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Colvin E, Tobon JI, Zipursky RB, Streiner DL, Ouimet AJ. Do anxiety and depression symptoms moderate the effect of motivational enhancement therapy as a pretreatment to dialectical behaviour therapy skills training? A follow-up analysis of a pilot randomised controlled trial for youth. Early Interv Psychiatry 2022; 16:1043-1048. [PMID: 34816601 DOI: 10.1111/eip.13244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 03/22/2021] [Accepted: 11/07/2021] [Indexed: 11/30/2022]
Abstract
AIM We conducted a follow-up analysis of a pilot randomised controlled trial to examine whether baseline depression and anxiety symptoms moderated the impact of a motivational enhancement therapy (MET) pretreatment to dialectical behaviour therapy skill training (DBT-ST) for EA experiencing emotion dysregulation. METHODS All participants completed a 12-week DBT-ST group intervention and participants in the MET/DBT-ST condition also completed a 4-week group MET pretreatment. Nineteen MET/DBT-ST participants and 26 DBT-ST only participants completed the treatment as per protocol. RESULTS Baseline anxiety and depression symptoms moderated the impact of the MET pretreatment for participants' reductions in emotion dysregulation and psychological distress, respectively, at a 3-month follow-up: participants with more severe baseline symptoms benefited more from the pretreatment. However, baseline symptoms did not moderate the effect of MET immediately after treatment. CONCLUSIONS These results identified for whom MET is most effective as a pretreatment for DBT-ST amongst a heterogenous sample of EA in a real-world setting.
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Affiliation(s)
- Eamon Colvin
- School of Psychology, University of Ottawa, Ottawa, Canada
| | - Juliana I Tobon
- Department of Community and Family Medicine, University of Toronto, Toronto, Canada.,St. Michael's Hospital Academic Family Health Team, Toronto, Canada
| | - Robert B Zipursky
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Canada.,Department of Psychiatry, University of Toronto, Toronto, Canada.,Centre for Addiction and Mental Health, Toronto, Canada
| | - David L Streiner
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Canada.,Department of Psychiatry, University of Toronto, Toronto, Canada.,Centre for Addiction and Mental Health, Toronto, Canada
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Tobon JI, Zipursky RB, Streiner DL, Colvin E, Bahl N, Ouimet AJ, Burckell L, Jeffs L, Bieling PJ. Motivational Enhancement as a Pretreatment to a Transdiagnostic Intervention for Emerging Adults with Emotion Dysregulation: A Pilot Randomized Controlled Trial. J Can Acad Child Adolesc Psychiatry 2020; 29:132-148. [PMID: 32774397 PMCID: PMC7391867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 02/07/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE New approaches are needed to help the large number of emerging adults (EA) presenting with early-stage mental health problems. The goal of this pilot study was to carry out a randomized controlled trial to investigate whether motivational enhancement therapy (MET) improved the treatment effects of a 12-week psychological intervention, Dialectical Behaviour Therapy Skills Training (DBT-ST), for EA presenting in the early stages of mental health difficulties. Participants were recruited from the Youth Wellness Centre at St. Joseph's Healthcare Hamilton and McMaster University's Student Wellness Centre in Hamilton, Canada. METHODS Seventy-five participants were randomized to receive MET followed by DBT-ST or to DBT-ST alone. We assessed psychological distress, emotion dysregulation, and depression and anxiety symptoms as outcomes. RESULTS We found that both treatment groups had significant reductions in emotional dysregulation, psychological distress, depression, and anxiety at post-treatment and at the three-month follow-up. Participants assigned to MET pre-treatment experienced greater improvement in psychological distress at the end of treatment. CONCLUSION This pilot study provides preliminary evidence of the potential augmentation of DBT-ST using MET in a real-world setting. Future studies should examine whether MET uniquely augments DBT-ST through the use of a comparable pre-treatment control group.
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Affiliation(s)
- Juliana I Tobon
- Youth Wellness Centre, St. Joseph's Healthcare Hamilton, Hamilton, Ontario
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, St. Joseph's Healthcare Hamilton, Hamilton, Ontario
| | - Robert B Zipursky
- Youth Wellness Centre, St. Joseph's Healthcare Hamilton, Hamilton, Ontario
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, St. Joseph's Healthcare Hamilton, Hamilton, Ontario
- Department of Psychiatry, University of Toronto, Toronto, Ontario
- Centre for Addiction and Mental Health, Toronto, Ontario
| | - David L Streiner
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, St. Joseph's Healthcare Hamilton, Hamilton, Ontario
- Department of Psychiatry, University of Toronto, Toronto, Ontario
- Centre for Addiction and Mental Health, Toronto, Ontario
| | - Eamon Colvin
- School of Psychology, University of Ottawa, Ottawa, Ontario
| | - Nancy Bahl
- School of Psychology, University of Ottawa, Ottawa, Ontario
| | | | - Lisa Burckell
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, St. Joseph's Healthcare Hamilton, Hamilton, Ontario
- Borderline Personality Disorder Service, St. Joseph's Healthcare Hamilton, Hamilton, Ontario
| | - Lisa Jeffs
- Youth Wellness Centre, St. Joseph's Healthcare Hamilton, Hamilton, Ontario
| | - Peter J Bieling
- Youth Wellness Centre, St. Joseph's Healthcare Hamilton, Hamilton, Ontario
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, St. Joseph's Healthcare Hamilton, Hamilton, Ontario
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3
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Wang A, Tobon JI, Bieling P, Jeffs L, Colvin E, Zipursky RB. Rethinking service design for youth with mental health needs: The development of the Youth Wellness Centre, St. Joseph's Healthcare Hamilton. Early Interv Psychiatry 2020; 14:365-372. [PMID: 31724296 DOI: 10.1111/eip.12904] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 10/04/2019] [Accepted: 10/31/2019] [Indexed: 11/30/2022]
Abstract
AIM This article describes the development and design of the Youth Wellness Centre (YWC), an innovative, youth-friendly centre providing mental health and addiction services for emerging adults aged 17 to 25 in Hamilton, Canada. We also report on demographic and clinical characteristics of clients to evaluate how the YWC is serving populations at increased risk of developing mental disorders. METHODS Data were extracted from clinic databases for 1520 youth at the YWC between March 2015 and 2018 to report on demographic characteristics, clinical profiles, primary presenting problems, service use and overall satisfaction with services. RESULTS Marginalized groups, particularly street-involved individuals and LGBTQ+ youth, are highly represented at the YWC, keeping with the centre's mandate of reaching at-risk populations. Youth at the YWC carry significant mental health burdens, with 80.8% having a history of suicidal ideation and 32.8% having a history of a substance use disorder. The primary route of referral is self-referral and the number of new clients has increased by nearly 20% in the first 3 years of operations. Overall satisfaction with the centre is on par with or slightly above provincial averages. CONCLUSIONS The YWC was developed to meet the mental health needs of transition-aged youth in Hamilton by providing early intervention, system navigation and transition services. The success of the YWC in reaching high-risk youth is demonstrated by the significant proportion of clients reporting demographic and clinical risk factors associated with increased risk for development of mental disorders. The increasing referrals to the YWC highlight the ongoing need for similar services.
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Affiliation(s)
- Alyssa Wang
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada
| | - Juliana I Tobon
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada.,Youth Wellness Centre, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Peter Bieling
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada.,Youth Wellness Centre, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Lisa Jeffs
- Youth Wellness Centre, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Eamon Colvin
- School of Psychology, University of Ottawa, Ottawa, Ontario, Canada
| | - Robert B Zipursky
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada.,Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
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4
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Takeuchi H, Siu C, Remington G, Fervaha G, Zipursky RB, Foussias G, Agid O. Does relapse contribute to treatment resistance? Antipsychotic response in first- vs. second-episode schizophrenia. Neuropsychopharmacology 2019; 44:1036-1042. [PMID: 30514883 PMCID: PMC6462044 DOI: 10.1038/s41386-018-0278-3] [Citation(s) in RCA: 98] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 11/13/2018] [Indexed: 01/20/2023]
Abstract
Although some studies have suggested that relapse may be associated with antipsychotic treatment resistance in schizophrenia, the number and quality of studies is limited. The current analysis included patients with a diagnosis of first-episode schizophrenia or schizoaffective disorder who met the following criteria: (1) referral to the First-Episode Psychosis Program between 2003 and 2013; (2) treatment with an oral second-generation antipsychotic according to a standardized treatment algorithm; (3) positive symptom remission; (4) subsequent relapse (i.e., second episode) in association with non-adherence; and (5) reintroduction of antipsychotic treatment with the same agent used to achieve response in the first episode. The following outcomes were used as an index of antipsychotic treatment response: changes in the brief psychiatric rating scale (BPRS) total and positive symptom scores and number of patients who achieved positive symptom remission and 20 and 50% response. A total of 130 patients were included in the analyses. Although all patients took the same antipsychotic in both episodes, there were significant episode-by-time interactions for all outcomes of antipsychotic treatment response over 1 year in favor of the first episode compared to the second episode (50% response rate: 48.7 vs. 10.4% at week 7; 88.2 vs. 27.8% at week 27, respectively). Although antipsychotic doses in the second episode were significantly higher than those in the first episode, results remained unchanged after adjusting for antipsychotic dose. The present findings suggest that antipsychotic treatment response is reduced or delayed in the face of relapse following effective treatment of the first episode of schizophrenia.
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Affiliation(s)
- Hiroyoshi Takeuchi
- 0000 0004 1936 9959grid.26091.3cDepartment of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan ,0000 0000 8793 5925grid.155956.bSchizophrenia Program, Centre for Addiction and Mental Health, Toronto, ON Canada
| | | | - Gary Remington
- 0000 0000 8793 5925grid.155956.bSchizophrenia Program, Centre for Addiction and Mental Health, Toronto, ON Canada ,0000 0001 2157 2938grid.17063.33Department of Psychiatry, University of Toronto, Toronto, ON Canada ,0000 0001 2157 2938grid.17063.33Institute of Medical Science, University of Toronto, Toronto, ON Canada ,0000 0000 8793 5925grid.155956.bCampbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON Canada
| | - Gagan Fervaha
- 0000 0000 8793 5925grid.155956.bSchizophrenia Program, Centre for Addiction and Mental Health, Toronto, ON Canada ,0000 0004 1936 8331grid.410356.5School of Medicine, Queen’s University, Kingston, ON Canada
| | - Robert B. Zipursky
- 0000 0000 8793 5925grid.155956.bSchizophrenia Program, Centre for Addiction and Mental Health, Toronto, ON Canada ,0000 0001 2157 2938grid.17063.33Department of Psychiatry, University of Toronto, Toronto, ON Canada
| | - George Foussias
- 0000 0000 8793 5925grid.155956.bSchizophrenia Program, Centre for Addiction and Mental Health, Toronto, ON Canada ,0000 0001 2157 2938grid.17063.33Department of Psychiatry, University of Toronto, Toronto, ON Canada ,0000 0001 2157 2938grid.17063.33Institute of Medical Science, University of Toronto, Toronto, ON Canada ,0000 0000 8793 5925grid.155956.bCampbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON Canada
| | - Ofer Agid
- Schizophrenia Program, Centre for Addiction and Mental Health, Toronto, ON, Canada. .,Department of Psychiatry, University of Toronto, Toronto, ON, Canada. .,Institute of Medical Science, University of Toronto, Toronto, ON, Canada.
