EPPIC: an evolving system of early detection and optimal management

The effectiveness of public health interventions, initiatives, and campaigns designed to improve pathways to care for individuals with psychotic disorders: A systematic review

PURPOSE

Lengthy duration of untreated psychosis (DUP) and duration of untreated illness (DUI) in people at clinical high-risk for psychosis (CHR-P) and first episode psychosis (FEP) is associated with poorer outcomes. However, individuals with FEP often experience negative pathways to care involving contacts with police, crisis services and requiring compulsory admissions, and evidence suggests individuals with both FEP and CHR-P often experience lengthy delays to treatment. Early detection interventions, such as public health interventions, may be one way to reduce delays. This systematic review aimed to synthesise the available evidence on such interventions.

METHODS

The EMBASE, PsychINFO, CINAHL, and MEDLINE databases were searched. Studies were included if they compared an intervention designed to improve timely access to treatment for individuals with FEP or CHR-P to standard treatment provision. Interventions may be targeted at potential patients, their families, the general public, or non-healthcare professionals. Outcomes of interest were DUP or DUI, and/or characteristics of pathways to care.

RESULTS

Nineteen studies met the inclusion criteria. All consisted of FEP populations, none of CHR-P populations. Employing narrative synthesis, we found mixed results about the effectiveness of interventions at reducing DUP and interventions appeared to differentially impact groups. Pathways to care information was limited and mixed.

CONCLUSION

Findings on the effectiveness of interventions designed to improve timely access to treatment were inconclusive. More research is warranted to better understand where delays occur and factors which may influence this for both FEP and CHR-P populations which may help to develop targeted interventions to address delays.

Duration of Untreated Psychosis and Outcomes in First-Episode Psychosis: Systematic Review and Meta-analysis of Early Detection and Intervention Strategies

BACKGROUND

The role of duration of untreated psychosis (DUP) as an early detection and intervention target to improve outcomes for individuals with first-episode psychosis is unknown.

STUDY DESIGN

PRISMA/MOOSE-compliant systematic review to identify studies until February 1, 2023, with an intervention and a control group, reporting DUP in both groups. Random effects meta-analysis to evaluate (1) differences in DUP in early detection/intervention services vs the control group, (2) the efficacy of early detection strategies regarding eight real-world outcomes at baseline (service entry), and (3) the efficacy of early intervention strategies on ten real-world outcomes at follow-up. We conducted quality assessment, heterogeneity, publication bias, and meta-regression analyses (PROSPERO: CRD42020163640).

STUDY RESULTS

From 6229 citations, 33 intervention studies were retrieved. The intervention group achieved a small DUP reduction (Hedges' g = 0.168, 95% CI = 0.055-0.283) vs the control group. The early detection group had better functioning levels (g = 0.281, 95% CI = 0.073-0.488) at baseline. Both groups did not differ regarding total psychopathology, admission rates, quality of life, positive/negative/depressive symptoms, and employment rates (P > .05). Early interventions improved quality of life (g = 0.600, 95% CI = 0.408-0.791), employment rates (g = 0.427, 95% CI = 0.135-0.718), negative symptoms (g = 0.417, 95% CI = 0.153-0.682), relapse rates (g = 0.364, 95% CI = 0.117-0.612), admissions rates (g = 0.335, 95% CI = 0.198-0.468), total psychopathology (g = 0.298, 95% CI = 0.014-0.582), depressive symptoms (g = 0.268, 95% CI = 0.008-0.528), and functioning (g = 0.180, 95% CI = 0.065-0.295) at follow-up but not positive symptoms or remission (P > .05).

CONCLUSIONS

Comparing interventions targeting DUP and control groups, the impact of early detection strategies on DUP and other correlates is limited. However, the impact of early intervention was significant regarding relevant outcomes, underscoring the importance of supporting early intervention services worldwide.

Cognitive behavioural therapy added to standard care for first-episode and recent-onset psychosis

BACKGROUND

Cognitive behavioural therapy (CBT) can be effective in the general population of people with schizophrenia. It is still unclear whether CBT can be effectively used in the population of people with a first-episode or recent-onset psychosis.

OBJECTIVES

To assess the effects of adding cognitive behavioural therapy to standard care for people with a first-episode or recent-onset psychosis.

SEARCH METHODS

We conducted a systematic search on 6 March 2022 in the Cochrane Schizophrenia Group's Study-Based Register of Trials, which is based on CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, PubMed, ClinicalTrials.gov, ISRCTN, and WHO ICTRP.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing CBT added to standard care vs standard care in first-episode or recent-onset psychosis, in patients of any age.

DATA COLLECTION AND ANALYSIS

Two review authors (amongst SFM, CC, LK and IB) independently screened references for inclusion, extracted data from eligible studies and assessed the risk of bias using RoB2. Study authors were contacted for missing data and additional information. Our primary outcome was general mental state measured on a validated rating scale. Secondary outcomes included other specific measures of mental state, global state, relapse, admission to hospital, functioning, leaving the study early, cognition, quality of life, satisfaction with care, self-injurious or aggressive behaviour, adverse events, and mortality.

MAIN RESULTS

We included 28 studies, of which 26 provided data on 2407 participants (average age 24 years). The mean sample size in the included studies was 92 participants (ranging from 19 to 444) and duration ranged between 26 and 52 weeks. When looking at the results at combined time points (mainly up to one year after start of the intervention), CBT added to standard care was associated with a greater reduction in overall symptoms of schizophrenia (standardised mean difference (SMD) -0.27, 95% confidence interval (CI) -0.47 to -0.08, 20 RCTs, n = 1508, I2 = 68%, substantial heterogeneity, low certainty of the evidence), and also with a greater reduction in positive (SMD -0.22, 95% CI -0.38 to -0.06, 22 RCTs, n = 1565, I² = 52%, moderate heterogeneity), negative (SMD -0.20, 95% CI -0.30 to -0.11, 22 RCTs, n = 1651, I² = 0%) and depressive symptoms (SMD -0.13, 95% CI -0.24 to -0.01, 18 RCTs, n = 1182, I² = 0%) than control. CBT added to standard care was also associated with a greater improvement in the global state (SMD -0.34, 95% CI -0.67 to -0.01, 4 RCTs, n = 329, I² = 47%, moderate heterogeneity) and in functioning (SMD -0.23, 95% CI -0.42 to -0.05, 18 RCTs, n = 1241, I² = 53%, moderate heterogeneity, moderate certainty of the evidence) than control. We did not find a difference between CBT added to standard care and control in terms of number of participants with relapse (relative risk (RR) 0.82, 95% CI 0.57 to 1.18, 7 RCTs, n = 693, I² = 48%, low certainty of the evidence), leaving the study early for any reason (RR 0.87, 95% CI 0.72 to 1.05, 25 RCTs, n = 2242, I² = 12%, moderate certainty of the evidence), adverse events (RR 1.29, 95% CI 0.85 to 1.97, 1 RCT, n = 43, very low certainty of the evidence) and the other investigated outcomes.

AUTHORS' CONCLUSIONS

This review synthesised the latest evidence on CBT added to standard care for people with a first-episode or recent-onset psychosis. The evidence identified by this review suggests that people with a first-episode or recent-onset psychosis may benefit from CBT additionally to standard care for multiple outcomes (overall, positive, negative and depressive symptoms of schizophrenia, global state and functioning). Future studies should better define this population, for which often heterogeneous definitions are used.

The Cost-Effectiveness of a Novel Online Social Therapy to Maintain Treatment Effects From First-Episode Psychosis Services: Results From the Horyzons Randomized Controlled Trial

BACKGROUND

Digital interventions have potential applications in promoting long-term recovery and improving outcomes in first-episode psychosis (FEP). This study aimed to evaluate the cost-effectiveness of Horyzons, a novel online social therapy to support young people aged 16-27 years following discharge from FEP services, compared with treatment as usual (TAU) from a healthcare sector and a societal perspective.

STUDY DESIGN

A cost-effectiveness analysis (CEA), based on the change in social functioning, and a cost-utility analysis (CUA) using quality-adjusted life years were undertaken alongside a randomized controlled trial. Intervention costs were determined from study records; resources used by patients were collected from a resource-use questionnaire and administrative data. Mean costs and outcomes were compared at 18 months and incremental cost-effectiveness ratios were calculated. Uncertainty analysis using bootstrapping and sensitivity analyses was conducted.

STUDY RESULTS

The sample included 170 participants: Horyzons intervention group (n = 86) and TAU (n = 84). Total costs were significantly lower in the Horyzons group compared with TAU from both the healthcare sector (-AU$4789.59; P < .001) and the societal perspective (-AU$5131.14; P < .001). In the CEA, Horyzons was dominant, meaning it was less costly and resulted in better social functioning. In the CUA, the Horyzons intervention resulted in fewer costs but also yielded fewer QALYs. However, group differences in outcomes were not statistically significant. When young people engaged more with the platform, costs were shown to decrease and outcomes improved.

CONCLUSIONS

The Horyzons intervention offers a cost-effective approach for improving social functioning in young people with FEP after discharge from early intervention services.

