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Abstract
Little is known about which factors actually motivate individuals with psychosis to seek help or how psychosis may complicate the help-seeking process. The aim of this article is to examine the steps of this process and how psychopathological experiences might affect and interfere with it. In this qualitative study we interviewed nine patients with a first episode of psychosis. The interviews were transcribed and analysed according to the principles of thematic analysis using inductive as well as deductive methods. The crucial step in help-seeking behaviour seemed to be for the patients to identify the kind of problem they were facing. None of them clearly recognized their psychotic or otherwise anomalous experiences as symptoms of a mental disorder, and most of them did not seriously question the reality status of these experiences. For most of the patients it was an untenable social situation that caused them to seek help. When they did seek help the majority did not initially contact the psychiatric services. It seems paradoxical to expect patients who experience symptoms of psychosis for the first time to be able to unambiguously identify them as being exactly that and accordingly seek out psychiatric help, as diminished insight into illness is an inherent feature of psychosis. However, the phenomenon of 'double bookkeeping' seemed to provide an opening for seeking help from psychiatry in spite of compromised insight. This observation should be included in everyday clinical work and in future information campaigns.
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Affiliation(s)
- Julie Nordgaard
- Mental Health Centre Amager, Gammel Kongevej 33, Copenhagen, Denmark. .,Faculty of Medical Sciences, University of Copenhagen, Blegdamsvej 9, Copenhagen, Denmark.
| | | | - Karina Gulstad
- Early Psychosis Intervention Centre, Psychiatry Region Zealand, Smedegade 16, Roskilde, Denmark
| | - Marlene Buch-Pedersen
- Early Psychosis Intervention Centre, Psychiatry Region Zealand, Smedegade 16, Roskilde, Denmark
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2
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Affiliation(s)
- Vinod H. Srihari
- Department of Psychiatry, Yale University School of Medicine, New
Haven, Conn
| | - Sinan Guloksuz
- Department of Psychiatry, Yale University School of Medicine, New
Haven, Conn
| | - Svein Friis
- Department of Research and Development, Division of Mental Health
and Addiction, Oslo University Hospital, Oslo
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MacDonald K, Malla A, Joober R, Shah JL, Goldberg K, Abadi S, Doyle M, Iyer SN. Description, evaluation and scale-up potential of a model for rapid access to early intervention for psychosis. Early Interv Psychiatry 2018; 12:1222-1228. [PMID: 29582562 DOI: 10.1111/eip.12564] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Revised: 10/22/2017] [Accepted: 02/04/2018] [Indexed: 11/29/2022]
Abstract
AIM This paper aims to describe the entry protocol of the Prevention and Early Intervention for Psychosis Program (PEPP)-Montreal, an early intervention program for psychosis. The protocol is designed to fulfil a key objective of the early intervention movement-reducing delays to accessing high-quality care. The paper also aims to describe how this rapid entry protocol can be deployed in other services interested in reducing delays in initiating treatment. METHODS PEPP provides rapid, easy access to quality care by placing a single, well-trained professional, the intake clinician, at the point of entry. Anyone can refer a youth directly and without formalities to the intake clinician who responds promptly and sensitively to all help-seeking, whether by a youth, a family member, a school counsellor or anyone acting on behalf of a youth in need. To promote accessibility, PEPP guarantees an initial assessment within 72 hours; maintains relationships with referral sources; and conducts awareness-enhancing outreach activities. RESULTS Since 2003, PEPP has received 1750 referrals, which have all been responded to within 72 hours. Families have been involved in the intake process in 60% of the cases and hospitalization may have been averted in over half of the referrals originating from emergency-room services. Another indicator of success is the very low turnover in the intake clinician's position. Overall, the PEPP model has succeeded in providing rapid, engaging, easy and youth-friendly access to high-quality care. CONCLUSION The success of this protocol at PEPP has inspired the entry protocols at other first-episode psychosis services. Its ability to provide rapid, engaging access to high-quality services may allow this protocol to become a model for other early intervention services for psychosis and other mental illnesses.