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5
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Becker M, Cunningham CE, Christensen BK, Furimsky I, Rimas H, Wilson F, Jeffs L, Madsen V, Bieling P, Chen Y, Mielko S, Zipursky RB. Investigating service features to sustain engagement in early intervention mental health services. Early Interv Psychiatry 2019; 13:241-250. [PMID: 28836377 DOI: 10.1111/eip.12470] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Revised: 05/13/2017] [Accepted: 06/17/2017] [Indexed: 01/05/2023]
Abstract
AIM To understand what service features would sustain patient engagement in early intervention mental health treatment. METHODS Mental health patients, family members of individuals with mental illness and mental health professionals completed a survey consisting of 18 choice tasks that involved 14 different service attributes. Preferences were ascertained using importance and utility scores. Latent class analysis revealed segments characterized by distinct preferences. Simulations were carried out to estimate utilization of hypothetical clinical services. RESULTS Overall, 333 patients and family members and 183 professionals (N = 516) participated. Respondents were distributed between a Professional segment (53%) and a Patient segment (47%) that differed in a number of their preferences including for appointment times, individual vs group sessions and mode of after-hours support. Members of both segments shared preferences for many of the service attributes including having crisis support available 24 h per day, having a choice of different treatment modalities, being offered help for substance use problems and having a focus on improving symptoms rather than functioning. Simulations predicted that 60% of the Patient segment thought patients would remain engaged with a Hospital service, while 69% of the Professional segment thought patients would be most likely to remain engaged with an E-Health service. CONCLUSIONS Patients, family members and professionals shared a number of preferences about what service characteristics will optimize patient engagement in early intervention services but diverged on others. Providing effective crisis support as well as a range of treatment options should be prioritized in the future design of early intervention services.
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Affiliation(s)
- Mackenzie Becker
- Department of Psychology, Neuroscience & Behaviour (PNB), McMaster University, Hamilton, Ontario, Canada
| | - Charles E Cunningham
- Department of Psychiatry & Behavioural Neurosciences, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada.,McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Bruce K Christensen
- Department of Psychology, Neuroscience & Behaviour (PNB), McMaster University, Hamilton, Ontario, Canada.,Department of Psychiatry & Behavioural Neurosciences, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada.,Mental Health and Addiction Program, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Ivana Furimsky
- Department of Psychiatry & Behavioural Neurosciences, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada.,Mental Health and Addiction Program, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Heather Rimas
- Department of Psychiatry & Behavioural Neurosciences, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Fiona Wilson
- Department of Psychiatry & Behavioural Neurosciences, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada.,Mental Health and Addiction Program, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Lisa Jeffs
- Mental Health and Addiction Program, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Victoria Madsen
- Department of Psychiatry & Behavioural Neurosciences, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada.,Mental Health and Addiction Program, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Peter Bieling
- Department of Psychiatry & Behavioural Neurosciences, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada.,Mental Health and Addiction Program, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Yvonne Chen
- Department of Psychiatry & Behavioural Neurosciences, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Stephanie Mielko
- Department of Psychiatry & Behavioural Neurosciences, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Robert B Zipursky
- Department of Psychiatry & Behavioural Neurosciences, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada.,Mental Health and Addiction Program, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
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Abstract
Schizophrenia is a chronic, debilitating and costly illness. The course of illness is often exacerbated by relapses which are associated with negative outcomes including rehospitalisation. The most important risk factor associated with relapse is medication nonadherence. Medication nonadherence is not specific to schizophrenia and is an issue across all of medicine. The objective of this paper is to present a narrative review which synthesizes the rates and predictors of medication nonadherence, as well as associated interventions, across schizophrenia, first episode psychosis and general medicine. Given the breadth of these topics, this paper does not aim to present a complete review of the data but rather a concise synthesis of several lines of research in order to provide a general framework for approaching this important topic. Overall, this paper identifies that rates and risk factors of nonadherence in schizophrenia are similar to those reported in general medicine. Rates of adherence are estimated at 50% for both. Predictors of nonadherence were also quite similar between various illnesses, with lack of insight, poor family support and substance abuse often being highlighted. Well studied approaches of improving adherence include simplifying medication regimens, psychoeducation, engaging family support and use of long-acting injectable antipsychotics. Emerging interventions included text-message reminders, financial incentives and MyCite technology. Additionally, several evidence based interventions were identified in general medicine that may have applicability in schizophrenia and first episode psychosis. Lastly, avenues of future research were identified including the need to further characterize the dichotomy between adherence, partial adherence and nonadherence.
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Affiliation(s)
- Alexander Dufort
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada
| | - Robert B Zipursky
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Centre for Addiction and Mental Health, Toronto, ON, Canada
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7
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Dufort A, Zipursky RB. Understanding and Managing Treatment Adherence in Schizophrenia. Clin Schizophr Relat Psychoses 2019. [PMID: 30605043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
Schizophrenia is a chronic, debilitating and costly illness. The course of illness is often exacerbated by relapses which are associated with negative outcomes including rehospitalisation. The most important risk factor associated with relapse is medication nonadherence. Medication nonadherence is not specific to schizophrenia and is an issue across all of medicine. The objective of this paper is to present a narrative review which synthesizes the rates and predictors of medication nonadherence, as well as associated interventions, across schizophrenia, first episode psychosis and general medicine. Given the breadth of these topics, this paper does not aim to present a complete review of the data but rather a concise synthesis of several lines of research in order to provide a general framework for approaching this important topic. Overall, this paper identifies that rates and risk factors of nonadherence in schizophrenia are similar to those reported in general medicine. Rates of adherence are estimated at 50% for both. Predictors of nonadherence were also quite similar between various illnesses, with lack of insight, poor family support and substance abuse often being highlighted. Well studied approaches of improving adherence include simplifying medication regimens, psychoeducation, engaging family support and use of long-acting injectable antipsychotics. Emerging interventions included text-message reminders, financial incentives and MyCite technology. Additionally, several evidence based interventions were identified in general medicine that may have applicability in schizophrenia and first episode psychosis. Lastly, avenues of future research were identified including the need to further characterize the dichotomy between adherence, partial adherence and nonadherence.
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Affiliation(s)
- Alexander Dufort
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada
| | - Robert B Zipursky
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
- Centre for Addiction and Mental Health, Toronto, ON, Canada
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8
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Affiliation(s)
- Robert B Zipursky
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada; Centre for Addiction and Mental Health, Toronto, ON M6J 1H4, Canada.
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9
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Affiliation(s)
- Robert B Zipursky
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada; Centre for Addiction and Mental Health, Toronto M6J 1H4, ON, Canada.
| | - Ofer Agid
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada; Centre for Addiction and Mental Health, Toronto M6J 1H4, ON, Canada
| | - Gary Remington
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada; Centre for Addiction and Mental Health, Toronto M6J 1H4, ON, Canada
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10
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Abstract
BackgroundNeurobiological studies of the early course of psychoses, such as schizophrenia, allow investigation of pathophysiology without the confounds of illness chronicity and treatment.AimsTo review the recent literature on the biology of the early course of psychoses.MethodWe carried out a critical appraisal of the recent findings in the neurobiology of early psychoses, using structural, functional and neurochemical imaging techniques.ResultsBrain structural alterations are present early in the illness and may predate symptom onset. Some changes, notably those in frontal and temporal lobes, can progress during the early phases of the illness. Functional and neurochemical brain abnormalities can also be seen in the premorbid and the early phases of the illness. Some, although not all, changes can be trait-like whereas some others might progress during the early years.ConclusionsA better understanding of such changes, especially during the critical periods of the prodrome, around the transition to the psychotic phase and during the early phases of the illness is crucial for continued research into preventive intervention strategies.
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Affiliation(s)
- Matcheri S Keshavan
- Department of Psychiatry and Behavioral Neurosciences, Wayne State University, UCH 9B, 4201 St Antoine Boulevard, Detroit, MI, USA.
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11
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Affiliation(s)
- Robert B Zipursky
- 1 Department of Psychiatry and Behavioural Neurosciences, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada.,2 Schizophrenia & Community Integration Service, Mental Health & Addiction Program, St. Joseph's Healthcare Hamilton, Hamilton, ON, Canada
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12
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Cunningham CE, Zipursky RB, Christensen BK, Bieling PJ, Madsen V, Rimas H, Mielko S, Wilson F, Furimsky I, Jeffs L, Munn C. Modeling the mental health service utilization decisions of university undergraduates: A discrete choice conjoint experiment. J Am Coll Health 2017; 65:389-399. [PMID: 28511031 DOI: 10.1080/07448481.2017.1322090] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Revised: 10/24/2016] [Accepted: 01/20/2017] [Indexed: 05/28/2023]
Abstract
OBJECTIVE We modeled design factors influencing the intent to use a university mental health service. PARTICIPANTS Between November 2012 and October 2014, 909 undergraduates participated. METHOD Using a discrete choice experiment, participants chose between hypothetical campus mental health services. RESULTS Latent class analysis identified three segments. A Psychological/Psychiatric Service segment (45.5%) was most likely to contact campus health services delivered by psychologists or psychiatrists. An Alternative Service segment (39.3%) preferred to talk to peer-counselors who had experienced mental health problems. A Hesitant segment (15.2%) reported greater distress but seemed less intent on seeking help. They preferred services delivered by psychologists or psychiatrists. Simulations predicted that, rather than waiting for standard counseling, the Alternative Service segment would prefer immediate access to E-Mental health. The Usual Care and Hesitant segments would wait 6 months for standard counseling. CONCLUSIONS E-Mental Health options could engage students who may not wait for standard services.
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Affiliation(s)
- Charles E Cunningham
- a Department of Psychiatry and Behavioural Neurosciences , McMaster University , Hamilton , Ontario , Canada
- b Hamilton Health Sciences Corporation , Hamilton , Ontario , Canada
| | - Robert B Zipursky
- a Department of Psychiatry and Behavioural Neurosciences , McMaster University , Hamilton , Ontario , Canada
- c Mental Health and Addiction Program, St. Joseph's Healthcare Hamilton , Hamilton , Ontario , Canada
| | - Bruce K Christensen
- d Research School of Psychology , The Australian National University , Canberra , Australia
| | - Peter J Bieling
- a Department of Psychiatry and Behavioural Neurosciences , McMaster University , Hamilton , Ontario , Canada
- c Mental Health and Addiction Program, St. Joseph's Healthcare Hamilton , Hamilton , Ontario , Canada
| | | | - Heather Rimas
- a Department of Psychiatry and Behavioural Neurosciences , McMaster University , Hamilton , Ontario , Canada
| | - Stephanie Mielko
- a Department of Psychiatry and Behavioural Neurosciences , McMaster University , Hamilton , Ontario , Canada
| | - Fiona Wilson
- a Department of Psychiatry and Behavioural Neurosciences , McMaster University , Hamilton , Ontario , Canada
- c Mental Health and Addiction Program, St. Joseph's Healthcare Hamilton , Hamilton , Ontario , Canada
| | - Ivana Furimsky
- c Mental Health and Addiction Program, St. Joseph's Healthcare Hamilton , Hamilton , Ontario , Canada
| | - Lisa Jeffs
- f Youth Wellness Centre, St. Joseph's Healthcare Hamilton , Hamilton , Ontario , Canada
| | - Catharine Munn
- a Department of Psychiatry and Behavioural Neurosciences , McMaster University , Hamilton , Ontario , Canada
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13
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Becker MPE, Christensen BK, Cunningham CE, Furimsky I, Rimas H, Wilson F, Jeffs L, Bieling PJ, Madsen V, Chen YYS, Mielko S, Zipursky RB. Preferences for Early Intervention Mental Health Services: A Discrete-Choice Conjoint Experiment. Psychiatr Serv 2016; 67:184-91. [PMID: 26369880 DOI: 10.1176/appi.ps.201400306] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Early intervention services (EISs) for mental illness may improve outcomes, although treatment engagement is often a problem. Incorporating patients' preferences in the design of interventions improves engagement. A discrete-choice conjoint experiment was conducted in Canada to identify EIS attributes that encourage treatment initiation. METHODS Sixteen four-level attributes were formalized into a conjoint survey, completed by patients, family members, and mental health professionals (N=562). Participants were asked which EIS option people with mental illness would contact. Latent-class analysis identified respondent classes characterized by shared preferences. Randomized first-choice simulations predicted which hypothetical options, based on attributes, would result in maximum utilization. RESULTS Participants in the conventional-service class (N=241, 43%) predicted that individuals would contact traditional services (for example, hospital location and staffed by psychologists or psychiatrists). Membership was associated with being a patient or family member and being male. Participants in the convenient-service class (N=321, 57%) predicted that people would contact services promoting easy access (for example, self-referral and access from home). Membership was associated with being a professional. Both classes predicted that people would contact services that included short wait times, direct contact with professionals, patient autonomy, and psychological treatment information. The convenient-service class predicted that people would use an e-health model, whereas the conventional-service class predicted that people would use a primary care or clinic-hospital model. CONCLUSIONS Provision of a range of services may maximize EIS use. Professionals may be more apt to adopt EISs in line with their beliefs regarding patient preferences. Considering several perspectives is important for service design.
