Correlates of substance use in a large naturalistic cohort of young people with early and emerging psychosis

BACKGROUND

Substance use remains a barrier to recovery for young people accessing early intervention services for psychosis. While correlates of use have been explored in populations experiencing a first episode of psychosis (FEP), sample sizes have been small and less research assesses cohorts at ultrahigh risk of psychosis (UHR).

METHODS

This study uses data from a naturalistic cohort including UHR and FEP participants (N = 1252) to elucidate clinical correlates of use in the past 3 months of any illicit substance, amphetamine-type stimulants (ATS), cannabis, and tobacco. Moreover, network analysis based on use of these substances and additionally alcohol, cocaine, hallucinogens, sedatives, inhalants, and opioids was completed.

RESULTS

Young people with FEP used substances at significantly higher rates than those at UHR. High concurrence of use was seen between substances. In the FEP group, participants who had used any illicit substance, ATS, and/or tobacco had increased positive symptoms and decreased negative symptoms. Young people with FEP who used cannabis had increased positive symptoms. In the UHR group, participants who had used any illicit substance, ATS, and/or cannabis in the past 3 months showed decreased negative symptoms compared to those who had not.

CONCLUSION

A distinct clinical picture of more florid positive symptoms and alleviated negative symptoms seen in those who use substances in the FEP group appears muted in the UHR cohort. Treating young people at UHR in early intervention services represents the earliest opportunity to address substance use early to improve outcomes.

Social disadvantage in early psychosis and its effect on clinical presentation and service access, engagement and use

Incidence of psychosis varies geographically due to factors such as social disadvantage. Whether this influences the clinical presentation and/or engagement of those experiencing psychosis remains relatively understudied. This study analysed data from young people across Australia accessing ultra-high risk (UHR) or first episode psychosis (FEP) services delivered through the headspace Early Psychosis (hEP) program between June 2017 and March 2021. The cohort was categorised into low, middle, and high tertiles of social disadvantage using the Index of Relative Socioeconomic Disadvantage (IRSD). Data from 3089 participants aged 15-25 were included (1515 UHR, 1574 FEP). The low and middle tertiles for both cohorts had greater percentages of those not in education or employment (NEET), with First Nations or culturally and linguistically diverse backgrounds. Clinical presentations to services were similar across all tertiles in both cohorts, however, functioning at presentation varied significantly within the FEP cohort. Significantly lower numbers of direct services were provided in the low tertile of both cohorts, with significantly poorer engagement in the initial three-months also occurring for these young people. This variation in early psychosis service patterns associated with geographical variation in social deprivation demonstrates the need for further research and fine tuning of national early psychosis services.

Co-occurring first-episode psychosis and borderline personality pathology in an early intervention for psychosis cohort

INTRODUCTION

Borderline personality disorder (BPD) is common among people diagnosed with first episode of psychosis (FEP), but is often under-recognized and under-researched. This study aimed to determine: (i) the prevalence of borderline personality pathology (subthreshold features and categorical disorder) in a FEP cohort (termed FEP + BPP); (ii) demographic and clinical factors associated with FEP + BPP; (iii) the symptomatic and functional outcomes.

METHODS

This study was conducted within the Early Psychosis Prevention and Intervention Centre (EPPIC) at Orygen over the 30-month period between 2014 and 2016. BPP was evaluated by using the Structured Clinical Interview for DSM-IV Axis II Personality Questionnaire BPD criteria.

RESULTS

In a cohort of 457 young people with a FEP (mean age 19.5 years, 56% male), 18.4% had borderline personality pathology (BPP). Compared with FEP alone, young people with FEP + BPP were more likely to be female, younger, Australian-born. In addition, young people with FEP + BPP were more likely to be diagnosed with Psychosis NOS, present with more severe hallucinations, and have alcohol abuse. Young people with FEP + BPP had more relationship difficulties at presentation and they were more likely to suffer of depression and to engage in self-harm throughout the follow-up. In relation to outcome, FEP + BPP was not associated with different rates of remission or relapse, however they were less likely to be admitted to hospital at presentation or involuntarily during their episode of care.

CONCLUSION

BPP is a common occurrence in psychotic disorders and is associated with more severe hallucinations and depression with higher risks of self-harm. Specific interventions need to be developed.

