Predictors of favourable outcome in young people with a first episode psychosis without antipsychotic medication

Influencing factors of medication adherence in schizophrenic patients: a meta-analysis

Medication adherence of schizophrenic patients is a growing public health problem. We conducted a meta-analysis on the influencing factors of medication compliance in schizophrenic patients. We searched PubMed, Embase, Cochrane Library, and Web Of Science for relevant articles published up to December 22, 2022. Combined odds ratios (ORs) and 95% confidence intervals (CIs) were used to assess influencing factors. Egger's test, funnel plot, the trim and fill method, and meta-regression analysis were used to assess publication bias. A total of 20 articles were included in the analysis. Twenty influencing factors were divided into seven categories: drug factors (OR = 1.96, 95% CI: 1.48-2.59), problem behavior (OR = 1.77, 95% CI: 1.43-2.19), income and quality of life (OR = 1.23, 95% CI: 1.08-1.39), personal characteristics (OR = 1.21, 95% CI: 1.14-1.30), disease factors (OR = 1.14, 95% CI: 1.98-1.21), support level (OR = 0.54, 95% CI: 0.42-0.70), and positive attitude and behavior (OR = 0.52, 95% CI: 0.45-0.62). This meta-analysis found that drug factors, disease factors, problem behavior, low income and quality of life, and factors related to personal characteristics appear to be risk factors for medication adherence in people with schizophrenia. And support level, positive attitude and behavior appear to be protective factors.

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.

Early intervention services, patterns of prescription and rates of discontinuation of antipsychotic treatment in first-episode psychosis

AIMS

Non-compliance is still an important problem in psychotic patients. Although antipsychotic (AP) treatment leads to a decrease in psychotic relapses, there are no clear recommendations about how long treatment should be maintained after first-episode psychosis (FEP) and no indication of the rates and causes of treatment withdrawal in this group.

METHODS

We evaluated a large sample of patients with FEP for 2 years to compare the time to all-cause treatment discontinuation of AP drugs and the time to the first relapse. We collected the sociodemographic and psychopathological characteristics of the sample. The number of relapses was also recorded.

RESULTS

A total of 310 FEP patients were assessed across seven early intervention teams (mean age = 30.2 years; SD = 11.2). The most prevalent diagnosis at baseline was psychotic disorder not otherwise specified (36.1%), and the most commonly used APs were risperidone (26.5%) and olanzapine (18.7%). A lack of efficacy was the most frequent reason for the withdrawal of the first AP prescribed, followed by non-compliance. There were no differences in the relapse rates between different APs. Patients treated with long-acting injectable (LAI) APs presented less disengagement from services than patients treated with oral APs.

CONCLUSIONS

Although there were no differences between the different APs in terms of relapse rates, LAIs had higher retention rates than oral APs in early intervention services. Compliance is still an important issue in Psychiatry, so clinicians should use different strategies to encourage it, such as the use of LAI treatments.

Premorbid functioning in schizophrenia spectrum disorders with comorbid substance use: A systematic review

Premorbid functioning has been related with several clinical features and prognosis of schizophrenia spectrum disorders. Comorbidity with substance use is highly prevalent and usually hinders clinical improvement in this kind of psychiatric disorders. This systematic review analyzes the differences in the premorbid functioning of subjects with a schizophrenia spectrum disorder with substance use (SSD+, dual psychosis) or without it (SSD-). A systematic review (PRISMA guidelines), including search in electronic databases (MEDLINE, Web of Science, and Cochrane Library), was performed. 118 published works were considered of which only 20 met our inclusion criteria. Although there is a great variability in methodologies, diagnoses included, and substances used, studies using the Premorbid Functioning Scale to assess the academic and/or social domains found that SSD+ subjects had a poorer academic but better social premorbid functioning than those with SSD-. Current evidence is not conclusive, so additional studies are required to integrate intervening factors in order to clarify the clinical implications of premorbid functioning to improve the course and therapeutic response of patients.

