Diagnosis Of First-episode Psychosis Research Articles

The physical health and premature mortality of Indigenous Māori following first-episode psychosis diagnosis: A 15-year follow-up study.

People experiencing psychosis are at greater risk of physical health conditions and premature mortality. It is likely that Indigenous Māori youth, who experience additional systemic inequities caused by settler-colonisation, face even greater physical health and mortality risks following a diagnosis of first-episode psychosis. Compare Māori and non-Māori for risk of hospitalisation and mortality for up to 15 years following first-episode psychosis diagnosis. A cohort (N = 14,122) of young people (16-24 years) with first-episode psychosis diagnosis between 2001 and 2019 were identified. Using crude Kaplan-Meier and adjusted Cox proportional hazards models, Māori (n = 5211) and non-Māori (n = 8911) were compared on hospitalisation and mortality outcomes for up to 15 years. In the 15 years following first-episode psychosis diagnosis, Māori had higher adjusted risk of all-cause mortality (hazard ratio = 1.21, 95% confidence interval = [1.01, 1.45]), hospitalisation with diabetes (hazard ratio = 1.44, 95% confidence interval = [1.15, 1.79]), injury/poisoning (hazard ratio = 1.11, 95% confidence interval = [1.05, 1.16]), general physical health conditions (hazard ratio = 1.07, 95% confidence interval = [1.02, 1.13]) and also appeared to be at greater risk of cardiovascular hospitalisations (hazard ratio = 1.34, 95% confidence interval = [0.97, 1.86]). Kaplan-Meier plots show hospitalisation and mortality inequities emerging approximately 4-7 years following first-episode psychosis diagnosis. Māori are at greater risk for hospitalisation and premature mortality outcomes following first-episode psychosis. Early screening and intervention, facilitated by culturally safe health service delivery, is needed to target these inequities early.

Development and initial evaluation of a clinical prediction model for risk of treatment resistance in first-episode psychosis: Schizophrenia Prediction of Resistance to Treatment (SPIRIT).

A clinical tool to estimate the risk of treatment-resistant schizophrenia (TRS) in people with first-episode psychosis (FEP) would inform early detection of TRS and overcome the delay of up to 5 years in starting TRS medication. To develop and evaluate a model that could predict the risk of TRS in routine clinical practice. We used data from two UK-based FEP cohorts (GAP and AESOP-10) to develop and internally validate a prognostic model that supports identification of patients at high-risk of TRS soon after FEP diagnosis. Using sociodemographic and clinical predictors, a model for predicting risk of TRS was developed based on penalised logistic regression, with missing data handled using multiple imputation. Internal validation was undertaken via bootstrapping, obtaining optimism-adjusted estimates of the model's performance. Interviews and focus groups with clinicians were conducted to establish clinically relevant risk thresholds and understand the acceptability and perceived utility of the model. We included seven factors in the prediction model that are predominantly assessed in clinical practice in patients with FEP. The model predicted treatment resistance among the 1081 patients with reasonable accuracy; the model's C-statistic was 0.727 (95% CI 0.723-0.732) prior to shrinkage and 0.687 after adjustment for optimism. Calibration was good (expected/observed ratio: 0.999; calibration-in-the-large: 0.000584) after adjustment for optimism. We developed and internally validated a prediction model with reasonably good predictive metrics. Clinicians, patients and carers were involved in the development process. External validation of the tool is needed followed by co-design methodology to support implementation in early intervention services.

Neural Antibodies in First-episode Psychosis Patients with Warning Signs for Autoimmune Encephalitis.

