Relapse risk assessment in early phase psychosis: the search for a reliable and valid tool

GDNF and miRNA-29a as biomarkers in the first episode of psychosis: uncovering associations with psychosocial factors

Aim

Schizophrenia involves complex interactions between biological and environmental factors, including childhood trauma, cognitive impairments, and premorbid adjustment. Predicting its severity and progression remains challenging. Biomarkers like glial cell line-derived neurotrophic factor (GDNF) and miRNA-29a may bridge biological and environmental aspects. The goal was to explore the connections between miRNAs and neural proteins and cognitive functioning, childhood trauma, and premorbid adjustment in the first episode of psychosis (FEP).

Method

This study included 19 FEP patients who underwent clinical evaluation with: the Childhood Trauma Questionnaire (CTQ), the Premorbid Adjustment Scale (PAS), the Positive and Negative Syndrome Scale (PANSS), and the Montreal Cognitive Assessment Scale (MoCA). Multiplex assays for plasma proteins were conducted with Luminex xMAP technology. Additionally, miRNA levels were quantitatively determined through RNA extraction, cDNA synthesis, and RT-qPCR on a 7500 Fast Real-Time PCR System.

Results

Among miRNAs, only miR-29a-3p exhibited a significant correlation with PAS-C scores (r = -0.513, p = 0.025) and cognitive improvement (r = -0.505, p = 0.033). Among the analyzed proteins, only GDNF showed correlations with MoCA scores at the baseline and after 3 months (r = 0.533, p = 0.0189 and r = 0.598, p = 0.007), cognitive improvement (r = 0.511, p = 0.025), and CTQ subtests. MIF concentrations correlated with the PAS-C subscale (r = -0.5670, p = 0.011).

Conclusion

GDNF and miR-29a-3p are promising as biomarkers for understanding and addressing cognitive deficits in psychosis. This study links miRNA and MIF to premorbid adjustment and reveals GDNF's unique role in connection with childhood trauma.

Speech markers to predict and prevent recurrent episodes of psychosis: A narrative overview and emerging opportunities

Preventing relapse in schizophrenia improves long-term health outcomes. Repeated episodes of psychotic symptoms shape the trajectory of this illness and can be a detriment to functional recovery. Despite early intervention programs, high relapse rates persist, calling for alternative approaches in relapse prevention. Predicting imminent relapse at an individual level is critical for effective intervention. While clinical profiles are often used to foresee relapse, they lack the specificity and sensitivity needed for timely prediction. Here, we review the use of speech through Natural Language Processing (NLP) to predict a recurrent psychotic episode. Recent advancements in NLP of speech have shown the ability to detect linguistic markers related to thought disorder and other language disruptions within 2-4 weeks preceding a relapse. This approach has shown to be able to capture individual speech patterns, showing promise in its use as a prediction tool. We outline current developments in remote monitoring for psychotic relapses, discuss the challenges and limitations and present the speech-NLP based approach as an alternative to detect relapses with sufficient accuracy, construct validity and lead time to generate clinical actions towards prevention.

Young Adults' Perspectives on Factors Related to Relapse After First-Episode Psychosis: Qualitative Focus Group Study

Relapse after first-episode psychosis (FEP) is a major clinical challenge for specialized early intervention services. Understanding patient perspectives on factors contributing to relapse can inform the development of risk assessments and preventive interventions. The objective of this study was to identify factors that may contribute to and prevent relapse from the perspectives of patients receiving services for FEP. Data from 25 participants across four focus groups in Canada were analyzed with a descriptive content analysis approach. Twelve factors were identified, of which four (social environment, technology use, medication, and lifestyle behaviors) had both contributory and preventive roles. In descending order of frequency, risk factors for relapse included substance use; unsupportive social environment; technology use; taking and not taking medication; lack of sleep; work, career, or school stress; significant life events; symptoms of depression or mania; generalized worry; and financial stress. Preventive factors consisted of having a supportive social environment, using technology, taking medication, using coping strategies, and engaging in healthy lifestyle behaviors and meaningful activities. These findings extend the literature on relapse vulnerability and protective factors. Importantly, the factors identified in this study are modifiable, and thereby provide insights for the development and optimization of relapse risk assessments and preventive interventions.