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Affiliation(s)
- Kathleen MacDonald
- Department of Psychiatry, McGill University, Montreal, Quebec, Canada.,Prevention and Early Intervention Program for Psychosis (PEPP), Douglas Mental Health University Institute, Montreal, Quebec, Canada.,ACCESS Open Minds (Pan-Canadian youth mental health services research network), Douglas Mental Health University Institute, Montreal, Quebec, Canada
| | - Ashok Malla
- Department of Psychiatry, McGill University, Montreal, Quebec, Canada.,Prevention and Early Intervention Program for Psychosis (PEPP), Douglas Mental Health University Institute, Montreal, Quebec, Canada.,ACCESS Open Minds (Pan-Canadian youth mental health services research network), Douglas Mental Health University Institute, Montreal, Quebec, Canada
| | - Ridha Joober
- Department of Psychiatry, McGill University, Montreal, Quebec, Canada.,Prevention and Early Intervention Program for Psychosis (PEPP), Douglas Mental Health University Institute, Montreal, Quebec, Canada.,ACCESS Open Minds (Pan-Canadian youth mental health services research network), Douglas Mental Health University Institute, Montreal, Quebec, Canada
| | - Jai L Shah
- Department of Psychiatry, McGill University, Montreal, Quebec, Canada.,Prevention and Early Intervention Program for Psychosis (PEPP), Douglas Mental Health University Institute, Montreal, Quebec, Canada.,ACCESS Open Minds (Pan-Canadian youth mental health services research network), Douglas Mental Health University Institute, Montreal, Quebec, Canada
| | - Karen Goldberg
- Douglas Mental Health University Institute, Montreal, Quebec, Canada
| | - Sherezad Abadi
- Douglas Mental Health University Institute, Montreal, Quebec, Canada
| | | | - Srividya N Iyer
- Department of Psychiatry, McGill University, Montreal, Quebec, Canada.,Prevention and Early Intervention Program for Psychosis (PEPP), Douglas Mental Health University Institute, Montreal, Quebec, Canada.,ACCESS Open Minds (Pan-Canadian youth mental health services research network), Douglas Mental Health University Institute, Montreal, Quebec, Canada
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Dixon LB, Goldman HH, Srihari VH, Kane JM. Transforming the Treatment of Schizophrenia in the United States: The RAISE Initiative. Annu Rev Clin Psychol 2018; 14:237-258. [PMID: 29328779 PMCID: PMC8990328 DOI: 10.1146/annurev-clinpsy-050817-084934] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/10/2023]
Abstract
The schizophrenia spectrum disorders are neurodevelopmental illnesses with a lifetime prevalence near 1%, producing extensive functional impairment and low expectations for recovery. Until recently, treatment in the United States has largely attempted to stabilize individuals with chronic schizophrenia. The identification and promotion of evidence-based practices for schizophrenia via the Patient Outcomes Research Team, combined with international studies supporting the value of early intervention, provided the foundation for the Recovery After an Initial Schizophrenia Episode (RAISE) project. The RAISE studies further supported the value of reducing the duration of untreated psychosis and providing a multi-element treatment called coordinated specialty care (CSC) to improve outcomes for patients in usual treatment settings. Although CSC programs have proliferated rapidly in the United States, many challenges remain in the treatment and recovery of individuals with schizophrenia in the aftermath of RAISE.
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Affiliation(s)
- Lisa B Dixon
- New York State Psychiatric Institute, Columbia University Medical Center, New York, NY 10032, USA;
| | - Howard H Goldman
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, Maryland 21201, USA
| | - Vinod H Srihari
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut 06511, USA
| | - John M Kane
- Zucker Hillside Hospital and the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York 11549, USA
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Hardy KV, Noordsy DL, Ballon JS, McGovern MP, Salomon C, Wiltsey Stirman S. Impact of age of onset of psychosis and engagement in higher education on duration of untreated psychosis. J Ment Health 2018; 27:257-262. [DOI: 10.1080/09638237.2018.1466047] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Kate V. Hardy
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA,
| | - Douglas L. Noordsy
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA,
| | - Jacob S. Ballon
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA,
| | - Mark P. McGovern
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA,
| | - Carmela Salomon
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA,
- Department of Developmental Disability Neuropsychiatry, University of New South Wales, Sydney, Australia, and
| | - Shannon Wiltsey Stirman
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA,
- National Center for PTSD, VA Palo Alto Healthcare System, Palo Alto, CA, USA
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6
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Srihari VH. Working toward changing the Duration of Untreated Psychosis (DUP). Schizophr Res 2018; 193:39-40. [PMID: 28779850 DOI: 10.1016/j.schres.2017.07.045] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 07/20/2017] [Accepted: 07/22/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Vinod H Srihari
- Department of Psychiatry, Yale University School of Medicine, United States; Connecticut Mental Health Center (CMHC), United States; Program for Specialized Treatment Early in Psychosis (STEP), United States.
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Murphy BP, Brewer WJ. Early intervention in psychosis: strengths and limitations of services. ACTA ACUST UNITED AC 2018. [DOI: 10.1192/apt.bp.110.008573] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
SummaryEarly intervention services were established on the basis of a number of fundamental principles, including the notions that intervening in the early stages of psychosis alters illness trajectory and prognosis, that multicomponent interventions promote psychosocial recovery and reduce iatrogenic damage, and that early targeting of non-responders reduces treatment resistance. There is growing evidence of the benefits of specialised early intervention services. These include improved clinical, social and vocational outcomes, reduced in-patient stays and better engagement. Early intervention services can also significantly reduce the risk of a second episode and are highly valued by service users and carers. Duration of treatment appears to determine long-term outcome and there remains uncertainty about how long such intensive intervention should last and whether all patients need the same length of care. Budgetary constraints are pervasive and are particularly likely to affect prodrome clinics and community awareness programmes.
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Abstract
SummaryThis issue of Advances carries two articles from Melbourne, Australia, outlining the rationale for, and implementation of, early psychosis services. Their publication provides an opportunity to address some of the more contentious issues relating to the early psychosis intervention movement.
