Duration of untreated psychosis and social function: 1-year follow-up study of first-episode schizophrenia

Determinants of Disability Among Individuals Living with Schizophrenia Attending Psychiatric Follow-Up Clinic in Jimma, Southwest Ethiopia: An Institution-Based Case-Control Study

Background

Disability due to schizophrenia ends up with a higher degree of impairment in occupational, social and interpersonal functioning than other chronic illnesses. Despite severe and long-lasting schizophrenia associated disability, little has been explored so far to identify determinants of disability among individuals living with schizophrenia in Ethiopia.

Objective

To identify the determinants of disability among individuals living with schizophrenia attending the psychiatric follow-up clinic at Jimma Medical Center (JMC).

Methods

An institution-based unmatched case-control study was conducted among 98 Cases and 98 controls of individuals living with schizophrenia attending the JMC psychiatric clinic from September 1 to October 30, 2022. Consecutive sampling technique was used to recruit the required sample size of both groups. The cases group were participants who scored >12 total on the WHO Disability Assessment Scale version 2-0 (WHODAS 2-0) whereas the control group were those who scored 12 total on the WHODAS 2-0.

Results

Being jobless (AOR = 2.29; 95% CI: 1.10-4.77), longer than 5-year duration of illness without treatment (AOR = 3.13; 95% CI: 1.23-7.98), poor social support (AOR = 2.54; 95% CI: 1.04-6.22), negative symptoms (AOR = 2.45; 95% CI: 1.14-5.29), known family history of mental illness (AOR = 3.59; 95%: 1.67-7.73) and risky khat use (AOR = 4.37; 95% CI: 1.86-10.29) were found to be determinants of disability among schizophrenia patients.

Conclusion

Joblessness, longer than 5-year duration of illness without treatment, poor social support, negative symptoms, known family history of mental illness and risky khat use were found to be determinants of disability in schizophrenia patients. Interventions targeting reducing of disability and improving quality of life of schizophrenia patients should consider the aforementioned determinants.

Add-on Sodium Benzoate and N-Acetylcysteine in Patients With Early Schizophrenia Spectrum Disorder: A Multicenter, Double-Blind, Randomized Placebo-Controlled Feasibility Trial

Background and Hypothesis

Oxidative stress pathways may play a role in schizophrenia through direct neuropathic actions, microglial activation, inflammation, and by interfering with NMDA neurotransmission. N-acetylcysteine (NAC) has been shown to improve negative symptoms of schizophrenia, however, results from trials of other compounds targeting NMDA neurotransmission have been mixed. This may reflect poor target engagement but also that risk mechanisms act in parallel. Sodium Benzoate (NaB) could have an additive with NAC to act on several pathophysiological mechanisms implicated in schizophrenia.

Study Design

A multicenter, 12 weeks, 2 × 2 factorial design, randomized double-blind placebo-controlled feasibility trial of NaB and NAC added to standard treatment in 68 adults with early schizophrenia. Primary feasibility outcomes included recruitment, retention, and completion of assessments as well as acceptability of the study interventions. Psychosis symptoms, functioning, and cognitive assessments were also assessed.

Study Results

We recruited our desired sample (n = 68) and retained 78% (n = 53) at 12 weeks, supporting the feasibility of recruitment and retention. There were no difficulties in completing clinical outcome schedules. Medications were well tolerated with no dropouts due to side effects. This study was not powered to detect clinical effect and as expected no main effects were found on the majority of clinical outcomes.

Conclusions

We demonstrated feasibility of conducting a clinical trial of NaB and NAC. Given the preliminary nature of this study, we cannot draw firm conclusions about the clinical efficacy of either agent, and a large-scale trial is needed to examine if significant differences between treatment groups emerge.

Trial Registration

ClinicalTrials.gov: NCT03510741.

Duration of untreated prodromal psychosis among individuals with clinical high risk for psychosis

The impact of the duration of untreated psychosis on the outcomes of schizophrenia has been extensively studied. However, there is a notable gap in the current understanding of the relationship between the duration of untreated prodromal symptoms (DUPrS) and the development of psychosis in individuals at clinical high risk (CHR). A sample of 704 individuals with CHR was identified through a structured interview, of who 145 (20.6 %) converted to psychosis (CHR-C) during the 3-year follow-up. The DUPrS was defined as the period between the onset of the first attenuated psychotic positive symptom and the commencement of professional assistance at mental health services. Quantile regression was applied for quantile levels between 0.1 and 0.9, and adjusted for age, sex, and education.The overall sample had a mean DUPrS of 7.1 months. No significant differences were observed in the DUPrS between the CHR-C and non-converter (CHR-NC) groups. Quantile regression analysis highlighted variations in the effects of the DUPrS on clinical variables across the different quantiles. We observed a positive association between DUPrS rank and positive symptoms below the 0.3 quantile, while a positive association between DUPrS rank and negative symptoms above the 0.3 quantile (except 0.7 and 0.9 quantile). A longer DUPrS (> 3 months) was associated with younger age (odds ratio [OR] = 0.948, p = 0.003), a higher proportion of women (OR = 1.474, p = 0.003), higher baseline global function (OR = 1.044, p = 0.003), lower previous global function (OR = 0.921, p < 0.001), and higher negative symptoms (OR = 1.061, p = 0.001). This study sheds light on the pivotal role of DUPrS as a potential intermediary factor in the complex pathway of psychosis.

Parental perceptions of second opinion consultations for recent onset schizophrenia

AIM

Correct early diagnosis and intervention for schizophrenia is associated with improved outcomes. This study sought to determine the potential value of specialized consultations for individuals thought to have a recent-onset schizophrenia spectrum disorder who were not receiving specialized care.

METHODS

121 consecutive one-time consultations were performed in a clinic specializing in recent-onset schizophrenia. Parents of 79 patients were questioned about the process and the value of the consultation.

RESULTS

Consultations were perceived by parents as both positive and helpful experiences. 85% of parents were somewhat or very happy with the consultation experience, and 86% found the consultation to be moderately or very helpful. A third of parents viewed the consultation as contributing to the long-term improvement of the patient's condition.

CONCLUSIONS

The findings demonstrate the potential value of consultations for individuals with possible schizophrenia spectrum disorders not receiving specialized treatment, and provide rationale for comprehensive studies investigating the widespread implementation of such consultations.

Off the RADAR; questions regarding the trial protocol of a randomised controlled trial of antipsychotic reduction and discontinuation

The randomised controlled trial of antipsychotic reduction and discontinuation addresses essential questions with regard to continued use of antipsychotics in schizophrenia, pertaining to social functioning and continued antipsychotic use. However, significant methodological issues stated in the trial protocol have the potential to confound interpretation of any findings. These include use of a non-blinded outcome measure, treatment as usual comparator and possible sample size issues.

Correlation between duration of untreated psychosis and long-term prognosis in chronic schizophrenia

OBJECTIVE

To explore the relationship between the Duration of Untreated Psychosis (DUP) and long-term clinical outcome, cognitive and social function in patients with chronic schizophrenia (SCZ).