: Autoimmune encephalitis (AE) remains an essential differential diagnosis in patients with first-episode psychosis (FEP). In this study, we aimed to assess to prevalence of AE in a cohort of FEP patients. : We used a phenotype-driven algorithm to detect AE in patients with FEP. Initially, we screened patients for warning signs with a low or high pre-test probability for AE, defined as "yellow" and "red flags", respectively. In the next step, patients with red flags underwent cerebrospinal fluid analysis (including neural antibodies), while patients with yellow flags underwent tests for serum neural antibodies, electroencephalography, and brain magnetic resonance imaging. : We screened 78 patients with FEP and found that eight (10.3%) had at least one warning sign for AE: four (5.13%) patients had at least one red flag, while four (5.13%) had only yellow flags. Among these, two patients (2.56%) had anti-N-methyl-D-aspartate receptor encephalitis, while the remaining six (7.69%) received a primary psychiatric disorder diagnosis. : Our study highlights the importance of considering AE in the differential diagnosis of FEP.

Inflammatory based psychotic symptoms: when psychosis means encephalitis

AbstractSchizophrenia, as one of the most common disorders from the psychotic spectrum is most commonly detected in the phase of first psychosis and may pose a diagnostic challenge, as commonly comprise a heterogeneous group of schizophrenias, with distinct clinical presentations. If it detected in its prodromal phase without clearly developed psychotic symptoms, the diagnosis is even more unreliable, as the transition to full blown psychosis in the next two years happens in 15-40% of more, depending probably on a variety of cumulative environmental risk factors (including childhood trauma, the use of high-potency cannabis, urbanicity, season of birth). Moreover, the first episode psychosis may underlie for example the first manic episode, brief intermittent psychotic symptoms in persons with borderline personality disorders, acute reaction to trauma, the use of cannabis and psychostimulants and different organics causes, such as endocrinologic disorders and autoimmune encephalitis. Therefore, in everyday clinical practice, the diagnosis of first episode psychosis always requires an assessment of possible causes of psychosis, and also factors that may influence prognosis and treatment. Usual assessment include detailed anamnestic and heteroanamnestic data, physical examination, standard blood laboratory findings, drugs in urine/ blood, EEG and CT/MR scan. The absence of typical risk factors for schizophrenia, as well as the absence of premorbid symptoms and developmental course typical for schizophrenia, abrupt course of psychotic symptoms, symptoms such as disorientation, catatonia, speech disturbances, alteration of consciousness, neurologic signs, autonomic dysfunction and laboratory aberrations may be especially indicative for organic cause and possibly encephalitis and require further confirmation with the analysis of cerebrospinal liquor with antineuronal antibodies.Disclosure of InterestNone Declared

Identification of Psychosis Risk and Diagnosis of First-Episode Psychosis: Advice for Clinicians.

Early detection of psychotic-spectrum disorders among adolescents and young adults is crucial, as the initial years after psychotic symptom onset encompass a critical period in which psychosocial and pharmacological interventions are most effective. Moreover, clinicians and researchers in recent decades have thoroughly characterized psychosis-risk syndromes, in which youth are experiencing early warning signs indicative of heightened risk for developing a psychotic disorder. These insights have created opportunities for intervention even earlier in the illness course, ideally culminating in the prevention or mitigation of psychosis onset. However, identification and diagnosis of early signs of psychosis can be complex, as clinical presentations are heterogeneous, and psychotic symptoms exist on a continuum. When a young person presents to a clinic, it may be unclear whether they are experiencing common, mild psychotic-like symptoms, early warning signs of psychosis, overt psychotic symptoms, or symptoms better accounted for by a non-psychotic disorder. Therefore, the purpose of this review is to provide a framework for clinicians, including those who treat non-psychotic disorders and those in primary care settings, for guiding identification and diagnosis of early psychosis within the presenting clinic or via referral to a specialty clinic. We first provide descriptions and examples of first-episode psychosis (FEP) and psychosis-risk syndromes, as well as assessment tools used to diagnose these conditions. Next, we provide guidance as to the differential diagnosis of conditions which have phenotypic overlap with psychotic disorders, while considering the possibility of co-occurring symptoms in which case transdiagnostic treatments are encouraged. Finally, we conclude with an overview of early detection screening and outreach campaigns, which should be further optimized to reduce the duration of untreated psychosis among youth.

