Causes and consequences of duration of untreated psychosis in schizophrenia

Duration of untreated or undiagnosed bipolar disorder and clinical characteristics and outcomes: systematic review and meta-analysis

BACKGROUND

The duration of undiagnosed or untreated bipolar disorder (DUBD) has become a focus of research interest. However, its relationship with clinical characteristics and outcomes remains poorly understood.

AIMS

The objective of this systematic review and meta-analysis was to examine DUBD and explore its relationships with clinical characteristics and outcomes in bipolar disorder.

METHODS

We conducted a systematic search of the literature to identify studies reporting on DUBD and its relationships with clinical characteristics and outcomes including frequency of relapse into mood episodes, severity and persistence of mood symptoms, functional and cognitive measures, suicidality, hospital admission rate, and comorbidities such as substance use disorders.

RESULTS

Thirty articles met inclusion criteria for the systematic review, and 23 studies were included in the three different sets of meta-analyses. The pooled mean DUBD across all studies was 9.10 years. Early onset, depression as the polarity of the first mood episode, lifetime suicide attempts, comorbid anxiety and alcohol use disorders, and family history of bipolar disorder were associated with significantly longer DUBD, whereas diagnosis of bipolar I disorder and lifetime psychotic symptoms were associated with shorter DUBD. Studies that investigated outcomes subsequent to the diagnosis of bipolar disorder yielded conflicting results.

CONCLUSION

DUBD may be associated with certain adverse outcomes. This association indicates the importance of adopting a more comprehensive approach to assessing mood disorders, with an emphasis on prioritising early screening for bipolar disorder. The significant heterogeneity among included studies suggests a need for improved methodological rigour in future research.

Associations between rural/urban status, duration of untreated psychosis and mode of onset of psychosis: a mental health electronic clinical records analysis in the East of England, UK

PURPOSE

The influence of rurality on the duration of untreated psychosis (DUP) in first-episode psychosis (FEP) is poorly understood. We investigated factors associated with FEP in rural/urban settings and whether there are rural/urban differences in DUP and the mode (speed) of onset of psychosis.

METHODS

We used the Cambridgeshire and Peterborough NHS Foundation Trust Research Database (CPFTRD) to identify all persons presenting to an early intervention for psychosis service with FEP between 2013 and 2015. We performed descriptive statistics and multivariable linear and multinomial regression to assess the relationships between the study outcomes and the independent variables.

RESULTS

One hundred and fifty-five FEP patients were identified, with a mean age of 23.4 (SD, 5.3) years. The median DUP was 129.0 (IQR: 27.5-524.0) days. In rural areas, FEP patients were more likely to be employed and live with family than those in urban areas. A longer DUP was observed among patients with an insidious onset of psychosis compared with an acute onset (619.5 (IQR: 333.5-945.0)) vs. (17.0 (IQR: 8.0-30.5)) days respectively, p < 0.0001. We found evidence that the mode of onset of psychosis differed by employment status and living circumstances. There was insufficient evidence of rural/urban differences in DUP and mode of onset of psychosis.

CONCLUSIONS

Our results suggest that the mode of onset of psychosis is an important indicator of treatment delay and could provide vital information for service planning and delivery. Sociodemographic variations in FEP exist in rural populations, and our findings are similar to those observed in urban settings.

Markedly Delayed Presentation of a Psychotic Disorder 10 Years After the First Onset of Symptoms

Schizophrenia affects 1% of the population, causing chronic debilitating symptoms with largely unknown causes. Structural brain changes and neurochemical alterations are believed to contribute to its etiology. Delayed treatment initiation is a major concern. This case involves a male patient with a decade-long history of psychosis, experiencing isolation, agoraphobia, and paranoid delusions. His situation deteriorated to the point where he lived in a self-imposed physically constraining environment for a year, leading to muscle atrophy and deteriorating health. Delayed help-seeking was driven by insurance concerns, despite prior academic success. Following extensive evaluation, he received the diagnosis of schizophrenia (first episode, severe), requiring multidisciplinary treatment, including medication adjustments and therapy. This case serves as a poignant illustration of a missed opportunity for early intervention, with treatment initiated only after symptoms became severe. Research indicates that early intervention in schizophrenia is crucial, typically leading to improved outcomes, emphasizing its critical importance.

Sociodemographic and clinical predictors of delay to and length of stay with early intervention for psychosis service: findings from the CRIS-FEP study

PURPOSE

We investigated the influence of sociodemographic and clinical characteristics on delay to early intervention service (EIS) and the length of stay (LOS) with EIS.

METHODS

We used incidence data linked to the Clinical Record Interactive Search-First Episode Psychosis (CRIS-FEP) study. We followed the patients from May 2010 to March 2016. We performed multivariable Cox regression to estimate hazard ratios of delay to EIS. Negative binomial regression was used to determine LOS with EIS by sociodemographic and clinical characteristics, controlling for confounders.

RESULTS

343 patients were eligible for an EIS, 34.1% of whom did not receive the service. Overall, the median delay to EIS was 120 days (IQR; 15-1668); and the median LOS was 130.5 days (IQR 0-663). We found that women (adj.HR 0.58; 95%C I 0.42-0.78), living alone (adj.HR: 0.63; 95% CI 0.43-0.92) and ethnicity ('Other': adj.HR 0.47; 95% CI 0.23-0.98) were associated with prolonged delay to EIS. However, family involvement in help-seeking for psychosis (adj.HR 1.37; 95% CI 1.01-1.85) was strongly associated with a shorter delay to EIS. Patients who have used mental health services previously also experienced long delays to EIS.

CONCLUSIONS

Our analyses highlight the link between sociodemographic status, help-seeking behaviours, and delay to EIS. Our findings also show the vulnerability faced by those with a previous mental health problem who later develop psychosis in receiving specialist treatment for psychosis. Initiatives that ameliorate indicators of social disadvantage are urgently needed to reduce health inequalities and improve clinical outcomes.

Psychological/Personal recovery and its correlates in patients with first episode psychosis

BACKGROUND

Recovery in psychosis is a multidimensional construct. The numbers of studies specially focusing on the recovery aspects in patients with first episode psychosis (FEP) are limited, with no study from India. Further, no study has looked specifically into the variables that affect recovery process in patients with FEP and little is known about factors which influence recovery in patients with FEP.

AIM

To evaluate psychological recovery and its correlates in patients with FEP, currently in clinical remission.

METHODOLOGY

One hundred three patients of FEP in clinical remission were assessed on Recovery Assessment Scale (RAS), Positive and Negative Syndrome Scale for Schizophrenia, Calgary Depression Rating Scale for Schizophrenia, Negative Symptom Assessment 16, Rosenberg Self-esteem Scale, Social and Occupational Functioning Assessment Scale, the Alcohol, Smoking and Substance Involvement Screening Test, Beck Cognitive Insight Scale, Internalized Stigma of Mental Illness Scale, the Everyday discrimination Scale, Subjective Scale to Investigate Cognition in Schizophrenia and social cognitive deficits in theory of mind was evaluated on the Social Cognition Rating Tools in Indian Setting-Theory of Mind. The needs of the participants were assessed on the Camberwell Assessment of Needs - Research version and Supplemental Assessment of Needs. Coping, social support, medication adherence were also assessed by standardized scales.

RESULTS

The mean weighted score was highest for goal and success orientation subscale followed by seeking and relying on social support, personal confidence and hope, overcome the illness and awareness and control over the illness as assessed by 41 items of the RAS. The main factors identified to affect psychological recovery in patients with FEP were duration of untreated psychosis, greater psychopathology, lower self-esteem, total unmet need, feeling of discrimination and stigmatization.

CONCLUSION

The present study suggests that treatment of FEP should be started at the earliest and issues such as residual psychopathology, lower self-esteem, total unmet need, feeling of discrimination and stigma during the remission phase should be addressed by psychosocial interventions to promote psychological recovery in patients with first episode psychosis.

The duration of untreated psychosis among U.S. Latinxs and social and clinical correlates

Purpose

This study (a) documents the duration of untreated psychosis (DUP) and (b) examines both social and clinical correlates of DUP in a sample of U.S. Latinxs with first-episode psychosis (FEP).