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Schiffman J, Stephan SH, Hong LE, Reeves G. School-based approaches to reducing the duration of untreated psychosis. Child Adolesc Psychiatr Clin N Am 2015; 24:335-51. [PMID: 25773328 DOI: 10.1016/j.chc.2014.11.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Students with emerging psychosis often experience delays in diagnosis and treatment that impact mental health and academic outcomes. School systems have tremendous potential to improve early identification and treatment of adolescent psychosis. As a community-based resource, schools can support outreach, education, and screening for adolescents with psychosis and engage identified students and their families for treatment. The concept of duration of untreated psychosis (DUP; the gap between symptom onset and treatment initiation) in adolescent psychosis and the potential role of schools in reducing DUP are reviewed. Future directions for clinical care and research needed to support school-based interventions are proposed.
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Affiliation(s)
- Jason Schiffman
- Department of Psychology, University of Maryland, 1000 Hilltop Circle, Baltimore County, Baltimore, MD 21250, USA.
| | - Sharon Hoover Stephan
- Division of Child and Adolescent Psychiatry, Department of Psychiatry, University of Maryland School of Medicine, 701 Pratt Street, Baltimore, MD 21201, USA
| | - L Elliot Hong
- Department of Psychiatry, Maryland Psychiatric Research Center, University of Maryland School of Medicine, MPRC - Tawes, PO Box 21247, Baltimore, MD 21228, USA
| | - Gloria Reeves
- Division of Child and Adolescent Psychiatry, Department of Psychiatry, University of Maryland School of Medicine, 701 Pratt Street, Baltimore, MD 21201, USA
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Srihari VH, Tek C, Pollard J, Zimmet S, Keat J, Cahill JD, Kucukgoncu S, Walsh BC, Li F, Gueorguieva R, Levine N, Mesholam-Gately RI, Friedman-Yakoobian M, Seidman LJ, Keshavan MS, McGlashan TH, Woods SW. Reducing the duration of untreated psychosis and its impact in the U.S.: the STEP-ED study. BMC Psychiatry 2014; 14:335. [PMID: 25471062 PMCID: PMC4262386 DOI: 10.1186/s12888-014-0335-3] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Accepted: 11/13/2014] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Early intervention services for psychotic disorders optimally interlock strategies to deliver: (i) Early Detection (ED) to shorten the time between onset of psychotic symptoms and effective treatment (i.e. Duration of Untreated Psychosis, DUP); and (ii) comprehensive intervention during the subsequent 2 to 5 years. In the latter category, are teams ('First-episode Services' or FES) that integrate several empirically supported treatments and adapt their delivery to younger patients and caregivers. There is an urgent need to hasten access to established FES in the U.S. Despite improved outcomes for those in treatment, these FES routinely engage patients a year or more after psychosis onset. The Scandinavian TIPS study was able to effectively reduce DUP in a defined geographic catchment. The guiding questions for this study are: can a U.S. adaptation of the TIPS approach to ED substantially reduce DUP and improve outcomes beyond existing FES? METHODS/DESIGN The primary aim is to determine whether ED can reduce DUP in the US, as compared to usual detection. ED will be implemented by one FES (STEP) based in southern Connecticut, and usual detection efforts will continue at a comparable FES (PREP(R)) serving the greater Boston metropolitan area. The secondary aim is to determine whether DUP reduction can improve presentation, engagement and early outcomes in FES care. A quasi-experimental design will compare the impact of ED on DUP at STEP compared to PREP(R) over 3 successive campaign years. The campaign will deploy 3 components that seek to transform pathways to care in 8 towns surrounding STEP. Social marketing approaches will inform a public education campaign to enable rapid and effective help-seeking behavior. Professional outreach and detailing to a wide variety of care providers, including those in the healthcare, educational and judicial sectors, will facilitate rapid redirection of appropriate patients to STEP. Finally, performance improvement measures within STEP will hasten engagement upon referral. DISCUSSION STEP-ED will test an ED campaign adapted to heterogeneous U.S. pathways to care while also improving our understanding of these pathways and their impact on early outcomes. TRIAL REGISTRATION ClinicalTrials.gov: NCT02069925 . Registered 20 February 2014.
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Affiliation(s)
- Vinod H Srihari
- Department of Psychiatry, Yale University, 34 Park Street, New Haven, CT, 06519, USA.
- Connecticut Mental Health Center, 34 Park Street, New Haven, CT, 06519, USA.
| | - Cenk Tek
- Department of Psychiatry, Yale University, 34 Park Street, New Haven, CT, 06519, USA.
- Connecticut Mental Health Center, 34 Park Street, New Haven, CT, 06519, USA.
| | - Jessica Pollard
- Department of Psychiatry, Yale University, 34 Park Street, New Haven, CT, 06519, USA.
- Connecticut Mental Health Center, 34 Park Street, New Haven, CT, 06519, USA.
| | - Suzannah Zimmet
- Commonwealth Research Center, Massachusetts Mental Health Center Division of Public Psychiatry, Beth Israel Deaconess Medical Center, Department of Psychiatry, Harvard Medical School, 75 Fenwood Road, 5th Floor, Boston, MA, 02115, USA.
| | - Jane Keat
- Department of Psychiatry, Yale University, 34 Park Street, New Haven, CT, 06519, USA.
| | - John D Cahill
- Department of Psychiatry, Yale University, 34 Park Street, New Haven, CT, 06519, USA.
