Treatment Of First-episode Schizophrenia Research Articles

Gender differences in cognitive improvements after two months of atypical antipsychotic treatment in first episode schizophrenia.

This study aims to explore the gender differences in cognitive improvements after two months of atypical antipsychotic treatment in first episode schizophrenia (FES). 82 patients with FES, including 50 male patients and 32 female patients, were enrolled in the present study. Positive and Negative Syndrome Scale (PANSS) and MATRICS Consensus Cognitive Battery (MCCB) were respectively conducted to evaluate the clinical symptoms and cognitive function of patients with FES at baseline and after treatment. Repeated measure ANOVA was performed to compare gender differences in cognitive domains scores between baseline and 2-month follow-up. Stepwise liner regression model was performed to explore the effect factors of cognitive improvements in patients. There was no significant difference in age of onset, education years, PANSS scores, duration of untreated psychosis and Olanzapine equivalent doses between male and female patients (all p > 0.05). In the comparisons of cognition function, male patients exhibited better performance in social cognition compared with female patients at baseline (t = 3.20, p < 0.05). After treatment, improvements of attention/vigilance and working memory were both found in male patients and female patients (attention/vigilance, F = 11.867, p < 0.05; working memory, F = 18.265, p < 0.05). In addition, improvement of speed of information processing was only found in female patients (F = 11.65, p < 0.01). Significant interaction between time and gender was found in speed information of processing (F = 4.140, p = 0.045). Stepwise liner regression model revealed that improvements of negative symptoms promote improvements of cognitive function in female patients (all p < 0.05). Our findings revealed gender differences of cognitive improvements in patients with FES after 2-month treatment. It provides new evidence for gender differences in cognitive symptoms of schizophrenia, and also provides preliminary clues for further individualized cognitive intervention strategies.

Weight changes following treatment with aripiprazole, risperidone and olanzapine: A 12-month study of first-episode schizophrenia patients in China.

This study aimed to assess weight changes following antipsychotic treatment in first-episode schizophrenia (FES) patients and make a comparison of aripiprazole, risperidone and olanzapine. Predictors for long-term clinically relevantweight gain (CRW, ≥7%) were examined. We carried out a second analysis of data from the Chinese First-Episode Schizophrenia Trial. Repeated measures general linear model (GLM) statistics were used to compare body weight at each follow-up point (month of 1, 2, 3, 6, 9and 12). Logistic regression models were constructed to evaluate possible predictors for CRW. Body weight increased with an average rate of 0.93 % per month, with the fastest growth rate occurring in first 3 months. CRW was observed in 79 % of patients. Participants from olanzapine group showed significantly higher weight gain than risperidone group and aripiprozole group. Repeated measures GLM revealed a significant main effect of time (p<0.001) and asignificant time*group interaction was revealed (p<0.001), while the between-subjectgroup effect was not statistically significant (p=0.272). Multivariate logistic regressionmodel showed that with smaller baseline BMI (OR = 1.33, p<0.001), with a family historyof mental disorder (OR = 5.08, p=0.004), receiving olanzapine (OR = 2.35, p=0.001), and CRW at first-month (OR = 4.29, p=0.032) were independent predictors for first-year CRW. Antipsychotics are associated with a clinically significant weight gain in FES patients, which occurs mostly in first 3 months. Aripiprazole might not be an ideal choice in terms of long-term metabolic side-effects. Early and close metabolicmonitoring should accompany antipsychotic prescription.

The effect of initial antipsychotic treatment on hippocampal and amygdalar volume in first-episode schizophrenia is influenced by age

