Introduction to ‘Early psychosis: abridge to the future’

A Treatment Model for Young Adults with Severe Mental Disorders in a Community Mental Health Center: The Crisalide Project and the Potential Space

In line with priorities set by the Italian Ministry of Health and international literature, the "Crisalide project" provides specific care pathways aimed at young adults (YA) with severe mental disorders (SMD). As described in Materials and Methods, it consists of three lines of activity: transition to adult mental health services (TSMREE/CSM 17-19); Diagnostic, Therapeutic, and Assistance Pathways for Young Adults (PDTA-YA); high-intensity treatment center for young adults "Argolab2 Potential Space". The aim of the study is to assess the results relating to the first three years of implementation of this clinical-organizational model (2018/2020) according to the process indicators identified by the ministry. Among the population aged 18-30 under treatment, results show increased prevalence (30%) and incidence (26%); 0% treatment conclusions due to the expiration of the conventional time limit; 0% involuntary hospitalizations (TSO); 0% STPIT hospitalizations; 0% repeated hospitalizations; 0% hospitalizations in the common mental disorders diagnostic group. Among the population of Argolab2 Potential Space, 45.4% have resumed studies; 40.9% have had a first work experience; 22.7% have obtained educational or training qualifications, and 18.2% live in independent houses. At a time when the academic literature underlines the terrible impact of the COVID-19 pandemic on this population, the present study confirms that specific treatment processes for young populations are a protective factor.

Paradigm shift? Purity, progress and the origins of first-episode psychosis

First-episode psychosis has garnered significant attention and resources within mental health services in North America, Europe and Australia/New Zealand since the 1990s. Despite this widespread embrace, little scholarship exists that examines underlying concepts, ideologies and imagery embedded within the early intervention paradigm. In this paper, I offer a sociohistorical analysis of the emergence of first-episode psychosis and early intervention as entities in psychiatry, drawing on contemporary philosophical thought to explore various concepts embedded in them. Although scattered references to 'prodrome' and 'incipient cases' exist in the historic psychiatric literature, the notion of first-episode psychosis as a distinct chronological stage emerged in the late 1980s. This occurred in response to a desire for a homogeneous, medication-naive population within schizophrenia research. Thematically, concerns regarding 'purity' as well as notions of 'progress' can be read off of the body of work surrounding the creation of the term and its development into a clinical organising concept. Furthermore, examining the sociohistorical context of the term demonstrates its entanglement with the course of atypical antipsychotic drug development, the expansion of clinical rating scales and wider neoliberal biopolitics within healthcare. Within psychiatry, the early intervention model has been termed a 'paradigm shift,' with the promise that earlier interventions will translate into shorter durations of untreated illness, improved utilisation of services and better prognoses for recovery. While these are laudable goals, they are tied to assumptions about biomedical progress and idealisations of clinical populations that feminist and disability critiques problematise.

Schizophrenia and violence: from correlations to preventive strategies

People with schizophrenia make a significant contribution to violence in our communities and, in so doing, often lay waste to their own lives. The 10% or so from which will emerge the perpetrators of most of the serious violence are identifiable in advance. A structured programme in which the criminogenic personality and behavioural factors, substance misuse and social dislocation are managed together with the active symptoms of the disorder could prevent the progress to violence. Such systems of care could significantly reduce serious criminal violence and homicide, reduce the number of people with schizophrenia who end up in prison, stop the rising number of forensic psychiatric beds and, most importantly, improve the lives of many of the most disturbed and disadvantaged of those with the disorder.

A review of spin and bias use in the early intervention in psychosis literature

OBJECTIVE

The early intervention in psychosis literature has recently appropriated clinical terms with etiologic implications such as staging and pluripotent from the oncology literature without adopting the methodological rigor of oncology research. Oncology research maintains this rigor, among other methods, by examining the literature for evidence of bias and spin, which obscures negative trials. This study was designed to detect possible use of reporting bias and spin in the early intervention in psychosis literature.

DATA SOURCES

Articles were selected from PubMed searches for early intervention in psychosis, duration of untreated psychosis, first-episode psychosis, ultra-high risk, and at risk mental state between January 1, 2000, and May 31, 2013.

STUDY SELECTION

38 RCT and quasi-experimental articles reporting results from early intervention in psychosis paradigms were selected for inclusion.

DATA EXTRACTION

Articles were examined for evidence of inappropriate reporting of primary and secondary end points in the abstract (reporting bias) and presentation as positive despite negative primary end points (spin).

