Which patients with non-affective functional psychosis are not admitted at first psychiatric contact?

Exploring the role of clinical and demographic characteristics on the effects of virtual reality cognitive behavioral therapy for psychosis: A moderator analysis

BACKGROUND

Virtual Reality cognitive behavioral therapy (VR-CBT) has proven to be an effective treatment method for paranoia and anxiety in psychosis. However, it is unknown, which individuals benefit most from VR-CBT. Previous studies examined factors affecting the treatment effect of regular CBTp, including illness duration, paranoia, depression, and pre-therapy avoidance behaviors, but results are inconsistent. The study aims to investigate the factors that influence the effectiveness of VR-CBT.

METHODS

A total of 95 participants with a psychotic disorder and at least moderate paranoia (GTPS >40) were included in this explorative study. Data were collected as part of a multicenter randomized controlled trial in which participants were assigned to VR-CBT or treatment as usual (TAU). The VR-CBT group received 16 sessions of individual treatment. A moderator analysis was conducted to examine the influence of baseline demographic (age, gender, and education level) and clinical characteristics (duration of illness, paranoia, anxiety, depression, safety behavior, self-esteem, and social functioning) on treatment effects of paranoia and anxiety as measured with questionnaires and the experience sampling method (ESM) directly after treatment (12 weeks after baseline).

RESULTS

More use of safety behavior at baseline resulted in greater benefits of VR-CBT on paranoid ideation and ESM paranoia. A higher age was associated with greater benefits of VR-CBT on social anxiety but not paranoia outcomes. There was no consistent evidence of moderation by any of the other sociodemographic or clinical variables for paranoid ideation and social anxiety.

CONCLUSIONS

Our findings suggest that a diverse spectrum of patients, with different backgrounds and symptom severity may be able to benefit from VR-CBT. VR-CBT can be recommended to a broad spectrum of patients with psychotic disorders, and particularly those with high levels of safety behaviors, including severe avoidance, seem to benefit more.

[Recent developments in the modeling and psychological management of persecutory ideation]

Persecutory ideas are a major clinical problem and are associated with impaired functioning, reduced compliance with medication and increased risk of hospitalization. Persecutory ideation is defined as the false conviction that others are threatening or conspiring against one. Although persecutory delusions are mainly described and experienced in schizophrenia spectrum disorders, they also occur in other neurological and psychiatric diagnoses including Alzheimer disease, epilepsy, depression, mania, dementia and post-traumatic stress disorder. Moreover, epidemiological data from general and clinical populations indicated that paranoid beliefs occur on a hierarchy of severity and are present to a lesser degree in the general population, with paranoid delusions representing the severe end of a continuum. In this review we focus on the important advances following a decade of research from psychological sciences, and more particularly the work of Daniel Freeman and Philippa Garety in England. Their work has demonstrated that a range of causal factors are involved in the development and maintenance of delusions beyond the traditional cognitive and behavioural models. Indeed, there is now well-validated evidence that sleep disturbances, worry proneness, reasoning biases, such as failure to consider alternative explanations or belief confirmation bias, abnormal experiences such as hallucinations, negative self-beliefs, and safety behaviours, are central factors that contribute to the paranoid phenomenon. In this review, we describe each of these causal factors in detail as well as the clinical interventions developed by Freeman and his collaborators, including the integrative and modular "Feeling Safe" intervention. Broadly speaking, the aim of this psychological intervention is for patients to relearn safety by exposing them to situations they consider as potentially dangerous after reduction of the influence of the maintenance factors described above. A recent publication showed that the Feeling Safe program led to recovery in persecutory delusions for 50% of patients having poor response to antipsychotic medication, making the intervention as the most effective psychological treatment for persecutory delusions. Finally, we will critically discuss the efficacy data from the numerous clinical studies validating its effectiveness. Prospects for the implementation of the Feeling Safe program in France also is discussed.

User-Centered Development of STOP (Successful Treatment for Paranoia): Material Development and Usability Testing for a Digital Therapeutic for Paranoia

BACKGROUND

Paranoia is a highly debilitating mental health condition. One novel intervention for paranoia is cognitive bias modification for paranoia (CBM-pa). CBM-pa comes from a class of interventions that focus on manipulating interpretation bias. Here, we aimed to develop and evaluate new therapy content for CBM-pa for later use in a self-administered digital therapeutic for paranoia called STOP ("Successful Treatment of Paranoia").

OBJECTIVE

This study aimed to (1) take a user-centered approach with input from living experts, clinicians, and academics to create and evaluate paranoia-relevant item content to be used in STOP and (2) engage with living experts and the design team from a digital health care solutions company to cocreate and pilot-test the STOP mobile app prototype.

METHODS

We invited 18 people with living or lived experiences of paranoia to create text exemplars of personal, everyday emotionally ambiguous scenarios that could provoke paranoid thoughts. Researchers then adapted 240 suitable exemplars into corresponding intervention items in the format commonly used for CBM training and created 240 control items for the purpose of testing STOP. Each item included newly developed, visually enriching graphics content to increase the engagement and realism of the basic text scenarios. All items were then evaluated for their paranoia severity and readability by living experts (n=8) and clinicians (n=7) and for their item length by the research team. Items were evenly distributed into six 40-item sessions based on these evaluations. Finalized items were presented in the STOP mobile app, which was co-designed with a digital health care solutions company, living or lived experts, and the academic team; user acceptance was evaluated across 2 pilot tests involving living or lived experts.

RESULTS

All materials reached predefined acceptable thresholds on all rating criteria: paranoia severity (intervention items: ≥1; control items: ≤1, readability: ≥3, and length of the scenarios), and there was no systematic difference between the intervention and control group materials overall or between individual sessions within each group. For item graphics, we also found no systematic differences in users' ratings of complexity (P=.68), attractiveness (P=.15), and interest (P=.14) between intervention and control group materials. User acceptance testing of the mobile app found that it is easy to use and navigate, interactive, and helpful.

CONCLUSIONS

Material development for any new digital therapeutic requires an iterative and rigorous process of testing involving multiple contributing groups. Appropriate user-centered development can create user-friendly mobile health apps, which may improve face validity and have a greater chance of being engaging and acceptable to the target end users.

Automated virtual reality cognitive therapy versus virtual reality mental relaxation therapy for the treatment of persistent persecutory delusions in patients with psychosis (THRIVE): a parallel-group, single-blind, randomised controlled trial in England with mediation analyses

BACKGROUND

Persecutory delusions are a major psychiatric problem that often do not respond sufficiently to standard pharmacological or psychological treatments. We developed a new brief automated virtual reality (VR) cognitive treatment that has the potential to be used easily in clinical services. We aimed to compare VR cognitive therapy with an alternative VR therapy (mental relaxation), with an emphasis on understanding potential mechanisms of action.

