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

A comparison of pathways to care in at-risk mental states and first episode psychosis: a mental health electronic clinical records analysis in the East of England, UK

PURPOSE

Delays in treatment for individuals experiencing early signs of psychosis are associated with poorer outcomes. Few people presenting with first episode psychosis (FEP) access early intervention in psychosis (EIP) services during the prodromal stage. In this study, we compared pathways to care (PtC) in people with At-Risk Mental States (ARMS) and FEP and explored the sociodemographic factors associated with accessing EIP during ARMS or FEP.

METHODS

Sociodemographic and PtC data were collected from the Cambridgeshire and Peterborough NHS Foundation Trust (CPFT) Research Database. All individuals referred and accepted to CPFT EIP services as either ARMS or FEP between 1st April 2018 and 31st October 2019 (N = 158) were included.

RESULTS

There was strong evidence that ARMS patients accessing EIP were younger and were less likely to have a minority ethnic status than FEP patients. In terms of PtC, ARMS patients had fewer numbers of contacts, were less likely to be referred via the acute services, less likely to be involuntarily admitted and had reduced family involvement in their help-seeking. No differences were identified between ARMS and FEP in terms of living circumstances, area-level deprivation, urbanicity, employment status, duration of PtC, or police involvement in PtC.

CONCLUSION

Our findings highlight that disparities exist between ARMS and FEP patients in terms of sociodemographic and PtC characteristics. Further research is required to replicate these findings and investigate the effectiveness of interventions to encourage and facilitate access to EIP at an earlier stage to improve outcomes.

Measures of Social and Occupational Function in Early Psychosis: A Systematic Review and Meta-analysis

Deficits in social and occupational function are widely reported in psychosis, yet no one measure of function is currently agreed upon as a gold standard in psychosis research. The aim of this study was to carry out a systematic review and meta-analysis of functioning measures to determine what measures were associated with largest effect sizes when measuring between-group differences, changes over time, or response to treatment. Literature searches were conducted based on PsycINFO and PubMed to identify studies for inclusion. Cross-sectional and longitudinal observational and intervention studies of early psychosis (≤5 years since diagnosis) that included social and occupational functioning as an outcome measure were considered. A series of meta-analyses were conducted to determine effect size differences for between-group differences, changes over time, or response to treatment. Subgroup analyses and meta-regression were carried out to account for variability in study and participant characteristics. One hundred and sixteen studies were included, 46 studies provided data (N = 13 261) relevant to our meta-analysis. Smallest effect sizes for changes in function over time and in response to treatment were observed for global measures, while more specific measures of social and occupational function showed the largest effect sizes. Differences in effect sizes between functioning measures remained significant after variability in study and participant characteristics were accounted for. Findings suggest that more specific measures of social function are better able to detect changes in function over time and in response to treatment.

Heterogeneity in the Course of Suicidal Ideation and its Relation to Suicide Attempts in First-Episode Psychosis: A 5-Year Prospective Study

OBJECTIVES

Although the risk of suicide is high in first-episode psychosis (FEP), little is known about the course of suicidal ideation and its relation to suicide attempts. Therefore, we aimed to identify 5-year trajectories of suicidal ideation and associated factors in FEP and compare how suicide attempts were distributed across these identified trajectories.

METHOD

This 5-year prospective study assessed suicidal ideation, suicide attempts and potentially associated factors through research interviews, chart review and coroners' reports in 382 FEP patients [mean age = 23.53 (SD = 3.61)] admitted to 2 5-year early psychosis services in Montreal, Canada. Trajectories were identified using a semiparametric mixture model, and associated factors with multinomial logistic regression.

RESULTS

Three suicidal ideation trajectories were identified: low and decreasing (n = 325, 85.08%); early decline, then increasing (n = 30, 7.85%), and persistent suicidal ideation (n = 27, 7.07%). Suicidal ideation prior to admission (OR = 2.85, 95% CI, 1.23 to 6.63, P < 0.05) and cocaine use disorder (OR = 6.78, 95% CI, 1.08 to 42.75, P < 0.05) were associated with the early decline, then increasing suicidal ideation trajectory. Persons with prior suicide ideation (OR = 4.33, 95% CI, 1.66 to 11.29, P < 0.05) and attempts (OR = 8.18, 95% CI, 2.39 to 27.97, P < 0.001) and alcohol use disorder (OR = 3.63, 95% CI, 1.4 to 9.42, P < 0.05) were more likely to belong to the persistent suicidal ideation trajectory, and to attempt suicide during follow-up.

