Beyond Symptom Reduction: A Call to Integrate Well-Being in Psychosis Research and Early Intervention.

Ashok Malla, MBBS, FRCPC1; Anthony J Pelosi, FRCP, FRCPsych2 Can J Psychiatry. 2010;55(1):3-8. Ample Evidence Supports Specialized Early Intervention The last decade has seen a burgeoning interest not only in research in first-episode psychosis (FEP), its treatment, and early detection but also in the establishment of several early intervention (EI) services. While the enthusiasm for EI is inherently appealing, it has its detractors. Whether the benefits of a specialized EI approach to treatment of FEP are worth the costs it may incur has generated some heated debate. While we do not have all the answers yet, I will argue that this new development in service delivery is based on good evidence and likely to be cost-beneficial in the long run. To shed more light, rather than simply generate more heat, it is important to examine several key questions related to EI and its benefits. What is EI? Is it effective? Is it worth the cost and should EI be incorporated into mental health policy in Canada? Should EI include services for patients in the so-called prodromal stage of psychosis? There are several sources of ambiguity in the term EI that go beyond semantics. In the treatment of an FEP, 2 components of EI need to be clearly defined, one that relates to a phase-specific and specialized approach to treatment and the other that addresses issues of reducing delay through early case identification. An additional and more contentious issue relates to treatment of prodromal state. The 2-pronged question most often raised is: Why establish a new and specialized service for this patient population, and why not treat them in the same services as those with more established and chronic illness? The argument for a specialized approach to treatment in the early phase of psychosis goes something like this: in routine care, clinical response to treatment of FEP is generally very good, with relatively high rates of reduction in level of psychotic symptoms and more modest reduction of negative symptoms, often, however, followed by relatively high rates of relapse within the first 2 to 5 years.' Trajectories of long-term outcome are often defined relatively early in the course of illness.2 More intensive efforts at treatment during the early phase may improve outcome, at least for a substantial proportion of patients. In routine psychiatric services, highly specialized and intensive care is usually not introduced until considerably later in the course of illness, after considerable decline in functioning develops. Interventions at this late stage are unlikely to result in any substantial clinical or functional gains. The existent system is generally not equipped to deal with special needs of the young patients (and their family) with a new onset of psychosis. For example, such needs are associated with a significantly younger age, specific developmental stage, nature of psychopathology leading to ambiguity in diagnosis, naivete to the mental health system, and high rate of recreational substance use. Such special characteristics of FEP patients render them unlikely to engage or stay in and be adherent to treatment. In general, most EI services provide a modified version of an assertive case management program along with rational pharmacotherapy and specific psychological interventions such as cognitive-behavioural therapy (CBT) and family intervention. Two recent randomized controlled studies and numerous, mostly uncontrolled and quasi-experimental, studies have shown that specialized EI services provide superior effectiveness on measures of psychopathology, rates of remission and relapse, adherence to and retention in treatment, greater family involvement in treatment, and better community adjustment.3-4 A recent meta-analysis has confirmed that an enriched intervention provided to patients with FEP is likely to produce significantly better clinical and functional outcome, compared with routine care. …

Correction to 'Beyond Symptom Reduction: A Call to Integrate Well-Being in Psychosis Research and Early Intervention'.

Validating the Predictive Accuracy of the NAPLS-2 Psychosis Risk Calculator in a Clinical High-Risk Sample From the SHARP (Shanghai At Risk for Psychosis) Program.

The Long and Winding Road to Bipolar Disorder.

<p>This article presents an overview of the strategies developed and implemented from 1997 to 2007 in an early detection site in Norway as part of the early Treatment and Intervention in Psychosis (TIPS) study. These strategies include intensive Information Campaigns (ICs) about the signs and symptoms of psychosis and easy access to low-threshold detection teams for rapid case identification. Few, if any other studies of first-episode psychosis, have used such a system over so many years in a regular and repeated fashion. The TIPS early intervention program reduced the healthcare sector’s median duration of untreated psychosis (DUP) in first-episode schizophrenia from 15 weeks to 4.5 weeks using a combination of these easy-access detection teams and massive ICs that targeted diverse audiences. Data on 5,230 referrals are presented in this article, along with their sources of referral and the actual number of cases who were identified with a first episode of psychosis via the detection teams as the initial contact point with specialized mental health services. The TIPS study has shown that such strategies are a vital part of bringing persons with first-episode psychosis into adequate treatment earlier, thereby reducing DUP. </p> <h4>ABOUT THE AUTHORS</h4> <p>Inge Joa, RN; Jan Olav Johannessen, MD; and Tor K. Larsen, MD, are with the Stavanger University Hospital, Department of Psychiatry, Regional Centre for Clinical Research in Psychosis, Stavanger, Norway. Thomas H. McGlashan, MD, is with Yale University School of Medicine, Department of Psychiatry, New Haven, CT. </p> <p>Ms. Joa, Dr. Johannessen, Dr. Larsen, and Dr. McGlashan have disclosed no relevant financial relationships. </p> <h4>EDUCATIONAL OBJECTIVES</h4> <ol><li>Explain the goals of the Early Treatment and Intervention in Psychosis (TIPS) study. </li> <li>Describe the strategies employed by the TIPS study to achieve its aims, especially through the utilization of information campaigns. </li> <li>Discuss the results of the TIPS study in terms of community median duration of untreated psychosis (DUP). </li></ol>

