Early Signs Of Psychosis Research Articles

Methylphenidate-induced psychosis in a young antipsychotic-naïve female patient

Methylphenidate (MPD) is commonly prescribed for patients with Attention Deficit/Hyperactivity Disorder (ADHD). Although used off-label, MPD forms part of complex and multifactorial treatment regimen for narcolepsy and hypersomnia, together with including behavioural interventions. The drug is sometimes also prescribed off-label to subjects with other mental illness or somatic condition to improve intellectual outcome, ease fatigue or enhance the ability to concentrate. Common side effects include headache, insomnia, decreased appetite and hypertension. Concurrently, clinicians should be aware of relatively rare but potentially threatening adverse effects including agitation and psychotic symptoms. Several case reports regarding MPD-induced psychosis have been published, but most of them regard children or teenagers (1) and much less is known about drug-induced psychosis in adults (2). In this article, we present a case report of MPD-induced psychosis in a 31-year-old, antipsychotic-naïve patient. Careful evaluation including clinical examination, medical and family history and possible early signs of psychosis is recommended each time before MPD treatment will be initiated.

The Provision of Education and Employment Support At the Outreach and Support in South London (OASIS) Service for People at Clinical High Risk for Psychosis.

Clinical services for the early detection of individuals at clinical high risk of psychosis, such as Outreach and Support in South-London (OASIS), have been successful in providing psychological intervention and psychosocial support to young people experiencing emerging signs of serious mental disorders. Despite this, several studies have repeatedly shown that vocational and functional recovery in the clinical high risk for psychosis population is still low. This study aimed at evaluating the presence and nature of educational and employment focused interventions within the OASIS service, in order to inform research and clinical interventions aimed at supporting young people with early signs of psychosis on their path to vocational recovery. The specific objectives were to compare current practice i) to standards defined by the National Institute of Care Excellence guidelines; and ii) to principles defined by Individual Placement and Support (IPS). Nine standards of practice were derived. The OASIS caseload electronic records entered between January 2015 and January 2017 were manually screened. Data collected include sociodemographic, assessment of employment and educational status and support needs, interventions received, contacts with schools, employers and external vocational providers, employment, and educational status. Standards were considered as “met” if they were met for at least 90% of clients. Results suggest that, two out of nine standards were met while the remaining standards were only partially met. In particular, support provided was always focused on competitive employment and mainstream education and support was always based on people’s interest. Implications for clinical and research practice are discussed.

34.3 IMPROVING THE DETECTION OF INDIVIDUALS AT RISK OF DEVELOPING PSYCHOSIS IN PRIMARY MENTAL HEALTH CARE

BackgroundGeneral practitioners are usually the first health professionals contacted by people with early signs of psychosis. It is unclear whether increasing the intensity of liaison between primary care and secondary care improves the clinical effectiveness and cost-effectiveness of detecting people with, or at clinical high-risk (CHR-P) of developing, a first-episode psychosis (FEP). This is important given political commitments to facilitate early intervention and decrease waiting times in mental health. We developed and tested a theory-based intervention to improve detection and referral of these mental states.MethodsThe LEGS study was a cluster randomised controlled trial (cRCT) involving primary care practices (clusters) in the county of Cambridgeshire and Peterborough, UK. Consenting practices were randomly allocated into two groups: (1) low-intensity liaison between primary care and secondary care, a postal campaign consisting of biannual guidelines to help in the identification and referral of individuals with early signs of psychosis and (2) the high-intensity intervention described in the previous section, which, in addition to the postal campaign, included a specialist mental health professional to liaise with each practice and support the theory-based educational package. Concealed randomisation involved a randomly permuted sequence in blocks, with 12 strata and 96 blocks. Practices that did not consent to be randomised constituted a practice-as-usual (PAU) group. The high- and low-intensity interventions were implemented over a period of 2 years for each practice during the study period April 2010 to October 2013.The primary outcome was the number of CHR-P referrals to Early Intervention in Psychosis Services per practice site predicated on an assumption that the intensive intervention would double them. New referrals were assessed clinically and stratified into those who met criteria for CHR-P or FEP (together: psychosis true positives) and those who did not fulfil such criteria for psychosis (false positives). Referrals from PAU practices were also analysed.An economic evaluation quantified the cost-effectiveness of the interventions and PAU, using decision-analytic modelling. Cost-effectiveness was expressed as the incremental cost per additional true positive identified.ResultsOf the 104 eligible practices, 54 consented to be randomised. Twenty-eight practices were randomised to low-intensity liaison and 26 practices were randomised to the high-intensity liaison. Two high-intensity practices withdrew. High-intensity practices referred more CHR-P (incidence rate ratio (IRR) 2.2, 95% CI 0.9 to 5.1; p = 0.08)), FEP (IRR 1.9, 95% CI 1.05 to 3.4; p = 0.04) and true positive (IRR 2.0, 95% CI 1.1 to 3.6; p = 0.02) cases. High-intensity practices also referred more false positives (IRR 2.6, 95% CI 1.3 to 5.0; p = 0.005); most (68%) of these were referred on to appropriate services.The total costs per true positive referral in high-intensity practices were lower than those in low-intensity or PAU practices; the high-intensity intervention was the most cost-effective strategy.DiscussionIncreasing the resources aimed at managing the primary–secondary care interface provides clinical and economic value in this setting. Early detection of CHR-P in primary care is clinically and cost-effectiveThis talk will also introduce the continuation of this work; a 5-year research programme that will focus on the treatment of individuals with psychotic experiences in primary care settings.

