New knowledge and new hope to people with emerging mental disorders

Moderated Online Social Therapy for Recovery From Early Psychosis

Early Intervention in Psychosis services improves outcomes for young people with psychosis, but 25% disengage in the first 12 months with costs to their mental health. To refine a toolkit and training and evaluate effectiveness, implementation, and cost-effectiveness of the Early Youth Engagement-2 intervention to reduce disengagement. Cluster randomised controlled trial with economic and process evaluation. Randomisation at team level stratified by site. Research assistants, outcome assessors and statisticians were masked to treatment allocation for the primary disengagement and cost-effectiveness outcomes. Participants and teams administering the interventions were unmasked. Twenty Early Intervention in Psychosis teams in five sites across England. A total of 1027 young people (14-35 years) with first-episode psychosis (F20-29, 31; ICD-10); 20-282 Early Intervention in Psychosis staff. Team-based motivational engagement (Early Youth Engagement-2) intervention, delivered by Early Intervention in Psychosis clinicians alongside standardised Early Intervention in Psychosis, supported by the implementation toolkit (training, website and booklet series). Standardised Early Intervention in Psychosis, including National Institute for Health and Care Excellence guidelines approved interventions. Primary outcome - time to disengagement over 26 months (days from date of allocation to care co-ordinator to date of last contact following refusal to engage with service, or lack of response to contact for consecutive 3-month period). Secondary outcomes - mental health, recovery, quality of life, service use, at 6 and 12 months. Economic outcomes - National Health Service mental healthcare costs, wider societal care costs, clinical and social outcomes over 12 months; cost-effectiveness. Process evaluation outcomes - fidelity to the Early Youth Engagement-2 model, implementation process scores, therapeutic alliance, qualitative outcomes. Disengagement was 16% across both arms. The multivariable Cox regression on 1005 participants estimated an adjusted hazard ratio for Early Youth Engagement-2 + standardised Early Intervention in Psychosis (n = 652) versus standardised Early Intervention in Psychosis service alone (n = 375) of 1.07 (95% confidence interval 0.76 to 1.49; p = 0.713). There were no observed differences between arms for any secondary outcomes. The health economic evaluation indicated lower mean mental healthcare costs of -£788 (95% CI -£3571 to £1994) and marginally improved mental health states for intervention participants. Early Youth Engagement-2 participants spent 30 more days per year in education and training (95% CI 1.52 to 53.68; probability positive outcome for the intervention: 99%), but these outcomes must be viewed very cautiously as only 22% of the sample provided data. The process evaluation revealed heterogeneous implementation fidelity and constant pressure to adapt to widespread disruption from COVID-19. There was no effect on therapeutic alliance: the most likely active change mechanism was through psychoeducation. Lower than expected disengagement, high loss to follow-up and impact of COVID-19 on fidelity, implementation and outcomes. In the primary clinical effectiveness analysis, 95% confidence limits ruled out a reduction of more than 24% in the risk of disengagement with the Early Youth Engagement-2 intervention. In a cost-effectiveness analysis, estimates fell in the direction of dominance of the Early Youth Engagement-2 intervention (reduced costs, marginally better mental health states). Dissemination of the booklet and website resources and an adapted version of the model as stand-alone tools for use in good-practice routine Early Intervention in Psychosis care. This study is registered as ISRCTN 51629746. This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 16/31/87) and is published in full in Health and Social Care Delivery Research; Vol. 13, No. 33. See the NIHR Funding and Awards website for further award information.

Early psychosis identification and intervention.

