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

The outcome of early intervention in first episode psychosis

The last 20 years have seen an increased focus on early intervention in psychotic disorders in research and clinical practice. Interventions have typically aimed at either reducing the duration of untreated psychosis (DUP), or developing specialized treatment facilities for patients with first episode psychosis (FEP). This review presents an overview of the most important trials and meta-analytic evidence within this field. The possibilities for reducing DUP and elements included in specialized early intervention treatment are discussed. Further, it examines long-term outcomes of early interventions and results from prolonged early intervention trials. Lastly, it analyses possible interactions between DUP and specialized early intervention treatment. In conclusion, both elements appear necessary in order to develop an integrated service that can provide the optimal treatment for patients with FEP. The aim of this article is to provide an overview over the most important trials and evidence regarding the outcome of early intervention in first episode psychosis.

Recent violence and legal involvement among young adults with early psychosis enrolled in Coordinated Specialty Care

AIM

Individuals with serious mental illnesses have a small increased risk of engaging in violence or legal involvement compared to the general population. This seems to be particularly true for young adults experiencing early stages of psychosis. This study analysed the prevalence of and risk factors for reports of violence and legal involvement in a sample of young adults receiving Coordinated Specialty Care for early non-affective psychosis.

METHODS

A total of 373 young adults (ages 16-30) within 2 years of the onset of non-affective psychosis were enrolled in 10 Coordinated Specialty Care sites in New York State from October 2013 to August 2016. Baseline violent ideation or behaviour and legal involvement was described and predictors identified.

RESULTS

Approximately one-quarter of individuals had either recent violent ideation or behaviour at baseline (n = 90, 24.6%); nearly one-tenth of the sample reported recent legal involvement (n = 33, 9.0%). Individuals with violent ideation or behaviour had lower levels of education and were less likely to be working. Those with recent legal involvement were more likely to be male and more likely to have substance use (alcohol, cannabis and other drugs).

CONCLUSIONS

The overall rate of recent violent ideation or behaviour is similar to other studies; up to one-third of individuals experiencing a first-episode of psychosis (FEP) report violence. Recent legal involvement was strongly associated with substance use. This study presents insight into violence and legal involvement among individuals with FEP and indicates the need for further research.

Short duration of untreated psychosis enhances negative symptom remission in extended early intervention service for psychosis

OBJECTIVE

To test whether duration of untreated psychosis (DUP) < 3 months, recommended by the World Health Organization/International Early Psychosis Association, enhances the effects of an extended early intervention service (EEIS) on symptom remission.

METHOD

We examined data from a randomized controlled trial in which patients who received 2 years of treatment in EIS for psychosis were subsequently randomized to either 3 years of EEIS or 3 years of regular care (RC). Using a DUP cut-off ≤ 12 weeks (approximately < 3 months), patients were split into two groups. Length of positive, negative and total symptom remission were the outcomes.

RESULTS

Patients (N = 217) were mostly male (68%) with schizophrenia spectrum disorder (65%); 108 (50%) received EEIS (58 had DUP ≤12 weeks; 50 had DUP >12 weeks). Interaction between treatment condition (EEIS vs. RC) and DUP cut-off ≤ 12 weeks was only significant in multiple linear regression model examining length of negative symptom remission as the outcome (adjusted β = 36.88 [SE = 15.88], t = 2.32, P = 0.02). EEIS patients with DUP ≤12 weeks achieved 25 more weeks of negative symptom remission than EEIS patients with DUP >12 weeks.

CONCLUSION

Having a short DUP may be critical in deriving long-term benefits from EIS for psychosis, including EEIS settings. This work empirically supports policy recommendations of reducing DUP <3 months.

Predictors of Hospitalization of Individuals With First-Episode Psychosis: Data From a 2-Year Follow-Up of the RAISE-ETP

OBJECTIVE

Despite treatment advances in other domains, inpatient psychiatric hospitalization rates for individuals with first-episode psychosis remain high. Even with early intervention services, a third or more of individuals are hospitalized over the first 2 years of treatment. Reducing hospitalization is desirable from the individual's perspective and for public health reasons because hospitalization costs are a major component of treatment costs.

METHODS

Univariate and multivariate baseline and time-varying covariate analyses were conducted to identify predictors of hospitalization in the Recovery After an Initial Schizophrenia Episode-Early Treatment Program (RAISE-ETP) study, a 2-year cluster randomized trial for participants experiencing a first episode of psychosis who were outpatients at study entry. The trial compared an early intervention treatment model (NAVIGATE) with usual community care at 34 clinics across the United States.

RESULTS

RAISE-ETP enrolled 404 participants of whom 382 had one or more postbaseline assessments that included hospitalization data. Thirty-four percent of NAVIGATE and 37% of usual-care participants were hospitalized during the trial. Risk analyses revealed significant predictors of hospitalization to be the number of hospitalizations before study entry; duration of untreated psychosis; and time-varying days of substance misuse, presence of positive symptoms, and beliefs about the value of medication.

CONCLUSIONS

These results indicate that hospital use may be decreased by reducing the duration of untreated psychosis and prior hospitalizations, minimizing residual symptoms, preventing substance misuse, and facilitating adherence to medication taking. Addressing these factors could enhance the impact of first-episode early intervention treatment models and also enhance outcomes of people with first-episode psychosis treated using other models.

Course and predictors of symptomatic remission in late-life schizophrenia: A 5-year follow-up study in a Dutch psychiatric catchment area

BACKGROUND

The number of older schizophrenia patients is growing, the majority being treated in outpatient settings. Reported symptomatic remission rates in younger cohorts vary largely. Further insight into course trajectories and putative predictors of remission in older persons with schizophrenia is needed.

METHODS

5-year follow-up course trajectories of symptomatic remission were examined in a catchment area-based group of 77 older Dutch patients (mean age 66.0 years) with schizophrenia or schizoaffective disorder. A modified version of the 'Remission in Schizophrenia Working Group' criteria was used to determine remission status. In individuals who did not fulfil remission criteria at baseline (n = 56), predictors of conversion to remission status at 5-year follow-up were analysed using multivariable regression analyses.

RESULTS

A substantial increase in remission rate at 5-year follow-up (27.3% at baseline (T1), 49.4% at follow-up (T2)) was found. Of all participants, 23.4% was in remission at both assessments and 46.8% was in non-remission at both assessments. 26.0% of the participants converted from non-remission at T1 to remission at T2, while 3.9% fell back from remission at T1 to non-remission at T2. Two significant baseline predictors of conversion to remission at follow-up were found: lower score on the PANSS positive symptom subscale, and having a partner.

CONCLUSION

Symptomatic remission was as an attainable goal for almost half of all older patients with schizophrenia or schizoaffective disorder at 5-year follow-up. With a lower PANSS positive symptom subscale score, and having a partner emerging as the only predictors of conversion to remission, there remains a need to search for modifiable predictors.

