Psychosis Program Research Articles

Impact of schizophrenia on anterior and posterior hippocampus during memory for complex scenes.

ObjectivesHippocampal dysfunction has been proposed as a mechanism for memory deficits in schizophrenia. Available evidence suggests that the anterior and posterior hippocampus could be differentially affected. Accordingly, we used fMRI to test the hypothesis that activity in posterior hippocampus is disproportionately reduced in schizophrenia, particularly during spatial memory retrieval.Methods26 healthy participants and 24 patients with schizophrenia from the UC Davis Early Psychosis Program were studied while fMRI was acquired on a 3 Tesla Siemens scanner. During encoding, participants were oriented to critical items through questions about item features (e.g., “Does the lamp have a square shade?”) or spatial location (e.g., “Is the lamp on the table next to the couch?”). At test, participants determined whether scenes were changed or unchanged. fMRI analyses contrasted activation in a priori regions of interest (ROI) in anterior and posterior hippocampus during correct recognition of item changes and spatial changes.ResultsAs predicted, patients with schizophrenia exhibited reduced activation in the posterior hippocampus during detection of spatial changes but not during detection of item changes. Unexpectedly, patients exhibited increased activation of anterior hippocampus during detection of item changes. Whole brain analyses revealed reduced fronto-parietal and striatal activation in patients for spatial but not for item change trials.ConclusionsResults suggest a gradient of hippocampal dysfunction in which posterior hippocampus – which is necessary for processing fine-grained spatial relationships – is underactive, and anterior hippocampus – which may process context more globally - is overactive.

Symptomatic and functional outcomes of substance use disorder persistence 2 years after admission to a first-episode psychosis program

Substance use disorders (SUD) in first-episode psychosis (FEP) are highly prevalent and linked with poor outcomes. However, most longitudinal studies investigating their impacts in FEP have not reported proportions of patients who ceased SUD. Our aim was to examine the influence of SUD course on functional and symptomatic outcomes as well as service use in FEP. We performed a 2-year longitudinal study of 212 FEP patients, aged between 18 and 30 years, admitted to 2 early psychosis services in Montréal, Québec, Canada. We observed that cannabis was the first substance abused (42.9% at baseline), followed by alcohol (19.3%). The SUD rate decreased by approximately 30% during the first year. Patients with persistent SUD had worse functional outcomes (Quality of Life Scale, Social and Occupational Functioning Assessment Scale, employment), more symptoms (Positive and Negative Symptoms Scale) and heavier service use (emergency and hospitalization). SUD persistence was associated with illness severity, homelessness and cluster-B personality. Those living with their parents and financially supported by them were more likely to cease SUD. Our results indicate that SUD course was more significant than having SUD at admission; persistent SUD was associated with worse outcomes. SUD decreased during a general early psychosis intervention program (with no specialized SUD treatment). An integrated, specialized approach targeting FEP patients with predictive factors of SUD persistence during the first years of treatment might increase SUD cessation and possibly improve outcomes.

Supported employment and education in comprehensive, integrated care for first episode psychosis: Effects on work, school, and disability income

BackgroundParticipation in work and school are central objectives for first episode psychosis (FEP) programs, but evidence effectiveness has been mixed in studies not focused exclusively on supported employment and education (SEE). Requirements for current motivation to work or go to school limit the generalizability of such studies. MethodsFEP participants (N=404) at thirty-four community treatment clinics participated in a cluster randomized trial that compared usual Community Care (CC) to NAVIGATE, a comprehensive, team-based treatment program that included ≥5h of SEE services per week, , grounded in many of the principles of the Individual Placement and Support model of supported employment combined with supported education services. All study participants were offered SEE regardless of their initial interest in work or school. Monthly assessments over 24months recorded days of employment and attendance at school, days of participation in SEE, and both employment and public support income (including disability income). General Estimation Equation models were used to compare CC and NAVIGATE on work and school participation, employment and public support income, and the mediating effect of receiving ≥3 SEE visits on these outcomes. ResultsNAVIGATE treatment was associated with a greater increase in participation in work or school (p=0.0486) and this difference appeared to be mediated by SEE. No group differences were observed in earnings or public support payments. ConclusionA comprehensive, team-based FEP treatment approach was associated with greater improvement in work or school participation, and this effect appears to be mediated, in part, by participation in SEE.