Frontostriatothalamic effective connectivity and dopaminergic function in the psychosis continuum

Dysfunction of fronto-striato-thalamic (FST) circuits is thought to contribute to dopaminergic dysfunction and symptom onset in psychosis, but it remains unclear whether this dysfunction is driven by aberrant bottom-up subcortical signalling or impaired top-down cortical regulation. We used spectral dynamic causal modelling of resting-state functional MRI to characterize the effective connectivity of dorsal and ventral FST circuits in a sample of 46 antipsychotic-naïve first-episode psychosis patients and 23 controls and an independent sample of 36 patients with established schizophrenia and 100 controls. We also investigated the association between FST effective connectivity and striatal 18F-DOPA uptake in an independent healthy cohort of 33 individuals who underwent concurrent functional MRI and PET. Using a posterior probability threshold of 0.95, we found that midbrain and thalamic connectivity were implicated as dysfunctional across both patient groups. Dysconnectivity in first-episode psychosis patients was mainly restricted to the subcortex, with positive symptom severity being associated with midbrain connectivity. Dysconnectivity between the cortex and subcortical systems was only apparent in established schizophrenia patients. In the healthy 18F-DOPA cohort, we found that striatal dopamine synthesis capacity was associated with the effective connectivity of nigrostriatal and striatothalamic pathways, implicating similar circuits to those associated with psychotic symptom severity in patients. Overall, our findings indicate that subcortical dysconnectivity is evident in the early stages of psychosis, that cortical dysfunction may emerge later in the illness, and that nigrostriatal and striatothalamic signalling are closely related to striatal dopamine synthesis capacity, which is a robust marker for psychosis.

The potential impact of COVID-19 on psychosis: A rapid review of contemporary epidemic and pandemic research

The COVID-19 outbreak may profoundly impact population mental health because of exposure to substantial psychosocial stress. An increase in incident cases of psychosis may be predicted. Clinical advice on the management of psychosis during the outbreak needs to be based on the best available evidence. We undertook a rapid review of the impact of epidemic and pandemics on psychosis. Fourteen papers met inclusion criteria. Included studies reported incident cases of psychosis in people infected with a virus of a range of 0.9% to 4%. Psychosis diagnosis was associated with viral exposure, treatments used to manage the infection, and psychosocial stress. Clinical management of these patients, where adherence with infection control procedures is paramount, was challenging. Increased vigilance for psychosis symptoms in patients with COVID-19 is warranted. How to support adherence to physical distancing requirements and engagement with services in patients with existing psychosis requires careful consideration. Registration details: https://osf.io/29pm4.

Testing the Interpersonal-Cognitive Model of Auditory Verbal Hallucinations in Youths with Either Early-Stage Borderline Personality Disorder or First-Episode Schizophrenia Spectrum Disorder

This is the first study to explore interpersonal schemata in outpatient youths (age 15-25 years) with early-stage borderline personality disorder (BPD) and auditory verbal hallucinations (AVH). It also aimed to replicate, in a transdiagnostic youth sample, the finding from studies of adults with AVH that negative beliefs about the self and others lead to negative appraisals of voices, which in turn elicits depression. The following 3 groups were compared: youth with BPD+AVH (n = 23), youth with schizophrenia spectrum disorder (SZ) with AVH (SZ+AVH, n = 20), and youths with BPD who did not experience AVH (BPD no AVH, n = 23). The BPD+AVH group reported more negative and fewer positive self schemata than the SZ+AVH group. They also saw themselves as being more socially inferior to others than did the SZ+AVH group, but they did not differ in appraisals of self or others, compared with the BPD no AVH group. In youths with AVH (BPD+AVH, SZ+AVH combined), the indirect effect of beliefs about self or others, via negative appraisals of voices on depression, was not significant. Instead, a significant indirect effect of negative appraisals of voices on depression, via negative beliefs about self, was found. The experience of AVH during adolescence and young adulthood, when the identity is still being formed, might have a more profound effect on the developing self than during later adulthood, when the self is more stable and resilient. Negative self-appraisals might constitute a treatment target for early intervention for youths with distressing voices, including those with BPD.

