Patient satisfaction with treatment in first-episode psychosis

Purpose: To examine first-episode psychotic patients' satisfaction with elements of a comprehensive 2-year treatment program. Subjects and method: The TIPS (Early Treatment and Intervention in Psychosis) project provided a 2-year treatment program consisting of milieu therapy (inpatient), individual psychotherapy, family intervention and medication. Of 140 patients at baseline, 112 were included at 2-year follow-up. Eighty-four participants were interviewed using a questionnaire eliciting levels of satisfaction with different treatment elements at two of the four sites. Results: Participants and non-participants did not differ on demographic or clinical data at baseline. Of those participating, 75% were satisfied with treatment in general. Individual and milieu therapy received higher rating than medication or family intervention. No predictors of general satisfaction with treatment were found, but continuously psychotic patients were the least satisfied with medication treatment. Discussion: As in most patient satisfaction studies within mental health treatment networks, there was high level of general satisfaction with the total package of treatment but considerable variation in satisfaction for specific interventions. In this sample of first-episode psychosis patients, there was general satisfaction with treatments based on one-to-one relationships while multi-family group intervention was consistently valued less enthusiastically.     

Neuropsychological functioning in early-onset first-episode psychosis: comparison of diagnostic subgroups

The aims of this study were to examine the nature and extent of cognitive impairment in first-episode early-onset psychosis (FE-EOP) soon after their stabilisation and to search for potential differences according to specific diagnostic sub-groups of patients. As part of a Spanish multicentre longitudinal study, 107 FE-EOP patients and 98 healthy controls were assessed on the following cognitive domains: attention, working memory, executive functioning, and verbal learning and memory. Three diagnostic categories were established in the patient sample: schizophrenia (n = 36), bipolar disorder (n = 19), and other psychosis (n = 52). Patients performed significantly worse than controls in all cognitive domains. The three diagnostic sub-groups did not differ in terms of impaired/preserved cognitive functions or degree of impairment. FE-EOP patients show significant cognitive impairment that, during this early phase, seems to be non-specific to differential diagnosis.     

Mentalizing in first-episode psychosis

Mentalizing deficits have often been observed in people with schizophrenia and a few recent studies suggest that such deficits are also present in patients with first episode psychosis (FEP). It is not clear, however, whether these mentalizing deficits in FEP can be accounted for by underlying processes such as social cue recognition, social knowledge and general reasoning. In this study, we assessed mentalizing abilities in 31 people with FEP and 31 matched controls using a novel, comprehensive mentalizing task validated through the present study. We also assessed social cue recognition, social knowledge and non-social (or general) reasoning performance in the same participants in order to determine if the mentalizing deficits in FEP can be at least partly explained by performance in these three underlying processes. Overall, the mentalizing task revealed the greatest impairment in FEP, an impairment that remained significant even after controlling for social cue recognition, social knowledge and non-social reasoning performance. Interestingly, non-social reasoning and social knowledge were both shown to contribute to mentalizing performance. In addition, social cognition measures were linked to social functioning in the FEP group, with the strongest correlation observed with mentalizing performance. Taken together, these results show that mentalizing is an aspect of social cognition that is particularly affected in FEP and might contribute to functional impairments in these patients. These deficits could be a prime target for cognitive remediation in FEP, and our results suggest that this could be done either directly or through improvement of related social and non-social cognitive skills such as social knowledge and general reasoning.     

Self-harm in first-episode psychosis

BACKGROUND: Little is known about self-harm occurring during the period of untreated first-episode psychosis. AIMS: To establish the prevalence, nature, motivation and risk factors for self-harm occurring during the untreated phase of first-episode psychosis. METHOD: As part of the AESOP (Aetiology and Ethnicity in Schizophrenia and Other Psychoses) study, episodes of self-harm were identified among all incident cases of psychosis presenting to services in south-east London and Nottingham over a 2-year period. RESULTS: Of the 496 participants, 56 (11.3%) had engaged in self-harm between the onset of psychotic symptoms and first presentation to services. The independent correlates of self-harm were: male gender, belonging to social class I/II, depression and a prolonged period of untreated psychosis. Increased insight was also associated with risk of self-harm. CONCLUSIONS: Self-harm is common during the pre-treatment phase of first-episode psychosis. A unique set of fixed and malleable risk factors appear to operate in those with first-episode psychosis. Reducing treatment delay and modifying disease attitudes may be key targets for suicide prevention.     

Functional neuroimaging in first-episode psychosis

Single photon emission computed tomography (SPECT) is a valuable tool for evaluating regional cerebral blood flow (rCBF) in patients with schizophrenia. Recently, various neuropharmacological studies using SPECT in patients with schizophrenia have also characterized dopamine D₂ receptors, their correlation with symptoms, as well as receptor occupancy after treatment with atypical antipsychotics.^1,2 We studies changes in rCBF in first-episode psychosis (FEP) before and after pharmacological treatment.     

