The key to reducing duration of untreated first psychosis: information campaigns

The TIPS early intervention program reduced the duration of untreated psychosis (DUP) in first-episode schizophrenia from 16 to 5 weeks in a health care sector using a combination of easy access detection teams (DTs) and a massive information campaign (IC) about the signs and symptoms of psychosis. This study reports what happens to DUP and presenting schizophrenia in the same health care sector when the IC is stopped. METHODS: Using an historical control design, we compare 2 cohorts of patients with first-episode Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition, non-affective psychosis at admission to treatment. The first cohort (N = 108) was recruited from January 1997 to December 2000, using an IC to raise awareness about recognizing psychosis to the public, the schools, and to general practitioners. The second cohort (N = 75) was recruited from January 2002 to June 2004 with no-IC. Easy access DTs were available to both cohorts. RESULTS: In the no-IC period, DUP increased back up to 15 weeks (median) and fewer patients came to clinical attention through the DTs. No-IC patients were diagnosed less frequently with schizophreniform disorder, more Positive and Negative Syndrome Scale positive and total symptoms, and poorer Global Assessment of Functioning (symptom) Scale scores. CONCLUSIONS: Intensive education campaigns toward the general public, the schools, and the primary health care services appear to be an important and necessary part of an early detection program. When such a campaign was stopped, there was a clear regressive change in help-seeking behavior with an increase in DUP and baseline symptoms.     

Early detection and intervention in first-episode schizophrenia: a critical review

OBJECTIVE: To review the literature on early intervention in psychosis and to evaluate relevant studies. Method: Early intervention was defined as intervention in the prodromal phase (primary prevention) and intervention after the onset of psychosis, i.e. shortening of duration of untreated psychosis (DUP) (secondary prevention). RESULTS: We found few studies aimed at early intervention, but many papers discussing the idea at a more general level. We identified no studies that prove that intervention in the prodromal phase is possible without a high risk for treating false positives. We identified some studies aimed at reducing DUP, but the results are ambiguous and, until now, no follow-up data showing a positive effect on prognosis have been presented. CONCLUSION: Early intervention in psychosis is a difficult and important challenge for the psychiatric health services. At the time being reduction of DUP seems to be the most promising strategy. Intervention in the prodromal phase is more ethically and conceptually problematic.     

Duration of untreated psychosis and outcome in first-episode psychosis. Perspective from a developing country

OBJECTIVE: To investigate the association between duration of untreated psychosis (DUP) and treatment outcome in a sample of subjects from a developing country. METHOD: Forty-eight subjects with a first episode of psychosis were evaluated prior to treatment and at 3-month intervals over a period of 24 months. We first examined correlations between DUP and symptom improvement as measured on the Positive and Negative Symptom Scale (PANSS), and then performed multivariate analysis to determine the validity of DUP as a predictor of outcome. RESULTS: DUP was significantly correlated with improvement in PANSS total and negative subscale scores as well as the PANSS depression factor at 21 and 24 months. Multivariate analysis found DUP to be the only significant predictor of improvement in negative symptoms at 24 months. CONCLUSION: DUP was a significant predictor of outcome in a cohort form a developing country. This study provides support for early detection and intervention strategies.     

Initial medical work-up of first-episode psychosis: a conceptual review

Aim: To help clinicians carry out a comprehensive, medical diagnostic assessment in first‐episode patients who are suspected of developing schizophrenia. Methods: Conceptual review of the published work with emphasis on the diagnostic goals of excluding medical causes of psychosis and establishing a medical baseline. Results: There is no agreed‐upon standard for the initial medical work‐up of first‐episode cases. Excluding secondary causes of schizophrenia requires consideration of likelihood of disease; laboratory test performance; and relevance of positive test results. Conclusions: We propose a medical work‐up for first‐episode psychosis that combines: (i) broad screening; (ii) exclusion of specific diseases informed by treatability and epidemiology; and (iii) medical baseline measures.     

