Duration of active psychosis and functional outcomes in first-episode non-affective psychosis

The relationship between levels of solution-focused thinking and internalized stigma and social functionality in mental disorders

OBJECTIVE

This study was conducted to determine the effect of the level of solution-focused thinking on internalized stigma and social functionality in mental illnesses.

DESIGN AND METHODS

This descriptive study was conducted with 497 patients with various mental disorders.

FINDINGS

A negative and strong correlation was found between the Solution-Focused Inventory and Internalized Stigma of Mental Illness Scale scores of the participants (r = -0.682, p = 0.001). A positive and weak correlation was found between the participants' Solution-Focused Inventory and Social Adaptation Self-Evaluation Scale scores (r = 0.396, p = 0.001).

PRACTICE IMPLICATIONS

It was determined that, as the solution-focused thinking levels of individuals with mental disorders increase, their level of internalized stigma decreases, and their social functionality increases.

The interrelationships of motivation, positive symptoms, stigma, and role functioning in early psychosis

AIM

Avolition, or the lack of motivation, has consistently been shown to be a significant predictor of poor psychosocial outcome, with decreased overall motivation as the single strongest predictor of poor work or school outcome in first episode psychosis. This study aimed to better understand the ways in which motivation impacts work and school functioning. This study first examined the factors related to motivation in people recovering from a recent onset of psychosis, then explored the unique interrelationships between positive symptoms, stigma, and motivation and how they influence role functioning.

METHODS

A total of 40 participants with early psychosis were recruited for this cross-sectional design study; with a mean of 14.5 months of treatment prior to study assessment.

RESULTS

Neither experienced nor internalized stigma were related to motivation in this sample, but internalized stigma was related to work and school functioning. Positive symptoms were significantly inversely related to both work and school functioning and motivation, with mediation analyses showing that motivation significantly mediates the relationship between positive symptoms and role functioning.

CONCLUSION

This relationship may shed light on the link between motivational deficits and work and school outcomes early in the course of psychosis, an area of critical importance for early intervention.

Effectiveness of a community health worker-led case management programme to improve outcomes for people with psychotic disorders in Thailand: a one-year prospective cohort study

BACKGROUND

Intensive case management (ICM) programmes for psychotic patients are effective in improving outcomes, but often unfeasible in resource-poor settings, as they typically require extensive human resources and expertise. We developed and evaluated the effectiveness of a less intensive case management program (LICM), led by community health workers, on one-year social functioning and service use.

METHODS

A prospective cohort study was conducted on patients aged 18 and above residing in a hospital catchment area. Outcomes were compared between LICM (n = 64) and non-LICM participants (n = 485). A counterfactual framework approach was applied to assess causal effects of the LICM on outcomes. The programme effectiveness was analyzed by augmented-inverse probability of treatment weighting (AIPW) to estimate potential outcome mean (POM) and average treatment effect (ATE). Outcomes were employment status and use of emergency, inpatient and outpatient services. Analyses were stratified by the number of previous psychotic relapse (≤ 1, > 1) to assess heterogeneity of treatment effect on those in an early and later stages of psychotic illness.

RESULTS

In the early-stage cohort, the likelihood of being employed at one year post-baseline was significantly greater in LICM participants than non-LICM participants (ATE 0.10, 95%CI 0.05-0.14, p < 0.001), whereas service use of all types, except outpatient, was not significantly different between the two groups. In the later-stage cohort, the likelihoods of employment between the two groups at post-baseline were similar (ATE -0.02, 95%CI -0.19-0.15, p = 0.826), whereas service use of all types was significantly higher in LICM participants.

CONCLUSION

LICM in a setting where community mental services are scarce may benefit those at an early stage of psychotic illness, by leading to better social functioning and no higher use of unscheduled services at the end of the programme, possibly through their better prognosis and medication adherence. A more intensive case management model may be appropriate for those in a later stage of the illness.