METHODS

THRIVE was a parallel-group, single-blind, randomised controlled trial across four UK National Health Service trusts in England. Participants were included if they were aged 16 years or older, had a persistent (at least 3 months) persecutory delusion held with at least 50% conviction, reported feeling threatened when outside with other people, and had a primary diagnosis from the referring clinical team of a non-affective psychotic disorder. We randomly assigned (1:1) patients to either THRIVE VR cognitive therapy or VR mental relaxation, using a permuted blocks algorithm with randomly varying block size, stratified by severity of delusion. Usual care continued for all participants. Each VR therapy was provided in four sessions over approximately 4 weeks, supported by an assistant psychologist or clinical psychologist. Trial assessors were masked to group allocation. Outcomes were assessed at 0, 2 (therapy mid-point), 4 (primary endpoint, end of treatment), 8, 16, and 24 weeks. The primary outcome was persecutory delusion conviction, assessed by the Psychotic Symptoms Rating Scale (PSYRATS; rated 0-100%). Outcome analyses were done in the intention-to-treat population. We assessed the treatment credibility and expectancy of the interventions and the two mechanisms (defence behaviours and safety beliefs) that the cognitive intervention was designed to target. This trial is prospectively registered with the ISRCTN registry, ISRCTN12497310.

FINDINGS

From Sept 21, 2018, to May 13, 2021 (with a pause due to COVID-19 pandemic restrictions from March 16, 2020, to Sept 14, 2020), we recruited 80 participants with persistent persecutory delusions (49 [61%] men, 31 [39%] women, with a mean age of 40 years [SD 13, range 18-73], 64 [80%] White, six [8%] Black, one [1%] Indian, three [4%] Pakistani, and six [8%] other race or ethnicity). We randomly assigned 39 (49%) participants assigned to VR cognitive therapy and 41 (51%) participants to VR mental relaxation. 33 (85%) participants who were assigned to VR cognitive therapy attended all four sessions, and 35 (85%) participants assigned to VR mental relaxation attended all four sessions. We found no significant differences between the two VR interventions in participant ratings of treatment credibility (adjusted mean difference -1·55 [95% CI -3·68 to 0·58]; p=0·15) and outcome expectancy (-0·91 [-3·42 to 1·61]; p=0·47). 77 (96%) participants provided follow-up data at the primary timepoint. Compared with VR mental relaxation, VR cognitive therapy did not lead to a greater improvement in persecutory delusions (adjusted mean difference -2·16 [-12·77 to 8·44]; p=0·69). Compared with VR mental relaxation, VR cognitive therapy did not lead to a greater reduction in use of defence behaviours (adjusted mean difference -0·71 [-4·21 to 2·79]; p=0·69) or a greater increase in belief in safety (-5·89 [-16·83 to 5·05]; p=0·29). There were 17 serious adverse events unrelated to the trial (ten events in seven participants in the VR cognitive therapy group and seven events in five participants in the VR mental relaxation group).

INTERPRETATION

The two VR interventions performed similarly, despite the fact that they had been designed to affect different mechanisms. Both interventions had high uptake rates and were associated with large improvements in persecutory delusions but it cannot be determined that the treatments accounted for the change. Immersive technologies hold promise for the treatment of severe mental health problems. However, their use will likely benefit from experimental research on the application of different therapeutic techniques and the effects on a range of potential mechanisms of action.

FUNDING

Medical Research Council Developmental Pathway Funding Scheme and National Institute for Health and Care Research Oxford Health Biomedical Research Centre.

A life more ordinary: A peer research method qualitative study of the Feeling Safe Programme for persecutory delusions

BACKGROUND

The Feeling Safe Programme is a cognitive therapy developed to improve outcomes for individuals with persecutory delusions. It is theoretically driven, modular and personalised, with differences in therapeutic style and content compared with first-generation cognitive behavioural therapy for psychosis.

OBJECTIVES

We set out to understand the participant experience of the Feeling Safe Programme.

DESIGN

A qualitative study employing interpretative phenomenological analysis.

METHODS

Using a peer research approach, semi-structured face-to-face interviews were conducted with six people who had received the Feeling Safe Programme as part of the outcome clinical trial.

RESULTS

Participants spoke of feeling 'unsafe' in their daily lives before the intervention. Openness to the intervention, facilitated by identification with the programme name, and willingness to take an active role were considered important participant attributes for successful outcomes. The therapist was viewed as a professional friend who cared about the individual, which enabled trust to form and the opportunity to consider new knowledge and alternative perspectives. Doing difficult tasks gradually and repeatedly to become comfortable with them was important for change to occur. The intervention helped people to do ordinary things that others take for granted and was perceived to produce lasting changes.

CONCLUSIONS

The Feeling Safe Programme was subjectively experienced very positively by interview participants, which is consistent with the results of the clinical trial. The successful interaction of the participant and therapist enabled trust to form, which meant that repeated practice of difficult tasks could lead to re-engagement with valued everyday activities.

Long-Term Outcomes of First-Admission Psychosis: A Naturalistic 21-Year Follow-Up Study of Symptomatic, Functional and Personal Recovery and Their Baseline Predictors

This study was aimed at characterizing long-term outcomes of first-admission psychosis and examining their baseline predictors. Participants were assessed at baseline for 38 candidate predictors and re-assessed after a median follow-up of 21 years for symptomatic, functional, and personal recovery. Associations between the predictors and the outcomes were examined using univariate and multivariate Cox regression models. At baseline, 623 subjects were assessed for eligibility, 510 met the inclusion/exclusion criteria and 243 were successfully followed-up (57.3% of the survivors). At follow-up, the percentages of subjects achieving symptomatic, functional, and personal recovery were 51.9%, 52.7%, and 51.9%, respectively; 74.2% met at least one recovery criterion and 32.5% met all three recovery criteria. Univariate analysis showed that outcomes were predicted by a broad range of variables, including sociodemographics, familial risk, early risk factors, premorbid functioning, triggering factors, illness-onset features, neurological abnormalities, deficit symptoms and early response to treatment. Many of the univariate predictors became nonsignificant when entered into a hierarchical multivariate model, indicating a substantial degree of interdependence. Each single outcome component was independently predicted by parental socioeconomic status, family history of schizophrenia spectrum disorders, early developmental delay, childhood adversity, and mild drug use. Spontaneous dyskinesia/parkinsonism, neurological soft signs and completion of high school remained specific predictors of symptomatic, functional, and personal outcomes, respectively. Predictors explained between 27.5% and 34.3% of the variance in the outcomes. In conclusion, our results indicate a strong potential for background and first-episode characteristics in predicting long-term outcomes of psychotic disorders, which may inform future intervention research.

Hebephrenia is dead, long live hebephrenia, or why Hecker and Chaslin were on to something

Since its first description in 1863, ‘hebephrenia’ has highlighted a group of patients characterised by an early onset of illness, formal thought disorder, bizarre behaviour and incongruent emotional expression. A proportion of patients with the most severe form of mental illness have a clinical presentation that is best captured by this diagnosis. Here, we outline the construct of hebephrenia and two of its core overlapping constituent parts: bizarre behaviour and the disorganisation dimension. We argue that, despite the removal of hebephrenia (disorganised schizophrenia) from DSM-5, clinicians should consider it as a differential diagnosis, particularly in suspected personality disorder.

Capturing behavioral indicators of persecutory ideation using mobile technology

Most existing measures of persecutory ideation (PI) rely on infrequent in-person visits, and this limits their ability to assess rapid changes or real-world functioning. Mobile health (mHealth) technology may address these limitations. Little is known about passively sensed behavioral indicators associated with PI. In the current study, sixty-two participants with schizophrenia spectrum disorders completed momentary assessments of PI on a smartphone that also passively collected behavioral data for one year. Results suggested that PI was prevalent (n = 50, 82% of sample) but had infrequent incidence (25.2% of EMA responses). PI was also associated with changes in several passively sensed variables, including decreases in distance traveled (M_kilometers = -1.20, SD = 18.88), time spent in a vehicle (M_minutes = -4.15, SD = 49.59), length of outgoing phone calls (M_minutes = -0.79, SD = 13.13), time spent proximal to human speech (M_minutes = -6.26, SD = 153.03), and an increase in time sitting still (M_minutes = 4.04, SD = 94.69). The present study suggests changes associated with PI may be detectable by passive sensors, including reductions in moving or traveling, and time spent around others or in self-initiated phone conversations. These constructs might constitute risk for PI.