Seven decades of antipsychotic drugs: Why is the life of Australians with schizophrenia still so suboptimal?

The advent of dopamine (D2) receptor-blocking medications over 70 years ago, ushered in a new era of biological treatment for schizophrenia. However, we argue that little subsequent progress has been made in translating this into fulfilled and fulfilling lives for people with schizophrenia. This Viewpoint asks why this is the case, and suggests ways forward for capitalising on extant and emerging new treatments for psychotic disorders, to the betterment of the lives of people living with schizophrenia.

Effect of early intervention for early-stage psychotic disorders on suicidal behaviours - a systematic review protocol

Background

The early stages of psychotic disorders correspond to the early phases of the disease and include the prodromal phase and first-episode psychosis; they constitute a period at high risk of suicidal behaviour. A long duration of untreated psychosis (DUP) is among the risk factors of suicidal behaviour identified in this early period. Many studies have shown the effectiveness of early interventions on the overall prognosis of psychotic disorders in the early stages, and early intervention strategies have been developed and tested worldwide. Several authors reported an improvement in suicidal behaviours; however, all these data have not been systematically analysed yet. The main objective of this systematic review was to collect evidence on the effect on suicidal behaviour of early interventions for patients in the early stages of psychotic disorders.

Methods

We will carry out a systematic review of the literature according to the PRISMA criteria by searching articles in five databases (PubMed, Cochrane, PsycINFO, Scopus, EMBASE), without restriction on the publication date. The selection criteria are: articles (any type; e.g. prospective, retrospective, controlled or uncontrolled, and literature reviews) on early interventions for psychotic disorders in the early stages with data on suicide attempts, death by suicide, suicidal ideation; articles written in English or French. Exclusion criteria are: articles on suicidal behaviours in patients with psychotic disorders in the early stages, but without early intervention, and articles on early-stage psychotic disorders without data on suicidal behaviours.

Discussion

If this review confirms the effectiveness on suicidal behaviours of early interventions for young patients with psychotic disorders, the development/implementation of such intervention programmes should be better promoted.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42021237833.

Policy Complexities in Financing First Episode Psychosis Services: Implementation Realities from a Home Rule State

Over the past decade, significant investments have been made in coordinated specialty care (CSC) models for first episode psychosis (FEP), with the goal of promoting recovery and preventing disability. CSC programs have proliferated as a result, but financing challenges imperil their growth and sustainability. In this commentary, the authors discuss (1) entrenched and emergent challenges in behavioral health policy of consequence for CSC financing; (2) implementation realities in the home rule context of Ohio, where significant variability exists across counties; and (3) recommendations to improve both care quality and access for individuals with FEP. The authors aim to provoke careful thought about policy interventions to bridge science-to-service gaps, and in this way, advance behavioral health equity.

Discharge destinations for young people with a first episode of psychosis after attending an early intervention for psychosis service

OBJECTIVE

Early intervention for psychosis services result in superior outcomes in the domains of symptomatic and functional recovery, hospitalisation and employment compared to standard services; however, the optimal duration of care with these services is unknown. Knowledge on the discharge destinations, specifically the proportion discharged to high- and low-intensity services, could provide insights into the proportion of who may require a longer tenure of care. This study aimed to determine (1) the discharge destinations from early intervention for psychosis services and (2) baseline and intra-episode factors associated with discharge to the secondary care/adult mental health service.

METHODOLOGY

This study was conducted at the Early Psychosis Prevention and Intervention Centre in Melbourne and included all young people treated by the service with a first episode of psychosis over a 6-year period. Discharge destinations were categorised according to high-intensity services, namely, secondary mental health care, or lower intensity services, such as private practitioners or primary care.

RESULTS

A total of 1101 young people with a first episode of psychosis were included in the study, of whom 58.8% were male and the median age was 20.0 years (interquartile range: 17-22). After a median of 95.4 weeks (interquartile range: 66.7-105.7), 36.6% were discharged to the adult mental health services, which was associated with being not in employment, education or training at presentation (odds ratio = 1.71, 95% confidence interval [1.23, 2.37]); experiencing a relapse (odds ratio = 1.76, 95% confidence interval [1.24, 2.49]); and being admitted to a mental health unit (odds ratio = 3.98, 95% confidence interval [2.61, 6.09]). Young people who lived with their parents were less likely to be discharged to secondary care services (odds ratio = 0.52, 95% confidence interval [0.37, 0.73]), as were those who were achieving symptomatic remission within 12 weeks (odds ratio = 0.60, 95% confidence interval [0.43, 0.83]). Migrant status and the duration of untreated psychosis were not associated with discharge destination.

CONCLUSION

These findings indicate that there is a sizable, identifiable minority who may benefit from a longer episode of care with early intervention for psychosis services.

Isolating the impact of antipsychotic medication on metabolic health: Secondary analysis of a randomized controlled trial of antipsychotic medication versus placebo in antipsychotic medication naïve first-episode psychosis (the STAGES study)

BACKGROUND

Cardiovascular and metabolic diseases are the leading contributors to the early mortality associated with psychotic disorders. To date, it has not been possible to disentangle the effect of medication and non-medication factors on the physical health of people with a first episode of psychosis (FEP). This study aimed to isolate the effects of antipsychotic medication on anthropometric measurements, fasting glucose and lipids.

METHODS

This study utilized data from a triple-blind randomized placebo-controlled trial comparing two groups of antipsychotic-naïve young people with a FEP who were randomized to receive a second-generation antipsychotic medication (FEP-medication group) or placebo (FEP-placebo group) for 6 months. Twenty-seven control participants were also recruited.

RESULTS

Eighty-one participants commenced the trial; 69.1% completed at least 3 months of the intervention and 33.3% completed the full 6 months. The FEP-placebo group gained a mean of 2.4 kg (±4.9) compared to 1.1 kg (±4.9) in the control participants (t = 0.76, p = .45). After controlling for multiple analyses, there was no difference in blood pressure, waist circumference or heart rate between the FEP-placebo group and controls. After 6 months, the FEP medication group had gained 4.1 kg (±4.5), higher than those receiving placebo but not statistically significant (t = 0.8, p = .44). There were no differences in fasting glucose or lipids between the FEP groups after 3 months.

CONCLUSIONS

While limited by small numbers and high attrition, these findings indicate that some of the metabolic complications observed in psychotic disorders could be attributable to factors other than medication. This emphasizes the need to deliver physical health interventions early in the course of FEP.

A Review of Potential Neuroimaging Biomarkers of Schizophrenia-Risk

The risk for developing schizophrenia is increased among first-degree relatives of those with psychotic disorders, but the risk is even higher in those meeting established criteria for clinical high risk (CHR), a clinical construct most often comprising of attenuated psychotic experiences. Conversion to psychosis among CHR youth has been reported to be about 15-35% over three years. Accurately identifying individuals whose psychotic symptoms will worsen would facilitate earlier intervention, but this has been difficult to do using behavior measures alone. Brain-based risk markers have the potential to improve the accuracy of predicting outcomes in CHR youth. This narrative review provides an overview of neuroimaging studies used to investigate psychosis risk, including studies involving structural, functional, and diffusion imaging, functional connectivity, positron emission tomography, arterial spin labeling, magnetic resonance spectroscopy, and multi-modality approaches. We present findings separately in those observed in the CHR state and those associated with psychosis progression or resilience. Finally, we discuss future research directions that could improve clinical care for those at high risk for developing psychotic disorders.

Understanding What Drives Long-term Engagement in Digital Mental Health Interventions: Secondary Causal Analysis of the Relationship Between Social Networking and Therapy Engagement

BACKGROUND

Low engagement rates with digital mental health interventions are a major challenge in the field. Multicomponent digital interventions aim to improve engagement by adding components such as social networks. Although social networks may be engaging, they may not be sufficient to improve clinical outcomes or lead users to engage with key therapeutic components. Therefore, we need to understand what components drive engagement with digital mental health interventions overall and what drives engagement with key therapeutic components.

OBJECTIVE

Horyzons was an 18-month digital mental health intervention for young people recovering from first-episode psychosis, incorporating therapeutic content and a private social network. However, it is unclear whether use of the social network leads to subsequent use of therapeutic content or vice versa. This study aimed to determine the causal relationship between the social networking and therapeutic components of Horyzons.

METHODS

Participants comprised 82 young people (16-27 years) recovering from first-episode psychosis. Multiple convergent cross mapping was used to test causality, as a secondary analysis of the Horyzons intervention. Multiple convergent cross mapping tested the direction of the relationship between each pair of social and therapeutic system usage variables on Horyzons, using longitudinal usage data.

RESULTS

Results indicated that the social networking aspects of Horyzons were most engaging. Posting on the social network drove engagement with all therapeutic components (r=0.06-0.36). Reacting to social network posts drove engagement with all therapeutic components (r=0.39-0.65). Commenting on social network posts drove engagement with most therapeutic components (r=0.11-0.18). Liking social network posts drove engagement with most therapeutic components (r=0.09-0.17). However, starting a therapy pathway led to commenting on social network posts (r=0.05) and liking social network posts (r=0.06), and completing a therapy action led to commenting on social network posts (r=0.14) and liking social network posts (r=0.15).

