Unemployment among patients with newly diagnosed first-episode psychosis: prevalence and clinical correlates in a U.S. sample

Psychosocial and vocational impact of an internship program for people diagnosed with severe mental illnesses

PURPOSE

Unemployment is an obstacle in recovery for people with severe mental illnesses (SMI), both in reducing psychopathological symptoms and in achieving a high quality of life. The aim of this study was to explore the impact of an internship program for people diagnosed with SMI on psychosocial variables using a pre-test and post-test design.

METHOD

Four scales were administered to a sample of 127 study participants, all of whom were diagnosed with SMI. The results of standard and sheltered employment outcomes were obtained by comparing the number and type of contracts gained by participants up to one year after program completion. A repeated measures ANOVA analysis was carried out with intervention being an independent intra-subject variable and type of participant diagnosis being a between-subjects variable.

RESULTS

A limited increase in social functioning was found, as well as a significant decrease in psychiatric distress for users diagnosed with personality disorders. Participants in the internship program obtained a greater number of employment contracts than their peers who did not participate in the program, albeit with a low effect size.

CONCLUSIONS

Though results were positive, extension of internship length and provision of more intensive counselling for participants may be useful.

Real-World Assessment of Psychotropic and Antiepileptic Drug Use During Pregnancy in Belgium: Trends, Predictors, and Comparative Risk of Congenital Anomalies (2010-2016)

PURPOSE

To analyze the prescription patterns and sociodemographic factors associated with the use of antipsychotic, antidepressant, and antiepileptic drugs during pregnancy in Belgium, and to investigate their potential association with congenital anomalies.

METHODS

Using a nationwide linked database, we identified antidepressants, antipsychotics, and antiepileptics via the Anatomical Therapeutic and Chemical Classification (ATC) codes. For each medication group, we calculated the overall prevalence and prevalence for the three most used medications at the fifth ATC level. Sociodemographic factors influencing medication use during pregnancy were analyzed, and potential associations with congenital anomalies were investigated through logistic regression models based on generalized estimating equations.

RESULTS

Overall, 828 016 live births pregnancies associated with 611 094 mothers were identified. We found that the use of antidepressants, antipsychotics, and antiepileptics was decreasing with the arrival of pregnancy. Mothers with a less favorable sociodemographic status were more likely to be exposed to these medications. Antiepileptics used in the first trimester were associated with an increased risk of congenital anomalies (aOR = 1.65, 95% CI 1.11-2.45) compared with unexposed women. The three most used antiepileptics were lamotrigine, valproate, and levetiracetam, among them, we found an association with congenital anomalies only for valproate (aOR = 3.92, 95% CI 2.30-6.67).

CONCLUSIONS

Psychotropic and antiepileptic drug use decreased during pregnancy. Pregnant women with a less favorable sociodemographic status were more likely to be exposed to psychotropics and antiepileptics during pregnancy. The elevated risk of congenital anomalies associated with antiepileptics use, particularly valproate, underscores the need for targeted interventions and increased awareness to improve maternal and fetal health outcomes.

Understanding social and clinical associations with unemployment for people with schizophrenia and bipolar disorders: large-scale health records study

PURPOSE

People with severe mental illness (SMI) experience high levels of unemployment. We aimed to better understand the associations between clinical, social, and demographic inequality indicators and unemployment.

METHODS

Data were extracted from de-identified health records of people with SMI in contact with secondary mental health services in south London, UK. A Natural Language Processing text-mining application was applied to extract information on unemployment in the health records. Multivariable logistic regression was used to assess associations with unemployment, in people with SMI.

RESULTS

Records from 19,768 service users were used for analysis, 84.9% (n = 16,778) had experienced unemployment. In fully adjusted models, Black Caribbean and Black African service users were more likely to experience unemployment compared with White British service users (Black Caribbean: aOR 1.62, 95% CI 1.45-1.80; Black African: 1.32, 1.15-1.51). Although men were more likely to have experienced unemployment relative to women in unadjusted models (OR 1.36, 95% CI 1.26-1.47), differences were no longer apparent in the fully adjusted models (aOR 1.05, 95% CI 0.97-1.15). The presence of a non-affective (compared to affective) diagnosis (1.24, 1.13-1.35), comorbid substance use (2.02, 1.76-2.33), previous inpatient admissions (4.18, 3.71-4.70), longer inpatient stays (78 + days: 7.78, 6.34-9.54), and compulsory admissions (3.45, 3.04-3.92) were associated with unemployment, in fully adjusted models.

CONCLUSION

People with SMI experience high levels of unemployment, and we found that unemployment was associated with several clinical and social factors. Interventions to address low employment may need to also address these broader inequalities.

Experiences of individuals with serious mental disorders in regular employment through the Individual Placement and Support model

Introduction

This study shows the perspective, meaning and satisfaction perceived by people with Serious Mental Disorders during their experiences in regular employment.

Methods

A mixed qualitative-quantitative methodology was used, applying semi-structured interview as qualitative information collection tool and the Indiana Job Satisfaction Scale as quantitative tool. The study period was from January 2021 to December 2022. A purposive sampling was performed with a sample of 24 people with Serious Mental Disorders who had obtained a job through an Individual Placement and Support (IPS) program during the study period. Semi-structured interview and the Indiana Job Satisfaction Scale were applied to this Serious Mental Disorder workers' sample. The Indiana Job Satisfaction Scale was also applied to a group of 24 workers without mental disorders in the same working conditions who served as control group.

Results

The results of the analyses of the Serious Mental Disorder workers' narratives show that perception of work experience is conditioned by individual, environmental and social predictors, as well as external factors as determining variables. Quantitative results obtained by the Indiana Job Satisfaction Scale reveal levels of job satisfaction resembling those of the rest of workers without Serious Mental Disorder.

Discussion

These findings reinforce the significance of employment in the recovery process for individuals with Serious Mental Disorders and emphasize the importance of understanding the subjective meaning individuals attribute to their work experiences.

Is there any job for me? Qualitative exploration of support needs among young Swedish adults with psychosis envisioning productive activities

BACKGROUND

Unemployment is high not only among people with mental illness, but also among young adults in general. The combination of having a severe mental illness and being young entails a particularly problematic situation for young people with psychosis. This study aimed to understand how this group envision their future possibilities for entering the labour market or engaging in other productive activities.

OBJECTIVE

To explore how young adults with psychosis perceive their possibilities, wishes and support needs for gaining employment or engaging in other productive activities.

METHODS

A descriptive design with qualitative individual in-depth interviews was used. Eighteen young adults with psychosis, aged 18-30 years, were interviewed. Data was analysed with qualitative content analysis.

RESULTS

Four categories based on the experiences of the participants as being vital for having work or other productive activities were generated: "Wishing for a role in the community", "Being my own coach", "Needing personal support" and "Having a supportive workplace". Each of them included sub-categories.

CONCLUSION

The young adults with psychosis were a long way from having paid work, but they desired to have a worker role in the community. They are a heterogeneous group, which entails that it is important that professionals and employers have a person-centered and holistic approach, listening to the individuals themselves.

