A multi‐site Canadian perspective: examining the functional outcome from first‐episode psychosis

Objective: To examine factors contributing to variance in functional outcome in first‐episode psychosis (FEP) following 1 year of treatment. Method: Naturalistic 1‐year follow‐up of a FEP cohort (n = 200), from programs in four university centers in Ontario, Canada. Functional recovery was defined by ‘Social and Occupational Functioning Assessment Scale’ (SOFAS) score>60. Regression analysis examined the contribution of independent variables to variance in functional outcome. Results: Twelve‐month outcome measures were available for 76.5% of the original cohort. Of these, 70% reported being in school/work and in satisfactory relationships. The functional recovery rate was 51%, compared to 74% attaining symptomatic remission. The greatest contributors to variance in outcome were ongoing symptoms at 6 months and substance abuse comorbidity. Conclusion: After 1 year of treatment, FEP patients show high rates of symptomatic remission and relatively lower rates of functional recovery. Symptoms and substance abuse contribute to variance in outcome.     

A 2‐year follow‐up of involuntary admission’s influence upon adherence and outcome in first‐episode psychosis

Opjordsmoen S, Friis S, Melle I, Haahr U, Johannessen JO, Larsen TK, Røssberg JI, Rund BR, Simonsen E, Vaglum P, McGlashan TH. A 2‐year follow‐up of involuntary admission’s influence upon adherence and outcome in first‐episode psychosis. Objective: To see, if voluntary admission for treatment in first‐episode psychosis results in better adherence to treatment and more favourable outcome than involuntary admission. Method: We compared consecutively first‐admitted, hospitalised patients from a voluntary (n = 91) with an involuntary (n = 126) group as to psychopathology and functioning using Positive and Negative Syndrome Scale and Global Assessment of Functioning Scales at baseline, after 3 months and at 2 year follow‐up. Moreover, duration of supportive psychotherapy, medication and number of hospitalisations during the 2 years were measured. Results: More women than men were admitted involuntarily. Voluntary patients had less psychopathology and better functioning than involuntary patients at baseline. No significant difference as to duration of psychotherapy and medication between groups was found. No significant difference was found as to psychopathology and functioning between voluntarily and involuntarily admitted patients at follow‐up. Conclusion: Legal admission status per se did not seem to influence treatment adherence and outcome.     

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.     

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.     

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.     

Encoding dysfunctions in a dynamic-static paradigm for visuospatial working memory in first-episode psychosis patients: a 2-year follow-up study

Aim: To investigate static and dynamic visuospatial working memory (VSWM) processes in first‐episode psychosis (FEP) patients and explore the validity of such measures as specific trait markers of schizophrenia. Methods: Twenty FEP patients and 20 age‐, sex‐, laterality‐ and education‐matched controls carried out a dynamic and static VSWM paradigm. At 2‐year follow up 13 patients met Diagnostic and Statistical Manual (of Mental Health Disorders) – Fourth Edition (DSM‐IV) criteria for schizophrenia, 1 for bipolar disorder, 1 for brief psychotic episode and 5 for schizotypal personality disorder. Results: Compared with controls, the 20 FEP patients showed severe impairment in the dynamic VSWM condition but much less impairment in the static condition. No specific bias in stimulus selection was detected in the two tasks. Two‐year follow‐up evaluations suggested poorer baseline scores on the dynamic task clearly differentiated the 13 FEP patients who developed schizophrenia from the seven who did not. Conclusions: Results suggest deficits in VSWM in FEP patients. Specific exploratory analyses further suggest that deficit in monitoring‐manipulation VSWM processes, especially involved in our dynamic VSWM task, can be a reliable marker of schizophrenia.     

Substance misuse over the first 18 months of specialized intervention for first episode psychosis

Aim: Examine substance misuse over the first 18 months of first‐episode psychosis treatment. Method: Clinicians rated alcohol and drug (mostly cannabis) misuse for 243 individuals followed prospectively. Assessments were completed at baseline and after 3, 6 and 18 months. Interventions relating to substance misuse included ongoing assessment of use, education and counselling to avoid. Results: Alcohol and drug misuse declined significantly between baseline and 3 months, especially among patients with a substance abuse or dependence diagnosis at baseline. Overall, these reductions were maintained over the 18‐month follow‐up period. The exception was worsening alcohol misuse over time among patients with alcohol abuse or dependence on entry. Conclusions: With good usual care, education and support, alcohol and drug misuse declined significantly during the first months of psychosis treatment. The improvements in drug misuse were generally maintained over the 18‐month follow‐up, and worsening alcohol misuse over time may be the greater issue.     