CONCLUSIONS

The online social network was a key driver of long-term engagement with the Horyzons intervention and fostered engagement with key therapeutic components and ingredients of the intervention. Online social networks can be further leveraged to engage young people with therapeutic content to ensure treatment effects are maintained and to create virtuous cycles between all intervention components to maintain engagement.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry: ACTRN12614000009617; https://www.australianclinicaltrials.gov.au/anzctr/trial/ACTRN12614000009617.

A randomized controlled trial of moderated online social therapy for family carers of first-episode psychosis patients in a specialist treatment setting

BACKGROUND

Family members, who provide the majority of informal care during the recovery period from first-episode psychosis (FEP), experience high levels of psychological distress. However, there is a lack of effective and accessible interventions for FEP carers.

OBJECTIVE

To determine the effectiveness of an online intervention ("Altitudes") in relation to the primary outcome of FEP-carer stress at 6 months follow-up.

METHODS

We conducted a cluster randomized controlled trial in which FEP carers were randomized to Altitudes combined with specialized treatment as usual (STAU) or STAU alone. In addition to questionnaires, we included multiple waves of intensive ecological momentary assessment (EMA) to measure carer stress and family outcomes in 164 carers of young (15-27 years) FEP patients.

RESULTS

Both groups improved over time on stress and a range of secondary outcomes, including mental health symptoms, self-efficacy, and expressed emotion with no group by time interactions. At 12 months there were significantly fewer visits to emergency departments by FEP patients in the Altitudes group (p = 0.022). Modelling of multiple EMA waves revealed that more time spent by carers with FEP patients predicted greater worry, expressed emotion, and adaptive coping.

CONCLUSIONS

Engagement and usability findings for Altitudes were positive. Further refinements to our online carer interventions may be needed to engage carers in purposeful skill development for improved management of stress and communication with the young person compared with existing specialist family interventions.

TRIAL REGISTRATION

ACTRN12616000968471.

Risk of first-episode psychosis in migrants to the Republic of Ireland

BACKGROUND

Migration is an established risk factor for developing a psychotic disorder in countries with a long history of migration. Less is known for countries with only a recent history of migration. This study aimed to determine the risk for developing a psychotic disorder in migrants to the Republic of Ireland.

METHODS

We included all presentations of first-episode psychosis over 8.5 years to the DETECT Early Intervention for psychosis service in the Republic of Ireland (573 individuals aged 18-65, of whom 22% were first-generation migrants). Psychotic disorder diagnosis relied on SCID. The at-risk population was calculated using census data, and negative binomial regression was used to estimate incidence rate ratios.

RESULTS

The annual crude incidence rate for a first-episode psychotic disorder in the total cohort was 25.62 per 100000 population at risk. Migrants from Africa had a nearly twofold increased risk for developing a psychotic disorder compared to those born in the Republic of Ireland (IRR = 1.83, 95% CI 1.11-3.02, p = 0.02). In contrast, migrants from certain Asian countries had a reduced risk, specifically those from China, India, Philippines, Pakistan, Malaysia, Bangladesh and Hong Kong (aIRR = 0.36, 95% CI 0.16-0.81, p = 0.01).

CONCLUSIONS

Further research into the reasons for this inflated risk in specific migrant groups could produce insights into the aetiology of psychotic disorders. This information should also be used, alongside other data on environmental risk factors that can be determined from census data, to predict the incidence of psychotic disorders and thereby resource services appropriately.

The clinical and functional outcomes of a large naturalistic cohort of young people accessing national early psychosis services

AIMS

Services for individuals with a first episode of psychosis or at ultra-high risk of psychosis have become a treatment model of choice in mental health care. The longitudinal changes in clinical and functional outcomes as a result of real-world treatment remain under-reported.

METHODS

We analysed data from first episode of psychosis and ultra-high risk services delivered across Australian primary youth mental health care services known as headspace between 19 June 2017 and 30 September 2019. Outcome measures were completed and entered into a minimum dataset every 90 days a participant was receiving treatment and included psychiatric symptomatology (Brief Psychiatric Rating Scale and psychological distress, K10) and psychosocial functioning (Social and Occupational Functioning Assessment Scale and My Life Tracker). Linear mixed-effects models were used to evaluate changes in outcome over time.

RESULTS

Outcome data from a total of 1252 young people were evaluated (643 first episode of psychosis, 609 ultra-high risk). Of those who entered ultra-high risk services, 11.8% transitioned to first episode of psychosis services. Overall, substantial improvement in clinical (Brief Psychiatric Rating Scale, K10) and functional (Social and Occupational Functioning Assessment Scale, My Life Tracker) outcomes were seen across groups and outcomes. Ultra-high risk patients showed a greater reduction in distress symptoms, while first episode of psychosis patients experienced a greater reduction in positive psychosis symptoms. Although clinical outcomes showed a plateau effect after approximately 3 months of care, improvement in functional outcomes (Social and Occupational Functioning Assessment Scale, My Life Tracker) continued later in treatment.

CONCLUSION

These findings support the use of real-time, real-world and low-cost administrative data to rigorously evaluate symptomatic and functional outcomes in early psychosis treatment settings. Findings that functional outcomes improve past the remittance of clinical outcomes also support the functional recovery focus of early psychosis services and remaining high levels of distress suggest the need for ultra-high risk services to extend beyond 6 months of care.

Co-occurring first-episode psychosis and borderline personality pathology in an early intervention for psychosis cohort

INTRODUCTION

Borderline personality disorder (BPD) is common among people diagnosed with first episode of psychosis (FEP), but is often under-recognized and under-researched. This study aimed to determine: (i) the prevalence of borderline personality pathology (subthreshold features and categorical disorder) in a FEP cohort (termed FEP + BPP); (ii) demographic and clinical factors associated with FEP + BPP; (iii) the symptomatic and functional outcomes.

METHODS

This study was conducted within the Early Psychosis Prevention and Intervention Centre (EPPIC) at Orygen over the 30-month period between 2014 and 2016. BPP was evaluated by using the Structured Clinical Interview for DSM-IV Axis II Personality Questionnaire BPD criteria.

RESULTS

In a cohort of 457 young people with a FEP (mean age 19.5 years, 56% male), 18.4% had borderline personality pathology (BPP). Compared with FEP alone, young people with FEP + BPP were more likely to be female, younger, Australian-born. In addition, young people with FEP + BPP were more likely to be diagnosed with Psychosis NOS, present with more severe hallucinations, and have alcohol abuse. Young people with FEP + BPP had more relationship difficulties at presentation and they were more likely to suffer of depression and to engage in self-harm throughout the follow-up. In relation to outcome, FEP + BPP was not associated with different rates of remission or relapse, however they were less likely to be admitted to hospital at presentation or involuntarily during their episode of care.

CONCLUSION

BPP is a common occurrence in psychotic disorders and is associated with more severe hallucinations and depression with higher risks of self-harm. Specific interventions need to be developed.

A comparison of experiences of care and expressed emotion among caregivers of young people with first-episode psychosis or borderline personality disorder features

OBJECTIVE

Caregivers of individuals with severe mental illness often experience significant negative experiences of care, which can be associated with higher levels of expressed emotion. Expressed emotion is potentially a modifiable target early in the course of illness, which might improve outcomes for caregivers and patients. However, expressed emotion and caregiver experiences in the early stages of disorders might be moderated by the type of severe mental illness. The aim was to determine whether experiences of the caregiver role and expressed emotion differ in caregivers of young people with first-episode psychosis versus young people with 'first-presentation' borderline personality disorder features.

METHOD

Secondary analysis of baseline (pre-treatment) data from three clinical trials focused on improving caregiver outcomes for young people with first-episode psychosis and young people with borderline personality disorder features was conducted (ACTRN12616000968471, ACTRN12616000304437, ACTRN12618000616279). Caregivers completed self-report measures of experiences of the caregiver role and expressed emotion. Multivariate generalised linear models and moderation analyses were used to determine group differences.

RESULTS

Data were available for 265 caregivers. Higher levels of negative experiences and expressed emotion, and stronger correlations between negative experiences and expressed emotion domains, were found in caregivers of young people with borderline personality disorder than first-episode psychosis. Caregiver group (borderline personality disorder, first-episode psychosis) moderated the relationship between expressed emotion and caregiver experiences in the domains of need to provide backup and positive personal experiences.

CONCLUSION

Caregivers of young people with borderline personality disorder experience higher levels of negative experiences related to their role and expressed emotion compared with caregivers of young people with first-episode psychosis. The mechanisms underpinning associations between caregiver experiences and expressed emotion differ between these two caregiver groups, indicating that different supports are needed. For borderline personality disorder caregivers, emotional over-involvement is associated with both negative and positive experiences, so a more detailed understanding of the nature of emotional over-involvement for each relationship is required to guide action.