Comparison of Caregiver Burden in First Episode Versus Chronic Psychosis

The aim of this study was to compare burden on caregivers of patients with first episode psychosis and caregivers of those with chronic psychosis. The study sample consisted of 39 caregivers of patients with first episode psychosis and 40 caregivers of patients with chronic psychosis. The Caregiver Burden Inventory (CBI) was used for data collection. The average caregiver burden in caregivers of patients with chronic psychosis was significantly higher than that in caregivers of patients with first episode psychosis. With regard to the subscales of CBI, there was a significantly higher level of burden in terms of time dependence, development, physical burden, and social burden in caregivers of patients with chronic psychosis than in caregivers of patients with first episode psychosis, while no such difference could be detected for the emotional burden. The absence of a difference in emotional burden suggests that caregivers of first episode psychosis may be going through an intense emotional experience, placing them in a high-risk status, despite an average caregiving experience duration of 11 months. Family interventions targeting the caregivers of patients with chronic psychosis or patients with first episode psychosis should be planned in accordance with the specific needs of these caregiver groups. It is also recommended to conduct programs involving the concurrent participation of the caregivers of patients with first episode psychosis and caregivers of patients with chronic psychosis and interventional programs such as “early psychosis support” for the caregivers of patients with first episode psychosis.

Personalized Prediction of Psychosis: External Validation of the NAPLS-2 Psychosis Risk Calculator With the EDIPPP Project.

As part of the second phase of the North American Prodrome Longitudinal Study (NAPLS-2), Cannon and colleagues report, concurrently with the present article, on a risk calculator for the individualized prediction of a psychotic disorder in a 2-year period. The present study represents an external validation of the NAPLS-2 psychosis risk calculator using an independent sample of patients at clinical high risk for psychosis collected as part of the Early Detection, Intervention, and Prevention of Psychosis Program (EDIPPP). Of the total EDIPPP sample of 210 subjects rated as being at clinical high risk based on the Structured Interview for Prodromal Syndromes, 176 had at least one follow-up assessment and were included in the construction of a new prediction model with six predictor variables in the NAPLS-2 psychosis risk calculator (unusual thoughts and suspiciousness, symbol coding test performance, verbal learning test performance, decline in social functioning, baseline age, and family history). Discrimination performance was assessed with the area under the receiver operating characteristic curve (AUC). The NAPLS-2 risk calculator was then used to generate a psychosis risk estimate for each case in the external validation sample. The external validation model showed good discrimination, with an AUC of 0.790 (95% CI=0.644-0.937). In addition, the personalized risk generated by the risk calculator provided a solid estimation of the actual conversion outcome in the validation sample. Two independent samples of clinical high-risk patients converge to validate the NAPLS-2 psychosis risk calculator. This prediction calculator represents a meaningful step toward early intervention and the personalized treatment of psychotic disorders.

An early intervention for psychosis and its effect on criminal accusations and suicidal behaviour using a matched-cohort design

BackgroundEarly interventions for psychosis have been shown to reduce psychotic symptoms and hospital use for first-episode patients, but the effect on suicidal and criminal behaviour has not been reliably determined. This study aimed to examine whether an early intervention for psychosis program (EPPIS) reduced criminal behaviour, suicide attempts, and hospital-based service use. MethodsThe study utilized administrative data to match clients of EPPIS to historical controls. Regression was used to determine the effect of treatment by EPPIS on inpatient use, emergency department use, suicide attempts/deaths, and criminal accusations. ResultsA sample of 244 patients was matched to 449 controls. EPPIS patients had lower odds of being accused of a crime both during and after treatment. Suicidal behavior was less frequent among patients, both during treatment (p<0.0001) and after (HR=0.39; 95% CI: 0.17 to 0.94). During treatment there were more emergency department visits for the patients (RR=2.54; 95% CI: 1.56 to 4.58), but no difference in inpatient usage compared to controls. Post-treatment, both emergency department and inpatient usage were higher among patients. ConclusionsEPPIS patients had reduced suicide attempts and criminal accusations. Increased emergency department use could indicate that encouraging treatment during a crisis may increase service use, while reducing suicidal and criminal behaviour.