Update on the 22q11.2 deletion syndrome and its relevance to schizophrenia

Schizophrenia occurs in ∼25% of individuals with 22q11.2 deletion syndrome (22q11.2DS), the strongest known molecular genetic risk factor for schizophrenia. This review highlights recent literature in 22q11.2DS as it pertains to psychosis and schizophrenia. Advances in noninvasive prenatal testing allow for early detection of 22q11.2DS in utero, whereas premature birth has been shown to be a significant risk factor for development of psychotic illness in 22q11.2DS. Impairments in various domains of cognitive and social functioning, as well as neuroanatomical alterations, are comparable with those in other high-risk groups and may serve as early signs of psychosis in 22q11.2DS. Novel research on the pathogenesis of schizophrenia in 22q11.2DS using cellular and mouse models indicates changes in expression of genes within the 22q11.2 deletion region and elsewhere in the genome, implicating molecular pathways involved in schizophrenia and associated neurocognitive deficits. Increased risks of obesity and of Parkinson's disease in 22q11.2DS warrant consideration in antipsychotic management. Progress in characterizing and predicting psychotic illness in 22q11.2DS supports this identifiable subpopulation as a molecular model with important implications for understanding the pathogenesis of schizophrenia in the general population and for development of potential novel therapies.

Understanding causes of and developing effective interventions for schizophrenia and other psychoses

Understanding causes of and developing effective interventions for schizophrenia and other psychoses

Clinical effectiveness and cost-effectiveness of tailored intensive liaison between primary and secondary care to identify individuals at risk of a first psychotic illness (the LEGs study): a cluster-randomised controlled trial

SummaryBackgroundGeneral practitioners are usually the first health professionals to be contacted by people with early signs of psychosis. We aimed to assess whether increased liaison between primary and secondary care improves the clinical effectiveness and cost-effectiveness of detection of people with, or at high risk of developing, a first psychotic illness.MethodsOur Liaison and Education in General Practices (LEGs) study was a cluster-randomised controlled trial of primary care practices (clusters) in Cambridgeshire and Peterborough, UK. Consenting practices were randomly allocated (1:1) to a 2 year low-intensity intervention (a postal campaign, consisting of biannual guidelines to help identify and refer individuals with early signs of psychosis) or a high-intensity intervention, which additionally included a specialist mental health professional who liaised with every practice and a theory-based educational package. Practices were not masked to group allocation. Practices that did not consent to be randomly assigned comprised a practice-as-usual (PAU) group. The primary outcome was number of referrals of patients at high risk of developing psychosis to the early intervention service per practice site. New referrals were assessed clinically and stratified into those who met criteria for high risk or first-episode psychotic illness (FEP; together: psychosis true positives), and those who did not fulfil such criteria for psychosis (false positives). Referrals from PAU practices were also analysed. We assessed cost-effectiveness with decision analytic modelling in terms of the incremental cost per additional true positive identified. The trial is registered at the ISRCTN registry, number ISRCTN70185866.FindingsBetween Dec 22, 2009, and Sept 7, 2010, 54 of 104 eligible practices provided consent and between Feb 16, 2010, and Feb 11, 2011, these practices were randomly allocated to interventions (28 to low intensity and 26 to high intensity); the remaining 50 practices comprised the PAU group. Two high-intensity practices were excluded from the analysis. In the 2 year intervention period, high-intensity practices referred more FEP cases than did low-intensity practices (mean 1·25 [SD 1·2] for high intensity vs 0·7 [0·9] for low intensity; incidence rate ratio [IRR] 1·9, 95% CI 1·05–3·4, p=0·04), although the difference was not statistically significant for individuals at high risk of psychosis (0·9 [1·0] vs 0·5 [1·0]; 2·2, 0·9–5·1, p=0·08). For high risk and FEP combined, high-intensity practices referred both more true-positive (2·2 [1·7] vs 1·1 [1·7]; 2·0, 1·1–3·6, p=0·02) and false-positive (2·3 [2·4] vs 0·9 [1·2]; 2·6, 1·3–5·0, p=0·005) cases. Referral patterns did not differ between low-intensity and PAU practices. Total cost per true-positive referral in the 2 year follow-up was £26 785 in high-intensity practices, £27 840 in low-intensity practices, and £30 007 in PAU practices.InterpretationThis intensive intervention to improve liaison between primary and secondary care for people with early signs of psychosis was clinically and cost effective.FundingUK National Institute for Health Research.

