Administrative incidence of psychosis assessed in an early intervention service in England: first epidemiological evidence from a diverse, rural and urban setting

Service evaluation of an embedded Early Intervention in Psychosis programme

BACKGROUND

An average of 1300 adults develop First Episode Psychosis (FEP) in Ireland each year. Early Intervention in Psychosis (EIP) is now widely accepted as best practice in the treatment of conditions such as schizophrenia. A local EIP programme was established in the Dublin South Central Mental Health Service in 2012.

METHODS

This is a cross-sectional study of service users presenting to the Dublin South Central Mental Health Service with FEP from 2016 to 2022 following the introduction of the EIP programme. We compared this to a previously published retrospective study of treatment as usual from 2002 to 2012.

RESULTS

Most service users in this study were male, single, unemployed and living with their partner or spouse across both time periods. Cognitive Behavioural Therapy for psychosis was provided to 12% (n = 8) of service users pre-EIP as compared to 52% (n = 30) post-programme introduction (p < 0.001), and 3% (n = 2) of service users engaged with behavioural family therapy pre-EIP as opposed to 15% (n = 9) after (p < 0.01). Rates of composite baseline physical healthcare monitoring improved significantly (p < 0.001).

CONCLUSION

Exclusive allocation of multidisciplinary team staff to EIP leads to improved compliance with recommended guidelines, particularly CBT-p, formal family therapy and physical health monitoring.

Social disadvantage in early psychosis and its effect on clinical presentation and service access, engagement and use

Incidence of psychosis varies geographically due to factors such as social disadvantage. Whether this influences the clinical presentation and/or engagement of those experiencing psychosis remains relatively understudied. This study analysed data from young people across Australia accessing ultra-high risk (UHR) or first episode psychosis (FEP) services delivered through the headspace Early Psychosis (hEP) program between June 2017 and March 2021. The cohort was categorised into low, middle, and high tertiles of social disadvantage using the Index of Relative Socioeconomic Disadvantage (IRSD). Data from 3089 participants aged 15-25 were included (1515 UHR, 1574 FEP). The low and middle tertiles for both cohorts had greater percentages of those not in education or employment (NEET), with First Nations or culturally and linguistically diverse backgrounds. Clinical presentations to services were similar across all tertiles in both cohorts, however, functioning at presentation varied significantly within the FEP cohort. Significantly lower numbers of direct services were provided in the low tertile of both cohorts, with significantly poorer engagement in the initial three-months also occurring for these young people. This variation in early psychosis service patterns associated with geographical variation in social deprivation demonstrates the need for further research and fine tuning of national early psychosis services.

Review of Major Social Determinants of Health in Schizophrenia-Spectrum Disorders: II. Assessments

BACKGROUND AND AIMS

Social determinants of health (SDoHs) impact the development and course of schizophrenia-spectrum psychotic disorders (SSPDs). Yet, we found no published scholarly reviews of psychometric properties and pragmatic utility of SDoH assessments among people with SSPDs. We aim to review those aspects of SDoH assessments.

STUDY DESIGN

PsychInfo, PubMed, and Google Scholar databases were examined to obtain data on reliability, validity, administration process, strengths, and limitations of the measures for SDoHs identified in a paired scoping review.

STUDY RESULTS

SDoHs were assessed using different approaches including self-reports, interviews, rating scales, and review of public databases. Of the major SDoHs, early-life adversities, social disconnection, racism, social fragmentation, and food insecurity had measures with satisfactory psychometric properties. Internal consistency reliabilities-evaluated in the general population for 13 measures of early-life adversities, social disconnection, racism, social fragmentation, and food insecurity-ranged from poor to excellent (0.68-0.96). The number of items varied from 1 to more than 100 and administration time ranged from less than 5 minutes to over an hour. Measures of urbanicity, low socioeconomic status, immigration status, homelessness/housing instability, and incarceration were based on public records or targeted sampling.

CONCLUSIONS

Although the reported assessments of SDoHs show promise, there is a need to develop and test brief but validated screening measures suitable for clinical application. Novel assessment tools, including objective assessments at individual and community levels utilizing new technology, and sophisticated psychometric evaluations for reliability, validity, and sensitivity to change with effective interventions are recommended, and suggestions for training curricula are offered.

Profiles and trajectories of mental health service utilisation during early intervention in psychosis

BACKGROUND

Early intervention in psychosis services (EIS) support individuals experiencing a first episode of psychosis. Support required will vary in response to the remittance and reoccurrence of symptoms, including relapses. Characterising individuals who will need more intensive support can inform care planning. This study explores service utilisation profiles and their trajectories of service use in a sample of individuals referred to EIS.

METHOD

We analysed service utilisation during the 3 years following referral to EIS (n = 2363) in West London between 2011 and 2020. Mental health service utilisation data were submitted to model-based clustering. Latent growth models were then estimated for identified profiles. Profiles were compared regarding clinical and demographic characteristics and onward pathways of care.

RESULTS

Analyses revealed 5 profiles of individuals attending EIS based on their service utilisation over 3 years. 55.5% of the sample were members of a low utilisation and less clinically severe profile. The distinct service use patterns of these profiles were associated with Health of the Nations Outcome Scale scores at treatment initiation (at total, subscale, and individual item level), along with age and gender. These patterns of use were also associated with onward care and ethnicity.

CONCLUSIONS

Profiles and trajectories of service utilisation call for development of integrated care pathways and use of more personalised interventions. Services should consider patient symptoms and characteristics when making clinical decisions informing the provision of care. The profiles represent typical patterns of service use, and identifying factors associated with these subgroups might help optimise EIS support.

Transitioning to age inclusive early intervention for psychosis

AIM

Early Intervention in psychosis Services (EIS) have previously restricted access based on age. However, there is now a move to age inclusive service. We aimed to examine differences between early and late onset (>35 years) psychosis to see if a threshold was valid. We also investigated the potential of a statistical modelling method to identify group characteristics which may be missed using a descriptive approach.

METHODS

Routine clinical data (n = 343), from an EIS, comprising socio-demographic, clinical, physical and treatment variables, were examined using descriptive and classification and regression tree (CART) analysis.

RESULTS

The findings suggest that age differences were best explained by social factors. There was no emerging evidence that the differences exhibited had a fundamental impact on the clinical outcomes of the clients in terms of support beyond EIS (ie, hospitalization and home treatment team involvement) and pharmacological and psychological interventions. CART analysis revealed distinct service user characteristics associated with the clinical outcomes.

CONCLUSION

There was no evidence to support a clinical cut off based on age providing support for age inclusive services. However, in the transition to age inclusive service delivery, EIS need to consider social/life stage variables, adapting provision where service delivery may operate a youth focused model. Routine analysis of clinical data should employ methods to identify groups of service users who may require adjusted service provision.

Estimated Proportions and Characteristics of National Survey Respondents Reporting New Diagnoses of Schizophrenia or Other Psychoses in the Past Year as Compared With Prior Years

Epidemiologic data on first-episode psychosis is limited due to the infrequency of cases in the general population. This study uses the National Epidemiologic Survey on Alcohol and Related Conditions-III (N = 36,309) to examine population-based estimates of early psychosis based on adults who report a first-time diagnosis of schizophrenia from a doctor in the past year and compares them with those receiving diagnoses in previous years. Altogether, 60 respondents reported past-year schizophrenia (170 per 100,000) or 6.7% of 901 with any reported schizophrenia. Mean age was 41.4 ± 2.1, and they reported significantly higher rates of any past-year substance use disorder (44.7%) than individuals diagnosed in previous years (27.7%), specifically alcohol use disorder. Compared with other samples (many of which excluded older adults), this study suggests that early psychosis may affect older populations more than previously recognized, but comorbidity with substance use disorders showed similar elevations.