White-matter hyperintensities in first-episode psychosis

BACKGROUND: White-matter hyperintensities have been associated with both schizophrenia and mood disorders, particularly bipolar disorder, but results are inconsistent across studies. AIMS: To examine whether white-matter hyperintensities are a vulnerability marker for psychosis or are specifically associated with bipolar disorder. METHOD: T(2)-weighted magnetic resonance imaging data were acquired in 129 individuals with first-episode psychosis (either affective or non-affective psychoses) and 102 controls who were randomly selected from the same geographical areas. Visual white-matter hyperintensity ratings were used for group and subgroup comparisons. RESULTS: There were no statistically significant between-group differences in white-matter hyperintensity frequency or severity scores. No significant correlations were found between white-matter hyperintensity scores and duration of illness, duration of untreated psychosis, or severity of psychotic, manic or depressive symptoms. CONCLUSIONS: White-matter hyperintensities are not associated with vulnerability to psychosis in general, or specifically with affective psychoses. Further, first-episode psychosis investigations using more quantitative methods are warranted to confirm these findings.     

Early intervention in first-episode psychosis

OBJECTIVE: Substantial delays in providing access to treatment in first-episode psychosis have been well documented. The present study examines the impact of strategies aimed at improving access and reducing delays. METHOD: A pilot community education campaign was conducted with the aim of reducing the duration of untreated psychosis (DUP) in a geographically defined intervention sector located in the northwestern region of Melbourne, Australia. Utilising a quasi-experimental design, a comparison sector with similar demographics was selected from another part of the north-western region. A mobile early detection team and the same treatment system served both sectors. RESULTS: While there was no significant difference between the mean DUP for intervention and comparison sectors, the distributional features of DUP between the two regions were significantly different. In the intervention sector, disproportionately more cases with very long DUP were detected. When a small number of outliers were removed, the mean and median DUP in the intervention sector was reduced. CONCLUSION: These findings highlight the complexity of treatment access and delay and suggest that efforts to reduce DUP may have two effects, not one. Firstly, a different sample of cases is treated through the detection of hidden "long DUP" cases that otherwise may have remained untreated. Secondly, the DUP for the remainder may indeed be reduced. More research with larger samples and more potent campaign strategies is clearly required. It may also be worth considering whether there is a safe and ethical way to undertake a RCT of early versus delayed antipsychotic treatment to perhaps settle the DUP debate once and for all.     

Homocysteine and cognition in first-episode psychosis patients

In the last years, there has been growing evidence linking elevated homocysteine levels with cognitive dysfunction in several neurological and neuropsychiatric diseases. The aim of the present study was to investigate the potential relationship between elevated homocysteine levels and cognitive deficits in first-episode psychosis patients. Plasma levels and cognitive performance of 139 patients and 99 healthy volunteers were compared. Patients were classified as elevated homocysteine (>90 percentile for controls) and normal and compared on 22 cognitive outcome measures grouped into cognitive domains known to be impaired in schizophrenia. Patients had a statistically significant increase in plasmatic homocysteine levels. In addition, they presented with significantly increased cognitive deficits. However, no relationship between homocysteine levels and cognitive impairment was detected. These results suggest the need for further studies to clarify the role of homocysteine in the etiology and prognosis of psychosis.     

Differential associations of cognitive insight components with pretreatment characteristics in first-episode psychosis

An increasing number of studies have focused on cognitive insight (i.e. awareness of one's own thinking) in psychotic disorders. However, little is known about the premorbid and pretreatment correlates of cognitive insight in the early course of psychosis. One hundred and three patients experiencing first-episode psychosis (FEP) were assessed shortly after treatment initiation for cognitive insight. Pretreatment and baseline clinical, functional and neurocognitive characteristics were examined. The self-reflectiveness dimension of cognitive insight was independently associated with clinical insight and executive functioning, whereas self-certainty was associated with premorbid IQ, premorbid academic adjustment and clinical insight. The amount of variance explained by the independent variables was small to moderate. Self-reflectiveness and self-certainty have differential pretreatment correlates in FEP and may reflect separate cognitive processes which require targeted interventions.     

Recovery style and outcome in first-episode psychosis

Our study aimed to investigate how recovery styles influence 12-month clinical outcome in first-episode psychosis patients. We hypothesised that patients who use an integrative recovery style would have better outcome than those who seal over. A total of 196 first-episode psychosis patients from the Early Psychosis Intervention Centre (EPPIC) participated in the study. Each patient was interviewed at stabilization of their acute psychotic episode, and then again 12 months later, using an Integration/Sealing-over measure. Our results suggest that recovery style may be a useful predictor of outcome. Integrative patients had better outcome and functioning at 12 months. These results were influenced by diagnosis and, unlike previous studies, recovery style changed over time, suggesting it was not a stable trait. The capacity for recovery style to change challenges the suggestion it is a personality trait and raises the need for psychoeducation and other psychological interventions that could improve outcome.     