- Connecticut Mental Health Center, 34 Park Street, New Haven, CT, 06519, USA.
| | - Suat Kucukgoncu
- Department of Psychiatry, Yale University, 34 Park Street, New Haven, CT, 06519, USA.
| | - Barbara C Walsh
- Department of Psychiatry, Yale University, 34 Park Street, New Haven, CT, 06519, USA.
| | - Fangyong Li
- Yale Center for Analytical Sciences (YCAS), 300 George Street, New Haven, CT, 06511, USA.
| | - Ralitza Gueorguieva
- Yale Center for Analytical Sciences (YCAS), 300 George Street, New Haven, CT, 06511, USA.
| | - Nina Levine
- Department of Psychiatry, Yale University, 34 Park Street, New Haven, CT, 06519, USA.
| | - Raquelle I Mesholam-Gately
- Commonwealth Research Center, Massachusetts Mental Health Center Division of Public Psychiatry, Beth Israel Deaconess Medical Center, Department of Psychiatry, Harvard Medical School, 75 Fenwood Road, 5th Floor, Boston, MA, 02115, USA.
| | - Michelle Friedman-Yakoobian
- Commonwealth Research Center, Massachusetts Mental Health Center Division of Public Psychiatry, Beth Israel Deaconess Medical Center, Department of Psychiatry, Harvard Medical School, 75 Fenwood Road, 5th Floor, Boston, MA, 02115, USA.
| | - Larry J Seidman
- Commonwealth Research Center, Massachusetts Mental Health Center Division of Public Psychiatry, Beth Israel Deaconess Medical Center, Department of Psychiatry, Harvard Medical School, 75 Fenwood Road, 5th Floor, Boston, MA, 02115, USA.
| | - Matcheri S Keshavan
- Commonwealth Research Center, Massachusetts Mental Health Center Division of Public Psychiatry, Beth Israel Deaconess Medical Center, Department of Psychiatry, Harvard Medical School, 75 Fenwood Road, 5th Floor, Boston, MA, 02115, USA.
| | - Thomas H McGlashan
- Department of Psychiatry, Yale University, 34 Park Street, New Haven, CT, 06519, USA.
- Connecticut Mental Health Center, 34 Park Street, New Haven, CT, 06519, USA.
| | - Scott W Woods
- Department of Psychiatry, Yale University, 34 Park Street, New Haven, CT, 06519, USA.
- Connecticut Mental Health Center, 34 Park Street, New Haven, CT, 06519, USA.
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O'Donoghue B, Lyne J, Kinsella A, Turner N, O'Callaghan E, Clarke M. Detection and characteristics of individuals with a very long duration of untreated psychosis in an early intervention for psychosis service. Early Interv Psychiatry 2014; 8:332-9. [PMID: 23786447 DOI: 10.1111/eip.12063] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2012] [Accepted: 05/04/2013] [Indexed: 12/01/2022]
Abstract
AIM Early intervention (EI) services for psychosis aim to reduce the duration of untreated psychosis (DUP) with intensive large-scale multi-focus initiatives, including public awareness campaigns. As a consequence of this approach, individuals with a very long DUP who might have otherwise remained undiagnosed may come to medical attention. The aim of this study was to investigate if an EI service detected additional cases of individuals with a first-episode psychosis (FEP) with a very long DUP and identify demographic and clinical characteristics associated with a very long DUP. METHODS We compared the distribution of the DUP in cases with FEP in a cohort from an EI service in a geographically defined catchment area with a historical control group. Participants were interviewed using the Structured Clinical Interview for DSM IV (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition) diagnoses and the Beiser scale to determine the DUP. RESULTS A total of 172 individuals were included in the EI service and 151 were included from the historical control. There was no difference in the distribution of the DUP in the EI service compared with the historical control group (χ(2) = 3.77, degrees of freedom (d.f.) = 3, P = 0.29). In the EI service, 7.6% of cases had a DUP between 24 and 35.9 months compared to 3.3% in the historical control, and 13.4% of cases in the EI service had a DUP of greater than three years compared to 10.6% in the historical control. A very long DUP was associated with unemployment, less insight and involuntary treatment. CONCLUSION Further examination of the pathways to care in cases with a long DUP may clarify the contribution of help-seeking and health system delays for these individuals.
