Episode Psychosis Program Research Articles

Adapting the Parent Connector program for caregivers of adults with SMI: the Family Connector experience

Caregivers play an essential role in the recovery of their adult loved ones with serious mental illness (SMI). Promoting caregiver empowerment and well-being is critical but has often been overlooked. Family peer interventions are well-suited to fill this need; however, research is limited supporting their use with caregivers of adults with SMI. Our team is currently engaged in a study evaluating an adapted version of the evidenced-based Parent Connectors program1,2, renamed Family Connectors (FC), for caregivers of young adults recently discharged from the First Episode Psychosis program in New York (OnTrackNY). This paper, written collaboratively with family peer professionals, describes the adaptation process we followed to systematically document the family peer professional experience one year into delivering the FC program to this novel population. Modifications made to improve intervention fit included tailoring the content of the intervention, incorporating an outside approach into the program, lengthening the service in some cases, and adding a weekly peer supervision meeting. We hope that these insights are used to inform future efforts to advance support for families of loved ones with SMI, and more broadly, that our approach serves as a model for effective collaboration to improve the application of peer support services for unique groups.

Development of empirically derived brief program evaluation measures in Pennsylvania first-episode psychosis coordinated specialty care programs.

The Pennsylvania first episode psychosis program evaluation (PA-FEP-PE) core assessment battery was developed as a standard and comprehensive clinical assessment and data collection tool in Pennsylvania coordinated specialty care programs (CSC). To reduce administrative time and maximize clinical utility by maintaining acceptable levels of precision, we aimed to generate a short form using item response theory (IRT)-based computer-adaptive test (CAT) simulation and analyse the implementation and acceptability of the short form among providers from PA-CSC. FEP participants (n=759; age 14-36) from nine coordinated specialty care programs completed 156 items drawn from the PA-FEP-PE battery. Multidimensional IRT-based CAT simulations were used to select the best PA-FEP-PE items for abbreviated forms. A 67-item PA-FEP-PE short form was developed to capture six factors: (1) positive affect and surgency (with negative loadings on Anxious-Misery items); (2) psychiatric services satisfaction; (3) antipsychotic side effect severity; (4) family turmoil and associated traumas; (5) trauma load; and (6) psychosis. The total number of items was reduced more than 50% in the PA-FEP-PE shortened forms. The short form demonstrated good psychometric properties, and it was well accepted by our providers in the implementation. The empirical derivation and implementation of abbreviated measures of key domains and constructs in FEP care have streamlined and facilitated PA-FEP program evaluation. Our work supports potential application of IRT based methods to empirically reduce core assessment battery measures in large-scale data collection efforts such as in the Early Psychosis Intervention Network.

Measurement Based Care in a first episode psychosis program: Development of an algorithm of care based on the Clinical Global Impressions Scale

IntroductionAdherence to therapeutic guidelines in psychiatry is anchored and facilitated by rating scales. However, they are rarely used in routine care, particularly for psychotic disorders. Consequently, adherence to treatment guidelines are not ideal and patient outcomes are often sub-optimal. In this study, we used the clinician-rated Clinical Global Impressions Scale (CGI) to implement a measurement-based care (MBC) approach and derive indices of quality of care at a first episode psychosis (FEP) program. MethodsAt the individual level, an algorithm was created using CGI scores and their changes over time to define the concept of Patient Requiring Clinical Attention (PRCA) that encompasses several categories (e.g. episode of severity, treatment inertia, or treatment resistance). At the service level, CGI scores were used to derive several indices of quality of care: severity of illness and its change over time, conformity to the use of low doses of antipsychotic medications, and clozapine offer index. Results135 Patients were included in this study of whom 19 patients were identified as PRCA. Of these, 12 (63%) received timely medication, and 7 (37%) were suspected cases of therapeutic inertia. Additionally, 15 patients met criteria for treatment resistance of whom 7 were offered clozapine (47%). At the service level, the average CGI improved by 2 points from baseline to month 1 and average doses of antipsychotic medications prescribed were in line with prescription guidelines for FEP patients. ConclusionThe proposed CGI-based treatment algorithm and service evaluation strategy can help to optimize quality care and services for patients.

