Outcomes following first-episode psychosis – Why we should intervene early in all ages, not only in youth

Self-Harm and Suicide Rates Before and After an Early Intervention Program for Patients With First-Episode Schizophrenia

Importance

Evidence on the association of early intervention services (EISs) with self-harm and suicide among patients with first-episode schizophrenia (FES) at older than 25 years is lacking.

Objective

To examine changes in self-harm and suicide rates among patients with FES before and after the implementation of an EIS program.

Design, Setting, and Participants

This population-based cohort study conducted among 37 040 patients aged 15 to 64 years with FES between January 1, 2001, and March 31, 2020, used electronic medical records from the Hong Kong Clinical Data Analysis and Reporting System. All patients were followed up from the first diagnosis of schizophrenia (the index date) until the date of their death or the end of the study period (March 31, 2021), whichever came first. Statistical analysis was performed from July to November 2023.

Exposure

The EIS extended the Early Assessment Service for Young People With Early Psychosis (EASY) program from patients aged 15 to 25 years to those aged 15 to 64 years (EASY Plus). The exposure was the implementation of the EASY Plus program in April 2011. The exposure period was defined as between April 2012 and March 2021 for the 1-year-time-lag analysis.

Main Outcomes and Measures

The outcomes were monthly rates of self-harm and suicide among patients with FES before and after the implementation of the EASY Plus program. Interrupted time series analysis was used for the main analysis.

Results

This study included 37 040 patients with FES (mean [SD] age at onset, 39 [12] years; 82.6% older than 25 years; 53.0% female patients). The 1-year-time-lag analysis found an immediate decrease in self-harm rates among patients aged 26 to 44 years (rate ratio [RR], 0.77 [95% CI, 0.59-1.00]) and 45 to 64 years (RR, 0.70 [95% CI, 0.49-1.00]) and among male patients (RR, 0.71 [95% CI, 0.56-0.91]). A significant long-term decrease in self-harm rates was found for all patients with FES (patients aged 15-25 years: RR, 0.98 [95% CI, 0.97-1.00]; patients aged 26-44 years: RR, 0.98 [95% CI, 0.97-0.99]; patients aged 45-64 years: RR, 0.97 [95% CI, 0.96-0.98]). Suicide rates decreased immediately after the implementation of the EASY Plus program among patients aged 15 to 25 years (RR, 0.33 [95% CI, 0.14-0.77]) and 26 to 44 years (RR, 0.38 [95% CI, 0.20-0.73]). Compared with the counterfactual scenario, the EASY Plus program might have led to 6302 fewer self-harm episodes among patients aged 26 to 44 years.

Conclusions and Relevance

This cohort study of the EASY Plus program suggests that the extended EIS was associated with reduced self-harm and suicide rates among all patients with FES, including those older than 25 years. These findings emphasize the importance of developing tailored interventions for patients across all age ranges to maximize the benefits of EISs.

A service evaluation study of the impact of ageless policy in a London inner-city early intervention in psychosis service

BACKGROUND

Schizophreniform disorders tend to have an early onset. Early intervention in psychosis (EIP) services aim to provide early treatment, reduce long-term morbidity and improve social functioning. In 2016, changes to mental health policy in England mandated that the primarily youth-focused model should be extended to an ageless one, to prevent ageism; however, this was without strong research evidence.

AIMS AND METHOD

An inner-city London EIP service compared sociodemographic and clinical factors between the under-35 years and over-35 years caseload cohorts utilising the EIP package following the implementation of the ageless policy.

RESULTS

Both groups received similar care, despite the younger group having significantly more clinical morbidity and needs.

CLINICAL IMPLICATIONS

Our results may indicate that service provisions are being driven by policy rather than clinical needs, potentially diverting resources from younger patients. These findings have important implications for future provision of EIP services and would benefit from further exploration.

Carepath for overcoming psychosis early (COPE): first 5 years of clinical operation and prospective research in the Cavan-Monaghan early intervention service

OBJECTIVES

As Ireland confronts the many challenges of broadening the introduction of early intervention services (EIS) for first episode psychosis (FEP) as national policy, this article describes Carepath for Overcoming Psychosis Early (COPE), the EIS of Cavan-Monaghan Mental Health Service, and presents prospective research findings during its first 5 years of operation.