Apathy in first episode psychosis patients: One year follow up

IntroductionThis study describes how the negative subsyndrome of apathy develops over the first year in first episode psychosis (FEP) patients, with an emphasis on the prevalence of enduring apathy and the relationship between apathy, other symptoms and functioning.MethodsEighty four FEP patients were assessed both at baseline and after one year with the abridged clinical version of the Apathy Evaluation Scale (AES-C-Apathy). Other symptoms were assessed with the Positive and Negative syndrome scale (PANSS) and functioning with the split version of the Global Assessment of Functioning Scale (GAF-F).ResultsThe mean level of AES-C-Apathy decreased from baseline to the one year follow up for the whole group of FEP patients. High levels of apathy at 1 year were best predicted by high levels of apathy at baseline, a long DUP and a diagnosis within the Schizophrenia spectrum. The presence of depression and level of medication only had a minor influence. AES-C-Apathy had a stronger association to GAF-F than other PANSS symptom areas.Twenty five (30%) FEP patients had high enduring levels of apathy. This group consisted of significantly more males, had a longer duration of untreated psychosis, a greater likelihood of a Schizophrenia spectrum diagnosis, fewer were in remission of positive symptoms and they had significantly poorer functioning at both baseline and follow up.ConclusionThis study confirms that the negative subsyndrome of apathy is significantly related to poor functioning in FEP. Including negative symptoms and its subsyndromes in early detection strategies are warranted.     

First-episode psychosis patients recruited into treatment via early detection teams versus ordinary pathways: course and health service use during 5 years

Aim: To compare the 5‐year course and outcome of first‐episode psychosis (FEP) patients recruited via active outreach detection teams (DTs) versus ordinary referral channels (not‐DT). Methods: Longitudinal comparison of two parallel consecutive samples on the Positive and Negative Syndrome Scale Score and the Global Assessment of Functioning Scale. Altogether, 203 FEP patients were identified, of whom 42 refused to participate. Included were 161 patients: 56 DT and 105 not‐DT. Results: After 2 years, the DT group developed more cases of schizophrenia with poorer prognostic features. However, the two groups did not differ significantly on outcome measures. More DT patients were treated as outpatients only and had fewer admissions and shorter total time as inpatients during the observation period. Conclusions: We have previously shown that detection teams recruited more chronic patients with poorer prognostic features, but fewer symptoms and better functioning at baseline. After 2 years, the DT patients functioned as well as the not‐DT patients. At 5 years, both groups have stabilized to the same plateau of low symptom severity.     

Sociodemographic and clinical characteristics of patients presenting with first-episode psychosis and concurrent substance misuse

Aims: To determine the incidence of concurrent substance misuse among individuals entering first‐episode psychosis treatment, and examine whether patients with concurrent substance misuse differ on variables relevant to service planning. Methods: Consecutive patients (n = 376) were assessed using standardized instruments. Results: Twenty‐two per cent met abuse or dependence criteria for a single substance, and 8% met criteria for two substances. Most met criteria for marijuana or marijuana and alcohol. The majority of patients with a concurrent disorder were male, and on average they were 3.5 years younger at psychosis onset. Patients with a concurrent disorder experienced worse ‘positive’ and anxiety symptoms in the month before treatment. Premorbidly they had better social functioning, but worse academic functioning. Conclusions: There are important differences between patients entering first‐episode psychosis treatment with and without a concurrent substance misuse. Early intervention efforts might be informed by our accumulating knowledge about the characteristics of patients who have both disorders.     

Substance abuse and first-episode schizophrenia-spectrum disorders. The Danish OPUS trial

Aim: To evaluate whether integrated treatment (given by OPUS), in comparison with standard treatment, significantly reduced the number of patients with substance abuse and improved clinical and social outcome in the group of substance abusers after 2 years. Methods: A total of 547 patients with first‐episode schizophrenia‐spectrum disorders were included in the study, 275 randomly assigned to OPUS treatment and 272 to standard treatment. OPUS treatment consisted of assertive community treatment with family involvement and social skills training. Standard treatment offered contact with a community mental health centre. Main outcome measure was reduction in comorbid substance abuse. Results: At 2‐year follow up, 42 (17.3%) patients from OPUS and 40 (20.7%) patients from standard treatment met criteria for substance abuse (odds ratio=0.5, 95% confidence interval 0.3–1.0). OPUS treatment compared with standard treatment significantly reduced negative and disorganized symptoms in the substance abuser group. Patients with substance abuse in the OPUS treatment spent significantly fewer days in hospital during the 2‐year period than patients given standard treatment (109 days vs. 167 days) and adhered to treatment significantly more often. Conclusions: Results from this trial indicate that integrated treatment given by OPUS reduced substance abuse and improved clinical outcome in the substance abuser group. Supplementing the OPUS treatment with therapeutic programmes for patients with a comorbid substance abuse would probably further improve outcome.     