Methods

Data were collected for a longitudinal study evaluating a community education campaign to help primarily Spanish-speaking Latinxs recognize psychotic symptoms and reduce the DUP, or the delay to first prescribed antipsychotic medication after the onset of psychotic symptoms. Social and clinical variables were assessed at first treatment presentation. A sequential hierarchical regression was conducted using √DUP to identify independent predictors of the DUP. A structural equation model was used to explore the association between DUP predictors, DUP, and clinical and social correlates.

Results

In a sample of 122 Latinxs with FEP, the median DUP was 39 weeks (M = 137.78, SD = 220.31; IQR = 160.39-5.57). For the full sample, being an immigrant and having self-reported relatively poor English-speaking proficiency and self-reported strong Spanish-speaking proficiency were related to a longer delay to first prescribed medication after psychosis onset. For the immigrant subgroup, being older at the time of migration was related to a longer delay. Self-reported English-speaking proficiency emerged as an independent predictor of the DUP. Although the DUP was not related to symptomatology, it was associated with poorer social functioning. Low self-reported English-speaking ability is associated with poorer social functioning via the DUP.

Conclusion

Latinxs with limited English language skills are especially at high risk for experiencing prolonged delays to care and poor social functioning. Intervention efforts to reduce the delay in Latinx communities should pay particular attention to this subgroup.

Characteristics and clinical correlates of risk symptoms in individuals at clinical high-risk for psychosis: A systematic review and meta-analysis

Emerging evidence suggests that the duration of risk symptoms (DUR) may have an impact on clinical outcomes in clinical high-risk for psychosis (CHRP) participants. To explore this hypothesis, we performed a meta-analysis on studies that examined DUR in CHR-P individuals in relation to their clinical outcomes. This review was conducted in accordance with the PRISMA guidelines and the protocol was registered with PROSPERO on 16th April 2021 (ID no. CRD42021249443). Literature searches were conducted using PsycINFO and Web of Science in March and November 2021, for studies reporting on DUR in CHR-P populations, in relation to transition to psychosis or symptomatic, functional, or cognitive outcomes. The primary outcome was transition to psychosis, while the secondary outcomes were remission from CHR-P status and functioning at baseline. Thirteen independent studies relating to 2506 CHR-P individuals were included in the meta-analysis. The mean age was 19.88 years (SD = 1.61) and 1194 individuals (47.65 %) were females. The mean length of DUR was 23.61 months (SD = 13.18). There was no meta-analytic effect of DUR on transition to psychosis at 12-month follow-up (OR = 1.000, 95%CI = 0.999-1.000, k = 8, p = .98), while DUR was related to remission (Hedge's g = 0.236, 95%CI = 0.014-0.458, k = 4, p = .037). DUR was not related to baseline GAF scores (beta = -0.004, 95%CI = -0.025-0.017, k = 3, p = .71). The current findings suggest that DUR is not associated with transition to psychosis at 12 months, but may impact remission. However, the database was small and further research in this area is required.

Development and Validation of Predictive Model for a Diagnosis of First Episode Psychosis Using the Multinational EU-GEI Case-control Study and Modern Statistical Learning Methods

Background and Hypothesis

It is argued that availability of diagnostic models will facilitate a more rapid identification of individuals who are at a higher risk of first episode psychosis (FEP). Therefore, we developed, evaluated, and validated a diagnostic risk estimation model to classify individual with FEP and controls across six countries.

Study Design

We used data from a large multi-center study encompassing 2627 phenotypically well-defined participants (aged 18-64 years) recruited from six countries spanning 17 research sites, as part of the European Network of National Schizophrenia Networks Studying Gene-Environment Interactions study. To build the diagnostic model and identify which of important factors for estimating an individual risk of FEP, we applied a binary logistic model with regularization by the least absolute shrinkage and selection operator. The model was validated employing the internal-external cross-validation approach. The model performance was assessed with the area under the receiver operating characteristic curve (AUROC), calibration, sensitivity, and specificity.

Study Results

Having included preselected 22 predictor variables, the model was able to discriminate adults with FEP and controls with high accuracy across all six countries (rangesAUROC = 0.84-0.86). Specificity (range = 73.9-78.0%) and sensitivity (range = 75.6-79.3%) were equally good, cumulatively indicating an excellent model accuracy; though, calibration slope for the diagnostic model showed a presence of some overfitting when applied specifically to participants from France, the UK, and The Netherlands.

Conclusions

The new FEP model achieved a good discrimination and good calibration across six countries with different ethnic contributions supporting its robustness and good generalizability.

An Update on Clinical Insight, Cognitive Insight, and Introspective Accuracy in Schizophrenia-Spectrum Disorders: Symptoms, Cognition, and Treatment

INTRODUCTION

Poor insight, or unawareness of morbid changes in cognition, emotional states, or behavior, is commonly observed among people with schizophrenia. Poor insight represents a persistent barrier to wellness because it interferes with treatment and self-direction. Paradoxically, good insight may also be a barrier to health when awareness of these changes leads to depression or self-stigma.

AREAS COVERED

This paper builds upon this previous work by exploring these issues in schizophrenia separately as they have appeared in published research over the last three years in three different kinds of insight: clinical, cognition, and introspective accuracy. Specifically, studies are reviewed that address: the adverse effects of poor insight, the paradoxical effects of good insight, correlates with other forms of cognition, and emerging treatments.

EXPERT OPINION

The evidence continues to offer a nuanced picture of the complex effects of good insight in schizophrenia. Incremental improvements were also found in the development of novel integrative treatment approaches. This work also highlights the intricacy of the concept of insight, the need for further exploration of the effects of culture, and conceptual work that distinguishes the points of convergence and divergence of these forms of insight.

How does attachment style affect psychosis? A systematic review of causal mechanisms and guide to future inquiry

PURPOSE

The link between attachment and psychosis is now well established, but less is known about the causal mechanisms underlying this relationship. This systematic review synthesises the studies that examine mediating mechanisms in the attachment and psychosis relationship, in both clinical and non-clinical samples.

METHOD

We conducted a database search (PsychINFO, MEDLINE, Web of Science) to identify all eligible studies irrespective of publication status, the language of article or article date. We assessed methodological quality and completed a narrative synthesis given the heterogeneity of studies to date.

RESULTS

We identified 17 papers, comprising 3,672 participants. The relationship between attachment and psychosis is mediated by four variables or groups of variables. There is good evidence for the causal role of affective factors (affective dysregulation and affective disturbances) and cognitive factors (e.g., self-beliefs and self-esteem and beliefs about symptoms). Affective factors differed by attachment style. Tentative evidence was found for the role of duration of untreated psychosis and baseline negative symptoms.

CONCLUSIONS

Cognitive and affective factors mediate the relationship between attachment style and psychosis. Whilst cognitive factors are routinely targeted in recommended psychological interventions for psychosis, affective factors and attachment style are less commonly considered. Psychological therapies may be improved by calibrating cognitive and affective interventions by attachment style, which should be subjected to experimental and then field studies to assess the impact on clinical and recovery outcomes.

PRACTITIONER POINTS

The relationship between attachment and psychosis is now well established, and studies have started to examine mediating mechanisms. Affective and cognitive factors mediate the attachment-psychosis relationship. Affective factors differ by attachment style. There is limited evidence for the duration of untreated psychosis and negative psychotic symptoms as mediating mechanisms, and research replication is needed. Cognitive factors are routinely targeted in recommended psychological therapies for psychosis, but affective factors and attachment style are less commonly considered. Research should be conducted into the effectiveness of psychological therapies which calibrate cognitive and affective interventions, according to attachment style.

Proportion and characteristics of young people in a first-episode psychosis clinic who first attended an at-risk mental state service or other specialist youth mental health service

BACKGROUND

Services for young people identified as having an 'at-risk mental state' (ARMS) aim to prevent transition to first-episode psychosis (FEP), in addition, early intervention services for other mental health disorders have also been developed. The aim of the current study was to determine the proportion of young people attending a specialist FEP service who had been referred via other early intervention clinics, including an ARMS clinic, and compare the characteristics to those who presented directly to the FEP service.

METHODS

We included young people diagnosed with FEP who received treatment at Orygen between 01.01.2012 and 31.12.2016. We examined rates of direct entry to the First Episode Psychosis service and rates from other early intervention services, specifically ARMS, personality disorders, mood disorders and a primary care youth mental health service clinics.

