Early Phase Of Psychotic Disorders Research Articles

Forecasting prognostic trajectories with mismatch negativity in early psychosis.

Prognostic heterogeneity in early psychosis patients yields significant difficulties in determining the degree and duration of early intervention; this heterogeneity highlights the need for prognostic biomarkers. Although mismatch negativity (MMN) has been widely studied across early phases of psychotic disorders, its potential as a common prognostic biomarker in early periods, such as clinical high risk (CHR) for psychosis and first-episode psychosis (FEP), has not been fully studied. A total of 104 FEP patients, 102 CHR individuals, and 107 healthy controls (HCs) participated in baseline MMN recording. Clinical outcomes were assessed; 17 FEP patients were treatment resistant, 73 FEP patients were nonresistant, 56 CHR individuals were nonremitters (15 transitioned to a psychotic disorder), and 22 CHR subjects were remitters. Baseline MMN amplitudes were compared across clinical outcome groups and tested for utility prognostic biomarkers using binary logistic regression. MMN amplitudes were greatest in HCs, intermediate in CHR subjects, and smallest in FEP patients. In the clinical outcome groups, MMN amplitudes were reduced from the baseline in both FEP and CHR patients with poor prognostic trajectories. Reduced baseline MMN amplitudes were a significant predictor of later treatment resistance in FEP patients [Exp(β) = 2.100, 95% confidence interval (CI) 1.104-3.993, p = 0.024] and nonremission in CHR individuals [Exp(β) = 1.898, 95% CI 1.065-3.374, p = 0.030]. These findings suggest that MMN could be used as a common prognostic biomarker across early psychosis periods, which will aid clinical decisions for early intervention.

Traumatisme sexuel ou physique dans l’enfance : quel impact sur l’évolution d’un premier épisode psychotique ?

BackgroundIf exposure to childhood trauma increases the risk to later develop a psychotic disorder, the impact of such events on clinical presentation and outcome after a first psychotic episode deserves attention both in order to identify specific patients’ needs and to develop adapted therapeutic interventions. MethodsThree hundred and sixty-two patients treated at TIPP-Lausanne, a specialized program for the treatment of the early phase of psychotic disorders, were assessed prospectively, from baseline and every six months until the end of the 36 months of treatment. We compared characteristics of patients exposed to childhood sexual and/or physical abuse to those of non-exposed patients. ResultsOne hundred and eight patients (29.8 %) were exposed to at least one episode of physical and/or sexual abuse during childhood. Exposed patients displayed higher levels of positive and depressive symptoms and had lower levels of functioning throughout the entire three year follow-up period. ConclusionsThe prevalence of exposure to major traumatic events during childhood in early psychosis patients is very high, and it has an important impact on symptomatic and functional outcome. However, when clinical care is adapted, such patients seem to have a great potential for recovery. This justifies the implementation of specialized early psychosis programs and additional research in order to develop specific and adapted therapeutic strategies for such patients.

Reliability and Feasibility of the First-Episode Psychosis Services Fidelity Scale-Revised for Remote Assessment.

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.

Elevated serum chemokine CCL22 levels in first-episode psychosis: associations with symptoms, peripheral immune state and in vivo brain glial cell function

Several lines of research support immune system dysregulation in psychotic disorders. However, it remains unclear whether the immunological marker alterations are stable and how they associate with brain glial cell function. This longitudinal study aimed at investigating whether peripheral immune functions are altered in the early phases of psychotic disorders, whether the changes are associated with core symptoms, remission, brain glial cell function, and whether they persist in a one-year follow-up. Two independent cohorts comprising in total of 129 first-episode psychosis (FEP) patients and 130 controls were assessed at baseline and at the one-year follow-up. Serum cyto-/chemokines were measured using a 38-plex Luminex assay. The FEP patients showed a marked increase in chemokine CCL22 levels both at baseline (p < 0.0001; Cohen’s d = 0.70) and at the 12-month follow-up (p = 0.0007) compared to controls. The group difference remained significant (p = 0.0019) after accounting for relevant covariates including BMI, smoking, and antipsychotic medication. Elevated serum CCL22 levels were significantly associated with hallucinations (ρ = 0.20) and disorganization (ρ = 0.23), and with worse verbal performance (ρ = −0.23). Brain glial cell activity was indexed with positron emission tomography and the translocator protein radiotracer [11C]PBR28 in subgroups of 15 healthy controls and 14 FEP patients with serum CCL22/CCL17 measurements. The distribution volume (VT) of [11C]PBR28 was lower in patients compared to controls (p = 0.026; Cohen’s d = 0.94) without regionally specific effects, and was inversely associated with serum CCL22 and CCL17 levels (p = 0.036). Our results do not support the over-active microglia hypothesis of psychosis, but indicate altered CCR4 immune signaling in early psychosis with behavioral correlates possibly mediated through cross-talk between chemokine networks and dysfunctional or a decreased number of glial cells.

