Duration of untreated psychosis as predictor of long-term outcome in schizophrenia: systematic review and meta-analysis

Effects of age and sex on clinical high-risk for psychosis in the community

BACKGROUND

Recent reports of both heightened prevalence rates and limited clinical relevance of clinical high-risk (CHR) criteria and their relevant symptoms in children and adolescents indicate an important role of neurodevelopment in the early detection of psychoses. Furthermore, sex effects in CHR symptoms have been reported, though studies were inconclusive. As sex also impacts on neurodevelopment, we expected that sex might have an additional contribution to age in the prevalence and clinical relevance of CHR symptoms and criteria.

AIM

To investigate age and sex effects on CHR criteria and symptoms and their association with psychosocial impairment and mental disorder.

METHODS

In this cross-sectional cohort study, n = 2916 8- to 40-year-olds, randomly drawn from the population register of the Swiss canton Bern, were assessed in semi-structured interviews by phone or face-to-face for CHR symptoms and criteria using the Structured Interview for Psychosis-Risk Syndromes and the Schizophrenia Proneness Instrument in its child and youth, and adult version, respectively. Furthermore, social and occupational functioning and DSM-IV axis I disorders were assessed. Simple and interaction effects of age and sex on CHR symptoms and criteria, and interaction effects of age, sex, and CHR symptoms and criteria on presentation of functional impairment and of non-psychotic disorder were investigated using logistic regression analyses.

RESULTS

Altogether, 542 (18.6%) participants reported any CHR symptom; of these, 261 (9.0%) participants reported any one of the 11 criteria relevant cognitive and perceptual basic symptoms, and 381 (13.1%) any one of the five attenuated or transient psychotic symptoms (attenuated psychotic symptoms/brief intermittent psychotic symptoms). Fewer participants met any one of the CHR criteria (n = 82, 2.8%) or any one of the three recently recommended CHR criteria (n = 38, 1.3%). Both age and sex were significantly (P < 0.05) associated with CHR symptoms and criteria, mostly by younger age and female sex. Though slightly differing between symptom groups, age thresholds were detected around the turn from adolescence to adulthood; they were highest for cognitive basic symptoms and CHR criteria. With the exception of the infrequent speech disorganization attenuated psychotic symptom, the interaction of age with CHR symptoms and criteria predicted functional impairment; whereas, independent of each other, sex and CHR symptoms mostly predicted mental disorders.

CONCLUSION

Age and sex differentially impact on CHR symptoms and criteria; these differences may support better understanding of causal pathways. Thus, future CHR studies should consider effects of sex and age.

Coordinated Specialty Care Discharge, Transition, and Step-Down Policies, Practices, and Concerns: Staff and Client Perspectives

OBJECTIVE

In recent years, optimizing the process of transition and discharge from coordinated specialty care (CSC), a program that provides early intervention in psychosis, has emerged as an important focus area for program administrators, clinicians, and policy makers. To explore existing CSC policies and practices and to understand frontline provider and client views on discharge, the authors conducted a comprehensive analysis of staff and client interview data from the Mental Health Block Grant 10% Set-Aside Study.

METHODS

Data from 66 interviews with groups of CSC providers and administrators representing 36 sites and 22 states were analyzed, as well as data from interviews with 82 CSC clients at 34 sites. Transcripts were coded by using systematic content analyses.

RESULTS

Analyses of data from providers and administrators showed the heterogeneity of CSC program practices and strategies regarding discharge and highlighted a range of concerns related to postdischarge service accessibility and quality. Analysis of data from client interviews reflected the heterogeneity of transition challenges that clients confront. A significant number of participants reported concerns about their readiness for discharge.

CONCLUSIONS

CSC discharge policies and practices vary across CSC programs and states. Frequent clinician and client concerns about optimal program length, transition, and postdischarge services highlight the importance of sustained policy and research efforts to develop evidence-informed practice guidelines and possible modifications to the time-limited CSC model that currently dominates the field.

Results of a prospective, mixed methods study to assess feasibility, acceptability and effectiveness of TRIumPH (Treatment and Recovery In PsycHosis): an integrated care pathway for psychosis, compared to usual treatment

OBJECTIVES

To evaluate whether a newly developed care pathway, Treatment and Recovery In PsycHosis (TRIumPH), is feasible, acceptable and effective in meeting National Institute of Health and Care Excellence (NICE) quality standards in a timely manner.

METHODS

This is a pragmatic, non-randomised, prospective, mixed methods study comparing an implementation (TRIumPH) and comparator site (not implementing TRIumPH) across three cohorts to assess feasibility, acceptability and effectiveness of the integrated pathway.

SETTING

Early intervention in psychosis (EIP) services at two National Health Service organisations in South of England.

PARTICIPANTS

All patients accepted into EIP services between 1 June 2014 and 31 May 2017 were each followed up for 1 year within their respective cohorts.

METHODOLOGY

Quantitative data consisted of routinely collected clinical data retrieved from patient records to assess whether the implementation of TRIumPH achieved better concordance to NICE standards. These included time to access services, physical health assessments, clinical outcomes based timeliness of delivery and acute data. The controlled trial has evaluated the effect of TRIumPH (Intervention) with Care As Usual (Comparator). Qualitative measures consisted of questionnaires, interviews and focus groups to assess acceptability and satisfaction. Outcome measures were compared within the baseline, year 1 and year 2 cohorts and between the two sites. Quantitative data were statistically analysed by comparing means and proportions.

RESULTS

Time to assessment improved in the implementation site and remained within the target in comparator site. Meeting of quality standards increased substantially in the implementation site but was more variable and reached lower levels in the comparator site especially for physical health standards. Cognitive therapy for psychosis, family intervention and carer and employment support were all offered to a greater extent in the implementation site and uptake increased over the period.

CONCLUSIONS

Pathway implementation generally led to greater improvements in achievement of access and quality standards compared with comparator site.

TRIAL REGISTRATION NUMBER

UK Clinical Research Network Portfolio (19187).

Early-Onset Schizophrenia With Predominantly Negative Symptoms: A Case Study of a Drug-Naive Female Patient Treated With Cariprazine

Schizophrenia is a chronic and severe mental disorder characterized by positive, negative, and cognitive symptoms. Negative symptoms are usually present from the prodromal phase; early diagnosis and management of negative symptoms is a major health concern since an insidious onset dominated by negative symptoms is associated with a worse outcome. Antipsychotic medications, which are effective for treating positive symptoms, are generally ineffective for treating negative or cognitive symptoms. We present a 23-year-old woman showing severe symptoms at her first visit to our department. The patient's parents reported that their daughter had experienced several years of psychosocial decline and putative psychiatric symptoms, but no medical attention had been previously sought; as such, the diagnosis of schizophrenia with predominantly negative symptoms was very much delayed. Early onset of schizophrenia, longer duration of untreated psychosis, and severe negative symptoms, which have limited treatment options, suggested a poor prognosis. We initiated monotherapy with cariprazine, a novel antipsychotic that has recently been proven efficacious in treating schizophrenia with predominantly negative symptoms. This report describes a 52-week cariprazine treatment regimen and follows the patient's impressive clinical improvement confirmed by PANSS and CGI scores, and psychological tests.

Early Intervention in Psychosis in Young People: A Population and Public Health Perspective

Over the past two decades or more, the creation of early intervention services (EIS) for psychoses has been regarded as one of the most significant developments in the reform of mental health services. The development of EIS is based on evidence of their superior effectiveness on multiple domains compared with regular care and the well-established relationship between delay in treatment of psychosis and outcome. The benefits of EIS may, however, be underutilized because of a patchy implementation even within high-income countries, low attention to actively reducing delays in treatment, inadequate knowledge about the length and dose of EIS required, and a lack of a population perspective in research and service planning. In this commentary, we offer some suggestions of how to address these challenges.