CONCLUSIONS

Our study highlights heterogeneity in the course of suicidal ideation over 5 years and the importance of ongoing assessment of suicidal risk in FEP patients, particularly for patients who persistently report suicidal ideation, as they are likelier to engage in suicide attempts. Patients with factors associated with increasing or persistent suicidal ideation trajectories should be targeted for suicide prevention interventions from the early phase of follow-up. Given the small number of persons in these trajectories and the wide CIs for some factors, larger studies are however needed to further characterize who belongs in each group.

Return to the labour market in schizophrenia and other psychoses: a register-based Northern Finland Birth Cohort 1966 study

PURPOSE

The prospects and predictors of returning to the labour market after long-term work disability in psychoses are unclear. Our aim was to study the proportion and characteristics of persons with schizophrenia and other psychoses who return to the labour market after receiving a disability pension.

METHODS

In this 50-year follow-up study in the Northern Finland Birth Cohort 1966 (NFBC1966), national registers on demographics, care, and disability pensions were used to detect and characterize individuals who had been on a disability pension for psychiatric reasons. We compared individuals with schizophrenia (SZ, n = 223) or other psychoses (OP, n = 200) to those with non-psychotic psychiatric disorders (NP, n = 1815) regarding demographics and end of pension by cross-tabulations and logistic regression.

RESULTS

Of the 170 (74%) persons with SZ who had been on disability pension for a psychiatric reason, 15 (9%) returned to the labour market. Corresponding percentages were 19% for OP and 28% for NP. In SZ, being married, a later onset age of psychosis, and better school performance, and in OP and NP, having children predicted returning to the labour market. In all groups, a shorter length of the latest disability pension associated with returning to the labour market.

CONCLUSION

Although rare, it is possible to return to the labour market after a disability pension due to psychosis. Factors predicting a return to the labour market could be taken into account when planning rehabilitation.

Vulnerability to psychosocial disability in psychosis

Psychosocial disability affects a number of individuals with psychosis and often begins years before the formal onset of disorder. This suggests that for many, their psychosocial disability is enduring, and targeted interventions are therefore needed earlier in their developmental trajectories to ensure that psychosocial disability does not become entrenched. Poor psychosocial functioning also affects individuals with a range of different emerging mental health problems, putting these young people at risk of long-term social marginalisation and economic disadvantage; all of which are known risk factors for the development of psychosis. Identification of the markers of poor psychosocial functioning will help to inform effective treatments. This editorial will discern the early trajectories and markers of poor psychosocial outcome in psychosis, and highlight which individuals are most at risk of having a poor outcome. This editorial will also discuss whether early interventions are currently being targeted appropriately and will propose how intervention and preventative strategies can be implemented, to restore psychosocial trajectories in a way that enables young people to maximise their life chances.

Subjective and objective quality of life at first presentation with psychosis

AIM

Quality of life (QOL) in first-episode psychosis (FEP) is impaired when compared to non-clinical controls and several clinical factors including symptoms and untreated psychosis have been linked with poorer QOL. Measurement methods are varied, however, resulting in inconsistent findings and there is a need to simultaneously combine subjective and objective measures of QOL.

METHODS

We examined both subjective (n = 128) and objective QOL (n = 178) in a catchment area cohort of individuals with FEP (n = 222) to determine correspondence between patient satisfaction and clinician-rated functional domains. We also examined the contribution of sociodemographic and clinical characteristics to both subjective and objective QOL.

RESULTS

There were complex relationships between subjective and objective QOL domains in that patient's assessments of health status (psychological well-being, symptoms/outlook, physical health) were not correlated with clinicians but there were strong correlations between social functioning domains (occupation, social relations, financial status and activities of daily living) assessed by patients and clinicians. Longer duration of untreated psychosis, being treated as an inpatient, higher positive symptoms and poorer social functioning in client-rated QOL domains predicted poorer objective QOL.

CONCLUSION

We found that both subjective and objective assessments of QOL displayed a degree of clinical utility demonstrated by relationships between clinical factors and both QOL perspectives. Moreover, the lack of association between patient characteristics and QOL shows some potential malleability of QOL outcomes through intervention as there were several clinical factors linked with both subjective and objective QOL.

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.

Do better communication skills promote sheltered employment in schizophrenia?

