Recovery In First-episode Psychosis Research Articles

SU106. Investigating the Short- and Long-Term Benefits of Exercise in Early Psychosis

Background: Exercise has previously been shown to reduce symptoms of schizophrenia in long-term patients, along with improving their physical health and cognitive functioning. However, the effects of exercise in first-episode psychosis (FEP) have not been widely investigated. Methods: Twenty-eight people with FEP participated in 10 weeks of supervised exercise twice weekly, using activities tailored to their own choice. Participant engagement was measured, and various aspects of physical health, mental health, and cognitive functioning were assessed. Participants were assessed at baseline, 10 weeks, and then 6 months after the supervised intervention, and compared to a group of patients with FEP who did not receive an exercise intervention. Results: Over the 10-week intervention, participants achieved 107 minutes (mean average) of moderate-to-vigorous exercise per week. Furthermore, at 10 weeks (ie, immediately postintervention), there were improvements in total symptoms, negative symptoms, waist circumference, verbal memory, social cognition, and social functioning (all P < .05). After 6 months, 55% of participants had continued to exercise. Psychiatric assessments at the 6-month follow-up showed that positive and negative symptoms were still significantly lower than preintervention scores. However, post hoc analyses revealed that only those who had maintained regular exercise over the 6 months had continued to show significantly reduced symptoms, whereas those who had ceased exercising had regressed to baseline scores. Previously observed benefits of exercise for social functioning were also maintained at the follow-up, although improvements in waist circumference and cognition were lost. Conclusion: Future research should aim to establish sustainable methods for maintaining regular exercise and explore the effectiveness of “step-down” support following supervised interventions in order to improve physical health outcomes and facilitate psychosocial recovery in FEP.

110. “With a Little Help from My Friends” Social Predictors of Clinical Recovery in First-Episode Psychosis

110. “With a Little Help from My Friends” Social Predictors of Clinical Recovery in First-Episode Psychosis

The Double-Edged Nature of Recovery in First-Episode Psychosis

The Double-Edged Nature of Recovery in First-Episode Psychosis

Prevalence and predictors of medication non-adherence among Chinese patients with first-episode psychosis

Medication non-adherence is one of the major obstacles to recovery in first-episode psychosis (FEP). This study aimed to identify the predictors and rates of medication non-adherence in the first and second year after the start of treatment (baseline) in urban Chinese FEP patients. Relevant information on medication non-adherence and potential baseline predictors, including demographic variables, clinical measures, violence/suicide attempts, stressful life experiences, intervention received, and follow-up attendance, were collected from case records of 1400 FEP patients in Hong Kong. The non-adherence rate was 16.2% in year 1 and 15.4% in year 2. Regression analyses revealed the predictors for non-adherence in year 1 were no hospitalization at baseline, non-schizophrenia diagnosis, and more years of education. Predictors of non-adherence in year 2 included acute/subacute onset and older age of onset. Predictors common in both years were defaulting from psychiatric follow-up during baseline, standard psychiatric care (no early intervention), and lower positive symptoms severity at baseline. In assessing non-adherence risk and for planning phase-specific early interventions for FEP, particularly in a Chinese context, healthcare professionals should consider the common and specific predictors for non-adherence identified in the first and second years of treatment and should not overlook patients with less clinically severe symptoms.

Predictors of recovery in first episode psychosis: The OPUS cohort at 10 year follow-up

BackgroundRecovery, the optimal goal in treatment, is the attainment of both symptomatic and functional remission over a sustained period of time. Identification of factors that promote recovery can help develop interventions that facilitate good outcomes for people with first episode psychosis. AimTo examine long-term outcomes within a cohort of people with first episode psychosis in relation to symptom remission, functioning and recovery, 10years after diagnosis. MethodThe study had a prospective design. Participants from the OPUS trial (1998–2000) (n=496) completed a series of interviews and questionnaires to measure current levels of psychopathology and social/vocational functioning, ten years after diagnosis. Predictors of recovery were identified using socio-demographic and clinical characteristics collected at baseline. ResultsA total of 304 participants were interviewed, giving a follow-up rate of 61%. A total of 42 people (14%) met the criteria for symptomatic and psychosocial recovery at 10years. A multivariable binary logistic regression analysis indicated that baseline predictors accounted for 22% of the variance of full recovery. Lower severity of negative symptoms at baseline (Odds Ratio (OR) 0.53, 95% confidence interval CI 0.36–0.78, p<0.001) and earlier age of diagnosis (OR 0.92, 95% CI 0.86–0.99, p<0.05) predicted better rates of recovery at 10years. ConclusionResults of this study indicated that negative symptoms could play a central role in the process of recovery from schizophrenia. A challenge for clinicians and researchers is to understand the mechanisms behind negative symptoms and develop interventions that can prevent or ameliorate these symptoms in order to promote recovery.