METHODS

COPE was launched as a rural EIS with an embedded research protocol in early 2012, following an education programme for general practitioners (GPs). Here, operational activities are documented and research findings presented through to late 2016.

RESULTS

During this period, 115 instances of FEP were incepted into COPE, 70.4% via their GP and 29.6% via the Emergency Department. The annual rate of inception was 24.8/100,000 of population aged > 15 years and was 2.1-fold more common among men than women. Mean duration of untreated psychosis was 5.7 months and median time from first psychotic presentation to initiation of antipsychotic treatment was zero days. Assessments of psychopathology, neuropsychology, neurology, premorbid functioning, quality of life, insight, and functionality compared across 10 DSM-IV psychotic diagnoses made at six months following presentation indicated minimal differences between them, other than more prominent negative symptoms in schizophrenia and more prominent mania in bipolar disorder.

CONCLUSIONS

COPE illustrates the actuality of introducing and the challenges of operating a rural EIS for FEP. Prospective follow-up studies of the 5-year COPE cohort should inform on the effectiveness of this EIS model in relation to long-term outcome in psychotic illness across what appear to be arbitrary diagnostic boundaries at FEP.

The tertiary service for psychosis: Holistic recommendations for people with complex psychosis

OBJECTIVE

To describe (i) the clinical characteristics of individuals referred to the Tertiary Referral Service for Psychosis (TRSP) and (ii) the recommendations TRSP made for future treatment across psychopharmacological and other intervention domains.

METHOD

Retrospective audit of clinical data collected during the assessment process of individuals who accessed TRSP between 02/06/2020 and 31/12/2022. Categories of recommendations made following collaborative care planning comprised psychopharmacological, neuropsychological, psychological, psychosocial, physical health, substance misuse and other domains.

RESULTS

Eighty-two individuals were included, with diagnoses most commonly of schizophrenia (54.9%) and schizoaffective disorder (30.5%). The median PANSS score was 88.0 (73-100). Social occupational functioning was very poor (SOFAS M = 37.0, SD = 15.1). Cognitive functioning was poor (RBANS: M = 74.6; SD: 15.0). 67.1% had physical health comorbidities, with high prevalence of smoking (52.4%) and substance misuse (25.6%). Psychopharmacological recommendations (made for 81.7%) included clozapine trial (25.6%), clozapine dose change/augmentation (22.0%) and rationalisation of polypharmacy (12.2%). Neuropsychological (73.2%), psychological (39.0%) and psychosocial (85.4%) recommendations included access to cognitive remediation, psychological therapy and disability support. Physical health and substance misuse interventions were recommended for 91.5% and 20.7%, respectively.

CONCLUSIONS

Individuals referred to the TRSP had marked clinical and functional impairments. Holistic collaborative care planning complemented psychopharmacological interventions with psychological, psychosocial and physical healthcare recommendations.

Psychosis Early Intervention Across the Life Span: A Service Perspective

Previously youth-orientated, UK early intervention in psychosis (EI) services expanded care in 2016 to adults of any age. To compare EI care offering, clinical characteristics, and potential benefits for under-35s and over-35s, an observational study considering anonymised data for users of London-based EI services between April 2016 and December 2019 was conducted. Descriptive statistics and between groups comparisons are reported. The analysis considered 692 service users (32.5% over-35). Over-35s were more likely to be female, of poorer physical health, with severer problems at intake (Health of the Nation Outcome Scale, HoNOS). Under-35s had poorer appointment attendance, required increased use of inpatient facilities, and demonstrated greater risks to themselves and others. At discharge, HoNOS ratings indicated improvements for both groups. Over-35s constitute a considerable proportion of EI service-users, their care may involve less crisis management, more recovery-oriented intervention and physical health needs consideration. Care offering should reflect these needs.