Aripiprazole compared with placebo for auditory verbal hallucinations in youth with borderline personality disorder: Protocol for the VERBATIM randomized controlled trial

AIM

Up to half of patients with borderline personality disorder report auditory verbal hallucinations that are phenomenologically indistinguishable from those in schizophrenia, occur early in the course of the disorder, and are enduring, distressing and disabling. In clinical practice, this symptom is widely assumed to be unresponsive to treatment with antipsychotic medication and early intervention is rarely offered. The Verbal Experiences Response in Borderline personality disorder to Aripiprazole TrIal Medication (VERBATIM) study aims to be the first controlled trial to investigate the effectiveness of conventional pharmacotherapy for this symptom in this patient group.

METHOD

VERBATIM is a 12-week, triple-blind, single-centre, parallel groups randomised controlled trial, with a 27-week follow-up period. Participants between the ages of 15 and 25 years receive either aripiprazole or placebo daily, commencing at 2 mg and increasing to 10 mg by day 15. Further dose escalations (up to 30 mg) may occur, as clinically indicated. This trial was prospectively registered with the Australian and New Zealand Clinical Trials Registry ACTRN12616001192471 on 30/08/2016.

RESULTS

The primary outcome is severity of auditory verbal hallucinations assessed using the Psychotic Symptom Rating Scale. Secondary outcomes include the severity of general psychopathology, borderline personality pathology, social and occupational functioning and change in brain resting state connectivity. The primary endpoint is week 12 and secondary endpoint is week 39.

CONCLUSION

The results will inform treatment decisions for individuals with borderline personality disorder who present with auditory verbal hallucinations.

Exploratory comparison of auditory verbal hallucinations and other psychotic symptoms among youth with borderline personality disorder or schizophrenia spectrum disorder

OBJECTIVE

This study explored phenomenological aspects of auditory verbal hallucinations (AVH) and other psychotic symptoms among youth with borderline personality disorder (BPD).

METHODS

Sixty-eight outpatients, aged 15 to 25 years, were categorized into three groups according to their primary Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnosis and AVH symptom profile; BPD + AVH (n = 23), schizophrenia spectrum disorder (SZ) + AVH (n = 22) and BPD with no AVH (n = 23).

RESULTS

No differences in AVH were found between BPD + AVH and SZ + AVH. Compared with SZ + AVH, BPD + AVH scored lower on delusions and difficulty in abstract thinking and higher on hostility. BPD + AVH reported more severe self-harm, paranoid ideation, dissociation, anxiety and stress than BPD no AVH.

CONCLUSIONS

This study replicates, in a sample of youth, the finding from studies of adults that AVH in BPD are indistinguishable from those in SZ, when assessed with the Psychotic Symptom Rating Scales (PSYRATS). Clinicians should specifically enquire about AVH among youth with BPD. When present, AVH appear to be an indicator of a more severe form of BPD.

Early psychosis workforce development: Core competencies for mental health professionals working in the early psychosis field

AIM

The aim of this study was to identify the core competencies required of mental health professionals working in the early psychosis field, which could function as an evidence-based tool to support the early psychosis workforce and in turn assist early psychosis service implementation and strengthen early psychosis model fidelity.

METHOD

The Delphi method was used to establish expert consensus on the core competencies. In the first stage, a systematic literature search was conducted to generate competency items. In the second stage, a panel consisting of expert early psychosis clinicians from around the world was formed. Panel members then rated each of the competency items on how essential they are to the clinical practice of all early psychosis clinicians.

RESULTS

In total, 1023 pieces of literature including textbooks, journal articles and grey literature were reviewed. A final 542 competency items were identified for inclusion in the questionnaire. A total of 63 early psychosis experts participated in 3 rating rounds. Of the 542 competency items, 242 were endorsed as the required core competencies. There were 29 competency items that were endorsed by 62 or more experts, and these may be considered the foundational competencies for early psychosis practice.

CONCLUSION

The study generated a set of core competencies that provide a common language for early psychosis clinicians across professional disciplines and country of practice, and potentially are a useful professional resource to support early psychosis workforce development and service reform.

