Improving access to Early Intervention in Psychosis (EIP): the 2-week wait for cancer comes to psychosis

SUICIDE AND PSYCHOSIS: Comparing the Characteristics of Patients Who Died by Suicide Following Recent Onset and Longer Duration of Schizophrenia and Other Primary Psychotic Disorders, 2008-2021

BACKGROUND AND HYPOTHESIS

Suicide rates among people with schizophrenia and other primary psychotic disorders are high, with the steepest increase in risk in the first years following contact with mental health services. Evidence suggests early intervention in psychosis services may reduce suicide risk for people experiencing first-episode psychosis. We aimed to compare the characteristics of patients with a recent (<12 month) onset of schizophrenia and other primary psychotic disorders with patients with a longer duration of illness (12 months and over) to identify key characteristics for patient suicide to aid services to effectively support patients during a particularly high-risk time.

STUDY DESIGN

A national clinical survey of patients with schizophrenia and other primary psychotic disorders who died by suicide in England and Wales between January 1, 2008 and December 31, 2021.

STUDY RESULTS

Of the 2828 (N = 18 487, 16%) patients with a diagnosis of schizophrenia and other primary psychotic disorders who died by suicide, ten percent (n = 288) were ill for less than 12 months. These patients were more often under the care of crisis teams or recently discharged from in-patient services than patients with a longer duration of illness (12 months and over), and they were more often seen by services within the week before they died. Patients with recent illness onset had fewer factors conventionally associated with suicide, such as alcohol or drug misuse, a history of violence, and self-harm. They were less likely to live alone and be unemployed.

CONCLUSIONS

Though all patients had contact with mental health services in the 12 months prior to death, patients with a recent onset of schizophrenia and other primary psychotic disorders were more commonly in recent contact with services at the time of death. They had fewer social and behavioral factors known to be common to suicide, suggesting lives recently disrupted by illness. Services should provide intensive support for patients who have been recently diagnosed, encouraging engagement and monitoring for deteriorating social factors.

Associations between rural/urban status, duration of untreated psychosis and mode of onset of psychosis: a mental health electronic clinical records analysis in the East of England, UK

PURPOSE

The influence of rurality on the duration of untreated psychosis (DUP) in first-episode psychosis (FEP) is poorly understood. We investigated factors associated with FEP in rural/urban settings and whether there are rural/urban differences in DUP and the mode (speed) of onset of psychosis.

METHODS

We used the Cambridgeshire and Peterborough NHS Foundation Trust Research Database (CPFTRD) to identify all persons presenting to an early intervention for psychosis service with FEP between 2013 and 2015. We performed descriptive statistics and multivariable linear and multinomial regression to assess the relationships between the study outcomes and the independent variables.

RESULTS

One hundred and fifty-five FEP patients were identified, with a mean age of 23.4 (SD, 5.3) years. The median DUP was 129.0 (IQR: 27.5-524.0) days. In rural areas, FEP patients were more likely to be employed and live with family than those in urban areas. A longer DUP was observed among patients with an insidious onset of psychosis compared with an acute onset (619.5 (IQR: 333.5-945.0)) vs. (17.0 (IQR: 8.0-30.5)) days respectively, p < 0.0001. We found evidence that the mode of onset of psychosis differed by employment status and living circumstances. There was insufficient evidence of rural/urban differences in DUP and mode of onset of psychosis.

CONCLUSIONS

Our results suggest that the mode of onset of psychosis is an important indicator of treatment delay and could provide vital information for service planning and delivery. Sociodemographic variations in FEP exist in rural populations, and our findings are similar to those observed in urban settings.

Sociodemographic and clinical predictors of delay to and length of stay with early intervention for psychosis service: findings from the CRIS-FEP study

PURPOSE

We investigated the influence of sociodemographic and clinical characteristics on delay to early intervention service (EIS) and the length of stay (LOS) with EIS.

METHODS

We used incidence data linked to the Clinical Record Interactive Search-First Episode Psychosis (CRIS-FEP) study. We followed the patients from May 2010 to March 2016. We performed multivariable Cox regression to estimate hazard ratios of delay to EIS. Negative binomial regression was used to determine LOS with EIS by sociodemographic and clinical characteristics, controlling for confounders.

RESULTS

343 patients were eligible for an EIS, 34.1% of whom did not receive the service. Overall, the median delay to EIS was 120 days (IQR; 15-1668); and the median LOS was 130.5 days (IQR 0-663). We found that women (adj.HR 0.58; 95%C I 0.42-0.78), living alone (adj.HR: 0.63; 95% CI 0.43-0.92) and ethnicity ('Other': adj.HR 0.47; 95% CI 0.23-0.98) were associated with prolonged delay to EIS. However, family involvement in help-seeking for psychosis (adj.HR 1.37; 95% CI 1.01-1.85) was strongly associated with a shorter delay to EIS. Patients who have used mental health services previously also experienced long delays to EIS.

CONCLUSIONS

Our analyses highlight the link between sociodemographic status, help-seeking behaviours, and delay to EIS. Our findings also show the vulnerability faced by those with a previous mental health problem who later develop psychosis in receiving specialist treatment for psychosis. Initiatives that ameliorate indicators of social disadvantage are urgently needed to reduce health inequalities and improve clinical outcomes.