Multidimensional analysis of adult patients’ care trajectories before a first diagnosis of schizophrenia

For patients at high-risk for developing schizophrenia, a delayed diagnosis could be affected, among many reasons, by their patterns of healthcare use. This study aims to describe and generate a typology of patients’ care trajectories (CTs) in the 2 years preceding a first diagnosis of schizophrenia, over a medico-administrative database of 3712 adults with a first diagnosis between April 2014 and March 2015 in Quebec, Canada. This study applied a multidimensional approach of State Sequence Analysis, considering together sequences of patients’ diagnoses, care settings and care providers. Five types of distinct CTs have emerged from this data-driven analysis: The type 1, shared by 77.6% of patients, predominantly younger men, shows that this group sought little healthcare, among which 17.5% had no healthcare contact for mental disorders. These individuals might benefit from improved promotion and prevention of mental healthcare at the community level. The types 2, 3 and 4, with higher occurrence of mental disorder diagnoses, represent together 19.5% of the study cohort, mostly middle-aged and women. These CTs, although displaying roughly similar profiles of mental disorders, revealed very dissimilar sequences and levels of care providers encounters, primary and specialized care use, and hospitalizations. Surprisingly, patients of these CTs had few consultations with general practitioners. An increased attentiveness for middle-aged patients and women with high healthcare use for mental disorders could help to reduce delayed diagnosis of schizophrenia. This calls for further consideration of healthcare services for severe mental illness beyond those offered to young adults.

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

PURPOSE OF REVIEW

Early intervention in first-episode psychosis (FEP) improves symptomatic and functional outcomes while programs last. However, these gains may not be sustained over time and not all individuals benefit equally from such programs. This review examines the efficacy of FEP programs, as well as step-down practices and long-term outcomes to identify ways to extend the gains made in FEP programs.

RECENT FINDINGS

FEP programs improve outcomes while services last, but effects diminish over time. Step-down and discharge practices vary widely with little randomized evidence guiding practice. Extending the duration of FEP programs for all does not consistently improve outcomes, but there is some encouraging evidence that targeted psychosocial interventions after program end may extend symptomatic and functional benefits. Members of marginalized groups and individuals with poorer outcomes during the FEP period may benefit from further specialized intervention after FEP.

SUMMARY

Step down practices from FEP programs should be structured and tailored to individual needs, and benefit from sustained connections to community resources. Psychosocial interventions like social skills training, peer support, and supported education and employment may help extend the benefit of FEP programs after more intensive services end.

Towards better care for women with schizophrenia-spectrum disorders

Women with a schizophrenia-spectrum disorder (SSD) have a better clinical profile than do men at the start of their illness but progress to the same state within the first few years of living with SSD. There are benefits to be gained across different areas in the care currently offered to women with psychosis. An important point for improvement is the early detection of female-specific signs of a first episode of psychosis, to shorten the duration of untreated psychosis, with prompt access to early intervention services. Special attention should be paid to sexual health, and to any history of childhood trauma. Antipsychotics require dosing and prescription tailored to the female physiology that consider hormonal life phases such as menopause. Switching to prolactin-sparing medications can benefit both mental and somatic health. Finally, hormone replacement therapy should be considered for postmenopausal women. By providing female-specific care, women with schizophrenia-spectrum disorders will have optimal chances to fare well.

A systematic review of longitudinal studies of suicidal thoughts and behaviors in first-episode psychosis: course and associated factors

PURPOSES

To better assess and reduce suicidal risk in first-episode psychosis (FEP), we aimed to investigate the evolution of suicidal thoughts and behaviors (STBs) and associated factors in FEP.

METHOD

This systematic review (PROSPERO-CRD42020168050) meets PRISMA guidelines. PubMed, Medline, PsycINFO, Embase, EBM Reviews and references lists of relevant articles were searched (February 2020) to identify longitudinal studies, published in English or in French, that assessed the prevalence of STBs at entry to services and over follow-up, and examined factors associated with STBs among all persons with affective and non-affective FEP from a defined catchment area. Screening, data extraction and quality assessment using the adapted Newcastle Ottawa Scale were done independently by two reviewers. Results on prevalence and associated factors are presented by type of STB.