Automated psychological therapy using virtual reality (VR) for patients with persecutory delusions: study protocol for a single-blind parallel-group randomised controlled trial (THRIVE)

Background

Persecutory delusions are a major psychiatric problem and are associated with a wide range of adverse outcomes. Our theoretical model views these delusions as unfounded threat beliefs which persist due to defence behaviours (e.g. avoidance) that prevent disconfirmatory evidence being processed. The treatment implications are that patients need to (1) go into feared situations and (2) not use defence behaviours. This enables relearning of safety and hence paranoia diminution. However, this is very difficult for patients due to their severe anxiety. A solution is to use virtual reality (VR) social situations, which are graded in difficulty and which patients find much easier to enter. We have now automated the provision of cognitive therapy within VR using an avatar coach, so that a therapist is not required and the treatment is scalable. In the THRIVE trial, the automated VR cognitive treatment will be tested against a VR control condition. It will contribute to our wider programme of work developing VR for patients with psychosis.

Methods

Patients with persistent persecutory delusions in the context of non-affective psychosis will be randomised (1:1) to the automated VR cognitive treatment or VR mental relaxation (control condition). Each VR treatment will comprise approximately four sessions of 30 min. Standard care will remain as usual in both groups. Assessments will be carried out at 0, 2, 4 (post treatment), 8, 16, and 24 weeks by a researcher blind to treatment allocation. The primary outcome is degree of conviction in the persecutory delusion (primary endpoint 4 weeks). Effect sizes will be re-established by an interim analysis of 30 patients. If the interim effect size suggests that the treatment is worth pursuing (d > 0.1), then the trial will go on to test 90 patients in total. Secondary outcomes include real world distress, activity levels, suicidal ideation, and quality of life. Mediation will also be tested. All main analyses will follow the intention-to-treat principle. The trial is funded by the Medical Research Council Developmental Pathway Funding Scheme.

Discussion

The trial will provide the first test of automated cognitive therapy within VR for patients with psychosis. The treatment is potentially highly scalable for treatment services.

Trial registration

ISRCTN, ISRCTN12497310. Registered on 14 August 2018.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3198-6) contains supplementary material, which is available to authorized users.

The paranoia as defence model of persecutory delusions: a systematic review and meta-analysis

BACKGROUND

An influential psychological model of persecutory delusions proposed that they are caused by a bias towards holding others responsible for negative events (an externalising attributional bias), preventing the individual from becoming aware of underlying low self-esteem. An early version of the model predicted self-esteem would, therefore, be preserved in people with these delusions, but a later version suggested it would be unstable, and that there would be a discrepancy between explicit and implicit self-esteem, with the latter being lower. We did a comprehensive meta-analytical test of the key predictions of this model and assessed the quality of evidence.

METHODS

We searched PubMed from Jan 1, 1994, to July 31, 2018, and collated systematic reviews of the defensive model's predictions in relation to persecutory delusions. We also searched PsycINFO, MEDLINE, Embase, and Web of Science for articles published from Jan 1, 2012, to Sept 10, 2016. Cross-sectional data from case-control, longitudinal, or experimental studies that examined self-esteem or the externalising attributional bias in individuals diagnosed as having schizophrenia-spectrum disorder were eligible for meta-analyses of group differences if at least 50% of participants with psychosis also had current persecutory delusions. Uncontrolled and longitudinal studies were included in meta-analyses of correlations and self-esteem instability, respectively. Study and outcome quality were assessed with the Agency for Healthcare Research and Quality assessment tool, and a modified version of Grading of Recommendations Assessment, Development and Evaluation, respectively. The study protocol is registered with PROSPERO, number CRD42016032782.

FINDINGS

We screened 3053 records, examined 104 full-text reports, and included 64 eligible studies. Consistent with the predictions of both versions of the model, paranoia severity in psychosis was positively correlated with the degree of externalising attributional bias (21 studies involving 1128 individuals; r=0·18, 95% CI 0·08 to 0·27, with moderate quality evidence). People with persecutory delusions also had a greater externalising attributional bias than non-clinical individuals (27 studies involving 1442 individuals; g=0·48, 95% CI 0·23 to 0·73) and depressed individuals (ten studies involving 421 individuals; g=1·06, 0·48 to 1·63), and people with psychosis without persecutory delusions (11 studies involving 480 individuals; g=0·40, 0·12 to 0·68), all based on moderate quality evidence. Contrary to the predictions in the early version of the model, paranoia severity in psychosis was negatively correlated with explicit self-esteem (23 studies involving 1866 individuals; r=-0·26, 95% CI -0·34 to -0·17, with high quality evidence). People with persecutory delusions also had lower explicit self-esteem than non-clinical individuals (22 studies involving 1256 individuals; g=-0·88, 95% CI -1·10 to -0·66, with high quality evidence) and explicit self-esteem similarly low to that in people with psychosis without persecutory delusions (11 studies involving 644 individuals; g=-0·26, -0·54 to 0·02, with moderate quality evidence). Consistent with the predictions in the later version of the model, self-esteem instability was positively correlated with paranoia severity in psychosis (four studies involving 508 individuals; r=0·23, 95% CI 0·11-0·34, with high quality evidence), and people with persecutory delusions had a greater discrepancy between their implicit and explicit self-esteem than depressed individuals (seven studies involving 398 individuals; g=0·61, 95% CI 0·37 to 0·85, with moderate quality evidence). They had higher explicit self-esteem than depressed individuals (13 studies involving 647 individuals; g=0·89, 95% CI 0·51 to 1·28, with moderate quality evidence), but similarly low implicit self-esteem (seven studies involving 398 individuals; g=-0·19, -0·45 to 0·07, with low quality evidence). In contrast to the later predictions, people with persecutory delusions did not have a greater self-esteem discrepancy than non-clinical individuals (ten studies involving 592 individuals; g=-0·17, 95% CI -0·45 to 0·12), although the evidence was very low quality. People with psychosis with or without persecutory delusions did not differ for implicit self-esteem (four studies involving 167 individuals; g=-0·24, 95% CI -0·77 to 0·30, with low quality evidence) or self-esteem discrepancies (four studies involving 165 individuals; g=0·17, -0·19 to 0·53, with moderate quality evidence).

INTERPRETATION

The predictions that self-esteem would be preserved in people with persecutory delusions in the early version of the paranoia as defence model and that implicit-explicit self-esteem discrepancy would be greater in people with persecutory delusions than in non-clinical individuals and people with psychosis without persecutory delusions in the later version of the model were not supported. By contrast, the later version correctly predicted that people with persecutory delusions have a greater self-esteem discrepancy than people with depression and a greater externalising attributional bias than all control groups, and that both this bias and self-esteem instability are associated with increased paranoia severity. Nevertheless, the reviewed data had limitations. Experimental studies, which might include interventionist-causal trials, are needed.

FUNDING

None.

