Later Stages Of Illness Research Articles

Clinical experience of professor ZHANG Ren in the staging treatment with characteristic acupuncture techniques for oculomotor paralysis.

The paper summarizes the clinical experience of professor ZHANG Ren in the staging treatment with characteristic acupuncture techniques for oculomotor paralysis. According to the symptoms of oculomotor paralysis, the staging treatment is given, in which acupuncture is dominant and the needling techniques are optioned in compliance with the symptoms. In the early, middle and late stages of illness, three different acupuncture therapies are delivered accordingly, i.e. the combination of the point-toward-point needling at the four acupoints located on the forehead and the electroacupuncture with disperse-dense wave, the surrounding needling and the triple needling at the acupoints around the eyeball, as well as the perpendicular needle insertion at the three acupoints within the orbit. Professor ZHANG Ren lays the stress on identifying the etiology and differentiating the symptoms, as well as the early intervention for the disease. For the intractable cases, the comprehensive regimen such as acupoint injection, dermal needling and auricular point sticking is supplemented. During treatment, the spirit harmonization is greatly considered to ensure the effectiveness. On the basis of the staging acupuncture therapy, the acupuncture technique for harmonizing the spirit and regulating qi is combined to obtain the favorable clinical effect on oculomotor paralysis.

Systematic Review and Meta-analysis: Rates of Violence During First-Episode Psychosis (FEP).

Most people with psychotic disorders will never commit an act of violence. However, the risk of violence committed by people with schizophrenia is higher than the general population. Violence risk is also known to be highest during the first episode of psychosis compared to later stages of illness. Despite this, there have been no comprehensive reviews conducted in the past 10 years examining rates of violence during FEP. We aimed to provide an updated review of the rate of violence in people with FEP. Meta-analytical techniques were used to identify pooled proportions of violence according to severity (less serious, serious, severe) and timing of violence (before presentation, at first presentation, after presentation to services). Twenty-two studies were included. The pooled prevalence was 13.4% (95% CI [9.0%-19.5%]) for any violence, 16.3% (95% CI [9.1%-27.4%]) for less serious violence, 9.7% (95% CI [5.4%-17.0%]) for serious violence and 2.7% for severe violence, regardless of time point. The pooled prevalence of any violence was 11.6% (95% CI [6.8%-18.9%]) before presentation, 20.8% (95% CI [9.8%-38.7%]) at first presentation and 13.3% (95% CI [7.3%-23.0%]) after presentation to services. Overall, rates of violence appear to be lower in more recent years. However, due to the high between-study heterogeneity related to study design, the findings must be interpreted with consideration of sample characteristics and other contextual factors. The prevalence of violence remained high at all-time points, suggesting that more targeted, holistic, and early interventions are needed for clinical FEP groups.

Network-Based Spreading of Gray Matter Changes Across Different Stages of Psychosis