Clinical high risk for psychosis in childhood and adolescence: findings from the 2-year follow-up of the ReARMS project

The clinical significance and the prognostic value of clinical high risk (CHR) for psychosis, while substantially corroborated in adults, remains less firmly established in children and early adolescents. This follow-up study, developed within the Reggio Emilia At Risk Mental States project, is meant to contribute to the reduction of such lacuna, and has two main aims: (1) to characterize the clinical profile of help seekers [stratified in non-CHR, CHR and first episode psychosis (FEP)] referred to child-adolescent mental health services; and (2) to monitor the cumulative transition rate from CHR to FEP in adolescents at the follow-up of 12 and 24 months. 112 adolescents (aged 13-18 years) were assessed with the Comprehensive Assessment of At-Risk Mental States and the Schizophrenia Proneness Instrument, Child and Youth version. 51 subjects met CHR criteria (45.5% of the sample) and 33 subjects met FEP criteria (29.5%) at baseline. The criterial transition rate from CHR to FEP was 7% over 12 months and 13% over 24 months; higher rates of cumulative transition were detected when also functional transition (indexed by the consensual introduction of antipsychotic medication by the treating clinical staff) was considered. The identification of CHR for psychosis in help-seeking adolescents is feasible and clinically relevant. Studies conducted in real world, publicly funded components of the national health system, should take into consideration not only criterial, psychometric transition, but also functional equivalents of transition.

Early intervention in psychosis in the North Lee Mental Health Services programme: a 5-year review

Objectives

An Early Intervention in Psychosis (EIP) programme aims to engage patients in early assessment and phase-specific interventions which are the key elements of the Irish National Clinical Programme for psychosis. This study aims to describe and review the EIP programme offered by Cork’s North Lee Mental Health Services over a 5-year period.

Methods

A retrospective descriptive study design was adopted to describe and review the EIP programme, patient demographics and treatments offered in the service over a 5-year period.

Results

A total of 139 patients were accepted into the programme over the 5-year period. The mean age of onset was 30 years (median = 28, SD = 9.9), and the mean duration of untreated psychosis was 8 months (median = 2.5, SD = 15.3). Two-thirds of patients were single on initial assessment, had a history of substance misuse and were unemployed. The majority of the cohort engaged with the keyworkers and occupational therapy but did not complete the full psychological or family programmes offered. Hospital admission was required for 12% of the cohort.

Conclusions

Patients experiencing their first episode of psychosis can successfully be treated in the community with appropriate professional and family support. However, deficiencies were noted in physical health monitoring, as well as in the availability and engagement with family and psychological therapies. Properly resourced early interventions in psychosis teams are necessary to deliver services at internationally recognised standards.

Predictors of remission during acute treatment of first-episode schizophrenia patients involuntarily hospitalized and treated with algorithm-based pharmacotherapy: Secondary analysis of an observational study

AIM

Early clinical response predicts symptomatic remission and recovery in the maintenance treatment phase of first-episode schizophrenia (FES). However, little is known about predictors of symptomatic remission during acute treatment of severely ill patients with FES. Here, we conducted a secondary analysis of our retrospective observational study, which examined response, remission and treatment-resistance rates in seriously ill patients with FES spectrum disorders involuntarily hospitalized and treated with algorithm-based pharmacotherapy.

METHODS

We performed a retrospective chart review of 131 involuntarily admitted patients with schizophrenia or schizoaffective disorder. Our algorithm aimed to delay olanzapine treatment, standardize medications and suggest initiation of clozapine after failure of third-line antipsychotic treatment. The duration of each adequate antipsychotic treatment at an optimal dosage was 4 weeks or more. Remission was defined using the symptom-severity component of consensus remission criteria. A logistic regression model was applied to identify significant predictors of remission at discharge.

RESULTS

Overall, 74 patients (56%) were in remission at discharge. Non-remitters were hampered from becoming remitters mainly by the presence of negative symptoms. There were no differences in first-line antipsychotics, dosage of antipsychotics at time of response and adherence rates to algorithm-based pharmacotherapy between remitters and non-remitters. Shorter duration of untreated psychosis, favourable early response and less negative symptoms at baseline were identified as independent predictors of remission at discharge.

CONCLUSIONS

The importance of early intervention and specific and adequate treatments of negative symptoms is highlighted.

Relationships between smartphone social behavior and relapse in schizophrenia: A preliminary report

Social dysfunction is a hallmark of schizophrenia. Social isolation may increase individuals' risk for psychotic symptom exacerbation and relapse. Monitoring and timely detection of shifts in social functioning are hampered by the limitations of traditional clinic-based assessment strategies. Ubiquitous mobile technologies such as smartphones introduce new opportunities to capture objective digital indicators of social behavior. The goal of this study was to evaluate whether smartphone-collected digital measures of social behavior can provide early indication of relapse events among individuals with schizophrenia. Sixty-one individuals with schizophrenia with elevated risk for relapse were given smartphones with the CrossCheck behavioral sensing system for a year of remote monitoring. CrossCheck leveraged the device's microphone, call record, and text messaging log to capture digital socialization data. Relapse events including psychiatric hospitalizations, suicidal ideation, and significant psychiatric symptom exacerbations were recorded by trained assessors. Exploratory mixed effects models examined relationships of social behavior to relapse, finding that reductions in number and duration of outgoing calls, as well as number of text messages were associated with relapses. Number and duration of incoming phone calls and in-person conversations were not. Smartphone enabled social activity may provide an important metric in determining relapse risk in schizophrenia and provide access to sensitive, meaningful and ecologically valid data streams never before available in routine care.

Recommendations and Challenges of the Clinical Services Panel of the PhenX Early Psychosis Working Group

Coordinated specialty care (CSC) is a promising multielement treatment for the care of individuals experiencing the onset of schizophrenia. The community mental health block grant program has increased federal support for CSC programs. In order to maximize the number of sites capable of science-to-service or service-to-science translation, the National Institute of Mental Health funded a supplement to the PhenX toolkit consisting of measures for early psychosis. The early psychosis working group included translational research and clinical services panels. The clinical services panel was charged with identifying low-burden and psychometrically sound measures for use in routine clinical settings. The 19 new clinical measures complement existing measures already in the toolkit. Measures cover a range of domains, including symptoms, social and occupational functioning, well-being, medication adherence and side effects, physical activity, and shared decision making and person-centered care. Several challenges are also discussed. The review process underscored the challenges facing nonacademic sites in collecting even low-burden assessments.

Factors related to duration of untreated psychosis of first episode schizophrenia spectrum disorder

AIM

Duration of untreated psychosis (DUP) is associated with outcome and functioning. It is expected that scientists will find factors that modulate DUP, but thus far, research on this topic has shown inconsistent results. Furthermore, similar studies in China are insufficient. This study aims to explore social and clinical factors for DUP in South China and to learn the influence that family plays on DUP through their awareness of psychosis.

METHODS

Participants included 216 patients with first episode schizophrenia spectrum disorder. The Nottingham Onset Schedule was used to assess DUP. The relationship between DUP and social and clinical characteristics were then analysed by correlation analysis, survival analysis and Cox regression analysis. The awareness of the patient's family for the cause of psychosis, the reason for treatment and the cause for delay of treatment were investigated using a questionnaire.

RESULTS

The median DUP was 64.5 days. Insidious onset and being unemployed were found to be risk factors for a long DUP. The family attributed the main cause of psychosis to stress. The main cause for the delay of treatment was because families misjudged the patients' disease. More family members of long DUP patients compared to short DUP patients thought the causes were due to ideological problems or puberty, rather than to mental health.

CONCLUSION

The results of this study indicated that some social or clinical characteristics influence DUP. The family's awareness plays an important role when seeking help. To reduce DUP, the public needs more knowledge of mental illness.