METHODS

A total of 248 subjects with chronic SCZ were enrolled in this study, including 156 in the short DUP group and 92 in the long DUP group. The Positive and Negative Symptoms Scale (PANSS), the Brief Negative Symptoms Scale (BNSS), the Global Assessment of Functioning (GAF) scale and the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) were used to assess all of the subjects.

RESULTS

The negative symptom scores (the PANSS and BNSS) of subjects with long DUP were significantly higher than that in subjects with short DUP. The scores of visual span and speech function in the short DUP group were significantly higher, indicative of decreasing cognitive function with time. In terms of social function, the short DUP group scored higher, with a statistically significant difference. Meanwhile, we found that the length of DUP was positively correlated with the negative symptom score of the PANSS, negatively correlated with visual span scores, and GAF scores.

CONCLUSION

This study demonstrated that the DUP remained a significant association with negative symptom and cognition in long period of chronic SCZ.

Clinical predictors of antipsychotic treatment resistance: Development and internal validation of a prognostic prediction model by the STRATA-G consortium

INTRODUCTION

Our aim was to, firstly, identify characteristics at first-episode of psychosis that are associated with later antipsychotic treatment resistance (TR) and, secondly, to develop a parsimonious prediction model for TR.

METHODS

We combined data from ten prospective, first-episode psychosis cohorts from across Europe and categorised patients as TR or non-treatment resistant (NTR) after a mean follow up of 4.18 years (s.d. = 3.20) for secondary data analysis. We identified a list of potential predictors from clinical and demographic data recorded at first-episode. These potential predictors were entered in two models: a multivariable logistic regression to identify which were independently associated with TR and a penalised logistic regression, which performed variable selection, to produce a parsimonious prediction model. This model was internally validated using a 5-fold, 50-repeat cross-validation optimism-correction.

RESULTS

Our sample consisted of N = 2216 participants of which 385 (17 %) developed TR. Younger age of psychosis onset and fewer years in education were independently associated with increased odds of developing TR. The prediction model selected 7 out of 17 variables that, when combined, could quantify the risk of being TR better than chance. These included age of onset, years in education, gender, BMI, relationship status, alcohol use, and positive symptoms. The optimism-corrected area under the curve was 0.59 (accuracy = 64 %, sensitivity = 48 %, and specificity = 76 %).

IMPLICATIONS

Our findings show that treatment resistance can be predicted, at first-episode of psychosis. Pending a model update and external validation, we demonstrate the potential value of prediction models for TR.

Global functioning, cognitive function, psychopathological symptoms in untreated patients with first-episode schizophrenia: A cross-sectional study

Although many studies have been conducted on the relationship between cognitive functioning, psychopathological symptoms, and global functioning in patients with schizophrenia, these studies frequently suffer from a lack of control for confounding variables, high attrition rates, and a lack of cognitive domains completed at each assessment point. The purpose of this study is to select patients with untreated first-episode schizophrenia to investigate the relationship between psychopathological symptoms, cognitive functioning, and global functioning. A total of 117 untreated first-episode schizophrenia patients were evaluated using the global assessment functions (GAF), the Positive And Negative Syndrome Scale (PANSS), the MATRICS Consensus Cognitive Battery (MCCB), and some social and role functional parameters. The GAF, PANSS, and MCCB scores of 117 patients were significantly lower than normal. Multiple stepwise linear regression analysis revealed that the negative symptom factor, positive symptom factor, excitation-hostility factor, and attention/vigilance were all independent factors influencing global functioning. Our findings show that the negative symptom factor, the positive symptom factor, the excitement hostility factor, and attention/vigilante are all independent risk factors for GAF in first-episode schizophrenia. The negative symptom factor had the most noticeable effect among these influencing factors, followed by the positive symptom factor, the excitement hostility factor, and attention/vigilance in that order.

Going deep into schizophrenia with artificial intelligence

Despite years of research, the mechanisms governing the onset, relapse, symptomatology, and treatment of schizophrenia (SZ) remain elusive. The lack of appropriate analytic tools to deal with the heterogeneity and complexity of SZ may be one of the reasons behind this situation. Deep learning, a subfield of artificial intelligence (AI) inspired by the nervous system, has recently provided an accessible way of modeling and analyzing complex, high-dimensional, nonlinear systems. The unprecedented accuracy of deep learning algorithms in classification and prediction tasks has revolutionized a wide range of scientific fields and is rapidly permeating SZ research. Deep learning has the potential of becoming a valuable aid for clinicians in the prediction, diagnosis, and treatment of SZ, especially in combination with principles from Bayesian statistics. Furthermore, deep learning could become a powerful tool for uncovering the mechanisms underlying SZ thanks to a growing number of techniques designed for improving model interpretability and causal reasoning. The purpose of this article is to introduce SZ researchers to the field of deep learning and review its latest applications in SZ research. In general, existing studies have yielded impressive results in classification and outcome prediction tasks. However, methodological concerns related to the assessment of model performance in several studies, the widespread use of small training datasets, and the little clinical value of some models suggest that some of these results should be taken with caution.

Investigating factors associated with the number of rehospitalizations among patients with schizophrenia disorder using penalized count regression models

BACKGROUND

Schizophrenia is a chronic, severe, and debilitating mental disorder always considered one of the recurrent psychiatric diseases. This study aimed to use penalized count regression models to determine factors associated with the number of rehospitalizations of schizophrenia disorder.

METHODS

This retrospective cohort study was performed on 413 schizophrenic patients who had been referred to the Sina (Farshchian) Educational and Medical Center in Hamadan, Iran, between March 2011 and March 2019. The penalized count regression models were fitted using R.3.5.2.

RESULTS

About 73% of the patients were male. The mean (SD) of age and the number of rehospitalizations were 36.16 (11.18) years and 1.21 (2.18), respectively. According to the results, longer duration of illness (P < 0.001), having a positive family history of psychiatric illness (P = 0.017), having at least three children (P = 0.013), unemployment, disability, and retirement (P = 0.025), residence in other Hamadan province townships (P = 0.003) and having a history of arrest/prison (P = 0.022) were significantly associated with an increase in the number of rehospitalizations.

CONCLUSION

To reduce the number of rehospitalizations among schizophrenic patients, it is recommended to provide special medical services for patients who do not have access to specialized medical centers and to create the necessary infrastructure for the employment of patients.

Entire duration of active psychosis and neurocognitive performance in first-episode non-affective psychosis

AIM

To explore if the entire duration of active psychosis (DAP) is related to neurocognitive performance at baseline and at 3-year follow-up in patients with first episode psychosis (FEP).

METHODS

DAP was estimated for 481 FEP patients. A neuropsychological battery was administered to measure neurocognitive specific domains, and a global indicator of neurocognitive impairment (global deficits score, GDS) was calculated. According to the DAP quartiles, four subgroups were formed, and these were compared. In addition, a logistic regression analysis was carried out to predict neurocognitive impairment at 3-year follow-up.