Change in incidence rates for psychosis in different ethnic groups in south London: findings from the Clinical Record Interactive Search-First Episode Psychosis (CRIS-FEP) study

BACKGROUND

A higher incidence of psychotic disorders has been consistently reported among black and other minority ethnic groups, particularly in northern Europe. It is unclear whether these rates have changed over time.

METHODS

We identified all individuals with a first episode psychosis who presented to adult mental health services between 1 May 2010 and 30 April 2012 and who were resident in London boroughs of Lambeth and Southwark. We estimated age-and-gender standardised incidence rates overall and by ethnic group, then compared our findings to those reported in the Aetiology and Ethnicity of Schizophrenia and Other Psychoses (ÆSOP) study that we carried out in the same catchment area around 10 years earlier.

RESULTS

From 9109 clinical records we identified 558 patients with first episode psychosis. Compared with ÆSOP, the overall incidence rates of psychotic disorder in southeast London have increased from 49.4 (95% confidence interval (CI) 43.6-55.3) to 63.1 (95% CI 57.3-69.0) per 100 000 person-years at risk. However, the overall incidence rate ratios (IRR) were reduced in some ethnic groups: for example, IRR (95% CI) for the black Caribbean group reduced from 6.7 (5.4-8.3) to 2.8 (2.1-3.6) and the 'mixed' group from 2.7 (1.8-4.2) to 1.4 (0.9-2.1). In the black African group, there was a negligible difference from 4.1 (3.2-5.3) to 3.5 (2.8-4.5).

CONCLUSIONS

We found that incidence rates of psychosis have increased over time, and the IRR varied by the ethnic group. Future studies are needed to investigate more changes over time and determinants of change.

Migration and psychosis: a meta-analysis of incidence studies

BACKGROUND

The aims of this meta-analysis are (i) to estimate the pooled relative risk (RR) of developing non-affective psychotic disorder (NAPD) and affective psychotic disorder (APD) among migrants and their children; (ii) to adjust these results for socioeconomic status (SES); (iii) to examine the sources of heterogeneity that underlie the risk of NAPD.

METHODS

We included population-based incidence studies that reported an age-adjusted RR with 95% confidence interval (CI) published 1 January 1977-12 October 2017 and used a random-effects model.

RESULTS

We retrieved studies performed in Europe (n = 43), Israel (n = 3), Canada (n = 2) and Australia (n = 1). The meta-analysis yielded a RR, adjusted for age and sex, of 2.13 (95% CI 1.99-2.27) for NAPD and 2.94 (95% CI 2.28-3.79) for APD. The RRs diminished, but persisted after adjustment for SES. With reference to NAPD: a personal or parental history of migration to Europe from countries outside Europe was associated with a higher RR (RR = 2.94, 95% CI 2.63-3.29) than migration within Europe (RR = 1.88, 95% 1.62-2.18). The corresponding RR was lower in Israel (RR = 1.22; 0.99-1.50) and Canada (RR = 1.21; 0.85-1.74). The RR was highest among individuals with a black skin colour (RR = 4.19, 95% CI 3.42-5.14). The evidence of a difference in risk between first and second generation was insufficient.

CONCLUSIONS

Positive selection may explain the low risk in Canada, while the change from exclusion to inclusion may do the same in Israel. Given the high risks among migrants from developing countries in Europe, social exclusion may have a pathogenic role.

Estimating the incidence of first-episode psychosis using population-based health administrative data to inform early psychosis intervention services

BACKGROUND

Discrepancies between population-based estimates of the incidence of psychotic disorder and the treated incidence reported by early psychosis intervention (EPI) programs suggest additional cases may be receiving services elsewhere in the health system. Our objective was to estimate the incidence of non-affective psychotic disorder in the catchment area of an EPI program, and compare this to EPI-treated incidence estimates.

METHODS

We constructed a retrospective cohort (1997-2015) of incident cases of non-affective psychosis aged 16-50 years in an EPI program catchment using population-based linked health administrative data. Cases were identified by either one hospitalization or two outpatient physician billings within a 12-month period with a diagnosis of non-affective psychosis. We estimated the cumulative incidence and EPI-treated incidence of non-affective psychosis using denominator data from the census. We also estimated the incidence of first-episode psychosis (people who would meet the case definition for an EPI program) using a novel approach.

RESULTS

Our case definition identified 3245 cases of incident non-affective psychosis over the 17-year period. We estimate that the incidence of first-episode non-affective psychosis in the program catchment area is 33.3 per 100 000 per year (95% CI 31.4-35.1), which is more than twice as high as the EPI-treated incidence of 18.8 per 100 000 per year (95% CI 17.4-20.3).

CONCLUSIONS

Case ascertainment strategies limited to specialized psychiatric services may substantially underestimate the incidence of non-affective psychotic disorders, relative to population-based estimates. Accurate information on the epidemiology of first-episode psychosis will enable us to more effectively resource EPI services and evaluate their coverage.

A New Method for Estimating Incidence of First Psychotic Diagnosis in a Medicaid Population

OBJECTIVE

Early intervention programs for first-episode psychosis (FEP) require population-based methods to identify individuals with FEP. This study adapted a previously published method to estimate incidence of first psychotic diagnosis in a state Medicaid program. Secondary aims were to examine demographic and service patterns associated with a first psychotic diagnosis in Medicaid.

METHODS

A retrospective, population-based study of New York State Medicaid data was conducted to identify first occurrence of psychotic diagnosis among persons ages 15-35 between January 1, 2013, and December 31, 2017 (N=31,606). Age-stratified incidence rates (IRs) were calculated by demographic characteristics, first-diagnosis type, and service-related characteristics. Review of charts from OnTrackNY and Medicaid managed care organizations (MCOs) was conducted to confirm identified cases. Initial IRs and confirmation rates were used to estimate adjusted IRs.

RESULTS

Age-stratified IRs varied by demographic, diagnostic, and service-related characteristic. IRs of FEP were higher for persons ages 15 to 25 relative to persons ages 26-35 if the first provider was an acute behavioral health emergency or inpatient setting (rate ratio=1.286; 95% confidence interval=1.24-1.33). Case confirmation rates were 90% for OnTrack NY and 53% for the MCOs. Adjusted annual IR of first diagnosis of psychosis was 272 per 100,000.

CONCLUSIONS

Incidence of first psychotic diagnosis in this Medicaid population was higher than previously found in insured populations. Future work will focus on algorithm refinements and piloting outreach. Administrative data algorithms may be useful to providers, Medicaid MCOs, and state Medicaid authorities to support case finding and early intervention.

Incidence of treated first episode psychosis from an Australian early intervention service and its association with neighbourhood characteristics

OBJECTIVES

Psychotic disorder incidence varies geographically and is associated with neighbourhood characteristics, including social deprivation, population density, unemployment, social capital or social fragmentation. Yet it is not known whether these findings are applicable to Australia's unique geography. This study aimed to determine whether the incidence of first episode psychosis (FEP) varies according to neighbourhood characteristics in an Australian cohort.

