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.     

'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.     

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.     

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.     

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.     

Intervention to improve level of overall functioning and mental condition of adolescents at high risk of developing first-episode psychosis in Finland

Aim: Being at high risk of developing psychosis has been suggested to be a result of a combination of acute life stressors and trait‐like vulnerability to psychosis. Reducing levels of stress could support overall functioning and mental condition in those at risk. Methods: The Jorvi Early Psychosis Recognition and Intervention (JERI) project at Helsinki University Central Hospital, Jorvi Hospital, Finland, is an early intervention team for adolescents at risk of developing first‐episode psychosis. The project is based on the idea of multiprofessional, community, home, family and network‐oriented, stress‐reducing, overall functioning‐supporting, low‐threshold care. The JERI team meets multiprofessionally with adolescents in their natural surroundings, for example, at school or at home, together with their parents, network and community co‐worker, who has originally contacted the JERI team because of unclear mental health problems. Subjects were assessed with the PROD‐prodromal screen to identify those at risk of developing first‐episode psychosis. Results: Statistically significant difference between baseline and follow‐up measures was found in at risk subjects (n = 28) in scales of overall functioning (P = 0.000), depression (P = 0.001), anxiety (P = 0.001), quality of life (QOL) and pre‐psychotic symptoms. Conclusions: JERI‐type intervention may improve level of overall functioning and support mental condition in adolescents at risk of developing first‐episode psychosis, even though further study with larger numbers of subjects, with a control group and with a longer follow‐up time, is needed.     

Are multi family groups appropriate for patients with first episode psychosis? A 5‐year naturalistic follow‐up study

Rossberg JI, Johannessen JO, Klungsoyr O, Opjordsmoen S, Evensen J, Fjell A, Haahr U, Joa I, Langeveld J, Larsen TK, Melle I, Rund BR, Simonsen E, ten Velden W, Vaglum P, Friis S, McGlashan T. Are multi family groups appropriate for patients with first episode psychosis? A 5‐year naturalistic follow‐up study. Objective: To compare outcome over 5 years for patients who participated in multi family groups (MFGs) to those who refused or were not offered participation. Method: Of 301 first episode psychotic patients aged 15–65 years, 147 participated in MFGs. Outcome was measured by drop‐out rates, positive and negative syndrome scale (PANSS) symptom scores, and duration of psychotic episodes during the follow‐up period. Results: Multi family group participants had a significantly lower drop‐out rates at 5‐year follow‐up than patients who did not participate. However, the MFG participants had significantly less improvement in PANSS positive and excitative symptoms and had significantly longer duration of psychotic symptoms during the follow‐up period. Conclusion: Multi family groups appear to increase the chance of retaining patients in a follow‐up study, but adjustment of the programme may be necessary with first episode psychosis patients to meet their needs better.     

Diagnostic stability 2 years after treatment initiation in the early psychosis intervention programme in Singapore

OBJECTIVE: To evaluate the diagnostic stability of psychotic disorders over a 2 year period in patients presenting with first-episode psychosis. METHODS: One hundred and fifty-four patients were recruited from an early psychosis intervention programme (EPIP). They were diagnosed by the attending psychiatrist using the Structured Clinical Interview for DSM-IV Axis I at first contact (baseline) and after 24 months. The diagnoses were classified into the following categories: schizophrenia spectrum disorders (schizophrenia, schizophreniform disorder and schizoaffective disorder), affective psychosis (bipolar and major depressive disorders with psychotic symptoms), and other non-affective psychosis (delusional disorder, psychosis not otherwise specified and brief psychotic disorder). Two measures of stability, the prospective and the retrospective consistency were determined for each diagnosis. RESULTS: The diagnoses with the best prospective consistency were schizophrenia (87.0%) and affective psychosis (54.5%). The shift into schizophrenia spectrum disorder was the most frequent diagnostic change. Duration of untreated psychosis was found to be the only significant predictor of shift. CONCLUSION: It is difficult to make a definitive diagnosis at first contact. The clinical need to review the diagnosis throughout the period of follow up is emphasized.     