Early intervention in psychosis in emerging countries: Findings from a first-episode psychosis programme in the Ribeirão Preto catchment area, southeastern Brazil

AIM

People presenting with first-episode psychosis (FEP) can benefit from early intervention programmes. However, such programmes are scarce in low- and middle-income countries (LMICs). In Brazil, there are a few programmes, but they are unequally distributed across the country. We aimed to describe the implementation and performance of the Ribeirão Preto Early Intervention in Psychosis Programme (Ribeirão Preto-EIP), an outpatient service for patients presenting with FEP residing in the Ribeirão Preto catchment area in Southeastern Brazil.

METHODS

A detailed description of the service, staff and theoretical framework was compiled. Furthermore, a retrospective cohort study of patients attending the programme throughout 4 years (2015-2018) was conducted. Data were obtained by analysing the medical records of all patients, and sociodemographic and diagnostic stability information for this period was recorded.

RESULTS

The Ribeirão Preto-EIP had 358 new referrals during the study period. Among them, 237 patients were assessed for an average (median) duration of 14 months. Most patients were male (64.1%) and single (84.8%). The median age was 23.5 years (range, 9-86 years). Schizophrenia was the main diagnosis (43.4%), followed by substance-induced (25.7%) and affective (18.6%) psychosis. Referrals occurred from emergency, inpatient, community-based mental health and primary care services.

CONCLUSIONS

Programmes such as the Ribeirão Preto-EIP demonstrate that early intervention in psychosis is feasible in LMICs despite significant challenges for their access and integration in the health system. Strategic scale-up policies could be undertaken to offer better short- and long-term outcomes for individuals presenting with FEP and their families.

The History of Coordinated Specialty Care for Early Intervention in Psychosis in the United States: A Review of Effectiveness, Implementation, and Fidelity

Coordinated Specialty Care (CSC) is a multidisciplinary team approach to providing care for young and emerging adults having their first episode of psychosis. CSC programs have expanded rapidly throughout the United States going from 12 programs in 2008 to over 160 programs a decade later. The purpose of this historical review is to document the process and conditions that led to the accelerated dissemination of these programs across the country. CSC models began in the US in the early 2000s, but nationwide expansion followed the 2008 Recovery After an Initial Schizophrenia Episode trial. As programs have grown, debates have risen about fidelity to CSC models. The challenges facing CSC programs today include lack of evidence on what are the core components of CSC and how fidelity monitoring relates to positive client outcomes.

Pineal morphology of the clinical high-risk state for psychosis and different psychotic disorders

BACKGROUND

Pineal volume reductions have been reported in schizophrenia and clinical high-risk states for the development of psychosis, supporting the role of melatonin dysregulation in the pathophysiology of psychosis. However, it remains unclear whether pineal volume is associated with the later onset of psychosis in individuals at clinical high-risk (CHR) of psychosis or if pineal atrophy is specific to schizophrenia among different psychotic disorders.

METHODS

This magnetic resonance imaging study examined the volume of and cyst prevalence in the pineal gland in 135 individuals at CHR of psychosis [52 (38.5%) subsequently developed psychosis], 162 with first-episode psychosis (FEP), 89 with chronic schizophrenia, and 87 healthy controls. The potential contribution of the pineal morphology to clinical characteristics was also examined in the CHR and FEP groups.

RESULTS

Pineal volumes did not differ significantly between the CHR, FEP, and chronic schizophrenia groups, but were significantly smaller than that in healthy controls. However, pineal volumes were not associated with the later onset of psychosis in the CHR group or FEP sub-diagnosis (i.e., schizophrenia, schizophreniform disorder, affective psychosis, and other psychoses). No significant differences were observed in the prevalence of pineal cysts between the groups, and it also did not correlate with clinical characteristics in the CHR and FEP groups.

CONCLUSION

These results suggest that pineal atrophy is a general vulnerability marker of psychosis, while pineal cysts do not appear to contribute to the pathophysiology of psychosis.

Has improved treatment contributed to the declining rate of transition to psychosis in ultra-high-risk cohorts?

BACKGROUND

The factors contributing to declining psychotic disorder transition rates in ultra-high-risk populations remain unclear. We examined the contribution of longitudinal changes in standard clinical treatment ('treatment as usual') to this decline.

METHOD

An audit was conducted on 105 clinical files of patients who received standard care at a specialised ultra-high-risk service. The session notes of these files were quantified, allowing examination of treatment quantity, targets, psychotherapy, and medication. Differences in these aspects across patients' year of clinic entry were assessed. Variables with significant differences across years were examined using cox regression to assess their contribution to psychosis transition rates.

RESULTS

Findings were that, as a function of patients' year of clinic entry, there were increases in: patients' number of sessions, cognitive behavioural therapy (CBT), problem and solving therapy. There was a relationship between baseline year cohort and psychosis transition rate, with lower rates observed in more recent cohorts. When changes in treatment between cohorts were adjusted for, the relationship between baseline year cohort and transition rate disappeared. The relationship between baseline year and transition rate was attenuated most by increases in CBT.

CONCLUSION

Changes in standard treatment, particularly increases in CBT, may have contributed to the decline in psychosis risk observed in recent ultra-high-risk cohorts, although these variables do not fully explain this trend. Implications for clinical practice, prediction and intervention research are discussed. Future ultra-high-risk research should investigate the impact of other treatment factors, such as therapeutic alliance.

Characterizing Use of a Multicomponent Digital Intervention to Predict Treatment Outcomes in First-Episode Psychosis: Cluster Analysis

BACKGROUND

Multicomponent digital interventions offer the potential for tailored and flexible interventions that aim to address high attrition rates and increase engagement, an area of concern in digital mental health. However, increased flexibility in use makes it difficult to determine which components lead to improved treatment outcomes.

OBJECTIVE

This study aims to identify user profiles on Horyzons, an 18-month digital relapse prevention intervention for first-episode psychosis that incorporates therapeutic content and social networking, along with clinical, vocational, and peer support, and to examine the predictive value of these user profiles for treatment outcomes. A secondary objective is to compare each user profile with young people receiving treatment as usual (TAU).

METHODS

Participants comprised 82 young people (aged 16-27 years) with access to Horyzons and 84 receiving TAU, recovering from first-episode psychosis. In addition, 6-month use data from the therapy and social networking components of Horyzons were used as features for K-means clustering for joint trajectories to identify user profiles. Social functioning, psychotic symptoms, depression, and anxiety were assessed at baseline and 6-month follow-up. General linear mixed models were used to examine the predictive value of user profiles for treatment outcomes and between each user profile with TAU.

RESULTS

A total of 3 user profiles were identified based on the following system use metrics: low use, maintained use of social components, and maintained use of both therapy and social components. The maintained therapy and social group showed improvements in social functioning (F_2,51=3.58; P=.04), negative symptoms (F_2,51=4.45; P=.02), and overall psychiatric symptom severity (F_2,50=3.23; P=.048) compared with the other user profiles. This group also showed improvements in social functioning (F_1,62=4.68; P=.03), negative symptoms (F_1,62=14.61; P<.001), and overall psychiatric symptom severity (F_1,63=5.66; P=.02) compared with the TAU group. Conversely, the maintained social group showed increases in anxiety compared with the TAU group (F_1,57=7.65; P=.008). No differences were found between the low use group and the TAU group on treatment outcomes.

CONCLUSIONS

Continued engagement with both therapy and social components might be key in achieving long-term recovery. Maintained social use and low use outcomes were broadly comparable with TAU, emphasizing the importance of maintaining engagement for improved treatment outcomes. Although the social network may be a key ingredient to increase sustained engagement, as users engaged with this more consistently, it should be leveraged as a tool to engage young people with therapeutic content to bring about social and clinical benefits.

First-episode psychosis integrative treatment: Estonian experience

PURPOSE

Research on first-episode psychosis early intervention has shown significant positive effects on psychopathological, functional and quality-of-life outcome measures. The effects reported have however been short-term and there is still only limited information about the long-term effects. This article will present the short-term results of an effectiveness study in a Baltic country and the first results of a registry-based long-term follow-up.

METHODS

One hundred and ninety-nine first-episode psychosis patients were included in the early intervention effectiveness study in 2004-2008, and 107 were available for a follow-up after two years. Registry-based ten-year follow-up (n = 116) was conducted with a retrospectively formed control group (n = 114).

RESULTS

Patients who received early intervention had substantial symptomatic improvement (BPRS score reduction > 50%) after 6 months of treatment, the Global Assessment of Functioning (GAF) scores were significantly improved after 6 months, and the quality of life after 12 months was significantly higher than at the beginning of treatment. After 2 years employment increased by 14% (43.9-57.9%). Long-term follow-up revealed that significantly fewer patients in the intervention group had been in supported housing compared to the control group. Patients in the intervention group had spent more time working during the follow-up period and had almost two times larger incomes, suggestive of higher employment/salary level.

CONCLUSIONS

Early intervention with flexible duration has positive long-term effects on the functioning of patients.

Proportion and characteristics of young people in a first-episode psychosis clinic who first attended an at-risk mental state service or other specialist youth mental health service

BACKGROUND

Services for young people identified as having an 'at-risk mental state' (ARMS) aim to prevent transition to first-episode psychosis (FEP), in addition, early intervention services for other mental health disorders have also been developed. The aim of the current study was to determine the proportion of young people attending a specialist FEP service who had been referred via other early intervention clinics, including an ARMS clinic, and compare the characteristics to those who presented directly to the FEP service.