RESULTS

While only 13% of early intervention articles reported positive primary end points, abstracts implied that 76% of articles were positive. There was evidence of bias in 58% of articles and spin in 66% of articles.

CONCLUSIONS

There was a high prevalence of spin and bias in the early intervention in psychosis literature compared to previous findings in the oncological literature. The most common techniques were changing the primary end point or focusing on secondary end points when the primary end point was negative and reporting analyses using only a subset of the data. There appears to be a need for greater scrutiny of the early intervention in psychosis literature by editors, peer reviewers, and critical readers of the literature.

Dynamic association between interpersonal functioning and positive symptom dimensions of psychosis over time: a longitudinal study of healthy adolescents

BACKGROUND

Cross-sectional studies have indicated that alterations in social functioning, particularly interpersonal functioning, are associated with the occurrence of psychotic symptoms and experiences at different levels of the extended psychosis phenotype (ranging from population psychometric expression of liability to overt psychotic disorder). However, more research is needed on the development of this association over time.

METHODS

Cross-lagged path modeling was used to analyze bidirectional, longitudinal associations between 4 dimensions of subclinical psychotic experiences (persecutory ideation, bizarre experiences, perceptual abnormalities, and magical thinking) and interpersonal functioning in an adolescent general population sample (N = 881 at T1, N = 652 at T2, and N = 512 at T3) assessed 3 times in 3 years.

RESULTS

All symptom dimensions showed some association with interpersonal functioning over time, but only bizarre experiences and persecutory ideation were consistently and longitudinally associated with interpersonal functioning. Poorer interpersonal functioning predicted higher levels of bizarre experiences and persecutory ideation at later measurement points (both T1 to T2 and T2 to T3).

CONCLUSIONS

Poor interpersonal functioning in adolescence may reflect the earliest expression of neurodevelopmental alterations preceding expression of psychotic experiences in a symptom-specific fashion.

Is early intervention in psychosis cost-effective over the long term?

OBJECTIVE

This study assesses the long-term cost-effectiveness of a comprehensive model of mental health care for first-episode psychosis. The study is an extension of a previous economic evaluation of the Early Psychosis Prevention and Intervention Centre (EPPIC) that assessed the first-year costs and outcomes of treatment.

METHOD

The current study used a matched, historical control group design with a follow-up of approximately 8 years. Complete follow-up data were available for 65 of the original 102 participants. Direct public mental health service costs incurred subsequent to the first year of treatment and symptomatic and functional outcomes of 32 participants initially treated for up to 2 years at EPPIC were compared with a matched cohort of 33 participants initially treated by generic mental health services. Treatment-related resource use was measured and valued using Australian published prices.

RESULTS

Almost 8 years after initial treatment, EPPIC subjects displayed lower levels of positive psychotic symptoms (P = .007), were more likely to be in remission (P = .008), and had a more favorable course of illness (P = .011) than the controls. Fifty-six percent of the EPPIC cohort were in paid employment over the last 2 years compared with 33% of controls (P = .083). Each EPPIC patient costs on average A$3445 per annum to treat compared with controls, who each costs A$9503 per annum.

CONCLUSIONS

Specialized early psychosis programs can deliver a higher recovery rate at one-third the cost of standard public mental health services. Residual methodological limitations and limited sample size indicate that further research is required to verify this finding.

Model fidelity of assertive community treatment for clients with first-episode psychosis: a target group-specific application

Assertive community treatment (ACT) is described as a team treatment model designed to provide assertive, outreaching, comprehensive, community-based, rehabilitation-oriented and supportive psychiatric services for people with severe mental illness as reported by Drake et al. (Psychiatr Serv 52: 179-182, 2001) and Teague et al. (Psychiatr Serv 68: 216-232, 1998). This study explores variations in the way the original components of ACT are implemented for the target group of clients with a first-episode psychosis, and establishes whether these variations lead the treatment model to a higher, more valuable, outcome level. The study also describes how to achieve this optimally effective application of target group-specific treatment services.

Detection of psychosis by mental health care services; a naturalistic cohort study

Background

Detection of psychotic disorders is an important issue, since early treatment might improve prognosis. Timely diagnosis of psychotic disorders depends on recognition of psychotic symptoms and their interpretation. The aim of this study is to examine to what extent reported psychotic symptoms are accounted for in clinical diagnosis.

Methods

The medical files of all patients who had a first contact with one of two mental health care services (N = 6477) were screened for reported psychotic symptoms and subsequent clinical diagnosis. Patients who reported psychotic symptoms and who were diagnosed with a psychotic disorder were followed-up for two years to register prescription of antipsychotic treatment and continuity of care.

