E. Y. H. Chen

Impacts of duration of untreated psychosis on cognition and negative symptoms in first-episode schizophrenia: a 3-year prospective follow-up study

BACKGROUND Cognitive impairment is a core feature of schizophrenia. Its relationship with duration of untreated psychosis (DUP), a potentially malleable prognostic factor, has been less studied, with inconsistent findings being observed in the literature. Previous research investigating such a relationship was mostly cross-sectional and none of those prospective studies had a follow-up duration beyond 2 years. Method A total of 93 Hong Kong Chinese aged 18 to 55 years presenting with first-episode schizophrenia-spectrum disorder were studied. DUP and pre-morbid adjustment were measured using a structured interview incorporating multiple sources of information. Psychopathological evaluation was administered at intake, after clinical stabilization of the first psychotic episode, and at 12, 24 and 36 months. Cognitive functions were measured at clinical stabilization, and at 12, 24 and 36 months. RESULTS DUP exerted differential effects on various cognitive domains, with memory deficits being the most related to DUP even when potential confounders including pre-morbid adjustment and sex were adjusted. Prolonged DUP was associated with more severe impairment in visual memory at clinical stabilization and verbal memory at 24 and 36 months. Further, patients with a long DUP were found to have worse outcomes on negative symptoms at 36 months. The effects of DUP on verbal memory remained significant even when negative symptoms were taken into consideration. CONCLUSIONS Our findings provided further supportive evidence that delayed treatment to first-episode psychosis is associated with poorer cognitive and clinical outcomes. In addition, DUP may specifically affect memory function and its adverse impact on verbal memory may only become evident at a later stage of the recovery process.

Relationship of amotivation to neurocognition, self-efficacy and functioning in first-episode psychosis: a structural equation modeling approach

BACKGROUND Better understanding of the complex interplay among key determinants of functional outcome is crucial to promoting recovery in psychotic disorders. However, this is understudied in the early course of illness. We aimed to examine the relationships among negative symptoms, neurocognition, general self-efficacy and global functioning in first-episode psychosis (FEP) patients using structural equation modeling (SEM). METHOD Three hundred and twenty-one Chinese patients aged 26-55 years presenting with FEP to an early intervention program in Hong Kong were recruited. Assessments encompassing symptom profiles, functioning, perceived general self-efficacy and a battery of neurocognitive tests were conducted. Negative symptom measurement was subdivided into amotivation and diminished expression (DE) domain scores based on the ratings in the Scale for the Assessment of Negative Symptoms. RESULTS An initial SEM model showed no significant association between functioning and DE which was removed from further analysis. A final trimmed model yielded very good model fit (χ2 = 15.48, p = 0.63; comparative fit index = 1.00; root mean square error of approximation <0.001) and demonstrated that amotivation, neurocognition and general self-efficacy had a direct effect on global functioning. Amotivation was also found to mediate a significant indirect effect of neurocognition and general self-efficacy on functioning. Neurocognition was not significantly related to general self-efficacy. CONCLUSION Our results indicate a critical intermediary role of amotivation in linking neurocognitive impairment to functioning in FEP. General self-efficacy may represent a promising treatment target for improvement of motivational deficits and functional outcome in the early illness stage.

The impacts of yoga and exercise on neuro-cognitive function and symptoms in early psychosis