Transition of Substance-Induced, Brief, and Atypical Psychoses to Schizophrenia: A Systematic Review and Meta-analysis

Some people who experience substance-induced psychosis later develop an enduring psychotic disorder such as schizophrenia. This study examines the proportion of people with substance-induced psychoses who transition to schizophrenia, compares this to other brief and atypical psychoses, and examines moderators of this risk. A search of MEDLINE, PsychINFO, and Embase identified 50 eligible studies, providing 79 estimates of transition to schizophrenia among 40 783 people, including 25 studies providing 43 substance-specific estimates in 34 244 people. The pooled proportion of transition from substance-induced psychosis to schizophrenia was 25% (95% CI 18%-35%), compared with 36% (95% CI 30%-43%) for brief, atypical and not otherwise specified psychoses. Type of substance was the primary predictor of transition from drug-induced psychosis to schizophrenia, with highest rates associated with cannabis (6 studies, 34%, CI 25%-46%), hallucinogens (3 studies, 26%, CI 14%-43%) and amphetamines (5 studies, 22%, CI 14%-34%). Lower rates were reported for opioid (12%), alcohol (10%) and sedative (9%) induced psychoses. Transition rates were slightly lower in older cohorts but were not affected by sex, country of the study, hospital or community location, urban or rural setting, diagnostic methods, or duration of follow-up. Substance-induced psychoses associated with cannabis, hallucinogens, and amphetamines have a substantial risk of transition to schizophrenia and should be a focus for assertive psychiatric intervention.

Lead-Time Bias Confounds Association Between Duration of Untreated Psychosis and Illness Course in Schizophrenia

OBJECTIVE

At first hospitalization, a long duration of untreated psychosis (DUP) predicts illness severity and worse treatment outcomes. The mechanism of this association, however, remains unclear. It has been hypothesized that lengthy untreated psychosis is toxic or that it reflects a more severe form of schizophrenia. Alternatively, the association may be an artifact of lead-time bias. These hypotheses are tested in a longitudinal study of schizophrenia with 2,137 observations spanning from childhood to 20 years after first admission.

METHODS

Data were from the Suffolk County Mental Health Project. The cohort included 287 individuals with schizophrenia or schizoaffective disorder. DUP was defined as days from first psychotic symptom to first psychiatric hospitalization. Psychosocial function was assessed using the Premorbid Adjustment Scale and the Global Assessment of Functioning Scale. Psychosocial function trajectories were estimated using multilevel spline regression models adjusted for gender, occupational status, race, and antipsychotic medication.

RESULTS

Both long- and short-DUP patients experienced similar declines in psychosocial function, but declines occurred at different times relative to first admission. Long-DUP patients experienced most of these declines prior to first admission, while short-DUP patients experienced declines after first admission. When psychosocial function was analyzed relative to psychosis onset, DUP did not predict illness course.

CONCLUSIONS

The association between DUP and psychosocial function may be an artifact of early detection, creating the illusion that early intervention is associated with improved outcomes. In other words, DUP may be better understood as an indicator of illness stage than a predictor of course.

Detecting motor slowing in clinical high risk for psychosis in a computerized finger tapping model

Finger tapping is sensitive to motor slowing and emerging symptoms in individuals at clinical high risk for psychosis (CHR). A sensitive, computerized finger tapping task would be beneficial in early psychosis screening batteries. The study included 41 CHR and 32 healthy volunteers, who completed a computerized finger tapping task and clinical interviews. This computerized finger tapping task was sensitive to slowing in the CHR group compared to healthy volunteers, and as expected negative but not positive symptoms related to motor slowing. Computerized finger tapping tasks may be an easily dispersible tool for early symptom detection battery relevant to emerging negative symptoms.

Psychosocial Intervention With or Without Antipsychotic Medication for First-Episode Psychosis: A Randomized Noninferiority Clinical Trial

This triple-blind (participants, clinicians, and researchers) randomized controlled noninferiority trial examined whether intensive psychosocial intervention (cognitive-behavioral case management, CBCM) for first-episode psychosis (FEP) in 15–25 year-olds managed in a specialized early intervention for psychosis service was noninferior to usual treatment of antipsychotic medication plus CBCM delivered during the first 6 months of treatment. To maximize safety, participants were required to have low levels of suicidality and aggression, a duration of untreated psychosis (DUP) of less than 6 months, and be living in stable accommodation with social support. The primary outcome was level of functioning as assessed by the Social and Occupational Functioning Scale (SOFAS) at 6 months. Ninety young people were randomized by computer, 46 to placebo, and 44 antipsychotic medication and 33% of those who commenced trial medication completed the entire 6-month trial period. On the SOFAS, both groups improved, and group differences were small and clinically trivial, indicating that treatment with placebo medication was no less effective than conventional antipsychotic treatment (mean difference = −0.2, 2-sided 95% confidence interval = −7.5 to 7.0, t = 0.060, P = .95). Within the context of a specialized early intervention service, and with a short DUP, the immediate introduction of antipsychotic medication may not be required for all cases of FEP in order to see functional improvement. However, this finding can only be generalized to a very small proportion of FEP cases at this stage, and a larger trial is required to clarify whether antipsychotic-free treatment can be recommended for specific subgroups of those with FEP.

Trial Registration: ACTRN12607000608460 (www.anzctr.org.au).

Frontal brain activity in individuals at risk for schizophrenic psychosis and bipolar disorder during the emotional Stroop task - an fNIRS study

OBJECTIVES

The emotional Stroop effect is defined as increased reaction times to emotional stimuli compared to neutral ones. It has been often reported in the literature, on both behavioral and neurophysiological level. The goal of this study was to investigate the frontal brain activation in individuals at risk for schizophrenic psychosis and bipolar disorder during an emotional Stroop task. We expected to observe decreased activation in the at-risk individuals compared to the healthy controls.

METHODS

Individuals at high risk for psychosis (HR), at ultra-high risk for psychosis (UHR), at risk for bipolar disorder (BIP) and healthy controls (HC) performed an emotional Stroop task, which included positively, negatively and neutrally valenced words. Functional near-infrared spectroscopy (fNIRS) was used to measure levels of oxygenated hemoglobin (O2Hb) representing brain activity in the dorsolateral prefrontal and frontotemporal cortex.

RESULTS

Results showed significantly decreased levels of O2Hb in the right dorsolateral prefrontal cortex (DLPFC) in the HR and UHR groups compared to the HC, indicating lower activity. Even though the decrease was independent from the valence of the words, it was the most visible for the negative ones. Moreover, significantly lower O2Hb levels in the frontotemporal cortex (FTC) were observed in all at risk groups compared to the HC.

CONCLUSIONS

Lower activity in the FTC in groups at risk for psychosis and bipolar disorder reflects unspecific dysfunctions. Decreased activity in the DLPFC in the HR and UHR groups indicates that hypofrontality can be found already in individuals at risk for schizophrenic psychosis.

Oxidative-Antioxidant Imbalance and Impaired Glucose Metabolism in Schizophrenia

Schizophrenia is a neurodevelopmental disorder featuring chronic, complex neuropsychiatric features. The etiology and pathogenesis of schizophrenia are not fully understood. Oxidative-antioxidant imbalance is a potential determinant of schizophrenia. Oxidative, nitrosative, or sulfuric damage to enzymes of glycolysis and tricarboxylic acid cycle, as well as calcium transport and ATP biosynthesis might cause impaired bioenergetics function in the brain. This could explain the initial symptoms, such as the first psychotic episode and mild cognitive impairment. Another concept of the etiopathogenesis of schizophrenia is associated with impaired glucose metabolism and insulin resistance with the activation of the mTOR mitochondrial pathway, which may contribute to impaired neuronal development. Consequently, cognitive processes requiring ATP are compromised and dysfunctions in synaptic transmission lead to neuronal death, preceding changes in key brain areas. This review summarizes the role and mutual interactions of oxidative damage and impaired glucose metabolism as key factors affecting metabolic complications in schizophrenia. These observations may be a premise for novel potential therapeutic targets that will delay not only the onset of first symptoms but also the progression of schizophrenia and its complications.

Stigmas toward psychosis-related clinical features among the general public in Taiwan

INTRODUCTION

Stigma can be a barrier to early intervention of severe mental illnesses, especially schizophrenia, which further leads to poor outcomes. Mental health campaigns were designed to educate the general public about signs for early identification of psychosis, but the line between schizophrenia and attenuated psychosis was not well demarcated. We wonder if people would generalize their stigmas towards schizophrenia to subjects with subthreshold psychotic symptoms.

METHODS

A cross-sectional survey was employed which used a structured questionnaire, comprised of four case vignettes describing attenuated psychosis syndrome (APS), schizophrenia, psychotic-like experiences (PLE), or depression, and was followed by two sets of questions using the 4-point Likert scale to measure discrimination and prejudices. Participants were chosen by convenience sampling of laypersons from different backgrounds.

RESULTS

A total of 268 subjects completed this survey. A gradient of stigmas, highest toward schizophrenia, followed by APS/depression, and lowest toward PLE was apparent across gender, all age groups, and education levels. Participants who were younger and had higher education revealed a trend of lower prejudice and discrimination. People who have visited a psychiatric hospital showed higher discrimination toward schizophrenia, APS, and depression. People who have seen mentally ill persons in public places showed lower stigma toward PLE.

