Depression in first episode psychosis: The role of subordination and shame

Depression in early psychosis is linked to poor outcome, relapse and risk of suicide, yet remains poorly understood. This article aims to examine the development of depression in acute and post psychotic phases of first episode psychosis (FEP), and its relationship to persecutors, voices, insight, and recovery. Data were gathered on 92 patients with acute FEP on depression course, severity and experience of positive symptoms, insight and appraisals of illness using validated semi-structured interviews and questionnaires. Measures were repeated at 12 months. Malevolent voices, use of safety behaviours and subordination to persecutors were associated with depression and suicidal behaviour in acute FEP. Loss, Shame, low level continuing positive symptoms and longer duration of untreated psychosis were associated with post psychotic depression. Negative appraisals remained stable despite recovery in other symptom domains. Thus, depression and risk in early psychosis may be propagated by the personal significance and content of positive symptoms experienced. When in recovery, low level symptoms, longer period of illness and negative appraisals are significant factors.     

Exploring potential associations of suicidal ideation and ideas of self‐harm in patients with congestive heart failure

Objective: To determine the factors, which are associated with suicidal ideation and ideas of self‐harm in patients with congestive heart failure (CHF). Methods: We examined 294 patients with documented CHF, New York Heart Association (NYHA) functional class II‐IV, in a cross sectional study at three cardiac outpatient departments. Measures included self‐reports of suicidal ideation and self‐harm (PHQ‐9), depression (SCID), health‐related quality of life (SF‐36), multimorbidity (CIRS‐G), consumption of alcoholic beverages, as well as comprehensive clinical status. Data were analyzed using logistic regression analyses. Results: 50 patients (17.1%) reported experiencing suicidal ideation and/or ideas of self‐harm on at least several days over the past two weeks. The final regression model revealed significant associations with health‐related quality of life, physical component (odds ratio [OR] 0.56; 95% confidence interval [CI]: 0.35–0.91), and mental component (OR 0.50; 95% CI: 0.31–0.82), consumption of alcoholic beverages (OR 1.27; 95% CI: 1.05–1.54), first‐episode depression (OR 3.92; 95% CI: 1.16–13.22), and lifetime depression (OR 10.89; 95% CI: 2.49–47.72). Age was only significant in the univariable (P=.03) regression analysis. NYHA functional class, left ventricular ejection fraction (LVEF), etiology of CHF, medication, cardiovascular interventions, multimorbidity, gender, and living situation were not significantly associated with suicidal ideation or ideas of self‐harm. Conclusions: Lifetime depression, in particular, increases the risk of suicidal ideation and ideas of self‐harm in CHF patients. Furthermore, the findings of our study underline the necessity of differentiating between first‐episode and lifetime depression in CHF‐patients in future research and clinical practice. Depression and Anxiety, 2009. © 2009 Wiley‐Liss, Inc.     

Subjective distress in first‐episode psychosis: role of symptoms and self‐esteem

Background: Patients with psychotic disorders are assumed to experience significant distress, especially during their first episode. It is unclear whether such distress is associated with the level of psychotic or other symptoms and/or to other characteristics such as level of self‐esteem. Methods: One hundred and five patients who presented with first episode psychosis (FEP) (54% male; mean age 22.74 years; 79.4% schizophrenia; 20.6% affective psychosis) were administered the Symptom Checklist 90‐Revised (SCL‐90‐R) at first presentation for treatment. Four indices derived from the SCL‐90‐R were used as measures of distress. Psychopathology was assessed with the Calgary Depression Scale, the Hamilton Anxiety Scale, the Scale for the Assessment of Positive Symptoms and the Scale for the Assessment of Negative Symptoms and self‐esteem with the Self‐esteem Rating Scale.Spearman's Correlation coefficients were calculated, followed by a regression analysis. Results: Measures of distress were highly correlated with depression (rho = 0.44–0.56), and anxiety (rho = 0.38–0.48), modestly with lack of judgement and insight (rho = ?0.28 to ?0.37) and not with positive or negative symptoms of psychosis. In a smaller sample (n = 68) distress measures were also highly correlated with self‐esteem (rho = ?0.55 to ?0.73). Logistic regression confirmed that self‐esteem explained 53% of the total variance explained (57%) by any combination of the independent variables. Conclusion: Distress experienced by individuals suffering from FEP is associated with levels of self‐esteem, depression and anxiety and not with the level of psychotic or negative symptoms. Self‐esteem may play a significant role in the magnitude of distress experienced by patients presenting with a FEP.     

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.     

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.     

