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Hyatt A, Mullin B, Hasler V, Madore D, Progovac AM, Cook BL, DeLisi LE. Predictors of relapse and engagement in care one year after ending services in an urban safety net coordinated specialty care program for first episode psychosis. Schizophr Res 2024; 264:140-146. [PMID: 38128345 PMCID: PMC10983670 DOI: 10.1016/j.schres.2023.12.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 11/08/2023] [Accepted: 12/17/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVE This study aimed to identify risk factors for relapse (psychiatric emergency department visits or hospitalization) and lack of follow-up with outpatient psychiatric care in the 12 months after ending services in an urban safety net coordinated specialty care (CSC) program for first episode psychosis (FEP). METHODS The study population (n = 143) were individuals with FEP who had any CSC care between 2014 and 2021. To identify risk factors for relapse and follow up after exit, multivariable logistic regression was performed using data from electronic health records and linked insurance claims data. RESULTS Individuals with any emergency department visit or hospitalization 12 months prior to ending CSC (aOR = 4.69, 95 % CI 1.78-12.34) and those who were using cannabis at last CSC contact (aOR = 4.06, 95 % CI 1.56-10.56) had a higher risk of relapse after ending CSC services. Cannabis use at last contact was also associated with lower rates of outpatient psychiatric follow-up (aOR = 0.32, 95 % CI 0.12-0.94), while CSC duration in months had a small positive association with post-CSC psychiatric follow-up. There were no differences in relapse or follow-up by race or ethnicity, primary diagnosis, or medication usage. CONCLUSIONS Prior relapse during CSC predicted relapse in the 12 months after ending CSC services, but not outpatient follow up. Cannabis use predicted both a higher rate of relapse and a lower rate of follow up after ending services. There were no differences by race or ethnicity in our sample, suggesting that once individuals engaged in FEP care there were no evident disparities in the observed outcomes.
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Affiliation(s)
- Andrew Hyatt
- Cambridge Health Alliance, Department of Psychiatry, 1493 Cambridge Street, Cambridge 02139, MA, United States; Harvard Medical School, Department of Psychiatry, 25 Shattuck Street, Boston 02115, MA, United States.
| | - Brian Mullin
- Cambridge Health Alliance, Department of Psychiatry, 1493 Cambridge Street, Cambridge 02139, MA, United States
| | - Victoria Hasler
- Cambridge Health Alliance, Department of Psychiatry, 1493 Cambridge Street, Cambridge 02139, MA, United States; Harvard Medical School, Department of Psychiatry, 25 Shattuck Street, Boston 02115, MA, United States
| | - Drew Madore
- Cambridge Health Alliance, Department of Psychiatry, 1493 Cambridge Street, Cambridge 02139, MA, United States; Harvard Medical School, Department of Psychiatry, 25 Shattuck Street, Boston 02115, MA, United States
| | - Ana M Progovac
- Cambridge Health Alliance, Department of Psychiatry, 1493 Cambridge Street, Cambridge 02139, MA, United States; Harvard Medical School, Department of Psychiatry, 25 Shattuck Street, Boston 02115, MA, United States
| | - Benjamin Lê Cook
- Cambridge Health Alliance, Department of Psychiatry, 1493 Cambridge Street, Cambridge 02139, MA, United States; Harvard Medical School, Department of Psychiatry, 25 Shattuck Street, Boston 02115, MA, United States
| | - Lynn E DeLisi
- Cambridge Health Alliance, Department of Psychiatry, 1493 Cambridge Street, Cambridge 02139, MA, United States; Harvard Medical School, Department of Psychiatry, 25 Shattuck Street, Boston 02115, MA, United States
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Hui CLM, Wong AKH, Ho ECN, Lam BST, Hui PWM, Tao TJ, Chang WC, Chan SKW, Lee EHM, Suen YN, Lam MML, Chiu CPY, Li FWS, Leung KF, McGhee SM, Law CW, Chung DWS, Yeung WS, Yiu MGC, Pang EPF, Tso S, Lui SSY, Hung SF, Lee WK, Yip KC, Kwan KL, Ng RMK, Sham PC, Honer WG, Chen EYH. Effectiveness and optimal duration of early intervention treatment in adult-onset psychosis: a randomized clinical trial. Psychol Med 2023; 53:2339-2351. [PMID: 35144700 DOI: 10.1017/s0033291721004189] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Contrasting the well-described effects of early intervention (EI) services for youth-onset psychosis, the potential benefits of the intervention for adult-onset psychosis are uncertain. This paper aims to examine the effectiveness of EI on functioning and symptomatic improvement in adult-onset psychosis, and the optimal duration of the intervention. METHODS 360 psychosis patients aged 26-55 years were randomized to receive either standard care (SC, n = 120), or case management for two (2-year EI, n = 120) or 4 years (4-year EI, n = 120) in a 4-year rater-masked, parallel-group, superiority, randomized controlled trial of treatment effectiveness (Clinicaltrials.gov: NCT00919620). Primary (i.e. social and occupational functioning) and secondary outcomes (i.e. positive and negative symptoms, and quality of life) were assessed at baseline, 6-month, and yearly for 4 years. RESULTS Compared with SC, patients with 4-year EI had better Role Functioning Scale (RFS) immediate [interaction estimate = 0.008, 95% confidence interval (CI) = 0.001-0.014, p = 0.02] and extended social network (interaction estimate = 0.011, 95% CI = 0.004-0.018, p = 0.003) scores. Specifically, these improvements were observed in the first 2 years. Compared with the 2-year EI group, the 4-year EI group had better RFS total (p = 0.01), immediate (p = 0.01), and extended social network (p = 0.05) scores at the fourth year. Meanwhile, the 4-year (p = 0.02) and 2-year EI (p = 0.004) group had less severe symptoms than the SC group at the first year. CONCLUSIONS Specialized EI treatment for psychosis patients aged 26-55 should be provided for at least the initial 2 years of illness. Further treatment up to 4 years confers little benefits in this age range over the course of the study.
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Affiliation(s)
| | | | - Elise Chun Ning Ho
- Department of Psychiatry, University of Hong Kong, Pok Fu Lam, Hong Kong
| | | | | | | | - Wing Chung Chang
- Department of Psychiatry, University of Hong Kong, Pok Fu Lam, Hong Kong
- State Key Laboratory of Brain and Cognitive Sciences, University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Sherry Kit Wa Chan
- Department of Psychiatry, University of Hong Kong, Pok Fu Lam, Hong Kong
- State Key Laboratory of Brain and Cognitive Sciences, University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Edwin Ho Ming Lee
- Department of Psychiatry, University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Yi Nam Suen
- Department of Psychiatry, University of Hong Kong, Pok Fu Lam, Hong Kong
| | - May Mei Ling Lam
- Department of Psychiatry, University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Cindy Pui Yu Chiu
- Department of Psychiatry, University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Frendi Wing Sai Li
- Department of Psychology, University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Kwok Fai Leung
- Department of Occupational Therapy, Queen Elizabeth Hospital, Yau Ma Tei, Hong Kong
| | - Sarah M McGhee
- School of Public Health, University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Chi Wing Law
- Department of Psychiatry, Queen Mary Hospital, Pok Fu Lam, Hong Kong
| | | | - Wai Song Yeung
- Department of Psychiatry, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong
| | | | - Edwin Pui Fai Pang
- Department of Psychiatry, United Christian Hospital, Kwun Tong, Hong Kong
| | - Steve Tso
- Department of Psychiatry, Castle Peak Hospital, Tuen Mun, Hong Kong
| | - Simon Sai Yu Lui
- Department of Psychiatry, Castle Peak Hospital, Tuen Mun, Hong Kong
| | - Se Fong Hung
- Department of Psychiatry, University of Hong Kong, Pok Fu Lam, Hong Kong
- Department of Psychiatry, Kwai Chung Hospital, Kwai Chung, Hong Kong
| | - Wing King Lee
- Department of Psychiatry, Kwai Chung Hospital, Kwai Chung, Hong Kong
| | - Ka Chee Yip
- Department of Psychiatry, Kowloon Hospital, Kadoorie Hill, Hong Kong
| | - Ka Lik Kwan
- Department of Psychiatry, Kowloon Hospital, Kadoorie Hill, Hong Kong
| | - Roger Man Kin Ng
- Department of Psychiatry, Kowloon Hospital, Kadoorie Hill, Hong Kong
| | - Pak Chung Sham
- State Key Laboratory of Brain and Cognitive Sciences, University of Hong Kong, Pok Fu Lam, Hong Kong
- Department of Psychiatry, King's College London, London, UK
| | - William G Honer
- Department of Psychiatry, University of British Columbia, Vancouver, Canada
| | - Eric Yu Hai Chen
- Department of Psychiatry, University of Hong Kong, Pok Fu Lam, Hong Kong
- State Key Laboratory of Brain and Cognitive Sciences, University of Hong Kong, Pok Fu Lam, Hong Kong
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Ferrari M, Pawliuk N, Pope M, MacDonald K, Boruff J, Shah J, Malla A, Iyer SN. A Scoping Review of Measures Used in Early Intervention Services for Psychosis. Psychiatr Serv 2022; 74:523-533. [PMID: 36321318 DOI: 10.1176/appi.ps.202100506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The early intervention service (EIS) model for psychosis has been implemented with increasing frequency; yet, improving outcomes across domains for all patients remains challenging. Measurement-based care can strengthen outcomes by optimizing interventions and promoting alignment with standards, but it is still not widely deployed in EIS. The authors conducted a scoping review by systematically identifying and synthesizing measures used in EIS related to purpose (i.e., to assess patients, families, and programs), domains (e.g., symptoms, quality of life), and reporting perspectives (of patients, families, and clinicians). METHODS EMBASE, MEDLINE, PsycINFO, CINAHL, and Cochrane Library databases were searched for pertinent literature published between 2000 and 2020. Two reviewers independently screened titles, abstracts, and full texts and extracted data. Measures were classified as clinician-reported outcome measures (CROMs), patient-reported outcome or experience measures (PROMs/PREMs), or family-reported outcome or experience measures (FROMs/FREMs). RESULTS In total, 172 measures of 27 domains were identified from 115 articles. Nineteen measures had been used to assess programs on fidelity, service engagement, and satisfaction; 136 to assess patients on duration of untreated psychosis, symptoms, functioning, quality of life, and others; and 17 to assess families on coping and burden, background, and others. Sixty percent were CROMs, 30% were PROMs/PREMs, and 10% were FROMs/FREMs. CONCLUSIONS Greater inclusion of PROMs and FROMs is needed because they align with the EIS philosophy of patient and family engagement and may improve shared decision making and outcomes. A comprehensive, meaningfully synthesized archive of measures can advance measurement-based care, services research, and data harmonization in early psychosis.