Helping patients with paranoid and suspicious thoughts: a cognitive–behavioural approach

Paranoid and suspicious thoughts are a significant clinical topic. They regularly occur in 10–15% of the general population, and persecutory delusions are a frequent symptom of psychosis. In the past, patients were discouraged from talking about paranoid experiences. In contrast, it is now recommended that patients are given time to talk about them, and cognitive–behavioural techniques are being used to reduce distress. In this article we present the theoretical understanding of paranoia that underpins this transformation in the treatment of paranoid thoughts and summarise the therapeutic techniques derived. Emphasis is placed on the clinician approaching the problem from a perspective of understanding and making sense of paranoid experiences rather than simply challenging paranoid thoughts. Ways of overcoming difficulties in engaging people with paranoid thoughts are highlighted.

The traumatic experience of first-episode psychosis: A systematic review and meta-analysis

INTRODUCTION

A psychotic episode may be sufficiently traumatic to induce symptoms of post-traumatic stress disorder (PTSD), which could impact outcomes in first-episode psychosis (FEP). The objectives of this systematic review and meta-analysis were to estimate the prevalence of PTSD symptoms in relation to psychosis in FEP and to identify risk factors for the development of PTSD symptoms.

METHODS

We searched electronic databases and conducted manual searching of reference lists and tables of contents to identify relevant studies. Quantitative studies were included if the population was experiencing FEP and if PTSD was measured in relation to psychosis. Prevalence of PTSD symptoms and diagnoses were meta-analyzed using a random effects model. Potential risk factors for PTSD symptoms were summarized qualitatively.

RESULTS

Thirteen studies were included. Eight studies assessed PTSD symptoms, three studies assessed full PTSD, and two studies assessed both. The pooled prevalence of PTSD symptoms was 42% (95% CI 30%-55%), and the pooled prevalence of a PTSD diagnosis was 30% (95% CI 21%-40%). Exploratory subgroup analyses suggest that prevalence may be higher in affective psychosis and inpatient samples. Evidence from included studies implicate depression and anxiety as potential risk factors for PTSD symptoms.

CONCLUSIONS

Approximately one in two people experience PTSD symptoms and one in three experience full PTSD following a first psychotic episode. Evidence-based interventions to treat PTSD symptoms in the context of FEP are needed to address this burden and improve outcomes after the first psychotic episode. Further studies are needed to clarify the associated risk factors.

Cognitive Bias Modification for paranoia (CBM-pa): study protocol for a randomised controlled trial

BACKGROUND

Persecutory delusions are the most common type of delusions in psychosis and present in around 10-15% of the general population. Persecutory delusions are thought to be sustained by biased cognitive and emotional processes. Recent advances favour targeted interventions, focussing on specific symptoms or mechanisms. Our aim is to test the clinical feasibility of a novel psychological intervention, which manipulates biased interpretations toward more adaptive processing, in order to reduce paranoia in patients.

METHODS

The 'Cognitive Bias Modification for paranoia' (CBM-pa) study is a feasibility, double-blind, randomised controlled trial (RCT) for 60 stabilised outpatients with persistent, distressing paranoid symptoms. Patients will be randomised at a 50:50 ratio, to computerised CBM-pa or a text-reading control intervention, receiving one 40-min session per week, for 6 weeks. CBM-pa involves participants reading stories on a computer screen, completing missing words and answering questions about each story in a way that encourages more helpful beliefs about themselves and others. Treatment as Usual will continue for patients in both groups. Patients will be assessed by a researcher blind to allocation, at baseline, each interim session, post treatment and 1- and 3-month follow-up post treatment. The primary outcome is the feasibility parameters (trial design, recruitment rate and acceptability) of the intervention. The secondary outcomes are clinical symptoms (including severity of paranoia) as assessed by a clinical psychologist, and 'on-line' measurement of interpretation bias and stress/distress. The trial is funded by the NHS National Institute for Health Research.

DISCUSSION

This pilot study will test whether CBM-pa has the potential to be a cost-effective, accessible and flexible treatment. If the trial proves feasible and demonstrates preliminary evidence of efficacy, a fully powered RCT will be warranted.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN: 90749868 . Retrospectively registered on 12 May 2016.

Factors Associated with Timely Physician Follow-up after a First Diagnosis of Psychotic Disorder

OBJECTIVE

Physician follow-up after a first diagnosis of psychotic disorder is crucial for improving treatment engagement. We examined the factors associated with physician follow-up within 30 days of a first diagnosis of schizophrenia.

METHOD

We conducted a retrospective cohort study using linked health administrative data to identify incident cases of schizophrenia between 1999 and 2008 among people aged 14 to 35 years in Ontario. We estimated the proportion of patients who had physician follow-up within 30 days of the index diagnosis. We used multilevel logistic regression models to examine the factors associated with any physician follow-up and follow-up by a psychiatrist.

RESULTS

We identified 20,096 people with a first diagnosis of schizophrenia. Approximately 40% of people did not receive any physician follow-up within 30 days, and nearly 60% did not receive follow-up by a psychiatrist. Males had lower odds of receiving any physician follow-up, and the odds of psychiatrist follow-up decreased with increasing age and were lower for those living in rural areas. Both prior contact with a general practitioner for a mental health reason and prior contact with a psychiatrist were strongly associated with higher odds of receiving both types of follow-up.

CONCLUSIONS

Many people do not have any physician contact within 30 days of the first diagnosis of schizophrenia, and patients without prior engagement with mental health services are at highest risk. We need information on the reasons behind this lack of physician follow-up to inform strategies aimed at improving engagement with services during the early stages of psychosis.

Persecutory delusions: a cognitive perspective on understanding and treatment

A spectrum of severity of paranoia (unfounded thoughts that others are deliberately intending to cause harm) exists within the general population. This is unsurprising: deciding whether to trust or mistrust is a vital aspect of human cognition, but accurate judgment of others' intentions is challenging. The severest form of paranoia is persecutory delusions, when the ideas are held with strong conviction. This paper presents a distillation of a cognitive approach that is being translated into treatment for this major psychiatric problem. Persecutory delusions are viewed as threat beliefs, developed in the context of genetic and environmental risk, and maintained by several psychological processes including excessive worry, low self-confidence, intolerance of anxious affect and other internal anomalous experiences, reasoning biases, and the use of safety-seeking strategies. The clinical implication is that safety has to be relearned, by entering feared situations after reduction of the influence of the maintenance factors. An exciting area of development will be a clinical intervention science of how best to enhance learning of safety to counteract paranoia.

Targeting Recovery in Persistent Persecutory Delusions: A Proof of Principle Study of a New Translational Psychological Treatment (the Feeling Safe Programme)

Background: Many patients do not respond adequately to current pharmacological or psychological treatments for psychosis. Persistent persecutory delusions are common in clinical services, and cause considerable patient distress and impairment. Our aim has been to build a new translational personalized treatment, with the potential for wide use, that leads to high rates of recovery in persistent persecutory delusions. We have been developing, and evaluating individually, brief modular interventions, each targeting a key causal factor identified from our cognitive model. These modules are now combined in “The Feeling Safe Programme”. Aims: To test the feasibility of a new translational modular treatment for persistent persecutory delusions and provide initial efficacy data. Method: 12 patients with persistent persecutory delusions in the context of non-affective psychosis were offered the 6-month Feeling Safe Programme. After assessment, patients chose from a personalized menu of treatment options. Four weekly baseline assessments were carried out, followed by monthly assessments. Recovery in the delusion was defined as conviction falling below 50% (greater doubt than certainty). Results: 11 patients completed the intervention. One patient withdrew before the first monthly assessment due to physical health problems. An average of 20 sessions (SD = 4.4) were received. Posttreatment, 7 out of 11 (64%) patients had recovery in their persistent delusions. Satisfaction ratings were high. Conclusions: The Feeling Safe Programme is feasible to use and was associated with large clinical benefits. To our knowledge this is the first treatment report focused on delusion recovery. The treatment will be tested in a randomized controlled trial.