The potential of digital behavioural tests as a diagnostic aid for psychosis

Timely interventions have a proven benefit for people experiencing psychotic illness. One bottleneck to accessing timely interventions is the referral process to the specialist team for early psychosis (STEP). Many general practitioners lack awareness or confidence in recognising psychotic symptoms or state. Additionally, referrals for people without apparent psychotic symptoms, although beneficial at a population level, lead to excessive workload for STEPs. There is a clear unmet need for accurate stratification of STEPs users and healthy cohorts. Here we propose a new approach to addressing this need via the application of digital behavioural tests. To demonstrate that digital behavioural tests can be used to discriminate between the STEPs users (SU; n = 32) and controls (n = 32, age and sex matched), we compared performance of five different classifiers applied to objective, quantitative and interpretable features derived from the 'mirror game' (MG) and trail making task (TMT). The MG is a movement coordination task shown to be a potential socio-motor biomarker of schizophrenia, while TMT is a neuropsychiatric test of cognitive function. All classifiers had AUC in the range of 0.84-0.92. The best of the five classifiers (linear discriminant classifier) achieved an outstanding performance, AUC = 0.92 (95%CI 0.75-1), Sensitivity = 0.75 (95%CI 0.5-1), Specificity = 1 (95%CI 0.75-1), evaluated on 25% hold-out and 1000 folds. Performance of all analysed classifiers is underpinned by the large effect sizes of the differences between the cohorts in terms of the features used for classification what ensures generalisability of the results. We also found that MG and TMT are unsuitable in isolation to successfully differentiate between SU with and without at-risk-mental-state or first episode psychosis with sufficient level of performance. Our findings show that standardised batteries of digital behavioural tests could benefit both clinical and research practice. Including digital behavioural tests into healthcare practice could allow precise phenotyping and stratification of the highly heterogenous population of people referred to STEPs resulting in quicker and more personalised diagnosis. Moreover, the high specificity of digital behavioural tests could facilitate the identification of more homogeneous clinical high-risk populations, benefiting research on prognostic instruments for psychosis. In summary, our study demonstrates that cheap off-the-shelf equipment (laptop computer and a leap motion sensor) can be used to record clinically relevant behavioural data that could be utilised in digital mental health applications.

Predictors of full recovery in patients with early stage schizophrenia spectrum disorders

To promote recovery in psychosis, targeting modifiable factors related to recovery is critical. Using more strict definition of full recovery, we examined predictors for recovery in patients with early stage schizophrenia spectrum disorders (SSD) followed up to 6.5 years. The target subjects were 375 patients with early stage SSD who had been over at least 1-year after registration and evaluated. The criteria for full recovery were having the score of the Positive and Negative Syndrome Scale (PANSS) 8-item ≤ 2 and adequate functional recovery for at least 1-year. We performed univariate Cox and stepwise Cox regression in both total and acute patients. In stepwise Cox regression, several independent predictors for recovery, i.e., negative symptoms of the PANSS, duration of untreated psychosis (DUP) and non-professional job were identified in patients with early stage SSD. In acute patients, other factors such as professional job and subjective well-being under neuroleptics were more important. The present study identified independent predictors for recovery modifiable by various psychosocial intervention and early intervention services. Moreover, it highlights the need of providing different treatment strategies depending on clinical status.

Three-year outcomes and predictors for full recovery in patients with early-stage psychosis

In the present study, various outcomes over 3-year period in patients with early stage psychosis including remission, recovery, relapse and medication adherence were investigated. Predictor for full recovery at year 3 was also examined. Three-year follow-up data in 534 patients with schizophrenia spectrum disorders (SSD) and psychotic disorder not otherwise specified (PNOS) were examined for overall outcome trajectories. The data of completers at year 3 (n = 157) were used to identify predictors for recovery using logistic regression. The rates of symptomatic remission and full recovery at 6-, 12-, 24-, and 36-month follow-up were 76.10, 69.20, 79.50, and 79.10%, and 22.80, 26.40, 28.60, and 39.60%, respectively. The rates of drop-out and relapse at 6-, 12-, 24-, and 36-month follow-up were 25.4, 29.5, 38.6, and 51.1%, and 3.7, 8.9, 19.0, and 38.9%, respectively. The rates of good adherence and prescription of Long-Acting Injectable Antipsychotics (LAIA) at 6-, 12-, 24- and 36-month follow-up were 87.8, 88.0, 91.9, and 93.9%, and 18.3, 21.7, 22.0, and 25.5%, respectively. Significant predictors for full recovery were duration of untreated psychosis (DUP), family intimacy and physical activity. We observed similar or better results on remission, recovery, and relapse rates compared to other previous studies. Effective psychosocial intervention should be provided to shorten the gap between remission and recovery rates and to address DUP, family issues, and exercise to enhance recovery.

Examining the effects of national initiatives to improve the physical health of people with psychosis in England: secondary analysis of data from the National Clinical Audit of Psychosis

AIMS AND METHODS

To examine whether national initiatives have led to improvements in the physical health of people with psychosis. Secondary analysis of a national audit of services for people with psychosis. Proportions of patients in 'good health' according to seven measures, and one composite measure derived from national standards, were compared between multiple rounds of data collection.

RESULTS

The proportion of patients in overall 'good health' under the care of 'Early Intervention in Psychosis' teams increased from 2014-2019, particularly for measures of smoking, alcohol and substance use. There was no overall change in the proportion of patients in overall 'good health' under the care of 'Community Mental Health Teams' from 2011-2017. However, there were improvements in alcohol use, blood glucose and lipid levels.

CLINICAL IMPLICATIONS

There have been modest improvements in the health of people with psychosis over the last nine years. Continuing efforts are required to translate these improvements into reductions in premature mortality.