Intersecting disadvantage: Unpacking poor outcomes within early intervention in psychosis services

AIM

In order to strengthen specialized early intervention in psychosis (EIP) services, a contextually nuanced understanding of psychosocial forces driving suboptimal treatment response is critical. This study sought to examine factors driving poor outcomes through a systematic emic coding of psychosocial assessments for discharged EIP clients categorized as leaving with all treatment goals met (AG) or no treatment goals met (NG).

METHODS

Psychosocial assessments at baseline, 1 year, 2 years and discharge were extracted from an EIP research registry and systematically coded. One hundred and thirty clients met the study's inclusion criteria (72 NG, 58 AG) from a larger pool of 278. Assessments were coded, quantized and analysed using a combination of basic inferential statistics and thematic analysis.

RESULTS

Structural adversity, individual trauma, history of aggression/violence, limited insight and long treatment histories prior to EIP, were strong and significant predictors of poor client outcomes (NG), while motivation for treatment, college goals or preparedness at baseline, baseline engagement in constructive activities, social strengths, individual strengths, talents and family support strongly predicted better outcomes (AG). Race/ethnicity also significantly predicted outcome group. Analyses underscore the powerful impact of multiple converging forms of structural disadvantage, on the one hand, and individual, family and social strengths and supports on the other, in shaping clients' response to EIP treatment.

CONCLUSIONS

Findings emphasize the importance of greater empirical attention to background structural and socio-economic conditions among early psychosis clients and their multifaceted impacts and underscore the potential value of programmatic components explicitly designed to support clients from multiply disadvantaged backgrounds.

Bipolar and psychotic disorders in elite athletes: a narrative review

Bipolar and psychotic disorders are relatively common and likely to have a significant impact on quality of life and functioning which, in the context of elite sport, includes a potential negative impact on sporting performance. For this narrative review article, the literature on bipolar and psychotic disorders in elite athletes was comprehensively searched, and little empirical research was found. A diagnosis of bipolar or psychotic disorders may be challenging in elite athletes because of complicating factors related to the modifying role of exercise and potential precipitating impact of substance use. Medications used to treat bipolar and psychotic disorders may have side effects particularly problematic for elite athletes. Future research should be tailored to the specific characteristics and needs of elite athletes and to the sporting context in which the disorders may arise. Specifically, further research is needed on the prevalence and incidence of these conditions in elite athletes and the impact of both the disorders and their treatments on sporting performance.

Refusing Medication Therapy in Involuntary Inpatient Treatment-A Multiperspective Qualitative Study

Objective: Between June 2012 and February 2013, two decisions by the German Federal Constitutional Court restricted the so-far common practice to use involuntary medication in inpatients who were involuntarily hospitalized. Up to then, involuntary medication was justified by a judge's decision on involuntary hospitalization. It could be applied according to clinical judgment even against the declared will of a patient. Since then, all domestic laws related to involuntary treatment had to be revised. For several months, involuntary medication was allowed only in an emergency. We were interested in the impact of the changed legal framework on the experiences of inpatients, their relatives, and clinical professionals during that time. Methods: Thirty-two interviews were analyzed qualitatively using a grounded theory methodology framework. Results: As a consequence of the restrictions to involuntary medication, special efforts by nursing and medical staff were required concerning de-escalation, ward management, and the promotion of treatment commitment in inpatients who refused medication. Family caregivers were also under strong pressure. They wanted to help and to protect their relatives, but some also welcomed the use of coercion if the patient refused treatment. Most of the interviewed patients had not even noticed that their rights to refuse medication had been strengthened. They complained primarily about the involuntary hospital stay and the associated limitations of their everyday lives. While patients and family members evaluated the refusal of medication from a biographical perspective, the mental health care professionals' focus was on the patients' symptoms, and they understood the situation from a professional perspective. It was obvious that, in any of the four perspectives, the problem of feeling restricted was crucial and that all groups strived to gain back their scope of action. Conclusion: The temporary ban on involuntary medication questioned the hitherto common routines in inpatient treatment, in particular when patients refused to take medication. Each of the different groups did not feel good about the situation, for different reasons, however. As a consequence, it might be indispensable to increase awareness of the different perspectives and to focus the efforts on the establishment of nonviolent treatment structures and practices.

Antipsychotics Do Not Influence Neurological Soft Signs in Children and Adolescents at Ultra-High Risk for Psychosis: A Pilot Study

OBJECTIVE

Ultra-high risk for psychosis (UHR) is considered as the condition that temporally precedes the onset of psychotic symptoms. In addition to the core symptoms, patients with schizophrenia show motor abnormalities, also known as neurological soft signs (NSS), that are considered an endophenotype for psychotic disorders and particularly for schizophrenia. Antipsychotic medications do not appear to influence NSS in individuals with schizophrenia. However, NSS in UHR subjects have been poorly studied and, to date, we do not know what effects antipsychotics have in early treated UHR subjects. Therefore, we evaluated NSS in treated UHR subjects in comparison with drug-naive UHR subjects and a group of healthy control subjects and the effect of pharmacological treatment on early treated UHR children and adolescents.

PATIENTS AND METHODS

Fifteen UHR subjects receiving pharmacological treatment, 15 drug-naive UHR subjects, and 25 healthy control subjects were evaluated for NSS to analyze any differences between clinical subjects and healthy controls and to evaluate the effect of antipsychotic medications in early treated UHR subjects.

RESULTS

Both clinical groups showed a greater number of NSS compared with the healthy control subjects. However, no significant differences in NSS were found between treated and drug-naive UHR subjects.

CONCLUSIONS

Consistent with what has been observed in the population of patients with a first psychotic episode and/or with schizophrenia, our results support the conclusion that antipsychotic medications do not influence NSS in children and adolescents who are at high risk for psychosis.

Proteomic analysis of lymphoblastoid cell lines from schizophrenic patients

Although a number of studies have identified several convincing candidate genes or molecules, the pathophysiology of schizophrenia (SCZ) has not been completely elucidated. Therapeutic optimization based on pathophysiology should be performed as early as possible to improve functional outcomes and prognosis; to detect useful biomarkers for SCZ, which reflect pathophysiology and can be utilized for timely diagnosis and effective therapy. To explore biomarkers for SCZ, we employed fluorescence two-dimensional differential gel electrophoresis (2D-DIGE) of lymphoblastoid cell lines (LCLs) (1st sample set: 30 SCZ and 30 CON). Differentially expressed proteins were sequenced by liquid chromatography tandem-mass spectrometry (LC-MS/MS) and identified proteins were confirmed by western blotting (WB) (1st and 2nd sample set: 60 SCZ and 60 CON). Multivariate logistic regression analysis was performed to identify an optimal combination of biomarkers to create a prediction model for SCZ. Twenty protein spots were differentially expressed between SCZ and CON in 2D-DIGE analysis and 22 unique proteins were identified by LC-MS/MS. Differential expression of eight of 22 proteins was confirmed by WB. Among the eight candidate proteins (HSPA4L, MX1, GLRX3, UROD, MAPRE1, TBCB, IGHM, and GART), we successfully constructed logistic regression models comprised of 4- and 6-markers with good discriminative ability between SCZ and CON. In both WB and gene expression analysis of LCL, MX1 showed reproducibly significant associations. Moreover, Mx1 and its related proinflamatory genes (Mx2, Il1b, and Tnf) were also up-regulated in poly I:C-treated mice. Differentially expressed proteins might be associated with molecular pathophysiology of SCZ, including dysregulation of immunological reactions and potentially provide diagnostic and prognostic biomarkers.

