine D2 receptor agonists are used for psychotic symptoms in adults with schizophrenia spectrum disorders. Recently, interest surged for partial dopamine D2 receptor agonists in substance use disorders (SUDs). Since it is believed that SUDs decrease the efficacy of pharmacotherapy of underlying psychiatric disorders, we tested the efficacy of the partial D2 agonist brexpiprazole in patients with schizophrenia who were either comorbid with a SUD (SUD group) or not comorbid (non-SUD) to assess treatment response and the effect of brexpiprazole on substance craving in SUD.

Methods

We included patients with DSM-5/DSM-5-TR schizophrenia (using SCID-5-CV) aged 18-66 years with either comorbid SUD or non-SUD to treat with brexpiprazole 4 mg/day for 6 months during February-October 2022. Patients were assessed with the Clinical Global Impressions-Severity (CGI-S) scale, the 24-item Brief Psychiatric Rating Scale (BPRS), and the Positive And Negative Syndrome Scale (PANSS) at baseline, weekly for the first 2 months and monthly for the next four. Furthermore, we assessed substance craving in SUD with a visual analog scale for craving (VAScrav) at the same timepoints.

Results

The total sample was 86 (85 analysable) 18- to 64-year-old (mean 39.32 ± 14.09) patients with schizophrenia [51 men (59.3%) and 35 women (40.7%)], of whom 48 SUD (55.8%) (37 men and 11 women) and 38 non-SUD (44.2%) (14 men and 24 women). No serious or persistent adverse events developed over the study period, but one patient dropped out for subjective akathisia. Results indicated the main effects of time with improvements over the course of the study for CGI-S, BPRS, and PANSS in both SUD and non-SUD groups and the entire sample, and for VAScrav in SUD. Brexpiprazole was associated with similar significant improvements in both groups at the 6 month endpoint compared to baseline.

Conclusion

Treatment with brexpiprazole for 6 months improved psychotic symptoms in patients with schizophrenia, independently from whether they belonged to the SUD or the non-SUD group; hence, SUD comorbidity did not confer treatment resistance to brexpiprazole. Furthermore, in the SUD group, we observed reduced substance craving.

Expanding Early Psychosis Care across a Large and Diverse State: Implementation Lessons Learned from Administrative Data and Clinical Team Leads in Texas

The U.S. is facing an unprecedented youth mental health crisis. Translating the findings from mental health intervention trials into large scale, accessible community-based services poses substantial challenges. Examination of state actions as a result of research-informed federal policy to improve youth access to quality mental healthcare is necessary. This mixed-methods study examines the implementation of evidence-informed multidisciplinary coordinated specialty care (CSC) for first-episode psychosis (FEP) services across Texas. The study explores CSC service model components, site location and participant characteristics, and implementation barriers. This cross-sectional study analyzes State of Texas public mental health administrative data from 2015 to 2020, including CSC site (n = 23) characteristics and CSC participant (n = 1682) demographics. Texas CSC site contracts were compared to OnTrackNY, a leading CSC model in the U.S. for CSC service element comparison. In-depth interviews with CSC Team Leads (n = 22) were analyzed to further understand CSC service elements and implementation barriers using qualitative content analysis. CSC was implemented across three waves in 2015, 2017, and 2019-serving 1682 participants and families. CSC sites were located in adult mental health programs; approximately one third of CSC participants were under 18 years. CSC implementation challenges reported by Team Leads included: staff role clarification, collaboration and turnover, community outreach and referrals, child and adult service billing issues, and adolescent and family engagement. Study findings have implications for large state-wide evidence-based practice implementation in transition-to-adulthood community mental health.

The effect of duration of untreated psychosis (DUP) on the risk for hospitalization after admission to a first episode service