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Affiliation(s)
- Mackenzie P E Becker
- Ms. Becker is with the Department of Psychology, Neuroscience and Behaviour, and Dr. Cunningham, Ms. Furimsky, Ms. Rimas, Ms. Wilson, Dr. Bieling, Ms. Chen, Ms. Mielko, and Dr. Zipursky are with the Department of Psychiatry and Behavioural Neurosciences, all at McMaster University, Hamilton, Ontario, Canada. Ms. Furimsky, Ms. Wilson, Dr. Bieling, and Dr. Zipursky are also with the Mental Health and Addiction Program, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, where Ms. Jeffs and Ms. Madsen are affiliated. Dr. Cunningham is also with the Department of Psychiatry, McMaster Children's Hospital, Hamilton, Ontario. Ms. Chen is also with the School of Business, University of Alberta, Edmonton, Alberta. Dr. Christensen is with the Research School of Psychology, Australian National University, Canberra, Australia. Send correspondence to Dr. Zipursky (e-mail: )
| | - Bruce K Christensen
- Ms. Becker is with the Department of Psychology, Neuroscience and Behaviour, and Dr. Cunningham, Ms. Furimsky, Ms. Rimas, Ms. Wilson, Dr. Bieling, Ms. Chen, Ms. Mielko, and Dr. Zipursky are with the Department of Psychiatry and Behavioural Neurosciences, all at McMaster University, Hamilton, Ontario, Canada. Ms. Furimsky, Ms. Wilson, Dr. Bieling, and Dr. Zipursky are also with the Mental Health and Addiction Program, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, where Ms. Jeffs and Ms. Madsen are affiliated. Dr. Cunningham is also with the Department of Psychiatry, McMaster Children's Hospital, Hamilton, Ontario. Ms. Chen is also with the School of Business, University of Alberta, Edmonton, Alberta. Dr. Christensen is with the Research School of Psychology, Australian National University, Canberra, Australia. Send correspondence to Dr. Zipursky (e-mail: )
| | - Charles E Cunningham
- Ms. Becker is with the Department of Psychology, Neuroscience and Behaviour, and Dr. Cunningham, Ms. Furimsky, Ms. Rimas, Ms. Wilson, Dr. Bieling, Ms. Chen, Ms. Mielko, and Dr. Zipursky are with the Department of Psychiatry and Behavioural Neurosciences, all at McMaster University, Hamilton, Ontario, Canada. Ms. Furimsky, Ms. Wilson, Dr. Bieling, and Dr. Zipursky are also with the Mental Health and Addiction Program, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, where Ms. Jeffs and Ms. Madsen are affiliated. Dr. Cunningham is also with the Department of Psychiatry, McMaster Children's Hospital, Hamilton, Ontario. Ms. Chen is also with the School of Business, University of Alberta, Edmonton, Alberta. Dr. Christensen is with the Research School of Psychology, Australian National University, Canberra, Australia. Send correspondence to Dr. Zipursky (e-mail: )
| | - Ivana Furimsky
- Ms. Becker is with the Department of Psychology, Neuroscience and Behaviour, and Dr. Cunningham, Ms. Furimsky, Ms. Rimas, Ms. Wilson, Dr. Bieling, Ms. Chen, Ms. Mielko, and Dr. Zipursky are with the Department of Psychiatry and Behavioural Neurosciences, all at McMaster University, Hamilton, Ontario, Canada. Ms. Furimsky, Ms. Wilson, Dr. Bieling, and Dr. Zipursky are also with the Mental Health and Addiction Program, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, where Ms. Jeffs and Ms. Madsen are affiliated. Dr. Cunningham is also with the Department of Psychiatry, McMaster Children's Hospital, Hamilton, Ontario. Ms. Chen is also with the School of Business, University of Alberta, Edmonton, Alberta. Dr. Christensen is with the Research School of Psychology, Australian National University, Canberra, Australia. Send correspondence to Dr. Zipursky (e-mail: )
| | - Heather Rimas
- Ms. Becker is with the Department of Psychology, Neuroscience and Behaviour, and Dr. Cunningham, Ms. Furimsky, Ms. Rimas, Ms. Wilson, Dr. Bieling, Ms. Chen, Ms. Mielko, and Dr. Zipursky are with the Department of Psychiatry and Behavioural Neurosciences, all at McMaster University, Hamilton, Ontario, Canada. Ms. Furimsky, Ms. Wilson, Dr. Bieling, and Dr. Zipursky are also with the Mental Health and Addiction Program, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, where Ms. Jeffs and Ms. Madsen are affiliated. Dr. Cunningham is also with the Department of Psychiatry, McMaster Children's Hospital, Hamilton, Ontario. Ms. Chen is also with the School of Business, University of Alberta, Edmonton, Alberta. Dr. Christensen is with the Research School of Psychology, Australian National University, Canberra, Australia. Send correspondence to Dr. Zipursky (e-mail: )
| | - Fiona Wilson
- Ms. Becker is with the Department of Psychology, Neuroscience and Behaviour, and Dr. Cunningham, Ms. Furimsky, Ms. Rimas, Ms. Wilson, Dr. Bieling, Ms. Chen, Ms. Mielko, and Dr. Zipursky are with the Department of Psychiatry and Behavioural Neurosciences, all at McMaster University, Hamilton, Ontario, Canada. Ms. Furimsky, Ms. Wilson, Dr. Bieling, and Dr. Zipursky are also with the Mental Health and Addiction Program, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, where Ms. Jeffs and Ms. Madsen are affiliated. Dr. Cunningham is also with the Department of Psychiatry, McMaster Children's Hospital, Hamilton, Ontario. Ms. Chen is also with the School of Business, University of Alberta, Edmonton, Alberta. Dr. Christensen is with the Research School of Psychology, Australian National University, Canberra, Australia. Send correspondence to Dr. Zipursky (e-mail: )
| | - Lisa Jeffs
- Ms. Becker is with the Department of Psychology, Neuroscience and Behaviour, and Dr. Cunningham, Ms. Furimsky, Ms. Rimas, Ms. Wilson, Dr. Bieling, Ms. Chen, Ms. Mielko, and Dr. Zipursky are with the Department of Psychiatry and Behavioural Neurosciences, all at McMaster University, Hamilton, Ontario, Canada. Ms. Furimsky, Ms. Wilson, Dr. Bieling, and Dr. Zipursky are also with the Mental Health and Addiction Program, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, where Ms. Jeffs and Ms. Madsen are affiliated. Dr. Cunningham is also with the Department of Psychiatry, McMaster Children's Hospital, Hamilton, Ontario. Ms. Chen is also with the School of Business, University of Alberta, Edmonton, Alberta. Dr. Christensen is with the Research School of Psychology, Australian National University, Canberra, Australia. Send correspondence to Dr. Zipursky (e-mail: )
| | - Peter J Bieling
- Ms. Becker is with the Department of Psychology, Neuroscience and Behaviour, and Dr. Cunningham, Ms. Furimsky, Ms. Rimas, Ms. Wilson, Dr. Bieling, Ms. Chen, Ms. Mielko, and Dr. Zipursky are with the Department of Psychiatry and Behavioural Neurosciences, all at McMaster University, Hamilton, Ontario, Canada. Ms. Furimsky, Ms. Wilson, Dr. Bieling, and Dr. Zipursky are also with the Mental Health and Addiction Program, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, where Ms. Jeffs and Ms. Madsen are affiliated. Dr. Cunningham is also with the Department of Psychiatry, McMaster Children's Hospital, Hamilton, Ontario. Ms. Chen is also with the School of Business, University of Alberta, Edmonton, Alberta. Dr. Christensen is with the Research School of Psychology, Australian National University, Canberra, Australia. Send correspondence to Dr. Zipursky (e-mail: )
| | - Victoria Madsen
- Ms. Becker is with the Department of Psychology, Neuroscience and Behaviour, and Dr. Cunningham, Ms. Furimsky, Ms. Rimas, Ms. Wilson, Dr. Bieling, Ms. Chen, Ms. Mielko, and Dr. Zipursky are with the Department of Psychiatry and Behavioural Neurosciences, all at McMaster University, Hamilton, Ontario, Canada. Ms. Furimsky, Ms. Wilson, Dr. Bieling, and Dr. Zipursky are also with the Mental Health and Addiction Program, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, where Ms. Jeffs and Ms. Madsen are affiliated. Dr. Cunningham is also with the Department of Psychiatry, McMaster Children's Hospital, Hamilton, Ontario. Ms. Chen is also with the School of Business, University of Alberta, Edmonton, Alberta. Dr. Christensen is with the Research School of Psychology, Australian National University, Canberra, Australia. Send correspondence to Dr. Zipursky (e-mail: )
| | - Yvonne Y S Chen
- Ms. Becker is with the Department of Psychology, Neuroscience and Behaviour, and Dr. Cunningham, Ms. Furimsky, Ms. Rimas, Ms. Wilson, Dr. Bieling, Ms. Chen, Ms. Mielko, and Dr. Zipursky are with the Department of Psychiatry and Behavioural Neurosciences, all at McMaster University, Hamilton, Ontario, Canada. Ms. Furimsky, Ms. Wilson, Dr. Bieling, and Dr. Zipursky are also with the Mental Health and Addiction Program, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, where Ms. Jeffs and Ms. Madsen are affiliated. Dr. Cunningham is also with the Department of Psychiatry, McMaster Children's Hospital, Hamilton, Ontario. Ms. Chen is also with the School of Business, University of Alberta, Edmonton, Alberta. Dr. Christensen is with the Research School of Psychology, Australian National University, Canberra, Australia. Send correspondence to Dr. Zipursky (e-mail: )
| | - Stephanie Mielko
- Ms. Becker is with the Department of Psychology, Neuroscience and Behaviour, and Dr. Cunningham, Ms. Furimsky, Ms. Rimas, Ms. Wilson, Dr. Bieling, Ms. Chen, Ms. Mielko, and Dr. Zipursky are with the Department of Psychiatry and Behavioural Neurosciences, all at McMaster University, Hamilton, Ontario, Canada. Ms. Furimsky, Ms. Wilson, Dr. Bieling, and Dr. Zipursky are also with the Mental Health and Addiction Program, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, where Ms. Jeffs and Ms. Madsen are affiliated. Dr. Cunningham is also with the Department of Psychiatry, McMaster Children's Hospital, Hamilton, Ontario. Ms. Chen is also with the School of Business, University of Alberta, Edmonton, Alberta. Dr. Christensen is with the Research School of Psychology, Australian National University, Canberra, Australia. Send correspondence to Dr. Zipursky (e-mail: )
| | - Robert B Zipursky
- Ms. Becker is with the Department of Psychology, Neuroscience and Behaviour, and Dr. Cunningham, Ms. Furimsky, Ms. Rimas, Ms. Wilson, Dr. Bieling, Ms. Chen, Ms. Mielko, and Dr. Zipursky are with the Department of Psychiatry and Behavioural Neurosciences, all at McMaster University, Hamilton, Ontario, Canada. Ms. Furimsky, Ms. Wilson, Dr. Bieling, and Dr. Zipursky are also with the Mental Health and Addiction Program, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, where Ms. Jeffs and Ms. Madsen are affiliated. Dr. Cunningham is also with the Department of Psychiatry, McMaster Children's Hospital, Hamilton, Ontario. Ms. Chen is also with the School of Business, University of Alberta, Edmonton, Alberta. Dr. Christensen is with the Research School of Psychology, Australian National University, Canberra, Australia. Send correspondence to Dr. Zipursky (e-mail: )
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Agid O, Mcdonald K, Fervaha G, Littrell R, Thoma J, Zipursky RB, Foussias G, Remington G. Values in First-Episode Schizophrenia. Can J Psychiatry 2015; 60:507-14. [PMID: 26720508 PMCID: PMC4679131 DOI: 10.1177/070674371506001106] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2014] [Accepted: 04/01/2015] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Functional impairment continues to represent a major challenge in schizophrenia. Surprisingly, patients with schizophrenia report a level of happiness comparable with control subjects, even in the face of the prominent functional deficits, a finding at odds with evidence indicating a positive relation between happiness and level of functioning. In attempting to reconcile these findings, we chose to examine the issue of values, defined as affectively infused criteria or motivational goals used to select and justify actions, people, and the self, as values are related to both happiness and functioning. METHODS Fifty-six first-episode patients in remission and 56 healthy control subjects completed happiness and values measures. Statistical analyses included correlations, analysis of variance, structural equation modelling, and smallest space analysis. RESULTS Results indicated that patients with schizophrenia placed significantly greater priority on the value dimensions of Tradition (P = 0.02) and Power (P = 0.03), and significantly less priority on Self-direction (P = 0.007) and Stimulation, (P = 0.008). CONCLUSIONS Essentially, people with schizophrenia place more emphasis on the customs and ideas that traditional culture or religion provide in conjunction with a decreased interest in change, which is at odds with the expectations of early adulthood. This value difference could be related to functional deficits. To this point, we have assumed that people hold to the same values that guided them before the illness' onset, but this may not be the case. Our study indicates that values differ in people with schizophrenia, compared with control subjects, even early in the illness and in the face of symptomatic remission.
