Matryoshka Project: lessons learned about early intervention in psychosis programme development

Aim: This part of the Matryoshka project sought to understand the processes with which early intervention in psychosis (EIP) programmes were implemented and developed. The goals were to understand the key influences of programme implementation in the context of rapid EIP service growth and lack of specific provincial guidelines. Methods: Sampling was purposive and data were collected with semi‐structured interviews. Five Matryoshka Project programmes were successfully contacted. All interviews were conducted by phone, recorded and transcribed verbatim. Emerging themes were analysed iteratively and discussed among authors. Key themes were validated with participants. Results: The new EIP services were significantly influenced by the provincial EIP network, advocacy groups and clinical mentors. EIP programme decision makers often relied on each other for guidance. Although the research evidence assisted programme decision makers to develop an effective EIP model for their region, implementation was often shaped by funding constraints. Programmes adapted their EIP models according to funding and local service characteristics. The lack of specific guidelines may have allowed innovation; programme creativity and diversity is consistent with EIP values. Despite the challenges related to geography and staffing, programmes experienced important successes such as partnerships across sectors, quality clinical service and the ability to engage hard‐to‐serve clientele. Conclusions: Although important, research evidence played only a secondary role. Relationships among providers and services, coupled with the dedication of front‐line staff, were more critical to knowledge exchange than written documents alone. These findings stress the importance of researcher–front‐line relationships to the adoption of evidence‐informed practice.     

Journey into and through an early detection of psychosis service: the subjective experience of persons at risk of developing psychosis

Aim: This study aimed to explore how persons who have been assessed as being at risk of developing psychosis make sense of and understand their experiences, using a qualitative approach. Methods: The sample comprised six female and four male participants (n = 10), ranging in age from 16 to 30 years, with a mean age of 21.8 years. All the participants had entered into a National Health Service Early Detection service in the North of England, which provides interventions for persons assessed as being at a high risk of developing psychosis. Individual semistructured interviews were conducted to study how persons at risk of developing psychosis construct their understanding and perception of their experiences. Results: The analyses identified three central themes: (i) ‘perception of needs’, which highlighted how participants recognized the need to enter services and how they identified what they required from the service; (ii) participants' subjective journey; and (iii) participants' orientation to the future. Conclusions: The journey described by participants assessed as being at risk of developing psychosis provides further insight into how persons make sense of their experiences from a qualitative ‘insider’ perspective. The findings are discussed in relation to the existing literature relating to the early detection and intervention of psychosis and clinical implications are identified.     

Specialized home treatment versus hospital-based outpatient treatment for first-episode psychosis: a randomized clinical trial

Objective: This pilot study compared the effectiveness of specialized care that was home based versus hospital based for individuals experiencing their first psychotic episode. Method: A randomized controlled trial design was used. A total of 29 subjects were interviewed at baseline, 3 and 9 months. Repeated measures analysis of variance was employed to test for statistically significant changes over time within and between groups with regard to community psychosocial functioning and symptom severity. Results: Our findings indicate that subjects in both the home‐based and hospital‐based programmes significantly improved with regard to symptoms and community functioning over time. However, the rates of change over time were not significantly different between the two programmes. There was a statistically significant difference between programmes with regard to the proportion of subjects with less than two visits (i.e. either did not attend their first assessment or attended follow‐up visits after their assessment). Conclusions: This was a modest pilot study and the sample was too small to allow definitive conclusions to be drawn. However, the results raise questions about differences in initial treatment engagement. They suggest the need for additional research focusing on interventions that promote initial treatment seeking.     

Pattern of health service utilization and predictors of readmission after a first admission for psychosis: a 2-year follow-up study

OBJECTIVE: To explore the pattern of health service utilization over 2 years following a first admission for psychosis and the baseline characteristics predicting readmission. METHOD: Patients included in a cohort of first-admitted subjects with psychosis (n = 84) were assessed at the end of a 2-year follow-up using multiple sources of information. RESULTS: At the end of the follow-up, one of three subjects had no contact with any mental health professional, and 38% of subjects had no contact with a psychiatrist. Half of the patients were readmitted over the 2-year follow-up. The baseline characteristics independently predicting psychiatric readmission were a high number of helping contacts before first admission and persistence of psychotic symptoms at discharge. CONCLUSION: Decreasing the frequency of readmission in the early course of psychosis is a public health priority. Development of psychotherapeutic programs for subjects with early psychosis who have enduring psychotic symptoms at first discharge should be promoted.     