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Affiliation(s)
- Manuela Ferrari
- Prevention and Early Intervention Program for Psychosis, Douglas Mental Health University Institute, Montreal (Ferrari, Pawliuk, Pope, MacDonald, Shah, Malla, Iyer); Department of Psychiatry (Ferrari, Shah, Malla, Iyer) and Schulich Library of Physical Sciences, Life Sciences, and Engineering (Boruff), McGill University, Montreal
| | - Nicole Pawliuk
- Prevention and Early Intervention Program for Psychosis, Douglas Mental Health University Institute, Montreal (Ferrari, Pawliuk, Pope, MacDonald, Shah, Malla, Iyer); Department of Psychiatry (Ferrari, Shah, Malla, Iyer) and Schulich Library of Physical Sciences, Life Sciences, and Engineering (Boruff), McGill University, Montreal
| | - Megan Pope
- Prevention and Early Intervention Program for Psychosis, Douglas Mental Health University Institute, Montreal (Ferrari, Pawliuk, Pope, MacDonald, Shah, Malla, Iyer); Department of Psychiatry (Ferrari, Shah, Malla, Iyer) and Schulich Library of Physical Sciences, Life Sciences, and Engineering (Boruff), McGill University, Montreal
| | - Kevin MacDonald
- Prevention and Early Intervention Program for Psychosis, Douglas Mental Health University Institute, Montreal (Ferrari, Pawliuk, Pope, MacDonald, Shah, Malla, Iyer); Department of Psychiatry (Ferrari, Shah, Malla, Iyer) and Schulich Library of Physical Sciences, Life Sciences, and Engineering (Boruff), McGill University, Montreal
| | - Jill Boruff
- Prevention and Early Intervention Program for Psychosis, Douglas Mental Health University Institute, Montreal (Ferrari, Pawliuk, Pope, MacDonald, Shah, Malla, Iyer); Department of Psychiatry (Ferrari, Shah, Malla, Iyer) and Schulich Library of Physical Sciences, Life Sciences, and Engineering (Boruff), McGill University, Montreal
| | - Jai Shah
- Prevention and Early Intervention Program for Psychosis, Douglas Mental Health University Institute, Montreal (Ferrari, Pawliuk, Pope, MacDonald, Shah, Malla, Iyer); Department of Psychiatry (Ferrari, Shah, Malla, Iyer) and Schulich Library of Physical Sciences, Life Sciences, and Engineering (Boruff), McGill University, Montreal
| | - Ashok Malla
- Prevention and Early Intervention Program for Psychosis, Douglas Mental Health University Institute, Montreal (Ferrari, Pawliuk, Pope, MacDonald, Shah, Malla, Iyer); Department of Psychiatry (Ferrari, Shah, Malla, Iyer) and Schulich Library of Physical Sciences, Life Sciences, and Engineering (Boruff), McGill University, Montreal
| | - Srividya N Iyer
- Prevention and Early Intervention Program for Psychosis, Douglas Mental Health University Institute, Montreal (Ferrari, Pawliuk, Pope, MacDonald, Shah, Malla, Iyer); Department of Psychiatry (Ferrari, Shah, Malla, Iyer) and Schulich Library of Physical Sciences, Life Sciences, and Engineering (Boruff), McGill University, Montreal
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Robinson DG, Schooler NR, Marcy P, Gibbons RD, Hendricks Brown C, John M, Mueser KT, Penn DL, Rosenheck RA, Addington J, Brunette MF, Correll CU, Estroff SE, Mayer-Kalos PS, Gottlieb JD, Glynn SM, Lynde DW, Gingerich S, Pipes R, Miller AL, Severe JB, Kane JM. Outcomes During and After Early Intervention Services for First-Episode Psychosis: Results Over 5 Years From the RAISE-ETP Site-Randomized Trial. Schizophr Bull 2022; 48:1021-1031. [PMID: 35689478 PMCID: PMC9434430 DOI: 10.1093/schbul/sbac053] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
To examine long-term effects of early intervention services (EIS) for first-episode psychosis, we compared Heinrichs-Carpenter Quality of Life (QLS) and Positive and Negative Syndrome Scale (PANSS) scores and inpatient hospitalization days over 5 years with data from the site-randomized RAISE-ETP trial that compared the EIS NAVIGATE (17 sites; 223 participants) and community care (CC) (17 sites; 181 participants). Inclusion criteria were: age 15-40 years; DSM-IV diagnoses of schizophrenia, schizoaffective disorder, schizophreniform disorder, brief psychotic disorder, or psychotic disorder not otherwise specified; first psychotic episode; antipsychotic medication taken for ≤6 months. NAVIGATE-randomized participants could receive NAVIGATE from their study entry date until NAVIGATE ended when the last-enrolled NAVIGATE participant completed 2 years of treatment. Assessments occurred every 6 months. 61% of participants had assessments conducted ≥2 years; 31% at 5 years. Median follow-up length was CC 30 months and NAVIGATE 38 months. Primary analyses assumed data were not-missing-at-random (NMAR); sensitivity analyses assumed data were missing-at-random (MAR). MAR analyses found no significant treatment-by-time interactions for QLS or PANSS. NMAR analyses revealed that NAVIGATE was associated with a 13.14 (95%CI:6.92,19.37) unit QLS and 7.73 (95%CI:2.98,12.47) unit PANSS better improvement and 2.53 (95%CI:0.59,4.47) fewer inpatient days than CC (all comparisons significant). QLS and PANSS effect sizes were 0.856 and 0.70. NAVIGATE opportunity length (mean 33.8 (SD = 5.1) months) was not associated (P = .72) with QLS outcome; duration of untreated psychosis did not moderate (P = .32) differential QLS outcome. While conclusions are limited by the low rate of five-year follow-up, the data support long-term benefit of NAVIGATE compared to community care.
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Affiliation(s)
- Delbert G Robinson
- To whom correspondence should be addressed; The Zucker Hillside Hospital, Psychiatry Research, 75-59 263rd Street, Glen Oaks, NY 11004, USA; tel: 718 470-8195, fax: 718 343-1659, e-mail:
| | - Nina R Schooler
- Department of Psychiatry, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | | | - Robert D Gibbons
- Center for Health Statistics, University of Chicago, Chicago, IL, USA
| | - C Hendricks Brown
- Departments of Psychiatry and Behavioral Sciences, Preventive Medicine and Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Majnu John
- The Feinstein Institutes for Medical Research, Institute of Behavioral Science, Manhasset, NY, USA
- Department of Mathematics, Hofstra University, Hempstead, NY, USA
| | - Kim T Mueser
- Center for Psychiatric Rehabilitation, Boston University, Boston, MA, USA
| | - David L Penn
- Department of Psychology, University of North Carolina-Chapel Hill, Chapel Hill, NC, USA
- School of Behavioural and Health Sciences, Australian Catholic University, Melbourne, Victoria, Australia
| | | | - Jean Addington
- Department of Psychiatry, University of Calgary Cumming School of Medicine, Calgary, AB, Canada
| | - Mary F Brunette
- Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Christoph U Correll
- Departments of Psychiatry and of Molecular Medicine, The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
- The Feinstein Institutes for Medical Research, Institute of Behavioral Science, Manhasset, NY, USA
- The Zucker Hillside Hospital, Psychiatry Research, North Shore - Long Island Jewish Health System, Glen Oaks, NY, USA
- Department of Child and Adolescent Psychiatry, Charite Universitatsmedizin, Berlin, Germany
| | - Sue E Estroff
- Department of Social Medicine, University of North Carolina-Chapel Hill, Chapel Hill, NC, USA
| | - Piper S Mayer-Kalos
- Department of Psychiatry & Behavioral Sciences, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Jennifer D Gottlieb
- Division of Population Behavioral Health Innovation and Harvard Medical School, Department of Psychiatry, Cambridge Health Alliance, Cambridge, MA, USA
| | - Shirley M Glynn
- Semel Institute of Neuroscience and Human Behavior, University of California, Los Angeles, CA, USA
| | - David W Lynde
- Departments of Psychiatry and of Molecular Medicine, The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Susan Gingerich
- Departments of Psychiatry and of Molecular Medicine, The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Ronny Pipes
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Alexander L Miller
- Department of Psychiatry and Behavioral Sciences San Antonio, UT Health San Antonio, TX, USA
| | - Joanne B Severe
- Departments of Psychiatry and of Molecular Medicine, The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - John M Kane
- Departments of Psychiatry and of Molecular Medicine, The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
- The Feinstein Institutes for Medical Research, Institute of Behavioral Science, Manhasset, NY, USA
- The Zucker Hillside Hospital, Psychiatry Research, North Shore - Long Island Jewish Health System, Glen Oaks, NY, USA
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Hyatt AS, Hasler V, Wilner EK. What happens after early intervention in first-episode psychosis? Limitations of existing service models and an agenda for the future. Curr Opin Psychiatry 2022; 35:165-170. [PMID: 35579870 DOI: 10.1097/yco.0000000000000785] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW Early intervention in first-episode psychosis (FEP) improves symptomatic and functional outcomes while programs last. However, these gains may not be sustained over time and not all individuals benefit equally from such programs. This review examines the efficacy of FEP programs, as well as step-down practices and long-term outcomes to identify ways to extend the gains made in FEP programs. RECENT FINDINGS FEP programs improve outcomes while services last, but effects diminish over time. Step-down and discharge practices vary widely with little randomized evidence guiding practice. Extending the duration of FEP programs for all does not consistently improve outcomes, but there is some encouraging evidence that targeted psychosocial interventions after program end may extend symptomatic and functional benefits. Members of marginalized groups and individuals with poorer outcomes during the FEP period may benefit from further specialized intervention after FEP. SUMMARY Step down practices from FEP programs should be structured and tailored to individual needs, and benefit from sustained connections to community resources. Psychosocial interventions like social skills training, peer support, and supported education and employment may help extend the benefit of FEP programs after more intensive services end.
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Affiliation(s)
- Andrew S Hyatt
- Department of Psychiatry, Cambridge Health Alliance, Cambridge
- Department of Psychiatry, Harvard Medical School, Boston, Massachu-setts, USA
| | - Victoria Hasler
- Department of Psychiatry, Cambridge Health Alliance, Cambridge
- Department of Psychiatry, Harvard Medical School, Boston, Massachu-setts, USA
| | - Emily K Wilner
- Department of Psychiatry, Cambridge Health Alliance, Cambridge
- Department of Psychiatry, Harvard Medical School, Boston, Massachu-setts, USA
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O'Sullivan S, Schmaal L, D'Alfonso S, Toenders YJ, Valentine L, McEnery C, Bendall S, Nelson B, Gleeson JF, Alvarez-Jimenez M. Characterizing Use of a Multicomponent Digital Intervention to Predict Treatment Outcomes in First-Episode Psychosis: Cluster Analysis. JMIR Ment Health 2022; 9:e29211. [PMID: 35389351 PMCID: PMC9030973 DOI: 10.2196/29211] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 06/18/2021] [Accepted: 01/10/2022] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Multicomponent digital interventions offer the potential for tailored and flexible interventions that aim to address high attrition rates and increase engagement, an area of concern in digital mental health. However, increased flexibility in use makes it difficult to determine which components lead to improved treatment outcomes. OBJECTIVE This study aims to identify user profiles on Horyzons, an 18-month digital relapse prevention intervention for first-episode psychosis that incorporates therapeutic content and social networking, along with clinical, vocational, and peer support, and to examine the predictive value of these user profiles for treatment outcomes. A secondary objective is to compare each user profile with young people receiving treatment as usual (TAU). METHODS Participants comprised 82 young people (aged 16-27 years) with access to Horyzons and 84 receiving TAU, recovering from first-episode psychosis. In addition, 6-month use data from the therapy and social networking components of Horyzons were used as features for K-means clustering for joint trajectories to identify user profiles. Social functioning, psychotic symptoms, depression, and anxiety were assessed at baseline and 6-month follow-up. General linear mixed models were used to examine the predictive value of user profiles for treatment outcomes and between each user profile with TAU. RESULTS A total of 3 user profiles were identified based on the following system use metrics: low use, maintained use of social components, and maintained use of both therapy and social components. The maintained therapy and social group showed improvements in social functioning (F2,51=3.58; P=.04), negative symptoms (F2,51=4.45; P=.02), and overall psychiatric symptom severity (F2,50=3.23; P=.048) compared with the other user profiles. This group also showed improvements in social functioning (F1,62=4.68; P=.03), negative symptoms (F1,62=14.61; P<.001), and overall psychiatric symptom severity (F1,63=5.66; P=.02) compared with the TAU group. Conversely, the maintained social group showed increases in anxiety compared with the TAU group (F1,57=7.65; P=.008). No differences were found between the low use group and the TAU group on treatment outcomes. CONCLUSIONS Continued engagement with both therapy and social components might be key in achieving long-term recovery. Maintained social use and low use outcomes were broadly comparable with TAU, emphasizing the importance of maintaining engagement for improved treatment outcomes. Although the social network may be a key ingredient to increase sustained engagement, as users engaged with this more consistently, it should be leveraged as a tool to engage young people with therapeutic content to bring about social and clinical benefits.
