Disorders - Psychosis Disorders
Morrison, A. P., Pyle, M., Stewart, S. L. K., French, P., Byrne, R., Flach, C., Birchwood, M., Fowler, D., Jones, P., Gumley, A.
Internalised stigma in young people meeting criteria for at risk mental states (ARMS) has been highlighted as an important issue, and it has been suggested that provision of cognitive therapy (CT) may increase such stigma. 288 participants meeting criteria for an at risk mental state were recruited as part of a multisite randomised controlled trial of cognitive behavioural therapy for people meeting criteria for ARMS (the EDIE-2 trial). Participants were assessed at baseline and at six, twelve, eighteen and twenty-four months using measures of psychotic experiences, depression, social anxiety and internalised stigma. The Personal Beliefs about Experiences Questionnaire (PBEQ) was validated for use within our ARMS sample. Correlational analyses at baseline indicated significant relationships between internalised stigma and (1) depression, (2) social anxiety (3) distress associated with unusual psychological experiences and (1) suicidal thinking. Regression analysis indicate negative appraisals of unusual experiences contributed significantly to depression scores at 6 month follow up, when controlling for baseline depression and unusual psychological experiences. Changes in internalised stigma were analysed using random effects regression (ANCOVA) adjusted for site and baseline symptoms on an intention-to-treat basis. Negative appraisals of experiences were significantly reduced in the group assigned to CT (estimated difference at 12 months was -1.36 (95% CI -2.69 to -0.02), p=0.047). There was no difference in social acceptability of experiences (estimated difference at 12 months was +0.46 (95% CI -0.05 to +0.98), p=0.079). These findings suggest that internalised stigma may contribute to the development and maintenance of depression in young people at risk of psychosis. They also suggest that, rather than increasing internalised stigma, CT decreases negative appraisals of unusual experiences in young people at risk of psychosis; as such, it is a non-stigmatising intervention for this population.
Schizophrenia Research, 153 : S42
- Year: 2014
- Problem: Psychosis Disorders
- Type: Randomised controlled trials
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Stage: At risk (indicated or selected prevention)
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Treatment and intervention: Psychological Interventions (any)
, Cognitive & behavioural therapies (CBT)
Molina, V., Taboada, D., Aragues, M., Hernandez, J. A., Sanz-Fuentenebro, J.
Cortical thickness may be useful as a treatment response predictor in first-episode (FE) patients with schizophrenia, although this possibility has been scarcely assessed. In this study we assessed the possible relation between cortical thickness in regions of interest selected because of previously reported structural alterations in schizophrenia and clinical and cognitive changes after two years of treatment with risperidone or clozapine in 31 neuroleptic-naïve FE patients with schizophrenia (16 of them treated with clozapine and 15 with risperidone). Using the last-observation-carried-forward (LOCF), a larger improvement in positive, negative and total symptoms was predicted by the amount of baseline cortical thinning in the right prefrontal cortex (pars orbitalis). After two years of treatment, cognitive status was reassessed in the 17 patients (11 on clozapine) who had not dropped out. Working memory improvement after reassessment was associated with a greater baseline cortical thinning in the left prefrontal cortex (pars orbitalis), and verbal memory improvement with a greater baseline cortical thinning in the left pars triangularis. Significant but weak cortical thickness decrease from baseline to follow-up was observed in patients in comparison to controls (left pars triangularis and opercularis, and left caudal middle frontal areas). These results may support a positive predictive role for cortical thinning in the frontal region with regard to clinical and cognitive improvement with clozapine and risperidone in FE patients with schizophrenia. © 2014 Elsevier B.V.
Schizophrenia Research, 158(1-3) : 223-229
- Year: 2014
- Problem: Psychosis Disorders
- Type: Randomised controlled trials
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Stage: First episode (psychosis only)
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Treatment and intervention: Biological Interventions (any)
, Atypical Antipsychotics (second generation)
Yuan, Y., Yang, F., Lu, Z., Wang, C. Y., Deng, H., Zhao, J., Yu, X.