Early Psychosis Prevention and Intervention Centre long-term follow-up study of first-episode psychosis: methodology and baseline characteristics

Aim: This paper reports the rationale, methodology and baseline characteristics of a large long‐term follow‐up study of first‐episode psychosis from a geographically defined catchment area. Method: A total of 723 first‐episode psychosis patients were recruited from a specialized early psychosis service between 1989 and 2001 and prospectively followed up at a median of 7.4 years after initial presentation. Participants’ baseline demographic, clinical and functional characteristics are described. Sampling bias at study recruitment was assessed by comparison with a more complete sample of Early Psychosis Prevention and Intervention Centre (EPPIC) cases rated directly from the medical records. Results: At baseline, 57% of the sample were diagnosed with schizophrenia or schizophreniform disorder, whereas the full range of psychotic disorders was represented. Statistical analysis confirmed that the sample recruited was representative of total EPPIC‐treated incident cases. Conclusions: The EPPIC long‐term follow‐up study is a large and epidemiologically representative first‐episode psychosis cohort that has been subsequently prospectively followed up over a long period. Such a sample provides a rare opportunity to study the course and outcome of psychotic disorders.     

Impact of a specialized early psychosis treatment programme on suicide. Retrospective cohort study

Background: Younger people, early in the course of psychotic illness, are at high risk of suicide. Aim: To investigate the impact of a specialized early psychosis (EP) treatment programme on risk of suicide up to 8.5 years following first contact with mental health services. Methods: A population‐based, retrospective cohort study of 7760 individuals with a psychotic disorder, aged 15–29 years at first contact, ascertained from a statewide psychiatric case register. Suicides were identified by linking the psychiatric register to a coronial register of unnatural deaths. Cox proportional hazards models were used to investigate potential risk factors, including specialized EP treatment, for suicide. Results: Our principal hypothesis, that suicide risk over the entire follow‐up period would be significantly lower for those who received specialized EP treatment compared with those who did not, was not supported. However, a secondary analysis found that, after adjusting for other socio‐demographic, clinical and treatment factors, suicide risk was 50% lower in the first 3 years following first contact with mental health services among those exposed to specialized EP treatment compared with those who were not. History of inpatient treatment, more treatment days per annum, and shorter time to establish a psychotic diagnosis were associated with increased risk. Non‐participation in the labour force or in study, compared with being unemployed, exerted a protective effect. Conclusions: The EP treatment model may afford protection from suicide whilst the EP intervention is delivered and for a limited period afterwards.     

Outcome of first-episode acute and transient psychotic disorder in Hong Kong Chinese: a 20-year retrospective follow-up study

Background: ‘Acute and transient psychotic disorder’ (ATPD) is a category in ICD-10 marked by psychosis with acute onset and early remission. It remains relatively under-researched, despite controversies over its nosological status in the current classification system.

Aims: (1) To assess the changes in diagnosis over time in patients initially diagnosed as ATPD. (2) To identify factors predicting changes in diagnosis, and compare the long-term outcomes of various patterns of diagnostic shift. (3) To make recommendations on the classification and treatment of ATPD based on the findings of the study.

Methods: This was a retrospective longitudinal study based on review of medical records of patients first admitted to a regional hospital in Hong Kong for ATPD during the period from 1990–2000.

Results: Of the 87 subjects initially diagnosed as ATPD, 64.4% had their diagnoses revised over an average of 20 years, mostly to bipolar disorder and schizophrenia. Among those with diagnosis of ATPD unchanged, 54.8% had one single episode, while the remaining 45.2% had recurrence. Subjects with diagnostic shift had significantly younger age of onset, more first-degree relatives with a history of mental illness, and more subsequent psychiatric admissions.

Conclusions: ATPD is likely a composite category consisting of clinically distinct outcome groups, for which further research is warranted to identify diagnostic features that distinguish them at initial presentation and revise the current nosological status of ATPD. Long-term follow-up, judicial use of antipsychotics, and education on prognosis are of paramount importance in managing patients diagnosed with ATPD.     