METHOD

This study included all young people, aged 15 to 24, with an FEP who attended Orygen Youth Health in Melbourne, from a geographically defined catchment area encompassing Northern and Western Melbourne, over a 44-month period. Neighbourhood demographic data was collected from the 2011 Australian National Census. Negative binomial regression was used to determine incidence rate ratios controlled for age, sex and migrant status.

RESULTS

A total of 747 young people had an FEP during the 44-month study period and 722 were included in this study. Of these, 58.0% were males and 67.9% had a non-affective psychotic disorder; the mean age of the cohort was 19.1 years. The incidence of FEP in young people aged 15 to 24 in the catchment area was 123.2 per 100,000 person-years. There was a higher incidence of FEP in neighbourhoods of greatest social deprivation (IRR = 1.65, CI = 1.06-2.51, p = .02), highest unemployment (IRR = 1.56, CI = 1.04-2.35, p = .03) and above average social fragmentation (IRR = 1.42, CI = 1.02-1.97, p = .04), when controlled for age, sex and migrant status.

CONCLUSIONS

This study highlights variation in psychotic disorder incidence and the need for this disparity to be reflected in appropriate resource allocation.

Financial difficulties and psychosis risk in British undergraduate students: a longitudinal analysis

Purpose

The purpose of this paper is to examine whether financial variables impact psychosis risk over time in students.

Design/methodology/approach

In total, 408 first-year British undergraduate students completed measures assessing psychosis risk and finances at three time points.

Findings

Greater financial difficulties increased psychosis risk cross sectionally both in terms of symptoms and distress. Other financial variables such as student loan amount were not significant. In longitudinal analysis financial difficulties increase psychotic symptoms and distress over time, but there was no impact of psychotic symptoms on later financial difficulties.

Research limitations/implications

The study used a relatively small and heavily female sample. Future research is needed to confirm the findings.

Practical implications

Whilst amount of debt does not appear to impact psychotic symptoms in students, greater financial difficulties appear to increase the risk of psychosis over time. Professionals working with students should be aware of this potential link.

Originality/value

This is the first time a longitudinal study has examined the effect of finances on psychosis symptoms.

Disparities in Access to Early Psychosis Intervention Services: Comparison of Service Users and Nonusers in Health Administrative Data

OBJECTIVE

There is a dearth of information on people with first-episode psychosis who do not access specialized early psychosis intervention (EPI) services. We sought to estimate the proportion of incident cases of nonaffective psychosis that do not access these services and to examine factors associated with EPI admission.

METHODS

Using health administrative data, we constructed a retrospective cohort of incident cases of nonaffective psychosis in the catchment area of the Prevention and Early Intervention Program for Psychoses (PEPP) in London, Ontario, between 1997 and 2013. This cohort was linked to primary data from PEPP to identify EPI users. We used multivariate logistic regression to model sociodemographic and service factors associated with EPI admission.

RESULTS

Over 50% of suspected cases of nonaffective psychosis did not have contact with EPI services for screening or admission. EPI users were significantly younger, more likely to be male (odds ratio [OR] 1.58; 95% confidence interval [CI] 1.24 to 2.01), and less likely to live in areas of socioeconomic deprivation (OR 0.51; 95% CI 0.36 to 0.73). EPI users also had higher odds of psychiatrist involvement at the index diagnosis (OR 7.35; 95% CI 5.43 to 10.00), had lower odds of receiving the index diagnosis in an outpatient setting (OR 0.50; 95% CI 0.38 to 0.65), and had lower odds of prior alcohol-related (OR 0.42; 95% CI 0.28 to 0.63) and substance-related (OR 0.68; 95% CI 0.50 to 0.93) disorders.

CONCLUSIONS

We need a greater consideration of patients with first-episode psychosis who are not accessing EPI services. Our findings suggest that this group is sizable, and there may be sociodemographic and clinical disparities in access. Nonpsychiatric health professionals could be targeted with interventions aimed at increasing detection and referral rates.

Retrospective study of first episode psychosis in the Dublin Southwest Mental Health Service: demographics, clinical profile and service evaluation of treatment

OBJECTIVE

In Ireland, National Clinical Programmes are being established to improve and standardise patient care throughout the Health Service Executive. In line with internationally recognised guidelines on the treatment of first episode psychosis the Early Intervention in Psychosis (EIP) programme is being drafted with a view to implementation by mental health services across the country. We undertook a review of patients presenting with a first episode of psychosis to the Dublin Southwest Mental Health Service before the implementation of the EIP. This baseline information will be used to measure the efficacy of our EIP programme.

METHODS

Patients who presented with a first episode psychosis were retrospectively identified through case note reviews and consultation with treating teams. We gathered demographic and clinical information from patients as well as data on treatment provision over a 2-year period from the time of first presentation. Data included age at first presentation, duration of untreated psychosis, diagnosis, referral source, antipsychotic prescribing rates and dosing, rates of provision of psychological interventions and standards of physical healthcare monitoring. Outcome measures with regards to rates of admission over a 2-year period following initial presentation were also recorded.

RESULTS

In total, 66 cases were identified. The majority were male, single, unemployed and living with their family or spouse. The mean age at first presentation was 31 years with a mean duration of untreated psychosis of 17 months. Just under one-third were diagnosed with schizophrenia. Approximately half of the patients had no contact with a health service before presentation. The majority of patients presented through the emergency department. Two-thirds of all patients had a hospital admission within 2 years of presentation and almost one quarter of patients had an involuntary admission. The majority of patients were prescribed antipsychotic doses within recommended British National Formulary guidelines. Most patients received individual support through their keyworker and family intervention was provided in the majority of cases. Only a small number received formal Cognitive-Behavioural Therapy. Physical healthcare monitoring was insufficiently recorded in the majority of patients.

CONCLUSIONS

There is a shortage of information on the profile and treatment of patients presenting with a first episode of psychosis in Ireland. This baseline information is important in evaluating the efficacy of any new programme for this patient group. Many aspects of good practice were identified within the service in particular with regards to the appropriate prescribing of antipsychotic medication and the rates of family intervention. Deficiencies remain however in the monitoring of physical health and the provision of formal psychological interventions to patients. With the implementation of an EIP programme it is hoped that service provision would improve nationwide and to internationally recognised standards.

First Presentation With Psychotic Symptoms in a Population-Based Sample

OBJECTIVE

Increasing evidence supports the effectiveness of comprehensive early intervention at first onset of psychotic symptoms. Implementation of early intervention programs will require population-based data on overall incidence of psychotic symptoms and on care settings of first presentation.

METHODS

In five large health care systems, electronic health records data were used to identify all first occurrences of psychosis diagnoses among persons ages 15-59 between January 1, 2007, and December 31, 2013 (N=37,843). For a random sample of these putative cases (N=1,337), review of full-text medical records confirmed clinician documentation of psychotic symptoms and excluded those with documented prior diagnosis of or treatment for psychosis. Initial incidence rates (based on putative cases) and confirmation rates (from record reviews) were used to estimate true incidence according to age and setting of initial presentation.