Diagnostic change 2 years after a first episode of psychosis

IntroductionPsychiatric diagnoses are derived from expert opinion (1). Since no objective tests or markers are on the horizon, clinical psychiatry is anchored to “the patient’s altered experience, expression and existence, associated with suffering in self and/or others”(2). Many studies have examined diagnostic stability over time. In the last years investigators have been reporting prospective and retrospective consistencies of diagnoses between two time points, specially in first episodes of psychosis (3).ObjectivesTo examine the prospective and retrospective stability of diagnostic categories 2 years after the first episode of psychosisMethodsData were examined from the First Episode Psychosis Program of Navarra (PEPsNA), a prospective observational study of a cohort of patients with first-episode psychosis in Navarra (Spain). Diagnosis was assigned using DSM-IV-TR at baseline and 24 months later. Diagnoses were divided into 5 categories: Affective psychosis, Schizophrenia spectrum psychosis, Schizoaffective disorder, acute psychosis and other diagnoses. Diagnostic change was examined using prospective and retrospective consistencyResultsA total of 78 first-episode psychosis cases with baseline and 24 months follow-up were identified. Table 1 shows the diagnosis movement matrix, and Figure 1 its graphical representation. Of cases, 71.8% (56/78) had the same baseline and 24 months follow-up diagnosis. Prospective and retrospective consistencies are shown in Table 2ConclusionsThe prospective and retrospective consistencies of Schizophrenia spectrum psychosis and acute psychosis were higher than others. Affective psychosis and Schizoaffective disorder show very variable consistencies

M246. DIGITAL SELF-MONITORING AND EMBODIMENT IN FIRST EPISODE PSYCHOSIS: ETHICAL CONSIDERATIONS

BackgroundSmartphone technology has seen expanding interest across nearly all areas of medicine, including psychiatry, where app-based technologies frequently function as proxies for digitized behavioural phenotypes (Firth and Torous 2015). In the area first episode psychosis especially, there has been a rising interest in the use of digital platforms for patient self-management as well as for assessment of symptom domains (Ben-Zeev et al. 2014; Bell et al. 2018).MethodsThis paper discusses findings from a 3 year-long ethnographic study carried out within a first episode psychosis program in Toronto, Canada, in combination with a discourse analysis of the clinical and research literature relating to the use of self-monitoring technologies within first episode psychosis contexts. The qualitative data consists of formal and informal interviews with psychiatric service users, family members, and clinicians (n=45 interviews), in addition to observational field work within the clinical setting. Data were analyzed thematically within an interpretivist-constructivist frame, and triangulated through reflexive field notes, member-checking, and the authors’ clinical experience within the field. Themes were reviewed with senior clinicians in the first episode clinic setting as well as psychiatric service users for reliability and fidelity.ResultsSelf-monitoring technologies are increasingly used in both research and clinical care settings, most frequently related to the management of medication side effects and the tracking of the phenomenological aspects of psychotic and psychotic-like experiences. The uptake of these technologies by psychiatric service users in this setting was varied: at times, symptom and side effect tracking faciliated conversations about uncomfortable topics such as sexual side effects of antipsychotics, while in other instances the use of self-monitoring technologies was intrusive. Challenges with self-monitoring were likely to arise when issues relevant to understanding complex phenomena such as medication adherence were prematurely narrowed or when experiential narratives were foreclosed by the structure imposed by the technologies themselves. Resistance to self-monitoring arose in novel and interesting ways.DiscussionEngaging in self-monitoring, whether for side effect tracking or phenomenological analysis of moment-to-moment experiences have significant material effects on those engaged in such practices. When we consider the study findings through the lens of contemporary mental health ethics, we can appreciate how such technologies carry with them a potential for what has been termed “epistemic injustice” (Medina 2013; Fricker 2007), even at the same time as they offer potentially novel, meaningful forms of health care engagement. Grappling with this tension is of critical importance in light of the expansion of such platforms in both clinical and research environments

Effectiveness of Cognitive Training in an Intensive Outpatient First Episode Psychosis Program.

