Duration of untreated illness and outcome in schizophrenia: test of predictions in relation to relapse risk

Relapse rate and predictors among people with severe mental illnesses at Debre Markos Comprehensive specialized hospital, Northwest Ethiopia: a prospective follow up study

Severe mental illness is usually marked by periods of remission, when symptoms are absent or well controlled, and of exacerbation, when symptoms return or worsen. Relapse of these severe illnesses costs a lot for patients and their families and imposes a financial burden on hospital and community services. Costs for relapse cases were four times higher than that of non-relapse cases. There is a dearth of evidence in on relapse rate on these vulnerable population in Sub-Saharan Africa, therefore this study assessed relapse rate and predictors among people with severe mental illnesses at Debre Markos Comprehensive specialized hospital, Northwest Ethiopia. Prospective follow up study design was employed among 315 people with severe mental illnesses who were selected by systematic random sampling technique. Epi.data version 4.2 was used for data entry and exported to STATA 14 for analysis. The Kaplan-Meier curve was used to estimate the median duration of occurrence and the Log rank test was used to compare survival curves between different categories of explanatory variables. A survival analysis was used to estimate the cumulative rate of relapse, Cox proportional hazards models was used to examine independent factors associated with time to develop relapse. To estimate the association between predictors and relapse, hazard ratio with 95% confidence intervals was used. Variables score p value < 0.25 with in the Bivariable analysis was entered in to the multivariable analysis model. The statistical significance was accepted at p-value < 0.05. Around 119 (37.78%) had develop relapse, and the remaining 196 (62.22%) were censored. The overall incidence rate of relapse was 3.66 per 100 person-month (95% CI:3.06-4.38) with a total of 3250 patient-month observations. Variables such as: age (18-36 years) [(AHR) = 3.42:95% (CI) :1.67,6.97)], marital status (single and widowed) 1.87 [AHR: 1.87; 95% CI: (1.06 ,3.27)] and 2.14 [AHR: 2.14; 95% CI: (1.03 ,4.44)], duration of delay in getting treatment ( > = 1 year) [(AHR = 2.55:CI:1.20, 5.38)], types of diagnosis (Major Depressive Disorder) (AHR = 2.38, CI:1.37 ,4.14), medication adherence (low adherence) (AHR = 5.252.45, 11.21) were statistically significant (P value < 0.05). Nearly two-fifth of people diagnosis with severe mental illnesses had develop relapse and the median survival time to develop relapse was nine months. It is advised that early detection of severe mental illness and early initiation of treatments are very crucial to prevent relapse. Psycho education, counseling that alleviates poor treatment adherence are highly recommended.

Childhood trauma and treatment resistance in first-episode psychosis: Investigating the role of premorbid adjustment and duration of untreated psychosis

BACKGROUND

Early identification of treatment non-response in first-episode psychosis (FEP) is essential to outcome. Despite indications that exposure to childhood trauma (CT) can have adverse effects on illness severity, its impact on treatment non-response and the interplay with other pre-treatment characteristics is sparsely investigated. We use a lack of clinical recovery as an early indicator of treatment resistance to investigate the relationship between CT and treatment resistance status at one-year follow-up and the potential mediation of this effect by other pre-treatment characteristics.

METHODS

This prospective one-year follow-up study involved 141 participants recruited in their first year of treatment for a schizophrenia-spectrum disorder. We investigated clinical status, childhood trauma (CT), premorbid adjustment (PA), and duration of untreated psychosis (DUP) at baseline and clinical status at one-year follow-up. Ordinal regression analyses were conducted to investigate how PA and DUP affected the relationship between CT and one-year outcome in FEP.

RESULTS

45 % of the FEP sample reported moderate to severe CT, with significantly higher levels of CT in the early treatment resistant group compared to participants with full or partial early recovery. Ordinal regression analysis showed that CT was a significant predictor of being in a more severe outcome group (OR = 4.59). There was a partial mediation effect of PA and a full mediation effect of DUP on the effect of CT on outcome group membership.

DISCUSSION

Our findings indicate that reducing treatment delays may mitigate the adverse effects of CT on clinical outcomes and support the inclusion of broad trauma assessment in FEP services.

The Impact of Prolonged Duration of Untreated Illness on Clinical Correlates in Chronic Schizophrenia: Exploring the Relationship With Suicide Risk

OBJECTIVE

Studies on duration of untreated psychosis are common in patients with schizophrenia, but few studies have investigated the relationship between duration of untreated illness (DUI) and suicide, especially in patients with chronic schizophrenia. Therefore, we intended to investigate the relationship between DUI and suicide and clinical correlates in patients with chronic schizophrenia.

METHODS

A total of 1,555 Chinese patients with chronic schizophrenia were enrolled in this study. DUI was measured in years, reflecting the prolonged untreated periods observed in this population. Clinical correlates were assessed, including symptoms, cognitive functioning, and body mass index. Suicidal ideation and attempts were also examined. Statistical analyses, including multivariate models, were employed to investigate the associations between DUI and clinical correlates while controlling for potential confounders.

RESULTS

The study revealed a significant proportion (23.3%) of patients with chronic schizophrenia in China received their first treatment after a 4-year delay, with the longest untreated duration reaching 39 years. Patients with longer DUI exhibited more severe negative symptoms, lower immediate memory scores, a higher likelihood of being overweight, and surprisingly, a reduced likelihood of suicidal ideation and attempts. Each additional year of untreated illness was associated with a 3% decrease in the risk of suicidal ideation and attempts.

CONCLUSION

The findings underscore the prevalence of extended untreated periods in Chinese patients with chronic schizophrenia and highlight the impact of DUI on negative symptoms, cognitive function, and body weight. Intriguingly, a longer DUI was associated with a lower risk of suicidal ideation and attempts.

Investigating factors associated with the number of rehospitalizations among patients with schizophrenia disorder using penalized count regression models

BACKGROUND

Schizophrenia is a chronic, severe, and debilitating mental disorder always considered one of the recurrent psychiatric diseases. This study aimed to use penalized count regression models to determine factors associated with the number of rehospitalizations of schizophrenia disorder.

METHODS

This retrospective cohort study was performed on 413 schizophrenic patients who had been referred to the Sina (Farshchian) Educational and Medical Center in Hamadan, Iran, between March 2011 and March 2019. The penalized count regression models were fitted using R.3.5.2.

RESULTS

About 73% of the patients were male. The mean (SD) of age and the number of rehospitalizations were 36.16 (11.18) years and 1.21 (2.18), respectively. According to the results, longer duration of illness (P < 0.001), having a positive family history of psychiatric illness (P = 0.017), having at least three children (P = 0.013), unemployment, disability, and retirement (P = 0.025), residence in other Hamadan province townships (P = 0.003) and having a history of arrest/prison (P = 0.022) were significantly associated with an increase in the number of rehospitalizations.

CONCLUSION

To reduce the number of rehospitalizations among schizophrenic patients, it is recommended to provide special medical services for patients who do not have access to specialized medical centers and to create the necessary infrastructure for the employment of patients.