Trois profils cliniques à risque de comportements violents dans une cohorte de patients présentant un premier épisode de psychose

ObjectiveThis study aims to determine whether it is possible to identify clinical profiles at risk of violent behaviors (VB) in the early phase of psychotic disorders, on the basis of the main dynamic psychopathological risk factors and describe characteristics of the groups with highest levels of violent behaviors. MethodA total of 265 patients, aged 18 to 35, treated at the Treatment and early Intervention in Psychosis Program (TIPP–Lausanne), a specialized early psychosis program, were included in this study. We conducted a latent-class analysis and a discriminative analysis on the basis of the main dynamic VB risk factors: substance use disorder, impulsivity, positive symptoms, insight, aggression, hostility, anger, emotional instability and adherence to treatment. These factors were evaluated by specialized scales and on the basis of the Positive and Negative Syndrome Scale (PANSS). VB were restricted to physical aggression against people, defined as “serious violence”. They were assessed on the basis of a questionnaire listing violent offenses (Swiss Criminal Code) and VB such as assault and battery, information through the forensic psychiatric services and on the basis of the Staff Observation Aggression Scale (SOAS-R scale) during inpatient treatment phase. ResultsFour heterogeneous subgroups were identified with respect to the studied clinical characteristics, including two groups with high rates of VB. The first group, comprising 46% of patients with VB, is distinguished by the prevalence of a range of dimensions related to hostility, impulsivity and emotional instability, associated with high levels of substance abuse and positive symptoms. These clinical dimensions are very significant at the statistical level, since they explain 70% of the construction of subgroups (discriminant analysis). The second group with 37% of patients with VB, is characterized by a lack of insight, lack of adherence to treatment and substance use. These two clinical profiles could increase the impairment of cognitive, functional and relational abilities and contribute to the development of VB in this early phase of psychosis. The third subgroup, with a violent behaviors rate of 28.6%, is distinguished by its high proportion of diagnoses of substance abuse (100%) and women (54%). A last subgroup of patients, the largest quantitatively, has a low proportion of VB (15%) and the lowest levels on the studied factors, suggesting that the majority of patients with this profile commit few VB. ConclusionOur results show that it is possible to identify groups at risk of violent behaviors during the early phase of psychosis on the basis of clinical characteristics that may evolve and therefore be the focus of preventive care. These results highlight the need to target substance use, impulsivity and lack of insight at follow-up in order to prevent VB.

Theory of mind in a first-episode psychosis population using the Hinting Task

Deficiencies in theory of mind (ToM) are common in psychosis and may largely explain impaired social functioning. Currently, it is unclear whether impairments in ToM are explained by the more general cognitive deficits related to psychosis or whether ToM is impaired in psychosis independently of other cognitive deficits. This study examined ToM using the Hinting Task in young adults (n = 66) with first-episode psychosis and matched controls (n = 62). The participants were administered a broad neuropsychological assessment. Participants with psychosis performed worse than controls on the Hinting Task. However, 75% of the variance between the groups was explained by general cognitive deficits, especially impaired processing speed and episodic memory. Hinting Task performance of the best functioning patient group did not differ from that of the control group. When the psychosis group was divided according to diagnosis, the Hinting Task difference between individuals with schizophrenia and controls remained significant even when general cognitive performance was controlled for, suggesting specific verbal ToM deficits in schizophrenia. In contrast, those with other psychotic disorders did not differ from controls. Our results suggest that ToM deficits can be seen in early phases of psychotic disorders, schizophrenia in particular, and are partly independent of other cognitive functions.

Brief interactive psychoeducation for caregivers of patients with early phase psychosis in Yogyakarta, Indonesia.