Background:Antipsychotic treatment has been shown to yield hippocampal and amygdalar volumetric changes in first-episode schizophrenia (FES). However, whether antipsychotic induced volumetric changes interact with age remains unclear. MethodsThe current study includes data from 120 medication naïve FES patients and 110 matched healthy controls (HC). Patients underwent MRI scans before (T1) and after (T2) antipsychotic treatment. HCs underwent MRI scans at baseline only. The hippocampus and amygdala were segmented via Freesurfer 7. General linear models were conducted to investigate the effect of age by diagnosis interaction on baseline volume. Linear mixed models (LMM) were used to detect the effect of age on volumetric changes from pre to post treatment in FES. ResultsGLM revealed a trending effect (F = 3.758, p = 0.054) of age by diagnosis interaction on the baseline volume of the left (whole) hippocampus, with older FES patients showing smaller hippocampal volumes, relative to HC, when controlled sex, education years, and ICV. LMM showed a significant age by time-point interaction effect (F = 4.194, estimate effect = −1.964, p = 0.043) on left hippocampal volume in all FES and significant time effect(F = 6.608,T1-T2(estimate effect) = 62.486, p = 0.011), whereby younger patients showed greater hippocampal volumetric decreases following treatment. At the subfield level, a significant time effect emerged in left molecular_layer_HP (F = 4.509,T1-T2(estimate effect) = 12.424, p = 0.032, FDR corrected) and left cornu ammonis(CA)4 (F = 4.800,T1-T2(estimate effect) = 7.527, p = 0.046, FDR corrected), implying volumetric reduction after treatment in these subfields. ConclusionsOur findings suggest that age plays an important role in the neuroplastic mechanisms of initial antipsychotics on the hippocampus and amygdala of schizophrenia.

Delay in psychiatric hospitalization from the diagnosis of first-episode schizophrenia and its association with clinical outcomes and direct medical costs: a nationwide, health insurance data-based study

BackgroundEarly intervention is essential for improving the prognosis in patients with first-episode schizophrenia (FES). The Mental Health Act limits involuntary hospitalization in South Korea to cases where an individual exhibits both a mental disorder and a potential for harming themselves or others, which could result in a delay in the required treatment in FES. We investigated the effect of delay in the first psychiatric hospitalization on clinical outcomes in FES.MethodsThe South Korean Health Insurance Review Agency database (2012–2019) was used. We identified 15,994 patients with FES who had a record of at least one psychiatric hospitalization within 1 year from their diagnosis. A multivariate linear regression model and a generalized linear model with a gamma distribution and log link were used to examine associations between the duration from the diagnosis to the first psychiatric admission and clinical outcomes as well as direct medical costs after 2 and 5 years.ResultsWithin both the 2-year and the 5-year period, longer durations from the diagnosis to the first psychiatric admission were associated with an increase in the number of psychiatric hospitalizations (2-y: B = 0.003, p = 0.003, 5-y: B = 0.007, p = 0.001) and an increase in direct medical costs (total: 2-y: B = 0.005, p < 0.001, 5-y: B = 0.004, p = 0.005; inpatient care: 2-y: B = 0.005, p < 0.001, 5-y: B = 0.004, p = 0.017).ConclusionsEarlier psychiatric admission from the diagnosis is associated with a decrease in the number of psychiatric admissions as well as in direct medical costs in patients with FES.

The trajectory of putative astroglial dysfunction in first episode schizophrenia: a longitudinal 7-Tesla MRS study

Myo-inositol is mainly found in astroglia and its levels has been shown to be reduced in the anterior cingulate cortex (ACC) of patients with schizophrenia. We investigate the status of astroglial integrity indexed by ACC myo-inositol at the onset and over the first 6 months of treatment of first episode schizophrenia. We employed 7 T magnetic resonance spectroscopy (1H-MRS) and quantified myo-inositol spectra at the dorsal ACC in 31 participants; 21 patients with schizophrenia with median lifetime antipsychotic exposure of less than 3 days, followed up after 6 months of treatment, and 10 healthy subjects scanned twice over the same period. We studied the time by group interaction for myo-inositol after adjusting for gender and age. We report significant reduction in myo-inositol concentration in the ACC in schizophrenia at an early, untreated state of acute illness that becomes insignificant over time, after instituting early intervention. This trajectory indicates that dynamic astroglial changes are likely to operate in the early stages of schizophrenia. MRS myo-inositol may be a critical marker of amelioration of active psychosis in early stages of schizophrenia.

Association of Aripiprazole With Reduced Hippocampal Atrophy During Maintenance Treatment of First-Episode Schizophrenia: Erratum.

Association of Aripiprazole With Reduced Hippocampal Atrophy During Maintenance Treatment of First-Episode Schizophrenia: Erratum.

Which Subgroup of First-Episode Schizophrenia Patients Can Remit During the First Year of Antipsychotic Treatment?