Perspective of patients with first-episode psychosis, their relatives, and mental health professionals on the design and usability of an app in clinical practice.

Therapeutic non-compliance remains the main difficulty for people with psychotic disorders, standing around 50% in people with schizophrenia. Lack of treatment adherence, either partial or total, to medication has economic and clinical consequences. E-health technologies may be a promising therapeutic tool to improve adherence, with the subsequent reduction in clinical and economic burden. Our aims were to know the preferences on how technologies in mental health treatment should be for use in clinical practice, and to learn about the opinion and preferences on the use of technologies in mental health treatment from the perspectives of patients with FEP, their relatives, and mental health professionals. Forty-one patients with a diagnosis of first-episode psychosis (FEP), 18 relatives and 49 mental health professionals were included in the study. They completed an online survey related to the use, availability and user-skill of online platforms and apps created by a group of experts in psychosis and in the use of technologies. Data were summarized in frequencies, percentages, and means, and Chi-square tests were used to calculate differences between-groups. An app directed to people with psychosis would be well received by users if it contains psychoeducational material, offers reminders for scheduled visits and treatment and allows online consultations. Co-creating an app with users, their families and mental health professionals allows incorporating their preferences to increase its use, improve outpatient care and creating an app that is viable in clinical practice.

Primer episodio psicótico

This clinical update addresses first-episode psychosis (FEP), a clinical disorder in which a patient experiences psychotic symptoms such as delirium, hallucinations, and/or disorganized thinking for the first time. The clinical manifestations of FEP are highly varied and it is common to find other types of accompanying signs and symptoms. Psychotic experiences are highly prevalent in the general population and can occur in a wide range of situations that range from normality to severe psychotic disorders. When a diagnosis of FEP is suspected, it is crucial to conduct a detailed assessment of the impact and intensity of the symptoms, an adequate differential diagnosis, and close monitoring of the case. FEP usually occurs in people aged 15 to 35 years and has a significant impact on the patient's life. Multifactorial in its etiology, FEP entails a challenge for research in the areas of psychiatry and neurosciences. Some factors related to its onset have been described and, due to their possible causal role, they are of particular interest for future preventive or treatment interventions. In addition to pharmacological treatment, a multidisciplinary intervention that involves different professionals and is conducted in specialized units for treating FEP are recommended.

Protocolo de intervención ante un primer episodio psicótico

This protocol for intervention lists the main clinical actions to take when faced with first-episode psychosis (FEP). The diagnosis of FEP is clinical, supported by a detailed case history and meticulous psychopathological examination. It is essential to rule out other medical causes that may justify the symptoms and conduct a detailed physical examination and full neurological examination. The action protocol in the initial evaluation, including some recommended additional tests, are listed. Pharmacological treatment is one of the fundamental pillars of early intervention. Some general guidelines for prescribing antipsychotics (the most commonly used drugs for FEP) are provided. According to the patient's clinical characteristics, some indications can be made for supplementing pharmacological treatment with other drugs, if applicable. Lastly, some general recommendations are given on non-pharmacological interventions, which are essential for a comprehensive, effective intervention when faced with FEP.

Development and Validation of Predictive Model for a Diagnosis of First Episode Psychosis Using the Multinational EU-GEI Case-control Study and Modern Statistical Learning Methods.

It is argued that availability of diagnostic models will facilitate a more rapid identification of individuals who are at a higher risk of first episode psychosis (FEP). Therefore, we developed, evaluated, and validated a diagnostic risk estimation model to classify individual with FEP and controls across six countries. We used data from a large multi-center study encompassing 2627 phenotypically well-defined participants (aged 18-64 years) recruited from six countries spanning 17 research sites, as part of the European Network of National Schizophrenia Networks Studying Gene-Environment Interactions study. To build the diagnostic model and identify which of important factors for estimating an individual risk of FEP, we applied a binary logistic model with regularization by the least absolute shrinkage and selection operator. The model was validated employing the internal-external cross-validation approach. The model performance was assessed with the area under the receiver operating characteristic curve (AUROC), calibration, sensitivity, and specificity. Having included preselected 22 predictor variables, the model was able to discriminate adults with FEP and controls with high accuracy across all six countries (rangesAUROC = 0.84-0.86). Specificity (range = 73.9-78.0%) and sensitivity (range = 75.6-79.3%) were equally good, cumulatively indicating an excellent model accuracy; though, calibration slope for the diagnostic model showed a presence of some overfitting when applied specifically to participants from France, the UK, and The Netherlands. The new FEP model achieved a good discrimination and good calibration across six countries with different ethnic contributions supporting its robustness and good generalizability.