Psychotic relapses from the perspective of patients and family members

This qualitative study was carried out with 10 dyads of patients-family members to explore their perception about psychotic relapses. Data were collected through a semi-structured interview from April to August 2019, in Brazil, and analyzed using the thematic analysis proposed by Braun & Clark. Four main themes emerged from the interviews: (1) defining and describing the psychotic relapses; (2) risk factors for psychotic relapse; (3) protective factors for psychotic relapse; and (4) early warning signs: identification of an episode of psychotic relapse. Exploring the perception of patients with psychotic disorders and their families about relapse is fundamental for the development of relapse risk assessment tools and to guide further research on this topic.

Prevalence and factors associated with relapse and long hospital stay among adult psychiatric patients with a history of childhood trauma

This cross-sectional multicentre-based study determined the magnitude of relapse, long hospital stay and factors of mental illness associated with a history of childhood trauma. We assessed 335 adult psychiatric patients and living in conflict areas, using a questionnaire established from items of the Adverse Childhood Experience International Questionnaire, Multidimensional Scale of Perceived Social Support, Rosenberg Self-esteem Questionnaire, Relapse Assessment Tool, and Self-report of hospital stay. Logistic regression analyses were used to determine associations between predictors and relapse and long hospital stay. 298 participants (88.9%) had experienced childhood adversities, among which 44.4% reported more than five childhood traumas. Relapse occurred in 40.9% of participants, whereas long hospital stay occurred in 71.1% of cases. Predictors of long hospital stay were emotional abuse, substance use and living in rural settings. Being an employed and experiencing a childhood trauma committed by a parent increase the likelihood risk of relapse of mental illness associated with childhood trauma. Being treated by childhood trauma-focused interventions decreases the risk of relapse and shorter the length of hospital stay. Building a mental health capacity should be centered on detecting patients with childhood trauma committed by the parent, those with low-self esteem, and victims of emotional abuse.

Hospitalizations in psychiatry during the month of Ramadan: A study at the Tunisian mental health hospital

BACKGROUND

Muslims fast each year during the Holy Month of Ramadan. This rite has major socio-cultural consequences. The circadian rhythms, energy expenditure, body temperature and biological clock are also influenced by Ramadan fasting. The impact of fasting on patients with mental disorders has been little studied. The aim of this study was to assess the number of hospitalizations in psychiatry during Ramadan compared to the other months of the lunar year.

METHOD

A cross-sectional and retrospective study was conducted at Razi hospital, the psychiatric hospital in Tunis. The following data over the five lunar years (1434-1438) was checked for: The monthly and the annual number of hospitalizations in the different departments of Razi mental health hospital in Tunis as well as the monthly and annual rates of different legal modalities of admissions.

RESULTS

An important decrease in the number of hospitalizations during Ramadan was observed each year followed by a constant increase during the following month.Ramadan was the only lunar month to have had a consistently below-average number of admissions. There has been a significant increase in the mean number of hospitalizations per month over the years. A general trend towards an increase in the proportion of enforced hospitalizations has been noted.

CONCLUSION

Ramadan stands out not only on a religious but also on a social level. Our results add support to the usefulness of research on mental health and Ramadan in the psychiatric community.

Prevalence and predictors of relapse among adolescent patients with mental illness in Butembo city (Eastern Part of the Democratic Republic of Congo)

This study aimed to determine the prevalence and predictors of relapse in adolescents with mental illness. To carry this cross-sectional study, we recruited participants from the patients who attended healthcare services at five mental healthcare units located in the eastern Democratic Republic of Congo. We enrolled patients aged between 10 and 17 years old, with a history of being readmitted at least once to a mental facility. Nearly one in 10 patients with mental illness is an adolescent, and seven in 10 adolescents with mental illness are readmissions. The majority of participants were males, aged 17 years old; lived in rural settings, were illiterate, and were single mothers/fathers. The predictors of relapse are low educational level, being a female or a single mother/father, having the age of 17 years, low self-esteem, perceived poor social support, living in rural areas, and the highly expression emotions. Being treated for bipolar and substance use disorder increases the risk of relapse in adolescents. Our results highlight the burden of mental illness in adolescents.