Functioning, symptom expression and risk along the psychosis continuum

BACKGROUND

The psychosis continuum implies that subclinical psychotic experiences (PEs) can be differentiated from clinically relevant expressions since they are not accompanied by a 'need for care'.

METHODS

Using data from Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC; N = 34 653), the current study examined variation in functioning, symptomology and aetiological risk across the psychosis phenotype [i.e. variation from (i) no PEs, 'No PEs' to (ii) non-distressing PEs, 'PE-Experienced Only' to (iii) distressing PEs, 'PE-Impaired' to (iv) clinically defined psychotic disorder, 'Diagnosed'].

RESULTS

A graded trend was present such that, compared to those with no PEs, the Diagnosed group had the poorest functioning, followed by the PE-Impaired then PE-Experienced Only groups. In relation to symptom expression, the PE-Impaired group were more likely than the PE-Experienced Only and the Diagnosed groups to endorse most PEs. Predictors of group membership tended to vary quantitatively rather than qualitatively. Trauma, current mental health diagnoses (anxiety and depression) and drug use variables differentiated between all levels of the continuum, with the exception of the extreme end (PE-Impaired v. Diagnosed). Only a few variables distinguished groups at the upper end of the continuum: female sex, older age, unemployment, parental mental health hospitalisation and lower likelihood of having experienced physical assault.

CONCLUSIONS

The findings highlight the importance of continuum-based interpretations of the psychosis phenotype and afford valuable opportunities to consider if and how impairment, symptom expression and risk change along the continuum.

Outcomes Among People With Schizophrenia Participating in General-Population Smoking Cessation Treatment: An Observational Study

OBJECTIVE

People with schizophrenia are much more likely than others to smoke tobacco, raising risks of disease and premature mortality. These individuals are also less likely to quit successfully after treatment, but the few existing clinical and observational studies have been limited by small sample sizes, and have generally considered specialized treatment approaches. In this analysis, we examine outcomes, service use, and potential explanatory variables in a large sample of people with schizophrenia treated in a general-population cessation program.

METHOD

Our sample comprised 3,011 people with schizophrenia and 77,790 controls receiving free nicotine replacement therapy through 400 clinics and health centres. We analysed self-reported 7-day abstinence or reduction at 6-month follow-up, as well as the number of visits attended and self-reported difficulties in quitting. We adjusted for demographic, socioeconomic, and health variables, and used multiple imputation to address missing data.

RESULTS

Abstinence was achieved by 16.2% (95% confidence interval [CI], 14.5% to 17.8%) of people with schizophrenia and 26.4% (95% CI, 26.0% to 26.7%) of others (absolute difference = 10.2%; 95% CI, 8.5% to 11.9%; P < 0.001). After adjustment, this difference was reduced to 7.3% (95% CI, 5.4% to 9.3%; P < 0.001). Reduction in use was reported by 11.8% (95% CI, 10.3% to 13.3%) and 12.5% (95% CI, 12.2% to 12.8%), respectively; this difference was nonsignificant after adjustment. People with schizophrenia attended more clinic visits (incidence rate ratio [IRR] = 1.15, 95% CI = 1.12% to 1.18%, P < 0.001) and reported more difficulties related to "being around other smokers" (odds ratio [OR] = 1.28; 95% CI, 1.11% to 1.47%; P = 0.001).

CONCLUSION

There is abundant demand for tobacco cessation treatment in this population. Outcomes were substantially poorer for people with schizophrenia, and this difference was not explained by covariates. Cessation remained much better than for unaided quit attempts, however, and engagement was high, demonstrating that people with schizophrenia benefit from nonspecialized pharmacological treatment programs.

A Scoping and Systematic Review of Employment Processes and Outcomes for Young Adults Experiencing Psychosis

Young adults who experience psychosis want to work but are less likely to be employed than their peers. Sixty two studies relating to young adults with psychosis and employment were reviewed following a systematic search of five databases: CINAHL, PsycINFO, MEDLINE, SCOPUS and EMBASE. Publication date ranged from 1973 to 2019 with > 70% between 2010 and 2019. Intervention was considered in 29 papers; critical appraisal revealed 90% of these had moderate to good methodological quality with only three RCTs. Of 11 intervention types "Early Intervention" and "Individual Placement and Support" were most common; both demonstrating positive impact on obtaining employment. The review identified minimal participant perspectives and great variability in: terminology used; the reporting of participant attributes; intervention characteristics and ways employment outcomes were measured. Employment processes identified were preparing for, seeking, obtaining, keeping and re-obtaining employment, with current research efforts focused on obtaining work. More focus is required on keeping and re-obtaining employment.

Profiles and factors associated with schizophrenia in eastern Ethiopia: A matched case-control study

Background

Despite its strong hereditary and genetic connections, there are other factors reported to be linked to schizophrenia, but not well studied in eastern Ethiopia.

Objective

This study was aimed to investigating the potential profiles and factors associated with schizophrenia in eastern Ethiopia.

Materials and methods

A matched case-control study was conducted in two public hospitals from December 1, 2021, to January 30, 2022. Cases were patients with schizophrenia who visited the hospitals, and controls were healthy individuals without any mental illness who visited the same hospitals. A questionnaire was used to collect the data. Cases and controls were matched using age and sex. STATA-14 was used for analysis. A conditional logistic regression with an adjusted odds ratio (AOR) and a 95% confidence interval (CI) was applied to identify the determinants. P-values of <0.05 were used to build the final model as a measure of statistical significance.

Results

The mean age of the study participants group was 28.6 (±8.44) years, mean age for cases was 28.7(±8.5) ranging from 18 to 56 years and the mean age for the controls was 28.4 (±8.5), ranging from 18 to 60 years. About 181 (83.03%) of the participants were male. The odds of having schizophrenia was about 12.2 times higher among participants with family history of mental illness (AOR: 12.21; 95% CI: 4.83-30.00). The odds of having schizophrenia was 4.5 times higher among polysubstance users (AOR: 4.45; 95% CI: 1.28-5.45) and 2.8 times higher among khat consumers (AOR: 2.82; 95% CI: 1.23-6.45) compared to their counterparts.

Conclusion

Our findings show that genetic risk factors as well as some modifiable behaviors are associated to schizophrenia in eastern Ethiopia. At all levels, special attention should be given to those who are at risk.

Implementation of occupational therapy within early intervention in psychosis services: Results from a national survey

AIM

Occupational therapy plays an important role in fostering community participation in areas such as education, employment, leisure, and social relationships, yet its added value within early intervention in psychosis services, especially in the United States, remains poorly understood. The purpose of this research was to conduct a national survey of early intervention in psychosis programs to: (1) understand the role and unique contributions of occupational therapists to early intervention teams, and (2) identify barriers and supports to the implementation of occupational therapy services within these programs.

METHODS

Fifty-one senior leaders from U.S.-based early intervention in psychosis programs participated in the national survey. The survey consisted of a series of closed and open-ended questions related to program staffing, the presence of specific services that fall within the occupational therapy scope of practice, and implementation barriers and supports.