PurposeThis article aims to summarise two papers from Australia on supporting young people in early intervention for psychosis. Both have implications for young people's social inclusion and the design of early intervention services.Design/methodology/approachThe first paper reports a new analysis of a trial of specialist employment and education support in an early intervention service. It used a statistical method called logistic regression to test whether only employment support predicted 41 participants’ success in getting into employment and education, or whether things like condition severity also mattered. The second paper reports on a new online support package for young people with “first episode psychosis” and how acceptable it was. The authors looked at 20 participants’ use of the package, and examined their well‐being before and after using it.FindingsThe first paper reported that nothing except getting specialist employment and education support predicted young people's entry to work or education. They recommend that young people in early intervention should not be denied vocational support because of things like “psychiatric symptoms”. In the second paper, young people in early intervention who used the online package reacted positively. The authors recommend a full controlled trial of the package. It could help young people when leaving the service to maintain their gains.Originality/valueThese papers advance research on early intervention psychosis services regarding young people's social inclusion needs. Specialist vocational support could prevent life‐long social exclusion. An innovative online support package has not yet been proven, but with fast‐evolving technology, it might help future service users stay well when leaving the service.

The case for early, medium and late intervention in psychosis

The authors sought to evaluate the interrater reliability and feasibility of the First-Episode Psychosis Services Fidelity Scale-Revised (FEPS-FS-R) for remote assessment of first-episode psychosis programs according to the coordinated specialty care model. The authors used the FEPS-FS-R to assess the fidelity of 36 first-episode psychosis program sites in the United States with information from three sources: administrative data, health record review, and phone interviews with staff. Four raters independently conducted fidelity assessments of five program sites by listening to each of the staff interviews and independently rating the two other data sources from each site. To calculate interrater reliability, the authors used intraclass correlation coefficients (ICCs) for each of the five sites and across the total scores for each site. Total interrater reliability was in the good to excellent range, with a mean ICC of 0.91 (95% confidence interval = 0.72-0.99, p<0.001). Two first-episode psychosis program sites (6%) achieved excellent fidelity, 25 (69%) good fidelity, and nine (25%) fair fidelity. Of the 32 distinct items on the FEPS-FS-R, 23 (72%) were used with good or excellent fidelity. Most sites achieved high fidelity on most items, but five items received ratings indicating low-fidelity use at most sites. The fidelity assessment proved feasible, and sites required on average 10.5 hours for preparing and conducting the fidelity review. The FEPS-FS-R has high interrater reliability and can differentiate high-, moderate-, and low-fidelity sites. Most sites had good overall fidelity, but the FEPS-FS-R identified some services that were challenging to implement at many sites.

The impossible dream: can psychiatry prevent psychosis?