RESULTS

FEP patients with the longest DAP (more than 18.36 months) presented a more severe global neurocognitive impairment evidenced in their GDS, both at baseline (F = 5.53; p˂ .01) and at 3-year follow-up (F = 4.16; p˂ .01). Moreover, a subgroup of participants with DAP between 7.40 and 18.36 months showed a specific attentional decline over the 3-year follow-up (F = 3.089; p˂ .05).The logistic regression model showed that sex (Wald = 7.29, p < .010), premorbid adjustment (Wald = 7.24, p < .010), attention (Wald = 12.10, p < .001), verbal memory (Wald = 16.29, p < .001) and visual memory (Wald = 9.41, p < .010) were significant predictors of neurocognitive impairment 3 years after the FEP. The variables composing the DAP were not significant predictors in this model.

CONCLUSIONS

DAP seems to be related to global neurocognitive impairment in FEP patients. These findings contribute in several ways to our understanding of the effects of active psychosis on the brain, and provide the basis for future research.

Associations of premorbid adjustment with type and timing of childhood trauma in first-episode schizophrenia spectrum disorders

Background

Childhood trauma may contribute to poorer premorbid social and academic adjustment which may be a risk factor for schizophrenia.

Aim

We explored the relationship between premorbid adjustment and childhood trauma, timing of childhood trauma's moderating role as well as the association of clinical and treatment-related confounders with premorbid adjustment.

Setting

We conducted a secondary analysis in 111 patients with first-episode schizophrenia (FES) disorders that formed part of two parent studies, EONKCS study (n =73) and the Shared Roots study (n =38).

Methods

Type of childhood trauma was assessed with the Childhood Trauma Questionnaire, short-form and premorbid adjustment using the Premorbid Adjustment Scale. Timing of childhood trauma was assessed using the Life Events Checklist and life events timeline. Linear regression analyses were used to assess the moderating effect of timing of childhood trauma. Clinical and treatment-related confounders were entered into sequential hierarchical regression models to identify independent predictors of premorbid adjustment across key life stages.

Results

Childhood physical neglect was associated with poorer premorbid academic functioning during childhood and early adolescence, and poorer premorbid social functioning during early and late adolescence. By hierarchical regression modelling (r ² = 0.13), higher physical neglect subscale scores (p = 0.011) independently predicted poorer premorbid social adjustment during early adolescence. Timing of childhood trauma did not moderate the relationship between childhood trauma and premorbid functioning.

Conclusion

In patients with FES, childhood physical neglect may contribute to poorer premorbid social functioning during early adolescence. This may provide us with an opportunity to identify and treat at-risk individuals earlier.

Duration of untreated illness predicts 3-year outcome in patients with obsessive-compulsive disorder: A real-world, naturalistic, follow-up study

Duration of untreated illness (DUI) is a predictor of outcome in psychotic and affective disorders. The few available data on the effect of DUI in obsessive-compulsive disorder (OCD) suggest an association between longer DUI and poorer response to treatments. This is a real-world, naturalistic, follow-up study evaluating the impact of DUI on long-term clinical outcomes. The sample consists of 83 outpatients with OCD with a mean DUI of 7.3 (5.8) years. Patients with symmetry/ordering cluster symptoms were younger at onset of the disease (20.4 ± 7.9 vs. 27.8 ± 10.6; p<.05, d = 0.79), had a longer duration of the illness (10.1 ± 4.6 vs. 6.8 ± 4.6, p<.05; d = 0.53) and a longer DUI (7.9 ± 6.5 vs. 5.4 ± 3.6, p<.05, d = 0.49) compared to patients not presenting with those symptoms. Fifty-nine patients completed the follow-up, and 33.9% (N = 20) met the criteria for partial remission, scoring <15 at the Y-BOCS for at least eight weeks. Patients in partial remission for more than 40% of the follow-up were defined as "good outcome" and they had a significantly shorter DUI compared to patients with "poor outcome". Access to adequate treatments is highly delayed in patients with OCD. DUI is strongly associated with poor treatment outcomes. Therefore, strategies to ensure an early diagnosis and treatment are needed.

Clinical Predictors of Duration of Untreated Psychosis: Exploring Psychosocial and Clinical Predictors of Duration of Untreated Psychosis in First-Episode Psychotic Patients in Mzuzu, Malawi

Introduction

The duration of untreated Psychosis (DUP) is a modifiable factor in the management and outcome of patients with psychosis. However, its predictive factors have not been studied much in Malawi. Our study was aimed at determining the psychosocial and clinical predictors of DUP in first episode psychosis in Malawi.

Method

A quantitative cross-sectional study, using secondary data from an early intervention study project was done in Mzuzu, Malawi. We analysed 140 adult participants enrolled in early intervention project in 2010. Data was collected using abstraction sheet to target predictive factors. We conducted univariate and multivariate logistic regression at confidence interval of 95%. We described the mean DUP, and looked at relationship of clinical and psychosocial factors with DUP.

Results

Most participants were male (60%, n=84) and single (51.4%, n=72). The median age of male participants was 31 years (Range=18 to 60), lower than females 35 years (Range=18 to 65). (what were the numbers of females). The majority of the participants' highest education level was secondary school (63.6%, n=89), and most had DUP of ≥ 6 months (74%, n=103). We found mean DUP of 42 months (SD= ±71). Employment status, diagnosis of schizophrenia (OR=10.93, 95% C.I 3.08-38.89), and negative symptoms of psychosis were associated with DUP of ≥ 6 months. Public self-consciousness and social quality of life were associated with long DUP.

Conclusion

Our study shows psychosocial and clinical factors that predict long DUP in Malawi. This highlights the need to target these factors when working on first episode psychosis for a better outcome.

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.

The report of the joint WPA/CINP workgroup on the use and usefulness of antipsychotic medication in the treatment of schizophrenia

This is a report of a joint World Psychiatric Association/International College of Neuropsychopharmacology (WPA/CINP) workgroup concerning the risk/benefit ratio of antipsychotics in the treatment of schizophrenia. It utilized a selective but, within topic, comprehensive review of the literature, taking into consideration all the recently discussed arguments on the matter and avoiding taking sides when the results in the literature were equivocal. The workgroup's conclusions suggested that antipsychotics are efficacious both during the acute and the maintenance phase, and that the current data do not support the existence of a supersensitivity rebound psychosis. Long-term treated patients have better overall outcome and lower mortality than those not taking antipsychotics. Longer duration of untreated psychosis and relapses are modestly related to worse outcome. Loss of brain volume is evident already at first episode and concerns loss of neuropil volume rather than cell loss. Progression of volume loss probably happens in a subgroup of patients with worse prognosis. In humans, antipsychotic treatment neither causes nor worsens volume loss, while there are some data in favor for a protective effect. Schizophrenia manifests 2 to 3 times higher mortality vs the general population, and treatment with antipsychotics includes a number of dangers, including tardive dyskinesia and metabolic syndrome; however, antipsychotic treatment is related to lower mortality, including cardiovascular mortality. In conclusion, the literature strongly supports the use of antipsychotics both during the acute and the maintenance phase without suggesting that it is wise to discontinue antipsychotics after a certain period of time. Antipsychotic treatment improves long-term outcomes and lowers overall and specific-cause mortality.

Impact and differences of illness course perception on the desire for social distance towards people with symptoms of depression or schizophrenia in Hanoi, Vietnam

OBJECTIVES

Public stigma against psychiatric disorders leads to delayed treatment utilization and worsens treatment outcome. This study analyses the impact of expectations regarding the course of illness and attribution as medical illness on the desire for social distance towards schizophrenia and depression in Vietnam.