The prevention of relapses in first episodes of schizophrenia: The 2EPs Project, background, rationale and study design

Up to 80% of first-episode psychosis patients suffer a relapse within five years of the remission. Relapse should be an important focus of prevention given the potential harm to the patient and family. It threatens to disrupt their psychosocial recovery, increases the risk of resistance to treatment and has been associated with greater direct and indirect costs for society. Based on a previous project entitled "Genotype-phenotype and environment. Application to a predictive model in first psychotic episodes" (PEPs Project), the project "Clinical and neurobiological determinants of second episodes of schizophrenia. Longitudinal study of first episode of psychosis" was designed, also known as the 2EPs Project. It aimed to identify and characterize those factors that predict a relapse within the years immediately following a first episode. This project has focused on following the clinical course, with neuropsychological assessments, biological and neuroanatomical measures, genetic adherence and physical health monitoring in order to compare a subgroup of patients with a second episode to another group of patients which remains in remission. The main objective of the present article is to describe the rationale of the 2EPs Project, explaining the measurement approach adopted and providing an overview of the selected clinical and functional measures. 2EPs Project is a multicenter, coordinated, naturalistic, longitudinal follow-up study over three years in a Spanish sample of patients in remission after a first-psychotic episode of schizophrenia. It is closely monitoring the clinical course of the cases recruited to compare the subgroup of patients with a second episode to that which remains in remission. The sample is composed of 223 subjects recruited from 15 clinical centres in Spain with experience of the preceding PEPs Study project, albeit 2EPs being an expanded version with new basic groups in biological research. From the total sample recruited, 63 patients presented a relapse (44%). 2EPs arose to characterize first episodes in an exhaustive, novel and multimodal way, thus contributing towards the development of a predictive model of relapse. Identifying the characteristics of patients who relapse could improve early detection and intervention.

The prevention of relapses in first episodes of schizophrenia: The 2EPs Project, background, rationale and study design

Up to 80% of first-episode psychosis patients suffer a relapse within five years of the remission. Relapse should be an important focus of prevention given the potential harm to the patient and family. It threatens to disrupt their psychosocial recovery, increases the risk of resistance to treatment and has been associated with greater direct and indirect costs for society. Based on a previous project entitled "Genotype-phenotype and environment. Application to a predictive model in first psychotic episodes" (PEPs Project), the project "Clinical and neurobiological determinants of second episodes of schizophrenia. Longitudinal study of first episode of psychosis" was designed, also known as the 2EPs Project. It aimed to identify and characterize those factors that predict a relapse within the years immediately following a first episode. This project has focused on following the clinical course, with neuropsychological assessments, biological and neuroanatomical measures, genetic adherence and physical health monitoring in order to compare a subgroup of patients with a second episode to another group of patients which remains in remission. The main objective of the present article is to describe the rationale of the 2EPs Project, explaining the measurement approach adopted and providing an overview of the selected clinical and functional measures. 2EPs Project is a multicenter, coordinated, naturalistic, longitudinal follow-up study over three years in a Spanish sample of patients in remission after a first-psychotic episode of schizophrenia. It is closely monitoring the clinical course of the cases recruited to compare the subgroup of patients with a second episode to that which remains in remission. The sample is composed of 223 subjects recruited from 15 clinical centres in Spain with experience of the preceding PEPs Study project, albeit 2EPs being an expanded version with new basic groups in biological research. From the total sample recruited, 63 patients presented a relapse (44%). 2EPs arose to characterize first episodes in an exhaustive, novel and multimodal way, thus contributing towards the development of a predictive model of relapse. Identifying the characteristics of patients who relapse could improve early detection and intervention.

eHealth tools for assessing psychomotor activity in schizophrenia: a systematic review

Objective:

Psychomotor abnormalities are relevant symptoms in the clinical presentation of schizophrenia, and assessing them could facilitate monitoring. New technologies can measure psychomotor activity objectively and continuously, but evidence on the topic is scarce. Our aim is to systematically review the existing evidence about eHealth tools for assessing psychomotor activity in patients diagnosed with schizophrenia.

Method:

We performed a systematic search of the PubMed and Embase databases and identified 15 relevant articles on eHealth tools for assessing psychomotor activity in schizophrenia.