Early treatment for individuals experiencing schizophrenia has received increasing attention because of its potential to alter the course of illness and improve outcomes (1). A critical component of optimal early treatment includes appropriate use of medications. Because of differential responses to medications in first-episode and multiepisode schizophrenia, prominent guidelines suggest different treatment practices for these patient groups (2, 3). For example, the 2010 Schizophrenia Patient Outcomes Research Team (PORT) underlines the importance of using low dosages of medication and specifies thatolanzapineandclozapineshouldnotbefirst-linetreatments because of their risks of adverse effects (3). Becausemedication experiences for individuals at the beginning of treatment may have a lasting impact on their attitudes toward medication and courseof illness, this is acritical timetooptimizeprescribing.To theextent thatadhering to theguidelines leads tobetterefficacy, tolerability, and positive interactions with mental health professionals, this could have a significant impact in first-episode patients. TheRecoveryAfteranInitialSchizophreniaEpisodeproject’s Early Treatment Program (RAISE-ETP) study is a nationwide comparative effectiveness trial that enrolled404 individualswith a schizophrenia spectrum diagnosis at 34 community sites throughout thecountry. Studyparticipantshadreceived less than 6monthsof antipsychotic treatmentat enrollment.Therelatively large sample and geographic breadth of the study provided the first opportunity to characterize typical community treatment of early-phase schizophrenia patients in the United States. In this issue, Robinson et al. (4) report on prescription practices observed in first-episode schizophrenia in the RAISE-ETP study. The investigators obtained detailed information regarding each participant’s prescribed medications at study entry and determined whether the medication treatment was consistent with practice guidelines. The investigators also examined participantand system-level factors associated with medication patterns that did not conform to practice guidelines and therefore could “benefit from changes.” Theinvestigators foundevidenceofpotentiallyproblematic prescribing for 159 individuals (39.4%of thesample).Themost common issues were use of an antidepressant along with an antipsychotic without a clear indication; prescription of olanzapine; and use of more than one antipsychotic. A small subgroup also had psychotropic medications prescribed without antipsychotics. While the article focuses on potential prescribing problems, it isfirstworthnoting that theprescribing formore than 60% of the sample appeared to follow existing guidelines. Given that guidelines are notmeant to dictate prescribing for an individual patient, the appropriate benchmark for conformant practice is not clear. In a study of quality of schizophrenia care, Young et al. (5) found that for 34 of 84 patients receiving poor-quality care, patient factors such as poor adherence and substanceusecontributedto theproblematicprescribing.Some nonconformant prescribing may in fact be appropriate for particular patients given their history of treatment response, their symptoms, and their preferences. It isalso important to note that prescribing that conforms to guidelines is not necessarily optimal. Guideline-conformant treatment suggests but is not synonymous with highquality care. Notwithstanding the limitations of prescribing guidelines, this studyunderlinesseveral concerns inprescribing psychotropic medications in individuals experiencing a first episode of psychosis. With respect to antipsychotic prescribing, use of combinations of antipsychotics is not supported by evidence and may be associated with more adverse effects (3, 6). This is particularly important in the careof individualswith first-episode psychosis, who are extraordinarily vulnerable to medication side effects (3). The increased complexity of dosage schedules involving polypharmacy, the increased likelihood of adverse effects, and the lack of evidence for effectiveness all argue strongly against polypharmacy in this population. If two individual antipsychotics do not provide adequate benefit, evidence strongly supports and guidelines recommend using clozapine rather than combinations of antipsychotics (2, 3). Clinicians who rarely treat first-episode patients may not be awareof the extent of problemswith olanzapine use in this population.ThePORTrecommends against usingolanzapine

Early intervention in psychosis has established itself as a cornerstone of service provision in psychosis over the last two decades. It is the latest in a line of key developments in the management of psychotic disorders over the last 60 years, following the introduction of antipsychotic medication, de-institutionalization, community care, and more effective psychosocial interventions. It borrows from principles that have emerged over the last few decades in other areas of medicine, social care, and education. Its focus is on early detection, prevention, and intervention in young people with emerging first-episode psychosis. It has become a social movement in its own right, developing its own national and international associations (e.g. the International Early Psychosis Association) World Health Organization-endorsed principles, and attracting considerable political, media, and community support. This explosion of interest in early intervention over the past two decades has prompted governments in many developed countries to adopt the early intervention model, with some promoting it as a top priority for mental health service planning. Countries such as UK, Canada, Australia, and New Zealand have committed to national roll-outs of these services. This has been further supported by recent economic evaluations highlighting the substantial health savings involved. The field is now moving into other forms of serious mental illness, not only in conditions typically affecting young people but even into old age psychiatry. However, questions remain regarding the long-term benefits of a focus on early intervention and there is much to discover about the true extent of its merits. There is still uncertainty about the ideal model. Early intervention services wrestle with the dilemma of whether they are for all age groups or specifically for young people, whether they are extensions of child and adolescent mental health services, or young adult services, or both, whether they are limited to non-affective psychoses or all forms of serious mental illness, and whether they are best provided independently of generic services or embedded as subcomponents of these services.