'I can see clearly now': clarifying the role of psychiatry in global disaster

OBJECTIVE

First, to review the principles and practice of disaster psychiatry, in light of recent global events. Second, to identify opportunities for research.

METHOD

A literature review of the MEDLINE database, UpToDate and the Cochrane Library was conducted. Reference lists were also reviewed.

RESULTS

Psychiatrists are well-positioned to contribute to positive outcomes at all stages of the disaster response. These contributions derive from their roles as doctors, mental illness specialists and clinical leaders.

CONCLUSION

A novel framework for the psychiatrist's contributions was proposed. Specific knowledge of disaster psychiatry may be worthwhile, and establishment of a public disaster psychiatry centre is reasonable. Research should further examine the role of tele-psychiatry and pursue a best practice for community and front-line employee psychological preparedness.

Intelligence decline across major depressive disorder, bipolar disorder, and schizophrenia

BACKGROUND

Major depressive disorder (MDD), bipolar disorder (BD), and schizophrenia (SCZ) are associated with impaired intelligence that predicts poor functional outcomes. However, little is known regarding the extent and severity of intelligence decline, that is, decreased present intelligence quotient (IQ) relative to premorbid levels, across psychiatric disorders and which clinical characteristics affect the decline.

METHODS

Premorbid IQ, present IQ, and intelligence decline were compared across patients with MDD (n = 45), BD (n = 30), and SCZ (n = 139), and healthy controls (HCs; n = 135). Furthermore, we investigated which factors contribute to the intelligence decline in each diagnostic group.

RESULTS

Significant differences were observed in premorbid IQ, present IQ, and intelligence decline across the diagnostic groups. Patients with each psychiatric disorder displayed lower premorbid and present IQ and more intelligence decline than HCs. Patients with SCZ displayed lower premorbid and present IQ and more intelligence decline than patients with MDD and BD, while there were no significant differences between patients with MDD and BD. When patients with BD were divided based on bipolar I disorder (BD-I) and bipolar II disorder (BD-II), degrees of intelligence decline were similar between MDD and BD-II and between BD-I and SCZ. Lower educational attainment was correlated with a greater degree of intelligence decline in patients with SCZ and BD but not MDD.

CONCLUSIONS

These findings confirm that although all psychiatric disorders display intelligence decline, the severity of intelligence decline differs across psychiatric disorders (SCZ, BD-I > BD-II, MDD > HCs). Higher educational attainment as cognitive reserve contributes to protection against intelligence decline in BD and SCZ.

Topology predicts long-term functional outcome in early psychosis

Early intervention in psychosis is crucial to improving patient response to treatment and the functional deficits that critically affect their long-term quality of life. Stratification tools are needed to personalize functional deficit prevention strategies at an early stage. In the present study, we applied topological tools to analyze symptoms of early psychosis patients, and detected a clear stratification of the cohort into three groups. One of the groups had a significantly better psychosocial outcome than the others after a 3-year clinical follow-up. This group was characterized by a metabolic profile indicative of an activated antioxidant response, while that of the groups with poorer outcome was indicative of oxidative stress. We replicated in a second cohort the finding that the three distinct clinical profiles at baseline were associated with distinct outcomes at follow-up, thus validating the predictive value of this new stratification. This approach could assist in personalizing treatment strategies.

Depressive symptoms during first episode psychosis and functional outcome: A systematic review and meta-analysis

OBJECTIVES

First episode psychosis (FEP) is associated with functional decline. Existing evidence was synthesised to explore the influence of depressive symptoms during FEP on future social, occupational and global functioning.

METHODS

Medline, Embase, PsychINFO, Cochrane Library, Open Grey, NICE Evidence and Web of Science were searched from inception to May 2018. Longitudinal studies of FEP patients were included. Study quality was assessed using the Downs and Black instrument. Two meta-analyses were performed using random effect models. The first meta-analysis correlates depressive symptoms during FEP with follow-up Global Assessment of Functioning (GAF) scores. The second meta-analysis shows the odds of long-term functional remission if depressive symptoms are present during FEP.