Long-Term Real-World Effectiveness of Aripiprazole Once-Monthly. Treatment Persistence and Its Correlates in the Italian and Spanish Clinical Practice: A Pooled Analysis

BACKGROUND

One of the most significant risk factors for relapse and hospitalization in schizophrenia is non-adherence to antipsychotic medications, very common in patients with schizophrenia. The aim of this analysis was to evaluate the treatment persistence to aripiprazole once-monthly (AOM) and the factors affecting it in the pooled population of two similar studies performed previously in two different European countries.

METHODS

Pooled analysis of two non-interventional, retrospective, patient record-based studies: DOMINO and PROSIGO. Both analyzed treatment persistence after starting AOM treatment in the real-world setting. The primary variable was persistence with AOM treatment during the first 6 months after treatment initiation. A multivariate Cox regression model was used to evaluate the influence of several baseline characteristics on the persistence.

RESULTS

The study population comprised 352 patients included in the two studies, DOMINO (n = 261) and PROSIGO (n = 91). The overall persistence with AOM treatment at the end of the 6-month observation period was 82.4%. The multivariate analysis showed that patients with "secondary school" level of education present a 67.4% lower risk of discontinuation within 6 months after AOM initiation when compared with "no/compulsory education patients" (p = 0.024). In addition, patients with an occupation present a 62.7% lower risk of discontinuation when compared with unemployed patients (p = 0.023). Regarding clinical history, patients with a Clinical Global Impression-Severity scale (CGI-S) score ≤3 present a 78.1% lower risk of discontinuation when compared with patients with a CGI-S score ≥6 (p = 0.044), while patients with a time since schizophrenia diagnosis ≤8.4 years present a 52.9% lower risk of discontinuation when compared with the rest of patients (p = 0.039).

CONCLUSION

The AOM persistence rate observed in this study was 82.4%, which was higher than that reported in clinical trials, aligned with other real-life studies and higher than reported for other long-acting injectable antipsychotics. The persistence rate was high in complex patients, although patients with higher level of education, active occupation, lower initial CGI-S score and shorter time since the diagnosis of schizophrenia appear to be more likely to remain persistent with AOM during the 6 months after initiation.

Entire duration of active psychosis and neurocognitive performance in first-episode non-affective psychosis

AIM

To explore if the entire duration of active psychosis (DAP) is related to neurocognitive performance at baseline and at 3-year follow-up in patients with first episode psychosis (FEP).

METHODS

DAP was estimated for 481 FEP patients. A neuropsychological battery was administered to measure neurocognitive specific domains, and a global indicator of neurocognitive impairment (global deficits score, GDS) was calculated. According to the DAP quartiles, four subgroups were formed, and these were compared. In addition, a logistic regression analysis was carried out to predict neurocognitive impairment at 3-year follow-up.

RESULTS

FEP patients with the longest DAP (more than 18.36 months) presented a more severe global neurocognitive impairment evidenced in their GDS, both at baseline (F = 5.53; p˂ .01) and at 3-year follow-up (F = 4.16; p˂ .01). Moreover, a subgroup of participants with DAP between 7.40 and 18.36 months showed a specific attentional decline over the 3-year follow-up (F = 3.089; p˂ .05).The logistic regression model showed that sex (Wald = 7.29, p < .010), premorbid adjustment (Wald = 7.24, p < .010), attention (Wald = 12.10, p < .001), verbal memory (Wald = 16.29, p < .001) and visual memory (Wald = 9.41, p < .010) were significant predictors of neurocognitive impairment 3 years after the FEP. The variables composing the DAP were not significant predictors in this model.

CONCLUSIONS

DAP seems to be related to global neurocognitive impairment in FEP patients. These findings contribute in several ways to our understanding of the effects of active psychosis on the brain, and provide the basis for future research.

Prevalence of hepatitis C in patients with non-affective psychotic disorders

INTRODUCTION

the goal of this study was to determine the prevalence of hepatitis C virus (HCV) infection in patients with non-affective psychotic disorders and to compare it with population-based data.

MATERIAL AND METHODS

an observational study was performed that measured anti-HCV antibodies (HCV-RNA in case of seropositivity) in 425 serum samples from patients with non-affective psychosis. Eight patients were positive for anti-HCV (1.9 %) and five had detectable HCV-RNA (1.2 %). The prevalence of viremia was significantly higher than in the general population (OR: 5.4; 95 % CI: 1.9-14.6).