Despite effective pharmacotherapy for positive symptoms of psychosis, cognitive deficits emerge early and are persistent. Efficacy studies have demonstrated cognitive training can produce improvement in cognition, symptoms, and functional outcomes for psychosis. A chart review of seventy-one first episode psychosis patients in a cognitive training program was designed to determine feasibility and effectiveness of the program in a non-research clinic setting. Cognitive testing data, symptom change, and re-hospitalization data were reviewed. The MATRICS Consensus Cognitive Battery (MCCB) was used to measure processing speed, attention, memory, verbal learning, visual learning, problem solving, and social cognition. Improvements in global cognition were found (p < .05), driven by changes in working memory and speed of processing. The expanded Brief Psychiatric Rating Scale (BPRS-E) was used to measure change in mental health symptoms. There were no significant changes in symptoms. Participants without comorbid diagnoses, who underwent cognitive training procedures, had lower re-hospitalization rates when compared to another comprehensive first episode program and routine practice. These findings indicate feasibility and effectiveness for implementing cognitive training for first episode patients in a day treatment setting.

Early interventions in a US military FIRST episode psychosis program.

Naval Medical Center San Diego's Psychiatric Transition Program is a specialized first episode psychosis treatment program that delivers coordinated specialty care to military service members with psychotic disorders. Due to the unique military environment, military service members with first episode psychosis are hypothesized to receive care very early after the emergence of first psychotic symptoms, resulting in significantly reduced duration of untreated psychosis. This study's aim is to calculate the duration of untreated psychosis for patients enrolled in Naval Medical Center San Diego's Psychiatric Transition Program (NMCSD PTP) from 01JUL2014-31DEC2016. Patients included in this study had a diagnosis of schizophreniform disorder (13.04%), schizophrenia (43.48%), schizoaffective disorder (8.70%), other specified schizophreniform disorder (30.43%), or brief psychotic disorder (4.35%) upon discharge from military service and NMCSD PTP. Duration of untreated psychosis was defined as the interval from emergence of positive psychotic symptoms to antipsychotic medication initiation. Duration of untreated psychosis was measured through retrospective review of the electronic medical record. A total of 69 subjects in the Naval Medical Center San Diego's Psychiatric Transition Program met inclusion criteria. Mean and median values as well as standard deviations were calculated for all included subjects. The mean duration to scheduled (non-PRN) neuroleptic medication was 37 days (median: 4 days). The mean duration to PRN neuroleptic medication was 21 days (median: 2 days). These data support our view that the structure of the military and military healthcare system markedly shortens the DUP for military service members who experience first episode psychosis.

Blind Spots: Spatial analytics can identify nonrandom geographic variation in first episode psychosis program enrollments.

To apply spatial analytics to an underway first episode psychosis program to identify areas of significant variation in the geographical distribution of program enrollees from an underlying at-risk population. Adaptive bandwidth kernel smoothing was used to estimate spatial density functions from program enrollee home addresses and a control population computed from US Census data. A relative risk surface derived from the ratio of these functions was used to discover under-represented areas, or areas from which fewer enrollees where produced than suggested by the underlying population density at the P < .05 level of statistical significance. As a test application of this analysis, a comprehensive list of primary care providers in the program catchment was extracted from the National Plan and Provider Enumeration System and spatially compared to the under-represented areas. This approach identified under-represented areas containing 27.5% of the total program catchment area and 16% of the control population, yet had yielded zero program participants. These under-represented areas contained 179 primary care providers of the 2,337 in the total catchment area. Findings of nonrandom spatial variation in program enrollment is valuable data for those evaluating the impact of and implementing improvements for recruitment to specialty clinics serving geographically-defined catchments. Positive findings from this preliminary study warrant further development of the predictive model as well as measurement of the impact on enrollment from recruitment interventions driven by these findings.