One‐year outcome of an early intervention in psychosis service: a naturalistic evaluation

Aim: We conducted a 1‐year prospective evaluation of an early intervention in psychosis service (Early Treatment and Home‐based Outreach Service (ETHOS)) during its first 3 years of operation in South‐west London, UK. Methods: All patients referred to ETHOS underwent structured assessments at baseline and at 1‐year follow‐up. In addition, hospitalization rates of ETHOS patients (intervention group) were compared with a non‐randomized parallel cohort (comparison group) of first‐episode patients treated by community mental health teams. Results: The Early Treatment and Home‐based Outreach Servicepatients experienced significant improvements in symptomatic and functional outcomes, especially vocational recovery. The service received only a quarter of eligible patients from referring teams. ETHOS patients did not differ from the comparison group in number of admissions, inpatient days or detention rates. Although number of referrals increased over time, there was no evidence that patients were being referred earlier. Conclusions: There is now robust evidence for the effectiveness of specialist early intervention services. However, such services must be adequate resourced, including an early detection team and provision of their own inpatient unit.     

Establishing and operating an early intervention service for psychosis in a defined catchment area of northwestern Greece within the context of the local mental health network

Aim: The study aims to present briefly the development of an early intervention service (EIS) for psychosis in a rural catchment area of north‐western Greece within the context of the local mental health network, its structure and procedures, and the results of its operation 2 years after its establishment. Method: Established in December 2007, our EIS is the first service in Greece for patients with a first‐episode psychosis. The context and the local mental health network are described, and the EIS operation, including clinical, educational, community and research activities, is outlined. Assessment measures are presented to evaluate the EIS progress 2 years after its establishment. Results: Between December 2007 and December 2009, EIS received 45 referrals, retaining 38 patients in its caseload. The mean duration of untreated psychosis was 26.6 ± 41.0 months (median = 12 months). Thirty‐seven patients (82.2%) were hospitalized after their first referral, 14 under a compulsory order (31.1%). The duration of hospitalization ranged from 2 to 69 days, with a median of 13 days. Mean (±SD) duration of the follow‐up was 14.8 ± 8.5 months, indicating adequate adherence to EIS, with particularly low relapse rates (20%). Conclusions: Our EIS seems to be successfully established within the local mental health network. Our collaboration with the local mobile mental health unit enabled our communication with rural primary healthcare centers. The collaboration of patients' family and the participation of the mobile mental health unit to the continuity of care contributed greatly to the brief duration of hospitalization and the high adherence to follow‐up rates.     

The Somerset team for early psychosis

Aim: To describe the development of an early intervention (EI) service in Somerset, and evaluate the progress after the first 2 years. Method: The Somerset Team for Early Psychosis (STEP) has been developed in stages from 2003 to the present ‘hub‐and‐spoke’ model. The framework, which the team operates, is outlined, the assessment and outcome measures are presented, and the interventions, with the emphasis on working with families, are discussed. Results: Two hundred fifty‐nine referrals have been received in the first 2 years, with the caseload currently standing at 153. The mean duration of untreated psychosis of STEP clients was just over 9 months; when those who developed psychosis before 2004 (pre‐STEP) were removed, this was reduced to 6.4 months. Eighty‐four per cent of STEP clients have had their families involved with our service in some way. Relapse rates of clients in the service for over 12 months have been encouragingly low (17%). Conclusions: We reflect on the challenges faced in relation to the EI service model described in the Department of Health's Policy Implementation Guide and, in particular, on having successfully built on the existing family interventions service.     

Involuntary hospitalization of first-episode psychosis with substance abuse during a 2-year follow-up

Opsal A, Clausen T, Kristensen Ø, Elvik I, Joa I, Larsen TK. Involuntary hospitalization of first‐episode psychosis with substance abuse during a 2‐year follow‐up. Objective: To investigate whether substance abuse (alcohol or illegal drugs) in patients with first‐episode psychosis (FEP) influenced treatment outcomes such as involuntary hospitalization during follow‐up. Method: First‐episode psychosis patients (n = 103) with consecutive admissions to a comprehensive early psychosis program were included and followed for 2 years. Assessment measures were the Positive and Negative Syndrome Scale, Global Assessment of Functioning, and the Clinician Rating Scale (for substance abuse). Results: Twenty‐four per cent of patients abused either alcohol or drugs at baseline. The dropout rate at 2 years was the same for substance abusers as for non‐abusers. Substance use was not reduced over the 2‐year period. At 2‐year follow‐up, 72% of substance abusers and 31% of non‐abusers had experienced at least one occasion of involuntary hospitalization. Patients with substance abuse had significantly higher risk for involuntary hospitalization during follow‐up (OR 5.2). Conclusion: To adequately treat patients with FEP, clinicians must emphasize treatment of the substance abuse disorder, as well as the psychotic illness. Patients with defined comorbid substance use disorders and FEP are likely to have poorer treatment response than those with psychosis alone.