Randomized controlled trial of a cannabis-focused intervention for young people with first-episode psychosis

OBJECTIVE: To evaluate a cannabis-focused intervention (cannabis and psychosis therapy: CAP) for patients continuing to use cannabis following initial treatment for first-episode psychosis (FEP). METHOD: Consecutive admissions to an early psychosis program were screened and consenting individuals using cannabis in the 4 weeks prior to assessment participated. A single-blind randomized controlled trial compared CAP (n = 23) with a clinical control condition (psychoeducation, PE; n = 24). There were no significant differences between the CAP and PE groups on cannabis use at end of treatment and 6 months post-intervention. RESULTS: There were no significant group differences on psychopathology and functional ratings at follow-up. A significant reduction in cannabis use was observed for both groups over time. CONCLUSION: PE and specific cannabis-focused intervention are associated with similar reductions in cannabis use in an FEP cohort. Simple interventions may therefore be worth considering prior to intensive psychotherapeutic efforts with this population.     

First-episode psychosis patients recruited into treatment via early detection teams versus ordinary pathways: course, outcome and health service use during first 2 years

Aim: Within an early detection sector, to compare the 1‐ and 2‐year course and outcome of first‐episode psychosis patients coming into the treatment system via active outreach detection teams (DTs) versus those achieving help via ordinary referral channels (not‐DT). Methods: Longitudinal, comparative study of two parallel consecutive samples using structured clinical interview for the DSM‐IV, Positive and Negative Syndrome Scale Score, Global Assessment of Functioning Scale and Premorbid Assessment of Functioning Scale. Results: The DT group had significantly better functioning at baseline, but this was reversed after 3 months. At 2 years the groups had similar outcome. The DT group developed a more serious diagnostic pattern, had more cases of schizophrenia, and was more frequently treated on an outpatient basis only. Conclusions: The DTs recruited more chronic patients with poorer prognostic features, but fewer symptoms and better functioning at baseline. At 2 years the DT‐patients did as well as the not‐DT patients. They recovered more slowly, but given sufficient time, responded as well to therapy as the not‐DT group.     

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.     

'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.     

Determinants of quality of life in first-episode psychosis

OBJECTIVE: To assess patient and/or illness characteristics associated with aspects of quality of life (QOL) in first-episode psychosis (FEP). METHOD: Patient characteristics, symptom ratings and Wisconsin QOL scale (client version) were assessed. Data were analysed with correlation coefficients and a hierarchical regression analysis. RESULTS: Patients presented with varying levels of QOL on different domains. The level of 'general satisfaction' was related to age of onset and social premorbid adjustment; 'weighted index of QOL' to social premorbid adjustment and inversely to educational premorbid adjustment; 'social relations' inversely to duration of untreated psychosis (DUP), length of prodrome and negative symptoms; 'psychological well-being' inversely to depression and educational premorbid adjustment; 'activities of daily living' to social premorbid adjustment and inversely to negative symptoms; and 'outlook on symptoms' to level of depression. CONCLUSION: Domains of self-rated QOL in FEP patients are differentially associated with malleable and non-malleable aspects of patient and illness characteristics.     

Neuropsychological functions predict 1- and 3-year outcome in first-episode psychosis

OBJECTIVE: To examine neuropsychological performance as a possible predictor of course and outcome in first-episode psychotic (FEP) patients. METHOD: A group of consecutive FEP patients (n = 120) tested with Wechsler Adult Intelligence Scales-Revised (WAIS-R) at baseline was compared with a healthy group (n = 30) matched for age, education and gender. Relationship between WAIS-R and both Brief Psychiatric Rating Scale and Global Assessment of Function (GAF) ratings were studied at baseline and at 1- and 3-year follow-ups. RESULTS: The performance of FEP patients was significantly lower (P < 0.001) than that of healthy comparison subjects on all WAIS-R subtests except for Information and Comprehension. The WAIS-R scores of patients with schizophrenia syndromes (DSM-IV) were lower than those of patients with non-schizophrenia syndromes on Block Design. Low WAIS-R Full-Scale IQ scores in FEP patients predicted the presence of negative symptoms at 1-year follow-up and of low GAF ratings at 3-year follow-up. CONCLUSION: Neurocognitive performance at admission appears to predict various aspects of functional outcome in FEP.     