The efficacy of a new translational treatment for persecutory delusions: study protocol for a randomised controlled trial (The Feeling Safe Study)

Background

Persecutory delusions (strong unfounded fears that others intend harm to the person) occur in more than 70 % of the patients diagnosed with schizophrenia. This major psychotic experience is a key clinical target, for which substantial improvement in treatment is needed. Our aim is to use advances in theoretical understanding to develop a much more efficacious treatment that leads to recovery in at least 50 % of people with persistent persecutory delusions. Our cognitive conceptualisation is that persecutory delusions are threat beliefs, developed in the context of genetic and environmental risk, maintained by a number of psychological processes including excessive worry, low self-confidence, intolerance of anxious affect and other internal anomalous experiences, reasoning biases, and safety-seeking strategies. The clinical implication is that safety has to be relearned, by entering the feared situations after reduction of the influence of the maintenance factors. We have been individually evaluating modules targeting causal factors. These will now be tested together as a full treatment, called The Feeling Safe Programme. The treatment is modular, personalised, and includes patient preference. We will test whether the new treatment leads to greater recovery in persistent persecutory delusions, psychological well-being, and activity levels compared to befriending (that is, controlling for therapist attention).

Methods/design

The Feeling Safe Study is a parallel group randomised controlled trial for 150 patients who have persecutory delusions despite previous treatment in mental health services. Patients will be randomised (1:1 ratio) to The Feeling Safe Programme or befriending (both provided in 20 sessions over 6 months). Standard care will continue as usual. Online randomisation will use a permuted blocks algorithm, with randomly varying block size, stratified by therapist. Assessments, by a rater blind to allocation, will be conducted at 0, 6 (post treatment), and 12 months. The primary outcome is the level of delusional conviction at 6 months. Secondary outcomes include levels of psychological well-being, suicidal ideation, and activity. All main analyses will be intention-to-treat. The trial is funded by the NHS National Institute for Health Research.

Discussion

The Feeling Safe study will provide a Phase II evaluation of a new targeted translational psychological treatment for persecutory delusions.

Trial registration

Current Controlled Trials ISRCTN18705064 (registered 11 November 2015).

The use of intuitive and analytic reasoning styles by patients with persecutory delusions

BACKGROUND AND OBJECTIVES

A previous study has shown an association of paranoid thinking with a reliance on rapid intuitive ('experiential') reasoning and less use of slower effortful analytic ('rational') reasoning. The objectives of the new study were to replicate the test of paranoia and reasoning styles in a large general population sample and to assess the use of these reasoning styles in patients with persecutory delusions.

METHOD

30 Patients with persecutory delusions in the context of a non-affective psychotic disorder and 1000 non-clinical individuals completed self-report assessments of paranoia and reasoning styles.

RESULTS

The patients with delusions reported lower levels of both experiential and analytic reasoning than the non-clinical individuals (effect sizes small to moderate). Both self-rated ability and engagement with the reasoning styles were lower in the clinical group. Within the non-clinical group, greater levels of paranoia were associated with lower levels of analytic reasoning, but there was no association with experiential reasoning.

LIMITATIONS

The study is cross-sectional and cannot determine whether the reasoning styles contribute to the occurrence of paranoia. It also cannot be determined whether the patient group's lower reasoning scores are specifically associated with the delusions.

CONCLUSIONS

Clinical paranoia is associated with less reported use of analytic and experiential reasoning. This may reflect patients with current delusions being unconfident in their reasoning abilities or less aware of decision-making processes and hence less able to re-evaluate fearful cognitions. The dual process theory of reasoning may provide a helpful framework in which to discuss with patients decision-making styles.

Altered medial prefrontal activity during dynamic face processing in schizophrenia spectrum patients

BACKGROUND

Processing the emotional content of faces is recognised as a key deficit of schizophrenia, associated with poorer functional outcomes and possibly contributing to the severity of clinical symptoms such as paranoia. At the neural level, fMRI studies have reported altered limbic activity in response to facial stimuli. However, previous studies may be limited by the use of cognitively demanding tasks and static facial stimuli. To address these issues, the current study used a face processing task involving both passive face viewing and dynamic social stimuli. Such a task may (1) lack the potentially confounding effects of high cognitive demands and (2) show higher ecological validity.

METHODS

Functional MRI was used to examine neural activity in 25 patients with a DSM-IV diagnosis of schizophrenia/schizoaffective disorder and 21 age- and gender-matched healthy controls while they participated in a face processing task, which involved viewing videos of angry and neutral facial expressions, and a non-biological baseline condition.

RESULTS

While viewing faces, patients showed significantly weaker deactivation of the medial prefrontal cortex, including the anterior cingulate, and decreased activation in the left cerebellum, compared to controls. Patients also showed weaker medial prefrontal deactivation while viewing the angry faces relative to baseline.

DISCUSSION

Given that the anterior cingulate plays a role in processing negative emotion, weaker deactivation of this region in patients while viewing faces may contribute to an increased perception of social threat. Future studies examining the neurobiology of social cognition in schizophrenia using fMRI may help establish targets for treatment interventions.

Persecutory delusions and psychological well-being

PURPOSE

Persecutory delusions are one of the key problems seen in psychotic conditions. The aim of the study was to assess for the first time the levels of psychological well-being specifically in patients with current persecutory delusions.

METHOD

One hundred and fifty patients with persecutory delusions in the context of a diagnosis of non-affective psychosis, and 346 non-clinical individuals, completed the Warwick-Edinburgh Mental Well-Being Scale and symptom assessments.

RESULTS

Well-being scores were much lower in the persecutory delusions group compared with the non-clinical control group. 47 % of the persecutory delusions group scored lower than two standard deviations below the control group mean score. Within the patient group, psychological well-being was negatively associated with depression, anxiety, and hallucinations. In both groups, lower levels of well-being were associated with more severe paranoia.

CONCLUSIONS

Levels of psychological well-being in patients with current persecutory delusions are strikingly low. This is likely to arise from the presence of affective symptoms and psychotic experiences. Measurement of treatment change in positive mental health for patients with psychosis is recommended.

Are lay people good at recognising the symptoms of schizophrenia?

AIM

The aim of this study was to explore the general public's perception of schizophrenia symptoms and the need to seek-help for symptoms. The recognition (or 'labelling') of schizophrenia symptoms, help-seeking behaviours and public awareness of schizophrenia have been suggested as potentially important factors relating to untreated psychosis.

METHOD

Participants were asked to rate to what extent they believe vignettes describing classic symptoms (positive and negative) of schizophrenia indicate mental illness. They were also asked if the individuals depicted in the vignettes required help or treatment and asked to suggest what kind of help or treatment.

RESULTS

Only three positive symptoms (i.e., Hallucinatory behaviour, Unusual thought content and Suspiciousness) of schizophrenia were reasonably well perceived (above 70%) as indicating mental illness more than the other positive or negative symptoms. Even when the participants recognised that the symptoms indicated mental illness, not everyone recommended professional help.