F127. GLOBAL RECOVERY IN A FIRST EPISODE PSYCHOSIS PROGRAM IN SOUTH AMERICA

BackgroundMetanalisis show that global recovery, (a state of clinical and social well functioning) is achieved by 13.5% patients (25%-75% quartiles 8.1–20%) (Jääskeläinen, 2013) diagnosed with schizophrenia. It has also been suggested that recovery is higher in low or lower middle-income countries compared to high and upper middle income countries. However, this is only based in a few studies. We here looked at the number of patients with first episode psychosis that met recovery criteria based on both clinical and social domains in a South American early intervention sample. We also examined whether recovery was associated with factors such as diagnoses, sex, education, substance use and duration of untreated psychosis.MethodsThis is a cross-sectionall study in an outpatient First Episode Psychosis program in Chile. We gathered information on different aspects of the patients, including sociodemographic, clinical, functional and metabolic status. FAST (Functional Assessment Short Test) and SS-DSM5 (Symptom Severity Scale of the DSM5 for Schizophrenia) were applied to patients. Global recovery was defined as the presence for at least 6 months of: 1. Working or studying. 2. SS-DSM5 scale with no dimension with score over two. 3. FAST with score under 21 (which correlates with GAF > 61). The group who met recovery criteria (improvement in both clinical and social domains) was identified, and correlation and regression analysis were performed to explore the association between global recovery and selected variables.ResultsWe included 80 patients in this study. Overall, 20% met global recovery criteria. Patients who did not accomplish recovery did so because of being unemployed (80.6%), not studying (79.7%), or scoring above threshold in SS-DSM5 cognitive (54.7%) and negative (54.7%) symptom domains. Univariate correlation analyses showed a significant association of global recovery with recreational drug use, diagnoses, and duration of untreated psychosis (all corrected for multiple comparisons). After multiple regression analysis including these variables, age and gender, the only one associated with recovery was shorter duration of untreated psychosis (p=0.02) OR 0.616 (IC95% 0.409–0.925).DiscussionThe number of patients achieving global recovery is consistent with the one reported for schizophrenia in previous meta-analysis and with studies on recovery after first episode psychosis (16.6% (25%-75% quartiles 9–20.4)) (Jääskeläinen, 2013). Negative and cognitive symptoms frequently impair patient recovery. On the other hand the duration of untreated psychosis shows itself as one of the most important characteristics related with functional prognoses.

Collaborating with Young Adults Diagnosed with Schizophrenia: A Participatory Design Study to Shape the Healthcare System

Introduction: Disengagement from mental health services in young adults with schizophrenia has been associated with dissatisfaction and unmet needs. Striving to improve engagement, we invited service users recently diagnosed with schizophrenia to be co-designers of a smartphone technology that will be responsive to their needs. Aim: This paper reports the first phase of a three-phased participatory design process. The objective was to identify needs of support in young adults recently diagnosed with schizophrenia and to generate ideas of how the needs could be accommodated using smartphone technology. Methods: Participatory design guided the research process and a qualitative approach was used to generate and analyse the data. Data were generated by means of participant observations (n = 45 hours) and interviews (n = 6) with young adults from a first episode psychosis program in Denmark. Findings: Low levels of knowledge and high levels of uncertainties are characteristic of young adults recently diagnosed with schizophrenia, bringing about a vast need of support in order for them to gain power over their new life situation. Our study suggests that the smartphone may be used to foster empowerment by guiding the young adult’s actions in situ, providing comprehensive and easily understood information on the go, allowing for recovery tracking, and notification of mental health changes, providing medication overview and giving easy access to healthcare providers. Conclusion: Young adults recently diagnosed with schizophrenia require comprehensive support in order to become empowered to confidently manage their new life situation. The smartphone holds this potential by offering flexible collaboration and timely access to self-management resources

Dual pathology in users of early intervention program in psychosis

IntroductionThe existence of independent services and facilities for mental health and for addictions in Andalusia stand in the way of addressing dual pathology. The strong comorbidity between substance use and early psychosis has been deeply studied in recent literature. The aim of this paper is to analyse a group of consumers in the First Episode Psychosis Program (FEP) to address the lack of the actual interventions performed.MethodsDescriptive statistical analysis of demographic and clinical variables of a group with drug consumption (n = 17) is compared to a non-consumer group (n = 7).ResultsOur sample of patients included, consumers who represent 71% of the sample. All consumers were users of cannabis or derivatives and 35% of consumers were diagnosed at some point of Toxic psychosis. Only 23% received care in drug addiction centers. They have less education. The duration of untreated psychosis (DUP) is greater than in non-users and only 35% of the cases were detected in Primary Care. PANSS with higher scores. Greater differences in general psychopathology. The Social Functioning Scale (SFS) were worse in the Isolation scale. The Family Questionnaire (FQ) showed more difficulties in the family setting. Finally the Global Assessment of Functioning (GAF) gives an average of 8 points lower (severe symptoms).DiscussionWe would like to point out the low percentage of users who receive specialized care for their addiction. Better collaboration with Primary Care is required to improve the capacity of detection to reduce the time slot of untreated symptoms.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Analysis of the duration of untreated illness (DUI) in the first episode psychosis Program (FEP) in AGS South Granada