Engagement with a first episode-psychosis service (FES) reduces the risk of psychiatric hospitalization. However, the role of the duration of untreated psychosis (DUP) in impacting this outcome is disputed. This study aimed to examine whether DUP was an effect modifier of the post-FES reduction of risk of hospitalization, and to explore associations between patients' characteristics and hospitalization post-FES. Individuals aged 16-35 with recent onset (< 3 years) of non-affective psychosis, admitted to the Program for Specialized Treatment Early in Psychosis (STEP), a FES serving the Greater New Haven area, Connecticut, between 2014 and 2019 were included (N = 189). Medical records were queried from 2013 through 2020 for number and duration of psychiatric hospitalizations. Poisson regression models were used to estimate incidence rate ratios for hospitalization rates across all explanatory variables. Negative binomial regression was used to compare the length of stay (LOS) before vs after STEP enrollment. STEP admission was associated with a significant 90 % reduction in the frequency and duration of hospitalizations. This effect was moderated by DUP: with 30-day prolongations in components of DUP (supply, demand, and total) there was less reduction in hospitalizations and LOS after FES enrollment (p < .0001). Only DUP supply (time from first antipsychotic use to STEP admission) differentiated those who were hospitalized during the first year after STEP enrollment from those who were not (median: 35 vs. 15 weeks, p = .003). To fully harness the positive impact of FES on hospitalization, a detailed effort should be pursued to reduce all DUP components.

Characterization of the extracellular free water signal in schizophrenia using multi-site diffusion MRI harmonization

Studies applying Free Water Imaging have consistently reported significant global increases in extracellular free water (FW) in populations of individuals with early psychosis. However, these published studies focused on homogenous clinical participant groups (e.g., only first episode or chronic), thereby limiting our understanding of the time course of free water elevations across illness stages. Moreover, the relationship between FW and duration of illness has yet to be directly tested. Leveraging our multi-site diffusion magnetic resonance imaging(dMRI) harmonization approach, we analyzed dMRI scans collected by 12 international sites from 441 healthy controls and 434 individuals diagnosed with schizophrenia-spectrum disorders at different illness stages and ages (15-58 years). We characterized the pattern of age-related FW changes by assessing whole brain white matter in individuals with schizophrenia and healthy controls. In individuals with schizophrenia, average whole brain FW was higher than in controls across all ages, with the greatest FW values observed from 15 to 23 years (effect size range = [0.70-0.87]). Following this peak, FW exhibited a monotonic decrease until reaching a minima at the age of 39 years. After 39 years, an attenuated monotonic increase in FW was observed, but with markedly smaller effect sizes when compared to younger patients (effect size range = [0.32-0.43]). Importantly, FW was found to be negatively associated with duration of illness in schizophrenia (p = 0.006), independent of the effects of other clinical and demographic data. In summary, our study finds in a large, age-diverse sample that participants with schizophrenia with a shorter duration of illness showed higher FW values compared to participants with more prolonged illness. Our findings provide further evidence that elevations in the FW are present in individuals with schizophrenia, with the greatest differences in the FW being observed in those at the early stages of the disorder, which might suggest acute extracellular processes.

Early trajectory of clinical global impression as a transdiagnostic predictor of psychiatric hospitalisation: a retrospective cohort study

BACKGROUND

Identifying patients most at risk of psychiatric hospitalisation is crucial to improving service provision and patient outcomes. Existing predictors focus on specific clinical scenarios and are not validated with real-world data, limiting their translational potential. This study aimed to determine whether early trajectories of Clinical Global Impression Severity are predictors of 6 month risk of hospitalisation.

METHODS

This retrospective cohort study used data from the NeuroBlu database, an electronic health records network from 25 US mental health-care providers. Patients with an ICD-9 or ICD-10 code of major depressive disorder, bipolar disorder, generalised anxiety disorder, post-traumatic stress disorder, schizophrenia or schizoaffective disorder, ADHD, or personality disorder were included. Using this cohort, we assessed whether clinical severity and instability (operationalised using Clinical Global Impression Severity measurements) during a 2-month period were predictors of psychiatric hospitalisation within the next 6 months.

FINDINGS

36 914 patients were included (mean age 29·7 years [SD 17·5]; 21 156 [57·3%] female, 15 748 [42·7%] male; 20 559 [55·7%] White, 4842 [13·1%] Black or African American, 286 [0·8%] Native Hawaiian or other Pacific Islander, 300 [0·8%] Asian, 139 [0·4%] American Indian or Alaska Native, 524 (1·4%) other or mixed race, and 10 264 [27·8%] of unknown race). Clinical severity and instability were independent predictors of risk of hospitalisation (adjusted hazard ratio [HR] 1·09, 95% CI 1·07-1·10 for every SD increase in instability; 1·11, 1·09-1·12 for every SD increase in severity; p<0·0001 for both). These associations were consistent across all diagnoses, age groups, and in both males and females, as well as in several robustness analyses, including when clinical severity and clinical instability were based on the Patient Health Questionnaire-9 rather than Clinical Global Impression Severity measurements. Patients in the top half of the cohort for both clinical severity and instability were at an increased risk of hospitalisation compared with those in the bottom half along both dimensions (HR 1·45, 95% CI 1·39-1·52; p<0·0001).