Brief psychoeducation for families of psychotic patients has been shown to significantly increase family members' knowledge of the disorder. This increase is associated with reductions in relapse and rehospitalization. The aim of this study was to assess the effectiveness of brief psychoeducation about schizophrenia to caregivers of patients in early phases of psychotic disorders in Yogyakarta, Indonesia. This study was a prospective, randomized trial with 2 parallel groups. Subjects were patients in the early phase of psychotic disorders and their respective caregivers. Inclusion criteria included a diagnosis of acute and transient psychotic disorders, schizophrenia, schizoaffective disorder or delusional disorder. Participants were randomly assigned to either control or intervention groups by means of paired simple randomization. A brief psychoeducation was conducted for both the patients and caregivers. The interventions were conducted in 4 interactive sessions, once per week. Effectiveness was measured using standardized instruments before the intervention, and at 1 and 6 months post-intervention. Assessment instruments included the Knowledge of Psychosis (KOP), the Compliance and Relapse Assessment, the Brief Psychiatric Rating Scale and the Positive and Negative Symptoms of Schizophrenia scale. Interventions improved KOP scores significantly in the intervention group. The intervention group had increased regularity of follow-up with health providers and improved compliance. No statistically significant difference in relapses/rehospitalization was observed. This study demonstrated that brief psychoeducation with caregivers of patients with early phase psychosis was feasible in our setting, significantly improved caregivers' knowledge, and resulted in improved regularity of contact with health providers and compliance with pharmacotherapy.

150. Maintenance Discontinuation After First Episode Psychosis May Increase Treatment Non-Responsiveness: 10-Year Follow-Up of an RCT

Background: Clinical decision to discontinue antipsychotics in patients remitted from first-episode psychosis is important. Existing short-term evidence suggests that patients who discontinued antipsychotics had more relapses. Data on long-term outcomes are lacking; with only one open-label study suggesting better long-term recovery outcome in patients who had early medication discontinuation. We compared the long-term clinical and functional outcomes at 10 years of remitted first-episode psychosis patients who had either discontinued or continued their antipsychotic medications in the early stage of the illness under a randomized controlled trial (RCT). Methods: We followed up 178 first-episode psychosis patients who participated in a 1-year RCT on medication discontinuation. In the RCT, patients were randomized into receiving either a medication maintenance group (MT) or a placebo discontinuation group (PL). In this follow-up study, 142 subjects were successfully traced and assessed at 10 years on their clinical, functional and cognitive outcomes. Results: There were no differences between patients who were included (n = 142) and excluded (n = 36) from the study with regard to their baseline demographics, clinical and functioning. At 10 years, patients in the PL group had more residual delusion as defined using PANSS P1 item score (15%) than those in the MT group (4%; P = .028). PL group also had more treatment refractory (as defined using residual delusion or on clozapine; 24%) than the MT group (8%; P = .011). Specifically, PL started to take clozapine significantly earlier than MT during the follow-up period (P = .04). We found no significant differences between MT and PL in terms of functioning, cognitive functioning, quality of life, and medication taken after 10 years. Conclusion: This is the first study to examine the long-term impacts of medication discontinuation during early phase of psychotic disorders. Our findings show that early decision to stop medication in remitted first-episode psychosis may result in less symptomatic remission and more treatment nonresponsiveness. The decision to discontinue medication during the early phase of psychosis should be considered carefully.

Barriers to the Use of Long-Acting Injectable Antipsychotics in the Management of Schizophrenia.

Schizophrenia and related disorders remain major disabling conditions, mainly due to antipsychotic treatment resistance and to relapses related to antipsychotic nonadherence. Treatment nonadherence rates are consistently high in long-term patients, but also in first-episode patients with schizophrenia. Long-acting injectable antipsychotics (LAIAs) were mainly developed to improve adherence to treatment and to reduce the rate of relapse and rehospitalization in schizophrenia due to treatment discontinuation. There is favorable clinical evidence, in terms of both efficacy and treatment adherence, that could support higher LAIA prescription rates, especially in patients in early phases of psychotic disorders. Several factors could be hindering wider use of LAIAs, mainly associated with perceptions and attitudes of patients, clinicians, and health managers or policy makers. The main aims of this review are (i) to summarize the existing data on the efficacy and tolerability of LAIAs compared with oral formulations in the management of schizophrenia and related disorders, focusing on the novel, second-generation LAIA options; (ii) to analyze the barriers that exist to the more widespread use of these formulations; and (iii) to discuss possible approaches to overcoming these barriers.