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Affiliation(s)
- Brian O'Donoghue
- DETECT, Early Intervention in Psychosis Service, Dublin, Ireland
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ten Velden Hegelstad W, Joa I, Barder H, Evensen J, Haahr U, Johannessen JO, Langeveld J, Melle I, Opjordsmoen S, Røssberg JI, Rund BR, Simonsen E, Vaglum P, McGlashan T, Friis S, Larsen TK. Variation in duration of untreated psychosis in an 18-year perspective. Early Interv Psychiatry 2014; 8:323-31. [PMID: 23773272 PMCID: PMC3870041 DOI: 10.1111/eip.12057] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Accepted: 05/04/2013] [Indexed: 12/01/2022]
Abstract
AIM The Scandinavian TIPS project engineered an early detection of psychosis programme that sought to reduce the duration of untreated psychosis (DUP) through early detection teams and extensive information campaigns since 1997. In 1997-2000, DUP was reduced from 26 to 4.5 weeks median. The programme was continued beyond the initial project in modified forms for over 13 years. The aim of this study was to track the vicissitudes of DUP over an 18-year period (1993-2010) with differing early detection efforts in a defined catchment area. METHOD The DUP of all patients meeting criteria for first episode psychosis was measured 1993-1994 and from 1997 to 2010 in a naturalistic long-term study. DUP values of all patients were included, irrespective of patients' participation in a clinical follow-up study, yielding a highly representative sample. RESULTS DUP varied across studies with differing information campaign intensity and content. These variations will be described and explored. CONCLUSIONS Early detection campaigns should have a stable focus and high intensity level. Future research should further elucidate pathways to care in order to establish principal targets for information campaigns.
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Affiliation(s)
- Wenche ten Velden Hegelstad
- Regional Centre for Clinical Research in Psychosis, Division of Psychiatry, Stavanger University Hospital, Norway; Faculty of Psychology, University of Bergen, Bergen
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Toxic psychosis? Duration of untreated psychosis, symptomatology and cognitive deterioration in first episode psychosis. Ir J Psychol Med 2014; 24:145-148. [DOI: 10.1017/s0790966700010582] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractObjectives: To examine the relationship between cognitive deficits, the duration of untreated psychosis (DUP) and positive and negative symptoms in a first episode psychosis sample.Method: We assessed a consecutive sample of first episode psychosis participants from a catchment area service with a comprehensive neuropsychology battery, a family and service-user based measure of DUP and measures of symptomatology.Results: Using correlations and stepwise linear regressions, we found strong relationships between measures of DUP and positive symptomatology. We found that positive and negative symptoms were associated with different time periods within DUP. However, we did not find evidence of a relationship between DUP and cognitive factors.Conclusions: There was no evidence of a relationship between DUP and cognitive deterioration. However, there does appear to be evidence of a relationship between positive symptoms and aspects of DUP. These results highlight the importance of the heterogeneity of DUP and the potential to reduce positive symptoms through early intervention.
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Hughes F, Stavely H, Simpson R, Goldstone S, Pennell K, McGorry P. At the heart of an early psychosis centre: the core components of the 2014 Early Psychosis Prevention and Intervention Centre model for Australian communities. Australas Psychiatry 2014; 22:228-234. [PMID: 24789848 DOI: 10.1177/1039856214530479] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To describe the core components of the Early Psychosis Prevention and Intervention Centre service model as the template agreed with the Australian Federal Government for national upscaling. The Early Psychosis Prevention and Intervention Centre model of early intervention has two main goals: to reduce the period of time between the onset of psychosis and the commencement of treatment and to bring about symptomatic recovery and restore the normal developmental trajectory as early as possible. CONCLUSIONS The Early Psychosis Prevention and Intervention Centre comprises three elements of service provision for young people experiencing a first episode of psychosis: (i) early detection; (ii) acute care during and immediately following a crisis; (iii) recovery-focused continuing care, featuring multimodal interventions to enable the young person to maintain or regain their social, academic and/or career trajectory during the critical first 2-5 years following the onset of a psychotic illness. It does this via a combination of 16 core components, which provide a flexible, comprehensive, integrated service that is able to respond quickly, appropriately and consistently to the individual needs of the young person and their family. Innovative service reforms, such as Early Psychosis Prevention and Intervention Centre, that recognise the value of early intervention are crucial to reducing the impact of serious mental illness on young people and their families and, ultimately, on our society.
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Affiliation(s)
- Frank Hughes
- Orygen Youth Health Research Centre and the Centre for Youth Mental Health, Department of Psychiatry, University of Melbourne, Parkville, VIC, Australia
| | - Heather Stavely
- Orygen Youth Health Research Centre and the Centre for Youth Mental Health, Department of Psychiatry, University of Melbourne, Parkville, VIC, Australia
| | - Raelene Simpson
- Orygen Youth Health Research Centre and the Centre for Youth Mental Health, Department of Psychiatry, University of Melbourne, Parkville, VIC, Australia
| | - Sherilyn Goldstone
- Orygen Youth Health Research Centre and the Centre for Youth Mental Health, Department of Psychiatry, University of Melbourne, Parkville, VIC, Australia
| | - Kerryn Pennell
- Orygen Youth Health Research Centre and the Centre for Youth Mental Health, Department of Psychiatry, University of Melbourne, Parkville, VIC, Australia
| | - Patrick McGorry
- Orygen Youth Health Research Centre and the Centre for Youth Mental Health, Department of Psychiatry, University of Melbourne, Parkville, VIC, Australia
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16
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McGorry P. At issue: Cochrane, early intervention, and mental health reform: analysis, paralysis, or evidence-informed progress? Schizophr Bull 2012; 38:221-4. [PMID: 22247539 PMCID: PMC3283140 DOI: 10.1093/schbul/sbr185] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Among the noncommunicable diseases, mental ill-health represents the major threat to social and economic progress because it impacts so powerfully on the most critical decades of life. Consequently, mental health reform is increasingly recognized as an urgent priority worldwide. This brings into sharp focus the role of evidence, and more specifically the Cochrane paradigm, in influencing decisions about health system reform. Cochrane clearly still has great value, especially in evidence-based medicine, where the focus is the evaluation of individual treatments. However, it cannot be allowed to be a dominant influence in evidence-based health care (EBHC) policy decisions for health system reform, unless it is modernized or complemented. Health services reform should definitely be as evidence-based as possible; however, the jury should consider its verdict on key reform proposals based on the balance of probabilities and informed by the best "available" evidence from all sources, not only randomized clinical trials, which in many domains may be never be feasible. This is particularly the case when reform is urgent, and the status quo has manifestly failed. So on the one hand, the evidence-based paradigm must not be misused to stifle or paralyze urgent reform. Alternatively, there is a real risk that, if we do not improve the sophistication of EBHC, the whole paradigm will be sidelined and reform will remain reactive, impulsive, and desultory. The recent Cochrane review on early intervention in psychosis provides an opportunity to consider these issues and their wider significance.