Preliminary Evidence for the Cognitive Model of Auditory Verbal Hallucinations in Youth With Borderline Personality Disorder

Objectives: This is the first study to explore cognitive, emotional, and behavioral responses to voices in youth with borderline personality disorder (BPD) compared with those with schizophrenia spectrum disorder (SZ), and to examine if negative appraisals of voices predict depression and anxiety across the groups. Methods: The sample comprised 43 outpatients, aged 15-25 years, who reported auditory verbal hallucinations (AVH) and were diagnosed with either Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) BPD or SZ. Data were collected using the Psychotic Symptom Rating Scales, the revised Beliefs About Voices Questionnaire, the Voice Rank Scale, and the Depression Anxiety Stress Scale. Results: Youth with BPD did not differ from youth with SZ in beliefs about the benevolence or malevolence of voices. Youth with BPD appraised their voices as more omnipotent and of higher social rank in relation to themselves, compared with youth with SZ. In both diagnostic groups, beliefs about malevolence and omnipotence of voices were correlated with more resistance toward voices, and beliefs about benevolence with more engagement with voices. In addition, perceiving the voices as being of higher social rank than oneself and negative voice content were both independent predictors of depression, irrespective of diagnostic group. In contrast, negative appraisals of voices did not predict anxiety after adjusting for negative voice content. Conclusions: This study replicated the link between negative appraisals of voices and depression that has been found in adults with SZ in a mixed diagnostic youth sample. It, thus, provides preliminary evidence that the cognitive model of AVH can be applied to understanding and treating voices in youth with BPD.

Factors influencing engagement with case managers: Perspectives of young people with a diagnosis of first episode psychosis

Holistic treatment during a first episode psychosis (FEP) can significantly impact the longevity and chronicity of the illness, as well as reduce the risk of premature death by suicide. However, treatment can only be effective if the young person participates. Given that 19-40% of young people disengage from early intervention services for FEP, this qualitative study aimed to understand how young people experienced engagement with case managers at an early intervention service. Semistructured interviews were conducted with seven young people and themes were identified using interpretive phenomenological analysis. Young people detailed how engagement with a service could be viewed as a process, following different stages between initial referral and discharge. Throughout this process, a number of factors influenced young people's decision to engage with, or disengage from, their case manager. This created a push-pull dynamic with periods of good engagement and poor engagement. Discussion of this dynamic adds nuance to established scholarship about engagement, including shifts over time in the importance of client empowerment and valued features of therapeutic relationships. Awareness and understanding of these concepts may guide changes to early intervention services and address the core issue of engagement.

Suicidal behaviours during treatment for first-episode psychosis: towards a comprehensive approach to service-based prevention

AIM

Suicidal behaviours (suicide attempts and suicides) are common among individuals experiencing, or having recently experienced, a first-episode psychosis (FEP). Current interventions for suicidal behaviours are crisis driven and focused on hospital admission of patients at imminent risk of ending their lives. This paper aims to describe ideas for universal, selective and indicated strategies that may complement existing practices to suicide risk management in first-episode patients.

METHODS

Key findings from the Suicidal Behaviours in FEP Project were used to develop suggested interventions. The project examined the temporal course of suicide risk, common characteristics of suicidal behaviours and predictors of suicidal behaviours in 699 patients with FEP.

RESULTS

Key findings included: (i) 12% of FEP cohort engaged in suicidal behaviours during treatment (up to 3 years); (ii) first month of treatment conferred the highest suicide risk; (iii) 64% of suicidal behaviours were overdoses, usually on antipsychotics; (iv) 20% of suicidal behaviours occurred on psychiatric units and all involved hanging/strangulation; (v) most suicidal behaviours were impulsive, precipitated by psychosocial stressors and with serious intent; and (vi) proximal non-suicidal self-injurious behaviour and proximal negative life events were the strongest predictors.

CONCLUSION

Comprehensive approach by mental health services to prevention of suicidal behaviours among first-episode patients could be facilitated by: delineating safe quantities of prescribed medications available to outpatients; regular audits of fixtures on inpatient units; enhancing risk recognition by family members; routinely monitoring suicide risk levels; developing crisis cards with all new FEP patients to facilitate help seeking during distress; and skills training programs targeting distress tolerance, interpersonal effectiveness and problem-solving.

Predictors of suicide-related behaviors during treatment following a first episode of psychosis: the contribution of baseline, past, and recent factors

BACKGROUND

Suicide-related behaviors (suicide attempts and suicides) are common in the early phase of psychotic disorders. Studies have examined risk factors among baseline and historical (i.e., past) variables, yet little is known about recent characteristics that increase suicide risk during treatment for first-episode psychosis (FEP). This study had two aims: first, to determine the relative importance of baseline, past, and recent variables to the prediction of suicide-related behaviors in patients with FEP; second, to identify recent characteristics that exert most influence on suicide risk levels and which could become foci of preventive interventions.