RESULTS

Annual incidence estimates based on putative cases were 126 per 100,000 among those ages 15-29 and 107 per 100,000 among those ages 30-59. Rates of chart review confirmation ranged from 84% among those ages 15-29 diagnosed in emergency department or inpatient mental health settings to 19% among those ages 30-59 diagnosed in general medical outpatient settings. Estimated true incidence rates were 86 per 100,000 per year among those ages 15-29 and 46 per 100,000 among those ages 30-59.

CONCLUSIONS

When all care settings were included, incidence of first-onset psychotic symptoms was higher than previous estimates based on surveys or inpatient data. Early intervention programs must accommodate frequent presentation after age 30 and presentation in outpatient settings, including primary care.

Factors Associated with Timely Physician Follow-up after a First Diagnosis of Psychotic Disorder

OBJECTIVE

Physician follow-up after a first diagnosis of psychotic disorder is crucial for improving treatment engagement. We examined the factors associated with physician follow-up within 30 days of a first diagnosis of schizophrenia.

METHOD

We conducted a retrospective cohort study using linked health administrative data to identify incident cases of schizophrenia between 1999 and 2008 among people aged 14 to 35 years in Ontario. We estimated the proportion of patients who had physician follow-up within 30 days of the index diagnosis. We used multilevel logistic regression models to examine the factors associated with any physician follow-up and follow-up by a psychiatrist.

RESULTS

We identified 20,096 people with a first diagnosis of schizophrenia. Approximately 40% of people did not receive any physician follow-up within 30 days, and nearly 60% did not receive follow-up by a psychiatrist. Males had lower odds of receiving any physician follow-up, and the odds of psychiatrist follow-up decreased with increasing age and were lower for those living in rural areas. Both prior contact with a general practitioner for a mental health reason and prior contact with a psychiatrist were strongly associated with higher odds of receiving both types of follow-up.

CONCLUSIONS

Many people do not have any physician contact within 30 days of the first diagnosis of schizophrenia, and patients without prior engagement with mental health services are at highest risk. We need information on the reasons behind this lack of physician follow-up to inform strategies aimed at improving engagement with services during the early stages of psychosis.

Understanding causes of and developing effective interventions for schizophrenia and other psychoses

Background

Early-intervention services (EISs) offer prompt and effective care to individuals with first-episode psychosis (FEP) and detect people at high risk (HR) of developing it.

Aims

We aimed to educate general practitioners about psychosis and guide their referrals to specialist care; investigate determinants of the transition of HR to FEP; and predict numbers of new cases to guide policy and service planning.

Incidence of psychosis in socially and ethnically diverse settings

We studied the incidence of new referrals for psychosis in a well-established EIS called CAMEO [seewww.cameo.nhs.uk(accessed 18 January 2016)] and built on other epidemiological studies. The overall incidence of FEP was 45.1 per 100,000 person-years [95% confidence interval (CI) 40.8 to 49.9 per 100,000 person-years]. This was two to three times higher than the incidence predicated by the UK Department of Health. We found considerable psychosis morbidity in diverse, rural communities.

Development of a population-level prediction tool for the incidence of FEP

We developed and validated a population-level prediction tool, PsyMaptic, capable of accurately estimating the expected incidence of psychosis [seewww.psymaptic.org/(accessed 18 January 2016)].

The Liaison with Education and General practiceS (LEGS) trial to detect HR

We tested a theory-based intervention to improve detection and referral of HR individuals in a cluster randomised controlled trial involving primary care practices in Cambridgeshire and Peterborough. Consenting practices were randomly allocated to (1) low-intensity liaison with secondary care, a postal campaign to help with the identification and referral of individuals with early signs of psychosis, or (2) the high-intensity theory-based intervention, which, in addition to the postal campaign, included a specialist mental health professional to liaise with each practice. Practices that did not consent to be randomised included a practice-as-usual (PAU) group. The approaches were implemented over 2 years for each practice between April 2010 and October 2013. New referrals were stratified into those who met criteria for HR/FEP (together: psychosis true positives) and those who did not fulfil such criteria (false positives). The primary outcome was the number of HR referrals per practice. Referrals from PAU practices were also analysed. We quantified the cost-effectiveness of the interventions and PAU using the incremental cost per additional true positive identified. Of 104 eligible practices, 54 consented to be randomised. Twenty-eight practices were randomised to low-intensity liaison and 26 practices were randomised to the high-intensity intervention. Two high-intensity practices withdrew. High-intensity practices referred more HR [incidence rate ratio (IRR) 2.2, 95% CI 0.9 to 5.1;p = 0.08], FEP (IRR 1.9, 95% CI 1.05 to 3.4;p = 0.04) and true-positive (IRR 2.0, 95% CI 1.1 to 3.6;p = 0.02) cases. High-intensity practices also referred more false-positive cases (IRR 2.6, 95% CI 1.3 to 5.0;p = 0.005); most (68%) of these were referred on to appropriate services. The total costs per true-positive referral in high-intensity practices were lower than those in low-intensity or PAU practices. Increasing the resources aimed at managing the primary–secondary care interface provided clinical and economic value.

The Prospective Analysis of At-risk mental states and Transitions into psycHosis (PAATH) study

We aimed to identify the proportion of individuals at HR who make the transition into FEP and to elucidate the common characteristics that can help identify them. Sixty help-seeking HR individuals aged 16–35 years were stratified into those who met the criteria for HR/FEP (true positives) according to the Comprehensive Assessment of At-Risk Mental States (CAARMS) and those who did not (false positives). HR participants were followed up over 2 years using a comprehensive interview schedule. A random sample of 60 healthy volunteers (HVs) matched for age (16–35 years), sex and geographical area underwent the same battery of questionnaires. Only 5% of our HR sample transitioned to a structured clinical diagnosis of psychosis over 2 years. HR individuals had a higher prevalence of moderate or severe depression, anxiety and suicidality than HVs. In fact, psychometric analyses in other population samples indicate that psychotic experiences measure the severe end of a common mental distress factor, consistent with these results. HR individuals also experienced significantly more traumatic events than HVs, but equivalent distress. Almost half of HR individuals had at least one Schneiderian first-rank symptom traditionally considered indicative of schizophrenia and 21.6% had more than one. HR individuals had very poor global functioning and low quality of life.

Conclusions

This National Institute for Health Research programme developed our understanding of the social epidemiology of psychosis. A new theory-based intervention doubled the identification of HR and FEP in primary care and was cost-effective. The HR mental state has much in common with depression and anxiety; very few people transitioned to full psychosis over 2 years, in line with other recent evidence. This new understanding will help people at HR receive appropriate services focused on their current mental state.

Trial registration

The primary LEGS trial is registered as ISRCTN70185866 and UKCRN ID 7036. The PAATH study is registered as UKCRN ID 7798.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

An exploration of what service users value about early intervention in psychosis services

OBJECTIVE

Given the potential severity of developing chronic mental health problems, particular attention has been paid to the first emergence of psychosis. Earlier detection is expected to lead to quicker access to the effective treatment that is necessary during the 'critical period' and is one of the main incentives for setting up early intervention in psychosis (EIP) services. EIP services have demonstrated good clinical outcomes since inception, but little is understood yet as to which specific element of EIP leads to these good outcomes. The aim of this research was to conduct an exploratory investigation of the elements that people experiencing a first episode of psychosis find most valuable about EIP treatment.