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Affiliation(s)
- Ofer Agid
- Associate Professor, Department of Psychiatry, University of Toronto, Toronto, Ontario; Staff Psychiatrist and Clinician Scientist,, Complex Mental Illness Program, Schizophrenia Division, Centre for Addiction and Mental Health, Toronto, Ontario
| | - Krysta Mcdonald
- Researcher, Complex Mental Illness Program, Schizophrenia Division, Centre for Addiction and Mental Health, Toronto, Ontario
| | - Gagan Fervaha
- Doctoral Student, Institute of Medical Science, University of Toronto, Toronto, Ontario
| | - Romie Littrell
- Associate Professor, Auckland University of Technology, Auckland, New Zealand
| | - Jessica Thoma
- Psychiatrist, Complex Mental Illness Program, Schizophrenia Division, Centre for Addiction and Mental Health, Toronto, Ontario
| | - Robert B Zipursky
- Professor, Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario
| | - George Foussias
- Psychiatrist, Complex Mental Illness Program, Schizophrenia Division, Centre for Addiction and Mental Health, Toronto, Ontario
| | - Gary Remington
- Professor, Department of Psychiatry, Complex Mental Illness Program, Schizophrenia Division, Centre for Addiction and Mental Health, Toronto, Ontario
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15
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Affiliation(s)
- Robert B Zipursky
- Department of Psychiatry and Behavioural Neurosciences, Michael G. DeGroote School of Medicine, McMaster University, and Schizophrenia and Community Integration Services, St. Joseph's Healthcare HamiltonHamilton, Ontario, Canada
| | - Ofer Agid
- Department of Psychiatry, Faculty of Medicine, University of Toronto, and Complex Mental Illness/Schizophrenia Services, Centre for Addiction and Mental HealthToronto, Ontario, Canada
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Abstract
Despite many advances in the treatment of schizophrenia over the past 50 years, the outcomes for many patients with schizophrenia remain poor. While the majority of patients with a first episode of schizophrenia may be able to achieve and maintain a remission of symptoms, only 1 in 7 patients are likely to meet criteria for recovery. These findings could be easily reconciled if schizophrenia could be established to be a progressive brain disease. Results from longitudinal studies of brain structure, cognitive functioning, and clinical outcomes, however, do not support this view. The poor outcomes so commonly observed are likely best explained by poor access to treatment, poor engagement in ongoing care, poor treatment response, and poor adherence together with the cumulative negative impact of substance abuse, comorbid psychiatric disorders, cognitive deficits, and multiple social determinants of health.
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Affiliation(s)
- Robert B Zipursky
- St Joseph's Healthcare Hamilton, 100 West 5th St, Hamilton, ON, L8N 3K7, Canada
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17
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Kiang M, Christensen BK, Zipursky RB. Event-related brain potential study of semantic priming in unaffected first-degree relatives of schizophrenia patients. Schizophr Res 2014; 153:78-86. [PMID: 24451397 DOI: 10.1016/j.schres.2014.01.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2013] [Revised: 12/25/2013] [Accepted: 01/02/2014] [Indexed: 10/25/2022]
Abstract
Schizophrenia is associated with abnormalities in using meaningful stimuli to activate or prime related concepts in semantic long-term memory. A neurophysiological index of this activation is the N400, an event-related brain potential (ERP) waveform elicited by meaningful stimuli, which is normally reduced (made less negative) by relatedness between the eliciting stimulus and preceding ones (N400 semantic priming). Schizophrenia patients exhibit N400 semantic priming deficits, suggesting impairment in using meaningful context to activate related concepts. To address whether this abnormality is a trait-like marker of liability to schizophrenia or, alternatively, a biomarker of the illness itself, we tested for its presence in schizophrenia patients' unaffected biological relatives. We recorded ERPs from 12 unaffected first-degree relatives of schizophrenia patients, 12 schizophrenia patients, and 12 normal control participants (NCPs) who viewed prime words each followed at 300- or 750-ms stimulus-onset asynchrony (SOA) by an unrelated or related target word, or a nonword, in a lexical-decision task. As expected, across SOAs, NCPs exhibited smaller (less negative) N400 amplitudes for related versus unrelated targets. The same pattern held in relatives, whose N400 amplitudes for related and unrelated targets did not differ from NCPs'. In contrast, consistent with previous results, schizophrenia patients exhibited larger N400 amplitudes than NCPs (and relatives) for related targets, such that patients' N400 amplitudes for related and unrelated targets did not differ. N400 amplitudes for unrelated targets did not differ between the three groups. Thus, N400 semantic priming deficits in a visual word-pair paradigm may be an illness biomarker for schizophrenia.
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Affiliation(s)
- Michael Kiang
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada; St. Joseph's Healthcare, Hamilton, Ontario, Canada.
| | - Bruce K Christensen
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada; St. Joseph's Healthcare, Hamilton, Ontario, Canada
| | - Robert B Zipursky
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada; St. Joseph's Healthcare, Hamilton, Ontario, Canada
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Zipursky RB, Menezes NM, Streiner DL. Risk of symptom recurrence with medication discontinuation in first-episode psychosis: a systematic review. Schizophr Res 2014; 152:408-14. [PMID: 23972821 DOI: 10.1016/j.schres.2013.08.001] [Citation(s) in RCA: 142] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Revised: 07/29/2013] [Accepted: 08/01/2013] [Indexed: 11/28/2022]
Abstract
The large majority of individuals with a first episode of schizophrenia will experience a remission of symptoms within their first year of treatment. It is not clear how long treatment with antipsychotic medications should be continued in this situation. The possibility that a percentage of patients may not require ongoing treatment and may be unnecessarily exposed to the long-term risks of antipsychotic medications has led to the development of a number of studies to address this question. We carried out a systematic review to determine the risk of experiencing a recurrence of psychotic symptoms in individuals who have discontinued antipsychotic medications after achieving symptomatic remission from a first episode of non-affective psychosis (FEP). Six studies were identified that met our criteria and these reported a weighted mean one-year recurrence rate of 77% following discontinuation of antipsychotic medication. By two years, the risk of recurrence had increased to over 90%. By comparison, we estimated the one-year recurrence rate for patients who continued antipsychotic medication to be 3%. These findings suggest that in the absence of uncertainty about the diagnosis or concerns about the contribution of medication side effects to problems with health or functioning, a trial off of antipsychotic medications is associated with a very high risk of symptom recurrence and should thus not be recommended.
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Affiliation(s)
- Robert B Zipursky
- Department of Psychiatry and Behavioural Neurosciences, Michael G. DeGroote School of Medicine, McMaster University, St. Joseph's Healthcare Hamilton, 100 West 5th Street, Hamilton, Ontario L8N 3K7, Canada.
| | - Natasja M Menezes
- Department of Psychiatry and Behavioural Neurosciences, Michael G. DeGroote School of Medicine, McMaster University, St. Joseph's Healthcare Hamilton, 100 West 5th Street, Hamilton, Ontario L8N 3K7, Canada.
| | - David L Streiner
- Department of Psychiatry and Behavioural Neurosciences, Michael G. DeGroote School of Medicine, McMaster University, St. Joseph's Healthcare Hamilton, 100 West 5th Street, Hamilton, Ontario L8N 3K7, Canada; Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
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Abstract
AIM While there is clearly much to be gained from ensuring that youth with emerging mental illness across a variety of psychiatric illnesses receive care that reduces symptoms and improves functioning, it is not at all clear how best to achieve these results within a health-care system that has limited resources. Outside of the area of psychosis, there is little evidence to guide us around a model of care that might be effective, efficient and linked to existing mental health systems. METHODS We summarize the literature on early intervention (EI) in psychosis and derive five key lessons for transdiagnostic prevention. We then broadened our search to find clinical and systems models that shared challenges similar to those identified for EI, high levels of patient and family distress, need for rapid yet comprehensive diagnostic assessment and timely initiation of specific treatment. RESULTS Cancer navigators have numerous functions that appear to overlap with the key issues in transdiagnostic psychiatric EI. A navigation clinic with a separate identity, but clearly connected to specialized mental health facilities has the potential to speed assessment, diagnosis and treatment streaming. Navigators would be involved with youth and their family throughout different levels of care, making clinical decisions based on illness and functional status. CONCLUSIONS In sum, the evidence from navigation services in cancer care offers the mental health field a progressive clinical model that might be an important guide for EI in youth.
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Affiliation(s)
- Peter J Bieling
- St. Joseph's Healthcare Hamilton, Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada
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Abstract
Schizophrenia has historically been considered to be a deteriorating disease, a view reinforced by recent MRI findings of progressive brain tissue loss over the early years of illness. On the other hand, the notion that recovery from schizophrenia is possible is increasingly embraced by consumer and family groups. This review critically examines the evidence from longitudinal studies of (1) clinical outcomes, (2) MRI brain volumes, and (3) cognitive functioning. First, the evidence shows that although approximately 25% of people with schizophrenia have a poor long-term outcome, few of these show the incremental loss of function that is characteristic of neurodegenerative illnesses. Second, MRI studies demonstrate subtle developmental abnormalities at first onset of psychosis and then further decreases in brain tissue volumes; however, these latter decreases are explicable by the effects of antipsychotic medication, substance abuse, and other secondary factors. Third, while patients do show cognitive deficits compared with controls, cognitive functioning does not appear to deteriorate over time. The majority of people with schizophrenia have the potential to achieve long-term remission and functional recovery. The fact that some experience deterioration in functioning over time may reflect poor access, or adherence, to treatment, the effects of concurrent conditions, and social and financial impoverishment. Mental health professionals need to join with patients and their families in understanding that schizophrenia is not a malignant disease that inevitably deteriorates over time but rather one from which most people can achieve a substantial degree of recovery.
