Informal caregivers in early psychosis: evaluation of need for psychosocial intervention and unresolved grief

Aim: Relatives of service users involved with Early Intervention in Psychosis services often experience substantial distress and need associated with their role as caregivers. This study adapted versions of the Relatives Cardinal Needs Schedule and the Texas Inventory of Grief and tested their utility for use among relatives of service users experiencing a first episode of psychosis. Methods: Staff, service users and relatives were consulted and a pilot took place which facilitated the creation of the Relatives' Urgent Needs Schedule – Early Intervention version (RUNS‐EI) and the Texas Inventory of Grief – Early Intervention version (TIG‐EI). Thirty service user‐caregiver dyads were recruited for the evaluation of reliability and validity. Results: The level of ‘urgent need’ identified by the RUNS‐EI demonstrated good concurrent validity with measures of service user social and global functioning as well as measures assessing relatives' distress, expressed emotion and grief. The measure demonstrated acceptable interrater and test–retest reliability. The profile of need is reported. The TIG‐EI demonstrated ‘excellent’ internal consistency. It also demonstrated good concurrent validity with increased TIG‐EI scores correlated with reduced service user social and global functioning as well as increased scores on measures assessing relatives' distress, expressed emotion and caregiving needs. Conclusions: Results appear to support these assessments' utility as measures of need for psychosocial intervention and grief among relatives supporting service users experiencing a first episode of psychosis.     

Course,outcomes, and psychosocial interventions for first‐episode mania

McMurrich S, Sylvia LG, Dupuy JM, Peckham AD, Peters AT, Deckersbach T, Perlis RH. Course, outcomes, and psychosocial interventions for first‐episode mania. Bipolar Disord 2012: 14: 797–808. © 2012 The Authors. Journal compilation © 2012 John Wiley & Sons A/S. Objectives: The course of bipolar disorder tends to worsen over time, highlighting the importance of early intervention. Despite the recognized need for adjunctive psychosocial treatments in first‐episode mania, very few studies have evaluated psychological interventions for this period of significant risk. In this empirical review, we evaluate existing research on first‐episode bipolar disorder, compare this body of research to parallel studies of first‐episode schizophrenia, and identify strategies for future research. Methods: A comprehensive literature search of the MEDLINE and PsychINFO databases was conducted to identify studies of first‐episode mania, as well as first‐episode schizophrenia. Recovery and relapse rates were compared across studies. Results: In contrast to a number of studies of first‐episode schizophrenia, the authors identified only seven independent programs assessing first‐episode mania. Findings from these studies suggest that, while pharmacological treatment helps patients achieve recovery from acute episodes, it fails to bring patients to sustained remission. Early psychosocial intervention may be imperative in reducing residual symptoms, preventing recurrence of mood episodes, and improving psychosocial functioning. However, very few studies of psychosocial interventions for first‐episode mania have been systematically studied. Conclusions: Studies of first‐episode mania indicate a gap between syndromal/symptomatic and functional recovery. Novel psychosocial interventions for first‐episode mania may help bridge this gap, but require controlled study.     

Clinical and sociodemographic comparison of people at high‐risk for psychosis and with first‐episode psychosis

Zimbrón J, Ruiz de Azúa S, Khandaker GM, Gandamaneni PK, Crane CM, González‐Pinto A, Stochl J, Jones PB, Pérez J. Clinical and sociodemographic comparison of people at high‐risk for psychosis and with first‐episode psychosis. Objective: To compare clinical and sociodemographic characteristics previously associated with psychosis, between individuals at high‐risk for psychosis (HR) and patients experiencing a first episode psychosis (FEP), to achieve a better understanding of factors associated with psychosis. Method: Cross‐sectional comparison of 30 individuals at HR with 30 age‐gender matched FEP, presenting to an early intervention service for psychosis. Participants were followed‐up for 2 years to establish the proportion of HR who made the transition into FEP. Results: Both groups showed similar socio‐clinical characteristics, including immigration status, employment history, marital status, family history of psychotic illness, self‐harm and alcohol and drug use. The HR group had a lower level of education, higher burden of trauma, earlier onset of psychiatric symptoms and a longer delay in accessing specialised services. A younger onset of symptoms was associated with a longer delay in accessing services in both groups. After a 2 year follow‐up, only three (10%) of the HR group made a transition into FEP. Conclusion: The similarities observed between individuals at HR and those with FEP suggest that known variables associated with psychosis may be equally prevalent in people at HR who do not develop a psychotic disorder.     