Short-term Efficacy and Safety of Lurasidone Versus Placebo in Antipsychotic-Naïve vs. Previously Treated Adolescents with an Acute Exacerbation of Schizophrenia

Background

To evaluate the efficacy of short-term lurasidone in antipsychotic treatment-naïve (TN) adolescents with schizophrenia versus those treated previously (TP) with antipsychotics.

Methods

Patients aged 13–17 with schizophrenia, and a Positive and Negative Symptom Scale (PANSS) score ≥ 70 and < 120, were randomized to 6 weeks of double-blind treatment with lurasidone (40 or 80 mg/day) or placebo. In a post-hoc, pooled-dose analysis, efficacy was evaluated for TN (criteria: never received antipsychotic treatment) versus TP at the time of the study. Treatment response criteria: ≥20% reduction in PANSS total score.

Results

Altogether, 57 TN and 269 TP patients enrolled in the 6-week DB study. Mean endpoint change in PANSS total score was significantly greater for lurasidone versus placebo in both the TN group (−25.0 vs. -14.4; p < 0.02; effect size = 0.75), and in the TP group (−17.3 vs. -10.0; p < 0.001; effect size = 0.45); and responder rates were higher for lurasidone versus placebo in both the TN group 84.6% versus 38.9%; number needed to treat [NNT] = 3 and in the TP group (60% vs. 42%; NNT = 6). Rates of treatment-emergent adverse events, and mean changes in body weight and metabolic parameters were similar for the TN and TP groups.

Conclusions

In a 6-week, placebo-controlled trial, lurasidone demonstrated significant efficacy in adolescents with schizophrenia regardless of previous antipsychotic therapy status; however, the effect size was notably larger in the TN patient group. In both the TN and TP groups, minimal effects were noted on weight, metabolic parameters, or prolactin.

Long-term safety and effectiveness of open-label lurasidone in antipsychotic-Naïve versus previously treated adolescents with Schizophrenia: A post-hoc analysis

BACKGROUND

There is a relative lack of long-term, prospective data evaluating the safety and effectiveness of treatment in early-onset adolescent patients with schizophrenia who are treatment-naïve. The aim of this post-hoc analysis was to examine the long-term safety and effectiveness of lurasidone in adolescents with schizophrenia who were antipsychotic treatment-naïve (TN; at the time of enrolment in the initial study) compared to adolescents treated previously (TP) with an antipsychotic.

METHODS

Patients aged 13-17 who completed 6 weeks of double-blind (DB), placebo-controlled treatment with lurasidone were enrolled in a 2-year, open-label (OL), flexible-dose (20-80 mg/day) lurasidone study.

RESULTS

The long-term analysis sample consisted of 50 TN and 221 TP patients, of whom 40% and 43%, respectively, discontinued prematurely. The three most common adverse events for TN and TP patients, respectively, were headache (26.0%, 23.5%); schizophrenia (14.0%, 12.2%), dizziness (16.0%, 4.1%), and nausea (16.0%, 11.8%). At endpoint, mean increase in weight was similar to expected weight gain based on growth charts for both TN (+4.5 kg vs. + 5.7 kg) and TP (+4.6 kg vs. + 6.6 kg) patients. Minimal changes were observed for each group in metabolic parameters and prolactin. Mean improvement was consistently greater in the TN vs. TP group (-19.2 vs. -15.9; effect size of 0.33) for between-group change in PANSS total score at Week 104.

CONCLUSIONS

In both TN and TP adolescents with schizophrenia, long-term treatment with lurasidone was associated with minimal effects on body weight, lipids, glycemic indices, and prolactin, with generally small differences noted in rates of reported AEs. Continued improvement in symptoms of schizophrenia was evident for both the TN and TP groups. These data indicate that lurasidone is a safe and efficacious treatment option for treatment-naïve youth with schizophrenia, who are generally most sensitive to antipsychotic adverse effects.

Risk Factors for Relapse in People with Severe Mental Disorders during the COVID-19 Pandemic: A Multicenter Retrospective Study

Background: Evidence suggests that different variables associated with the COVID-19 pandemic may increase the risk of relapse in people with Severe Mental Disorders (SMDs). However, no studies have yet looked closely at the different risk factors involved to determine their influence on the worsening of these patients’ illnesses. Objective: To analyze which variables related to the COVID-19 pandemic have increased the risk of relapse in patients with SMDs. Method: A multicenter retrospective cohort study in which data were collected from 270 patients with mental disorders who had been under follow-up in day hospitals during the year 2020. Results: The proportion of full mental health inpatient admissions was significantly higher in those who lost their employment (40.7% vs. 18.1%; p = 0.01), in those who were not receiving psychotherapy interventions (33.9% vs. 16.6%; p = 0.006), and in those who were not receiving occupational therapy (25.7% vs. 13.6%: p = 0.013). Significant associations were detected between urgent mental health consultations, the number of COVID-19 symptoms (B = 0.274; p = 0.02), and the low-income group (1.2424 vs. 0.4583; p = 0.018). Conclusions: COVID-19 symptoms and certain consequences of the pandemic, such as loss of employment, economic hardship, and loss of interventions, have brought about clinical worsening in people with SMDs. Knowledge of these factors is important for health-related decision-making in future outbreaks or pandemics.

Lead-Time Bias Confounds Association Between Duration of Untreated Psychosis and Illness Course in Schizophrenia

OBJECTIVE

At first hospitalization, a long duration of untreated psychosis (DUP) predicts illness severity and worse treatment outcomes. The mechanism of this association, however, remains unclear. It has been hypothesized that lengthy untreated psychosis is toxic or that it reflects a more severe form of schizophrenia. Alternatively, the association may be an artifact of lead-time bias. These hypotheses are tested in a longitudinal study of schizophrenia with 2,137 observations spanning from childhood to 20 years after first admission.

METHODS

Data were from the Suffolk County Mental Health Project. The cohort included 287 individuals with schizophrenia or schizoaffective disorder. DUP was defined as days from first psychotic symptom to first psychiatric hospitalization. Psychosocial function was assessed using the Premorbid Adjustment Scale and the Global Assessment of Functioning Scale. Psychosocial function trajectories were estimated using multilevel spline regression models adjusted for gender, occupational status, race, and antipsychotic medication.

RESULTS

Both long- and short-DUP patients experienced similar declines in psychosocial function, but declines occurred at different times relative to first admission. Long-DUP patients experienced most of these declines prior to first admission, while short-DUP patients experienced declines after first admission. When psychosocial function was analyzed relative to psychosis onset, DUP did not predict illness course.

CONCLUSIONS

The association between DUP and psychosocial function may be an artifact of early detection, creating the illusion that early intervention is associated with improved outcomes. In other words, DUP may be better understood as an indicator of illness stage than a predictor of course.