RESULTS

1138 young people were diagnosed with a FEP, of whom 13.7% first attended an ARMS clinic and a further 7.6% attended other youth mental health services. Individuals who first presented to an ARMS clinic were more likely to be female, younger, and less likely to be migrants or use substances. Rates of both voluntary and involuntary hospital admissions were significantly reduced for young people who transitioned from the ARMS clinic, the personality disorder clinic or the primary care service compared to those who presented directly with FEP.

CONCLUSIONS

A significant proportion of young people with FEP initially attended another specialist youth mental health service, and importantly, they had much lower rates of hospital admission at the time of transition to FEP.

The effects of childhood adversity on treatment delays and its components in first-episode psychosis

Apart from increasing risk for psychotic disorders, childhood adversity has been associated with worse outcomes. One way in which childhood adversity may worsen outcomes is by lengthening treatment delays, which are associated with negative impacts. We tested the influence of childhood trauma on treatment delays, measured as the duration of untreated psychosis (DUP), and its help-seeking and referral components, in a first-episode psychosis cohort (N = 203). We accounted for pertinent social (e.g., migrant status) and other determinants (i.e., age at onset, diagnosis, symptoms) of treatment delays. Multiple linear regression analyses revealed that for a one-unit increase in Childhood Trauma Questionnaire (CTQ) scores, average overall DUP increased by 25%. Higher CTQ scores also significantly predicted help-seeking and referral DUPs. Patients with schizophrenia-spectrum psychosis had longer help-seeking and total DUPs than those with affective psychosis. More severe positive symptoms predicted longer help-seeking DUPs, while more severe negative symptoms predicted longer referral DUPs. Indicators of social disadvantage did not affect DUP. Our results show that childhood trauma increases DUP by prolonging the help-seeking process and delaying access to mental healthcare even after help is sought. Early identification of psychosis among populations with trauma histories seems warranted and can likely positively impact outcomes.

Psychosis-Spectrum Screening and Assessment Within a College Counseling Center: A Pilot Study Exploring Feasibility and Clinical Need

Evidence supports the use of brief psychosis-spectrum screening tools for identifying individuals at an increased risk of developing a psychotic disorder. Screening has not been well studied in general mental health settings that serve young adults in the age range associated with highest risk for psychosis. This study explored the feasibility of psychosis-risk screening and assessment among help-seeking students at a university counseling center. The PRIME Screen-Revised was administered to students at clinic intake. Participants who screened positively were offered a follow-up assessment using the Structured Interview for Psychosis-risk Syndromes (SIPS). At intake, 510 students completed the PRIME Screen-Revised, with 132 (25.9%) screening positive. Comprehensive psychosis-spectrum evaluations were completed with 38 participants, and 22 met criteria for a psychosis-spectrum disorder, representing 57.9% of this subsample. Findings suggest that psychosis-risk screening in a college clinic is a promising approach to identifying those at high risk for or in the early stages of psychosis.

Can Intergroup Contact in Virtual Reality (VR) Reduce Stigmatization Against People with Schizophrenia?

People with mental disorders such as schizophrenia do not only suffer from the symptoms of their disorders but also from the stigma attached to it. Although direct intergroup contact is an effective tool to reduce stigmatization, it is rare in real life and costly to be established in interventions, and the success of traditional media campaigns is debatable. We propose Virtual Reality (VR) as a low-threshold alternative for establishing contact since it involves less barriers for affected and unaffected persons. In a 2 + 1 experiment (n = 114), we compared the effects of encounters with a person with schizophrenia through a VR video with contact through a regular video and no contact at all on anxiety, empathy, social proximity, and benevolence towards people with schizophrenia. We found that contact via VR reduced stigmatization only for participants who liked the person encountered. Our data suggest that it is crucial how participants evaluate the person that they encounter and that stronger perception of spatial presence during reception plays an important role, too. Therefore, we discussvarious boundary conditions that need to be considered in VR interventions and future research on destigmatization towards mental disorders, especially schizophrenia.

Ethnic variations in duration of untreated psychosis: report from the CRIS-FEP study

OBJECTIVES

There is inconsistent evidence on the influence of ethnicity on duration of untreated psychosis (DUP). We investigated ethnic differences in DUP in a large epidemiological dataset of first episode psychosis patients in an inner city area of south London, UK.

METHODS

We analysed data on 558 first episode psychosis patients at the South London and Maudsley NHS Trust, between 2010 and 2012. We performed multivariable logistic regression to estimate the odds of a short DUP (≤ 6 months) by ethnic group, controlling for confounders.

RESULTS

There was no evidence that ethnicity is associated with duration of untreated psychosis. However, we found evidence that a short DUP was strongly associated with age, living circumstances, and pathways to care variables (involuntary admission, out of office hour contact, accident and emergency referral, criminal justice agency referral and family involvement in help-seeking). Conversely, a long DUP was associated with report of social isolation, living alone, being single and General Practitioner referral.

CONCLUSION

Our findings suggest that indicators of social isolation were associated with long DUP. Our data also show that pathways into care characteristics play significant role in DUP. Thus, the challenge of tackling the issue of timely access to EI under the new Access and Waiting Time standard for psychosis requires a multilevel approach, including joint working with communities, public awareness of psychosis, less restrictive referral pathways and adequate resourcing of early intervention for psychosis services. These will go a long way in addressing patients' needs rather than be determined by service structures.

Two-year diagnostic stability in a real-world sample of individuals with early psychosis

OBJECTIVES

Diagnostic shifts in first episode psychosis (FEP) are not uncommon. Many studies examining diagnostic stability use structured diagnostic interviews. Less is known about the stability of FEP diagnoses made clinically.

METHODS

We conducted a retrospective chart review of patients enrolled in a transdiagnostic FEP clinic. For the 96 patients followed clinically at least 2 years, we compared diagnoses at intake and 24 months.

RESULTS

Diagnostic stability was high for bipolar disorder (89%), schizoaffective disorder (89%), and schizophrenia (82%). Psychosis not otherwise specified (13%) was more unstable, with limited baseline differences that would enable clinicians to predict who would convert to a primary psychotic vs affective psychotic disorder.

CONCLUSIONS

Our real-world clinical sample shows that FEP diagnoses, with the exception of unspecified psychosis, are diagnostically stable, even without structured diagnostic interviews.

Similarities and Differences in Associations Between Duration of Untreated Psychosis (DUP) and Demographic, Premorbid, and Symptom Severity Measures in Two Samples of First-Episode Psychosis Patients from Mexico and the United States

Early-psychosis researchers have documented that duration of untreated psychosis (DUP) is an important predictor of outcomes in first-episode psychosis. Very few cross-national studies have been conducted, and none have been carried out involving patients from both Mexico and the U.S. We collaborated to answer three questions: (1) Are DUP estimates similar in two very different settings and samples? (2) Are demographic variables, premorbid adjustment, and symptom severity similarly related to DUP in the two different settings? (3) Does the same set of variables account for a similar proportion of variance in DUP in the two settings? Data on sociodemographic characteristics, premorbid adjustment, symptom severity, and DUP were available for 145 Mexican and 247 U.S. first-episode psychosis patients. DUP was compared, and bivariate analyses and multiple linear regressions were carried out in each sample. DUP estimates were similar (medians of 35 weeks in Mexico and 38 weeks in the U.S.). In the Mexican sample, DUP was associated with gender, employment status, premorbid social adjustment, and positive symptom severity (explaining 18% of variance). In the U.S. sample, DUP was associated with age, employment status, premorbid social adjustment, and positive symptom severity (but in the opposite direction of that observed in the Mexican sample), accounting for 25% of variance. Additional cross-national collaborations examining key facets of early-course psychotic disorders, including DUP, will clarify the extent of generalizability of findings, strengthen partnerships for more internationally relevant studies, and support the global movement to help young people struggling with first-episode psychosis and their families.

Understanding Individual and Family Experiences Associated with DUP: Lessons from the Early Assessment and Support Alliance (EASA) Program in Oregon, USA

Research shows that a longer duration of untreated psychosis (DUP) is associated with worse psychiatric outcomes, with average length of DUP of 73 weeks in the U.S. The aim was to examine the DUP period for first episode psychosis in Oregon, with a focus on the processes between the first positive symptoms and first treatment. To investigate DUP, researchers used methods consistent with grounded theory to collect data from 9 participants and their families about the process between onset of psychotic symptoms and entrance into treatment. Results suggest that recognition of symptoms was the primary driver of help-seeking in this study, and this was influenced by type of symptom as well as the presence or absence of supportive others, which in most cases was regular family contact. Implications indicate a need for in-depth research on individual and family recognition of symptoms, as well as underscoring the need for community education.