RESULTS

Despite there being strong interest in employing occupational therapists, a small proportion of programs (31%) reported having them on staff. Occupational therapists supported clients across multiple life areas and were significantly more likely than other team members to promote daily living activities (e.g., cooking) and to address sensory processing needs and challenges. Implementation was influenced by environmental/organizational and staff factors; the primary barrier was funding.

CONCLUSIONS

Findings support the role occupational therapists may play in facilitating the community participation of clients of early intervention services, but significant barriers to implementation of occupational therapy services remain. Additional research is needed to further identify the impact of occupational therapy services within the early intervention model.

Interventions for adolescents and adults with psychosis in Africa: a systematic review and narrative synthesis

Background

The Global Burden of Disease attributable to psychotic disorders in African countries is high and has increased sharply in recent years. Yet, there is a scarcity of evidence on effective, appropriate and acceptable interventions for schizophrenia and other psychotic disorders on the continent.

Methods

We carried out a systematic review and narrative synthesis of peer-reviewed literature evaluating the impact of non-pharmacological interventions for adolescents and adults (10-65 years) in African countries. Two reviewers independently double-screened all articles and performed data extraction and quality appraisal using standardized tools.

Results

Of the 8529 unique texts returned by our search, 12 studies were identified for inclusion, from seven countries: Egypt, Ethiopia, Ghana, Kenya, Nigeria, South Africa and Sudan. They evaluated a range of interventions with one or more clinical, psychological or psychosocial, education or awareness or traditional or faith-based components, and were delivered by either mental health specialists or non-specialist health workers. Ten of the 12 included studies reported significant, positive effects on a range of outcomes (including functioning, symptoms and stigma). Nearly half of the interventions were based out of health facilities. Based on quality appraisals, confidence in these studies' findings is only rated low to medium.

Conclusion

Further research is needed to develop and evaluate interventions that meet the diverse needs of people with psychosis, within and beyond the health sector.

Geographical variation in hospitalization for psychosis associated with cannabis use and cannabis legalization in the United States: Submit to: Psychiatry Research

The 2017 National Inpatient Sample database was utilized to investigate the association between cannabis legalization in the United States and hospitalizations for psychosis associated with cannabis use. We compared the odds of hospital discharges for psychosis associated with cannabis use in adults between the Pacific census division (where most states legalized recreational cannabis use) and other divisions using multivariable logistic regression, adjusting for confounders. We calculated a score for each census division representing cannabis legality as the population-weighted sum of state scores: 1=illegal or cannabidiol/low potency cannabis; 2= medical marijuana; and 3=recreational and medical marijuana legalized. Pearson's correlation coefficients (r) quantified the relationship between scores and the proportion of hospitalizations with psychosis associated with cannabis. In 2017, there were an estimated 129,070 hospital discharges for psychosis associated with cannabis use. The Pacific census division had significantly higher odds of discharges than other divisions (adjusted odds ratio 1.55; 95% confidence interval 1.25 - 1.93). There was a significant correlation between the cannabis legality score and proportion of hospital discharges for psychosis associated with cannabis use (r = 0.67, p<0.05). In conclusion, we observed a higher proportion of hospital discharges for psychosis associated with cannabis use in areas with more liberal cannabis legalization laws.

Does theory of mind predict specific domains of social functioning in individuals following a first episode psychosis?

Social functioning is a central aspect in the treatment of people with psychosis, even more so with the recovery movement promoting an optimal life in one's environment. A good ability to function socially is, among other things, associated with fewer future complications and a better overall quality of life. However, prognostic markers currently in use (i.e., cognitive functioning) to predict an individual's subsequent functioning do not always produce conclusive results in individuals who have recently experienced a first episode of psychosis (FEP). The objective of this study was to evaluate the prognostic value of theory of mind in FEP individuals. Thirty-seven individuals who were followed in a FEP clinic were recruited for the study. Multiple linear regressions were performed for data analysis. The results suggest that theory of mind may be, for specific domains of social functioning in this sub-population, a more important predictor than cognitive functioning variables; though studies with larger samples are needed to support these results.

Engagement with online psychosocial interventions for psychosis: A review and synthesis of relevant factors

BACKGROUND

Little is known about factors associated with engagement with online interventions for psychosis. This review aimed to synthesise existing data from relevant literature to develop a working model of potential variables that may impact on engagement with online interventions for psychosis.

METHODS

Online databases were searched for studies relevant to predictors of engagement with online interventions for psychosis; predictors of Internet use amongst individuals with psychosis; and predictors of engagement with traditional psychosocial treatments for psychosis. Data were synthesised into a conceptual model highlighting factors relevant to engagement with online interventions for psychosis.

RESULTS

Sixty-one studies were identified. Factors relevant to engagement related directly to the impact of psychosis, response to psychosis, integration of technology into daily lives and intervention aspects.

CONCLUSION

While several candidate predictors were identified, there is minimal research specifically investigated predictors of engagement with online interventions for psychosis. Further investigation examining both individual- and intervention-related factors is required to inform effective design and dissemination of online interventions for psychosis.

Could health-improving interventions address the growing unemployment crisis?

The COVID-19 pandemic is causing unprecedented rates of unemployment. Poorer mental health is a cause and a consequence of unemployment, and job seekers with poorer mental health remain unemployed for longer. The review in this month's Cochrane Corner aimed to evaluate the effects of health-improving interventions on job seeker's re-employment rates. This commentary critically evaluates the review and explores the relevance of its findings.

Shared Decision Making With Young People at Ultra High Risk of Psychotic Disorder

Introduction: While the majority of young people who meet the criteria for being considered at increased risk of psychosis do not go on to develop a psychotic disorder, young people are currently being identified and treated in early intervention services. Ethical concerns have been raised concerning the decision about whether or not to provide treatment, and if so, what type of treatment. This study sought to support young people themselves to make these decisions with support from their clinician through a shared decision-making approach, facilitated by an online decision aid. Methods: This project used the International Patient Decision Aid Standards (IPDAS) to guide the development and piloting of an online decision aid across two phases: (1) qualitative, semi-structured focus groups with young people who were past clients and clinicians from an early psychosis service; and (2) pilot testing of the decision aid with clinicians and young people who were current clients to finalize the development. Results: Issues discussed by clinicians in the focus group were grouped into three main areas: (1) engagement phase; (2) assessment and priorities for treatment; and (3) initial and ongoing decision making. Clients focused on the context in which the decisions were made, including as they experienced initial feelings of resistance, and then acceptance of efforts made to describe and treat their mental health challenges. Clients highlighted the need for collaboration between themselves and their clinician, and the need to be equipped with the knowledge and tools to take care of themselves. These focus group data were used to refine the online decision aid. Pilot testing revealed that while it was overall useful and relevant, important limitations were noted by both clients and clinicians. Discussion: The use of a decision aid to facilitate shared decision making (SDM) in this area is feasible and has utility for both clients and clinicians. Use of such a tool can help to address the need to uphold the rights of young people as decision makers about their own care. Future efforts should embed decision aids within complex SDM interventions, and research to understand issues relating to implementation of these interventions.