DISCUSSION

Our respondents posed a differentiable attitude towards PLE, APS, and schizophrenia, while exhibiting no difference between APS and depression. Certain personal attributes were correlated with stigma levels. Further investigation about mental health literacy and attitudes towards subjects with psychotic symptoms in the general public is warranted.

Duration of untreated psychosis and response to treatment: an analysis of response in the OPTiMiSE cohort

Some, but not all, studies have found longer duration of untreated psychosis (DUP) to be associated with poor response to treatment and more severe negative symptoms in schizophrenia. The aim of the current analysis was to investigate these parameters in a large cohort of patients in their first psychotic episode. The OPTiMiSE cohort included 446 patients with DUP up to two years, who were administered amisulpride for 4 weeks (Phase I). Patients who did not meet Andreasen remission criteria were randomized to double-blind continuation of amisulpride or olanzapine for 6 additional weeks in a blinded study (Phase II). Analyses showed that shorter DUP was associated with lower baseline CGI scores (p<0.001, r = 0.184), PANSS total (p = 0.025, r = 0.106) and PANSS negative subscale scores (p = 0.023, r = 0.107). Remitters had a significantly shorter mean DUP compared to non-remitters both in Phase I (24.5 weeks ±24.3 vs. 35 weeks ± 32.2, p = 0.01, t=-2.521) and in Phase II (24.3 weeks ± 26.4 vs. 38.3 weeks ± 31.3, p = 0.031, t=-2.194). Logistic regression analyses showed a significant effect of DUP on treatment response both in phase I (p = 0.008) and phase II (p = 0.041). Linear regression analyses found that DUP significantly affects PANSS Total change at the end of phase I (p = 0.028) but not at the end of phase II (p = 0.236). Based on these findings, it is possible to conclude that shorter DUP is associated with better response to treatment, particularly during the first weeks after treatment initiation. These findings highlight the need for early identification of the first psychotic episode.

Factors Influencing Professional Help-Seeking Behavior During First Episode Psychosis in Schizophrenia: An Exploratory Study on Caregivers' Perspective

Schizophrenia is a severe mental illness that leads to significant productivity loss and is listed in the top 15 global burdens of disease. One important contributor to the high disease burden is duration of untreated psychosis (DUP) which can be shortened with promotion of professional help-seeking behavior. This study explored caregivers' perspective on factors influencing professional help-seeking behavior during first episode psychosis (FEP) in schizophrenia in Malaysia. The results of this study would inform the development of intervention strategies targeted at promoting professional help-seeking behavior in caregivers of individuals experiencing first episode psychosis (FEP). This is a thematic exploratory study which employed purposive sampling using focus group discussion (FGD). These interviews were audio recorded and transcribed verbatim. Basic thematic approach was used in analyzing the transcribed interviews. Two main themes identified were adequacy of knowledge and stigma. These two factors were found to co-influence each other. Stigma undermined the impact of knowledge on professional help-seeking; likewise, the reverse was also observed. Intervention strategies for promoting help-seeking behavior during FEP should simultaneously focus on improving knowledge about schizophrenia and reducing the stigma attached to it.

Gender and 5-years course of psychosis patients: focus on clinical and social variables

Most studies on gender and psychosis have focused on gender differences at illness onset or on the long-term outcome, whereas little is known about the impact of gender on the first years after psychosis onset. A total of 185 first episode psychosis (FEP) patients were followed for 5 years after psychosis onset, and gender differences were explored in psychopathology (PANSS), needs for care (CAN), and insight (SAI-E). Male patients showed more negative symptoms than females over time, whereas female patients showed higher levels of depressive symptoms than males throughout the study period. In addition, female patients presented more functioning unmet needs for care, but higher levels of insight into illness than males. Therapy and rehabilitative programs for FEP patients should be gender-targeted, as gender has proved to impact on psychopathology, needs for care, and insight in the very first years following psychosis onset.

Duration of the psychosis prodrome

The recognition of a prodromal period preceding the onset of frank psychosis dates back to its first descriptions. Despite insights gained from a prospective approach to the study of the Clinical High Risk syndrome for psychosis (CHR-P), a prospectively-based understanding of the duration of the psychosis prodrome and the factors that may influence is not well-established. Here we analyze data from the second North American Prodrome Longitudinal Study (NAPLS-2) to characterize prodrome duration in those who converted to psychosis. Of the 764 participants identified as being at CHR-P, 94 converted to psychosis and 92 of these had recorded estimates of prodrome onset. Estimates of prodrome duration were derived from CHR-P syndrome onset and conversion dates from the Structured Interview for Psychosis-risk Syndromes. Results identified a mean prodrome duration of 21.6 months. Neither CHR-P sub-syndrome nor medication exposure was found to significantly influence prodrome duration in this sample. These results provide the most precise estimate of prodrome duration to date, although results are limited to prodromes identified by ascertainment as being at CHR-P. Our findings also suggest a rule of thirds with regard to prodrome duration in those followed for two years: one third of CHR-P patients who convert will do so by 1 year after CHR-P syndrome onset, another third 1-2 years after onset, and the final third more than 2 years after onset.

Clozapine response trajectories and predictors of non-response in treatment-resistant schizophrenia: a chart review study

Although clozapine is the main antipsychotic medication for treatment-resistant schizophrenia, 40-70% of patients on clozapine have persistent psychotic symptoms (i.e. ultra-treatment-resistant schizophrenia, UTRS). We aimed to examine clozapine response/non-response patterns in patients with treatment-resistant schizophrenia, as well as determine patient clinico-demographic factors associated with long-term clozapine non-response. Clinico-demographic characteristics of 241 patients on clozapine were collected through a retrospective chart review. The median (interquartile range, IQR) follow-up from illness onset was 25.0 (IQR = 24.0) years. Clozapine response was assessed at median 10.8 (IQR = 14.0) months (Time 1, T1) and 7.2 (IQR = 13.5) years (Time 2, T2) after its initiation. It was evaluated by chart reviewers based on the information provided in clinical notes. Binomial logistic regression was used to determine clinico-demographic factors associated with clozapine non-response at both T1 and T2 (i.e. stable UTRS, S-UTRS) compared to clozapine response at both times (i.e. stable clozapine responders, S-ClozResp). Among clozapine responders (n = 122) at T1, 83.6% remained clozapine responsive and 16.4% became non-responsive at T2. In the UTRS group (n = 119) at T1, 87.4% remained clozapine non-responsive and 12.6% became responsive at T2. Duration of delay in clozapine initiation (OR = 0.94, Wald χ² = 5.33, p = 0.021) and number of pre-clozapine hospitalizations (OR = 0.95, Wald χ² = 5.20, p = 0.023) were associated with S-UTRS. Most UTRS patients were non-responsive to clozapine from the start of treatment. Preventing delay in initiating clozapine and relapses could help promote long-term clozapine response in patients with treatment-resistant schizophrenia. Future longitudinal studies are required to explore the neuropathological correlates of relapses and delay in clozapine initiation.

Early and very early-onset schizophrenia compared with adult-onset schizophrenia: French FACE-SZ database

OBJECTIVE

To compare the clinical symptomatology in patients with Early-Onset Schizophrenia (EOS, N = 176), especially the subgroup Very Early Onset Schizophrenia (VEOS) and Adult Onset Schizophrenia (AOS, N = 551).

METHOD

In a large French multicentric sample, 727 stable schizophrenia patients, classified by age at onset of the disorder, were assessed using standardized and extensive clinical and neuropsychological batteries: AOS with onset ≥ 18 years and EOS with onset < 18 years (including 22 VEOS < 13 years).

RESULTS

The importance of better diagnosing EOS group, and in particularly VEOS, appeared in a longer DUP Duration of Untreated Psychosis (respectively, 2.6 years ± 4.1 and 8.1 years ± 5.7 vs. 1.0 years ± 2.5), more severe symptomatology (PANSS Positive And Negative Syndrome Scale scores), and lower educational level than the AOS group. In addition, the VEOS subgroup had a more frequent childhood history of learning disabilities and lower prevalence of right-handedness quotient than the AOS.

CONCLUSION

The study demonstrates the existence of an increased gradient of clinical severity from AOS to VEOS. In order to improve the prognosis of the early forms of schizophrenia and to reduce the DUP, clinicians need to pay attention to the prodromal manifestations of the disease.