IntroductionDuration of untreated illness (DUI) has been considered as a relevant variable used to measure the degree of disabilities that are associated with psychotic disorders. In this paper we describe a cluster of patients with a DUI superior to 1 year according to their symptoms and sociofamiliar functioning.MethodsWe compare a group with a DUI superior to 1 year (n = 7) against a group with a DUI inferior to 1 year (n = 17).ResultsThe group with a DUI superior to 1 year showed an average age of 4 years younger (21) as the duration of untreated psychosis (DUP) of 1 to 3 months in the 80% of cases and higher percentage of unemployed or without occupation. The 60% were derived from primary care, compared to the 17% of the other group. Although the consumption of toxic substances was similar in both groups, no toxic psychosis were found in comparison with the 35% present in the group with a DUI inferior to 1 year. PANSS’ profile scored more positive and less negative symptoms. Both have similar general psychopathology. There were group differences in the Social Functioning Scale (SFS) with lower scores in the superior to 1 year DUI, in the following scales: Prosocial, Autonomy, Execution and Employment. The Global Assessment of Functioning (GAF) gives an average of almost 8 points higher.DiscussionWhile the SFS shows significant differences in several areas of social functioning, both PANSS’ profile and the family questionnaire do not support greater deterioration, as evidenced in the GAF's average score.Disclosure of interestThe authors have not supplied their declaration of competing interest.

“at-risk Mental States” Clinical Program in Lausanne: extension of the Staging Approach Model for Psychotic Disorders

Context Intervention in the prodromal phase of psychosis remains controversial due to poor specificity of current criterion and ethical issues arising when developing interventions. There is less controversy regarding the need for specialist first episode psychosis intervention programs. Aims In the context of the implementation of an early intervention strategy in Lausanne, we focused on a first episode psychosis program and checked if need for an early detection program for UHR subjects would emerge over time. We recently structured a specialist At Risk Mental State (ARMS) clinic. Methods Help seeking patients aged 14–35, referred for a 'prodromal psychotic state” are assessed with: Mini-SCID; SPI-A; SIPS-PANSS; MARDS; Yung Mania scale and classified as ARMS on the basis of SPI-Cy (COPER and COGDIS criteria) and SIPS criteria (APS; BLIPS or Genetic Criterion). Results Since January 2014, twenty-four patients were addressed to our clinic, and diagnoses were: ARMS (33%); first episode psychosis (8%); schizotypal disorder (25%); other axis I or II diagnosis (13%); drop out before diagnosis (5%); still in investigation (16%). Conclusions Our data shows that there is a need for specialist ARMS clinic when developing early intervention programs. The proximity with a well implanted first episode program offers the possibility to treat patients who have already developed full blown psychosis or for those who make the transition. Ethically, it is our impression that having both structures is necessary in order to have adequate treatment to offer is patients develop full blown psychosis.

Too Late and Too Little: Narratives of Treatment Disconnect in Early Psychosis.

Schizophrenia and other psychotic disorders are a source of significant morbidity, both for patients and caregivers. The first 2-5 years after the onset of psychosis are a critical period wherein treatment might effect disproportionate improvements in long-term outcomes. Specialized services have been developed with the goal of providing early and effective treatment-however, engaging young patients in these services remains a challenge. In this study we sought to uncover possible reasons for this finding by collecting participants' narratives of their early treatment experience. We conducted in-depth, semi-structured interviews with 11 patients currently enrolled in a first episode psychosis program in Connecticut. Transcripts were analyzed using inductive thematic analysis. Participants reported that prior to them entering specialized treatment services, their initial contact with psychiatric care was brought about by abrupt behavioral changes that were noticed by others, and that this lead to treatment that was disconnected from their own concerns, which centered around more everyday challenges. This initial contact did not serve to engender trust or facilitate engagement in further treatment. Additional examples of disconnect were noted even after participants had entered specialized services, and these centered around the patients preference for conceptualizing their difficulties, treatment and recovery in multi-dimensional terms that emphasized social inclusion and vocational achievement. Participants in our study highlighted several areas of disconnect in the course of their early treatment. There is an opportunity to enhance early engagement by offering patients concrete evidence that their treatment priorities are understood and will be addressed.

