Symptomatic and Functional Outcomes Among Individuals at High Risk for Psychosis Participating in Step-Based Care

Validated, multicomponent treatments designed to address symptoms and functioning of individuals at clinical high risk for psychosis are currently lacking. The authors report findings of a study with such individuals participating in step-based care-a program designed to provide low-intensity, non-psychosis-specific interventions and advancement to higher-intensity, psychosis-specific interventions only if an individual is not meeting criteria for a clinical response. Among individuals with symptomatic or functional concerns at enrollment, 67% met criteria for a symptomatic response (median time to response=11.1 weeks), and 64% met criteria for a functional response (median time to response=8.9 weeks).

Effects of Recreational Cannabis Legalization on Mental Health: Scoping Review

OBJECTIVE

Recreational cannabis legalization (RCL) is expanding rapidly. RCL's effects on mental health issues are of particular concern because cannabis use is more frequent among people receiving psychiatric care and is associated with several psychiatric disorders. The authors conducted a scoping review to examine the evidence and discern gaps in the literature concerning the effects of RCL on mental health and to assess the factors responsible for an observed heterogeneity in research results.

METHODS

This scoping literature review followed PRISMA guidelines. Five databases-MEDLINE, CINAHL, Embase, APA PsycInfo, and Web of Science-were searched for English- or French-language reports published between January 1, 2012, and April 30, 2023.

RESULTS

Twenty-eight studies from the United States and Canada were found. The studies were classified by category of the study's data (patients receiving psychiatric care [k=1], death records [k=4], emergency department or hospital records [k=10], and the general population [k=13]) and by the diagnosis (schizophrenia or psychoses, mood disorders, anxiety disorders and symptoms, suicide or suicidal ideation, or other mental health issues) examined. The review findings revealed a paucity of research and indicated mixed and largely inconclusive results of the studies examined. Research gaps were found in the examination of potential changes in cannabis use patterns among people receiving psychiatric care and in the availability of longitudinal studies.

CONCLUSIONS

Clinicians, researchers, and policy makers need to collaborate to address the research gaps and to develop evidence-based policies that reflect a thorough understanding of the effects associated with RCL.

The Characteristics of People with Serious Mental Illness Who are at High Risk for Hospitalization or Death

Many individuals with serious mental illness are at high risk for hospitalization or death due to inadequate treatment of medical conditions or unhealthy behaviors. The authors describe demographic and clinical characteristics associated with increased risk in this population. Electronic data were obtained for individuals in treatment at a large Veterans' healthcare system who were at high risk according to a validated model. A random sample of these individuals was assessed in person. Multivariable regressions estimated the effect of numerous demographic, health, and clinical characteristics on risk. Emergency visits and hospitalizations were common. Greater risk was associated with being male, not married, and having more diagnoses. While risk varied by race, this effect was no longer significant after controlling for other factors. Health-related quality of life worsened with increasing risk. Routine data identify a large population of high-risk individuals who may benefit from outreach to provide healthcare services.

The Cascade of Care for Early Psychosis Detection in a College Counseling Center

OBJECTIVE

Programs for early detection of psychosis help identify individuals experiencing emerging psychosis and link them with appropriate services, thereby reducing the duration of untreated psychosis (DUP). The authors used the cascade-of-care framework to identify various care stages between screening and enrollment in coordinated specialty care (CSC) and to determine attrition at each stage, with the goal of identifying points in the referral process that may affect DUP.

METHODS

Project partners included a college counseling center and CSC program. All college students seeking mental health services at a counseling center between 2020 and 2022 (N=1,945) completed the Prodromal Questionnaire-Brief (PQ-B) at intake. Students who met the distress cutoff score were referred for a phone screening. Those who met criteria on the basis of this screening were referred for assessment and possible enrollment into CSC.

RESULTS

Six stages in the cascade of care for early detection were identified. Of the students who completed the PQ-B as part of intake (stage 1), 547 (28%) met the PQ-B cutoff score (stage 2). Counselors referred 428 (78%) students who met the PQ-B cutoff score (stage 3), and 212 (50%) of these students completed the phone screening (stage 4). Seventy-two (34%) students completed a CSC eligibility assessment (stage 5), 21 (29%) of whom were enrolled in CSC (stage 6).

CONCLUSIONS

The cascade-of-care framework helped conceptualize the flow within a program for early psychosis detection in order to identify stages that may contribute to lengthier DUP. Future research is warranted to better understand the factors that contribute to DUP at these stages.

Spongiform leukoencephalopathy unveiled in an autopsy of a drug abuser

Toxic leukoencephalopathy (TLE) is a rare neurological debilitating and fatal condition. It has been previously associated with exposure to leukotoxic offenders such as chemotherapy, cranial radiation, certain drugs, and environmental factors. Currently, it is a commoner white matter syndrome resulting from increased substance abuse, classically by inhaled heroin and other opioids. Herein, we report a case of fatal TLE unveiled in an autopsy of a drug abuser. A 24-year-old male was found dead on the roadside. A day before, he was located in a state of delirium. In this case, the autopsy findings and histopathology characteristics of cerebral cortex involvement particularly directed to speculate the heroine as the principal offender.

Inflammation and cognitive performance in first-episode schizophrenia spectrum disorders: The moderating effects of childhood trauma

In this study, we aimed to determine whether childhood trauma moderated the relationship between inflammation and cognitive functioning in persons with first-episode schizophrenia spectrum disorders (SSDs). We included data from 92 individuals who participated in the nationwide Early-Stage Schizophrenia Outcome study. These individuals completed the Childhood Trauma Questionnaire, provided a fasting blood sample for high-sensitivity C-reactive protein analysis, and underwent extensive neuropsychological testing. The intervening effects of age, sex, education, smoking status, and body mass index were controlled. Results indicated that childhood trauma levels significantly moderated the relationship between inflammation and four cognitive domains: speed of processing, working memory, visual memory, and verbal memory. Inflammation also predicted verbal memory scores irrespective of childhood trauma levels or the covariates. Upon further exploration, the significant moderation effects appeared to be primarily driven by males. In conclusion, a history of childhood trauma may be an important determinant in evaluating how inflammation relates to the cognitive performance of people with first-episode SSDs, particularly in speed of processing, working memory, visual memory, and verbal memory. We recommend that future researchers examining the effect of inflammation on cognitive functioning in SSDs include trauma as a moderating variable in their models and further examine additional moderating effects of sex.

Neurodegenerative pathologies associated with behavioral and psychological symptoms of dementia in a community-based autopsy cohort

In addition to the memory disorders and global cognitive impairment that accompany neurodegenerative diseases, behavioral and psychological symptoms of dementia (BPSD) commonly impair quality of life and complicate clinical management. To investigate clinical-pathological correlations of BPSD, we analyzed data from autopsied participants from the community-based University of Kentucky Alzheimer's Disease Research Center longitudinal cohort (n = 368 research volunteers met inclusion criteria, average age at death 85.4 years). Data assessing BPSD were obtained approximately annually, including parameters for agitation, anxiety, apathy, appetite problems, delusions, depression, disinhibition, hallucinations, motor disturbance, and irritability. Each BPSD was scored on a severity scale (0-3) via the Neuropsychiatric Inventory Questionnaire (NPI-Q). Further, Clinical Dementia Rating (CDR)-Global and -Language evaluations (also scored on 0-3 scales) were used to indicate the degree of global cognitive and language impairment. The NPI-Q and CDR ratings were correlated with neuropathology findings at autopsy: Alzheimer's disease neuropathological changes (ADNC), neocortical and amygdala-only Lewy bodies (LBs), limbic predominant age-related TDP-43 encephalopathy neuropathologic changes (LATE-NC), primary age-related tauopathy (PART), hippocampal sclerosis, and cerebrovascular pathologies. Combinations of pathologies included the quadruple misfolding proteinopathy (QMP) phenotype with co-occurring ADNC, neocortical LBs, and LATE-NC. Statistical models were used to estimate the associations between BPSD subtypes and pathologic patterns. Individuals with severe ADNC (particularly those with Braak NFT stage VI) had more BPSD, and the QMP phenotype was associated with the highest mean number of BPSD symptoms: > 8 different BPSD subtypes per individual. Disinhibition and language problems were common in persons with severe ADNC but were not specific to any pathology. "Pure" LATE-NC was associated with global cognitive impairment, apathy, and motor disturbance, but again, these were not specific associations. In summary, Braak NFT stage VI ADNC was strongly associated with BPSD, but no tested BPSD subtype was a robust indicator of any particular "pure" or mixed pathological combination.

