A. Prosser

The relationship between duration of untreated psychosis and outcome: an eight-year prospective study.

Longer duration of untreated psychosis (DUP) prior to the initiation of treatment has been found to predict poorer short-term clinical and functional outcomes in patients with first-episode psychosis (FEP). The extent to which the relationship between DUP and outcome is maintained in the medium-to-long term however remains unclear. We examined the influence of DUP on clinical and functional outcomes in a prospective, naturalistic study of 318 FEP patients followed up 8 years after initial treatment at a specialist early psychosis service. Quality of life, social and occupational functioning, positive and negative symptoms at 8 years were assessed using standardized instruments. Multiple linear regression analyses indicated that, after controlling for the effects of other factors, shorter DUP correlated moderately with decreased severity of positive symptoms, and enhanced social and occupational functioning and quality of life. There was no uniform point associated with medium-to-long term impairment, with some domains of outcome more sensitive to treatment delay than others. However a consistent finding was that outcomes for these domains were significantly worse when DUP exceeded 3 months. Among those with a schizophrenia-spectrum diagnosis, DUP exceeding 1 year was associated with poorer outcome. No association was found between DUP and negative symptoms in either diagnostic group. As with short-term prognosis, DUP appears to be an independent predictor of prognosis in the medium-to-long term. Results support the need for assertive early detection strategies to facilitate the timely delivery of effective intervention programs to those with emerging psychotic illness in order to reduce the risk of long term deleterious outcomes.

The EPPIC Follow-Up Study of First-Episode Psychosis: Longer-Term Clinical and Functional Outcome 7 Years After Index Admission

OBJECTIVE To describe the longer-term clinical and functional outcome of a large, epidemiologic representative cohort of individuals experiencing a first episode of psychosis. METHOD A naturalistic, prospective follow-up of an epidemiologic sample of 723 consecutive first-episode psychosis patients, followed between January 1998 and April 2005, at a median of 7.4 years after initial presentation to the Early Psychosis Prevention and Intervention Centre (EPPIC) in Melbourne, Australia. EPPIC is a frontline public mental health early psychosis program, servicing a geographically defined catchment area with a population of about 800,000 people. The main outcome measures included the Brief Psychiatric Rating Scale, the Schedule for the Assessment of Negative Symptoms, the Beck Depression Inventory, the Global Assessment of Functioning Scale, the Social and Occupational Functioning Assessment Scale, the Quality of Life Scale, and the remission criteria developed by the Remission in Schizophrenia Working Group. RESULTS Follow-up information was collected on up to 90.0% (n = 651) of the baseline cohort of 723 participants, with 66.9% (n = 484) interviewed. In the last 2 years, 57% of individuals with schizophrenia/schizophreniform, 54% with schizoaffective disorder, 62% with affective psychosis, and 68% with other psychotic disorders reported some paid employment. Depending upon the criteria applied, symptomatic remission at follow-up was observed in 37%-59% of the cohort. Social/vocational recovery was observed in 31% of the cohort. Approximately a quarter achieved both symptomatic remission and social/vocational recovery. CONCLUSION The relatively positive outcomes are consistent with a beneficial effect of specialized early intervention programs; however it is premature to draw firm conclusions. There was no control group and there are many differences between the relevant comparison studies and the present one. Although difficult to conduct, large scale controlled health services research trials are required to definitively determine the impact and optimal duration of specialized early psychosis programs.

Suicide attempt in first-episode psychosis: A 7.4 year follow-up study

BACKGROUND Individuals with first-episode psychosis demonstrate high rates of suicide attempt (SA). AIMS 1) To examine the prevalence of, and risk factors for, SA in a first-episode psychosis (FEP) cohort over a 7.4 year follow-up period. 2) To investigate differences between single versus multiple suicide attempters. METHODS This study reports baseline and follow-up data from a naturalistic, prospective follow-up of 413 FEP patients treated at a specialist early psychosis centre. Assessments were conducted at treatment entry, initial symptom remission or stabilization, and long term follow-up. Binary logistic regression models were used to assess unadjusted and adjusted associations between early illness and sociodemographic characteristics and two outcome measures: any SA during follow-up; and multiple SAs. RESULTS Follow-up data were available for 282 participants. Sixty-one (21.6%) made a suicide attempt over the follow-up period, including 12 successful suicides. The following baseline risk factors increased the risk of any SA: history of self-harm (OR=4.27; p<0.001), suicidal tendencies (OR=2.30; p=0.022), being depressed for >50% of the initial psychotic episode (OR=2.49; p=0.045), and hopelessness (OR=2.03; p=0.030). History of problem alcohol use increased the risk of multiple SAs (OR=4.43; 95% CI (1.05-18.7); p=0.043). DISCUSSION The prevalence of suicide attempt in this study exceeds reports from short-term FEP studies but is comparable to longer term follow-up studies, indicating that risk remains elevated for at least 7 years following commencement of treatment. The key predictor of future suicide attempt was previous self-harm, indicating that interventions for self-harm are required.