Assertive outreach for “difficult to engage” patients: A useful tool for a subgroup of patients in specialized early psychosis intervention programs

PurposeMost specialized Early Psychosis (EP) programs include assertive outreach (AO) principles, either for all patients or as an intensive case management (ICM) subprogram in selected situations. The objective of this study is to examine prevalence, characteristics and outcomes of patients who needed additional ICM in a specialized EP program. MethodsIn a 3-year prospective naturalistic study of 229 consecutive EP patients treated at TIPP-Lausanne we compared characteristics of those who needed ICM and those who did not. Results60 (26.2%) TIPP patients needed ICM. At baseline, ICM-patients showed a poorer academic premorbid functioning (p=0.019); lower level of insight (p<0.001); had a previous history of alcohol (p=0.043) and cannabis (p=0.040) use. ICM-patients were less likely to be adherent to medication during the early phase of treatment but differences disappeared during follow-up. ICM-patients showed globally a poorer functional level and higher level of positive and negative symptoms during the follow-up. ConclusionsAbout one quarter of EP patients needed a combination of ICM and assertive outreach. Despite the high treatment adherence in both groups, psychotic symptoms remained higher in ICM-patients. In a real live setting with limited resources, combination of ICM and AO in selected situations seems a valid solution.

Nutrition interventions in people with severe mental illness: Novel strategies for addressing physical health co-morbidity in a high-risk population

IntroductionNutrition interventions are critical for weight management and cardiometabolic risk reduction in people experiencing severe mental illness (SMI). As mental health teams evolve to incorporate nutrition interventions, evidence needs to guide clinical practice.AimsA systematic review and meta-analysis was performed to assess whether nutrition interventions improve:– anthropometric and biochemical measures,– nutritional intake of people experiencing SMI.To evaluate the effectiveness of a dietician-led nutrition intervention, as part of a broader lifestyle intervention, in the early stages of antipsychotic prescription.MethodAn electronic database search was conducted to identify all trials with nutritional components. Included trials were pooled for meta-analysis. Meta-regression analyses were run on potential anthropometric moderators. Weekly individualised dietetic consultations plus group cooking classes were then offered to clients attending a Community Early Psychosis Programme, who had recently commenced antipsychotics for a 12-week period.ResultsFrom pooled trials, nutrition interventions resulted in significant weight loss (19 studies, g = –0.39, P &lt; 0.001), reduced BMI (17 studies, g = –0.40, P &lt; 0.001), decreased waist circumference (10 studies, g = –0.27, P &lt; 0.001) and lower blood glucose levels (5 studies, g = –0.37, P = 0.02). Dietician-led interventions (g = –0.90) and trials focussing on preventing weight gain (g = –0.61) were the most effective. The 12-week nutrition intervention resulted in a 47% reduction in discretionary (junk) food intake (P &lt; 0.001) and reductions in daily energy (–24%, P &lt; 0.001) and sodium intakes (–26%, P &lt; 0.001), while improving diet quality (P &lt; 0.05).ConclusionEvidence supports the inclusion of nutrition interventions as part of standard care for preventing weight gain and metabolic deterioration among people with SMI.Disclosure of interestThe authors have not supplied their declaration of competing interest.

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.

Cost for early intervention of FEB justified by improved outcomes

Are increased costs of comprehensive first‐episode psychosis (FEP) programs offset by reduced inpatient costs? Does the value of health benefits justify the additional costs? These are the questions Yale researchers set out to address in new research that evaluated the cost‐effectiveness of a team‐based treatment approach for FEP versus community care (CC).