Psychosis Outside the Box: A User-Led Project to Amplify the Diversity and Richness of Experiences Described as Psychosis

Despite some progress toward greater inclusion, individuals with personal experience of psychosis are rarely integrated into the training of clinicians or knowledge generation. Their exclusion increases the risk that dominant ways of conceptualizing psychosis primarily reflect second- and third-person observations rather than first-person experiences. Observed only from the outside, the richness, complexity, and depth of experiences falling under the psychosis umbrella are easily lost. The authors describe a project-Psychosis Outside the Box-to solicit, compile, and amplify direct accounts of experiences that have been neglected in mainstream research and pedagogy, including the subjective experiences of visuals, felt presences, alterations of time and space, and "negative symptoms."

Young Adults' Perspectives on Factors Related to Relapse After First-Episode Psychosis: Qualitative Focus Group Study

Relapse after first-episode psychosis (FEP) is a major clinical challenge for specialized early intervention services. Understanding patient perspectives on factors contributing to relapse can inform the development of risk assessments and preventive interventions. The objective of this study was to identify factors that may contribute to and prevent relapse from the perspectives of patients receiving services for FEP. Data from 25 participants across four focus groups in Canada were analyzed with a descriptive content analysis approach. Twelve factors were identified, of which four (social environment, technology use, medication, and lifestyle behaviors) had both contributory and preventive roles. In descending order of frequency, risk factors for relapse included substance use; unsupportive social environment; technology use; taking and not taking medication; lack of sleep; work, career, or school stress; significant life events; symptoms of depression or mania; generalized worry; and financial stress. Preventive factors consisted of having a supportive social environment, using technology, taking medication, using coping strategies, and engaging in healthy lifestyle behaviors and meaningful activities. These findings extend the literature on relapse vulnerability and protective factors. Importantly, the factors identified in this study are modifiable, and thereby provide insights for the development and optimization of relapse risk assessments and preventive interventions.

Client Racial Composition in First-Episode Psychosis Programs Compared With Compositions in Program Service Areas

OBJECTIVE

The authors examined the extent to which clients served by first-episode psychosis programs reflected the racial composition of the surrounding service area and, to the extent that they did not, explored possible explanatory factors.

METHODS

As part of a national study of coordinated specialty care (CSC) sites in the United States, 35 programs documented race for 772 clients. Programs identified a geographic service area for their clients. Using Census data, the authors identified the proportion of clients in this service area who were Black and then examined the extent of disproportionality, calculated as a risk ratio and as a relative difference in racial composition between CSC programs and their service areas.

RESULTS

Overall, 71% of CSC programs had a disproportionately greater proportion of Black clients than Black residents within the service area. This disproportionality was still evident after conducting sensitivity analyses that included adjusting for sampling error in the service area population estimates; however, smaller study sites displayed greater fluctuations in disproportionality in the sensitivity analyses.

CONCLUSIONS

Using data from diverse CSC programs, the authors illustrate that the odds of Blacks receiving services through a CSC program are much higher than would be expected on the basis of the population living in the area being served by the program. Multiple reasons may explain this finding, but in the absence of clear explanatory factors, this result may be ripe for discussion and further investigation.

A Recovery-Oriented Intervention for People With Psychosis: A Pilot Randomized Controlled Trial

OBJECTIVE

This pilot randomized controlled trial evaluated the effectiveness of critical time intervention-task shifting (CTI-TS) for people with psychosis in Santiago, Chile, and Rio de Janeiro. CTI-TS is a 9-month intervention involving peer support workers and is designed to maintain treatment effects up to 18 months.

METHODS

A total of 110 people with psychosis were recruited when they enrolled in community mental health clinics (Santiago, N=60; Rio de Janeiro, N=50). Participants within each city were randomly assigned to either CTI-TS or usual care for 9 months. Primary outcomes were quality of life, measured with the World Health Organization Quality of Life Assessment-Brief Version (WHOQOL-BREF), and unmet needs, measured with the Camberwell Assessment of Need (CAN), at 18-month follow-up. Results were analyzed according to intention-to-treat guidelines. Generalized estimating equations, with observations clustered within cities, and multiple imputation for missing data were used.

RESULTS

At 18 months, both groups showed improved primary outcomes. In both unadjusted and fully adjusted analyses, no significant differences between CTI-TS and usual care (WHOQOL-BREF question on quality of life and CAN mean number of unmet needs) were found.

CONCLUSIONS

Three factors might explain the lack of difference between CTI-TS and usual care: first-contact enrollment precluded rapport prior to randomization, a minority of patients were uncomfortable with peers being on the treatment team, and primary outcome measures may not have been sensitive enough to capture the effects of a recovery-oriented intervention. The results have implications for the design of transitional services for people with psychosis, especially in Latin America.

The Natural History of Initial Antipsychotic Treatment Among Men Admitted to a State Prison

OBJECTIVE

This study examined the natural history of antipsychotic medication treatment for men with a psychotic disorder who entered the North Carolina prison system in 2016-2017.

METHODS

The authors used prison records to identify individuals with a psychotic illness who were prescribed an index antipsychotic medication on prison entry (N=245). Data were analyzed to determine persistence of antipsychotic therapy and potential associations with treatment discontinuation.

RESULTS

About 28% of the patients had stopped their antipsychotic medication by day 50; the median time until stopping was 248 days (95% confidence interval=147-355). Younger patients and those not continuing a preincarceration medication regimen discontinued treatment sooner than their respective counterparts.

CONCLUSIONS

The early weeks of incarceration are a period of increased risk for antipsychotic discontinuation, particularly among younger individuals and those prescribed a new medication. These findings may help guide prison systems in implementing interventions that reduce antipsychotic treatment interruptions.

Character Strength-Focused Positive Psychotherapy on Acute Psychiatric Wards: A Feasibility and Acceptability Study

OBJECTIVE

A manualized single-session positive psychotherapy intervention was developed and tested on acute psychiatric wards.

METHODS

Participants were invited in 2018-2019 to identify positive experiences, link them to a personal character strength, and plan a strengths-based activity. The intervention's feasibility was evaluated through fidelity to session components, character strengths identification, and activity completion. Acceptability was evaluated with self-reported pre- and postsession mood ratings, a postsession helpfulness rating, and narrative feedback.

RESULTS

Participants (N=70) had complex and severe mental health conditions. In 18 group sessions, 89% of components were delivered with fidelity; 80% of the participants identified a character strength, of whom 71% identified a strengths-based activity, and 58% completed the activity. The mean±SD helpfulness rating (N=23) was 8.5±1.5 (on a 10-point Likert scale), and positive mood significantly increased postsession (5.9 presession vs. 7.2 postsession).

CONCLUSIONS

Positive psychotherapy is feasible in challenging inpatient settings, and service users with severe and complex mental health conditions find it helpful.

Cost-Effectiveness of Early Intervention in Psychosis: A Modeling Study

OBJECTIVE

Programs for early intervention in psychosis have shown clinical efficacy. The authors aimed to evaluate the cost-effectiveness of early intervention programs compared with standard care for the treatment of first-episode psychosis in the United States.