DESIGN

The study employed a single group design and utilized Q-methodology.

METHOD

20 people with first-episode psychosis aged between 18 and 35 were recruited and asked what they valued most about EIP.

RESULTS

Four separate factors were identified, which were interpreted and named as 'therapeutic relationship', 'medical care', 'psychological interventions', and 'support, coping and recovery'. Three of the factors were consistent with a biopsychosocial approach of EIP that is recommended by expert professionals working in EIP services and Government guidance on service delivery.

CONCLUSIONS

The factor that accounted for the most variance is 'therapeutic relationship', highlighting the importance of non-specific factors in mental health care and recovery from a first episode of psychosis.

PRACTITIONER POINTS

Service users reported that four main components of Early Intervention in Psychosis Services were helpful to them. These included a strong and effective therapeutic relationship, as well as medication, psychological therapies, and practical help and support. Services are valued both for the quality of the therapeutic relationship but also for their ability to deliver meaningful and valued treatments in this context.

Substance use in people at clinical high-risk for psychosis

BACKGROUND

Some high-risk (HR) mental states for psychosis may lack diagnostic specificity and predictive value. Furthermore, psychotic-like experiences found in young populations may act not only as markers for psychosis but also for other non-psychotic psychiatric disorders. A neglected consideration in these populations is the effect of substance misuse and its role in the development of such mental states or its influence in the evolution toward full psychotic presentations. Therefore, the main aim of this study was to thoroughly describe past and current substance use profiles of HR individuals by comparing a consecutive cohort of young people at high risk referred to a population-based early intervention clinical service with a random sample of healthy volunteers (HV) recruited from the same geographical area.

METHODS

We compared alcohol and substance use profiles of sixty help-seeking HR individuals and 60 healthy volunteers (HV). In addition to identification of abuse/dependence and influence on psychotic-like experiences, differences between HR individuals and HV were assessed for gender, ethnicity, occupational status, age of lifetime first substance use, prevalence and frequency of substance use.

RESULTS

There were no cases of substance use disorder or dependence in either groups. HR individuals were significantly younger than HV when they first started to use substances (p = 0.014). The prevalence of overall HR substance use was similar to that of HV. Although HR individuals reported less cannabinoid use than HV currently (15% vs. 27%), and more in the past (40% vs. 30%), the differences were not statistically significant (p = 0.177 & 0.339 respectively). Current frequency of use was significantly higher for HR individuals than HV for alcohol (p = 0.001) and cannabinoids (p = 0.03). In this sample, only 5% of HR individuals converted to psychosis over a two-year follow-up.

CONCLUSIONS

Certain profiles of substance use could potentially play a significant part in the evolution of HR presentations. Therefore, substance use may well represent a clinical domain that requires further emphasis and more detailed consideration in future studies.

Trauma history characteristics associated with mental states at clinical high risk for psychosis

Traumatic experiences have been positively associated with both severity of attenuated psychotic symptoms in individuals at high risk (HR) for psychosis and transitions into psychotic disorders. Our aim was to determine what characteristics of the trauma history are more likely to be associated with individuals at HR. The Trauma History Screen (THS) was used to enable emphasis on number and perceived intensity of adverse life events and age at trauma exposure. Sixty help-seeking individuals who met HR criteria were compared to a random sample of 60 healthy volunteers. Both groups were aged 16-35 and resided in the same geographical location. HR participants experienced their first trauma at an earlier age, continued to experience trauma at younger developmental stages, especially during early/mid adolescence and were exposed to a high number of traumas. They were more depressed and anxious, but did not experience more distress in relation to trauma. Both incidences of trauma and age at which trauma occurred were the most likely predictors of becoming HR. This work emphasises the importance of assessing trauma characteristics in HR individuals to enable differentiation between psychotic-like experiences that may reflect dissociative responses to trauma and genuine prodromal psychotic presentations.

Direct comparison of first-contact versus longitudinal register-based case finding in the same population: early evidence that the incidence of schizophrenia may be three times higher than commonly reported

BACKGROUND

The incidence of schizophrenia is commonly estimated by screening for psychosis among subjects presenting to psychiatric services. This approach (using a first-contact sampling frame) cannot account for cases that did not meet criteria for schizophrenia at first contact. We compared the usual approach directly with a register-based approach (using a longitudinal sampling frame) that also includes subjects initially diagnosed with other non-schizophrenic disorders.

METHOD

We compared data from the Longitudinal Psychiatric Register (LPR) of The Hague over 1980-2009 with data previously collected in a first-contact study, and applied both methods to calculate the incidence of schizophrenia for subjects aged 20-54 years in the same catchment area and over the same period (October 2000 to September 2005). We reconstructed treatment pathways and diagnostic histories up to the end of 2009 and performed sensitivity analyses.

RESULTS

The LPR identified 843 first onsets of schizophrenia, corresponding to a treated incidence rate (IR) of 69 per 100,000 person-years [95% confidence interval (CI) 64-74]. The first-contact study identified 254 first onsets, corresponding to a treated IR of 21 per 100,000 person-years (95% CI 18-23). Two-thirds of the difference was accounted for by subjects treated for other disorders before the onset of psychosis, and by patients in older age groups.

CONCLUSIONS

The incidence of schizophrenia was three times higher in a longitudinal register study than in a high-quality first-contact study conducted in the same population. Risk estimates based only on first-contact studies may have been affected by selection bias.

Rural and remote early psychosis intervention services: the Gordian knot of early intervention

AIM

One of the basic challenges of Early Psychosis Intervention (EPI) programs for rural populations is translating best practice which developed for urban high-population density areas to rural and remote settings. This paper presents data from two different models (hub and spoke and specialist outreach) of rural EPI practice in Ontario, Canada.

METHODS

This cross-sectional study used a convenience sample of clients from two rural EPI programs between 2005 and 2007. Data about client outcomes specific to general functioning, admissions to hospital and emergency room (ER) visits were collected. For all dichotomous variables, chi-square tests were used to test differences between two groups.

RESULTS

The total clients served in hub and spoke were 457 compared to 91 in specialist outreach. Although not statistically significant, the hub and spoke group showed better functioning in the community. There was a significant difference between the two groups with regard to hospital admissions. Although not significant, there was a greater percentage (58.3%) of specialist outreach clients who visited the ER in the previous 12 months as compared to clients serviced by the hub and spoke model (34.9%).

CONCLUSIONS

The observed data from these two rural models suggest that there may be differing outcomes. There are limitations to this study, and this paper does not address why there are differences. Future work needs to continue to further explore why differences exist and whether they persist so we can provide equity and quality care for rural and remote populations.

First-contact incidence of psychosis in north-eastern Italy: influence of age, gender, immigration and socioeconomic deprivation

BACKGROUND

Considerable variations in the incidence of psychosis have been observed across countries, in terms of age, gender, immigration status, urbanicity and socioeconomic deprivation.

AIMS

To evaluate the incidence rate of first-episode psychosis in a large area of north-eastern Italy and the distribution of the above-mentioned risk factors in individuals with psychoses.

METHOD

Epidemiologically based survey. Over a 3-year period individuals with psychosis on first contact with services were identified and diagnosed according to ICD-10 criteria.