A randomized controlled trial of vocational intervention for young people with first‐episode psychosis: method

Young people who are experiencing first-episode psychosis (FEP) are at increased risk of being unemployed compared to either their same age peers in the general population, or those with other mental illnesses. Significant research has been conducted examining employment interventions for those with chronic psychotic illness. This has yielded strong results in favour of an intervention called individual placement and support (IPS). However, significantly less work has examined the benefit of this approach to those in FEP when the potential for vocational rehabilitation is perhaps greater. This study adds to the knowledge of vocational intervention in first-episode psychotic illness. Additionally, it expands this work into the areas of cognition, social cognition, social inclusion and economics. The study is a single-blind, randomized controlled trial comparing receiving high-quality FEP treatment as usual plus IPS (IPS + TAU) to a FEP treatment as usual (TAU) intervention alone within a specialized FEP service. The study recruited 146 people attending a first-episode psychosis service over 2 years. They were assessed at baseline, 6 months (end of intervention) 12 and 18 months with a battery covering psychopathology, economic, demographic, social cognitive, cognitive and diagnostic variables. This paper describes the methodology for the largest attempted study of IPS in FEP. This study has the capacity to answer questions about the benefits on illness and economic impacts of vocational recovery in FEP. Further, it has the capacity to extend knowledge about the contribution of cognitive and social cognitive factors to recovery in this domain.

Risk of arrested recovery following first episode psychosis: An integrative approach to psychotherapy.

The empirical study of the prediction of outcome in First Episode Psychosis (FEP) shows that outcome is predicted by poorer premorbid functioning and longer duration of untreated psychosis. These findings raise important implications for the study of developmental and interpersonal processes underpinning recovery after FEP. In this article we argue that recovery in FEP can be understood through the development of a coherent narrative, which enables the individual to place their experiences within their wider historical, interpersonal, and developmental context. We emphasize that the development of a coherent narrative requires the cultivation of compassion toward ones experiences including an attuned sensitivity to one’s distress, and the alleviation of distress through expressions of acceptance, nonjudgement, empathy, forgiveness, and care.

On the HORYZON: Moderated online social therapy for long-term recovery in first episode psychosis

BackgroundEarly intervention services have demonstrated improved outcomes in first episode psychosis (FEP); however, recent evidence shows that treatment benefits may not be sustainable over time. These findings have resulted in repeated recommendations for the implementation of longer term treatment programs. An Internet-based intervention specifically designed for young people with psychosis may provide a cost-effective alternative to prevent loss of treatment benefits from early intervention. MethodsOur multi-disciplinary team has developed a highly novel online intervention (HORYZONS) in regular consultation with stakeholders within a specialist early psychosis program. HORYZONS integrates: i) peer-to-peer social networking, ii) individually tailored interactive psychosocial interventions, and iii) expert interdisciplinary and peer-moderation in a coherent platform designed to improve long-term outcomes in FEP. The acceptability, safety and initial clinical benefits of HORYZONS were examined through a 1-month pilot study with 20 participants with FEP. ResultsThere were no dropouts during the pilot study. Seventy per cent of participants utilised the system for at least 3weeks, 95% used the social networking features, and 60% completed at least 3 therapy modules. System usage was high during the study. There were no incidents and the majority of participants reported feeling safe, empowered and more socially connected using HORYZONS. Analysis revealed a significant reduction in depressive symptoms at follow-up. ConclusionsOur results indicate that HORYZONS is feasible, engaging and safe and may augment social connectedness and empowerment in FEP. These findings have significant implications for the enhancement of specialist FEP services. The potential of HORYZONS to improve long-term recovery is worthy of further investigation.

Second-Generation Antipsychotic Discontinuation in First Episode Psychosis: An Updated Review

"All-causes discontinuation" refers to discontinuation of treatment for any reason, and medication adherence is an important component of this measure. Similar to our previous results, we found that almost 30% of patients with first-episode psychosis (FEP) discontinue medication in the first 9 months of treatment, a finding that has important implications for long-term outcomes. Many newer second-generation antipsychotics have not been studied in FEP. The self-reported Drug Attitude Inventory may help identify patients at heightened risk for medication discontinuation. In addition to vigilant monitoring for and adequate treatment of psychopathology and medication side effects, Relapse Prevention Therapy and the use of long-acting injectable agents may be effective interventions decrease discontinuation rates in FEP. There is currently no consensus on how long a patient should remain on an antipsychotic medication following remission of FEP. Studies are needed to identify predictors of which patients in remission from FEP are less likely to relapse when medication is discontinued. Taken together, our findings presented here underscore the importance of addressing medication discontinuation both as a means of preventing long-term morbidity and enhancing remission and functional recovery in FEP.