Pathways to care, DUP, and types of interventions over 5 years following psychosis onset: findings from a naturalistic study conducted in routine generalist mental health services

PURPOSE

To describe pathways to care, duration of untreated psychosis (DUP), and types of interventions provided to first-episode psychosis (FEP) patients by routine Italian mental health services over 5 years since the first service contact.

METHODS

Naturalistic study conducted in Veneto, within the context of the Psychosis Incident Cohort Outcome Study (PICOS). A comprehensive set of measures was used, including schedules designed to collect information on referrals to psychiatric services and on psychological and pharmacological treatments at 1, 2, and 5 years since first service contact.

RESULTS

Overall, 397 patients were assessed. Most engaged with services with the help of family members (47.4%) and through emergency routes (60.3%). Those referred by clinicians were more likely to access care in a non-emergency way. Mean DUP was 5.62 months (SD 11.8) and longer DUP was associated with poorer functioning at 2 and 5 years. Interventions provided over 5 years were mainly constituted by antipsychotic medications (95.4% at 1 year; 85.8% at 2 years; 80.6% at 5 years), whereas a lower percentage (69.1% at 1 year; 61.5% at 2 years; 44.9% at 5 years) also received some forms of psychological interventions, mainly consisting of unspecific support sessions. Other structured interventions, such as CBT or family interventions, were seldom provided at each time-point.

CONCLUSIONS

Mental health services in Veneto seem effective in engaging FEP patients within a short time since illness onset. However, type of care provided does not meet quality standards recommended by treatment guidelines, especially regarding psychological interventions.

Unmedicated patients with schizophrenia in economically underdeveloped areas of China

OBJECTIVES

Untreated schizophrenia commonly leads to poor prognosis. The medication treatment rate of schizophrenia patients in economically underdeveloped areas of China has not been well-studied. This study aimed to examine the pattern of unmedicated schizophrenia patients in economically underdeveloped rural and urban areas of China.

METHOD

A total of 4240 schizophrenia patients in Lanzhou (1720 rural and 2520 urban patients) registered in the community mental-health service system in Lanzhou, Gansu province were included. Their socio-demographic and clinical characteristics including medication treatment status were collected and analyzed.

RESULTS

The proportion of unmedicated schizophrenia patients was 22.5% (n = 953) in the whole sample, with 32.3% (556/1720) in rural and 15.8% (397/2520) in urban patients (X²=161.1, P < 0.001). Multiple logistic regression analyses revealed that unmedicated schizophrenia patients in rural area were more likely to be older (OR=1.02, 95%CI: 1.01-1.03), male (OR=1.35, 95%CI: 1.07-1.71), unmarried (OR=0.71, 95%CI: 0.55-0.91), and have lower educational level (OR=0.39, 95%CI: 0.24-0.65), longer illness duration (OR=1.01, 95%CI: 1.00-1.02) and less frequent admissions (OR=0.46, 95%CI: 0.38-0.54). In contrast, unmedicated patients in urban area were more likely to be older (OR=1.01, 95%CI: 1.00-1.02), unmarried (OR=0.77, 95%CI: 0.61-0.98), employed (OR=2.38, 95%CI: 1.87-3.04), and have lower educational level (OR=0.49, 95%CI: 0.37-0.65), better financial status (OR=0.60, 95%CI: 0.48-0.76) and less frequent admissions (OR=0.81, 95%CI: 0.75-0.87).

CONCLUSIONS

The rate of unmedicated schizophrenia patients is high in economically underdeveloped areas of China, particularly in rural areas. Effective policies and measures should be implemented urgently to improve the treatment rate in this population.

Mismatch Negativity Predicts Remission and Neurocognitive Function in Individuals at Ultra-High Risk for Psychosis

BACKGROUND

In the early intervention in psychosis, ultra-high risk (UHR) criteria have been used to identify individuals who are prone to develop psychosis. Although the transition rate to psychosis in individuals at UHR is 10% to 30% within several years, some individuals at UHR present with poor prognoses even without transition occurring. Therefore, it is important to identify biomarkers for predicting the prognosis of individuals at UHR, regardless of transition. We investigated whether mismatch negativity (MMN) in response to both duration deviant stimuli (dMMN) and frequency deviant stimuli (fMMN) could predict prognosis, including remission and neurocognitive function in individuals at UHR.

MATERIALS AND METHODS

Individuals at UHR (n = 24) and healthy controls (HC; n = 18) participated in this study. In an auditory oddball paradigm, both dMMN and fMMN were measured at baseline. Remission and neurocognitive function after > 180 days were examined in the UHR group. Remission from UHR was defined as functional and symptomatic improvement using the Global Assessment of Functioning (GAF) score and Scale of Prodromal Symptoms (SOPS) positive subscales. Neurocognitive function was measured using the Brief Assessment of Cognition in Schizophrenia (BACS). We examined differences in MMN amplitude at baseline between those who achieved remission (remitters) and those who did not (non-remitters). Multiple regression analyses were performed to identify predictors for functioning, positive symptoms, and neurocognitive function.

RESULTS

Compared with the HC group, the UHR group had a significantly attenuated dMMN amplitude (p = 0.003). In the UHR group, GAF scores significantly improved during the follow-up period (mean value 47.1 to 55.5, p = 0.004). The dMMN amplitude at baseline was significantly larger in the remitter (n = 6) than in the non-remitter group (n = 18) (p = 0.039). The total SOPS positive subscale scores and fMMN amplitude at baseline could predict BACS attention subscore at the follow-up point (SOPS positive subscales, p = 0.030; fMMN, p = 0.041).

CONCLUSION

Our findings indicate that dMMN and fMMN predicted remission and neurocognitive function, respectively, in individuals at UHR, which suggests that there are both promising biomarker candidates for predicting prognosis in individuals at UHR.

Cognition and functionality in delusional disorder

Background:

Even if neurocognition is known to affect functional outcomes in schizophrenia, no previous study has explored the impact of cognition on functionality in delusional disorder (DD). We aimed to assess the effect of clinical characteristics, symptom dimensions and neuropsychological performance on psychosocial functioning and self-perceived functional impairment in DD.

Methods:

Seventy-five patients with a SCID-I confirmed diagnosis of DD underwent neurocognitive testing using a neuropsychological battery examining verbal memory, attention, working memory and executive functions. We assessed psychotic symptoms with the Positive and Negative Syndrome Scale, and calculated factor scores for four clinical dimensions: Paranoid, Cognitive, Affective and Schizoid. We conducted hierarchical linear regression models to identify predictors of psychosocial functioning, as measured with the Global Assessment of Functioning scale, and self-perceived functional impairment, as measured with the Sheehan’s Disability Inventory.

Results:

In the final linear regression models, higher scores in the Paranoid (β= 0.471, p <.001, r2 = 0.273) and Cognitive (β = 0.325, p <.001, r2 = 0.180) symptomatic dimensions and lower scores in verbal memory (β = −0.273, p <.05, r2 = 0.075) were significantly associated with poorer psychosocial functioning in patients with DD. Lower scores in verbal memory (β= −0.337, p <.01, r2 = 0.158) and executive functions (β= −0.323, p <.01, r2 = 0.094) were significantly associated with higher self-perceived disability.

Conclusions:

Impaired verbal memory and cognitive symptoms seem to affect functionality in DD, above and beyond the severity of the paranoid idea. This suggests a potential role for cognitive interventions in the management of DD.

Familiarity for Serious Mental Illness in Help-Seeking Adolescents at Clinical High Risk of Psychosis

Aim: Ultrahigh-risk (UHR) individuals have an increased vulnerability to psychosis because of accumulating environmental and/or genetic risk factors. Although original research examined established risk factors for psychosis in the UHR state, these findings are scarce and often contradictory. The aims of this study were (a) to investigate the prevalence of severe mental illness (SMI) in family members of distinct subgroups of adolescents identified through the UHR criteria [i.e., non-UHR vs. UHR vs. first-episode psychosis (FEP)] and (b) to examine any relevant associations of family vulnerability and genetic risk and functioning deterioration (GRFD) syndrome with clinical and psychopathological characteristics in the UHR group. Methods: Adolescents (n = 147) completed an ad hoc sociodemographic/clinical schedule and the Comprehensive Assessment of At-Risk Mental States to investigate the clinical status. Results: More than 60% UHR patients had a family history of SMI, and approximately a third of them had at least a first-degree relative with psychosis or other SMI. A GRFD syndrome was detected in ~35% of UHR adolescents. GRFD adolescents showed baseline high levels of positive symptoms (especially non-bizarre ideas) and emotional disturbances (specifically, observed inappropriate affect). Conclusions: Our results confirm the importance of genetic and/or within-family risk factors in UHR adolescents, suggesting the crucial need of their early detection, also within the network of general practitioners, general hospitals, and the other community agencies (e.g., social services and school).