Alongside various psychopathological symptoms and neurocognitive dysfunctions, communication skill impairments may be considered core feature of schizophrenia. Although many studies examined the relation between employment status and neurocognition in schizophrenia, we still know very little about the role of communication skills in vocational status among people with schizophrenia. The purpose of this study is to identify the most characteristic communication, neurocognitive and social cognition differences which separate the employed schizophrenia outpatients from those who do not work. The study included three groups: 33 schizophrenia outpatients employed in social firms, 29 unemployed schizophrenia outpatients participating in occupational therapy and sex & age matched 31 healthy controls. We assessed communication skills, global cognitive functioning, executive functions, memory, social cognition as well as severity of psychopathology. Our results indicate that the most characteristic differences between employed and unemployed schizophrenia outpatients are associated with selective language and communication skills, i.e. paralinguistic aspects of communication, understanding of discrete meaning of linguistic context and figurative meaning of language. We find no significant differences between both clinical groups with regard to neurocognition and social cognition. Moreover, unemployed group had more severe psychopathology than the employed group, so we re-analyzed results controlling for symptom severity. The only differences that endured were related to general communication skills and explanation of pictured metaphors, but only when controlling solely for positive or negative syndrome. In conclusion, the present study indicates that employment in schizophrenia is associated with better symptomatic remission and communication skills, but not with better neurocognition and social cognition.

Influence of cognition, premorbid adjustment and psychotic symptoms on psycho-social functioning in first-episode psychosis

OBJECTIVE

The aim of this study is to evaluate the relationship between psycho-social functioning and symptoms, cognitive function, and premorbid adjustment, in patients with a first-episode psychosis.

METHOD

Clinical data were obtained from 90 patients, who were assessed with the Disability Assessment Scale (DAS-sv), the Positive and Negative Syndrome Scale (PANSS), the Premorbid Adjustment Scale (PAS-S) and with a battery of cognitive tests including Trail Making Tests A and B (TMTA- B), Continous Performance Test (CPT), some subscales of the Wechler Adult Intelligence Scale (WAIS), and the Verbal Learning Test España-Complutense (TAVEC).

RESULTS

The results of the study suggest that psycho-social functioning in first-episode psychosis is significantly related to: positive, negative, excitative, affective and disorganized symptoms, social premorbid adjustment, cognitive flexibility, working memory, short term and long term memory. Of these, those which best explained psycho-social functioning are the positive and excitative symptoms, premorbid adjustment, flexibility and memory.

CONCLUSIONS

These findings highlight the importance early intervention on cognitive and clinical variables to help provide a better psycho-social functioning in people with a first-episode of psychosis.

The impact of premorbid adjustment, neurocognition, and depression on social and role functioning in patients in an early psychosis treatment program

OBJECTIVE

Functional impairments are debilitating concomitants of psychotic disorders and are present early in the illness course and, commonly, prior to psychosis onset. The factors affecting social and role functioning in early psychosis (EP) following treatment are unclear. We evaluated whether six months of participation in the PREP(R), Boston, EP treatment program, part of a public-academic community mental health center, was related to improvements in social and role functioning and whether premorbid adjustment in adolescence, baseline neurocognition, and depression symptoms predicted functional improvement.

METHOD

The Global Functioning Social and Role scales, MATRICS neurocognitive battery, and Calgary Depression Scale were assessed at baseline and six months during naturalistic treatment, while premorbid adjustment was measured at baseline. All participants were psychotic disorder patients in PREP(R) (n = 46 with social functioning and 47 with role functioning measures at both time points).

RESULTS

Large improvements were observed in role functioning (d = 0.84) and medium to large improvements were observed in social functioning (d = 0.70). Models consisting of adolescent premorbid adjustment and change in depression symptoms predicted social and role functioning change, whereas neuropsychological functioning did not.

CONCLUSIONS

Substantial improvements in social and role functioning were observed among this sample participating in a recovery-based EP program. The impact of clinical factors on social and role functioning was highlighted. Further studies of premorbid adjustment in adolescence and the treatment of depression in EP programs in controlled treatment trials are needed to confirm these findings.

Clinical and cognitive predictors of vocational outcome in first-episode schizophrenia: a prospective 3 year follow-up study

Schizophrenia is associated with pronounced vocational impairment. Previous research has mostly focused on chronic patients and few studies were conducted to investigate predictors of work outcome in first-episode populations. The impact of cognitive dysfunction on employment outcome in early psychosis was under-studied. In this study, we prospectively followed up 93 patients aged 18-55 years presented with first-episode schizophrenia-spectrum disorder for 3 years with an aim to identify early clinical and cognitive predictors of vocational outcome. Pre-morbid adjustment, baseline symptomatology and cognitive functions, and employment outcome were assessed. Result indicated that approximately half of the patients (53.8%) were engaged in full-time work at intake and at 3 years. Pre-morbid adjustment, baseline occupational status and Wisconsin Card Sorting Test (WCST) performance were found to predict vocational outcome. Analysis on a subgroup of patients who were unemployed at intake showed that subjects who remained unemployed over 3 years had poorer WCST performance and more severe positive symptoms at baseline than those having job attainment during follow-up. Our results thus confirmed predictive value of pre-morbid functioning and baseline occupational status on vocational outcome. In addition, our findings suggested that executive function might be a critical cognitive determinant of employment outcome in the early course of schizophrenia.