Functional Connectivity Between Sensory-Motor Subnetworks Reflects the Duration of Untreated Psychosis and Predicts Treatment Outcome of First-Episode Drug-Naïve Schizophrenia

BACKGROUND

Somatic symptoms and motor abnormalities have been consistently reported as typical symptoms of schizophrenia, but evidence linking impaired functional connectivity among the primary sensory-motor network and its associations to schizophrenia is largely lacking. The present study aims to examine abnormal functional connectivity in the sensory-motor network in schizophrenia and its associations with the duration of untreated psychosis and medication treatment effects. We hypothesize that patients with schizophrenia suffer from disrupted functional connectivity between the sensory-motor subnetworks. The degree of impairment in the connectivity could reflect the duration of untreated psychosis and predict outcomes of medication treatment.

METHODS

At baseline, resting-state functional magnetic resonance imaging data were acquired from 60 first-episode patients with drug-naïve schizophrenia (36 were female) and 60 matching normal control subjects (31 were female). After 2 months, 23 patients who received medication treatment and 32 normal control subjects were rescanned. Functional connectivity among subnetworks in the sensory-motor system was compared between the groups and correlated with the duration of untreated psychosis and the treatment outcome.

RESULTS

Patients with schizophrenia showed significantly disrupted functional connectivity in the sensory-motor network. The degree of impairment reflected the duration of untreated psychosis and motor-related symptoms. It further predicted the improvement of positive scores after medication.

CONCLUSIONS

These findings suggest that functional connectivity in the sensory-motor network could indicate the severity of neural impairment in schizophrenia, and it deserves more attention in the search for neuroimaging markers for evaluating neural impairment and prognosis.

University students' understanding and perceptions of schizophrenia in the UK: a qualitative study

OBJECTIVE

To explore lay understanding and perceptions of schizophrenia in university students.

DESIGN

Qualitative study using semi-structured interviews and thematic analysis.

SETTING

The University of Birmingham, West Midlands.

PARTICIPANTS

20 UK home students of white British (n=5), Indian (n=5), Pakistani (n=5), African Caribbean (n=4) and dual white British and African Caribbean ethnicity (n=1).

RESULTS

Findings revealed a lack of knowledge about schizophrenia, particularly the negative symptoms that were not mentioned. There were mixed ideas on the causes and sources of available help for schizophrenia; however, positively many said they would consult their general practitioner. While there was a general misconception among the students that schizophrenia caused multiple personalities and was a dangerous illness, there were some differences in perceptions and understanding between ethnic groups, with more Indian students perceiving upbringing as a causal factor in the development of the illness and more Pakistani students perceiving possession by a spirit as a cause.

CONCLUSIONS

The university students interviewed lacked knowledge about schizophrenia and stigma was widespread, both of which may delay help-seeking. Public health campaigns educating young people about schizophrenia are required to improve early identification and intervention and improve outcomes. Further research exploring ways to effectively tackle stigma is also required.

Early Signs of Schizophrenia and Autonomic Nervous System Dysregulation: A Literature Review

OBJECTIVE

Recent research suggests that early signs of schizophrenia can be detected several years before its onset. Evidence suggests that the identification of at-risk individuals before the psychotic onset can significantly improve the course of the disorder. However, instruments employed for the detection of prodromal symptoms are far from being accurate in the prediction of a future transition to psychosis. The aim of the present review is to summarize literature on the early signs of schizophrenia and to identify physiological markers that may aid the identification of the disorder before psychotic transition.

METHOD

This critical review includes studies published between 1979 and 2018 that were indexed in major databases with the following keywords: schizophrenia, prodromal phase, basic symptoms, autonomic nervous system, heart rate variability.

RESULTS

The examination of the relevant literature showed that, despite recent progress in the identification of at-risk states, the currently employed instruments do not allow an effective prediction of a future psychotic onset. Also, evidence suggests a significant association between alterations in the autonomic nervous system (ANS) functioning and psychotic disorders. However, literature on the association between ANS functioning and at-risk states for psychosis is still scarce. The addition of physiological risk indicators may represent a step forward in the detection of at-risk individuals.

CONCLUSIONS

Overall, the present literature review highlights that a future schizophrenic onset cannot be strongly predicted with current available measures. Given the established correlation between schizophrenia and autonomic dysregulation, an investigation of the ANS functioning in individuals who are at increased risk of developing schizophrenia may be particularly useful to improve the quality of the assessment, to identify at an early stage the dysregulated physiological patterns that have been linked with schizophrenia, and therefore to develop tailored interventions. Accordingly, it is crucial that future research investigates the presence of autonomic deficits in individuals at risk for psychosis.

Being Parent Caregivers for Adult Children with Schizophrenia

Parent caregivers support the health and well-being of their adult children with schizophrenia. As a result, parent caregivers spend vast amounts of time providing care, which necessitates changes to their relationships and lives. In this qualitative study, the experiences of parent caregivers for adult children with schizophrenia were explored. Interpretive Description guided the study design, and data were collected through interviews with 12 English-speaking participants. Data were analyzed according to conventional content analysis. The themes "Uncertainty, Change, and Challenges" and "The Meaning of It All" help to articulate the participants' experiences. Overall, the participants reported tremendous distress in their roles. This was compounded by difficulties accessing and navigating the healthcare system and interactions with police. Effective strategies are needed to help parent caregivers cope within their role and gain access to timely and appropriate care.

Pathways to specialist care for eating disorders: An Italian multicentre study

Two hundred forty six patients with eating disorders (EDs) recruited from eight Italian specialized treatment centres were administered with the World Health Organization "Encounter Form," a standardized schedule that makes it possible to characterize the clinical pathways that patients follow to reach specialized care. The median time from symptoms onset to specialized care was 114 weeks. Primary "points of access to care" were general practitioners (25%), psychiatrists (18%), and clinical nutritionists (17%), followed by various other carers. All patients received specific psychotherapy, whereas only 11% of them were given psychotropic drugs. EDs are characterized by complex care pathways, with low rates of direct access to specialized care. Although the role of general practitioners remains crucial, they tend to follow different clinical routes to refer ED patients. Educational programmes on EDs should be addressed to general practitioners and clinical nutritionists, in order to ease the transition of ED patients to a mental health care setting.

Long-acting injectable second-generation antipsychotics in first-episode psychosis: a narrative review

Long-acting injectable (LAI) antipsychotics could be a favorable option of treatment and have some advantages over oral medications. The aim of this study was to review the published data on the use of LAI formulation of second-generation antipsychotics (SGA) in first-episode psychosis (FEP). Using PubMed and Scopus databases, we performed a systematic literature search of articles published between 1 January 2000 and 30 April 2018, that reported clinical trials on the use of LAI SGAs in patients with FEP. Seventy-seven articles were considered eligible and full-text revised. Five studies fulfilled the inclusion criteria and evaluated the effect of LAI risperidone in FEP patients. Treatment with LAI SGAs was well accepted, and the majority of FEP patients agreed to change from an oral to an injectable formulation. At the 12-month follow-up, between 68 and 95% of FEP patients treated with LAI risperidone showed a good clinical response and 64% achieved remission of symptoms for at least 24 months of follow-up. Treatment with LAI SGAs can offer significant advantages over oral antipsychotics to FEP patients, especially to improve the adherence to medication and prevent the worsening of symptoms, the relapse, and rehospitalization associated with the discontinuation of treatment.