What Causes the Onset of Psychosis in Individuals at Clinical High Risk? A Meta-analysis of Risk and Protective Factors

Twenty percent of individuals at clinical high risk for psychosis (CHR-P) develop the disorder within 2 years. Extensive research has explored the factors that differentiate those who develop psychosis and those who do not, but the results are conflicting. The current systematic review and meta-analysis comprehensively addresses the consistency and magnitude of evidence for non-purely genetic risk and protective factors associated with the risk of developing psychosis in CHR-P individuals. Random effects meta-analyses, standardized mean difference (SMD) and odds ratio (OR) were used, in combination with an established stratification of evidence that assesses the association of each factor and the onset of psychotic disorders (from class I, convincing evidence to class IV weak evidence), while controlling for several types of biases. A total of 128 original controlled studies relating to 26 factors were retrieved. No factors showed class I-convincing evidence. Two further factors were associated with class II-highly suggestive evidence: attenuated positive psychotic symptoms (SMD = 0.348, 95% CI: 0.280, 0.415) and global functioning (SMD = -0.291, 95% CI: -0.370, -0.211). There was class III-suggestive evidence for negative psychotic symptoms (SMD = 0.393, 95% CI: 0.317, 0.469). There was either class IV-weak or no evidence for all other factors. Our findings suggest that despite the large number of putative risk factors investigated in the literature, only attenuated positive psychotic symptoms, global functioning, and negative psychotic symptoms show suggestive evidence or greater for association with transition to psychosis. The current findings may inform the refinement of clinical prediction models and precision medicine in this field.

Aggressive behavior and metacognitive functions: a longitudinal study on patients with mental disorders

BACKGROUND

Metacognitive functions play a key role in understanding which psychological variables underlying the personality might lead a person with a severe mental disorder to commit violent acts against others. The aims of this study were to: (a) investigate the differences between patients with poor metacognitive functioning (PM group) and patients with good metacognitive functioning (GM group) in relation to a history of violence; (b) investigate the differences between the two groups in relation to aggressive behavior during a 1-year follow-up; and (c) analyze the predictors of aggressive behavior.

METHODS

In a prospective cohort study, patients with severe mental disorders with and without a lifetime history of serious violence were assessed with a large set of standardized instruments and were evaluated bi-monthly with MOAS in order to monitor any aggressive behavior. The total sample included 180 patients: 56% outpatients and 44% inpatients, and the majority were male (75%) with a mean age of 44 (± 9.8) years, and half of them had a history of violence. The sample was split into two groups: poor metacognition (PM) group and good metacognition (GM) group, according to MAI evaluation scores.

RESULTS

The PM patients reported a history of violence more frequently than GM patients, during the 1-year follow-up, but no differences between groups in aggressive and violent behavior were found. The strongest predictors of aggressive behavior were: borderline and passive-aggressive personality traits and a history of violence, anger, and hostility. The metacognitive functions alone did not predict aggressive behavior, but metacognitive functions interacted with hostility and angry reactions in predicting aggressive behavior.

CONCLUSIONS

This study led to some important conclusions: (a) some aspects closely related to violence are predictive of aggressive behavior only in patients with poor metacognition, thus good metacognition is a protective factor; (b) poor metacognition is associated with a history of violence, which in turn increases the risk of committing aggressive behavior.

Subjective Quality of Life and Its Associations among First Episode Psychosis Patients in Singapore

Background—Mental disorders have been found to affect quality of life (QOL) in patients. The current study aimed to determine QOL among first episode psychosis (FEP) patients and explore its associations with sociodemographic as well as clinical factors. Methods—Data for this study were collected as a part of an Early Psychosis Intervention Program (EPIP)-Smoking and Alcohol use survey. At baseline, 280 outpatients aged 15–40 years old diagnosed with FEP, with no prior or minimal treatment, no history of medical or neurological disorder, and no history of substance abuse, were recruited. Sociodemographic details, diagnosis, length of duration of untreated psychosis (DUP), and World Health Organization Quality of Life assessment—abbreviated version (WHOQOL-BREF) scores were obtained. Results—After adjusting for all covariates, older age (p = 0.036), females, and participants diagnosed with brief psychotic disorder (p = 0.04) were associated positively, whereas separated/divorced participants, those with lower education, unemployed (p = 0.01), and longer DUP were seen to be negatively associated with different domains of QOL. Conclusion—Higher WHOQOL-BREF scores denote better QOL. Overall, female participants as compared to male participants and those diagnosed with brief psychotic disorder in this sample reported better QOL.

An Examination of the Community Participation Interests of Young Adults with Serious Mental Illnesses

Participation in various aspects of community life (e.g., education, employment) plays a critical role in fostering young adult development and health. To support behavioral health services in addressing a broader array of meaningful community participation areas, the current study examined the participation interests of young adults with serious mental illnesses via a literature review and focus groups interviews. Literature review results revealed a range of community participation areas of interest to these individuals, including employment, education, religion and spirituality, social networking (e.g., using social media), volunteering activities, socializing, and civic and artistic participation (e.g., attending a political event, playing music). Focus group participants named many of these same areas, but also mentioned unique areas of participation that have not been the focus of previous research (i.e., playing games, sports, exploration of other communities (e.g., traveling), hanging out, and nature-based participation). Implications for future research and behavioral health practice are discussed.

Patterns of symptoms before a diagnosis of first episode psychosis: a latent class analysis of UK primary care electronic health records

BACKGROUND

The nature of symptoms in the prodromal period of first episode psychosis (FEP) remains unclear. The objective was to determine the patterns of symptoms recorded in primary care in the 5 years before FEP diagnosis.

METHODS

The study was set within 568 practices contributing to a UK primary care health record database (Clinical Practice Research Datalink). Patients aged 16-45 years with a first coded record of FEP, and no antipsychotic prescription more than 1 year prior to FEP diagnosis (n = 3045) was age, gender, and practice matched to controls without FEP (n = 12,180). Fifty-five symptoms recorded in primary care in the previous 5 years, categorised into 8 groups (mood-related, 'neurotic', behavioural change, volition change, cognitive change, perceptual problem, substance misuse, physical symptoms), were compared between cases and controls. Common patterns of symptoms prior to FEP diagnosis were identified using latent class analysis.

RESULTS

Median age at diagnosis was 30 years, 63% were male. Non-affective psychosis (67%) was the most common diagnosis. Mood-related, 'neurotic', and physical symptoms were frequently recorded (> 30% of patients) before diagnosis, and behavioural change, volition change, and substance misuse were also common (> 10%). Prevalence of all symptom groups was higher in FEP patients than in controls (adjusted odds ratios 1.33-112). Median time from the first recorded symptom to FEP diagnosis was 2-2.5 years except for perceptual problem (70 days). The optimal latent class model applied to FEP patients determined three distinct patient clusters: 'no or minimal symptom cluster' (49%) had no or few symptoms recorded; 'affective symptom cluster' (40%) mainly had mood-related and 'neurotic' symptoms; and 'multiple symptom cluster' (11%) consulted for three or more symptom groups before diagnosis. The multiple symptom cluster was more likely to have drug-induced psychosis, female, obese, and have a higher morbidity burden. Affective and multiple symptom clusters showed a good discriminative ability (C-statistic 0.766; sensitivity 51.2% and specificity 86.7%) for FEP, and many patients in these clusters had consulted for their symptoms several years before FEP diagnosis.

CONCLUSIONS

Distinctive patterns of prodromal symptoms may help alert general practitioners to those developing psychosis, facilitating earlier identification and referral to specialist care, thereby avoiding potentially detrimental treatment delay.

The "Reggio Emilia At-Risk Mental States" program: A diffused, "liquid" model of early intervention in psychosis implemented in an Italian Department of Mental Health

AIM

From September 2012, the Reggio Emilia Department of Mental Health developed a specific program (the "Reggio Emilia At-Risk Mental States" [ReARMS] protocol) as a diffused, "liquid" infrastructure for early intervention in psychosis. Aims of the current study are (a) to describe the ReARMS macroscopic organization and (b) to examine specific process indicators during the first 5 years of clinical activity.

METHODS

All participants (n = 300) were young help-seekers, aged 13 to 35 years, who completed the Comprehensive Assessment of At-Risk Mental States (CAARMS).