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Affiliation(s)
- Robert B. Zipursky
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada;,To whom correspondence should be addressed; St Joseph’s Healthcare Hamilton, 100 West 5th Street, Hamilton, Ontario L8N3K7, Canada; tel: 905-522-1155 x 36250, fax: 905-381-5633, e-mail:
| | - Thomas J. Reilly
- Department of Psychosis Studies, Institute of Psychiatry, Kings College, De Crespigny Park, London, UK
| | - Robin M. Murray
- Department of Psychosis Studies, Institute of Psychiatry, Kings College, De Crespigny Park, London, UK
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Agid O, Siu CO, Potkin SG, Kapur S, Watsky E, Vanderburg D, Zipursky RB, Remington G. Meta-regression analysis of placebo response in antipsychotic trials, 1970-2010. Am J Psychiatry 2013; 170:1335-44. [PMID: 23896810 DOI: 10.1176/appi.ajp.2013.12030315] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Large placebo response presents a major challenge for psychopharmacologic drug development and contributes to the increasing failure of psychiatric trials. The objective of this meta-regression analysis was to identify potential contributors to placebo response in randomized controlled trials of antipsychotic treatment in schizophrenia. METHOD The authors extracted trial design and clinical variables from eligible randomized controlled trials (N=50) identified through searches of MEDLINE (1960-2010) and other sources. Standardized mean change (SMC) was used as the effect size measure for placebo response, based on change scores on the Brief Psychiatric Rating Scale or the Positive and Negative Syndrome Scale from baseline to endpoint (2 to 12 weeks). RESULTS The results suggest significant heterogeneities (Q=387.83, df=49) in the magnitude of placebo response (mean SMC, -0.33, range -1.4 to 0.9) and in study quality. Both placebo SMC and study quality increased over time. Younger age, shorter duration of illness, greater baseline symptom severity, and shorter trial duration were significantly associated with greater placebo response, while country (United States compared with other countries) was not. More study sites, fewer university or Veterans Affairs treatment settings, and a lower percentage of patients assigned to receive placebo were associated with a greater placebo response, but these were not independent of publication year. Study quality affected the variability but not mean levels of placebo response. CONCLUSIONS This study identified important patient characteristics and trial design factors affecting the level of placebo response and hence the likelihood of detecting efficacy signals in randomized controlled trials. Future studies should test whether controlling these factors improves the detection of an antipsychotic effect.
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Christensen BK, Patrick RE, Stuss DT, Gillingham S, Zipursky RB. CE verbal episodic memory impairment in schizophrenia: a comparison with frontal lobe lesion patients. Clin Neuropsychol 2013; 27:647-66. [PMID: 23634645 DOI: 10.1080/13854046.2013.780640] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Schizophrenia (SCZ)-related verbal memory impairment is hypothesized to be mediated, in part, by frontal lobe (FTL) dysfunction. However, little research has contrasted the performance of SCZ patients with that of patients exhibiting circumscribed frontal lesions. The current study compared verbal episodic memory in patients with SCZ and focal FTL lesions (left frontal, LF; right frontal, RF; and bi-frontal, BF) on a four-trial list learning task consisting of three lists of varying semantic organizational structure. Each dependent variable was examined at two levels: scores collapsed across all four trials and learning scores (i.e., trial 4-trial 1). Performance deficits were observed in each patient group across most dependent measures at both levels. Regarding patient group differences, SCZ patients outperformed LF/BF patients (i.e., either learning scores or scores collapsed across trial) on free recall, primacy, primary memory, secondary memory, and subjective organization, whereas they only outperformed RF patients on the semantically blocked list on recency and primary memory. Collectively, these results indicate that the pattern of memory performance is largely similar between patients with SCZ and those with RF lesions. These data support tentative arguments that verbal episodic memory deficits in SCZ may be mediated by frontal dysfunction in the right hemisphere.
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Affiliation(s)
- Bruce K Christensen
- Department of Psychiatry & Behavioural Neuroscience, McMaster University, Hamilton, Ontario, Canada.
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Kiang M, Christensen BK, Streiner DL, Roy C, Patriciu I, Zipursky RB. Association of abnormal semantic processing with delusion-like ideation in frequent cannabis users: an electrophysiological study. Psychopharmacology (Berl) 2013; 225:95-104. [PMID: 22782461 PMCID: PMC5045303 DOI: 10.1007/s00213-012-2800-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2012] [Accepted: 06/27/2012] [Indexed: 01/23/2023]
Abstract
RATIONALE Frequent cannabis use is a risk marker for schizophrenia and delusions, but the neurocognitive mechanisms of this relationship remain unclear. OBJECTIVES We sought evidence that cannabis users have deficits in processing relationships between meaningful stimuli, similar to abnormalities reported in schizophrenia, and that these deficits are associated with delusion-like ideation. We used the N400 event-related brain potential (ERP) waveform as a neurophysiological probe of activation of concepts in semantic memory. We hypothesized that cannabis users would exhibit larger (more negative) than normal N400 amplitudes in response to stimuli meaningfully related to a preceding prime-reflecting deficient activation of concepts related to the prime. We further hypothesized that the magnitude of this abnormality would correlate with severity of delusion-like ideation. METHODS We recorded ERPs in 24 frequent cannabis users and 24 non-using comparison participants who viewed prime words followed by targets which were either words related or unrelated to the prime or pronounceable nonwords. The participants' task was to indicate whether the target was a word. Delusion-like ideation was measured via the Schizotypal Personality Questionnaire. RESULTS Contrary to our hypothesis, cannabis users exhibited smaller than normal N400s to both related and unrelated targets. These abnormalities correlated with delusion-like ideation in cannabis users only. CONCLUSIONS The results are consistent with a generalized abnormality of activation within semantic memory neural networks in cannabis users. Further research is needed to investigate whether such an abnormality plays a role in the development of delusion-like ideation in cannabis users.
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Affiliation(s)
- Michael Kiang
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada.
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Kiang M, Patriciu I, Roy C, Christensen BK, Zipursky RB. Test-retest reliability and stability of N400 effects in a word-pair semantic priming paradigm. Clin Neurophysiol 2012; 124:667-74. [PMID: 23122708 DOI: 10.1016/j.clinph.2012.09.029] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2012] [Revised: 08/31/2012] [Accepted: 09/09/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Elicited by any meaningful stimulus, the N400 event-related potential (ERP) component is reduced when the stimulus is related to a preceding one. This N400 semantic priming effect has been used to probe abnormal semantic relationship processing in clinical disorders, and suggested as a possible biomarker for treatment studies. Validating N400 semantic priming effects as a clinical biomarker requires characterizing their test-retest reliability. METHODS We assessed test-retest reliability of N400 semantic priming in 16 healthy adults who viewed the same related and unrelated prime-target word pairs in two sessions one week apart. RESULTS As expected, N400 amplitudes were smaller for related versus unrelated targets across sessions. N400 priming effects (amplitude differences between unrelated and related targets) were highly correlated across sessions (r=0.85, P<0.0001), but smaller in the second session due to larger N400s to related targets. CONCLUSIONS N400 priming effects have high reliability over a one-week interval. They may decrease with repeat testing, possibly because of motivational changes. SIGNIFICANCE Use of N400 priming effects in treatment studies should account for possible magnitude decreases with repeat testing. Further research is needed to delineate N400 priming effects' test-retest reliability and stability in different age and clinical groups, and with different stimulus types.
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Affiliation(s)
- Michael Kiang
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada.
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Agid O, McDonald K, Siu C, Tsoutsoulas C, Wass C, Zipursky RB, Foussias G, Remington G. Happiness in first-episode schizophrenia. Schizophr Res 2012; 141:98-103. [PMID: 22901593 DOI: 10.1016/j.schres.2012.07.012] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2012] [Revised: 07/07/2012] [Accepted: 07/11/2012] [Indexed: 01/06/2023]
Abstract
UNLABELLED Happiness is a core dimension of a person's life, related to both functioning and success. As patients with schizophrenia experience marked functional deficits, it would be informative to investigate their level of happiness. There are limited data currently available, perhaps due to the longstanding belief that anhedonia is an inherent feature of this illness. The present study set out to specifically assess happiness in schizophrenia in relation to both clinical and functional measures of outcome. METHOD Thirty-one first-episode remitted patients and 29 age- and sex-matched controls participated in the study. Patients' clinical status was assessed and a series of self-report questionnaires were used to measure levels of happiness, life satisfaction, success and functioning in both patients and controls. RESULTS Patients experienced marked functional impairment versus healthy controls (p<0.001), while reporting comparable levels of happiness (p=0.113) and satisfaction with life (p=0.350). In the patient group, we found that higher happiness ratings were significantly associated with less depression, less negative symptoms, less social withdrawal, greater life satisfaction, and higher social and occupational functioning. Both cognitive functioning and insight had no significant direct effects on ratings of happiness in the patient group. CONCLUSIONS Despite marked functional impairment, individuals with first-episode schizophrenia are as happy as controls. Mechanisms that might allow for this are discussed, as are the implications for rehabilitation efforts that assume an individual holds to the same drives and goals as before the illness onset and/or is unhappy with their present functional status.
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Affiliation(s)
- Ofer Agid
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Canada.
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Blumberger DM, Christensen BK, Zipursky RB, Moller B, Chen R, Fitzgerald PB, Daskalakis ZJ. MRI-targeted repetitive transcranial magnetic stimulation of Heschl’s gyrus for refractory auditory hallucinations. Brain Stimul 2012; 5:577-85. [DOI: 10.1016/j.brs.2011.12.002] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2011] [Revised: 11/30/2011] [Accepted: 12/09/2011] [Indexed: 12/22/2022] Open
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Kiang M, Christensen BK, Kutas M, Zipursky RB. Electrophysiological evidence for primary semantic memory functional organization deficits in schizophrenia. Psychiatry Res 2012; 196:171-80. [PMID: 22460130 PMCID: PMC4075227 DOI: 10.1016/j.psychres.2012.02.026] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2011] [Revised: 10/28/2011] [Accepted: 02/21/2012] [Indexed: 11/29/2022]
Abstract
N400, an event-related brain potential (ERP) waveform elicited by meaningful stimuli, is normally reduced by stimulus repetition (N400 repetition priming), and relatedness between the eliciting stimulus and preceding ones (relatedness priming). Schizophrenia patients' N400 relatedness priming deficits suggest impairment in using meaningful prime stimuli to facilitate processing of related concepts in semantic memory. To examine whether this deficiency arises from difficulty activating the prime concept per se, as indexed by reduced N400 repetition priming; or from impaired functional connections among concepts in semantic memory, as reflected by reduced relatedness priming but normal repetition priming; we recorded ERPs from 16 schizophrenia patients and 16 controls who viewed prime words each followed at 300- or 750-ms stimulus-onset asynchrony (SOA) by an unrelated, related or repeated target word, or a nonword, in a lexical-decision task. In both groups, N400s were largest (most negative) for unrelated, intermediate for related, and smallest for repeated targets. Schizophrenia patients exhibited subnormal N400 relatedness priming at the 300-ms SOA, but normal repetition priming at both SOAs, suggesting that their impairment in using prime words to activate related concepts results from abnormal functional connections among concepts within semantic memory, rather than inability to activate the prime concept itself.
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Affiliation(s)
- Michael Kiang
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada.
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Abstract
BACKGROUND Typically, studies investigating those at clinical high risk for psychosis have focused on predictors of conversion and treatments that might prevent conversion to full-blown psychosis. Few studies have followed those who do not go on to develop a psychotic illness. METHODS Participants were 48 young people who were at risk for developing psychosis based on the Structured Interview for Prodromal Symptoms criteria and participated in a treatment programme where they were offered up to 6 months of psychosocial treatment and psychiatric management. Attenuated psychotic symptoms, negative symptoms, depression, anxiety, social functioning, alcohol and drug use, and meta-cognitive beliefs were assessed at baseline, 6, 12 and 18 months. Personality characteristics were assessed at baseline. Medication use was tracked and psychiatric visits were logged over the 18-month study period. RESULTS On average, participants attended 12 sessions of psychosocial treatment and had one meeting with the psychiatrist every 6 months. Only 24% were ever prescribed any psychotropic medications, and antipsychotics were not used. Significant improvements were found over time in attenuated positive symptoms, negative symptoms, depression, anxiety, meta-cognitions and social functioning with most improvement occurring in the first 6 months. There was no change in the level of substance use. For personality assessment, participants generally scored high on neuroticism and openness and had low scores on extraversion, agreeableness and conscientiousness. CONCLUSION With minimal treatment and no antipsychotics, young people who present as being at risk for developing a psychotic disorder demonstrate clinical improvement over time. However, a few continued to have the liability of ongoing attenuated psychotic symptoms.