CONCLUSIONS

patients with non-affective psychotic disorder have a higher prevalence of active infection than that of the general population and should undergo systematic screening.

Aripiprazole vs Risperidone for the acute-phase treatment of first-episode psychosis: A 6-week randomized, flexible-dose, open-label clinical trial

Selecting the first antipsychotic agent for the acute phase of a first episode of psychosis (FEP) is a critical task that may impact on the long-term outcome. Despite that, there is a lack of research comparing head-to-head different second-generation antipsychotics at this stage. The aim of this study was to compare the effectiveness of aripiprazole and risperidone in the treatment of the acute phase after a FEP. For that purpose, from February 2011 to October 2018, a prospective, randomized, open-label study was undertaken. Two hundred-sixty-six first-episode, drug-naïve patients were randomly assigned to aripiprazole (n = 136), or risperidone (n = 130) and followed-up for 6-weeks. The primary effectiveness measure was all-cause treatment discontinuation. In addition, an analysis based on intention-to-treat principle was conducted to assess clinical efficacy. The overall dropout rate at 6-week reached 19.5%. Effectiveness measures were similar between both treatment groups as treatment discontinuation rates (χ2 = 1.863; p = 0.172) and mean time until all-cause discontinuation (log rank = 1.421; p = 0.233) showed no statistically significant differences. In terms of clinical efficacy, risperidone proved a statistically significant better performance according to BPRS mean change between baseline and 6-week total score (t = 3.187; p = 0.002). Patients under risperidone treatment were significantly more likely to suffer sex-related adverse events. In conclusion, no differences regarding effectiveness were found between aripiprazole and risperidone for the acute-phase treatment of FEP. Despite the importance of efficacy during this phase of treatment, selecting the most effective treatment for the long-term outcome, requires addressing safety and patient´s preferences.

Predictors of persistence in patients with schizophrenia treated with aripiprazole once-monthly long-acting injection in the Spanish clinical practice: a retrospective, observational study

Background

Poor adherence to antipsychotic drugs is a major problem in schizophrenia management and one of the most important risk factors for relapse and hospitalization. To date, there is little evidence on persistence predictors with long-acting injectable antipsychotics, especially with aripiprazole once-monthly (AOM). This study (NCT03130478) aimed to describe the impact of demographic and clinical characteristics on persistence with AOM treatment in real-world setting.

Methods

This was an observational, retrospective, non-interventional study that included adult patients with schizophrenia who were initiated on AOM during a schizophrenia-related hospitalization. Data were retrospectively collected from patients’ medical records. The primary variable was persistence with AOM, measured as the number of days from AOM initiation up to all-cause AOM discontinuation during the first six months after treatment index.

Results

140 patients were enrolled and 91 fulfilled the selection criteria. Six months after AOM initiation, 65 (71.4%) patients were still receiving AOM treatment, whereas 26 (28.6%) were not. The mean (standard deviation) time to AOM treatment discontinuation in the first six months was 138.1 (6.8) days, with most of the patients discontinuing at the first 28 days. The risk of AOM discontinuation in the first six months increases 1.05-fold annually since schizophrenia diagnosis (p=0.003); moreover, this risk increases 2.86-fold in patients with concomitant schizophrenia medication at AOM initiation compared to patients without concomitant schizophrenia treatments (p=0.02).

Conclusions

Main factors predicting persistence with AOM treatment at six months in clinical practice are fewer years since schizophrenia diagnosis and not receiving concomitant schizophrenia treatments at AOM initiation.

A network analysis approach to functioning problems in first psychotic episodes and their relationship with duration of untreated illness: Findings from the PAFIP cohort

BACKGROUND

The domains of functioning affected by first episode of psychosis (FEP) could be analysed as forming a network of interacting or even reinforcing elements. The reasons why longer duration of untreated psychosis (DUP) might be related to higher disability are not still clear. The aim of the present study is to evaluate how different areas of functioning are inter-related according to the length of DUP in patients with FEP, with a particular focus on studying the relative influence of each other according to lengthy delays in initial treatment.