RESULTS

At baseline, 95 (31.7%) participants did not meet CAARMS-defined criteria, while 205 (68.3%) were offered a dedicated protocol of care: 154 (75.1%) of them were enrolled in the program, 19 (9.3%) refused and 32 (15.6%) dropped out during the first year of treatment. Individuals enrolled in the ReARMS protocol were mainly referred by general practitioners (33.3%), emergency room/general hospital (24%) or they were self-referred (15%). In comparison with ultra-high risk individuals, patients with first episode psychosis showed significantly higher mean age at entry and preponderance of males, as well as higher percentages of history of substance abuse and previous hospitalization.

CONCLUSIONS

An early intervention in psychosis service in Italian child/adolescent and adult mental health services are feasible and clinically relevant, also in adolescents, who have a high risk of falling through the child-adult service gap as they cross the transition boundary between services.

Simulated long-term outcomes of early use of long-acting injectable antipsychotics in early schizophrenia

AIM

Duration of untreated psychosis in early schizophrenia impacts long-term outcomes. Because long-acting injectable (LAI) antipsychotic drugs improve adherence in early-stage patients, they could reduce additional time in uncontrolled psychosis (TUP) during the critical period of the illness. However, the long-term benefit of early LAI use over oral formulations has not been quantified. This study explores the potential magnitude of the benefit with a simulation approach.

METHODS

A microsimulation models the effects of 11 treatment pathways reflecting alternative decisions on whether and when LAI agents are used during a "calibration phase" that starts at treatment entry and lasts until the end of the 3-year critical period. Treatment failure prolongs time in psychosis. Long-term outcomes are predicted over the ensuing 7-year period as a function of TUP.

RESULTS

An "early LAI" pathway where LAI treatment follows the second oral treatment failure is compared to an oral-only pathway. Under these pathways, 69% and 46% of patients, respectively, are estimated to exit the calibration phase with adequate symptom control (total positive and negative syndrome scale score below 68). Relative to the oral-only pathway, the early LAI pathway is predicted to increase competitive employment by 39% (25% vs 18%) and independent or family living by 22% (71% vs 58%), and to decrease receipt of disability benefits by 36% (42% vs 66%) and hospital admissions per 1000 patient-years by 15% (249% vs 294%).

CONCLUSIONS

While these simulation results need to be confirmed empirically, they suggest that earlier use of LAI antipsychotics can meaningfully improve patient outcomes.

Effects of socio-demographic characteristics, premorbid functioning, and insight on duration of untreated psychosis in first-episode schizophrenia or schizophreniform disorder in Northern Malawi

AIM

Long duration of untreated psychosis (DUP) is prevalent and has been shown to be associated with poorer prognosis. Thus, knowledge of its determinants may help to target early interventions to reduce DUP on the needed population. Previous studies seeking to understand determinants of DUP have been inconclusive. Therefore, this study aimed to investigate the effects of socio-demographic characteristics, premorbid functioning, and insight on DUP in patients with first-episode schizophrenia or schizophreniform disorder.

METHODS

This cross-sectional study recruited 110 subjects (aged 18-65) during a pilot early intervention service for psychosis in Northern Malawi, between June 2009 and September 2012. Short DUP was defined as ≤6 months, whereas long DUP was defined as >6 months. Unadjusted and adjusted analyses were performed to identify determinants of DUP.

RESULTS

Of the 110 subjects, 99 (90%) had schizophrenia. Median DUP was 27.5 months, while mean (SD) DUP was 71.24 (92.32) months. In addition, at least 75% had long DUP, which was associated with lower level of education, poor insight, younger age at onset, and at least one parent deceased.

CONCLUSIONS

Long DUP is prevalent in Northern Malawi. Thus, early interventions to reduce DUP are warranted in this population. Although having at least one parent deceased predicted long DUP in this study, this remains speculative because factors, such as timing of parents' death and grief reactions of the patients were not assessed. Therefore, further investigations incorporating these factors are needed to ascertain this result.

Relationship between duration of untreated prodromal symptoms and symptomatic and functional recovery

Our previous study has found that a long duration of untreated prodromal symptoms (DUPrS) does not increase the conversion risk to psychosis in individuals with attenuated psychosis syndrome (APS). However, whether a long DUPrS will lead to other poor outcomes remains unknown. The purpose of this study was to analyse the association between the DUPrS and outcomes (symptomatic and functional recovery) in APS population. A post hoc analysis was performed in 391 individuals with APS as identified by the structured interview. APS subjects had follow-up interviews every 6 months for 2 years following diagnosis. Poor functional outcome was defined as a Global Assessment of Functioning (GAF) score less than 60 at the time of follow-up. Poor symptomatic outcome was defined as at least one of the positive symptoms rated scores of 3 or higher. A post hoc analysis was performed in 391 individuals with APS as identified by the structured interview. APS subjects had follow-up interviews every 6 months for 2 years following diagnosis. Poor functional outcome was defined as a Global Assessment of Functioning (GAF) score less than 60 at the time of follow-up. Poor symptomatic outcome was defined as at least one of the positive symptoms rated scores of 3 or higher. Of total 391 individuals, 334 were followed up for 2 years to assess clinical outcome, 82 (24.6%) had shown conversion to psychosis, 79 (23.7%) met the criteria of poor functioning outcome, and 145 (43.4%) met the criteria of poor symptomatic outcome. A significant correlation between GAF scores and DUPrS was observed in the non-converter group, but not in the converters. Individuals with APS who had a longer DUPrS were correlated with poorer functional outcome. However, it was not correlated with poorer symptomatic outcome. While a longer DUPrS was not related to poor symptomatic outcome, it was significantly related to poor functional outcome. Our findings highlight the importance of reducing DUPrS to decrease future functional impairment in populations at risk for psychosis.

The Predicted Long-Term Benefits of Ensuring Timely Treatment and Medication Adherence in Early Schizophrenia

The impact of initiatives aimed at reducing time in untreated psychosis during early-stage schizophrenia will be unknown for many years. Thus, we simulate the effect of earlier treatment entry and better antipsychotic drug adherence on schizophrenia-related hospitalizations, receipt of disability benefits, competitive employment, and independent/family living over a ten-year horizon. We predict that earlier treatment entry reduces hospitalizations by 12.6-14.4% and benefit receipt by 7.0-8.5%, while increasing independent/family living by 41.5-46% and employment by 42-58%. We predict larger gains if a pro-adherence intervention is also used. Our findings suggest substantial benefits of timely and consistent early schizophrenia care.

Treatment Adherence in Youth with First-Episode Psychosis: Impact of Family Support and Telehealth Delivery

Mental health-care delivery to young people with first-episode schizophrenia presents significant challenges especially in underserved areas. This chart review reveals the importance of family support as a predictor for medication and treatment adherence with this vulnerable group. An unexpected disengagement rate of 47% was discovered. It was further discovered that receiving care with telehealth delivery was a significant predictor of lost to follow-up or treatment nonadherence. Recommendations include psychoeducation for families during the initial crisis, initiation of long-acting injectable antipsychotics early in care, a hybrid telehealth intervention with in-home medication delivery, and collaboration with educational, vocational county agencies for employment support. A system of care must be developed to support young people with this severe illness for optimum outcome and protection of long-term cognitive functioning.

The association between early-onset schizophrenia with employment, income, education, and cohabitation status: nationwide study with 35 years of follow-up

PURPOSE

Individuals with schizophrenia have been reported to have low employment rates. We examined the associations of schizophrenia with employment, income, and status of cohabitation from a work life course perspective.

METHODS

Nationwide cohort study including all individuals (n = 2,390,127) born in Denmark between 1955 and 1991, who were alive at their 25th birthday. Diagnosis of schizophrenia (yes/no) between ages 15 and 25 was used as an exposure. Employment status, annual wage or self-employment earnings, level of education, and cohabitant status from the age of 25-61 (years 1980-2016) were used as outcomes.

RESULTS

Schizophrenia diagnosis between ages 15 and 25 (n = 9448) was associated with higher odds of not being employed (at the age of 30: OR 39.4, 95% CI 36.5-42.6), having no secondary or higher education (7.4, 7.0-7.8), and living alone (7.6, 7.2-8.1). These odds ratios were two-to-three times lower and decreasing over time for those individuals who did not receive treatment in a psychiatric inpatient or outpatient clinic for schizophrenia after the age of 25. Between ages 25-61, individuals with schizophrenia have cumulative earning of $224,000, which is 14% of the amount that the individuals who have not been diagnosed with schizophrenia earn.