Effect of delaying treatment of first-episode psychosis on symptoms and social outcomes: a longitudinal analysis and modelling study

BACKGROUND

Delayed treatment for first episodes of psychosis predicts worse outcomes. We hypothesised that delaying treatment makes all symptoms more refractory, with harm worsening first quickly, then more slowly. We also hypothesised that although delay impairs treatment response, worse symptoms hasten treatment, which at presentation mitigates the detrimental effect of treatment delay on symptoms.

METHODS

In this longitudinal analysis and modelling study, we included two longitudinal cohorts of patients with first-episode psychosis presenting to English early intervention services from defined catchments: NEDEN (recruiting 1003 patients aged 14-35 years from 14 services between Aug 1, 2005, and April 1, 2009) and Outlook (recruiting 399 patients aged 16-35 years from 11 services between April 1, 2006, and Feb 28, 2009). Patients were assessed at baseline, 6 months, and 12 months with the Positive and Negative Symptom Scale (PANSS), Calgary Depression Scale for Schizophrenia, Mania Rating Scale, Insight Scale, and Social and Occupational Functioning Assessment Scale. Regression was used to compare different models of the relationship between duration of untreated psychosis (DUP) and total symptoms at 6 months. Growth curve models of symptom subscales tested predictions arising from our hypotheses.

FINDINGS

We included 948 patients from the NEDEN study and 332 patients from the Outlook study who completed baseline assessments and were prescribed dopamine antagonist antipsychotics. For both cohorts, the best-fitting models were logarithmic, describing a curvilinear relationship of DUP to symptom severity: longer DUP predicted reduced treatment response, but response worsened more slowly as DUP lengthened. Increasing DUP by ten times predicted reduced improvement in total symptoms (ie, PANSS total) by 7·339 (95% CI 5·762 to 8·916; p<0·0001) in NEDEN data and 3·846 (1·689 to 6·003; p=0·0005) in Outlook data. This was true of treatment response for all symptom types. Nevertheless, longer DUP was not associated with worse presentation for any symptoms except depression in NEDEN (coefficients 0·099 [95% CI 0·033 to 0·164]; p=0·0028 in NEDEN and 0·007 [-0·081 to 0·095]; p=0·88 in Outlook).

INTERPRETATION

Long DUP was associated with reduced treatment response across subscales, consistent with a harmful process upstream of individual symptoms' mechanisms; response appeared to worsen quickly at first, then more slowly. These associations underscore the importance of rapid access to a comprehensive range of treatments, especially in the first weeks after psychosis onset.

FUNDING

UK Department of Health, National Institute of Health Research, and Medical Research Council.

Results of a prospective, mixed methods study to assess feasibility, acceptability and effectiveness of TRIumPH (Treatment and Recovery In PsycHosis): an integrated care pathway for psychosis, compared to usual treatment

OBJECTIVES

To evaluate whether a newly developed care pathway, Treatment and Recovery In PsycHosis (TRIumPH), is feasible, acceptable and effective in meeting National Institute of Health and Care Excellence (NICE) quality standards in a timely manner.

METHODS

This is a pragmatic, non-randomised, prospective, mixed methods study comparing an implementation (TRIumPH) and comparator site (not implementing TRIumPH) across three cohorts to assess feasibility, acceptability and effectiveness of the integrated pathway.

SETTING

Early intervention in psychosis (EIP) services at two National Health Service organisations in South of England.

PARTICIPANTS

All patients accepted into EIP services between 1 June 2014 and 31 May 2017 were each followed up for 1 year within their respective cohorts.

METHODOLOGY

Quantitative data consisted of routinely collected clinical data retrieved from patient records to assess whether the implementation of TRIumPH achieved better concordance to NICE standards. These included time to access services, physical health assessments, clinical outcomes based timeliness of delivery and acute data. The controlled trial has evaluated the effect of TRIumPH (Intervention) with Care As Usual (Comparator). Qualitative measures consisted of questionnaires, interviews and focus groups to assess acceptability and satisfaction. Outcome measures were compared within the baseline, year 1 and year 2 cohorts and between the two sites. Quantitative data were statistically analysed by comparing means and proportions.

RESULTS

Time to assessment improved in the implementation site and remained within the target in comparator site. Meeting of quality standards increased substantially in the implementation site but was more variable and reached lower levels in the comparator site especially for physical health standards. Cognitive therapy for psychosis, family intervention and carer and employment support were all offered to a greater extent in the implementation site and uptake increased over the period.

CONCLUSIONS

Pathway implementation generally led to greater improvements in achievement of access and quality standards compared with comparator site.

TRIAL REGISTRATION NUMBER

UK Clinical Research Network Portfolio (19187).

Duration of untreated psychosis and response to treatment: an analysis of response in the OPTiMiSE cohort

Some, but not all, studies have found longer duration of untreated psychosis (DUP) to be associated with poor response to treatment and more severe negative symptoms in schizophrenia. The aim of the current analysis was to investigate these parameters in a large cohort of patients in their first psychotic episode. The OPTiMiSE cohort included 446 patients with DUP up to two years, who were administered amisulpride for 4 weeks (Phase I). Patients who did not meet Andreasen remission criteria were randomized to double-blind continuation of amisulpride or olanzapine for 6 additional weeks in a blinded study (Phase II). Analyses showed that shorter DUP was associated with lower baseline CGI scores (p<0.001, r = 0.184), PANSS total (p = 0.025, r = 0.106) and PANSS negative subscale scores (p = 0.023, r = 0.107). Remitters had a significantly shorter mean DUP compared to non-remitters both in Phase I (24.5 weeks ±24.3 vs. 35 weeks ± 32.2, p = 0.01, t=-2.521) and in Phase II (24.3 weeks ± 26.4 vs. 38.3 weeks ± 31.3, p = 0.031, t=-2.194). Logistic regression analyses showed a significant effect of DUP on treatment response both in phase I (p = 0.008) and phase II (p = 0.041). Linear regression analyses found that DUP significantly affects PANSS Total change at the end of phase I (p = 0.028) but not at the end of phase II (p = 0.236). Based on these findings, it is possible to conclude that shorter DUP is associated with better response to treatment, particularly during the first weeks after treatment initiation. These findings highlight the need for early identification of the first psychotic episode.

Evidence-based guidelines for the pharmacological treatment of schizophrenia: Updated recommendations from the British Association for Psychopharmacology

These updated guidelines from the British Association for Psychopharmacology replace the original version published in 2011. They address the scope and targets of pharmacological treatment for schizophrenia. A consensus meeting was held in 2017, involving experts in schizophrenia and its treatment. They were asked to review key areas and consider the strength of the evidence on the risk-benefit balance of pharmacological interventions and the clinical implications, with an emphasis on meta-analyses, systematic reviews and randomised controlled trials where available, plus updates on current clinical practice. The guidelines cover the pharmacological management and treatment of schizophrenia across the various stages of the illness, including first-episode, relapse prevention, and illness that has proved refractory to standard treatment. It is hoped that the practice recommendations presented will support clinical decision making for practitioners, serve as a source of information for patients and carers, and inform quality improvement.

Simulated long-term outcomes of early use of long-acting injectable antipsychotics in early schizophrenia

AIM

Duration of untreated psychosis in early schizophrenia impacts long-term outcomes. Because long-acting injectable (LAI) antipsychotic drugs improve adherence in early-stage patients, they could reduce additional time in uncontrolled psychosis (TUP) during the critical period of the illness. However, the long-term benefit of early LAI use over oral formulations has not been quantified. This study explores the potential magnitude of the benefit with a simulation approach.

METHODS

A microsimulation models the effects of 11 treatment pathways reflecting alternative decisions on whether and when LAI agents are used during a "calibration phase" that starts at treatment entry and lasts until the end of the 3-year critical period. Treatment failure prolongs time in psychosis. Long-term outcomes are predicted over the ensuing 7-year period as a function of TUP.

RESULTS

An "early LAI" pathway where LAI treatment follows the second oral treatment failure is compared to an oral-only pathway. Under these pathways, 69% and 46% of patients, respectively, are estimated to exit the calibration phase with adequate symptom control (total positive and negative syndrome scale score below 68). Relative to the oral-only pathway, the early LAI pathway is predicted to increase competitive employment by 39% (25% vs 18%) and independent or family living by 22% (71% vs 58%), and to decrease receipt of disability benefits by 36% (42% vs 66%) and hospital admissions per 1000 patient-years by 15% (249% vs 294%).

