Implementation of early intervention clinical services within the National Health System in Italy: Third wave survey with focus on structures, resources, and fidelity to the evidence-based model

BACKGROUND

Early intervention in psychosis (EIP) is a well-established approach aimed at detecting and treating early signs and symptoms of psychosis to prevent its long-term consequences. The present study aimed at detailing the current status of EIP services in Italy, covering all the Departments of Mental Health (DMHs) operating in 2018.

METHODS

All directors of public DMHs operating in Italy in 2018 (n = 127) were invited to fill in a Census form about EIP structure and activities. The first episode psychosis services fidelity scale (FEPS-FS) was used to investigate fidelity to the EIP model of the centre.

RESULTS

An active EIP service was reported by 41 DMHs (32% of the total DMHs; 56% of those who took part in the survey). Most EIP services had an autonomous team. The large majority of the Italian EIP centres provided psychosocial interventions to their patients, principally psychotherapy, family support, and psychoeducation. Among those with an active EIP, 29 DMHs filled in the FEPS-FS. Internal consistency was good when based on the replies of the respondents, but reliability was weak when measured on the basis of an independent evaluation (Cohen's kappa = 0.571). The fidelity to the guidelines for early intervention was uneven, with some criteria met by most centres, especially those peculiar to the Italian community psychiatry.

CONCLUSION

A further spreading of the early intervention model across the Italian DMHs was found. A lack of resources might limit the use of specific psychosocial treatments, such as cognitive-behavioural therapy or manualized family support.

Time-course of clinical symptoms in young people at ultra-high risk for transition to psychosis

BACKGROUND

Ultra-high risk (UHR) people are a heterogeneous group with variable outcomes. This study aimed at (a) estimating trajectories of response to treatment to identify homogeneous subgroups; (b) establishing the impact on these trajectories of known predictors of outcome in UHR subjects.

METHODS

Mixed models of growth curves and latent class growth analysis (LCGA) were applied to the 24-item brief psychiatric rating scale (BPRS) to measure the response to treatment over 2 years in 125 UHR participants. Group differences were tested on sociodemographic variables and clinical indicators that are known to affect the outcome in UHR people.

RESULTS

BPRS scores decreased across all tested models, with a greater decrease for affective and positive symptoms than for all other dimensions of BPRS. Past admissions to the hospital for psychiatric reasons other than psychosis and the presence of a decline in premorbid functioning before the episode were associated with a slower decrease of BPRS score. LCGA identified three classes, one (82% of participants) with a progressive decrease in the BPRS scores, a second class with a moderate improvement (10%), and a third with no improvement (8%). Those in the 'no improvement' class had a higher chance of receiving a diagnosis of psychosis within the spectrum of schizophrenia.

CONCLUSION

Most UHR individuals that are treated within a specialized service undergo substantial improvement in their psychopathology, but some seem resistant to the protocol of treatment and need close reevaluation within the first 12 months of treatment.

Antipsychotics are related to psychometric conversion to psychosis in ultra-high-risk youth

BACKGROUND

The prescription of antipsychotics outside overt psychotic conditions remains controversial, especially in youth where it is relatively widespread. Furthermore, some studies seem to indicate that antipsychotic exposure in individuals at ultra-high-risk (UHR) for psychosis is associated with higher conversion rates. This study was set up to test whether the inter-current prescription of antipsychotics in UHR patients was related to the psychometric threshold for a diagnosis of psychosis.

METHODS

The 24-item Brief Psychiatric Rating Scale (BPRS) was used to quantify treatment response up to 2 years in 125 UHR participants. Standard psychometric criteria were used to quantify conversion to psychosis. Kaplan-Mayer and Cox proportional hazard survival analysis were applied to determine the impact of having or not received the prescription of an antipsychotic drug.

RESULTS

Over the study period 30 (24%) subjects received the prescription of an antipsychotic. In the sample, there were 31 participants (25%) who had reached the psychometric threshold for conversion to psychosis after 2 years of treatment. UHR people who received a prescription of antipsychotics during the first 2 years of treatment were statistically more likely to reach the psychometric threshold for conversion to psychosis on the BPRS: Hazard ratio = 3.03 (95%CI: 1.49-6.16); p = .003.

CONCLUSION

This finding supports the hypothesis that the prescription of antipsychotics within UHR cohorts is to be considered a red flag for higher incipient risk of conversion to psychosis.

Through the prism of comorbidity: A strategic rethinking of early intervention in obsessive-compulsive disorder

The diagnostic criteria for obsessive-compulsive disorder (OCD) have undergone minor changes in DSM-5 yet a major turnaround intervened in the overarching categorical allocation. OCD indeed has been separated from the anxiety disorders and included in an autonomous class of OCD-related disorders. Converging factors, i.e., the specificity of the clinical phenotype, the robust evidence for familial aggregation, the availability of effective treatments, and the increasing awareness of the role of environmental factors in its onset and course make OCD a suited target for tailored early intervention programs. However, studies on the topic are still scarce and OCD remains marginally conceptualized within an overdue early detection/intervention framework. Starting from the consolidated clinical evidence of OCD extensive comorbidity with schizophrenia-spectrum and bipolar disorders, we articulate a strategic proposal for a more integral incorporation of OCD within early detection and intervention paradigm.

International application of standards for health care quality, access and evaluation of services for early intervention in psychotic disorders

AIM

Standards for health care quality, access and evaluation of early intervention in psychosis services are required to assess implementation, provide accountability to service users and funders and support quality assurance. The aim of this article is to review the application of standards in Europe and North America.

METHODS

Descriptive methods will be used to illustrate the organizational context in which standards are being applied and used, specific measures being applied and results so far.

RESULTS

Both fidelity scales and quality indicators of health care are being used. Fidelity scales are being applied in Australia, Canada, Denmark, Italy and United States. In England, quality indicators derived from the National Institute for Health and Care Excellence guidance are being used.

CONCLUSION

In the last 4 years, significant progress has been made in the development and application of measures that assess quality and access to evidence-based practices for early intervention in psychosis services. This represents an important step towards providing accountability, improving outcomes and service user experience. The methods used allow for comparison between the services that are assessed with the same methods, but there is a need to compare the different methods. Further research is also required to explore links between quality of care and outcomes for community mental health services that deliver early intervention in psychotic disorders.