Hebephrenia is dead, long live hebephrenia, or why Hecker and Chaslin were on to something

Since its first description in 1863, ‘hebephrenia’ has highlighted a group of patients characterised by an early onset of illness, formal thought disorder, bizarre behaviour and incongruent emotional expression. A proportion of patients with the most severe form of mental illness have a clinical presentation that is best captured by this diagnosis. Here, we outline the construct of hebephrenia and two of its core overlapping constituent parts: bizarre behaviour and the disorganisation dimension. We argue that, despite the removal of hebephrenia (disorganised schizophrenia) from DSM-5, clinicians should consider it as a differential diagnosis, particularly in suspected personality disorder.

Treatment outcomes and associations in an adolescent-specific early intervention for psychosis service

AIM

Compared with adult onset psychosis, adolescent psychosis has been associated with poorer outcomes in terms of social and cognitive functioning and negative symptoms. Young people experiencing first episode psychosis have developmental needs that frequently pre-date and are compounded by psychosis onset (a previous study). There is a lack of published studies of adolescent onset psychosis and further information is needed so that developmentally appropriate interventions can be developed. We report an observational naturalistic cohort study of an adolescent specific service, the Early Psychosis Support service (EPSS).

METHOD

We examined baseline demographic and clinical variables, treatments outcomes and predictors of outcome for this population.

RESULTS

The mean age of our sample was 16.3 years. Median duration of untreated illness (DUI) was 88 weeks, and median duration of untreated psychosis (DUP) was 16 weeks. We found significant improvements in positive symptoms, negative symptoms, disorganization, excitement, emotional distress and depression from 0 to 12 months. We found that baseline positive symptoms and DUI significantly predicted positive symptoms at 12 months and only negative symptoms at baseline predicted 12-month negative symptoms.

CONCLUSION

Our finding that specialist early intervention for adolescents experiencing psychosis is effective suggests that such treatment should be routinely offered in line with existing clinical guidelines. Our finding that DUI is predictive of poorer outcome at 12 months suggests that even earlier intervention from a specialist team may further improve treatment outcomes.

Effects of Prodromal Stage and Untreated Psychosis on Subsequent Psychopathology of Schizophrenia: A Path Analysis

BACKGROUND

To examine psychopathology present under prolonged antipsychotic treatment in schizophrenia and to analyse their relationship to both the duration of the prodromal stage (DPS; time between onset of first unspecific psychological symptoms and first schizophrenic symptoms) and the duration of untreated psychosis (DUP; time between the onset of psychosis and the initiation of antipsychotic treatment).

METHODS

The psychopathology of 93 patients was assessed cross-sectionally using the Scales for the Assessment of Negative and Positive Symptoms and the Brief Psychiatric Rating Scale. DPS and DUP were assessed by means of the patient records and the Interview for the Retrospective Assessment of the Onset and Course of Schizophrenia and Other Psychoses. A path analysis using maximum likelihood estimation was conducted with the program Analysis of Moment Structures for Windows.

RESULTS

The resulting path model indicated that DPS was predictive for a more severe negative symptomatology in schizophrenia, whereas DUP was associated with a more severe positive symptomatology in the long-term. Furthermore, DUP showed an inverse correlation with the age of the patients at the onset of both first unspecific psychological symptoms and first schizophrenic symptoms.

CONCLUSION

A long prodromal stage suggests an increased risk of a long-term progression with negative symptoms in schizophrenia, whereas a delayed start of antipsychotic treatment could lead to an increased manifestation and severity of positive symptoms in the long term. These results underline the need to shorten the duration of the prodrome by an early detection and adequate intervention in patients with increased risk to develop psychosis.

GWAS analysis of treatment resistant schizophrenia: interaction effect of childhood trauma

Aims: In the current study, we aimed to compare the prevalence of adverse lifetime events in treatment resistant and non-treatment resistant schizophrenia in a genome-wide association study. Materials & methods: Our sample consisted of 84 Caucasian participants with schizophrenia spectrum disorders, assessed cross-sectionally to collect information regarding drug effectiveness and childhood trauma. Using a genome-wide association analysis, we tested single-nucleotide polymorphisms for their association with resistance to antipsychotics defined according to American Psychiatric Association criteria. Two models were tested: a main model and an interaction model with the childhood trauma. Results: Our analysis failed to demonstrate a significant relationship among 1,178,234 single-nucleotide polymorphisms and treatment-resistance in both the main model and in the childhood trauma interaction model. Conclusion: Even though we could not find any significant association, treatment resistance has clinical relevance and it may be determined by the interaction between biological and non biological factors.

New evidence in support of staging approaches in schizophrenia: Differences in clinical profiles between first episode, early stage, and late stage

Few studies have examined the progression of symptom dimensions in schizophrenia patients over the course of the illness. The objective of this study was to investigate whether clinical and psychopathological differences exist between first-episode schizophrenia (FES) and multiple-episode patients in an inpatient setting. Patients (N=203) were evaluated using the Positive and Negative Syndrome Scale (PANSS) over time. Five different generalized estimating equations were built for the PANSS factors using the following as covariates: sex, patient's age, assessment time point (i.e., moment of patient's evaluation, with a minimum of two and a maximum of four assessments throughout the study timeframe). The FES group was used as the reference to which the groups with up to five years of illness and more than five years of illness were compared. Remission rates and treatment resistance (TRS) rates were also compared. Generalized estimating equations were used to allow for different numbers of assessments over the study period. Patients with FES showed significantly milder severity in positive, disorganized, and hostility factors. Also, FES patients were more likely to achieve remission (P=0.002) and had lower rates of TRS (P=0.001). First-episode schizophrenia seems to be the critical period to improve outcome, as multiple-episode patients were similar in clinical characteristics regardless of illness duration.

The Reliability and Validity of Liu´s Self-Report Questionnaire for Screening Putative Pre-Psychotic States (BQSPS) in Adolescents

The usage of rigorous analyses based on contemporary methods to enhance psychometric properties of screening questionnaires aimed to address psychotic-like experiences (PLE) is currently being encouraged. The Brief Self-Report Questionnaire for Screening Putative Pre-psychotic States (BQSPS) is a recently created tool addressing PLE beyond attenuated positive symptoms (APS). Its psychometric properties as a screening tool for first step assessment seems to be adequate, but further research is needed to evaluate certain validity aspects, particularly its dimensionality, internal structure, and psychometric properties in different populations. We assessed the reliability, construct validity, and criterion validity of BQSPS in two samples: 727 adolescents aged 13-18 years, and 245 young adults aged 18-33 years. We used exploratory structural equation modeling (ESEM), confirmatory factor analysis (CFA), and Structural Equation Modeling (SEM). The original four-factor structure was not replicated. The best fit in adolescents was obtained by a structure of three-correlated factors: social anxiety (SA), negative symptoms (NS), and positive symptoms (PS). This structure was confirmed in young adult subjects. The three-factor model reached a predictive capability with suicidality as external criterion. PLE are represented by a three-factor structure, which is highly stable between adolescent and young-adult samples. Although the BQSPS seems to be a valid tool for screening PLE, its psychometric properties should be improved to obtain a more accurate measurement.