METHODS

A decision-analytic model integrating published data on clinical efficacy, costs, and health utilities was developed to evaluate early intervention versus standard care over the lifetime of patients after their first psychotic episode. Model input data were derived from meta-analyses, clinical trials, and U.S. national data. The main outcomes included hospitalizations, employment rate, quality-adjusted life years (QALYs), lifetime health care costs, and incremental cost-effectiveness ratios (ICERs).

RESULTS

Compared with patients receiving standard care, patients in the early intervention strategy had 3.2 fewer hospitalizations and 2.7 more years of employment over the course of their remaining life expectancy. From a health care perspective, early intervention had an ICER of approximately $51,600 per QALY. From a societal perspective, early intervention saved costs (i.e., yielded greater health benefits and had lower costs compared with standard care). Results were sensitive to the effect of early intervention on suicide, cost of standard care, cost of early intervention, and the effect (relative risk) of early intervention on employment. A scenario analysis that excluded the effect (i.e., hazard ratio) of early intervention on suicide yielded an ICER of approximately $197,000 per QALY.

CONCLUSIONS

These results suggest that it is economically beneficial to fund early intervention in psychosis programs in the United States. The findings indicate that early intervention in psychosis saves costs (from the societal perspective) and is cost-effective (health care sector perspective).

Online Psychosis Screening: Characterizing an Underexamined Population to Improve Access and Equity

OBJECTIVE

Online resources represent an important avenue to identify and support individuals who may be experiencing symptoms of psychosis but have yet to engage in care. Understanding the experiences and needs of this group is critical to inform outreach for early psychosis and improve outcomes by addressing barriers to early treatment.

METHODS

The authors conducted a retrospective, explorative, cross-sectional analysis by using data collected by Mental Health America as part of their online psychosis screening and support program. Data included scores from the Prodromal Questionnaire-Brief, basic demographic information, and respondents' plans for next steps.

RESULTS

Of 120,937 respondents, most (82.1%) reported distressing psychosis-like experiences at levels sufficient to merit a referral to specialty care for additional evaluation. However, only 17.1% planned to seek treatment as a next step, with most (53.6%) wanting instead more information. Higher distress was only weakly associated with the plan to seek treatment. In the multivariable analysis, respondents who were younger; lesbian, gay, bisexual, transgender, or queer; or Native American or who had lower income reported the greatest symptom-related distress. Younger and higher-income respondents were less likely to plan to seek treatment next. Across race-ethnicity, African Americans were most likely to plan to seek treatment.

CONCLUSIONS

Most respondents reported that psychosis-like experiences caused significant distress, but they did not plan to seek treatment next. Addressing this treatment gap requires careful consideration regarding what services individuals want, how services should be presented, and what barriers may limit help seeking. These steps are critical to improve access to early intervention for individuals with psychosis spectrum disorders.

Impact of childhood trauma on antipsychotic effectiveness in schizophrenia spectrum disorders: A prospective, pragmatic, semi-randomized trial

Antipsychotic medications are generally effective in ameliorating psychotic symptoms in schizophrenia spectrum disorders (SSDs). Identifying predictors associated with poor treatment response is important for a personalized treatment approach. Childhood trauma (CT) may have a general and differential effect on the effectiveness of different types of antipsychotics in SSDs. The Bergen-Stavanger-Trondheim-Innsbruck (BeSt InTro) study is a pragmatic, researcher-initiated, semi-randomized trial. The present study aimed to investigate symptom change (the Positive and Negative Syndrome Scale) from baseline to 1, 3, 6, 12, 26, 39 and 52 weeks of antipsychotic treatment (amisulpride, aripiprazole and olanzapine) by group (CT/no CT). Participants (n = 98) with diagnoses within the schizophrenia spectrum (F20-29 in the International Classification of Diseases - 10th Revision) were randomized to receive amisulpride, aripiprazole or olanzapine, and for this study categorized into groups of none and low CT, and moderate to severe CT according to thresholds defined by the Childhood Trauma Questionnaire Short-Form manual. CT in SSDs predicted an overall slower treatment response and less antipsychotic effectiveness after 26 weeks of treatment, which was statistically nonsignificant at 52 weeks. Secondary analyses showed a differential effect of CT related to type of antipsychotic medication: patients with SSDs and CT who received olanzapine showed less antipsychotic effectiveness throughout 52 weeks of treatment. The intention-to-treat and per-protocol analyses were convergent. Our findings indicate that in patients with SSD and CT, delayed response to antipsychotics could be expected, and a longer evaluation period before considering change of medication may be recommended.

Health Care Costs of Individuals With Chronic Psychotic Disorders Who Experience Incarceration in Ontario

OBJECTIVE

Little is known about the health care costs of individuals with chronic psychotic disorders who experience incarceration. This study sought to address this knowledge gap.

METHODS

The authors analyzed linked 2007-2010 correctional and administrative health care data on sex- and age-matched individuals with chronic psychotic disorders with and without known incarceration in prison for up to 2 years in the Ontario correctional system. Mean 1-year health care costs (overall and by sex) in the year before incarceration (when release occurred in 2010) were estimated from third-party payer data and compared between the two groups. Costs were calculated in 2018 Canadian dollars.

RESULTS

Individuals who experienced incarceration (N=3,197) had mean 1-year costs of $15,728 in the year before incarceration, whereas those who did not (N=6,393) had 1-year costs of $11,588. This difference was mostly due to costs arising from psychiatric hospitalizations, emergency department visits, and physician services. The main factors associated with the difference were incarceration in the following year (increase of $4,827, p<0.001), being age 18-29 years compared with ages 30-39 or 40-49 (increase of $4,448 and $4,218, respectively, p<0.001), and chronic psychotic disorder duration of 1-2 years compared with ≤1 year duration (increase of $6,812, p=0.004). Women who experienced incarceration had higher costs than incarcerated men ($20,648 vs. $14,763).

CONCLUSIONS

Individuals with chronic psychotic disorders who experienced incarceration had higher health care costs than comparable individuals who did not. These higher health care costs may signal the need for interventions and policies that help individuals with psychotic disorders avoid criminal justice system involvement.

Providing Home Treatment for Acute Mental Illness During the COVID-19 Pandemic

The Intensive Home Treatment Team in Edinburgh provides care at home for those with acute and severe mental health problems. During the first COVID-19 lockdown, the team conducted and evaluated video and telephone calls but also continued seeing most patients face to face to ensure adequate care. The in-person care was achieved safely, without an increase in staff sickness events. During the lockdown, the team observed more cases of psychosis, particularly acute and transient psychosis and first-episode psychosis, particularly among women.

Rapprochement and Reform: Overcoming Factionalism in Policy Making for Serious Mental Illness

This article traces the history of factionalism in policy making and advocacy for persons with serious mental illness from deinstitutionalization to the present. The authors draw on deliberative democratic theory to illustrate how factionalist advocacy causes advocates and policy makers to fail in their duties to represent and develop policy in support of people with serious mental illness. The authors discuss how this factionalism has bred distrust and undermined efforts to address the needs of people with serious mental illness. They propose the formation of a Public Mental Health Policy Commission, guided by principles of deliberative democracy, to overcome factionalism and to improve policy making to meet the needs of people with serious mental illness. The commission must include a diverse array of stakeholders, especially individuals with lived experience of serious mental illness.

Developing an International Standard Set of Patient-Reported Outcome Measures for Psychotic Disorders

OBJECTIVE

The objective of this project was to develop a set of patient-reported outcome measures for adolescents and adults who meet criteria for a psychotic disorder.

METHODS

A research team and an international consensus working group, including service users, clinicians, and researchers, worked together in an iterative process by using a modified Delphi consensus technique that included videoconferencing calls, online surveys, and focus groups. The research team conducted systematic literature searches to identify outcomes, outcome measures, and risk adjustment factors. After identifying outcomes important to service users, the consensus working group selected outcome measures, risk adjustment factors, and the final set of outcome measures. International stakeholder groups consisting of >100 professionals and service users reviewed and commented on the final set.