Suicide prevention in first episode psychosis: the development of a randomised controlled trial of cognitive therapy for acutely suicidal patients with early psychosis

BACKGROUND: Young people with early psychosis are at particularly high risk of suicide. However, there is evidence that early intervention can reduce this risk. Despite these advances, first episode psychosis patients attending these new services still remain at risk. To address this concern, a program called LifeSPAN was established within the Early Psychosis Prevention and Intervention Centre (EPPIC). The program developed and evaluated a number of suicide prevention strategies within EPPIC and included a cognitively oriented therapy (LifeSPAN therapy) for acutely suicidal patients with psychosis. We describe the development of these interventions in this paper. METHOD: Clinical audit and surveys provided an indication of the prevalence of suicidality among first episode psychosis patients attending EPPIC. Second, staff focus groups and surveys identified gaps in service provision for suicidal young people attending the service. Third, a suicide risk monitoring system was introduced to identify those at highest risk. Finally, patients so identified were referred to and offered LifeSPAN therapy whose effectiveness was evaluated in a randomised controlled trial. RESULTS: Fifty-six suicidal patients with first episode psychosis were randomly assigned to standard clinical care or standard care plus LifeSPAN therapy. Forty-two patients completed the intervention. Clinical ratings and measures of suicidality and risk were assessed before, immediately after the intervention, and 6 months later. Benefits were noted in the treatment group on indirect measures of suicidality, e.g., hopelessness. The treatment group showed a greater average improvement (though not significant) on a measure of suicide ideation. CONCLUSIONS: Early intervention in psychosis for young people reduces the risk of suicide. Augmenting early intervention with a suicide preventative therapy may further reduce this risk.     

'Jumping to conclusions' in first-episode psychosis

Aim: People with psychotic symptoms are reported to have a characteristic reasoning style in which they jump to conclusions (JTC). The aims of this research were threefold. The first was to establish how prevalent this style is in people with first‐episode psychosis. The second was to examine the specificity of JTC to delusions. The third was to examine explanatory factors that may account for the JTC style. This was investigated by attempting to replicate, with a large sample, previous studies indicating that JTC is associated with specific psychotic and non‐psychotic symptoms and processes. Methods: Seventy‐seven service users were recruited from a first‐episode service and completed measures of reasoning and psychotic and non‐psychotic symptomatologies. A well‐established criterion was used to compare the JTC performance of those people with and without JTC. Results: JTC was present in over 40% of the sample, which is consistent with previous studies of people with long‐standing psychotic symptoms. Unlike previous research, no strong associations were found in relation to symptoms and other processes. Conclusions: JTC is a phenomenon common in many people in first‐episode services. In this large cohort sample, no clear associations with symptoms or other psychological processes were evident. Hence, the reason people JTC is still unclear.     

Cognitive insight and verbal memory in first episode of psychosis

Beck and collaborators have proposed a distinction between clinical insight and cognitive insight and have developed a tool for the assessment of the latter, namely the Beck Cognitive Insight Scale (BCIS). The present study explored in 51 patients with a first episode of psychosis the neurocognitive correlates of cognitive insight as assessed with the BCIS. Global measures for seven domains of cognition including verbal learning and memory, visual learning and memory, working memory, speed of processing, reasoning and problem solving, attention, and social cognition were examined. Secondly, we examined whether two clinical insight measures, the Scale to assess Unawareness of Mental Disorder (SUMD) and the insight item from the Positive and Negative Symptoms Scale (PANSS), could produce similar or different patterns of association with neurocognitive functions as those identified with the BCIS. Correlational analyses revealed significant associations between the BCIS Composite Index and the verbal learning and memory. No significant associations were observed between any of the neurocognitive domains and the PANSS or SUMD clinical insight measures, despite high inter-correlations among the three insight measures. These results suggest that cognitive insight, but not clinical insight, may rely on memory processes whereby current experiences are appraised based on previous ones.     