The effect of brexpiprazole in adult outpatients with early-episode schizophrenia: an exploratory study

The aim of this study was to evaluate flexibly dosed brexpiprazole for early-episode schizophrenia through the assessment of efficacy, social functioning, and tolerability. This was an exploratory, 16-week, open-label, flexible-dose (1, 2, 3, or 4 mg/day; target dose 3 mg/day) study in outpatients with early-episode schizophrenia (18-35 years old, ≤5 years' duration of illness). Efficacy was assessed by the Positive and Negative Syndrome Scale score (PANSS) and social functioning was assessed by changes from baseline in PANSS modified prosocial subscale, personal and social performance (PSP), and specific levels of functioning (SLOF) scales. Safety and tolerability were also evaluated. Overall, 25/49 patients completed the study. Symptoms of schizophrenia improved over the entire treatment period, as evidenced by reductions in PANSS total score from baseline (least squares mean change at week 16: -10.2). Improvements in social functioning were shown by least squares mean changes from baseline at week 16 in the PANSS prosocial subscale (-2.0), PSP (6.6), and SLOF (13.1). Brexpiprazole was generally well tolerated; the most common adverse events were insomnia (7/49 patients), somnolence (4/49), sedation, weight increase, and nausea (each 3/49). Brexpiprazole may represent a novel and effective treatment strategy for patients with early-episode schizophrenia and may be effective for improving social function.

Psychotic relapse and associated factors among patients attending health services in Southwest Ethiopia: a cross-sectional study

BACKGROUND

Psychotic relapse leads to repeated hospitalization and negatively affects the clinical prognosis of the patients. Information on prevalence of relapse among patients with psychotic disorders in Ethiopian setting is scarce. This study aimed to assess the prevalence of relapse among patients with psychotic disorders attending services in Jimma University Specialized Hospital (JUSH).

METHODS

Data were collected using interviewer administered questionnaire. We used medication adherence rating scale (MARS) to assess compliance to medication and abnormal involuntary movement scale (AIMS) to detect medication side effects. Logistic regression analysis was used to identify independent predictors of psychotic relapse. All variables with P-value <0.25 in the bivariate analyses were entered into multivariate logistic regression and variables with P-value < 0.05 in the final model were declared to be significantly associated with the outcome variable.

RESULTS

The prevalence of relapse among patients with psychotic disorder was 24.6 % (n = 95). Of this, 25.4 and 22.4 % were males and females respectively. The odds of developing psychotic relapse among patients living with family was 72 % lower than that of patients living alone (aOR = 0.28, 95 % CI = 0.08, 0.93). The odds of developing psychotic relapse among patients compliant to medication was 69 % lower than that of patients who were not compliant to medications (aOR = 0.31, 95 % CI = 0.12, 0.80). The odds of developing psychotic relapse among patients having high score on social support score was 48 % lower than that of patients who were compliant to medications (aOR = 0.52, 95 % CI = 0.28, 0.95). The odds of developing psychotic relapse among patients reporting to have sought religious support was 45 % lower than that of patients who have not sought religious support (aOR = 0.55, 95 % CI = 0.31, 0.96). On the other hand, the odds of developing psychotic relapse among participants who have experienced medication side effects was 1.83 times higher when compared to those who have never experienced medication side effects (aOR = 1.83, 95 % CI = 1.01, 3.31).

CONCLUSIONS

The high prevalence of relapse among patients with psychotic disorder needs special attention. Clinicians need to pay attention to medication side effects the patient faces. Intervening noncompliance to medication and appropriately managing medication side effects may help in preventing psychotic relapse that may result because of non-compliance. The provision of counseling, psycho education, psycho social support may help patients in improving compliance to medication and reducing psychotic relapse. Developing and strengthening community based rehabilitation services should be emphasized as part of mental healthcare services.

[Advantages and controversies of depot antipsychotics in the treatment of patients with schizophrenia]

BACKGROUND

The objective of this article is to give an overview of the advantages and disadvantages of the use of depot antipsychotics in the treatment of schizophrenia. The focus is on efficacy, tolerability, relapse prevention, patient compliance and satisfaction compared to oral administration forms.

MATERIAL AND METHODS

A literature search was conducted in medical databases. The results of meta-analyses, randomized controlled trials and systematic reviews from the years 1999-2014 were included.

RESULTS AND DISCUSSION

Depot antipsychotics ensure maintenance of constant blood levels and a continuous medication delivery. The efficacy and tolerability of depot antipsychotics are comparable to oral administration forms. Due to an improved medication compliance a reduction of relapse and hospitalization rates can be achieved. This is a key focus for improving outcomes and reducing costs in the treatment of schizophrenia.

Criminal justice pathways to psychiatric care for psychosis

BACKGROUND

Some patients are at higher risk of contact with criminal justice agencies when experiencing a first episode of psychosis.

AIMS

To investigate whether violence explains criminal justice pathways (CJPs) for psychosis in general, and ethnic vulnerability to CJPs.

METHOD

Two-year population-based survey of people presenting with a first-episode of psychosis. A total of 481 patients provided information on pathways to psychiatric care. The main outcome was a CJP at first contact compared with other services on the care pathway.

RESULTS

CJPs were more common if there was violence at first presentation (odds ratio (OR) = 4.23, 95% CI 2.74-6.54, P<0.001), drug use in the previous year (OR = 2.28, 95% CI 1.50-3.48, P<0.001) and for high psychopathy scores (OR = 2.54, 95% CI 1.43-4.53, P = 0.002). Compared with White British, CJPs were more common among Black Caribbean (OR = 2.97, 95% CI 1.54-5.72, P<0.001) and Black African patients (OR = 1.95, 95% CI 1.02-3.72, P = 0.01). Violence mediated 30.2% of the association for Black Caribbeans, but was not a mediator for Black African patients. These findings were sustained after adjustment for age, marital status, gender and employment.

CONCLUSIONS

CJPs were more common in violent presentations, for greater psychopathy levels and drug use. Violence presentations did not fully explain ethnic vulnerability to CJPs.

Variants Near CCK Receptors are Associated With Electrophysiological Responses to Pre-pulse Startle Stimuli in a Mexican American Cohort

Neurophysiological measurements of the response to pre-pulse and startle stimuli have been suggested to represent an important endophenotype for both substance dependence and other select psychiatric disorders. We have previously shown, in young adult Mexican Americans (MA), that presentation of a short delay acoustic pre-pulse, prior to the startle stimuli can elicit a late negative component at about 400 msec (N4S), in the event-related potential (ERP), recorded from frontal cortical areas. In the present study, we investigated whether genetic factors associated with this endophenotype could be identified. The study included 420 (age 18-30 years) MA men (n = 170), and women (n = 250). DNA was genotyped using an Affymetrix Axiom Exome1A chip. An association analysis revealed that the CCKAR and CCKBR (cholecystokinin A and B receptor) genes each had a nearby variant that showed suggestive significance with the amplitude of the N4S component to pre-pulse stimuli. The neurotransmitter cholecystokinin (CCK), along with its receptors, CCKAR and CCKBR, have been previously associated with psychiatric disorders, suggesting that variants near these genes may play a role in the pre-pulse/startle response in this cohort.

