Glutamate and glutamine measured with 4.0 T proton MRS in never-treated patients with schizophrenia and healthy volunteers

OBJECTIVE

This in vivo (1)H magnetic resonance spectroscopy study examined levels of glutamate, glutamine, and N-acetylaspartate in patients experiencing their first episode of schizophrenia.

METHOD

Localized in vivo (1)H spectra were acquired at 4.0 T from the left anterior cingulate and thalamus of 21 never-treated patients with schizophrenia and 21 comparable healthy volunteers.

RESULTS

The level of glutamine was significantly higher in the left anterior cingulate cortex and thalamus of the patients with schizophrenia than in the healthy subjects. No differences were found between groups in the levels of other metabolites in the anterior cingulate or thalamus.

CONCLUSIONS

Higher than normal glutamine levels in the left anterior cingulate and thalamus provide in vivo evidence of greater than normal glutamatergic activity proposed by glutamatergic models of schizophrenia. In contrast to other studies in chronically ill patients, no differences were seen in the levels of N-acetylaspartate in either location, suggesting that the findings in patients with chronic schizophrenia may be related to the effect of medication or the progression of the illness.

A meta-analysis of the risk for psychotic disorders among first- and second-generation immigrants

BACKGROUND

There is increasing acceptance of migration as a risk factor for schizophrenia and related disorders; however, the magnitude of the risk among second-generation immigrants (SGIs) remains unclear. Generational differences in the incidence of psychotic disorders among migrants might improve our understanding of the relationship between migration, ethnicity and psychotic disorders. This meta-analysis aimed at determining the risk of psychotic disorders among SGIs in comparison with non-migrants and first-generation immigrants (FGIs).

METHOD

Medline, EMBASE and PsycINFO databases were searched systematically for population-based studies on migration and psychotic disorders published between 1977 and 2008. We also contacted experts, tracked citations and screened bibliographies. All potential publications were screened by two independent reviewers in a threefold process. Studies were included in the meta-analysis if they reported incidence data, differentiated FGIs from SGIs and provided age-adjusted data. Data extraction and quality assessment were conducted for each study.

RESULTS

Twenty-one studies met all inclusion criteria. A meta-analysis of 61 effect sizes for FGIs and 28 for SGIs yielded mean-weighted incidence rate ratios (IRRs) of 2.3 [95% confidence interval (CI) 2.0-2.7] for FGIs and 2.1 (95% CI 1.8-2.5) for SGIs. There was no significant risk difference between generations, but there were significant differences according to ethno-racial status and host country.

CONCLUSIONS

The increased risk of schizophrenia and related disorders among immigrants clearly persists into the second generation, suggesting that post-migration factors play a more important role than pre-migration factors or migration per se. The observed variability suggests that the risk is mediated by the social context.

Duration of untreated psychosis: a critical examination of the concept and its importance

BACKGROUND

The concept of duration of untreated psychosis (DUP) has recently attracted much interest because of its possible relationship to treatment outcome and implications for preventive efforts with reference to psychotic disorders, especially schizophrenia. In this paper we review critically the literature concerning the concept and its importance.

METHODS

Articles concerned with measuring DUP and those that have been suggested to provide indirect or direct evidence of the effect of DUP on treatment outcome are reviewed.

RESULTS

Evidence thus far suggests that DUP may be related to ease of reducing psychotic symptoms once treatment begins for first episode patients, but there is no evidence of a relationship to likelihood of relapse. There has been little investigation of the relationship of DUP to other long-term outcomes such as negative symptoms and cognitive functioning neither have the possible confounds of DUP been widely investigated or controlled.

CONCLUSIONS

It is important that there should be more thorough investigations of DUP, its correlates, and the extent to which it does mediate any advantages of earlier intervention.

Stressful life events and schizophrenia. I: A review of the research

Empirical research concerning the relationship between life event stressors and schizophrenia is critically reviewed. In accordance with the view that patients suffering from schizophrenia are vulnerable to stress, there is evidence of a relationship between stressors and variation in severity of symptoms over time. There is less indication that schizophrenic patients have had higher levels of stressors than the general population or than patients suffering from other psychiatric disorders. These findings are consistent with vulnerability-stress models of the development of schizophrenia.