Even in countries whose mental health services are comparatively well resourced, the care offered to those in the early stages of psychotic illnesses is not what it could be. Patients often have to progress to chronicity before receiving adequate interventions, by which stage there has been great potential for harm, not only through the psychosis, but also to the quality of life of the individual who has often missed or not completed adequately, several important developmental tasks. Further, evidence indicates that delay in treatment is positively associated with poorer outcome. This paper puts the case for early intervention in psychosis. Based on the experience of the Early Psychosis Prevention and Intervention Centre in Melbourne, the paper reviews the evidence for and the criticisms of, early intervention. Using the concept of indicated prevention, it suggests ways in which clinicians can improve the interventions available to those experiencing the onset of psychosis and suggests that pre-psychotic intervention may be possible. Evidence discussed in this paper indicates that the development of mental illness is a major health issue in young people; that there is a positive correlation between duration of untreated psychosis and outcome; that it is possible to identify a proportion of those at high risk of developing mental illness; that through intervention it may be possible to reduce the transition rate to illness. Primary prevention is beyond the capacity of our present knowledge. Indicated prevention in the form of early intervention and optimal, sustained treatment is a paradigm for which there is increasing supportive evidence. It is a paradigm which is appealing to clinicians, patients, families and which has the potential to reduce the secondary impact of serious mental illness such as suicide, stigma, isolation and reduction in social status.

This study was undertaken to assess the potential effect of duration of untreated illness on outcome in a group of first-episode schizophrenic patients. Seventy patients with schizophrenia diagnosed according to the Research Diagnostic Criteria entered the study and were followed for up to 3 years. All patients received standardized treatment and uniform assessments both during the acute phase of their illness and throughout the follow-up period. Outcome was measured in terms of time to remission of acute psychotic symptoms as well as degree of symptom remission. The mean duration of psychotic symptoms before initial treatment was 52 weeks, preceded by a substantial prepsychotic period. According to survival analysis, duration of illness before treatment was found to be significantly associated with time to remission as well as with level of remission. The effect of duration of illness on outcome remained significant when diagnosis and gender variables, themselves associated with outcome, were controlled in a regression analysis. Duration of illness was not correlated with age at onset, mode of onset, premorbid adjustment, or severity of illness at entry into the study. Duration of psychosis before treatment may be an important predictor of outcome in first-episode schizophrenia. Acute psychotic symptoms could reflect an active morbid process which, if not ameliorated by neuroleptic drug treatment, may result in lasting morbidity. Further implications of these findings are discussed.

