Measuring schizophrenia remission in clinical practice

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.

Discharge destinations for young people with a first episode of psychosis after attending an early intervention for psychosis service

OBJECTIVE

Early intervention for psychosis services result in superior outcomes in the domains of symptomatic and functional recovery, hospitalisation and employment compared to standard services; however, the optimal duration of care with these services is unknown. Knowledge on the discharge destinations, specifically the proportion discharged to high- and low-intensity services, could provide insights into the proportion of who may require a longer tenure of care. This study aimed to determine (1) the discharge destinations from early intervention for psychosis services and (2) baseline and intra-episode factors associated with discharge to the secondary care/adult mental health service.

METHODOLOGY

This study was conducted at the Early Psychosis Prevention and Intervention Centre in Melbourne and included all young people treated by the service with a first episode of psychosis over a 6-year period. Discharge destinations were categorised according to high-intensity services, namely, secondary mental health care, or lower intensity services, such as private practitioners or primary care.

RESULTS

A total of 1101 young people with a first episode of psychosis were included in the study, of whom 58.8% were male and the median age was 20.0 years (interquartile range: 17-22). After a median of 95.4 weeks (interquartile range: 66.7-105.7), 36.6% were discharged to the adult mental health services, which was associated with being not in employment, education or training at presentation (odds ratio = 1.71, 95% confidence interval [1.23, 2.37]); experiencing a relapse (odds ratio = 1.76, 95% confidence interval [1.24, 2.49]); and being admitted to a mental health unit (odds ratio = 3.98, 95% confidence interval [2.61, 6.09]). Young people who lived with their parents were less likely to be discharged to secondary care services (odds ratio = 0.52, 95% confidence interval [0.37, 0.73]), as were those who were achieving symptomatic remission within 12 weeks (odds ratio = 0.60, 95% confidence interval [0.43, 0.83]). Migrant status and the duration of untreated psychosis were not associated with discharge destination.

CONCLUSION

These findings indicate that there is a sizable, identifiable minority who may benefit from a longer episode of care with early intervention for psychosis services.

Pathways to care for first-generation migrants with first episode psychosis in northwestern metropolitan Melbourne

OBJECTIVE

Understanding the pathways to care for migrants experiencing a first episode of psychosis is important, as they are more likely to experience longer delays to treatment and negative experiences, such as involuntary treatment. Despite the increased risk of developing a psychotic illness and barriers associated with pathways to care, there are limited studies exploring pathways to care in migrants in Australia. This study seeks to examine pathways to care for young people with a first episode of psychosis to a publicly funded youth mental health service.

METHODS

This study included all young people aged 15-24 years who presented with a first episode of psychosis to the Early Psychosis Prevention and Intervention Centre (EPPIC) between 1 February 2011 and 31 December 2016. Referral sources and place of birth were recorded at the time of presentation. The severity of psychotic symptoms was rated at baseline.

RESULTS

A total of 1220 young people presented with a first episode of psychosis during the study period, including 293 (24.5%) first-generation migrants. First-generation migrants with a first episode of psychosis were more likely to be admitted to hospital than Australian-born youth (odds ratio = 1.67, 95% confidence interval = [1.27, 2.18], p < 0.001) and this remained significant when controlled for demographic (adjusted odds ratio = 1.41, 95% confidence interval = [1.07, 1.88], p = 0.016) and clinical factors (adjusted odds ratio = 1.38,95% confidence interval = [1.01, 1.89], p = 0.044). First-generation migrants were also more likely to have an involuntary admission (odds ratio = 1.67, 95% confidence interval = [1.26, 2.21], p < 0.001) and this remained significant when controlled for demographic (adjusted odds ratio = 1.42, 95% confidence interval = [1.05, 1.91], p = 0.022) and clinical factors (adjusted odds ratio = 1.50, 95% confidence interval = [1.08, 2.09], p = 0.017). Migrants had more severe delusions (p = 0.005), bizarre behavior (p < 0.001) and positive formal thought disorder (p = 0.003) at the time of presentation. Migrants were also more likely to attend the emergency department during their presentation with first episode of psychosis (odds ratio = 1.76, 95% confidence interval = [1.31, 2.36], p < 0.001).

CONCLUSION

First-generation migrants who develop a psychotic disorder are at greater risk of experiencing negative pathways to care than the Australian-born population. Further research is needed to identify the factors that lead to migrants being involuntarily admitted to hospital for first episode of psychosis.