First self‐perceived signs and symptoms in emerging psychosis compared with depression

Aim: To investigate differences between the early symptoms of schizophrenia and depressive disorders. Methods: Sixty‐one individuals with an at‐risk mental state (ARMS), 17 of whom later made the transition to psychosis, 37 patients with a first episode of psychosis and 16 controls with depressive disorders were interviewed about first self‐perceived signs and symptoms. Results: In ARMS and first episode of psychosis, on average, first self‐perceived signs or symptoms had occurred about 5–6 years before the interview. In ARMS, including transition to psychosis, ‘loss of energy’ and ‘difficulties concentrating’ were the most frequently recalled first signs. There was much overlap for the four most frequently mentioned symptoms in the three groups. As compared with ARMS, controls with depressive disorders significantly more often recalled ‘depression’ and ‘social isolation’ as the very first signs of disease. Conclusions: Clinicians should consider the development of self‐recalled first signs over time carefully when assessing suspected early prodromal stages of schizophrenia and beginning depressive disorder.     

First-episode psychosis, early intervention, and outcome: what have we learned?

OBJECTIVE: There has been increased interest in the potential of early intervention to positively influence outcome in first-episode psychosis (FEP) and, consequently, to influence mental health policy and practice. This study's objective was to examine the concept of early intervention and the evidence that currently exists to support such a shift in the delivery of care. METHOD: We examined the evidence for phase-specific treatment of FEP, looking for interventions that attempt to arrest the transition from a putative prodromal state to full psychosis, as well as for interventions that attempt to reduce delay in treatment. RESULTS: Some evidence supports specialized FEP interventions for short-term outcome in terms of symptom reduction, relapse rates, and greater adherence to and retention in treatment. As well, there is modest support for benefits to aspects of social and community functioning and satisfaction with life. Limited evidence supports a positive effect of community-wide case detection in terms of reduced delays in treatment and pharmacologic and psychological interventions in the prodromal phase. CONCLUSIONS: The field of early intervention in psychosis is young, with encouraging preliminary results, especially for improving outcome in established FEP. It requires further study, especially of longer-term outcome. Further studies need to examine the effects of a specialized approach on longer-term outcome and to explore cost-effective methods to reduce delays in treatment and provide interventions in the prodromal phase.     

A comparison of correlates of suicidal ideation prior to initial hospitalization for first-episode psychosis with prior research on correlates of suicide attempts prior to initial treatment seeking

Aim: Individuals with first‐episode psychosis, like those with chronic psychotic disorders, are at elevated risk for suicidal ideation and suicide attempts. However, relatively little is known about suicidality among first‐episode patients prior to their initial presentation for treatment. This analysis was designed as a US‐based examination of recent findings on prior suicide attempts from Dublin, Ireland, here focusing on prevalence and correlates of suicidal ideation during the weeks prior to initial treatment‐seeking. Methods: Participants included 109 first‐episode inpatients with primary psychotic disorders in public‐sector settings that serve an urban, low‐income, socially disadvantaged, predominantly African American population. Eligible patients had received <3 months of prior antipsychotic treatment and had not been hospitalized for psychosis >3 months prior to the index admission, though most were completely treatment naïve. Assessments included the Positive and Negative Syndrome Scale, Calgary Depression Scale for Schizophrenia, Birchwood Insight Scale, and a rigorous method for determining age at onset of first psychotic symptoms and duration of untreated psychosis. Results: Disconcertingly, nearly one quarter of patients (23%) endorsed a history of suicidal ideation in the 2 weeks prior to first admission. In the model designed to replicate the prior study in Ireland, Calgary Depression score (calculated omitting hopelessness and suicidal ideation as these were separate variables in the analysis) was a predictor of suicidal ideation (P < 0.01). In separate bivariate analyses analogous to the original study, two domains of insight were associated with suicidal ideation. Conclusions: Findings suggest that depression, insight, and suicidality should be carefully monitored among first‐episode patients initiating treatment and during the early course of illness. As insight improves, coping strategies should be enhanced with a goal of minimizing depression and preventing suicidality.     

When things are not as they seem: detecting first‐episode psychosis upon referral to ultra high risk (‘prodromal’) clinics

The current paper examines a neglected function of ‘ultra high risk’ (UHR) clinics: to detect first‐episode psychosis (FEP) mistakenly identified as a prodrome. A clinical audit was conducted of referrals to a UHR service, the Personal Assessment and Crisis Evaluation Clinic, over a 12‐month period (April 2005–March 2006). In this audit, 11.4% of the total number of referrals (n= 149) and 11.9% of those who attended a first appointment were psychotic on referral. These figures indicate that a substantial proportion of individuals thought to be prodromal are in fact suffering FEP. UHR clinics minimize duration of untreated psychosis for FEP patients mistaken as prodromal.     