Road to full recovery: longitudinal relationship between symptomatic remission and psychosocial recovery in first-episode psychosis over 7.5 years

In recent years there has been increasing interest in functional recovery in the early phase of schizophrenia. Concurrently, new remission criteria have been proposed and several studies have examined their clinical relevance for prediction of functional outcome in first-episode psychosis (FEP). However, the longitudinal interrelationship between full functional recovery (FFR) and symptom remission has not yet been investigated. This study sought to: (1) examine the relationships between FFR and symptom remission in FEP over 7.5 years; (2) test two different models of the interaction between both variables. Altogether, 209 FEP patients treated at a specialized early psychosis service were assessed at baseline, 8 months, 14 months and 7.5 years to determine their remission of positive and negative symptoms and functional recovery. Multivariate logistic regression and path analysis were employed to test the hypothesized relationships between symptom remission and FFR. Remission of both positive and negative symptoms at 8-month follow-up predicted functional recovery at 14-month follow-up, but had limited value for the prediction of FFR at 7.5 years. Functional recovery at 14-month follow-up significantly predicted both FFR and remission of negative symptoms at 7.5 years, irrespective of whether remission criteria were simultaneously met. The association remained significant after controlling for baseline prognostic indicators. These findings provided support for the hypothesis that early functional and vocational recovery plays a pivotal role in preventing the development of chronic negative symptoms and disability. This underlines the need for interventions that specifically address early psychosocial recovery.

Neurocognition and recovery in first episode psychosis

Cognitive functioning has been found to be a predictor of functional outcome of schizophrenia. It is unclear, however, whether clinical recovery can be predicted by scores on specific cognitive domains. The predictive value of specific neurocognitive domains and other clinical variables for symptomatic and functional outcome and clinical recovery after a 2-year follow-up is explored in a group of 51 patients with non-affective first-episode psychosis. A comprehensive neurocognitive battery was administered 18 and 41weeks after inclusion. Other patient characteristics, which were expected to independently predict clinical recovery, were assessed at baseline. Several neurocognitive tests, especially tests measuring speed of processing, and among others, Duration of Untreated Psychosis (DUP), were significant predictors of clinical recovery. Poor neuropsychological performance accurately predicted non-recovery, but improved neuropsychological performance did not accurately predict recovery. This study confirms previous findings of an association between neurocognition and outcome, but the results also suggest that in order to accurately predict recovery, the role of other factors needs to be investigated.

Meaningful lives: supporting young people with psychosis in education, training and employment: an international consensus statement

Unemployment is the major disability faced by people with psychotic illness. Unemployment rates of 75–95% are found among those with schizophrenia. Unemployment is associated with poorer social and economic inclusion, greater symptomatology, decreased autonomy and generally poorer life functioning. Unemployment also makes up over half of the total costs associated with psychotic illness. A meeting was convened in London in June 2008. Invitees to this meeting included people from the USA, Canada and the UK interested in vocational intervention in early psychosis from either a research, clinical, economic or policy point of view. From this meeting a larger group–the International First Episode Vocational Recovery (iFEVR) group–has developed an international consensus statement about vocational recovery in first episode psychosis. The document is a basic statement of the rights of young people with psychosis to pursue employment, education and training; the evidence which exists to help them do this; and ways in which individuals, organizations and governments can assist the attainment of these ends. It is hoped that the Meaningful Lives consensus statement will increase the focus on the area of functional recovery and lift it to be seen in parallel with symptomatic recovery in the approach to treating early psychosis.

Clinical Recovery in First-Episode Psychosis

Introduction: Generally agreed outcome criteria in psychosis are required to evaluate the effectiveness of new treatment strategies. The aim of this study is to explore clinical recovery in first-episode patients, defined by meeting criteria for both symptomatic and functional remission. Method: In a sample of first-episode patients (N = 125), symptomatic and functional remission during the last 9 months of a 2-year follow-up period were examined, as well as recovery and its predictors. Results: Half the patients (52.0%) showed symptomatic remission and a quarter (26.4%) functional remission, while one-fifth (19.2%) met both criteria sets and were considered recovered. Recovery was significantly associated with short duration of untreated psychosis and better baseline functioning. Conclusion: Most functionally remitted patients were also symptomatically remitted, while a minority of symptomatically remitted patients were also functionally remitted. Treatment delay may affect chance of recovery.