The journey of young people in an early psychosis program involved in participatory photography

Introduction The purpose of this study was to examine the experiences and perceptions of young people in an early psychosis program towards participating in a 10-week photovoice and exhibition project and the themes that had emerged from their photographs. Method Photographs create meanings and participants are able to tell their stories in a meaningful way. Eleven clients who had gone through a prior 10-week photovoice project and exhibition consented to being interviewed for this study. Clients chose and brought to the interview photos of theirs that had been exhibited. Structured questions were asked to generate discussions. Findings Findings illustrated that participants were keen to educate the general public on mental health issues. They craved acceptance and were keen to make connections and build relationships. They were their own agents of change. Supportive networks create hope, which in turn helps people with mental health issues to reframe their outlook. Conclusion The results of this study are important and provide occupational therapists with another tool for intervention and advocacy. As both photovoice and occupational therapy focus on the process rather than the product, occupational therapists can utilize photography in groups creatively to generate more client- and peer-led discussions.

Early Detection, Intervention and Prevention of Psychosis Program: Community Outreach and Early Identification at Six U.S. Sites.

This study assessed the effects of a community outreach and education model implemented as part of the Early Detection, Intervention and Prevention of Psychosis Program (EDIPPP), a national multisite study in six U.S. regions. EDIPPP's model was designed to generate rapid referrals of youths at clinical high risk of psychosis by creating a network of professionals and community members trained to identify signs of early psychosis. Qualitative and quantitative data were gathered through an evaluation of outreach efforts at five sites over a two-year period and through interviews with staff at all six sites. All outreach activities to groups (educational, medical, and mental health professionals; community groups; media; youth and parent groups; and multicultural communities) were counted for the six sites to determine correlations with total referrals and enrollments. During the study period (May 2007-May 2010), 848 formal presentations were made to 22,840 attendees and 145 informal presentations were made to 11,528 attendees at all six sites. These presentations led to 1,652 phone referrals. A total of 520 (31%) of these individuals were offered in-person orientation, and 392 (75%) of those were assessed for eligibility. A total of 337 individuals (86% of those assessed) met criteria for assignment to the EDIPPP study. EDIPPP's outreach and education model demonstrated the effectiveness of following a protocol-defined outreach strategy combined with flexibility to reach culturally diverse audiences or initially inaccessible systems. All EDIPPP sites yielded appropriate referrals of youths at risk of psychosis.

Early Intervention in Mood and Anxiety Disorders: The First Episode Mood and Anxiety Program (FEMAP).

The First Episode Mood and Anxiety Program (FEMAP) was developed for youth with mood and/or anxiety concerns in London, Ontario, to provide early intervention for these disorders, similar to the first-episode psychosis programs across Ontario and Canada. The logic and causal models of the pathway to and through FEMAP are described and inclusion/exclusion criteria are delineated. Results of the process evaluation of the model and preliminary data from a treatment-effectiveness evaluation and ongoing cost-comparison evaluation are provided. Several characteristic quotes from youth utilizing the service are included, as is an overview of utilization statistics. Challenges and lessons learned are conveyed.

Acute Psychiatric Problems among Migrants Living in Switzerland- a Retrospective Study from a Swiss University Emergency Department

Background: Switzerland is a traditional immigration country with immigrants from both neighbouring, and less developed countries. Since the early 1990s, the migration rate has continuously increased and in 2013 almost a quarter of Swiss residents had an immigration background. Immigrants in Switzerland had fewer psychiatric hospitalisations, but more emergency and compulsory admissions than the local population. Therefore it is important to study the characteristics of the immigrant population presenting at the emergency department for mental health problems. Methods: Our retrospective data analysis included adult patients (age ≥ 16 years) admitted to our emergency department who consulted a psychiatrist, between 1st of January 2007 and 30th of October 2012. Results: Clinical data from a total of 1115 patients were available for analysis. Of these, 58.6% (n=654) were male and 41.4% (n=461) female. The mean age was 36.3 years, with a range of 16–85 years. The most common reason for psychiatric presentation to the emergency department was psychosis (n=227, 20.3%), followed by social problems with 18.2 % (n=203), auto-aggression with 16.4% (n=193) and 16.2% (n=181) suffering from depression. Conclusions: Translation services are very important. Therapy adherence programs for psychosis and autoaggression prevention programs are especially important for immigrants.

Incidence of Oculogyric Crisis and Long-Term Outcomes With Second-Generation Antipsychotics in a First-Episode Psychosis Program.