The effectiveness of early psychosis programming for young women: a systematic review protocol

A systematic literature review of early posttraumatic interventions for victims of violent crime

Objectives To synthesize the available epidemiological and clinical evidence relevant to the mental health care of migrant, ethnic minority and Indigenous populations in the context of early psychosis. Methods This study provides a narrative review of the literature on psychosis in these populations, including issues related to the provision of early intervention services for psychosis. Results Migrant status has long been reported as a significant risk factor for psychosis in many geographic contexts. This increased risk among migrants seems to persist beyond the first generation and has been found to be higher in all migrant populations, but especially for black ethnic minorities and individuals migrating from economically developing countries to developed ones. Recent evidence suggests that this higher risk is at least in part due to migrants' and minorities' cumulative exposure to social adversities, such as racial discrimination, marginalization and socio-economic disadvantage. Systemic racism affects migrant and minority populations by creating bias in diagnostic practices and aggravating treatment disparities in addition to contributing to causation of psychosis. Furthermore, migrant and ethnic minority groups are known to seek mental healthcare after longer delays, to be more frequently forcibly hospitalized, to disengage from treatment prematurely and to be less satisfied with their treatment. The consideration of social and cultural context and factors is essential to the provision of good healthcare, especially in a culturally diverse society. Furthermore, acknowledging power relationships that stem from the societal context and shape institutions and models of care is a key step towards structural competence and safety in mental healthcare. Several strategies have been proposed to make mental healthcare services and systems more culturally and structurally competent. These include the use of interpreters and cultural brokers, tailored assessments and specialised cultural interventions. However, these strategies have yet to be adopted broadly in early intervention for psychosis. Conclusion Given its emphasis on meaningful engagement and person-centered care, early intervention should integrate inclusive, structurally competent and context-informed interventions as a priority. Efforts must be made to apply knowledge from and adapt the tools of social and cultural psychiatry to the field of early intervention in psychosis. Sociocultural considerations, hitherto inconsistently applied in psychosis research and service design in Quebec, are especially relevant to the province given its distinct linguistic context, its increasing cultural diversity, and its ongoing effort to systematize and expand the delivery of early intervention services.

Early detection and intervention (EDI) is a main challenge in psychosis research. The Chilean schizophrenia (SZ) national program has universal support and treatment by law for all SZ patients, but this does not yet extend to earlier stages of illness. Therefore, we have piloted an ultra-high risk (UHR) program to demonstrate the utility and feasibility of this public health approach in Chile. We introduce "The University of Chile High-risk Intervention Program," which is the first national EDI program for UHR youths. Longitudinal follow-up included clinical and cognitive assessments, and monitoring of physiological sensory and cognitive indices, through electroencephalographic techniques. We recruited 27 UHR youths over 2 years. About 92.6% met criteria for attenuated psychosis syndrome (APS). Mean Scale of Psychosis-Risk Symptoms (SOPS) ratings in the cohort were 6.9 (SD 4.6) for positive, 9.1 (SD 8.3) for negative, 5.4 (SD 5.3) for disorganized and 6.3 (SD 4.1) for general symptoms. About 14.8% met criteria for comorbid anxiety disorders and 44.4% for mood disorders. Most participants received cognitive behavioural therapy (62.9%) and were prescribed low dose antipsychotics (85.2%). The transition rate to psychosis was 22% within 2 years. We describe our experience in establishing the first EDI program for UHR subjects in Chile. Our cohort is similar in profile and risk to those identified in higher-income countries. We will extend our work to further optimize psychosocial and preventive interventions, to promote its inclusion in the Chilean SZ national program and to establish a South American collaboration network for SZ research.

Issues related to early detection and intervention, primary prevention, and re-conceptualizing therapeutic targets are important current themes in psychosis research. Extensive heterogeneity within each diagnostic class and overlap in clinical features, risk factors and associated features between diagnostic classes, all result in critical limitations in clinical care and research. In this chapter, concrete approaches are suggested to make progress in psychosis research. Each partial solution has a different profile of strengths and weaknesses. New knowledge will be needed to make progress, and that knowledge will be acquired incrementally.