CONCLUSION

There may be a need to improve public awareness of schizophrenia and psychosis symptoms, particularly regarding an awareness of the importance of early intervention for psychosis.

The effects of reducing worry in patients with persecutory delusions: study protocol for a randomized controlled trial

Background

Our approach to advancing the treatment of psychosis is to focus on key single symptoms and develop interventions that target the mechanisms that maintain them. In our theoretical research we have found worry to be an important factor in the development and maintenance of persecutory delusions. Worry brings implausible ideas to mind, keeps them there, and makes the experience distressing. Therefore the aim of the trial is to test the clinical efficacy of a cognitive-behavioral intervention for worry for patients with persecutory delusions and determine how the worry treatment might reduce delusions.

Methods/Design

An explanatory randomized controlled trial - called the Worry Intervention Trial (WIT) - with 150 patients with persecutory delusions will be carried out. Patients will be randomized to the worry intervention in addition to standard care or to standard care. Randomization will be carried out independently, assessments carried out single-blind, and therapy competence and adherence monitored. The study population will be individuals with persecutory delusions and worry in the context of a schizophrenia spectrum diagnosis. They will not have responded adequately to previous treatment. The intervention is a six-session cognitive-behavioral treatment provided over eight weeks. The control condition will be treatment as usual, which is typically antipsychotic medication and regular appointments. The principal hypotheses are that a worry intervention will reduce levels of worry and that it will also reduce the persecutory delusions. Assessments will be carried out at 0 weeks (baseline), 8 weeks (post treatment) and 24 weeks (follow-up). The statistical analysis strategy will follow the intention-to-treat principle and involve the use of linear mixed models to evaluate and estimate the relevant between- and within-subjects effects (allowing for the possibility of missing data). Both traditional regression and newer instrumental variables analyses will examine mediation. The trial is funded by the UK Medical Research Council (MRC)/NHS National Institute of Health Research (NIHR) Efficacy and Mechanism Evaluation (EME) Programme.

Discussion

This will be the first large randomized controlled trial specifically focused upon persecutory delusions. The project will produce a brief, easily administered intervention that can be readily used in mental health services.

Trial registration

Current Controlled Trials ISRCTN23197625

Sex steroids and schizophrenia

The peak in incidence for schizophrenia is during late adolescence for both sexes, but within this time frame the peak is both earlier and steeper for males. Additionally, women have a second peak in incidence following menopause. Two meta-analyses have reported that men have an overall ∼40% greater chance of developing schizophrenia than do women (Aleman et al., 2003; McGrath et al., 2004). These and other findings have led to the suggestion that ovarian hormones may be protective against schizophrenia. Less explored is the potential role of testosterone in schizophrenia, although disruptions in steroid levels have also been reported in men with the illness. The relationship between increased gonadal hormone release per se and peri-adolescent vulnerability for psychiatric illness is difficult to tease apart from other potentially contributory factors in clinical studies, as adolescence is a turbulent period characterized by many social and biological changes. Despite the obvious opportunity provided by animal research, surprisingly little basic science effort has been devoted to this important issue. On the other hand, the animal work offers an understanding of the many ways in which gonadal steroids exert a powerful impact on the brain, both shaping its development and modifying its function during adulthood. Recently, investigators using preclinical models have described a greater male vulnerability to neurodevelopmental insults that are associated with schizophrenia; such studies may provide clinically relevant insights into the role of gonadal steroids in psychiatric illness.

Examining a cognitive model of persecutory ideation in the daily life of people with schizophrenia: a computerized experience sampling study

Contemporary theoretical models of paranoia suggest that negative emotions, perceptual anomalies, and recent life events are important predictors of experiencing persecutory ideation. In the current experience sampling study, these factors are examined prospectively for the first time as predictors of the occurrence of persecutory ideation, as well as persecutory belief conviction, and associated distress in real time in the context of daily life. One hundred and forty five community-dwelling participants with schizophrenia or schizoaffective disorder completed self-report assessments generated by a personal digital assistant multiple times a day for 1 week. Their responses were time lagged to allow examination of dynamic prospective relationships between variables as they occur within days. Approximately half of the participants reported having some persecutory thoughts, with a total of 378 reported occurrences of persecutory thoughts across participants during the week. Negative emotional states of anxiety and sadness were significant predictors of the occurrence of subsequent persecutory ideation, but hallucinations and recent life events were not. In a subsample of people who had multiple persecutory thoughts, anxiety was a significant predictor of belief conviction and associated distress, while sadness was only predictive of distress. The findings are consistent with recent cognitive theory that proposes a causal role for negative emotional states in the formation and maintenance of persecutory ideation and suggest that persecutory ideation may be addressed indirectly by interventions targeting anxiety and depression.

First-ever admitted psychiatric inpatients in Italy: clinical characteristics and reasons contributing to admission: findings from a national survey

The aim of this study was to describe the sociodemographic, clinical and treatment-related characteristics of patients admitted to any acute psychiatric inpatient facilities in Italy for the first time in their life, and to identify reasons contributing to admission. Data from the PROGRES-Acute Project, a national survey on facilities admitting acute psychiatric patients in Italy, were used. A cluster analysis was carried out in order to identify patients' groups sharing similar sociodemographic and clinical characteristics. Among patients admitted during the index period, 337 were at their first-ever admission. Median age at admission was 40, and about 46% of patients were not receiving any treatment in the month prior to admission. Social/work functioning problems, social withdrawal and conflict with family members were the most common reasons contributing to admission. Cluster analysis yielded four patient groups: two groups of younger subjects, differentiating each other for frequency of antisocial behaviors, compulsory admissions, treatment at time of admission and family support; two groups of older subjects, with high rates of affective disorders, who showed remarkable differences with regard to their living situation and family support. Our study shows that first-ever admitted patients represent a highly heterogeneous group. Early intervention research should take this sociodemographic and clinical diversity into account, in order to better allocate resources and develop special intervention programs.

Thought suppression and persecutory delusion-like beliefs in a nonclinical sample

INTRODUCTION

Thought suppression may play a role in the formation and/or maintenance of persecutory delusions, although this possibility has not yet been empirically studied. We investigated thought suppression levels in relation to the presence of persecutory delusion-like beliefs (PDLBs), and hypothesised that only when levels of anxiety or negative affect were high would thought suppression predict levels of PDLBs.

METHOD

Thought suppression, anxiety, negative affect, social desirability, and persecutory ideation were assessed in a nonclinical sample (N=183) using online questionnaires.

RESULTS

When gender, anxiety, and negative affect were controlled, the interaction between thought suppression and anxiety predicted levels of PDLBs. Further analysis of this interaction showed that thought suppression was positively associated with PDLBs only when anxiety was high. Neither thought suppression by itself, nor the two-way interaction between negative affect and thought suppression, nor the three-way interaction between negative affect, anxiety, and thought suppression, were predictors of PDLB levels.

CONCLUSION

The results are consistent with a proposed interaction between thought suppression and anxiety in the development of PDLBs. Possible causal mechanisms underlying this relation are considered further, future research in the area proposed, and potential clinical implications examined.