“Setting up and Tailoring Early Intervention Teams in a Already Established Healthcare System: the Experience of the Greater Lyon”

The implementation of early intervention services (EIS) dedicated to first episode psychosis (FEP) remains a challenge in France. In 2016, the London School of Economics published a report in which France appeared as a poorly developed country in terms of early intervention services. Since the 1980s, the French psychiatric “sectorization” system offers access to general psychiatric care with a graduated intensity (outpatient consultations, day hospitalization, full time hospitalization) targeting territories (“sectors”) of approximately 70,000 inhabitants. While this system has advantages in terms of universal access to care, it leaves little room for specialized services. The Greater Lyon agglomeration (2.4 million inhabitants) is composed of several psychiatric sectors administered by 3 psychiatric hospitals and a psychiatric emergency system administered by a University Hospital. Since 2018, various hospital and university stakeholders, patient associations and international partners, have been working together to tailor, set up and organize a care system for FEP patients. We present here how we have federated workforce resources initially working within 11 general psychiatric “sectors” and covering a population of 850,000 inhabitants. A 3-step process of (1) field analysis, (2) the creation of a community of practice composed of healthcare workers, researchers and service users, and (3) confrontation of the already existing healthcare with the logic of “principal components” for FEP care, allowed the creation of the outpatient “PEPS” service, which now offers continuous case management, a functional recovery program and new pathways to care to more than 200 patients with a diagnosis of first episode psychosis.DisclosureNo significant relationships.

Anti-NMDA Receptor Encephalitis Associated With an Ovarian Teratoma Presenting as First-episode Psychosis: A Case Report

We report an unusual case of a 27-year-old previously healthy female who presented with a 15-day history of psychotic, cognitive, and unspecified somatic symptoms. She was admitted to the psychiatric ward of an early intervention in psychosis team and medicated with aripiprazole. The young age of onset, the rapid onset, the absent history of psychiatric disease, and the persistence of a marked memory deficit after the psychotic symptoms remitted strongly suggested a nonpsychiatric etiology and led us to hypothesize autoimmune encephalitis as the most probable diagnosis. An investigation was carried out for anti-N-methyl-D-aspartate (anti-NMDA) receptor antibodies in the patient's serum and cerebrospinal fluid, and both tests were positive. The patient was transferred to the neurology ward, where an endovaginal ultrasound showed an ovarian teratoma in her right ovary. She underwent laparoscopic surgery without complications. She was initially treated with intravenous immunoglobulin and methylprednisolone for 5 days, which resulted in marked improvement of her memory and attention performance. Anti-NMDA receptor encephalitis, first described in 2007 by Dalmau and colleagues, is a form of auto-immune encephalitis with prominent neuropsychiatric manifestations, particularly psychotic symptoms. At symptom onset, distinguishing the disease from a primary psychiatric disorder is challenging. This case report highlights the importance of early psychosis treatment teams considering the diagnosis of anti-NMDA receptor encephalitis when evaluating new referrals with a potential diagnosis of first-episode psychosis, particularly when young patients with no relevant personal or familial psychiatric history present with neuropsychiatric symptoms and a distinctive pattern of symptom fluctuation over time.

Duration of Untreated Psychosis in First-Episode Psychosis is not Associated With Common Genetic Variants for Major Psychiatric Conditions: Results From the Multi-Center EU-GEI Study.