The effect of lifetime adversities on resistance to antipsychotic treatment in schizophrenia patients

AIM

The aim of this study is to examine whether there is an association between cumulative life adversities and treatment-resistant schizophrenia.

METHODS

We recruited 186 participants diagnosed with schizophrenia spectrum disorders. Adverse life-events were assessed using the Stressful Life Events Screening Questionnaire (SLESQ) and the Childhood Trauma Questionnaire (CTQ). Treatment resistant status was identified using the criteria of the American Psychiatric Association for refractory schizophrenia. We performed a multiple logistic regression model, including life adversities, to predict the treatment resistant status controlling for confounding variables.

RESULTS

Forty two percent of the patients were found to be treatment resistant (n=78) and 58% were non-treatment resistant (n=108). The treatment resistant group had higher score on both SLESQ and CTQ (4.5±3.3 and 54.7±19.7) than the non-treatment resistant group (2.5±2.3 and 47.7±17.5) and the difference between the two groups was significant for both SLESQ (p<0.001) and CTQ (p=0.011). After adjustment for demographic variables and previously reported risk factors of treatment resistance, the association remained significant for SLESQ (OR=1.20, 95% CI 1.05-1.38; p=0.009) but not for CTQ (p=0.13).

DISCUSSION

The results suggest that cumulative lifetime adversities could have an independent effect on the resistance to treatment in schizophrenia spectrum disorders. Routine assessment of trauma exposures and an individualized bio-psycho-social formulation is necessary for a personalized treatment.

The availability and quality across Europe of outpatient care for difficult-to-engage patients with severe mental illness: a survey among experts

BACKGROUND

As many patients with severe mental illness (SMI) who have complex needs are difficult to engage, outreach mental health services are needed to engage them into treatment. The extent to which these services exist in large European cities is unknown.

METHODS

Experts in 29 European countries were sent a structured questionnaire containing two case vignettes of difficult-to-engage patients (a first-episode psychosis patient and a homeless chronic schizophrenia patient). The type and quality of outpatient care was assessed and related to several national indices.

RESULTS

The questionnaire was returned by experts from 22 countries (76%) representing 92% of the EU population. Six countries (21%) had a systematic method for detecting difficult-to-engage patients. The most important route whereby such patients entered the mental health system was through informal care; the most important reasons for entering it were the level of psychiatric symptoms, nuisance and violence. Assertive outreach was available in nine countries (41%), with coverage ranging from a few teams (sometimes for a specific target group) to most of the country. The case vignettes showed that outpatient care for these difficult-to-engage patients varied widely. In seven (30%) of the 22 countries, a hospital would take no action if such patients who had been admitted voluntarily discharged themselves prematurely. On a scale of 0-10, the experts' mean scores regarding the quality of outpatient care for patients with SMI in general were 5.2 (SD = 1.9) and 3.2 (SD = 2.2) in difficult-to-engage ones. Explorative analyses showed that the quality of outpatient care for difficult-to-engage patients was associated with gross national income and the number of psychiatrists per capita.

CONCLUSIONS

Outpatient mental health services for difficult-to-engage SMI patients varied widely among European countries; experts judged their overall quality to be poor. It is now important to achieve consensus on a minimum European standard for the quality of care for such patients.

Demographic features and premorbid personality disorder traits in relation to age of onset and sex in paranoid schizophrenia

Personality disorders in the premorbid period of schizophrenia and particularly in relation to age of onset and sex, seem to be a rather under-researched area. In the present study, 88 patients with paranoid schizophrenia were examined, regarding demographic characteristics and premorbid personality disorder traits, in order to investigate for differences in the premorbid period of the disease, in relation to age of onset and sex. Age cutoff points were set at <30 years and ≥35 years of age for young and late onset groups, respectively. The Structured Clinical Interview for DSM-IV-Patient Edition for Axis I disorders (SCID-P) was used prospectively for diagnoses. Premorbid personality disorder traits were retrospectively assessed by using the Structured Clinical Interview for DSM-IV-Patient Edition for Axis II disorders (SCID-II). Comparisons were performed by applying the two-tailed Wilcoxon rank-sum and the χ(2) statistical tests. Young onset patients were characterized by significantly higher proportion of urban birth, single status, more avoidant premorbid personality disorder traits, and less passive-aggressive premorbid personality disorder traits, than late onset counterparts. Differences were more prominently shown in men. Earlier age of onset seems to be associated to increased social inhibition and worse psychosocial adaptation in the premorbid period of paranoid schizophrenia.

Prospective relationship between duration of untreated psychosis and 13-year clinical outcome: a first-episode psychosis study

BACKGROUND

The adverse effects of a long duration of untreated psychosis (DUP) have been explored in numerous short-term studies. These studies support the development of early interventions that reduce treatment delay and promote recovery. However, the enduring impact of DUP is largely unknown, partly due to the paucity of prospective long-term studies. Although the DUP-outcome relationship is commonly assumed to be linear, the threshold effect has not been adequately examined.

OBJECTIVE

To explore the relationship between DUP and long-term symptomatic remission.

METHODS

This was a prospective study of a cohort of 153 first-episode psychosis patients in Hong Kong at the 13-year follow-up. The patients were categorized into short (≤30days), medium (31-180days) and long (>180days) DUP groups.

RESULTS

The long-term outcome was ascertained in 73% of the patients. Nearly half of the patients (47%) fulfilled the criteria for symptomatic remission. The short DUP group experienced a significantly higher remission rate over the course of the illness. The odds of long-term symptomatic remission was significantly reduced in the medium DUP (by 89%) and long DUP (by 85%) groups compared with the short DUP group. Further analysis showed that DUP had a specific impact on negative symptom remission.

CONCLUSION

The findings support the threshold theory that DUP longer than 30days adversely impacts the long-term outcome. The present study is one of the few studies that confirmed the enduring impact of DUP on long-term outcomes based on well-defined criteria and adequate statistical adjustment.

Duration of untreated psychosis is associated with temporal and occipitotemporal gray matter volume decrease in treatment naïve schizophrenia

Background

Long duration of untreated psychosis (DUP) is associated with poor treatment outcome. Whether or not DUP is related to brain gray matter volume abnormalities in antipsychotic medication treatment naïve schizophrenia remains unclear at this time.

Methods

Patients with treatment-naïve schizophrenia and healthy controls went through brain scan using high resolution Magnetic Resonance Imaging. DUP was evaluated using the Nottingham Onset Schedule (NOS), and dichotomized as short DUP (≤ 26 weeks) or long DUP (>26 weeks). Voxel-based methods were used for volumetric measure in the brain.

Results

Fifty-seven patients (27 short DUP and 30 long DUP) and 30 healthy controls were included in the analysis. There were significant gray matter volumetric differences among the 3 groups in bilateral parahippocampus gyri, right superior temporal gyrus, left fusiform gyrus, left middle temporal gyrus, and right superior frontal gyrus (p's<0.01). Compared with healthy controls, the long DUP group had significantly smaller volume in all these regions (p's <0.05). Compared with the short-DUP group, the long-DUP group had significantly smaller volume in right superior temporal gyrus, left fusiform gyrus, and left middle temporal gyrus (p's<0.01).