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Affiliation(s)
- Shaunagh O'Sullivan
- Orygen, Parkville, Australia.,Centre for Youth Mental Health, University of Melbourne, Melbourne, Australia
| | - Lianne Schmaal
- Orygen, Parkville, Australia.,Centre for Youth Mental Health, University of Melbourne, Melbourne, Australia
| | - Simon D'Alfonso
- Orygen, Parkville, Australia.,School of Computing and Information Systems, University of Melbourne, Melbourne, Australia
| | - Yara Jo Toenders
- Orygen, Parkville, Australia.,Centre for Youth Mental Health, University of Melbourne, Melbourne, Australia
| | - Lee Valentine
- Orygen, Parkville, Australia.,Centre for Youth Mental Health, University of Melbourne, Melbourne, Australia
| | - Carla McEnery
- Orygen, Parkville, Australia.,Centre for Youth Mental Health, University of Melbourne, Melbourne, Australia
| | - Sarah Bendall
- Orygen, Parkville, Australia.,Centre for Youth Mental Health, University of Melbourne, Melbourne, Australia
| | - Barnaby Nelson
- Orygen, Parkville, Australia.,Centre for Youth Mental Health, University of Melbourne, Melbourne, Australia
| | - John F Gleeson
- Health Brain and Mind Research Centre, Australian Catholic University, Melbourne, Australia.,School of Behavioural and Health Sciences, Australian Catholic University, Melbourne, Australia
| | - Mario Alvarez-Jimenez
- Orygen, Parkville, Australia.,Centre for Youth Mental Health, University of Melbourne, Melbourne, Australia
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7
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Szmulewicz A, Öngür D, Shinn AK, Carol EE, Dow J, Yilmaz N, Durning PT, Sastry JM, Hsu J. Impact of the COVID-19 Pandemic on the Employment and Educational Outcomes of Individuals in a First-Episode Psychosis Clinic. Psychiatr Serv 2022; 73:165-171. [PMID: 34189932 DOI: 10.1176/appi.ps.202100114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE A central objective of early psychosis therapy is to restore social functioning (e.g., through employment and education). Employment and educational outcomes during the COVID-19 pandemic were examined in a well-defined cohort of patients receiving care in an early psychosis clinic. METHODS Data were extracted from the electronic health records of 128 patients receiving care at McLean Hospital's first-episode psychosis (FEP) clinic between January 1 and September 21 in 2019 and 2020. Using a generalized linear model with a Gaussian distribution and robust standard errors, the authors compared the average changes in the weekly employment and education proportions before and after COVID-19 lockdowns with the same changes in 2019. RESULTS Employment losses among patients with FEP were greater than among the general population and persisted through the end of follow-up. In 2020, average employment after a stay-at-home order was instituted was 33% lower than before the order compared with the change in employment during the same period in 2019. The effect was stronger among men and those who identified as non-White, were age <21 years, or did not have a college education. Although educational engagement recovered in the fall of 2020, it still remained below the 2019 levels. CONCLUSIONS Employment disruptions were major and persistent among the FEP population, which might affect short- and long-term outcomes. Innovative approaches are needed to help patients transition to remote employment, file unemployment claims, and use online hiring platforms to ameliorate the indirect effects of the COVID-19 pandemic.
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Affiliation(s)
- Alejandro Szmulewicz
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston (Szmulewicz); Psychotic Disorders Division, McLean Hospital, Belmont, Massachusetts (Öngür, Shinn, Carol, Dow, Yilmaz, Durning); Department of Psychiatry (Öngür, Shinn, Carol) and Department of Health Care Policy (Hsu), Harvard Medical School, Boston; Mongan Institute, Massachusetts General Hospital, Boston (Sastry, Hsu)
| | - Dost Öngür
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston (Szmulewicz); Psychotic Disorders Division, McLean Hospital, Belmont, Massachusetts (Öngür, Shinn, Carol, Dow, Yilmaz, Durning); Department of Psychiatry (Öngür, Shinn, Carol) and Department of Health Care Policy (Hsu), Harvard Medical School, Boston; Mongan Institute, Massachusetts General Hospital, Boston (Sastry, Hsu)
| | - Ann K Shinn
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston (Szmulewicz); Psychotic Disorders Division, McLean Hospital, Belmont, Massachusetts (Öngür, Shinn, Carol, Dow, Yilmaz, Durning); Department of Psychiatry (Öngür, Shinn, Carol) and Department of Health Care Policy (Hsu), Harvard Medical School, Boston; Mongan Institute, Massachusetts General Hospital, Boston (Sastry, Hsu)
| | - Emily E Carol
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston (Szmulewicz); Psychotic Disorders Division, McLean Hospital, Belmont, Massachusetts (Öngür, Shinn, Carol, Dow, Yilmaz, Durning); Department of Psychiatry (Öngür, Shinn, Carol) and Department of Health Care Policy (Hsu), Harvard Medical School, Boston; Mongan Institute, Massachusetts General Hospital, Boston (Sastry, Hsu)
| | - Jacqueline Dow
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston (Szmulewicz); Psychotic Disorders Division, McLean Hospital, Belmont, Massachusetts (Öngür, Shinn, Carol, Dow, Yilmaz, Durning); Department of Psychiatry (Öngür, Shinn, Carol) and Department of Health Care Policy (Hsu), Harvard Medical School, Boston; Mongan Institute, Massachusetts General Hospital, Boston (Sastry, Hsu)
| | - Nergiz Yilmaz
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston (Szmulewicz); Psychotic Disorders Division, McLean Hospital, Belmont, Massachusetts (Öngür, Shinn, Carol, Dow, Yilmaz, Durning); Department of Psychiatry (Öngür, Shinn, Carol) and Department of Health Care Policy (Hsu), Harvard Medical School, Boston; Mongan Institute, Massachusetts General Hospital, Boston (Sastry, Hsu)
| | - Peter T Durning
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston (Szmulewicz); Psychotic Disorders Division, McLean Hospital, Belmont, Massachusetts (Öngür, Shinn, Carol, Dow, Yilmaz, Durning); Department of Psychiatry (Öngür, Shinn, Carol) and Department of Health Care Policy (Hsu), Harvard Medical School, Boston; Mongan Institute, Massachusetts General Hospital, Boston (Sastry, Hsu)
| | - Jayram M Sastry
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston (Szmulewicz); Psychotic Disorders Division, McLean Hospital, Belmont, Massachusetts (Öngür, Shinn, Carol, Dow, Yilmaz, Durning); Department of Psychiatry (Öngür, Shinn, Carol) and Department of Health Care Policy (Hsu), Harvard Medical School, Boston; Mongan Institute, Massachusetts General Hospital, Boston (Sastry, Hsu)
| | - John Hsu
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston (Szmulewicz); Psychotic Disorders Division, McLean Hospital, Belmont, Massachusetts (Öngür, Shinn, Carol, Dow, Yilmaz, Durning); Department of Psychiatry (Öngür, Shinn, Carol) and Department of Health Care Policy (Hsu), Harvard Medical School, Boston; Mongan Institute, Massachusetts General Hospital, Boston (Sastry, Hsu)
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8
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Kam CTK, Chang WC, Kwong VWY, Lau ESK, Chan GHK, Jim OTT, Hui CLM, Chan SKW, Lee EHM, Chen EYH. Patterns and predictors of trajectories for subjective quality of life in patients with early psychosis: Three-year follow-up of the randomized controlled trial on extended early intervention. Aust N Z J Psychiatry 2021; 55:983-992. [PMID: 33938260 DOI: 10.1177/00048674211009603] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Subjective quality of life is an important outcome of psychotic disorders. However, longitudinal course of subjective quality of life in the early illness stage is under-studied. We aimed to investigate the patterns and baseline predictors of subjective quality of life trajectories over 3 years in early psychosis patients, utilizing growth mixing modeling analysis, in the context of a 3-year follow-up of a randomized controlled trial comparing 1-year extension of early intervention with step-down psychiatric care for first-episode psychosis. METHOD One hundred sixty Chinese patients were recruited from specialized early intervention program for first-episode psychosis in Hong Kong after they had completed this 2-year early intervention service, and underwent 1-year randomized controlled trial as well as 2-year post-randomized controlled trial follow-up (i.e. 3-year follow-up). Assessments on premorbid adjustment, onset profile, psychopathology, functioning and treatment characteristics were conducted. Individual class membership of subjective quality of life trajectory derived from growth mixing modeling was based on the 36-Item Short Form Health Survey mental component summary scores measured at four different time-points (baseline, 1, 2 and 3 years) among 142 participants across 3-year follow-up. RESULTS Three distinct subjective quality of life trajectories were identified including higher-improving (68.3%, n = 97), lower-stable (24.6%, n = 35) and deteriorating (7%, n = 10) trajectories. Age of onset; duration of untreated psychosis; depressive, positive and negative symptoms; and intervention condition were significantly different between good (higher-improving trajectory) and poor (combined lower-stable and deteriorating trajectories) trajectory groups. Multiple regression analysis revealed that younger age of onset, more severe depression and receipt of step-down care independently predicted poor subjective quality of life trajectory. CONCLUSION Approximately one-third of patients displayed poor subjective quality of life trajectory in the early phase of psychotic illness. Our results affirm depression as a critical determinant of prospective subjective quality of life and underscores positive effect of extended early intervention on sustained subjective quality of life improvement. Further longitudinal research is warranted to facilitate better characterization of subjective quality of life course patterns and development of targeted intervention to optimize subjective quality of life in patients with early psychosis.
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Affiliation(s)
| | - Wing Chung Chang
- Department of Psychiatry, The University of Hong Kong, Queen Mary Hospital, Pokfulam, Hong Kong.,State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong, Pokfulam, Hong Kong
| | - Vivian Wing Yan Kwong
- Department of Psychiatry, The University of Hong Kong, Queen Mary Hospital, Pokfulam, Hong Kong
| | - Emily Sin Ki Lau
- Department of Psychiatry, The University of Hong Kong, Queen Mary Hospital, Pokfulam, Hong Kong
| | - Gloria Hoi Kei Chan
- Department of Psychiatry, The University of Hong Kong, Queen Mary Hospital, Pokfulam, Hong Kong
| | - Olivia Tsz Ting Jim
- Department of Psychiatry, The University of Hong Kong, Queen Mary Hospital, Pokfulam, Hong Kong
| | - Christy Lai Ming Hui
- Department of Psychiatry, The University of Hong Kong, Queen Mary Hospital, Pokfulam, Hong Kong
| | - Sherry Kit Wa Chan
- Department of Psychiatry, The University of Hong Kong, Queen Mary Hospital, Pokfulam, Hong Kong.,State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong, Pokfulam, Hong Kong
| | - Edwin Ho Ming Lee
- Department of Psychiatry, The University of Hong Kong, Queen Mary Hospital, Pokfulam, Hong Kong
| | - Eric Yu Hai Chen
- Department of Psychiatry, The University of Hong Kong, Queen Mary Hospital, Pokfulam, Hong Kong.,State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong, Pokfulam, Hong Kong
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9
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Haesebaert F, El Oussoul S, Pavard A, Fabre D, Cellard C, Magaud L, Subtil F, Damiolini E, Fakra E, Haesebaert J. PLAN-e-PSY, a mobile application to improve case management and patient's functioning in first episode psychosis: protocol for an open-label, multicentre, superiority, randomised controlled trial. BMJ Open 2021; 11:e050433. [PMID: 34521670 PMCID: PMC8442045 DOI: 10.1136/bmjopen-2021-050433] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION The prognosis of first episode psychosis (FEP), which is a severe disorder, can be notably impaired by patients' disengagement from healthcare providers. Coordinated specialty care with case management is now considered as the gold standard in this population, but there are still challenges for engagement with subsequent functional impairments. Youth-friendly and patient-centred clinical approaches are sought to improve engagement in patients with FEP. Mobile applications are widely used by young people, including patients with FEP, and can increase the youth friendliness of clinical tools. We hypothesise that a co-designed mobile application used during case management can improve functioning in patients with FEP as compared with usual case management practices. METHODS AND ANALYSIS A mobile case management application for planning and monitoring individualised care objectives will be co-designed with patients, caregivers and health professionals in a recovery-oriented approach. The application will be compared with usual case management practices in a multicentre, two-arm and parallel groups clinical trial. Patients will be recruited by specialised FEP teams. Impact on functioning will be assessed using the Personal and Social Performance Scale; the variation between baseline and 12 months in each group (control and active) will be the primary outcome. ETHICS AND DISSEMINATION This study has been approved by the Inserm Institutional Review Board IRB00003888 (Comité d'évaluation éthique de l'INSERM, reference number 20-647). The results of the study will be published in a peer-reviewed journal and presented at national and international conferences. We will also communicate the results to patients and family representatives' associations. An optimised version of the application will be then disseminated through the French FEP network (Transition Network). TRIAL REGISTRATION NUMBER ClinicalTrials.gov: NCT04657380.