The 10-year functional outcome of schizophrenia in Butajira, Ethiopia

BACKGROUND

Long-term functional schizophrenia outcomes are not well characterized in low-income environments because of the rarity of prospective studies.

OBJECTIVES

To assess and describe long-term schizophrenia's functional outcomes and potential outcome predictors.

METHODS

Following a baseline assessment, 316 people with schizophrenia were studied for 10 years, on average. Of the total, 79 were incident cases: cases with onset of the illness occurring two years or less from entry into the study. SF-36 scores of physical and social functioning were used to assess functional outcomes. Linear mixed models were employed to evaluate the association of functioning with potential predictors.

RESULTS

Social and physical functioning scores regarding the cohort were lower than the population's norm for most of the follow-up period. Incident cases had better function than prevalent cases. Fifteen percent of incident and 30% of prevalent cases had reduced social functioning for at least six years. Declining symptom severity during the follow-up period was significantly associated with improvement in social functioning. When baseline functioning was controlled for, the long-term trend in functionality was not associated with demographic or illness characteristics (age and speed of onset, duration of illness and neuroleptic use at entry, substance use, and medication adherence).

CONCLUSION

Long-term physical and social functioning of the population with schizophrenia were significantly lower than the population norm. A significant proportion of the cohort had lower functioning for the long-term. Functioning was not associated with demographic or illness characteristics of the study population.

Specialized Consultation for Suspected Recent-onset Schizophrenia: Diagnostic Clarity and the Distorting Impact of Anxiety and Reported Auditory Hallucinations

Early detection of psychotic disorders is now recognized as vital in reducing dysfunction, morbidity, and mortality. However, making the diagnosis of a psychotic disorder, especially earlier in the course of disease, can be challenging, and an incorrect diagnosis of a psychotic disorder may also have significant consequences. We therefore, conducted a retroactive chart review of 78 patients referred to a specialty early psychosis consultation clinic to examine the role of specialty clinics in clarifying the diagnosis of early psychosis, especially potential schizophrenia. Of the 78 patients, 43 (55%) had a primary diagnosis at referral of a schizophrenia spectrum disorder. The primary diagnosis in the consultation clinic was different in 22 (51%) of these 43 cases, and 18 (42%) of these patients were not diagnosed with any form of primary psychotic disorder. These patients were more likely to report anxiety and less likely to report thought disorder than patients with a consultation diagnosis of schizophrenia or schizoaffective disorder. Clinicians may therefore overdiagnose schizophrenia, demonstrating the value of second opinions from clinics specializing in the diagnosis of recent-onset psychosis.

Maximizing response to first-line antipsychotics in schizophrenia: a review focused on finding from meta-analysis

RATIONALE

There are many psychotropic drugs available for treatment of schizophrenia. The clinician's choice of the most effective first-line antipsychotic treatment for patients with schizophrenia should balance considerations of differential efficacy of antipsychotics against the relative risk of different side effects.

METHOD

We reviewed recent studies using meta-analytic techniques and additional studies of new antipsychotics which quantitatively evaluate the efficacy of side effects of first- and second-generation antipsychotics and studies of the efficacy on add-on secondary medications. We present an integrated summary of these results to guide a clinician's decision-making.

RESULTS

Recent meta-analyses have suggested that antipsychotics are not equivalent in efficacy. Clozapine (effect size [SMD] 0.88 vs. placebo), amisulpride (effect size 0.6 vs placebo), olanzapine (effect size 0.59 vs. placebo), and risperidone (effect size 0.56 vs placebo) show small but statistically significant differences compared to a number of other antipsychotics on measures of overall efficacy (effect sizes 0.33-0.50). However, increasing placebo response remains a concern in interpreting these data. Amisulpride (effect size 0.47 vs placebo) and cariprazine (effect size in one trial compared to risperidone 0.29) have the strongest evidence indicating greater efficacy for treating primary negative symptoms relative to other antipsychotics. In terms of side effects, clozapine and olanzapine have among the highest weight gain potential and sertindole and amisulpride have more effects on QTc prolongation than other commonly used antipsychotics. Prolactin elevation is highest with paliperidone, risperidone, and amisulpride. Adjunctive treatment with an antidepressant drug may improve response in patients with schizophrenia who also have severe depressive or negative symptoms. For multi-episode patients with an inadequate response to an adequate dose and duration of the initial antipsychotic choice, switching to another antipsychotic, with a different receptor profile, may improve response, although evidence is very limited. In first-episode patients, a recent study on switching to another antipsychotic, with a different receptor profile after 4 weeks demonstrated no beneficial effects. There is little evidence to support using doses above the therapeutic range other than in exceptional circumstances.

CONCLUSIONS

Our review of recent studies using meta-analytic techniques has provided evidence that all antipsychotics are not equal in the severity of different side effects and in some measures of clinical efficacy. Comparative analysis and rankings from network meta-analyses can provide guidance to clinicians in choosing the most appropriate antipsychotic for first-line treatment, if used in conjunction with available information of the patient's history of previous clinical response or higher risks for specific side effects.

Ten-year follow up of patients with first-episode schizophrenia spectrum disorder from an early intervention service: Predictors of clinical remission and functional recovery

The long-term recovery rate of patients with schizophrenia-spectrum disorders has been persistently low despite the implementation of early intervention (EI) services internationally. It is, therefore, important to identify the modifiable factors during the early stage of the illness that predict long-term remission and recovery. The aim of this study is to explore the predictive value of the early stage clinical factors on the clinical remission and functional recovery at 10-year follow-up of patients with schizophrenia-spectrum disorders who received a 2-year EI service. Patients who received the EI service throughout the region of Hong Kong between 1st July 2001 and 30th June 2002 and with a diagnosis of schizophrenia-spectrum disorder were identified from the centralized hospital database (Clinical Management system, CMS). Semi-structured clinical interview was conducted at 10-year follow-up with a successful interview rate of 74.3% (n = 107). Clinical data was systematically retrieved each month for the first three years from the CMS and written clinical records using a standardized data entry form based on operationalized definitions. Results found shorter duration of untreated psychosis (DUP) predicted long-term clinical remission; higher educational level and shorter period of unemployment during the initial three years of the illness predicted functional recovery. Higher educational level, longer period of employment and planned medication discontinuation during the initial three years predicted complete recovery. The current study demonstrates the long-term impact of DUP and suggests improvement of employment during the early stage of illness could be a potential target for further improvement of the service.

Factor structure models of the SCL-90-R: Replicability across community samples of adolescents

Derogatis' Symptom Checklist-90-Revised (SCL-90-R) is one of the most widely used measures of psychological distress in both the clinical and the research settings, although its factor structure is still debated. In this study, the factor structure of the SCL-90-R has been investigated in two independent samples of Italian adolescents. Two samples of 817 (urban sample) and 507 (rural sample) adolescents attending high schools were involved. Confirmatory factorial analysis (CFA) was used alongside hierarchical nested, progressively constrained models to assess configural, metric and scalar invariance of the best models fitted by CFA. The standard nine-factor structure of the SCL-90-R resulted reproducible and invariant between the two samples, in both its correlated and hierarchical second-order implementations. Estimated reliability of the nine scales of the SCL-90-R was optimal. This study also confirmed the reproducibility of the bifactor models of the SCL-90-R with nine orthogonally independent factors and with nine correlated primary factors, which have been tested in some recent studies. Overall, the SCL-90-R measures both common and unique features of psychological distress in community samples. The measurement invariance across different levels of psychological distress in the factor structure of the SCL-90-R is an issue deserving further testing and investigation.