Measurement of glutamate and glutamine in the medial prefrontal cortex of never-treated schizophrenic patients and healthy controls by proton magnetic resonance spectroscopy

BACKGROUND

Positron emission tomographic and postmortem studies comparing schizophrenic patients with healthy control subjects have found medial prefrontal cortical and anterior cingulate abnormalities that suggest dysfunction in glutamatergic neurons. The glutamate used for nerve signal transduction is predominantly derived from glutamine. After signal transduction, glutamate released into the synapse is converted to glutamine in glial cells, transported back to the presynaptic neuron, and reconverted to glutamate for reuse. In this study, levels of glutamate and glutamine were examined by means of in vivo proton (1H) magnetic resonance spectroscopy.

METHODS

Localized in vivo 1H spectra were acquired from a 4.5-cm3 volume in the left medial prefrontal cortex encompassing portions of Brodmann areas 24, 32, and 9 in 10 never-treated schizophrenic subjects and 10 healthy controls of comparable age, sex, handedness, education, and parental education. From each spectrum, metabolite levels were estimated for glutamate and glutamine, as well as 10 other metabolites and 3 macromolecules, by means of a noninteractive computer program that combined modeled in vitro spectra of every metabolite to reconstruct each in vivo spectrum.

RESULTS

A significant increase in glutamine level was found in the medial prefrontal cortex of the schizophrenic patients compared with controls. N-acetylaspartate and other measured metabolites and macromolecules were not significantly changed in schizophrenics.

CONCLUSION

Increased glutamine levels in the medial prefrontal region most likely reflect decreased glutamatergic activity in this region in never-treated schizophrenic patients compared with healthy controls.

First-episode psychosis: psychopathology, quality of life, and functional outcome

The burgeoning interest in investigating the first episode of schizophrenia and related disorders provides an opportunity to examine how this approach has assisted our understanding of the heterogeneity of psychopathology of this disorder and the trajectories of its outcome. We present a review of relevant literature on categorical versus dimensional perspectives on psychopathology, with special reference to early signs, its relationship with other patient- and system-related characteristics, and the status and determinants of functional outcome and quality of life. The findings from longitudinal studies of the dimensional psychopathology of first-episode psychosis suggest continuity of some psychopathological dimensions from premorbid through prodromal to post-onset phases of psychosis and some aspects of longer-term course. Short-term functional outcome improves after treatment of the first episode, but longer-term outcome remains relatively poor for a substantial proportion of patients and is associated with preadolescent onset, poor premorbid adjustment, poor cognitive functioning, cerebral asymmetry, and negative symptoms during prodromal and post-onset phases. Poor quality of life is related to residual psychopathology, long delays in treatment, and poor premorbid adjustment. The potential effects of improved treatment and/or early intervention on functional outcome and quality of life have not been adequately examined, nor have the interrelationships between predictors and the underlying processes involved in determining variations in outcome. Studies of functional outcome still lack the rigor of operational definitions, choice of specific instruments for measurement, and use of large enough samples to generate meaningful results.

Predictors of rate and time to remission in first-episode psychosis: a two-year outcome study

BACKGROUND

The evidence regarding the independent influence of duration of untreated psychosis (DUP) on rate and time to remission is far from unequivocal. The goal of the current study was to examine the role of predictors for rate and time to remission in first-episode psychosis (FEP).

METHOD

The differential effect of age, gender, age of onset, duration of untreated psychosis (DUP), duration of untreated illness (DUI), pre-morbid adjustment, co-morbid diagnosis of substance abuse and adherence to medication on the rate of and time to remission were estimated using a logistic and Poisson regression, and survival analysis respectively, in FEP patients.