INTERPRETATION

Clinical instability and severity are independent predictors of future risk of hospitalisation, across diagnoses, age groups, and in both males and females. These findings could help clinicians make prognoses and screen patients who are most likely to benefit from intensive interventions, as well as help health-care providers plan service provisions by adding additional detail to risk prediction tools that incorporate other risk factors.

FUNDING

National Institute for Health and Care Research, National Institute for Health and Care Research Oxford Health Biomedical Research Centre, Medical Research Council, Academy of Medical Sciences, and Holmusk.

Machine Learning and Non-Affective Psychosis: Identification, Differential Diagnosis, and Treatment

PURPOSE OF REVIEW

This review will cover the most relevant findings on the use of machine learning (ML) techniques in the field of non-affective psychosis, by summarizing the studies published in the last three years focusing on illness detection and treatment.

RECENT FINDINGS

Multiple ML tools that include mostly supervised approaches such as support vector machine, gradient boosting, and random forest showed promising results by applying these algorithms to various sources of data: socio-demographic information, EEG, language, digital content, blood biomarkers, neuroimaging, and electronic health records. However, the overall performance, in the binary classification case, varied from 0.49, which is to be considered very low (i.e., noise), to over 0.90. These results are fully justified by different factors, some of which may be attributable to the preprocessing of the data, the wide variety of the data, and the a-priori setting of hyperparameters. One of the main limitations of the field is the lack of stratification of results based on biological sex, given that psychosis presents differently in men and women; hence, the necessity to tailor identification tools and data analytic strategies. Timely identification and appropriate treatment are key factors in reducing the consequences of psychotic disorders. In recent years, the emergence of new analytical tools based on artificial intelligence such as supervised ML approaches showed promises as a potential breakthrough in this field. However, ML applications in everyday practice are still in its infancy.

Identifying Diagnoses of Schizophrenia Spectrum Disorder in Large Data Sets

Objective

The authors used a large clinical data set to determine which index diagnoses of schizophrenia spectrum disorder were new diagnoses.

Methods

Using the Massachusetts All-Payer Claims Database (2012–2016), the authors identified patients with a schizophrenia spectrum disorder diagnosis in 2016 (index diagnosis) and then reviewed patients’ care histories for the previous 12, 24, 36, and 48 months to identify previous diagnoses. Logistic regression was used to examine patient characteristics associated with the index diagnosis being a new diagnosis.

Results

Overall, 7,217 individuals ages 15–35 years had a 2016 diagnosis of schizophrenia spectrum disorder; 67.7% had at least 48 months of historical data. Among those with at least 48 months of care history, 23% had no previous diagnoses. Diagnoses from inpatient psychiatric admissions or among female or younger patients were more likely to represent new diagnoses, compared with diagnoses from most other diagnosis locations or among males or older age groups, and outpatient diagnoses were less likely to represent new diagnoses than were most other diagnosis settings. Reviewing 48 instead of 12 months of data reduced estimated rates of new diagnoses from 112 to 66 per 100,000 persons; historical diagnoses were detected for 61% and 77% of patients with 12 or 48 months of care history, respectively.

Conclusions

Examining multiple years of patient history spanning all payers and providers is critical to identifying new schizophrenia spectrum disorder diagnoses in large data sets. Review of 48 months of care history resulted in lower rates of new schizophrenia spectrum disorder diagnoses than previously reported.

Relapse of first-episode schizophrenia patients and neurocognitive impairment: The role of dopaminergic and anticholinergic burden

BACKGROUND

The prevention of relapse may be a key factor to diminish the cognitive impairment of first-episode schizophrenia (FES) patients. We aimed to ascertain the effects of relapse, and dopaminergic and anticholinergic treatment burdens on cognitive functioning in the follow-up.

METHODS

Ninety-nine FES patients participated in this study. Cognitive assessments were performed at baseline and after 3 years of follow-up or, in those patients who relapsed, after &gt;2 months of stabilization of the new acute psychotic episode. The primary outcomes were final cognitive dimensions.