Outcome at 2-year of treatment in first-episode psychosis patients who were enrolled in a specialized early intervention program

Treatment in early intervention services (EIS) seems superior to treatment as usual on several outcomes, but the extent of heterogeneity in response is unclear. In this study, treatment response trajectories up to 2 years in first-episode psychosis (FEP) patients enrolled in an Italian early intervention service (EIS) have been quantified. The 24-item Brief Psychiatric Rating Scale (BPRS) was used to quantify treatment response up to 2 years in 129 participants. Conditional growth modeling and latent class growth analysis were used to test changes over time in the BPRS and separation into independent classes over time. Group differences were tested on socio-demographic and clinical variables known to be related to outcome in psychosis. Scores on the BPRS showed a statistically significant decrease in overall scores across all tested models. Four trajectories were identified across 2 years. Most patients showed a progressive decrease in the BPRS scores; a scant fraction showed a more stepped decrease from very high levels of psychopathology. No potential predictor was statistically related to the time course of BPRS scores. Most patients that undergo treatment within an EIS are characterized by amelioration, but patients that have higher baseline scores of psychopathology require more intensive treatment.

Anxiety sensitivity dimensions in young individuals with at-risk-mental states

Anxiety Sensitivity (AS) is a transdiagnostic risk factor involved in the development and maintenance of different psychopathological conditions including anxiety disorders and psychosis. It consists of Physical Concerns (e.g., the belief that palpitations lead to a cardiac arrest), Social Concerns (the belief that observable anxiety reactions will elicit social rejection), and Cognitive Concerns (the belief that cognitive difficulties lead to mental incapacitation). No study investigated whether specific AS dimensions are related to At-Risk Mental States (ARMS). This study compared AS dimensions between young individuals with ARMS, patients after a recently occurred First-Episode Psychosis (FEP) and matched community controls. Based on models of ARMS and previous evidence, it was hypothesized that ARMS individuals have higher physical, social and cognitive concerns than FEP patients and controls. Thirty individuals with ARMS and 30 with FEP and 30 controls recruited from the general population completed the Anxiety Sensitivity Index-3 (ASI-3) and Penn State Worry Questionnaire. ARMS and FEP individuals had higher scores than controls on ASI-3 Cognitive Concerns [F_{( 2,87)}= 11.48, p<.001]. Individuals with ARMS had higher ASI-3 Physical Concerns scores than FEP patients [F_{( 2,87)}= 5.10, p<.01] and at a marginal significance level than controls. No between-group difference was found on Social Concerns. Higher ASI-3 Physical Concerns scores [B = -.324, Wald's χ² ₍₁₎ = 8.29, p < .01] and psychiatric comorbidities [B = -2.726, Wald's χ² ₍₁₎ = 9.33, p < .01] were significantly related to ARMS than FEP. Higher ASI-3 Social Concerns scores were related to FEP, despite at a marginal significance level [B =.213, Wald's χ² ₍₁₎ = 3.79, p = .052]. Interventions for AS Cognitive/Physical Concerns could be incorporated in the treatment of ARMS. A replication of the findings is required. Future longitudinal studies should examine whether Cognitive Concerns predict development of FEP in ARMS to improve early detection and prevention strategies.

EPA guidance on the early intervention in clinical high risk states of psychoses

This guidance paper from the European Psychiatric Association (EPA) aims to provide evidence-based recommendations on early intervention in clinical high risk (CHR) states of psychosis, assessed according to the EPA guidance on early detection. The recommendations were derived from a meta-analysis of current empirical evidence on the efficacy of psychological and pharmacological interventions in CHR samples. Eligible studies had to investigate conversion rate and/or functioning as a treatment outcome in CHR patients defined by the ultra-high risk and/or basic symptom criteria. Besides analyses on treatment effects on conversion rate and functional outcome, age and type of intervention were examined as potential moderators. Based on data from 15 studies (n = 1394), early intervention generally produced significantly reduced conversion rates at 6- to 48-month follow-up compared to control conditions. However, early intervention failed to achieve significantly greater functional improvements because both early intervention and control conditions produced similar positive effects. With regard to the type of intervention, both psychological and pharmacological interventions produced significant effects on conversion rates, but not on functional outcome relative to the control conditions. Early intervention in youth samples was generally less effective than in predominantly adult samples. Seven evidence-based recommendations for early intervention in CHR samples could have been formulated, although more studies are needed to investigate the specificity of treatment effects and potential age effects in order to tailor interventions to the individual treatment needs and risk status.

Assessing physical activity in people with mental illness: 23-country reliability and validity of the simple physical activity questionnaire (SIMPAQ)

BACKGROUND

Physical inactivity is a key contributor to the global burden of disease and disproportionately impacts the wellbeing of people experiencing mental illness. Increases in physical activity are associated with improvements in symptoms of mental illness and reduction in cardiometabolic risk. Reliable and valid clinical tools that assess physical activity would improve evaluation of intervention studies that aim to increase physical activity and reduce sedentary behaviour in people living with mental illness.

METHODS

The five-item Simple Physical Activity Questionnaire (SIMPAQ) was developed by a multidisciplinary, international working group as a clinical tool to assess physical activity and sedentary behaviour in people living with mental illness. Patients with a DSM or ICD mental illness diagnoses were recruited and completed the SIMPAQ on two occasions, one week apart. Participants wore an Actigraph accelerometer and completed brief cognitive and clinical assessments.

RESULTS

Evidence of SIMPAQ validity was assessed against accelerometer-derived measures of physical activity. Data were obtained from 1010 participants. The SIMPAQ had good test-retest reliability. Correlations for moderate-vigorous physical activity was comparable to studies conducted in general population samples. Evidence of validity for the sedentary behaviour item was poor. An alternative method to calculate sedentary behaviour had stronger evidence of validity. This alternative method is recommended for use in future studies employing the SIMPAQ.

CONCLUSIONS

The SIMPAQ is a brief measure of physical activity and sedentary behaviour that can be reliably and validly administered by health professionals.

Dimensional structure of first episode psychosis

AIM

Current diagnostic systems, DSM-5 and ICD-10, still adopt a categorical approach to classify psychotic disorders. The present study was aimed at investigating the structure of psychotic symptomatology in both affective and non-affective psychosis from a dimensional approach.