Association Between Duration of Untreated Psychosis and Frontostriatal Connectivity During Maintenance of Visuospatial Working Memory

BACKGROUND

A longer duration of untreated psychosis (DUP) has been linked with poor clinical outcomes and variation in resting-state striatal connectivity with central executive regions. However, the link between DUP and task-based activation of executive neurocognition has not previously been examined. This functional magnetic resonance imaging study examined the association between DUP and both activation and frontostriatal functional connectivity during a visual working memory (WM) paradigm in patients with first-episode psychosis.

METHODS

Patients with first-episode psychosis (n = 37) underwent functional magnetic resonance imaging scanning while performing a visual WM task. At the single-subject level, task conditions were modeled; at the group level, each condition was examined along with DUP. Activation was examined within the dorsolateral prefrontal cortex, a primary region supporting visual WM activation. Frontostriatal functional connectivity during the WM was examined via psychophysical interaction between the dorsal caudate and the dorsolateral prefrontal cortex. Results were compared with a reference range of connectivity values in a matched group of healthy volunteers (n = 25). Task performance was also examined in relation to neuroimaging findings.

RESULTS

No significant association was observed between DUP and WM activation. Longer DUP showed less functional frontostriatal connectivity with the maintenance of increasing WM load. Results were not related to task performance measures, consistent with previous work.

CONCLUSIONS

Our data suggest that DUP may affect frontostriatal circuitry that supports executive functioning. Future work is necessary to examine if these findings contribute to the mechanism underlying the relationship between DUP and worsened clinical outcomes.

Mismatch negativity and cognitive performance in the course of schizophrenia

BACKGROUND

Cognitive deficits and abnormal event-related brain potentials (ERP) have been proposed as risk markers for the development of schizophrenia. Evidence is inconclusive whether these markers indicate a risk for the development of psychosis or illness progression.

METHODS

The present study aimed at further clarification by comparing symptom expression (Brief Psychiatric Rating Scale, BRPS), the ERP Mismatch Negativity (MMN), and neuropsychological performance on the MATRICS Consensus Cognitive Battery between healthy controls (HC, n = 38) and individuals at different stages of illness: individuals at risk for psychosis (ARP, n = 33), patients at first admission, thus, early stage (ES, n = 35), chronic schizophrenia patients (CS, n = 25). Moreover, symptom expression was reassessed for ARP and ES at a 6 months follow-up.

RESULTS

MMN was smaller in individuals with manifest psychosis (ES, CS) than in HC, but did not differ between ARP and HC. In contrast, ARP showed similar cognitive deficits as ES and CS, all three groups differing from HC. Lower cognitive performance predicted higher symptom severity at index assessments and 6 months follow-up in ARP and ES, while MMN did not explain additional variance.

CONCLUSION

MMN seems to mark manifest psychosis, independent of early or chronic stage, while cognitive deficits mark early present psychopathology in individuals at risk for and with diagnosed psychosis rather than illness progression.

CBT in the prevention of psychosis and other severe mental disorders in patients with an at risk mental state: A review and proposed next steps

Patients with an 'At risk mental state' (ARMS) for developing psychosis can be treated successfully with CBT to postpone and prevent the transition to a first psychotic episode. A characteristic of individuals that meet ARMS criteria is that they are still open for multiple explanations for extraordinary experiences. CBT aims to normalize extraordinary experiences with education and to prevent delusional explanations. The treatment is not only effective, but also cost-saving in averting psychosis as well as in reducing disability adjusted life years at 18- and 48-month follow-up. Profiling within the ARMS group results in a personalized treatment. The screening and early treatment for ARMS fulfills all the criteria of the World Health Organization and is ready to be routine screening and treatment in mental health care. At the same time, ARMS patients are complex patients with multi-morbid disorders. Especially childhood trauma is associated to ARMS status, together with co-morbid PTSD, depression, substance abuse and anxiety disorders. Psychotic symptoms appear to be severity markers in other non-psychotic disorders. Preventing psychosis in ARMS patients should be broadened to also address other disorders and aim to reduce chronicity of psychopathology and improve social functioning in general. Several mechanisms play a part in psychopathology in ARMS patients such as stress sensitivity as a result of adverse experiences, dopamine sensitivity that is associated with salience and aggravates several cognitive biases, dissociation mediating between trauma and hallucinations, and low self-esteem and self-stigma. New avenues to treat the complexity of ARMS patients will be proposed.

Effects of Prodromal Stage and Untreated Psychosis on Subsequent Psychopathology of Schizophrenia: A Path Analysis

BACKGROUND

To examine psychopathology present under prolonged antipsychotic treatment in schizophrenia and to analyse their relationship to both the duration of the prodromal stage (DPS; time between onset of first unspecific psychological symptoms and first schizophrenic symptoms) and the duration of untreated psychosis (DUP; time between the onset of psychosis and the initiation of antipsychotic treatment).

METHODS

The psychopathology of 93 patients was assessed cross-sectionally using the Scales for the Assessment of Negative and Positive Symptoms and the Brief Psychiatric Rating Scale. DPS and DUP were assessed by means of the patient records and the Interview for the Retrospective Assessment of the Onset and Course of Schizophrenia and Other Psychoses. A path analysis using maximum likelihood estimation was conducted with the program Analysis of Moment Structures for Windows.

RESULTS

The resulting path model indicated that DPS was predictive for a more severe negative symptomatology in schizophrenia, whereas DUP was associated with a more severe positive symptomatology in the long-term. Furthermore, DUP showed an inverse correlation with the age of the patients at the onset of both first unspecific psychological symptoms and first schizophrenic symptoms.

CONCLUSION

A long prodromal stage suggests an increased risk of a long-term progression with negative symptoms in schizophrenia, whereas a delayed start of antipsychotic treatment could lead to an increased manifestation and severity of positive symptoms in the long term. These results underline the need to shorten the duration of the prodrome by an early detection and adequate intervention in patients with increased risk to develop psychosis.

Clinical Effects of Mindfulness-Based Intervention in Patients With First Episode Psychosis and in Individuals With Ultra-High Risk for Transition to Psychosis: A Review

Objectives: Recent clinical studies and meta-analyses have reported the clinical effects of mindfulness-based interventions as a complementary treatment for patients with schizophrenia, but their possible efficacy in patients with first episode of psychosis (FEP) and in individuals with ultra-high risk (UHR) of transition to psychosis is less clear. Here, we investigated the current evidence on the usefulness of mindfulness-based interventions in these two populations. Methods: We conducted a systematic search of the literature according to the PRISMA guidelines. Results: Among the 102 references retrieved, 9 responded to the inclusion criteria (8 in FEP patients and 1 in UHR individuals). In FEP patients, mindfulness interventions are well-tolerated and have a satisfactory level of adherence. The clinical benefits consist primarily of reduced anxiety and sadness and improved quality of life. None of the studies reported any increase in positive symptoms. Conclusion: Future sham-controlled studies with large sample sizes are needed to definitively conclude on the clinical interest of mindfulness-based interventions in FEP patients and UHR individuals as well as to understand their underlying mechanisms of action.