Neurocognitive functioning in patients recently diagnosed with bipolar disorder

Hellvin T, Sundet K, Simonsen C, Aminoff SR, Lagerberg TV, Andreassen OA, Melle I. Neurocognitive functioning in patients recently diagnosed with bipolar disorder. Bipolar Disord 2012: 14: 227–238. © 2012 The Authors. Journal compilation © 2012 John Wiley & Sons A/S. Objectives: Cognitive dysfunction in bipolar disorder (BD) is well established in the literature; however, there are few studies of neurocognition in patients early in the course of the illness. In this study we compare neurocognitive function in a cohort of first‐contact mania patients with a healthy control group matched for age, gender, and education. Methods: Patients with a first manic episode (FM) (n = 34) or previous untreated manic episodes (PM) (n = 21) were neuropsychologically tested following their first treated manic episode. A total of 110 matched healthy control comparison subjects were also tested. The following cognitive domains were evaluated: verbal and visual learning and memory, attention, processing speed, executive functioning, and IQ. Results were corrected for speed of processing differences and were compared with previously reported results for multiple‐episode BD patients. Results: BD patients early in their disease course showed impairments in psychomotor speed, attention, learning and memory, executive functioning, and IQ. When controlling for speed of processing, measures of visuoconstructive reasoning and motor dexterity remained statistically significant. Eighteen percent of FM and 16% of PM patients were found to have clinically significant neurocognitive impairment. No significant relationship between clinical symptoms and neurocognition was found. The first‐contact mania patients studied were found to have smaller neurocognitive deficits compared to multiple‐episode patients in previous studies. Conclusions: Neurocognitive dysfunction is present in early BD and is clinically significant for a proportion of patients. Our findings also suggest that neurocognitive dysfunction may increase with illness progression.     

Improving detection of first-episode psychosis by mental health-care services using a self-report questionnaire

Objective: To examine the utility of the Community Assessment of Psychic Experiences (CAPE)‐42, a self‐report questionnaire, to improve detection of first‐episode psychosis in new referrals to mental health services. Method: At first contact with mental health‐care services patients were asked to complete the CAPE‐42 and were then routinely diagnosed by a clinician. Standard diagnoses were obtained by means of the mini‐Schedule for Clinical Assessment in Neuropsychiatry. Results: Of the 246 included patients, 26 (10.6%) were diagnosed with psychosis according to the mini‐Schedule for Clinical Assessment in Neuropsychiatry. Only 10 of them were recognized by clinical routine, and 16 psychotic patients were not properly identified. Using an optimal cut‐off of 50 on the frequency or distress dimension of the positive subscale of the CAPE‐42 detected 14 of these misdiagnosed patients. The sensitivity of the CAPE‐42 at this cut‐off point was 77.5 and the specificity 70.5. Conclusion: Systematic screening of patients using a self‐report questionnaire for psychotic symptoms improves routine detection of psychotic patients when they first come into contact with mental health services.     