RESULTS

Repeated measures MANOVA analyses showed improvements in the whole sample on the end-point assessments in processing speed and social cognition. However, only impairment in social cognition showed a significant interaction with relapse by time in this sample. Relapse in FES patients was significantly associated with poor performance on end-point assessments of working memory, social cognition and global cognitive score. Anticholinergic burden, but not dopaminergic burden, was associated with verbal memory impairment. These significant associations resulted after controlling for baseline cognitive functioning, relapse and dopaminergic burden.

CONCLUSIONS

The relationship between relapse and cognitive impairment in recovered FES patients seems to be particularly complex at the short-term follow-up of these patients. While relapse was associated with working memory, social cognition impairments and global cognitive score, anticholinergic burden might play an additional worsening effect on verbal memory. Thus, tailoring or changing antipsychotics and other drugs to reduce their anticholinergic burden may be a potential modifiable factor to diminish cognitive impairment at this stage of the illness.

A naturalistic study on the effectiveness of long-acting antipsychotics in an early intervention program for patients with recent-onset psychosis

AIM

To evaluate the impact of long-acting injectable antipsychotics (LAIs) on the risk of hospitalization and the length of hospitalization in the setting of an early intervention program for patients with recent-onset psychosis.

METHODS

Observational, retrospective study conducted under routine clinical practice conditions. We included all patients admitted from July 2015 to April 2020 to the Early Intervention Program in Psychosis. We analysed the incidence of hospitalization and hospitalization days before and after treatment with LAIs and calculated the incidence rate ratio (IRR). We also compared the outcomes of patients treated with LAIs with those of the patients maintained on oral antipsychotics using a binomial negative regression analysis.

RESULTS

A total of 170 patients were included in the program. Of them, 34 (20%) received LAIs (aripiprazole [n = 22], and paliperidone/risperidone [n = 12]). There was an 89% reduction in the incidence of hospitalizations after treatment with LAIs (IRR 0.11, 95%CI 0.05-0.21; p < .0001). The IRR for LAIs vs. oral antipsychotics was 0.87 (95%CI, 0.24-3.18; p = .829). The presence of a substance use disorder significantly increased the rate of hospitalizations by 123% (IRR 2.23, 95%CI 1.31-3.78). Analyses of hospitalization days showed similar results.

CONCLUSIONS

Our results suggest that LAIs are useful for the management of patients with recent-onset psychosis who fail treatment with oral antipsychotics. Whether LAIs are superior to oral antipsychotics as first-line treatment of patients with early psychosis and/or could play a special role in managing patients with early psychosis and comorbid substance use disorders should be further evaluated.

Patient Journey of Veterans with Schizophrenia: An Analysis of Treatment Patterns, Healthcare Resource Utilization and Costs

INTRODUCTION

Little is known about the burden of schizophrenia among United States veterans early after diagnosis. This retrospective study describes treatment patterns, healthcare resource utilization (HRU) and healthcare costs among veterans with a recent schizophrenia diagnosis.

METHODS

Adults with a schizophrenia diagnosis recorded between 1 April 2014 and 31 December 2017 and no history of schizophrenia over the preceding 12 months were identified from a Veterans Health Administration (VHA) database. Continuous enrollment in the VHA was required for ≥ 12 months before and after the index date when the first schizophrenia diagnosis code was identified. Baseline characteristics and follow-up treatment patterns, HRU and costs were examined descriptively.

RESULTS

The study population (20,389 patients) had a high baseline mental health comorbidity burden. Despite a schizophrenia diagnosis, 32.1% of patients received no antipsychotic medication during the follow-up period. Among those with ≥ 1 antipsychotic prescription fill, 64.0% received ≥ 1 oral antipsychotic (OAP) therapy and 11.6% received ≥ 1 long-acting injectable (LAI). A delay was observed between diagnosis and treatment for both OAPs (39.0 ± 67.2 days) and LAIs (69.4 ± 96.2 days). Adherence to therapy (defined as proportion of days covered ≥ 80%) was greater with LAIs (34.5%) vs OAPs (27.3%). Inpatient stays were reported for 33.8% of patients during the 12-month follow-up period, and 5.5% of patients had readmissions. All-cause inpatient stay costs with 12-month follow-up equaled $7999 per patient per year.

CONCLUSIONS

These data indicate that pharmacotherapy after a recent diagnosis of schizophrenia in the VHA system is suboptimal, and that these patients face a considerable burden in terms of hospitalization, other HRU, and healthcare costs.