METHODS

This was a case-control study of 180 patients from a cohort entering a specialist FEP service between 1/12/2002 and 30/11/2005. Data for 72 cases and 108 matched controls were obtained via medical record audit. Multivariate logistic regression models assessed the contribution of baseline, past, and recent domains. Suicide attempt or suicide during treatment was the outcome variable.

RESULTS

The strongest risk factors for suicide-related behaviors were: baseline depressive symptoms, baseline suicidal ideation/intent, past negative events, past non-suicidal self-injurious behavior, recent negative events, recent depressive symptoms, and recent non-suicidal self-injurious behavior. However, when these were entered into a hierarchical logistic regression model, only recent non-suicidal self-injurious behavior (AOR=72.96, p<0.001), and recent negative events (AOR=1.90, p=0.003) remained significant predictors. The final model accurately classified 75.5% of cases and 89.2% of controls, and explained 72.0% of variance in the suicide attempt status.

CONCLUSIONS

Since recent negative events and recent non-suicidal self-injurious behavior were the strongest predictors of suicide-related behaviors during treatment for FEP, psychiatric services could consider incorporating psychosocial interventions addressing affect regulation, interpersonal effectiveness, stress management and problem solving, alongside case management and pharmacotherapy, to help to reduce the rates of suicide attempts and suicides in first-episode patients.

Study protocol: The development of a pilot study employing a randomised controlled design to investigate the feasibility and effects of a peer support program following discharge from a specialist first-episode psychosis treatment centre

BACKGROUND

Young people with first-episode psychosis (FEP) are at risk of a range of negative outcomes. Specialist FEP services have been developed to provide comprehensive, multi-disciplinary treatment. However, these services are often available for a restricted period and the services that young people may be transferred to are less comprehensive. This represents a risk of drop out from treatment services in a group already considered to be at risk of disengagement. Peer support groups have been shown to improve social relationships among people with psychosis however individual peer support programs have not been tested on young people with first-episode psychosis; nor have they been tested at the point of discharge from services.

METHODS/DESIGN

The study is an 18-month randomised controlled trial being conducted at Orygen Youth Health Research Centre in Melbourne, Australia. The aim of the study is to test the feasibility and effects of a 6-month peer support intervention delivered to young people with FEP over the period of discharge. Participants are young people aged 15-24 who are being discharged from a specialist first-episode psychosis treatment centre. There is a 6-month recruitment period. The intervention comprises two hours of contact per fortnight during which peer support workers can assist participants to engage with their new services, or other social and community activities. Participants will be assessed at baseline and post intervention (6 months).

DISCUSSION

This paper describes the development of a randomised-controlled trial which aims to pilot a peer support program among young people who are being discharged from a specialist FEP treatment centre. If effective, the intervention could lead to benefits not only for participants over the discharge period, but for peer support workers as well.

Declining transition rate in ultra high risk (prodromal) services: dilution or reduction of risk?

There is growing interest in the prodromal stage of psychotic disorders, with many services now providing care for these "ultra high risk" (UHR) individuals. However, a reduction in the rate of transition to psychosis has been suspected over the last few years. This has implications for the use of interventions in this population and for the validity of research findings. This study examined the transition rate in one UHR service, the Personal Assessment and Crisis Evaluation Clinic, over the years 1995-2000 and investigated possible causes for the transition rate reduction. There was evidence for a declining transition rate, with each successive year showing a rate 0.80 times that of the preceding year. Functioning and symptom level were not responsible for the change. The decreased transition rate was partly explained by a reduction in the duration of symptoms of patients prior to receiving help. That is, UHR individuals are being detected and provided with care earlier than in the past. Thus, the decline in transition rate may be due to treatment being more effective at this very early stage of illness or it may be due to finding more false positives who were never at risk of psychosis, ie, a "dilution" effect. Given that it is not possible to distinguish between these alternatives at least phenotypically at present, perhaps it is time to rethink the role and practice of UHR clinics. Patients presenting to them need help. It may be that we need to aim to prevent a range of target syndromes.