Reinforcement and reversal learning in first-episode psychosis

Background: Abnormalities in reinforcement learning and reversal learning have been reported in psychosis, possibly secondary to subcortical dopamine abnormalities. Methods: We studied simple discrimination (SD) learning and reversal learning in a sample of 119 first-episode psychosis patients from the Cambridge early psychosis service (CAMEO) and 107 control participants. We used data on reinforcement learning and reversal learning extracted from the Cambridge Neuropsychological Test Automated Battery Intradimensional-Extradimensional shift task, which measures cognitive flexibility but also involves simple reinforcement learning (SD learning) and reversal learning stages. We also gathered diagnostic information to examine whether there were any differences between patients ultimately diagnosed with schizophrenia-spectrum disorders and those diagnosed with affective psychosis. Results: Psychosis patients demonstrated deficits in simple reinforcement learning (SD learning) and in reversal learning, with no differences between affective psychosis and schizophrenia-spectrum psychosis. There was a significant modest correlation between reversal errors and negative symptoms (Spearman rho = 0.3, P = .02). Conclusions: There are reinforcement learning abnormalities in first-episode psychosis, which correlate with negative symptoms, suggesting a possible role for orbitofrontal cortex and ventral striatal pathology in the pathogenesis of motivational deficits in psychosis.     

'Social dysmetria' in first-episode psychosis patients

Waters F, Rock D, Dragovic M, Jablensky A. ‘Social dysmetria’ in first‐episode psychosis patients. Objective: The ‘embodied cognition’ hypothesis suggests a close relationship between internal self‐representations and the outward expression of social behaviours and emotions. Given self‐awareness disturbances in patients with first‐rank symptoms (FRS), we hypothesized that these patients would show abnormal social behaviours. In this study, we examined the social interactive skills of patients with first‐episode psychosis during an interview, together with changes in performance over time. Method: We analysed previously unreported data from 227 patients with first‐episode psychosis (90 with, and 137 without, FRS) who took part in the WHO multicentre study on the Determinants of Outcome of Severe Mental Disorders. They were assessed on the Psychological Impairment Rating Schedule (PIRS) and examined again after 2 years. Results: A principal component analysis on the Psychosocial Impairment Rating Schedule produced two factors (interactive skills; withdrawal from interactions). Patients with FRS showed greater impairments in the domain linked to ‘interactive skills’, which remained 2 years after the first experience of a psychotic illness. These findings were not explained by clinical characteristics, or presence of non‐FRS delusions. Conclusion: Self‐awareness deficits, as indexed by the FRS symptom cluster, are linked to deficits in social interactive behaviours. These abnormalities are indicative of ‘social dysmetria’ in this group, which involves difficulties conveying motor aspects of behaviours, volition and affect to facilitate mutual communication. These findings point to the utility of behavioural assessment scales in clinical and research settings.     

Temporal lobe abnormalities in first-episode psychosis

OBJECTIVE: The nature and time course of temporal lobe abnormalities in psychotic illness remain controversial. Confounds include disease chronicity, gender, and handedness. The present study investigated temporal substructures in right-handed male patients experiencing their first episode of psychotic illness. METHOD: Magnetic resonance imaging scans were obtained for 25 minimally treated patients experiencing their first psychotic episode and 16 healthy comparison subjects. Group differences in volumes of the hippocampus, amygdala, planum temporale, and Heschl's gyrus were tested. RESULTS: The patients had smaller bilateral hippocampal and left planum temporale volumes than the comparison subjects. Paranoid and nonparanoid patients differed in left amygdala volume. CONCLUSIONS: The authors conclude that bilateral hippocampal and left planum temporale abnormalities are present near the onset of psychosis.     

'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.     

Substance abuse in first-episode non-affective psychosis

Abuse of alcohol and drugs is an important and clinically challenging aspect of first-episode psychosis. Only a few studies have been carried out on large-sized and reliably characterized samples. These are reviewed, and the results are compared with a sample of 300 first-episode psychosis patients recruited for the TIPS (Early Treatment and Identification of Psychosis) study from Norway and Denmark. Prevalence rates from the literature vary from 6% to 44% for drugs and 3% to 35% for alcohol. In our sample, 23% abused drugs and 15% abused alcohol during the last 6 months. When compared to non-abusers, the drug-abusing group is characterized by the following: male gender, younger age, better premorbid social, poor premorbid academic functioning, and more contact with friends in the last year before onset. Alcohol abusers were the oldest group and they had the least contact with friends. A group of patients abusing both drugs and alcohol had poor premorbid academic functioning from early childhood. Overall, drug and alcohol abuse are highly prevalent in contemporary first-episode psychosis samples. In our study, substance abuse comorbidity did not generate differences on diagnosis, duration of untreated psychosis, psychiatric symptoms, or global functioning at onset/baseline. The premorbid profiles of the substance abusers were clearly different from the non-abusers. Drug abusers, in particular, were more socially active both premorbidly and during the year preceding the start of treatment.