Early Intervention for Psychosis in Canada: What Is the State of Affairs?

OBJECTIVE

Early intervention services (EIS) for psychosis have been developed in several countries, including Canada. There is some agreement about the program elements considered essential for improving the long-term outcomes for patients in the early phase of psychotic disorders. In the absence of national standards, the current state of EIS for psychosis in Canada needs to be examined in relation to expert recommendations currently available.

METHOD

A detailed online benchmark survey was developed and administered to 11 Canadian academic EIS programs covering administrative, clinical, education, and research domains. In addition, an electronic database and Internet search was conducted to find existing guidelines for EIS. Survey results were then compared with the existing expert recommendations.

RESULTS

Most of the surveyed programs offer similar services, in line with published expert recommendations (i.e., easy and rapid access, intensive follow-up through case management with emphasis on patient engagement and continuity of care, and a range of integrated evidence-based psychosocial interventions). However, differences are observed among programs in admission and discharge criteria, services for patients at ultra high risk (UHR) for psychosis, patient to clinician ratios, accessibility of services, and existence of specific inpatient units. These seem to diverge from expert recommendations.

CONCLUSIONS

Although Canadian programs are following most expert recommendations on clinical components of care, some programs lack administrative and organizational elements considered essential. Continued mentoring and networking of clinicians through organizations such as the Canadian Consortium for Early Intervention in Psychosis (CCEIP), as well as the development of a fidelity scale through further research, could possibly help programs attain and maintain the best standards of early intervention. However, simply making clinical guidelines available to care providers is not sufficient for changing practices; this will need to be accompanied by adequate funding and support from organizations and policy makers.

Où en sommes-nous? An Overview of Successes and Challenges after 30 Years of Early Intervention Services for Psychosis in Quebec: Où en sommes-nous? Un aperçu des réussites et des problèmes après 30 ans de services d'intervention précoce pour la psychose au Québec

INTRODUCTION

Over the last 30 years, early intervention services (EIS) for first-episode psychosis (FEP) were gradually implemented in the province of Quebec. Such implementation occurred without provincial standards/guidelines and policy commitment to EIS until 2017. Although the literature highlights essential elements for EIS, studies conducted elsewhere reveal that important EIS components are often missing. No thorough review of Quebec EIS practices has ever been conducted, a gap we sought to address.

METHODS

Adopting a cross-sectional descriptive study design, an online survey was distributed to 18 EIS that existed in Quebec in 2016 to collect data on clinical, administrative, training, and research variables. Survey responses were compared with existing EIS service delivery recommendations.

RESULTS

Half of Quebec's population had access to EIS, with some regions having no programs. Most programs adhered to essential components of EIS. However, divergence from expert recommendations occurred with respect to variables such as open referral processes and patient-clinician ratio. Nonurban EIS encountered additional challenges related to their geography and lower population densities, which impacted their team size/composition and intensity of follow-up.

CONCLUSIONS

Most Quebec EIS offer adequate services but lack resources and organizational support to adhere to some core components. Recently, the provincial government has created EIS guidelines, invested in the development of new programs and offered implementation support from the National Centre of Excellence in Mental Health. These changes, along with continued mentoring and networking of clinicians and researchers, can help all Quebec EIS to attain and maintain recommended quality standards.

Examination of toxicity and collagen linearity after the administration of the protein cross-linker genipin in equine tendon and dermis: a pilot study

OBJECTIVE

Collagen cross-linking is an attractive therapeutic route aimed at supplementing natural collagen stabilisation. In this study the toxicity of the cross-linker genipin (GP) was examined in avascular (tendon) and vascular (dermis) tissue.

METHODS

High doses of GP were injected intratendinously into three yearling horses and evaluated at various time points up to 30 days. A second group of three yearlings were injected into the dermis and evaluated at various time points up to 1 year. Metrics used included lameness, circumferential swelling, ultrasound evaluation, microscopic morphology, collagen production and systemic effect on blood parameters.

RESULTS

The tendon injection sites exhibited mild lameness and swelling with no apparent systemic toxicity or stabilisation defects. Treated tendons exhibited increased linear collagen microscopically. Dermal injections showed similar results, with mild swelling at the injection site. Microscopic morphology resulted in a decrease in dermal collagen at 30 days post-injection. Dermis injected at the high dose of 355 mmol/L examined 1 year post-treatment appeared similar to the untreated biopsies; however, there was an increase in mature collagen.

CONCLUSION

GP injection appeared to be well tolerated, with transient lameness and mild circumferential swelling when injected into the tendon and local tissue swelling when injected into the dermis. No systemic hypersensitivities or toxicities were observed. Microscopically, GP resulted in increased linear collagen in tendons at 30 days post-injection and overall increased collagen in dermal tissue when evaluated 1 year post-injection.