Schizophrenia in the context of mental health services in Palestine: a literature review

BACKGROUND

Mental health conditions remain a significant cause of disability in the Arab World. Palestinians are predominantly at a higher risk for mental health problems due to their chronic exposure to political violence, prolonged displacement, and others as limited professional, educational, financial opportunities and mental health services. Schizophrenia is an overwhelming mental illness that affects nearly one percent of the various populations throughout the world. Studies have shown patients with schizophrenia die prematurely and have lower life expectancy compared to the general population. Moreover, antipsychotic medications and client's lifestyle play a significant role in increased morbidity and mortality in these patients. The present study willingly undertakes a literature review on schizophrenia in the context of mental health services in Palestine.

METHODS

Studies were identified through PubMed, Science Direct, Google Scholar, CINAHL, Semantic Scholar and Elsevier.

RESULTS

Twenty-four studies were included in this review; 11 articles related to schizophrenia and thirteen articles related to mental health services in Westbank and Gaza. Results revealed the life of patients with schizophrenia in Palestine is complicated. Barriers as lacking awareness about mental illness, stigma, inconsistent availability of medications, absence of multidisciplinary teamwork, insufficient specialists, fragmented mental health system, occupation, and other obstacles stand in the face of improving the quality of life among these patients.

LIMITATIONS

Palestine is a state that is seeking independence with a scarcity of resources. It has been described as "uncharted territories'' due to a lack of data, resources and records. As a result, there is insufficient data regarding schizophrenia in Palestine. Therefore, a thesis study that estimated 10 years' risk of coronary heart diseases in patients with schizophrenia was included.

CONCLUSIONS

Recommendations include ending the occupation as the leading cause of mental illness for Palestinians and implementing efficient and effective mental health nursing care through the multidisciplinary work and raising awareness regarding mental illness to fight the stigma.

Negative symptom subgroups have different effects on the clinical course of schizophrenia after the first episode: A 24-month follow up study

Objective:

The aim of this study was to assess the factor structure of negative symptoms in first-episode schizophrenia (FES), and to examine the relationship of these factors with clinical course and functioning of patients during the two-year follow up.

Method:

We assessed 174 drug-naïve patients with FES using Brief Psychiatric Rating Scale-Expanded (BPRS), Scale for the Assessment of Negative Symptoms (SANS), Scale for the Assessment of Positive Symptoms (SAPS), and Global Assessment of Functioning (GAF) and a cognitive battery at admission. The scales were repeated monthly during follow up. We recorded the patients’ functioning levels, remission, and work status after 12 and 24 months.

Results:

A two-factor structure was found at the baseline, whereas one factor was found after 12 and 24 months. Expressive deficit (ED) factor consisted of alogia and blunted affect, and motivation-pleasure deficit (MPD) factor consisted of avolition and anhedonia. ED factor was related to earlier onset and remission, and it was negatively correlated with duration of education and cognitive test scores. MPD factor was related to duration of untreated psychosis, family history of schizophrenia, and work status, and it appeared as the only independent variable that contributed to the baseline GAF score in linear regression analysis.

Conclusion:

Our findings suggest that the factors have different aetiologies and impacts on the clinical course of schizophrenia and functioning after FES.

Impact of integrated mental health care on food insecurity of households of people with severe mental illness in a rural African district: a community-based, controlled before-after study

OBJECTIVES

To evaluate the impact of integrated mental health care upon food insecurity (FI) in households of people with severe mental illness (SMI) in a rural Ethiopian district, and to investigate mediation by improved work impairment and discrimination.

METHODS

A community-based, controlled before-after study was conducted. People with probable SMI were identified in the community, diagnosed by primary healthcare workers, with diagnostic confirmation from a psychiatric nurse. Households of a person with SMI were matched to control households. District-wide integration of mental health care was implemented. Change in FI status over 12 months of follow-up was measured using the Household Food Insecurity Access Scale. Multivariable models were used to assess improvement in FI. Direct and indirect mediators of change in FI status were modelled using path analysis.

RESULTS

A total of 239 (81.8%) people with SMI and 273 (96.5%) control households were assessed after 12 months. Maintenance of food security or improvement in food insecurity status was observed in 51.5% of households of a person with SMI vs. 39.7% of control households (adjusted risk ratio 1.41: 95% CI 1.11, 1.80). Reduction in symptom severity was indirectly associated with improved FI status via an impact on reducing work impairment and discrimination (P < 0.001).

CONCLUSIONS

Improving access to mental health care may reduce food insecurity in households of people with SMI. Optimising engagement in care and adding interventions to improve work functioning and tackle discrimination may further reduce food insecurity.

Societal Costs of Schizophrenia in Denmark: A Nationwide Matched Controlled Study of Patients and Spouses Before and After Initial Diagnosis

BACKGROUND

Information on welfare cost of patients with schizophrenia and spouses is limited.

AIM

The main aim of this study to investigate factual societal mean annual costs per individual during 5 years before and after the initial diagnosis of schizophrenia.

METHOD

A register-based cohort study of 12 227 patients with incident schizophrenia (International Classification of Diseases, Tenth Revision F20-F20.99) with spouses and 48 907 matched controls in Denmark during 2002-2016.

RESULTS

The total annual costs of health care and lost productivity were Euro 43 561 higher for patients with schizophrenia and health care costs and costs of lost productivity were increased during 5 years before the initial diagnosis. The total annual direct health care and indirect costs of lost productivity were Euro 21 888 higher for spouses to patients with schizophrenia than spouses of individuals with no diagnosis of schizophrenia. Also before initial diagnosis, health care costs and lost productivity were increased among spouses of patients with schizophrenia.

CONCLUSION

Patients with schizophrenia differed from the general population with respect to all included costs. The study documented a significant burden on spouses. The excess health care costs of schizophrenia are further increased by psychiatric and somatic comorbidity, and the societal costs are 4-10 times higher than chronic neurological disorders such as epilepsy and multiple sclerosis. Early onset of schizophrenia implies that patients are affected before finishing school and before entrance to labor market. Cost savings could be achieved by investments in preventive interventions reaching young people's needs; in initiatives to reduce hospital admissions caused by medication side effects, substance misuse, and lifestyle factors; and in occupational training.

Service Use Following First-Episode Schizophrenia Among Commercially Insured Youth

OBJECTIVE

To investigate patterns of mental health service and antipsychotic use following a first-episode schizophrenia (FES) and to examine the role of the treatment setting in which individuals are first diagnosed.

METHOD

Analysis of de-identified administrative claims data from the OptumLabs Data Warehouse was used to identify 1450 privately insured youth and young adults aged 14 through 30 with FES from January 1, 2011 through December 31, 2015. Regression analysis was used to estimate the use of mental health services during the year following FES, by type of service and by site of index diagnosis.