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Affiliation(s)
- Catherine Marshall
- Hotchkiss Brain Institute, Department of Psychiatry, University of Calgary, Calgary, Alberta, Canada
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Kiang M, Christensen BK, Zipursky RB. Depth-of-processing effects on semantic activation deficits in schizophrenia: an electrophysiological investigation. Schizophr Res 2011; 133:91-8. [PMID: 21868201 DOI: 10.1016/j.schres.2011.08.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2011] [Revised: 07/29/2011] [Accepted: 08/01/2011] [Indexed: 11/16/2022]
Abstract
N400, an event-related brain potential (ERP) waveform elicited by meaningful stimuli, is normally reduced (made less negative) by relatedness between the eliciting stimulus and preceding ones (N400 semantic priming). Schizophrenia patients' N400 semantic priming deficits suggest impairment in using meaningful context to activate related concepts in semantic memory. We aimed to examine the degree to which this impairment can be ameliorated by task instructions that more explicitly require processing of stimulus meaning. We recorded ERPs from 16 schizophrenia patients and 16 controls who viewed prime words each followed at 750-ms stimulus-onset asynchrony by an unrelated or related target word, or a nonword, in a non-semantic task (indicating whether a letter occurred in the target) compared to an explicit semantic task (judging prime-target relatedness). Consistent with previous work, controls exhibited greater N400 semantic priming (larger amplitude reductions for related versus unrelated targets) in the semantic task than in the orthographic task. Schizophrenia patients showed this same pattern, although their N400 semantic priming effects were smaller than controls' across tasks. Nevertheless, patients' priming effects increased as much as did controls' from the orthographic to the semantic task. Thus, connections among related concepts in schizophrenia patients' semantic memory appear grossly intact, such that, given a meaningful stimulus, they can make use of explicit cues to activate related concepts at a neurophysiological level, although their ability to do so remains less than normal. These data provide support for further research on semantic-cueing strategies for cognitive remediation of verbal memory in schizophrenia.
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Affiliation(s)
- Michael Kiang
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Ontario, Canada L8S 4K1
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Agid O, Arenovich T, Sajeev G, Zipursky RB, Kapur S, Foussias G, Remington G. An algorithm-based approach to first-episode schizophrenia: response rates over 3 prospective antipsychotic trials with a retrospective data analysis. J Clin Psychiatry 2011; 72:1439-44. [PMID: 21457676 DOI: 10.4088/jcp.09m05785yel] [Citation(s) in RCA: 163] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2009] [Accepted: 04/26/2010] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Early, effective treatment in first-episode schizophrenia is advocated, although evidence based on a systematic approach over multiple antipsychotic trials is lacking. Employing a naturalistic design, we examined response rates over 3 circumscribed antipsychotic trials. METHOD Between June 2003 and December 2008, 244 individuals with first-episode schizophrenia or schizoaffective disorder according to DSM-IV criteria were treated at the Centre for Addiction and Mental Health, Toronto, Ontario, Canada, following an algorithm that moved them through 2 antipsychotic trials, followed by a trial with clozapine. For the first 2 trials, treatment consisted of risperidone followed by olanzapine, or vice versa; each trial consisted of 3 stages (low-, full-, or high-dose) lasting up to 4 weeks at each level and adjusted according to response/tolerability. Clinical response was defined as a Clinical Global Impressions-Improvement score of 2 (much improved) or 1 (very much improved) and/or a Brief Psychiatric Rating Scale Thought Disorder subscale score ≤ 6. Data were analyzed retrospectively, and publication of anonymized clinical data was approved by the Research Ethics Board of the Centre for Addiction and Mental Health in May 2003. RESULTS In trial 1, 74.5% of individuals responded, with rates significantly higher for olanzapine (82.1%, 115/140) versus risperidone (66.3%, 69/104; P = .005). With trial 2, response rate dropped dramatically to 16.6% but again was significantly higher for olanzapine (25.7%, 9/35) compared to risperidone (4.0%, 1/25; P = .04). Response rate climbed above 70% once more, specifically 75.0% (21/28), in those individuals who agreed to a third trial with clozapine. CONCLUSIONS Results confirm a high response rate (75%) to initial antipsychotic treatment in first-episode schizophrenia. A considerably lower response rate (< 20%) occurs with a second antipsychotic trial. Results here were specific to olanzapine and risperidone, suggesting clinical differences (ie, olanzapine more effective than risperidone). A subsequent trial with clozapine is clearly warranted, although it remains unclear whether outcome would be further enhanced if it were used earlier in the treatment algorithm.
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Affiliation(s)
- Ofer Agid
- Schizophrenia Program, Centre for Addiction and Mental Health, 250 College St, Toronto, Ontario, M5T 1R8, Canada.
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Addington J, Epstein I, Liu L, French P, Boydell KM, Zipursky RB. A randomized controlled trial of cognitive behavioral therapy for individuals at clinical high risk of psychosis. Schizophr Res 2011; 125:54-61. [PMID: 21074974 DOI: 10.1016/j.schres.2010.10.015] [Citation(s) in RCA: 172] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2010] [Revised: 10/10/2010] [Accepted: 10/14/2010] [Indexed: 12/12/2022]
Abstract
BACKGROUND There has been increasing interest in early detection during the prodromal phase of a psychotic disorder. To date a few treatment studies have been published with some promising results for both pharmacological treatments, using second generation antipsychotics, and psychological interventions, mainly cognitive behavioral therapy. The purpose of this study was to determine first if cognitive behavioral therapy (CBT) was more effective in reducing the rates of conversion compared to a supportive therapy and secondly whether those who received CBT had improved symptoms compared to those who received supportive therapy. METHOD Fifty-one individuals at clinical high risk of developing psychosis were randomized to CBT or a supportive therapy for up to 6 months. The sample was assessed at 6, 12 and 18 months post baseline on attenuated positive symptoms, negative symptoms, depression, anxiety and social functioning. RESULTS Conversions to psychosis only occurred in the group who received supportive therapy although the difference was not significant. Both groups improved in attenuated positive symptoms, depression and anxiety and neither improved in social functioning and negative symptoms. There were no differences between the two treatment groups. However, the improvement in attenuated positive symptoms was more rapid for the CBT group. CONCLUSIONS There are limitations of this trial and potential explanations for the lack of differences. However, both the results of this study and the possible explanations have significant implications for early detection and intervention in the pre-psychotic phase and for designing future treatments.
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Affiliation(s)
- Jean Addington
- Department of Psychiatry, University of Calgary, Alberta, Canada.
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Zipursky RB. Second generation antipsychotics are not superior in relieving family burden in schizophrenia compared with the first generation antipsychotic perphenazine. Evid Based Ment Health 2010; 13:84. [PMID: 20682824 DOI: 10.1136/ebmh.13.3.84] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Affiliation(s)
- Robert B Zipursky
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
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Dewa CS, Jacobson N, Durbin J, Lin E, Zipursky RB, Goering P. Examining the Effects of Enhanced Funding for Specialized Community Mental Health Programs on Continuity of Care. ACTA ACUST UNITED AC 2010. [DOI: 10.7870/cjcmh-2010-0032] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
In this paper we examine the changes in continuity of care (CoC) likely to be affected by new system investments and the contributing factors. A mixed method approach was used. Decision-makers participated in two rounds of qualitative interviews. A 3-year cross-sectional quantitative data collection approach was used with clients and case managers. A main finding was that new system investments can improve CoC in terms of increased care access. However, it is not clear how other CoC dimensions will be affected. New funding can also have negative consequences related to the service models in which investments are made.
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Affiliation(s)
- Carolyn S. Dewa
- Centre for Addiction and Mental Health, University of Toronto
| | - Nora Jacobson
- Centre for Addiction and Mental Health, University of Toronto
| | - Janet Durbin
- Centre for Addiction and Mental Health, University of Toronto
| | - Elizabeth Lin
- Centre for Addiction and Mental Health, University of Toronto
| | | | - Paula Goering
- Centre for Addiction and Mental Health, University of Toronto
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Dewa CS, Zipursky RB, Chau N, Furimsky I, Collins A, Agid O, Goering P. Specialized home treatment versus hospital-based outpatient treatment for first-episode psychosis: a randomized clinical trial. Early Interv Psychiatry 2009; 3:304-11. [PMID: 22642735 DOI: 10.1111/j.1751-7893.2009.00139.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE This pilot study compared the effectiveness of specialized care that was home based versus hospital based for individuals experiencing their first psychotic episode. METHOD A randomized controlled trial design was used. A total of 29 subjects were interviewed at baseline, 3 and 9 months. Repeated measures analysis of variance was employed to test for statistically significant changes over time within and between groups with regard to community psychosocial functioning and symptom severity. RESULTS Our findings indicate that subjects in both the home-based and hospital-based programmes significantly improved with regard to symptoms and community functioning over time. However, the rates of change over time were not significantly different between the two programmes. There was a statistically significant difference between programmes with regard to the proportion of subjects with less than two visits (i.e. either did not attend their first assessment or attended follow-up visits after their assessment). CONCLUSIONS This was a modest pilot study and the sample was too small to allow definitive conclusions to be drawn. However, the results raise questions about differences in initial treatment engagement. They suggest the need for additional research focusing on interventions that promote initial treatment seeking.
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Affiliation(s)
- Carolyn S Dewa
- Health Systems Research and Consulting Unit, Centre for Addiction and Mental Health, University of Toronto, Toronto, Ontario, Canada.
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35
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Menezes NM, Malla AM, Norman RM, Archie S, Roy P, Zipursky RB. A multi-site Canadian perspective: examining the functional outcome from first-episode psychosis. Acta Psychiatr Scand 2009; 120:138-46. [PMID: 19207130 DOI: 10.1111/j.1600-0447.2009.01346.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To examine factors contributing to variance in functional outcome in first-episode psychosis (FEP) following 1 year of treatment. METHOD Naturalistic 1-year follow-up of a FEP cohort (n = 200), from programs in four university centers in Ontario, Canada. Functional recovery was defined by 'Social and Occupational Functioning Assessment Scale' (SOFAS) score>60. Regression analysis examined the contribution of independent variables to variance in functional outcome. RESULTS Twelve-month outcome measures were available for 76.5% of the original cohort. Of these, 70% reported being in school/work and in satisfactory relationships. The functional recovery rate was 51%, compared to 74% attaining symptomatic remission. The greatest contributors to variance in outcome were ongoing symptoms at 6 months and substance abuse comorbidity. CONCLUSION After 1 year of treatment, FEP patients show high rates of symptomatic remission and relatively lower rates of functional recovery. Symptoms and substance abuse contribute to variance in outcome.
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Affiliation(s)
- N M Menezes
- Schizophrenia Program, Centre for Addiction and Mental Health, Toronto, Ontario, Canada.
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36
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Hawkins KA, Keefe RSE, Christensen BK, Addington J, Woods SW, Callahan J, Zipursky RB, Perkins DO, Tohen M, Breier A, McGlashan TH. Neuropsychological course in the prodrome and first episode of psychosis: findings from the PRIME North America Double Blind Treatment Study. Schizophr Res 2008; 105:1-9. [PMID: 18774696 DOI: 10.1016/j.schres.2008.07.008] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2007] [Revised: 07/09/2008] [Accepted: 07/15/2008] [Indexed: 11/30/2022]
Abstract
OBJECTIVE There is uncertainty regarding the onset timing of the cognitive deficiencies of schizophrenia. We investigated whether conversion to psychosis and/or olanzapine altered the neuropsychological course of subjects within the first-ever double blind medication study of the putative schizophrenia first episode prodrome. METHOD Sixty participants in a double blind trial of olanzapine as a treatment for putative prodromal states were assessed at entry (pre-randomization), and again at 6 and 12 months (if they remained non-psychotic), or at any of these points prior to psychosis followed by post-psychosis and 6 months post-psychosis assessments. RESULTS Participants who converted to psychosis did not differ from placebo non-converters in pre-randomization global neuropsychological status. Early converters did not differ from later converters in entry neuropsychological status. Subjects who converted after 6 months did not show neuropsychological declines during the initial, pre-psychosis, 6 months. Neuropsychological course did not differ between converters to psychosis and non-converters, or between olanzapine and placebo-assigned subjects. CONCLUSIONS Neither the onset of frank psychosis nor olanzapine treatment of the prodrome significantly alters neuropsychological course in persons considered to be at high risk at their initial (pre-psychosis) assessment. These findings suggest that the neuropsychological deficiencies associated with psychotic conditions largely pre-exist the first frank psychotic episode.