Background: It was well known that different atypical antipsychotics had similar efficacy for acute phase treatment in first-episode schizophrenic patients. The troublesome problem for clinicians is how to keep the patients in their treatment as long as possible until full recovery. We compared the effectiveness of three atypical antipsychotic-initiated treatments (risperidone-, olanzapine-or aripiprazole-initiated) on treatment discontinuation for all cause during 12 months of follow-up. Methods: We did an open randomized controlled trial of three atypical antipsychotic-initiated treatments in 6 sites located in 4 cities of China. Eligible patients were aged 16-45 years, and fulfilled DSM-IV diagnostic criteria for schizophrenia ascertained by SCID-I/P. A total of 600 unselected first-episode patients were randomly assigned to risperidone (2-6 mg per day; n=200), olanzapine (5-20 mg per day; n=200), or aripiprazole (10-30 mg per day; n=200); for those patients with poor efficacy or intolerable side effects (including obvious weight gain), they will be changed into second single-drug stage using another different drug from risperidone, olanzapine or aripiprazole; and then the third stage using any other antipsychotics including clozapine, add-ons or combinations; follow-up was at 1 year. The primary outcome measure was treatment discontinuation for any cause. Analysis was by intention to treat. Results: The proportion of patients (Kaplan-Meier estimate) who discontinued treatment after three stages within 12 months was 25.1% for risperidone-initiated group, 26.5% for olanzapine-initiated group, and 31.1% for aripiprazole-initiated group, but without no significant difference. Discussion: This trial suggests that whatever the types of initiated atypical antipsychotic, a clinically satisfactory treatment retention rate for first-episode schizophrenic patients is achievable for at least 1 year.
Schizophrenia Research, 153 : S218
- Year: 2014
- Problem: Psychosis Disorders
- Type: Randomised controlled trials
-
Stage: First episode (psychosis only)
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Treatment and intervention: Biological Interventions (any)
, Atypical Antipsychotics (second generation)
Schneider, C., Corrigall, R., Hayes, D., Kyriakopoulos, M., Frangou, S.
Background: The use of clozapine (CLZ) for treatment-resistant schizophrenia is well established in adults. However, it is seldom used in youth with early onset schizophrenia (EOS) largely because of lack of clarity about its risk benefit ratio. This review synthesises and evaluates available evidence regarding the efficacy and tolerability of CLZ in EOS with the aim to assist clinical decision-making. Methods: We conducted a systematic review of the primary literature on the clinical efficacy and adverse drug reactions (ADRs) observed during CLZ treatment in EOS. We also identified relevant practice guidelines and summarised current guidance. Results: CLZ showed superior efficacy than other antipsychotics in treating refractory EOS patients; short-term clinical trials suggest an average improvement of 69% on the Brief Psychiatric Rating Scale that was sustained during long-term follow-up (up to 9 years). No fatalities linked to CLZ treatment were reported. Sedation and hypersalivation were the most common complaints, reported by over 90% of patients. Other common ADRs (reported in 10-60% of patients) were enuresis, constipation, weight gain, and non-specific EEG changes. Less common ADRs (reported in 10-30% of patients) were akathisia, tachycardia and changes in blood pressure. Neutropenia was reported in 6-15% of cases but was usually transient while agranulocytosis was rare (< 0.1%). Seizures were also uncommon (< 3%). Metabolic changes were relatively common (8-22%) but emergent diabetes was not frequently observed (< 6%). Overall the rate of discontinuation was low (3-6%). Current guidelines recommend the use of CLZ in EOS patients who have failed to respond to two adequate trials with different antipsychotics and provide detailed schedules of assessments to evaluate and assess potential ADRs both prior to initiation and throughout CLZ treatment. Conclusion: Available data although limited in terms of number of studies are consistent in demonstrating that CLZ is effective and generally safe in the treatment of refractory EOS provided patients are regularly monitored (PsycINFO Database Record (c) 2014 APA, all rights reserved) (journal abstract).
European Psychiatry, 29(1) : 1-10
- Year: 2014
- Problem: Psychosis Disorders
- Type: Systematic reviews
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Stage: Disorder established (diagnosed disorder)
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Treatment and intervention: Biological Interventions (any)
, Atypical Antipsychotics (second generation)
Zdanowicz, N., Mees, L., Jacques, D., Tordeurs, D., Reynaert, C.