Changing the Name of Schizophrenia: Patient Perspectives and Implications for DSM-V

IntroductionThe diagnosis of schizophrenia is increasingly contested by researchers, clinicians, patients and family members. Preeminent researchers proposed its replacement with the salience syndrome concept, arguing for increased validity and less stigmatizing potential. This is the first study exploring the effects on stigma of this nosological proposal.MethodsTwo studies were conducted: one with 161 undergraduate students regarding their stigmatizing attitudes linked to the label of schizophrenia or salience syndrome, the other involved in-depth qualitative interviews with 19 participants treated in a first episode psychosis program. The interviews explored the subjective validity, acceptability and effects on stigma of a diagnosis of schizophrenia or salience syndrome.ResultsOverall, no significant differences were found between labels in study 1. For study 2, the majority of participants preferred a diagnosis of salience syndrome, considering it less stigmatizing mostly because of its novelty and the concealing potential of the new diagnostic entity, though many found it hard to relate to and somewhat difficult to understand.DiscussionOur results suggest that the label change does not impact the stigmatizing potential for individuals who are not familiar with mental illness - they appear to base their attitudes on descriptions rather than the label alone. For those suffering from mental illness, a name change for schizophrenia to “salience syndrome” might offer only a temporary relief from stigma. Claims of de-stigmatizing effects should be grounded in sound scientific models of stigma and ideally in empirical data.

118 – TIPP – Lausanne first episode psychosis program: Patients' baseline characteristics and impact of the program on adherence to psychosocial treatment

118 – TIPP – Lausanne first episode psychosis program: Patients' baseline characteristics and impact of the program on adherence to psychosocial treatment

Weight gain, dyslipidemia and altered parameters for metabolic syndrome on first episode psychotic patients after six-month follow-up

Obesity and metabolic abnormalities are frequent in psychotic patients, including first-episode psychosis. We evaluated weight and metabolic parameters in first-episode psychotic outpatients from the First Episode Psychosis Program, Universidade Federal de São Paulo. Weight, height, waist and hip circumferences, glucose and lipid levels were measured at baseline and after a six-month period. Fifty-seven patients were included and 44 (77.2%) of them finished the study. Patients had a median age of 26.3 years, 60% were men and 43% had a diagnosis of schizophrenia at the endpoint. Weight and BMI values increased significantly during the follow-up (p < 0.01). The average weight gain at the follow-up was 10.1% of the baseline weight (SD = 11.9). Only women presented significant waist abnormalities: at the first assessment the waist mean was 79.12 cm (SD = 10.68) and 6 months later it had increased to 89.65 cm (SD = 11.19, z = -3.182, p = 0.001). After 6 months, the total cholesterol (p = 0.004), and triglyceride levels (p = 0.016) increased, while HDL-cholesterol levels decreased (p = 0.025). During the follow-up period one patient (2.3%) developed diabetes mellitus, one (2.3%) presented altered fasting glucose, 12 (27.2%) patients developed at least two altered parameters for metabolic syndrome and 3 (6.8%) patients developed metabolic syndrome (p = 0.001). The results of this study showed that in a short period of time individuals under antipsychotic treatment had their weight increased significantly and developed important metabolic abnormalities. Clinicians should be aware of these risks, choose an antipsychotic that causes less weight gain and should monitor these patients carefully, and recommend prophylactic measures as diet restriction and physical activities.