Results:

eHealth devices accurately assessed psychomotor activity and were well accepted. Abnormalities in psychomotor activity helped differentiate between different subtypes of schizophrenia. Abnormal increases in psychomotor activity were correlated with acute presentations, while lower activity was associated with relapses, deterioration, and negative symptoms.

Conclusion:

Actigraphy is still the preferred eHealth device in research settings, but mobile applications have great potential. Further studies are needed to explore the possibilities of psychomotor monitoring and mobile health applications for preventing relapses in schizophrenia. eHealth could be useful for monitoring psychomotor activity, which might help prevent relapses.

Can Cognitive Remediation in Groups Prevent Relapses?: Results of a 1-Year Follow-up Randomized Controlled Trial

International guidelines define relapse prevention for schizophrenia patients as a key therapeutic aim. However, approximately 80% to 90% of schizophrenia patients experience further symptom exacerbation after the first episode. The purpose of this study was to investigate whether group integrated neurocognitive therapy (INT), a cognitive remediation approach, reduces relapse rates in schizophrenia outpatients. INT was compared with treatment as usual (TAU) in a randomized controlled trial. Fifty-eight stabilized outpatients participated in the study with 32 allocated to the INT group and 26 to the TAU group. A test battery was used at baseline, posttreatment at 15 weeks, and a 1-year follow-up. Relapse rates were significantly lower in the INT condition compared with TAU during therapy as well as at follow-up. The relapse rate after therapy was associated with significant reductions in negative and general symptoms, improvements in functional outcome, and overall cognition. Out of these variables, negative symptoms were identified to show the strongest association with relapses after therapy. The primary outcome of this study suggests that INT can prevent relapses in schizophrenia outpatients.

Patterns of recovery course in early intervention for FIRST episode non-affective psychosis patients: The role of timing

BACKGROUND

Prevention of symptom relapse and promotion of functional recovery are the two main goals of early intervention following a first episode of non-affective psychosis (FEP). The identification of patterns of recovery is important in developing and implementing recovery focused interventions at set time interval.

METHOD

Patterns of recovery course, in terms of symptomatic and functional remission, were explored at 1 and 3-year follow-up in a sample of 373 consecutive FEP patients. Relapses during this period were considered.

RESULTS

Four patterns of recovery course were defined: good stable (26%), good unstable (21%), poor unstable (10%), poor stable (43%). Those who met criteria for good stable recovery were more likely have less severe baseline negative symptoms (OR = 2.092; 95% CI = 0.99-4.419) and to not be diagnosed with schizophrenia (OR = 2.242; 95% CI = 1.015-4.954). Short DUP (OR = 2.152; 95% CI = 0.879-5.27) and low premorbid IQ (OR = 2.281; 95% CI = 0.954-5.457) increased the likelihood of good unstable recovery. Less severe baseline negative symptoms (OR = 3.851; 95% CI = 1.422-10.435) and single status (OR = 4.307; 95% CI = 1.014-18.293) increased the likelihood of a poor unstable recovery. Poor unstable pattern was significantly associated with a high relapse rate (73%).

CONCLUSIONS

Our results shed light on identifying different recovery patterns in FEP. Despite evidence for early intervention effectiveness, we should explore ways to prevent relapse and improve long-term recovery, particularly in reference to the role of timing in the design of interventions.

"Worried about relapse": Family members' experiences and perspectives of relapse in first-episode psychosis

BACKGROUND

The purpose of this study was to gain an in-depth understanding on the subject of relapse from the perspectives of family members of young people receiving services for a first-episode psychosis (FEP).

METHODS

A qualitative descriptive approach, using focus group methods, was used to elicit experiences, understandings, and knowledge of relapse in FEP. Family members were recruited from 4 specialized early intervention programmes for psychosis in Canada. A total of 24 (6 male, 18 female) family members participated in the study. Thematic analysis was used to examine the data.

RESULTS

The core underlying theme in all focus groups was worrying about relapse, which was often accompanied by significant levels of fear and anxiety, and was influenced by: (1) impact of an episode of psychosis; (2) limited confidence in recognizing and coping with relapse; (3) unmet needs for coping skills and emotional support and (4) unmet needs regarding frequency and continuity of communication with clinicians.