Background: When psychosis first presents, and particularly in the case of schizophrenia, the guidelines recommend rapid institution of treatment with atypical antipsychotics. Two different clinical pictures can be observed: psychoses with acute onset and those with insidious onset. Acute cases (60% of the total) have a favourable course in 85% of young patients but where onset is insidious and the symptoms are predominantly negative, the course is poor in 25% of subjects. Since acute symptoms are relatively easy to diagnose, it is diagnosis of the "insidious/negative" cases that represents a major challenge. Is such a diagnosis possible yet? How can we limit the number of false negatives and false positives with the attendant risk of stigma? What treatment should be administered? Methods: Review of the literature (PubMed, PsycARTICLES, PsycINFO) and comparison with clinical practice here. Results: Young people with a high risk of developing psychosis can be identified using scales such as SOPS (Scale of Prodromal Symptoms), PACE (Personal Assessment and Crisis Evaluation) or from the presence of neuroanatomical and genetic characteristics. Unfortunately, these tools are more specific for positive symptoms, and therefore identify a sub-population of young people at risk: those at Ultra-High Risk (UHR). It can be argued that effective treatment is available for these UHR young people to prevent the condition from developing into schizophrenia. On the other hand, the problem persists for young people presenting an insidious onset and predominantly negative symptoms: to date we have no real way of either screening them or assessing the efficacy of a treatment. Conclusion: "Ultra-High Risk" patients are starting to represent a separate nosological entity. This entity is made up of young patients, most of whom have positive symptoms. If left untreated, the course will lead to seriously compromised social and psychological functioning. Rapid diagnosis and treatment for UHRs is therefore essential. In the future we need to refine our diagnostic tools to make them sufficiently specific and sensitive but also so that the widest category of "Risk Syndrome for Psychosis" includes young patients with mostly negative symptoms. (PsycINFO Database Record (c) 2014 APA, all rights reserved) (journal abstract).
Psychiatria Danubina, 26(2) : 115-121
- Year: 2014
- Problem: Psychosis Disorders
- Type: Systematic reviews
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Stage: At risk (indicated or selected prevention)
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Treatment and intervention: Biological Interventions (any)
, Psychological Interventions (any)
Zhang, Z., Zhai, J., Wei, Q., Qi, J., Guo, X., Zhao, J.
Background: A combination of psychosocial interventions and medications has been highly recommended as a successful treatment package for schizophrenia. Its cost-effectiveness has not been fully explored yet. The aim of the present analysis was to evaluate the cost-effectiveness of antipsychotics combined with psychosocial treatment and treatment as usual for patients with early-stage schizophrenia. Method: Patients with schizophrenia (N = 1, 268) were assigned to the combination of medication and psychosocial intervention or treatment as usual for up to 12 months. Cost analysis included direct medical costs, direct nonmedical costs and indirect costs. Quality-adjusted life year (QALY) ratings were assessed with Short- Form 6D. Results: Average monthly psychosocial intervention costs for combined treatment were higher than treatment as usual (p = 0.005), but no significant differences were found in direct costs, indirect costs, and total costs between two groups (all p-values > 0.556). Combined treatment was associated with significant higher QALY ratings than treatment as usual (p = 0.039). Compared with treatment as usual, combined treatment resulted in a gain of 0.031 QALY ratings at an additional cost of US$ 56.4, yielding an incremental cost-effectiveness ratio of US$ 1819.4 per QALY gained. Conclusions: Despite some limitations, our results supported that medication combined with psychosocial treatment was more cost-effective than treatment as usual for patients with early-stage schizophrenia. Trial registration: clinicaltrials.gov Identifier: NCT00654576 (PsycINFO Database Record (c) 2014 APA, all rights reserved) (journal abstract).
BMC Psychiatry, 14 : 212
- Year: 2014
- Problem: Psychosis Disorders
- Type: Randomised controlled trials
-
Stage: Disorder established (diagnosed disorder)
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Treatment and intervention: Biological Interventions (any)
, Typical Antipsychotics (first generation)
, Atypical Antipsychotics (second generation)
, Psychological Interventions (any)
, Cognitive & behavioural therapies (CBT)
, Psychoeducation, Skills training, Other Psychological Interventions
Zhou, F-C., Xiang, Y-T., Wang, C-Y., Dickerson, F., Kreyenbuhl, J., Ungvari, G. S., Au, R. W., Zhou, J-J., Zhou, Y., Shum, D., Man, D., Lai, K. Y., Tang, W-K., Yu, X., Chiu, H. F.
Purpose: The study examined the rate of remission in individuals experiencing a first episode of schizophrenia (FES) in China and explored predictors of remission in the acute phase of the illness. Design and Methods: Fifty-five FES patients were randomly treated with risperidone, olanzapine, or aripiprazole at therapeutic doses for 8 weeks, and their clinical profiles and cognition were assessed using standardized assessment instruments at entry and the end of the study. Findings: Of the 55 patients, 30 (54.5%) remitted by the end of the 8-week study. In univariate analyses, shorter duration of untreated psychosis, higher scores on both the time-based prospective memory (TBPM) and event-based prospective memory tasks and the Hopkins Verbal Learning Test-revised, and less severe negative symptoms were significantly associated with remission. In stepwise multiple logistic regression analyses, only higher scores on the TBPM significantly predicted remission. Individuals having higher scores reflecting better TBPM at baseline were more likely to achieve remission after 8 weeks of optimized antipsychotic treatment. Practice Implications: TPBM may be useful in helping clinicians identify those FES patients most likely to achieve a favorable treatment response. (PsycINFO Database Record (c) 2014 APA, all rights reserved) (journal abstract).