Early Psychosis Prevention and Intervention Centre long‐term follow‐up study of first‐episode psychosis: methodology and baseline characteristics

Aim:  This paper reports the rationale, methodology and baseline characteristics of a large long‐term follow‐up study of first‐episode psychosis from a geographically defined catchment area.

Predictors of Pain 12 Months after Serious Injury

OBJECTIVE The majority of patients will report pain 12 months after a serious injury. Determining the independent risk factors for pain after serious injury will establish the degree to which high-risk patients can be detected in the acute setting and the viability of early triage to specialist pain services. DESIGN A prospective cohort study of patients following serious injury was conducted. The initial assessment comprised a comprehensive battery of known and possible risk factors for persistent pain. Patients were assessed at 12 months for pain severity and for the presence of chronic pain. RESULTS Two hundred ninety patients underwent an initial assessment of whom 238 (82%) were followed up at 12 months. At 12 months, 171 (72%) patients reported some pain over the past 24 hours. Thirty-five patients (14.7%) reported chronic pain. Five factors independently predicted the 24-hour pain severity: preinjury physical role function, preinjury employment status, initial 24 hours pain score, higher beliefs in the need for medication, and compensable injury (R(2) = 0.21, P < 0.0001). Four factors predicted the presence of chronic pain at 12 months: not working prior to injury, total Abbreviated Injury Scale, initial pain severity, and initial pain control attitudes (pseudo R(2) = 0.24, P = 0.0001). CONCLUSIONS Factors present at the time of injury can allocate patients into high- or low-risk groups. The majority of cases of chronic pain emerging from the high-risk group warrant more intense clinical attention. We recommend recording these factors in discharge documentation as indicators of persistent pain.

Predictors of Pain Severity 3 Months after Serious Injury

OBJECTIVE Injury is a common initiating event for persistent pain. The presentation of injured patients to hospital represents an opportunity to identify patients at high risk of persistent pain and triage them to early intervention. Although a range of physical, psychological, and social risk factors have been implicated in the transition from acute to persistent pain, these factors have not been tested concurrently in a prospective study. This study aimed to determine the degree to which pain severity at 3 months can be predicted at the time of injury and which independent factors predicted pain severity. DESIGN A large prospective cohort study was conducted recruiting patients from two trauma hospitals during their acute admission. Patients were assessed with a comprehensive battery of known and possible risk factors for persistent pain. Patients were assessed for pain severity on a visual analog scale over the past 24 hours at 3 months. RESULTS Two hundred ninety patients were recruited, and 242 were followed up at 3 months. Older age, female gender, past alcohol dependence, lower physical role function, pain severity, amount of morphine equivalents administered on the day of assessment, and pain control attitudes predicted pain severity at 3 months. The variance attributed to these factors was 22%. CONCLUSIONS Injured patients with a number of these factors may warrant increased monitoring and early triage to specialist pain services.

Prevalence and correlates of comorbidity 8 years after a first psychotic episode

Objective:  While rates and correlates of comorbidity have been investigated in the early course of psychosis, little is known about comorbidity in the medium‐to‐longer term or its relationship with outcome.