CONCLUSIONS

Family members' unmet needs for relapse-focused education, support and communication with service providers and peers, can have a negative impact on relapse prevention. Addressing family members' education and support needs in a tailored manner (including preferences for types of peer support) can contribute positively to their confidence and ability to recognize and respond to relapse. This can help reduce fear and anxieties about relapse, and positively influence the ability to function as caregivers. Future research should focus on best approaches for providing education, sustained contact with the clinical team and family peer support.

Relapse prediction in schizophrenia through digital phenotyping: a pilot study

Among individuals diagnosed, hospitalized, and treated for schizophrenia, up to 40% of those discharged may relapse within 1 year even with appropriate treatment. Passively collected smartphone behavioral data present a scalable and at present underutilized opportunity to monitor patients in order to identify possible warning signs of relapse. Seventeen patients with schizophrenia in active treatment at a state mental health clinic in Boston used the Beiwe app on their personal smartphone for up to 3 months. By testing for changes in mobility patterns and social behavior over time as measured through smartphone use, we were able to identify statistically significant anomalies in patient behavior in the days prior to relapse. We found that the rate of behavioral anomalies detected in the 2 weeks prior to relapse was 71% higher than the rate of anomalies during other time periods. Our findings show how passive smartphone data, data collected in the background during regular phone use without active input from the subjects, can provide an unprecedented and detailed view into patient behavior outside the clinic. Real-time detection of behavioral anomalies could signal the need for an intervention before an escalation of symptoms and relapse occur, therefore reducing patient suffering and reducing the cost of care.

Early psychosis intervention outpatient service of the 1st Psychiatric University Clinic in Athens: 3 Years of experience

To present the 3-year experience of the early intervention in psychosis (EIP) service implementation of the 1st Psychiatric University Clinic in Athens. An overview of: (1) the purpose of our service, (2) the referral network, (3) the selection criteria, (4) the diagnostic procedures, (5) the therapeutic interventions and (6) the research activities. The service was established in 2012 and developed gradually aiming to provide information, early detection, treatment and support to people aged 15 to 40 years with psychotic manifestations, who are either at increased risk of developing psychosis (at-risk mental state [ARMS]) or with first episode psychosis (FEP). In order to assess individuals with ARMS, we used the comprehensive assessment of at-risk mental states interview and the Social and Occupational Functioning Assessment Scale The duration of untreated psychosis was estimated by using the Nottingham Onset Schedule. So far we have had 65 referrals, of which 26 were ARMS and 17 FEP. Based on the individual needs, they were offered psychotherapeutic and/or pharmacological treatment. After 3 years, the rate of transition to psychosis was 19.2% and the rate of psychosis relapse was 11.7%. The implementation of our service has had positive results, enabling young people with early psychosis to receive prompt and effective care. The rates of transition to psychosis are the first to be published from a Greek EIP service. Further development of our referral network and inter-hospital collaboration will allow us to address the needs of a wider part of the population.

Embracing Psychosis: A Cognitive Insight Intervention Improves Personal Narratives and Meaning-Making in Patients With Schizophrenia

Schizophrenia is a complex psychiatric disorder with unknown and presumably heterogeneous etiology. While the disorder can have various outcomes, research is predominantly "deficit-oriented" emphasizing the hardship that the disorder inflicts on sufferers as well as their families and society. Beyond symptom reduction, imparting patients with hope and meaning in life is increasingly considered an important treatment target, which may raise self-esteem, and reduce self-stigma and suicidal ideation. The present study compared a psychotherapeutic treatment aimed at improving cognitive insight, individualized metacognitive intervention (MCT+), with an active control in order to elucidate if personal meaning-making and hope can be improved in patients with psychosis across time. A total of 92 patients were randomized to either individualized metacognitive therapy (MCT+) or CogPack (neuropsychological training) and followed up for up to 6 months. The "Subjective Sense in Psychosis Questionnaire" (SUSE) was administered which covers different salutogenetic vs pathogenetic views of the disorder, valence of symptom experiences and the consequences of psychosis. Patients in the MCT+ group showed a significant positive shift in attitudes towards the consequences of their illness over time relative to patients in the active control condition. There was some evidence that MCT+ also enhanced meaning-making. The perceived negative consequences of psychosis were highly correlated with depression and low self-esteem, as well as suicidality. The study shows that a cognitive insight training can improve meaning-making in patients and help them come to terms with their diagnosis.