METHODS

In 2013, a survey (n = 771) using unlabelled vignettes either depicting a person with symptoms typical for schizophrenia or major depression was carried out in Hanoi. All respondents had to indicate whether the person was suffering from a medical illness or not. As an indicator of public stigma, the desire for social distance was measured. A possible correlation between expectations towards the course of illness and social distance was evaluated using a linear regression model.

RESULTS

85 % of respondents endorsed that the person depicted in the schizophrenia vignette had a mental illness, compared to only 60 %, who were confronted with the depression vignette. This attribution of mental illness was correlated with higher levels of desire for social distance only in the schizophrenia vignette. While in the case of schizophrenia negative prognostic perceptions were associated with more desire for social distance, in the event of depression, it was only the expectation of lifelong dependency. Moreover, only for depression, positive expectations towards the course of illness correlated with less desire for social distance.

CONCLUSION

These results indicate an impact of prognostic expectations on the desire for social distance and support strategies that aim at maintaining social integration and strengthening autonomy.

Quantitative efficacy of three antipsychotic drugs for schizophrenia based on a real-world study in China

Atypical antipsychotics exert remarkable long-term efficacy on the personal and social functions of schizophrenic patients. However, quantitative information on the social function of schizophrenic patients treated with atypical antipsychotics is scarce in the current clinical guidelines. In this study, we established pharmacodynamic models to quantify the time–efficacy relationship of three antipsychotic drugs based on the data from a real-world study conducted in China. A total of 373 schizophrenic patients who received antipsychotic monotherapy with olanzapine (n = 144), risperidone (n = 160), or aripiprazole (n = 69) were selected from a three-year prospective, multicenter study. The follow-up times were 13, 26, 52, 78, 104, 130, and 156 weeks after baseline. A time–efficacy model was developed with nonlinear mixed effect method based on changes in Personal and Social Performance (PSP) score compared with the baseline level. Crucial pharmacodynamic parameters, including maximum efficacy and drug onset time, were used to distinguish the efficacy of the three drugs. We quantified the time course of PSP improvement in patients after treatment with these three antipsychotics: olanzapine, risperidone, and aripiprazole reached an E_max value of 80.3%, 68.2%, and 23.9% at weeks 56.7, 29.2, and 36.8, respectively. General psychotic symptoms, onset frequency, and illness course were identified as significant factors affecting the efficacy of these drugs. The newly constructed models provide an evidence of the benefit of long-term maintenance therapy with atypical antipsychotics in individualized schizophrenia treatment in China.

Relationship between duration of untreated prodromal symptoms and symptomatic and functional recovery

Our previous study has found that a long duration of untreated prodromal symptoms (DUPrS) does not increase the conversion risk to psychosis in individuals with attenuated psychosis syndrome (APS). However, whether a long DUPrS will lead to other poor outcomes remains unknown. The purpose of this study was to analyse the association between the DUPrS and outcomes (symptomatic and functional recovery) in APS population. A post hoc analysis was performed in 391 individuals with APS as identified by the structured interview. APS subjects had follow-up interviews every 6 months for 2 years following diagnosis. Poor functional outcome was defined as a Global Assessment of Functioning (GAF) score less than 60 at the time of follow-up. Poor symptomatic outcome was defined as at least one of the positive symptoms rated scores of 3 or higher. A post hoc analysis was performed in 391 individuals with APS as identified by the structured interview. APS subjects had follow-up interviews every 6 months for 2 years following diagnosis. Poor functional outcome was defined as a Global Assessment of Functioning (GAF) score less than 60 at the time of follow-up. Poor symptomatic outcome was defined as at least one of the positive symptoms rated scores of 3 or higher. Of total 391 individuals, 334 were followed up for 2 years to assess clinical outcome, 82 (24.6%) had shown conversion to psychosis, 79 (23.7%) met the criteria of poor functioning outcome, and 145 (43.4%) met the criteria of poor symptomatic outcome. A significant correlation between GAF scores and DUPrS was observed in the non-converter group, but not in the converters. Individuals with APS who had a longer DUPrS were correlated with poorer functional outcome. However, it was not correlated with poorer symptomatic outcome. While a longer DUPrS was not related to poor symptomatic outcome, it was significantly related to poor functional outcome. Our findings highlight the importance of reducing DUPrS to decrease future functional impairment in populations at risk for psychosis.

Randomised controlled trial of gradual antipsychotic reduction and discontinuation in people with schizophrenia and related disorders: the RADAR trial (Research into Antipsychotic Discontinuation and Reduction)

INTRODUCTION

Antipsychotic medication is effective in reducing acute symptoms of psychosis, but it has a range of potentially serious and debilitating adverse effects and is often disliked by patients. It is therefore essential it is only used when benefits outweigh harms. Although multiple trials conducted with people with schizophrenia indicate an increased risk of relapse in the short-term following abrupt antipsychotic discontinuation, there is little evidence about the long-term outcome of a gradual process of reduction and discontinuation on social functioning, relapse and other outcomes.

METHODS AND ANALYSIS

This is a multicentre, randomised controlled trial involving people with schizophrenia and related disorders who have had more than one episode. Participants are randomised to have a clinically-supervised, gradual reduction of antipsychotic medication, leading to discontinuation when possible, or to continue with maintenance treatment. Blinded follow-up assessments are conducted at 6, 12 and 24 months and the primary outcome is social functioning, measured by the Social Functioning Scale at 24 months. A minimum of 134 evaluable participants provides 90% power to detect a five-point difference, and 206 to detect a four-point difference. Secondary outcomes include severe relapse (admission to hospital) and the study is also intended to detect a minimum 10% difference in severe relapse, which requires 402 participants, assuming a 15% loss to follow-up. Other secondary outcomes include all relapses, as identified by an independent and blinded endpoint committee, symptoms measured by the Positive and Negative Syndrome Scale, quality of life, adverse effects, self-rated recovery and neuropsychological measures. Enrolment started in 2016. The trial is scheduled to finish in June 2022.

ETHICS AND DISSEMINATION

Ethical approval was initially obtained on 27 October 2016 (UK Research Ethics Committee reference 16/LO/1507). Results will be published in peer-reviewed journals and disseminated to the public.

TRIAL REGISTRATION NUMBER

ISRCTN90298520. EudraCT: 2016-000709-36. Pre-results.

The iHOPE-20 study: Relationships between and prospective predictors of remission, clinical recovery, personal recovery and resilience 20 years on from a first episode psychosis

OBJECTIVE

Knowledge of outcome in psychotic illness is limited by the paucity of very long-term epidemiologically representative studies of incidence first episode psychosis (FEP) cohorts that measure and compare outcomes reflecting modern clinical practice, mental health policy and research agendas. Our study aimed to address this gap.

METHOD

iHOPE-20 is a prospective 20-year follow-up study of a FEP incidence cohort (N = 171) conducted between 2014 and 2017 in Ireland. Data from previous studies and medical records were used to recruit cohort members. We assessed remission, clinical recovery, personal recovery and resilience at 20 years; explored the relationships between these outcomes and examined the predictive value of baseline characteristics in determining them.