METHODS

Participants with a first episode psychosis (FEP) were recruited from a cluster-randomized controlled trial (GET-UP PIANO TRIAL), offered to all Community Mental Health Centres (CMHCs) located across two northern Italian regions. After clinical stabilization, patients were assessed with a comprehensive set of psychopathological measures including the Positive and Negative Syndrome Scale, the Hamilton Depression Rating Scale and the Bech-Rafaelsen Mania Rating Scale. A two-step cluster analysis was performed.

RESULTS

Overall, 257 FEP patients (male, n = 171, 66.5%; mean age = 24.96 ± 4.56) were included in the study. The cluster analysis revealed a robust four-cluster solution: delusional-persecutory (n = 82; 31.9%), depressed (n = 95; 37%), excited (n = 26; 10.1%) and negative-disorganized (n = 54; 21%), thus suggesting a quadripartite structure with both affective and non-affective dimensions. Among non-affective dimensions, negative and disorganization symptoms constituted a unique construct apart from positive symptoms.

CONCLUSIONS

Symptom dimensions may represent a useful tool for dissecting the indistinct and non-specific psychopathology of FEP in order to better target specific interventions.

Secondary school teachers and mental health competence: Italy-United Kingdom comparison

AIM

The aim of this study was to evaluate the differences between teachers' knowledge about early psychosis among three different Italian cities and a UK sample.

METHODS

The sample consisted of 556 secondary school teachers from three different cities in Italy (Milan, Rome and Lamezia Terme) and London (UK). The research was based on the Knowledge and Experience of Social Emotional Difficulties Among Young People Questionnaire. The Italian version of the questionnaire was used in Italy.

RESULTS

Overall, 67.6% of English teachers, 58.5% of Milan's teachers, 41.8% of Rome's teachers and 33.3% of Lamezia Terme's teachers were able to recognize psychotic symptoms from a case vignette. Logistic regression analysis showed that 'city' was the only independent variable significantly related to the correct/wrong answer about diagnosis.

CONCLUSIONS

We found statistically significant differences between the three Italian samples and the UK sample regarding teachers' knowledge about first signs of psychosis. English teachers showed a better knowledge than Italian teachers in general. Teachers from Milan, where a specific early detection program was established in 2000, seemed to be more familiar with early signs of psychosis than teachers in the other two Italian towns.

Implementation and development of early intervention in psychosis services in Italy: a national survey promoted by the Associazione Italiana Interventi Precoci nelle Psicosi

AIM

This is the first comprehensive, nationwide survey aimed at collecting evidence about the process of implementation and development of early intervention in psychosis (EIP) services (EIPs) in Italy, following the establishment of the pilot program 'Programma 2000' in 1999 and the publishing of the Italian National Guidelines in 2007. This survey covers all the Departments of Mental Health (DMHs) operating in Italy in 2013.

METHODS

Using a purpose-designed form to assess EIP implementation, all directors of public mental health services for adults throughout Italy (n = 216) were asked to provide information about the activities of EIP-relevant local services. The initial delivery was followed by a request for a prompt response.

RESULTS

Out of 216 enquired DMHs, 103 provided computable answers to the survey (response rate = 48%). Among responders, 45 (44%) reported the implementation of EIP (one out of five DMHs operating in Italy). About a half of the active EIPs also targeted patients at ultra-high risk of psychosis (n = 27). Strict application of guidelines related to drug prescription was reported in 35% of EIPs. Conversely, 90% provided some kind of structured psychotherapy and psychoeducation. Among EIPs, a minority reported willingness to provide initial assessment/contact at the patient's home.

CONCLUSION

Albeit slowly, the implementation of EIP is spreading throughout the Italian public network of mental health. There is still a wide variability in the distribution of EIP services across the Italian territory. Further efforts are necessary to stimulate policy endorsement and resource allocation, as well as to support the poorest zones.

Influence of childhood trauma on diagnosis and substance use in first-episode psychosis

BackgroundChildhood trauma has been significantly associated with first-episode psychosis, affective dysfunction and substance use.AimsTo test whether people with first-episode psychosis who had experienced childhood trauma, when compared with those who had not, showed a higher rate of affective psychosis and an increased lifetime rate of substance use.MethodThe sample comprised 345 participants with first-episode psychosis (58% male, mean age 29.8 years, s.d. = 9.7).ResultsSevere sexual abuse was significantly associated with a diagnosis of affective psychosis (χ² = 4.9, P = 0.04) and with higher rates of lifetime use of cannabis (68% v 41%; P = 0.02) and heroin (20% v 5%; P = 0.02). Severe physical abuse was associated with increased lifetime use of heroin (15% v 5%; P = 0.03) and cocaine (32% v 17%; P = 0.05).ConclusionsPatients with first-episode psychosis exposed to childhood trauma appear to constitute a distinctive subgroup in terms of diagnosis and lifetime substance use.

Predictors and moderators of treatment outcome in patients receiving multi-element psychosocial intervention for early psychosis: results from the GET UP pragmatic cluster randomised controlled trial

BackgroundThe GET UP multi-element psychosocial intervention proved to be superior to treatment as usual in improving outcomes in patients with first-episode psychosis (FEP). However, to guide treatment decisions, information on which patients may benefit more from the intervention is warranted.AimsTo identify patients' characteristics associated with (a) a better treatment response regardless of treatment type (non-specific predictors), and (b) a better response to the specific treatment provided (moderators).MethodSome demographic and clinical variables were selected a priori as potential predictors/moderators of outcomes at 9 months. Outcomes were analysed in mixed-effects random regression models. (Trial registration: ClinicalTrials.gov, NCT01436331)ResultsAnalyses were performed on 444 patients. Education, duration of untreated psychosis, premorbid adjustment and insight predicted outcomes regardless of treatment. Only age at first contact with the services proved to be a moderator of treatment outcome (patients aged ⩾35 years had greater improvement in psychopathology), thus suggesting that the intervention is beneficial to a broad array of patients with FEP.ConclusionsExcept for patients aged over 35 years, no specific subgroups benefit more from the multi-element psychosocial intervention, suggesting that this intervention should be recommended to all those with FEP seeking treatment in mental health services.

