Does prodromal diagnosis delay early intervention?

Shared Decision Making With Young People at Ultra High Risk of Psychotic Disorder

Introduction: While the majority of young people who meet the criteria for being considered at increased risk of psychosis do not go on to develop a psychotic disorder, young people are currently being identified and treated in early intervention services. Ethical concerns have been raised concerning the decision about whether or not to provide treatment, and if so, what type of treatment. This study sought to support young people themselves to make these decisions with support from their clinician through a shared decision-making approach, facilitated by an online decision aid. Methods: This project used the International Patient Decision Aid Standards (IPDAS) to guide the development and piloting of an online decision aid across two phases: (1) qualitative, semi-structured focus groups with young people who were past clients and clinicians from an early psychosis service; and (2) pilot testing of the decision aid with clinicians and young people who were current clients to finalize the development. Results: Issues discussed by clinicians in the focus group were grouped into three main areas: (1) engagement phase; (2) assessment and priorities for treatment; and (3) initial and ongoing decision making. Clients focused on the context in which the decisions were made, including as they experienced initial feelings of resistance, and then acceptance of efforts made to describe and treat their mental health challenges. Clients highlighted the need for collaboration between themselves and their clinician, and the need to be equipped with the knowledge and tools to take care of themselves. These focus group data were used to refine the online decision aid. Pilot testing revealed that while it was overall useful and relevant, important limitations were noted by both clients and clinicians. Discussion: The use of a decision aid to facilitate shared decision making (SDM) in this area is feasible and has utility for both clients and clinicians. Use of such a tool can help to address the need to uphold the rights of young people as decision makers about their own care. Future efforts should embed decision aids within complex SDM interventions, and research to understand issues relating to implementation of these interventions.

The responses of young people to their experiences of first-episode psychosis: harnessing resilience

There is a burgeoning literature on first-episode psychosis, the focus of which is early intervention. Little emphasis has been placed on the responses of young people to their experiences of psychosis. This study, therefore, aimed to describe and explain the responses of young people to their first episode of psychosis. Data obtained from ten young people who attended a community early intervention recovery program in Perth Western Australia were analysed using a grounded theory method. The results revealed that the basic psychosocial problem experienced by participants was loss of control resulting in disrupted lives and that the core variable, harnessing resilience, accounted for most of the variance in their behaviour to overcome this problem. The resultant framework described and explained how participants resiled and established direction in their lives. Although there are limitations with this qualitative study, such as the small size and the demographics of the sample, the findings have potential implications for approaches to service provision and phase specific interventions.

Prediction of remission and recovery in young people presenting with first-episode psychosis in Hong Kong: a 3-year follow-up study

OBJECTIVE

The aim of the current study was to investigate the rates and predictors of symptomatic remission and recovery in patients presenting with first-episode psychosis 3 years after treatment initiation.

METHODS

Seven hundred participants aged 15-25 years consecutively enrolled in a territory-wide early intervention programme in Hong Kong from July 2001 to August 2003 fulfilled study inclusion criteria, with 539 completing 3-year follow-up. Baseline and follow-up variables were collected via systematic medical file review. The operational criteria for recovery were based on clinical definition incorporating both symptom and functional dimensions.

RESULTS

By the end of 3-year follow-up, 58.8% (n = 317) and 17.4% (n = 94) of participants met criteria for symptomatic remission and recovery, respectively. Around half (51.2%, n = 276) were not remitted either symptomatically or functionally in the last 12 months of follow-up. Of those who achieved sustained symptomatic remission, only 43.1% were also in functional remission. Patients in symptomatic remission had lower rate of admissions, shorter duration of hospitalisations and more favourable psychosocial functioning than non-remitted counterparts. Logistic regression analysis revealed that female sex, older age of onset of psychosis, shorter duration of untreated psychosis (DUP) and early symptom resolution predicted symptomatic remission at the end of follow-up. Higher educational attainment, superior baseline occupational status and shorter DUP were found to be predictive of recovery.

CONCLUSION

In a large representative cohort of Chinese young people presenting with first-episode psychosis, although more than half achieved symptomatic remission 3 years after service entry, the rates of functional remission and recovery were low. More intensive psychosocial interventions may be required to further improve patients' functional outcome.