Early psychosis in Asia: Insights from Japan

Childhood and adolescence is a crucial period for establishing healthy emotional and behavioural capabilities which can sustain a lifetime of positive mental health and well-being. Unfortunately, this period is also a critical window for the onset of potentially lifelong mental health problems, with 50% of lifetime psychiatric conditions estimated to begin by 14 years old.1 Between 10 and 19 years old, no other health outcome contributes more to global disability than unipolar depressive disorders, with self-harm ranked fifth, and—for women—anxiety disorders are ranked fourth.2 These harmful patterns of mental ill health contribute to suicide risk, which is the third leading cause of death amongst 15- to 19-year-olds worldwide, only behind road injury and HIV/AIDS.2 Early therapeutic intervention for mental health problems which emerge in adolescence provides an opportunity to help young people manage and recover from episodes of poor mental health to minimise disruption to their future mental, physical and social well-being. Thus, timely, equitable and appropriate access to affordable psychiatric care—where and when needed—would ideally form the foundation of a just public mental health strategy in any given nation. Such efforts would need to be informed by the ability to identify high-risk subsets of the population. While no one is immune to mental health disorders, certain factors have been identified which increase risk, and which thus serve as potential signposts to aid early detection and treatment. Of particular note, and appearing to act non-specifically across a range of neuropsychiatric conditions and risk-taking behaviours,3, 4 is the role of adverse childhood experiences, including exposure to bullying, parental loss, maltreatment, violence or other traumatic life events. Within this context, children and adolescents from refugee backgrounds are likely to have been exposed to severe—and perhaps multiple—traumas associated with malnutrition and famine, conflict, violence and persecution, and standout as a potential high-risk group for whom mental health services could be readily provided to prevent or ameliorate potentially deleterious mental health problems emerging in adolescence. Previous epidemiological studies have found strong evidence that refugees are—perhaps unsurprisingly, given these patterns of exposure—ten times more likely to experience post-traumatic stress disorder than the general population.5 In Sweden, evidence suggests that refugees are also up to three times more likely to experience a psychotic disorder before 30 years old, a risk that is 60% higher than for non-refugee migrants from the same regions of origin.6 And while the risks of both substance abuse disorders7 and suicide8 are approximately 50% and 30% lower, respectively, for refugees on arrival to Sweden than the background Swedish-born population, these risks converge towards the Swedish rate over time. This suggests that post-migratory environmental characteristics—including barriers to timely, appropriate early intervention—affect the future chances of young people seeking to rebuild their lives following a period of trauma exposure. In this edition of Acta Paediatrica, Berg and colleagues’ investigation of psychiatric care utilisation by adolescent refugees living in Sweden elegantly extends our understanding of these needs against the opportunities for intervention available and, in so doing, informs both the clinical and public health agendas for prioritising care provision to some of the most vulnerable young people in our society.9 Taking longitudinal, regional health data from over 90 000 adolescents living in Stockholm County—including over almost 19 000 with a refugee background—Berg et al found that rates of first psychiatric care use before age 18 were, on average, 41%-55% lower in refugee teens compared with Swedish adolescents born to two Swedish-born parents, even after adjusting for possible differences in birth year, sex and parental education. Further investigation revealed notable differences in psychiatric service utilisation by length of time in Sweden, type of residence permit granted to refugees by the Swedish Migration Agency and region-of-origin. First, regardless of permit type, more recent teenage refugee migrants to Sweden were less likely to use psychiatric care services (55% reduction), with the highest rates (although still appreciably lower than in the Swedish-born reference group) amongst Swedish-born teens to refugee parents (41% reduction). Second, refugee teens who were granted residency based on a family reunification permit were found to use psychiatric services to an even lesser extent (63%-75% reduction, depending on time in Sweden), while those granted residency as asylum refugees had more modest reductions in psychiatric care use (between 26% and 41% of the Swedish reference group). Finally, while the authors found strong evidence of lower psychiatric care use for refugee teens from low- and middle-income countries, no differences in rates of psychiatric care use were found between refugees from high-income countries and Swedish-born teens; the large sample size and hazard ratios for this effect, which were close to unity, make power an unlikely explanation of this null result. The rich and detailed set of analyses provided by Berg and colleagues lead to several important implications. First, and most obviously perhaps, is that despite elevated need, refugee adolescents—in Sweden and perhaps elsewhere—under-utilise psychiatric care services. Under a strict interpretation of the survival analyses presented by Berg et al, the processes which result in this paradox imply that refugee teenagers take twice as long to access first psychiatric care than the majority of Swedish teens. Logically, this implies that a substantial proportion of refugee teens in need of mental health care experience delays in receiving treatment and as a result face greater distress and poorer long-term mental and social outcomes as a result. This has the potential to selectively and inequitably erode the potential benefits of early intervention in psychiatry, which has become a cornerstone of contemporary care in many settings.10 Second, Berg et al's work emphasises how imperative it is for clinical, academic, social and public health services to work together to identify and remove the barriers that result in delays to care in refugee teens. In Sweden, all residents including refugees can access healthcare services free-at-the-point-of-care and can access compensation for any parental leave from work to care for a child who is unwell. This means both direct and indirect economic barriers to accessing psychiatric care are unlikely to have explained under-utilisation rates in this study, although may still be relevant in other settings. Other, indirect, economic barriers to care may still affect refugee families, including parental leave from paid employment to attend healthcare appointments with their child and potential childcare costs for other children during these periods. Family reunification refugee teens were less likely to use services than those arriving via asylum routes. This may reflect more traumatic experiences or increased access to care for refugees arriving via the asylum route, who are both more likely to be exposed to additional traumas and more likely to receive health checks as part of Sweden's reception programme than family reunification refugees.9 Other research has highlighted further important potential barriers, including the lack of culturally appropriate services for some migrants groups, language issues, other intersectional minority issues (including sexual identity11) and the roles of both stigma and racism in accessing mental health services.12 Interestingly, Berg et al found important socio-demographic differences in their sample that may reveal important, differential patterns of selection into psychiatric care; while Swedish-born teens who utilised psychiatric care were more likely to come from families whose parents had shorter education and lower incomes, the reverse was true for refugee adolescents, whose parents were—on average—more likely to have more education and higher incomes. Although parental education did not account for differences in psychiatric care utilisation in their study, one important implication is that children and adolescents from the most socio-economically disadvantaged refugee families are least likely to access care, despite likely need. This care gap provides a ready target for public health intervention, both in Sweden and other countries. Such initiatives are already underway13 and aim to provide culturally appropriate community and individual interventions for child and adolescent migrant mental health. There is already good evidence about the likely core elements required for successful interventions in refugee mental health, including the use of ethnically matched therapists, availability of services in different languages and the role of ‘community peers’ to strengthen outreach services.14 More such initiatives should follow, potentially including trauma-informed models of care which are gaining traction in adult mental health,15 but still require demonstration of efficacy for children and adolescents. Nordic countries are particularly well-placed to lead this effort, combining their rich, detailed register-based health data with their legacy of compassionate resettlement for displaced individuals. These settings should provide fertile ground for developing and testing (via, for example, randomised controlled trials) clinical and public health interventions targeted at refugee populations, which—when linked with register data—could provide robust evidence of their short, medium and long-term physical, mental, social and economic benefits. The best of these interventions, then, would surely enrich both the lives of refugee communities and the whole population alike. Berg et al's study provides a rallying call to remove disparities in child and adolescent mental health treatment for some of our most vulnerable citizens. The author has no conflicts of interest to declare.