Psychotic illness is associated with anatomically distributed gray matter reductions that can worsen with illness progression, but the mechanisms underlying the specific spatial patterning of these changes is unknown. To test the hypothesis that brain network architecture constrains cross-sectional and longitudinal gray matter alterations across different stages of psychotic illness and to identify whether certain brain regions act as putative epicenters from which volume loss spreads. This case-control study included 534 individuals from 4 cohorts, spanning early and late stages of psychotic illness. Early-stage cohorts included patients with antipsychotic-naive first-episode psychosis (n = 59) and a group of patients receiving medications within 3 years of psychosis onset (n = 121). Late-stage cohorts comprised 2 independent samples of people with established schizophrenia (n = 136). Each patient group had a corresponding matched control group (n = 218). A sample of healthy adults (n = 356) was used to derive representative structural and functional brain networks for modeling of network-based spreading processes. Longitudinal illness-related and antipsychotic-related gray matter changes over 3 and 12 months were examined using a triple-blind randomized placebo-control magnetic resonance imaging study of the antipsychotic-naive patients. All data were collected between April 29, 2008, and January 15, 2020, and analyses were performed between March 1, 2021, and January 14, 2023. Coordinated deformation models were used to estimate the extent of gray matter volume (GMV) change in each of 332 parcellated areas by the volume changes observed in areas to which they were structurally or functionally coupled. To identify putative epicenters of volume loss, a network diffusion model was used to simulate the spread of pathology from different seed regions. Correlations between estimated and empirical spatial patterns of GMV alterations were used to quantify model performance. Of 534 included individuals, 354 (66.3%) were men, and the mean (SD) age was 28.4 (7.4) years. In both early and late stages of illness, spatial patterns of cross-sectional volume differences between patients and controls were more accurately estimated by coordinated deformation models constrained by structural, rather than functional, network architecture (r range, >0.46 to <0.57; P < .01). The same model also robustly estimated longitudinal volume changes related to illness (r ≥ 0.52; P < .001) and antipsychotic exposure (r ≥ 0.50; P < .004). Network diffusion modeling consistently identified, across all 4 data sets, the anterior hippocampus as a putative epicenter of pathological spread in psychosis. Epicenters of longitudinal GMV loss were apparent in posterior cortex early in the illness and shifted to the prefrontal cortex with illness progression. These findings highlight a central role for white matter fibers as conduits for the spread of pathology across different stages of psychotic illness, mirroring findings reported in neurodegenerative conditions. The structural connectome thus represents a fundamental constraint on brain changes in psychosis, regardless of whether these changes are caused by illness or medication. Moreover, the anterior hippocampus represents a putative epicenter of early brain pathology from which dysfunction may spread to affect connected areas.

Cholinesterase Inhibitors for Delusions and Hallucinations in Alzheimer Disease and Parkinson Disease: Questionably Significant Benefits.

Delusions and hallucinations are common in Alzheimer disease (AD) and Parkinson disease (PD), especially in the later stages of illness. Antipsychotic drugs are effective in treating these psychotic symptoms but are associated with an increased risk of serious adverse events, including mortality. There is therefore a need to explore other treatment approaches. In this context, a recent individual patient data meta-analysis of 17 randomized controlled trials (RCTs) conducted in AD (12 RCTs) and PD (5 RCTs) found that the cholinesterase inhibitor (ChEI) drugs donepezil, rivastigmine, and galantamine attenuated the severity of both delusions and hallucinations in both AD and PD. Most of these trials were 24 weeks in duration. The effect sizes, expressed as standardized mean differences (SMDs), were, however, small, lying in the -0.08 to -0.14 range. These values are so small as to be perhaps clinically insignificant. When analyses were restricted to data from patients who actually had delusions and hallucinations at baseline, all effect sizes became larger, lying in the -0.13 to -0.39 range; however, after correcting for multiple hypothesis testing, only the finding for delusions in PD remained statistically significant. The meta-analysis did not provide information on what the best doses were, how long it took for improvement to become evident, and what proportion of patients showed remission from psychotic symptoms. Whereas the signal identified in this meta-analysis merits examination in appropriately designed RCTs, the findings of the meta-analysis may not much change current treatment strategies because patients with dementia would probably anyway receive a ChEI. Therefore, if psychotic symptoms persist for 24 weeks despite optimally dosed ChEI treatment, and if behavioral and psychosocial interventions do not help, clinicians may need to consider the potential benefits vs risks of other drugs, such as atypical antipsychotics and pimavanserin, in a shared decision-making process.

Kampo medicine for COVID‐19 prevention, treatment, and recovery in clinical and pharmacological aspect

Kampo medicine for <scp>COVID</scp>‐19 prevention, treatment, and recovery in clinical and pharmacological aspect