CONCLUSIONS

While these simulation results need to be confirmed empirically, they suggest that earlier use of LAI antipsychotics can meaningfully improve patient outcomes.

Differences in duration of untreated psychosis for racial and ethnic minority groups with first-episode psychosis: an updated systematic review and meta-analysis

PURPOSE

Ethnic minority groups with early psychosis may have longer treatment delays, potentially leading to poorer outcomes. We updated a previous systematic review of the literature on racial and ethnic differences in duration of untreated psychosis (DUP) among people with first-episode psychosis.

RESULTS

Six of 17 studies described significant differences across aggregated racial groups; however, the pooled estimates did not show differences across groups. Additional data from this update allowed for disaggregated analyses, finding that Black-African groups have a shorter DUP, whereas Black-Caribbean groups have longer DUP, relative to White groups.

CONCLUSIONS

These findings highlight the importance of in-depth research on disaggregated ethnic groups to inform targeted early intervention strategies for minority populations.

Specificity of Childhood Trauma Type and Attenuated Positive Symptoms in a Non-Clinical Sample

BACKGROUND

Childhood traumatic experiences have been consistently associated with psychosis risk; however, the specificity of childhood trauma type to interview-based attenuated positive psychotic symptoms has not been adequately explored. Further, previous studies examining specificity of trauma to specific positive symptoms have not accounted for co-occurring trauma types, despite evidence of multiple victimization.

METHODS

We examined the relationship between childhood trauma (Childhood Trauma Questionnaire) with type of attenuated positive symptom, as measured by the Structured Interview for Psychosis-risk Syndromes (SIPS) among a non-clinical, young adult sample (n = 130). Linear regressions were conducted to predict each attenuated positive symptom, with all trauma types entered into the model to control for co-occurring traumas.

RESULTS

Results indicated that childhood sexual abuse was significantly associated with disorganized communication and childhood emotional neglect was significantly associated with increased suspiciousness/persecutory ideas, above and beyond the effect of other co-occurring traumas. These relationships were significant even after removing individuals at clinical high-risk (CHR) for psychosis (n = 14).

CONCLUSIONS

Our results suggest that there are differential influences of trauma type on specific positive symptom domains, even in a non-clinical sample. Our results also confirm the importance of controlling for co-occurring trauma types, as results differ when not controlling for multiple traumas.

Duration of untreated psychosis and clinical outcomes of first episode psychosis: An observational and an instrumental variables analysis

AIM

Duration of untreated psychosis (DUP) is considered as a key prognostic variable in psychosis. Yet, it is unclear whether a longer DUP causes worse outcomes or whether reported associations have alternative explanations.

METHODS

Data from 2 cohorts of patients with first episode psychosis were used (n = 2134). Measures of DUP were assessed at baseline and outcomes at 12 months. Regression models were used to investigate the associations between DUP and outcomes. We also investigated whether any associations were replicated using instrumental variables (IV) analysis to reduce the effect of residual confounding and measurement bias.

RESULTS

There were associations between DUP per 1-year increase and positive psychotic symptoms (7.0% in symptom score increase 95% confidence interval (CI) 4.0%, 10.0%, P < .001), worse recovery (risk difference [RD] 0.78, 95%, CI 0.68, 0.83, P < .001) and worse global functioning (0.62 decrease in functioning score 95% CI -1.19, -0.04, P = .035). There was no evidence of an association with negative psychotic symptoms (1.0%, 95%, CI -2.0%, 5.0%, P = .455). The IV analysis showed weaker evidence of associations in the same direction between DUP per 1-year increase and positive psychotic symptoms, recovery and global functioning. However, there was evidence of an inverse association with negative psychotic symptoms (decrease of 15.0% in symptom score 95% CI -26.0%, -3.0%, P = .016).

CONCLUSIONS

We have confirmed previous findings of a positive association between positive psychotic symptoms, global functioning and recovery and DUP using regression analysis. IV analysis shows some support for these findings. Future investigation using IV analysis should be repeated in large data sets.

Individual factors influencing the duration of untreated psychosis

AIM

Duration of untreated psychosis (DUP), or the time between onset of psychosis and treatment initiation, is a prognostic factor of schizophrenia. However, few studies evaluated the relative influence of individual-related factors on this duration. The objective of this study was to evaluate the influence of socio-demographic, clinical and cannabis use on DUP.

METHODS

This study was part of a large prospective study in help-seeking individuals referred to our specialized early detection / intervention clinic in the Service Hospitalo-Universitaire of Sainte-Anne Hospital in Paris (ICAAR study). We explored 33 consecutive patients who crossed the CAARMS' threshold of psychosis. The DUP and cannabis consumption history were explored during the baseline comprehensive assessment using all available sources (direct interviews of patients, parents, practitioners). Correlations between socio-demographic, clinical and cannabis use, and DUP were studied. A multiple linear regression model was used to determine the variables that could significantly predict DUP.

RESULTS

When considered individually, none of the socio-demographic and disease characteristic factors was associated with DUP, with the exception of level of education. In the multivariate analysis, age at inclusion, negative symptoms and history of cannabis use significantly influenced DUP.

CONCLUSION

The determinants of DUP are multi-factorial and include individual centred factors, such as age, cannabis and negative symptoms. The identification of factors resulting in delayed access to care may promote the development of effective strategies to reduce DUP in early psychosis and target effective early intervention.

Psychosis screening practices in schools: A survey of school-based mental health providers

AIM

Many school districts in the United States employ mental health professionals to provide assessment, counselling and crisis interventions within the school setting; however, little is known about actual clinical practices of psychosis screening in schools. The aim of the present study is to examine attitudes and practices regarding psychosis screening among school mental health providers in metropolitan Boston, Massachusetts.

METHODS

School-based mental health clinicians (N = 100) completed an anonymous survey assessing familiarity, screening, and involvement with psychosis and psychosis risk prior to attending trainings on psychosis.

RESULTS

Providers reported screening for psychosis less often than other mental health problems and rated themselves as less confident treating psychosis relative to other mental health concerns. Frequency of screening for psychosis was significantly associated with familiarity with psychosis assessment and case management, confidence providing treatment for individuals experiencing psychosis, and the number of students with or at risk for psychosis with whom providers had been involved. Frequency of screening for psychosis was not associated with years of practice, suggesting that both novice and experienced school-based providers may benefit from training on this issue.

CONCLUSIONS

Community outreach via school-based provider training on assessment and management of psychosis may help to increase providers' understanding of psychosis and increase the practice of verbal or written screening for psychosis and psychosis risk within schools.

Cognitive capacity similarly predicts insight into symptoms in first- and multiple-episode psychosis

BACKGROUND

Lack of insight is a frequent characteristic of psychotic disorders, both in patients who recently experienced a first episode of psychosis (FEP) and those who experience recurrent multiple episodes (MEP). Insight is a multifaceted construct: its clinical form notably includes the unawareness of being ill, of symptoms, and of the need for treatment. Cognitive capacity is among the key determinants of insight into symptoms, but less is known about whether stage of illness (FEP vs. MEP) moderates this association.

METHODS

Our aim is to evaluate the association between cognitive capacity and symptom unawareness using structural equation modeling and moderated multiple regression. A total of 193 FEP and MEP patients were assessed using the CogState battery and the Scale to Assess Unawareness of Mental Disorder.

RESULTS

Analyses suggest that cognitive capacity accounts for a relatively small proportion of the total variation in symptom unawareness (6.4%). There was no evidence to suggest a moderating effect of stage of illness on this association.

CONCLUSIONS

The effect of general cognitive capacity on symptom unawareness is relatively small, and this basic relation was unrelated to stage of illness. It is possible that stage of illness could moderate this association only for certain facets of insight not assessed in this study (e.g., unawareness of the need for treatment).

Short-term outcome of first episode delusional disorder in an early intervention population

BACKGROUND

Previous evidence suggests that delusional disorder has a later onset and better functional outcomes compared to schizophrenia. However, studies have not examined longitudinal outcomes in a first episode population, where confounding factors may be adjusted for.