RESULTS

In a sample of 107 FEP patients 82.2% achieved remission over a period of 2 years after a mean of 10.3 weeks (range 1-72). Regression analysis, based on complete data on all variables of interest (n=80), showed status of remission to be positively influenced by better pre-morbid adjustment (RR 0.57, 95% CI 0.34-0.95, p<0.05), later age of onset (RR 1.09, 95% CI 1.05-1.13, p<0.0001), higher level of adherence to medication (RR 1.96, 95% CI 1.38-2.76, p<0.001) and shorter DUI (RR 0.99, 95% CI 0.997-0.999, p<0.005). Time to remission was influenced by age of onset (HR 1.04, 95% CI 1.00-1.08, p<0.04) and adherence to medication (HR 1.58, 95% CI 1.11-2.23, p<0.01).

CONCLUSIONS

Improving adherence to medication early in the course of treatment may be an important intervention to improve short-term outcome.

One year outcome in first episode psychosis: influence of DUP and other predictors

BACKGROUND

A number of studies have reported evidence of a relationship between longer duration of untreated psychosis (DUP) and poorer outcome at 1 year while others have failed to find such evidence. It is possible that several other predictors may confound this relationship and there may be different predictors for different dimensions of outcome. In the current study we examined relationship between DUP and several other predictors, and 1 year outcome on rate and level of remission as well as level of positive, negative, depressive and anxiety symptoms in a community cohort of first episode psychosis patients.

METHOD

All potential cases of a first episode of non-affective psychosis were assessed and offered treatment in a comprehensive treatment program. Data were collected on all patients who completed 1 year of treatment on a number of predictor variables (DUP, length of the prodromal period, age of onset, gender, pre-morbid adjustment during childhood and adolescence, diagnosis) and outcome variables (level of remission, positive, negative, depression and anxiety symptoms based on ratings on SAPS, SANS, CDS and HAS, respectively). Data were analysed using an analysis of variance, bivariate correlations and hierarchical regression analysis.

RESULTS

Of a total of 130 patients were offered treatment, 106 completed 1 year of treatment and complete data were available on 88 subjects, 80% of whom met criteria for schizophrenia spectrum psychosis. The rate and level of remission were significantly higher for patients with shorter DUP (<22 weeks). DUP was the only independent predictor of the level of remission as well as reality distortion at 1 year; for disorganization syndrome and negative symptoms it was the age of onset and level of premorbid adjustment in adolescence, respectively; while the level of anxiety was predicted by the length of the prodrome. Additional predictors increased the variance explained by each model.

CONCLUSION

Our results confirmed the independent role of DUP in remission and positive symptom outcome at 1 year, thus providing support for the enthusiasm for early intervention. However, the model including DUP and premorbid adjustment in early adolescence explained a greater amount of variance in outcome on positive symptoms than DUP alone. On the other hand, outcome on negative symptoms, disorganization and anxiety are more likely to be influenced by longer term characteristics such as premorbid adjustment, earlier age of onset, gender and the length of the prodromal period, and therefore may not be as responsive to effects of early intervention.

Understanding delay in treatment for first-episode psychosis

BACKGROUND

A lengthy delay often occurs between the onset of symptoms of psychotic disorders and initiation of adequate treatment. In this paper we examine the extent to which this represents a delay in individuals contacting health professionals or a delay in receiving treatment once such contact is made.

METHOD

Pathways to care were examined in 110 patients of the Prevention and Early Intervention Program for Psychosis in London, Canada. Data were collected using structured interviews with patients, family members, consultation with clinicians and review of case records.

RESULTS

Family physicians and hospital emergency rooms were prominent components of pathways to care. Both delay to contact with a helping professional and delay from such contact to initiation of adequate treatment appear to be about equally important for the sample as a whole, but some individuals appear to be at risk for particularly lengthy delay in the second component. Individuals with younger age of onset, or who had initial contact with professional helpers before the onset of psychosis and were being seen on an ongoing basis at the time of onset of psychosis, had longer delays from first service contact after onset to initiation of adequate treatment. The greater delay to treatment for those being seen at the onset of psychosis does not appear to reflect differences in age, gender, symptoms, drug use or willingness to take medication.