METHODS

We included young people diagnosed with FEP who received treatment at Orygen between 01.01.2012 and 31.12.2016. We examined rates of direct entry to the First Episode Psychosis service and rates from other early intervention services, specifically ARMS, personality disorders, mood disorders and a primary care youth mental health service clinics.

RESULTS

1138 young people were diagnosed with a FEP, of whom 13.7% first attended an ARMS clinic and a further 7.6% attended other youth mental health services. Individuals who first presented to an ARMS clinic were more likely to be female, younger, and less likely to be migrants or use substances. Rates of both voluntary and involuntary hospital admissions were significantly reduced for young people who transitioned from the ARMS clinic, the personality disorder clinic or the primary care service compared to those who presented directly with FEP.

CONCLUSIONS

A significant proportion of young people with FEP initially attended another specialist youth mental health service, and importantly, they had much lower rates of hospital admission at the time of transition to FEP.

Neurocognition, functional outcome, and quality of life in remitted and non-remitted schizophrenia: A comparison with euthymic bipolar I disorder and a control group

There are discrepancies about if the severity of the symptomatology in schizophrenia is related to neurocognitive performance, functional outcome, and quality of life (QoL). Also, there are controversial data about the comparison between euthymic bipolar patients and different subgroups of schizophrenia in neurocognition, functioning, and QoL level. The present study aimed to compare the neurocognitive performance, functional outcome, and QoL of remitted and non-remitted patients with SC with respect to a group of euthymic patients with BD, and a control group. It included 655 subjects: 98 patients with schizophrenia in remission (SC-R), 184 non-remitted patients with schizophrenia (SC-NR), 117 euthymic patients with bipolar I disorder (BD), and 256 healthy subjects. A comprehensive clinical, neurocognitive (six cognitive domains), functional, and QoL assessment was carried out. Remission criteria of Andreasen were used to classify schizophrenia patients as remitted or non-remitted. Compared with control subjects all groups of patients showed impaired neurocognitive performance, functioning and QoL. SC-R patients had an intermediate functioning between control subjects and SC-NR, all at a neurocognitive, functional, or QoL level. There were no significant differences between SC-R and BD. These results suggest that reaching clinical remission is essential to achieve a better level of psychosocial functioning, and QoL. Likewise, the results of this study suggest that euthymic patients with bipolar disorder and patients with schizophrenia in remission are comparable at the neurocognitive and functional levels, which might have implications in the pathophysiology of both disorders.

A pilot study of a yoga intervention for the treatment of anxiety in young people with early psychosis

BACKGROUND

Anxiety is common in young people with early psychosis and treatment options for this co-morbidity remain limited. Yoga is a promising adjunct intervention that has been shown to reduce anxiety for adults with schizophrenia, therefore this pilot study evaluated the acceptability and potential effectiveness of yoga for anxiety in early psychosis.

METHODS

A prospective single arm pilot study of a yoga intervention was conducted within an Early Intervention for psychosis service. Rates of attendance, as well as symptoms of anxiety pre and post yoga session were measured.

RESULTS

A total of 14 young people participated in the study and over 70% attended half or more of the yoga sessions offered. Significant transient reduction in state anxiety after a single session of yoga was observed (p < 0.01).

CONCLUSIONS

Yoga was found to be an acceptable and potentially effective adjunctive treatment for anxiety in early psychosis and the results warrant further clinical trials.

Cariprazine on Psychosis: Beyond Schizophrenia - A Case Series

Cariprazine is an atypical antipsychotic that has D2 and D3 partial agonism properties in addition to the usual 5-HT2A receptor antagonist action of second-generation antipsychotics. It has a distinctly higher affinity for D3 receptors, which is 10-fold higher than for D2 receptors. Cariprazine is also a 5-HT1A partial agonist, with a potential antidepressant effect. Cariprazine has been approved for treatment of both positive and negative symptoms of schizophrenia and for treatment of bipolar disorder. It could potentially be used in depression as an add-on treatment. There are few data reporting effectiveness of cariprazine in the broader spectrum of psychosis. In this paper, the authors report three cases where cariprazine was used in the treatment of psychotic conditions other than schizophrenia, namely a first episode psychosis, a case of delusional disorder, and a case of a patient with borderline personality disorder and psychotic symptoms. The authors suggest that cariprazine may be effective in the treatment of psychosis in a broader sense and should be considered a first-line treatment option.

Predictors of admission to an assertive outreach service for psychosis in Lebanon

Schizophrenia is a chronic, debilitating mental illness that contributes significantly to the global burden of disease. Assertive outreach treatment for patients with schizophrenia and psychotic disorders has been implemented to improve treatment adherence and outcomes. The suitability of this model of care outside the western context has not been fully established. We describe the characteristics of 45 patients enrolled in the Psychosis Recovery Outreach Program (PROP), a program developed at a leading psychiatric facility in Lebanon. We collected twelve-month data for patients and used logistic regression models to identify predictor variables for enrollment in the service compared to those receiving standard treatment. Patients were mostly males (77.8%), younger than 39 years (80%), of college or higher education (68.2%), and diagnosed with schizophrenia (46.7%) or schizoaffective disorder (48.9%). About one-quarter (22.7%) had a comorbid cannabis use disorder. A majority received more than one oral antipsychotic (75.6%) while half (51.1%) were maintained on a long-acting injectable (LAI) antipsychotic. The following variables were significant predictors of enrollment in PROP: having a comorbid cannabis use disorder (OR 2.83 [1.25 - 6.37]), being prescribed a LAI antipsychotic (OR 9.99 [4.93-20.24]) or more than one oral antipsychotic (OR 4.57 [2.22-9.39]), visiting the emergency department more than once (OR 8.7 [2.64-28.68]), and admission to the psychiatry unit (OR 13.91 [3.17-60.94]). In addition, those following up in PROP were younger and less likely to be in the oldest age group (over 54 years) [OR 0.11 (0.01-0.93)], less likely to be females (OR 0.39 [0.18-0.81]), and less likely to be diagnosed with "other psychotic disorder" as compared to schizophrenia (OR 0.14 [0.03 - 0.62]). Our findings highlight that the assertive outreach model of care is applicable to its target population in the context of psychiatric care in Lebanon, namely young individuals with psychosis, higher comorbidities and a severe course of illness.

The Link Between Cannabis Use and Violent Behavior in the Early Phase of Psychosis: The Potential Role of Impulsivity

INTRODUCTION

Recently, the literature has shown that Cannabis Use (CU) was a risk factor for Violent Behavior (VB) in patients with psychosis, and those in the early phase of psychosis (EPP). These findings are relevant because of the high prevalence of CU in this EPP, and the potential for prevention during this phase of illness. However, there is still a lack of clear explanations, supported by empirical evidence, about what underlies the link between CU and VB against other.

METHOD

This viewpoint reviews the scientific literature on the link between CU and VB, and the involvement of impulsivity in this relationship. This last point will be addressed at clinical and neurobiological levels.

RESULTS

Recent studies confirmed that CU is particularly high in the EPP, and is a risk factor for VB in the EPP and schizophrenia. Studies have also shown that impulsivity is a risk factor for VB in psychosis, is associated with CU, and may mediate the link between CU and VB. Research suggests a neurobiological mechanism, as CU affects the structures and function of frontal areas, known to play a role in impulsive behavior.

CONCLUSION

Scientific evidence support the hypothesis of an involvement of impulsivity as a variable that could mediate the link between CU and aggression, particularly, when CU has an early onset. However, this hypothesis should be confirmed with longitudinal studies and by taking into account confounding factors. The studies highlight the relevance of early prevention in the EPP, in addition to interventions focusing on psychotic disorders.

First-episode psychosis in the Ferrara Mental Health Department: Incidence and clinical course within the first 2 years

AIM

To examine the incidence of with first-episode psychosis (FEP) in the Integrated Department of Mental Health and Pathological Addictions in Ferrara, Italy, and to examine the association between the Duration of Untreated Psychosis (DUP) and the clinical course.

METHODS

Participants recruited in 2013-2019 were assessed with the Health of the Nation Outcome Scale (HoNOS) every 6 months for 24 months. Hierarchical growth models analysed changes of global severity (HoNOS total scores) and symptom dimensions. Regression modelled factors associated with remission (HoNOS < 8) and clinical improvement (<12).

RESULTS

The incidence of FEP was 21.5 (95%CI: 21.2-21.9) cases per 100 000 person year. Among participants (n = 86, mean age 23, 76% males), baseline HoNOS scores were higher for those with a longer DUP. More than half subjects reached clinical remission (61.6%) or improvement (82.6%), while very few (2.3%) were re-hospitalized. HoNOS total scores decayed with a mixed linear/quadratic trend, with a slower decay among migrants. A longer DUP was associated with reduced improvements of positive symptoms and lower likelihood of clinical improvement (OR: 0.84; 95%CI: 0.73-0.96).