Autism Spectrum Disorder (ASD) is a developmental disability manifested early in life. About 26–40% of young children with ASD have intellectual disability (ID). Applied Behavior Analysis (ABA) has been shown to be effective in reducing symptoms of ASD and improving cognitive and language function. The purpose of this study was to examine the optimal age, number of treatment hours and domains, for which ABA was effective in a community based early intervention program. An ABA program was implemented with 106 toddlers under 40 months, many of whom were from immigrant families with limited English proficiency. Bayley Scales, VBMAPP and CARS-2 were administered as Pre-and Post-intervention program measures. The children showed significant improvement in all Bayley and VBMAPP measures as well as reduction in symptoms of ASD. The current study shows that ABA early intervention in a community setting provides statistically significant improvement in cognitive, communication, motor, socio-emotional, adaptive and criterion referenced behavior as well as a reduction in symptoms of ASD and barriers to learning.

Background: About 40% of rape victims develop post-traumatic stress disorder (PTSD) within three months after the assault. Considering the high personal and societal impact of PTSD, there is an urgent need for early (i.e. within three months after the incident) interventions to reduce post-traumatic stress in victims of rape. Objective: To assess the effectiveness of early intervention with eye movement desensitization and reprocessing (EMDR) therapy to reduce symptoms of post-traumatic stress, feelings of guilt and shame, sexual dysfunction, and other psychological dysfunction (i.e. general psychopathology, anxiety, depression, and dissociative symptoms) in victims of rape. Method: This randomized controlled trial included 57 victims of rape, who were randomly allocated to either two sessions of EMDR therapy or treatment as usual (‘watchful waiting’) between 14 and 28 days post-rape. Psychological symptoms were assessed at pre-treatment, post-treatment, and 8 and 12 weeks post-rape. Linear mixed models and ANCOVAs were used to analyse differences between conditions over time. Results: Within-group effect sizes of the EMDR condition (d = 0.89 to 1.57) and control condition (d = 0.79 to 1.54) were large, indicating that both conditions were effective. However, EMDR therapy was not found to be more effective than watchful waiting in reducing post-traumatic stress symptoms, general psychopathology, depression, sexual dysfunction, and feelings of guilt and shame. Although EMDR therapy was found to be more effective than watchful waiting in reducing anxiety and dissociative symptoms in the post-treatment assessment, this effect disappeared over time. Conclusions: The findings do not support the notion that early intervention with EMDR therapy in victims of rape is more effective than watchful waiting for the reduction of psychological symptoms, including symptoms of post-traumatic stress. Further research on the effectiveness of early interventions, including watchful waiting, for this specific target group is needed.

The impossible dream: can psychiatry prevent psychosis?

The intervention focused on starting treatment at an early age to develop the child’s full potential, which is known as early intervention. Given that autistic symptoms and language deficits occur at an early age and affect other areas of development in children with autistic spectrum disorder, we wanted to examine if early intervention is more effective in the reduction in autistic symptoms and language deficits in children aged 36–47 months old when compared to children 48–60 months old. The sample consisted of 29 children diagnosed with ASD who were admitted for integrative therapy. All participants were divided into two groups based on age: G1: 36–47 months old children, and G2: 48–60 months old children. To estimate the presence of autistic symptoms, we used the GARS-3, and for the assessment of speech–language abilities, we used the subscale Estimated Speech and Language Development (ESLD). Our results regarding the effect of the group on the difference in the scores at two time points showed that there was a statistically significant effect of the group on the reduction in autistic symptoms (p < 0.05) but no effect of the group on the differences in speech–language abilities between the two time points (p > 0.05). Our study highlights the importance of emphasizing the exact age when using the terms “early intervention” and “early development” in future studies and practice because it is necessary to determine and establish guidelines about which particular ages are crucial for starting treatment in certain developmental aspects.

Research on individuals at clinical high risk for psychological and physical disorders has grown exponentially in recent years, with a variety of new screening tools and early intervention techniques being implemented. One recent example is Attenuated Psychosis Syndrome, a diagnosis for individuals who are at clinical high risk for psychosis, which was recently included in Section III of the Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Given the focus on prevention at early stages, at-risk individuals will continue to be a topic of significance not only in psychosis research but also in other illnesses. This document provides a comprehensive summary of the ethical dilemmas that clinicians or researchers may encounter in this domain, and possible actions consistent with the current Canadian Code of Ethics for Psychologists. We use clinical high risk for psychosis and the Canadian Code of Ethics for Psychologists as a way to illuminate these ethical issues; however, application to other jurisdictions and disciplines, as well as other high-risk populations, is also of relevance.