RESULTS

4751 unique abstracts were found. 36 articles were included. The first meta-analysis included 7 studies (932 participants) and showed depressive symptoms during FEP were negatively correlated with follow-up GAF scores (r = -0.16, 95% CI: -0.24 to -0.09, p < 0.001). The second meta-analysis of 9 studies (2265 participants) showed weak evidence of an association between the presence of depressive symptoms in FEP and reduction in functional remission (OR = 0.87, 95% CI: 0.68 to 1.13, p = 0.294).

CONCLUSION

Depressive symptoms during FEP are associated with poorer long-term global functioning and may be associated with a reduced chance of achieving functional remission. Clinical trials are needed to identify efficacious management of depressive symptoms in early psychosis.

Traumatic loss and psychosis - reconceptualising the role of trauma in psychosis

Literature suggests that the occurrence of psychological trauma (PT) from various negative life experiences beyond events mentioned in the DSM-criterion A, receives little to no attention when comorbid with psychosis. In fact, despite research indicating the intricate interplay between PT and psychosis, and the need for trauma-focused interventions (TFI), there continue to be mixed views on whether treating PT would worsen psychosis, with many practitioners hesitating to initiate treatment for this reason. This study, therefore, aimed to understand patient perspectives on the role of PT in psychosis and related treatment options. A qualitative exploratory approach was adopted using in-depth interviews with individuals experiencing psychosis. The Global Assessment of Functioning (GAF) scale was administered on a predetermined maximum variation sample resulting in two groups of participants- those with moderate-mild disability (GAF 54-80; n = 10) and those experiencing moderate-severe disability (GAF 41-57; n = 10). With the former group, a semi-structured interview schedule was used, while with the latter, owing to multiple symptoms and difficulty in cognitive processing, a structured interview schedule was used. Results from interpretative phenomenological analysis (IPA) indicated that traumatic loss was central to experienced PT, but received no attention; this often contributed to the psychotic experience and/or depression, through maintenance factors such as cognitive distortions and attenuated affective responses. Further, the experience of loss seems to be more consequential to trauma-related symptoms than the event itself. Participants opined strongly the need for TFI and the role of it in promoting recovery from psychosis.

[Evidence-based treatment of acute psychotic episode and schizophrenia in children and adolescents]

Children and adolescents are a special group in the context of psychopharmacotherapy. Given the limited choice of registered antipsychotics permitted in childhood, caution should be exercised in the choice of medication. This literature review reviews the current evidence base for pharmacotherapy of acute psychotic episode and schizophrenia in children and adolescents. The results of major systematic reviews and meta-analyses are compared. Meta-analyses of pharmacotherapy studies of the first psychotic episode are considered separately. Antipsychotics of the first and second generation are comparable in effectiveness for children and adolescents with acute psychotic episode. Olanzapine demonstrates higher efficacy in reducing negative symptoms. Ziprasidone and asenapine are less effective in treating schizophrenia in children and adolescents than other antipsychotics. Compared to adults, children and adolescents are at higher risk of metabolic impairments when taking antipsychotics.

Early recovery and employment outcome 13 years after first episode psychosis

175 cases of first episode psychosis were recruited to the Parachute project in 1996-97. The program offered highly available and continuous psychosocial support and a cautious use of antipsychotic medication for 5 years from inclusion. Outcome-data for year 13 after inclusion, were retrieved from Swedish population registries on 161 of the original cases. During the first year after inclusion the cohort improved in the scores of the Brief Psychiatric Rating Scale (BPRS) and Global Assessment of Function (GAF) to median levels that later remained rather stable. By month 12 the median GAF score was 65. 68% of the cases were in remission from psychotic symptoms as assessed with BPRS. 38% of the cases in remission and 60% not in remission had prescriptions of antipsychotic medication by month 12. By year 13 after inclusion, 42% were in employment and 55% had any dispensation of antipsychotic medication. 70% of the cases with employment had no dispensations of antipsychotic medication. In conclusion, Many first episode psychosis cases that were offered extensive psychosocial support and cautious use of antipsychotic medication had good early recovery and good late employment outcome.