A controlled trial of cognitively oriented psychotherapy for early psychosis (COPE) with four-year follow-up readmission data

OBJECTIVES

Cognitively oriented psychotherapy for early psychosis (COPE) is aimed at facilitating the adjustment of the person, and preventing or alleviating secondary morbidity in the wake of the first psychotic episode. The present study reports on the outcomes of a controlled trial comparing two conditions: COPE versus No-COPE.

METHOD

Ninety-one people participated in the trial which was analysed by intention-to-treat, including 12 people who were assigned to COPE but refused to participate. Assessments were conducted at pre-treatment, mid-treatment and post-treatment. Hospital readmission data were obtained through a Psychiatric Case Register. The study was conducted in a front-line public mental health service, the Early Psychosis Prevention and Intervention Centre (EPPIC). Clients in both COPE and No-COPE were provided with full access to the complete range of EPPIC services.

RESULTS

There were no significant differences between the two conditions on the nine primary outcome variables. Hospital readmissions were assessed for each client at yearly intervals up to 4 years following the completion of treatment and again there were no significant between-group differences.

CONCLUSIONS

The study indicated that there was no significant advantage to COPE over and above routine care at EPPIC.

Randomized controlled trial of interventions designed to reduce the risk of progression to first-episode psychosis in a clinical sample with subthreshold symptoms

BACKGROUND

Most disability produced by psychotic illnesses, especially schizophrenia, develops during the prepsychotic period, creating a case for intervention during this period. However, only recently has it been possible to engage people in treatment during this phase.

METHODS

A randomized controlled trial compared 2 interventions in 59 patients at incipient risk of progression to first-episode psychosis. We termed this group ultra-high risk to emphasize the enhanced risk vs conventional genetic high-risk studies. Needs-based intervention was compared with specific preventive intervention comprising low-dose risperidone therapy (mean dosage, 1.3 mg/d) and cognitive behavior therapy. Treatment was provided for 6 months, after which all patients were offered ongoing needs-based intervention. Assessments were performed at baseline, 6 months, and 12 months.

RESULTS

By the end of treatment, 10 of 28 people who received needs-based intervention progressed to first-episode psychosis vs 3 of 31 from the specific preventive intervention group (P=.03). After 6-month follow-up, another 3 people in the specific preventive intervention group became psychotic, and with intention-to-treat analysis, the difference was no longer significant (P=.24). However, for risperidone therapy-adherent patients in the specific preventive intervention group, protection against progression extended for 6 months after cessation of risperidone use.

CONCLUSIONS

More specific pharmacotherapy and psychotherapy reduces the risk of early transition to psychosis in young people at ultra-high risk, although their relative contributions could not be determined. This represents at least delay in onset (prevalence reduction), and possibly some reduction in incidence.

Shedding of Escherichia coli O157:H7 in dairy cattle housed in a confined environment following waterborne inoculation

A study of Escherichia coli O157:H7 transmission and shedding was conducted with bull calves housed in individual pens within a confined environment. For comparative purposes, the numbers and duration of E. coli O157:H7 shedding in naturally infected calves were monitored after a single purchased calf (calf 156) tested positive prior to inoculation. During the next 8 days, the calves in adjacent pens and a pen directly across a walkway from calf 156 began to shed this serotype O157:H7 strain. Five of the eight calves in this room shed this O157:H7 strain at some time during the following 8 weeks. The numbers of E. coli O157:H7 isolates shed in these calves varied from 60 to 10(5) CFU/g of feces, and the duration of shedding ranged from 17 to >31 days. The genomic DNAs from isolates recovered from these calves were indistinguishable when compared by using XbaI digestion and pulsed-field gel electrophoresis. Inoculation of calves with 1 liter of water containing ca. 10(3) to 10(4) CFU of E. coli O157:H7/ml resulted in shedding in 10 of 12 calves (trial 1, 4 of 4 calves; trial 2, 6 of 8 calves). The inoculated calves shed the inoculation strain (FRIK 1275) as early as 24 h after administration. The duration of shedding varied from 18 to >43 days at levels from 10(2) to 10(6) CFU/g of feces. The numbers of doses necessary to initiate shedding varied among calves, and two calves in trial 2 never shed FRIK 1275 after four doses (ca. 10(6) CFU per dose). Results from this study confirm previous reports of animal-to-animal and waterborne dissemination of E. coli O157:H7 and highlight the need for an effective water treatment to reduce the spread of this pathogen in cattle.