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Affiliation(s)
- Patrick McGorry
- Orygen Youth Health Research Centre, University of Melbourne, Locked Bag 10 (35 Poplar Road), Parkville, VIC 3052, Australia.
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Wisdom JP, Manuel JI, Drake RE. Substance use disorder among people with first-episode psychosis: a systematic review of course and treatment. Psychiatr Serv 2011; 62:1007-12. [PMID: 21885577 PMCID: PMC3575521 DOI: 10.1176/appi.ps.62.9.1007] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE People experiencing a first episode of psychosis frequently have co-occurring substance use disorders, usually involving alcohol and cannabis, which put them at risk for prolonged psychosis, psychotic relapse, and other adverse outcomes. Yet few studies of first-episode psychosis have addressed the course of substance use disorders and the response to specialized substance abuse treatments. METHODS The authors searched MEDLINE, PsycINFO, and other medical databases for English-language articles published between 1990 and 2009. Included studies addressed two research questions. First, do some clients become abstinent after a first episode of psychosis without specialized substance abuse treatments? Second, for clients who continue to use substances after a first episode of psychosis, does the addition of specialized substance abuse treatment enhance outcomes? RESULTS Nine studies without specialized substance abuse treatment and five with specialized substance abuse treatment assessed the course of substance use (primarily cannabis and alcohol) after a first episode of psychosis. Many clients (approximately half) became abstinent or significantly reduced their alcohol and drug use after a first episode of psychosis. The few available studies of specialized substance abuse treatments did not find better rates of abstinence or reduction. CONCLUSIONS Experience, education, treatment, or other factors led many clients to curtail their substance use disorders after a first episode of psychosis. Specialized interventions for others need to be developed and tested.
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Affiliation(s)
- Jennifer P. Wisdom
- Dr. Wisdom and Dr. Manuel are affiliated with the Division of Mental Health Services and Policy Research, New York State Psychiatric Institute, 1051 Riverside Drive, Box 100, New York, NY 10032 (). Dr. Drake is with the Departments of Psychiatry and Community and Family Medicine, Dartmouth University, Lebanon, New Hampshire
| | - Jennifer I. Manuel
- Dr. Wisdom and Dr. Manuel are affiliated with the Division of Mental Health Services and Policy Research, New York State Psychiatric Institute, 1051 Riverside Drive, Box 100, New York, NY 10032 (). Dr. Drake is with the Departments of Psychiatry and Community and Family Medicine, Dartmouth University, Lebanon, New Hampshire
| | - Robert E. Drake
- Dr. Wisdom and Dr. Manuel are affiliated with the Division of Mental Health Services and Policy Research, New York State Psychiatric Institute, 1051 Riverside Drive, Box 100, New York, NY 10032 (). Dr. Drake is with the Departments of Psychiatry and Community and Family Medicine, Dartmouth University, Lebanon, New Hampshire
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Petrakis M, Hamilton B, Penno S, Selvendra A, Laxton S, Doidge G, Svenson M, Castle D. Fidelity to clinical guidelines using a care pathway in the treatment of first episode psychosis. J Eval Clin Pract 2011; 17:722-8. [PMID: 20973872 DOI: 10.1111/j.1365-2753.2010.01548.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To evaluate the implementation of clinical practice guidelines in the initial stages of treatment of first episode psychosis, through use of a care pathway within one area mental health service. METHODS A fidelity audit was undertaken using data from local Early Psychosis Care Pathway documents, completed for the cohort of clients with early psychosis seen in the first 2 years of an integrated early psychosis programme model, at St Vincent's Mental Health Service, Melbourne, Australia. RESULTS The utilisation of a care pathway greatly supported both the documentation of clinical process and fidelity to clinical guidelines in early psychosis treatment. Excellent adherence (over 80%) was achieved for therapeutic alliance with the client, conducting a comprehensive bio-psychosocial assessment, medical investigations, reduction of client trauma and increased orientation to the service and the mental health systems of care, and for contact with family. Good adherence (over 70%) was achieved for client re-integration to the community and promotion of carer well-being; the service plans to focus on these areas in future service improvement initiatives, along with a focus on physical health assessment and enhancing primary care liaison. CONCLUSIONS The process of formally operationalizing and implementing clinical guidelines utilizing a care pathway within an area mental health service has proved to be an effective way to ensure fidelity with standard agency practices and protocols. The integrated approach, supported by quality assurance initiatives, provides an excellent goodness-of-fit within an established area mental health service.