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

Aim: Easy access to first‐episode psychosis (FEP) services is critical in reducing the duration of untreated illness. However, primary caregivers can encounter difficulties accessing services on behalf of young people with FEP. This qualitative study describes the lived experience of first‐time primary caregivers of young adults with FEP, with a focus on examining how they access specialist FEP services. Methods: A qualitative study was undertaken using semi‐structured, in‐depth interviews with 20 caregivers in Melbourne. Results: Most carers were women (85%, n = 17) and parents (85%, n = 17). Nearly all lived in the same households as the young people with FEP (90%, n = 18). The mean duration of their involvement with the FEP service was 14.5 months (standard deviation = 8.9). Three competing themes were identified in the data, reflecting caregivers' polarized experiences accessing FEP services. First, general practitioners were regarded as either a resourceful or an unresourceful means of access to FEP services. Second, caregivers often encountered service‐focused and carer‐focused barriers when initially accessing services. Third, a combination of acquired knowledge, experience with services and caregiver assertiveness enhanced access on subsequent occasions. Conclusion: This study highlights the important contribution and experience of first‐time primary caregivers and the difficulties they face accessing services. The findings suggest access should be influenced more by clinical need and less by caregivers' perseverance. The findings also underline the importance of providing clinical training that acknowledges the needs and contributions of caregivers, as well as interventions that meet the unique challenges faced by first‐time caregivers accessing services after the onset of FEP.     

Incidence and diagnostic diversity in first‐episode psychosis

Reay R, Mitford E, McCabe K, Paxton R, Turkington D. Incidence and diagnostic diversity in first‐episode psychosis. Objective: To investigate the incidence and range of diagnostic groups in patients with first‐episode psychosis (FEP) in a defined geographical area. Method: An observational database was set up on all patients aged 16 years and over presenting with FEP living in a county in Northern England between 1998 and 2005. Results: The incidence of all FEP was 30.95/100 000. The largest diagnostic groups were psychotic depression (19%) and acute and transient psychotic disorder (19%). Fifty‐four per cent of patients were aged 36 years and over. Patients with schizophrenia spectrum disorder only accounted for 55% of cases. Conclusion: This clinical database revealed marked diversity in age and diagnostic groups in FEP with implications for services and guidelines. These common presentations of psychoses are grossly under researched, and no treatment guidelines currently exist for them.     

Using the global functioning social and role scales in a first-episode sample

Aims: Dysfunction in social and role functioning is a hallmark of schizophrenia, which is present in both the prodromal phase and at the first episode of the illness. Two new measures, Global Functioning: Social and Global Functioning: Role, were developed to address functioning in the prodromal phase of the illness. The purpose of this study was to determine if these measures would be useful in a first episode population. Methods: Forty‐eight stable outpatients were assessed using the new social and role scales. A subsample of 33 subjects was assessed at 6 and 12 months. All subjects were additionally assessed using standardized measures of psychotic symptoms, social functioning, self‐esteem and beliefs about illness. Results: Average ratings on the Global Functioning: Social and Role scales were 6 (standard deviation (SD) = 1.60) and 5.5 (SD = 2.2), respectively. Both social and role scales were significantly correlated with relevant subscales on the Social Functioning Scale. Good social but not role functioning was related to low levels of both positive and negative symptoms and to high self‐esteem. Role but not social functioning was related to personal beliefs about the illness, such as having control over illness and feeling less stigmatized. Repeated measures analyses demonstrated no change over time for either social or role functioning. Conclusion: The Global Functioning: Social and Role scales appear to be useful and valid measures of functioning in first‐episode patients. These ratings are similar to those reported in prodromal studies supporting the idea that poor functioning may be a stable long‐standing deficit.     

Magnetic Resonance Imaging and the Prediction of Outcome in First-Episode Schizophrenia: A Review of Current Evidence and Directions for Future Research

Magnetic Resonance Imaging (MRI) measures are promising outcome markers for schizophrenia, since regional frontal and temporal grey matter volumes reductions, and enlargement of the ventricles, have been associated with outcome in this disorder. However, a number of methodological issues have limited the potential clinical utility of these findings. This article reviewed studies that examined brain structure at illness onset as a predictor of outcome, discusses the limitations of the findings, and highlights the challenges that would need to be addressed if structural data are to inform the management of an individual patient. Methods: Using a set of a priori criteria, we systematically searched Medline and EMBASE databases for articles evaluating brain structure at the time of the first psychotic episode and assessed response to treatment, symptomatic outcome, or functional outcome at any point in the first 12 months of illness. Results: The 11 studies identified suggest that alterations in medial temporal and prefrontal cortical areas, and in the networks that connect them with subcortical structures, are promising neuroanatomical markers of poor symptomatic and functional outcomes. Conclusion: Neuroimaging data, possibly in combination with other biomarkers of disease, could help stratifying patients with psychoses to generate patient clusters clinically meaningful, and useful to detect true therapeutic effects in clinical trials. Optimization of Treatment and Management of Schizophrenia in Europe (OPTiMiSE), a large multicenter study funded by the FP7 European Commission, could generate these much-needed findings.Key words: psychosis, MRI, brain structure, treatment response, OPTiMiSE     