METHOD

441 participants in an epidemiological and intervention program of first episode psychosis (PAFIP) were included in our study. Functioning problems at baseline were assessed with the WHO Disability Assessment Schedule (DAS). Three networks of functioning domains have been estimated according to the length of DUP.

RESULTS

All the DAS items took part in the different networks. We have not found differences across the edge weights in the short, medium and long DUP groups. The domains "social withdrawal", "participation in the household activities", "general interest and information", and "low level of activity" seem to act as bridge items with other areas of functioning in people with longer DUP.

CONCLUSIONS

Our results could have clinical implications for patients with longer DUP, in which case, social withdrawal, household activities, level of activity and general interest in the world around them, could be high-priority target areas of treatment, since they seem to be mediating the relation between others areas of functioning.

Active psychosis and pro-inflammatory cytokines in first-episode of psychosis

Higher levels of pro-inflammatory cytokines are consistently found in the serum of first episode psychosis (FEP) patients and this immune dysfunction could contribute to neural harm. On the other hand, lengthy periods of active psychosis during the early phases of the illness appear to be associated to worst functional outcome. We aim to explore the possible relationship between lengthy periods of active psychosis during early phases of the illness and the levels of pro-inflammatory cytokines. This is a prospective clinical study consisting of a 3-year clinical follow-up. We assessed the relation between the duration of active psychosis in patients with FEP and the serum levels of 21 cytokines at baseline and 3 months after initiating antipsychotic medication. We used the Human High Sensitivity T Cell Magnetic Bead Panel protocol from the Milliplex® Map Kit. The sample consisted of 59 patients with a FEP. The percentage of variation of the serum levels of the chemokine MIP-3α during the first 3 months of antipsychotic treatment and the score in negative psychotic symptoms 3 months after the initiation of antipsychotic medication, acted as predictors of the initial time to remission of positive psychotic symptoms. Our findings open the possibility to investigating the potential use of the variation in chemokine MIP-3α serum levels during the first months of antipsychotic treatment to identify a subtype of FEP patients that could benefit from an add-on treatment with immune modulators. CLINICALTRIALS.GOV ID: NCT02897167. DATE OF FIRST REGISTRATION: September 13, 2016. "Study of the Activation of Proinflammatory Pathways of Toll-like Receptors in Schizophrenia Patients (PAFIP_TLR)". https://clinicaltrials.gov/ct2/show/NCT02897167.

Duration of active psychosis during early phases of the illness and functional outcome: The PAFIP 10-year follow-up study

INTRODUCTION

Longer duration of active psychosis (presence of positive psychotic symptoms) has been associated to worsening of functional and symptomatic outcome in patients with a first-episode of psychosis. There could be a "critical period" of increased brain vulnerability in the early phases of the illness when the effect of active psychosis would be exceptionally pernicious.

OBJECTIVES

We aim to explore the impact of lengthy periods of active psychosis during early phases of illness on long-term functional outcome.

METHODS

This is a prospective clinical study. We assessed the effect of the duration active psychosis in patients with a first-episode of nonaffective psychosis on long-term social functioning and functional recovery. The study consisted of a 3-year clinical follow-up and a functional evaluation performed after a 10-year period.

RESULTS

The sample consisted of 169 patients with a first-episode of non-affective psychosis. The duration of active psychosis after treatment (DAT) during the 3-year clinical follow-up acted as predictor of social functioning at the 10-year functional evaluation (Wald: 10.705; p = .001), but not of functional recovery. The duration of untreated psychosis (DUP) did not act as a predictor of any of the two long-term measures of functional outcome.

CONCLUSIONS

Active psychosis in early phases of the illness seems to be correlated to worst long-term functionality. In this study the duration of active psychosis after treatment (DAT) was a better predictor of long-term outcome than the duration of untreated psychosis (DUP). Reducing DAT should be considered an important objective for early intervention programs.