Specialized inpatient treatment for young people with early psychosis: acute-treatment and 12-month results

The objective of the study was to investigate the development of clinical outcomes of young people with early psychosis in a specialized inpatient treatment and assess the feasibility of such an intervention in an inpatient setting. The study was a prospective cohort study of patients with early psychosis treated at the specialized inpatient treatment "Fühinterventions-und Therapiezentrum, FRITZ" (early intervention and therapy center) in Berlin, Germany. The primary outcomes were attitudes towards psychiatric medication and patient satisfaction with treatment after 6 weeks. Secondary outcomes were clinical symptoms, functioning, remission, recovery, all-cause treatment discontinuation, and rehospitalisation at 6 and 12 months after inpatient treatment. We recruited 95 inpatients with early psychosis. Attitudes towards psychiatric medication (Δ_6weeks = 3.00, d_6weeks = 0.55; Δ_6mo = 2.15, d_6mo = 0.35; Δ_12mo = 3.03, d_12mo = 0.52) and patient satisfaction (Δ_6weeks = 0.21, d_6weeks = 0.40; Δ_6mo = 0.32, d_6mo = 0.43; Δ_12mo = 0.13, d_12mo = 0.17) changed with medium effect sizes at six weeks up to a 6- and 12-month follow-up. Clinical outcomes changed significantly with medium-to-large-effect sizes over 12 months CGI_Δ12mo = 1.64, d_12mo = -1.12; PANSS total_Δ12mo = 20.10, d_12mo = -0.76; GAF_Δ12mo = 19.58, d_12mo = 1.25). The all-cause treatment discontinuation rate was 13.69% (n = 13) at a 6-month and 35.79% (n = 34) at a 12-month follow-up. The rehospitalization rate was 30.53% (n = 29) at a 6-month and 43.16% (n = 41) at a 12-month follow-up. Patients with specialized inpatient treatment for early psychosis showed improvements in attitude towards psychiatric medication, patient satisfaction, symptoms, and functioning for up to 12 months.Trial registration: DRKS00024351, 2021/02/11 retrospectively registered.

The interplay between functioning problems and symptoms in first episode of psychosis: An approach from network analysis

The relationship between psychotic symptoms and global measures of functioning has been widely studied. No previous study has assessed so far the interplay between specific clinical symptoms and particular areas of functioning in first-episode psychosis (FEP) using network analysis methods. A total of 191 patients with FEP (age 24.45 ± 6.28 years, 64.9% male) participating in an observational and longitudinal study (AGES-CM) comprised the study sample. Functioning problems were assessed with the WHO Disability Assessment Schedule (WHODAS), whereas the Positive and Negative Syndrome Scale (PANSS) was used to assess symptom severity. Network analysis were conducted with the aim of analysing the patterns of relationships between the different dimensions of functioning and PANSS symptoms and factors at baseline. According to our results, the most important nodes were "conceptual disorganization", "emotional withdrawal", "lack of spontaneity and flow of conversation", "delusions", "unusual thought content", "dealing with strangers" and "poor rapport". Our findings suggest that these symptoms and functioning dimensions should be prioritized in the clinical assessment and management of patients with FEP. These areas may also become targets of future early intervention strategies, so as to improve quality of life in this population.

Predictors of Intensive Treatment in Patients With Obsessive-Compulsive Disorder

Background: Few studies have investigated which patients with obsessive-compulsive disorder (OCD) do not recover through regular cognitive behavior therapy or pharmacotherapy and subsequently end up in intensive treatment like day treatment or inpatient treatment. Knowing the predictors of intensive treatment in these patients is significant because it could prevent intensive treatment. This study has identified predictors of intensive treatment in patients with OCD. Methods: Using 6-year longitudinal data of the Netherlands Obsessive Compulsive Disorder Association (NOCDA), potential predictors of intensive treatment were assessed in patients with OCD (n = 419). Intensive treatment was assessed using the Treatment Inventory Costs in Patients with Psychiatric Disorders (TIC-P). Examined potential predictors were: sociodemographics, and clinical and psychosocial characteristics. Logistic Generalized Estimating Equations was used to estimate to what extent the various characteristics (at baseline, 2- and 4-year assessment) predicted intensive treatment in the following 2 years, averaged over the three assessment periods. Results: Being single, more severe comorbid depression, use of psychotropic medication, and a low quality of life predicted intensive treatment in the following 2 years. Conclusions: Therapists should be aware that patients with OCD who are single, who have more severe comorbid depression, who use psychotropic medication, and who have a low quality of life or a drop in quality of life are at risk for intensive treatment. Intensive treatment might be prevented by focusing regular treatment not only on OCD symptoms but also on comorbid depression and on quality of life. Intensive treatment might be improved by providing extra support in treatment or by adjusting treatment to impairments due to comorbid depressive symptoms or a low quality of life.