Early Use of Clozapine for Poorly Responding First-Episode Psychosis

Although most patients treated for first-episode schizophrenia will experience considerable improvement with initial antipsychotic therapy, a subgroup experiences significant ongoing positive symptoms. Clozapine has unique efficacy in improving treatment-resistant patients with chronic schizophrenia, but its role in the treatment of first-episode patients remains unclear. A standardized treatment algorithm was implemented in our First Episode Psychosis Program, with patients receiving 2 trials with 2 second-generation antipsychotics (olanzapine, quetiapine, or risperidone at low, medium, and high doses), followed by a trial of clozapine as early as 25 weeks into the start of their treatment. Patients progress along the algorithm according to their response as defined by clinical rating scales. To date, 123 patients with first-episode schizophrenia have been treated according to the algorithm. Of these, 93 (76%) responded to the first trial of an antipsychotic. Only 7 (23%) of the remaining 30 patients responded to a second antipsychotic trial; 13 of the remaining 23 individuals agreed to a trial of clozapine. We compared the clozapine-treated group with a group of 9 patients who refused clozapine and chose to continue the same antipsychotic treatment as before. Subjects who received clozapine experienced a mean Brief Psychiatric Rating Scale change of 19 points (from 53.5 to 34.5) and a change in the Clinical Global Inventory severity rating from 5.4 to 3.5 (from severely ill to mildly ill); those who refused clozapine had a 2-point increase in mean Brief Psychiatric Rating Scale (from 53 to 55) and a 0.6-point increase in the mean Clinical Global Inventory severity rating from 5.4 to 6 (remaining markedly to severely ill). In clinical practice, there is a hesitancy to switch individuals to clozapine given its side effect profile and position as treatment of "last resort." The present findings suggest that clozapine may have an important role in the early treatment of first-episode patients whose psychosis does not remit with other second-generation antipsychotics during the first months of treatment.

Antipsychotic use in a first episode psychosis program

Objective. To conduct a naturalistic, longitudinal study of prescribing patterns of atypical neuroleptics in predominantly drug-naïve first episode non-affective psychosis patients. Methods. Patients with a first episode psychosis were prescribed an antipsychotic as part of a clinical protocol and followed-up for 2 years. Comparisons were made between risperidone and olanzapine, the two most commonly prescribed antipsychotics. Socio-demographic variables and clinical characteristics such as diagnosis, duration of untreated illness and psychosis and level of positive and negative symptoms were assessed using well-established methods. We examined the first antipsychotic given, starting dose, time taken to start and to reach the maximum dose, time on first medication, maximum dose, medication change and concomitant medication use. Results. One hundred and ninety-three consecutive patients consented to start on antipsychotic. The results are provided for risperidone (N = 133) and olanzapine (N=38). The time to initiate antipsychotic medications was significantly longer for outpatients than inpatients. There were no differences between the two groups for time taken to reach the maximum dose, drop out rates or concomitant medication use. The percentage of patients taking an antipsychotic agent at any given time was high (range 79–91%), but half of the patients had changed from their first antipsychotic by 6 months. Conclusions: The reality of clinical practice can be much different than rigid protocols or treatment algorithms of pre-marketing studies or clinical trials. In this sample of first episode psychosis patients, although the majority of patients remained on an antipsychotic, changes in medication over the first 2 years were common. Polypharmacy was not a common practice.

Cognitive functioning in the early course of first-episode schizophrenia spectrum disorders

The aim of this study was to examine possible cognitive changes throughout the early course of schizophrenia spectrum disorders. Forty-two patients, aged 15-50 years, admitted to a first episode psychosis program (PAFIP) serving to the community of Cantabria (Spain) and 43 healthy volunteers completed a brief battery of five neurocognitive tests at four time-points over 3 months. The cognitive testing comprise five domains: attention, visuomotor speed, declarative memory, working memory and executive function. Baseline assessment occurred within 72 hour after the initiation of standard pharmacological treatment, and after then parallel forms of the tests were applied at week-2, week-6, and month-3. Patient scores showed a significant impairment compared to healthy volunteers in the five cognitive domains at baseline and week-2 assessments. After the first 3 months of antipsychotic treatment, the patient group performance reached healthy volunteers level on executive function (Stroop interference) and immediate verbal memory tests. In contrast, performance on working memory, sustained attention, visuomotor speed, and verbal memory delayed recall domains still remained below healthy volunteers, although visuomotor processing speed showed a significant improvement. Schizophrenia spectrum patients show heterogeneous patterns and degrees of cognitive changes that contribute to stress the importance of when, what, and how neurocognitive functioning in the early phases of the illness is evaluated.