Clinical and demographic predictors of continuing remission or relapse following discontinuation of antipsychotic medication after a first episode of psychosis. A systematic review

BACKGROUND

Clinical guidelines recommend maintenance treatment with antipsychotic medication for one to two years following remission of symptoms after a first episode of psychosis. However, recent research has suggested that this may not be indicated. Consistent predictors of outcome would be beneficial to guide clinicians as to which individuals are likely to have a successful discontinuation.

OBJECTIVES

This study reviews the literature with the aim of identifying demographic and clinical predictors of either relapse or continued remission in those with a first episode of psychosis following discontinuation of antipsychotic medication.

METHODOLOGY

Data Sources: A systematic search of PubMed, CINAHL, and PsychInfo databases was performed. Eligibility Criteria: Cohort, case-control and clinical trials that were published in English, included participants with a first episode of psychosis, and examined clinical and demographic predictors of relapse or continued remission after antipsychotic discontinuation.

RESULTS

Eleven studies fulfilled inclusion criteria. No positive findings were replicated across cohorts. Predictors of relapse: male sex, unemployment, prior psychiatric admission, premorbid adjustment, childhood isolation, premorbid functioning, schizoid-schizotypal traits, schizophrenia diagnosis, concomitant medication, and more severe negative symptoms. Some positive findings must be interpreted in the context of conflicting and replicated negative findings: sex, employment status, level of education, premorbid functioning, symptom severity, and schizophrenia diagnosis. Other replicated non-predictive findings: age, ethnicity, marital status, family history, disorganized thoughts, affective symptoms, cannabis abuse, clinical global impression, social integration, duration and dose of antipsychotic treatment, and compliance.

CONCLUSION

No positive findings have been replicated across study cohorts. Non-predictive findings have been replicated.

Recovery from schizophrenia: is it possible?

PURPOSE OF REVIEW

Schizophrenia has a heterogeneous range of end states, from severe cases requiring repeated hospitalization to cases in which a single illness episode is followed by complete remission. The purpose of the present review is to examine recent literature on recovery in schizophrenia, focusing on the predictive factors and on the possibility to achieve it.

RECENT FINDINGS

Roughly half of schizophrenia patients recovered or significantly improved over the long term, suggesting that functional remission is possible. Several factors predict the course of schizophrenia, including demographic, clinical, and treatment characteristics, as well as socioeconomic variables. Antipsychotics are a fundamental element of schizophrenia treatment, although the available antipsychotics have significant limitations. In this context, psychosocial interventions are supported by substantial evidence of efficacy in many outcome measures and rehabilitation interventions should be considered as an evidence-based practice and need to become a part of the standard treatment of schizophrenia.

SUMMARY

As recovery is a multidimensional concept, some authors suggested that at least two areas should be taken into account: clinical remission and social functioning. Functional outcome should be a priority target for therapeutic interventions in schizophrenia and in this perspective measuring treatment response, remission and functional recovery is essential. Only an integrated and multifaceted approach involving pharmacotherapy, psychosocial interventions, and attention to environmental circumstances can improve outcome in schizophrenia.

Outcome and recovery in first-episode psychosis

There is now a good body of evidence about factors that determine outcome and recovery in a first episode of psychosis. However, so far, this is of limited benefit when making predictions at an individual level. Treatment protocols are one size fits all and the recommended duration of medication remains unclear. What is needed is a more sophisticated approach to predicting outcomes and tailoring treatment options to the individual. Removing predisposing factors is an important aspect of this.