Are the short term cost savings and benefits of an early psychosis program maintained at 8 year follow up

This study aims to identify correlates of vocational functioning in a first episode psychosis (FEP) sample 7.5 years after presentation at a specialized early psychosis treatment service. The study involved a prospective, naturalistic follow-up of FEP patients commencing treatment with the Early Psychosis Prevention & Intervention Centre (EPPIC) in Melbourne, Australia, between 1995 and 1997. At treatment entry the Royal Park Multidiagnostic Instrument for Psychosis was used to assess duration of untreated psychosis (DUP), age at onset of psychotic disorder, and premorbid work/social functioning. At 7.5-year follow-up measures included the Brief Psychiatric Rating Scale (Thinking Disturbance subscale), Scale for the Assessment of Negative Symptoms (Alogia subscale), WHO Life Chart Schedule (to assess course of illness, treatment history, and duration of receipt of a disability support pension (DSP)), and the Structured Clinical Interview for DSM-IV (to derive Axis I diagnoses). Analyses involved 180 participants. Univariate and multivariate logistic regression analyses were used to estimate the effects of demographic, clinical and treatment variables on two outcomes: current employment; and durable employment (employment for more than 6 months in the past 2 years). The sample was primarily male (72%), with a mean age at follow-up of 29 years (sd=3.4). 45% reported current participation in competitive employment at 7.5 year follow-up (28% full-time, 17% part-time), and 53% reported recent durable employment. Multivariate analyses showed that, after controlling for other variables (including positive and negative thought disorder, premorbid functioning, and recent psychiatric treatment), current employment was negatively associated with continuous or episodic illness course characterized by worsening trajectory or incomplete remissions, disrupted education, and receiving a DSP for longer than 2 years. Lifetime diagnosis of schizophrenia, receipt of a DSP (regardless of duration) and disrupted education were negatively associated with durable employment. Educational attainment appears to be an important predictor of vocational outcome in the Australian labor market, although its relationship with premorbid functioning requires further investigation. The inverse relationship between DSP and employment, after controlling for symptom levels and course of illness, supports evidence from US studies that such payments may act as a disincentive to employment.The purpose of this study is to examine the long-term clinical and functional outcome of first-episode psychosis (FEP). The study was a naturalistic, prospective follow-up of a large epidemiologically representative sample of 765 FEP patients, mean 7.4-years after initial presentation to a specialist early psychosis service (EPPIC) in Melbourne, Australia. Standardised assessments were used at the followup to assess participants’ demographic characteristics, axis I diagnosis, psychopathology and level of work and social functioning. Follow-up interviews were conducted on 511 participants; 133 refused; 39 were deceased and 82 were un-contactable. No participant bias due to study attrition was found. Some 230 (45.0%) of the interviewed group, met DSM-IV criteria of a current psychotic disorder; 281 (55.0%) individuals received a lifetime diagnosis of psychotic disorder. Numbers of individuals diagnosed with schizophrenia, schizoaffective disorder, affective psychosis and other psychosis, were 306 (59.6%), 48 (9.4%), 110 (21.5%) and 47 (9.2%), respectively. Comparisons between the diagnostic groups found the schizophrenia group to have significantly higher BPRS (total, psychotic subscale) and SANS (total) mean scores and significantly lower GAF, SOFAS and QLS mean scores than the other diagnostic groups at follow-up. The prevalence of current psychotic disorder was significantly higher in the schizophrenia group (60.1%) as compared to the other diagnostic groups (χ2=78.4, df=3, p<0.001). Considering the course of the psychotic disorder over the most recent two years, the majority (49.1%) reported that they have never been actively psychotic, 31.6% reported a continuous course, 17.1% reported an episodic course and 2.2% individuals neither episodic nor continuous course of illness. In contrast to previous medium and longer term follow-up studies of first episode schizophrenia where 19-37% were reported to be occupationally engaged,(and 10-15% of those with established schizophrenia in Australia) the proportion of individuals observed in this study with some level of employment in the last two years was substantially higher (schizophrenia, 52%; affective psychosis, 74.5%; schizoaffective, 60.4%; and other psychotic group, 72.3%). Findings from the EPPIC long term follow-up study emphasis that a specialised early intervention service program might result in better functional outcomes in contrast to previous assumptions, especially for those with schizophrenia.