CONCLUSIONS

Interventions to reduce treatment delay should increase the public's awareness of the symptoms of psychotic illness and the need to seek treatment, but of equal importance is the education of service providers to recognize such illness and the potential benefits of earlier intervention.

The relationship of symptoms and level of functioning in schizophrenia to general wellbeing and the Quality of Life Scale

OBJECTIVE

Reports suggesting that quality of life in schizophrenia is more highly related to negative rather than positive symptoms are largely based on use of the Quality of Life Scale which was devised to assess deficit symptoms and does not include an assessment of subjective general wellbeing. In the current paper we examined symptoms, level of community functioning as well as living circumstances as correlates of Quality of Life Scale scores and scores on the General Well-Being Scale.

METHOD

One hundred and twenty-eight patients completed the General Well-Being Scale and were rated on the Quality of Life Scale as well as scales assessing positive and negative symptoms.

RESULTS

While negative symptoms, level of functioning and positive symptoms all were related to the scores on the Quality of Life Scale, General Well-Being Scale scores were primarily related to positive symptoms, particularly reality distortion.

CONCLUSION

The results highlight the importance of recognizing the complex nature of the concept of quality of life. They demonstrate that varying indices of quality of life are likely to have different predictors.

An in vivo study of the prefrontal cortex of schizophrenic patients at different stages of illness via phosphorus magnetic resonance spectroscopy

BACKGROUND

In this study, phospholipid metabolism of cell membranes, high-energy phosphate metabolism, and intracellular free magnesium concentration in the prefrontal cortex of first-episode drug-naive schizophrenic patients and medicated schizophrenic patients at different stages of illness were compared with those of controls.

METHODS

Localized in vivo phosphorus 31 magnetic resonance spectra of the left dorsolateral prefrontal cortex of 11 drug-native, eight newly diagnosed medicated, and 10 chronic medicated patients with schizophrenia were compared with controls of similar gender, education, parental education, and handedness.

RESULTS

Significantly decreased levels of phosphomonoesters in drug-native, newly diagnosed medicated, and chronic medicated patients and significantly increased levels of phosphodiesters in drug-native patients were observed when compared with controls. There were no significant differences in the levels of high-energy phosphate metabolites between the groups except for a significant decrease in the inorganic orthophosphate levels of newly diagnosed medicated patients. A significant increase in the intracellular free magnesium concentration was observed in drug-naive, newly diagnosed medicated, and chronic medicated patients compared with controls. There were no correlations between the patients' negative and positive symptoms and the observed phosphorus-containing metabolites.

CONCLUSIONS

A reduction in precursors of membrane phospholipid are observed during the early and chronic stages of the schizophrenia illness, and breakdown products of membrane phospholipids are increased at the early stage of illness before medication treatment.

Longitudinal grey-matter and glutamatergic losses in first-episode schizophrenia

BACKGROUND

Progressive volumetric changes in the brains of people with schizophrenia have been attributed to a number of factors.

AIMS

To determine whether glutamatergic changes in patients with schizophrenia correlated with grey-matter losses during the first years of illness.

METHOD

Left anterior cingulate and thalamic glutamatergic metabolite levels and grey-matter volumes were examined in 16 patients with first-episode schizophrenia before and after 10 months and 30 months of antipsychotic treatment and in 16 healthy participants on two occasions 30 months apart.

RESULTS

Higher than normal glutamine levels were found in the anterior cingulate and thalamus of never-treated patients. Thalamic levels of glutamine were significantly reduced after 30 months. Limited grey-matter reductions were seen in patients at 10 months followed by widespread grey-matter loss at 30 months. Parietal and temporal lobe grey-matter loss was correlated with thalamic glutamine loss.

CONCLUSIONS

Elevated glutamine levels in never-treated patients followed by decreased thalamic glutamine and grey-matter loss in connected regions could indicate either neurodegeneration or a plastic response to reduced subcortical activity.