Premorbid intra-individual variability in intellectual performance and risk for schizophrenia: a population-based study

BACKGROUND

Some, but not most, schizophrenia patients have below-average intelligence years before they manifest psychosis. However, it is not clear if those whose intelligence falls within-normal-range nevertheless have cognitive abnormalities. We examined the association between intra-individual variability in intellectual performance and risk for schizophrenia in individuals with normal IQ.

METHODS

555,326 adolescents, mandatory assessed by the Israeli Draft Board were followed up over 8 to 17 years for psychiatric hospitalization by means of the Israeli National Psychiatric Hospitalization Case Registry. Data were available on 4 intelligence sub-tests, and on behavioral and psychosocial variables. Variability was computed from the variance of the four intelligence tests' standardized scores.

RESULTS

There was a significant monotonic association between increased intra-individual variability in intellectual performance and risk of schizophrenia in individuals with within-normal-range IQ. Individuals with the highest variability were 3.8 times more likely to have schizophrenia [95%CI: 2.32-6.08; p < 0.0001] compared with individuals with the lowest variability. This association held after controlling for the effects of potential confounders.

CONCLUSIONS

Despite within-normal-range premorbid IQ, apparently healthy adolescents who will later on manifest schizophrenia, nevertheless have cognitive abnormalities such as increased variability across intellectual tasks, possibly related to frontal lobe abnormalities.

Pattern and correlates of inpatient admission during the initial acute phase of first-episode psychosis

OBJECTIVES

The first aim of this study was to examine the rate, pattern and correlates of inpatient admission during the first 3 months of treatment for first-episode psychosis (FEP). The second aim was to determine whether the pattern of inpatient admission during this period was associated with remission of psychotic symptoms or inpatient service use at 15-month follow-up.

METHOD

One hundred and four consecutive patients with FEP at a specialist treatment service were approached to participate in a follow-up study. Patients were grouped on the basis of the pattern of inpatient admission (none, one, or multiple) during the first 3 months of treatment. Clinical ratings at baseline and 3-month follow-up, and ratings of remission of psychotic symptoms at 3 and 15-month follow-up, were available for two-thirds of the patients. Inpatient data for the 15-month follow-up period were derived from an electronic database for most patients (n = 98).

RESULTS

Eighty (76.9%) of the 104 patients were admitted to an inpatient unit during the first 3 months of treatment. Fifty-nine (56.7%) patients had a single admission and 21 (20.2%) had multiple admissions. At baseline, inpatient admission was associated with a diagnosis of affective psychosis and more severe behavioural and functional disturbance but not positive psychotic symptoms. Multiple admissions were associated with risks to self or others at baseline and 3-month follow-up, and lack of remission of positive symptoms at 3 and 15-month follow-up. There was no association between the pattern of inpatient admission during the initial 3-month period and inpatient service use during the following 12-month period.

CONCLUSIONS

The substantial proportion of young patients with FEP admitted to hospital emphasizes the need for youth-friendly treatment environments and practices. Although patients with multiple admissions during the initial treatment period are less likely to achieve remission, these patients are no more likely to establish a pattern of revolving-door hospitalizations compared with other patients.

Hospital comorbidity bias and the concept of schizophrenia

BACKGROUND

The comorbidity bias predicts that if disease definition is based on observations of patients in the hospital, spurious comorbidity of psychopathological dimensions that increase the probability of hospital admission will be included in the disease concept, whereas comorbid dimensions that are not associated with admission will be excluded. The direction of any dimensional comorbidity bias in psychotic illness was assessed in a longitudinal analysis of the psychopathology of patients assessed both inside and outside the hospital.

METHOD

Four hundred and eighty patients with broadly defined psychotic disorders were assessed between one and nine times (median two times) over a 5-year period with, amongst others, the Brief Psychiatric Rating Scale. Dimensional comorbidities between positive symptoms, negative symptoms, depression/anxiety, and manic excitement were compared, in addition to their associations with current and future admission status.

RESULTS

Higher levels of psychopathology in all symptom domains were associated with both current and future hospital admissions. Associations between the positive, negative, and manic symptom domains were higher for patients in the hospital than for patients outside the hospital, in particular, between positive symptoms and manic excitement (beta=0.28, p<0.001). However, associations between depression and other symptom domains were higher in out-patients as compared to in-patients (positive symptoms and depression, beta=-0.26; p<0.002).

CONCLUSION

The current analyses suggest that, to the extent that disease concepts of psychosis do not take into account effects of dimensional comorbidity biases occasioned by differential psychopathology according to treatment setting, "florid" psychotic psychopathology may be overrepresented, whereas depressive symptoms may be spuriously excluded.

Violence, self-harm, victimisation and homelessness in patients admitted to an acute inpatient unit in South Australia

OBJECTIVES

To measure the incidence of traumatic and potentially socially disruptive events prior to admission to a psychiatric hospital.

METHOD

One hundred and nineteen patients were interviewed and further information was obtained from case notes. Data were collected concerning rates of violence, self-harm, threats of violence or self-harm, physical assault and homelessness.

RESULTS

The patients' mean age was 35 years, 70% were male and 77% were currently single. More than half were legally detained. The most common diagnoses were substance abuse disorders, schizophrenia and related psychoses and mood disorders. Eighteen per cent of patients were physically violent at the time of admission. They were more likely to have a diagnosis of substance abuse. Significantly more men (30%) than women (8%) made threats of violence. Eighteen per cent of patients had physically harmed themselves. Significantly more women (70%) than men (40%) had threatened to harm themselves. Eight per cent of patients had been physically assaulted prior to admission. Twenty-seven per cent of patients were homeless.

CONCLUSION

These patients were severely disabled with high rates of comorbidity. Socially disruptive behaviours were common, and almost a quarter of the patients were homeless. This study highlights the need for development of targeted services in the community.

Ethnic variations in pathways to and use of specialist mental health services in the UK. Systematic review

BACKGROUND

Inequalities of service use across ethnic groups are important to policy makers, service providers and service users.

AIMS

To identify ethnic variations in pathways to specialist mental health care, continuity of contact, voluntary and compulsory psychiatric in-patient admissions; to assess the methodological strength of the findings.

METHOD

A systematic review of all quantitative studies comparing use of mental health services by more than one ethnic group in the UK. Narrative analysis supplemented by meta-analysis, where appropriate.

RESULTS

Most studies compared Black and White patients, finding higher rates of in-patient admission among Black patients. The pooled odds ratio for compulsory admission, Black patients compared with White patients, was 4.31 (95% CI 3.33-5.58). Black patients had more complex pathways to specialist care, with some evidence of ethnic variations in primary care assessments.

CONCLUSIONS

There is strong evidence of variation between ethnic groups for voluntary and compulsory admissions, and some evidence of variation in pathways to specialist care.

Patterns and predictors of hospitalisation in first-episode psychosis. Prospective cohort study

BACKGROUND

Little is known about predictors of hospitalisation in patients with first-episode psychosis.

AIMS

To identify the pattern and predictors of hospitalisation of patients with a first psychotic episode making their first contact with specialist services.

METHOD

Three-year follow-up of a cohort of 166 patients with a first episode of psychosis making contact with psychiatric services in Nottingham between June 1992 and May 1994.

RESULTS

Eighty-eight (53.0%) patients were admitted within 1 week of presentation; 32 (19.3%) were never admitted during the 3 years of follow-up. Manic symptoms at presentation were associated with an increased risk of rapid admission and an increased overall risk of admission; negative symptoms and a longer duration of untreated illness had an increased risk of late admission.