RESULTS

In the year following FES, 79.7% of youth received outpatient mental health services and 35.8% filled a prescription for antipsychotic medication. Among service users, mean outpatient visits were 15.9 and mean antipsychotic fills were 8.3. Youth who received an index diagnosis of FES in an inpatient setting were more likely to fill an antipsychotic medication than youth with FES in other settings. Youth who received an index diagnosis of FES during a specialty mental health outpatient visit had greater use of outpatient mental health than youth who received their diagnosis during a primary care visit.

CONCLUSIONS

Despite evidence-based guidelines supporting outpatient psychosocial care and antipsychotic treatment for FES, one-fifth of this cohort did not use outpatient services and the majority did not fill any prescriptions for antipsychotic medications during the year following FES. Our findings provide renewed urgency to ongoing efforts to accelerate early identification and care coordination for youth with FES.

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.

Demographic and clinical profiles of admitted psychiatric patients of the East London Mental Health Unit in the Eastern Cape, South Africa

Integration of psychiatric care at the Primary Health Care (PHC) could be an important strategy towards addressing the shortages of in-patient mental health care services in South Africa. This study describes the profiles of admitted psychiatric patients at the East London Mental Health Unit (ELMHU) of the Eastern Cape from January 2016 to December 2016.In this retrospective cross-sectional study, an audit of medical records of all psychiatric in-patients managed at the ELMHU during the study period was undertaken. Simple descriptive and inferential statistics were used to describe the profiles and examine the associations with the common psychiatric conditions.Of the participants with complete data (n = 186), the majority were males (n = 108); single (72.6%) and had secondary education (45.7%). The majority of in-patients were psychotic (38%), violent (31%), manic (16%) or suicidal (9.2%) at the time of admission. Patients who were 35 years and above, resided in urban areas, and presented with suicidal and depressive symptoms were more likely to be admitted voluntarily. Schizophrenia (31.6%), cannabis-related psychiatric disorders (31.6%), bipolar Type-1 disorder (21.9%) and alcohol related disorders (15.5%) were the main reasons for admission. There was a significant association between demographic characteristics and the common psychiatric disorders of the patients.Schizophrenia, bipolar 1 disorder, cannabis-related disorders and alcohol-related disorders are the predominant disorders leading to in- patient mental health care services being utilized in the study setting. Findings might inform training of health care workers at the PHCs with a view to integrating mental health care services in the Eastern Cape.

Group differences in social inclusion between young adults aged 18 to 25 with serious mental illness and same-aged peers from the general community

AIMS

Young adults with serious mental illness (SMI) are thought to be socially excluded. However, psychometric measures of social inclusion have not been employed to examine group differences relative to peers from the general community. The aim of this study was to employ such a measure to determine differences in social inclusion between young adults with SMI and peers from the general community.

METHODS

A cross-sectional hierarchical logistic regression was conducted to identify which dimensions and individual indicators from the Filia Social Inclusion Measure (F-SIM) discriminated between n = 152 young adults aged 18-25 from the general community (M = 21.36, SD = 2.16) and n = 159 young adults aged 18-25 with SMI (M = 21.13, SD = 2.21).

RESULTS

Group membership was accounted for by Interpersonal Connections (Nagelkerke R² = .32), Vocational & Financial Security (Nagelkerke R² = .32) and Healthy Independent Lifestyle (Nagelkerke R² = .08) dimensions of the F-SIM. Relative to young adults from the general community, those with SMI were five times less likely to feel they had friends who would call on them in a crisis, odds ratio (OR) = .19 (95%CI = .04, .53), p = .04, almost five times more likely to live with their parents, OR = 4.79 (95%CI = 1.98,11.15), p = .004, almost four times less likely to have worked/studied any time over the past 12 months, OR = .27 (95%CI = .11,.64), p < .001, and three-and-a-half times more likely to report unstable accommodation, OR = 3.58 (95%CI = 1.14, 11.15), p = .03.

CONCLUSION

Young adults with SMI are socially excluded relative to peers from the general community in terms of interpersonal connections, vocational engagement, autonomy/independence and housing stability. In addition to the well-established focus on vocational engagement, interventions to improve social inclusion in this population must promote reciprocity within social relationships and healthy autonomy/independence (including stable housing).

First-episode psychosis and vocational outcomes: A predictive model

Most studies on predictors of vocational outcomes are cross-sectional and results are varied. This study aimed to examine the vocational rates of patients with first-episode psychosis (FEP), identify factors predicting a lack of engagement in age-appropriate roles, and evaluate the predictive ability of a model with baseline sociodemographic information and 2-year symptom and functioning trajectories on vocational outcomes. The Singapore Early Psychosis Intervention Program (EPIP) has maintained a standing database on patient clinico-demographic information. The primary outcome, vocational status, was operationalized as "meaningfully employed", that is, being gainfully employed or engaged in an age-appropriate role, and "unemployed". Using logistic regression, the predictive ability of the proposed model was evaluated. Vocational data was available for 1177 patients accepted into EPIP between 2001 and 2012. At the end of two years in the service, 829 (70.4%) patients were meaningfully employed and 348 (29.6%) patients were unemployed. The binary logistic regression model on the prediction of 2-year vocational outcomes yielded an AUC of 0.759 (SE = 0.016, p-value < 0.001). Clinico-demographic risk factors for being unemployed at the end of two years included being Malay, single, and unemployed at baseline; having a longer duration of untreated psychosis (DUP); a diagnosis of schizophrenia, schizophreniform, or delusional disorder at baseline; and belonging to the 'delayed response' or 'slower response and no response' general psychopathology trajectories. We have proposed a model that allows vocational outcomes to be predicted with high specificity. The results of this study will be relevant in developing future intervention models to improve outcomes among FEP patients with different illness trajectories.

The Life Course Paradigm as a Lens for Holistic Nursing Research in Older Adults Diagnosed With Schizophrenia

Older adults diagnosed with schizophrenia (OADWS) have unique needs for care and live longer today than their forebears who were diagnosed with schizophrenia. As a result, nurses need to be prepared for the specific care of individuals who live with schizophrenia as they age. Together, Life Course Theory and holistic nursing suggest a good fit in the quest for successful solutions and/or outcomes for the unique problems that OADWS face. Holistic nursing views the patient as a whole person, considering all aspects of the patient’s experiences within life’s broader environment. The life course paradigm offers an effective way for nurses to understand issues that patients face throughout their lives, thus enhancing holistic nursing with a historical perspective. This is especially important for the care of OADWS, who face unique disparities as well as physical and psychological comorbidities over their life course. This article is intended to initiate a discussion of OADWS, focused with Life Course Theory as a holistic lens. Literature pertinent to the life course of OADWS is reviewed, followed by an analysis of the life course paradigm in relation to OADWS’ unique experiences. Conclusions support the holistic use of Life Course Theory in research and interventions for OADWS.

Employment as a Social Determinant of Health: Exploring the Relationship Between Neurocognitive Function and Employment Status

Purpose:

To explore employment as a social determinant of health through examining the relationship between neurocognitive function and employment status.