ObjectiveTo investigate the persistent remission rate (PRR) and its predictors within the first year of antipsychotic treatment in first-episode schizophrenia (FES) patients.MethodsIn a sample of 301 FES patients who remained in antipsychotic treatment for 1 year, we assessed symptoms with the Positive and Negative Syndrome Scale (PANSS), cognition in six domains and functioning with the Personal and Social Performance Scale (PSP).ResultsIn total, 75.4% (227/301) of FES patients remaining in antipsychotic treatment reached persistent remission (PR) in one year. The PSP score was higher in remitters than non-remitters at the endpoint of the 1-year follow-up (P <0.0001). The PANSS negative score—but not the PANSS total score, positive score or general psychopathological score; PSP score; or cognitive performance at baseline—was negatively associated with PR. Lower scores for “abstract thinking” and “stereotyped thinking” were independent predictors of PR.ConclusionsIn FES, nearly 3/4 patients could achieve PR with 1 year of antipsychotic treatment, and having fewer negative symptoms, especially thinking and volition symptoms, can predict PR.Clinical Trial Registrationwww.ClinicalTrials.gov, identifier NCT01057849.

Efficacy of Sulpiride and Risperidone in the Treatment of First-episode Schizophrenia

Efficacy of Sulpiride and Risperidone in the Treatment of First-episode Schizophrenia

Predictors of psychosis breakthrough during 24 months of long-acting antipsychotic maintenance treatment in first episode schizophrenia

BackgroundSome patients develop breakthrough psychotic symptoms on antipsychotic maintenance medication (BAMM), despite receiving therapeutic antipsychotic doses to which they previously responded. MethodsWe examined the occurrence of BAMM in previously minimally treated first-episode patients with schizophrenia-spectrum disorders who were treated according to a standard protocol with a long-acting injectable antipsychotic and regularly assessed over 24 months. ResultsOf 99 patients (age = 24.1 ± 6.5 years, male = 73.7%) who received treatment for ≥6 months (mean follow-up = 20.0 ± 6.5 months) and had responded well to treatment, 21 (21.2%) developed BAMM using operationally defined criteria, after a mean of 17.4 ± 6.1 months. Baseline risk factors for BAMM included lower baseline Positive and Negative Syndrome Scale positive symptoms, poorer quality of life in social relationships and higher blood - high-density lipoprotein-cholesterol. Regarding intra-treatment-factors, BAMM was independently predicted by an increase in low-density lipoprotein-cholesterol and current cannabis use. We did not find a relationship between BAMM and cumulative antipsychotic exposure or dose escalation. While symptoms of the BAMM episode were less severe than during the first episode, the post-BAMM treatment response was poorer than that for the first psychotic episode, suggesting a relationship between BAMM and emergent treatment refractoriness. ConclusionsAbout one in five patients with first-episode schizophrenia developed BAMM during the first two years of treatment, despite assured antipsychotic LAI treatment, indicating that this phenomenon is not restricted to the chronic stages of illness. The role of cannabis use and a possible link between BAMM and blood lipids should be further explored.

A Study on the Characteristics of Patients Who do not Recover in the Long-term Treatment of First Episode Schizophrenia

A Study on the Characteristics of Patients Who do not Recover in the Long-term Treatment of First Episode Schizophrenia

Service Use Following First-Episode Schizophrenia Among Commercially Insured Youth.

To investigate patterns of mental health service and antipsychotic use following a first-episode schizophrenia (FES) and to examine the role of the treatment setting in which individuals are first diagnosed. Analysis of de-identified administrative claims data from the OptumLabs Data Warehouse was used to identify 1450 privately insured youth and young adults aged 14 through 30 with FES from January 1, 2011 through December 31, 2015. Regression analysis was used to estimate the use of mental health services during the year following FES, by type of service and by site of index diagnosis. In the year following FES, 79.7% of youth received outpatient mental health services and 35.8% filled a prescription for antipsychotic medication. Among service users, mean outpatient visits were 15.9 and mean antipsychotic fills were 8.3. Youth who received an index diagnosis of FES in an inpatient setting were more likely to fill an antipsychotic medication than youth with FES in other settings. Youth who received an index diagnosis of FES during a specialty mental health outpatient visit had greater use of outpatient mental health than youth who received their diagnosis during a primary care visit. Despite evidence-based guidelines supporting outpatient psychosocial care and antipsychotic treatment for FES, one-fifth of this cohort did not use outpatient services and the majority did not fill any prescriptions for antipsychotic medications during the year following FES. Our findings provide renewed urgency to ongoing efforts to accelerate early identification and care coordination for youth with FES.