Group cognitive behavioural therapy for first episode psychosis: who's referred,who attends and who completes it?

Aim: Most national guidelines recommend psychological therapy for people with first‐episode psychosis (FEP) but interventions proven effective in randomized control trials (RCTs) conducted in research settings do not always translate effectively to real‐world clinical environments. In a limited health system, it is important to understand the system and patient barriers to participation in effective treatment. We sought to determine what patient characteristics influenced clinicians' decision to refer or not to refer to group cognitive behavioural therapy for FEP and what characteristics were associated with those referred attending/not attending and adhering/not adhering to the programme. Methods: Between 2006 and 2008, all cases of confirmed FEP from a defined geographical region were examined using the Structured Clinical Interview for DSM‐IV‐TR Axis I Disorders for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM‐IV) diagnoses, the Scale for Assessment of Positive Symptoms, Scale for Assessment of Negative Symptoms, Calgary Depression Scale for Schizophrenia and Birchwood Insight Scale. Duration of untreated psychosis was established using the Beiser Scale. Results: Of the 124 (77 males, 47 females) people in the final sample, 88 (72%) were referred for cognitive behavioural therapy (CBT), 52 (59%) attended and 12 (23%) did not complete CBT. Those with higher levels of insight into the need for treatment (U = 740.00, z = −2.63, P = 0.008) and higher levels of positive symptoms (t (120) = −3.064, P = 0.003) were more likely to be referred to CBT. Those with higher educational attainment (χ² = 9.48, P = 0.03) and fewer negative symptoms, particularly in relation to global attention (t (85) = 2.32, P = 0.03), were more likely to attend and complete CBT. Conclusion: Within an early intervention service for FEP, it appears that individuals with less education, more negative symptoms and less insight experienced significant barriers to successfully completing group CBT. More information for referring clinicians about the benefits of CBT for FEP could help increase referral rates. Assertive outreach for people at risk of disengaging or non‐adherence should also be considered.     

Substance use and abuse in first-episode psychosis: prevalence before and after early intervention

Despite the high prevalence of substance abuse among first-episode psychosis (FEP) populations, few studies examine whether early intervention (EI) improves substance abuse. OBJECTIVE: To examine the prevalence and pattern of substance use and abuse among an FEP sample over 12 months. METHODS: All the participants were diagnosed with a first episode of a schizophrenia spectrum disorder. The participants were followed prospectively. The prevalence rates of substance use and abuse from this sample were compared before and after 12 months of EI services and were compared with rates observed in a sample from the general population. RESULTS: A total of 200 participants (80.0% males; mean age 24 years) entered the study: 183 participants completed all the assessments at baseline, 131 participants completed all the assessments at 12 months. At baseline, the findings showed similar prevalence rates between the FEP sample and the general sample for lifetime cannabis use (60% vs 55%, respectively) and hazardous alcohol use (26% vs 21%) but significantly different prevalence rates for lifetime hallucinogen (29% vs 15%; P < .001) and cocaine use (20% vs 14%; P < .001). At 12 months, the prevalence rates for drug abuse (P < .01), hazardous alcohol use (P < .01), and concurrent drug abuse and hazardous alcohol use (P < .05) were significantly lower than at baseline. CONCLUSION: Substance use and abuse decreased significantly after 12 months of EI services; EI services may be able to detect and to reduce substance use among FEP patients before it becomes a more serious disorder.     

Is psychosis in DSM‐IV mania due to severity? The relevance of selected demographic and comorbid social‐phobic features

Objective: We tested whether factors other than episode severity contributed to psychosis in mania. Method: Psychiatrists collected systematic clinical data on 1090 hospitalized DSM‐IV manic patients in France, and completed the Mania Rating Scale (MRS) and the Scale for the Assessment of Positive Symptoms (SAPS). Results: Using DSM‐IV specifiers, 21.9% were non‐severe, 28.2% severe without psychosis, and 49.9% severe with psychosis. On the MRS, patients with psychosis scored significantly higher (P < 0.0001) than non‐severe, but did not differ from the severe without psychosis. We found significant correlations between both the Hallucination and the Delusion subscores of the SAPS and the MRS, as well as correlations between age, single marital status, comorbid social phobia and psychotic mania. Conclusion: Apart from episode severity, social isolation – associated with younger age, single marital status and social phobia – seems to make a contribution to the origin of manic psychosis largely independent from such severity.     