Duration of untreated psychosis (DUP) is associated with clinical outcomes in people with a diagnosis of first-episode psychosis (FEP), but factors associated with length of DUP are still poorly understood. Aiming to obtain insights into the possible biological impact on DUP, we report genetic analyses of a large multi-center phenotypically well-defined sample encompassing individuals with a diagnosis of FEP recruited from 6 countries spanning 17 research sites, as part of the European Network of National Schizophrenia Networks Studying Gene-Environment Interactions (EU-GEI) study. Genetic propensity was measured using polygenic scores for schizophrenia (SZ-PGS), bipolar disorder (BD-PGS), major depressive disorder (MDD-PGS), and intelligence (IQ-PGS), which were calculated based on the results from the most recent genome-wide association meta-analyses. Following imputation for missing data and log transformation of DUP to handle skewedness, the association between DUP and polygenic scores (PGS), adjusting for important confounders, was investigated with multivariable linear regression models. The sample comprised 619 individuals with a diagnosis of FEP disorders with a median age at first contact of 29.0 years (interquartile range [IQR] = 22.0–38.0). The median length of DUP in the sample was 10.1 weeks (IQR = 3.8–30.8). One SD increases in SZ-PGS, BD-PGS, MDD-PGS or IQ-PGS were not significantly associated with the length of DUP. Our results suggest that genetic variation does not contribute to the DUP in patients with a diagnosis of FEP disorders.

Employment and relationship outcomes in first-episode psychosis: A systematic review and meta-analysis of longitudinal studies

As employment and relationship status are important long-term outcomes in individuals with a diagnosis of first episode psychosis (FEP) disorders, there is a need to elucidate more accurately the extent of these social deficits in people with FEP. This in turn can aid treatment planning and policy development ultimately ensuring more complete and sustainable recoveries. We carried out a systematic review and meta-analysis of longitudinal studies in FEP reporting on employment and relationship status during the illness course. Random effects meta-analyses and meta-regression analyses were employed. Seventy-four studies were included with a sample totalling 15,272 (range = 20–1724) FEP cases with an average follow-up duration of 8.3 years (SD = 7.2). 32.5% (95%CI = 28.5–36.9) of people with a diagnosis of FEP disorders were employed and 21.3% (95%CI = 16.5–27.1) were in a relationship at the end of follow-up. Studies from high-income countries and Europe had a higher proportion of people in employment at the end of follow-up compared to middle-income nations and non-European countries. The inverse was found for relationship status. The proportion of people with a diagnosis of FEP in employment decreased significantly with longer follow-up. Living with family, being in a relationship at first contact and Black and White ethnicities were identified as significant moderators of these outcomes. These findings highlight marked functional recovery deficits for people with FEP, although cultural factors need to be considered. They support the need for interventions to improve employment opportunities, and social functioning, both in early psychosis and during the longitudinal illness course.

Association Between Race/Ethnicity and Disparities in Health Care Use Before First-Episode Psychosis Among Privately Insured Young Patients