Assertive Interventions for First Episode Psychoses: The Italian Experience

In Italy, despite the favourable conditions created by the 1978 reform law and the community psychiatry, at the end of the past century there were no culture or initiatives oriented to innovative and evidence-based founded interventions in early psychosis. The watershed was the setting up in the MHD of Niguarda (Milan) of Programma 2000, addressed to FEP and HR mostly inspired by the knowledge of existing studies and experiences and with the recommended characteristics of specificity, multicomponentiality, assertiveness and doctrinal orientation. From the very start, one fundamental aim was to disseminate information, training, supervision, and to raise consensus and initiatives throughout Italy, as well as to improve international links. In many ways, the consequences have been extremely positive. In 2005, Angelo Cocchi and Programma 2000 team founded the AIPP (Italian Association for Early Intervention in Psychosis), now named Italian Association for Prevention and Early Intervention in Mental Health. Over the years, the Association has organized conferences, scientific days, working network, two national surveys on EIS and produced a document to favour their development. The results of the second survey are the more updated and articulated about the number of early interventions services, their characteristics and distribution in the different Italian regions. The survey conclusion is that EI Services implementation in Italy has been proceeding, albeit slowly. Nevertheless, there is still a great variability of therapeutic strategies and further efforts are then necessary to stimulate resources allocation as well as to assess and address adherence and fidelity to guidelines recommendations.

Disclosure of interest

The author has not supplied his declaration of competing interest.

Feasibility and Effectiveness of a Multi-Element Psychosocial Intervention for First-Episode Psychosis: Results From the Cluster-Randomized Controlled GET UP PIANO Trial in a Catchment Area of 10 Million Inhabitants

Integrated multi-element psychosocial interventions have been suggested to improve the outcomes of first-episode psychosis (FEP) patients, but they have been studied primarily in experimental settings and in nonepidemiologically representative samples. Thus, we performed a cluster-randomized controlled trial, comparing an integrated multi-element psychosocial intervention, comprising cognitive behavioral therapy, family intervention, and case management, with treatment as usual (TAU) for FEP patients in 117 community mental health centers (CMHCs) in a large area of northern Italy (10 million inhabitants). The randomized units (clusters) were the CMHCs, and the units of observation the patients (and, when available, their family members). The primary hypotheses were that add-on multicomponent intervention: (1) results in greater improvements in symptoms, as assessed with positive and negative syndrome scale and (2) reduces in-hospital stay, based on days of hospitalization over the 9-month follow-up. Four hundred and forty-four FEP patients received the intervention or TAU and were assessed at baseline and 9 months. Based on the retention rates of patients (and families) in the experimental arm, multi-element psychosocial interventions can be implemented in routine mental health services. Regarding primary outcomes, patients in the experimental arm showed greater reductions in overall symptom severity, while no difference could be found for days of hospitalization. Among the secondary outcomes, greater improvements were detected in the experimental arm for global functioning, emotional well-being, and subjective burden of delusions. No difference could be found for service disengagement and subjective burden of auditory hallucinations. These findings support feasibility and effectiveness of early interventions for psychosis in generalist mental health services.

Early intervention in psychosis: a feasibility study financed by the Italian Center on Control of Maladies

AIM

In November 2005 the Italian Center on Control of Maladies, a department operating under the Ministry of Health, financed a project aimed at evaluating the feasibility of a protocol of intervention based on the early intervention in psychosis (EIP) model within the Italian public mental health-care network.

METHODS

The study was carried out between March 2007 and December 2009. It involved five centres operating under the Departments of Mental Health of Milan (Programma 2000), Rome (area D), Grosseto, Salerno (Nocera) and Catanzaro (Soverato).

RESULTS

Enrolment lasted 12 months, at the end of which 43 patients were enrolled as first-episode psychosis (FEP), and 24 subjects as ultra high-risk (UHR) patients. Both FEP and UHR samples included a preponderance of male patients. A family history of psychosis was rarely reported in both samples. The FEP incidence rate was lower than expected on the basis of international estimates of the incidence of schizophrenia but within the expected figure for the estimated Italian rates in three centres out of five.

CONCLUSIONS

Overall, the study proved that an EIP centre can be established within the public Department of Mental Health to reach a good fraction of the cases in need of treatment. Since then, several studies have been set up to assess the feasibility of EIP in the Italian public mental health sector in Lombardy and Tuscany, and in 2012 the Emilia-Romagna Regional Authority started an educational plan aimed at implementing the EIP model in all the Mental Health Departments in the region.

EPA guidance on the early detection of clinical high risk states of psychoses

The aim of this guidance paper of the European Psychiatric Association is to provide evidence-based recommendations on the early detection of a clinical high risk (CHR) for psychosis in patients with mental problems. To this aim, we conducted a meta-analysis of studies reporting on conversion rates to psychosis in non-overlapping samples meeting any at least any one of the main CHR criteria: ultra-high risk (UHR) and/or basic symptoms criteria. Further, effects of potential moderators (different UHR criteria definitions, single UHR criteria and age) on conversion rates were examined. Conversion rates in the identified 42 samples with altogether more than 4000 CHR patients who had mainly been identified by UHR criteria and/or the basic symptom criterion 'cognitive disturbances' (COGDIS) showed considerable heterogeneity. While UHR criteria and COGDIS were related to similar conversion rates until 2-year follow-up, conversion rates of COGDIS were significantly higher thereafter. Differences in onset and frequency requirements of symptomatic UHR criteria or in their different consideration of functional decline, substance use and co-morbidity did not seem to impact on conversion rates. The 'genetic risk and functional decline' UHR criterion was rarely met and only showed an insignificant pooled sample effect. However, age significantly affected UHR conversion rates with lower rates in children and adolescents. Although more research into potential sources of heterogeneity in conversion rates is needed to facilitate improvement of CHR criteria, six evidence-based recommendations for an early detection of psychosis were developed as a basis for the EPA guidance on early intervention in CHR states.