Co-occurring first-episode psychosis and borderline personality pathology in an early intervention for psychosis cohort

INTRODUCTION

Borderline personality disorder (BPD) is common among people diagnosed with first episode of psychosis (FEP), but is often under-recognized and under-researched. This study aimed to determine: (i) the prevalence of borderline personality pathology (subthreshold features and categorical disorder) in a FEP cohort (termed FEP + BPP); (ii) demographic and clinical factors associated with FEP + BPP; (iii) the symptomatic and functional outcomes.

METHODS

This study was conducted within the Early Psychosis Prevention and Intervention Centre (EPPIC) at Orygen over the 30-month period between 2014 and 2016. BPP was evaluated by using the Structured Clinical Interview for DSM-IV Axis II Personality Questionnaire BPD criteria.

RESULTS

In a cohort of 457 young people with a FEP (mean age 19.5 years, 56% male), 18.4% had borderline personality pathology (BPP). Compared with FEP alone, young people with FEP + BPP were more likely to be female, younger, Australian-born. In addition, young people with FEP + BPP were more likely to be diagnosed with Psychosis NOS, present with more severe hallucinations, and have alcohol abuse. Young people with FEP + BPP had more relationship difficulties at presentation and they were more likely to suffer of depression and to engage in self-harm throughout the follow-up. In relation to outcome, FEP + BPP was not associated with different rates of remission or relapse, however they were less likely to be admitted to hospital at presentation or involuntarily during their episode of care.

CONCLUSION

BPP is a common occurrence in psychotic disorders and is associated with more severe hallucinations and depression with higher risks of self-harm. Specific interventions need to be developed.

Rates and Predictors of Relapse in First-Episode Psychosis: An Australian Cohort Study

Background

Clinical and functional recovery is usually achieved after treatment for a first episode of psychosis (FEP). Unfortunately, subsequent relapse remains common, occurring within a year for approximately 30% of individuals and up to 80% over 5 years. Factors that make relapse more likely in any given individual remain poorly understood.

Methods

This article presents a naturalistic cohort study of young people (15–24 years old) accessing an early intervention in psychosis service in Melbourne, Australia between January 1, 2011 and December 31, 2016. Demographic and clinical predictors of relapse were collected and analyzed using Cox regression analysis.

Results

A total of 1220 young people presented with an FEP during the study period; 37.7% (N = 460) experienced at least 1 relapse during their episode of care. Over half of all relapses resulted in an admission to hospital. Non-adherence to medication, substance use, and psychosocial stressors were commonly noted as clinical precipitants of relapse. Significant predictors of relapse (vs no relapse) were a diagnosis of schizophrenia spectrum disorder (adjusted hazard ratio [aHR] = 1.62) or affective psychotic disorder (aHR = 1.37), lifetime amphetamine use (aHR = 1.48), and any substance use during treatment (aHR = 1.63).

Conclusion

These findings suggest that relapse occurs frequently for young people who have experienced FEP. This is one of the first studies to report that amphetamine use (predominantly illicit methamphetamine) increases the risk of relapse. Clinical services, especially in Australasia, need to consider how best to manage this comorbidity in young people with FEP.

Measurement based care in schizophrenia-Feasibility in routine clinical practice

Measurement based care (MBC) implies the utilization of structured objective scales/batteries in the assessment and monitoring of an illness. Patients with schizophrenia with heterogeneous presentation would potentially benefit better through MBC. Time constraints and additional work burden are frequently cited as barriers in implementing objective assessments. In this selective review, the authors discuss the available standard scales for assessment in schizophrenia, the advantages and disadvantages in implementing MBC and a feasible approach to overcome the barriers by adapting shorter versions of structured scales.

Prevalence and outcomes of young people with concurrent autism spectrum disorder and first episode of psychosis

BACKGROUND

The intersect and blurring of boundaries between schizophrenia spectrum disorders and autism spectrum disorder (ASD) has long been an area of confusion, in both nosology and clinical practice. Individuals with a comorbid presentation of the two spectra can present with a distinct phenomenological profile to those with psychosis or ASD alone.

AIMS

To examine the prevalence rates of ASD in a cohort of young people presenting with a first episode of psychosis (FEP) and compare the demographic and clinical characteristics and functional outcomes between individuals with concurrent FEP and ASD, and individuals with FEP only.

METHODS

Young people aged 15 to 24 who presented with FEP to the Early Psychosis Prevention and Intervention Centre (EPPIC) between 1st January 2011 and 31st December 2013 were included in the study.