Functional outcomes in schizophrenia: understanding the competence-performance discrepancy

A problem in the study and treatment of functional disability in schizophrenia is that factors other than competence (what one can do) can limit real-world performance (what one does). We examined predictors of the competence-performance discrepancy in both adaptive and interpersonal domains. Patients with schizophrenia (N = 96) were evaluated at baseline of a clinical treatment study. Discrepancy scores were created by considering each subject’s competence relative to their real-world performance in interpersonal and adaptive behaviour domains. Logistic regression analyses revealed that for the interpersonal competence-performance discrepancy, living in a group home, better neurocognition, more time spent in the hospital since a first episode of psychosis, and a longer first hospitalization predicted a greater discrepancy between interpersonal competence and performance measures. For adaptive behaviour, shorter time since most recent hospitalization, more depressive symptoms, greater number of months of first hospitalization, older age at baseline, younger age at first hospitalization, and more time spent in the hospital since a first episode of psychosis predicted a greater adaptive competence-performance discrepancy. A different pattern of demographic and clinical features may limit the extent to which patients are deploying interpersonal versus adaptive skills in everyday life.     

Can a targeted psychological intervention be effective for young people following a first manic episode? Results from an 18‐month pilot study

Aim: There is a scarce literature describing psychological interventions for a young, first‐episode cohort who have experienced psychotic mania. This study aimed to assess whether a manualized psychological intervention could be effective in reducing symptomatology and relapse, and improve functional outcome in this population. Methods: The study was an open‐label design, drawn from a larger pharmacotherapy trial. All participants in the pharmacotherapy trial were offered a manualized psychological intervention in addition to case management. Inclusion in the psychotherapy group was based on participant's choice, and on completion of four or more of the eight modules offered. All clinical files were audited to ensure accuracy of group allocation. Forty young people aged 15 to 25 years old who had experienced a manic episode with psychotic features were recruited into the study, with 20 people in the combined treatment as usual plus psychotherapy group (P+TAU), and an equal number of matched control participants who received treatment as usual (TAU) within the same service. All participants were prescribed antipsychotic and mood‐stabilizing medication. Symptomatic, functional and relapse measures were taken both at baseline and at 18‐month follow‐up. Results: Manic symptoms improved significantly for both groups, with no differences between groups. Depression scores and overall symptom severity were significantly lower in the P + TAU group. No differences were evident between groups with regard to numbers or type of relapse. The P + TAU group had significantly better social and occupational functioning after 18 months. Conclusion: This study suggests that a manualized psychological intervention targeted to a first‐episode population can be effective in reducing depression and overall symptom severity, and can improve functional outcome following a first episode of psychotic mania.     