Rates and predictors of one-year antipsychotic treatment discontinuation in first-episode schizophrenia: Results from an open-label, randomized, “real world” clinical trial

Antipsychotic treatment discontinuation is a major challenge in the treatment of first-episode schizophrenia (FES) patients. However, the rate and predictors remain unclear. Five hundred and sixty-nine FES patients were randomized to risperidone (n = 190), olanzapine (n = 185) or aripiprazole (n = 194) in a six-site study in China with 1-year follow-up. Patients failing the initially assigned antipsychotic were switched to one of the other 2 antipsychotics. By 52 weeks, 47.1% of FES patients discontinued all antipsychotics. In the 8-week acute phase, an antipsychotic switch was protective against antipsychotic discontinuation, whereas higher positive symptoms at the endpoint predicted discontinuation. In the maintenance phase, discontinuation was predicted by male gender and higher CGI-S score at the endpoint. The findings indicate that in China nearly half of patients with FES discontinued antipsychotic treatment during one year treatment. Clinicians should employ strategies other than medication choice to keep them from discontinuing.

PMH7 - Finding Early Improvement Threshold to Predict Response After 8 Weeks of Treatment Using Olanzapine in First-Episode Schizophrenia

Presently, schizophrenia guidelines recommend waiting for 8 weeks before considering a patient as non-responder. This study aims to assess whether the early response (week 2,3 and 4) can predict the outcome at 8th week for the treatment of first episode schizophrenia (FES) using olanzapine. A prospective observational study was conducted in 36 adult FES patients with four points follow up (week 2,3,4 and 8). Patients with any other psychiatric co-morbidities and/or taking any antipsychotics were excluded from the study. A reduction of 25% in PANNS score from the base line at week 3 and 30% at week 4 were considered as early response. A reduction of 50% at week 8 was considered as responders. Receiver Operating Characteristics (ROC) curves were implemented to detect the optimal threshold of early response (AUC>80%) at 2nd, 3rd and 4th weeks. To identify the variables that are predictive of treatment responses at Week 8, binary logistic regression was performed. The mean total PANSS baseline score of the study population was 106.66 (95% C.I, 100.4-112.9). Week 2 (AUC=50.5, P=0.964) and week 3 (AUC=64.9, P=0.136) responses failed to predict the 8th week response. Week 4 response (AUC = 92%, P<0.001) can be taken for the prediction of 8th week response (specificity=72%, sensitivity=100%, Positive Predictive Value=61.1%, Negative Predictive Value=100% and OER was <29.4% reduction). 25 patients (69%) achieved more than 50% reduction (responders) in PANSS score after 8 weeks of treatment. Independent predictors for good treatment responses at Week 8 were female gender (P=0.032), a higher educational level(P=0.021) and non-smoking(P=0.014) and non-alcoholics (P=0.048). Our study suggests that patients with early response at week 4 are likely to achieve positive response after 8 weeks. This may help in appropriate clinical decision making for early non-responders.

20-Year Nationwide Follow-Up Study on Discontinuation of Antipsychotic Treatment in First-Episode Schizophrenia.

It is generally believed that after the first episode of schizophrenia, the risk of relapse decreases with time in patients who are stabilized. Many treatment guidelines recommend that after stabilization, antipsychotic treatment should be continued for 1-5 years, and longer exposure should be avoided if possible. However, there is no published evidence to substantiate this view. The authors used nationwide databases to investigate this issue. Prospectively gathered nationwide register data were used to study the risk of treatment failure (psychiatric rehospitalization or death) after discontinuation of antipsychotic treatment. Multivariate Cox regression was used to assess outcomes among all patients hospitalized for the first time with a schizophrenia diagnosis in Finland during the period of 1996-2014 (N=8,719). The lowest risk of rehospitalization or death was observed for patients who received antipsychotic treatment continuously (adjusted hazard ratio=1.00), followed by patients who discontinued antipsychotic use immediately after discharge from the first hospital treatment (hazard ratio=1.63, 95% CI=1.52-1.75), within 1 year (hazard ratio=1.88, 95% CI=1.57-2.24), within 1-2 years (hazard ratio=2.12, 95% CI=1.43-3.14), within 2-5 years (hazard ratio=3.26, 95% CI=2.07-5.13), and after 5 years (a median of 7.9 years) (hazard ratio=7.28, 95% CI=2.78-19.05). Risk of death was 174%-214% higher among nonusers and patients with early discontinuation of antipsychotics compared with patients who received antipsychotic treatment continuously for up to 16.4 years. Whatever the underlying mechanisms, these results provide evidence that, contrary to general belief, the risk of treatment failure or relapse after discontinuation of antipsychotic use does not decrease as a function of time during the first 8 years of illness, and that long-term antipsychotic treatment is associated with increased survival.