Stress and protective factors in individuals at ultra-high risk for psychosis, first episode psychosis and healthy controls

Stress-vulnerability models of schizophrenia regard psychosocial stress as an important factor in the onset and aggravation of psychotic symptoms, but such research in the early phases of psychosis is limited. Protective factors against the effects of stress might be the key to understanding some inconclusive findings and to the development of optimal psychosocial interventions. The present study compared self-reported levels of stress, self-esteem, social support and active coping in 32 patients with a first episode of psychosis (FEP), 30 individuals at ultra-high risk for psychosis (UHR) and 30 healthy controls. Associations with symptoms of psychosis were assessed in both patient groups. Individuals at UHR reported significantly higher stress levels compared to FEP patients. Both patient groups showed lower self-esteem compared to controls, and the UHR group reported lower social support and active coping than controls. These group differences could not be explained by age and dose of antipsychotic medication in the FEP group. In the UHR group, higher stress levels and lower self-esteem were associated with more severe positive and depressive symptoms on the Brief Psychiatric Rating Scale. Multiple regression analyses revealed that stress was the only significant predictor for both symptom measures and that the relationship was not moderated by self-esteem. Our findings show that individuals at UHR for psychosis experience high levels of psychosocial stress and marked deficits in protective factors. The results suggest that psychosocial interventions targeted at reducing stress levels and improving resilience in this population may be beneficial in improving outcomes.

The pathways to mental health care of first-episode psychosis patients: a systematic review

BACKGROUND

Although there is agreement on the association between delay in treatment of psychosis and outcome, less is known regarding the pathways to care of patients suffering from a first psychotic episode. Pathways are complex, involve a diverse range of contacts, and are likely to influence delay in treatment. We conducted a systematic review on the nature and determinants of the pathway to care of patients experiencing a first psychotic episode.MethodWe searched four databases (Medline, HealthStar, EMBASE, PsycINFO) to identify articles published between 1985 and 2009. We manually searched reference lists and relevant journals and used forward citation searching to identify additional articles. Studies were included if they used an observational design to assess the pathways to care of patients with first-episode psychosis (FEP).

RESULTS

Included studies (n=30) explored the first contact in the pathway and/or the referral source that led to treatment. In 13 of 21 studies, the first contact for the largest proportion of patients was a physician. However, in nine of 22 studies, the referral source for the greatest proportion of patients was emergency services. We did not find consistent results across the studies that explored the sex, socio-economic, and/or ethnic determinants of the pathway, or the impact of the pathway to care on treatment delay.

CONCLUSIONS

Additional research is needed to understand the help-seeking behavior of patients experiencing a first-episode of psychosis, service response to such contacts, and the determinants of the pathways to mental health care, to inform the provision of mental health services.

Integrated (one-stop shop) youth health care: best available evidence and future directions

Although mental health problems represent the largest burden of disease in young people, access to mental health care has been poor for this group. Integrated youth health care services have been proposed as an innovative solution. Integrated care joins up physical health, mental health and social care services, ideally in one location, so that a young person receives holistic care in a coordinated way. It can be implemented in a range of ways. A review of the available literature identified a range of studies reporting the results of evaluation research into integrated care services. The best available data indicate that many young people who may not otherwise have sought help are accessing these mental health services, and there are promising outcomes for most in terms of symptomatic and functional recovery. Where evaluated, young people report having benefited from and being highly satisfied with these services. Some young people, such as those with more severe presenting symptoms and those who received fewer treatment sessions, have failed to benefit, indicating a need for further integration with more specialist care. Efforts are underway to articulate the standards and core features to which integrated care services should adhere, as well as to further evaluate outcomes. This will guide the ongoing development of best practice models of service delivery.

Social support and three-year symptom and admission outcomes for first episode psychosis

This paper presents the first published findings examining the relationship of social support to three-year symptom outcome and hospitalizations for a group of first episode patients with psychotic disorders. Social support was measured using items from the provider version of the Wisconsin Quality of Life Scale as assessed at the time of initiation of treatment for 113 patients. Outcome was assessed by level of positive and negative symptoms at three-year follow-up and number of psychiatric admissions during those three years. Higher levels of social support were found to correlate with lower levels of positive symptoms and few hospitalizations at follow-up. The relationship of social support to follow-up symptoms and hospitalization was independent of other potential predictors such as gender, age, premorbid adjustment and duration of untreated illness.