Conclusion

Our findings suggest that DUP is associated with temporal and occipitotemporal gray matter volume decrease in treatment naïve schizophrenia. The brain structural changes in untreated psychosis might contribute to poor treatment response and long-term prognosis in this patient population.

Duration of untreated illness (DUI) and schizophrenia sub-types: a collaborative study between the universities of Milan and Moscow

BACKGROUND

Several studies show an association between a long duration of untreated illness (DUI) and poor outcome in schizophrenic patients. DUI, in turn, may be influenced by different variables including specific illness-related factors as well as access to local psychiatric services.

AIMS

The purposes of the present study were to detect differences in terms of DUI among schizophrenics coming from different geographic areas and to evaluate differences in DUI across diagnostic sub-types.

METHOD

One hundred and twenty-five (125) schizophrenic patients of the Psychiatric Clinic of Milan (n = 51) and Moscow (n = 74) were enrolled. SCID-I was administered to all patients and information about DUI was obtained by consulting clinical charts and health system databases, and by means of clinical interviews with patients and their relatives. DUI was defined as the time between the onset of illness and the administration of the first antipsychotic drug. One-way analyses of variance (ANOVAs) were performed to find eventual differences in terms of DUI across diagnostic sub-types.

RESULTS

Italian patients showed a longer DUI (M = 4.14 years, SD = 4.95) than Russians (M = 1.16 years, SD = 1.43) (F = 24.03, p < .001). DUI was found to be longer in paranoid schizophrenics (M = 3.47 years, SD = 4.19) compared to catatonic patients (M = 0.96 years, SD = 0.94) (F = 3.56, p = .016).

CONCLUSIONS

The results of the present study suggest that the different schizophrenic sub-types may differ in terms of DUI, likely due to different clinical severity and social functioning. Studies with larger samples are needed to confirm the data of the present study.

Relationship between vocational status and perceived stress and daily hassles in first-episode psychosis: an exploratory study

PURPOSE

Vocational recovery is a primary treatment goal of young people with first-episode psychosis (FEP), yet treatment in this domain is often delayed due to concerns that it might be too stressful. This study aimed to examine whether a relationship exists between vocational status and level of perceived stress and daily hassles in FEP.

METHODS

Forty-seven FEP participants were recruited upon admission to the Early Psychosis Prevention and Intervention Centre (EPPIC), Melbourne. Demographics, psychopathology, perceived stress (Perceived Stress Scale; PSS) and daily hassles (Hassles Scale; HS) were measured.

RESULTS

Regarding vocational status, 19 participants were unemployed, 13 were employed, 14 were students, and 1 reported 'home duties'. ANOVAs and post hoc tests comparing the first three groups on perceived stress and daily hassles revealed that the mean PSS Total and mean PSS Distress scores of the employed group were significantly lower than those of the unemployed and student groups. Regarding hassles scores, the employed group had a significantly lower mean Hassles Intensity score than the unemployed group. Results were largely unchanged when covariates were included. There were no significant differences between the three groups in levels of anxiety, negative or positive symptoms. The employed group reported lower depression than the student group, but this finding disappeared after controlling for gender.

CONCLUSIONS

These results provide preliminary evidence supporting the notion that working or studying is not associated with increased perceived stress or daily hassles in FEP. The findings require replication in larger samples and in different phases of psychosis.

Factors associated with relapse in patients with schizophrenia

OBJECTIVE

To assess risk factors for relapse in patients with schizophrenia attended in daily practice.

METHODS

Patients with schizophrenia admitted consecutively to short-stay/acute-care psychiatric units over a 6-month period were eligible. Variables statistically significant in the univariate logistic regression analysis were then subjected to multivariate analysis.

RESULTS

The study population included 1646 patients (67.6% men). In the univariate analysis, low family support, duration of illness > 5 years, number of previous hospitalizations, cocaine and cannabis consumption, and number of different antipsychotic drug classes were risk factors for relapse. In the multivariate analysis, number of previous hospitalizations (odds ratio [OR] 1.29, 95% confidence interval [CI] 1.21-1.36) and number of different antipsychotics previously used (OR = 1.13, 95% CI 1.03-1.24) were significant predictors of relapse. The absence of cannabis consumption was a protective factor (OR = 0.72, 95% CI 0.58-0.89). Neither adherence to treatment in the previous 3 years nor type of antipsychotic regimen was significantly associated with relapse.

CONCLUSIONS

Number of previous hospitalizations and number of different types of antipsychotic drugs were associated with relapse. Absence of cannabis consumption was a protective factor.

Association between the duration of untreated psychosis and short- and long-term outcome in schizophrenia within the Northern Finland 1966 Birth Cohort

BACKGROUND

Long duration of untreated psychosis (DUP) may relate to poor outcome in schizophrenia. However, the associations between DUP and outcomes, particularly in later course of illness, remain unclear. Our aim was to explore the associations between DUP and short- and long-term outcomes in schizophrenia.

METHODS

Data was collected for subjects with schizophrenia (n=89) in the population-based Northern Finland 1966 Birth Cohort. DUP was obtained from medical records, and its associations with short- (under 2years) and long-term clinical and social outcomes were assessed extending to 20years after the onset of the illness.

RESULTS

Longer DUP predicted longer length of first hospitalisation and increased the risk of rehospitalisation during the first two years. Longer DUP associated with decreased probability of disability pension, smaller amount of time spent in hospital, and higher proportion of time at work during the first 10years of the follow-up.

CONCLUSIONS

Regarding early outcome, long DUP may be a modest marker and proxy measure of a more severe clinical phenotype. The divergent results of earlier studies and the association between long DUP and better long-term outcome in our study, indicate that the length of DUP does not necessarily predict poor outcome in long-term follow-up. This may also be due to methodical difficulties, e.g. insufficient power and residual confounding linked to long follow-up studies.

The duration of untreated psychosis is associated with social support and temperament

The duration of untreated psychosis (DUP) has been suggested to be a modifiable factor influencing psychosis outcome. There are many studies on the factors that predict DUP, although with contradictory findings. Although temperament has been associated with seeking help in other pathologies, studies about how temperament influences DUP are lacking. This study explored the role of temperament (measured by the Eysenck Personality Inventory Questionnaire) on DUP and tested the hypothesis that social support modifies the effects of neuroticism and extraversion on DUP. We evaluated 97 first-episode psychosis patients. The effect of temperament, affective diagnosis and social support (measured by the Social Support Index) on DUP was explored through a multivariate analysis using Cox regression model. Once psychotic symptoms had started, a patient with affective psychosis was 76% more likely to start antipsychotic medications than a patient with non-affective psychosis of comparable time without treatment (adjusted hazard ratio, HR, 1.76; 95% CI, (1.07, 2.9)). There was a significant interaction between diffuse social support and neuroticism (p=0.04). Among patients who had a good diffuse social support, a patient with a high neuroticism score was 45% less likely to start antipsychotic medication than a time-comparable patient with a low neuroticism (HR, 0.55 (0.32, 0.95)). Among patients who had a low neuroticism score, a patient with poor diffuse social support was 56% less likely to start antipsychotic medication than a comparable patient with good support (HR, 0.44 (0.23, 0.86)). In conclusion, patients with affective psychosis had significantly shorter DUPs. In patients with a good diffuse social support, low neuroticism scores were significantly associated with decreased DUP. In patients with low neuroticism scores, a poor diffuse social support was associated with a significant increase in DUP.