Early detection and optimal treatment may improve outcome in early-onset schizophrenia: Evidence from the EPPIC medium-term follow-up study of first episode psychosis

This study aims to identify correlates of vocational functioning in a first episode psychosis (FEP) sample 7.5 years after presentation at a specialized early psychosis treatment service. The study involved a prospective, naturalistic follow-up of FEP patients commencing treatment with the Early Psychosis Prevention & Intervention Centre (EPPIC) in Melbourne, Australia, between 1995 and 1997. At treatment entry the Royal Park Multidiagnostic Instrument for Psychosis was used to assess duration of untreated psychosis (DUP), age at onset of psychotic disorder, and premorbid work/social functioning. At 7.5-year follow-up measures included the Brief Psychiatric Rating Scale (Thinking Disturbance subscale), Scale for the Assessment of Negative Symptoms (Alogia subscale), WHO Life Chart Schedule (to assess course of illness, treatment history, and duration of receipt of a disability support pension (DSP)), and the Structured Clinical Interview for DSM-IV (to derive Axis I diagnoses). Analyses involved 180 participants. Univariate and multivariate logistic regression analyses were used to estimate the effects of demographic, clinical and treatment variables on two outcomes: current employment; and durable employment (employment for more than 6 months in the past 2 years). The sample was primarily male (72%), with a mean age at follow-up of 29 years (sd=3.4). 45% reported current participation in competitive employment at 7.5 year follow-up (28% full-time, 17% part-time), and 53% reported recent durable employment. Multivariate analyses showed that, after controlling for other variables (including positive and negative thought disorder, premorbid functioning, and recent psychiatric treatment), current employment was negatively associated with continuous or episodic illness course characterized by worsening trajectory or incomplete remissions, disrupted education, and receiving a DSP for longer than 2 years. Lifetime diagnosis of schizophrenia, receipt of a DSP (regardless of duration) and disrupted education were negatively associated with durable employment. Educational attainment appears to be an important predictor of vocational outcome in the Australian labor market, although its relationship with premorbid functioning requires further investigation. The inverse relationship between DSP and employment, after controlling for symptom levels and course of illness, supports evidence from US studies that such payments may act as a disincentive to employment.The purpose of this study is to examine the long-term clinical and functional outcome of first-episode psychosis (FEP). The study was a naturalistic, prospective follow-up of a large epidemiologically representative sample of 765 FEP patients, mean 7.4-years after initial presentation to a specialist early psychosis service (EPPIC) in Melbourne, Australia. Standardised assessments were used at the followup to assess participants’ demographic characteristics, axis I diagnosis, psychopathology and level of work and social functioning. Follow-up interviews were conducted on 511 participants; 133 refused; 39 were deceased and 82 were un-contactable. No participant bias due to study attrition was found. Some 230 (45.0%) of the interviewed group, met DSM-IV criteria of a current psychotic disorder; 281 (55.0%) individuals received a lifetime diagnosis of psychotic disorder. Numbers of individuals diagnosed with schizophrenia, schizoaffective disorder, affective psychosis and other psychosis, were 306 (59.6%), 48 (9.4%), 110 (21.5%) and 47 (9.2%), respectively. Comparisons between the diagnostic groups found the schizophrenia group to have significantly higher BPRS (total, psychotic subscale) and SANS (total) mean scores and significantly lower GAF, SOFAS and QLS mean scores than the other diagnostic groups at follow-up. The prevalence of current psychotic disorder was significantly higher in the schizophrenia group (60.1%) as compared to the other diagnostic groups (χ2=78.4, df=3, p<0.001). Considering the course of the psychotic disorder over the most recent two years, the majority (49.1%) reported that they have never been actively psychotic, 31.6% reported a continuous course, 17.1% reported an episodic course and 2.2% individuals neither episodic nor continuous course of illness. In contrast to previous medium and longer term follow-up studies of first episode schizophrenia where 19-37% were reported to be occupationally engaged,(and 10-15% of those with established schizophrenia in Australia) the proportion of individuals observed in this study with some level of employment in the last two years was substantially higher (schizophrenia, 52%; affective psychosis, 74.5%; schizoaffective, 60.4%; and other psychotic group, 72.3%). Findings from the EPPIC long term follow-up study emphasis that a specialised early intervention service program might result in better functional outcomes in contrast to previous assumptions, especially for those with schizophrenia.

The 8 year functional and symptomatic outcome of first episode psychosis (FEP)

This is the Special Issue: Abstracts of the 20th International Congress on Schizophrenia Research 2005This journal issue entitled: Special Issue: Abstracts of the XX International Congress on Schizophrenia Research