RESULTS

The consensus working group identified four outcome domains: symptoms, recovery, functioning, and treatment. The domains encompassed 14 outcomes of importance to service users. The research team identified 131 measures from the literature. The consensus working group selected nine measures in an outcome set that takes approximately 35 minutes to complete.

CONCLUSIONS

A set of patient-reported outcome measures for use in routine clinical practice was identified. The set is free to service users, is available in at least two languages, and reflects outcomes important to users. Clinicians can use the set to improve clinical decision making, and administrators and researchers can use it to learn from comparing program outcomes.

Impact of the COVID-19 Pandemic on the Employment and Educational Outcomes of Individuals in a First-Episode Psychosis Clinic

OBJECTIVE

A central objective of early psychosis therapy is to restore social functioning (e.g., through employment and education). Employment and educational outcomes during the COVID-19 pandemic were examined in a well-defined cohort of patients receiving care in an early psychosis clinic.

METHODS

Data were extracted from the electronic health records of 128 patients receiving care at McLean Hospital's first-episode psychosis (FEP) clinic between January 1 and September 21 in 2019 and 2020. Using a generalized linear model with a Gaussian distribution and robust standard errors, the authors compared the average changes in the weekly employment and education proportions before and after COVID-19 lockdowns with the same changes in 2019.

RESULTS

Employment losses among patients with FEP were greater than among the general population and persisted through the end of follow-up. In 2020, average employment after a stay-at-home order was instituted was 33% lower than before the order compared with the change in employment during the same period in 2019. The effect was stronger among men and those who identified as non-White, were age <21 years, or did not have a college education. Although educational engagement recovered in the fall of 2020, it still remained below the 2019 levels.

CONCLUSIONS

Employment disruptions were major and persistent among the FEP population, which might affect short- and long-term outcomes. Innovative approaches are needed to help patients transition to remote employment, file unemployment claims, and use online hiring platforms to ameliorate the indirect effects of the COVID-19 pandemic.

Clinical characterization of brief psychotic disorders triggered by the COVID-19 pandemic: a multicenter observational study

This study aimed to characterize the clinical profile of patients with brief psychotic disorders (BPD) triggered by the psychosocial distress derived from the COVID-19 crisis. A multicenter study was conducted from March 14 to May 14, 2020 (the peak weeks of the pandemic in Europe). All consecutive patients presenting non-affective psychotic episodes with a duration of untreated psychosis of less than 1 month and whose onset was related to the COVID-19 crisis were recruited, but only those patients meeting Diagnostic Statistical Manual 5th edition (DSM-5) criteria for "BPD with marked stressors" (DSM-5 code: 298.8) during follow-up were finally included. Patients' sociodemographic and clinical characteristics were collected at baseline and summarized with descriptive statistics. During the study period, 57 individuals with short-lived psychotic episodes related to the emotional stress of the COVID-19 pandemic were identified, of whom 33 met DSM-5 criteria for "BPD with marked stressors". The mean age was 42.33 ± 14.04 years, the gender distribution was almost the same, and the majority were rated as having good premorbid adjustment. About a quarter of the patients exhibited suicidal symptoms and almost half presented first-rank schizophrenia symptoms. None of them were COVID-19 positive, but in more than half of the cases, the topic of their psychotic features was COVID-19-related. The coronavirus pandemic is triggering a significant number of BPD cases. Their risk of suicidal behavior, their high relapse rate, and their low temporal stability make it necessary to closely monitor these patients over time.

Central Assessment of Psychosis Service: A Tele-evaluation Service to Support Early Identification of Psychosis

Duration of untreated psychosis (DUP) is a reliable predictor of longitudinal psychosis trajectory. The limited availability of specialized assessment needed for early identification contributes to a lengthy average DUP in the United States. This column outlines the development of the Central Assessment of Psychosis Service (CAPS), a novel tele-evaluation service that extends specialized expertise in screening and assessment of psychosis and psychosis risk to publicly funded early psychosis clinics. Preliminary implementation outcomes among the first five CAPS sites suggest that CAPS is acceptable, appropriate, and feasible to implement. Programmatic data collection is underway and will be reported at a future date.

Ethnoracial Differences in Coercive Referral and Intervention Among Patients With First-Episode Psychosis

OBJECTIVE

Using a retrospective sample, the authors sought to determine whether Black patients with first-episode psychosis (FEP) in Canada were at a higher risk for coercive referral and coercive intervention than non-Black patients with FEP.

METHODS

Retrospective data from patients referred to an FEP program in 2008-2018 were collected via chart review (N=208). The authors used chi-square and logistic regression analyses to explore the relationships among race-ethnicity, diagnosis of psychosis, and coercive referral and intervention.

RESULTS

Results showed that Black persons of Caribbean or African descent with FEP were significantly more likely to be coercively referred (χ²=9.24, df=2, p=0.010) and coercively treated (χ²=9.21, df=2, p=0.010) than were non-Black individuals with FEP. Age and violent or threatening behavior were predictors of coercive referral. Ethnoracial status, age, and violent or threatening behavior were predictors of coercive intervention.

CONCLUSIONS

This study contributes to the dearth of research on Black Canadians and offers insight into factors that may place patients with FEP at risk for coercive treatment. More research is needed to explore the role that ethnoracial status may play in hospital admissions and to uncover the role of racial prejudices in the assessment of danger.

Characteristics of Hispanics Referred to Coordinated Specialty Care for First-Episode Psychosis and Factors Associated With Enrollment

OBJECTIVE

The primary objectives of this study were to examine referral sources and demographic, clinical, and socioenvironmental characteristics of Hispanics referred to and enrolled in a program of coordinated specialty care (Early CSC program) for first-episode psychosis, to compare them with characteristics of other referred and enrolled racial-ethnic groups, and to identify factors associated with enrollment in the program.

METHODS

A retrospective review was conducted for all individuals referred to and enrolled in the Early CSC program over a 2-year period. Extracted data included referral sources and demographic and clinical characteristics. Zip code-level data from publicly available sources were cross-referenced with individual records. Nonparametric tests and appropriate secondary analysis were used to determine significant differences across racial-ethnic groups referred to (N=180) or enrolled in (N=75) the Early CSC program. A random forest model was used to determine which factors or interacting factors were associated with enrollment among the eligible referrals (N=114).

RESULTS

Hispanic individuals were more likely to be referred from inpatient or outpatient mental health providers and not from other community sources. Among eligible Hispanic referrals, those who lived in areas with a lower percentage of Spanish speaking in the home were more likely to enroll in services, compared with those who lived in areas with a higher percentage of Spanish speaking.

CONCLUSIONS

Continued exploration of factors associated with referral and enrollment in CSC programs for the growing Hispanic ethnic group in the United States can help determine best steps for developing these programs.

Psychosis REACH: Effects of a Brief CBT-Informed Training for Family and Caregivers of Individuals With Psychosis

OBJECTIVE

Psychosis Recovery by Enabling Adult Carers at Home (Psychosis REACH) is a training for families of individuals with psychosis that consists of recovery-oriented psychosis psychoeducation, caregiver self-care, and skills training informed by cognitive-behavioral therapy for psychosis (CBTp). The authors assessed the effects of a 1-day and a 4-day training on the natural supports (i.e., family and other caregivers) of individuals with psychotic disorders.

METHODS

Attendees of a 1-day (N=168) and a 4-day (N=29) Psychosis REACH training were surveyed at three timepoints: pretraining, posttraining, and 4-month follow-up. Longitudinal changes across the full sample were evaluated by paired-sample t tests or a one-way repeated-measures analysis of variance (ANOVA). Two-way mixed ANOVAs were conducted with training condition, time, and the training condition × time interactions entered into the model.