Treatment delay and response rate in first episode psychosis

OBJECTIVE: There is no consistent evidence of long duration of untreated psychosis (DUP) predicting long time to response (TTR) in first psychosis. This study aims to investigate the predictors of DUP and TTR in a first episode patient population. METHOD: An epidemiologically representative sample of 157 non-affective first psychotic episode patients was interviewed and followed-up for at least half a year. RESULTS: The mean DUP was 46 weeks, the median 31 days. Long DUP was associated with being unemployed before treatment and male gender. Short DUP, having a job, and living with a partner before treatment predicted early response. CONCLUSION: Early intervention likely improves short-term treatment response in first episode psychosis. The best strategy to reduce DUP probably is to direct attention to the substantial number of patients who do not engage in regular treatment.     

Diagnostic stability 18 months after treatment initiation for first-episode psychosis

OBJECTIVES: (1) Assessment of diagnostic stability of psychotic disorders or psychotic mood disorders from 6 weeks to 18 months after initiation of treatment in a representative first-episode psychosis (FEP) sample. (2) Comparison between those patients who shifted from DSM-IV schizophreniform disorder to schizophrenia or schizo-affective disorder and those whose diagnosis of schizophreniform disorder remained stable. METHOD: The Early Psychosis Prevention and Intervention Centre (EPPIC) in Australia admitted 786 FEP patients from January 1998 to December 2000. Data were collected from patients' medical records (MRs) using a standardized questionnaire. Seven hundred four MRs were available, 36 of which were excluded owing to nonpsychotic diagnoses or a psychotic disorder due to a general medical condition. Of the remaining 668 patients, 176 (26.3%) were lost to follow-up. Four hundred ninety-two subjects were analyzed. Strategies to assure validity and reliability of diagnoses were applied. RESULTS: The same diagnosis was made at baseline (< or = 6 weeks after admission into EPPIC) and 18 months for 69.9% of the patients. Among the most consistent diagnoses were schizophrenia (97.3%), schizoaffective disorder (94.1%), and bipolar disorder (83.2%); the least stable, as expected, was schizophreniform disorder (40.0%). In subjects with schizophreniform disorder at baseline, the best predictors of a shift from schizophreniform disorder to schizophrenia or schizoaffective disorder were a higher baseline Clinical Global Impressions-Severity of Illness scale score and lower premorbid Global Assessment of Functioning score, although the variance accounted for was small (R2 = .07). CONCLUSIONS: A longitudinally based diagnostic process in FEP samples is needed, especially in schizophreniform disorder and bipolar disorder. However, a thorough initial assessment of patient and family by a specialized team of investigators regarding the kind and duration of patient symptoms may lead to high diagnostic stability, especially in schizophrenia and schizoaffective disorder, even in a FEP sample with a relatively short duration of untreated psychosis.     

Treated incidence of first-episode psychosis in the catchment area of EPPIC between 1997 and 2000

OBJECTIVE: To identify the treated incidence of psychosis in catchment of the Early Psychosis Prevention and Intervention Centre (EPPIC), Melbourne, Australia. METHOD: Cases were aged 15-29 years with a first episode of a psychotic disorder accepted into EPPIC between 1997 and 2000. Age- and sex-specific incidence rates per 10,000 person-years were calculated in 5 year age bands. Rate ratios were used for age group comparisons. RESULTS: The age-specific treated incidence of first-episode psychosis in 15-29-year old individuals was 16.7 per 10,000 person-years in males, and 8.1 per 10,000 person-years in females. The incidence was highest in 20-24-year-old males and in 15-19-year-old females. For both sexes, incidence rates were significantly lower in the 25-29-year age group. CONCLUSIONS: The incidence of psychosis in the catchment of EPPIC was higher than previously reported, especially in female teenagers. Peak rates in 15-24 year olds suggest a youth model approach to early psychosis may be indicated.     

Early identification of non‐remission in first‐episode psychosis in a two‐year outcome study