Cognitively oriented psychotherapy for early psychosis (COPE): a 1-year follow-up

OBJECTIVES

Cognitively oriented psychotherapy for early psychosis (COPE) is aimed at facilitating the adjustment of the person, and at preventing or alleviating secondary morbidity in the wake of the first psychotic episode.

DESIGN

A total of 80 people participated in the initial trial and completed assessments on a range of outcome measures. Post-treatment assessment results from a non-randomized controlled trial of COPE have been previously reported. The present paper describes the results obtained from 51 patients who attended a follow-up assessment 1 year subsequent to the end-of-treatment assessment.

METHOD

The 51 patients formed three groups: (1) those who were offered and accepted COPE; (2) those who were offered COPE but refused it, and continued to receive other services from the Early Psychosis Prevention and Intervention Centre (EPPIC) (refusal subjects); and (3) those who were offered neither COPE nor any other continuing treatment from EPPIC (control subjects).

RESULTS

At 1-year follow-up, there was only one significant difference and this was between the COPE and refusal groups on the Integration/Sealing Over (I/SO) measure (p = .008). End-of-treatment differences were mostly sustained over the 1-year follow-up period. When the complete sample of 80 was considered, there were no differences between the three groups in terms of hospital admissions, community episodes, or time taken to first in-patient re-admission.

CONCLUSIONS

The study was weakened by the poor follow-up rates in the two control groups. This reduced power to detect differences between groups on the seven major measures. However, the relapse data gathered on the complete set of 80 patients were discouraging and suggest that the present formulation of COPE does not confer any advantage to those patients receiving the therapy over those not receiving the therapy.

Prediction of psychosis. A step towards indicated prevention of schizophrenia

BACKGROUND

The identification of people at high risk of becoming psychotic within the near future creates opportunities for early intervention prior to the onset of psychosis to prevent or minimise later ill-health. The present study combines current knowledge about risk factors for schizophrenia with our knowledge of psychotic prodromes in an attempt to identify a group particularly vulnerable to impending psychosis. We wanted to identify people with high likelihood of transition to psychosis within a follow-up period of 12 months, and to determine the rate of transition to psychosis in this group.

METHOD

Various state and trait risk factors for psychosis were used alone and in combination to operationally define a putatively high-risk group. Operationalised criteria for onset of psychosis were established. The individuals were assessed monthly on measures of psychopathology for six months.

RESULTS

Eight out of 20 people made the transition to frank psychosis within a six-month follow-up period. Follow-up of this group is still in progress, and the 12 month transition rate might prove to be higher still.

CONCLUSIONS

We have demonstrated that it is possible to identify individuals with a high likelihood of onset of psychosis within a brief follow-up period. This lays the foundation for early treatment in an attempt to prevent, delay or minimise the severity of first onset of schizophrenia.

Cognitively-oriented psychotherapy for early psychosis (COPE). Preliminary results

BACKGROUND

The present study describes the results of the pilot testing of a therapy we have developed for people with first-episode psychosis. Cognitively-oriented psychotherapy for early psychosis (COPE) is aimed at facilitating the adjustment of the person, and at preventing or alleviating secondary morbidity in the wake of the first psychotic episode.

METHOD

Eighty people formed three groups: those who were offered and accepted COPE (COPE subjects); those who refused COPE (refusal subjects); and those who were offered neither COPE nor any other continuing treatment from our service (control subjects). The individuals were assessed prior to, and at the end of, COPE treatment (a 12-month period) on the Integration/Sealing Over, Explanatory Model, Scale for the Assessment of Negative Symptoms, Brief Psychiatric Rating Scale, Quality of Life, SCL-90-R, and Beck Depression Inventory measures.

RESULTS

People who received COPE obtained significantly superior scores (P < 0.05) to the control group on four of the seven measures but only significantly out-performed the refusal group on one of the seven measures (P < 0.05). The COPE group performed significantly worse on the BDI than the refusal group (P < 0.05). Effect sizes are also provided for each measure.

CONCLUSIONS

There seems to be a place for psychological therapy in this group of people but our results need to be replicated in a more definitive randomised controlled trial and such a study is now in progress.