RESULTS

Of 3,177 references, 17 studies of 11 non-overlapping samples (n = 14,907) with varying lengths of follow-up (1-41.7 years) were included. The prevalence of STBs decreased over follow-up. Up to 21.6% made at least one suicide attempt, 27% had suicidal ideation, and 1-4.3% died by suicide during follow-up. Of 53 factors assessed across studies, only male sex, depressive symptoms, and STBs occurring early during follow-up were associated with subsequent STBs. Early intervention for psychosis decreased STBs in the first three years. Other factors were assessed in a single study, yielded conflicting results, or were not associated with STBs.

CONCLUSIONS

The high prevalence of STBs following onset of psychosis highlights the need for early detection and intervention and ongoing assessment of suicidal risk throughout follow-up, with attention to identified risk factors. The heterogeneity of the studies precluded a meta-analysis and several factors were each assessed by a single study. Additional well-designed longitudinal studies of STBs and associated factors are warranted.

Patterns of Primary Care Use Prior to a First Diagnosis of Nonaffective Psychotic Disorder in Ontario, Canada: Modèles d'utilisation des soins de première ligne avant un premier diagnostic de trouble psychotique non affectif en Ontario, Canada

BACKGROUND

Many people experience early signs and symptoms before the onset of psychotic disorder, suggesting that there may be help-seeking prior to first diagnosis. The family physician has been found to play a key role in pathways to care. This study examined patterns of primary care use preceding a first diagnosis of psychotic disorder.

METHODS

We used health administrative data from Ontario (Canada) to construct a population-based retrospective cohort. We investigated patterns of primary care use, including frequency and timing of contacts, in the 6 years prior to a first diagnosis of psychosis, relative to a general population comparison group matched on age, sex, geographic area, and index date. We used latent class growth modeling to identify distinct trajectories of primary care service use, and associated factors, preceding the first diagnosis.

RESULTS

People with early psychosis contacted primary care over twice as frequently in the 6 years preceding first diagnosis (RR = 2.22; 95% CI, = 2.19 to 2.25), relative to the general population, with a sharp increase in contacts 10 months prior to diagnosis. They had higher contact frequency across nearly all diagnostic codes, including mental health, physical health, and preventative health. We identified 3 distinct service use trajectories: low-, medium-, and high-increasing usage.

DISCUSSION

We found elevated patterns of primary care service use prior to first diagnosis of psychotic disorder, suggesting that initiatives to support family physicians in their role on the pathway to care are warranted. Earlier intervention has implications for improved social, educational, and professional development in young people with first-episode psychosis.

Transitioning to age inclusive early intervention for psychosis

AIM

Early Intervention in psychosis Services (EIS) have previously restricted access based on age. However, there is now a move to age inclusive service. We aimed to examine differences between early and late onset (>35 years) psychosis to see if a threshold was valid. We also investigated the potential of a statistical modelling method to identify group characteristics which may be missed using a descriptive approach.

METHODS

Routine clinical data (n = 343), from an EIS, comprising socio-demographic, clinical, physical and treatment variables, were examined using descriptive and classification and regression tree (CART) analysis.

RESULTS

The findings suggest that age differences were best explained by social factors. There was no emerging evidence that the differences exhibited had a fundamental impact on the clinical outcomes of the clients in terms of support beyond EIS (ie, hospitalization and home treatment team involvement) and pharmacological and psychological interventions. CART analysis revealed distinct service user characteristics associated with the clinical outcomes.

CONCLUSION

There was no evidence to support a clinical cut off based on age providing support for age inclusive services. However, in the transition to age inclusive service delivery, EIS need to consider social/life stage variables, adapting provision where service delivery may operate a youth focused model. Routine analysis of clinical data should employ methods to identify groups of service users who may require adjusted service provision.

Women and Stigma: A Protocol for Understanding Intersections of Experience through Body Mapping

This paper outlines a research and dissemination protocol to be undertaken with specific groups of marginalised women in Australia. Women impacted by significant mental distress, disability, or refugee status are among society’s most vulnerable and disenfranchised groups. They can experience significant social exclusion, marginalisation and stigma, associated with reduced help seeking, deprivation of dignity and human rights, and threats to health, well-being and quality of life. Previous research has assessed the experiences of discrete groups of women but has to date failed to consider mental health–refugee–disability intersections and overlaps in experience. Using body mapping, this research applies an intersectional approach to identify how women impacted by significant mental distress, disability, and refugee status negotiate stigma and marginalisation. Findings on strategies to cope with, negotiate and resist stigmatised identities will inform health policy and yield targeted interventions informed by much-needed insights on women’s embodied experience of stigma. The women’s body maps will be exhibited publicly as part of an integrated knowledge translation strategy. The aim is to promote and increase sensitivity and empathy among practitioners and policy makers, strengthening the basis for social policy deliberation.