Early Intervention for Psychosis in Canada: What Is the State of Affairs?

Early intervention services (EIS) for psychosis have been developed in several countries, including Canada. There is some agreement about the program elements considered essential for improving the long-term outcomes for patients in the early phase of psychotic disorders. In the absence of national standards, the current state of EIS for psychosis in Canada needs to be examined in relation to expert recommendations currently available. A detailed online benchmark survey was developed and administered to 11 Canadian academic EIS programs covering administrative, clinical, education, and research domains. In addition, an electronic database and Internet search was conducted to find existing guidelines for EIS. Survey results were then compared with the existing expert recommendations. Most of the surveyed programs offer similar services, in line with published expert recommendations (i.e., easy and rapid access, intensive follow-up through case management with emphasis on patient engagement and continuity of care, and a range of integrated evidence-based psychosocial interventions). However, differences are observed among programs in admission and discharge criteria, services for patients at ultra high risk (UHR) for psychosis, patient to clinician ratios, accessibility of services, and existence of specific inpatient units. These seem to diverge from expert recommendations. Although Canadian programs are following most expert recommendations on clinical components of care, some programs lack administrative and organizational elements considered essential. Continued mentoring and networking of clinicians through organizations such as the Canadian Consortium for Early Intervention in Psychosis (CCEIP), as well as the development of a fidelity scale through further research, could possibly help programs attain and maintain the best standards of early intervention. However, simply making clinical guidelines available to care providers is not sufficient for changing practices; this will need to be accompanied by adequate funding and support from organizations and policy makers.

A five-year randomized parallel and blinded clinical trial of an extended specialized early intervention vs. regular care in the early phase of psychotic disorders: study protocol

BackgroundSpecialized Early Intervention services (SEI) for first episode psychosis are shown to be effective for the treatment of positive and negative symptoms, medication adherence, rates of relapse, substance abuse disorders, functional outcome and quality of life at two-year treatment follow up. However, it is also reported that these benefits are not maintained when SEI is not sustained. The objective of this trial is to test the efficacy of a 3-year extension of a SEI service (following 2 years of SEI prior to randomization) for the maintenance and consolidation of therapeutic gains as compared to regular care in the community.MethodsFollowing an initial 2 years of SEI, patients are randomized to receive either 3-years of continued SEI or regular care. SEI provided at three sites within the McGill network of SEI services, using a model of treatment comprised of: modified assertive case management; psycho education for families; multiple family intervention; cognitive behavioural therapy; and substance abuse treatment and monitoring. Blinded research assistants conduct ongoing evaluation of the outcome variables every three months. The primary outcome measure is remission status measured both as the proportion of patients in complete remission and the mean length of remission achieved following randomization during the additional three years of follow up. Based on preliminary data, it is determined that a total of 212 patients are needed to achieve adequate statistical power. Intent to treat with the last observation carried forward will be the primary method of statistical analysis.DiscussionThe “critical period” hypothesis posits that there is a five year window during which the effects of the nascent psychotic illness can be countered and the impact of the disorder on symptomatic and functional outcomes can be offset through active and sustained treatment. Providing SEI throughout this critical period may solidify the benefits of treatment such that gains may be more sustainable over time as compared to intervention delivered for a shorter period. Findings from this study will have implications for service provision in first episode psychosis.Trial registrationISRCTN11889976