CONCLUSIONS

Patients from the FEP program of Ferrara reached good clinical outcomes. Nonetheless, individuals with a longer DUP may need additional clinical attention. Systematic monitoring of clinical outcomes may be an optimal strategy to improve the outcomes of FEP in the real world.

Prodromal features in first-psychotic episodes of major affective and schizoaffective disorders

BACKGROUND

Study aims were to analyze psychopathological details of prodromes leading to first-lifetime psychotic episodes and apply them to improve prediction of final diagnoses.

METHODS

Comprehensive records of subjects with final diagnoses of bipolar I (BD-I; n = 216), schizoaffective (SzAffD; n = 71), or psychotic major-depressive (MDD; n = 42) disorders in the Harvard-McLean First-Psychotic Episode Project were analyzed to identify psychopathological details of prodromes leading to first-lifetime episodes with psychotic features and their ability to predict final diagnoses tested with multivariable logistic regression modeling.

RESULTS

While held blind to final diagnoses, we identified 84 distinct psychopathological characteristics of prodromes to first-psychotic episodes, including perceptual disturbances, affective symptoms, sleep disturbances, onset rate, and duration. Prevalence of 19 factors appeared to differ among final diagnoses, and were tested with multivariable regression modeling. Significantly and independently more associated with final diagnoses of MDD than BD-I were 7 features: suicidal ideation, somatic delusions, anorexia, lack of insomnia, older presenting age, depressive symptoms, and lack of impulsivity; 9 others were associated more with later SzAffD than MDD or BD-I: lack of insomnia, homicidal behavior, lack of excitement, visual hallucinations, command hallucinations, longer prodrome, male sex, responding to internal stimuli, and younger age at presentation.

LIMITATIONS

Historical-retrospective and prospective assessments may have misidentified some prodromal features, and subjects with final psychotic-MDD diagnosis were relatively few.

CONCLUSIONS

Psychopathological features identified during prodromes leading to first-episodes with psychotic features predicted and distinguished among final diagnoses of MDD, BD-I, and SzAffD. The findings add to growing impressions that early psychopathology has value in predicting final diagnoses of major affective and schizoaffective disorders.

PLAN-e-PSY, a mobile application to improve case management and patient's functioning in first episode psychosis: protocol for an open-label, multicentre, superiority, randomised controlled trial

INTRODUCTION

The prognosis of first episode psychosis (FEP), which is a severe disorder, can be notably impaired by patients' disengagement from healthcare providers. Coordinated specialty care with case management is now considered as the gold standard in this population, but there are still challenges for engagement with subsequent functional impairments. Youth-friendly and patient-centred clinical approaches are sought to improve engagement in patients with FEP. Mobile applications are widely used by young people, including patients with FEP, and can increase the youth friendliness of clinical tools. We hypothesise that a co-designed mobile application used during case management can improve functioning in patients with FEP as compared with usual case management practices.

METHODS AND ANALYSIS

A mobile case management application for planning and monitoring individualised care objectives will be co-designed with patients, caregivers and health professionals in a recovery-oriented approach. The application will be compared with usual case management practices in a multicentre, two-arm and parallel groups clinical trial. Patients will be recruited by specialised FEP teams. Impact on functioning will be assessed using the Personal and Social Performance Scale; the variation between baseline and 12 months in each group (control and active) will be the primary outcome.

ETHICS AND DISSEMINATION

This study has been approved by the Inserm Institutional Review Board IRB00003888 (Comité d'évaluation éthique de l'INSERM, reference number 20-647). The results of the study will be published in a peer-reviewed journal and presented at national and international conferences. We will also communicate the results to patients and family representatives' associations. An optimised version of the application will be then disseminated through the French FEP network (Transition Network).

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov: NCT04657380.

The Horyzons project: a randomized controlled trial of a novel online social therapy to maintain treatment effects from specialist first-episode psychosis services

This study aimed to determine whether, following two years of specialized support for first-episode psychosis, the addition of a new digital intervention (Horyzons) to treatment as usual (TAU) for 18 months was more effective than 18 months of TAU alone. We conducted a single-blind randomized controlled trial. Participants were people with first-episode psychosis (N=170), aged 16-27 years, in clinical remission and nearing discharge from a specialized service. They were randomly assigned (1:1) to receive Horyzons plus TAU (N=86) or TAU alone (N=84) between October 2013 and January 2017. Horyzons is a novel, comprehensive digital platform merging: peer-to-peer social networking; theory-driven and evidence-informed therapeutic interventions targeting social functioning, vocational recovery and relapse prevention; expert clinician and vocational support; and peer support and moderation. TAU involved transfer to primary or tertiary community mental health services. The primary outcome was social functioning at 18 months as measured by the Personal and Social Performance Scale (PSP). Forty-seven participants (55.5%) in the Horyzons plus TAU group logged on for at least 6 months, and 40 (47.0%) for at least 9 months. Social functioning remained high and stable in both groups from baseline to 18-month follow-up, with no evidence of significant between-group differences (PSP mean difference: -0.29, 95% CI: -4.20 to 3.63, p=0.77). Participants in the Horyzons group had a 5.5 times greater increase in their odds to find employment or enroll in education compared with those in TAU (odds ratio, OR=5.55, 95% CI: 1.09-28.23, p=0.04), with evidence of a dose-response effect. Moreover, participants in TAU were twice as likely to visit emergency services compared to those in the Horyzons group (39% vs. 19%; OR=0.31, 95% CI: 0.11-0.86, p=0.03, number needed to treat, NNT=5). There was a non-significant trend for lower hospitalizations due to psychosis in the Horyzons group vs. TAU (13% vs. 27%; OR=0.36, 95% CI: 0.11-1.08, p=0.07, NNT=7). So, although we did not find a significant effect of Horyzons on social functioning compared with TAU, the intervention was effective in improving vocational or educational attainment, a core component of social recovery, and in reducing usage of hospital emergency services, a key aim of specialized first-episode psychosis services. Horyzons holds significant promise as an engaging and sustainable intervention to provide effective vocational and relapse prevention support for young people with first-episode psychosis beyond specialist services.

Temporal variation in the incidence of treated psychotic disorders in young people

INTRODUCTION

The incidence of psychotic disorders varies between geographical areas, however less is known about whether it varies over time in the same region. Analyzing this temporal variation of incidence could improve the allocation of healthcare resources and our understanding of the aetiology of psychotic disorders. This study aimed to determine whether there was a change in the incidence of psychotic disorders over a six-year period.

METHODS

Young people aged 15 to 24 presenting with a first episode of psychosis (FEP) attending an early intervention service in Melbourne between 2011 and 2016 were included. The population at-risk was determined from the two corresponding census periods and analyses were adjusted for age, sex and migrant status.

RESULTS

A total of 1217 young people presented with a FEP over the six-year period and the crude incidence rate in 2011 was 102.4 per 100,000 population at-risk, compared to 125.4 in 2016. There was an increase in the incidence by 33% in 2015 (aIRR = 1.33, 95% CI 1.09-1.63) and 28% in 2016 (aIRR = 1.28, 95% CI 1.05-1.56). When examined according to diagnostic groups, there was an increase in the incidence of substance-induced psychotic disorders among females in 2015 (aIRR = 4.62, 95% CI 1.02-20.8).

DISCUSSION

This study shows significant temporal variations in the incidence of treated psychotic disorders. These findings demonstrate that early intervention services should continually monitor incidence case numbers and funding should be provided accordingly, to ensure the required intensive and comprehensive treatments can be sustained.

The Early Youth Engagement in first episode psychosis (EYE-2) study: pragmatic cluster randomised controlled trial of implementation, effectiveness and cost-effectiveness of a team-based motivational engagement intervention to improve engagement

BACKGROUND

Early Intervention in Psychosis (EIP) services improve health outcomes for young people with psychosis in the medium-long term, but 25% of young people disengage in the first 12 months with costs to their mental health, families, society and the NHS. This study will evaluate the effectiveness, cost-effectiveness and implementation of a team-based motivational Early Youth Engagement (EYE-2) intervention.

METHOD

The study design is a cluster randomised controlled trial (RCT) with economic evaluation, comparing the EYE-2 intervention + standardised EIP service to standardised EIP service alone, with randomisation at the team level. A process evaluation will evaluate the delivery of the intervention qualitatively and quantitatively across contexts. The setting is 20 EIP teams in 5 sites: Manchester, South London, East Anglia, Thames Valley and Hampshire. Participants are young people (14-35 years) with first episode psychosis, and EIP staff. The intervention is the team-based motivational engagement (EYE-2) intervention, delivered alongside standardised EIP services, and supported by additional training, website, booklets and social groups. The comparator is the standardised EIP service. Both interventions are delivered by EIP clinicians. The primary outcome is time to disengagement (time in days from date of allocation to care coordinator to date of last contact following refusal to engage with EIP service, or lack of response to EIP contact for a consecutive 3-month period). Secondary outcomes include mental and physical health, deaths, social and occupational function, recovery, satisfaction and service use at 6, 12, 18 and 24 months. A 12-month within-trial economic evaluation will investigate cost-effectiveness from a societal perspective and from an NHS perspective.