Early Intervention in Psychosis Treatment Components Utilization in Patients Aged Over 35

Early Intervention in Psychosis (EIP) services have been youth-focused since their inception. In England, recent National Institute for Health and Care Excellence (NICE) guidelines and new National Health Service (NHS) Standards for EIP recommend the expansion of the age acceptability criterion from 14-35 to 14-65. In the Cambridgeshire and Peterborough EIP service (CAMEO), we ran a service evaluation to assess the initial impact of this policy change. It aimed to elicit EIP treatment components utilization by patients with first-episode psychosis (FEP) aged over 35, in comparison with those under 35. We found that the over-35s required more contacts from EIP healthcare professionals, especially from care coordinators (coefficient = .239; Robust SE = .102; Z = 6.42; p = 0.019) and social workers (coefficient = 18.462; Robust SE = .692; Z = .016; p < 0.001). These findings indicate that FEP patients aged over 35 may present with more complex and sustained clinical/social needs. This may have implications for EIP service development and commissioning.

Stable patients with schizophrenia switched to paliperidone palmitate 3-monthly formulation in a naturalistic setting: impact of patient age and disease duration on outcomes

BACKGROUND

Paliperidone palmitate 3-monthly (PP3M) is a second-generation, long-acting injectable antipsychotic formulation indicated for the maintenance treatment of adults with schizophrenia first stabilized with paliperidone palmitate 1-monthly (PP1M). This exploratory post hoc subgroup analysis of the 52-week, phase 3b REMISSIO study analysed outcomes according to patient age and disease duration in a naturalistic clinical setting.

METHODS

Outcomes of patients with schizophrenia were analysed according to age [<35 years (n = 123) versus ⩾35 years (n = 182)] and disease duration [⩽3 years (n = 72) versus >3 years (n = 233)]. The primary efficacy outcome was the proportion of patients achieving symptomatic remission according to the Andreasen criteria. Adverse events were monitored throughout the study.

RESULTS

At endpoint (last observation carried forward), 60.7% (95% CI: 51.4%, 69.4%) of younger patients and 54.1% of older patients (95% CI: 46.6%, 61.6%) achieved symptomatic remission. The proportions for patients with disease duration ⩽3 years and >3 years were similar: 57.8% (45.4%, 69.4%) versus 56.5% (49.8%, 62.9%). Functional remission was reached by 45.4% (36.2%, 54.8%) of patients aged <35 years and 36% (28.9%, 43.6%) of patients aged ⩾35 years with a similar pattern when analysed by disease duration. PP3M had a favourable safety profile and was generally well tolerated in both age groups.

CONCLUSION

Patients with schizophrenia, previously stabilized on PP1M, may benefit from PP3M treatment with some additional potential improvements if started early in the disease course.

CLINICAL TRIALSGOV

NCT02713282.

Estimating the incidence of first-episode psychosis using population-based health administrative data to inform early psychosis intervention services

BACKGROUND

Discrepancies between population-based estimates of the incidence of psychotic disorder and the treated incidence reported by early psychosis intervention (EPI) programs suggest additional cases may be receiving services elsewhere in the health system. Our objective was to estimate the incidence of non-affective psychotic disorder in the catchment area of an EPI program, and compare this to EPI-treated incidence estimates.

METHODS

We constructed a retrospective cohort (1997-2015) of incident cases of non-affective psychosis aged 16-50 years in an EPI program catchment using population-based linked health administrative data. Cases were identified by either one hospitalization or two outpatient physician billings within a 12-month period with a diagnosis of non-affective psychosis. We estimated the cumulative incidence and EPI-treated incidence of non-affective psychosis using denominator data from the census. We also estimated the incidence of first-episode psychosis (people who would meet the case definition for an EPI program) using a novel approach.