From early intervention in psychosis to youth mental health reform: a review of the evolution and transformation of mental health services for young people

PURPOSE

The objective of this review is to report on recent developments in youth mental health incorporating all levels of severity of mental disorders encouraged by progress in the field of early intervention in psychotic disorders, research in deficiencies in the current system and social advocacy.

METHODS

The authors have briefly reviewed the relevant current state of knowledge, challenges and the service and research response across four countries (Australia, Ireland, the UK and Canada) currently active in the youth mental health field.

RESULTS

Here we present information on response to principal challenges associated with improving youth mental services in each country. Australia has developed a model comprised of a distinct front-line youth mental health service (Headspace) to be implemented across the country and initially stimulated by success in early intervention in psychosis; in Ireland, Headstrong has been driven primarily through advocacy and philanthropy resulting in front-line services (Jigsaw) which are being implemented across different jurisdictions; in the UK, a limited regional response has addressed mostly problems with transition from child-adolescent to adult mental health services; and in Canada, a national multi-site research initiative involving transformation of youth mental health services has been launched with public and philanthropic funding, with the expectation that results of this study will inform implementation of a transformed model of service across the country including indigenous peoples.

CONCLUSIONS

There is evidence that several countries are now engaged in transformation of youth mental health services and in evaluation of these initiatives.

A Canadian programme for early intervention in non-affective psychotic disorders

OBJECTIVES

To provide a brief overview of the development of clinical services and research for early intervention in psychotic disorders in Canada; to describe components of a comprehensive clinical/research programme for nonaffective psychotic disorders; and to present a summary of results of clinical and social outcomes achieved.

METHOD

This is a descriptive paper providing some details of how clinical services are being developed in Canada and concentrating on one particular early intervention programme, Prevention and Early intervention Programme for Psychoses (PEPP) London, Ontario, which is using a historical control design to evaluate the impact of an assertive approach to community case detection. Components of a phase-specific treatment programme and early case detection are described followed by results based on clinical and psychosocial data collected according to a defined protocol.

RESULTS

One year outcome for patients treated in PEPP shows use of low dose, pre-dominantly novel antipsychotics and high (81.5%) retention and remission (75%) rates. Highly significant improvements were also reported for self-rated quality of life and cognition. Duration of untreated psychosis (DUP) and premorbid adjustment were associated with improvement in positive and negative symptoms, respectively. Systemic changes to improve access to the service resulted in substantial increases in number of cases treated and a> 50% decline in DUP.

CONCLUSIONS

Phase-specific treatment approach and case identification strategies to reduce delay in treatment are likely to substantially improve outcome in nonaffective psychotic disorders compared with what has been reported with traditional approaches.

Symptoms, cognition, treatment adherence and functional outcome in first-episode psychosis

BACKGROUND

The differential strength of correlation between symptoms, cognition and other patient characteristics with community functioning in first-episode psychosis has not been fully investigated.

METHOD

In a sample of 66 first-episode psychosis patients demographic variables, ratings of pre-morbid adjustment, positive and negative symptoms, duration of untreated psychosis (DUP) and assessment of cognitive functions at baseline, and symptoms, cognitive functions and adherence to medication 1 year, were correlated with scores on social relations and activities of daily living (ADL) (outcome) at 1 year. Hierarchical regression analysis was used to confirm the independent contribution of baseline and concurrent variables to functional outcome at 1 year.

RESULTS

Scores on functioning related to social relations and ADL were both significantly correlated with pre-morbid adjustment, all dimensions of residual positive and negative symptoms and adherence to medication at 1 year. Scores on social relations were also modestly correlated with DUP and several cognitive measures at baseline and 1 year (verbal IQ, attention, visual memory, word fluency and working memory). Hierarchical regression confirmed independent contribution of pre-morbid adjustment, total residual symptoms and adherence to medication at 1 year for both dimensions of outcome, and psychomotor poverty and working memory for social relations.