RESULTS

Reductions were noted in self-perceived depression, anxiety, negative aspects of the caregiving experience, and expressed emotion. Trainees also showed more prosocial attitudes toward psychosis immediately and at 4 months after the training.

CONCLUSIONS

This evaluation of the launch of Psychosis REACH in the United States suggests that the training can improve the mental health, attitudinal, and relational outcomes of family and caregivers of individuals with psychosis. Given the dearth of CBTp and family interventions for psychosis in mental health services in the United States, short-term, intensive training that supplements clinical services has intuitive appeal as a means of surmounting the barriers that have plagued family interventions.

Implementing Evidence-Based Interventions to Improve Vocational Recovery in Early Psychosis: A Quality-Improvement Report

OBJECTIVE

After young adults experience a first episode of psychosis, many express a need for help with education and employment. A quality improvement collaborative (QIC) launched in the Netherlands aimed to reinforce vocational recovery by improving participation in education and employment and by enhancing cognitive skills and self-management. This study examined methods used to implement interventions, barriers and facilitators, and implementation outcomes (fidelity, uptake, and availability).

METHODS

The Breakthrough Series was the model for change. Three evidence-based interventions were implemented to achieve targeted goals: individual placement and support (IPS), cognitive remediation, and shared decision making. Fidelity scores were obtained with fidelity scales.

RESULTS

Eighty-five professionals and 332 patients representing 14 teams treating patients with early psychosis were included in the 24-month QIC. Of this group, 252 patients participated in IPS, 52 in cognitive remediation, and 39 in shared decision making. By month 22, teams attained moderate-to-high mean fidelity scores, with an average of 3.2 on a 4-point scale for cognitive remediation, 3.7 on a 5-point scale for IPS, and 4.9 on a 6-point scale for shared decision making.

CONCLUSIONS

Over 24 months, use of a Breakthrough QIC to implement three interventions aimed at improving vocational recovery in teams delivering services for early psychosis yielded mixed results in terms of uptake and availability and moderate-to-high results in terms of fidelity. When implementing these types of interventions in this population, a multifaceted implementation model and a focused testing phase for computerized interventions appear needed, preferably with a maximum of two interventions implemented simultaneously.

Insurance Status and Continuity for Young Adults With First-Episode Psychosis

OBJECTIVE

Insurance status and continuity may affect access to and quality of care. The authors characterized patterns of and changes in insurance status over 1 year among people with first-episode psychosis (FEP), comparing insurance patterns with adults of similar age in the general population.

METHODS

Longitudinal data on insurance status and predictors of insurance status among adults with FEP were obtained from RAISE-ETP (Recovery After an Initial Schizophrenia Episode-Early Treatment Program) study participants with complete 1-year data (N=288). The frequencies of insurance status and transitions are presented. Bivariate comparisons were used to assess the impact of the comprehensive coordinated care intervention in RAISE-ETP on insurance changes. These data were compared with contemporaneous longitudinal data in the 2011 Medical Expenditures Panel Study.

RESULTS

The RAISE-ETP experimental intervention did not significantly change insurance status. At baseline, levels of uninsurance (47%) and public insurance (31%) were higher among RAISE-ETP participants than among a similar age group in the general public (29% and 13%, respectively). Insurance transitions were common among people with FEP, although 79% of those with public insurance at baseline also had public insurance at 1 year. Of studied RAISE-ETP participants, 60% had a period of uninsurance during the year studied.

CONCLUSIONS

Compared with a national sample, people with FEP were more likely to use public insurance but still had high persistence of 12-month uninsurance. That over half of the RAISE-ETP participants had a period of uninsurance suggests that more research is needed on whether these periods affect treatment continuity and medication adherence.

Mobile Health for Caregivers of Young Adults With Early Psychosis: A Survey Study Examining User Preferences

OBJECTIVE

Caregivers play a key role in supporting the recovery of young adults with early psychosis. This role often involves considerable responsibilities and burden. Despite the considerable needs of caregivers, troubling service gaps addressing these needs remain. Digital technologies may increase caregivers' access to supportive resources; however, technologies developed specifically for caregivers lag far behind those developed for their relatives affected by early psychosis. In particular, little is known about the mobile health (mHealth) features that may be most acceptable to caregivers.

METHODS

The authors surveyed a sample of 43 caregivers on their interests regarding various features of a proposed mHealth intervention.

RESULTS

Caregivers of young adults with early psychosis were highly interested in a caregiver-facing mHealth intervention, specifically one providing information about psychosis, treatments, and communication with their affected family member.

CONCLUSIONS

Future caregiver-focused mHealth intervention interventions may be highly acceptable to this population and may address pressing service gaps.

Associations Between Childhood and Adolescence Adversity and Risk for Arrest Among Patients With First-Episode Psychosis

OBJECTIVE

The authors assessed associations between childhood and adolescent adversity and arrest among individuals with first-episode psychosis (FEP). The authors also sought to determine which domains of adversity had the greatest impact and whether associations varied by gender.

METHODS

Data were analyzed from 247 patients with FEP admitted to inpatient psychiatric units between August 2008 and June 2013. Analyses focused on self-reported history of arrest and seven scales of past adversity, with 14 subscales reduced to three factors. Binary logistic regression and negative binomial regression determined associations between the three childhood adversity factors and having ever been arrested and number of arrests, respectively.

RESULTS

Past experience of violence and environmental adversity was significantly (p<0.001) associated with both history of arrest (odds ratio=2.29) and number of arrests (β=0.60), and this association was stronger for female patients than for male patients.

CONCLUSIONS

Findings suggest a need to address both past adversity and criminal justice system involvement in the context of early psychosis specialty care.

The use of first-generation long-acting injectable antipsychotics in children and adolescents-A retrospective audit from India

OBJECTIVES

There is a dearth of knowledge regarding the usage of first-generation long-acting injectable (LAI) antipsychotics in children and adolescents, despite their off-label use, in low and middle-income countries (LAMIC).

METHODS

Case records of subjects less than 18 years of age who received any first-generation LAI antipsychotics in the last 10 years(between 2010-19) were reviewed. Details documented for the study from the records included ICD-10 diagnoses, clinical profile, indication for use, medication details, severity of illness, improvement, and global functioning.

RESULTS

Forty-five subjects (55.3 % male) received first-generation LAI antipsychotics during the study period. All subjects were diagnosed to have serious mental illnesses, with Schizophrenia (52.6 %) and Bipolar Affective Disorder (31.6 %) being the most common diagnoses. At baseline, according to Clinical Global Impressions-Severity (CGI-S) scale, a majority (94.7 %) were severely or markedly ill. Fluphenazine decanoate (60.5 %), flupenthixol decanoate (34.2 %), and zuclopenthixol decanoate (18.4 %) were the first- generation LAI antipsychotics used. Nearly half the subjects (47.4 %) experienced at least one acute adverse event. The most common acute adverse events noted included tremors, rigidity, sialorrhea, and bradykinesia. 31/34 subjects showed improvement at follow-up.

CONCLUSIONS

The profile of patients for whom first-generation LAI antipsychotics were used included children and adolescents who had severe mental illnesses and were considerably ill. Acute adverse events were common. Short and- long-term follow-up studies are needed to evaluate the efficacy and safety of first-generation LAI antipsychotics in children and adolescents, especially in low and middle-income countries, given that they are reasonably priced and efficacious for severe mental illnesses.

Psychoeducation for Inpatients With First-Episode Psychosis: Results From a Survey of Psychiatry Trainees in New York City

OBJECTIVE

In this study, the authors aimed to characterize psychoeducation provided to inpatients with first-episode psychosis (FEP) and their families.

METHODS

Psychiatrists were surveyed about how they provide psychoeducation to this population.

RESULTS

In total, 60 psychiatry trainees at nine New York City hospitals responded to the survey invitation. Almost all reported that they provide psychoeducation. Most (81% for patients, 84% for families) reported that psychoeducation content and delivery method were not uniform. The most frequently used delivery method was unstructured conversation (98%), followed by handouts (25% for patients, 26% for families). Responses from a national sample (N=167) revealed similar trends.