METHODS

A nested case control study was designed within the National EDEN study; a cohort of 1027 first episode psychosis patients. Patients with a baseline diagnosis of delusional disorder (n = 48) were compared with schizophrenia (n = 262) at 6 and 12 months with respect to symptomatic and functional outcomes. Regression analysis was used to adjust for possible confounders.

RESULTS

Delusional disorder patients had a shorter duration of untreated psychosis compared to schizophrenia but were similar in other baseline characteristics. At baseline, delusional disorder patients had lower symptom scores but higher function scores compared to those with schizophrenia. At 12 months the differences persisted for symptoms scores but not overall function scores. After adjusting for baseline score, age and duration of untreated psychosis, differences between the groups remained significant only for Positive and Negative Syndrome Scale (PANNS) negative, general and total scores and recovery rates. There were no differences in changes in outcomes scores.

CONCLUSIONS

Delusional disorder in a first episode psychosis population presents with less severe symptoms, higher recovery rates and better functioning than schizophrenia, but at 12 months differences are ameliorated when adjusting for baseline differences.

Ethnic inequalities and pathways to care in psychosis in England: a systematic review and meta-analysis

BACKGROUND

As part of a national programme to tackle ethnic inequalities, we conducted a systematic review and meta-analysis of research on ethnic inequalities in pathways to care for adults with psychosis living in England and/or Wales.

METHODS

Nine databases were searched from inception to 03.07.17 for previous systematic reviews, including forward and backward citation tracking and a PROSPERO search to identify ongoing reviews. We then carried forward relevant primary studies from included reviews (with the latest meta-analyses reporting on research up to 2012), supplemented by a search on 18.10.17 in MEDLINE, Embase, PsycINFO and CINAHL for primary studies between 2012 and 2017 that had not been covered by previous meta-analyses.

RESULTS

Forty studies, all conducted in England, were included for our updated meta-analyses on pathways to care. Relative to the White reference group, elevated rates of civil detentions were found for Black Caribbean (OR = 3.43, 95% CI = 2.68 to 4.40, n = 18), Black African (OR = 3.11, 95% CI = 2.40 to 4.02, n = 6), and South Asian patients (OR = 1.50, 95% CI 1.07 to 2.12, n = 10). Analyses of each Mental Health Act section revealed significantly higher rates for Black people under (civil) Section 2 (OR = 1.53, 95% CI = 1.11 to 2.11, n = 3). Rates in repeat admissions were significantly higher than in first admission for South Asian patients (between-group difference p < 0.01). Some ethnic groups had more police contact (Black African OR = 3.60, 95% CI = 2.15 to 6.05, n = 2; Black Caribbean OR = 2.64, 95% CI = 1.88 to 3.72, n = 8) and criminal justice system involvement (Black Caribbean OR = 2.76, 95% CI = 2.02 to 3.78, n = 5; Black African OR = 1.92, 95% CI = 1.32 to 2.78, n = 3). The White Other patients also showed greater police and criminal justice system involvement than White British patients (OR = 1.49, 95% CI = 1.03 to 2.15, n = 4). General practitioner involvement was less likely for Black than the White reference group. No significant variations over time were found across all the main outcomes.

CONCLUSIONS

Our updated meta-analyses reveal persisting but not significantly worsening patterns of ethnic inequalities in pathways to psychiatric care, particularly affecting Black groups. This provides a comprehensive evidence base from which to inform policy and practice amidst a prospective Mental Health Act reform.

TRIAL REGISTRATION

CRD42017071663.

The acute efficacy of antipsychotics in schizophrenia: a review of recent meta-analyses

Schizophrenia is the eighth leading cause of disability worldwide in people aged 15-44 years. Before antidopaminergic antipsychotics were introduced in the 1950s, no effective medications existed for the treatment of schizophrenia. This review summarizes key meta-analytic findings regarding antipsychotic efficacy in the acute treatment of schizophrenia, including clozapine in treatment-resistant patients. In the most comprehensive meta-analysis of randomized controlled trials conducted in multi-episode schizophrenia, antipsychotics outperformed placebo regarding total symptoms, positive symptoms, negative symptoms, depressive symptoms, quality of life and social functioning. Amongst these outcomes, the standardized mean difference for overall symptoms was largest, that is, 0.47 (95% credible interval = 0.42-0.51), approaching a medium effect size, being reduced to 0.38 when publication bias and small-trial effects were accounted for. A comparison of two meta-analyses indicated that first-episode patients, compared with multi-episode patients, were more likely to have at least minimal treatment response [⩾20% Positive and Negative Syndrome Scale (PANSS)/Brief Psychiatric Rating Scale (BPRS) score reduction: 81% versus 51%] and good response (⩾50% PANSS/BPRS score reduction: 52% versus 23%). In multi-episode schizophrenia, no response or worsening after 2 weeks of a therapeutic antipsychotic dose was highly predictive of not achieving a good response at endpoint (median treatment = 6 weeks: specificity = 86%; positive predictive value = 90%), suggesting a change in treatment should be considered in such cases. In first-episode psychosis, adequately dosed antipsychotic treatment trials for more than 2 weeks are recommended before using no response or worsening as a decision point for aborting a given antipsychotic. In clearly defined treatment-resistant schizophrenia, clozapine generally outperformed other antipsychotics, especially when dosed appropriately (target = 3-6 months' duration; trough clozapine level ⩾350-400 μg/L) with a response rate (⩾20% PANSS/BPRS) of 33% by 3 months of treatment. High antipsychotic doses and psychotropic combinations are unlikely to be superior to standard doses of antipsychotic monotherapy. Acute antipsychotic efficacy in schizophrenia depends on the targeted symptom domain (greater efficacy: total and positive symptoms, lesser efficacy: negative symptoms, depressive symptoms, social functioning and quality of life). Greater antipsychotic efficacy is associated with higher total baseline symptom severity, treatment-naïveté/first-episode status, shorter illness duration, and trials that are nonindustry sponsored and that have a lower placebo effect. The heterogeneity of antipsychotic response across individuals and key symptom domains, the considerable degree of nonresponse/treatment resistance in multi-episode patients, and the adverse effect potential of antipsychotics are major limitations, underscoring the need to develop new medications for the treatment of schizophrenia. Drug development should include matching patient subgroups, which are identified by means of clinical and biomarker variables, to mechanisms of action of novel medications, targeting specific symptom domains, and investigating mechanisms of action other than dopaminergic blockade.

Time-Dependent Alterations in the Expression of NMDA Receptor Subunits along the Dorsoventral Hippocampal Axis in an Animal Model of Nascent Psychosis

Psychosis is a mental condition that is characterized by hallucinations, delusions, disordered thought, as well as socio-emotional and cognitive impairments. Once developed, it tends to progress into a chronic psychotic illness. Here, the duration of untreated psychosis plays a crucial role: the earlier the treatment begins, relative to the first episode of the disease, the better the patient's functional prognosis. To what extent the success of early interventions relate to progressive changes at the neurotransmitter receptor level is as yet unclear. In fact, very little is known as to how molecular changes develop, transform, and become established following the first psychotic event. One neurotransmitter receptor for which a specific role in psychosis has been discussed is the N-methyl-d-aspartate receptor (NMDAR). This receptor is especially important for information encoding in the hippocampus. The hippocampus is one of the loci of functional change in psychosis, to which a role in the pathophysiology of psychosis has been ascribed. Here, we examined whether changes in NMDAR subunit expression occur along the dorsoventral axis of the hippocampus 1 week and 3 months after systemic treatment with an NMDAR antagonist (MK801) that initiates a psychosis-like state in adult rats. We found early (1 week) upregulation of the GluN2B levels in the dorso-intermediate hippocampus and late (3 month) downregulation of GluN2A expression across the entire CA1 region. The ventral hippocampus did not exhibit subunit expression changes. These data suggest that a differing vulnerability of the hippocampal longitudinal axis may occur in response to MK801-treatment and provide a time-resolved view of the putative development of pathological changes of NMDAR subunit expression in the hippocampus that initiate with an emulated first episode and progress through to the chronic stabilization of a psychosis-like state in rodents.