Perspectives in Psychiatric Care, 50(2) : 102-110
- Year: 2014
- Problem: Psychosis Disorders
- Type: Randomised controlled trials
-
Stage: First episode (psychosis only)
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Treatment and intervention: Biological Interventions (any)
, Atypical Antipsychotics (second generation)
Zipursky, R. B., Menezes, N. M., Streiner, D. L.
The large majority of individuals with a first episode of schizophrenia will experience a remission of symptoms within their first year of treatment. It is not clear how long treatment with antipsychotic medications should be continued in this situation. The possibility that a percentage of patients may not require ongoing treatment and may be unnecessarily exposed to the long-term risks of antipsychotic medications has led to the development of a number of studies to address this question. We carried out a systematic review to determine the risk of experiencing a recurrence of psychotic symptoms in individuals who have discontinued antipsychotic medications after achieving symptomatic remission from a first episode of non-affective psychosis (FEP). Six studies were identified that met our criteria and these reported a weighted mean one-year recurrence rate of 77% following discontinuation of antipsychotic medication. By two years, the risk of recurrence had increased to over 90%. By comparison, we estimated the one-year recurrence rate for patients who continued antipsychotic medication to be 3%. These findings suggest that in the absence of uncertainty about the diagnosis or concerns about the contribution of medication side effects to problems with health or functioning, a trial off of antipsychotic medications is associated with a very high risk of symptom recurrence and should thus not be recommended. (PsycINFO Database Record (c) 2014 APA, all rights reserved) (journal abstract).
Schizophrenia Research, 152(2-3) : 408-414
- Year: 2014
- Problem: Psychosis Disorders
- Type: Systematic reviews
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Stage: Relapse prevention, First episode (psychosis only)
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Treatment and intervention: Biological Interventions (any)
, Typical Antipsychotics (first generation)
, Atypical Antipsychotics (second generation)
, Medication dose reduction/discontinuation
Malla, A., Joober, R., Iyer, S., Schmitz, N., Norman, R., Brown, T., Jarvis, E., Abdel-Baki, A., Margolese, H.
In this presentation, two challenges, namely, failure to infl uence pathways to care and optimum length of EI service, will be addressed. Most patients with a first episode of psychosis (FEP) make their first contact with primary care services but few get into an EI service directly, resulting in systemic delay. We report the results of a study evaluating the impact of direct training of all potential points of contact by new patients on the referral portion of duration of untreated psychosis (DUP-R). Following the intervention, the number of referrals from primary care services (health and education) increased substantially but majority of these did not have a FEP; DUP-R remained longest for patients referred from primary care and shortest for patients presenting directly to the hospital emergency service; there was little change in the pathways to care for patients who presented first to primary care; and patients with very long DUP were younger and most likely to have been referred from primary care. For the challenge of duration of EI service, we will present the methodology and preliminary results of a single blind RCT comparing extension of an EI service (N = 111) from 2 to 5 years compared to routine care (N = 109), following first 2 years of EI service. Preliminary data suggest that a higher proportion of patients drop out of the routine care arm (51/109, 47%) compared to the EI (16/108, 15%) arm and obstacles in transferring patients to routine care and its signifi- cance for interpretation of results are discussed.
Early Intervention in Psychiatry, 8 : 10
- Year: 2014
- Problem: Psychosis Disorders
- Type: Randomised controlled trials
-
Stage: Disorder established (diagnosed disorder)
, First episode (psychosis only)
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Treatment and intervention: Service Delivery & Improvement, Other service delivery and improvement interventions
Killackey, E., Allott, K., Cotton, S., Chinnery, G., Jackson, H.