Studies Point to Benefits of Early Treatment With Long-Acting Antipsychotics

Back to table of contents Previous article Next article Clinical & ResearchFull AccessStudies Point to Benefits of Early Treatment With Long-Acting AntipsychoticsNick ZagorskiNick ZagorskiSearch for more papers by this authorPublished Online:23 Nov 2022https://doi.org/10.1176/appi.pn.2022.12.10.39AbstractPatients with schizophrenia who were prescribed oral antipsychotics for less than three years saw greater symptom improvements when switching to long-acting injectable formulations than those who had been taking the oral medications longer.iStock/Rawf8Numerous studies have pointed to the benefits of long-acting injectable antipsychotics (LAIs) at reducing the risk of symptom relapse, hospitalizations, and other adverse outcomes in patients with schizophrenia. A pair of recent studies provide evidence that switching from oral antipsychotics to LAIs within the first two to three years of a diagnosis may provide the greatest benefit.One study involved data collected from Taiwan’s national health insurance on over 19,000 people aged 16 to 65 who had a schizophrenia diagnosis, were taking oral antipsychotics, and were hospitalized for acute psychosis between 2002 and 2005. Among this group, Joni Yu-Hsuan Shao, Ph.D., a professor of biomedical informatics at Taipei Medical University in Taiwan, and colleagues identified 678 patients who were switched from oral antipsychotics to an LAI during hospitalization and who continued to receive the LAI at least 12 months after discharge; 312 received LAIs within three years of their first oral antipsychotic prescription (early stage of treatment), while 366 transitioned following three or more years of oral medication use (late stage of treatment).As described in the Journal of Clinical Psychiatry, each of these patients was matched to a patient of similar age, sex, hospitalization date, and psychiatric comorbidities who continued taking oral antipsychotics following discharge from the hospital. All patients were followed up from their date of hospitalization until the end of the study period (December 31, 2015) or death, whichever came first. During this period the researchers recorded all instances of rehospitalizations (psychiatric or other medical), psychiatric emergency room (ER) visits, or death.Early LAI switchers had the following:37% reduced risk of psychiatric hospitalization.44% reduced risk of any hospitalization.42% reduced risk of a psychiatric ER visit.51% reduced risk of death by any cause.The reductions in adverse health outcomes were not seen in patients who were switched during the late stage of illness; in fact, patients who switched to LAIs in the late stage of treatment had a 34% increased risk of psychiatric rehospitalization during the follow-up period compared with patients who stayed on oral antipsychotics.“These real-world data demonstrated that LAIs in the early stage of treatment of hospitalized patients increased disease control and had long-term benefits,” Shao and colleagues wrote.The other study was published in JAMA Network Open and conducted by Yue Wei, M.P.H., of the University of Hong Kong and colleagues. The investigators used health records data to identify 23,719 individuals diagnosed with schizophrenia between 1993 and 2019 who were prescribed at least one oral and LAI antipsychotic during this time. They compared the health outcomes of these patients during periods while taking oral antipsychotics with periods while taking LAIs.As expected, patients had lower rates of emergency department visits, hospitalizations, and suicide attempts while taking an LAI antipsychotic relative to their time taking an oral antipsychotic. The benefits were more pronounced for those who began taking LAI antipsychotics within two years of a schizophrenia diagnosis; compared with periods they were taking the oral medication, these patients had the following:76% reduced risk of a psychiatric hospitalization.65% reduced risk of any hospitalization.33% reduced risk of an emergency department visit.72% reduced risk of a suicide attempt while on an LAI.Shao said these findings support the critical period hypothesis, which posits that schizophrenia-related deterioration is particularly aggressive in the two to five years after the first episode of psychosis.The Shao study was supported by the Bali Psychiatric Center, Taiwan. The Wei study was supported by The Excellent Young Scientists Fund of the National Natural Science Foundation of China. ■Resources“Long-term Outcomes of Early Use of Long-Acting Injectable Antipsychotics in Schizophrenia”“Association of Long-Acting Injectable Antipsychotics and Oral Antipsychotics With Disease Relapse, Health Care Use, and Adverse Events Among People With Schizophrenia” ISSUES NewArchived

No perfect therapy for the imperfect COVID-19 cytokine storm

More than 2 years into the pandemic, almost 6 million people have died from COVID-19 worldwide. Many people who succumbed to the virus had cytokine storm syndrome, a dysregulated immune response to the pathogen.1 Progress toward treating COVID-19 has been substantial on several fronts, including rapidly developed safe and effective vaccines, and various antiviral therapies (eg, monoclonal antibody therapies, protease inhibitors, and nucleoside analogues). Antiviral approaches are particularly effective early during infection, but cytokine targeted therapies have shown benefit during later stages of illness, when hyperinflammation is present.