How does social functioning in the early stages of psychosis relate to depression and social anxiety?

Aims: The study aims to compare social functioning in young people considered to be at risk of psychosis with those meeting criteria for first episode psychosis (FEP) and controls, and to determine the association between social functioning and positive and negative symptoms, depressive symptoms, and social anxiety. Methods: This study examined social functioning in 20 individuals at risk of psychosis, 20 FEP patients and 20 healthy controls. Social functioning was measured using the Social Functioning Scale and World Health Organization Disability Assessment Scale. Psychiatric variables were also measured using the Comprehensive Assessment of At‐Risk Mental States, the Brief Psychiatric Rating Scale, the Brief Social Phobia Scale, and the Depression Anxiety and Stress Scale. Results: At‐risk individuals had comparable social deficits to the FEP group, and both patient groups had significantly poorer social functioning than controls. Importantly, social functioning was most strongly associated with depressive and social anxiety symptoms and to a lesser extent with positive symptoms. However, negative symptoms did not appear to relate to social functioning. Conclusion: Social functioning impairments precede the onset of full‐threshold psychosis and may therefore be a significant marker for the illness. Additionally, associated psychiatric symptoms such as depression and social anxiety may provide an avenue for early interventions of social functioning deficits in psychosis.     

Psychosocial correlates with depressive symptoms six years after a first episode of psychosis as compared with findings from a general population sample

Background  

Depression is frequently occurring during and after psychosis. The aim of this study was to analyze if the psychosocial characteristics associated with depression/depressive symptoms in the late phase of a first episode psychosis (FEP) population were different compared to persons from the general population.     

The First‐Episode Psychosis Outcome Study: premorbid and baseline characteristics of an epidemiological cohort of 661 first‐episode psychosis patients

Aims: Studies conducted in first‐episode psychosis (FEP) samples avoid many biases. However, very few studies are based on epidemiological cohorts treated in specialized FEP services. The aim of this file audit study was to examine premorbid and baseline characteristics of a large epidemiological sample of FEP. Methods: File audit study of all patients admitted to the Early Psychosis Prevention and Intervention Centre between 1998 and 2000 using a specialized questionnaire. Results: There were 661 patient files included in the study. Premorbid evaluation revealed high rates of substance use disorder (74.1%), history of psychiatric disorder (47.5%), past traumatic events (82.7%) suicide attempts (14.3%) and family history of psychiatric illness (55.6%). Baseline characteristics revealed high intensity of illness (mean CGI 5.5), high prevalence of lack of insight (62%) and high rate of comorbidity (70%). Conclusion: High rates of traumatic events or episodes of mental illness before treatment for FEP must be considered when designing treatment approaches because a too narrow focus on positive psychotic symptoms will inevitably lead to incomplete treatment. Additionally, early intervention programmes need sufficient range of resources to address the multiple challenges presented by FEP patients such as high severity of illness, comorbidities and functional impairment. Finally, observation of an important degree of functional impairment despite short duration of untreated psychosis suggests that while early detection of FEP is a necessary step in early intervention, it may not be sufficient to improve functional recovery in psychosis and that efforts aimed at identifying people during the prodromal phase of psychotic disorders should be pursued.     

Concerns reported by family members of individuals with first-episode psychosis

Aim: Our aim was to examine the concerns reported by family members and other caregivers of individuals with first‐episode psychosis (FEP). Methods: Family members who attended group psychoeducation selected their top two concerns from a list of nine concerns: stigma, medication, substance abuse, social behaviour, stressful situations, self‐esteem and identity, sexuality and intimacy, early warning signs, and resources and support. Results: Parents, particularly mothers, were a significant majority of those who attended psychoeducation sessions. In order of frequency of endorsement, the concerns endorsed were self‐esteem and identity, social behaviour, substance abuse, medications, stressful situations, early warning signs, resources and support, stigma, and sexuality and intimacy. Conclusion: Families were most concerned about the self‐esteem and identity of their young relatives with FEP. Our findings suggest that early intervention programmes should specifically address issues of self‐esteem and identity. Further research on the concerns shared by families of individuals with FEP is needed.     