RESULTS

In total, 558 individuals with first-episode psychosis were identified during 3,077,555 person-years at risk. The annual incidence rate per 100,000 was 18.1 for all psychoses, 14.3 for non-affective psychoses and 3.8 for affective psychoses. The rate for all psychoses was higher in young people aged 20-29 (incidence rate ratio (IRR) = 4.18, 95% CI 2.77-6.30), immigrants (IRR = 2.26, 95% CI 1.85-2.75) and those living in the most deprived areas (IRR = 2.09, 95% CI 1.54-2.85).

CONCLUSIONS

The incidence rate in our study area was lower than that found in other European and North American studies and provides new insights into the factors that may increase and/or decrease risk for developing psychosis.

Modelling the incidence and mortality of psychotic disorders: data from the second Australian national survey of psychosis

OBJECTIVES

The aim of this study was to model estimates related to (a) the incidence of psychotic disorders and (b) the mortality associated with these disorders based on a large, population-based prevalence study.

METHODS

Data were drawn from the second national survey of adults with psychotic disorders conducted in seven Australian catchment areas during March to December 2010. To generate incidence rate estimates, we identified recent onset cases recruited as part of the prevalence study and then imputed population-based incidence rates using a set of conservative assumptions. Similarly, for mortality rates, we identified individuals who had died after being identified as 'screen-positive' for psychosis, but prior to full clinical assessment. Using a set of conservative assumptions, we then used these estimates to infer population-based mortality rates.

RESULTS

Based on our models, we estimated that the incidence rate for psychotic disorders was 28 cases per 100,000 population. The rate estimates were significantly higher in males than females, with an overall male:female ratio of 1.57:1. Incidence rate estimates peaked in the youngest age group (18-24 years). The adjusted mortality rate estimated during the whole period of observation was 12.5 per 1000 persons, with a standardised mortality ratio of 5.5.

CONCLUSIONS

Using treated prevalence data and observed deaths with appropriate algorithms, we were able to impute incidence and mortality rates for psychotic disorders consistent with the published literature. While the second national survey of psychotic disorders was not designed to identify mortality, our estimates provide a stark reminder of the increased mortality associated with these disorders.

Antibodies to the N-methyl-D-aspartate receptor and other synaptic proteins in psychosis

This review concentrates on the evidence for autoantibodies to cell surface synaptic proteins in psychosis and schizophrenia. We and others have recently found antibodies to the N-methyl-D-aspartate receptor in first-episode psychosis. We describe the evidence for pathogenicity and disease-relevance of these antibodies, which builds on the novel field in neuroimmunology of cell surface antibody-associated central nervous system disorders. Relevant autoantibodies in psychosis and schizophrenia are likely to be those directed to cell surface proteins, in which the likelihood of pathogenicity is greater. We discuss the evidence for this from the field of paraneoplastic neurologic syndromes and the discovery of novel cell surface antigen central nervous system autoimmune syndromes.

Recording of severe mental illness in United Kingdom primary care, 2000-2010

Background

There is increasing emphasis on primary care services for individuals with severe mental illnesses (SMI), including schizophrenia, bipolar disorder, and other non-organic psychotic disorders. However we lack information on how many people receive these different diagnoses in primary care. Primary care databases offer an opportunity to explore the recording of new SMI diagnoses in representative general practices.

Methods

We used data from The UK Health Improvement Network (THIN) primary care database including longitudinal patient records for individuals aged over 16 years from 437 general practices. We determined the annual GP recorded rate of first diagnosis of SMI by age, gender, social deprivation and urbanicity between 2000 and 2010.

Results

We identified 10,520 individuals with a first record of schizophrenia, bipolar disorder or other non-organic psychosis among 4,164,794 patients. This corresponded to a rate of first diagnosis of 46.4 per 100,000 person years at risk (PYAR) (95% CI 45.4 to 47.4) in the 16–65 age group. The rate of first record of schizophrenia was 9.2 per 100,000 PYAR (95% CI 8.7 to 9.6) in this age group, bipolar disorder was 15.0 per 100,000 PYAR (95% CI 14.4 to 15.5) and other non-organic psychotic disorder was 22.3 per 100,000 PYAR (95% CI 21.6 to 23.0).

Conclusions

The rates of GP recorded SMI in primary care records were broadly comparable to incidence rates from previous epidemiological studies of SMI and show similar patterns by socio-demographic characteristics. However there were some differences by specific diagnoses. GPs may be recording rates that are higher than those used to commission services.

Mental illness and a high-risk, elderly Japanese population: characteristic differences related to gender and residential location

PURPOSE

Examining the sociodemographic determinants of psychological distress is important in identifying specific subgroups in need of further intervention. However, there are few studies focusing on older populations and on the role of gender or location of residence. To try to clarify characteristics of a population at high risk for mental illness, we examined the sociodemographic determinants of psychological distress in older adults living in three different locations.

METHODS

A mail survey was used to collect data on levels of psychological distress and sociodemographic characteristics from a population-based sample of 1894 older adults who lived in Bunkyo (urban setting), Fuchu (suburban setting) and Oyama (rural setting) in Japan (aged 65-74 years, 51.3% men). Psychological distress level was measured based on Kessler's six-item psychological distress scale (K6) and dichotomized into two groups with a cut-off score of 5 (0-4 or 5-24). Multiple logistic regression analyses were used to examine the associations between sociodemographic factors, specifically gender and location of residence, and psychological distress levels.

RESULTS

The variables of older age, living in Bunkyo, living in Oyama and living alone were significantly associated with high psychological distress. Although these associations were observed in men, no associations were observed in women. Location-specific analyses showed significant associations between sociodemographic and psychological distress among men living in Oyama, but not among those in Bunkyo or Fuchu.

CONCLUSIONS

Sociodemographic factors were significantly correlated with psychological distress, particularly among older men in rural areas. Characteristics of a population at high risk for mental illness may vary based on gender and location of residence. Health promotion initiatives for older adults may be more effective if they take these demographic factors into account.

Psychiatric morbidity, functioning and quality of life in young people at clinical high risk for psychosis

OBJECTIVE

Recent studies suggest that psychotic-like experiences may also act as markers for non-psychotic psychiatric disorders, which may indicate that the focus of research in individuals at high risk (HR) for psychosis needs updating. In this study we thoroughly examined the clinical and functional characteristics of a consecutive cohort of young people at HR for psychosis and compared them to a matched sample of healthy volunteers.

METHOD

Between February 2010 and September 2012 60 help-seeking HR individuals, aged 16-35, were recruited from CAMEO Early Intervention in Psychosis Service, Cambridgeshire, UK. Forty-five age- and gender-matched healthy volunteers were randomly recruited from the same geographical area. Sociodemographic, psychiatric morbidity, functioning and quality of life measures were compared between both groups.

RESULTS

HR individuals suffered a wide range of DSM-IV psychiatric disorders, mainly within the affective and anxiety diagnostic spectra. In comparison to healthy volunteers, young people at HR reported more suicidal ideation/intention, depressive and anxiety symptoms and presented with remarkably poor functioning and quality of life.

CONCLUSION

The presence of co-morbid moderate or severe depressive and anxiety symptoms was common in our sample of young people at enhanced risk for psychosis. A HR mental state may be associated not only with an increased risk for psychosis, but also other psychiatric disorders. Our findings may have implications for the future implementation of therapeutic interventions that this population could benefit from.