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Affiliation(s)
- Keith A Hawkins
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT 06519, USA.
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Addington J, Epstein I, Reynolds A, Furimsky I, Rudy L, Mancini B, McMillan S, Kirsopp D, Zipursky RB. Early detection of psychosis: finding those at clinical high risk. Early Interv Psychiatry 2008; 2:147-53. [PMID: 21352147 DOI: 10.1111/j.1751-7893.2008.00078.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIM In early detection work, recruiting individuals who meet the prodromal criteria is difficult. The aim of this paper was to describe the development of a research clinic for individuals who appear to be at risk of developing a psychosis and the process for educating the community and obtaining referrals. METHODS The outcome of all referrals to the clinic over a 4-year period was examined. RESULTS Following an ongoing education campaign that was over inclusive in order to aid recruitment, approximately 27% of all referrals met the criteria for being at clinical high risk of psychosis. CONCLUSIONS We are seeing only a small proportion of those in the community who eventually go on to develop a psychotic illness. This raises two important issues, namely how to remedy the situation, and second, the impact of this on current research in terms of sampling bias and generalizability of research findings.
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Affiliation(s)
- Jean Addington
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada.
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Chui HT, Christensen BK, Zipursky RB, Richards BA, Hanratty MK, Kabani NJ, Mikulis DJ, Katzman DK. Cognitive function and brain structure in females with a history of adolescent-onset anorexia nervosa. Pediatrics 2008; 122:e426-37. [PMID: 18676530 DOI: 10.1542/peds.2008-0170] [Citation(s) in RCA: 98] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE Abnormalities in cognitive function and brain structure have been reported in acutely ill adolescents with anorexia nervosa, but whether these abnormalities persist or are reversible in the context of weight restoration remains unclear. Brain structure and cognitive function in female subjects with adolescent-onset anorexia nervosa assessed at long-term follow-up were studied in comparison with healthy female subjects, and associations with clinical outcome were investigated. PATIENTS AND METHODS Sixty-six female subjects (aged 21.3 +/- 2.3 years) who had a diagnosis of adolescent-onset anorexia nervosa and treated 6.5 +/- 1.7 years earlier in a tertiary care hospital and 42 healthy female control subjects (aged 20.7 +/- 2.5 years) were assessed. All participants underwent a clinical examination, magnetic resonance brain scan, and cognitive evaluation. Clinical data were analyzed first as a function of weight recovery (n = 14, <85% ideal body weight; n = 52, >or=85% ideal body weight) and as a function of menstrual status (n = 18, absent/irregular menses; n = 29, oral contraceptive pill; n = 19, regular menses). Group comparisons were made across structural brain volumes and cognitive scores. RESULTS Compared with control subjects, participants with anorexia nervosa who remained at low weight had larger lateral ventricles. Twenty-four-hour urinary free-cortisol levels were positively correlated with volumes of the temporal horns of the lateral ventricles and negatively correlated with volumes of the hippocampi in clinical participants. Participants who were amenorrheic or had irregular menses showed significant cognitive deficits across a broad range of many domains. CONCLUSIONS Female subjects with adolescent-onset anorexia nervosa showed abnormal cognitive function and brain structure compared with healthy individuals despite an extended period since diagnosis. To our knowledge, this is the first study to report a specific relationship between menstrual function and cognitive function in this patient population. Possible mechanisms underlying neural and cognitive deficits with anorexia nervosa are discussed. Additional examination of the effects of estrogen on cognitive function in female subjects with anorexia nervosa is necessary.
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Affiliation(s)
- Harold T Chui
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
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Cantor JM, Kabani N, Christensen BK, Zipursky RB, Barbaree HE, Dickey R, Klassen PE, Mikulis DJ, Kuban ME, Blak T, Richards BA, Hanratty MK, Blanchard R. Cerebral white matter deficiencies in pedophilic men. J Psychiatr Res 2008; 42:167-83. [PMID: 18039544 DOI: 10.1016/j.jpsychires.2007.10.013] [Citation(s) in RCA: 129] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2007] [Revised: 10/24/2007] [Accepted: 10/26/2007] [Indexed: 10/22/2022]
Abstract
The present investigation sought to identify which brain regions distinguish pedophilic from nonpedophilic men, using unbiased, automated analyses of the whole brain. T1-weighted magnetic resonance images (MRIs) were acquired from men who demonstrated illegal or clinically significant sexual behaviors or interests (n = 65) and from men who had histories of nonsexual offenses but no sexual offenses (n = 62). Sexual interest in children was assessed by participants' admissions of pedophilic interest, histories of committing sexual offenses against children, and psychophysiological responses in the laboratory to erotic stimuli depicting children or adults. Automated parcellation of the MRIs revealed significant negative associations between pedophilia and white matter volumes of the temporal and parietal lobes bilaterally. Voxel-based morphometry corroborated the associations and indicated that the regions of lower white matter volumes followed, and were limited to, two major fiber bundles: the superior fronto-occipital fasciculus and the right arcuate fasciculus. No significant differences were found in grey matter or in cerebrospinal fluid (CSF). Because the superior fronto-occipital and arcuate fasciculi connect the cortical regions that respond to sexual cues, these results suggest (1) that those cortical regions operate as a network for recognizing sexually relevant stimuli and (2) that pedophilia results from a partial disconnection within that network.
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Affiliation(s)
- James M Cantor
- Law and Mental Health Program, Centre for Addiction and Mental Health, 250 College Street, Toronto, Ontario, Canada M5T 1R8.
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Jensen J, Willeit M, Zipursky RB, Savina I, Smith AJ, Menon M, Crawley AP, Kapur S. The formation of abnormal associations in schizophrenia: neural and behavioral evidence. Neuropsychopharmacology 2008; 33:473-9. [PMID: 17473838 DOI: 10.1038/sj.npp.1301437] [Citation(s) in RCA: 177] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
It is hypothesized that due to an abnormal functioning of the reward system patients with schizophrenia form context-inappropriate associations. It has been shown that the dopamine target regions, especially the ventral striatum, are critical in the formation of reward associations. We wanted to examine how the ventral striatum responds as patients learn reward-related associations and how this neural response is linked to objective and subjective behavioral measures. Functional magnetic resonance imaging (fMRI) Blood oxygen level dependent (BOLD) responses were examined using aversive Pavlovian learning in 13 medicated patients with schizophrenia and 13 matched healthy controls. Colored circles served as conditioned stimulus (CS+) while a loud, individually adjusted, noise served as the unconditioned stimulus. Circles of another color served as neutral comparators (CS-). Subjective indices were assessed by a post-scan self-report, and galvanic skin responses (GSR) were used as objective measures of associative learning. fMRI data were analyzed using a random effects model in SPM2. Patients showed inappropriately strong activations in the ventral striatum in response to the neutral stimulus (CS-) as compared to the healthy controls. Consistent with this neural evidence of aberrant learning, patients also showed evidence of abnormal learning by self-report and as indexed by GSR. The main finding here is that patients with schizophrenia, when exposed to neutral stimuli in a threatening situation, show an abnormal pattern of learning. The aberrant activations and response are consistent with the idea that patients aberrantly assign motivational salience to neutral stimuli, and this process may be one of the aberrations that predisposes them to psychosis.
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Affiliation(s)
- Jimmy Jensen
- Schizophrenia Program and the PET Centre, Centre for Addiction and Mental Health, Toronto, ON, Canada
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Archie S, Rush BR, Akhtar-Danesh N, Norman R, Malla A, Roy P, Zipursky RB. Substance use and abuse in first-episode psychosis: prevalence before and after early intervention. Schizophr Bull 2007; 33:1354-63. [PMID: 17337748 PMCID: PMC2779870 DOI: 10.1093/schbul/sbm011] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
UNLABELLED Despite the high prevalence of substance abuse among first-episode psychosis (FEP) populations, few studies examine whether early intervention (EI) improves substance abuse. OBJECTIVE To examine the prevalence and pattern of substance use and abuse among an FEP sample over 12 months. METHODS All the participants were diagnosed with a first episode of a schizophrenia spectrum disorder. The participants were followed prospectively. The prevalence rates of substance use and abuse from this sample were compared before and after 12 months of EI services and were compared with rates observed in a sample from the general population. RESULTS A total of 200 participants (80.0% males; mean age 24 years) entered the study: 183 participants completed all the assessments at baseline, 131 participants completed all the assessments at 12 months. At baseline, the findings showed similar prevalence rates between the FEP sample and the general sample for lifetime cannabis use (60% vs 55%, respectively) and hazardous alcohol use (26% vs 21%) but significantly different prevalence rates for lifetime hallucinogen (29% vs 15%; P < .001) and cocaine use (20% vs 14%; P < .001). At 12 months, the prevalence rates for drug abuse (P < .01), hazardous alcohol use (P < .01), and concurrent drug abuse and hazardous alcohol use (P < .05) were significantly lower than at baseline. CONCLUSION Substance use and abuse decreased significantly after 12 months of EI services; EI services may be able to detect and to reduce substance use among FEP patients before it becomes a more serious disorder.
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Affiliation(s)
- Suzanne Archie
- Department of Psychiatry and Behavioural Neurosciences, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada.
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Malla A, Schmitz N, Norman R, Archie S, Windell D, Roy P, Zipursky RB. A multisite Canadian study of outcome of first-episode psychosis treated in publicly funded early intervention services. Can J Psychiatry 2007; 52:563-71. [PMID: 17953160 DOI: 10.1177/070674370705200904] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The aim of this study was to determine 1-year symptomatic outcome and its predictors in patients with FEP treated at 3 different publicly funded sites. METHOD We evaluated FEP patients (n = 172) treated in specialized programs in 2 medium-sized centres and 1 large urban centre with an identical protocol for demographic variables, diagnosis, and duration of untreated psychosis (DUP) at entry, and positive, negative, and general psychopathology symptoms at entry, 6 months, and 1 year. We used a mixed model analysis of variance, with time and centre and interaction between time and centre as fixed effects and sex and DUP as covariates, to analyze data. RESULTS A significant effect of time and time x centre interaction on positive, negative, and general symptom outcome was shown after controlling for ethnicity, education, and diagnosis. Patients showed significantly better outcome on all dimensions of symptoms in the 2 medium-sized centres, compared with the 1 large urban centre. Sex had a significant effect on negative and general symptoms, while DUP had no effect on any outcome measure. CONCLUSIONS Similarly enriched EI services may produce different outcomes, even within a relatively homogeneous mental health system.
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Affiliation(s)
- Ashok Malla
- Department of Psychiatry, McGill University, Douglas Hospital Research Centre, Montreal, Quebec.