The Role of Cognition in Outcome in Schizophrenia and Related Disorders

Schizophrenia and related psychotic disorders can be regarded primarily as disorders of cognition, perception, and volition. Deficits in cognitive functions, including those in meta-cognition, are present in a substantial proportion of patients with these disorders and often predate the onset of psychosis.1 Neurocognition has been the subject of investigation for several decades as part of an attempt to better understand the putative underlying neurobiology of these disorders. More recently, such investigations have included its relation to course and outcome on several dimensions, including clinical and functional. In the 2 In Review articles published on this topic in this issue,2,3 the authors have provided a thorough review of the role of cognition in the context of functional outcome and, in the case of Dr Martin Lepage and colleagues,2 also included clinical outcome. In the first article, Dr Lepage and colleagues have approached the subject first from the perspective of clinical remission, especially within the context of the recent consensus definition,4 and presented evidence specifically in relation to early phase of psychotic disorders. They have concluded that there is more concrete evidence for the role of verbal memory as a marker for early remission in psychotic disorders as well as some tentative evidence in relation to social cognition. For other domains of cognition as markers of clinical remission, the evidence appears to remain equivocal or weak. In the second part of their review, they have provided evidence for the role of cognition in relation to several domains of functioning, including self-care, independent living, work, and social and interpersonal functioning. They have suggested that different domains of functional recovery may be associated with different domains of cognition. In the second article, Dr Tarek K Rajji and colleagues3 report the results of a systematic examination of longitudinal studies related to cognition and functioning across the life span and different phases of the illness, including the early as well as the later, more chronic phases. The findings from the 2 reviews are generally consistent as far as association of cognitive functioning and functional outcomes are concerned. Both reviews appear to conclude that several domains of cognition, especially verbal memory, executive function, and social cognition, are strong determinants of different domains of functioning relevant to patients’ daily lives. While both reviews have concentrated primarily on cognition, there has been an attempt to examine possible influence of other variables on functional outcome. However, this relation has been examined mostly in relation to how these other variables may influence the role of cognition in shaping functional outcome. The variables examined include, for example, the role of functional capacity, motivation, premorbid adjustment, and delay in treatment. What remains unclear is the relative and independent role of symptomatic remission and cognition, respectively, on their influence on functional outcomes, especially given the more inclusive definition of remission now applied.4,5 This may be important for several reasons. Prolonged remission of symptoms is likely to be influenced by variables that are different from those that affect cognition. For example, adherence to medication, cognitive-behavioural therapy, assertive case management, and family and other psychosocial interventions are more likely to assist in lengthening periods of remission than having any effect on cognitive functions. The latter are more likely influenced by either trait factors or variables that predate the onset of psychosis and its treatment but may be influenced by cognitive remediation, which requires a different set of skills on the part of therapists than those associated with treatment interventions outlined above. Beneficial effects of sustained remission as well as improvement in cognitive functions may both require to be combined with other ecologically sound interventions, such as supported employment, to produce any real change in patients’ lives. It remains to be seen what other variables may influence the interactional effect of interventions, such as supported employment and cognitive remediation, and (or) interventions that boost sustained remission. The 2 reviews in this issue of the journal provide further thought to making investigations of cognition in psychotic disorders relevant to improving outcomes meaningful to patients’ lives. It is hoped that future investigations will encompass all possible influences on outcomes, not limited to cognition and (or) remission of symptoms but including patients’ own strengths, such as self-esteem, social and family support, and personal resilience, as well as examine recovery outcomes that encompass patients’ perspectives.6,7

Anomalous self-experiences contribute independently to social dysfunction in the early phases of schizophrenia and psychotic bipolar disorder

BackgroundPsychotic disorders are associated with significant social dysfunction. Anomalous self-experiences (ASE) present in psychotic disorders could contribute to social dysfunction. AimTo investigate if ASE contribute to social dysfunction in the early phases of psychotic disorders after controlling for factors related to social functioning including diagnoses. MethodsASE were assessed by means of the EASE (Examination of Anomalous Self-Experience) in 76 patients referred to their first adequate treatment for schizophrenia or psychotic bipolar disorder. Diagnoses, symptom severity, and functioning were assessed using the Structured Clinical Interview for the Positive and Negative Syndrome Scale, Calgary Depression Scale for Schizophrenia, Premorbid Adjustment Scale, Global Assessment of Functioning—Split Version, and Social Functioning Scale. Neurocognitive assessments included measures of psychomotor speed, working memory, executive and memory functions. Duration of untreated psychosis was also assessed. ResultsHigh levels of ASE were significantly associated with poorer social functioning in the early phases of schizophrenia and psychotic bipolar disorder also after correcting for diagnosis. ConclusionThis study demonstrates the significance of ASE for social dysfunction in patients with psychotic disorders, and contributes to the understanding of the complexity of illness-related factors that affect social functioning.