Shades of vulnerability: latent structures of clinical caseness in prodromal and early phases of schizophrenia

The underlying structures of clinical caseness and need of care in prodromal (i.e., at-risk) and early phases of schizophrenia remain poorly characterized in their essential psycho-behavioral coherence. To identify the schizophrenia proneness-related subtypes within a population of young help-seekers referred to a dedicated, community-based early detection program (Programma 2000). A sample of consecutive referrals (n = 168) for suspected psychosis or first-episode schizophrenia spectrum psychosis received a detailed clinical assessment, including the early recognition inventory for the retrospective assessment of the onset of schizophrenia checklist. We used exploratory factor analysis (EFA) to determine the underlying dimensional structure and latent class analysis (LCA) to identify putative vulnerability subtypes. EFA identified four factors: dysphoria (irritability tension), paranoid autocentrism, introversive withdrawal, and disturbed subjective experience. LCA distinguished three classes, interpretable as carrying different degrees of "proneness to schizophrenia psychosis," which best captured the underlying continuum of clinical severity. The validity of the three classes was supported by distinct patterns of association with major clinical variables (i.e., diagnostic staging at referral). Vulnerability to schizophrenia psychosis in young help-seekers may manifest in three major clinical prototypes, presenting common levels of dysphoria and social withdrawal but different degrees of paranoid autocentrism and disturbed subjective experience. Overall, the results provide the empirical background to dissect shared features of clinical caseness from more schizophrenia-specific vulnerability components. This is of value for the refinement of the clinical staging model as well as for the pragmatic implementation of multiple-gate screening programs.

Sex differences in first-episode psychosis and in people at ultra-high risk

Sex-related differences in the clinical expression and outcome of schizophrenia have long been recognized; this study set out to evaluate whether they extend to those subjects who are at high risk of developing psychosis. In a sample enrolled in two early intervention programs in northern Italy, patients with first-episode psychosis (FEP; n=152) were compared to patients at ultra-high risk of psychosis (UHR; n=106) on a series of sex-related clinical characteristics of schizophrenia. In both the FEP and the UHR samples, males outnumbered females. In FEP patients, women had been referred at an older age than men and had a shorter duration of untreated illness (DUI) and of untreated psychosis. In UHR patients no sex differences were found in age of onset or DUI. There was no diagnosis by sex interaction on symptoms severity or level of functioning at presentation. The limited number of women in both samples, and the exclusion of people who were older than 30 and of those with substance dependence may have reduced the extent of sex-related differences in this study. Sex differences of precipitating factors for psychosis might be worthy of further investigation.

Patients With First-Episode Psychosis are Not a Homogeneous Population: Implications for Treatment

Objective: This study aimed at defining the characteristics of a population of patients diagnosed with first-episode psychosis (FEP), and accessing for the first time a center for early intervention in psychosis in the health district of Milan and its surroundings. Methods: Patients were included in the study from January 2007 to December 2008; criteria: first contact with any public mental health service of the catchment area for a first episode of schizophrenia or related syndromes according to the ICD-10 criteria. Cluster analysis was used to divide patients into groups based on the main socio-demographic and clinical characteristics at presentation. Results: Overall, 91 FEP patients were enrolled in the study. Two clusters were identified, which differed principally by symptom profile. Patients in cluster 1 (n=36) had severe agitation, and a history of alcohol and/or substance abuse at presentation more often than those in cluster 2 (n=55), who were more likely to suffer at presentation from severe depression or apathy, anxiety, poor self-care, functional or work impairment and severe social withdrawal. After six months of treatment patients improved on almost all symptomatic dimensions on the Health of the Nation Outcome Scale and the Brief Psychiatric Rating Scale, with greater improvement in cluster 1 than in cluster 2. Conclusions: The findings of this study need replication in larger samples and on a wider severity scale. Nevertheless, the heterogeneity of patients with FEP might impact on treatment. Policymakers should recognize the importance of the diagnostic and outcome assessment in the treatment of severe mental disorders.

Validation of the Health of the Nation Outcome Scales as a routine measure of outcome in early intervention programmes

AIM

So far, no study has assessed the validity of the Health of the Nation Outcome Scales (HoNOS) in patients enrolled in early intervention programmes, nor has any study evaluated the validity of the HoNOS in people at ultra high-risk (UHR) of psychosis. This study set out to assess the validity and reliability of the HoNOS as a measure of outcome in the patients enrolled in an early intervention programme.

METHODS

The concurrent, discriminant and predictive validity, and the reliability of the HoNOS as a measure of outcome in an early intervention programe were assessed in 87 first-episode psychosis (FEP) patients, and in 81 patients at UHR of psychosis.

RESULTS

Reliability indexes were good in the FEP sample, and less good in the UHR sample. HoNOS total scores differentiated between FEP and UHR patients, and the HoNOS subscales proved able to assess a specific profile of symptoms in the two samples, demonstrating a helpful adjunctive measure of health status without complete overlap with other scales. Sensitivity to change was also very good, again with differences between FEP and UHR patients. HoNOS scores at intake did not predict failure to attain remission in FEP patients. There were too few cases of transition to psychosis (n = 2) to assess predictive validity of HoNOS in the UHR sample.

CONCLUSION

HoNOS possesses satisfactory sensitivity and validity to be used in the routine assessment in early intervention programmes.

A multi-element psychosocial intervention for early psychosis (GET UP PIANO TRIAL) conducted in a catchment area of 10 million inhabitants: study protocol for a pragmatic cluster randomized controlled trial

BACKGROUND

Multi-element interventions for first-episode psychosis (FEP) are promising, but have mostly been conducted in non-epidemiologically representative samples, thereby raising the risk of underestimating the complexities involved in treating FEP in 'real-world' services.

METHODS/DESIGN

The Psychosis early Intervention and Assessment of Needs and Outcome (PIANO) trial is part of a larger research program (Genetics, Endophenotypes and Treatment: Understanding early Psychosis - GET UP) which aims to compare, at 9 months, the effectiveness of a multi-component psychosocial intervention versus treatment as usual (TAU) in a large epidemiologically based cohort of patients with FEP and their family members recruited from all public community mental health centers (CMHCs) located in two entire regions of Italy (Veneto and Emilia Romagna), and in the cities of Florence, Milan and Bolzano. The GET UP PIANO trial has a pragmatic cluster randomized controlled design. The randomized units (clusters) are the CMHCs, and the units of observation are the centers' patients and their family members. Patients in the experimental group will receive TAU plus: 1) cognitive behavioral therapy sessions, 2) psycho-educational sessions for family members, and 3) case management. Patient enrollment will take place over a 1-year period. Several psychopathological, psychological, functioning, and service use variables will be assessed at baseline and follow-up. The primary outcomes are: 1) change from baseline to follow-up in positive and negative symptoms' severity and subjective appraisal; 2) relapse occurrences between baseline and follow-up, that is, episodes resulting in admission and/or any case-note records of re-emergence of positive psychotic symptoms. The expected number of recruited patients is about 400, and that of relatives about 300. Owing to the implementation of the intervention at the CMHC level, the blinding of patients, clinicians, and raters is not possible, but every effort will be made to preserve the independency of the raters. We expect that this study will generate evidence on the best treatments for FEP, and will identify barriers that may hinder its feasibility in 'real-world' clinical settings, patient/family conditions that may render this intervention ineffective or inappropriate, and clinical, psychological, environmental, and service organization predictors of treatment effectiveness, compliance, and service satisfaction.