Trends and issues in community mental health programs in India: The Ranchi Institute of Neuropsychiatry and Allied Sciences experience

Psychiatric disorders are among the leading causes of disability the world over. With the World Health Organization, spearheading the crusade to incorporate the mental health component into primary health care, developing countries also have accepted the need for community care of patients with psychiatric disorders. Since independence various initiatives by the government has led to a significant change in the place of mental health care as part of the general health care. At the time of independence apart from mental hospitals, there was practically no organized mental health care. Since then General Hospital Psychiatry units and also Psychiatric Nursing homes have started. Currently, mental health issues are actively seen as part of the public agenda in the various forms. The overall effect has been the movement to recognize mental health as an important issue in the community and services to move beyond mental hospital care to care to the community. Majority of population in Jharkhand is residing in rural areas. Due to the lack of proper communications and infrastructure, Ranchi Institute of Neuropsychiatry and Allied Sciences (RINPAS) had started community outreach program way back in 1999. At present, these centers are running in four different areas of the state with great success. RINPAS experience shows that how even with resource constraints, quality services can be provided to unreached population.

Reliability and Feasibility of the First-Episode Psychosis Services Fidelity Scale-Revised for Remote Assessment

OBJECTIVE

The authors sought to evaluate the interrater reliability and feasibility of the First-Episode Psychosis Services Fidelity Scale-Revised (FEPS-FS-R) for remote assessment of first-episode psychosis programs according to the coordinated specialty care model.

METHODS

The authors used the FEPS-FS-R to assess the fidelity of 36 first-episode psychosis program sites in the United States with information from three sources: administrative data, health record review, and phone interviews with staff. Four raters independently conducted fidelity assessments of five program sites by listening to each of the staff interviews and independently rating the two other data sources from each site. To calculate interrater reliability, the authors used intraclass correlation coefficients (ICCs) for each of the five sites and across the total scores for each site.

RESULTS

Total interrater reliability was in the good to excellent range, with a mean ICC of 0.91 (95% confidence interval = 0.72-0.99, p<0.001). Two first-episode psychosis program sites (6%) achieved excellent fidelity, 25 (69%) good fidelity, and nine (25%) fair fidelity. Of the 32 distinct items on the FEPS-FS-R, 23 (72%) were used with good or excellent fidelity. Most sites achieved high fidelity on most items, but five items received ratings indicating low-fidelity use at most sites. The fidelity assessment proved feasible, and sites required on average 10.5 hours for preparing and conducting the fidelity review.

CONCLUSIONS

The FEPS-FS-R has high interrater reliability and can differentiate high-, moderate-, and low-fidelity sites. Most sites had good overall fidelity, but the FEPS-FS-R identified some services that were challenging to implement at many sites.

Specialised early intervention teams for recent-onset psychosis

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.

Predictors of psychosis breakthrough during 24 months of long-acting antipsychotic maintenance treatment in first episode schizophrenia

BACKGROUND

Some patients develop breakthrough psychotic symptoms on antipsychotic maintenance medication (BAMM), despite receiving therapeutic antipsychotic doses to which they previously responded.

METHODS

We examined the occurrence of BAMM in previously minimally treated first-episode patients with schizophrenia-spectrum disorders who were treated according to a standard protocol with a long-acting injectable antipsychotic and regularly assessed over 24 months.