DISCUSSION

The trial will provide the first test of an engagement intervention in standardised care, with the potential for significant impact on the mental health and wellbeing of young people and their families, and economic benefits for services. The intervention will be highly scalable, supported by the toolkit including manuals, commissioning guide, training and resources, adapted to meet the needs of the diverse EIP population, and based on an in-depth process evaluation.

TRIAL REGISTRATION

ISRCTN 51629746 prospectively registered 7th May 2019. Date assigned 10th May 2019.

Research findings on Greek forensic patients found not guilty by reason of insanity. A juxtaposition of patients who committed a criminal offense during their first psychotic episode with those who did so later in the course of their illness

The aim of this study was to compare the baseline characteristics (demographic, psychiatric-psychopathological and legal) among Greek forensic patients found not guilty by reason of insanity. The first step of this approach being differentiating patients who committed a criminal offense during their first psychotic episode from the ones who did so later in the course of their illness. All patients were hospitalized in the Department of Forensic Psychiatry (DFP) of the Psychiatric Hospital of Thessaloniki (PHT) from January 2015 to January 2020 and were examined in order to be included in the study. The final research sample consisted of 78 patients (70 identifying themselves as males and 8 identifying themselves as females) aged 18 and older, 21 of whom committed a criminal offense during their first psychotic episode (FEP, N = 21) and 57 did so later on in the course of their illness (Course, N = 57). Data were collected from multiple sources and several psychometric tools were used (Mini International Neuropsychiatric Interview-M.I.N·I, Positive And Negative Syndrome Scale-PANSS, Addiction Severity Index-ASI, CAGE Questionnaire, Hostility and Direction of Hostility Questionnaire-HDHQ, Global Assessment of Functioning-GAF and Aggression Questionnaire). Comparing the two groups (FEP vs. Course) we found that patients in FEP were younger, had experienced stressful life events in the last 24 months, committed more serious violent crimes, and more frequently attempted suicide after the crime. Their victims were usually members of their family. The main psychometric disparities between the two groups were found in the "Hostility" score of the Aggression questionnaire, and the items "Criticism of Others" and "Paranoid Hostility" of the HDHQ questionnaire, where patients in FEP scored lower. Patients in FEP scored significantly higher in items P1 (delusions), P4 (excitement), P6 (suspiciousness/persecution) and P7 (hostility) of the PANSS scale. No statistically significant differences were found between the two groups regarding their evaluation with the CAGE, ASI or GAF questionnaires. When comparing the patients' present scores in PANSS scale, the patients in FEP had lower total scores in the Positive and the General Psychopathology subscales. Both groups showed significant improvement during hospitalization in all scales (PANSS & GAF), except for the Negative Subscale of the PANSS scale. Through logistic regression analysis, we found that patients in FEP were younger, more likely to have recently experienced stressful life events and more likely to have assaulted a member of their family. Patients with higher scores in the "Hostility" subscale of the Aggression questionnaire were found to remain at risk for committing a crime during the course of their illness. These findings underline the need to design and develop specialized mental health services in order to identify and treat patients involved in violent crime in a timely and effective manner addressing their multiple needs.

The clinical significance of duration of untreated psychosis: an umbrella review and random-effects meta-analysis

The idea that a longer duration of untreated psychosis (DUP) leads to poorer outcomes has contributed to extensive changes in mental health ser-vices worldwide and has attracted considerable research interest over the past 30 years. However, the strength of the evidence underlying this notion is unclear. To address this issue, we conducted an umbrella review of available meta-analyses and performed a random-effects meta-analysis of primary studies. MEDLINE, Web of Science, PsycINFO and EMBASE were searched from inception to September 3, 2020 to identify relevant meta-analyses of studies including patients with schizophrenia spectrum disorders, first-episode psychosis, or affective and non-affective psychosis. Thirteen meta-analyses were included, corresponding to 129 individual studies with a total sample size of 25,657 patients. We detected potential violations of statistical assumptions in some of these meta-analyses. We therefore conducted a new random-effects meta-analysis of primary studies. The association between DUP and each outcome was graded according to a standardized classification into convincing, highly suggestive, suggestive, weak, or non-significant. At first presentation, there was suggestive evidence for a relationship between longer DUP and more severe negative symptoms (beta=-0.07, p=3.6×10^-5 ) and higher chance of previous self-harm (odds ratio, OR=1.89, p=1.1×10^-5 ). At follow-up, there was highly suggestive evidence for a relationship between longer DUP and more severe positive symptoms (beta=-0.16, p=4.5×10^-8 ), more severe negative symptoms (beta=-0.11, p=3.5×10^-10 ) and lower chance of remission (OR=2.16, p=3.0×10^-10 ), and suggestive evidence for a relationship between longer DUP and poorer overall functioning (beta=-0.11, p=2.2×10^-6 ) and more severe global psychopathology (beta=-0.16, p=4.7×10^-6 ). Results were unchanged when analysis was restricted to prospective studies. These effect sizes are clinically meaningful, with a DUP of four weeks predicting >20% more severe symptoms at follow-up relative to a DUP of one week. We conclude that DUP is an important prognostic factor at first presentation and predicts clinically relevant outcomes over the course of illness. We discuss conceptual issues in DUP research and methodological limitations of current evidence, and provide recommendations for future research.

The role of key workers in improving physical health in first episode psychosis: A scoping review

AIM

Studies have demonstrated that a majority of the decline in health status and functioning emerges during the first few years following the onset of psychosis. This knowledge led to the development of specialized early intervention services (EIS) targeting patients experiencing their first episode of psychosis (FEP). The central component of EIS is often assertive case management delivered by a multidisciplinary team, where an appointed key worker is responsible for coordinating treatment and delivering various psychosocial interventions to service users. The aim of this scoping review was to examine how key workers can enhance the physical health outcomes in people with FEP by addressing the factors associated with increased mortality in this population.

METHODS

The scoping review framework comprised a five-stage process developed by Arksey and O'Malley. The search process was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

RESULTS

A total of 27 studies conducted across 10 countries were analysed. These studies discussed the various ways in which key workers can mediate enhancements in the various factors contributing to the increased mortality rates in FEP patients.

CONCLUSIONS

A broad range of key worker-mediated outcomes was identified, which were broadly classified into three themes: influences on lifestyle, influences on effects of psychosis and influences on organizational barriers. Our findings suggest that key workers primarily mediated the amelioration of psychosis-induced effects and the reduction of organizational barriers. Further trials of key worker interventions to enhance physical health outcomes in this cohort are warranted.

Third external replication of an individualised transdiagnostic prediction model for the automatic detection of individuals at risk of psychosis using electronic health records

BACKGROUND

Primary indicated prevention is a key target for reducing the incidence and burden of schizophrenia and related psychotic disorders. An individualised, clinically-based transdiagnostic model for the detection of individuals at risk of psychosis has been developed and validated in two large, urban healthcare providers. We tested its external validity in a geographically and demographically different non-urban population.

METHOD

Retrospective EHR cohort study. All individuals accessing secondary healthcare provided by Oxford Health NHS Foundation Trust between 1st January 2011 and 30th November 2019 and receiving a primary index diagnosis of a non-psychotic or non-organic mental disorder were considered eligible. The previously developed model was applied to this database and its external prognostic accuracy was measured with Harrell's C.

FINDINGS

The study included n = 33,710 eligible individuals, with an average age of 27.7 years (SD = 19.8), mostly white (92.0%) and female (57.3%). The mean follow-up was 1863.9 days (SD = 948.9), with 868 transitions to psychosis and a cumulative incidence of psychosis at 6 years of 2.9% (95%CI: 2.7-3.1). Compared to the urban development database, Oxford Health was characterised by a relevant case mix, lower incidence of psychosis, different distribution of baseline predictors, higher proportion of white females, and a lack of specialised clinical services for at risk individuals. Despite these differences the model retained an adequate prognostic performance (Harrell's C = 0.79, 95%CI: 0.78-0.81), with no major miscalibration.

INTERPRETATION

The transdiagnostic, individualised, clinically-based risk calculator is transportable outside urban healthcare providers. Further research should test transportability of this risk prediction model in an international setting.

The reality of at risk mental state services: a response to recent criticisms

BACKGROUND

In the 1990s criteria were developed to detect individuals at high and imminent risk of developing a psychotic disorder. These are known as the at risk mental state, ultra high risk or clinical high risk criteria. Individuals meeting these criteria are symptomatic and help-seeking. Services for such individuals are now found worldwide. Recently Psychological Medicine published two articles that criticise these services and suggest that they should be dismantled or restructured. One paper also provides recommendations on how ARMS services should be operate.

METHODS

In this paper we draw on the existing literature in the field and present the perspective of some ARMS clinicians and researchers.

RESULTS

Many of the critics' arguments are refuted. Most of the recommendations included in the Moritz et al. paper are already occurring.