Do all schizophrenia patients need antipsychotic treatment continuously throughout their lifetime? A 20-year longitudinal study

BACKGROUND

The prevailing standard of care in the field involves background assumptions about the importance of prolonged use of antipsychotic medications for all schizophrenia (SZ) patients. However, do all SZ patients need antipsychotics indefinitely? Are there factors that help to identify which SZ patients can enter into prolonged periods of recovery without antipsychotics? This 20-year longitudinal research studied these issues.

METHOD

A total of 139 early young psychotic patients from the Chicago Follow-up Study, including 70 patients with SZ syndromes and 69 with mood disorders, were assessed, prospectively, at the acute phase and then followed up six times over the next 20 years. Patients were assessed with standardized instruments for major symptoms, psychosocial functioning, personality, attitudinal variables, neurocognition and treatment.

RESULTS

At each follow-up, 30-40% of SZ patients were no longer on antipsychotics. Starting at the 4.5-year follow-ups and continuing thereafter, SZ patients not on antipsychotics for prolonged periods were significantly less likely to be psychotic and experienced more periods of recovery; they also had more favorable risk and protective factors. SZ patients off antipsychotics for prolonged periods did not relapse more frequently.

CONCLUSIONS

The data indicate that not all SZ patients need treatment with antipsychotics continuously throughout their lives. SZ patients not on antipsychotics for prolonged periods are a self-selected group with better internal resources associated with greater resiliency. They have better prognostic factors, better pre-morbid developmental achievements, less vulnerability to anxiety, better neurocognitive skills, less vulnerability to psychosis and experience more periods of recovery.

Young people with depression and their experience accessing an enhanced primary care service for youth with emerging mental health problems: a qualitative study

BACKGROUND

Despite the emergence of mental health problems during adolescence and early adulthood, many young people encounter difficulties accessing appropriate services. In response to this gap, the Australian Government recently established new enhanced primary care services (headspace) that target young people with emerging mental health problems. In this study, we examine the experience of young people with depression accessing one of these services, with a focus on understanding how they access the service and the difficulties they encounter in the process.

METHOD

Individual, in-depth, audio-recorded interviews were used to collect data. Twenty-six young people with depression were recruited from a headspace site in Melbourne, Australia. Interpretative phenomenological analysis was used to analyse the data.

RESULTS

Four overlapping themes were identified in the data. First, school counsellors as access mediators, highlights the prominent role school counsellors have in facilitating student access to the service. Second, location as an access facilitator and inhibitor. Although the service is accessible by public transport, it is less so to those who do not live near public transport. Third, encountering barriers accessing the service initially. Two main service access barriers were experienced: unfamiliarity with the service, and delays in obtaining initial appointments for ongoing therapy. Finally, the service's funding model acts as an access facilitator and barrier. While the model provides a low or no cost services initially, it limits the number of funded sessions, and this can be problematic.

CONCLUSIONS

Young people have contrasting experiences accessing the service. School counsellors have an influential role in facilitating access, and its close proximity to public transport enhances access. The service needs to become more prominent in young people's consciousness, while the appointment system would benefit from providing more timely appointments with therapists. The service's funding model is important in enabling access initially to young people from low socioeconomic backgrounds, but the government needs to reassess the model for those who require additional support.

Risk factors for relapse following treatment for first episode psychosis: a systematic review and meta-analysis of longitudinal studies

BACKGROUND

Preventing relapse is an essential element of early intervention in psychosis, but relevant risk factors and precise relapse rates remain to be clarified. The aim of this study was to systematically compile and analyse risk factors for and rates of relapse in the early course of psychosis.

METHODS

Systematic review and meta-analysis of English and non-English language, peer-reviewed, longitudinal studies, with a minimum 12-month follow-up and at least 80% of participants diagnosed with a first episode of psychosis (FEP) that reported risk factors for relapse.

RESULTS

Of 153 potentially relevant articles, 29 were included in the study. Pooled prevalence of relapse of positive symptoms was 28% (range=12-47%), 43% (35-54%), 54% (40-63%) at 1, 1.5-2, and 3 years follow-up, in that order. A total of 109 predictors were analysed, with 24 being assessed in at least 3 studies. Of those, 20 predictors could be extracted for meta-analysis. Medication non-adherence, persistent substance use disorder, carers' critical comments (but not overall expressed emotion) and poorer premorbid adjustment, increased the risk for relapse 4-fold, 3-fold, 2.3-fold and 2.2-fold, respectively.

CONCLUSIONS

Clinical variables and general demographic variables have little impact on relapse rates. Conversely, non-adherence with medication, persistent substance use disorder, carers' criticism and poorer premorbid adjustment significantly increase the risk for relapse in FEP. Future studies need to address the methodological limitations of the extant research (e.g. definition of relapse), focus on the identification of protective factors and evaluate theoretically derived models of relapse.

The role of treatment delay in predicting 5-year outcomes in an early intervention program

BACKGROUND

Past research on the relationship between treatment delay and outcomes for first-episode psychosis has primarily focused on the role of duration of untreated psychosis (DUP) in predicting symptomatic outcomes up to 2 years. In the current study we examine the influence of both DUP and duration of untreated illness (DUI) on symptoms and functioning at 5 years follow-up while controlling for other early characteristics.

METHOD

A total of 132 patients with first-episode psychosis and treated in an early intervention program were prospectively followed up for 5 years. Outcomes assessed included positive and negative symptoms, overall functioning, weeks on disability pension and weeks of full-time competitive employment.

RESULTS

While DUP showed a significant correlation with level of positive symptoms at follow-up, this was not independent of pre-morbid social adjustment. DUI emerged as a more robust independent predictor of negative symptoms, social and occupational functioning and use of a disability pension.

CONCLUSIONS

Delay between onset of non-specific symptoms and treatment may be a more important influence on long-term functioning for first-episode patients than DUP. This suggests the possible value of treating such signs and symptoms as early as possible regardless of the effectiveness of such interventions in reducing likelihood or severity of psychotic symptoms.

Duration of untreated illness in schizophrenia is not associated with 5-year brain volume change

OBJECTIVES

Evidence for an association between duration of untreated illness (DUI) with clinical and functional outcome or brain volume (change) in schizophrenia patients is inconclusive. We aimed to investigate the relationship between DUI, outcome and brain volume at illness onset or brain volume change during the first five years of the illness in first-episode patients.