Comparison of social function, adverse reaction and medication adherence of Paliperidone, Amisulpride and Olanzapine in patients with first-episode schizophrenia

Objective To investigate the social function, adverse reaction and medication adherence of paliperidone, amisulpride, and olanzapine in patients with first episode schizophrenia. Methods A total of 96 patients with first episode of schizophrenia was randomly divided into three groups, with reference to random numbers, among which there were 32 in paliperidone group, 32 cases in amisulpride group, and 32 in olanzapine group. All the patients in all groups were assessed with negative and positive scale (PANSS), personal and social performance scale (PSP), drug attitude inventory (DAI) at baseline and the end of 6 months. Results ⑴ There was no significant difference in the therapeutic effect between three groups (P>0.05); ⑵ The scores of PSP and DAI were increased in three groups after treatment, and the difference was statistically significant compared to that before treatment (P<0.05). Conclusions Three drugs have similar efficacy in the treatment of first-episode schizophrenia, and there is no significant difference in improving medication compliance and social function. Key words: Antipsychotic agents/TU; Isoxazoles/AA; Isoxazoles/TU; Benzodiazepines/TU; Schizophrenia/DT; Treatment outcome

Effects of different antipsychotics on sugar, lipid metabolism and body mass in female patients with first-episode schizophrenia

Objective To study the effects of atypical antipsychotic drugs on glucose and lipid metabolism and body weight in female patients with schizophrenia. Methods 120 patients with schizophrenia were randomly divided into three groups according to the number randomized method.Group 1(olanzapine group) was treated with olanzapine, group 2(ziprasidone group) was treated with ziprasidone, group 3(risperidone group) was treated with risperidone.The total cholesterol (TC), triglyceride (TG) and body mass index (BMI) in the three groups were analyzed retrospectively. Results After treatment for 8 weeks, the fasting blood glucose of the olanzapine group and risperidone group increased significantly compared with before treatment, the differences were statistically significant(t=-2.81, P 0.05). After treatment for 8 weeks, the BMI of the olanzapine group and risperidone group had statistically significant difference compared with before treatment(t=-3.62, P 0.05). After treatment for 8 weeks, the TG, TC levels of the olanzapine group had statistically significant differences compared with before treatment (t=-3.89, P 0.05; t=-1.06, P>0.05; t=-0.55, P>0.05; t=-0.62, P>0.05). Conclusion Ziprasidone in the treatment of female first episode schizophrenia, has less influence on sugar, lipid metabolism and weight, with high compliance and more advantages compared with other atypical antipsychotics. Key words: Schizophrenia; Antipsychotics agents; Metabolism; Body weight; Female

Efficacy and Metabolic Influence on Blood-Glucose and Serum Lipid of Ziprasidone in the Treatment of Elderly Patients with First-Episode Schizophrenia.

BackgroundAs the age of the population in China rises, the occurrence of first-episode of schizophrenia in elderly persons is also gradually increasing. However, studies examining selection of therapeutic drugs for this population are relatively few.ObjectiveTo examine the therapeutic efficacy and metabolic influence on blood-glucose and serum lipid of ziprasidone in the treatment of elderly patients with first-episode schizophrenia.MethodsUsing randomized grouping, 38 elderly patients with first-episode schizophrenia were randomly divided into the ziprasidone treatment group (i.e. the study group) and the olanzapine treatment group (i.e. the control group), with 19 cases in either group respectively. The positive and negative symptoms scale (PANSS) was used to evaluate the efficacy, and adverse drug reaction scale (TESS) was used to evaluate adverse drug reactions, at the points prior to the treatment, at the end of 4th, 8th, and 12th weeks of treatment, respectively. Fasting blood glucose (FBG), total cholesterol (TC), triglyceride (TG), and low density lipoprotein (LDL-c) were also measured.ResultsThere was no significant difference between the two groups in PANSS score at the end of week 4, week 8 and week 12. The curative effect on the two groups was similar. The results of repeated measure ANOVA showed that there were significant differences in FBG (Ftime×group=7.539, p=0.001), TC(Ftime×group=32.194, p<0.001), TG(Ftime×group=488.312, p<0.001), and LDL-c (Ftime×group=9.380, p<0.001)between the study group and the control group across the different time points.ConclusionZiprasidone in the treatment of first episode schizophrenia in elderly patients has efficacy and less effect on blood-glucose and serum lipid metabolism.