Gender and duration of untreated psychosis: a systematic review and meta-analysis

AIM

Duration of untreated psychosis (DUP) can influence the prognosis of schizophrenia. Previous studies have suggested that gender may influence the length of DUP. This study reports the result of the first systematic literature review and meta-analysis on the role of gender in influencing DUP in first-episode psychosis.

METHOD

Systematic literature search in PubMed/Medline and Ovid/PsychINFO. Twenty-seven studies presenting data on 4721 patients diagnosed with psychosis at their first episode (2834 males and 1887 females) were included in the analysis.

RESULTS

Samples had a higher proportion of males: odds ratio = 2.5 (95% confidence interval: 1.8-3.3). Mean age at first contact was 25.4 for males and 27.5 for females. Patients from non-Western countries were older at first contact than patients from Western countries. Average DUP in schizophrenia was 64 weeks and did not differ between genders but was shorter in Western compared with non-Western countries.

CONCLUSION

Earlier age at first contact and larger incidence in males support the existence of specific gender differences in first-episode psychosis; however, these are not associated with DUP length.

Expressed emotion in first-episode schizophrenia and in ultra high-risk patients: results from the Programma2000 (Milan, Italy)

Expressed emotion (EE) was examined in a large sample of families of patients with either first-episode psychosis (FEP) within the schizophrenia spectrum, or who met the criteria for ultra high-risk (UHR) of psychosis. The aim of our study was to determine the patterns and relationship of EE with the duration of untreated illness (DUI) or of untreated psychosis (DUP), as well as with illness severity. The sample used in our study included 77 FEP and 66 UHR families. The Camberwell Family Interview was used to assess EE. In both samples, about one-third of patients' families were classified as high EE, with emotional over-involvement (EOI) being the most frequent reason for a family to be classified as high EE. In FEP, higher EE correlated with longer DUI, and higher paternal EOI with longer DUP. DUI, however, was not found to correlate to EE in UHR patients. Severity of illness at the initial assessment did not relate to EE in either FEP or UHR families. Families of FEP and UHR patients were not found to differ in terms of the prevalence of a high EE rating, or of any of its subcomponents. The results of this study only partially support the hypothesis that high EE develops as a reaction to patient status. Patients from families with high EE could possibly benefit from interventions that are targeted at improving their resilience when dealing with problematic family environments.

Cost-effectiveness of treating first-episode psychosis: five-year follow-up results from an Italian early intervention programme

AIM

Early intervention programmes are expected to result in the reduction of illness severity in patients with schizophrenia, and contain health-care costs by reducing hospital admissions and improving the social functioning of patients. This study aimed to investigate the cost-effectiveness of treatment in an early intervention programme in comparison to standard care.

METHODS

Retrospective analysis of data prospectively recorded in an urban area (Milan, Italy). Twenty-three patients from an early intervention programme and 23 patients from standard care with first-episode psychosis were evaluated on their use of services over a 5-year period. The Health of the Nation Outcome Scale was used to measure clinical status.

RESULTS

Significant changes with respect to initial assessment were recorded on the Health of the Nation Outcome Scale, with larger effect sizes in the early intervention programme than in the standard care group. Consequently, the cost-effectiveness ratio per reduced score of severity was lower in the early intervention programme than in standard care (€ 4802 vs. € 9871), with an incremental cost-effectiveness ratio, or net saving of €-1204 for every incremental reduced score of severity. Over time, greater recourse to hospital and residential facilities to obtain comparable improvement in symptoms resulted in a steady cost increase for the patients in standard care.

CONCLUSIONS

Allocation of funds to specialized early intervention programmes is the best alternative, as it can save costs by reducing the use of hospitals and residential facilities, and may produce net savings of costs in the long term.

'Programma2000': a multi-modal pilot programme on early intervention in psychosis underway in Italy since 1999

AIM

The aim of this study was to describe a service operating in Milan, Italy, that provides early intervention for young people aged 17-30 years at the onset and at high risk of psychosis.

METHOD

Following 2 years of preliminary study and organization, Programma2000 was launched in Milan in 1999. This programme was targeted at early detection and intervention in subjects at the onset of, at risk of, or showing 'prodromal' signs of psychosis. This paper contains data on the organization and activities of Programma2000.

RESULTS

The service has been active since its launch and has received 378 referrals as of March 2009, 342 of which were thoroughly evaluated. At entry, patients undergo a detailed evaluation of their psychopathology, personal and social role functioning, and cognitive status, with repeated testing over time in order to multidimensionally assess outcome. Treatment involves cognitive-behavioural psychotherapy, structured and unstructured psychosocial interventions, and pharmacotherapy when deemed necessary. Treatment appears effective in reducing morbidity and improving social functioning.

CONCLUSION

A team dedicated to the early identification and treatment of young people with early psychosis is a feasible and sustainable extension of the traditional methods of care for people with mental disorders in Italy.

Risk of suicide and suicidal ideation in psychosis: results from an Italian multi-modal pilot program on early intervention in psychosis

Suicidality is high in schizophrenia, particularly in first-episode patients. Little is known about patients with prodromal symptoms of psychosis or otherwise high-risk persons. In a sample enrolled in an early intervention program implemented in Milan (Italy), a history of attempted suicide before enrollment was found in 6 first-episode schizophrenia (out of 87, 6.9%), and 7 high-risk of psychosis (out of 81, 8.6%) patients. In the first-episode group, a history of suicide attempts was related to a shorter duration of untreated psychosis. In the high-risk group, a family psychiatric history in first/second degree relatives of patients and a personal history of substance abuse were both associated with an enhanced risk of attempted suicide before enrollment. During the first year of treatment, 3 new attempted suicides were recorded among 57 (5.3%) high-risk patients, and none among first-episode patients (n=58) (no dropout in the sample). The levels of suicide ideation on the BPRS did not differ by group at assessment, and significantly declined from assessment at entry to 1-year follow-up, except in seven HRP patients who become positive for core symptoms of schizophrenia, as measured on the BPRS. At enrollment, patients at high risk of psychosis had the same prevalence of past suicide attempts than first-episode schizophrenia patients: since suicide attempt is the most important predictor of a future suicidal attempt, the assessment of suicide risk should be given a privileged role in patients at high risk of psychosis as well.