RESULTS

At follow-up, 20 out of 171 cohort members (11.70%) were deceased. We assessed 80 out of 151 alive cohort members (53% recruitment rate); 65% were in remission; 35.2% were in Full Functional Recovery and 53.7% confirmed they were fully recovered according to their personal definition of recovery. A complex array of relationships between outcomes was found. Outcomes were better for people who had a short duration of untreated psychosis, displayed higher premorbid social adjustment (between the ages of 5-11) and at baseline, were older, not living alone, in full-time employment, given a non-affective diagnosis, and had lower Global Assessment of Functioning scores.

CONCLUSION

Among participants, full remission of psychotic symptoms and personally defined recovery was not just possible but likely in the very long term. However, attaining positive functional outcomes and building resilience in FEP remain key challenges for mental health services.

M. Staging of Schizophrenia With the Use of PANSS: An International Multi-Center Study

INTRODUCTION

A specific clinically relevant staging model for schizophrenia has not yet been developed. The aim of the current study was to evaluate the factor structure of the PANSS and develop such a staging method.

METHODS

Twenty-nine centers from 25 countries contributed 2358 patients aged 37.21 ± 11.87 years with schizophrenia. Analysis of covariance, Exploratory Factor Analysis, Discriminant Function Analysis, and inspection of resultant plots were performed.

RESULTS

Exploratory Factor Analysis returned 5 factors explaining 59% of the variance (positive, negative, excitement/hostility, depression/anxiety, and neurocognition). The staging model included 4 main stages with substages that were predominantly characterized by a single domain of symptoms (stage 1: positive; stages 2a and 2b: excitement/hostility; stage 3a and 3b: depression/anxiety; stage 4a and 4b: neurocognition). There were no differences between sexes. The Discriminant Function Analysis developed an algorithm that correctly classified >85% of patients.

DISCUSSION

This study elaborates a 5-factor solution and a clinical staging method for patients with schizophrenia. It is the largest study to address these issues among patients who are more likely to remain affiliated with mental health services for prolonged periods of time.

A machine learning approach to predicting psychosis using semantic density and latent content analysis

Subtle features in people’s everyday language may harbor the signs of future mental illness. Machine learning offers an approach for the rapid and accurate extraction of these signs. Here we investigate two potential linguistic indicators of psychosis in 40 participants of the North American Prodrome Longitudinal Study. We demonstrate how the linguistic marker of semantic density can be obtained using the mathematical method of vector unpacking, a technique that decomposes the meaning of a sentence into its core ideas. We also demonstrate how the latent semantic content of an individual’s speech can be extracted by contrasting it with the contents of conversations generated on social media, here 30,000 contributors to Reddit. The results revealed that conversion to psychosis is signaled by low semantic density and talk about voices and sounds. When combined, these two variables were able to predict the conversion with 93% accuracy in the training and 90% accuracy in the holdout datasets. The results point to a larger project in which automated analyses of language are used to forecast a broad range of mental disorders well in advance of their emergence.

Recycling N-acetylcysteine: A review of evidence for adjunctive therapy in schizophrenia

Introduction

All symptoms in schizophrenia may impact functioning. Although Food and Drug Administration-approved medications typically benefit positive symptoms, negative symptoms are generally refractory to medication interventions. N-acetylcysteine's (NAC) influence on glutamatergic neurotransmission has been established. An emerging body of research has attempted to correlate this action with reduction in symptom severity, evaluating response in positive, negative, and cognitive symptom domains.

Methods

A literature review was performed to analyze available data on NAC intervention and improvement in the positive, negative, and cognitive symptom domains in patients with schizophrenia. Quality of evidence was systematically assessed to determine level of certainty in results.

Results

Three randomized controlled trials were identified. Across studies, negative symptoms decreased more with NAC compared to placebo; ranging between 11.9% and 24.1%. The assessment determined a low level of certainty regarding benefit of NAC on negative and cognitive symptoms and moderate certainty for NAC regarding findings of side effects and lack of benefit on positive symptoms.

Discussion

Consistent reporting of benefit in negative symptoms is found across studies of NAC intervention. These improvements are notable for symptoms that have generally remained refractory to medication intervention. Inconsistent benefit was reported in positive and cognitive symptoms. GRADE (grading of recommendations assessment, development and evaluation) assessment of current evidence indicates a low certainty of benefit for negative symptoms with standard use of NAC in patients with schizophrenia. However, a trial of this low-risk intervention may be warranted in patients with resistant negative symptoms and subsequent impaired functioning despite appropriate antipsychotic therapy as they may experience additional benefit in this symptom domain.

Treatment-Resistant to Antipsychotics: A Resistance to Everything? Psychotherapy in Treatment-Resistant Schizophrenia and Nonaffective Psychosis: A 25-Year Systematic Review and Exploratory Meta-Analysis

Background: Roughly 30% of schizophrenia patients fail to respond to at least two antipsychotic trials. Psychosis has been traditionally considered to be poorly sensitive to psychotherapy. Nevertheless, there is increasing evidence that psychological interventions could be considered in treatment-resistant psychosis (TRP). Despite the relevance of the issue and the emerging neurobiological underpinnings, no systematic reviews have been published. Here, we show a systematic review of psychotherapy interventions in TRP patients of the last 25 years. Methods: The MEDLINE/PubMed, ISI WEB of Knowledge, and Scopus databases were inquired from January 1, 1993, to August 1, 2018, for reports documenting augmentation or substitution with psychotherapy for treatment-resistant schizophrenia (TRS) and TRP patients. Quantitative data fetched by Randomized Controlled Trials (RCTs) were pooled for explorative meta-analysis. Results: Forty-two articles have been found. Cognitive behavioral therapy (CBT) was the most frequently recommended psychotherapy intervention for TRS (studies, n = 32, 76.2%), showing efficacy for general psychopathology and positive symptoms as documented by most of the studies, but with uncertain efficacy on negative symptoms. Other interventions showed similar results. The usefulness of group therapy was supported by the obtained evidence. Few studies focused on negative symptoms. Promising results were also reported for resistant early psychosis. Limitations: Measurement and publication bias due to the intrinsic limitations of the appraised original studies. Conclusions: CBT, psychosocial intervention, supportive counseling, psychodynamic psychotherapy, and other psychological interventions can be recommended for clinical practice. More studies are needed, especially for non-CBT interventions and for all psychotherapies on negative symptoms.

Impact of perceived course of illness on the desire for social distance towards people with symptoms of schizophrenia in Hanoi, Vietnam

In Vietnam, stigmatisation and discrimination of patients with mental illness are highly prevalent. This study explores whether the perception of course of illness of people with symptoms indicating schizophrenia is associated with the desire for social distance in the Vietnamese public. A population-based survey (n = 455) using unlabelled vignettes for schizophrenia was carried out in the Hanoi municipality in 2013. First, a factor analysis was performed to group items indicating perception of prognosis. Second, a linear regression analysis was used to search for correlations between these expectations and desire for social distance. The factor analysis revealed three independent factors of perception of course of illness: (1) loss of social integration and functioning, (2) lifelong dependency on others, and (3) positive expectations towards treatment outcome. Both factors with negative prognostic perceptions (1&2) were associated with more desire for social distance. The results indicate a link between social acceptance and the perceived ability to maintain a social role including a capability of reciprocity within the Vietnamese society. Additionally, these findings highlight the importance of preserving social functioning in any treatment approach for patients with schizophrenia, which includes psychosocial intervention and rehabilitation programs.