Implementing 21st century "end-to-end" and technology-enhanced care for young people.

Implementing 21st century "end-to-end" and technology-enhanced care for young people.

Talking With Patients and Care Partners About Treatment Goals and Challenges in Early-Stage Alzheimer Disease.

Alzheimer disease (AD) requires timely diagnosis and treatment initiation as early as possible to delay further loss of functioning. Clinicians must attempt to answer patients' and care partners' questions about treatment goals and expected challenges. In this webcast, Drs Burke and Apostolova address topics critical to the care of patients with early-stage AD. They highlight barriers to diagnosis, describe genetic risk factors, and emphasize the role of neuropsychologic testing. Drs Burke and Apostolova agree that, although current medications slow symptom progression associated with AD, emerging therapies offer hope for disease modification. These experts also talk about important conversations to have with patients and their care partners, such as about diet, exercise, driving, and plans for the later stage of illness.

Space-Time Trends in Lassa Fever in Sierra Leone by ELISA Serostatus, 2012-2019.

Lassa fever (LF) is a viral hemorrhagic disease found in Sub-Saharan Africa and is responsible for up to 300,000 cases and 5000 deaths annually. LF is highly endemic in Sierra Leone, particularly in its Eastern Province. Kenema Government Hospital (KGH) maintains one of only a few LF isolation facilities in the world with year-round diagnostic testing. Here we focus on space-time trends for LF occurring in Sierra Leone between 2012 and 2019 to provide a current account of LF in the wake of the 2014–2016 Ebola epidemic. Data were analyzed for 3277 suspected LF cases and classified as acute, recent, and non-LF or prior LF exposure using enzyme-linked immunosorbent assays (ELISAs). Presentation rates for acute, recent, and non-LF or prior LF exposure were 6.0% (195/3277), 25.6% (838/3277), and 68.4% (2244/3277), respectively. Among 2051 non-LF or prior LF exposures, 33.2% (682/2051) tested positive for convalescent LF exposure. The overall LF case-fatality rate (CFR) was 78.5% (106/135). Both clinical presentations and confirmed LF cases declined following the Ebola epidemic. These declines coincided with an increased duration between illness onset and clinical presentation, perhaps suggesting more severe disease or presentation at later stages of illness. Acute LF cases and their corresponding CFRs peaked during the dry season (November to April). Subjects with recent (but not acute) LF exposure were more likely to present during the rainy season (May to October) than the dry season (p < 0.001). The findings here suggest that LF remains endemic in Sierra Leone and that caseloads are likely to resume at levels observed prior to the Ebola epidemic. The results provide insight on the current epidemiological profile of LF in Sierra Leone to facilitate LF vaccine studies and accentuate the need for LF cohort studies and continued advancements in LF diagnostics.

Detection and quantification of SARS-CoV-2 by droplet digital PCR in real-time PCR negative nasopharyngeal swabs from suspected COVID-19 patients.

Since SARS-CoV-2-based disease (COVID-19) spreads as a pandemic, the necessity of a highly sensitive molecular diagnosis that can drastically reduce false negatives reverse transcription PCR (rtPCR) results, raises as a major clinical need. Here we evaluated the performance of a ddPCR-based assay to quantify SARS-CoV-2 titer in 55 suspected COVID-19 cases with negative rtPCR results thanks to in-house ddPCR assay (targeting RdRp and host RNaseP). Samples were collected at ASST-GOM Niguarda between February and May 2020 at hospital admission. Clinical and imaging data were obtained for clinical staging and definition of disease severity. Patients were mainly female (45.5%) with a median age of 73 (57–84) years. ddPCR-based assay detected SARS-CoV-2 genome in nasopharyngeal samples of 19 (34.5%) patients (median viral-load: 128 copies/mL, IQR: 72–345). In 15 of them (78.9%), chest CT showed a classical COVID-19 bilateral interstitial pneumonia; 14 patients (73.7%) showed severe COVID-19 manifestations. ddPCR did not identify any trace of SARS-CoV-2 genome in the respiratory samples of the remaining 36 patients. The serological assay performed in a subgroup of 34 patients at the later stage of illness (from 3 days to 90 days after) confirmed the presence of SARS-CoV-2 antibodies in all patients tested positive for SARS-CoV-2 in ddPCR (100%). Contrariwise, negative tests were observed in 95.0% ddPCR negative patients (P<0.001). Thanks to a ddPCR-based assay, we achieved a rapid and accurate SARS-CoV-2 diagnosis in rtPCR-negative respiratory samples of individuals with COVID-19 suspect, allowing the rapid taking care and correct management of these patients.