RESULTS

Of the 544 individuals presenting with a FEP, 3.7% (N = 20) had a diagnosis of ASD. Individuals with a concurrent diagnosis of FEP and ASD were more likely to be male and less likely to have comorbid substance use issues. There was no difference found in the severity of psychotic symptoms or diagnoses between groups. Those with FEP and ASD were more likely to experience impairments in interpersonal skills and be more likely to be engaged in employment or education at time of discharge from service.

CONCLUSIONS

Individuals with concurrent FEP and ASD can present with distinct clinical characteristics that require specialised assessment and treatment. Further large-scale studies with control groups could help to better understand the phenomenological specificity of this subgroup.

Characteristics and outcomes of young people with substance induced psychotic disorder

BACKGROUND

Substance induced psychotic disorders (SIPD) have been historically considered as associated with better clinical and functional outcomes than other psychotic diagnoses. As a result, treatments for those with SIPD are often considerably less intensive, yet this is not based on evidence. The present study aimed to examine whether differences exist between those with SIPD and other first episode psychosis (FEP) diagnoses in regards to demographic and clinical factors, and to determine the symptomatic, clinical and functional outcomes in those with SIPD.

METHODS

This study included all young people aged 15-24 who presented with a FEP to the Early Psychosis Prevention and Intervention Centre between 01/01/2011 and 31/12/2013. Group differences were analysed with independent samples t-tests and chi-square analyses and equivalent non-parametric tests as appropriate. Where applicable, odds ratios were calculated.

RESULTS

544 young people presented with a FEP and 10.3% (N = 56) were diagnosed with SIPD. Individuals with SIPD were more likely to be male, unemployed, and have a comorbid substance use disorder. There were no significant differences between groups regarding duration of untreated psychosis, severity of psychotic symptoms, time to remission, or rates of relapse. Those with SIPD were less likely to be employed or engaged in study at discharge and 35.7% of those with SIPD had a change of diagnosis to a schizophrenia spectrum or bipolar disorder after a median of 84 weeks.

CONCLUSION

Young people diagnosed with SIPD should be an important focus of early intervention services and receive comparable treatment to those with other psychotic diagnoses.

Rates, determinants and outcomes associated with the use of community treatment orders in young people experiencing first episode psychosis

BACKGROUND

Community treatment orders (CTOs) are a controversial form of involuntary treatment for individuals affected by mental health disorders and yet little is known about the use of CTOs in first presentations. Therefore, this study aimed to determine the rates, determinants and outcomes associated with the use of CTOs in young people with a first episode of psychosis (FEP).

METHODS

This epidemiological cohort study included all individuals aged 15-24 who presented with a FEP to the Early Psychosis Prevention and Intervention Centre (EPPIC) in Melbourne between 01.01.2011 and 31.12.13.

RESULTS

A total of 544 young people presented with a FEP during the study period and of these, 93 (17.3%) were subject to a CTO during their episode of care. A total of 69.7% of CTOs were commenced after the first three months of treatment and the median duration of CTOs was 168.5 days. Males, a diagnosis of a schizophrenia spectrum disorder and a concurrent substance abuse disorder were associated with the use of CTOs. Additionally, young people with more severe positive psychotic symptoms were more likely to be subject to a CTO. At the time of discharge, only 38.7% of those subject to a CTO were in education or employment compared to 65.4% of those who had not been subject to a CTO.

CONCLUSIONS

The majority of CTOs are commenced after at least three months of treatment, however the optimal timing of CTO implementation needs to be determined. The poor functioning of young people on a CTO should be the focus of future interventional studies.

Clozapine use in early psychosis

BACKGROUND

The superior efficacy of clozapine in treatment resistant schizophrenia has been clearly demonstrated, yet there are often delays in the commencement of clozapine. In this study, we aimed to determine; the proportion of young people with a first episode of psychosis (FEP) who would be considered eligible for clozapine treatment, the theoretical delay in commencing clozapine and to compare the outcomes of those treated with clozapine to those who were eligible but not treated with clozapine.

METHODS

This study was conducted at Orygen Youth Health (OYH), a youth mental health service for young people aged 15-24. All clients who were treated at the Early Psychosis Prevention and Intervention Centre (EPPIC) clinic between 01.01.2011 and 31.12.2013 were included.

RESULTS

544 young people presented with a FEP in the study period and 9.4% (N = 51) subsequently fulfilled criteria for treatment-resistant schizophrenia. Of these individuals, thirty (58.8%) were commenced on clozapine, in addition to a further eleven. The median delay to the commencement of clozapine was 42 weeks (I.Q.R. = 7.5-64). Of those commenced on clozapine, 76.6% achieved remission of positive psychotic symptoms and 50% were in employment or education by the time of discharge or transfer to the adult mental health services. The rate of discontinuation of clozapine was 24.4% and 60.0% of discontinuations were due to cardiac complications and the remainder were due to non-compliance.