Predictors of suicide-related behaviors during treatment following a first episode of psychosis: The contribution of baseline, past, and recent factors

BackgroundSuicide-related behaviors (suicide attempts and suicides) are common in the early phase of psychotic disorders. Studies have examined risk factors among baseline and historical (i.e., past) variables, yet little is known about recent characteristics that increase suicide risk during treatment for first-episode psychosis (FEP). This study had two aims: first, to determine the relative importance of baseline, past, and recent variables to the prediction of suicide-related behaviors in patients with FEP; second, to identify recent characteristics that exert most influence on suicide risk levels and which could become foci of preventive interventions. MethodsThis was a case–control study of 180 patients from a cohort entering a specialist FEP service between 1/12/2002 and 30/11/2005. Data for 72 cases and 108 matched controls were obtained via medical record audit. Multivariate logistic regression models assessed the contribution of baseline, past, and recent domains. Suicide attempt or suicide during treatment was the outcome variable. ResultsThe strongest risk factors for suicide-related behaviors were: baseline depressive symptoms, baseline suicidal ideation/intent, past negative events, past non-suicidal self-injurious behavior, recent negative events, recent depressive symptoms, and recent non-suicidal self-injurious behavior. However, when these were entered into a hierarchical logistic regression model, only recent non-suicidal self-injurious behavior (AOR=72.96, p<0.001), and recent negative events (AOR=1.90, p=0.003) remained significant predictors. The final model accurately classified 75.5% of cases and 89.2% of controls, and explained 72.0% of variance in the suicide attempt status. ConclusionsSince recent negative events and recent non-suicidal self-injurious behavior were the strongest predictors of suicide-related behaviors during treatment for FEP, psychiatric services could consider incorporating psychosocial interventions addressing affect regulation, interpersonal effectiveness, stress management and problem solving, alongside case management and pharmacotherapy, to help to reduce the rates of suicide attempts and suicides in first-episode patients.

The Personal Meaning of Recovery Among Individuals Treated for a First Episode of Psychosis

There is little understanding of service users' conceptions of recovery in the early phase of psychotic disorders. An enhanced understanding of personal notions of recovery may help with the development and evaluation of interventions that address the concerns of service users. This study examined personal definitions of recovery among individuals recently treated in a specialized early-intervention service in Canada. Semistructured interviews were carried out with 30 individuals three to five years after initial treatment of a first episode of psychosis. Interpretative phenomenological analysis was used to examine participants' personal meanings of recovery. A typology of recovery definitions was constructed. A majority of individuals considered themselves to be recovered. Responses indicated that recovery is a multidimensional experience and is often a personalized and achievable goal at this early stage in treatment. Individuals described recovery as improvement in one or more of three domains: illness recovery, psychological and personal recovery, and social and functional recovery. There was variation in the extent to which individuals perceived that recovery involved alleviation of symptoms and elimination of underlying vulnerability to illness. There were several components of the personal meanings of recovery from a first episode of psychosis and variations in the emphasis that individuals placed on each component. An overall positive outlook may be a function of younger age, shorter duration of illness, and receipt of client-centered comprehensive and phase-specific treatment. Improved understanding of personal notions of recovery can guide clinical practices to address service users' recovery goals.

Cannabis use and anticipatory pleasure as reported by subjects with early psychosis and community controls

BackgroundThere is evidence of decreased pleasure and deficits in the anticipation of reward in both psychotic illness and drug addiction. Individuals with low anticipatory pleasure may preferentially engage in behaviours associated with immediate reward such as cannabis use. MethodNinety-one psychosis patients and 91 controls without history of psychosis were administered the Temporal Experience of Pleasure Scale (TEPS), a self report which measures anticipatory and consummatory pleasure. Cannabis use diagnosis was assessed using the Structured Clinical Interview for DSM IV (SCID). Subjects reported the frequency of cannabis consumption and time since last use. ResultsPatients did not show a significant deficit in anticipatory or consummatory pleasure compared to controls; however, patients with an active cannabis-use disorder tended to have lower consummatory pleasure than controls with active cannabis disorder (p<.05). Patients who continued to use cannabis during treatment of their first episode of psychosis reported significantly lower anticipatory pleasure compared to those who had a lifetime cannabis diagnosis but were able to maintain abstinence (F(1,60)=5.6, p=.021). Frequency of cannabis use was negatively correlated to anticipatory and consummatory pleasure (Pearson R=−.46, −.48 respectively) in 37 patients currently using cannabis but not in 46 cannabis-using controls (partial R=−.04, −.07 respectively). ConclusionAnticipatory pleasure may not be decreased in early psychosis patients. Lower hedonic response may be associated with persistent, heavy cannabis use in patients in the early phase of psychotic disorders.