OBJECTIVE: We sought to examine the independent and interactive effects of common mental health disorders and chronic pain conditions on employment and work outcomes among individuals younger than 65 years of age. METHODS: We analyzed cross-sectional data from the second wave of Healthcare for Communities (HCC2), a household telephone survey of U.S. civilian adults conducted in 2000 to 2001 (N=5328). Common mental disorders were assessed using the short-form versions of the World Health Organization’s Composite International Diagnostic Interview (CIDI-SF). Chronic pain conditions and labor market outcomes were identified by self report. Logistic and linear regression analysis was used to provide estimates for work impairment based on the presence of a mental health disorder and/or a chronic pain condition. RESULTS: The interaction between presence of a mental health disorder and presence of a chronic pain condition was significantly associated with no work for pay in the past 12 months (OR 2.3 [1.2–4.2]) and number of days of work missed in the past month due to health (regression coefficient 1.5 [0.6]). In stratified analyses, this effect persisted in women but not men. The presence of a mental health disorder or chronic pain condition were each independently associated with limitations in work and any work missed in the past 30 days due to health, although the interaction was not significant. CONCLUSION: Mental health disorders and chronic pain are each associated with work disability. Mental health disorders are more highly associated with some work disability outcomes when accompanied by chronic pain, especially in women.

&lt;p&gt;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. &lt;/p&gt; &lt;h4&gt;ABOUT THE AUTHORS&lt;/h4&gt; &lt;p&gt;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. &lt;/p&gt; &lt;p&gt;Ms. Joa, Dr. Johannessen, Dr. Larsen, and Dr. McGlashan have disclosed no relevant financial relationships. &lt;/p&gt; &lt;h4&gt;EDUCATIONAL OBJECTIVES&lt;/h4&gt; &lt;ol&gt;&lt;li&gt;Explain the goals of the Early Treatment and Intervention in Psychosis (TIPS) study. &lt;/li&gt; &lt;li&gt;Describe the strategies employed by the TIPS study to achieve its aims, especially through the utilization of information campaigns. &lt;/li&gt; &lt;li&gt;Discuss the results of the TIPS study in terms of community median duration of untreated psychosis (DUP). &lt;/li&gt;&lt;/ol&gt;