"Individual Placement and Support" boosts employment for early psychosis clients, even when baseline rates are high.

Individual Placement and Support is an effective vocational intervention for increasing competitive employment for people with severe mental illness. Little is known, however, about its effectiveness in the context of early psychosis. This study assesses improvements in clients' employment in a phase of illness during which functional abilities often decline. The trial design is an assessor-blinded randomized clinical trial, set in the context of a population-based Early Psychosis Intervention program in British Columbia, Canada. Participants were randomized either to 1 year of employment support added to treatment-as-usual, or the latter alone. Interviews at intake captured data regarding demographics, symptom severity, and employment; assessments at 6 and 12 months repeated queries about employment activities. A total of 109 clients were recruited. Employment rates in the Individual Placement and Support group increased over time, unlike the control group. Further, the number of days worked over the 12-month intervention period, compared to the 6 months prior to the study, improved for both groups, but the increase was greater among clients receiving IPS. Sensitivity analysis indicated the advantage in days worked was evident in the second half of the intervention period (6-12 months), but not the first half. Employment rates, for younger clients in both early-psychosis groups, were high compared to older clients in later stages of illness. In this study, use of the Individual Placement and Support strategy further increased employment, despite the high baseline rates. Further research is needed to identify the optimal timing of employment support for these clients.

Antibody Responses to SARS-CoV-2 in Patients With Novel Coronavirus Disease 2019.

BackgroundThe novel coronavirus SARS-CoV-2 is a newly emerging virus. The antibody response in infected patient remains largely unknown, and the clinical values of antibody testing have not been fully demonstrated.MethodsA total of 173 patients with SARS-CoV-2 infection were enrolled. Their serial plasma samples (n=535) collected during the hospitalization were tested for total antibodies (Ab), IgM and IgG against SARS-CoV-2. The dynamics of antibodies with the disease progress was analyzed.ResultsAmong 173 patients, the seroconversion rate for Ab, IgM and IgG was 93.1%, 82.7% and 64.7%, respectively. The reason for the negative antibody findings in 12 patients might due to the lack of blood samples at the later stage of illness. The median seroconversion time for Ab, IgM and then IgG were day-11, day-12 and day-14, separately. The presence of antibodies was <40% among patients within 1-week since onset, and rapidly increased to 100.0% (Ab), 94.3% (IgM) and 79.8% (IgG) since day-15 after onset. In contrast, RNA detectability decreased from 66.7% (58/87) in samples collected before day-7 to 45.5% (25/55) during day 15-39. Combining RNA and antibody detections significantly improved the sensitivity of pathogenic diagnosis for COVID-19 (p<0.001), even in early phase of 1-week since onset (p=0.007). Moreover, a higher titer of Ab was independently associated with a worse clinical classification (p=0.006).ConclusionsThe antibody detection offers vital clinical information during the course of SARS-CoV-2 infection. The findings provide strong empirical support for the routine application of serological testing in the diagnosis and management of COVID-19 patients.