Factors associated with a positive occupational outcome during long-term central stimulant treatment in adult ADHD

There is a lack of long-term studies of central stimulant (CS) treatment in adult attention-deficit/hyperactivity disorder (ADHD), and studies on functional outcomes like occupational status are rare. The current study investigated occupational status in adult ADHD patients before and after long-term CS treatment (median duration of treatment 33 months) and aimed to identify variables associated with improvement in occupational status. The collection of data was based on a naturalistic, retrospective approach using the medical records of a sample of all 117 adult ADHD patients consecutively starting treatment with CS in a specific catchment area in Norway in the period 1997 to May 2005. Most patients did not improve in occupational status during long-term CS treatment. The improved group had significantly higher baseline ADHD symptoms as measured by the general adult ADD symptom checklist (83.7 vs. 76.2, p=0.024) and had a significantly shorter period from the first contact with adult psychiatry until they got the ADHD diagnosis (11.7 vs. 50.9 months, p=0.001). The results indicate that long-term CS treatment itself may have limited effect on occupational status in functionally impaired and highly comorbid patients with adult ADHD. A high baseline ADHD symptom level may be related to a superior outcome in occupational status.

A comparative analysis of disability in individuals with bipolar affective disorder and schizophrenia in a sub-Saharan African mental health hospital: towards evidence-guided rehabilitation intervention

PURPOSE

Bipolar affective disorder (BAD) and schizophrenia are two severe psychotic conditions that are associated with disability. The present study was designed to compare the pattern of disability between clinically stable individuals with BAD and schizophrenia in a sub-Saharan mental health facility.

METHODS

A total of 200 consecutive participants (made up of 100 each among clinically stable individuals with BAD and schizophrenia) were recruited. All participants had their diagnoses confirmed using Structured Clinical Interview for DSM-IV-TR Axis I Disorders (SCID), after which the designed questionnaire and the 36-item World Health Organisation Disability Assessment Schedule interview (WHODAS II) were administered to them.

RESULTS

In this study, the level of disability among participants with BAD was better compared to those with schizophrenia as determined by mean WHODAS score of 24.93 and 27.02, respectively. Similarly, there was a significant difference between participants with BAD and schizophrenia with respect to four domains of the WHODAS-II, viz, self-care (p < 0.001), getting along with others (p < 0.001), life activities (p < 0.001) and participation in the society (p < 0.001). The factors that were significantly associated with disability in the two groups (BAD and schizophrenia) were: unemployment status (p < 0.001) and remittance source of income (p < 0.001), while those that spent not more than ₦2,000 (13 dollars) per month on treatment (p = 0.004) were observed to be less disabled.

CONCLUSIONS

Overall, participants with BAD fared better in the level of disability and most of the measured domains of disability in comparison with those with schizophrenia. Both socio-demographic and treatment-related factors seem to define the pattern disability among participants. Thus, evidence-guided preventive and rehabilitative treatment strategies directed against functional impairment using prioritized model among individuals with BAD and schizophrenia are advocated.

Occupational functioning, symptoms and neurocognition in patients with psychotic disorders: investigating subgroups based on social security status

PURPOSE

Reported employment rates for patients with psychosis are low, but vary partly depending on illness phase. Illness-related factors such as neurocognition and negative symptoms are associated with occupational functioning, while external factors may also act as barriers for employment. The current study investigated the relationship between neurocognition, symptoms and employment using a threefold division of employment status: employed, receiving temporary benefits and receiving disability benefits. The latter group was divided into two based on level of social functioning.

METHODS

A total of 155 patients with broad DSM-IV schizophrenia spectrum disorder were assessed with clinical, neurocognitive and social and occupational functioning measures. Group differences were analyzed with ANOVAs and hierarchical regression analysis.

RESULTS

Thirteen percent were employed, 52 % received temporary benefits and 35 % received disability benefits. There were no differences in symptom level and neurocognitive functioning between groups. Among patients on disability benefits, the subgroup with higher social functioning had fewer negative and general symptoms and a trend for better neurocognition compared with those with lower social functioning, thus being more similar to employed patients. Negative symptoms and executive functioning explained 26 % of the variance in social functioning for patients receiving disability benefits.

CONCLUSIONS

The association between neurocognition and employment may not be as strong as previously assumed, due to external factors that may influence this relationship. Patients on disability benefits rated high on social functioning showed similarities with employed patients. This could imply that these patients have some work capacity. This issue needs further investigation.

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.