Method:

The authors explored the causal relationship between employment status and neurocognitive function by conducting a systematic review of 15 longitudinal studies. The identified studies were conducted in Australia, Denmark, Norway, and the United States.

Results:

Five neurocognitive function domains were identified (i.e., complex attention, executive function, learning and memory, language, perceptual-motor function) across diagnosis (i.e., bipolar disorder, first-episode psychosis, human immunodeficiency virus, major depression, schizophrenia-spectrum disorders, traumatic brain injury). Unemployment was correlated with poorer attention, executive function, learning and memory, perceptual-motor function, and language. Employment was correlated with better attention, executive function, learning and memory, perceptual-motor function.

Conclusion:

The acknowledgment of the relationship between neurocognitive function and employment status can assist service providers in assessing and developing strategies to enhance and maintain employment outcomes. The assessment of neurocognitive function could be further explored by identifying standard measures and assessment timelines to assess the six domains across diagnosis. Vocational rehabilitation services could integrate cognitive interventions (cognitive rehabilitation, cognitive enhancement therapy, cognitive remediation) to explore the effect on neurocognitive function and employment outcomes. Further longitudinal research studies are needed, for both persons with disabilities and persons without disabilities, to elucidate the relationship between employment status and neurocognitive function.

Career Decision-Making Processes of Young Adults With First-Episode Psychosis

The first episode of psychosis often emerges during young adulthood, when individuals are pursuing important educational and career goals that can become derailed because of the development of major impairments. Past research has neglected the developmental nature of employment and education decisions that young adults with first-episode psychosis make within the context of their lives. The purpose of this grounded theory study was to advance a model of the career decision-making processes of young adults with first-episode psychosis, and the influences that affect their career decision-making. The career decision-making of young adults with first-episode psychosis emerged as a multistaged, iterative process that unfolded over three phases of illness, and was affected by several internal and environmental influences. These findings suggest the phase of illness and career decision-making stage should be considered in future vocational programming for young adults with first-episode psychosis.

Sex differences and the influence of social factors in a Chilean urban psychiatric hospital population

BACKGROUND

The epidemiological literature has reported differences by sex in the prevalence of psychiatric diagnoses. However, we know little about how other socio-demographic factors participate in these differences.

AIM

To identify the socio-demographic factors that correlate with prevalent psychiatric diagnoses in women and men in a Chilean urban psychiatric hospital population.

METHOD

Socio-demographic information (age, educational level, marital status, family group and work status), psychiatric diagnoses and sex of the population were collected for 3,920 patients of a tertiary care hospital during a period of 8 years (2007-2014). The data were subjected to bivariate and multivariate analyses comparing the results by sex.

RESULTS

Among the most prevalent psychiatric diagnoses, those significantly correlated with sex were eating disorders and major depression (women) and schizophrenia (men). Socio-demographic factors behave differently in men and women regarding those diagnoses. Among the differences, working and being married correlated directly with the diagnosis of depression only among women. Living alone correlated directly with the diagnosis of schizophrenia among men, but correlated inversely among women.

CONCLUSION

Dissimilar associations between sex, psychiatric diagnosis and socio-demographic factors found in this Latin American sample invite us to reflect on how social conditions crosscut the relation between sex and psychopathology and to include gender perspectives in psychiatric practices.

Predictors of functional status at service entry and discharge among young people with first episode psychosis

OBJECTIVE

Most patients with first episode psychosis (FEP) are neither studying nor employed (have a poor functional status) when first accessing care. Knowledge of the characteristics of patients with poor functioning and the features influencing functional status over time may pave the way to better treatment.

METHOD

A medical file audit was used to collect data on premorbid, entry, treatment and 18-month outcome characteristics on 661 FEP patients who consecutively attended the Early Psychosis Prevention and Intervention Centre, Melbourne, Australia, between 1998 and 2000. Functional status was ascertained using the modified vocational status index and was rated at baseline (poor or good) and according to its evolution over the treatment period (stable good, stable poor, deteriorating or improved functional status).

RESULTS

52.0% of patients had a poor functional status at service entry. They were more likely to be male with a non-affective psychosis. They also had lower levels of premorbid global functioning and education, and were more likely to have self-reported histories of learning disability, forensic issues, traumatic experiences and substance use. At service entry, they had more severe symptoms and poorer global functioning. 37% of these patients maintained a poor functional status at discharge, and 18% of those with a good functional status at service entry experienced a decline.

CONCLUSIONS

Although psychosocial interventions might assist a young person with FEP with working towards functional goals, for some, the impact of factors such as ongoing substance use and forensic issues on functional status needs to be addressed.

Further evidence of a cumulative effect of social disadvantage on risk of psychosis

BACKGROUND

A growing body of evidence suggests that indicators of social disadvantage are associated with an increased risk of psychosis. However, only a few studies have specifically looked at cumulative effects and long-term associations. The aims of this study are: To compare the prevalence of specific indicators of social disadvantage at, and prior to, first contact with psychiatric services in patients suffering their first episode of psychosis and in a control sample. To explore long-term associations, cumulative effects, and direction of effects.

METHOD

We collected information on social disadvantage from 332 patients and from 301 controls recruited from the local population in South London. Three indicators of social disadvantage in childhood and six indicators of social disadvantage in adulthood were analysed.

RESULTS

Across all the domains considered, cases were more likely to report social disadvantage than were controls. Compared with controls, cases were approximately two times more likely to have had a parent die and approximately three times more likely to have experienced a long-term separation from one parent before the age of 17 years. Cases were also more likely than controls to report two or more indicators of adult social disadvantage, not only at first contact with psychiatric services [odds ratio (OR) 9.5], but also at onset of psychosis (OR 8.5), 1 year pre-onset (OR 4.5), and 5 years pre-onset (OR 2.9).

CONCLUSIONS

Greater numbers of indicators of current and long-term exposure are associated with progressively greater odds of psychosis. There is some evidence that social disadvantage tends to cluster and accumulate.

Cognitive and Social Functioning Correlates of Employment Among People with Severe Mental Illness

We assess how social and cognitive functioning is associated to gaining employment for 213 people diagnosed with severe mental illness taking part in employment programs in Andalusia (Spain). We used the Repeatable Battery for the Assessment of Neuropsychological Status and the Social Functioning Scale and conducted two binary logistical regression analyses. Response variables were: having a job or not, in ordinary companies (OCs) and social enterprises, and working in an OC or not. There were two variables with significant adjusted odds ratios for having a job: "attention" and "Educational level". There were five variables with significant odds ratios for having a job in an OC: "Sex", "Educational level", "Attention", "Communication", and "Independence-competence". The study looks at the possible benefits of combining employment with support and social enterprises in employment programs for these people and underlines how both social and cognitive functioning are central to developing employment models.