Quetiapine in treatment of first episode schizophrenia

IntroductionAlthough there is no cure, schizophrenia is highly treatable disease. Successful first episode schizophrenia (FES) treatment is crucial to minimize personal, vocational and social deterioration. Quetiapine is atypical, second generation antipsychotic, serotonin-dopamine antagonist. Quetiapine is potent blocker of D2, 5HT2A and 5HT1A receptors.ObjectiveTo estimate efficacy of quetiapine in treatment of first episode schizophrenia.MethodsThis study included 70 patients with FES diagnosed by ICD-10 criteria, who are divided into haloperidol (H) 35 patients and quetiapine (Q) group 35 patients. Patients were observed for 6 months in hospital and extra hospital conditions, according to protocol which included Positive and Negative Symptom Schedule Scale (PANSS) and the number of withdrawals attributed to adverse event (AE). Control group was treated with haloperidol 5–20 mg/24 h and experimental group was treated with quetiapine 400–800 mg/24 h.ResultsAverage pretrial PANSS score was 110.1 in quetiapine and 108.5 in haloperidol group. Average PANSS score after 180 days was 50.6 in Q and 60.4 in H group. There is no statistical difference in pretrial scores between groups for PANSS score (P = 0.647). There is significant statistical difference in PANSS score reduction after 180 days in both groups (P &lt; 0.001). There is significant statistical difference in PANSS score reduction between Q and H group after 180 days (P &lt; 0.001). Overall, 8.6% AEs occurred in Q, and 25.8% in H group.ConclusionQuetiapine has shown better efficacy in treatment of FES comparing to haloperidol, with statistically significant lower adverse effects rate.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Joint Decision Making and Reduced Need for Compulsory Psychiatric Admission