A Review of Second-Generation Antipsychotic Discontinuation in First-Episode Psychosis

"All-causes discontinuation" refers to discontinuation of treatment for any reason, and adherence to medication is an important component of this measure. Two recent landmark studies suggest that adherence is a major issue in patients with first-episode psychosis (FEP) right from the onset of treatment. In this review, the incidence, reasons for, and clinical outcomes of medication discontinuation in FEP are considered. More than 40% of patients with FEP discontinue medication during the first 9 months of treatment, at which point the chances of relapse increase dramatically. Findings concerning predictors of medication discontinuation in this patient population that have been replicated in more than one study include severity of psychopathology, lack of insight into illness, negative attitudes towards medications, comorbid substance use, and medication side effects. Interventions that have the potential to decrease discontinuation rates in patients with psychotic disorders include orally disintegrating tablets, long-acting injectable drugs, cognitive-behavioral therapy, compliance therapy, family support/intervention, and peer support, although these strategies have largely been unexplored in FEP. In addition to the question of medication discontinuation in the acute treatment of FEP, another important issue is how long patients with FEP should be treated with antipsychotics once they have achieved remission; unfortunately, little evidence is available to guide the decision as to whether medication should be discontinued or maintenance treatment provided in this situation. Studies are therefore needed to identify predictors of patients with remitted FEP who are less likely to relapse when medication is discontinued. Taken together, the findings presented in this article underscore the importance of addressing issues related to medication discontinuation as a means of preventing long-term morbidity and enhancing remission and functional recovery in FEP.

Prolonged recovery in first-episode psychosis

Early identification and specialised treatment of individuals with enduring positive symptoms may assist in alleviating symptoms and has the potential to change the course of illness. Prevalence and descriptive data on enduring positive symptoms in two first-episode samples are outlined. Attempts to incorporate the focus of early intervention for persisting psychosis into routine clinical care of individuals with first-episode psychosis are described. Of the 227 individuals with first-episode psychosis who were assessed using the Brief Psychiatric Rating Scale at 3/6 months and 12 months following initial stabilisation (from a total sample of 347), 6.6% experienced enduring positive symptoms at all three time points. When the analysis was restricted to schizophrenia, schizophreniform and schizoaffective disorders (n = 158) the percentage increased to 8.9%. These patients had significantly longer mean duration of untreated psychosis prior to initiation of treatment and, at 12-month follow-up, significantly higher depression and poorer psychosocial functioning. The association of untreated psychosis with treatment resistance supports the argument for early intervention as soon as possible following the onset of psychotic symptoms.

The deficit state in first-episode schizophrenia.

The prevalence, clinical correlates, and outcome of the deficit syndrome were determined for 70 patients ascertained in their first episode of schizophrenia and then followed through their recovery. Patients were treated in a standardized manner and underwent baseline assessments of symptoms and adverse effects that were repeated at intervals throughout their inpatient and subsequent outpatient course. Forty-seven patients were followed for a minimum of 6 months after remission of their positive symptoms, allowing for an assessment of their deficit syndrome status. Using modified criteria of Carpenter et al. for the deficit syndrome, the authors found that two patients (4%) met all criteria for the deficit syndrome, nine (19%) had deficit symptoms (questionable deficit state), and 36 (77%) had no deficit symptoms. When patients who had not fully remitted or had remitted for less than 6 months were included, seven (10%) met deficit syndrome criteria, 11 (16%) had deficit symptoms, and 52 (74%) had no deficit symptoms. The prevalence of the deficit syndrome in first-episode schizophrenia varies depending on the criteria used and is lower than that previously described in more chronic patient samples. Patients without deficit symptoms had better premorbid functioning and a better global outcome than patients with deficit symptoms.

Duration of psychosis and outcome in first-episode schizophrenia.

This study was undertaken to assess the potential effect of duration of untreated illness on outcome in a group of first-episode schizophrenic patients. Seventy patients with schizophrenia diagnosed according to the Research Diagnostic Criteria entered the study and were followed for up to 3 years. All patients received standardized treatment and uniform assessments both during the acute phase of their illness and throughout the follow-up period. Outcome was measured in terms of time to remission of acute psychotic symptoms as well as degree of symptom remission. The mean duration of psychotic symptoms before initial treatment was 52 weeks, preceded by a substantial prepsychotic period. According to survival analysis, duration of illness before treatment was found to be significantly associated with time to remission as well as with level of remission. The effect of duration of illness on outcome remained significant when diagnosis and gender variables, themselves associated with outcome, were controlled in a regression analysis. Duration of illness was not correlated with age at onset, mode of onset, premorbid adjustment, or severity of illness at entry into the study. Duration of psychosis before treatment may be an important predictor of outcome in first-episode schizophrenia. Acute psychotic symptoms could reflect an active morbid process which, if not ameliorated by neuroleptic drug treatment, may result in lasting morbidity. Further implications of these findings are discussed.