Review of the operational definition for first-episode psychosis

Aim: Given the growing interest in the study of first‐episode psychosis, clinical and research programmes would benefit from a conceptual clarification of how to operationalize ‘first‐episode psychosis’. We review the variety of definitions in use and discuss their relative merits with respect to both clinical (e.g. early treatment) and research (e.g. obtaining meaningfully homogeneous populations) agendas. Methods: We completed a selective review of the literature to investigate how first‐episode psychosis was operationally defined. Results: Operational definitions for ‘first‐episode psychosis’ fall largely into three categories: (i) first treatment contact; (ii) duration of antipsychotic medication use; and (iii) duration of psychosis. Each definitional category contains a number of underlying assumptions that contribute to the strengths and weaknesses of the definition. Conclusions: The term ‘first‐episode psychosis’ as used within clinical and research settings is misleading regardless of which operational definition is used. This term is typically used to refer to individuals early in the course of a psychotic illness or treatment rather than individuals who are truly in the midst of a first ‘episode’ of illness. The alternative of ‘recent‐onset psychosis’ with related definitions based on ‘duration of psychosis’ is proposed. Based on this review, we provide suggestions with regard to the overarching pragmatic consideration of setting up a clinical service that can attract and assemble a population of early psychosis patients for the related purposes of treatment and research.     

Factors associated with functional psychosocial status in first-episode psychosis

Aim: This study aimed to determine which of demographic/premorbid, psychiatric or neuropsychological variables are most closely associated with functional status around the time of diagnosis of first‐episode psychosis. This was with a view to determining factors that should be the focus of intervention in these early stages of illness. Methods: The Western Sydney First Episode Psychosis Project collected data on young persons (aged 13–25) with newly diagnosed psychosis (n = 92). Psychosocial functional status was measured using the Role Functioning Scale (RFS). Multiple regression analyses were carried out to identify predictors of RFS score from a wide range of predictor variables. Results: Psychiatric variables accounted for the most variance in RFS score. Positive and Negative Syndrome Scale (PANSS) Negative subscale and Young Mania Rating Scale score were found to be significant individual predictors, with variables from the other domains failing to contribute to the overall model. In separate models, demographic/premorbid and neuropsychological factors weakly related to functional status. Conclusions: Psychiatric factors were the main influence on psychosocial functioning in first‐episode psychosis at baseline. Evidence suggests the relationships between symptoms, cognition and demographics with function might change over time, depending on the stage of illness being examined.     

Improving detection of first-episode psychosis by mental health-care services using a self-report questionnaire

Objective: To examine the utility of the Community Assessment of Psychic Experiences (CAPE)‐42, a self‐report questionnaire, to improve detection of first‐episode psychosis in new referrals to mental health services. Method: At first contact with mental health‐care services patients were asked to complete the CAPE‐42 and were then routinely diagnosed by a clinician. Standard diagnoses were obtained by means of the mini‐Schedule for Clinical Assessment in Neuropsychiatry. Results: Of the 246 included patients, 26 (10.6%) were diagnosed with psychosis according to the mini‐Schedule for Clinical Assessment in Neuropsychiatry. Only 10 of them were recognized by clinical routine, and 16 psychotic patients were not properly identified. Using an optimal cut‐off of 50 on the frequency or distress dimension of the positive subscale of the CAPE‐42 detected 14 of these misdiagnosed patients. The sensitivity of the CAPE‐42 at this cut‐off point was 77.5 and the specificity 70.5. Conclusion: Systematic screening of patients using a self‐report questionnaire for psychotic symptoms improves routine detection of psychotic patients when they first come into contact with mental health services.     

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.