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Affiliation(s)
- Frédéric Haesebaert
- SUR-CL3R-PEPS, CH Vinatier, Bron, Rhône-Alpes, France
- PSYR2 Team, INSERM U1028, CNRS UMR5292, Lyon Neuroscience Research Center, Université Claude Bernard Lyon 1, Lyon, France, Lyon, France
| | | | - Amélie Pavard
- SUR-CL3R-PEPS, CH Vinatier, Bron, Rhône-Alpes, France
| | - Delphine Fabre
- PSYR2 Team, INSERM U1028, CNRS UMR5292, Lyon Neuroscience Research Center, Université Claude Bernard Lyon 1, Lyon, France, Lyon, France
- Service Universitaire des Pathologies Psychiatriques Résistantes, CH Vinatier, Bron, Rhône-Alpes, France
| | | | - Laurent Magaud
- Service Recherche et Epidémiologie Cliniques, Hospices Civils de Lyon, Pôle de Santé Publique, Lyon, Auvergne-Rhône-Alpes, France
| | - Fabien Subtil
- Service de biostatistiques, Hospices Civils de Lyon, Pôle de Santé Publique, Lyon, Auvergne-Rhône-Alpes, France
- Laboratoire de Biométrie et Biologie Evolutive, UMR5558, Villeurbanne, Rhône-Alpes, France
| | - Eleonore Damiolini
- Service Recherche et Epidémiologie Cliniques, Hospices Civils de Lyon, Pôle de Santé Publique, Lyon, Auvergne-Rhône-Alpes, France
| | - Eric Fakra
- PSYR2 Team, INSERM U1028, CNRS UMR5292, Lyon Neuroscience Research Center, Université Claude Bernard Lyon 1, Lyon, France, Lyon, France
- Pôle Psychiatrie, Centre Hospitalier Universitaire de Saint-Etienne, Saint-Etienne, Rhône-Alpes, France
| | - Julie Haesebaert
- Service Recherche et Epidémiologie Cliniques, Hospices Civils de Lyon, Pôle de Santé Publique, Lyon, Auvergne-Rhône-Alpes, France
- Université Claude Bernard Lyon 1, Research on Healthcare Performance (RESHAPE), INSERM U1290, Lyon, France
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10
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Alvarez-Jimenez M, Koval P, Schmaal L, Bendall S, O'Sullivan S, Cagliarini D, D'Alfonso S, Rice S, Valentine L, Penn DL, Miles C, Russon P, Phillips J, McEnery C, Lederman R, Killackey E, Mihalopoulos C, Gonzalez-Blanch C, Gilbertson T, Lal S, Cotton SM, Herrman H, McGorry PD, Gleeson JFM. The Horyzons project: a randomized controlled trial of a novel online social therapy to maintain treatment effects from specialist first-episode psychosis services. World Psychiatry 2021; 20:233-243. [PMID: 34002511 PMCID: PMC8129860 DOI: 10.1002/wps.20858] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
This study aimed to determine whether, following two years of specialized support for first-episode psychosis, the addition of a new digital intervention (Horyzons) to treatment as usual (TAU) for 18 months was more effective than 18 months of TAU alone. We conducted a single-blind randomized controlled trial. Participants were people with first-episode psychosis (N=170), aged 16-27 years, in clinical remission and nearing discharge from a specialized service. They were randomly assigned (1:1) to receive Horyzons plus TAU (N=86) or TAU alone (N=84) between October 2013 and January 2017. Horyzons is a novel, comprehensive digital platform merging: peer-to-peer social networking; theory-driven and evidence-informed therapeutic interventions targeting social functioning, vocational recovery and relapse prevention; expert clinician and vocational support; and peer support and moderation. TAU involved transfer to primary or tertiary community mental health services. The primary outcome was social functioning at 18 months as measured by the Personal and Social Performance Scale (PSP). Forty-seven participants (55.5%) in the Horyzons plus TAU group logged on for at least 6 months, and 40 (47.0%) for at least 9 months. Social functioning remained high and stable in both groups from baseline to 18-month follow-up, with no evidence of significant between-group differences (PSP mean difference: -0.29, 95% CI: -4.20 to 3.63, p=0.77). Participants in the Horyzons group had a 5.5 times greater increase in their odds to find employment or enroll in education compared with those in TAU (odds ratio, OR=5.55, 95% CI: 1.09-28.23, p=0.04), with evidence of a dose-response effect. Moreover, participants in TAU were twice as likely to visit emergency services compared to those in the Horyzons group (39% vs. 19%; OR=0.31, 95% CI: 0.11-0.86, p=0.03, number needed to treat, NNT=5). There was a non-significant trend for lower hospitalizations due to psychosis in the Horyzons group vs. TAU (13% vs. 27%; OR=0.36, 95% CI: 0.11-1.08, p=0.07, NNT=7). So, although we did not find a significant effect of Horyzons on social functioning compared with TAU, the intervention was effective in improving vocational or educational attainment, a core component of social recovery, and in reducing usage of hospital emergency services, a key aim of specialized first-episode psychosis services. Horyzons holds significant promise as an engaging and sustainable intervention to provide effective vocational and relapse prevention support for young people with first-episode psychosis beyond specialist services.
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Affiliation(s)
- Mario Alvarez-Jimenez
- Orygen, Parkville, VIC, Australia
- Centre for Youth Mental Health, University of Melbourne, Melbourne, VIC, Australia
| | - Peter Koval
- Melbourne School of Psychological Sciences, University of Melbourne, Melbourne, VIC, Australia
| | - Lianne Schmaal
- Orygen, Parkville, VIC, Australia
- Centre for Youth Mental Health, University of Melbourne, Melbourne, VIC, Australia
| | - Sarah Bendall
- Orygen, Parkville, VIC, Australia
- Centre for Youth Mental Health, University of Melbourne, Melbourne, VIC, Australia
| | - Shaunagh O'Sullivan
- Orygen, Parkville, VIC, Australia
- Centre for Youth Mental Health, University of Melbourne, Melbourne, VIC, Australia
| | - Daniela Cagliarini
- Orygen, Parkville, VIC, Australia
- Centre for Youth Mental Health, University of Melbourne, Melbourne, VIC, Australia
| | - Simon D'Alfonso
- Orygen, Parkville, VIC, Australia
- School of Computing and Information Systems, University of Melbourne, Melbourne, VIC, Australia
| | - Simon Rice
- Orygen, Parkville, VIC, Australia
- Centre for Youth Mental Health, University of Melbourne, Melbourne, VIC, Australia
| | - Lee Valentine
- Orygen, Parkville, VIC, Australia
- Centre for Youth Mental Health, University of Melbourne, Melbourne, VIC, Australia
| | - David L Penn
- Department of Psychology and Neuroscience, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Healthy Brain and Mind Research Centre and School of Behavioural and Health Sciences, Australian Catholic University, Melbourne, VIC, Australia
| | - Chris Miles
- Orygen, Parkville, VIC, Australia
- Centre for Youth Mental Health, University of Melbourne, Melbourne, VIC, Australia
| | - Penni Russon
- Orygen, Parkville, VIC, Australia
- Centre for Youth Mental Health, University of Melbourne, Melbourne, VIC, Australia
| | - Jessica Phillips
- Orygen, Parkville, VIC, Australia
- Centre for Youth Mental Health, University of Melbourne, Melbourne, VIC, Australia
| | - Carla McEnery
- Orygen, Parkville, VIC, Australia
- Centre for Youth Mental Health, University of Melbourne, Melbourne, VIC, Australia
| | - Reeva Lederman
- School of Computing and Information Systems, University of Melbourne, Melbourne, VIC, Australia
| | - Eoin Killackey
- Orygen, Parkville, VIC, Australia
- Centre for Youth Mental Health, University of Melbourne, Melbourne, VIC, Australia
| | - Cathrine Mihalopoulos
- School of Health and Social Development, Deakin Health Economics, Deakin University, Geelong, VIC, Australia
| | - Cesar Gonzalez-Blanch
- Centre for Youth Mental Health, University of Melbourne, Melbourne, VIC, Australia
- University Hospital Marques de Valdecilla-IDIVAL, Santander, Spain
| | - Tamsyn Gilbertson
- Orygen, Parkville, VIC, Australia
- Centre for Youth Mental Health, University of Melbourne, Melbourne, VIC, Australia
| | - Shalini Lal
- School of Rehabilitation, Faculty of Medicine, University of Montreal, Montreal, QC, Canada
- Health Innovation and Evaluation Hub, University of Montreal Hospital Research Centre, Montreal, QC, Canada
- Douglas Mental Health University Institute, Montreal, QC, Canada
| | - Sue Maree Cotton
- Orygen, Parkville, VIC, Australia
- Centre for Youth Mental Health, University of Melbourne, Melbourne, VIC, Australia
| | - Helen Herrman
- Orygen, Parkville, VIC, Australia
- Centre for Youth Mental Health, University of Melbourne, Melbourne, VIC, Australia
| | - Patrick D McGorry
- Orygen, Parkville, VIC, Australia
- Centre for Youth Mental Health, University of Melbourne, Melbourne, VIC, Australia
| | - John F M Gleeson
- Healthy Brain and Mind Research Centre and School of Behavioural and Health Sciences, Australian Catholic University, Melbourne, VIC, Australia
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11
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Heun-Johnson H, Menchine M, Axeen S, Lung K, Claudius I, Wright T, Seabury SA. Association Between Race/Ethnicity and Disparities in Health Care Use Before First-Episode Psychosis Among Privately Insured Young Patients. JAMA Psychiatry 2021; 78:311-319. [PMID: 33355626 PMCID: PMC7758828 DOI: 10.1001/jamapsychiatry.2020.3995] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
IMPORTANCE Racial/ethnic disparities in health care use and clinical outcomes for behavioral health disorders, including psychosis, are well documented, but less is known about these disparities during the period leading up to first-episode psychosis (FEP). OBJECTIVE To describe the racial/ethnic disparities in behavioral health care use and prescription drug use of children and young adults before the diagnosis of FEP. DESIGN, SETTING, AND PARTICIPANTS An observational cohort study was conducted using medical and prescription drug claims from January 1, 2007, to September 30, 2015, obtained from Optum's deidentified Clinformatics Data Mart Database, a commercial claims database augmented with race/ethnicity and socioeconomic variables. Data analysis was performed from February 6, 2018, to October 10, 2020. First-episode psychosis was determined by the presence of psychosis diagnoses on claims for at least 1 hospitalization or 2 outpatient events, with a continuous enrollment requirement of at least 2 years before the first diagnosis. Participants included 3017 Black, Hispanic, or White patients who were continually enrolled in commercial insurance plans and received an FEP diagnosis between the ages of 10 and 21 years. MAIN OUTCOMES AND MEASURES Race/ethnicity was determined from a commercial claims database. Rates of inpatient admission, emergency department presentation, and outpatient visits (including psychotherapy), behavioral health disorder diagnoses, and antipsychotic/antidepressant prescription fills were determined for the year before FEP. Race/ethnicity was also obtained from Optum's claims database. With use of multivariable logistic regression, results were adjusted for covariates including estimated household income, age, sex, and geographic division in the US. RESULTS Of the 3017 patients with FEP, 643 Black or Hispanic patients (343 [53.3%] Black, 300 [46.7%] Hispanic, 324 [50.4%] male, mean [SD] age, 17.2 [2.76] years) were less likely than 2374 White patients (1210 [51.0%] male, mean age, 17.0 [2.72] years) to receive comorbid behavioral health disorder diagnoses in the year before the diagnosis of FEP (410 [63.8%] vs 1806 [76.1%], χ2 = 39.3; P < .001). Except for emergency care, behavioral health care use rates were lower in Black and Hispanic patients vs White patients (424 [65.9%] vs 1868 [78.7%]; χ2 = 45.0; P < .001), particularly for outpatient visits with behavioral health care professionals (232 [36.1%] vs 1236 [52.1%]; χ2 = 51.7; P < .001). After adjustment for socioeconomic covariates, behavioral health care use rates (68.9% vs 79.2%; P < .001), outpatient visits with behavioral health professionals (37.7% vs 51.2%; P < .001), and other outcomes remained significantly lower for Black and Hispanic patients vs White patients. CONCLUSIONS AND RELEVANCE The results of this study extend existing research findings of well-known racial/ethnic disparities in the population of patients who are diagnosed with FEP. These differences were apparent in young patients with continuous commercial health insurance and after controlling for household income. Providing equal access to preventive outpatient behavioral health care may increase opportunities for timely detection of psychotic symptoms and early intervention and improve differential outcomes after FEP.