CONCLUSIONS

Individuals with schizophrenia are at high risk of being outside the labour market and living alone throughout their entire life, resulting in an enormous societal loss in earnings. Individuals with less chronic course of schizophrenia had a gradual but substantial improvement throughout their work life.

Patterns of Health Care Utilization Before First Episode Psychosis in Racial and Ethnic Groups

Objective

To compare patterns of health care utilization associated with first presentation of psychosis among different racial and ethnic groups of patients.

Design

The study was a retrospective observational design.

Setting

The study was conducted in five health care systems in the western United States. All sites were also part of the National Institute of Mental Health-funded Mental Health Research Network (MHRN).

Participants

Patients (n = 852) were aged 15 - 59 years (average 26.9 ± 12.2 years), 45% women, and primarily non-Hispanic White (53%), with 16% Hispanic, 10% non-Hispanic Black, 6% Asian, 1% Native Hawaiian/Pacific Islander, 1% Native American/ Alaskan Native, and 12% unknown race/ethnicity.

Main Outcome Measures

Variables examined were patterns of health care utilization, type of comorbid mental health condition, and type of treatment received in the three years before first presentation of psychosis.

Methods

Data abstracted from electronic medical records and insurance claims data were organized into a research virtual data warehouse (VDW) and used for analysis.

Results

Compared with non-Hispanic Whites, Asian patients (16% vs 34%; P=.007) and non-Hispanic Black patients (20% vs 34%; P=.009) were less likely to have a visit with specialty mental health care before their first presentation of psychosis.

Conclusions

Early detection of first episode psychosis should start with wider screening for symptoms outside of any indicators for mental health conditions for non-Hispanic Black and Asian patients.

Analysis of Gut Microbiota and Their Metabolic Potential in Patients with Schizophrenia Treated with Olanzapine: Results from a Six-Week Observational Prospective Cohort Study

Accumulating evidence indicates the potential effect of microbiota on the pathogenesis and course of schizophrenia. However, the effects of olanzapine, second-generation antipsychotics, on gut microbiota have not been investigated in humans. This study aimed to analyze fecal microbiota in schizophrenia patients treated with olanzapine during six weeks of their hospital stay. After a seven-day washout from all psychotropic medications, microbiota compositions were evaluated at baseline and after six weeks of hospitalization using 16S rRNA sequencing. The study was conducted in 20 inpatients, who followed the same hospital routine and received 5–20 mg daily doses of olanzapine. Olanzapine treatment was associated with clinical improvements in all patients and significant increases in body mass index in females, but not changes in gut microbiota compositions and predicted function. The severity of symptoms at the beginning of treatment varied in accordance with the predicted metabolic activity of the bacteria. The present findings indicate that the microbiota of schizophrenia patients is highly individual and has different taxonomical (Type 1, with a predominance of Prevotella, and Type 2 with a higher abundance of Bacteroides, Blautia and Clostridium) and functional clusters, and it does not change following six weeks of olanzapine therapy; in addition, the microbiota is not associated with either the weight gain observed in women or the effectiveness of olanzapine therapy.

Four reasons why early detection centers for psychosis should be renamed and their treatment targets reconsidered: we should not catastrophize a future we can neither reliably predict nor change

Since the 1990s, facilities for individuals at putative risk for psychosis have mushroomed and within a very short time have become part of the standard psychiatric infrastructure in many countries. The idea of preventing a severe mental disorder before its exacerbation is laudable, and early data indeed strongly suggested that the sooner the intervention, the better the outcome. In this paper, the authors provide four reasons why they think that early detection or prodromal facilities should be renamed and their treatment targets reconsidered. First, the association between the duration of untreated psychosis and outcome is empirically established but has become increasingly weak over the years. Moreover, its applicability to those who are considered at risk remains elusive. Second, instruments designed to identify future psychosis are prone to many biases that are not yet sufficiently controlled. None of these instruments allows an even remotely precise prognosis. Third, the rate of transition to psychosis in at-risk patients is likely lower than initially thought, and evidence for the success of early intervention in preventing future psychosis is promising but still equivocal. Perhaps most importantly, the treatment is not hope-oriented. Patients are more or less told that schizophrenia is looming over them, which may stigmatize individuals who will never, in fact, develop psychosis. In addition self-stigma has been associated with suicidality and depression. The authors recommend that treatment of help-seeking individuals with mental problems but no established diagnosis should be need-based, and the risk of psychosis should be de-emphasized as it is only one of many possible outcomes, including full remission. Prodromal clinics should not be abolished but should be renamed and restructured. Such clinics exist, but the transformation process needs to be facilitated.

Basic self-disturbances independently predict recovery in psychotic disorders: A seven year follow-up study

BACKGROUND

Recovery is the ultimate goal of psychosis treatment. Basic self-disturbances (BSDs) are non-psychotic phenomena associated with clinical outcome, present in prodromal, psychotic and residual phases of psychotic disorders.

AIM

To investigate the relationship between BSDs and recovery seven years after first treatment in patients with psychotic disorders.

METHOD

Prospective longitudinal study of 56 patients recruited during first adequate treatment for schizophrenia (n = 35) and other psychotic disorders (n = 21) (psychotic bipolar disorder, delusional disorder, psychotic disorder NOS). At baseline and follow-up BSDs were assessed using the Examination of Anomalous Self-Experience (EASE) manual, while standard clinical instruments were used to ascertained diagnosis, clinical symptom severity, and functioning. Recovery was defined as absence of psychotic symptoms and regaining of functioning that persisted the last two years before follow-up.

RESULTS

At follow up, 34% achieved recovery (5 (14%) with schizophrenia and 14 (67%) with other psychoses at baseline). Recovery was predicted by an absence of a schizophrenia diagnosis, low baseline level of BSDs and further reductions in BSDs from baseline to follow-up. Change in BSDs was the strongest predictor, also after adjusting for premorbid adjustment and duration of untreated psychosis, and was not confounded by diagnosis.

CONCLUSION

Low baseline levels of basic self-disturbances and further reductions over time independently predict recovery seven years later in first treated psychosis patients.

22q11 microdeletion syndrome and ultra-high risk for psychosis: The role of neurological soft signs as an independent marker of vulnerability for psychosis

AIM

22q11 microdeletion syndrome has an increased risk for psychosis, similar to subjects at ultra-high risk for psychosis. Neurological soft signs are considered an endophenotype of psychotic disorders and a marker of vulnerability to Schizophrenia, consisting of overflow movements, dysrhythmia and speed of timed activities. To date, there are no studies that have evaluated the presence of the neurological soft signs in subjects with 22q11 microdeletion syndrome and there are a few studies that have analysed this issue in subjects at ultra-high risk.

METHODS

We sought to measure neurological soft signs in these two conditions, compared to healthy controls and to analyse the possible correlation between neurological soft signs and positive/negative symptoms both in 22q11 microdeletion syndrome and ultra-high-risk groups. 54 drug-naive patients (29 with 22q11 microdeletion syndrome and 25 at ultra-high risk for psychosis) and 25 healthy controls were evaluated for neurological soft signs.

RESULTS

Both clinical groups showed a greater number of neurological soft signs compared to healthy control, although the two clinical groups did not differ for the number of neurological soft signs. Positive correlation between speed of timed activities and negative symptoms was found in subjects at ultra-high risk.

CONCLUSION

Neurological soft signs could represent a marker of atypical neurodevelopment in the two populations examined. Since we did not found a strong correlation between neurological soft signs and positive/negative symptoms, we suggest that neurological soft signs could be indicators of vulnerability to psychosis independent from the psychopathology.

M. Staging of Schizophrenia With the Use of PANSS: An International Multi-Center Study

INTRODUCTION

A specific clinically relevant staging model for schizophrenia has not yet been developed. The aim of the current study was to evaluate the factor structure of the PANSS and develop such a staging method.

METHODS

Twenty-nine centers from 25 countries contributed 2358 patients aged 37.21 ± 11.87 years with schizophrenia. Analysis of covariance, Exploratory Factor Analysis, Discriminant Function Analysis, and inspection of resultant plots were performed.

RESULTS

Exploratory Factor Analysis returned 5 factors explaining 59% of the variance (positive, negative, excitement/hostility, depression/anxiety, and neurocognition). The staging model included 4 main stages with substages that were predominantly characterized by a single domain of symptoms (stage 1: positive; stages 2a and 2b: excitement/hostility; stage 3a and 3b: depression/anxiety; stage 4a and 4b: neurocognition). There were no differences between sexes. The Discriminant Function Analysis developed an algorithm that correctly classified >85% of patients.