Pre-morbid and outcome correlates of first episode mania with psychosis: Is a distinction between schizoaffective and bipolar I disorder valid in the early phase of psychotic disorders?

Objectives The validity of schizoaffective disorder (SA) diagnosis has for long been a matter of controversy and its delineation from bipolar I disorders (BD) has often been questioned. However, most studies have been conducted in chronic samples and have therefore been biased towards patients with poorer outcome, which may have hampered the possibility to identify significant differences between both diagnoses. Methods 108 subjects presenting a first DSM-III-R manic episode with psychotic features were assessed at baseline and 12 months after stabilisation on symptoms and functional characteristics, and patients with BD ( n = 87) were compared with those with SA bipolar subtype (SAB) ( n = 21). Results SAB patients had a higher prevalence of first degree relatives with schizophrenia and a lower premorbid functional level. They had a longer prodromal phase, a longer duration of untreated psychosis and remained symptomatic for a longer period. They also had higher levels of positive symptoms in the acute manic phase; however, with two exceptions, the type of psychotic symptoms were similar in both groups. At stabilisation and 12 months after stabilisation, SA patients had higher levels of negative symptoms, with poorer functional level at 12 months. Conclusions These data suggest SA is a valid diagnosis in the early phase of psychotic disorders considering it defines a subgroup of first episode psychotic mania patients with distinct characteristics compared to BD. While a dimensional approach to diagnosis may be more adapted to this phase of illness, SA disorder offers, in the context of categorical classifications, a useful intermediate category that reflects a clinical reality.

Mentalization‐based psychodynamic psychotherapy for psychosis

This article discusses and illustrates the use of mentalization-based psychodynamic psychotherapy for disturbances of awareness of the self and others in patients with psychotic-spectrum disorders. The literature on impairments of mental processes involved in self-awareness and awareness of others occurring in psychotic illnesses and the relationship between childhood trauma and the emergence of psychotic symptoms is reviewed. A case illustrates how mentalization-based treatment can facilitate treatment engagement and be used to manage enactments in the psychotherapy with a patient with a psychotic disorder. Mentalization-based psychotherapy may offer a useful adjunct to antipsychotic medication and psychosocial evidence-based treatments in the care of individuals in the early phase of psychotic disorders.

The promises and challenges of early intervention in psychotic disorders

The promises and challenges of early intervention in psychotic disorders

Identifying the Ultra-High Risk (Prodromal) Population: Evaluation of Training Workshops with Mental Health Services

Recent years have witnessed widespread interest in the early phase of psychotic disorders. The most widely used approach to identify individuals in the prodromal phase is the ultra-high risk (UHR) approach, which combines known trait and state risk factors for psychotic disorder. The Personal Assessment and Crisis Evaluation Clinic introduced the Comprehensive Assessment of At Risk Mental States (CAARMS) in order to assess UHR status. A training DVD and manual in the use of the CAARMS was recently developed in order to assist with UHR identification. The current paper reports the outcome of a series of training workshops with mental health professionals based around this DVD. The research aim was to investigate whether the training workshops assisted mental health professionals in their confidence and ability to accurately identify UHR cases and distinguish these from non-UHR and first-episode psychosis (FEP) cases. A total of 137 mental health workers participated in the training sessions across eight training sites. The training sessions consisted of four modules: theoretical background; rating written vignettes for UHR, non-UHR or FEP status; viewing and discussing the CAARMS Training DVD; and re-rating matched written vignettes for UHR, non-UHR or FEP status. Participants' confidence in identifying UHR cases and in using the CAARMS increased as a result of the workshop. Participants' ability to correctly identify UHR-positive cases did not improve as a result of the workshop. This may have been the result of a ceiling effect due to the baseline ability to identify UHR-positive cases being high. But there was a trend for participants' ability to correctly identify UHR-negative cases to improve as a result of the workshop. UHR training workshops are a valuable means of increasing mental health workers' confidence in identifying UHR patients. Future UHR training programmes with experienced mental health professionals should pay particular attention to the correct identification of UHR-negative cases.