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Abstract
Although most patients treated for first-episode schizophrenia will experience considerable improvement with initial antipsychotic therapy, a subgroup experiences significant ongoing positive symptoms. Clozapine has unique efficacy in improving treatment-resistant patients with chronic schizophrenia, but its role in the treatment of first-episode patients remains unclear. A standardized treatment algorithm was implemented in our First Episode Psychosis Program, with patients receiving 2 trials with 2 second-generation antipsychotics (olanzapine, quetiapine, or risperidone at low, medium, and high doses), followed by a trial of clozapine as early as 25 weeks into the start of their treatment. Patients progress along the algorithm according to their response as defined by clinical rating scales. To date, 123 patients with first-episode schizophrenia have been treated according to the algorithm. Of these, 93 (76%) responded to the first trial of an antipsychotic. Only 7 (23%) of the remaining 30 patients responded to a second antipsychotic trial; 13 of the remaining 23 individuals agreed to a trial of clozapine. We compared the clozapine-treated group with a group of 9 patients who refused clozapine and chose to continue the same antipsychotic treatment as before. Subjects who received clozapine experienced a mean Brief Psychiatric Rating Scale change of 19 points (from 53.5 to 34.5) and a change in the Clinical Global Inventory severity rating from 5.4 to 3.5 (from severely ill to mildly ill); those who refused clozapine had a 2-point increase in mean Brief Psychiatric Rating Scale (from 53 to 55) and a 0.6-point increase in the mean Clinical Global Inventory severity rating from 5.4 to 6 (remaining markedly to severely ill). In clinical practice, there is a hesitancy to switch individuals to clozapine given its side effect profile and position as treatment of "last resort." The present findings suggest that clozapine may have an important role in the early treatment of first-episode patients whose psychosis does not remit with other second-generation antipsychotics during the first months of treatment.
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Affiliation(s)
- Ofer Agid
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada.
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Agid O, Mamo D, Ginovart N, Vitcu I, Wilson AA, Zipursky RB, Kapur S. Striatal vs extrastriatal dopamine D2 receptors in antipsychotic response--a double-blind PET study in schizophrenia. Neuropsychopharmacology 2007; 32:1209-15. [PMID: 17077809 DOI: 10.1038/sj.npp.1301242] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Blockade of dopamine D2 receptors remains a common feature of all antipsychotics. It has been hypothesized that the extrastriatal (cortical, thalamic) dopamine D2 receptors may be more critical to antipsychotic response than the striatal dopamine D2 receptors. This is the first double-blind controlled study to examine the relationship between striatal and extrastriatal D2 occupancy and clinical effects. Fourteen patients with recent onset psychosis were assigned to low or high doses of risperidone (1 mg vs 4 mg/day) or olanzapine (2.5 mg vs 15 mg/day) in order to achieve a broad range of D2 occupancy levels across subjects. Clinical response, side effects, striatal ([11C]-raclopride-positron emission tomography (PET)), and extrastriatal ([11C]-FLB 457-PET) D2 receptors were evaluated after treatment. The measured D2 occupancies ranged from 50 to 92% in striatal and 4 to 95% in the different extrastriatal (frontal, temporal, thalamic) regions. Striatal and extrastriatal occupancies were correlated with dose, drug plasma levels, and with each other. Striatal D2 occupancy predicted response in positive psychotic symptoms (r=0.62, p=0.01), but not for negative symptoms (r=0.2, p=0.5). Extrastriatal D2 occupancy did not predict response in positive or negative symptoms. The two subjects who experienced motor side effects had the highest striatal occupancies in the cohort. Striatal D2 blockade predicted antipsychotic response better than frontal, temporal, and thalamic occupancy. These results, when combined with the preclinical data implicating the mesolimbic striatum in antipsychotic response, suggest that dopamine D2 blockade within specific regions of the striatum may be most critical for ameliorating psychosis in schizophrenia.
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Affiliation(s)
- Ofer Agid
- Schizophrenia Program, Centre for Addiction and Mental Health, Toronto, ON, Canada
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Mizrahi R, Rusjan P, Agid O, Graff A, Mamo DC, Zipursky RB, Kapur S. Adverse subjective experience with antipsychotics and its relationship to striatal and extrastriatal D2 receptors: a PET study in schizophrenia. Am J Psychiatry 2007; 164:630-7. [PMID: 17403977 DOI: 10.1176/ajp.2007.164.4.630] [Citation(s) in RCA: 101] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Antipsychotic medications improve psychosis but often induce a state of dysphoria in patients. Blockade of the dopamine D(2) receptors, which is thought to mediate their efficacy, has also been implicated in producing this adverse subjective experience. The authors present the first double-blind controlled study to examine the relationship between striatal and extrastriatal dopamine D(2) receptor binding potential and occupancy values and adverse subjective experience. METHOD Patients with recent-onset psychosis (N=12) were randomly assigned to low or high doses of olanzapine or risperidone. Subjective experiences, motor side effects, and striatal and extrastriatal dopamine D(2) receptors (determined with [(11)C]raclopride and [(11)C]FLB 457 PET scans, respectively) were evaluated after 2 weeks of continuous antipsychotic treatment. RESULTS Higher dopamine D(2) receptor occupancy and binding potentials in the striatal (dorsal and ventral), temporal, and insular regions were associated with subjective experience. The finding was confirmed with two convergent methods of analysis (region-of-interest and voxel-based statistics), and the same relationship was observed using two different dopamine receptor measures (observed binding potential values and age- and sex-corrected occupancy values). CONCLUSIONS Higher D(2) receptor occupancy is associated with negative subjective experience in patients taking risperidone or olanzapine. These negative subjective effects may be related to the high discontinuation rates seen in usual practice. Understanding the neurobiological mechanism of these negative subjective experiences and developing antipsychotics with novel (i.e., non D(2)) mechanisms may be critical in improving the treatment of psychosis.
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Affiliation(s)
- Romina Mizrahi
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada M5S 2S1
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Abstract
BACKGROUND Deficits in a patient's 'theory of mind' (TOM) have been proposed to lead to psychosis. However, it remains unclear whether TOM deficits constitute a trait- or a state-related deficit and whether they respond to antipsychotic treatment, and also whether the change in TOM and change in psychosis are associated. METHOD In the cross-sectional component of this study, 71 patients with psychotic disorders were included and TOM ability was measured using a hinting task in which subjects had to infer real intentions behind indirect speech. In the longitudinal study, a different cohort of 17 drug-free patients were included wherein they received antipsychotic treatment for 6 weeks and the effect on psychotic symptoms and TOM was measured every 2 weeks. Associations between TOM and psychopathology were assessed and a mixed effects model was used to investigate the rate of change over time. RESULTS Positive and Negative Syndrome Scale (PANSS) total scores were significantly associated with TOM scores. The hinting task was not associated with positive symptoms but was significantly associated with negative and general symptoms. The longitudinal arm of the study showed that both PANSS positive scores and TOM improved after medication was started, particularly during the first 2 weeks of antipsychotic treatment, but these changes were not associated. The TOM response at 2 weeks of antipsychotic treatment reached similar values to those obtained in the cross-sectional sample. CONCLUSIONS Although TOM and psychotic symptoms are related to each other, antipsychotic treatment impacts each independently, suggesting a dissimilar cognitive or neurobiological substrate for the two.
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Affiliation(s)
- Romina Mizrahi
- Centre for Addiction and Mental Health, and Department of Psychiatry, Faculty of Medicine, University of Toronto, Ontario, Canada
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Abstract
OBJECTIVES To review recent findings from positron emission tomography (PET) and single photon emission computed tomography (SPECT) studies that investigate the pathophysiology and treatment of schizophrenia, depression, and dementia. METHODS We carried out a review of the literature. RESULTS PET and SPECT studies have provided evidence of dopamine system dysregulation in patients with schizophrenia and variable loss of monoamines in patients with depression. Antipsychotic response has been demonstrated to be associated with blockade of dopamine D2 receptors, and antidepressant response has now been linked to blockade of serotonin transporter receptors. PET and SPECT have been extensively evaluated as diagnostic procedures for dementia. Substantial progress has been made in developing radioligands that bind to amyloid deposits in the brain, which should provide new opportunities for early diagnosis and treatment monitoring in Alzheimer's disease. CONCLUSION Advances in PET and SPECT imaging have provided new insights into the biology of major psychiatric disorders and their treatment. In the future, we can expect that these imaging techniques will become more central to the management of psychiatric disorders.
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Affiliation(s)
- Robert B Zipursky
- Department of Psychiatry and Behavioural Neurosciences, Michael G DeGroote School of Medicine, McMaster University, Hamilton, Ontario.
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Mizrahi R, Kiang M, Mamo DC, Arenovich T, Bagby RM, Zipursky RB, Kapur S. The selective effect of antipsychotics on the different dimensions of the experience of psychosis in schizophrenia spectrum disorders. Schizophr Res 2006; 88:111-8. [PMID: 16956747 DOI: 10.1016/j.schres.2006.07.013] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2006] [Revised: 07/04/2006] [Accepted: 07/10/2006] [Indexed: 10/24/2022]
Abstract
While most standard symptom scales regard the 'psychotic' or 'positive' dimension of schizophrenia as a single factor, several lines of evidence suggest that psychosis itself is a multidimensional phenomenon. The foregoing literature suggested at least five distinct dimensions to psychosis; to test this, we developed, validated and applied an instrument to measure these dimensions and then applied it to examine the effect of antipsychotics on the different dimensions of the psychotic experience. The Dimensions of Psychosis Instrument (DIPI) was administered to 91 psychotic patients with schizophrenia spectrum disorders and a confirmatory factor analyses (CFA) was carried out to examine the five dimensions: cognitive preoccupation (CP) with the psychotic experience; emotional involvement (EM); behavioural impact (BI) of the experience; conviction (CO) in it; emotional; and external perspective (EP) about the experience. In a separate cohort of 17 prospectively treated patients, the impact of antipsychotics on these dimensions was assessed. BI showed the greatest improvement (32%) at 2 weeks, while CP and emotional improved somewhat less (22% and 14%, respectively). Improvement in CO was limited (6%) while EP showed no change. These results suggest that over the first few weeks of treatment, antipsychotics rapidly reduce the behavioural impact of the principal psychotic symptom and decrease cognitive and emotional preoccupation with it, without greatly altering the patients' conviction in or perspective about their psychotic experience.
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Affiliation(s)
- Romina Mizrahi
- CAMH, and Department of Psychiatry, Faculty of Medicine, University of Toronto, Ontario, Canada
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Keefe RSE, Perkins DO, Gu H, Zipursky RB, Christensen BK, Lieberman JA. A longitudinal study of neurocognitive function in individuals at-risk for psychosis. Schizophr Res 2006; 88:26-35. [PMID: 16930949 DOI: 10.1016/j.schres.2006.06.041] [Citation(s) in RCA: 186] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2006] [Revised: 06/27/2006] [Accepted: 06/28/2006] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Clinically defined prodromal diagnostic criteria identify at-risk individuals with a 35-40% likelihood of developing a psychotic disorder within a year. The time course and predictive value of cognitive deficits in the development of psychosis has not been established. METHODS A comprehensive neurocognitive battery and clinical assessments were administered to 37 subjects meeting Criteria of Prodromal States (COPS) criteria for being at risk for psychosis, and two comparison groups: 59 first episode and 47 healthy subjects. Subjects were also evaluated at 6-month and 1-year follow-up periods. Primary analyses used a neurocognitive composite score derived from individual neurocognitive measures, including measures of vigilance, verbal memory, working memory, and processing speed. RESULTS At-risk subjects performed more poorly than healthy subjects (t=2.93, P=0.01), but better than first episode subjects (t=4.72, p<0.0001). At-risk subjects were particularly impaired on measures of vigilance and processing speed. Cognitive composite scores were significantly lower in at-risk subjects who progressed to psychosis (N=11; z=-1.2), while those at-risk subjects who did not progress to psychosis (N=17) performed better (z=-0.5), and not significantly different from controls. Poor CPT performance combined with better WAIS-R digit symbol performance predicted progression to psychosis. Severity of neurocognitive deficits was not related to duration of prodrome or to time to development of psychosis and neurocognitive function improved in all subjects except those who progressed to psychosis. CONCLUSION Neurocognitive impairment emerges early in the course of psychotic illness. Performance on tests of neurocognition may prove to be an early risk predictor for subsequent development of psychotic disorders.
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Affiliation(s)
- Richard S E Keefe
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC 27710, USA.
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