CONCLUSIONS

Community-oriented psychiatric services might only delay, rather than prevent, admission of patients with predominantly negative symptoms and a longer duration of untreated illness. First-episode studies based upon first admissions are likely to be subject to selection biases, which may limit their representativeness.

Three-year outcome of first-episode psychoses in an established community psychiatric service

BACKGROUND

Changes in service provision, secular trends in substance misuse and changing social structures might affect outcome in psychosis.

AIMS

To assess the three-year outcome of an inception cohort of first-episode psychoses treated in a modern, community-oriented service; to compare outcomes with an earlier cohort treated in hospital-based care; and to examine the predictive validity of ICD-10 diagnostic criteria.

METHOD

Three-year follow-up (1995-1997) of an inception cohort of first-episode psychoses and comparison with two-year follow-up (1980-1982) of the Determinants of Outcome of Severe Mental Disorders (DOSMED) Nottingham cohort.

RESULTS

On most outcome measures, non-affective psychoses had a worse outcome than affective psychoses. Affective psychoses had better outcome than previously reported. Substance-related psychoses had very poor occupational outcome. Similar proportions of the current and DOSMED cohort were in remission but the former were rated as having greater disability.

CONCLUSIONS

In a modern community service, 30-60% of patients with first-episode psychoses experience a good three-year outcome. The ICD-10 criteria have good predictive validity.

Behavioral and intellectual markers for schizophrenia in apparently healthy male adolescents

OBJECTIVE

Subtle behavioral and intellectual abnormalities are often present in apparently healthy adolescents who later develop schizophrenia. The authors investigated whether these abnormalities can predict vulnerability for schizophrenia before the first psychotic manifestation.

METHOD

The study consisted of linking the Israeli Draft Board Registry with the National Psychiatric Hospitalization Case Registry. The draft board tests measure intelligence, social functioning, organizational ability, interest in physical activity, and individual autonomy. Patients (N = 509) were compared to nonpatients, i.e., adolescents not appearing in the National Psychiatric Registry (N = 9,215), matched to patients by age, gender, and school attended at time of testing.

RESULTS

Healthy male adolescents who were later hospitalized for schizophrenia had significantly lower test scores on all measures than adolescents not reported to the National Psychiatric Registry. The strongest predictors for schizophrenia were deficits in social functioning, organizational ability, and intellectual functioning. When patients were compared to matched nonpatients, the prediction model had a 75% sensitivity, a 100% specificity, a positive predictive value of 72%, and an overall rate of correct classification of 87.5%. Applied to the Israeli Draft Board Registry, the model yielded a sensitivity of 74.7%, a validated specificity of 99.7%, and a positive predictive value of 42.7%.

CONCLUSIONS

This study demonstrated that simple assessment tools can predict predisposition to schizophrenia in healthy male adolescents. The model's predictive ability does not change as a function of the time elapsed between testing and first hospitalization. This suggests that the model identifies apparently healthy individuals who will manifest the disease later who are not prodromal to psychosis. Easily applied tools allowing early identification of schizophrenia or vulnerability to it may enable early intervention.

Schizophrenic subjects with no history of admission to hospital

It has often been assumed that all subjects with schizophrenia will eventually be admitted to hospital and therefore little bias is introduced by restricting research to hospitalized subjects. Using the Lothian Psychiatric Case Register, 66 subjects were identified who had been diagnosed in Edinburgh as suffering from schizophrenia between 1978 and 1989 but had no history of hospital admission by December 1991. This represented an adjusted average of 6.7% of the estimated annual rate of first diagnosis of schizophrenia: the proportion of such patients did not change over the period. Using a case-control design, the index cases were compared with a control group of schizophrenic patients who had been admitted to hospital within 3 months of diagnosis. At the time of diagnosis, the cases were generally less disturbed with lower levels of violent behaviour and less evidence of neglect or hallucinations. They had a longer duration of illness prior to diagnosis, were more often diagnosed by a consultant and unemployed. In a follow-up study of the index cases, 59 (89%) were traced, of whom 6 (10%) were deceased. The outcome of the illness was heterogeneous although the course was often chronic. The general practitioner provided most of the care they received. The small proportion of such patients suggests that their exclusion from most published series does not seriously bias our picture of the natural history of schizophrenia. Moreover, as there was no increase in the proportion over the period, first admission rates for schizophrenia in Scotland are a reasonable approximation to incidence rates.

Cerebral ventricle dimensions as risk factors for schizophrenia and affective psychosis: an epidemiological approach to analysis

A case-control study was undertaken of volumetric computerized tomographic scan measures in 216 consecutive admissions for functional psychosis and 67 healthy community controls. Odds ratio analysis demonstrated significant linear trends in the association between increasing lateral and third ventricle volumes, and both RDC schizophrenia (N = 121) and schizo-affective disorder (N = 41); cases were consistently associated with larger volumes than controls. There was an association between larger third, but not lateral, ventricle size in affective psychoses (N = 54). These associations were statistically independent of intracranial volume, sex, social class and ethnicity, factors which were significantly associated with ventricular measures in the controls. There was no evidence of a threshold corresponding to the notion of normal versus enlarged ventricles. Within the schizophrenia group, there were no large or significant associations between ventricle dimensions and age at onset, duration of illness or pre-morbid social functioning. Neither obstetric complications nor a family history of schizophrenia or other psychiatric illness was associated with large ventricles in these cases.

The criminal careers of incident cases of schizophrenia

We present a population-based, longitudinal study of all incident cases (N = 538) of schizophrenia in the London Borough of Camberwell between 1964 and 1984. Cases were selected from the Camberwell Cumulative Psychiatric Case Register. Case-notes were obtained, and further classified using a computerized operational check list for rating psychotic illness. Cases are not restricted to hospital discharges, as in previous studies, and account is taken of time at liberty to offend. In order to test the hypothesis that schizophrenia makes an independent contribution to criminality over other mental disorders, controls were chosen to be representative of nonschizophrenic mental disorders matched for age, sex and period. The rate of conviction is increased in women with schizophrenia compared to other mental disorders for most offence categories (rate ratio = 3.3). In men overall rates do not differ (rate ratio = 1.03), although there is an interaction between gender, schizophrenia and ethnicity, with young black men with schizophrenia being most at risk. The rate ratio for violent offences in men with schizophrenia is 3.8, confirming recent studies from Sweden. Subjects with schizophrenia were more likely to acquire any criminal record than those with other mental disorders. The rate of lifetime conviction was greater in those with schizophrenia than either a sample of working-class boys from the same area followed by Farrington & West, or National data. The risk of first conviction is increased by schizophrenia, unemployment, ethnic group, substance abuse and low social class, and decreased by being employed, married, female and older age of onset. Adjustment using survival analysis showed that schizophrenia made a small independent contribution to the risk of acquiring a criminal record (hazard ratio = 1.4) but gender, substance abuse, ethnicity and age of onset were more substantial. Previous criminality was the strongest independent association of post-illness conviction, with schizophrenia only a trend. Although subjects with schizophrenia were more likely to acquire a criminal record, criminal careers began later and were shorter than those of the controls. The risk of criminality increased throughout the study period, but suggestions of a specific increase in those with schizophrenia as a result of changes in community care were not confirmed. These results confirm that women with schizophrenia are at increased risk of acquiring a criminal record, but the effect in men is for violent convictions only. The strongest associations of criminal conviction remain those recognized in non-schizophrenic subjects.