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.     

Duration of untreated psychosis: a proposition regarding treatment definition

Aim: Duration of untreated psychosis (DUP) refers to the time elapsing between psychosis onset and treatment initiation. Despite a certain degree of consensus regarding the definition of psychosis onset, the definition of treatment commencement varies greatly between studies and DUP may be underestimated due to lack of agreement. In the present study, three sets of criteria to define the end of the untreated period were applied in a first‐episode psychosis cohort to assess the impact of the choice of definition on DUP estimation. Methods: The DUP of 117 patients admitted in the Treatment and Early Intervention in Psychosis Program Psychosis in Lausanne was measured using the following sets of criteria to define treatment onset: (i) initiation of antipsychotic medication; (ii) entry into a specialized programme; and (iii) entry into a specialized programme and adequate medication with a good compliance. Results: DUP varied greatly according to definitions, the most restrictive criteria leading to the longest DUP (median DUP1 = 2.2 months, DUP2 = 7.4 months and DUP3 = 13.6 months). A percentage of 19.7 of the patients who did not meet these restrictive criteria had poorer premorbid functioning and were more likely to use cannabis. Longer DUP3 was associated with poorer premorbid functioning and with younger age at onset of psychosis. Conclusion: These results underline the need for a unique and standardized definition of the end of DUP. We suggest that the most restrictive definition of treatment should be used when using the DUP concept in future research.     

Recent approaches to psychological interventions for people at risk of psychosis

With the emerging global focus on early psychosis, indicated prevention in schizophrenia has increasingly become a focus of psychiatric research interests. It has been argued that CBT may have some advantages compared with antipsychotics regarding this issue. According to MEDLINE, EMBASE and Psycinfo two completed randomised controlled trials (RCTs; PACE, Melbourne, Australia; EDIE, Manchester, United Kingdom) and one ongoing RCT with only preliminary results published so far (FETZ, Cologne/Bonn, Germany) on indicated prevention in schizophrenia including manualised and standardised psychological treatment can be identified. The aims of the present paper are to present and discuss the three approaches with regard to (I) inclusion, exclusion and exit criteria, (II) characteristics of interventions and (III) evaluations. All interventions use intake, exclusion and exit criteria, which have been evaluated in prospective follow-along studies. The approaches are based on the general structure and principles of cognitive behavioural therapy which have been developed, applied and evaluated in a wide range of mental health problems. Despite several methodological limitations, the first evaluations indicate some effects with regard to three possible aims of early intervention: (1) improvement of present possible pre-psychotic symptoms, (2) prevention of social decline/stagnation and (3) prevention or delay of progression to psychosis. Even though the first results are promising, we conclude that several ethical issues have to be taken into consideration and further predictive and therapeutic research is needed to judge whether psychological intervention is a realistic option for the treatment of people at risk of psychosis.