Prevalence of suicide risk factors in people at ultra-high risk of developing psychosis: a service audit

Background: Little data is available on the prevalence of suicide risk factors in people at ultra‐high risk (UHR) of developing psychosis. Aim: The aim of this study was to provide an estimate of the cross‐sectional prevalence of possible suicide risk factors in those attending a routine clinical service for people at UHR of developing psychosis. Methods: For all patients in treatment (n = 34) over a 4‐week period, levels of suicidal ideation and depression upon entry to the service were assessed by auditing intake scores on the Beck Depression Inventory, second edition. Level of engagement with services, social isolation, substance and alcohol misuse, ready access to means, current suicidal ideation, previous suicide attempts, current or previous self‐harm, expressions of concern from others, depression, agitation, hopelessness, worthlessness, suspiciousness and fears of mental disintegration were all assessed by case note review and interview with the treating clinician. Results: There was a high prevalence of at least mild suicidal ideation (58.8%, n = 20) and severe depressed mood (47%, n = 16) in this client group at point of entry to the service. Seven people (20.6%) had engaged in serious self‐harm (including attempted suicide) during the time they were in contact with the service. Forty‐seven per cent (n = 16) reported at least 27 suicide attempts between them; the mean number of attempts being 1.69 (standard deviation = 1.08). Conclusion: Suicide risk was high in this small sample of people at UHR of developing psychosis. Controlled research with larger samples and better methodology is urgently required to inform legal, ethical and scientific debates surrounding this group.     

A community intervention for early identification of First Episode Psychosis

Abstract Objective The aim of this study was to assess the impact of a community case identification program on duration of untreated psychosis (DUP) (a measure of delay in treatment) and characteristics of patients entering treatment for a first episode of psychosis. Method Using a quasi-experimental historical control design, patients within a defined geographic catchment area who met DSM-IV criteria for a first episode of a psychotic disorder (FEP) were assessed on a number of demographic and clinical variables including DUP, length of prodromal period and symptoms at initial presentation, for 2 years prior to and 2 years after the introduction of a community-wide Early Case Identification Program (ECIP). The ECIP was designed to promote early recognition and referral of individuals with a FEP from any possible source of referral including self-referrals. Treatment interventions offered were the same throughout the two phases. Results In all, 88 and 100 patients met criteria respectively in phases I and II. There were no significant differences in rates of treated incidence or DUP between the two phases. Patients recruited in phase II had significantly longer prodromal periods and higher level of psychotic and disorganization symptoms. There were no differences in level of negative symptoms or pre-morbid adjustment. Conclusion A community-wide approach to early case identification may not be the most effective way to reduce delay in treatment of psychosis, but may bring into treatment patients who have been ill for long periods of time and have a higher level of psychopathology. A more targeted approach directed at primary care and emergency services may achieve different results in reducing delay in treatment.     

Suicidality prior to presentation in first-episode psychosis

Introduction: Suicide and attempted suicide contribute significantly to the increased mortality and morbidity associated with psychotic illness. The period of highest risk is reportedly in the early years of illness. While the literature concentrates on completed suicide in chronic psychosis, less is understood about attempted suicide in first‐episode psychosis (FEP). Aim: We aimed to examine rates and correlates of suicide attempts in individuals with FEP. Method: Individuals in this study were all those, both in‐ and outpatients, diagnosed with FEP over a 2‐year period, from a defined catchment area. Assessment included Structured Clinical Interview for DSM‐IV, Schedule for Assessment of Positive Symptoms, Schedule for Assessment of Negative Symptoms, Calgary Scale, Beiser Scale and Birchwood Insight Scale. Results: Of 107 patients with FEP, 50 (47%) individuals reported suicidal ideation: 41 (38%) in the month prior to first presentation. Ten individuals (9%) made a suicide attempt. The only factor significantly associated with previous suicide attempt was higher insight scores at first presentation (P = 0.04). Conclusion: Individuals with a history of suicide attempt tend to have higher insight into having a mental illness at first presentation.     

Predictors of cognition in first episode psychosis

PurposeCognitive deficits are common in the first episode of psychosis (FEP) and may begin much earlier. While some evidence suggests that the decline in cognition occurs over the untreated symptomatic period, including the prodromal phase, others point to these deficits being present even earlier. We aimed to investigate the differential effect of untreated symptomatic and pre-morbid phases on cognition in a large sample of FEP.MethodsTwo hundred and sixty eight FEP patients, admitted into a specialized early intervention service, were administered neuro-cognitive tests. The Circumstances of Onset and Relapse Schedule (CORS) was administered for measurement of duration of untreated psychosis (DUP), the duration of untreated illness (DUI) and demographic factors. The Pre-morbid Adjustment Scale (PAS) was used to measure different domains of pre-morbid adjustment. Seventy three healthy controls were also recruited for neuro-cognitive comparison.ResultsWe observed no effect of DUP and a minimal effect of DUI on cognitive functioning in FEP. Instead, the early educational pre-morbid adjustment domain was most strongly associated with cognition and predicted both global cognitive and verbal memory outcome in FEP.ConclusionOur results suggest that symptoms associated with the symptomatic phase of a FEP do not influence cognitive functioning in FEP. Instead, cognitive deficits in FEP may predate illness onset and may indicate susceptibility to such illness.     