Does Employment Promote Recovery? Meanings from Work Experience in People Diagnosed with Serious Mental Illness

Employment has been highlighted as a determinant of health and as an essential milestone in the recovery process of people with serious mental illness. Different types of programs and public services have been designed to improve the employability of this population. However, there has not been much interest in the meanings attributed to these experiences and the negative aspects of work experience. In this research, we explored the meanings that participants attributed to their work experience and the impact of work on their recovery process. Research participants lived in Andalusia (Spain), a region in southern Europe with a high unemployment rate. Two versions of a semi-structured interview were designed: one for people who were working, and one for unemployed people. Participants' narratives were categorized according to grounded theory and the analyses were validated in group sessions. Apart from several positive effects for recovery, the analysis of the narratives about work experience outlined certain obstacles to recovery. For example, participants mentioned personal conflicts and stress, job insecurity and meaningless jobs. While valid, the idea that employment is beneficial for recovery must be qualified by the personal meanings attributed to these experiences, and the specific cultural and economic factors of each context.

Association between actigraphy-derived physical activity and cognitive performance in patients with schizophrenia

BACKGROUND

An association between low levels of physical activity and impaired cognitive performance in schizophrenia has been proposed, but most studies have relied on self-report measures of activity. This study examined the association between actigraphy-derived physical activity and cognitive performance adjusting for multiple covariates in patients with schizophrenia.

METHOD

Patients with schizophrenia (n = 199) were recruited from chronic psychiatric wards, and 60 age-, sex- and body mass index-matched comparison participants were recruited from the staff of two hospitals and universities. Physical activity was assessed objectively for 7 days using an ActiGraph. Cognitive performance was assessed with the Cognitrone test from the Vienna Test System and the Grooved Pegboard Test. Demographic variables, metabolic parameters, positive and negative symptoms, duration of illness and hospitalization, and medication use were included as covariates. Pearson correlations and multivariable linear regressions were conducted to examine the associations between physical activity levels and cognitive performance.

RESULTS

Patients with schizophrenia were less physically active and had poorer performance on attention/concentration and speed of processing than the comparison group. Patients with schizophrenia who spent more time in light physical activity showed better performance on attention/concentration (β = 0.198, p = 0.020) and speed of processing (β= -0.169, p = 0.048) tasks than those who were less active. Cognitive performance was also associated with moderate-vigorous physical activity, but the effect was no longer significant once light physical activity had been taken into account.

CONCLUSIONS

This study provides evidence for a positive association between objectively measured light physical activity and cognitive performance in people with schizophrenia, after adjustment for multiple confounders.

Effectiveness of individual placement and support supported employment for young adults

AIM

The individual placement and support (IPS) model of supported employment was first developed in community mental health centres for adults with severe mental illness. While IPS is an established evidence-based practice in this broad population, evidence on its effectiveness focused specifically on young adults has been limited. The current study aimed to address this gap.

METHODS

To investigate the effects of IPS on young adults, the authors conducted a secondary analysis on a pooled sample of 109 unemployed young adults (under age 30) from four randomized controlled trials employing a common research protocol that included a standardized measurement battery and rigorous fidelity monitoring. Researchers assessed these participants over 18 months on nine competitive employment outcome measures.

RESULTS

On all measures, the IPS group had significantly better employment outcomes. Overall, 40 (82%) of IPS participants obtained employment during follow-up compared with 25 (42%) of control participants, χ(2) = 17.9, P < .001. IPS participants averaged 25.0 weeks of employment, compared with 7.0 weeks for control participants, t = 4.50, P < .001.

CONCLUSIONS

The current analysis supports a small number of previous studies in showing that IPS is highly effective in helping young adults with severe mental illness to attain competitive employment. When young adults acquire competitive jobs and initiate a path towards normal adult roles, they may avoid the cycle of disability and psychiatric patient roles that are demeaning and demoralizing.

Recovery in Schizophrenia: What Consumers Know and Do Not Know

The recovery model has permeated mental health systems by leading to the development of new psychiatric interventions and services and the reconfiguration of traditional ones. There is growing evidence that these interventions and services confer benefits in clinical and recovery-oriented outcomes. Despite the seeming adoption of recovery by policy makers, the transformation of mental health systems into recovery-oriented systems has been fraught with challenges.

Predictors of vocational activity over the first year in inner-city early intervention in psychosis services

AIM

Work and educational activities are an important part of recovery for young people with psychosis, and improving vocational outcomes is a key target for early intervention services (EIS). This study evaluated predictors of vocational activity for first-episode psychosis (FEP) patients during the first year of EIS care. It was hypothesized that longer duration of untreated psychosis (DUP) and minority ethnic status would predict poorer vocational outcomes, whereas a history of good vocational functioning would predict better vocational functioning during follow up.

METHODS

FEP patients aged 14-35 years, who presented to seven EIS in London, UK, between 2003 and 2010, were followed for 1 year. Sociodemographic, clinical and vocational information (qualifications obtained and paid employment) were collected using the MiData audit tool at entry to EIS and 1 year later.

RESULTS

Approximately one-third of patients (n = 345/1013) were studying or employed at some point during the first year of EIS care. Baseline vocational activity was the strongest predictor of vocational functioning during 1 year of follow up. Moreover, employment prior to entry into EIS strongly predicted change in vocational activity during 1 year of follow up. Individuals with DUP <6 months or of Asian or black African origin were more likely to be studying than their white British counterparts.

CONCLUSION

This study confirms that a significant proportion of FEP patients are able to engage in meaningful vocational activities even within the first year of EIS care. However, services need to focus more resources on getting patients with poor educational or employment histories into training programmes to improve their vocational outcomes.

Psychosis, Socioeconomic Disadvantage, and Health Service Use in South Australia: Findings from the Second Australian National Survey of Psychosis

The association between mental illness and poor physical health and socioeconomic outcomes has been well established. In the twenty-first century, the challenge of how mental illnesses, such as psychosis, are managed in the provision of public health services remains complex. Developing effective clinical mental health support and interventions for individuals requires a coordinated and robust mental health system supported by social as well as health policy that places a priority on addressing socioeconomic disadvantage in mental health cohorts. This paper, thus, examines the complex relationship between socioeconomic disadvantage, family/social supports, physical health, and health service utilization in a community sample of 402 participants diagnosed with psychosis. The paper utilizes quantitative data collected from the 2010 Survey of High Impact Psychosis research project conducted in a socioeconomically disadvantaged region of Adelaide, SA, Australia. Participants (42% female) provided information about socioeconomic status, education, employment, physical health, contact with family and friends, and health service utilization. The paper highlights that socioeconomic disadvantage is related to increased self-reported use of emergency departments, decreased use of general practitioners for mental health reasons, higher body mass index, less family contact, and less social support. In particular, the paper explores the multifaceted relationship between socioeconomic disadvantage and poor health confronting individuals with psychosis, highlighting the complex link between socioeconomic disadvantage and poor health. It emphasizes that mental health service usage for those with higher levels of socioeconomic disadvantage differs from those experiencing lower levels of socioeconomic disadvantage. The paper also stresses that the development of health policy and practice that seeks to redress the socioeconomic and health inequalities created by this disadvantage be an important focus for mental health services. Such health policy would provide accessible treatment programs and linked pathways to illness recovery and diminish the pressure on the delivery of health services. Consequently, the development of policy and practice that seeks to redress the socioeconomic and health inequalities created by disadvantage should be an important focus for the improvement of mental health services.