Duration of untreated psychosis (DUP) and outcome of people with schizophrenia in rural China: 14-year follow-up study

This study aims to examine the relationship between the duration of untreated psychosis (DUP) and 14-year outcomes of schizophrenia in a Chinese rural area. Participants with schizophrenia (n = 510) were identified in an epidemiological investigation of 123 572 people aged 15 years and older in 1994 and followed up in 2008 in Xinjin, Chengdu, China. Longer DUP (>6 months) was common in participants (27.3%). In 1994, participants with DUP ≤ 6 months were more likely to have a significantly lower rate of suicide attempts, shorter duration of illness and higher rate of full remission compared with those with DUP > 6 months. No significant differences were found regarding the rates of survival, suicide, death due to other causes and homelessness between individuals with shorter and longer DUP in 2008. Nevertheless, longer DUP (>6 months) of participants in 2008 was significantly associated with higher mean of PANSS total negative and general mental scores, longer duration of illness and higher rate of live alone in the logistic regression model. Earlier identification, treatment and rehabilitation, and family intervention should be addressed when developing mental health policies and delivering community mental health services.

Towards a comprehensive routine outcome monitoring program for people with psychotic disorders: The Pharmacotherapy Monitoring and Outcome Survey (PHAMOUS)

BACKGROUND

Patients with psychotic disorders are at risk of developing mental health and social problems, and physical disorders. To monitor and treat these problems when indicated, an annual routine outcome monitoring program, Pharmacotherapy Monitoring and Outcome Survey (PHAMOUS), was developed. This paper presents the background and content of PHAMOUS, implementation of PHAMOUS, characteristics of the patients screened in 2015, and the outcome of patients with three annual screenings between 2011 and 2015.

METHODS

PHAMOUS was implemented in four mental health institutions in the Northern Netherlands in 2006. During the PHAMOUS screening, patients are assessed on socio-demographics, psychiatric symptoms, medication, physical parameters, lifestyle, (psycho)social functioning and quality of life, using internationally validated instruments.

RESULTS

In 2015, 1955 patients with psychotic disorders were enrolled in the PHAMOUS screening. The majority (72%) was receiving mental healthcare for ten years or longer. A small group was hospitalized (10%) in the past year. Half of the patients were in symptomatic remission. Less than 10% had a paid job. More than half of the patients fulfilled the criteria for metabolic syndrome (54%). The subsample with three annual screenings from 2011 to 2015 (N = 1230) was stable, except the increasing prevalence of high glucose levels and satisfaction with social relationships (Cochran's Q = 16.33, p = .001 resp. Q = 14.79, p = .001).

CONCLUSION

The annual PHAMOUS screening enables to follow the mental, physical and social health problems of patients, which offers a good basis for shared-decision making with regard to updating the annual treatment plan, next to a wealth of data for scientific research.

Duration of untreated prodromal symptoms in a Chinese sample at a high risk for psychosis: demographic, clinical, and outcome

BACKGROUND

The duration of untreated psychosis (DUP) has been widely studied. However, for individuals with attenuated psychosis syndrome (APS), it is unclear whether the duration of untreated prodromal symptoms (DUPrS) also has a negative effect on the progression of psychosis. Our aim was to identify demographic and clinical factors contributing to the DUPrS in a large sample of individuals with APS, and to evaluate the association between DUPrS and the conversion to psychosis.

METHOD

A sample of 391 individuals with APS, who were identified through a structured interview for prodromal syndromes, were included in this study, of whom a total of 334 patients had completed at least a 1-year clinical follow-up. A total of 57 individuals had converted to psychosis.

RESULTS

The average DUPrS was 4.8 months for the whole sample. Individuals with a longer DUPrS were likely to be men, non-local residents, with abnormal thought symptoms, a higher severity level of negative symptoms, the lower severity level of general symptoms, and lower level of general function before the onset of attenuated positive symptoms. A DUPrS of less than 2 months, or more than 6 months, lowered the risk for conversion to psychosis.

CONCLUSIONS

Our data suggested that the association between the DUPrS and outcome in individuals with APS were likely to be different, which is either long or short DUPrS was not related to future psychosis onset. Individuals with APS were more likely to have a group of features associated with a longer DUPrS.

Socioeconomic inequalities in duration of untreated psychosis: evidence from administrative data in England

BACKGROUND

Duration of untreated psychosis (DUP) is an important measure of access to care as it predicts prognosis and treatment outcomes. Little is known about potential socioeconomic inequalities in DUP. The aim of this study was to investigate inequalities in DUP associated with socioeconomic deprivation in a national cohort in England.

METHOD

We analysed a cohort of 887 patients with a first-episode in psychosis using the administrative Mental Health Services Dataset in England for 2012/13-2014/15. We used a Generalised Linear Model to account for non-linearity in DUP and looked at inequalities across the whole distribution of DUP using quantile regression.

RESULTS

The median DUP was 22 days (mean = 74 days) with considerable variations between and within the 31 hospital providers. We found evidence of significant inequalities regarding the level of socioeconomic deprivation. Patients living in the second, third and fourth deprived neighbourhood quintiles faced a 36, 24 and 31 day longer DUP than patients from the least deprived neighbourhoods. Inequalities were more prevalent in higher quantiles of the DUP distribution. Unemployment prolonged DUP by 40 days. Having been in contact with mental health care services prior to the psychosis start significantly reduced the DUP by up to 53 days.

CONCLUSIONS

Socioeconomic deprivation is an important factor in explaining inequalities in DUP. Policies to improve equitable access to care should particularly focus on preventing very long delays in treatment and target unemployed patients as well as people that have not been in contact with any mental health professional in the past.

Duration of untreated psychosis and neurocognition in first-episode psychosis: A meta-analysis

Neurocognitive impairment is a well-established feature of first-episode psychosis (FEP). Neurotoxicity hypothesis of psychosis suggests that untreated psychosis before the initiation of first effective treatment is associated with loss of acquired cognitive abilities. However, the outcome of the studies investigating the relationship between duration of untreated psychosis (DUP) and cognitive impairment in FEP remains inconclusive. No previous meta-analysis investigating the relationship between DUP and cognitive impairment in FEP has been published. Following the systematic review of FEP studies, a random-effects meta-analysis of the relationship between DUP and neurocognition in schizophrenia was conducted. Current meta-analysis included 27 studies including 3127 patients with first-episode psychosis. Overall, DUP and cognitive abilities were not significantly related, with the exception of evidence for a weak relationship with a single cognitive domain. There was a very small but significant association between longer DUP and reduced performance in planning/problem-solving ability (r=-0.09, CI=-0.14 to -0.03). Current findings do not provide support for the neurotoxicity hypothesis of psychosis.

Openness to experience shortens duration of untreated psychosis in Serbian clinical population

AIM

To determine duration of untreated psychosis (DUP) in patients with schizophrenia-spectrum disorders from Serbia and to analyse factors that potentially contribute to the treatment delay, with focus on personality traits.

METHODS

Fifty seven patients (males 54.4%; age = 29.9 ± 6.0 yrs; age at the illness onset = 24.9 ± 5.1 yrs; IQ = 93.5 ± 12.2) were included. The assessment consisted of Nottingham Onset Schedule (NOS), Premorbid Adjustment Scale (PAS) and NEO Personality Inventory (NEO-PI-R). We used Cox regression model to evaluate relationship between DUP and explanatory variables.

RESULTS

Based on the most restrictive definition, the length of DUP in our sample was 77.8 ± 120.6 weeks (MED = 25.0 weeks). DUP was negatively associated with openness to experience (B = -0.804, P = 0.024).

CONCLUSIONS

We report the first evidence of DUP in Serbia, emphasizing that the personality domains are likely to impact the use of mental health care in persons with psychosis.

Schizophrenia outcome measures in the wider international community

Background

Outcome of schizophrenia has been described as favourable in low-and middle-income countries. Recently, researchers have questioned these findings

Aims

To examine the outcome studies carried out in different countries specifically looking atthose from low-and middle-income countries

Methods

Long-term course and outcome studies in schizophrenia were reviewed

Results

A wide variety of outcome measures are used. The most frequent are clinical symptoms, hospitalisation and mortality (direct indicators), and social/ occupational functioning, marriage, social support and burden of care (indirect indicators). Areas such as cognitive function, duration of untreated psychosis, quality of life and effect of medication have not been widely studied in low-and middle-income countries

Conclusions

The outcome of schizophrenia appears to be better in low-and middle-income countries. A host of sociocultural factors have been cited as contributing to this but future research should aim to understand this better outcome. There is a need for more culture-specific instruments to measure outcomes

Problems with early and very early intervention in psychosis

‘Early intervention’ can refer to two different approaches-intervention when the psychosis is already evident and intervention before a psychosis is fully apparent. Each carries a distinctly different set of risks. The hoped-for benefits of early intervention in a fully evident psychosis are based on research that reveals an association between intervention early in the illness and good outcome. Those suffering from a psychosis of recent onset, however, are more likely to experience a spontaneous remission of illness, and this may readily explain the observed association. Early intervention in such cases of good-prognosis psychosis may lead to unnecessary and, sometimes, protracted treatment for those who would do well with no treatment. Intervention in the supposed prodromal phase of psychosis presents more serious hazards. The screening instruments currently available are inadequate for the accurate prediction of psychosis, and the risks of negative effects for the large numbers of people who screen false-positive are considerable. These risks include unnecessary fear of illness, restriction of life goals, use of medication and their side-effects.