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Affiliation(s)
- Melissa Petrakis
- St Vincent's Mental Health Service, Hawthorn Community Mental Health Service, Melbourne, Vic., Australia.
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Petrakis M, Penno S, Oxley J, Bloom H, Castle D. Early psychosis treatment in an integrated model within an adult mental health service. Eur Psychiatry 2011; 27:483-8. [PMID: 21664801 DOI: 10.1016/j.eurpsy.2011.03.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2010] [Revised: 02/17/2011] [Accepted: 03/17/2011] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE To compare the treatment of patients with early psychosis, 2 years after the introduction of an integrated model of enhanced management within a public adult mental health service, with an historic cohort from the same service. METHOD Variables examined in the 2001 cohort were compared with 2008 patients. Computer database review and a file audit were conducted for all patients with early psychosis across the first 2 years of the program. RESULTS Compared to the historic cohort, patients in the current cohort were 24% less likely to have been admitted (P=0.004). There were statistically significant reductions in involuntary status and use of a locked unit. Rates of police involvement in admission and use of seclusion were also reduced, though this trend was not significant. Average length of stay was reduced. Median duration of untreated psychosis was 3 months in both 2001 and 2008 cohorts. CONCLUSIONS The introduction of an integrated model of management within an area mental health service for patients with early psychosis contributed to significant reductions in admissions, involuntary status and use of a locked ward. The data suggests that enhanced treatment of early psychosis patients can be offered within generic services.
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Affiliation(s)
- M Petrakis
- St Vincent's Mental Health Service, Hawthorn Community Mental Health Service, 642, Burwood Road, Hawthorn East 3123, Melbourne, Australia.
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Abstract
OBJECTIVE People experiencing a first episode of psychosis often have co-occurring substance use, which increases risk of prolonged psychosis and impairs recovery. This article examines the prevalence of substance use in people with first-episode psychosis. METHODS The authors searched MEDLINE and other databases for articles published between 1990 and 2009 that described current or lifetime prevalence of substance use, misuse, abuse, or dependence in individuals with first-episode psychosis. RESULTS Forty-four unique studies provided information. More than 25% of individuals with first-episode psychosis in reviewed studies indicated current or lifetime alcohol use, lifetime alcohol abuse/dependence, current or lifetime cannabis use, or lifetime cannabis abuse or dependence. For all substances, lifetime prevalence of abuse/dependence was higher than current abuse/dependence. CONCLUSIONS Despite variation in assessment methods, findings were generally consistent. Individuals with first-episode psychosis have lower current substance prevalence than lifetime prevalence, suggesting cessation of some substance use prior to seeking treatment for psychosis.
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Affiliation(s)
- Jennifer P Wisdom
- a Columbia University and New York State Psychiatric Institute , New York , New York , USA
| | - Jennifer I Manuel
- a Columbia University and New York State Psychiatric Institute , New York , New York , USA
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21
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Nielssen O, Large M. Rates of homicide during the first episode of psychosis and after treatment: a systematic review and meta-analysis. Schizophr Bull 2010; 36:702-12. [PMID: 18990713 PMCID: PMC2894594 DOI: 10.1093/schbul/sbn144] [Citation(s) in RCA: 162] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The observation that almost half of the homicides committed by people with a psychotic illness occur before initial treatment suggests an increased risk of homicide during the first episode of psychosis. The aim of this study was to estimate the rates of homicide during the first episode of psychosis and after treatment. A systematic search located 10 studies that reported details of all the homicide offenders with a psychotic illness within a known population during a specified period and reported the number of people who had received treatment prior to the offense. Meta-analysis of these studies showed that 38.5% (95% confidence interval [CI] = 31.1%-46.5%) of homicides occurred during the first episode of psychosis, prior to initial treatment. Homicides during first-episode psychosis occurred at a rate of 1.59 homicides per 1000 (95% CI = 1.06-2.40), equivalent to 1 in 629 presentations. The annual rate of homicide after treatment for psychosis was 0.11 homicides per 1000 patients (95% CI = 0.07-0.16), equivalent to 1 homicide in 9090 patients with schizophrenia per year. The rate ratio of homicide in the first episode of psychosis in these studies was 15.5 (95% CI = 11.0-21.7) times the annual rate of homicide after treatment for psychosis. Hence, the rate of homicide in the first episode of psychosis appears to be higher than previously recognized, whereas the annual rate of homicide by patients with schizophrenia after treatment is lower than previous estimates. Earlier treatment of first-episode psychosis might prevent some homicides.