CONCLUSIONS

Most respondents provided some form of psychoeducation to hospitalized patients with FEP and their families. Few utilized a standardized method, and less than one-third incorporated supplemental materials. Inpatient psychoeducation for this population was largely informal, and patients and their families were not receiving consistent content and quality of information.

The Effect of Intensive Implementation Support on Fidelity for Four Evidence-Based Psychosis Treatments: A Cluster Randomized Trial

PURPOSE

Service providers need effective strategies to implement evidence-based practices (EBPs) with high fidelity. This study aimed to evaluate an intensive implementation support strategy to increase fidelity to EBP standards in treatment of patients with psychosis.

METHODS

The study used a cluster randomized design with pairwise assignment of practices within each of 39 Norwegian mental health clinics. Each site chose two of four practices for implementation: physical health care, antipsychotic medication management, family psychoeducation, illness management and recovery. One practice was assigned to the experimental condition (toolkits, clinical training, implementation facilitation, data-based feedback) and the other to the control condition (manual only). The outcome measure was fidelity to the EBP, measured at baseline and after 6, 12, and 18 months, analyzed using linear mixed models and effect sizes.

RESULTS

The increase in fidelity scores (within a range 1-5) from baseline to 18 months was significantly greater for experimental sites than for control sites for the combined four practices, with mean difference in change of 0.86 with 95% CI (0.21; 1.50), p = 0.009). Effect sizes for increase in group difference of mean fidelity scores were 2.24 for illness management and recovery, 0.68 for physical health care, 0.71 for antipsychotic medication management, and 0.27 for family psychoeducation. Most improvements occurred during the first 12 months.

CONCLUSIONS

Intensive implementation strategies (toolkits, clinical training, implementation facilitation, data-based feedback) over 12 months can facilitate the implementation of EBPs for psychosis treatment. The approach may be more effective for some practices than for others.

Maternal infection exposure and the risk of psychosis in the offspring: A systematic review and meta-analysis

The relationship between maternal infection exposure and the risk of psychosis in the offspring is inconsistent. We systematically assessed this relationship. Unrestricted searches of the PubMed and Embase databases were conducted, with an end date of February 1, 2020, to identify relevant studies that met predetermined inclusion criteria. Random-effects models were adopted to estimate the overall relative risk. Twenty-three observational studies were included in the analysis. The results showed that mothers who had a history of infection during pregnancy experienced a significantly increased risk of developing psychosis in offspring (OR = 1.25, 95% confidence interval (CI): 1.1-1.41; P = 0.001). Sensitivity and subgroup analyses yielded consistent results. For specific pathogens, the risk of developing psychosis in offspring was increased among mothers with herpes simplex virus 2 (HSV-2) exposure (OR, 1.32; 95% CI, 1.09-1.6; P = 0.004). However, other maternal-specific pathogen exposures were not significantly associated with the risk of psychosis in offspring. No evidence of publication bias was observed. Although evidence of heterogeneity should be carefully evaluated, our findings suggest that maternal infection exposure may be associated with a greater risk of psychosis in the offspring.

The search for an autoimmune origin of psychotic disorders: Prevalence of autoantibodies against hippocampus antigens, glutamic acid decarboxylase and nuclear antigens

The etiology of psychotic disorders is still unknown, but in a subgroup of patients symptoms might be caused by an autoimmune reaction. In this study, we tested patterns of autoimmune reactivity against potentially novel hippocampal antigens. Serum of a cohort of 621 individuals with psychotic disorders and 257 controls were first tested for reactivity on neuropil of rat brain sections. Brain reactive sera (67 diseased, 27 healthy) were further tested for antibody binding to glutamic acid decarboxylase (GAD) isotype 65 and 67 by cell-based assay (CBA). A sub-cohort of 199 individuals with psychotic disorders and 152 controls was tested for the prevalence of anti-nuclear antibodies (ANA) on HEp2-substrate as well as for reactivity to double-stranded DNA, ribosomal P (RPP), and cardiolipin (CL). Incubation of rat brain with serum resulted in unidentified hippocampal binding patterns in both diseased and control groups. Upon screening with GAD CBA, one of these patterns was identified as GAD65 in one individual with schizophrenia and also in one healthy individual. Two diseased and two healthy individuals had low antibody levels targeting GAD67 by CBA. Antibody reactivity on HEp-2-substrate was increased in patients with schizoaffective disorder, but only in 3 patients did antibody testing hint at a possible diagnosis of systemic lupus erythematosus. Although reactivity of serum to intracellular antigens might be increased in patients with psychotic disorder, no specific targets could be identified. GAD antibodies are very rare and do not seem increased in serum of patients with psychotic disorders.

Association of Pharmaceutical Industry Payments to Physicians With Prescription and Medicare Expenditures for Pimavanserin

OBJECTIVE

This study aimed to quantify the association between pharmaceutical industry payments to physicians for pimavanserin and both pimavanserin prescription volume and Medicare expenditures.

METHODS

This retrospective cross-sectional study used 2016 and 2017 data from Open Payments and the Medicare Part D Prescriber Public Use Files. The authors used Poisson regression models to quantify the association between physician payments for pimavanserin and pimavanserin prescription volume and linear regression models to quantify the association with Medicare expenditures for pimavanserin.

RESULTS

Of 1,609 physicians who prescribed pimavanserin, 45% received payments, which totaled to $6,369,922. Each $10,000 in physician payments was associated with a 14% increase in pimavanserin prescription volume (incident rate ratio=1.14, 95% confidence interval [CI]=1.13-1.14). Every $100 in physician payments was associated with a $175.84 increase in Medicare pimavanserin expenditures (95% CI=$161.55-$190.13).

CONCLUSIONS

Extensive physician payments have been associated with increased pimavanserin prescription volume and Medicare expenditures.

Disengagement From Early Intervention Services for Psychosis: A Systematic Review

OBJECTIVE

Therapeutic benefits associated with early services for psychosis are influenced by the degree to which participants engage in treatment. The main objective of this review was to analyze rates of disengagement in early psychosis services and identify predictors of disengagement in these settings.

METHODS

A systematic search for studies published in the 1966-2019 period was conducted in PubMed, Google Scholar, EBSCO, Ovid, and Embase. The Observational Cohort and Cross-Sectional Studies scale was used to assess the methodological quality of reports identified in this search. A revised version of the behavioral model of health service use was employed to evaluate and understand predictors of disengagement (categorized as predisposing, enabling, and need factors) identified in the studies with the highest quality.

RESULTS

Twenty studies met the inclusion criteria. Disengagement rates (12% to 53%) and definitions of disengagement varied widely across these studies. Most did not find a compelling association between predisposing factors (e.g., age) and disengagement. Enabling factors, such as lack of family support and living alone, were consistently found to be related to increased disengagement across studies. Finally, need factors, such as lower medication adherence and higher drug misuse, were associated with higher risk for disengagement.

CONCLUSIONS

Enabling and need factors seemed to be the most predictive of disengagement from early psychosis services. Substantial between-study variation in identified predictors of disengagement may be addressed by developing and applying a consensus definition of disengagement in future research.

Predictors of Early Discharge From Early Intervention Services for Psychosis in New York State

OBJECTIVE

Although specialized early intervention services (EISs) for psychosis promote engagement in care, a substantial number of individuals who receive these services are discharged from care earlier than expected. The main goal of this study was to examine predictors of early discharge in a large sample of individuals enrolled in an EIS program in the United States.

METHODS

This cohort study (N=1,349) used programmatic data from OnTrackNY, an EIS program that delivers evidence-based interventions to youths across New York State experiencing a first episode of nonaffective psychosis. The main outcome was "early discharge," which was operationalized as discharge prior to completing 12 months of treatment. Cox proportional hazard regression models were used to assess the association between sociodemographic, clinical, and support system predictors and early discharge.