Employment and the associated impact on quality of life in people diagnosed with schizophrenia

A systematic review was conducted to assess the employment rate of people with schizophrenia. Additionally, information from the selected studies concerning factors associated with employment and health-related quality of life (HRQoL) was examined. Employment rates ranged from 4% to 50.4%. The studies differed considerably in design, patient settings, and methods of recruitment. The most frequently reported factors associated with employment were negative and cognitive symptoms, age of onset, and duration and course of the disease. Individual characteristics associated with unemployment were older age, lower education, and sex (female). Additionally, environmental factors, eg, the availability of welfare benefits and vocational support programs, seemed to play a role. Generally, being employed was positively associated with HRQoL. However, the causal direction of this association remained unclear, as studies on the bidirectional relationship between employment and HRQoL were lacking.

Insight development in schizophrenia: the construction of dangerousness in relapse

Mental health professionals believe that lack of insight is a major problem in schizophrenia because it significantly interferes with adherence to medical treatment. Yet few researchers have attempted to ask people with schizophrenia for their views on how insight develops and impacts on their quality of life. We explored these questions in interviews and focus groups with 19 Canadian people who had been diagnosed with schizophrenia and identified as having good insight, and with New Zealand and Canadian treatment providers. We found that participants developed insight in three stages, which we labeled the period of chaos, the dynamic period, and the period of wisdom. Crises led participants to realize that their safety and their relationships with loved ones would continue to be dangerously imperiled unless they made sustained efforts to maintain wellness. We propose the Theory of Dangerousness to explain how participants developed and maintained their motivation to remain well.

Subtyping first-episode non-affective psychosis using four early-course features: potentially useful prognostic information at initial presentation

AIM

Heterogeneity of symptoms, course and outcomes in primary psychotic disorders complicates prognosis, treatment and diverse aspects of research. This study aimed to identify interpretable subtypes of first-episode non-affective psychosis based on four early-course features (premorbid academic functioning, premorbid social functioning, duration of the prodrome and age at onset of psychosis).

METHODS

Data from 200 well-characterized patients hospitalized in public-sector inpatient units for first-episode non-affective psychosis were used in latent profile analyses. Derived subtypes were then compared along a number of clinical dimensions using analyses of variance.

RESULTS

Using four early-course features, three classes were derived. A good premorbid/short prodrome subtype was characterized by a lower severity of positive symptoms, better social/occupational/global functioning, and a shorter duration of untreated psychosis; a poor premorbid/early onset subtype demonstrated greater negative and preoccupation symptoms, as well as greater psychosocial problems; and a long prodrome/late onset subtype was characterized by greater dysphoric symptoms.

CONCLUSIONS

Findings indicate a need for further research with first-episode samples on the utility of subtyping based on early-course (premorbid, prodromal and onset-related) characteristics. Such efforts could enhance the parsing of heterogeneity, thereby advancing clinical practice and research.

Measuring psychosocial outcome is good

PURPOSE OF REVIEW

Poor psychosocial functioning in schizophrenia can be conceptualized as an early indicator of chronic neurodevelopmental illness. Alternatively, impaired psychosocial functioning could be the result of social and environmental factors associated with the onset of psychotic illness. We review recent evidence on psychosocial outcome in the early phases of psychotic illness, when young people are less removed from their developmental trajectory, any brain changes may be mutable and there may be greater opportunity for intervention.

RECENT FINDINGS

In samples with first-episode psychosis, poor premorbid functioning, stable negative symptoms and impaired social cognition and neurocognition may indicate individuals likely to experience poor psychosocial outcome. There is also some evidence of social/environmental predictors of poor outcome. Recent findings from at-risk samples suggest similar patterns, although more research is needed.

SUMMARY

It is likely that for some patients poor psychosocial outcome is the result of longstanding neurological changes, whereas for others it is related to the secondary consequences of having psychosis. We suggest that measuring psychosocial outcome in the early stages of psychosis is important for our understanding of the cause of schizophrenia, but argue for the importance of the patient's subjective view on their psychosocial recovery.

Psychosocial outcome in patients at clinical high risk of psychosis: a prospective follow-up

PURPOSE

In patients at clinical high risk (CHR) of psychosis, transition to psychosis has been the focus of recent studies. Their broader outcome has received less attention. We studied psychosocial state and outcome in CHR patients.

METHODS

In the European Prediction of Psychosis Study, 244 young help-seeking CHR patients were assessed with the Strauss and Carpenter Prognostic Scale (SCPS) at baseline, and 149 (61.1%) of them were assessed for the second time at the 18-month follow-up. The followed patients were classified into poor and good outcome groups.

RESULTS

Female gender, ever-married/cohabitating relationship, and good working/studying situation were associated with good baseline SCPS scores. During follow-up, patients' SCPS scores improved significantly. Good follow-up SCPS scores were predicted by higher level of education, good working/studying status at baseline, and white ethnicity. One-third of the followed CHR patients had poor global outcome. Poor working/studying situation and lower level of education were associated with poor global outcome. Transition to psychosis was associated with baseline, but not with follow-up SCPS scores or with global outcome.

CONCLUSION

The majority of CHR patients experience good short-term recovery, but one-third have poor psychosocial outcome. Good working situation is the major indicator of good outcome, while low level of education and non-white ethnicity seem to be associated with poor outcome. Transition to psychosis has little effect on psychosocial outcome in CHR patients. In treating CHR patients, clinicians should focus their attention on a broader outcome, and not only on preventing transition to psychosis.

Factors associated with occupational and academic status in patients with first-episode psychosis with a particular focus on neurocognition

PURPOSE

Employment rates for patients with chronic schizophrenia and first-episode psychosis (FEP) are low despite a larger variation in reported rates for FEP patients. This could partly be due to various methodologies used. The association between neurocognition and occupational functioning is well known in patients with chronic schizophrenia, while corresponding FEP studies are scarce and results more ambiguous. The current study investigated employment rates in a FEP sample using a threefold division of activity that separated students from employed and unemployed patients. Further, it investigated the relationship between students, employed and unemployed patients and clinical, neurocognitive, global, and social functioning.

METHODS

A total of 128 FEP patients with a broad DSM-IV schizophrenia spectrum disorder were assessed with clinical, neurocognitive, and global and social functioning measures. Three groups were defined based on occupational and academic status.

RESULTS

Twenty-six percent of the patients were employed, and 23% were students. The students and the employed patients performed better than the unemployed patients on clinical and global and social functioning measures. There were no differences between employed patients and students on any of the investigated measures, although there was a non-significant trend for the students to show better working memory capacity compared to the other two groups.

CONCLUSIONS

Students and employed patients showed better clinical, global and social functioning compared with unemployed patients. There were no significant differences between the three groups on neurocognitive measures. The results pose an argument for grouping the students with the employed patients if a dichotomous variable is preferred.