Social adjustment based on reported behaviour in bipolar affective disorder

OBJECTIVES: To determine the effects of mood and additional clinical variables on different domains of current interviewer-rated social adjustment reflecting the reported behaviour of patients with bipolar disorder (BD). METHOD: Multi-center cross-sectional study employing multiple linear regression to investigate whether mood and other clinical features, previously linked to self-rated social adjustment, were associated with eight domains of interviewer-rated social adjustment in 253 BD patients. Baseline variables were entered sequentially in blocks representing current mood, demographic, current other psychiatric, past psychiatric and current treatment variables. RESULTS: Mood episode or symptoms together with five other variables (borderline/antisocial personality disorder, male gender, living alone, hypnotic drug and drugs for physical illness) were associated with impairment on two or more domains of interviewer-rated social adjustment. They explained up to 31% of the variance in social adjustment, although friction, dependence and overactivity were associated with a different pattern of variables. Hypomanic symptoms were associated with increased friction and worse social adjustment with the extended family in the whole sample but improved performance and social and leisure activities in patients who were not in acute bipolar episode. CONCLUSION: Clinicians may determine up to about 30% of outcome in current social adjustment in BD patients from the patient's current mood episode or symptoms and a small number of other clinical or demographic variables. Hypomanic episodes and symptoms usually worsen friction and overall social adjustment, but in patients who are not in acute episode, hypomanic symptoms can increase performance and social and leisure activities.     

Initial medical work-up of first-episode psychosis: a conceptual review

Aim: To help clinicians carry out a comprehensive, medical diagnostic assessment in first‐episode patients who are suspected of developing schizophrenia. Methods: Conceptual review of the published work with emphasis on the diagnostic goals of excluding medical causes of psychosis and establishing a medical baseline. Results: There is no agreed‐upon standard for the initial medical work‐up of first‐episode cases. Excluding secondary causes of schizophrenia requires consideration of likelihood of disease; laboratory test performance; and relevance of positive test results. Conclusions: We propose a medical work‐up for first‐episode psychosis that combines: (i) broad screening; (ii) exclusion of specific diseases informed by treatability and epidemiology; and (iii) medical baseline measures.     

Correlates of subjective recovery in an early intervention program for psychoses

Aim: To examine the relative importance of symptoms and components of social support in predicting subjective recovery from psychosis. Methods: Eighty‐four clients of a first‐episode program for psychotic disorders completed measures of subjective recovery (the Recovery Assessment Scale and the Modified Engulfment Scale) and measures of social support related to appraisal support, tangible support, general sense of belongingness and perceived relational evaluation (PRE). Measures of positive and negative symptoms of psychosis were completed by an independent assessor. Results: Although symptoms, particularly negative symptoms, were correlated with several indices of recovery, PRE generally emerged as the most consistent and important predictor. Conclusions: PRE appears to be a particularly important aspect of social support in predicting subjective recovery. Prospective studies of the importance of PRE are warranted.     

Understanding the experiences and service needs of siblings of individuals with first-episode psychosis: a phenomenological study

Background: Despite recent focus on developing family‐inclusive services to meet the needs of young people with first‐episode psychosis, the needs of their siblings are often overlooked. Aims: This study explored the experiences and needs of siblings of young adults with first‐episode psychosis receiving support from two Early Intervention in Psychosis Services in South‐East England. Methods: Thirty‐one siblings aged 11–35 years, were given a semi‐structured interview to gather their perspectives and accounts of their lived experiences. The resultant rich qualitative data was analysed using responsive‐reader and framework methods. Results: Six themes were identified: siblings' roles and involvement; emotions; impact on relationships; coping patterns; resilience; and siblings' service needs. Conclusion: All participants had been greatly affected by the onset of the psychosis in their brother or sister. Most siblings did not identify themselves as carers, although most played a significant part in their brother's or sister's life. Participants wanted dynamic, robust and accessible services, especially information and peer support to meet their needs.     

Course of cognitive functioning in first episode schizophrenia spectrum disorders

Studies of cognitive functioning in patients with first episode schizophrenia spectrum disorders can be particularly informative. Through the use of electronic- and bibliography-based searches, the authors identified studies examining the course of cognitive functioning in first episode patients. The results of this review indicated that first episode patients at presentation for treatment often show compromised cognitive functioning, particularly in the domains of verbal learning and memory, psychomotor speed and attention. However, in comparison with patients with a longer illness history, first episode patients demonstrate significantly superior performance. In longitudinal studies of first episode patients, cognitive functioning generally remained static, suggesting limited change in performance over the first several years of the illness. The implications of these findings for future research are discussed.