Proteomic Studies of Psychiatric Disorders

Many diseases result from programming effects in utero. This chapter describes recent advances in proteomic studies which have improved our understanding of the underlying pathophysiological pathways in the major psychiatric disorders, resulting in the development of potential novel biomarker tests. Such tests should be based on measurement of blood-based proteins given the ease of accessibility of this medium and the known connections between the periphery and the central nervous system. Most importantly, emerging biomarker tests should be developed on lab-on-a-chip and other handheld devices to enable point-of-care use. This should help to identify individuals with psychiatric disorders much sooner than ever before, which will allow more rapid treatment options for the best possible patient outcomes.

Association of Pre-onset Subthreshold Psychotic Symptoms With Longitudinal Outcomes During Treatment of a First Episode of Psychosis

IMPORTANCE

The clinical high-risk state in psychosis is most often characterized by subthreshold psychotic symptoms (STPS) and represents a target for psychosis prevention. However, evidence suggests that between 30% and 50% of patients with a first episode of psychosis (FEP) report no prior history of STPS, indicating that not all patients with FEP experience a previous clinical high-risk phase. As with other early characteristics of illness onset, this diversity in the early course of symptoms may offer prognostic value for subsequent clinical trajectories.

OBJECTIVE

To determine whether a history of pre-onset STPS is associated with differential 1-year treatment outcomes in an early intervention service for FEP.

DESIGN, SETTING, AND PARTICIPANTS

Data on 195 patients 15 to 35 years of age who were recruited between January 17, 2003, and October 17, 2013, were collected from a catchment-based specialized early intervention service for FEP. Patients who reported experiencing at least 1 STPS prior to the onset of FEP were identified as STPS present (STPSp; n = 135); those who reported no such history were identified as STPS absent (STPSa; n = 60). Statistical analysis was conducted from December 15, 2016, to February 15, 2018.

MAIN OUTCOMES AND MEASURES

Summary scores on the Scale for the Assessment of Positive Symptoms and the Scale for the Assessment of Negative Symptoms, Calgary Depression Scale for Schizophrenia, Hamilton Anxiety Rating Scale, Global Assessment of Functioning scores, and Social and Occupational Functioning Assessment Scale scores at baseline and after 1 year of treatment were analyzed to evaluate 1-year outcomes.

RESULTS

Individuals in the STPSp group (39 female and 96 male participants; mean [SD] age, 23.4 [4.2] years) and the STPSa group (20 female and 40 male participants; mean [SD] age, 23.9 [5.1] years) did not differ in symptom severity or functioning at baseline. Although both groups improved by 1 year of treatment, mixed analyses of covariance (controlling for duration of untreated psychosis) revealed group-by-time interactions for scores on the Scale for the Assessment of Negative Symptoms (F1,192 = 6.17; P = .01), the Global Assessment of Functioning (F1,188 = 7.54; P = .006), and the Social and Occupational Functioning Assessment Scale (F1,192 = 3.79; P = .05). Mixed analyses of covariance also revealed a group effect for scores on the Scale for the Assessment of Positive Symptoms (F1,192 = 5.31; P = .02). After controlling for multiple comparisons, all significant results indicate poorer 1-year outcomes for patients with STPSp compared with patients with STPSa.

CONCLUSIONS AND RELEVANCE

A history of pre-onset STPS consistent with a prior clinical high-risk state is associated with poorer outcomes in psychotic symptoms and global functioning for patients after 1 year of treatment for FEP. The presence or absence of pre-onset STPS therefore has prognostic value for treatment outcomes, even during a later stage of psychotic illness.

Brain Age in Early Stages of Bipolar Disorders or Schizophrenia

BACKGROUND

The greater presence of neurodevelopmental antecedants may differentiate schizophrenia from bipolar disorders (BD). Machine learning/pattern recognition allows us to estimate the biological age of the brain from structural magnetic resonance imaging scans (MRI). The discrepancy between brain and chronological age could contribute to early detection and differentiation of BD and schizophrenia.

METHODS

We estimated brain age in 2 studies focusing on early stages of schizophrenia or BD. In the first study, we recruited 43 participants with first episode of schizophrenia-spectrum disorders (FES) and 43 controls. In the second study, we included 96 offspring of bipolar parents (48 unaffected, 48 affected) and 60 controls. We used relevance vector regression trained on an independent sample of 504 controls to estimate the brain age of study participants from structural MRI. We calculated the brain-age gap estimate (BrainAGE) score by subtracting the chronological age from the brain age.

RESULTS

Participants with FES had higher BrainAGE scores than controls (F(1, 83) = 8.79, corrected P = .008, Cohen's d = 0.64). Their brain age was on average 2.64 ± 4.15 years greater than their chronological age (matched t(42) = 4.36, P < .001). In contrast, participants at risk or in the early stages of BD showed comparable BrainAGE scores to controls (F(2,149) = 1.04, corrected P = .70, η2 = 0.01) and comparable brain and chronological age.

CONCLUSIONS

Early stages of schizophrenia, but not early stages of BD, were associated with advanced BrainAGE scores. Participants with FES showed neurostructural alterations, which made their brains appear 2.64 years older than their chronological age. BrainAGE scores could aid in early differential diagnosis between BD and schizophrenia.

Determinants of treatment response in first-episode psychosis: an 18F-DOPA PET study

Psychotic illnesses show variable responses to treatment. Determining the neurobiology underlying this is important for precision medicine and the development of better treatments. It has been proposed that dopaminergic differences underlie variation in response, with striatal dopamine synthesis capacity (DSC) elevated in responders and unaltered in non-responders. We therefore aimed to test this in a prospective cohort, with a nested case-control comparison. 40 volunteers (26 patients with first-episode psychosis and 14 controls) received an ¹⁸F-DOPA Positron Emission Tomography scan to measure DSC (Ki^cer) prior to antipsychotic treatment. Clinical assessments (Positive and Negative Syndrome Scale, PANSS, and Global Assessment of Functioning, GAF) occurred at baseline and following antipsychotic treatment for a minimum of 4 weeks. Response was defined using improvement in PANSS Total score of >50%. Patients were followed up for at least 6 months, and remission criteria applied. There was a significant effect of group on Ki^cer in associative striatum (F_{(2, 37)} = 7.9, p = 0.001). Ki^cer was significantly higher in responders compared with non-responders (Cohen's d = 1.55, p = 0.01) and controls (Cohen's d = 1.31, p = 0.02). Ki^cer showed significant positive correlations with improvements in PANSS-positive (r = 0.64, p < 0.01), PANSS negative (rho = 0.51, p = 0.01), and PANSS total (rho = 0.63, p < 0.01) ratings and a negative relationship with change in GAF (r = -0.55, p < 0.01). Clinical response is related to baseline striatal dopaminergic function. Differences in dopaminergic function between responders and non-responders are present at first episode of psychosis, consistent with dopaminergic and non-dopaminergic sub-types in psychosis, and potentially indicating a neurochemical basis to stratify psychosis.