Disparate patterns of hospitalisation reflect unmet needs and persistent ethnic inequalities in mental health care: the Scottish health and ethnicity linkage study

OBJECTIVES

The presence and extent of mental health inequalities in Scotland is unclear. We investigated ethnic variations in psychiatric hospitalisations and compulsory treatment in relation to socioeconomic indicators.

DESIGN

In a retrospective cohort study design, using data linkage methods, we examined ethnic variations in psychiatric [any psychiatric, mood (affective), and psychotic disorders) hospitalisations and use of the Mental Health (Care and Treatment) (Scotland) Act 2003 (Emergency Detentions (ED), Short-Term Detentions (STD) and Compulsory Treatment Orders (CTO)] using age (and sex for compulsory treatment), car ownership, and housing tenure adjusted risk ratios (RR). 95% CIs for the data below exclude the reference White Scottish group value (100).

RESULTS

Compared to the White Scottish population, Other White British men and women had lower hospitalisation from any psychiatric disorder (RR = 77.8, 95% CI: 71.0-85.2 and 85.8, 95% CI: 79.3-92.9), mood disorder (91.2, 95% CI: 86.9-95.8 and 83.6, 95% CI: 75.1-93.1), psychotic disorder (67.1, 95% CI: 59.9-75.2 and 78.5, 95% CI: 67.6-91.1), CTO (84.6, 95% CI: 72.4-98.9) and STD (88.2, 95% CI: 78.6-99.0). Any Mixed Background women had higher hospitalisation from any psychiatric disorder (137.2, 95% CI: 110.9-169.6) and men and women had a higher risk of psychotic disorder (200.6, 95% CI: 105.7-380.7 and 175.5, 95% CI: 102.3-301.2), CTO (263.0, 95% CI: 105.4-656.3), ED (245.6, 95% CI: 141.6-426.1) and STD (311.7, 95% CI: 190.2-510.7). Indian women had lower risk of any psychiatric disorder (43.2, 95% CI: 28.0-66.7). Pakistani men had lower risk of any psychiatric disorder (78.7, 95% CI: 69.3-89.3), and higher risk of mood disorders (117.5, 95% CI: 100.2-137.9). Pakistani women had similar risk of any psychiatric and mood disorder however, a twofold excess risk of psychotic disorder (227.3, 95% CI: 195.8-263.8). Risk of STD was higher in South Asians (136.9, 95% CI: 109.0-171.9). Chinese men and women had the lowest risk of hospitalisation for any psychiatric disorder (35.3, 95% CI: 23.2-53.7 and 44.5, 95% CI: 30.3-65.5) and mood disorder (51.5, 95% CI: 31.0-85.4 and 47.5, 95% CI: 23.2-97.4) but not psychotic disorders and higher risk for CTO (181.4, 95% CI: 121.0-271.0). African women had higher risk of any psychiatric disorder (139.4, 95% CI: 119.0-163.2). African men and women had the highest risk for psychotic disorders (230.8, 95% CI: 177.8-299.5 and 240.7, 95% CI: 163.8-353.9) and were also overrepresented in STD (214.3, 95% CI: 122.4-375.0) and CTO (486.6, 95% CI: 231.9-1021.1). Differences in hospitalisations were not fully attenuated when adjusted for car ownership and housing tenure and the effect of these adjustments varied by ethnic group.

CONCLUSION

Our data show disparate patterns of psychiatric hospitalisations by ethnic group in Scotland providing new observations concerning the mental health care experience of Chinese, Mixed background and White subgroups not fully explained by socioeconomic indicators. For South Asian and Chinese groups in particular, our data indicate under and late utilisation of mental health services. These data call for monitoring and review of services.

Clinical and sociodemographic comparison of people at high-risk for psychosis and with first-episode psychosis

OBJECTIVE

To compare clinical and sociodemographic characteristics previously associated with psychosis, between individuals at high-risk for psychosis (HR) and patients experiencing a first episode psychosis (FEP), to achieve a better understanding of factors associated with psychosis.

METHOD

Cross-sectional comparison of 30 individuals at HR with 30 age-gender matched FEP, presenting to an early intervention service for psychosis. Participants were followed-up for 2 years to establish the proportion of HR who made the transition into FEP.

RESULTS

Both groups showed similar socio-clinical characteristics, including immigration status, employment history, marital status, family history of psychotic illness, self-harm and alcohol and drug use. The HR group had a lower level of education, higher burden of trauma, earlier onset of psychiatric symptoms and a longer delay in accessing specialised services. A younger onset of symptoms was associated with a longer delay in accessing services in both groups. After a 2 year follow-up, only three (10%) of the HR group made a transition into FEP.

CONCLUSION

The similarities observed between individuals at HR and those with FEP suggest that known variables associated with psychosis may be equally prevalent in people at HR who do not develop a psychotic disorder.

Ethnic minority position and risk for psychotic disorders

PURPOSE OF REVIEW

This article reviews the recent literature about migration, ethnic minority position and the risk of psychotic disorders.

RECENT FINDINGS

A meta-analysis found that both first and second-generation migrants have on average a two-fold increase in risk for psychotic disorders. In the Netherlands, the risk was most elevated for individuals who migrated in early childhood. Several studies investigated diagnostic ethnic bias and reported greater likelihood of schizophrenia diagnosis in ethnic minority patients at the cost of diagnosis of affective psychotic disorders. Neighbourhood ethnic density was related to prevalence of psychotic experiences in ethnic minority populations in the UK. Perceived discrimination was associated with severity of psychotic and depressive symptoms in ethnic minority patients. Both weak and strong ethnic identification, as well as experiences of social adversity, were related to risk for psychosis. Low neonatal vitamin D was associated with adult risk for psychosis and vitamin D levels in childhood were associated with nonclinical psychotic experiences.

SUMMARY

The risk for psychotic disorders is increased among ethnic minority populations. Experiences of social adversity and having a disadvantaged outsider status may explain the excess risk. More research is needed into potential biological mechanisms, including vitamin D.

A population-level prediction tool for the incidence of first-episode psychosis: translational epidemiology based on cross-sectional data

OBJECTIVES

Specialist early intervention services (EIS) for people aged 14-35 years with first episodes of psychosis (FEP) have been commissioned throughout England since 2001. A single estimate of population need was used everywhere, but true incidence varies enormously according to sociodemographic factors. We sought to develop a realistically complex, population-based prediction tool for FEP, based on precise estimates of epidemiological risk.

DESIGN AND PARTICIPANTS

Data from 1037 participants in two cross-sectional population-based FEP studies were fitted to several negative binomial regression models to estimate risk coefficients across combinations of different sociodemographic and socioenvironmental factors. We applied these coefficients to the population at-risk of a third, socioeconomically different region to predict expected caseload over 2.5 years, where the observed rates of ICD-10 F10-39 FEP had been concurrently ascertained via EIS.

SETTING

Empirical population-based epidemiological data from London, Nottingham and Bristol predicted counts in the population at-risk in the East Anglia region of England.

MAIN OUTCOME MEASURES

Observed counts were compared with predicted counts (with 95% prediction intervals (PI)) at EIS and local authority district (LAD) levels in East Anglia to establish the predictive validity of each model.