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.     

Substance misuse at presentation to an early psychosis program

BACKGROUND: Substance misuse is a significant problem in schizophrenia. The purpose of this study was to examine the prevalence and correlates of substance misuse in individuals with a first episode of psychosis at the time they first present for treatment. METHOD: The first 357 consecutive admissions to a comprehensive early psychosis program were included. Assessment measures were the Positive and Negative Syndrome Scale, the Calgary Depression Scale for Schizophrenia, the Quality of Life Scale, the Case Manager Rating Scale and the Premorbid Adjustment Scale. RESULTS: Forty-four percent of the sample, the majority of whom used alcohol or cannabis, met diagnostic criteria for substance abuse/dependence. The prevalence was significantly higher than in the general population. Substance misuse was significantly associated with male gender, young age and age of onset. CONCLUSIONS: This study confirms the high rates of substance misuse, in particular cannabis, in first-episode psychosis. Implications for treatment are addressed.     

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.     

A descriptive study of 'non-cases' and referral rates to an early intervention for psychosis service

Aim: Despite there being approximately 200 early intervention services for psychosis worldwide, little is known about the referral rates to these services, the diagnoses and needs of individuals found not to have a first episode of psychosis (FEP). Firstly, we aimed to describe the diagnoses for individuals who were found not to have a FEP (non‐cases) following an assessment using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders IV (SCID). We then aimed to examine the referral rates of cases and non‐cases to an early intervention service. Methods: All individuals referred to the early intervention service underwent a clinical assessment using the SCID. Results: In a 4‐year period, there were 632 referrals to the early intervention service for psychosis, and of these, 53% (n = 338) were found to have a FEP, 5% (n = 34) were found to have an at‐risk mental state for psychosis and 41% (n = 260) were found to be ‘non‐cases’. This represents a ratio of 1.9:1 of referrals to cases, or approximately 2:1. Of the non‐cases, 27% (n = 62) satisfied criteria for a mood disorder, with major depressive disorder the commonest diagnosis. A further 18% (n = 42) of non‐cases satisfied criteria for an anxiety disorder and nearly half of these were diagnosed with social phobia. The ratio of referrals to cases was not consistent over time and rose from 1.3:1 in the first year to 2:1 in the fourth year. Conclusion: A large proportion of individuals referred to an early intervention for psychosis service were found not to have psychotic disorder, however they still have significant needs regarding their mental health.     

Extrapyramidal symptoms in substance abusers with and without schizophrenia and in nonabusing patients with schizophrenia

Extrapyramidal symptoms (EPS) such as parkinsonism, dystonia, dyskinesia, and akathisia are conditions of impaired motor function, which are associated with chronic antipsychotic treatment in schizophrenia. In addition, EPS is often exacerbated by psychoactive substance (PAS) abuse, which is frequently observed in this population. Few studies, however, have investigated the contribution of PAS abuse on EPS in PAS‐abusers without comorbid psychosis. This study compared the occurrence of EPS in outpatient schizophrenia patients with (DD group; n= 36) and without PAS abuse (SCZ group; n = 41) as well as in nonschizophrenia PAS abusers undergoing detoxification [substance use disorder (SUD) group; n = 38]. Psychiatric symptoms were measured using the Positive and Negative Syndrome Scale and the Calgary Depression Scale for schizophrenia. Extrapyramidal symptoms were evaluated with the Extrapyramidal Symptoms Rating Scale and the Barnes Akathisia Scale. SUD diagnoses were complemented with urine drug screenings. We found that DD patients exhibited significantly more parkinsonism than SCZ patients. Our subanalyses revealed that cocaine and alcohol abuse/dependence was responsible for the increase in parkinsonism in DD patients. Additionally, we found that SUD individuals exhibited significantly more akathisia than SCZ patients. In these latter individuals, subanalyses revealed that alcohol and cannabis abuse/dependence was responsible for the increase in akathisia. Our results suggest that PAS abuse is a contributor to EPS in individuals with and without schizophrenia. © 2010 Movement Disorder Society.