Demographic and socioenvironmental predictors of premorbid marijuana use among patients with first-episode psychosis

OBJECTIVE

We identified, in subjects with first-episode psychosis, demographic and socioenvironmental predictors of three variables pertaining to premorbid marijuana use: age at initiation of marijuana use, trajectories of marijuana use in the five years prior to onset of psychosis, and the cumulative "dose" of marijuana intake in that same premorbid period.

METHODS

We enrolled 247 first-episode psychosis patients and collected data on lifetime marijuana/alcohol/tobacco use, age at onset of psychosis, diverse socioenvironmental variables, premorbid adjustment, past traumatic experiences, perceived neighborhood-level social disorder, and cannabis use experiences. Bivariate tests were used to examine associations between the three premorbid marijuana use variables and hypothesized predictors. Regression models determined which variables remained independently significantly associated.

RESULTS

Age at initiation of cigarette smoking was linked to earlier initiation, faster escalation, and higher cumulative dose of premorbid marijuana use. During childhood, poorer academic performance was predictive of an earlier age at initiation of marijuana use, while poorer sociability was related to more rapid escalation to daily use and a higher cumulative dose. As expected, experiencing euphoric effects was positively correlated with trajectories and cumulative dose, but having negative experiences was unrelated. Traumatic childhood/adolescent experiences were correlated with rapid escalation and amount of marijuana used, but not with age at initiation of marijuana use.

CONCLUSION

These data expand the very limited literature on predictors of premorbid marijuana use in first-episode psychosis. Given its association with earlier age at onset of psychosis, and poorer outcomes among first-episode patients, prevention and treatment efforts should be further developed.

Social anxiety and risk factors in patients with schizophrenia: Relationship with duration of untreated psychosis

Social anxiety is commonly reported as a comorbid condition among people with schizophrenia. The aims of this study were to elucidate the associations between demographic/clinical features and social anxiety. A total of 207 outpatients with schizophrenia underwent assessments for social anxiety, psychiatric symptoms, social cognition, cognitive function, social functioning, and quality of life (QOL). To confirm the prediction model for social anxiety, we conducted multiple linear regressions using the Liebowitz Social Anxiety Scale (LSAS) score as an outcome variable and demographic/clinical variables as predictors. Of the 207 patients, 30 (14.5%) met the criteria for social anxiety disorder and 109 (52.7%) had a mean LSAS score higher than 30, suggesting that their social anxiety symptoms had reached a clinical level. Social anxiety was significantly correlated with psychiatric symptoms, social functioning, and QOL, whereas significant correlations with social cognition and cognitive function were not observed. A multiple regression analysis identified social functioning, gender, age of onset, and duration of untreated psychosis (DUP) as predictors that were most closely associated with the LSAS score. We confirmed that social anxiety symptoms were highly prevalent among outpatients with schizophrenia and were closely associated with social functioning and DUP, rather than social cognitive impairments.

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.

Reactions to symptoms of mental disorder and help seeking in Sabah, Malaysia

BACKGROUND

A better understanding is needed about how people make decisions about help seeking.

MATERIALS

Focus group and individual interviews with patients, carers, healthcare staff, religious authorities, traditional healers and community members.

DISCUSSION

Four stages of help seeking were identified: (1) noticing symptoms and initial labelling, (2) collective decision-making, (3) spiritual diagnoses and treatment and (4) psychiatric diagnosis and treatment.

CONCLUSION

Spiritual diagnoses have the advantage of being less stigmatising, giving meaning to symptoms, and were seen to offer hope of cure rather than just symptom control. Patients and carers need help to integrate different explanatory models into a meaningful whole.

Predictors of current functioning and functional decline in schizophrenia

Positive, negative, and cognitive symptoms of schizophrenia may affect functional outcomes. However, these factors alone do not account for a large percentage of variance in outcomes. We investigated demographic, cognitive, symptom, and functional capacity predictors of current functional status in 280 outpatients with schizophrenia or schizoaffective disorder. Functional decline over the lifespan was also examined in a subset of participants. Stepwise regressions modeled predictors of current functional status and functional decline as measured by the Assessment of Lifespan Functioning Attainment (ALFA). ALFA functional domains included paid employment, independence in living situation, romantic relationships, close friendships, and recreational engagement. More severe depressive symptoms were consistently associated with worse current community integration (lower levels of close friendships and recreational engagement). Better working memory performance was associated with higher rates of current paid employment. There were no consistent modifiable predictors of decline in functioning, but women reported less functional decline in the domains of employment and close friendships than men. Better cognitive performance was associated with less decline in living independence and romantic relationships, but more decline in paid employment and recreational engagement. Increased assessment and treatment of comorbid depressive symptoms may improve functional outcomes in people with schizophrenia.

Individual negative symptoms and domains - Relevance for assessment, pathomechanisms and treatment

The negative symptoms of schizophrenia can be divided into two domains. Avolition/apathy includes the individual symptoms of avolition, asociality and anhedonia. Diminished expression includes blunted affect and alogia. Until now, causes and treatment of negative symptoms have remained a major challenge, which is partially related to the focus on negative symptoms as a broad entity. Here, we propose that negative symptoms may become more tractable when the different domains and individual symptoms are taken into account. There is now increasing evidence that the relationship with clinical variables - in particular outcome - differs between the domains of avolition/apathy and diminished expression. Regarding models of negative symptom formation, those relevant to avolition/apathy are now converging on processes underlying goal-directed behavior and dysfunctions of the reward system. In contrast, models of the diminished expression domains are only beginning to emerge. The aim of this article is to review the specific clinical, behavioral and neural correlates of individual symptoms and domains as a better understanding of these areas may facilitate specific treatment approaches.

Relationship between duration of untreated psychosis and neurocognition and social cognition in first-episode psychosis

Cognitive impairment is common in first-episode psychosis (FEP); however, the relationship between duration of untreated psychosis (DUP) and neurocognition remains controversial, and no studies have examined the relationship between DUP and social cognition. This study involved secondary data analysis of baseline data from a randomised controlled trial of supported employment; 122 out 146 young people with FEP met inclusion criteria for this study. Results showed that DUP was not associated with neurocognitive or social cognitive performance. Results do not provide support for the neurotoxicity hypothesis of psychosis.