Integrating non-drug treatments in early schizophrenia

There is a range of psychological interventions for established schizophrenia. These include family interventions, motivational interventions for substance misuse and for non-adherence to medication, cognitive remediation for neurocognitive deficits and cognitive–behavioural therapy for symptoms. Psychological interventions may explicitly target risk factors for poor outcome, such as substance use, or protective factors, such as adherence to medication, or be directed at specific symptoms or deficits. There is emerging evidence for efficacy of psychological treatments during, following and even prior to the first episode. Important areas for further study are how different treatment modalities can interact productively and patient and carer preferences for treatment. Many trials of psychological treatments have design flaws and this tends to overestimate the treatment effect.

Duration of untreated psychosis and its relationship to clinical outcome

Background

A major reason for interest in early intervention for psychotic disorders is the hypothesised relationship between longer duration of untreated psychosis (DUP) and poorer outcome of treatment.

Aims

To critically examine the evidence concerning DUP being related to treatment outcome and possible mediators of any such relationship.

Method

A systematic review of studies in which DUP is assessed and its relationship to treatment outcome is examined. In addition, studies relevant to possible neurotoxic effects of DUP were reviewed.

Results

The research is entirely of a correlational nature and, therefore, firm conclusions regarding causation are not possible. There is, however, substantial evidence of DUP being an independent predictor of treatment outcome, particularly remission of positive symptoms, over the first year or so of treatment. Findings regarding the possible neurotoxic effects of DUP are inconsistent.

Conclusions

There continues to be evidence consistent with DUP influencing aspects of treatment outcome. Non-correlational studies, such as quasi-experimental designs, could provide stronger evidence regarding causality.

First-episode schizophrenia, bipolar disorder and other psychoses in a rural Irish catchment area: Incidence and gender in the Cavan–Monaghan study at 5 years

Background

The potential of first-episode studies in schizophrenia is maximised through systematic epidemiological, clinical and biological comparisons between homogeneous populations of the psychoses.

Aims

To conduct prolonged accrual of ‘all’ cases of non-affective and affective psychotic illness on an epidemiologically complete basis.

Method

Within the region covered by Cavan–Monaghan psychiatric service (population 102 810), all putative cases of first-episode psychosis were diagnosed using DSM–IV.

Results

From 1995 to 2000, 69 cases of psychosis were ascertained, the incidence being 2.3-fold lower in females than in males. On resolving the ‘core’ diagnoses of schizophrenia and bipolar disorder, incidence of schizophrenia among women was 7.5-fold lower than among men whereas incidence of bipolar disorder among women was 6.6-fold lower than among men.

Conclusions

This homogeneous population, which eliminates factors associated with urbanicity and minimises confounding factors such as socioeconomic, ethnic and geographical diversity, shows a markedly reduced incidence among females both of schizophrenia and of bipolar disorder.

Randomised controlled trial of early detection and cognitive therapy for preventing transition to psychosis in high-risk individuals

Background

There is interest in the possibility of indicated prevention of psychosis. There is a strong case for using psychological approaches to prevent transition to psychosis in high-risk patients.

Aims

To identify individuals at high risk of transition to psychosis, and psychological characteristics relevant to the development of psychosis in this group.

Method

The design of a randomised controlled trial of cognitive therapy for the prevention of psychosis in people at high risk (meeting operational criteria of brief or attenuated psychotic symptoms, or first-degree family history with functional decline) is outlined. The first patients recruited are compared with non-patient samples on cognitive and personality factors; an interim analysis of transition rate is reported.

Results

Cases (n=31) were recruited mainly from primary care. Of the 23 high-risk patients monitored for 6–12 months, 5 (22%) made the transition to psychosis. The high-risk group scored significantly higher than non-patients on measures of schizotypy, metacognitive beliefs and dysfunctional self-schemas (sociotropy).

Conclusions

The findings validate the methods of identifying individuals at high risk of experiencing a psychotic episode. Compared with non-patient controls, the cases showed dysfunctional metacognitive beliefs and self-schemas.

Duration of untreated psychosis and pathways to care in first-episode psychosis

Background

Studies have consistently found that many individuals with first-episode psychosis experience significant delays before receiving treatment. Current research investigating treatment delays has focused on the relationship between demographic factors and duration of untreated psychosis (DUP). However, treatment-seeking behaviours in this group have not been investigated.

Aims

To examine psychological processes that influence the decision-making process to contact primary care, in individuals with emerging psychosis.

Method

The influence of coping style, health locus of control and past health help-seeking behaviour on DUP was investigated in clients with a first episode of psychosis. This involved scrutiny of general practitioner (GP) records in an average of 6 years before the first treatment.

Results

Shorter DUP was associated with more frequent GP attendance in the 6 years before the onset of psychosis and lower health threat avoidant coping scores.

Conclusions

Patients with short DUP have a history of higher contact with their GP and, as a group, tend not to avoid health threats. The study underlines the importance of engaging young people and their families with primary care as one of a series of strategies to reduce DUP.

Associations between duration of untreated psychosis and domains of positive and negative symptoms

AIM

The duration of untreated psychosis (DUP) has been established as an independent and significant predictor of negative outcomes in first-episode psychosis samples. Whereas literature has supported the association between DUP and severity of positive and negative symptoms, surprisingly little research to date has explored specifically what types of positive and negative symptoms are most associated with DUP.

METHODS

DUP, Scale for the Assessment of Positive Symptoms (SAPS) and Scale for the Assessment of Negative Symptoms (SANS) data were collected in 247 first-episode psychosis participants (mean age: 23.9 ± 4.8) between August 2008 and June 2013.

RESULTS

DUP was significantly but modestly associated with the severity of hallucinations (ρ = 0.222; P = 0.001), delusions (r = 0.202; P = 0.003) and formal thought disorder (ρ = 0.138; P = 0.043) but was not associated with bizarre behaviour. DUP was significantly but modestly associated with SANS avolition-apathy (ρ = 0.164; P = 0.016) and anhedonia-asociality (r = 0.321; P < 0.001) subscales but was not associated with affective flattening or blunting, alogia or attention.

CONCLUSIONS

DUP is a complex and multifaceted phenomenon that is associated with early-course illness development. In efforts to improve early intervention services, prognoses and outcomes, it is vital to understand both the factors that contribute to lengthy untreated psychosis as well as the illness characteristics that are impacted by untreated psychosis.

Comparing the mental health literacy of Chinese people in Australia, China, Hong Kong and Taiwan: Implications for mental health promotion

Using data of 200, 522, 572, and 287 Chinese from Australia, China, Hong Kong and Taiwan respectively, this study aimed at comparing the mental health literacy of Chinese people from different communities, and between Chinese communities and the Australian general public. The participants were asked questions that assessed their recognition of depression and schizophrenia. Compared with the Australians, much lower percentages of Chinese in the four Chinese communities could correctly identify depression and early schizophrenia. Commonalities in the preference for 'psychiatrist', 'psychologist', 'Chinese medical doctor', and 'Chinese traditional healer', a lack of knowledge of medications, and a higher likelihood of endorsement of traditional Chinese medicines were found among the four Chinese communities. Differences in the preference for 'general practitioner' and 'social worker', and a higher percentage of endorsement of herbal medicines were observed among the different Chinese communities. Cultural factors such as Chinese perceptions of mental illness, and socio-contextual factors such as differences in mental health care system in the four communities were offered to explain these commonalities and differences. Mental health promotion programmes for Chinese people may need to consider the above-mentioned cultural and socio-contextual factors so that specific promotion programmes can be developed.