Serology characteristics of SARS-CoV-2 infection after exposure and post-symptom onset

BackgroundTimely diagnosis of SARS-CoV-2 infection is a prerequisite for treatment and prevention. The serology characteristics and complement diagnosis value of the antibody test to RNA test need to be demonstrated.MethodSerial sera of 80 patients with PCR-confirmed COVID-19 were collected at the First Affiliated Hospital of Zhejiang University, China. Total antibody (Ab), IgM and IgG antibodies against SARS-CoV-2 were detected, and the antibody dynamics during the infection were described.ResultsThe seroconversion rates for Ab, IgM and IgG were 98.8%, 93.8% and 93.8%, respectively. The first detectible serology marker was Ab, followed by IgM and IgG, with a median seroconversion time of 15, 18 and 20 days post exposure (d.p.e) or 9, 10 and 12 days post onset (d.p.o), respectively. The antibody levels increased rapidly beginning at 6 d.p.o. and were accompanied by a decline in viral load. For patients in the early stage of illness (0–7 d.p.o), Ab showed the highest sensitivity (64.1%) compared to IgM and IgG (33.3% for both, p<0.001). The sensitivities of Ab, IgM and IgG increased to 100%, 96.7% and 93.3% 2 weeks later, respectively. When the same antibody type was detected, no significant difference was observed between enzyme-linked immunosorbent assays and other forms of immunoassays.ConclusionsA typical acute antibody response is induced during SARS-CoV-2 infection. Serology testing provides an important complement to RNA testing in the later stages of illness for pathogenic specific diagnosis and helpful information to evaluate the adapted immunity status of patients.

Cohort profile: the Brain and Mind Centre Optymise cohort: tracking multidimensional outcomes in young people presenting for mental healthcare

PurposeThe Brain and Mind Centre (BMC) Optymise cohort assesses multiple clinical and functional domains longitudinally in young people presenting for mental health care and treatment. Longitudinal tracking of this cohort...

Expanding the search for emerging mental ill health to safeguard student potential and vocational success in high school: A narrative review.

Young people experiencing mental ill health are more likely than their healthy aged peers to drop out of high school. This can result in social exclusion and vocational derailment. Identifying young people at risk and taking action before an illness is established or school dropout occurs is an important goal. This study aimed to examine evidence for the risk markers and at risk mental states of the clinical staging model (stage 0-1b) and whether these risk states and early symptoms impact school participation and academic attainment. This narrative review assembles research from both the psychiatry and education literature. It examines stage 0 to stage 1b of the clinical staging model and links the risk states and early symptoms to evidence about the academic success of young people in high school. In accordance with the clinical staging model and evidence from education literature, childhood trauma and parental mental illness can impact school engagement and academic progress. Sleep disturbance can result in academic failure. Undifferentiated depression and anxiety can increase the risk for school dropout. Subthreshold psychosis and hypomanic states are associated with functional impairment and high rates of Not in Employment, Education, or Training (NEET) but are not recognized in the education literature. Risk markers for emerging mental ill health can be identified in education research and demonstrate an impact on a student's success in high school. Clear referral protocols need to be embedded into school life to reduce risk of progression to later stages of illness and support school participation and success.