CONCLUSIONS

In addition to pre-morbid adjustment potentially malleable variables such as level of residual (but not acute) symptoms, adherence to medication and cognitive deficits are likely to influence outcome on aspects of community functioning in individuals treated for first episode of psychosis.

Is adolescent-onset first-episode psychosis different from adult onset?

OBJECTIVE

To examine whether first-episode psychosis patients with onset during adolescence (ages 15-18) differ significantly from those with young-adult onset (ages 19-30).

METHOD

Consecutive patients presenting with first-episode psychosis (N = 242) were assessed for demographic and illness characteristics such as duration of untreated psychosis, diagnosis, length of prodromal period, premorbid adjustment, level of psychotic, negative, depressive, anxiety, and extrapyramidal symptoms, and alcohol and drug use.

RESULTS

Eighty-two patients (40.8%) had an onset of psychosis during adolescence (ages 15-18) and 119 (59.2%) during young adulthood (ages 19-30). The adolescent-onset group experienced longer delays in treatment of psychosis (duration of untreated psychosis) (p < .02), showed modestly worse premorbid functioning during late adolescence (p < .05), and were more likely to present with bizarre behavior (p < .01) and primary negative symptoms (p < .01).

CONCLUSIONS

Patients with adolescent onset of psychosis are more likely to present with clinical characteristics that portend a poorer outcome and may require a different approach to early identification and treatment.

Psychological and psychosocial interventions for negative symptoms in psychosis: systematic review and meta-analysis

BackgroundNegative symptoms observed in patients with psychotic disorders undermine quality of life and functioning. Antipsychotic medications have a limited impact. Psychological and psychosocial interventions, with medication, are recommended. However, evidence for the effectiveness of specific non-biological interventions warrants detailed examination.AimsTo conduct a meta-analytic and systematic review of the literature on the effectiveness of non-biological treatments for negative symptoms in psychotic disorders.MethodWe searched for randomised controlled studies of psychological and psychosocial interventions in psychotic disorders that reported outcome on negative symptoms. Standardised mean differences (SMDs) in values of negative symptoms at the end of treatment were calculated across study domains as the main outcome measure.ResultsA total of 95 studies met our criteria and 72 had complete quantitative data. Compared with treatment as usual cognitive-behavioural therapy (pooled SMD -0.34, 95% CI -0.55 to -0.12), skills-based training (pooled SMD -0.44, 95% CI -0.77 to -0.10), exercise (pooled SMD -0.36, 95% CI -0.71 to -0.01), and music treatments (pooled SMD -0.58, 95% CI -0.82 to -0.33) provide significant benefit. Integrated treatment models are effective for early psychosis (SMD -0.38, 95% CI -0.53 to -0.22) as long as the patients remain in treatment. Overall quality of evidence was moderate with a high level of heterogeneity.ConclusionsSpecific psychological and psychosocial interventions have utility in ameliorating negative symptoms in psychosis and should be included in the treatment of negative symptoms. However, more effective treatments for negative symptoms need to be developed.

Youth Mental Health Should Be a Top Priority for Health Care in Canada

In this article we have provided a perspective on the importance and value of youth mental health services for society and argued that advancing youth mental health services should be the number one priority of health services in Canada. Using the age period of 12-25 years for defining youth, we have provided justification for our position based on scientific evidence derived from clinical, epidemiological and neurodevelopmental studies. We have highlighted the early onset of most mental disorders and substance abuse as well as their persistence into later adulthood, the long delays experienced by most help seekers and the consequence of such delays for young people and for society in general. We have also provided a brief review of the current gross inadequacies in access and quality of care available in Canada. We have argued for the need for a different conceptual framework of youth mental disorders as well as for a transformation of the way services are provided in order not only to reduce the unmet needs but also to allow a more meaningful exploration of the nature of such problems presenting in youth and the best way to treat them. We have offered some ideas based on previous work completed in this field as well as current initiatives in Canada and elsewhere. Any transformation of youth mental health services in Canada must take into consideration the significant geographic, cultural and political diversity across the provinces, territories and indigenous peoples across this country.