Racial/ethnic disparities in health care use and clinical outcomes for behavioral health disorders, including psychosis, are well documented, but less is known about these disparities during the period leading up to first-episode psychosis (FEP). To describe the racial/ethnic disparities in behavioral health care use and prescription drug use of children and young adults before the diagnosis of FEP. An observational cohort study was conducted using medical and prescription drug claims from January 1, 2007, to September 30, 2015, obtained from Optum's deidentified Clinformatics Data Mart Database, a commercial claims database augmented with race/ethnicity and socioeconomic variables. Data analysis was performed from February 6, 2018, to October 10, 2020. First-episode psychosis was determined by the presence of psychosis diagnoses on claims for at least 1 hospitalization or 2 outpatient events, with a continuous enrollment requirement of at least 2 years before the first diagnosis. Participants included 3017 Black, Hispanic, or White patients who were continually enrolled in commercial insurance plans and received an FEP diagnosis between the ages of 10 and 21 years. Race/ethnicity was determined from a commercial claims database. Rates of inpatient admission, emergency department presentation, and outpatient visits (including psychotherapy), behavioral health disorder diagnoses, and antipsychotic/antidepressant prescription fills were determined for the year before FEP. Race/ethnicity was also obtained from Optum's claims database. With use of multivariable logistic regression, results were adjusted for covariates including estimated household income, age, sex, and geographic division in the US. Of the 3017 patients with FEP, 643 Black or Hispanic patients (343 [53.3%] Black, 300 [46.7%] Hispanic, 324 [50.4%] male, mean [SD] age, 17.2 [2.76] years) were less likely than 2374 White patients (1210 [51.0%] male, mean age, 17.0 [2.72] years) to receive comorbid behavioral health disorder diagnoses in the year before the diagnosis of FEP (410 [63.8%] vs 1806 [76.1%], χ2 = 39.3; P < .001). Except for emergency care, behavioral health care use rates were lower in Black and Hispanic patients vs White patients (424 [65.9%] vs 1868 [78.7%]; χ2 = 45.0; P < .001), particularly for outpatient visits with behavioral health care professionals (232 [36.1%] vs 1236 [52.1%]; χ2 = 51.7; P < .001). After adjustment for socioeconomic covariates, behavioral health care use rates (68.9% vs 79.2%; P < .001), outpatient visits with behavioral health professionals (37.7% vs 51.2%; P < .001), and other outcomes remained significantly lower for Black and Hispanic patients vs White patients. The results of this study extend existing research findings of well-known racial/ethnic disparities in the population of patients who are diagnosed with FEP. These differences were apparent in young patients with continuous commercial health insurance and after controlling for household income. Providing equal access to preventive outpatient behavioral health care may increase opportunities for timely detection of psychotic symptoms and early intervention and improve differential outcomes after FEP.

A qualitative study exploring how Practitioners within Early Intervention in Psychosis Services engage with Service Users' experiences of voice hearing?

WHAT IS KNOWN ON THE SUBJECT?: The experience of hearing distressing voices is commonly reported by service users with a diagnosis of first-episode psychosis, but their access to formal conversations about voices in the form of psychological therapies can be limited. Service users within Early Intervention in Psychosis (EIP) services can benefit from informal opportunities to talk about their voice hearing experiences. However, they can be reluctant to engage with these conversations. Little is known about the experiences of EIP practitioners as they try to engage service users in conversations about their voices. WHAT DOES THE PAPER ADD TO EXISTING KNOWLEDGE?: Despite EIP Services specializing in the treatment of the symptoms of psychosis such as voice hearing, practitioners can still be reluctant to initiate and continue informal conversations about voices. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: EIP practitioners may benefit from the introduction of interview guides and brief interventions to assist them with the initiation and continuation of conversations about voices. ABSTRACT: Introduction Hearing voices is a common and distressing symptom of first-episode psychosis. Formal and informal conversations about voices are helpful, but service users within Early Intervention in Psychosis (EIP) Services can be reluctant to discuss their voice hearing experiences. There is currently no literature that explores the experiences of EIP practitioners as they try to facilitate conversations about distressing voices. Aim/Question A qualitative methodology was used to investigate how EIP practitioners work with service users who hear voices. Ten practitioners were interviewed, and interviews were analysed using template analysis. Results Two themes that offer novel insights are presented: "starting a conversation about voices" and "continuing the conversation about voices." Discussion Starting and continuing a conversation about voices was considered important but not all practitioners were confident in this respect. The initiation and continuation of these conversations may need to be systematically supported. Implications for practice To support the initiation of informal conversations, a standardized interview guide for voice hearing could be introduced and systematically utilized. The continuation of these conversations could be supported by practitioners being given the opportunity to receive training in and the opportunity to deliver brief symptom-specific therapies for distressing voices.