The article by de Jong et al1 in this issue of JAMA Psychiatry raises fundamental questions about the practice of psychiatry. In essence, the review finds that advance statements can reduce the occurrence of compulsory admissions by approximately one-quarter, while community treatment orders, medication compliance enhancement, and integrated treatment measures were ineffective in reducing compulsory admissions. Why is this issue important? Writing in On Liberty, John Stuart Mill differentiated between liberty as the freedom to act and liberty as the absence of coercion. Yet, it is clear that inmost countries of theworld (whether codified and regulated by law or not) measures to treat people withmental illness on a basis of compulsory admissions are used and are sometimes commonly used. Within the psychiatric profession, therehasbeenanuneasyelisionbetween theduty tocare forpatientsandtheresponsibilitytoact forsociety,onwhosebehalfphysiciansoftenusecompulsoryadmissions (eg, toprotect the public from risk by peoplewho arementally unwell). Variouswordinghasbeenusedtotry toreconcile theseseparateand oftencontradictory roles, suchas theprovisionof the“least restrictive alternative” formof treatment by the physician. This dual professional role is now subject to a profound challenge from the United Nations Convention on the Rights of PersonsWithDisabilities (CRPD).2 Amongmany other provisions, the CPRDmakes clear that direct decisionmaking by patients and forms of supported decisionmaking are permissibleunder the convention, but that substituteddecisionmaking (which is the essence of compulsory treatment decisions by psychiatrists) is not allowed. Because the CPRD has now been signedby 159 countriesworldwide and ratified (made legally binding) by 151, a vital question arises over whether the traditional practices of psychiatrists’ exercising legally authorizedordefactopowersofcompulsoryadmissions, inbothhospital and community settings, are compatible with the CRPD or not.3 These considerations are complex issues that need to respect the fundamental human rights of all persons, including those with disabilities. They also need to take into account theday-to-dayclinicaldilemmas facedbystaffwho treat and care for people who at timesmay lackmental capacity in specific domains andwho, for example,mayactively threaten toharmthemselvesorothers.Therefore, theresponsible implementationof theCRPD is a pressing international challenge to the mental health sector. Against this background, the article by de Jong et al1 adds important evidence to support these debates on how to reduce compulsory admissions in mental health care. The authors tested the following 4 candidate interventions to reduce compulsoryhospital admissions: community treatment orders (sometimes called involuntary outpatient commitment) (3studies), complianceenhancement techniques (2studies), and augmentation of standard care (which they termed integrated treatment) (4 studies), alongside assessing the effect of advance statements (including advance directives and joint crisisplans [JCPs]) (4 studies).For the first 3options, there was no evidence that they were effective. Admittedly, the samplesize foreachcategorywassmall, andarguably theyeach contained somewhat heterogeneous interventions. For example, integrated treatment included several different types of augmented standard care, namely, crisis resolution teams, integrated treatment in first-episode schizophrenia, and psychoeducation. For the community treatment orders and compliance enhancement interventions, these studies (both individually and when analyzed by group) also demonstrated no evidence of benefit, as shown in the forest plot in the article by de Jong et al.1 Yet, advance statements showed a 23% risk reduction in compulsory admissions. The term advance statements covers a rangeof decision-making interventions,whichvarywith respect to their basis in legislation and the manner in which health professionals are involved in their creation.4 Advance directives lie at one extreme of this range because their content is determined solely by the patient or consumer. In the United States, supporting people to create a psychiatric advance directive is viewed as a component of recoveryoriented treatmentplanning, and indeed thesedirectivesmay have the power of law. Psychiatric advance directives aim to promoteconsumerchoice,prioritize thegoalof autonomy,and improve the working alliance withmental health professionals. However, they have not been shown to have an effect on ratesof involuntaryhospitalization.Themost likely reason for this observation is that they are enactedonlywhen theholder is deemed to have lost capacity tomake treatment decisions, are onlyused at a late stage of a relapse of illness, andmaynot be able to prevent such admissions. Routine treatment or care plans lie at the other, more paternalistic, end of the crisis planning spectrum because they may be produced without any patient or consumer involvement, although by consensus it is not seen as good practice. This formof treatmentplanninghasgenerallyactedas thecontrol in trials of other types of advance statements. In addition to advanced statement and care plans, the third type of such advance statements includes JCPs, which lie toward the cenRelated article page 657 Opinion

Subjective experience of diagnosis and treatment in two adolescents with first-episode schizophrenia

The results of a qualitative study on the subjective experience of two adolescents in treatment for first-episode schizophrenia (FESZ) are presented here. We reconstructed the relevant aspects of the diagnosis and treatment processes based on the elaboration of said experience carried out by the participants. We therefore incorporated the perspective of the patients, family members and psychotherapists. The recovery from FESZ, understood as a positive adaptation to the experience of psychosis, is closely connected with the possibility of the adolescent to re-embark on his/her biographical trajectory. In this sense, the concept of recovery from FESZ increasingly emphasizes the subjective dimension of this process. The aim of the study is to understand the subjective experience of diagnosis and treatment processes from the perspective of two patients with FESZ who received comprehensive treatment in the Chilean public health system, their family members and their psychotherapists. The study performed semi-structured interviews and a qualitative content analysis in order to understand and describe, from their perspectives, the subjective experiences associated with the processes of diagnosis and treatment of FESZ. The inclusion of patients, relatives and psychotherapists allowed complementing the perspectives on the phenomenon under study. The results suggest that the central phenomena of appropriation of FESZ and resistance to the appropriation of FESZ are relevant in the accounts of these two cases. The family’s emotional climate associated with the experience of FESZ converge in these phenomena, as well as the participation of the adolescent in the processes of diagnosis and treatment, specifically as these processes favor or hinder an appropriation of the psychopathological experience and this enables the reestablishment of the autobiographical continuity. Appropriation of FESZ seems to rely on future prospects that preserve some possibility of performing prior potentialities and expectations, or at least to adapt them in a tolerable way for the adolescents and their environment. Such findings highlight the relevance of developing interventions that encourage more hopeful future perspectives for individuals facing a first psychotic episode and their families.