Treating co-occurring first-episode psychosis and borderline personality: a pilot randomized controlled trial

Aim: First‐episode psychosis and borderline personality disorder are severe mental disorders that have their onset in youth. Their co‐occurrence is clinically well recognized, is associated with significant risks and is complex to treat. Yet, there is no published specific intervention for this problem. This study reports a pilot randomized controlled trial comparing combined specialist first‐episode treatment plus specialist early intervention for borderline personality, entitled Helping Young People Early, with specialist first‐episode treatment alone. We aimed to evaluate the safety and feasibility of adding early intervention for borderline personality. Methods: The study investigated the safety of specialist first‐episode treatment plus specialist early intervention for borderline personality in relation to deterioration in psychosis, aggression, self‐harm and suicidality, and feasibility in relation to the completion of therapy phases. Sixteen patients meeting Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition‐Text Revision (DSM‐IV‐TR) criteria for first‐episode psychosis and borderline personality (four or more DSM‐IV criteria) were randomized either to specialist first‐episode treatment alone or specialist first‐episode treatment plus specialist early intervention for borderline personality and were followed up at the end of treatment and 6 months later. Results: The results showed that it was feasible to recruit and assess a high risk and complex group of patients who were agreeable to study participation. Specialist first‐episode treatment plus specialist early intervention for borderline personality was an acceptable and safe treatment. Conclusion: A larger‐scale randomized controlled trial of early intervention for borderline personality for young first‐episode psychosis patients with co‐occurring full or subsyndromal borderline personality is warranted.     

Psychotic‐like experiences are associated with suicidal feelings and deliberate self‐harm behaviors in adolescents aged 12–15 years

Nishida A, Sasaki T, Nishimura Y, Tanii H, Hara N, Inoue K, Yamada T, Takami T, Shimodera S, Itokawa M, Asukai N, Okazaki Y. Psychotic‐like experiences are associated with suicidal feelings and deliberate self‐harm behaviors in adolescents aged 12–15 years. Objective: Psychotic disorders are a significant risk factor for suicide, especially among young people. Psychotic‐like experiences (PLEs) in the general population may share an etiological background with psychotic disorders. Therefore, the present study examined the association between PLEs and risk of suicide in a community sample of adolescents. Method: Psychotic‐like experiences, suicidal feelings, and self‐harm behaviors were studied using a self‐report questionnaire administered to 5073 Japanese adolescents. Depression and anxiety were evaluated using the 12‐item General Health Questionnaire (GHQ). Results: The presence of PLEs was significantly associated with suicidal feelings (OR = 3.1, 95% CI = 2.2–4.5) and deliberate self‐harm behaviors (OR = 3.1, 95% CI = 2.0–4.8) after controlling for the effects of age, gender, GHQ‐12 score, victimization, and substance use. Suicidal feelings and behaviors were more prevalent in subjects with a greater number of PLEs. Conclusion: Psychotic‐like experiences may increase the risk of suicidal problems among adolescents.     

Illicit substance use and its correlates in first episode psychosis

Mazzoncini R, Donoghue K, Hart J, Morgan C, Doody GA, Dazzan P, Jones PB, Morgan K, Murray RM, Fearon P. Illicit substance use and its correlates in first episode psychosis. Objective: To determine if substance use (particularly cannabis) is more frequent among first episode psychosis patients and associated with a more problematic clinical presentation. Method: All first episode psychosis (FEP) patients presenting to secondary services were recruited from London and Nottingham, over 2 years, in the Aetiology and Ethnicity of Schizophrenia and Other Psychoses study broad framework. Clinical and sociodemographic variables were assessed using a set of standardized instruments. A schedule was created to retrospectively collate substance use data from patients, relatives and clinicians. Results: Five hundred and eleven FEP were identified. They used three to five times more substances than general population. Substance use was associated with poorer social adjustment and a more acute mode of onset. Cannabis use did not affect social adjustment, but was associated with a more acute mode of onset. Conclusion: Cannabis has a different impact on FEP than other substances. Large epidemiological studies are needed to disentangle cannabis effect.