RESULTS

Our case definition identified 3245 cases of incident non-affective psychosis over the 17-year period. We estimate that the incidence of first-episode non-affective psychosis in the program catchment area is 33.3 per 100 000 per year (95% CI 31.4-35.1), which is more than twice as high as the EPI-treated incidence of 18.8 per 100 000 per year (95% CI 17.4-20.3).

CONCLUSIONS

Case ascertainment strategies limited to specialized psychiatric services may substantially underestimate the incidence of non-affective psychotic disorders, relative to population-based estimates. Accurate information on the epidemiology of first-episode psychosis will enable us to more effectively resource EPI services and evaluate their coverage.

The over-35s: early intervention in psychosis services entering uncharted territory

Aims and methodFollowing the introduction of new standards for early intervention in psychosis (EIP) in England, EIP services are accepting referrals for people aged 35-65. The Cambridgeshire and Peterborough EIP service (CAMEO) aimed to explore the immediate implications for the service, especially with regards to referral numbers and sources. Data were collected from April 2016 to June 2017.

RESULTS

Referrals for over-35s represented 25.7% of all new referrals. Fifty per cent of referrals for over-35s were accepted onto caseload (40.2% for under-35s). The over-35s were more likely to be referred from acute and secondary mental health services (P < 0.01) and had longer durations of untreated psychosis than the under-35s (P = 0.02).Clinical implicationsCAMEO has received a significantly higher number of referrals as a result of age inclusivity, with an increased proportion of patients suffering from severe, acute psychotic presentations and existing mental health difficulties. This has implications for service planning.Declaration of interestNone.

Disparities in Access to Early Psychosis Intervention Services: Comparison of Service Users and Nonusers in Health Administrative Data

OBJECTIVE

There is a dearth of information on people with first-episode psychosis who do not access specialized early psychosis intervention (EPI) services. We sought to estimate the proportion of incident cases of nonaffective psychosis that do not access these services and to examine factors associated with EPI admission.

METHODS

Using health administrative data, we constructed a retrospective cohort of incident cases of nonaffective psychosis in the catchment area of the Prevention and Early Intervention Program for Psychoses (PEPP) in London, Ontario, between 1997 and 2013. This cohort was linked to primary data from PEPP to identify EPI users. We used multivariate logistic regression to model sociodemographic and service factors associated with EPI admission.

RESULTS

Over 50% of suspected cases of nonaffective psychosis did not have contact with EPI services for screening or admission. EPI users were significantly younger, more likely to be male (odds ratio [OR] 1.58; 95% confidence interval [CI] 1.24 to 2.01), and less likely to live in areas of socioeconomic deprivation (OR 0.51; 95% CI 0.36 to 0.73). EPI users also had higher odds of psychiatrist involvement at the index diagnosis (OR 7.35; 95% CI 5.43 to 10.00), had lower odds of receiving the index diagnosis in an outpatient setting (OR 0.50; 95% CI 0.38 to 0.65), and had lower odds of prior alcohol-related (OR 0.42; 95% CI 0.28 to 0.63) and substance-related (OR 0.68; 95% CI 0.50 to 0.93) disorders.

CONCLUSIONS

We need a greater consideration of patients with first-episode psychosis who are not accessing EPI services. Our findings suggest that this group is sizable, and there may be sociodemographic and clinical disparities in access. Nonpsychiatric health professionals could be targeted with interventions aimed at increasing detection and referral rates.

Treated Incidence of Psychotic Disorders in the Multinational EU-GEI Study

Importance

Psychotic disorders contribute significantly to the global disease burden, yet the latest international incidence study of psychotic disorders was conducted in the 1980s.

Objectives

To estimate the incidence of psychotic disorders using comparable methods across 17 catchment areas in 6 countries and to examine the variance between catchment areas by putative environmental risk factors.