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Affiliation(s)
- Hanke Heun-Johnson
- Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles,Sol Price School of Public Policy, University of Southern California, Los Angeles
| | - Michael Menchine
- Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles,Department of Emergency Medicine, Keck School of Medicine, University of Southern California, Los Angeles
| | - Sarah Axeen
- Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles,Department of Emergency Medicine, Keck School of Medicine, University of Southern California, Los Angeles
| | - Khristina Lung
- Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles,Sol Price School of Public Policy, University of Southern California, Los Angeles
| | - Ilene Claudius
- Department of Emergency Medicine, David Geffen School of Medicine, University of California Los Angeles
| | - Tyler Wright
- LAC+USC Medical Center, Los Angeles, California,University of Southern California, Los Angeles
| | - Seth A. Seabury
- Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles,Department of Pharmaceutical and Health Economics, School of Pharmacy, University of Southern California, Los Angeles
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12
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Puntis S, Minichino A, De Crescenzo F, Cipriani A, Lennox B, Harrison R. Specialised early intervention teams (extended time) for recent-onset psychosis. Cochrane Database Syst Rev 2020; 11:CD013287. [PMID: 33135812 PMCID: PMC8094422 DOI: 10.1002/14651858.cd013287.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Psychosis is an illness characterised by the presence of hallucinations and delusions that can cause distress or a marked change in an individual's behaviour (e.g. social withdrawal, flat or blunted effect). A first episode of psychosis (FEP) is the first time someone experiences these symptoms that can occur at any age, but the condition is most common in late adolescence and early adulthood. This review is concerned with FEP and the early stages of a psychosis, referred to throughout this review as 'recent-onset psychosis.' Specialised early intervention (SEI) teams are community mental health teams that specifically treat people who are experiencing, or have experienced, a recent-onset psychosis. SEI teams provide a range of treatments including medication, psychotherapy, psychoeducation, educational and employment support, augmented by assertive contact with the service user and small caseloads. Treatment is time limited, usually offered for two to three years, after which service users are either discharged to primary care or transferred to a standard adult community mental health team. Evidence suggests that once SEI treatment ends, improvements may not be sustained, bringing uncertainty about the optimal duration of SEI to ensure the best long-term outcomes. Extending SEI has been proposed as a way of providing continued intensive treatment and continuity of care, of usually up to five years, in order to a) sustain the positive initial outcomes of SEI; and b) improve the long-term trajectory of the illness. OBJECTIVES To compare extended SEI teams with treatment as usual (TAU) for people with recent-onset psychosis. To compare extended SEI teams with standard SEI teams followed by TAU (standard SEI + TAU) for people with recent-onset psychosis. SEARCH METHODS On 3 October 2018 and 22 October 2019, we searched Cochrane Schizophrenia's study-based register of trials, including registries of clinical trials. SELECTION CRITERIA We selected all randomised controlled trials (RCTs) comparing extended SEI with TAU for people with recent-onset psychosis and all RCTs comparing extended SEI with standard SEI + TAU for people with recent-onset psychosis. We entered trials meeting these criteria and reporting usable data as included studies. DATA COLLECTION AND ANALYSIS We independently inspected citations, selected studies, extracted data and appraised study quality. For binary outcomes we calculated the risk ratios (RRs) and their 95% confidence intervals (CIs). For continuous outcomes we calculated the mean difference (MD) and their 95% CIs, or if assessment measures differed for the same construct, we calculated the standardised mean difference (SMD) with 95% CIs. We assessed risk of bias for included studies and created a 'Summary of findings' table using the GRADE approach. MAIN RESULTS We included three RCTs, with a total 780 participants, aged 16 to 35 years. All participants met the criteria for schizophrenia spectrum disorders or affective psychoses. No trials compared extended SEI with TAU. All three trials randomly allocated people approximately two years into standard SEI to either extended SEI or standard SEI + TAU. The certainty of evidence for outcomes varied from low to very low. Our primary outcomes were recovery and disengagement from mental health services. No trials reported on recovery, and we used remission as a proxy. Three trials reported on remission, with the point estimate suggesting a 13% increase in remission in favour of extended SEI, but this included wide confidence intervals (CIs) and a very uncertain estimate of no benefit (RR 1.13, 95% CI 0.97 to 1.31; 3 trials, 780 participants; very low-certainty evidence). Two trials provided data on disengagement from services with evidence that extended SEI care may result in fewer disengagements from mental health treatment (15%) in comparison to standard SEI + TAU (34%) (RR 0.45, 95% CI 0.27 to 0.75; 2 trials, 380 participants; low-certainty evidence). There may be no evidence of a difference in rates of psychiatric hospital admission (RR 1.55, 95% CI 0.68 to 3.52; 1 trial, 160 participants; low-certainty evidence), or the number of days spent in a psychiatric hospital (MD -2.70, 95% CI -8.30 to 2.90; 1 trial, 400 participants; low-certainty evidence). One trial found uncertain evidence regarding lower global psychotic symptoms in extended SEI in comparison to standard SEI + TAU (MD -1.90, 95% CI -3.28 to -0.52; 1 trial, 156 participants; very low-certainty evidence). It was uncertain whether the use of extended SEI over standard SEI + TAU resulted in fewer deaths due to all-cause mortality, as so few deaths were recorded in trials (RR 0.38, 95% CI 0.09 to 1.64; 3 trials, 780 participants; low-certainty evidence). Very uncertain evidence suggests that using extended SEI instead of standard SEI + TAU may not improve global functioning (SMD 0.23, 95% CI -0.29 to 0.76; 2 trials, 560 participants; very low-certainty evidence). There was low risk of bias in all three trials for random sequence generation, allocation concealment and other biases. All three trials had high risk of bias for blinding of participants and personnel due to the nature of the intervention. For the risk of bias for blinding of outcome assessments and incomplete outcome data there was at least one trial with high or unclear risk of bias. AUTHORS' CONCLUSIONS There may be preliminary evidence of benefit from extending SEI team care for treating people experiencing psychosis, with fewer people disengaging from mental health services. Evidence regarding other outcomes was uncertain. The certainty of evidence for the measured outcomes was low or very low. Further, suitably powered studies that use a consistent approach to outcome selection are needed, but with only one further ongoing trial, there is unlikely to be any definitive conclusion for the effectiveness of extended SEI for at least the next few years.
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Affiliation(s)
- Stephen Puntis
- Department of Psychiatry, University of Oxford, Oxford, UK
| | | | | | | | - Belinda Lennox
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - Rachael Harrison
- Oxford University Medical School, Medical Sciences Divisional Office, Oxford, UK
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13
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Puntis S, Minichino A, De Crescenzo F, Cipriani A, Lennox B, Harrison R. Specialised early intervention teams for recent-onset psychosis. Cochrane Database Syst Rev 2020; 11:CD013288. [PMID: 33135811 PMCID: PMC8092671 DOI: 10.1002/14651858.cd013288.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Psychosis is an illness characterised by the presence of hallucinations and delusions that can cause distress or a marked change in an individual's behaviour (e.g. social withdrawal, flat or blunted effect). A first episode of psychosis (FEP) is the first time someone experiences these symptoms that can occur at any age, but the condition is most common in late adolescence and early adulthood. This review is concerned with first episode psychosis (FEP) and the early stages of a psychosis, referred to throughout this review as 'recent-onset psychosis.' Specialised early intervention (SEI) teams are community mental health teams that specifically treat people who are experiencing, or have experienced a recent-onset psychosis. The purpose of SEI teams is to intensively treat people with psychosis early in the course of the illness with the goal of increasing the likelihood of recovery and reducing the need for longer-term mental health treatment. SEI teams provide a range of treatments including medication, psychotherapy, psychoeducation, and occupational, educational and employment support, augmented by assertive contact with the service user and small caseloads. Treatment is time limited, usually offered for two to three years, after which service users are either discharged to primary care or transferred to a standard adult community mental health team. A previous Cochrane Review of SEI found preliminary evidence that SEI may be superior to standard community mental health care (described as 'treatment as usual (TAU)' in this review) but these recommendations were based on data from only one trial. This review updates the evidence for the use of SEI services. OBJECTIVES To compare specialised early intervention (SEI) teams to treatment as usual (TAU) for people with recent-onset psychosis. SEARCH METHODS On 3 October 2018 and 22 October 2019, we searched Cochrane Schizophrenia's study-based register of trials, including registries of clinical trials. SELECTION CRITERIA We selected all randomised controlled trials (RCTs) comparing SEI with TAU for people with recent-onset psychosis. We entered trials meeting these criteria and reporting useable data as included studies. DATA COLLECTION AND ANALYSIS We independently inspected citations, selected studies, extracted data and appraised study quality. For binary outcomes we calculated the risk ratios (RRs) and their 95% confidence intervals (CIs). For continuous outcomes we calculated the mean difference (MD) and their 95% CIs, or if assessment measures differed for the same construct, we calculated the standardised mean difference (SMD) with 95% CIs. We assessed risk of bias for included studies and created a 'Summary of findings' table using the GRADE approach. MAIN RESULTS We included three RCTs and one cluster-RCT with a total of 1145 participants. The mean age in the trials was between 23.1 years (RAISE) and 26.6 years (OPUS). The included participants were 405 females (35.4%) and 740 males (64.6%). All trials took place in community mental healthcare settings. Two trials reported on recovery from psychosis at the end of treatment, with evidence that SEI team care may result in more participants in recovery than TAU at the end of treatment (73% versus 52%; RR 1.41, 95% CI 1.01 to 1.97; 2 studies, 194 participants; low-certainty evidence). Three trials provided data on disengagement from services at the end of treatment, with fewer participants probably being disengaged from mental health services in SEI (8%) in comparison to TAU (15%) (RR 0.50, 95% CI 0.31 to 0.79; 3 studies, 630 participants; moderate-certainty evidence). There was low-certainty evidence that SEI may result in fewer admissions to psychiatric hospital than TAU at the end of treatment (52% versus 57%; RR 0.91, 95% CI 0.82 to 1.00; 4 studies, 1145 participants) and low-certainty evidence that SEI may result in fewer psychiatric hospital days (MD -27.00 days, 95% CI -53.68 to -0.32; 1 study, 547 participants). Two trials reported on general psychotic symptoms at the end of treatment, with no evidence of a difference between SEI and TAU, although this evidence is very uncertain (SMD -0.41, 95% CI -4.58 to 3.75; 2 studies, 304 participants; very low-certainty evidence). A different pattern was observed in assessment of general functioning with an end of trial difference that may favour SEI (SMD 0.37, 95% CI 0.07 to 0.66; 2 studies, 467 participants; low-certainty evidence). It was uncertain whether the use of SEI resulted in fewer deaths due to all-cause mortality at end of treatment (RR 0.21, 95% CI 0.04 to 1.20; 3 studies, 741 participants; low-certainty evidence). There was low risk of bias for random sequence generation and allocation concealment in three of the four included trials; the remaining trial had unclear risk of bias. Due to the nature of the intervention, we considered all trials at high risk of bias for blinding of participants and personnel. Two trials had low risk of bias and two trials had high risk of bias for blinding of outcomes assessments. Three trials had low risk of bias for incomplete outcome data, while one trial had high risk of bias. Two trials had low risk of bias, one trial had high risk of bias, and one had unclear risk of bias for selective reporting. AUTHORS' CONCLUSIONS There is evidence that SEI may provide benefits to service users during treatment compared to TAU. These benefits probably include fewer disengagements from mental health services (moderate-certainty evidence), and may include small reductions in psychiatric hospitalisation (low-certainty evidence), and a small increase in global functioning (low-certainty evidence) and increased service satisfaction (moderate-certainty evidence). The evidence regarding the effect of SEI over TAU after treatment has ended is uncertain. Further evidence investigating the longer-term outcomes of SEI is needed. Furthermore, all the eligible trials included in this review were conducted in high-income countries, and it is unclear whether these findings would translate to low- and middle-income countries, where both the intervention and the comparison conditions may be different.
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Affiliation(s)
- Stephen Puntis
- Department of Psychiatry, University of Oxford, Oxford, UK
| | | | | | | | - Belinda Lennox
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - Rachael Harrison
- Oxford University Medical School, Medical Sciences Divisional Office, Oxford, UK
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14
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Chang WC, Strauss GP, Ahmed AO, Wong SCY, Chan JKN, Lee EHM, Chan SKW, Hui CLM, James SH, Chapman HC, Chen EYH. The Latent Structure of Negative Symptoms in Individuals With Attenuated Psychosis Syndrome and Early Psychosis: Support for the 5 Consensus Domains. Schizophr Bull 2020; 47:386-394. [PMID: 32909606 PMCID: PMC7965067 DOI: 10.1093/schbul/sbaa129] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Negative symptoms are prevalent in the prodromal and first-episode phases of psychosis and highly predictive of poor clinical outcomes (eg, liability for conversion and functioning). However, the latent structure of negative symptoms is unclear in the early phases of illness. Determining the latent structure of negative symptoms in early psychosis (EP) is of critical importance for early identification, prevention, and treatment efforts. In the current study, confirmatory factor analysis was used to evaluate latent structure in relation to 4 theoretically derived models: 1. a 1-factor model, 2. a 2-factor model with expression (EXP) and motivation and pleasure (MAP) factors, 3. a 5-factor model with separate factors for the 5 National Institute of Mental Health (NIMH) consensus development conference domains (blunted affect, alogia, anhedonia, avolition, and asociality), and 4. a hierarchical model with 2 second-order factors reflecting EXP and MAP, as well as 5 first-order factors reflecting the 5 consensus domains. Participants included 164 individuals at clinical high risk (CHR) who met the criteria for a prodromal syndrome and 377 EP patients who were rated on the Brief Negative Symptom Scale. Results indicated that the 1- and 2-factor models provided poor fit for the data. The 5-factor and hierarchical models provided excellent fit, with the 5-factor model outperforming the hierarchical model. These findings suggest that similar to the chronic phase of schizophrenia, the latent structure of negative symptom is best conceptualized in relation to the 5 consensus domains in the CHR and EP populations. Implications for early identification, prevention, and treatment are discussed.