Background: Young people with mental illness, especially those with firstepisode psychosis (FEP), nominate employment as a number one goal. Despite this in most places, young people with psychosis have high rates of unemployment at entry to service and these rates increase rapidly. Individual placement and support (IPS) is an employment intervention with a growing evidence base in FEP. Method: IPS was compared to high-quality early psychosis treatment as usual (TAU) for 146 young people attending an FEP clinic in Melbourne, Australia. Assessments were conducted a four time points baseline, 6 months (end of intervention) and 18 months. Results: The IPS group achieved higher employment and education rates, although this was only significant for employment at 6 months end of intervention (71.6% vs 47.5%, p = 0.005). Interestingly, the control group achieved outcomes that mimic IPS intervention groups in other RCTs. Results were maintained across the follow-up period with 52.5% and 64.2% in the TAU and IPS groups, respectively. When education was factored in 75.4%, and 81.8% of the TAU and IPS groups, respectively, were either in education, training or employment at 18 months. Conclusion : IPS produced a significant early benefit in terms of employment. This advantage was lost over time, however. Overall, participants in both groups had outcomes significantly better than those in routine early psychosis settings and those in non-specialised mental health settings.
Early Intervention in Psychiatry, 8 : 152
- Year: 2014
- Problem: Psychosis Disorders
- Type: Randomised controlled trials
-
Stage: First episode (psychosis only)
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Treatment and intervention: Service Delivery & Improvement, Individual placement and support (IPS), vocational interventions
Killackey, E., Jackson, H., Allott, K., Cotton, S.
Background: Vocational recovery has been consistently shown to be a number-one priority of people with mental illness generally, and schizophrenia and first episode psychosis (FEP) specifically. Two previous randomised controlled trials (RCT) demonstrated the benefit of an employment intervention called Individual Placement and Support (IPS) for young people with FEP. The current study was conducted in order to examine not only the vocational benefits of such an approach, but to study a wide range of predictors and consequences of vocational recovery in FEP Methods: 146 young people with FEP were recruited to a RCT of IPS versus treatment as usual at the Early Psychosis Prevention and Intervention Centre (EPPIC) in Melbourne. Those randomised to IPS received 6 months of vocational intervention with a specialist employment consultant. Follow up assessments occurred at 6, 12 and 18 months post baseline. The aims of this presentation will be to present the data pertaining to the vocational recovery at the 6 month time point of this study. Results: In terms of studying at the six month time point there was no difference between the two groups (χ2(1)=2.08, p=0.149), nor of the number currently in paid work on the day of assessment at 6 months. (χ2(1)=3.42 p=0.065). However, when employment over 6 months was compared there was a difference (χ2(1)=5.74, p=0.017). Discussion: The preliminary results of this study indicate that IPS is effective at getting people into employment.
Schizophrenia Research, 153 : S282
- Year: 2014
- Problem: Psychosis Disorders
- Type: Randomised controlled trials
-
Stage: First episode (psychosis only)
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Treatment and intervention: Service Delivery & Improvement, Individual placement and support (IPS), vocational interventions
Klein, C., Bespalov, A.
Introduction: Typical and atypical antipsychotics are efficacious treatments for early-onset schizophrenia (EOS) with very subtle differences in their efficacy. Therefore, when choosing an antipsychotic, the side-effect profile of the individual antipsychotic needs to be taken into account. There is a growing body of neurobiological and genetic evidence for early-onset patients, but these findings have not yet translated into the clinic.Areas covered: The authors summarize the current treatment options for EOS and discuss the novel treatment options that are under evaluation. The authors focus specifically on Phase II and Phase III clinical trials.Expert opinion: Currently, there are no truly groundbreaking pharmacological treatment options emerging in EOS. There are several newer antipsychotic agents (iloperidone, lurasidone, asenapine, blonanserin) that are currently in clinical trials. It is unclear whether therapeutic efficacy of any of these agents will be superior or even similar to the existing treatment and the main differentiating factor between individual drugs remains to be their side-effect profile. Beyond these antipsychotics, oxytocin and N-acetylcysteine are the only new pharmacological treatment options that are being evaluated in EOS. Therefore, a major change in the treatment development paradigm is necessary to identify novel and efficacious drugs.
Expert Opinion on Investigational Drugs, 23(11) : 1531-1540
- Year: 2014
- Problem: Psychosis Disorders
- Type: Randomised controlled trials
-
Stage: Disorder established (diagnosed disorder)
, At risk (indicated or selected prevention)
-
Treatment and intervention: Biological Interventions (any)
, Typical Antipsychotics (first generation)
, Atypical Antipsychotics (second generation)
, Complementary & Alternative Interventions (CAM)
, Fish oil (Omega-3 fatty acids)
, Omega 3 fatty acids (e.g. fish oil, flax oil)