Data regarding active psychosis and functional outcome, among other clinical variables, during early phases of the illness in first-episode psychosis in the PAFIP 10-year follow-up program

This article describes data related to the research study entitled "Duration of active psychosis during early phases of the illness and functional outcome: The PAFIP 10-year follow-up study." [1]. We present data concerning the clinical and sociodemographic characteristics of a sample of drug-naïve patients with a first episode of non-affective psychosis. The dataset was obtained from a 3-year longitudinal intervention program as part of an ongoing 10-year epidemiological study. The tables and figure shown present the data from the analysis between the active psychosis (presence of positive psychotic symptoms), among other sociodemographic and clinical predictor variables, recorded during the 3-year longitudinal intervention program and the evaluation of the functional outcome (social functioning and functional recovery) present at the 10-year mark. The data explores how those early parameters could influence long-term outcome.

Antipsychotic Treatment Effectiveness in First Episode of Psychosis: PAFIP 3-Year Follow-Up Randomized Clinical Trials Comparing Haloperidol, Olanzapine, Risperidone, Aripiprazole, Quetiapine, and Ziprasidone

BACKGROUND

Different effectiveness profiles among antipsychotics may be a key point to optimize treatment in patients suffering a first episode of psychosis to impact on long-term outcome. The aim of this study is to compare the clinical effectiveness of olanzapine, risperidone, haloperidol, aripiprazole, ziprasidone, and quetiapine in the treatment of first episode of psychosis at 3-year follow-up.

METHOD

From February 2001 to January 2011, 2 phases of a prospective, randomized, open-label study were undertaken. A total of 376 first-episode drug-naïve patients were randomly assigned to olanzapine (n = 55), risperidone (n = 63), haloperidol (n = 56), aripiprazole (n = 78), ziprasidone (n = 62), or quetiapine (n = 62) and followed up for 3 years. The primary effectiveness measure was all cause of treatment discontinuation. In addition, an analysis based on intention-to-treat principle was conducted in the analysis for clinical efficacy.

RESULTS

The overall dropout rate at 3 years reached 20.75%. Treatment discontinuation rates were significantly different among treatment groups (olanzapine = 69.09, risperidone = 71.43, aripiprazole = 73.08%, ziprasidone = 79.03%, haloperidol = 89.28%, and quetiapine = 95.53%) (χ2 = 79.86; P = .000). Statistically significant differences in terms of lack of efficacy, adherence, and tolerability were observed among treatment groups along the 3-year follow-up, determining significant differences in time to all-cause discontinuation (log-rank = 92.240; P = .000). Significant differences between treatments were found in the categories of sleepiness/sedation, increased sleep duration, akinesia, weight gain, ejaculatory dysfunction, extrapyramidal-symptoms, and amenorrhea.

CONCLUSIONS

Olanzapine, risperidone, and aripiprazole presented advantages for the first-line treatment of first episode of psychosis in terms of effectiveness. Identifying different discontinuation patterns may contribute to optimize treatment selection after first episode of psychosis.ClinicalTrials.gov Identifier: NCT02526030 https://clinicaltrials.gov/show/NCT02526030.

Predicting real-world functioning in outpatients with schizophrenia: Role of inflammation and psychopathology

Several studies indicate that negative and cognitive symptoms are determining factors of functioning in patients with schizophrenia. However, they do not usually include biological aspects, such as inflammatory markers. The current prospective study aims to identify clinical and biological factors predicting real-world functioning, at baseline and at one-year follow-up, of outpatients in an early stage of schizophrenia. Sample consist of 73 clinically stable patients with schizophrenia, of which 57 completed the one-year follow-up. Accurate psychopathology, functioning, and cognitive assessments were performed at baseline and follow-up (Positive and Negative Syndrome, Brief Negative Symptom, Calgary Depression, Personal and Social Performance Scales, and MATRICS Cognitive Consensus Battery). Biological biomarkers including anthropometric data and blood parameters were collected. Pearson correlation and multiple regression analyses including potential confounding factors were performed. Negative symptoms (especially asociality and avolition), along with the inflammatory biomarker interleukin-2, are the most important determining factors of poor real-world functioning in early-stage schizophrenia. The previous functioning, along with baseline cognitive performance in attention and vigilance, predicts functioning at one-year follow-up in these patients. Strategies aimed at improving negative and cognitive symptoms, as well as modifying certain inflammatory pathways, should be the targets to achieve functional recovery in the first years of schizophrenia.