F135. BODY MASS INDEX TRAJECTORIES IN CHILDHOOD AND RISK FOR NON-AFFECTIVE PSYCHOSIS – A GENERAL POPULATION COHORT STUDY

BackgroundIt is well known that underweight in adolescence and early adulthood predicts later schizophrenia.1 Some studies have shown an association between future schizophrenia or psychosis and underweight in children, starting at the age of 7.2 There are very few previous studies concerning underweight in early childhood and the risk of psychosis as well as other psychiatric outcomes. Our aim was to study whether deviation from normal weight, i.e. underweight or overweight, in early childhood and adolescence predicts later development of non-affective psychosis. And if so, whether the mechanism is specific to psychosis or also predicts other psychiatric disorders.MethodsThe participants were derived from a general population cohort study ‘Cardiovascular Risk of Young Finns’, which was started in 1980 with 3596 children and adolescents participating from six different age groups (3–18 years), with a continued follow-up. BMI was recorded before the first hospitalization due to a psychiatric disorder (≤18 years of age) and categorized as underweight, normal weight or overweight using the BMI classification for children and adolescents provided by Cole et al.3,4 All psychiatric diagnoses of the participants were acquired from the Finnish Hospital Discharge Register. We formed DSM-IV diagnostic groups of non-affective psychosis (n=70, including a schizophrenia subgroup, n=41), personality disorders (n=44), affective disorders (mood- and anxiety disorders, n=115), and substance-related disorders (n=53). Participants in the diagnostic groups were compared with subjects with no psychiatric diagnoses (n=3313). Sex, age, low birth weight and mother’s mental disorders were used as potential confounders in the analyses.ResultsUnderweight, but not overweight, during the age of 3 to 18 years independently predicted later development of non-affective psychosis. Underweight in childhood and/or adolescence increased the risk of psychosis over two-fold (relative risk (RR) [95% CI] 2.31 [1.2–4.4]). Results were similar for schizophrenia; underweight was associated with nearly 2.5-fold risk of schizophrenia (RR 2.44 [1.03–5.8]). Underweight or overweight in childhood and adolescence was not significantly associated with any other studied psychiatric disorder with a more severe clinical phenotype that required hospital treatment.DiscussionUnderweight in childhood and adolescence is an independent risk factor for later non-affective psychosis. The mechanism behind underweight in premorbid phase of psychosis is not known but e.g. low level of insulin-like growth factor-I (IGF-I) may be involved. These results support the hypothesis of schizophrenia as a neurodevelopmental disorder with somatic aspects appearing already in early childhood and psychosis as a late stage of illness.

Suicidal Ideation in First-Episode Psychosis (FEP): Examination of Symptoms of Depression and Psychosis Among Individuals in an Early Phase of Treatment.

First-episode psychosis (FEP) is a particularly high-risk period for suicide, in which risk elevates by 60% within a first year of treatment as compared to later stages of illness. To date, much of the literature has focused on individuals with a longer duration of psychosis; thus, there is an urgency for research to examine suicide risk among individuals in FEP in the beginning stage of treatment. This study aimed to identify the relationships between demographic characteristics, symptoms of depression, psychosis (particularly positive symptoms of psychosis), and suicidal ideation among individuals in FEP. Secondary data were obtained from National Institute of Mental Health's Early Treatment Program of the Recovery After an Initial Schizophrenia Episode project (N=404). Consistent with prior research, participants who experienced suicidal ideation during the study period reported having a longer duration of untreated psychosis and greater symptoms of depression. Further, positive symptoms of psychosis, namely hallucinations and delusions, were found to increase the odds of experiencing suicidal ideation. Findings point toward the implication that depression and positive symptoms of psychosis relate to the experience of suicidal ideation among individuals with a FEP and should be evaluated for and treated in the early stages of treatment.

National Ovarian Cancer pathway initiative in collaboration with National Cancer Control Programme (NCCP), Obstetrics/Gynaecology group (Obs/Gynae) and General Practice (GP) group