Social anxiety in young people with first‐episode psychosis: Pilot study of the EMBRACE moderated online social intervention

We conducted a single-group pilot study to evaluate the feasibility, acceptability and safety of a novel online intervention (entitled EMBRACE) that includes expert and peer moderation, therapeutic comics and social networking features. The cognitive-behavioural-based intervention was specifically designed to treat social anxiety as a primary treatment target in youth with first-episode psychosis (FEP). The 10 participants (17-26 years; Mage = 23 years) had a diagnosis of FEP and experienced significant levels of social anxiety as defined by exceeding a sub-threshold clinical score (>30) on the Social Interaction Anxiety Scale (SIAS). They had access to the EMBRACE intervention for 2 months. In total, seven out of ten participants completed eight modules or more (total of 12 modules). All participants rated the intervention as positive and safe, and endorsed recommending it to others who experience social anxiety. Improvement in pre-post social anxiety symptoms, as measured via the SIAS (d = -1.70, P = .0005) and the Liebowitz Social Anxiety Scale (d = -1.35, P = .002) were found. No statistically significant pre-post improvements were found for depressive or loneliness symptoms. EMBRACE was shown to be a feasible, acceptable, and safe online intervention to specifically target social anxiety as a primary treatment concern in young people with FEP.

Patterns of symptoms before a diagnosis of first episode psychosis: a latent class analysis of UK primary care electronic health records

BackgroundThe nature of symptoms in the prodromal period of first episode psychosis (FEP) remains unclear. The objective was to determine the patterns of symptoms recorded in primary care in the 5 years before FEP diagnosis.MethodsThe study was set within 568 practices contributing to a UK primary care health record database (Clinical Practice Research Datalink). Patients aged 16–45 years with a first coded record of FEP, and no antipsychotic prescription more than 1 year prior to FEP diagnosis (n = 3045) was age, gender, and practice matched to controls without FEP (n = 12,180). Fifty-five symptoms recorded in primary care in the previous 5 years, categorised into 8 groups (mood-related, ‘neurotic’, behavioural change, volition change, cognitive change, perceptual problem, substance misuse, physical symptoms), were compared between cases and controls. Common patterns of symptoms prior to FEP diagnosis were identified using latent class analysis.ResultsMedian age at diagnosis was 30 years, 63% were male. Non-affective psychosis (67%) was the most common diagnosis. Mood-related, ‘neurotic’, and physical symptoms were frequently recorded (> 30% of patients) before diagnosis, and behavioural change, volition change, and substance misuse were also common (> 10%). Prevalence of all symptom groups was higher in FEP patients than in controls (adjusted odds ratios 1.33–112). Median time from the first recorded symptom to FEP diagnosis was 2–2.5 years except for perceptual problem (70 days). The optimal latent class model applied to FEP patients determined three distinct patient clusters: ‘no or minimal symptom cluster’ (49%) had no or few symptoms recorded; ‘affective symptom cluster’ (40%) mainly had mood-related and ‘neurotic’ symptoms; and ‘multiple symptom cluster’ (11%) consulted for three or more symptom groups before diagnosis. The multiple symptom cluster was more likely to have drug-induced psychosis, female, obese, and have a higher morbidity burden. Affective and multiple symptom clusters showed a good discriminative ability (C-statistic 0.766; sensitivity 51.2% and specificity 86.7%) for FEP, and many patients in these clusters had consulted for their symptoms several years before FEP diagnosis.ConclusionsDistinctive patterns of prodromal symptoms may help alert general practitioners to those developing psychosis, facilitating earlier identification and referral to specialist care, thereby avoiding potentially detrimental treatment delay.

The "Parma-Early Psychosis" program: General description and process analysis after 5 years of clinical activity.