Difficulty in making contact with others and social withdrawal as early signs of psychosis in adolescents – the Northern Finland Birth Cohort 1986

Social withdrawal is among the first signs of the prodromal state of psychosis seen in clinical samples. The aim of this prospective study was to find out whether difficulty in making contact with others and social withdrawal precede first episode psychosis in the young general population. The members of the Northern Finland Birth Cohort 1986 (n=6274) completed the PROD-screen questionnaire in 2001-2002. The Finnish Hospital Discharge Register was used to detect both new psychotic and non-psychotic disorders requiring hospitalisation during 2003-2008. Twenty-three subjects developed psychosis and 89 developed a non-psychotic mental disorder requiring hospitalisation during the follow-up. Of those who developed psychosis, 35% had reported difficulty or uncertainty in making contact with others and 30% social withdrawal in adolescence. In hospitalised non-psychotic disorder, the corresponding precentages were 10 and 13% and in the control group without hospital-treated mental disorder 9 and 11%. The differences between psychotic and non-psychotic hospitalised subjects (P<0.01) as well as controls (P<0.001) were statistically significant regarding difficulty or uncertainty in making contact with others. In this general population-based sample self-reported difficulty or uncertainty in making contact with others in adolescence preceded psychosis specifically compared to hospitalised non-psychotic mental disorders and controls.

Opinion des mères tunisiennes concernant le premier épisode psychotique de leur enfant

Initiating psychiatric treatment depends on several factors including clinical, personal, familial and economic factors. In the case of a first psychotic episode in an adolescent, parents, especially mothers, have a critical role in initiating psychiatric treatment for their child. In this study, we investigated mothers' beliefs about their child's first psychotic episode. Participants were adolescents consulting the department of Child and Adolescent Psychiatry of the Razi hospital in Tunisia. They were aged from 12 to 19 years at the onset of their medical follow-up. Their diagnoses were schizophrenia, schizoaffective disorder and schizophreniform disorder according to DSM-IV. A questionnaire was submitted to patients' mothers after their approval. It was divided into two parts. The first part was used to collect information on socio-demographic and clinical characteristics of the mothers and their children. The second part was composed of the following four questions in Tunisian dialect: (1) what did you think was the matter when you first noticed psychotic symptoms in your child? (2) what was the main reason for which you thought psychiatric treatment was necessary? (3) what obstacles did you perceive in initiating psychiatric treatment? (4) do you have any advice or suggestions for caregivers on how they could facilitate an early start of treatment? Twenty-two mothers were included. The mean age of the mothers at onset of the follow-up of their child was 42 years (SD: 4.81). Ten mothers had never been schooled, five had primary school level, four had secondary school level, three had bachelor's degree and two had a diploma of doctorate; 63.6% of the mothers were housewives. The mean age of patients was 13.77 years at the start of their medical follow-up (SD= ± 2.14). Most of the patients were male (14 males for eight girls). Most patients were diagnosed as having schizophrenia (91%); 4.5% were diagnosed with schizoaffective disorder and 4.5% with schizophreniform disorder. The duration of untreated psychosis (DUP) was 11.5 months. Longer duration of untreated psychosis was associated with male gender (P=0.008). A significant relationship was also found between long DUP and stigmatization of mental hospital and psychiatry (respectively P=0.04 and P=0.05). Most of the mothers did not think that their child initially suffered from a psychotic disorder. In 63.3%, the cause of the child's symptomatology was attributed to spirit possession. The others reasons for seeking psychiatric treatment were: behavioral disorder in 77.3%, inefficacity of traditional practices in 54.5%, and patient refusal (40.9%). Stigmatization of the Razi hospital, the unique psychiatric hospital in the country, and of psychiatry in general were evoked by mothers as the main obstacles in initiating psychiatric treatment in more than half of the cases (70%). Others obstacles were: fear of side effects of psychiatric treatment (50%), patient refusal (40.9%), inaccessibility to psychiatric services (31.8%) and fear of an addiction to psychotropic agents (31.8%). Thirty-six percent of mothers underlined the need to consult in the occurrence of school difficulties or any change in the child's behavior; 27% proposed educational and anti-stigmatizing campaigns about the signs of early psychosis through radio, newspapers, cinema, and TV media advertisements. Making teachers and educators sensitive to psychosis was proposed by 13.6% of mothers; 9.1% thought that diagnostic skills should be improved in general practitioners. Knowledge of attitudes of mothers towards the illness of their child prior to psychiatric treatment and towards the start of treatment is essential for the development of interventions for reducing duration of untreated psychosis.