A 4.0-T fMRI study of brain connectivity during word fluency in first-episode schizophrenia

OBJECTIVE

To use functional magnetic resonance imaging (fMRI) to investigate functional connectivity, and hence, underlying neural networks, in never-treated, first-episode patients with schizophrenia using a word fluency paradigm known to activate prefrontal, anterior cingulate, and thalamic regions. Abnormal connectivity between the prefrontal cortex (PFC) and other brain regions has been demonstrated in chronic, medicated patients in previous positron emission tomography (PET) studies, but has not to our knowledge, previously been demonstrated using both first-episode, drug-naïve patients and fMRI technology.

METHODS

A 4.0-Tesla (T) fMRI was used to examine activation and functional connectivity [psychophysiological interactions (PPIs)] during a word fluency task compared to silent reading in 10 never-treated, first-episode patients with schizophrenia and 10 healthy volunteers of comparable age, sex, handedness, and parental education.

RESULTS

Compared to healthy volunteers, the schizophrenia patient group exhibited less activation during the word fluency task, mostly in the right anterior cingulate and prefrontal regions. Psychophysiological interactions between right anterior cingulate and other parts of the brain revealed a localized interaction with the left temporal lobe in healthy volunteers during the task and a widespread unfocussed interaction in patients.

CONCLUSION

These findings suggest anterior cingulate involvement in the neuronal circuitry underlying schizophrenia.

Social cognitive impairments in first episode psychosis

BACKGROUND

Social cognition is a complex phenomenon involving several distinct processes. Numerous studies have shown that individuals with schizophrenia are largely impaired on this domain of cognition. However, most have focused on a single aspect of social cognition, namely "theory of mind" and/or included patients with long standing illness.

OBJECTIVE

The main objective of the present study was to identify social cognition deficits in first episode of schizophrenia spectrum psychosis using a case control design and a comprehensive assessment that allowed the exploration of several dimensions of this phenomenon.

SUBJECTS

36 patients with a first episode of psychosis and 25 healthy controls participated in this study.

MATERIAL

Measures of social cognition included the Hinting Task and the Four Factor Test of Social Intelligence.

RESULTS

Significant group differences were found on both tasks, but the Four Factor Test of Social Intelligence revealed a stronger group effect and the effects observed remained significant once IQ was covaried. Social cognition did not show any correlations with level of symptoms.

CONCLUSION

Social cognition deficits are present during the first episode of psychosis. These impairments do not seem to be a consequence of group differences in overall intellectual functioning and are likely to be state-independent.

Testing definitions of symptom remission in first-episode psychosis for prediction of functional outcome at 2 years

BACKGROUND

To determine the clinical relevance of different definitions of symptom remission for prediction of functional outcome in first-episode psychosis (FEP).

METHODS

One hundred forty-one individuals receiving treatment for an FEP at a specialized early intervention service had positive and negative symptoms and functional status rated every month over the first 2 years of treatment using the Scale for the Assessment of Positive Symptoms, Scale for the Assessment of Negative Symptoms, and Social and Occupational Functioning Assessment Scale. Subjects were classified according to 4 definitions of remission varying the criteria for severity (negative symptom inclusion/exclusion) and duration (3/6 mo sustained).

RESULTS

Positive symptom remission was achieved by 94% and 84% of subjects for 3 and 6 months, respectively, compared with 70% and 56% for positive and negative symptom remission, respectively. Linear regression analyses showed that only definitions of remission containing both positive and negative symptoms independently predicted functional outcome. This was confirmed by receiver operating characteristic analyses where remission based on positive and negative symptoms was marginally better than positive symptoms alone (difference in area under the curve; z = 1.94, P = .052). There was little difference between a time criterion of remission of positive and negative symptoms of 3 (sensitivity = 100%, specificity = 42%) or 6 (sensitivity = 90%, specificity = 57%) months.

DISCUSSION

Consistent with the consensus definition of remission in schizophrenia, severity of both positive and negative symptoms in defining remission in FEP is necessary although a 3-month criterion had equal predictive validity to the 6-month criterion.