From January 2013, the Parma Department of Mental Health developed a specific protocol of care (the "Parma-Early Psychosis" [Pr-EP] program) as a diffused service for early intervention in psychosis. The aims of the present research are (a) to describe the Pr-EP macroscopic organization and (b) to analyse specific process indicators across the first 5 years from its establishment. All participants were adolescent and adult help-seekers, aged 12-54 years, with a First Episode Psychosis (FEP) or at Ultra-High Risk for developing psychosis, according to well-defined diagnostic criteria. At baseline, 358 individuals were offered a dedicated protocol of care and only 40 (11.8%) dropped out during the first year of intervention. In particular, an increase of referrals over time was notably found (especially in adolescence). Furthermore, Duration of Untreated Psychosis decreased over time. The baseline prevalence of FEP diagnosis was 61.4%, with schizophrenia as markedly prevalent Diagnostic and Statistical Manual of mental disorders, IV edition, Text Revised (DSM-IV-TR) diagnosis (41%). The vast majority of UHR individuals met criteria for "Attenuated Psychotic Symptoms" (>90%), and major depressive disorder was the most frequent diagnosis (>55%). Finally, we found considerable percentages of current history of substance abuse (>58%) and of comorbidity with DSM-IV-TR personality disorders (60%). An "Early Intervention in psychosis" service in Italian child/adolescent and adult mental health services is feasible, also in adolescents, who have a high risk of falling through the child-adult service gap.

Good Intentions: Exploring Narratives of Preferred Parenting in Families of a Young Person Who Has Experienced a First Episode of Psychosis (FEP)

This research used a multimethod design to explore the narratives of seven parents of young people with a diagnosis of first episode psychosis. Findings revealed narratives in which parents described a range of adverse experiences in their childhoods and attempts were made to "normalise” these events. The core narrative themes that emerged from the analysis were supported by the AAI interviews, which revealed indicators of unresolved traumas and dismissive attachment strategies.The parents intentions to do things differently from how they were parented varied in their extremity and at times appeared to have become counterproductive for their parenting.

Assessing Brain Metabolism With 7-T Proton Magnetic Resonance Spectroscopy in Patients With First-Episode Psychosis

The use of high-field magnetic resonance spectroscopy (MRS) in multiple brain regions of a large population of human participants facilitates in vivo study of localized or diffusely altered brain metabolites in patients with first-episode psychosis (FEP) compared to healthy participants. To compare metabolite levels in 5 brain regions between patients with FEP (evaluated within 2 years of onset) and healthy controls, and to explore possible associations between targeted metabolite levels and neuropsychological test performance. Cross-sectional design used 7-T MRS at a research MR imaging facility in participants recruited from clinics at the Johns Hopkins Schizophrenia Center and the local population. Eighty-one patients who had received a DSM-IV diagnosis of FEP within the last 2 years and 91 healthy age-matched (but not sex-matched) volunteers participated. Brain metabolite levels including glutamate, glutamine, γ-aminobutyric acid (GABA), N-acetylaspartate, N-acetylaspartyl glutamate, and glutathione, as well as performance on neuropsychological tests. The mean (SD) age of 81 patients with FEP was 22.3 (4.4) years and 57 were male, while the mean (SD) age of 91 healthy participants was 23.3 (3.9) years and 42 were male. Compared with healthy participants, patients with FEP had lower levels of glutamate (F1,162 = 8.63, P = .02), N-acetylaspartate (F1,161 = 5.93, P = .03), GABA (F1,163 = 6.38, P = .03), and glutathione (F1,162 = 4.79, P = .04) in the anterior cingulate (all P values are corrected for multiple comparisons); lower levels of N-acetylaspartate in the orbitofrontal region (F1,136 = 7.23, P = .05) and thalamus (F1,133 = 6.78, P = .03); and lower levels of glutathione in the thalamus (F1,135 = 7.57, P = .03). Among patients with FEP, N-acetylaspartate levels in the centrum semiovale white matter were significantly correlated with performance on neuropsychological tests, including processing speed (r = 0.48; P < .001), visual (r = 0.33; P = .04) and working (r = 0.38; P = .01) memory, and overall cognitive performance (r = 0.38; P = .01). Seven-tesla MRS offers insights into biochemical changes associated with FEP and may be a useful tool for probing brain metabolism that ranges from neurotransmission to stress-associated pathways in participants with psychosis.