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Affiliation(s)
- Wing Chung Chang
- Department of Psychiatry, University of Hong Kong, Pok Fu Lam, Hong Kong,State Key Laboratory of Brain and Cognitive Sciences, University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Gregory P Strauss
- Department of Psychology, University of Georgia, Athens, GA,To whom correspondence should be addressed; tel: +1-706-542-0307, fax: +1-706-542-3275, e-mail:
| | - Anthony O Ahmed
- Department of Psychiatry, Weill Cornell Medicine, New York, NY
| | - Sandra C Y Wong
- Department of Psychiatry, University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Joe K N Chan
- Department of Psychiatry, University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Edwin H M Lee
- Department of Psychiatry, University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Sherry K W Chan
- Department of Psychiatry, University of Hong Kong, Pok Fu Lam, Hong Kong,State Key Laboratory of Brain and Cognitive Sciences, University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Christy L M Hui
- Department of Psychiatry, University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Sydney H James
- Department of Psychology, University of Georgia, Athens, GA
| | | | - Eric Y H Chen
- Department of Psychiatry, University of Hong Kong, Pok Fu Lam, Hong Kong,State Key Laboratory of Brain and Cognitive Sciences, University of Hong Kong, Pok Fu Lam, Hong Kong
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15
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Jones N, Gius B, Daley T, George P, Rosenblatt A, Shern D. Coordinated Specialty Care Discharge, Transition, and Step-Down Policies, Practices, and Concerns: Staff and Client Perspectives. Psychiatr Serv 2020; 71:487-497. [PMID: 32188363 DOI: 10.1176/appi.ps.201900514] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE In recent years, optimizing the process of transition and discharge from coordinated specialty care (CSC), a program that provides early intervention in psychosis, has emerged as an important focus area for program administrators, clinicians, and policy makers. To explore existing CSC policies and practices and to understand frontline provider and client views on discharge, the authors conducted a comprehensive analysis of staff and client interview data from the Mental Health Block Grant 10% Set-Aside Study. METHODS Data from 66 interviews with groups of CSC providers and administrators representing 36 sites and 22 states were analyzed, as well as data from interviews with 82 CSC clients at 34 sites. Transcripts were coded by using systematic content analyses. RESULTS Analyses of data from providers and administrators showed the heterogeneity of CSC program practices and strategies regarding discharge and highlighted a range of concerns related to postdischarge service accessibility and quality. Analysis of data from client interviews reflected the heterogeneity of transition challenges that clients confront. A significant number of participants reported concerns about their readiness for discharge. CONCLUSIONS CSC discharge policies and practices vary across CSC programs and states. Frequent clinician and client concerns about optimal program length, transition, and postdischarge services highlight the importance of sustained policy and research efforts to develop evidence-informed practice guidelines and possible modifications to the time-limited CSC model that currently dominates the field.
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Affiliation(s)
- Nev Jones
- Department of Psychiatry and Behavioral Neurosciences (Jones) and Department of Psychology (Gius), University of South Florida, Tampa; Westat, Inc., Rockville, Maryland (Daley, George, Rosenblatt); National Association of State Mental Health Program Directors, Alexandria, Virginia (Shern)
| | - Becky Gius
- Department of Psychiatry and Behavioral Neurosciences (Jones) and Department of Psychology (Gius), University of South Florida, Tampa; Westat, Inc., Rockville, Maryland (Daley, George, Rosenblatt); National Association of State Mental Health Program Directors, Alexandria, Virginia (Shern)
| | - Tamara Daley
- Department of Psychiatry and Behavioral Neurosciences (Jones) and Department of Psychology (Gius), University of South Florida, Tampa; Westat, Inc., Rockville, Maryland (Daley, George, Rosenblatt); National Association of State Mental Health Program Directors, Alexandria, Virginia (Shern)
| | - Preethy George
- Department of Psychiatry and Behavioral Neurosciences (Jones) and Department of Psychology (Gius), University of South Florida, Tampa; Westat, Inc., Rockville, Maryland (Daley, George, Rosenblatt); National Association of State Mental Health Program Directors, Alexandria, Virginia (Shern)
| | - Abram Rosenblatt
- Department of Psychiatry and Behavioral Neurosciences (Jones) and Department of Psychology (Gius), University of South Florida, Tampa; Westat, Inc., Rockville, Maryland (Daley, George, Rosenblatt); National Association of State Mental Health Program Directors, Alexandria, Virginia (Shern)
| | - David Shern
- Department of Psychiatry and Behavioral Neurosciences (Jones) and Department of Psychology (Gius), University of South Florida, Tampa; Westat, Inc., Rockville, Maryland (Daley, George, Rosenblatt); National Association of State Mental Health Program Directors, Alexandria, Virginia (Shern)
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16
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Lane NM, Hunter SA, Lawrie SM. The benefit of foresight? An ethical evaluation of predictive testing for psychosis in clinical practice. Neuroimage Clin 2020; 26:102228. [PMID: 32173346 PMCID: PMC7229349 DOI: 10.1016/j.nicl.2020.102228] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 02/05/2020] [Accepted: 02/23/2020] [Indexed: 12/12/2022]
Abstract
Risk prediction for psychosis has advanced to the stage at which it could feasibly become a clinical reality. Neuroimaging biomarkers play a central role in many risk prediction models. Using such models to predict the likelihood of transition to psychosis in individuals known to be at high risk has the potential to meaningfully improve outcomes, principally through facilitating early intervention. However, this compelling benefit must be evaluated in light of the broader ethical ramifications of this prospective development in clinical practice. This paper advances ethical discussion in the field in two ways: firstly, through in-depth consideration of the distinctive implications of the clinical application of predictive tools; and, secondly, by evaluating the manner in which newer predictive models incorporating neuroimaging alter the ethical landscape. We outline the current state of the science of predictive testing for psychosis, with a particular focus on emerging neuroimaging biomarkers. We then proceed to ethical analysis employing the four principles of biomedical ethics as a conceptual framework. We conclude with a call for scientific advancement to proceed in tandem with ethical consideration, informed by empirical study of the views of high risk individuals and their families. This collaborative approach will help ensure that predictive testing progresses in an ethically acceptable manner that minimizes potential adverse effects and maximizes meaningful benefits for those at high risk of psychosis.
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Affiliation(s)
- Natalie M Lane
- Department of Psychiatry, NHS Lanarkshire, Glasgow, Scotland G71 8BB, United Kingdom.
| | - Stuart A Hunter
- Department of Psychiatry, NHS Lothian, Edinburgh, Scotland EH1 3EG, United Kingdom
| | - Stephen M Lawrie
- Division of Psychiatry, University of Edinburgh, Royal Edinburgh Hospital, Edinburgh, Scotland EH10 5HF, United Kingdom
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Coentre R, Mendes T, Rebelo A, Fonseca A, Levy P. PROFIP: A Portuguese early intervention programme for first-episode psychosis in Lisbon. Early Interv Psychiatry 2019; 13:1525-1529. [PMID: 31264775 DOI: 10.1111/eip.12852] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 04/25/2019] [Accepted: 06/09/2019] [Indexed: 12/15/2022]
Abstract
AIM There is currently no national plan for early intervention in first-episode psychosis in Portugal. Consequently, there is some heterogeneity in the evaluation and treatment of first-episode psychosis across the country. The aim of this article is to provide a complete description of the early intervention programme Programa de Intervenção nas Fases Iniciais da Psicose (PROFIP) in Lisbon, a pioneering team in Portugal for treating first-episode psychosis (FEP) patients. We also describe the baseline socio-demographic and clinical data obtained from new patients over a 1-year period. PROFIP programme accepts all cases of FEP, taking a transdiagnostic approach. METHODS Description of PROFIP programme and baseline socio-demographic and clinical data obtained from new patients over a 1-year period. RESULTS The team was constituted to provide early detection, treatment and support to people aged 16 to 35 years with affective and non-affective FEP. Over a 1-year period, 39 patients were included in the PROFIP programme. The majority of patients were young male patients with a diagnosis of non-affective psychosis, and with 56% of patients reporting cannabis use. Patients received pharmacological and psychosocial interventions based on evidence and individual needs. CONCLUSIONS Our team allowed young people with early psychosis to receive effective care. We do need improvements, namely in referrals and the education of health professionals. More teams in our country should be constituted, allowing larger numbers of patients with early psychosis to be treated by specialized teams.
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Affiliation(s)
- Ricardo Coentre
- Department of Psychiatry, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte EPE, Lisbon, Portugal.,Faculty of Medicine, University of Lisbon, Lisbon, Portugal
| | - Tiago Mendes
- Department of Psychiatry, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte EPE, Lisbon, Portugal.,Faculty of Medicine, University of Lisbon, Lisbon, Portugal
| | - Ana Rebelo
- Department of Psychiatry, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte EPE, Lisbon, Portugal
| | - Alexandra Fonseca
- Department of Psychiatry, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte EPE, Lisbon, Portugal
| | - Pedro Levy
- Department of Psychiatry, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte EPE, Lisbon, Portugal
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18
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Abstract
The last 20 years have seen an increased focus on early intervention in psychotic disorders in research and clinical practice. Interventions have typically aimed at either reducing the duration of untreated psychosis (DUP), or developing specialized treatment facilities for patients with first episode psychosis (FEP). This review presents an overview of the most important trials and meta-analytic evidence within this field. The possibilities for reducing DUP and elements included in specialized early intervention treatment are discussed. Further, it examines long-term outcomes of early interventions and results from prolonged early intervention trials. Lastly, it analyses possible interactions between DUP and specialized early intervention treatment. In conclusion, both elements appear necessary in order to develop an integrated service that can provide the optimal treatment for patients with FEP. The aim of this article is to provide an overview over the most important trials and evidence regarding the outcome of early intervention in first episode psychosis.
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Affiliation(s)
- Nikolai Albert
- Copenhagen Research Center for Mental Health - CORE, Copenhagen Mental Health Centre , Copenhagen , Denmark
| | - Melissa Authen Weibell
- Regional Centre for Clinical Research in Psychosis, Division of Psychiatry, Stavanger University Hospital , Stavanger , Norway
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19
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Dama M, Shah J, Norman R, Iyer S, Joober R, Schmitz N, Abdel-Baki A, Malla A. Short duration of untreated psychosis enhances negative symptom remission in extended early intervention service for psychosis. Acta Psychiatr Scand 2019; 140:65-76. [PMID: 30963544 DOI: 10.1111/acps.13033] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/03/2019] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To test whether duration of untreated psychosis (DUP) < 3 months, recommended by the World Health Organization/International Early Psychosis Association, enhances the effects of an extended early intervention service (EEIS) on symptom remission. METHOD We examined data from a randomized controlled trial in which patients who received 2 years of treatment in EIS for psychosis were subsequently randomized to either 3 years of EEIS or 3 years of regular care (RC). Using a DUP cut-off ≤ 12 weeks (approximately < 3 months), patients were split into two groups. Length of positive, negative and total symptom remission were the outcomes. RESULTS Patients (N = 217) were mostly male (68%) with schizophrenia spectrum disorder (65%); 108 (50%) received EEIS (58 had DUP ≤12 weeks; 50 had DUP >12 weeks). Interaction between treatment condition (EEIS vs. RC) and DUP cut-off ≤ 12 weeks was only significant in multiple linear regression model examining length of negative symptom remission as the outcome (adjusted β = 36.88 [SE = 15.88], t = 2.32, P = 0.02). EEIS patients with DUP ≤12 weeks achieved 25 more weeks of negative symptom remission than EEIS patients with DUP >12 weeks. CONCLUSION Having a short DUP may be critical in deriving long-term benefits from EIS for psychosis, including EEIS settings. This work empirically supports policy recommendations of reducing DUP <3 months.