Summary: Ovarian cancer is the sixth commonest cancer and the fourth commonest cancer cause of death in women in Ireland. Five year survival rates are Introduction: Ovarian cancer is the main cause of death from gynaecological cancer. Around 370 women are diagnosed each year; 80% are over 50 years of age. Most have advanced disease at presentation. Fewer than one-third have stage I or stage II disease at diagnosis. Ireland’s survival rate for ovarian cancer compares poorly internationally - less than 40% at 5 years (3). If diagnosed at an early disease stage, ovarian cancer has an excellent prognosis (stage I disease, five year survival >90%).(4) However, over 70% of cases are diagnosed at a late stage of illness with much poorer prognosis. Delay in diagnosis is often due to failure to recognise the symptoms of ovarian cancer which are non-specific. A collaboration involving GPs, the NCCP, Obstetrics/gynaecology and the Clinical Programme for Radiology developed a set of GP referral guidelines. Context: The guideline requires general practitioners (GPs) to undertake some investigations in the Primary Care setting if a woman is symptomatic i.e. serum CA125 and pelvic ultrasound. Pelvic ultrasound investigation of possible gynaecological pathology can be a multistep process. In most cases an initial trans-abdominal pelvic ultrasound (TAUS) is undertaken. This may be followed by a trans-vaginal pelvic ultrasound (TVUS). The TVUS may be undertaken during the same appointment as the TAUS or a follow up appointment may be arranged. The ultrasound is ordered if the CA125 is elevated (≥35 IU/ml) and gynae-oncology referral is only appropriate if ultrasound findings are suspicious of cancer, the CA125 is greater than 200 IU/ml or there are suspicious findings on clinical examination suggestive of ovarian cancer (1). The GP ovarian referral guideline was implemented on a pilot basis in an area of the country where GP access to ultrasound investigations was 100%. The aim of the pilot was to quantify any impact of this guideline on radiology and gynaecology services. This took place at St James’s Hospital. A survey was undertaken to assess the capacity of radiology departments in acute hospitals to implement the planned GP Ovarian Cancer Referral Guideline. The results of the survey revealed that CA125 increased by 28% but with no increase in U/S exams or at referrals to gynaecology/oncology. Aim and theory of change: All acute hospitals, where the service is available, should provide GP access to ultrasound investigations for suspected ovarian cancer. Standardised national criteria for referral for an ultrasound should be followed. Ultrasound facilities that are located in the Primary Care setting should adhere to these standardised referral criteria. These referral criteria should be monitored and evaluated periodically in conjunction with representatives from relevant disciplines such as radiology, gynaecology and general practice. Targeted population and stakeholders: Women (especially aged over 50 years) who present with the following persistent and frequent symptoms (i.e. more than 12 times per month): Abdominal distension, Early satiety, Loss of appetite, Pelvic or abdominal pain, Increasing urinary urgency or frequency, New onset Irritable Bowel Syndrome (IBS). Consider ovarian cancer in women who present with unexplained:· Ascites, DVT, Change in bowel habit, Weight loss, Fatigue. Sustainability: Once implemented, the guidelines should lead to a greater awareness of ovarian cancer, prompt referral and earlier diagnosis. Dissemination is taking place through ‘Train the Trainer’ and at GP study days.

Staging in bipolar disorder: from theoretical framework to clinical utility

Illness staging is widely utilized in several medical disciplines to help predict course or prognosis, and optimize treatment. Staging models in psychiatry in general, and bipolar disorder in particular, depend on the premise that psychopathology moves along a predictable path: an at-risk or latency stage, a prodrome progressing to a first clinical threshold episode, and one or more recurrences with the potential to revert or progress to late or end-stage manifestations. The utility and validity of a staging model for bipolar disorder depend on its linking to clinical outcome, treatment response and neurobiological measures. These include progressive biochemical, neuroimaging and cognitive changes, and potentially stage-specific differences in response to pharmacological and psychosocial treatments. Mechanistically, staging models imply the presence of an active disease process that, if not remediated, can lead to neuroprogression, a more malignant disease course and functional deterioration. Biological elements thought to be operative in bipolar disorder include a genetic diathesis, physical and psychic trauma, epigenetic changes, altered neurogenesis and apoptosis, mitochondrial dysfunction, inflammation, and oxidative stress. Many available agents, such as lithium, have effects on these targets. Staging models also suggest the utility of stage-specific treatment approaches that may not only target symptom reduction, but also impede illness neuroprogression. These treatment approaches range from prevention for at-risk individuals, to early intervention strategies for prodromal and newly diagnosed individuals, complex combination therapy for rapidly recurrent illness, and palliative-type approaches for those at chronic, late stages of illness. There is hope that prompt initiation of potentially disease modifying therapies may preclude or attenuate the cognitive and structural changes seen in the later stages of bipolar disorder. The aims of this paper are to: a) explore the current level of evidence supporting the descriptive staging of the syndromal pattern of bipolar disorder; b) describe preliminary attempts at validation; c) make recommendations for the direction of further studies; and d) provide a distillation of the potential clinical implications of staging in bipolar disorder within a broader transdiagnostic framework.