Results

In the files of 242 (3.7%) patients specific psychotic symptoms were recorded. 37% of these patients were diagnosed with a non-affective psychotic disorder, 7% with other psychotic disorders and 56% with non-psychotic disorders or no diagnosis at all. About 90% of the patients diagnosed with a psychotic disorder did receive any prescription of antipsychotics, and about 50% were in continuous care during the first 2 years.

Conclusion

Relatively large proportions of patients presenting with psychotic symptoms were diagnosed with a non-psychotic diagnosis or not diagnosed at all. This applies also to patients reporting at least two or more psychotic symptoms. Although we did not verify the appropriateness of clinical diagnosis, these findings are an indication that psychotic disorders may be underdetected. Improving the diagnostic process in mental health care services may be the most obvious way to promote early intervention in psychosis.

The promise of early intervention

The focus of this review is the research and clinical work in early psychosis and early intervention which over the past 10-15 years has had a tremendous impact on the field of schizophrenia. Unparalleled progress has been made in programme and service development with a wide range of reported research results, outcome studies, treatment approaches and new initiatives. Traditional areas are being explored in the first episode that can add to our knowledge of schizophrenia. New areas that have a specific relevance for early intervention such as the duration of untreated psychosis and pathways to care are being widely studied. Despite the criticism of the lack of randomized controlled trials, there is a wealth of positive outcome from both effectiveness studies and limited controlled trials. However, there are still many unanswered issues which are in developing stages or which require further investigation.

Early intervention in psychotic disorders: detection and treatment of the first episode and the critical early stages

The two main goals of early intervention in psychotic disorders are to reduce the period of time between the onset of psychosis and the commencement of effective treatment, and to provide consistent and comprehensive care during the critical early years of illness. Effective care during the critical early years involves proactive engagement and initiation of drug and psychosocial treatments, aiming for maximal symptomatic and functional recovery and the prevention of relapse. Over the past 15 years, an increasing number of specialised or streamed treatment delivery systems for early psychosis have been established around the world. There is now evidence that these services can reduce the duration of untreated psychosis and produce better symptomatic and functional recovery. In addition, they are more cost-effective than standard models of mental health care for these patients. Fully fledged, specialised early intervention services should be established, with full integration with local communities, as well as enhanced primary care systems focused on young people.

Effectiveness of early intervention in psychosis

PURPOSE OF REVIEW

Over 15 years, early intervention in psychosis has grown to become a mainstream funded approach to clinical care. This review examines recent developments in evaluating the effectiveness of early intervention. It considers identification and treatment of those at risk of psychosis, as well as interventions in the post-onset phase of illness.

RECENT FINDINGS

Development of methods identifying those at risk of psychosis continues to evolve. Promising results in the prevention and delay of transition to psychotic disorder from a high-risk state have been found. Psychological and psychosocial interventions are important components of these preventive programmes. Two recent meta-analyses indicate that there is a consistent relationship between duration of untreated psychosis and outcome independent of other factors. Further evidence shows that early intervention reduces the duration of untreated psychosis, produces better outcomes in terms of symptomatic and functional domains, and is cheaper than standard models of care.

SUMMARY

There is evidence that early intervention is effective for early psychosis. Some challenges remain. These include developing a greater focus on functional recovery and prevention of relapse.

Reducing Polypharmacy Through the Introduction of a Treatment Algorithm: Use of a Treatment Algorithm on the Impact on Polypharmacy

Introduction: Polypharmacy is very common in the psychiatric setting despite the lack of evidence to justify its use. The objective of this study was to review the prescription patterns in a tertiary mental health institute in Asia and evaluate the impact of a treatment algorithm for patients with first-episode psychosis (FEP) on the use of polypharmacy. Materials and Methods: A treatment algorithm was implemented for patients accepted into an Early Psychosis Intervention Programme (EPIP) and the prescription patterns of these patients were compared with a comparator group (pre-EPIP) before the use of the algorithm. The prescribing pattern was established at 2 points: at baseline after the diagnosis was made, and 3 months later. Results: There were 68 subjects in the comparator group and 483 EPIP patients; the latter were on the average younger. None in the comparator group was diagnosed to have an affective psychosis. There was a significant reduction in the rate of antipsychotic polypharmacy, prolonged use of benzodiazepines and anticholinergic medication in EPIP patients. This group also had an increase in the use of second-generation antipsychotics and received lower doses of antipsychotics. Conclusion: The implementation of a treatment algorithm coupled with audit has changed the trend towards polypharmacy among patients with FEP. Key words: Antipsychotics, Drug use review, Psychosis