Drug and alcohol misuse in first episode psychosis: An observational study

BACKGROUND: There have been very few observational studies of drug and alcohol misuse in first-episode psychosis in the UK. METHOD: Using an observational database of first episode psychosis in Northumberland, a county in Northern England, information on patients aged 16 to 36 years were collected at presentation and annual follow-up between October 1998 and October 2005. Patterns of drug and alcohol misuse were compared using hospitalization as an outcome measure, and violence rates were examined retrospectively. RESULTS: Drug misuse without alcohol misuse was associated with a highly significant increase in hospital days. An alcohol problem, either with or without coexisting drug misuse, was not predictive of increased hospital days. Drug and alcohol misuse together was associated with violence. CONCLUSIONS: This paper lends some support to those Early Intervention in Psychosis (EIP) teams currently advising patients that drug misuse may have a greater impact than alcohol use on the outcome of first-episode psychosis.     

The outcome of early intervention in first episode psychosis

Abstract

The last 20?years have seen an increased focus on early intervention in psychotic disorders in research and clinical practice. Interventions have typically aimed at either reducing the duration of untreated psychosis (DUP), or developing specialized treatment facilities for patients with first episode psychosis (FEP). This review presents an overview of the most important trials and meta-analytic evidence within this field. The possibilities for reducing DUP and elements included in specialized early intervention treatment are discussed. Further, it examines long-term outcomes of early interventions and results from prolonged early intervention trials. Lastly, it analyses possible interactions between DUP and specialized early intervention treatment. In conclusion, both elements appear necessary in order to develop an integrated service that can provide the optimal treatment for patients with FEP. The aim of this article is to provide an overview over the most important trials and evidence regarding the outcome of early intervention in first episode psychosis.     

Trajectory to a first episode of psychosis: a qualitative research study with families

Aim: The trajectory in psychotic disorders which leads from a relatively normal premorbid state in young people to a first episode of psychosis is only partly understood. Qualitative research methods can be used to begin to elucidate the temporal unfolding of symptoms leading to a first episode of psychosis, and its impact on families. Methods: We conducted open‐ended interviews with family members of 13 patients with recent onset non‐affective psychotic disorders, which focused on changes observed, effects on the family, explanatory models, help‐seeking patterns and future expectations. Standard data analytic methods employed for qualitative research were used. Results: Narratives by family members were remarkably similar. First, social withdrawal and mood symptoms developed in previously normal children; these changes were typically ascribed to drugs or stress, or to the ‘storminess’ of adolescence. Coping strategies by family members included prayer and reasoning/persuasion with the young person, and family initially sought help from friends and religious leaders. Entry into the mental health system was then catalysed by the emergence of overt symptoms, such as ‘hearing voices’, or violent or bizarre behaviour. Family members perceived inpatient hospitalization as traumatic or difficult, and had diminished expectations for the future. Conclusions: Understanding families' explanatory models for symptoms and behavioural changes, and their related patterns of help‐seeking, may be useful for understanding evolution of psychosis and for the design of early intervention programmes. Dissatisfaction with hospitalization supports the mandate to improve systems of care for recent‐onset psychosis patients, including destigmatization and a focus on recovery.     

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.     

Maintenance antipsychotic medication patterns in outpatient schizophrenia patients: a naturalistic cohort study

OBJECTIVE: Newer antipsychotics are increasingly used in schizophrenia maintenance. The UK change has been slow with little known on switching patterns. We aimed to investigate antipsychotic prescribing patterns in schizophrenia patients. METHOD: A naturalistic six-site cohort sample of 600 patients were interviewed by researchers at 6-monthly intervals for 2 years to record their clinical and social functioning; use of services and medication for the preceding 6 months was obtained by structured extraction from clinical case notes. RESULTS: Alterations in antipsychotic medication were frequent in this group, mainly during periods of inpatient care. Atypical prescribing increased steadily, though slowly, across the period. Polypharmacy was less than anticipated. CONCLUSION: Inpatient care remains the main forum for switching of antipsychotics. The UK maintains a slow shift to atypical antipsychotics.     

Performance measures for evaluating services for people with a first episode of psychosis

Aim: The purpose of this project was to operationalize and apply a previously identified set of performance measures designed to evaluate services for those experiencing a first episode of a schizophrenia spectrum disorder. Methods: Operational definitions were developed for previously identified measures through an iterative process of discussions between clinical experts and health‐care evaluators. Data were collected from existing sources including corporate databases, clinical databases and chart review. Results: Definitions were developed for 44 measures covering seven of eight domains recommended for service level evaluation by the Canadian Institute for Health Information domains. Forty measures could be calculated. Conclusions: The measures represent a comprehensive set of performance measures suitable for the evaluation of services for people with a first‐episode psychosis. The measures could be used by other services in order to establish standards and norms for routine clinical practice.     

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.     

Clinical correlates of early medication adherence: West London first episode schizophrenia study

OBJECTIVE: Little is known about factors that mediate adherence with medication during the early stages of antipsychotic treatment in schizophrenia. This study sought to identify factors that may be associated with medication adherence in first-episode schizophrenia. METHOD: In 101 patients, adherence was assessed along with potentially relevant variables, including attitudes toward medication, insight, substance misuse, side effects and psychopathology. RESULTS: In a linear regression analysis, negative attitudes toward medication and a relative lack of insight contributed significantly towards poor adherence. Although poorly adherent patients had significantly higher scores on negative and disorganization syndromes, these did not contribute significantly towards adherence. Adverse medication side effects, subjective well-being and substance misuse showed no significant association with adherence. CONCLUSION: At the initiation of drug treatment, attitudes toward medication and insight appear more relevant to medication adherence than side effects. Adherence appears to reflect a complex interaction of influences, which may change over time.     

Medication adherence of individuals with a first episode of psychosis

OBJECTIVE: To determine rates of adherence to antipsychotic medication in first episode patients and the correlates of adherence in this group. METHOD: Subjects were the first 200 admissions to an Early Psychosis Program. Adherence was determined on a three-point scale. Symptoms, medication side-effects, quality of life, substance use and family involvement were examined longitudinally. RESULTS: In their first year in the program 39% were non-adherent, 20% inadequately adherent, and 41% adherent. Non-adherent patients demonstrated more positive symptoms, more relapses, more alcohol and cannabis use, reduced insight, and poorer quality of life. They were younger, had an earlier age of onset and less likely to have a family member involved in treatment. CONCLUSION: Results for this group are similar to those reported in the literature. Correlates are often the consequence of non-adherence. Non-compliance has to be anticipated and relationships maintained with patients and families to intervene as soon as possible to minimize the consequence of non-compliance.