RESULTS

The estimated probability of discharge before 1 year was 32%. Participants who at baseline had poor medication adherence, had no health insurance, were living alone or with nonparental family, or were using cannabis were at higher risk of leaving services within the first 12 months after enrollment. Individuals with higher social functioning were at lower risk of being discharged early from OnTrackNY, but those with higher occupational functioning were at a higher risk.

CONCLUSIONS

Predictors of early discharge from EISs largely overlapped with previously identified predictors of poor prognosis in early psychosis. However, the association between early discharge and high occupational functioning indicates that trajectories leading up to discharge are heterogeneous.

The Physical Health Care Fidelity Scale: Psychometric Properties

Mental health programs need an instrument to monitor adherence to evidence-based physical health care for people with serious mental illness. The paper describes the Physical Health Care Fidelity Scale and study interrater reliability, frequency distribution, sensitivity to change and feasibility. Four fidelity assessments were conducted over 18 months at 13 sites randomized to implementation support for evidence-based physical health care. We found good to excellent interrater reliability, adequate sensitivity for change, good feasibility and wide variability in fidelity across sites after 18 months of implementation. Programs were more successful in establishing Policies stating physical health care standards than in implementing these Policies. The Physical Health Care Fidelity Scale measures and guides implementation of evidence-based physical health care reliably.Trial registration: ClinicalTrials.gov Identifier: NCT03271242.

Using the CHIME Personal Recovery Framework to Evaluate the Validity of the MHRM-10 in Individuals with Psychosis

The recovery movement has revealed that outcomes which focuses on just symptoms and functioning may not be holistic and that consumer-rated outcomes may contribute to a more holistic and person-centric care model. However, a brief and effective measure is required in clinical settings; hence, the aim of the current study is to evaluate the psychometric properties of the briefest personal recovery measure- Mental Health Recovery Measure-10 items, using the CHIME (Connectedness, Hope and optimism about the future, Identity, Meaning in life, Empowerment) personal recovery framework. 64 outpatients with schizophrenia or schizoaffective disorder were assessed at two time points, 2 weeks apart. Data collected included sociodemographic information, MHRM-10, Psychological factors related to the CHIME framework, in respective order: RYFF subscale positive relations with others; Herth Hope Index (HHI); Internalized Stigma of Mental Illness (ISMI) and RYFF subscale self-acceptance; World Health Organization Quality of Life- BRIEF (WHOQOL-BREF); Empowerment, and Clinical factors- symptoms as measured by Positive and Negative Syndrome Scale, functioning (PSP) and depressive symptoms (CDSS). MHRM-10 demonstrated convergent validity with CHIME personal recovery psychological factors (all ρ > 0.5). MHRM-10 had excellent internal consistency (Cronbach's alpha = 0.904) and adequate test-retest reliability (ρ = 0.742, p < 0.001). Initial factor structure analysis revealed a one factor structure. The MHRM-10 is a valid instrument for use and can serve as a tool to facilitate a more collaborative and person-centric model of care for individuals with psychosis.

From Knowledge Transfer to Action: An Example of a Community of Practice for First-Episode Psychosis in Lyon, France

Despite the proven effectiveness of early intervention services for first-episode psychosis (FEP), these services are poorly implemented in France. This column describes the establishment in 2018 of a community of practice dedicated to the implementation of early intervention services for FEP at the Vinatier Hospital in Lyon, France, in 2019. To evaluate the implementation process, the authors analyzed materials produced during the process of conceiving and developing the community of practice, reviewed participant observation notes, and examined responses to a satisfaction survey completed by community of practice members. Creation of the community of practice network has led to substantial changes in care pathways for FEP patients in Greater Lyon.

Effect of the C-reactive protein gene on risk and clinical characteristics of schizophrenia in winter-born individuals

C-reactive protein (CRP) levels are elevated in a subset of schizophrenia patients and correlated with more severe symptoms, which makes CRP a potential theranostic biomarker for the disease. However, genotypes associated with higher CRP concentrations have the protective effect against schizophrenia. To resolve this discrepancy, more research on the role of CRP in schizophrenia is needed. The present study aimed to investigate the effects on schizophrenia of the CRP gene in combination with season of birth (SOB), the known risk factor for the disease. We first examined the impact of seasonality on schizophrenia risk in the Russian population, using samples of 2452 patients and 1203 controls, and then assessed the CRP rs2794521 polymorphism × SOB interaction effect on the disease risk, age-of-onset and symptoms severity in 826 patients and 476 controls. An excess of winter births in patients was not significant. At the same time, we found that winter-born patients carrying the CRP GG genotype, which is associated with low transcriptional activity, had an earlier age at onset than the other patients. The findings are in line with the protective role of high active CRP genetic variants in the development of schizophrenia and provide support for the hypothesis that this effect of CRP takes place early in life.

Benefits and Harms of Prescription Drugs and Supplements for Treatment of Clinical Alzheimer-Type Dementia

BACKGROUND

Effects of drug treatment of clinical Alzheimer-type dementia (CATD) are uncertain.

PURPOSE

To summarize evidence on the effects of prescription drugs and supplements for CATD treatment.

DATA SOURCES

Electronic bibliographic databases (inception to November 2019), ClinicalTrials.gov (to November 2019), and systematic review bibliographies.

STUDY SELECTION

English-language trials of prescription drug and supplement treatment in older adults with CATD that report cognition, function, global measures, behavioral and psychological symptoms of dementia (BPSD), or harms. Minimum treatment was 24 weeks (≥2 weeks for selected BPSD).

DATA EXTRACTION

Studies with low or medium risk of bias (ROB) were analyzed. Two reviewers rated ROB. One reviewer extracted data; another verified extraction accuracy.

DATA SYNTHESIS

Fifty-five studies reporting non-BPSD outcomes (most ≤26 weeks) and 12 reporting BPSD (most ≤12 weeks) were analyzed. Across CATD severity, mostly low-strength evidence suggested that, compared with placebo, cholinesterase inhibitors produced small average improvements in cognition (median standardized mean difference [SMD], 0.30 [range, 0.24 to 0.52]), no difference to small improvement in function (median SMD, 0.19 [range, -0.10 to 0.22]), no difference in the likelihood of at least moderate improvement in global clinical impression (median absolute risk difference, 4% [range, 2% to 4%]), and increased withdrawals due to adverse events. In adults with moderate to severe CATD receiving cholinesterase inhibitors, low- to insufficient-strength evidence suggested that, compared with placebo, add-on memantine inconsistently improved cognition and improved global clinical impression but not function. Evidence was mostly insufficient about prescription drugs for BPSD and about supplements for all outcomes.

LIMITATION

Most drugs had few trials without high ROB, especially for supplements, active drug comparisons, BPSD, and longer trials.

CONCLUSION

Cholinesterase inhibitors and memantine slightly reduced short-term cognitive decline, and cholinesterase inhibitors slightly reduced reported functional decline, but differences versus placebo were of uncertain clinical importance. Evidence was mostly insufficient on drug treatment of BPSD and on supplements for all outcomes.

PRIMARY FUNDING SOURCE

Agency for Healthcare Research and Quality. (PROSPERO: CRD42018117897).

Coordinated Specialty Care Discharge, Transition, and Step-Down Policies, Practices, and Concerns: Staff and Client Perspectives

OBJECTIVE

In recent years, optimizing the process of transition and discharge from coordinated specialty care (CSC), a program that provides early intervention in psychosis, has emerged as an important focus area for program administrators, clinicians, and policy makers. To explore existing CSC policies and practices and to understand frontline provider and client views on discharge, the authors conducted a comprehensive analysis of staff and client interview data from the Mental Health Block Grant 10% Set-Aside Study.