Simonsen E, Friis S, Opjordsmoen S, Mortensen EL, Haahr U, Melle I, Joa I, Johannessen JO, Larsen TK, Røssberg JI, Rund BR, Vaglum P, McGlashan TH. Early identification of non‐remission in first‐episode psychosis in a two‐year outcome study. Objective: To identify predictors of non‐remission in first‐episode, non‐affective psychosis. Method: During 4 years, we recruited 301 patients consecutively. Information about first remission at 3 months was available for 299 and at 2 years for 293 cases. Symptomatic and social outcomes were assessed at 3 months, 1 and 2 years. Results: One hundred and twenty‐nine patients (43%) remained psychotic at 3 months and 48 patients (16.4%) remained psychotic over 2 years. When we compared premorbid and baseline data for the three groups, the non‐remitted (n = 48), remitted for <6 months (n = 38) and for more than 6 months (n = 207), duration of untreated psychosis (DUP) was the only variable that significantly differentiated the groups (median DUP: 25.5, 14.4 and 6.0 weeks, respectively). Three months univariate predictors of non‐remission were being single, longer DUP, core schizophrenia, and less excitative and more negative symptoms at baseline. Two‐year predictors were younger age, being single and male, deteriorating premorbid social functioning, longer DUP and core schizophrenia. In multivariate analyses DUP, negative and excitative symptoms predicted non‐remission at 3 months, but only DUP predicted at 2 years. Conclusion: Long DUP predicted both 3 month and 2‐year non‐remission rates in first‐episode psychosis.     

Mood disorders and prospective suicidality in young adults: a population‐based cohort study

Objective

To assess the prospective associations of mood disorders and suicidality in a community sample of young adults from south Brazil.

Method

Prospective population‐based cohort study. Young adults (18–24 years old) were recruited and followed up on 5 years later; people were interviewed at their homes. Suicidality, as well as mood and anxiety disorders, was assessed using the Mini‐International Neuropsychiatric Interview. The impact of mood episodes on suicidality was both evaluated when they occurred in the same wave (a current episode) and when suicidality occurred prospectively, with suicidality measured at follow‐up (a past episode).

Results

The sample included 1560 young adults at baseline, with 1244 reassessed at follow‐up (80.6%). Depressive episodes, both current and past, had a significant impact on suicidality in the final multivariable model. Manic episodes, however, were less consistently associated with suicidality.

Conclusion

Depressive episodes have a strong, independent, and robust association with prospective suicidality. The association between manic episodes and suicidality, on the other hand, was dependent on the analysis and deserves further exploration.     

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.     

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.     

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.     

EEG abnormalities and 3-year outcome in first episode psychosis

Objective: This study assesses the relationship of EEG to several aspects of 3 year symptomatic and functional outcome in first episode psychosis. Method: A total of 117 patients with first episode psychosis had their baseline EEG classified by modified Mayo Clinic criteria as normal, essentially normal or dysrhythmia. Socio‐demographic variables, duration of illness and of untreated psychosis and premorbid adjustment were also recorded. Positive and negative symptoms of psychoses, depression, anxiety and global functioning were rated on entry and after 3 years of treatment. Results: Patients with a dysrhythmic EEG at entry into treatment showed significantly greater persistence in both positive and negative symptoms of psychoses as well as anxiety and depression over 3 years. These findings were independent of duration of untreated illness or premorbid adjustment. Conclusion: An abnormal baseline EEG in patients with first episode psychosis is associated with a poorer symptomatic outcome at 3‐year follow‐up.     

Early intervention and a five year follow up in young adults with a short duration of untreated psychosis: ethical implications

In a Dutch treatment intervention study of patients (n=76) with first psychotic episodes of schizophrenia the hypothesis tested was whether early differential treatment after an acute psychotic break improved outcome as compared with other studies. Patients had a relatively short duration of untreated psychosis. No significant effect between two treatment conditions on relapse rate was found. The 15-month intervention program kept the psychotic relapse rate as low as 15%; lower than comparable studies. Thus, the initial results were in support of the hypothesis.After completion of the 15 months study, patients were referred to other agencies and followed for five years. Results of the follow up study showed that the low relapse rate could not be maintained. Of the remaining 71 patients of the initial sample, 52% had one or more psychotic relapses, 25% developed chronic positive symptoms and 23% did not have another psychotic episode. In addition, the level of social functioning turned out to be low: the majority of patients were dependent upon their parents, few held down a skilled or paid job and also their quality of life seemed low, results indicate that early intervention may improve short term but not long term outcome in schizophrenia.Our results also suggest that referral to other mental health agencies after intervention is not sufficient. Continuity of outpatient care, including continuity of a professional relationship, continuity of support for the family, and the continuity in management of illness, medication and stress may be a key issue in the first five years after the onset of psychosis in schizophrenia. Early recognition and intervention may not nearly be as important for outcome as continuity in care and caregivers. At present, however, it remains questionable whether early intervention programs in first-episode patients with a short duration of untreated psychosis can offer the prospect of altering the course of schizophrenia without a sustained comprehensive treatment program.