Design, Setting, and Participants

An international multisite incidence study (the European Network of National Schizophrenia Networks Studying Gene-Environment Interactions) was conducted from May 1, 2010, to April 1, 2015, among 2774 individuals from England (2 catchment areas), France (3 catchment areas), Italy (3 catchment areas), the Netherlands (2 catchment areas), Spain (6 catchment areas), and Brazil (1 catchment area) with a first episode of nonorganic psychotic disorders (International Statistical Classification of Diseases and Related Health Problems, Tenth Revision [ICD-10] codes F20-F33) confirmed by the Operational Criteria Checklist. Denominator populations were estimated using official national statistics.

Exposures

Age, sex, and racial/ethnic minority status were treated as a priori confounders. Latitude, population density, percentage unemployment, owner-occupied housing, and single-person households were treated as catchment area-level exposures.

Main Outcomes and Measures

Incidence of nonorganic psychotic disorders (ICD-10 codes F20-F33), nonaffective psychoses (ICD-10 codes F20-F29), and affective psychoses (ICD-10 codes F30-F33) confirmed by the Operational Criteria Checklist.

Results

A total of 2774 patients (1196 women and 1578 men; median age, 30.5 years [interquartile range, 23.0-41.0 years]) with incident cases of psychotic disorders were identified during 12.9 million person-years at risk (crude incidence, 21.4 per 100 000 person-years; 95% CI, 19.4-23.4 per 100 000 person-years). A total of 2183 patients (78.7%) had nonaffective psychotic disorders. After direct standardization for age, sex, and racial/ethnic minority status, an 8-fold variation was seen in the incidence of all psychotic disorders, from 6.0 (95% CI, 3.5-8.6) per 100 000 person-years in Santiago, Spain, to 46.1 (95% CI, 37.3-55.0) per 100 000 person-years in Paris, France. Rates were elevated in racial/ethnic minority groups (incidence rate ratio, 1.6; 95% CI, 1.5-1.7), were highest for men 18 to 24 years of age, and were lower in catchment areas with more owner-occupied homes (incidence rate ratio, 0.8; 95% CI, 0.7-0.8). Similar patterns were observed for nonaffective psychoses; a lower incidence of affective psychoses was associated with higher area-level unemployment (incidence rate ratio, 0.3; 95% CI, 0.2-0.5).

Conclusions and Relevance

This study confirmed marked heterogeneity in risk for psychotic disorders by person and place, including higher rates in younger men, racial/ethnic minorities, and areas characterized by a lower percentage of owner-occupied houses.

Predictors and moderators of treatment outcome in patients receiving multi-element psychosocial intervention for early psychosis: results from the GET UP pragmatic cluster randomised controlled trial

BackgroundThe GET UP multi-element psychosocial intervention proved to be superior to treatment as usual in improving outcomes in patients with first-episode psychosis (FEP). However, to guide treatment decisions, information on which patients may benefit more from the intervention is warranted.AimsTo identify patients' characteristics associated with (a) a better treatment response regardless of treatment type (non-specific predictors), and (b) a better response to the specific treatment provided (moderators).MethodSome demographic and clinical variables were selected a priori as potential predictors/moderators of outcomes at 9 months. Outcomes were analysed in mixed-effects random regression models. (Trial registration: ClinicalTrials.gov, NCT01436331)ResultsAnalyses were performed on 444 patients. Education, duration of untreated psychosis, premorbid adjustment and insight predicted outcomes regardless of treatment. Only age at first contact with the services proved to be a moderator of treatment outcome (patients aged ⩾35 years had greater improvement in psychopathology), thus suggesting that the intervention is beneficial to a broad array of patients with FEP.ConclusionsExcept for patients aged over 35 years, no specific subgroups benefit more from the multi-element psychosocial intervention, suggesting that this intervention should be recommended to all those with FEP seeking treatment in mental health services.

Women and schizophrenia: planning for the future

The aim of this narrative review is to provide readers with a summary of the recent literature on women and schizophrenia and to address commonly asked questions about the role of gender in this illness. Important gender distinctions were found in the knowledge base around schizophrenia, particularly in the areas of symptom onset, hormonal and immune effects, and antipsychotic drug kinetics and their consequences. We also discuss and address commonly asked questions about gender and schizophrenia. This review concludes that gender differences influence the effectiveness of various treatments and need to be taken into account when planning comprehensive care services for individuals with schizophrenia.