Oculogyric crisis (OGC) is an often recurrent dystonic adverse effect of antipsychotic treatment characterized by a sustained fixed upward gaze lasting minutes to hours. The risk of OGC has not been established. We prospectively estimated the incidence rate of OGC in an early intervention service for psychosis and provided details regarding the antipsychotics implicated, clinical presentation, and long-term outcomes of OGC. The Nova Scotia Early Psychosis Program provides comprehensive, team-based care to youth and young adults with schizophrenia spectrum disorder. For 6 years (April 2008 to March 2014), 452 new patients were admitted to the program and participated in an individualized program of care. Eight patients (4 females; mean age, 19.8 years) developed recurrent episodes of OGC after 3 months to 2 years of treatment with 1 or more second-generation antipsychotics, yielding an incidence rate of 1.8% (95% confidence interval, 0.9%-3.4%). Risperidone or olanzapine (alone or in combination with a second antipsychotic) seemed causative in each case. Also implicated in the onset or recurrence of oculogyric episodes were ziprasidone, quetiapine, clozapine, aripiprazole, and the first-generation antipsychotic loxapine. Follow-up ranged between 2 and 7 years. Episodes stopped after switching antipsychotic treatment in 4 cases and after stopping antipsychotic treatment in 2 cases. In the other 2 cases, recurrences were ongoing at last follow-up 2 and 6 years after onset with antipsychotic treatment continuing. We observed a high rate of tardive-onset, recurrent, and potentially chronic ocular dystonias in patients with first-episode psychosis caused by the use of second-generation antipsychotics.

Federal leaders, field promote benefits of first‐episode psychosis programs

This fall, there has been a plethora of undertakings related to the need for funding support and expansion of early intervention services for young people experiencing first‐episode psychosis (FEP) to communities across the country. Among the activities are the release of a landmark study to announce new findings from a multiyear study of FEP programs, a Capitol Hill briefing to announce those results and new Medicaid coverage guidance for early intervention in psychosis programs.

Federal leaders, field promote benefits of first-episode psychosis programs

Federal leaders, field promote benefits of first-episode psychosis programs

A Multidisciplinary First-Episode Psychosis Program

Understanding that young patients with first-episode psychosis have many continuities with the characteristics of older patients was a step forward in the field and led to the development of initiating first-episode psychosis programs and reducing the duration of untreated psychosis. As programs have developed, so have strategies to develop initial evaluations to clarify the health of the young patient with psychosis. The next steps of treatment include medication, talk therapy, family therapy, and team work. Beyond starting treatment, there are significant emerging issues such as use of long-acting injectable medication and strategies for patients who do not respond to first-line treatments, such as using clozapine. The integration of cognitive-behavioral therapy, cognitive remediation, and a day treatment center for the first-episode psychosis program are integral. [ Psychiatr Ann . 2015;45(11):561–568.]

Predictors of Relapse and Functioning in First-Episode Psychosis: A Two-Year Follow-Up Study.

First-episode psychosis has an annual incidence rate of 24.6 to 40.9 per 100,000 population, and most individuals develop chronic disorders, such as schizophrenia or affective psychosis. The first two to five years are thought to be key determinants of long-term functional and clinical prognosis. This study aimed to determine the two-year course of illness in first-episode psychosis, including diagnosis, relapse, and functioning and factors related to these variables. A total of 140 patients who experienced a first episode of psychosis were recruited and evaluated between 2008 and 2012 in a first-episode psychosis program in Barcelona, Spain. Regression models were used to determine factors predicting relapse and functioning. A general trend was noted toward improved functioning and less severe psychotic symptoms. However, after two years, one-third of the patients had a diagnosis of schizophrenia and more than 40% had a diagnosis of affective psychosis. Rates of relapse were 31% after one year and 43% at two years. Cannabis use after illness onset and poor insight were the best predictors of relapse. Being male and severity of negative symptoms at baseline predicted worse functioning at two years. Patients with first-episode psychosis were found to have high relapse rates during the first years after illness onset. Further studies evaluating treatment strategies focused on reducing cannabis use and improving insight in first-episode psychosis should be encouraged.