CONCLUSIONS

ARMS services provide management of current problems, treatment to reduce risk of onset of psychotic disorder and monitoring of mental state, including attenuated psychotic symptoms. These symptoms are associated with a range of poor outcomes. It is important to assess them and track their trajectory over time. A new approach to detection of ARMS individuals can be considered that harnesses broad youth mental health services, such as headspace in Australia, Jigsaw in Ireland and ACCESS Open Minds in Canada. Attention should also be paid to the physical health of ARMS individuals. Far from needing to be dismantled we feel that the ARMS approach has much to offer to improve the health of young people.

Economic Evaluation of Extended Early Intervention Service vs Regular Care Following 2 Years of Early Intervention: Secondary Analysis of a Randomized Controlled Trial

Cost-effectiveness studies of early intervention services (EIS) for psychosis have not included extension beyond the first 2 years. We sought to evaluate the cost-effectiveness of a 3-year extension of EIS compared to regular care (RC) from the public health care payer's perspective. Following 2 years of EIS in a university setting in Montreal, Canada, patients were randomized to a 3-year extension of EIS (n = 110) or RC (n = 110). Months of total symptom remission served as the main outcome measure. Resource use and cost data for publicly covered health care services were derived mostly from administrative systems. The incremental cost-effectiveness ratio (ICER) and cost-effectiveness acceptability curve were produced. Relative cost-effectiveness was estimated for those with duration of untreated psychosis (DUP) of 12 weeks or less vs longer. Extended early intervention had higher costs for psychiatrist and nonphysician interventions, but total costs were not significantly different. The ICER was $1627 per month in total remission. For the intervention to have an 80% chance of being cost-effective, the decision-maker needs to be willing to pay $5942 per month of total symptom remission. DUP ≤ 12 weeks was associated with a reduction in costs of $12 276 even if no value is placed on additional months in total remission. Extending EIS for psychosis for people, such as those included in this study, may be cost-effective if the decision-maker is willing to pay a high price for additional months of total symptom remission, though one commensurate with currently funded interventions. Cost-effectiveness was much greater for people with DUP ≤12 weeks.

Review of Early Intervention Programmes in Psychosis: Implementation Proposal for Peru

A delay in receiving an antipsychotic treatment is associated with unfavourable clinical and functional outcomes in patients with a first episode of psychosis. In recent years, early psychosis intervention programmes have been implemented that seek the early detection and treatment of patients who begin to describe psychotic symptoms. These programmes have shown to be more effective than standard care in improving the symptoms of the disorder and recovering the patient's functionality, in turn proving to be more cost-effective. The benefits of these programmes have led to their implementation in high-income countries. However, implementation in medium- and low-income countries has been slower. Peru, a Latin American country with an upper middle income, is undergoing a mental health reform that prioritises health care based on the prevention, treatment and psychosocial recovery of patients from a comprehensive and community approach. The present manuscript describes the characteristics and structure of the pioneering and more developed programmes for early psychosis intervention, and discusses the benefits and challenges of implementing an early psychosis intervention programme in Peru in the current context of mental health reform.

Community mental healthcare in Lebanon

Lebanon is a medium-income country in the Eastern Mediterranean which has seen a surge in interest in mental health over the past two decades following years of stagnation. The mental health needs of the country at primary care level and for severe psychiatric disorders are underserved. Political instability, chronic underfunding and widespread stigma have all contributed to maintaining a traditional model of private clinics affiliated with inpatient and long-stay psychiatric units. A number of initiatives have recently been launched to cater for patients with psychotic disorders and also to offer partial hospitalization for others with mood-related conditions. In parallel, the Ministry of Public Health,with international funding, has been instrumental in its efforts to standardize care at a national level, particularly for early detection and treatment in primary care settings. The priorities of the national mental health programme are consistent with the global trend in shifting services to the community. Hurdles remain, in line with those facing countries with similar socio-demographics and resources. These include limited third-party coverage of mental health,absence of training opportunities in multidisciplinary community settings and some clinicians' reluctance to update their ways of working. Development of a local workforce, familiar with evidence-based models of care and dedicated to providing a patient-centred approach in the least restrictive settings, is essential for consolidating community carein Lebanon. This would be reinforced by (overdue) legislation and implementation of a mental health law.

Neuropsychological profile of children and adolescents with psychosis risk syndrome: the CAPRIS study

Neuropsychological underperformance is well described in young adults at clinical high risk for psychosis, but the literature is scarce on the cognitive profile of at-risk children and adolescents. The aim of this study is to describe the neuropsychological profile of a child and adolescent sample of patients with psychosis risk syndrome (PRS) compared to healthy controls and to analyze associations between attenuated psychotic symptoms and cognitive impairment. Cross-sectional baseline data analysis from a longitudinal, naturalistic, case-control, two-site study is presented. Eighty-one help-seeking subjects with PRS and 39 healthy controls (HC) aged between 10 and 17 years of age were recruited. PRS was defined by: positive or negative attenuated symptoms, Brief Limited Intermittent Psychotic Symptoms (BLIPS), genetic risk (first- or second-degree relative), or schizotypal personality disorder plus impairment in functioning. A neuropsychological battery was administered to assess general intelligence, verbal and visual memory, visuospatial abilities, speed processing, attention, and executive functions. The PRS group showed lower general neuropsychological performance scores at a multivariate level and lower scores than controls in general intelligence and executive functions. Lower scores on executive function and poorer attention were associated with high scores of positive attenuated psychotic symptoms. No association with attenuated negative symptoms was found. This study provides evidence of cognitive impairment in PRS children and adolescents and shows a relationship between greater cognitive impairment in executive functions and attention tasks and severe attenuated positive symptoms. However, longitudinal studies are needed to clarify the nature of cognitive impairment as a possible vulnerability marker.

Evaluation of an exercise physiology service in a youth mental health service

Background

Individuals who experience serious mental health disorders are at an increased risk of physical illness co-morbidity and early intervention is crucial. Recommendations to embed an exercise physiologist service into a mental health service have not been fully evaluated.

Objectives

This study aimed to determine (i) demographics and clinical characteristics of the young people referred to exercise physiology, (ii) adherence to metabolic monitoring, (iii) baseline physical health and (iv) level of engagement after referral.

Methods

This is a naturalistic cohort study and included all young people referred to the exercise physiology service between 2015 and 2019 at Orygen, a specialist youth mental health service in the north-western region of Melbourne.

Results

During the study period of 45 months, 312 young people were referred to exercise physiology, and of those, 51.3% were male. The mean age was 19.8 years. In regard to primary diagnoses, 47.4% had a psychotic disorder and 33.7% an affective disorder. Baseline weight measurements were completed for 71.8% of young people. The proportion of young people who were classified as overweight or obese increased from 55.1% to 70.4% (p < 0.001). For those referred, 61.5% attended either an individual session or a group session. A total of 29.5% did not attend their appointment following referral.

Conclusions

As over half of young people had poor physical health at presentation, integrating an exercise physiology service into a youth mental health service is a novel and needed intervention. However, there still needs to be an emphasis on metabolic monitoring and engagement.

The need for early intervention for psychosis to persist throughout the COVID-19 pandemic and beyond

In the last three decades, early intervention for psychosis (EIP) services have been established worldwide and have resulted in superior symptomatic and functional outcomes for people affected by psychotic disorders. These improved outcomes are a result of reducing delays to treatment and the provision of specialised, holistic interventions. The COVID-19 pandemic poses significant challenges to the delivery of these services, such as undetected cases or long delays to treatment. Furthermore, the COVID-19 pandemic will likely increase the mental health needs of communities, including the incidence of psychotic disorders. In this perspective piece, we provide suggestions as to how EIP services can adapt within this environment, such as utilising novel technologies. Finally, we argue that despite the economic consequences of the pandemic, the funding for mental health services, including EI services, should be increased in line with the need for these services during and beyond the pandemic.

Tobacco smoking in young people seeking treatment for mental ill-health: what are their attitudes, knowledge and behaviours towards quitting?

INTRODUCTION

Tobacco smoking is a leading cause of preventable death and disease worldwide. Adults with mental ill-health smoke tobacco at substantially higher rates than other adults, with public health approaches effective in the population overall having less impact on those with mental ill-health. However, less is known about the tobacco smoking behaviours, attitudes and knowledge of young people with mental ill-health, despite this being the peak period of onset for both mental illness and cigarette smoking.

METHODS

Young people attending a youth mental health centre (providing both primary and specialist care) in Melbourne, Australia were approached by youth peer researchers and asked to complete a survey about smoking behaviours, attitudes and knowledge. We examined smoking and associated attitudes in the sample overall, and as a function of the services accessed.

RESULTS

In total, 114 young people completed the survey, with 56.3% reporting lifetime cigarette smoking, 42.0% smoking in the last 12 months and 28.6% in the past week. Of current regular smokers, 75.0% acknowledged they should quit in the future; however, only 23.5% planned to do so in the next month, with 44.4% confident that they could quit. Participants lacked knowledge about interactions between tobacco smoking, mental and physical health.

CONCLUSIONS

Youth presenting for mental ill-health had high rates of cigarette smoking relative to population rates. Presentation at youth mental health services may represent a critical window for early intervention to reduce the lifetime impacts of cigarette smoking in mental ill-health. Interventions to support smoking cessation in this group are urgently needed.