Schizophrenia, Not a Psychotic Disorder: Bleuler Revisited

Current diagnostic criteria delineate schizophrenia as a discrete entity essentially defined by positive symptoms. However, the role of positive symptoms in psychiatry is being questioned. There is compelling evidence that psychotic manifestations are expressed in the population in a continuum of varying degrees of severity, ranging from normality to full-blown psychosis. In most cases, these phenomena do not persist, but they constitute risk factors for psychiatric disorders in general. Psychotic symptoms are also present in most non-psychotic psychiatric diagnoses, being a marker of severity. Research revealed that hallucinations and delusions appear to have distinct, independent biological underpinnings-in the general population, in psychotic, and in non-psychotic disorders as well. On the other hand, negative symptoms were seen to be far more restricted to schizophrenia, have other underlying pathophysiology than positive symptoms, predict outcome and treatment response in schizophrenia, and start before the first psychotic outbreak. The current work discusses the concept of schizophrenia, suggesting that a greater emphasis should be put on cases where psychotic symptoms emerge in a premorbid subtly increasing negative/cognitive symptoms background. In those cases, psychosis would have a different course and outcome while psychosis occurring in the absence of such background deterioration would be more benign-probably having no, or a milder, underlying degenerative process. This reformulation should better drive psychopathological classification, face positive symptoms as epiphenomenon of the schizophrenia process, and dishevel stigma from schizophrenia and from delusions and hallucinations.

Adherence, insight and disability in paranoid schizophrenia

Insight has long been linked to both prognosis and functioning in patients with schizophrenia; likewise, it is key to treatment adherence. This study seeks to assess the association between insight, adherence to pharmacological treatment, and disability in schizophrenia, and to study the potential mediating role of adherence between insight and disability. Insight (SUMD), adherence (CRS), and disability (WHO-DAS) were measured in 80 clinically stable patients with DSM-IV TR paranoid schizophrenia. Psychopathology was assessed with the Positive and Negative Syndrome Scale (PANSS). In a first step, predictors of disability were identified using linear regression to identify variables related to disability and further a mediation analysis was carried out. Negative symptoms, insight, and adherence account for 54.2% of the variance in disability. Negative symptoms act directly on disability, while the effect of insight on disability is partially mediated by adherence. Insight is key in disability in schizophrenia and should be leveraged in treatment programs.

Identifying a neuroanatomical signature of schizophrenia, reproducible across sites and stages, using machine learning with structured sparsity

OBJECTIVE

Structural MRI (sMRI) increasingly offers insight into abnormalities inherent to schizophrenia. Previous machine learning applications suggest that individual classification is feasible and reliable and, however, is focused on the predictive performance of the clinical status in cross-sectional designs, which has limited biological perspectives. Moreover, most studies depend on relatively small cohorts or single recruiting site. Finally, no study controlled for disease stage or medication's effect. These elements cast doubt on previous findings' reproducibility.

METHOD

We propose a machine learning algorithm that provides an interpretable brain signature. Using large datasets collected from 4 sites (276 schizophrenia patients, 330 controls), we assessed cross-site prediction reproducibility and associated predictive signature. For the first time, we evaluated the predictive signature regarding medication and illness duration using an independent dataset of first-episode patients.

RESULTS

Machine learning classifiers based on neuroanatomical features yield significant intersite prediction accuracies (72%) together with an excellent predictive signature stability. This signature provides a neural score significantly correlated with symptom severity and the extent of cognitive impairments. Moreover, this signature demonstrates its efficiency on first-episode psychosis patients (73% accuracy).

CONCLUSION

These results highlight the existence of a common neuroanatomical signature for schizophrenia, shared by a majority of patients even from an early stage of the disorder.

Guidelines for the public on how to provide mental health first aid: narrative review

BACKGROUND

Expert-consensus guidelines have been developed for how members of the public should assist a person with a mental health problem or in a mental health crisis.

AIMS

This review aimed to examine the range of guidelines that have been developed and how these have been implemented in practice.

METHOD

A narrative review was carried out based on a systematic search for literature on the development or implementation of the guidelines.

RESULTS

The Delphi method has been used to develop a wide range of guidelines for English-speaking countries, Asian countries and a number of other cultural groups. The primary implementation has been through informing the content of training courses.

CONCLUSION

Further work is needed on guidelines for low- and middle-income countries.

DECLARATION OF INTEREST

A.F.J. is an unpaid member of the Board of Mental Health First Aid International (trading as Mental Health First Aid Australia), which is a not-for-profit organisation.

The impact of waiting time on patient outcomes: Evidence from early intervention in psychosis services in England

Recently, new emphasis was put on reducing waiting times in mental health services as there is an ongoing concern that longer waiting time for treatment leads to poorer health outcomes. However, little is known about delays within the mental health service system and its impact on patients. We explore the impact of waiting times on patient outcomes in the context of early intervention in psychosis (EIP) services in England from April 2012 to March 2015. We use the Mental Health Services Data Set and the routine outcome measure the Health of the Nation Outcome Scale. In a generalised linear regression model, we control for baseline outcomes, previous service use, and treatment intensity to account for possible endogeneity in waiting time. We find that longer waiting time is significantly associated with a deterioration in patient outcomes 12 months after acceptance for treatment for patients that are still in EIP care. Effects are strongest for waiting times longer than 3 months, and effect sizes are small to moderate. Patients with shorter treatment periods are not affected. The results suggest that policies should aim to reduce excessively long waits in order to improve outcomes for patients waiting for treatment for psychosis.

Diverse definitions of the early course of schizophrenia-a targeted literature review

Schizophrenia is a debilitating psychiatric disorder and patients experience significant comorbidity, especially cognitive and psychosocial deficits, already at the onset of disease. Previous research suggests that treatment during the earlier stages of disease reduces disease burden, and that a longer time of untreated psychosis has a negative impact on treatment outcomes. A targeted literature review was conducted to gain insight into the definitions currently used to describe patients with a recent diagnosis of schizophrenia in the early course of disease ('early' schizophrenia). A total of 483 relevant English-language publications of clinical guidelines and studies were identified for inclusion after searches of MEDLINE, MEDLINE In-Process, relevant clinical trial databases and Google for records published between January 2005 and October 2015. The extracted data revealed a wide variety of terminology and definitions used to describe patients with 'early' or 'recent-onset' schizophrenia, with no apparent consensus. The most commonly used criteria to define patients with early schizophrenia included experience of their first episode of schizophrenia or disease duration of less than 1, 2 or 5 years. These varied definitions likely result in substantial disparities of patient populations between studies and variable population heterogeneity. Better agreement on the definition of early schizophrenia could aid interpretation and comparison of studies in this patient population and consensus on definitions should allow for better identification and management of schizophrenia patients in the early course of their disease.

Family member engagement with early psychosis specialty care

BACKGROUND

Family members of individuals with early psychosis (EP) play critical roles in their engagement with EP services, but family member experiences of those roles are insufficiently understood.

METHODS

We conducted semi-structured interviews with 18 family members of individuals enrolled in EP services during the Recovery After an Initial Schizophrenia Episode-Implementation Evaluation Study (RAISE-IES study), to better understand their experiences engaging with EP specialty care and their roles in client engagement in services.

RESULTS

Family members described diverse experiences with the interplay among distress regarding their loved one's illness, uncertainty engaging with programme staff and highly valued facets of the clinical programme. These included ongoing family outreach and support, frequent communication from staff, programme flexibility and individualization of care. They also described varied and stressful complexities involved in providing practical assistance and encouragement to support their loved one's engagement in care. Competing responsibilities, time and resource limitations, and the intricacy of providing support while fostering autonomy impacted their roles and experiences.

CONCLUSIONS

Given key family roles for most EP clients, understanding family members' highly individual experiences and responding to them in tailored ways is necessary to best support families in helping their loved ones engage in care and recovery as well as navigate their own worry and stress. Recommendations for engaging and supporting family members are highlighted.