Duration of untreated prodromal symptoms and 12-month functional outcome of individuals at risk of psychosis

Individuals seeking help from prodromal services may have been experiencing attenuated psychotic features and psychosocial impairments for a long period prior to referral. The effect of an extended duration of these untreated ;at risk' symptoms on patients' long-term functional outcome was assessed in a 12-month longitudinal observational study (n=49). A longer duration of untreated ;at risk' symptoms was correlated with a reduced improvement in Global Assessment of Functioning scores after 12 months (beta=-0.375, P=0.008). This effect was independent of age and gender and may have implications for the improvement of treatment strategies in pre-psychotic phases.

Programma 2000: celebrating 10 years of activity of an Italian pilot programme on early intervention in psychosis

OBJECTIVE

This paper describes the structure and the organization of the single Italian programme specifically targeted at the early detection of and interventions for subjects at onset of or at high risk of psychosis, Programma 2000.

METHODS

Programma 2000 is a comprehensive multi-modal protocol of early intervention in psychosis, set up in Milan in 1999. The service has been very active since its opening, and at the time of writing (spring (April) 2008), more than 300 young patients have been evaluated through a detailed protocol that embraces Health of the Nation Outcome Scale (HoNOS), Brief Psychiatric Rating Scale (BPRS), Cognitive Behavioural Assessment 2.0, Disability Assessment Schedule, Camberwell Family Interview, Wechsler Adult Intelligence Scale and the Early Recognition Inventory Retrospective Assessment of Symptoms. The treatment includes psychoeducation, cognitive behavioural therapy (CBT), both structured and unstructured psychosocial interventions and pharmacotherapy, when necessary.

RESULTS

The programme focuses on young people aged 17-30 years: to date, a total of 132 subjects with definite psychosis or within the high-risk category have been enrolled in treatment after assessment. Patients with first-episode psychosis were, on average and expectedly, more severe than those in the at-risk group, and were more likely to be prescribed antipsychotic drugs. A large majority of patients in both groups received tailored CBT; individual sessions of skills training were provided to two-thirds of patients. In both groups, improvement was found in both the BPRS and HoNOS, and in the level of global functioning as assessed on Global Assessment of Functioning at 6 month and 1 year follow up. Global functioning was more sensitive to change than symptom severity, reflecting the intensive and personalized efforts to improve social and role functioning in patients.

CONCLUSIONS

Programma 2000 is still in development but it has already gained the support of therapists and other relevant people involved in the life of subjects at onset, or at high risk of psychosis.

The Italian guidelines for early intervention in schizophrenia: development and conclusions

AIM

The effectiveness of early intervention in schizophrenia is still under discussion. The guidelines described in the present paper were aimed at contributing to the current debate by providing Italian practitioners, families, patients and health managers with evidence-based information on early intervention. They also examined the diagnostic tools that are currently available for assessing different stages of psychotic disorders.

METHODS

A multidisciplinary panel of experts (the Guidelines Development Group) used a set of key-questions to develop an explicit search strategy to conduct a systematic review of the literature published from January 2000 to June 2006. Trained personnel then selected papers from those yielded by the literature search. The Guidelines Development Group's final recommendations were scaled according to the Italian National Guidelines System grading system.

RESULTS

The evidence available up to the time of the literature search does not allow for recommendation of early intervention targeting prodromal or at-risk patients to prevent progression from the prodromal phase to acute, full-blown psychosis, nor to improve prognosis. Conversely, identification and timely treatment of first-episode psychotic patients through specific early intervention programmes are highly recommended.

CONCLUSIONS

The Italian Guidelines on early intervention in schizophrenia are based on a comprehensive assessment of an updated, large-scale body of literature. They draw specific, evidence-based conclusions to assist clinicians and stakeholders in the planning and implementation of appropriate intervention programmes. Further research is needed to ascertain the effectiveness of early intervention in delaying or preventing the conversion to psychosis and improving prognosis in prodromal or at-risk patients. Further investigation is also required for first-episode and critical period patients.

[Working with families in the early stages of psychosis: a structured intervention for caregivers]

In the field of early psychosis psychoeducation is considered fundamental to increase coping skills with diseases and to improve the quality of life of patients and their families. The more recent and updated guidelines on schizophrenia underline the extreme importance of the families involvement in treatment of young people in the initial phases of illness. "Families are the main support for many young patients. They could be the primary carers but they have also to face individual and social consequences following the onset course. Where feasible, family members must be involved in the treatment". This work describes the components of the work with families carried on by the Centre for the early detection of psychoses and high-risk situations--Programma 2000 ("Niguarda Ca' Granda" Hospital-Milan) and is mostly focused on psychoeducation and on Expressed Emotions aspects. Even the advances suggested by the international literature drove Programma 2000 to define both the steps of caregivers assessment and intervention. During the last ten years, Programma 2000 has followed 191 caregivers. Aims of this work is to verifier the outcome of the "pilot project", started in 2007, projected specifically to increase the normally used strategies to improve the caregivers adherence and involvement in the therapeutic process. The individualized multi-componential intervention has been structured in 8 session over one years. Outcome measures used in this article are the scores of the Camberwell Family Interview and from the Psychosis Knowledge Assessement Semistructured Interview (VCP). The subjects enrolled in the structured pilot project were 25 family caregiver to young (18-30 yrs old) patients. Results shows change in the Expressed Emotion level: 13% of families moved from High Expressed Emotion to Low Expressed Emotion. Furthermore data on the knowledge of illness knowledge level illustrate a reduction in the percentage, from 47% to 18%, of carers who have just a very vague knowledge of illness, and an increase from 16% to 27% of carers who obtain a good level of specific knowledge. In conclusion we can sustain mental health expert with aim to treatment project programme individualized and multi-componential tailored for young's caregiver at the onset phase of psychosis.

Night eating and binge eating disorder in obese patients

OBJECTIVE

To investigate the relationships between binge eating disorder and night eating in severely obese patients.