METHODS

Data from 66 interviews with groups of CSC providers and administrators representing 36 sites and 22 states were analyzed, as well as data from interviews with 82 CSC clients at 34 sites. Transcripts were coded by using systematic content analyses.

RESULTS

Analyses of data from providers and administrators showed the heterogeneity of CSC program practices and strategies regarding discharge and highlighted a range of concerns related to postdischarge service accessibility and quality. Analysis of data from client interviews reflected the heterogeneity of transition challenges that clients confront. A significant number of participants reported concerns about their readiness for discharge.

CONCLUSIONS

CSC discharge policies and practices vary across CSC programs and states. Frequent clinician and client concerns about optimal program length, transition, and postdischarge services highlight the importance of sustained policy and research efforts to develop evidence-informed practice guidelines and possible modifications to the time-limited CSC model that currently dominates the field.

Racial-Ethnic Differences in Service Use Patterns Among Young, Commercially Insured Individuals With Recent-Onset Psychosis

OBJECTIVE

The aim of this study was to investigate racial-ethnic differences in use of mental health services and antipsychotic medication in the year following the recent onset of a psychotic disorder and to examine the role of household income as a proxy for socioeconomic status.

METHODS

Deidentified administrative claims data from the OptumLabs Data Warehouse were used to identify 8,021 commercially insured individuals ages 14 through 30 with a recent-onset psychotic disorder (January 1, 2011, through December 31, 2015). The authors compared mental health service use among African-American (11.5%), Hispanic (11.0%), and non-Hispanic white (77.4%) individuals during the year following an index diagnosis and adjusted these analyses for household income.

RESULTS

The probability of any use of outpatient mental health services was lower among African-American (67.4%±1.4%) and Hispanic individuals (66.5%±1.5%) compared with non-Hispanic white patients (72.3%±0.6%; p<0.05 for each comparison). Among those who used services, African-American and Hispanic individuals had fewer mean outpatient mental health visits per year compared with non-Hispanic whites (9.7±0.7 and 10.2±0.7 versus 14.3±0.5, respectively, p<0.001 for each comparison). These racial-ethnic differences in service use remained after adjustment for household income.

CONCLUSIONS

Among young, commercially insured individuals using outpatient services following an index diagnosis of psychotic disorder, African Americans and Hispanics received less intensive outpatient mental health care than their non-Hispanic white counterparts. Amid the upsurge of early intervention programs, special attention should be paid to increasing access to mental health services for racial-ethnic minority groups.

Depressive symptoms during first episode psychosis and functional outcome: A systematic review and meta-analysis

OBJECTIVES

First episode psychosis (FEP) is associated with functional decline. Existing evidence was synthesised to explore the influence of depressive symptoms during FEP on future social, occupational and global functioning.

METHODS

Medline, Embase, PsychINFO, Cochrane Library, Open Grey, NICE Evidence and Web of Science were searched from inception to May 2018. Longitudinal studies of FEP patients were included. Study quality was assessed using the Downs and Black instrument. Two meta-analyses were performed using random effect models. The first meta-analysis correlates depressive symptoms during FEP with follow-up Global Assessment of Functioning (GAF) scores. The second meta-analysis shows the odds of long-term functional remission if depressive symptoms are present during FEP.

RESULTS

4751 unique abstracts were found. 36 articles were included. The first meta-analysis included 7 studies (932 participants) and showed depressive symptoms during FEP were negatively correlated with follow-up GAF scores (r = -0.16, 95% CI: -0.24 to -0.09, p < 0.001). The second meta-analysis of 9 studies (2265 participants) showed weak evidence of an association between the presence of depressive symptoms in FEP and reduction in functional remission (OR = 0.87, 95% CI: 0.68 to 1.13, p = 0.294).

CONCLUSION

Depressive symptoms during FEP are associated with poorer long-term global functioning and may be associated with a reduced chance of achieving functional remission. Clinical trials are needed to identify efficacious management of depressive symptoms in early psychosis.

Substance use disorders before, at and after first episode psychosis hospitalizations in a young national Swedish cohort

BACKGROUND

Comorbidity between Substance use disorders (SUD) and psychotic disorders is common but the temporal relation of the first episodes of SUD and psychosis and how it affects the disorders has not been extensively investigated.

METHODS

A nation-wide cohort (n = 2494) with a first hospitalization for psychosis at ages between 16 and 25 was identified. Psychiatric hospitalizations were followed from birth until up to 5 years after the first psychosis hospitalization. Risk factors for new SUD or psychosis hospitalization after the index hospitalization were analyzed by Cox regression.

RESULTS

30 % of the cases had SUD hospitalizations in the 5 years before or as a comorbid diagnosis at the first psychosis hospitalization. An additional 9% had a first SUD hospitalization in the five years after. The incidence of SUD hospitalizations increased year by year before and decrease year by year after the index hospitalization. The hazard ratio for a new SUD hospitalizations after the index hospitalization was significantly higher (hazard ratio 6.7, p-value<0.001) in cases with SUD before or at the index hospitalization compared to in cases without previous SUD. In cases with previous SUD, there was a strong association (p < 0.001) between a new psychosis hospitalization and a new SUD hospitalization the year after the index hospitalization, indicating that SUD may continue to aggravate the psychotic disorder in this group.

CONCLUSIONS

SUD is very common before a first hospital treated psychosis. The SUD likely aggravates early psychotic disorders in many cases.

Employment Status and Personal Income Before and After Onset of a Severe Mental Disorder: A Case-Control Study

OBJECTIVE

Individuals with severe mental disorders have an impaired ability to work and are likely to receive income transfer payments as their main source of income. However, the magnitude of this phenomenon remains unclear. Using longitudinal population cohort register data, the authors conducted a case-control study to examine the levels of employment and personal income before and after a first hospitalization for a serious mental disorder.

METHODS

All individuals (N=50,551) who had been hospitalized for schizophrenia, other nonaffective psychosis, or bipolar disorder in Finland between 1988 and 2015 were identified and matched with five randomly selected participants who were the same sex and who had the same birth year and month. Employment status and earnings, income transfer payments, and total income in euros were measured annually from 1988 to 2015.

RESULTS

Individuals with serious mental disorders had notably low levels of employment before, and especially after, the diagnosis of a severe mental disorder. Their total income was mostly constituted of transfer payments, and this was especially true for those diagnosed as having schizophrenia. More than half of all individuals with a serious mental disorder did not have any employment earnings after they received the diagnosis.

CONCLUSIONS

The current study shows how most individuals in Finland depend solely on income transfer payments after an onset of a severe mental disorder.

An ecological momentary intervention incorporating personalised feedback to improve symptoms and social functioning in schizophrenia spectrum disorders

This study examined the feasibility and effectiveness of an interactive smartphone application that aimed to improve daily-life social functioning and symptoms in schizophrenia spectrum disorders (SZ) with Experience Sampling Method (ESM) derived personalised feedback.Two groups of outpatients with a diagnosis of SZ were included (one receiving ESM-derived personalised feedback (n = 27) and one without feedback (n = 23)) and used the interactive smartphone application for three weeks. Main outcomes were momentary symptoms and social functioning, as assessed by ESM questionnaires. Additionally, feasibility and user-friendliness of the application were assessed. The response rate was 64% for the ESM questionnaires. In the feedback group, participants indicated that on 49% of the ESM days they acted on at least one personalised feedback prompt per day. Momentary psychotic symptoms significantly decreased over time only in the feedback group. Momentary loneliness and questionnaire-assessed psychotic symptoms decreased over time, irrespective of feedback. Participants evaluated the app as user-friendly and understandable. Momentary personalised feedback may impact momentary psychosis in daily life. Feelings of loneliness and questionnaire-based measured psychotic symptoms may be more responsive to non-specific effects of daily-life self-monitoring, not requiring specific feedback. Ecological momentary interventions offer opportunities for accessible and effective interventions in SZ.