DISCUSSION

This study elaborates a 5-factor solution and a clinical staging method for patients with schizophrenia. It is the largest study to address these issues among patients who are more likely to remain affiliated with mental health services for prolonged periods of time.

A minimum evaluation protocol and stepped-wedge cluster randomized trial of ACCESS Open Minds, a large Canadian youth mental health services transformation project

BACKGROUND

Many Canadian adolescents and young adults with mental health problems face delayed detection, long waiting lists, poorly accessible services, care of inconsistent quality and abrupt or absent inter-service transitions. To address these issues, ACCESS Open Minds, a multi-stakeholder network, is implementing and systematically evaluating a transformation of mental health services for youth aged 11 to 25 at 14 sites across Canada. The transformation plan has five key foci: early identification, rapid access, appropriate care, the elimination of age-based transitions between services, and the engagement of youth and families.

METHODS

The ACCESS Open Minds Research Protocol has multiple components including a minimum evaluation protocol and a stepped-wedge cluster randomized trial, that are detailed in this paper. Additional components include qualitative methods and cost-effectiveness analyses. The services transformation is being evaluated at all sites via a minimum evaluation protocol. Six sites are participating in the stepped-wedge trial whereby the intervention (a service transformation along the key foci) was rolled out in three waves, each commencing six months apart. Two sites, one high-population and one low-population, were randomly assigned to each of the three waves, i.e., randomization was stratified by population size. Our primary hypotheses pertain to increased referral numbers, and reduced wait times to initial assessment and to the commencement of appropriate care. Secondary hypotheses pertain to simplified pathways to care; improved clinical, functional and subjective outcomes; and increased satisfaction among youth and families. Quantitative measures addressing these hypotheses are being used to determine the effectiveness of the intervention.

DISCUSSION

Data from our overall research strategy will help test the effectiveness of the ACCESS Open Minds transformation, refine it further, and inform its scale-up. The process by which our research strategy was developed has implications for the practice of research itself in that it highlights the need to actively engage all stakeholder groups and address unique considerations in designing evaluations of complex healthcare interventions in multiple, diverse contexts. Our approach will generate both concrete evidence and nuanced insights, including about the challenges of conducting research in real-world settings. More such innovative approaches are needed to advance youth mental health services research.

TRIAL REGISTRATION NUMBER

Clinicaltrials.gov, ISRCTN23349893 (Retrospectively registered: 16/02/2017).

Ontological insecurity I: Psychometric development of a new measure and relationship to subclinical psychotic-like experiences

OBJECTIVES

The present study sought to develop a new psychometrically sound measure of ontological insecurity, the OIS-34 and, determine its relationship with subclinical psychotic-like experiences (PLEs).

METHODS

A nonclinical sample (N = 600) completed an initial 60-item version of the new scale along with measures of PLEs, psychosis proneness, and mental health history.

RESULTS

Exploratory factor analysis indicated a single factor, ontological insecurity, with 34 items loading positively and above a criterion of 0.4. Internal consistency and test-retest reliability were excellent. The OIS-34 correlated positively and significantly with psychosis proneness and subclinical positive and negative symptom PLEs. The OIS-34 also differentiated significantly between participants with and without a history of mental health problems, including psychosis.

CONCLUSIONS

The OIS-34 appears to represent a psychometrically sound measure of ontological insecurity. The results suggest that the concept is associated with PLEs. Directions for further research are discussed.

The Role of Biomarkers in Psychiatry

Psychiatric illnesses are cognitive and behavioral disorders of the brain. At present, psychiatric diagnosis is based on DSM-5 criteria. Even if endophenotype specificity for psychiatric disorders is discussed, it is difficult to study and identify psychiatric biomarkers to support diagnosis, prognosis, or clinical response to treatment. This chapter investigates the innovative biomarkers of psychiatric diseases for diagnosis and personalized treatment, in particular post-genomic data and proteomic analyses.

Using proton magnetic resonance spectroscopic imaging to study glutamatergic alterations in patients with schizophrenia: A systematic review

The glutamate hypothesis of schizophrenia posits aberrant glutamatergic activity in patients with schizophrenia. Levels of glutamate and glutamine can be detected and quantified in vivo by proton magnetic resonance spectroscopy. A related technique, proton magnetic resonance spectroscopic imaging (¹H-MRSI), is particularly useful as it simultaneously collects multiple spectra, across multiple voxels, from a single acquisition. The primary aim of this study was to review and discuss the use of ¹H-MRSI to measure levels of glutamate and glutamine in patients with schizophrenia. Additionally, the advantages and disadvantages of using ¹H-MRSI to examine schizophrenia pathophysiology are discussed. A literature search was conducted through Ovid. English language studies utilizing ¹H-MRSI to measure glutamate and glutamine in patients with schizophrenia were identified. Six studies met the inclusion criteria. The included studies provide inconclusive support for glutamatergic elevations within frontal brain regions in patients with schizophrenia. The key benefit of employing ¹H-MRSI to examine schizophrenia pathophysiology appears to be its broader spatial coverage. Future ¹H-MRSI studies utilizing large sample sizes and longitudinal study designs are necessitated to further our understanding of glutamatergic alterations in patients with schizophrenia.

A New Method for Estimating Incidence of First Psychotic Diagnosis in a Medicaid Population

OBJECTIVE

Early intervention programs for first-episode psychosis (FEP) require population-based methods to identify individuals with FEP. This study adapted a previously published method to estimate incidence of first psychotic diagnosis in a state Medicaid program. Secondary aims were to examine demographic and service patterns associated with a first psychotic diagnosis in Medicaid.

METHODS

A retrospective, population-based study of New York State Medicaid data was conducted to identify first occurrence of psychotic diagnosis among persons ages 15-35 between January 1, 2013, and December 31, 2017 (N=31,606). Age-stratified incidence rates (IRs) were calculated by demographic characteristics, first-diagnosis type, and service-related characteristics. Review of charts from OnTrackNY and Medicaid managed care organizations (MCOs) was conducted to confirm identified cases. Initial IRs and confirmation rates were used to estimate adjusted IRs.

RESULTS

Age-stratified IRs varied by demographic, diagnostic, and service-related characteristic. IRs of FEP were higher for persons ages 15 to 25 relative to persons ages 26-35 if the first provider was an acute behavioral health emergency or inpatient setting (rate ratio=1.286; 95% confidence interval=1.24-1.33). Case confirmation rates were 90% for OnTrack NY and 53% for the MCOs. Adjusted annual IR of first diagnosis of psychosis was 272 per 100,000.

CONCLUSIONS

Incidence of first psychotic diagnosis in this Medicaid population was higher than previously found in insured populations. Future work will focus on algorithm refinements and piloting outreach. Administrative data algorithms may be useful to providers, Medicaid MCOs, and state Medicaid authorities to support case finding and early intervention.

Parsing the impact of early detection on duration of untreated psychosis (DUP): Applying quantile regression to data from the Scandinavian TIPS study

BACKGROUND

Prolonged duration of untreated psychosis (DUP) is associated with poor outcomes. The TIPS study halved DUP with an early detection (ED) campaign; however, conventional statistical analyses, focused on mean estimates, failed to reveal the effects of ED across the full DUP distribution, restricting inferences about ED's effectiveness. Utilizing a novel quantile regression based analysis, we examined the differential impact of ED across DUP. Secondary analysis explored possible predictors of DUP, and moderators of the effect of the campaign.

METHODS

The TIPS ED campaign was conducted in two health care sectors in Norway, with two equivalent health care sectors serving as controls. Quantile regression analysis was performed to analyze ED campaign's effect.

RESULTS

281 patients with first episode psychosis were recruited, including 141 from the ED area. ED had no effect on the first quartile (Q1) of DUP, whereas a significant reduction in Q2 (11weeks), and Q3 (41weeks) of DUP was observed. The effect of ED was significantly stronger on reducing Q3 than Q1 or Q2, suggesting that the campaign was more effective in longer DUP samples. Male gender and single status predicted longer DUP in Q3: by 38 and 27weeks, respectively. Single status, but not gender, emerged as a significant moderator of ED campaign effect.

CONCLUSIONS

Quantile regression provided in depth information about the non-uniformity, and moderators, of TIPS's ED effort across the full distribution of DUP, demonstrating the value of this analytic approach to re-examine prior, and plan analyses for future, early detection efforts.