Positive schizotypy and negative schizotypy are associated with differential patterns of episodic memory impairment

Cognitive impairment is a hallmark of schizophrenia; however, studies have not comprehensively examined such impairments in non-clinically ascertained schizotypic young adults. The present study employed a series of measures to assess episodic memory in high positive schizotypy, high negative schizotypy, and comparison groups (each group n = 25). Consistent with diminished cognitive functioning seen in negative symptom schizophrenia, the negative schizotypy group exhibited deficits on free recall, recognition, and source memory tasks. The positive schizotypy group did not demonstrate deficits on the above mentioned tasks. However, in contrast to the other groups, the positive schizotypy group showed an unexpected set-size effect on the cued-recall task. Set-size effect, which refers to the finding that words that have smaller networks of associates tend to have a memory advantage, is usually found in associative-cuing, but not cued-recall, tasks. The finding for the positive schizotypy group is consistent with heightened spreading activation and reduced executive control suggested to underlie psychotic symptoms. The findings support a multidimensional model of schizotypy and schizophrenia, and suggest that positive and negative schizotypy involve differential patterns of cognitive impairment.

Influence of cognition, premorbid adjustment and psychotic symptoms on psycho-social functioning in first-episode psychosis

OBJECTIVE

The aim of this study is to evaluate the relationship between psycho-social functioning and symptoms, cognitive function, and premorbid adjustment, in patients with a first-episode psychosis.

METHOD

Clinical data were obtained from 90 patients, who were assessed with the Disability Assessment Scale (DAS-sv), the Positive and Negative Syndrome Scale (PANSS), the Premorbid Adjustment Scale (PAS-S) and with a battery of cognitive tests including Trail Making Tests A and B (TMTA- B), Continous Performance Test (CPT), some subscales of the Wechler Adult Intelligence Scale (WAIS), and the Verbal Learning Test España-Complutense (TAVEC).

RESULTS

The results of the study suggest that psycho-social functioning in first-episode psychosis is significantly related to: positive, negative, excitative, affective and disorganized symptoms, social premorbid adjustment, cognitive flexibility, working memory, short term and long term memory. Of these, those which best explained psycho-social functioning are the positive and excitative symptoms, premorbid adjustment, flexibility and memory.

CONCLUSIONS

These findings highlight the importance early intervention on cognitive and clinical variables to help provide a better psycho-social functioning in people with a first-episode of psychosis.

Substance use and duration of untreated psychosis in KwaZulu-Natal, South Africa

BACKGROUND

Substance use and psychiatric disorders cause significant burden of disease in low- and middle-income countries. Co-morbid psychopathology and longer duration of untreated psychosis (DUP) can negatively affect treatment outcomes.

OBJECTIVES

The study assessed substance use amongst adults with severe mental illness receiving services at a regional psychiatric hospital in KwaZulu-Natal (South Africa). We describe the prevalence and correlates of lifetime substance use and examine the association between substance use and DUP.

METHODS

A cross-sectional survey recruited adults diagnosed with severe mental illness and assessed lifetime and past 3-month substance use using the World Health Organization Alcohol, Smoking and Substance Involvement Screening Test. Regression analyses were conducted to determine associations between lifetime substance use (other than alcohol and tobacco) and DUP as measured by the World Health Organization Encounter Form.

RESULTS

Amongst 87 participants, alcohol (81.6%), tobacco (75.6%) and cannabis (49.4%) were the most common substances reported for lifetime use. Risk of health-related problems (health, social, financial, legal and relationship) of cannabis use was associated with younger age, single marital status and lower education. Adjusted regression analyses indicated that use of amphetamines and methaqualone is associated with longer DUP.

CONCLUSIONS

Substance use is prevalent amongst psychiatric patients in KwaZulu-Natal and may contribute to longer DUP. Mental health services in this region should address co-morbid substance use and psychiatric disorders.

Impact of dopamine supersensitivity psychosis in treatment-resistant schizophrenia: An analysis of multi-factors predicting long-term prognosis

BACKGROUND

Although a variety of factors are known to be significantly related to poor prognosis in schizophrenia, their interactions remain unclear. Dopamine supersensitivity psychosis (DSP) is a clinical concept related to long-term pharmacotherapy and could be one of the key factors contributing to the development of treatment-resistant schizophrenia (TRS). The present study aims to explore the effect of DSP on progression to TRS.

METHODS

Two-hundreds and sixty-five patients were classified into either a TRS or Non-TRS group based on retrospective survey and direct interview. The key factors related to prognosis, including the presence or absence of DSP episodes, were extracted, and each factor was compared between the two groups.

RESULTS

All parameters except for the duration of untreated psychosis (DUP) were significantly worse in the TRS group compared to the Non-TRS group. In particular, the TRS group presented with a significantly higher rate of DSP episodes than the Non-TRS group. Regression analysis supported the notion that DSP plays a pivotal role in the development of TRS. In addition, deficit syndrome was suggested to be a diagnostic subcategory of TRS.

CONCLUSIONS

Our data confirmed that the key predicting factors of poor prognosis which have been established would actually affect somehow the development of TRS. In addition, the occurrence of a DSP episode during pharmacotherapy was shown to promote treatment refractoriness.

Improvement in social and cognitive functioning associated with paliperidone extended-release treatment in patients with schizophrenia: a 24-week, single arm, open-label study

PURPOSE

This single-arm, open-label study aimed to explore the effects of extended-release paliperidone on social and cognitive function in patients with schizophrenia.

METHODS

Paliperidone extended-release (flexible dose ranging from 3 to 12 mg/day orally) was administered for 24 weeks in patients with schizophrenia. Patient function was assessed using the personal and social performance scale, measurement and treatment research to improve cognition in schizophrenia initiative-consensus cognitive battery, positive and negative syndrome scale, and clinical global impression-severity.

RESULTS

Ninety patients were included in the full analysis set, while 72 patients were included in the per protocol set. The personal and social performance score was 54.3±14.3 at baseline, and significantly increased to 73.4±12.6 at week 24 (P<0.001). For the measurement and treatment research to improve cognition in schizophrenia initiative-consensus cognitive battery assessment, six of the nine individual subtests, six of the seven cognitive domains, and total cognitive scores improved significantly (P<0.05) between baseline and endpoint. positive and negative syndrome scale total scores and clinical global impression-severity scores decreased gradually (P<0.001) from week 4 to the conclusion of the study.

CONCLUSION

Paliperidone extended-release treatment significantly improves social and neurocognitive function as well as symptoms in Chinese patients with schizophrenia.

Conceptualization and treatment of negative symptoms in schizophrenia

Negative symptoms of schizophrenia including social withdrawal, diminished affective response, lack of interest, poor social drive, and decreased sense of purpose or goal directed activity predict poor functional outcomes for patients with schizophrenia. They may develop and be maintained as a result of structural and functional brain abnormalities, particularly associated with dopamine reward pathways and by environmental and psychosocial factors such as self-defeating cognitions and the relief from overstimulation that accompanies withdrawal from social and role functioning. Negative symptoms are more difficult to treat than the positive symptoms of schizophrenia and represent an unmet therapeutic need for large numbers of patients with schizophrenia. While antipsychotic medications to treat the symptoms of schizophrenia have been around for decades, they have done little to address the significant functional impairments in the disorder that are associated with negative symptoms. Negative symptoms and the resulting loss in productivity are responsible for much of the world-wide personal and economic burden of schizophrenia. Pharmacologic treatments may be somewhat successful in treating secondary causes of negative symptoms, such as antipsychotic side effects and depression. However, in the United States there are no currently approved treatments for severe and persistent negative symptoms (PNS) that are not responsive to treatments for secondary causes. Pharmacotherapy and psychosocial treatments are currently being developed and tested with severe and PNS as their primary targets. Academia, clinicians, the pharmaceutical industry, research funders, payers and regulators will need to work together to pursue novel treatments to address this major public health issue.