METHODS

Magnetic resonance images were acquired at baseline (T0) and after 5-year (T5) of 57 schizophrenia patients. Correlations were calculated in patients between brain volume (change), DUI and outcome variables.

RESULTS

We found no significant correlation between DUI and brain volume (change) in schizophrenia patients. A longer DUI was significantly correlated with higher PANSS scores at T0 and T5, and with higher scores on the Camberwell Assessment of Need scale at T5. Baseline volume of the cerebrum and lateral ventricles, and cerebellum volume (change) were associated with PANSS scores at T0 and T5.

CONCLUSION

Although clinical outcome is associated with both brain volume (change) and DUI, we found no evidence for a relationship between DUI and brain volume (change). DUI and baseline brain volume or 5-year brain volume (change) seem to explain different parts of the variation in clinical outcome.

Primary caregivers' satisfaction with clinicians' response to them as informal carers of young people with first-episode psychosis: a qualitative study

AIM

To explore first-time primary caregivers' experience of the way mental health nurses and other mental health clinicians respond to them as carers of young people with first-episode psychosis.

BACKGROUND

Caregivers have a key role in supporting family members/relatives with mental illness, but their contribution is undervalued frequently by mental health nurses and other mental health clinicians. Design.  Qualitative interpretative phenomenological analysis.

METHOD

A qualitative interpretative design was undertaken, using semi-structured, audio-recorded interviews. Twenty primary caregivers were recruited through Orygen Youth Health, a first-episode psychosis centre in Melbourne. Interpretative phenomenological analysis was used to identify themes in the data.

RESULTS

Two competing themes were identified in the data, highlighting caregivers' contrasting experience with mental health nurses and other mental health clinicians. First, most clinical staff were approachable and supportive. Second, several carers felt their contribution was undervalued by some clinical staff. This was as a consequence of being excluded from clinical deliberations because of clinical staffs' concerns and young people's requests about maintaining confidentiality regarding treatment, as well as carers feeling their role was not taken seriously by clinical staff.

CONCLUSION

First-time primary carers have positive and negative experiences with first-episode psychosis mental health nurses and other clinicians, and these competing events are interrelated. Experiences are affected directly by the manner they are treated by clinical staff and this may, in turn, affect carers' commitment to caring, the way they engage with clinical staff on subsequent occasions and towards the first-episode psychosis service generally.

RELEVANCE TO CLINICAL PRACTICE

Greater appreciation is needed of the contribution, experience and difficulties caregivers encounter in their role and in engaging with mental health nurses and other clinicians. Additional training is required for clinical staff in family interventions and to familiarise them with legislation and mental health policies relating to carers.

First-time primary caregivers' experience accessing first-episode psychosis services

AIM

Easy access to first-episode psychosis (FEP) services is critical in reducing the duration of untreated illness. However, primary caregivers can encounter difficulties accessing services on behalf of young people with FEP. This qualitative study describes the lived experience of first time primary caregivers of young adults with FEP, with a focus on examining how they access specialist FEP services.

METHODS

A qualitative study was undertaken using semi-structured, in-depth interviews with 20 caregivers in Melbourne.

RESULTS

Most carers were women (85%, n = 17) and parents (85%, n = 17). Nearly all lived in the same households as the young people with FEP (90%, n = 18). The mean duration of their involvement with the FEP service was 14.5 months (standard deviation = 8.9). Three competing themes were identified in the data, reflecting caregivers' polarized experiences accessing FEP services. First, general practitioners were regarded as either a resourceful or an unresourceful means of access to FEP services. Second, caregivers often encountered service-focused and carer-focused barriers when initially accessing services. Third, a combination of acquired knowledge, experience with services and caregiver assertiveness enhanced access on subsequent occasions.

CONCLUSION

This study highlights the important contribution and experience of first-time primary caregivers and the difficulties they face accessing services. The findings suggest access should be influenced more by clinical need and less by caregivers'perseverance. The findings also underline the importance of providing clinical training that acknowledges the needs and contributions of caregivers, as well as interventions that meet the unique challenges faced by first-time caregivers accessing services after the onset of FEP.

Questioning the 'neuroprotective' hypothesis: does drug treatment prevent brain damage in early psychosis or schizophrenia?

The idea that psychotic disorders are characterised by progressive neurodegeneration that can be reversed by drug treatment is used to justify early treatment of increasing numbers of mostly young people. I argue that there is little evidence to support the view that old- or new-generation antipsychotics are 'neuroprotective', and some evidence that the drugs themselves may be responsible for the decline in brain matter observed in some studies.

Prediction of a single psychotic episode: a 7.5-year, prospective study in first-episode psychosis

BACKGROUND

Around 20% of patients who suffer from psychosis will experience a single psychotic episode (SPE), but relatively little is known about the characteristics and predictors for this group of patients. This study sought to: 1) characterise the subgroup of first-episode psychosis (FEP) patients who experienced a SPE over a 7.5-year follow-up; and 2) to identify significant predictors for this subgroup independent of potential confounders.

METHODS

A representative sample of 413 FEP patients treated at a specialist early psychosis service were assessed at baseline and followed-up for 7.5 years. Binary logistic regression models were employed to investigate univariate and adjusted associations between baseline predictors and experiencing a SPE. Results were adjusted for the influence of known prognostic factors for psychosis.

RESULTS

Follow-up data was available for 274 participants. Forty-six (16.5%) achieved clinical remission and experienced no recurrence over the follow-up period. Duration of untreated psychosis (DUP) shorter than 60 days (OR=3.89, p=0.007), more rapid response to antipsychotic treatment (OR=0.33, p=0.019) and no parental loss (OR=5.25, p=0.045) significantly predicted a SPE. The association remained significant after controlling for potential confounders.

CONCLUSIONS

Early treatment (within two months of onset of psychotic symptoms) and social support significantly reduce vulnerability to subsequent psychotic episodes. Future studies need to investigate the interplay between biological factors (i.e. sensitized dopaminergic system), environmental variables (i.e. exposure to trauma, stigma and discrimination), and psychological attributes (i.e. cognitive schemata) in order to elucidate the processes underlying the vulnerability to recurrent psychotic episodes.

First episode psychosis and employment: a review

Despite considerable growth in treatments, interventions, services and research of young people with a first episode of psychosis, little attention has been given to the priorities of these young people, in particular, gaining employment. A literature review was undertaken with the aim of investigating: 1) whether young people with a first episode of psychosis want to work, 2) what challenges they experience regarding work, 3) what is understood about employment outcomes, 4) what the most effective interventions to enable them to gain employment may be, and 5) what the associated costs may be. The review found that these young people appear to want to work yet face a range of psychological and social challenges to achieving this. Typically by the time they first come into contact with mental health services a proportion are already falling out of education and employment, and this decline continues with contact with services. However, there are specific interventions that can support them to gain employment. The Individual Placement and Support approach, adapted to include support to fulfil educational goals, has demonstrated that a mean of 69% of young people with a first episode of psychosis can gain education and employment compared to 35% of controls.