DESIGN

Longitudinal study following biliopancreatic diversion, when any preoccupation with food and weight is completely abandoned.

MATERIALS AND METHODS

Structured interview prior to the operation and at the 1, 2, and 3-year follow-up visit.

RESULTS

Nearly complete disappearance of binging behavior and no changes in the frequency of night eating.

CONCLUSION

Binge eating and night eating are widely overlapping but different behaviors; night eating appears to be fully independent of preoccupation with food and dieting.

Body image in obese patients before and after stable weight reduction following bariatric surgery

The role of possessing an abnormal body weight in the body image alterations of obese patients was evaluated in bariatric surgery subjects prior to and at long term after operation, when body weight and shape had become steadily normalized. Body image was assessed by the body dissatisfaction scale of the Eating Disorders Inventory, the Body Shape Questionnaire, and the Body Attitude Questionnaire. When the individuals were obese, a sharply impaired body image was observed; following operation, weight loss corresponded to normalization of body dissatisfaction, feeling of fatness, and physical attractiveness, whereas body disparagement and salience of shape, although improved in comparison to preoperative data, remained significantly different from that of controls. In the obese patients, some aspects of body image alterations are substantially accounted for by overweight status; other aspects reflect inner feelings, which are partially independent of the actual body weight and shape.

Body image and body weight in obese patients

OBJECTIVE

To evaluate the influence of body weight on body image.

METHODS

The study was carried out in severely obese patients and in postobese subjects, having attained and maintaining a normal or nearly normal weight following biliopancreatic diversion; body image was assessed by self-report questionnaires.

RESULTS

The obese patients' scores were different from those of postobese subjects. In postobese individuals with adult-onset obesity, body image was very similar to that of controls, whilst in those with early-onset obesity it was abnormal.

DISCUSSION

In the adult-onset obese patients, since the weight normalization causes a sharp improvement of body image, its alterations could be accounted for by a body shape far different from that socially acceptable. In the early-onset obese patients, being the postoperative findings similar to those of the obese patients and different from those of never-obese controls, the body image disparagement might reflect inner feelings, independent of body weight.

Night eating syndrome in individuals with Mediterranean eating-style

Night eating syndrome is identified with no appetite for breakfast, 50% or more of food intake after 7 p.m. and trouble getting to sleep and/or staying asleep. In a population with a Mediterranean eating style more than 25% of lean healthy subjects should be considered as affected by night eating syndrome, thus making the definition criteria and even the syndrome itself clinically meaningless. Therefore, to assess the presence of night eating syndrome in a population with Mediterranean eating and lifestyle, the following definition criteria were employed: no food or only a little food for breakfast, sleep disturbances and usual consumption of some food just before going to sleep or waking up during sleeptime. According to these criteria, 3.5% of lean subjects should be considered as affected by night eating syndrome, without any relationship between reported psychological distress or tendency to lose control over food intake. Further studies in populations with Mediterranean eating style are mandatory to assess the true clinical significance of night eating syndrome.

Binge eating in obesity: a longitudinal study following biliopancreatic diversion

OBJECTIVE

Evaluating the influence of dieting and of being overweight on binge-eating episodes and on psychological traits in severely obese patients.

METHODS

Clinical interviews and self-report questionnaires prior to and 2 years following biliopancreatic diversion (BPD) when subjects adopt a completely free eating style and achieve in maintaining a normal or nearly normal body weight.

RESULTS

At two years following the operation, the prevalence of binge-eating episodes sharply fell and the subjects' overall psychological conditions improved; only a few patients started binging.

DISCUSSION

These results point out the importance of dieting and of overweight itself in determining eating behavior disturbances or psychopathology. The fact that only a very small number of patients continue or start binging following BDP suggests that a minority of obese bingers should be considered as true eating-disordered patients.

Food- and weight-related attitudes in obese persons: a longitudinal study over two years following biliopancreatic diversion

Food- and weight-related attitudes were assessed in obese subjects prior to biliopancreatic diversion (BPD) and at 1 and 2 years after BPD, when any preoccupation with dieting and body weight and shape should have been abandoned. A decrease in the number of subjects whose food attitudes suggested some loss of control over food consumption, such as snacking, nibbling, getting hungry and eating in response to non-alimentary stimuli or arousal conditions was observed, confirming the role of dieting in leading to loss of control over food intake. The stable weight loss correlated with changes in the body attitudes and in the overall psychological status. The changes observed in obese persons after BPD suggest that 1) the food-related attitudes are influenced by the preoccupation with food and with dieting; 2) the weight-related attitudes are accounted for more by dissatisfaction with a body shape that is very different from the socially accepted one than by an individual's psychological traits.

Preoperative Eating Behavior and Weight-loss Following Gastric Banding for Obesity

BACKGROUND AND METHODS: The relationships between cognitive restraint and the tendency to disinhibition, as assessed by the Three Factor Eating Questionnaire (TFEQ), and the weight loss at 1 year following gastric banding are evaluated. RESULTS: A significant predictability of the TFEQ Disinhibition score on the postoperative weight reduction was observed, while the amount of weight lost was negatively related to the preoperative TFEQ Cognitive Restraint score. CONCLUSION: It must then be hypothesized that the operated subjects feel a strong aversive stimulus and then they are led to reduce their food consumption only when they lose control and tend to overeat. The discomfort due to proximal gastric pouch distention facilitates the development of food aversion and then both the decrease of food intake and a change in eating behavior. The subjects must therefore be encouraged to adopt an eating style that cannot allow them to avoid such a feeling.

[Preoperative eating behavior and weight loss after gastric banding for obesity]

The relationships between the cognitive restraint and the tendency to disinhibition prior to gastric banding for obesity, as assessed by the Three Factor Eating Questionnaire, and the weight loss at one year following the operation were investigated. The amount of overall weight loss was correlated positively to the disinhibition and negatively to the cognitive restraint score. When the food consumption overtakes the proximal gastric pouch capacity, the patient feels a strong aversive stimulus, thus stopping eating. Therefore, more is the patient's tendency to lose the control on food intake more is the postoperative weight loss. On the contrary, the high restraint patient only seldom feels such an aversive stimulus, and only seldom stops eating, thus the weight loss is smaller. Except for the overeating due to the disinhibition, the aversive stimulus arising from the gastric restriction cannot influence by itself any other aspect of eating behavior.