RESULTS

Of 99 patients (age = 24.1 ± 6.5 years, male = 73.7%) who received treatment for ≥6 months (mean follow-up = 20.0 ± 6.5 months) and had responded well to treatment, 21 (21.2%) developed BAMM using operationally defined criteria, after a mean of 17.4 ± 6.1 months. Baseline risk factors for BAMM included lower baseline Positive and Negative Syndrome Scale positive symptoms, poorer quality of life in social relationships and higher blood - high-density lipoprotein-cholesterol. Regarding intra-treatment-factors, BAMM was independently predicted by an increase in low-density lipoprotein-cholesterol and current cannabis use. We did not find a relationship between BAMM and cumulative antipsychotic exposure or dose escalation. While symptoms of the BAMM episode were less severe than during the first episode, the post-BAMM treatment response was poorer than that for the first psychotic episode, suggesting a relationship between BAMM and emergent treatment refractoriness.

CONCLUSIONS

About one in five patients with first-episode schizophrenia developed BAMM during the first two years of treatment, despite assured antipsychotic LAI treatment, indicating that this phenomenon is not restricted to the chronic stages of illness. The role of cannabis use and a possible link between BAMM and blood lipids should be further explored.

Effects of Omega 3 Fatty Acids on Main Dimensions of Psychopathology

The usefulness of polyunsaturated fatty acids on inflammatory, cardiovascular, and the nervous system was studied in the last decades, but the mechanisms underlying their benefic properties are still partially unknown. These agents seem to express their action on the membrane phospholipid composition and permeability and modulation of second messenger cascades. In psychiatry, the efficacy and tolerability of omega-3 fatty acids were investigated in several psychiatric disorders, including major depression, bipolar disorder, personality disorders, high-risk conditions to develop psychosis, attention-deficit hyperactivity disorder, and autism spectrum disorders. Initial findings in this field are promising, and some relevant questions need to be addressed. In particular, the effects of these agents on the main symptom dimensions have to be investigated in a trans-diagnostic perspective. The present systematic review is aimed to examine the available data on the efficacy of omega-3 fatty acids on domains of psychotic symptoms, affective symptoms, impulsivity, and aggressiveness, and harmful behaviors, and suicide risk.

Psychiatric hospitalization following psychosis onset: A retrospective cohort study using health administrative data

AIM

There is limited evidence examining admissions in early psychosis. We sought to estimate the proportion of people with a psychiatric admission within 2 years of the first diagnosis of psychosis, and to identify associated risk factors.

METHOD

We constructed a cohort of incident non-affective psychosis cases using health administrative data and identified the first psychiatric hospitalization after psychosis onset. We compared hospitalization rates across sociodemographic, clinical and service-use factors.

RESULTS

One in three patients had an admission within 2 years of first diagnosis. Younger age, migrant status, diagnosis of psychosis not otherwise specified, and prior substance use were associated with increased hospitalization rates, whereas family physician involvement in diagnosis was protective.

CONCLUSIONS

Adolescents, immigrants and people presenting with diagnostic instability or prior substance use issues may benefit from interventions aimed at reducing hospitalization risk. Increasing primary care access and utilization among youth with early psychosis may also reduce hospitalization rates.

Polyunsaturated Fatty Acids: What is Their Role in Treatment of Psychiatric Disorders?

In the central nervous system omega-3 fatty acids modulate cell signaling and affect dopaminergic and serotonergic pathways. On this basis, a new application for omega-3 fatty acids has been proposed, concerning the treatment of several psychiatric disorders. The present article is an update of a previous systematic review and is aimed to provide a complete report of data published in the period between 1980 and 2019 on efficacy and tolerability of omega-3 fatty acids in psychiatric disorders. In July 2019, an electronic search on PUBMED, Medline and PsychINFO of all RCTs, systematic reviews and meta-analyses on omega-3 fatty acids and psychiatric disorders without any filter or MESH restriction was performed. After eligibility processes, the final number of records included in this review was 126. One hundred and two of these studies were RCTs, while 24 were reviews and meta-analyses. The role of omega-3 fatty acids was studied in schizophrenia, major depression, bipolar disorder, anxiety disorders, obsessive-compulsive disorder, post-traumatic stress disorder, attention deficit hyperactivity disorder (ADHD), autism spectrum disorders, eating disorders, substance use disorder and borderline personality disorder. The main evidence of the efficacy of omega-3 fatty acids has been obtained in treating depressive symptoms in patients with major depression and, to a lesser degree, bipolar depression. Some efficacy was also found in early phases of schizophrenia in addition to antipsychotic treatment, but not in the chronic phases of psychosis. Small beneficial effects of omega-3 fatty acids were observed in ADHD and positive results were reported in a few trials on core symptoms of borderline personality disorder. For other psychiatric disorders results are inconsistent.