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Affiliation(s)
- M Dama
- Prevention and Early Intervention Program for Psychosis (PEPP-Montreal), Douglas Mental Health University Institute, Montreal, QC, Canada
| | - J Shah
- Department of Psychiatry, McGill University, Montreal, QC, Canada
| | - R Norman
- Departments of Psychiatry and Epidemiology & Biostatistics, Western University, London, ON, Canada
| | - S Iyer
- Department of Psychiatry, McGill University, Montreal, QC, Canada
| | - R Joober
- Department of Psychiatry, McGill University, Montreal, QC, Canada
| | - N Schmitz
- Department of Psychiatry, McGill University, Montreal, QC, Canada
| | - A Abdel-Baki
- Department of Psychiatry, Universite de Montreal, Montreal, QC, Canada
| | - A Malla
- Department of Psychiatry, McGill University, Montreal, QC, Canada
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20
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Alvarez-Jimenez M, Bendall S, Koval P, Rice S, Cagliarini D, Valentine L, D’Alfonso S, Miles C, Russon P, Penn DL, Phillips J, Lederman R, Wadley G, Killackey E, Santesteban-Echarri O, Mihalopoulos C, Herrman H, Gonzalez-Blanch C, Gilbertson T, Lal S, Chambers R, Daglas-Georgiou R, Latorre C, Cotton SM, McGorry PD, Gleeson JF. HORYZONS trial: protocol for a randomised controlled trial of a moderated online social therapy to maintain treatment effects from first-episode psychosis services. BMJ Open 2019; 9:e024104. [PMID: 30782893 PMCID: PMC6368148 DOI: 10.1136/bmjopen-2018-024104] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 10/09/2018] [Accepted: 10/10/2018] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION Specialised early intervention services have demonstrated improved outcomes in first-episode psychosis (FEP); however, clinical gains may not be sustained after patients are transferred to regular care. Moreover, many patients with FEP remain socially isolated with poor functional outcomes. To address this, our multidisciplinary team has developed a moderated online social media therapy (HORYZONS) designed to enhance social functioning and maintain clinical gains from specialist FEP services. HORYZONS merges: (1) peer-to-peer social networking; (2) tailored therapeutic interventions; (3) expert and peer-moderation; and (4) new models of psychological therapy (strengths and mindfulness-based interventions) targeting social functioning. The aim of this trial is to determine whether following 2 years of specialised support and 18-month online social media-based intervention (HORYZONS) is superior to 18 months of regular care. METHODS AND ANALYSIS This study is a single-blind randomised controlled trial. The treatment conditions include HORYZONS plus treatment as usual (TAU) or TAU alone. We recruited 170 young people with FEP, aged 16-27 years, in clinical remission and nearing discharge from Early Psychosis Prevention and Intervention Centre, Melbourne. The study includes four assessment time points, namely, baseline, 6-month, 12-month and 18-month follow-up. The study is due for completion in July 2018 and included a 40-month recruitment period and an 18-month treatment phase. The primary outcome is social functioning at 18 months. Secondary outcome measures include rate of hospital admissions, cost-effectiveness, vocational status, depression, social support, loneliness, self-esteem, self-efficacy, anxiety, psychological well-being, satisfaction with life, quality of life, positive and negative psychotic symptoms and substance use. Social functioning will be also assessed in real time through our Smartphone Ecological Momentary Assessment tool. ETHICS AND DISSEMINATION Melbourne Health Human Research Ethics Committee (2013.146) provided ethics approval for this study. Findings will be made available through scientific journals and forums and to the public via social media and the Orygen website. TRIAL REGISTRATION NUMBER ACTRN12614000009617; Pre-results.
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Affiliation(s)
- Mario Alvarez-Jimenez
- Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, Victoria, Australia
- Centre for Youth Mental Health, The University of Melbourne, Parkville, Victoria, Australia
| | - Sarah Bendall
- Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, Victoria, Australia
- Centre for Youth Mental Health, The University of Melbourne, Parkville, Victoria, Australia
| | - Peter Koval
- Melbourne School of Psychological Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Simon Rice
- Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, Victoria, Australia
- Centre for Youth Mental Health, The University of Melbourne, Parkville, Victoria, Australia
| | - Daniela Cagliarini
- Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, Victoria, Australia
- Centre for Youth Mental Health, The University of Melbourne, Parkville, Victoria, Australia
| | - Lee Valentine
- Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, Victoria, Australia
- Centre for Youth Mental Health, The University of Melbourne, Parkville, Victoria, Australia
| | - Simon D’Alfonso
- Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, Victoria, Australia
- School of Computing and Information Systems, University of Melbourne, Parkville, Victoria, Australia
| | - Christopher Miles
- Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, Victoria, Australia
- Centre for Youth Mental Health, The University of Melbourne, Parkville, Victoria, Australia
| | - Penni Russon
- Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, Victoria, Australia
- Centre for Youth Mental Health, The University of Melbourne, Parkville, Victoria, Australia
| | - David L Penn
- School of Behavioural and Health Sciences, Australian Catholic University, Melbourne, Victoria, Australia
- Department of Psychology, University of North Carolina Chapel Hill, NC, United Stated
| | - Jess Phillips
- Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, Victoria, Australia
- Centre for Youth Mental Health, The University of Melbourne, Parkville, Victoria, Australia
| | - Reeva Lederman
- School of Computing and Information Systems, University of Melbourne, Parkville, Victoria, Australia
| | - Greg Wadley
- School of Computing and Information Systems, University of Melbourne, Parkville, Victoria, Australia
| | - Eoin Killackey
- Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, Victoria, Australia
- Centre for Youth Mental Health, The University of Melbourne, Parkville, Victoria, Australia
| | - Olga Santesteban-Echarri
- Hotchkiss Brain Institute, Department of Psychiatry, University of Calgary, Calgary, Alberta, Calgary, Alberta, Canada
| | - Cathrine Mihalopoulos
- School of Health and Social Development, Deakin University, Geelong, Victoria, Australia
| | - Helen Herrman
- Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, Victoria, Australia
- Centre for Youth Mental Health, The University of Melbourne, Parkville, Victoria, Australia
| | | | - Tamsyn Gilbertson
- Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, Victoria, Australia
- Centre for Youth Mental Health, The University of Melbourne, Parkville, Victoria, Australia
| | - Shalini Lal
- School of Rehabilitation, Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada
- University of Montreal Hospital Research Center, Health Innovation and Evaluation Hub, Montreal, Quebec, Canada
- Douglas Mental Health University Institute, Montreal, Quebec, Canada
| | | | - Rothanthi Daglas-Georgiou
- Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, Victoria, Australia
- Centre for Youth Mental Health, The University of Melbourne, Parkville, Victoria, Australia
| | | | - Sue M Cotton
- Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, Victoria, Australia
- Centre for Youth Mental Health, The University of Melbourne, Parkville, Victoria, Australia
| | - Patrick D McGorry
- Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, Victoria, Australia
- Centre for Youth Mental Health, The University of Melbourne, Parkville, Victoria, Australia
| | - John F Gleeson
- School of Behavioural and Health Sciences, Australian Catholic University, Melbourne, Victoria, Australia
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Lutgens D, Joober R, Iyer S, Lepage M, Norman R, Schmitz N, Mustafa S, Abadi S, Malla A. Progress of negative symptoms over the initial 5 years of a first episode of psychosis. Psychol Med 2019; 49:66-74. [PMID: 29534765 DOI: 10.1017/s003329171800048x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Specialized early intervention (EI) following a first episode of psychosis (FEP) are effective at reducing negative symptoms, although its trajectory warrants systematic assessment. However, findings are equivocal as to whether extended gains are made post 2 years of EI and whether there is additional benefit of extending EI for an additional 3 years. METHODS Data on 178 FEP patients, from a randomized controlled trial of a 3-year extension of EI service v. transfer to regular care following 2 years of EI service, were used for this report. Repeated measures analysis of variance were conducted separately for the initial 2 years of treatment in an EI service, and for the 3-year post-randomization to examine trajectories of negative symptoms over the two periods in the two arms of the study. RESULTS There were significant improvements in total negative symptoms over the first 2 years of EI F(4.612, 797.905) = 25.263, p < 0.001 and in domains of 'expressivity' and 'motivation'. In the following 3 years, there were further significant improvements in negative symptoms F(4.318, 759.908) = 4.182, p = 0.002 with no difference between groups F(4.318, 759.908) = 1.073, p = 0.371. Changes in negative symptoms over the extension period were driven by expressivity F(4.01, 674.73) = 7.19, p < 0.01, but not motivation F(6.58, 1112.18) = 0.95, p = 0.46. CONCLUSION Negative symptoms improve significantly over the first 2 years of EI. Subsequent amelioration was largely the result of expressivity. Motivation deficits remained stable. Extended EI offered no advantage over regular care post-randomization.
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Affiliation(s)
- Danyael Lutgens
- Department of Psychiatry,McGill University,Douglas Mental Health University Institute; Prevention and Early Intervention Program for Psychosis (PEPP-Montreal),Montreal,QC,Canada
| | - Ridha Joober
- Department of Psychiatry,McGill University,Douglas Mental Health University Institute; Prevention and Early Intervention Program for Psychosis (PEPP-Montreal),Montreal,QC,Canada
| | - Srividya Iyer
- Department of Psychiatry,McGill University,Douglas Mental Health University Institute; Prevention and Early Intervention Program for Psychosis (PEPP-Montreal),Montreal,QC,Canada
| | - Martin Lepage
- McGill University,Douglas Hospital Research Centre,Montreal,QC,Canada
| | - Ross Norman
- Department of Psychiatry,Western University; Prevention and Early Intervention Program for Psychosis (PEPP-London) London,Ontario,Canada
| | - Norbert Schmitz
- Department of Psychiatry,McGill University,Douglas Mental Health University Institute; Prevention and Early Intervention Program for Psychosis (PEPP-Montreal),Montreal,QC,Canada
| | - Sally Mustafa
- Department of Psychiatry,McGill University,Douglas Mental Health University Institute; Prevention and Early Intervention Program for Psychosis (PEPP-Montreal),Montreal,QC,Canada
| | - Sherezad Abadi
- Department of Psychiatry,McGill University,Douglas Mental Health University Institute; Prevention and Early Intervention Program for Psychosis (PEPP-Montreal),Montreal,QC,Canada
| | - Ashok Malla
- Department of Psychiatry,McGill University,Douglas Mental Health University Institute; Prevention and Early Intervention Program for Psychosis (PEPP-Montreal),Montreal,QC,Canada
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22
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Chang WC, Kwong VWY, Or Chi Fai P, Lau ESK, Chan GHK, Jim OTT, Hui CLM, Chan SKW, Lee EHM, Chen EYH. Motivational impairment predicts functional remission in first-episode psychosis: 3-Year follow-up of the randomized controlled trial on extended early intervention. Aust N Z J Psychiatry 2018; 52:1194-1201. [PMID: 29475381 DOI: 10.1177/0004867418758918] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Functional remission represents an intermediate functional milestone toward recovery. Differential relationships of negative symptom sub-domains with functional remission in first-episode psychosis are understudied. We aimed to examine rate and predictors of functional remission in people with first-episode psychosis in the context of a 3-year follow-up of a randomized controlled trial comparing 1-year extension of early intervention (i.e. 3-year early intervention) with step-down psychiatric care (i.e. 2-year early intervention). METHOD A total of 160 participants were recruited upon completion of a 2-year specialized early intervention program for first-episode psychosis in Hong Kong and underwent a 1-year randomized controlled trial comparing 1-year extended early intervention with step-down care. Participants were followed up and reassessed 3 years after inclusion to the trial (i.e. 3-year follow-up). Functional remission was operationalized as simultaneous fulfillment of attaining adequate functioning (measured by Social and Occupational Functioning Scale and Role Functioning Scale) at 3-year follow-up and sustained employment in the last 6 months of 3-year study period. Negative symptom measure was delineated into amotivation (i.e. motivational impairment) and diminished expression (i.e. reduced affect and speech output). Data analysis was based on 143 participants who completed follow-up functional assessments. RESULTS A total of 31 (21.7%) participants achieved functional remission status at 3-year follow-up. Multivariate regression analysis showed that lower levels of amotivation (p = 0.010) and better functioning at study intake (p = 0.004) independently predicted functional remission (Final model: Nagelkerke R2 = 0.40, χ2 = 42.9, p < 0.001). Extended early intervention, duration of untreated psychosis and diminished expression did not predict functional remission. CONCLUSION Only approximately one-fifths of early psychosis patients were found to achieve functional remission. Functional impairment remains an unmet treatment need in the early stage of psychotic illness. Our results further suggest that amotivation may represent a critical therapeutic target for functional remission attainment in early psychosis.