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Affiliation(s)
- Olav Nielssen
- Clinical Research Unit for Anxiety Disorders, School of Psychiatry, UNSW at St Vincent's Hospital, 299 Forbes Street, Darlinghurst, NSW, 2010, Australia
- Private Practice, Sydney, Australia
- Discipline of Psychological Medicine, University of Sydney
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McGorry P, Johanessen JO, Lewis S, Birchwood M, Malla A, Nordentoft M, Addington J, Yung A. Early intervention in psychosis: keeping faith with evidence-based health care. Psychol Med 2010; 40:399-404. [PMID: 19775497 DOI: 10.1017/s0033291709991346] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- P McGorry
- Orygen Youth Health Research Centre and Centre for Youth Mental Health, University of Melbourne, Australia.
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Abstract
This paper reviews the literature on early intervention in psychotic disorders, weighs the cons of this approach, and makes suggestions for clinicians and researchers regarding how to interpret and respond to what is still an embryonic evidence-base, notably in terms of any long-term benefits.
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24
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Davidson L, Roe D. Recovery from versus recovery in serious mental illness: One strategy for lessening confusion plaguing recovery. J Ment Health 2009. [DOI: 10.1080/09638230701482394] [Citation(s) in RCA: 167] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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SALOKANGAS RAIMOK. Staging intervention and meeting needs in early psychosis. World Psychiatry 2008; 7:160-2. [PMID: 18836538 PMCID: PMC2559922 DOI: 10.1002/j.2051-5545.2008.tb00186.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Affiliation(s)
- RAIMO K.R. SALOKANGAS
- Department of Psychiatry, University of Turku; Psychiatric Clinic, Turku University Central Hospital, Kiinamyllynkatu 4-8, 20520 Turku, Finland
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26
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Cassidy CM, Schmitz N, Norman R, Manchanda R, Malla A. Long-term effects of a community intervention for early identification of first-episode psychosis. Acta Psychiatr Scand 2008; 117:440-8. [PMID: 18479319 DOI: 10.1111/j.1600-0447.2008.01188.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To assess whether an Early Case Identification Program (ECIP) for first-episode psychosis (FEP), which showed no significant short-term effects, has a delayed impact on duration of untreated psychosis (DUP). METHOD Using a historical control design, FEP patients were assessed on clinical variables over three consecutive phases, 2 years prior, 2 years during and 3 years after implementation of the ECIP. Additional analyses were conducted on non-affective and schizophrenia spectrum psychoses cases only. RESULTS There was no overall significant difference in DUP across the three phases. For cases treated within the first year of illness a nonsignificant reduction in DUP to less than 2 months observed during the active phase was sustained post-ECIP. CONCLUSION In some jurisdictions community-wide early case detection may fail to have an immediate or delayed effect on DUP, especially for cases who normally present for treatment with DUP >1 year.
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Affiliation(s)
- C M Cassidy
- Department of Psychiatry, Douglas Hospital Research Centre, McGill University, Montréal, Quebec, Canada
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Yung AR, Killackey E, Hetrick SE, Parker AG, Schultze-Lutter F, Klosterkoetter J, Purcell R, Mcgorry PD. The prevention of schizophrenia. Int Rev Psychiatry 2007; 19:633-46. [PMID: 18092241 DOI: 10.1080/09540260701797803] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Preventive strategies can be divided into universal, selective and indicated prevention and early intervention. Universal interventions are directed to the general population. Selective approaches are targeted at people who have risk factors for an illness, but who do not show any current signs. Indicated approaches target high risk individuals with minimal signs or symptoms foreshadowing mental disorder, but who do not meet diagnostic levels at the current time. Early intervention involves treating those with already diagnosable disorder in a timely and optimal manner aiming to decrease the severity of the illness, and reduce secondary morbidity. Although universal and selective interventions are not yet viable strategies, indicated prevention and early intervention are now realistic possibilities in schizophrenia. Development of methods to identify those at risk of psychosis continues to evolve. Promising results in the prevention and delay of transition to psychotic disorder from high risk state have been found. Early intervention in schizophrenia, including promotion of early help-seeking, has been shown to reduce the duration of untreated psychosis, which is known to be associated with poor outcome in schizophrenia. Early intervention programmes which optimise the care of the first episode have been shown to produce better outcomes than routine management.
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Affiliation(s)
- A R Yung
- The Department of Psychiatry, The University of Melbourne, Victoria, Australia and ORYGEN Research Centre, Parkville, Victoria, Australia.
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Abstract
The focus of this review is the research and clinical work in early psychosis and early intervention which over the past 10-15 years has had a tremendous impact on the field of schizophrenia. Unparalleled progress has been made in programme and service development with a wide range of reported research results, outcome studies, treatment approaches and new initiatives. Traditional areas are being explored in the first episode that can add to our knowledge of schizophrenia. New areas that have a specific relevance for early intervention such as the duration of untreated psychosis and pathways to care are being widely studied. Despite the criticism of the lack of randomized controlled trials, there is a wealth of positive outcome from both effectiveness studies and limited controlled trials. However, there are still many unanswered issues which are in developing stages or which require further investigation.
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Affiliation(s)
- Jean Addington
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada.
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