Predictors of vocational activity over the first year in inner-city early intervention in psychosis services

AIM

Work and educational activities are an important part of recovery for young people with psychosis, and improving vocational outcomes is a key target for early intervention services (EIS). This study evaluated predictors of vocational activity for first-episode psychosis (FEP) patients during the first year of EIS care. It was hypothesized that longer duration of untreated psychosis (DUP) and minority ethnic status would predict poorer vocational outcomes, whereas a history of good vocational functioning would predict better vocational functioning during follow up.

METHODS

FEP patients aged 14-35 years, who presented to seven EIS in London, UK, between 2003 and 2010, were followed for 1 year. Sociodemographic, clinical and vocational information (qualifications obtained and paid employment) were collected using the MiData audit tool at entry to EIS and 1 year later.

RESULTS

Approximately one-third of patients (n = 345/1013) were studying or employed at some point during the first year of EIS care. Baseline vocational activity was the strongest predictor of vocational functioning during 1 year of follow up. Moreover, employment prior to entry into EIS strongly predicted change in vocational activity during 1 year of follow up. Individuals with DUP <6 months or of Asian or black African origin were more likely to be studying than their white British counterparts.

CONCLUSION

This study confirms that a significant proportion of FEP patients are able to engage in meaningful vocational activities even within the first year of EIS care. However, services need to focus more resources on getting patients with poor educational or employment histories into training programmes to improve their vocational outcomes.

Attitudes of Mental Health Workers Towards Early Interventions in Psychiatry: A National Survey

Early intervention (EI) is an effective strategy to improve outcomes of psychiatric disorders, but there is little evidence on mental health professionals' opinions on this approach. Hence, during conferences on this topic, we surveyed participants on the benefits, aims, and barriers to implementation of EI. Participants reported that the most important outcomes of EI were decreasing the risk of long-term social consequences, of severe psychopathological conditions, and chronicization. EI would primarily need to be implemented in the care of psychotic, eating, and mood disorders, whereas the main barriers to EI implementation were the lack of funding and of a prevention-oriented culture. Although these results might be biased by a generic attitude favoring EI, participants showed a very positive attitude towards EI and stated the need of a culture shift towards a more prevention-oriented model in a mental health setting.

Stigma- and non-stigma-related treatment barriers to mental healthcare reported by service users and caregivers

Delayed treatment seeking for people experiencing symptoms of mental illness is common despite available mental healthcare. Poor outcomes are associated with untreated mental illness and caregivers may eventually need to seek help on the service user's behalf. More attention has recently focused on the role of stigma in delayed treatment seeking. This study aimed to establish the frequency of stigma- and non-stigma-related treatment barriers reported by 202 service users and 80 caregivers; to compare treatment barriers reported by service users and caregivers; and to investigate demographic predictors of reporting stigma-related treatment barriers. The profile of treatment barriers differed between service users and caregivers. Service users were more likely to report stigma-related treatment barriers than caregivers across all stigma-related items. Service users who were female, had a diagnosis of schizophrenia or with GCSEs (UK qualifications usually obtained at age 16) were significantly more likely to report stigma-related treatment barriers. Caregivers who were female or of Black ethnicities were significantly more likely to report stigma-related treatment barriers. Multifaceted approaches are needed to reduce barriers to treatment seeking for both service users and caregivers, with anti-stigma interventions being of particular importance for the former group.

Effect of time and duration of untreated psychosis on cognitive and social functioning in Chinese patients with first-episode schizophrenia: A 1-year study

BACKGROUND

Duration of untreated psychosis (DUP) is believed to exert a deleterious effect on cognitive and social function. However, to date, results remain inconclusive.

AIMS

To investigate the effect of time and DUP on cognitive and social functioning in first-episode schizophrenia (FES) subjects in Shanghai, China.

METHODS

FES patients were subjected to a comprehensive neuropsychological battery, the Personal and Social Performance scale (PSP) and the Positive and Negative Symptoms Scale (PANSS) at baseline, 6 month and 1 year. DUP was defined as the time from onset of first psychotic symptoms to first contact made with psychiatric services.

RESULTS

Though the rate of non-completers in our observational study was relatively high (40%), we did not find any significant differences between the completers and non-completers (P-values > 0.05). Significant impairments in verbal learning and memory and executive function were noted over the course of 1 year. Meanwhile, social function improved significantly over the course of 1 year. Although, DUP did not share any significant relationship with cognitive or social function the effect estimate (range: - 0.03 to 0.02) of an increase of 1 month in DUP was clinically non-negligible in this study.

CONCLUSIONS

In Chinese FES patients, the longitudinal course of cognitive function tends to worsen in verbal learning and memory, executive function and motor speed, while that of social function tends to improve. DUP was not found to be associated with cognitive or social deterioration in Chinese FES.

The benefit of minocycline on negative symptoms in early-phase psychosis in addition to standard care - extent and mechanism (BeneMin): study protocol for a randomised controlled trial

BACKGROUND

Negative symptoms of psychosis do not respond to the traditional therapy with first- or second-generation antipsychotics and are among main causes of a decrease in quality of life observed in individuals suffering from the disorder. Minocycline, a broad-spectrum tetracyclic antibiotic displaying neuroprotective properties has been suggested as a new potential therapy for negative symptoms. In the two previous clinical trials comparing minocycline and placebo, both added to the standard care, patients receiving minocycline showed increased reduction in negative symptoms. Three routes to neuroprotection by minocycline have been identified: neuroprotection against grey matter loss, anti-inflammatory action and stabilisation of glutamate receptors. However, it is not yet certain what the extent of the benefit of minocycline in psychosis is and what its mechanism is. We present a protocol for a multi-centre double-blind randomised placebo-controlled clinical trial entitled The Benefit of Minocycline on Negative Symptoms of Psychosis: Extent and Mechanism (BeneMin).

METHODS

After providing informed consent, 226 participants in the early phase of psychosis will be randomised to receive either 100 mg modified-release capsules of minocycline or similar capsules with placebo for 12 months in addition to standard care. The participants will be tested for outcome variables before and after the intervention period. The extent of benefit will be tested via clinical outcome measures, namely the Positive and Negative Syndrome Scale score, social and cognitive functioning scores, antipsychotic medication dose equivalent and level of weight gain. The mechanism of action of minocycline will be tested via blood screening for circulating cytokines and magnetic resonance imaging with three-dimensional T1-weighted rapid gradient-echo, proton density T2-weighted dual echo and T2*-weighted gradient echo planar imaging with N-back task and resting state. Eight research centres in UK and 15 National Health Service Trusts and Health Boards will be involved in recruiting participants, performing the study and analysing the data.

DISCUSSION

The BeneMin trial can inform as to whether in minocycline we have found a new and effective therapy against negative symptoms of psychosis. The European Union Clinical Trial Register: EudraCT 2010-022463-35 with the registration finalised in July 2011. The recruitment in the trial started in January 2013 with the first patient recruited in March 2013.