RESULTS

A model with age, sex, ethnicity and population density performed most strongly, predicting 508 FEP participants in EIS in East Anglia (95% PI 459, 559), compared with 522 observed participants. This model predicted correctly in 5/6 EIS and 19/21 LADs. All models performed better than the current gold standard for EIS commissioning in England (716 cases; 95% PI 664-769).

CONCLUSIONS

We have developed a prediction tool for the incidence of psychotic disorders in England and Wales, made freely available online (http://www.psymaptic.org), to provide healthcare commissioners with accurate forecasts of FEP based on robust epidemiology and anticipated local population need. The initial assessment of some people who do not require subsequent EIS care means additional service resources, not addressed here, will be required.

First-episode psychosis at the West Bologna Community Mental Health Centre: results of an 8-year prospective study

BACKGROUND

Research mostly conducted in the UK and northern Europe has established that there are high rates of first-episode psychosis (FEP) in large cities and immigrant populations; moreover, psychosis has been found to be associated with cannabis use and early trauma. The present study aimed to evaluate the incidence rate of FEP and the distribution of several risk factors (e.g. age, ethnicity, substance abuse) in Bologna, Italy.

METHOD

The Bologna FEP (BoFEP) study is an 8-year prospective study. All FEP patients, 18-64 years old, consecutively referred to the West Bologna Community Mental Health Centre (CMHC) from 2002 to 2009 were evaluated. Sociodemographic information, migration history and clinical data were collected through an ad-hoc schedule. Psychiatric diagnoses were recorded using the Schedule for Clinical Assessment of Neuropsychiatry (SCAN).

RESULTS

The overall incidence rate (IR) in the BoFEP study was 16.4 per 100 000 person-years [95% confidence interval (CI) 13.9-18.9]. The incidence was higher in young people, men and migrants (MI).

CONCLUSIONS

The IR of FEP found by the Bologna study is lower than that found by other European studies. However, as in other studies, the incidence was higher in certain groups. This heterogeneity has implications for policy and mental health service development, and for understanding the aetiology of psychosis.

The incidence of first-episode schizophrenia-spectrum psychosis in adolescents and young adults in montreal: an estimate from an administrative claims database

OBJECTIVE

There has been increasing interest in the psychiatric literature on research and service delivery focused on first-episode psychosis (FEP), and accurate information on the incidence of FEP is crucial for the development of services targeting patients in the early stages of illness. We sought to obtain a population-based estimate of the incidence of first-episode schizophrenia-spectrum psychosis (SSP) among adolescents and young adults in Montreal.

METHODS

Population-based administrative data from physician billings, hospitalizations, pharmacies, and public health clinics were used to estimate the incidence of first-episode SSP in Montreal. A 3-year period (2004-2006) was used to identify patients with SSP aged 14 to 25 years. We used a 4- to 6-year clearance period to remove patients with a history of any psychotic disorder or prescription for an antipsychotic.

RESULTS

We identified 456 patients with SSP, yielding a standardized annual incidence of 82.9 per 100 000 for males (95% CI 73.7 to 92.1), and 32.2 per 100 000 for females (95% CI 26.7 to 37.8). Using ecologic indicators of material and social deprivation, we found a higher-incidence proportion of SSP among people living in the most deprived areas, relative to people living in the least deprived areas.

CONCLUSIONS

Clinical samples obtained from psychiatric services are unlikely to capture all treatment-seeking patients, and epidemiologic surveys have resource-intensive constraints, making this approach challenging for rare forms of psychopathology; therefore, population-based administrative data may be a useful tool for studying the frequency of psychotic disorders.

Incidence of schizophrenia and other psychoses in England, 1950-2009: a systematic review and meta-analyses

BACKGROUND

We conducted a systematic review of incidence rates in England over a sixty-year period to determine the extent to which rates varied along accepted (age, sex) and less-accepted epidemiological gradients (ethnicity, migration and place of birth and upbringing, time).

OBJECTIVES

To determine variation in incidence of several psychotic disorders as above.

DATA SOURCES

Published and grey literature searches (MEDLINE, PSycINFO, EMBASE, CINAHL, ASSIA, HMIC), and identification of unpublished data through bibliographic searches and author communication.

STUDY ELIGIBILITY CRITERIA

Published 1950-2009; conducted wholly or partially in England; original data on incidence of non-organic adult-onset psychosis or one or more factor(s) pertaining to incidence.

PARTICIPANTS

People, 16-64 years, with first -onset psychosis, including non-affective psychoses, schizophrenia, bipolar disorder, psychotic depression and substance-induced psychosis.

STUDY APPRAISAL AND SYNTHESIS METHODS

Title, abstract and full-text review by two independent raters to identify suitable citations. Data were extracted to a standardized extraction form. Descriptive appraisals of variation in rates, including tables and forest plots, and where suitable, random-effects meta-analyses and meta-regressions to test specific hypotheses; rate heterogeneity was assessed by the I²-statistic.

RESULTS

83 citations met inclusion. Pooled incidence of all psychoses (N = 9) was 31.7 per 100,000 person-years (95%CI: 24.6-40.9), 23.2 (95%CI: 18.3-29.5) for non-affective psychoses (N = 8), 15.2 (95%CI: 11.9-19.5) for schizophrenia (N = 15) and 12.4 (95%CI: 9.0-17.1) for affective psychoses (N = 7). This masked rate heterogeneity (I²: 0.54-0.97), possibly explained by socio-environmental factors; our review confirmed (via meta-regression) the typical age-sex interaction in psychosis risk, including secondary peak onset in women after 45 years. Rates of most disorders were elevated in several ethnic minority groups compared with the white (British) population. For example, for schizophrenia: black Caribbean (pooled RR: 5.6; 95%CI: 3.4-9.2; N = 5), black African (pooled RR: 4.7; 95%CI: 3.3-6.8; N = 5) and South Asian groups in England (pooled RR: 2.4; 95%CI: 1.3-4.5; N = 3). We found no evidence to support an overall change in the incidence of psychotic disorder over time, though diagnostic shifts (away from schizophrenia) were reported.

LIMITATIONS

Incidence studies were predominantly cross-sectional, limiting causal inference. Heterogeneity, while evidencing important variation, suggested pooled estimates require interpretation alongside our descriptive systematic results.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

Incidence of psychotic disorders varied markedly by age, sex, place and migration status/ethnicity. Stable incidence over time, together with a robust socio-environmental epidemiology, provides a platform for developing prediction models for health service planning.

Psychosis incidence through the prism of early intervention services

We know little about first-episode psychosis epidemiology beyond cities or when measured through early intervention in psychosis services. We present results from 18 months of the 3-year Social Epidemiology of Psychoses in East Anglia (SEPEA) study of incepted incidence observed through five early intervention services. We identified 378 eligible individuals (incidence: 45.1/100 000 person-years, 95% CI 40.8-49.9). Rates varied across these services, but were 2-3 times higher than those on which services were commissioned. Risk decreased with age, was nearly doubled among men and differed by ethnic group; doubled in people of mixed ethnicity but lower for those of Asian origin, compared with White British people. Psychosis risk among ethnic minorities was lower than reported in urban settings, which has potential implications for aetiology. Our data suggest considerable psychosis morbidity in diverse, rural communities.