P1255Comparative safety and effectiveness of standard doses of apixaban versus dabigatran, rivaroxaban, and VKAs in non-valvular atrial fibrillation patients in France: the NAXOS study

Background

Real-world data comparing all available oral anticoagulants (OAC) on a nationwide scale (i.e. in France: apixaban, rivaroxaban, dabigatran and vitamin K antagonists – VKAs) are lacking. In everyday practice, oral anticoagulants are often underdosed, which may render comparisons between agents difficult.

Purpose and methods

NAXOS is a French real-world study comparing the safety (major bleeding), effectiveness (stroke, systemic thromboembolic events (STE)) and all-cause mortality for apixaban, dabigatran, rivaroxaban, and VKAs, in adult patients with non-valvular atrial fibrillation (NVAF) initiating a given OAC between 2014 and 2016. The French national health insurance data (SNIIRAM) were used. Analyses were performed with adjustment on propensity scores. To avoid bias potentially related to underdosing, the present analysis included only patients receiving standard doses of apixaban (5mg bid), rivaroxaban (20mg od), and dabigatran (150 mg bid), or VKAs. Only OAC naïve patients were included.

Results

In the OAC-naive cohorts treated with apixaban, rivaroxaban, and dabigatran, 54,575 (62.3%), 65,208 (65.2%), and 9,000 (42.4%), respectively, had the standard dose at the index dispensation, and 112,628 patients received VKAs. After adjustment on propensity scores, apixaban 5 mg was associated with a lower risk of major bleeding, compared to VKAs (Hazard Ratio: 0.47; 95% CI: 0.43–0.51) and rivaroxaban 20mg (HR: 0.64; 0.59–0.71), but not to dabigatran 150 mg (HR: 0.97; 0.79–1.18). Apixaban was associated with a lower risk of stroke and STE, compared to VKAs (HR: 0.62; 0.56–0.69) but not to rivaroxaban (HR: 1.03; 0.92–1.16), and dabigatran (HR: 0.96; 0.76–1.21). Apixaban showed a lower risk of all-cause mortality compared to VKAs (HR: 0.44; 0.41–0.47) and rivaroxaban (HR: 0.87; 0.81–0.94) but not to dabigatran (HR: 1.10; 0.92–1.32).

Figure 1. Forest plot presenting the results of the standard dose analysis (PS adjusted).

Conclusions

The NAXOS population-based country-wide observational study shows that 42% to 65% of patients were treated with standard doses of OACs. Analyses of standard doses confirmed the superiority of apixaban compared with VKAs for the three studied outcomes and suggests better safety profile of apixaban compared to rivaroxaban but similar to dabigatran.

Acknowledgement/Funding

The Alliance Bristol-Myers Squibb/Pfizer

[Early Detection and Intervention for Psychosis: Why and How?]

Objectives This article aims to synthesize the critical stages in the development of early detection and intervention services (EIS) for psychosis over the past 30 years, and to review key literature on the essential components and effectiveness of these programs. Method We conducted a narrative review of the literature on the international development of EIS leading to its endorsement as a service delivery model for young people with first-episode psychosis (FEP). We also reviewed various international and Canadian guidelines to identify consensus about the essential components of EIS for psychosis and their effectiveness. Challenges to the implementation of these different essential components are presented, along with practical solutions to addressing them. A particular emphasis is placed on implementing EIS in the Quebec context. Results Based on a model developed in the early 1990s, EIS for psychosis have now been disseminated worldwide and are deployed on a large scale in some regions, such as the United Kingdom and Quebec. The model's gradual expansion has been facilitated by efforts to identify its main objectives and the components essential to achieve them, and by several studies demonstrating its effectiveness. Along with an important philosophical shift to optimism and hope, EIS have typically focused on the twin aims of reducing treatment delay (or the duration of untreated psychosis) and enhancing engagement in specialized, phase-specific, developmentally appropriate treatment. A meta-analysis (published in 2018) demonstrated the superiority of EIS for psychosis compared to standard treatment on several outcomes including hospitalizations, relapse of symptoms, treatment discontinuation, and vocational and social functioning. Based on these studies and expert consensus, many jurisdictions around the world have developed guidelines to ensure compliance with essential components that are associated with the effectiveness of EIS, while accounting for their contextual realities. The components that have been prioritized include outreach to enable early identification and referral; rapid access to care and youth-friendly services; a range of biopsychosocial interventions (pharmacotherapy, cognitive behavioral therapy, psychoeducation, family interventions, integrated substance use interventions, employment and educational support); a shared-decision making approach; and the intensive case management approach adapted to FEP, which are all delivered by an interdisciplinary team. There is also increasing acknowledgement of the value of continuous evaluation that informs treatment decision-making and quality improvement. Conclusion EIS for psychosis have developed gradually and research has demonstrated its effectiveness. Disseminating the model in ways that ensure fidelity to its core values and the implementation of its essential components is needed to ensure effectiveness; and instill hope for recovery and improve the quality of lives of young people with psychosis and their families.