Teachers' awareness for psychotic symptoms in secondary school: the effects of an early detection programme and information campaign

The objective of the study was to investigate high school teacher's literacy on psychosis symptoms and teachers' confidence in the positive effects of psychosis treatment on the mental health of students with psychotic symptoms at two sites: one site with an extensive early detection of psychosis programme including an ongoing information campaign (IC) on early signs of psychosis and a control site with no early detection or IC aimed at psychosis. A cross-sectional comparative design was employed using a using a structured survey questionnaire. Four schools from Rogaland County and four schools from Nord-Trøndelag County were selected by strategic sampling. Teachers at the study site with an ongoing IC and access to an outreaching team for early detection and treatment of psychosis demonstrated a higher level of confidence in the effects of treatment on psychosis. At both sites, we found that teachers who have participated in mental health literacy training programmes do show better mental health literacy. No significant effect of study site on mental health literacy was found. Access to a detection and treatment programme for psychosis can provide more confidence in the effect of treatment for psychosis in young people. Mental health literacy training programmes for teachers seem to have the expected effect: better mental health literacy, including more knowledge on early signs of psychosis.

Early psychosis: raising awareness among non-mental health nurses

People developing psychosis often seek help several times before receiving effective support and treatment, and frequently present to general healthcare staff. Therefore, awareness and knowledge of early psychosis among non-mental health nurses should be promoted. This article aims to provide an overview of psychosis, including signs and symptoms of the condition. Nurses need to be able to direct people displaying signs of early psychosis to the most appropriate services for timely assessment, support and treatment.

Outpatient vs. comprehensive first-episode psychosis services, a 5-year follow-up of Soteria Nacka

Three years experience of an outpatient unit for first-episode psychosis showed that most of the patients at some point became hospitalized in a psychiatric ward with discontinuity in care as a consequence. Adding “need-adapted” inpatient care in the form of a small and calm crisis home guaranteed continuity in approach and treatment, as the same caregivers staffed the inpatient and outpatient parts of Soteria. Information on early signs of psychosis was given to other units of the psychiatric clinic and to general practitioners. As the organization was considerably changed from that point of time, the patients could be divided into two separate groups. The aim of the present study was to follow the patients in the two groups for 5 years, comparing the outcome. The results showed that easily accessible need-adapted treatment with integrated overnight care might be advantageous for first-episode psychotic patients. The duration of untreated psychosis was shorter and the outcome better.