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Affiliation(s)
- Wing Chung Chang
- Queen Mary Hospital and Department of Psychiatry, The University of Hong Kong, Hong Kong, China.,State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong, Hong Kong, China
| | - Vivian Wing Yan Kwong
- Queen Mary Hospital and Department of Psychiatry, The University of Hong Kong, Hong Kong, China
| | | | - Emily Sin Kei Lau
- Queen Mary Hospital and Department of Psychiatry, The University of Hong Kong, Hong Kong, China
| | - Gloria Hoi Kei Chan
- Queen Mary Hospital and Department of Psychiatry, The University of Hong Kong, Hong Kong, China
| | - Olivia Tsz Ting Jim
- Queen Mary Hospital and Department of Psychiatry, The University of Hong Kong, Hong Kong, China
| | - Christy Lai Ming Hui
- Queen Mary Hospital and Department of Psychiatry, The University of Hong Kong, Hong Kong, China
| | - Sherry Kit Wa Chan
- Queen Mary Hospital and Department of Psychiatry, The University of Hong Kong, Hong Kong, China.,State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong, Hong Kong, China
| | - Edwin Ho Ming Lee
- Queen Mary Hospital and Department of Psychiatry, The University of Hong Kong, Hong Kong, China
| | - Eric Yu Hai Chen
- Queen Mary Hospital and Department of Psychiatry, The University of Hong Kong, Hong Kong, China.,State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong, Hong Kong, China
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23
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Puntis S, Oke J, Lennox B. Discharge pathways and relapse following treatment from early intervention in psychosis services. BJPsych Open 2018; 4:368-374. [PMID: 30202598 PMCID: PMC6127960 DOI: 10.1192/bjo.2018.50] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 07/19/2018] [Accepted: 03/03/2018] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Early intervention in psychosis (EIP) services are the dominant service model in the treatment of first-episode psychosis. They are a time-limited intervention and little is known about discharge destinations and outcomes once EIP treatment has concluded. AIMS To understand discharge pathways and predictors of relapse in an EIP service. METHOD We collected data on all patients with an electronic health record treated by EIP services in Oxford Health NHS Foundation Trust in the UK between 12 January 2006 and 7 March 2017 (n = 701). Our primary outcomes were discharge destination at end of treatment and relapse. RESULTS Most patients (83.5%) were discharged to primary care. Transfer to secondary care was associated with previous in-patient admissions (odds ratio (OR) = 1.92, 95% CI 1.54-2.39) and longer EIP treatment (OR = 1.04, 95% CI 1.03-1.06). Relapse rate was highest shortly after leaving EIP services. Relapse was associated with transfer to secondary care (hazard ratio (HR) = 2.75, 95% CI 1.75-4.31), higher deprivation (HR = 1.03, 95% CI, 1.01-1.05), a substance misuse disorder (HR = 1.81, 95% CI 1.01-3.26) and a comorbid diagnosis of a personality disorder (HR = 2.96, 95% CI 1.39-6.29). CONCLUSIONS Most patients treated by the EIP service in Oxfordshire did not receive ongoing mental healthcare from secondary mental health services. We identified high deprivation and those with substance misuse problems or personality disorders as EIP populations with a high risk of relapse. DECLARATION OF INTEREST None.
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Affiliation(s)
- Stephen Puntis
- Research Fellow, Department of Psychiatry, University of Oxford, Warneford Hospital, UK
| | - Jason Oke
- Senior Statistician, Nuffield Department of Primary Care Health Sciences, University of Oxford, UK
| | - Belinda Lennox
- Associate Professor, Department of Psychiatry, University of Oxford, Warneford Hospital, UK
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24
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Solmi F, Mohammadi A, Perez JA, Hameed Y, Jones PB, Kirkbride JB. Predictors of disengagement from Early Intervention in Psychosis services. Br J Psychiatry 2018; 213:477-483. [PMID: 30027874 PMCID: PMC6071847 DOI: 10.1192/bjp.2018.91] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Revised: 04/11/2018] [Accepted: 04/12/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND The effectiveness of Early Intervention in Psychosis (EIP) services for individuals with a first episode of psychosis (FEP) could be thwarted by high rates of early disengagement.AimsTo investigate which factors predict disengagement with EIP services. METHOD Using data from a naturalistic cohort of 786 EIP clients in East Anglia (UK), we investigated the association between sociodemographic and clinical predictors and disengagement using univariable and multivariable Cox proportional hazards models. RESULTS Over half (54.3%) of our sample were discharged before receiving 3 years of EIP care, with 92 (11.7%) participants discharged due to disengagement. Milder negative symptoms, more severe hallucinations, not receiving an FEP diagnosis, polysubstance use and being employed were associated with greater disengagement. CONCLUSIONS Our findings highlight heterogeneous reasons for disengagement with EIP services. For some patients, early disengagement may hinder efforts to sustain positive long-term EIP outcomes. Efforts to identify true FEP cases and target patients with substance use problems and more severe positive symptoms may increase engagement.Declaration of interestNone.
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Affiliation(s)
- Francesca Solmi
- Research Associate, Division of Psychiatry, University College London, UK
| | | | - Jesus A. Perez
- Consultant Psychiatrist, Department of Psychiatry, University of Cambridge, UK, Cambridgeshire and Peterborough Foundation Trust and National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care East of England, UK
| | - Yasir Hameed
- Honorary Lecturer, Norfolk and Suffolk Foundation Trust, UK
| | - Peter B. Jones
- Professor of Psychiatry, Department of Psychiatry, University of Cambridge, UK, Cambridgeshire and Peterborough Foundation Trust and National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care East of England, UK
| | - James B. Kirkbride
- Reader in Epidemiology, Division of Psychiatry, University College London, UK
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25
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Patterns and predictors of trajectories for social and occupational functioning in patients presenting with first-episode non-affective psychosis: A three-year follow-up study. Schizophr Res 2018; 197:131-137. [PMID: 29395604 DOI: 10.1016/j.schres.2018.01.021] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Revised: 10/18/2017] [Accepted: 01/21/2018] [Indexed: 11/20/2022]
Abstract
BACKGROUND Functional impairment is prevalent in patients with first-episode psychosis (FEP). Longitudinal course of functioning in the early stage of psychotic illness is under-studied. In this report, we aimed to investigate the patterns and baseline predictors of social-occupational functional trajectories over 3 years, utilizing growth mixture modeling (GMM) analysis, in a large representative Chinese young FEP cohort in Hong Kong. METHOD Six hundred seventeen consecutive patients aged 15-25 years presenting with first-episode non-affective psychosis to a specialized early intervention service were studied. Data on demographic, pre-treatment and baseline clinical characteristics were collected. Individual class membership of functioning derived from GMM was based on ratings on Social and Occupational Functioning Scale (SOFAS) measured at five different time-points (baseline, 6, 12, 24 and 36 months) across 3-year follow-up. RESULTS Four distinct functional trajectories were identified including persistently poor (48.1%, n = 320), early improved (31.3%, n = 203), gradually improved (14.8%, n = 69) and improved-deteriorated (5.8%, n = 25) trajectories. Multinomial regression analysis revealed that male gender, lower educational attainment, a diagnosis of schizophrenia-spectrum disorder and a receipt of inpatient treatment upon initial presentation independently predicted persistently poor trajectory membership. CONCLUSION The current study reveals a heterogeneous course of social-occupational functioning in FEP. Our finding that approximately half of the patients displaying persistently poor trajectory over 3 years indicates functional impairment as an unmet therapeutic need in early illness phase. Further research applying individual-based trajectory analysis in FEP is warranted to facilitate better characterization of longitudinal patterns of functioning and development of targeted intervention to promote early recovery.
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26
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Dixon LB, Goldman HH, Srihari VH, Kane JM. Transforming the Treatment of Schizophrenia in the United States: The RAISE Initiative. Annu Rev Clin Psychol 2018; 14:237-258. [PMID: 29328779 PMCID: PMC8990328 DOI: 10.1146/annurev-clinpsy-050817-084934] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/10/2023]
Abstract
The schizophrenia spectrum disorders are neurodevelopmental illnesses with a lifetime prevalence near 1%, producing extensive functional impairment and low expectations for recovery. Until recently, treatment in the United States has largely attempted to stabilize individuals with chronic schizophrenia. The identification and promotion of evidence-based practices for schizophrenia via the Patient Outcomes Research Team, combined with international studies supporting the value of early intervention, provided the foundation for the Recovery After an Initial Schizophrenia Episode (RAISE) project. The RAISE studies further supported the value of reducing the duration of untreated psychosis and providing a multi-element treatment called coordinated specialty care (CSC) to improve outcomes for patients in usual treatment settings. Although CSC programs have proliferated rapidly in the United States, many challenges remain in the treatment and recovery of individuals with schizophrenia in the aftermath of RAISE.
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Affiliation(s)
- Lisa B Dixon
- New York State Psychiatric Institute, Columbia University Medical Center, New York, NY 10032, USA;
| | - Howard H Goldman
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, Maryland 21201, USA
| | - Vinod H Srihari
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut 06511, USA
| | - John M Kane
- Zucker Hillside Hospital and the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York 11549, USA
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27
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Ho RWH, Chang WC, Kwong VWY, Lau ESK, Chan GHK, Jim OTT, Hui CLM, Chan SKW, Lee EHM, Chen EYH. Prediction of self-stigma in early psychosis: 3-Year follow-up of the randomized-controlled trial on extended early intervention. Schizophr Res 2018; 195:463-468. [PMID: 28888358 DOI: 10.1016/j.schres.2017.09.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2017] [Revised: 09/01/2017] [Accepted: 09/02/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Self-stigma represents a major barrier to recovery in people with psychotic disorders but is understudied in early illness stage. Longitudinal investigation of prediction for self-stigma is scarce and none is conducted in early psychosis. We aimed to prospectively examine baseline predictors of self-stigma in early psychosis patients in the context of a 3-year follow-up of a randomized-controlled trial (RCT) comparing 1-year extension of early intervention (EI) with step-down psychiatric care for first-episode psychosis (FEP). METHOD One hundred sixty Chinese patients were recruited from a specialized EI program for FEP in Hong Kong after they had completed this 2-year EI service, and underwent a 12-month RCT. Participants were followed up and reassessed 3years after inclusion to the trial. Comprehensive evaluation encompassing clinical, functional, subjective quality of life and treatment-related variables were conducted. Data analysis was based on 136 participants who completed self-stigma assessment at 3-year follow-up. RESULTS Fifty patients (36.8%) had moderate to high levels of self-stigma at 3-year follow-up. Multivariate regression analysis revealed that female gender, prior psychiatric hospitalization, longer duration of untreated psychosis and greater positive symptom severity at study intake independently predicted self-stigma at the end of 3-year study period. CONCLUSION Our results of more than one-third of early psychosis patients experienced significant self-stigma underscore the clinical needs for early identification and intervention of self-stigmatization in the initial years of psychotic illness. Further research is warranted to clarify prediction profile and longitudinal course of self-stigma in the early illness phase.
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Affiliation(s)
- Ryan Wui Hang Ho
- Department of Psychiatry, The University of Hong Kong, Queen Mary Hospital, Hong Kong
| | - Wing Chung Chang
- Department of Psychiatry, The University of Hong Kong, Queen Mary Hospital, Hong Kong; State Key Laboratory of Brain and Cognitive Sciences, the University of Hong Kong, Hong Kong.
| | - Vivian Wing Yan Kwong
- Department of Psychiatry, The University of Hong Kong, Queen Mary Hospital, Hong Kong
| | - Emily Sin Kei Lau
- Department of Psychiatry, The University of Hong Kong, Queen Mary Hospital, Hong Kong
| | - Gloria Hoi Kei Chan
- Department of Psychiatry, The University of Hong Kong, Queen Mary Hospital, Hong Kong
| | - Olivia Tsz Ting Jim
- Department of Psychiatry, The University of Hong Kong, Queen Mary Hospital, Hong Kong
| | - Christy Lai Ming Hui
- Department of Psychiatry, The University of Hong Kong, Queen Mary Hospital, Hong Kong
| | - Sherry Kit Wa Chan
- Department of Psychiatry, The University of Hong Kong, Queen Mary Hospital, Hong Kong; State Key Laboratory of Brain and Cognitive Sciences, the University of Hong Kong, Hong Kong
| | - Edwin Ho Ming Lee
- Department of Psychiatry, The University of Hong Kong, Queen Mary Hospital, Hong Kong
| | - Eric Yu Hai Chen
- Department of Psychiatry, The University of Hong Kong, Queen Mary Hospital, Hong Kong; State Key Laboratory of Brain and Cognitive Sciences, the University of Hong Kong, Hong Kong
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28
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Hansen H, Stige SH, Davidson L, Moltu C, Veseth M. How Do People Experience Early Intervention Services for Psychosis? A Meta-Synthesis. QUALITATIVE HEALTH RESEARCH 2018; 28:259-272. [PMID: 29039239 DOI: 10.1177/1049732317735080] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
We conducted a study to explore how people diagnosed with first-episode psychosis experienced their contact with early intervention services for psychosis and the way these experiences relate to their recovery processes. Our aim was to integrate and describe the service users' experiences in a rigorous and comprehensive way. A broad literature search was performed in June and July 2016. After screening, 17 qualitative studies were included. We analyzed the findings in two main steps: (a) translating studies into one another and (b) synthesizing the findings from the studies. Through these interpretative processes, we found five new and overarching themes: (a) something is wrong, (b) do for myself, (c) it's about people, (d) a price to pay, and (e) ongoing vulnerability. We describe these themes as a process that service users' maneuver through in their contact with the services. Our findings are discussed in light of relevant research.
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Affiliation(s)
- Hege Hansen
- 1 Western Norway University of Applied Sciences, Bergen, Norway
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