CONCLUSIONS

These findings suggest that early intervention for psychosis services have a crucial role in ensuring timely initiation of clozapine in individuals with a diagnosis of treatment-resistant schizophrenia.

Rates and predictors of relapse following discontinuation of antipsychotic medication after a first episode of psychosis

BACKGROUND

There is uncertainty about the required duration of long-term antipsychotic maintenance medication after a first episode of psychosis. Robust predictors of relapse after discontinuation are yet to be identified. The present study aimed to determine the proportion of young people who discontinue their antipsychotic medication after a first episode of psychosis, the proportion who experience relapse, and predictors of relapse.

METHODS

A retrospective study of all individuals presenting to the Early Psychosis Prevention and Intervention Centre between 01/01/11 and 31/12/13 was conducted. A Cox regression analysis was conducted to identify predictors of relapse.

RESULTS

A total of 544 young people with a FEP were included. A trial of discontinuation was undertaken by 61% of the cohort. Median duration of antipsychotic medication prior to first trial of discontinuation was 174.50days. Amongst those trialing discontinuation, 149 (45.8%) experienced relapse in a median follow-up time post discontinuation of 372days. On multivariate analysis, predictors of relapse were a diagnosis of cannabis abuse disorder (HR: 1.40), and longer duration of antipsychotic medication (HR: 1.05).

CONCLUSION

Antipsychotic discontinuation frequently occurs earlier than guidelines recommend. Individuals with a diagnosis of cannabis abuse are more likely to experience relapse and addressing this substance abuse prior to discontinuation could possibly reduce relapse rates.

Which nontraditional outcomes should be measured in healthcare decision-making in schizophrenia? A systematic review

PURPOSE

  This article aims to define the utility of nontraditional outcomes (NTOs) in healthcare decision-making in schizophrenia.

DESIGN AND METHODS

  A systematic review of studies published between January 1, 1996, and December 31, 2008, was performed. A 10-point evidence-based utility index (UI) was used to assess the utility of NTOs: high (UI: 7.5-10), medium (UI: ≥ 5 to <7.5), and low (UI: <5) utility.

FINDINGS

  Of 736 citations identified, 94 met inclusion criteria. One hundred ninety-four NTOs were identified (patient reported outcomes [38.7%] and economic outcomes [61.3%]). Of these, 68 (35.1%) were appropriate for decision making.

PRACTICE IMPLICATIONS

  Numerous NTOs with low utility in schizophrenia are being used for healthcare policy and clinical care by policy makers, managers, and healthcare professionals. Medium and low utility NTOs should be used with caution.

Relapse and therapeutic interventions in a 1-year observational cohort study of nonadherent outpatients with schizophrenia

OBJECTIVES

To evaluate the incidence rate of relapse, the clinical profiles, and the therapeutic interventions employed for patients with schizophrenia deemed as likely nonadherers to oral antipsychotic drugs.

METHODS

A cohort of 597 outpatients whose therapy was modified because of a psychiatrist-perceived risk of nonadherence was followed for 12 months in an observational study. Baseline correlates of subsequent relapse were analyzed with Cox regression.

RESULTS

At baseline, patients' mean (SD) age and time since diagnosis were 40.1 (11.1) and 15.2 (10.0) years, respectively; 63.7% were males. The Clinical Global Impression scale-Severity (CGI-S) score was ≥ 4 in 87.3% of the patients. Antipsychotic drugs were modified in 506 patients (84.8%); nonpharmacologic therapies were modified in 190 patients (31.8%). In both cases, the primary reason for the modifications was insufficient efficacy of current therapeutic regimen. The proportion of patients in oral antipsychotic monopharmacy decreased from 83.8% to 57.6%; 15.4% started long-acting (depot) formulations. Over the 12-month observation period, 90 patients (15.1%) relapsed. The hazard rate of relapse was higher in patients with substance use disorder or familial psychiatric antecedents and lower in patients who underwent modifications of nonpharmacological therapies or with negative attitude toward antipsychotic medication at baseline.

CONCLUSIONS

Effective interventions to prevent relapse in patients with long-standing schizophrenia involving therapeutic challenges related to nonadherence are feasible. Rationale for the baseline correlates, and cues for clinical prevention of relapse in these patients are provided.