AControlled Study Of Formal Thought Disorder in Children with Autism and Multiple Complex Developmental Disorders

Along with well-defined categories in classification systems (e.g., autistic disorders and attention-deficit/hyperactivity disorder (ADHD)), practitioners are confronted with many children showing mixed forms of developmental psychopathology. These clusters of symptoms are on the borderlines of more defined categories. The late Donald Cohen proposed heuristic criteria to study a group defined by impaired social sensitivity, impaired regulation of affect, and thinking disorders under the name multiple complex developmental disorders (MCDD). Although these children meet criteria for pervasive developmental disorder--not otherwise specified (PDD-NOS), they have additional important clinical features, such as thought disorder. After highlighting similarities and differences between MCDD and comparable groups (e.g., multidimensionally impaired children), this paper presents the findings of a study comparing formal thought disorder scores in children with MCDD to children with autism spectrum diagnoses, such as autistic disorder (AD), and to children with nonspectrum diagnoses, such as ADHD and anxiety disorders. Videotaped speech samples of four groups of high-functioning, latency-aged children with MCDD, AD, ADHD, and anxiety disorders were compared to a control group of normal children using the Kiddie Formal Thought Disorder Rating Scale (K-FTDS). High formal thought disorder scores were found both in the AD and MCDD groups, low rates in the ADHD groups, and no thought disorder in the anxiety disorder and normal control groups. The severity of formal thought disorder was related to verbal IQ scores within the AD and MCDD groups. High formal thought scores in children with complex developmental disorders, such as AD and MCDD, appear to reflect impaired communication skills rather than early signs of psychosis.

Detecting early signs of psychosis. Vignettes presented to professionals in primary healthcare and psychiatry

Among personnel in primary healthcare and psychiatric care, the ability to detect early signs of psychosis was examined and compared. Differences due to sex, age, profession or time in the profession were explored. Three different vignettes concerning patients with mental illness were presented to the respondents, and every respondent was to mark what they thought were early signs of psychosis in the vignettes. The findings were compared with a pre-set standard of symptoms and signs. Healthcare personnel from two different administrative districts, Umeå and Örnsköldsvik in northern Sweden, participated in the study. The response rate was 77%, but for district nurses in the administrative district of Umeå it was only 25%, so therefore complementary interviews with nine district nurses in that district, representing the drop-outs, were performed. There was no difference whatsoever in ability to detect early signs of psychosis between personnel in primary healthcare and psychiatric care; nor were there any significant differences due to sex, age, profession or time in their profession. Detecting early signs of psychosis requires training and the ability to communicate with patients, as well as a special sensitivity to psychiatric conditions. This can be achieved by enhancing accessibility and continuity of primary healthcare for these patients. Furthermore, a greater sensitivity to early signs of psychosis must be created among all healthcare personnel. The co-operation between primary healthcare and psychiatric care must increase. Primary care physicians need opportunities to see patients over time in order to correctly interpret early signs and symptoms of psychiatric illness.

Recognition of early warning signs in patients with schizophrenia: a review of the literature.

This article reviews and discusses the literature on the recognition of the early warning signs of psychosis. The assumption is that nurses, in the everyday exercise of their profession, can contribute to the prevention of psychotic relapse in schizophrenic patients by the early recognition of warning signs. First, the process of psychotic relapse and the factors that influence it are described. Then research on the early signs of psychosis is discussed. This article questions the most common early signs, when they occur, and who can recognize them. Then the predictive value of the early signs is considered: how well can psychotic relapse be predicted with these early signs? Finally, the research on the effects of early recognition and early intervention is discussed, primarily with respect to the question of whether psychotic relapses can actually be prevented by making use of preventive intervention strategies. The conclusion is that the preliminary results are hopeful and invite further research on such matters as the application of this intervention strategy within nursing practice.

General Practice Recruitment for People at Risk of Schizophrenia: The Buckingham Experience

Objective The process of detecting people at high risk of schizophrenia from a community sample is a major challenge for prevention of psychotic disorders. The aim of this paper is to describe early detection procedures that can be implemented in primary care settings. Methods A selected literature review is supplemented by experiences and data obtained during the Buckingham Integrated Mental Health Care Project. Results General medical practitioners have been favoured as the agents most likely to prove helpful in detecting the key risk factors that predict the onset of schizophrenic disorders, as well as in recognising the earliest signs and symptoms of these conditions. However, the practical problems of screening for multiple and subtle risk factors in general practice are substantial, and general practitioners (GPs) often have difficulty recognising the earliest signs of a psychotic episode. A range of strategies to assist GPs detect early signs of psychosis in their patients are considered. Conclusions It is feasible to implement primary care setting early detection procedures for people at risk of schizophrenia. Implementation is aided by the use of a brief screening questionnaire, training sessions and case supervision; and increased collaboration with mental health services and other community agencies.