Background: The large variation in individual clinical responses to antipsychotic treatment hampers the management of psychotic disorders. Genetic factors are considered a main cause of this variation. Pharmacogenetics studies have demonstrated significant associations between several candidate genes (a.o. D2, D3, 5HTR2A and 5HTR2C, GRM3, COMT and MTHFR) and the response to antipsychotic drugs. The present study investigates the effect of 12 polymorphisms for an association with antipsychotic treatment response in patients with a psychotic disorder. Methods: 335 Caucasian patients with a non-affective psychotic disorder using antipsychotics were included. All patients participated in the longitudinal GROUP-study in The Netherlands. We genotyped 12 SNPs in 7 candidate genes (DRD2: TaqI-A, TaqI-D, -141-C, C957T; DRD3: Ser9Gly; HTR2A: 102-T/C, His452Tyr; HTR2C: Cys23Ser, -759-T/C; COMT: Val108/158Met; MTHFR: 677-C/T, GRM3: rs274622) using standard protocols. Polymorphisms were based on previous studies showing associations with treatment response. The Clinical Global Impression- Schizophrenia scale was cross-sectionally used to assess improvement in positive psychotic symptoms since the start of current antipsychotic treatment. Ordinal regression was used to test for an association between polymorphisms and improvement in positive symptoms. All polymorphisms were tested in an additive model, with minor allele dose as the dependent variable. Results: Ninety percent of the patients used atypical antipsychotics, with olanzapine (31%) and risperidone (29%) being the most prescribed drugs. Ser9Gly of the dopamine D3 receptor gene (P value .029) and 677-C/T of MTHFR (P value .029) were tested significant. Gly carriers and T-carriers, respectively, showed better clinical improvement on the positive scale. All other polymorphisms did not show any association with treatment response (all P values >.10). Conclusion: We were able to replicate only two of the previously reported associations between polymorphisms and treatment response. Heterogeneity in patient samples and outcome variables as well as publication bias and false positive findings may all play a role in lack of replication, found in our study, as in others. The direction of the associations presented here in D3 (Ser9Gly) and MTHFR (677-C/T) are in line with previous association studies in Caucasian patients. These polymorphisms may be of value for predicting clinical response.

The Impacts of Yoga On Cortical Thickness, Neural Connectivity and Cognitive Function in Early Psychosis: Preliminary Results From a Randomized Controlled Clinical Trial

Background Impairments of attention and memory are evident in early psychosis, and often lead to severe, longstanding functional disability. Effective non-pharmacological interventions are needed due to the unsuccessful results of pharmacological interventions. Aims To determine whether yoga is effective for cognitive impairments, and the neural mechanism underlying these effects. Methods It was a randomized controlled study of 12-week of yoga and aerobic exercise (walking and cycling) intervention vs wait-list control for female early psychotic patients. Memory was measured with Hong Kong List Learning Test and Digit Span test, and attention was measured with Letter Cancellation test. Cognitive data analysis was based on the Intention-to-Treat method using a mixed-model analysis. Seed based functional connectivity was applied using posterior cingulate cortex (PCC) as seed with AFNI. Cortical thickness analyses were performed using FreeSurfer. Results from yoga and control groups were presented. Results A total of 140 women were recruited and randomized into three groups. 95 completed the study, and 115 were included for cognitive data analysis. For imaging data, 42 participants were used for cortical thickness analyses; and 60 were included for neural connectivity analyses. Yoga group demonstrated significant improvements in working memory, verbal acquisition and attention (P=.01). Cortical thickness increased in the postcentral gyrus (P Conclusions Yoga has been found to be effective for memory and attention in early psychotic patients. The increases of thickness and neural connectivity indicate the possible neural mechanisms underlying the improvements of cognition.

The effect of media reporting of a homicide committed by a patient with schizophrenia on the public stigma and knowledge of psychosis among the general population of Hong Kong

PurposeThis study aimed to investigate the effects of media reporting of a homicide committed by a patient with schizophrenia on the knowledge about and stigma regarding psychosis among the general Hong Kong population. The effects of using the term ‘schizophrenia (jing-shen-fen-lei)’ in the news on the perceptions of the new Chinese term ‘psychosis (si-jue-shi-tiao)’ were explored.MethodsRandom telephone surveys of the general Hong Kong population were conducted in April 2009 (1 month before the incident) and June 2009 (1 week after the incident). Stigma was measured with the Link’s Perceived Discrimination-Devaluation Scale (LPDDS). Knowledge about the symptoms, treatment and belief of dangerousness of psychosis were assessed. The emotional reaction of the public to the news was explored, and its effects on knowledge and stigma were studied.ResultsOverall, 1016 and 506 participants completed the two surveys. More participants in the post-incident survey agreed that people with psychosis are dangerous to the public (χ2 = 4.934, p = 0.026). However, no significant differences were observed in the LPDDS scores. Participants who reported a high level of distress related to the news were more likely to perceive people with psychosis as dangerous to the public (χ2 = 6.738, p = 0.009). Women and older people reported greater distress.ConclusionsThese findings suggest that media reporting of violent incidents involving people with schizophrenia increases the public belief in the dangerousness of people with psychosis but not the overall stigma. Further studies of the differential effects of violence reporting on public perceptions about people with psychosis and schizophrenia are warranted.

Negative symptom dimensions differentially impact on functioning in individuals at-risk for psychosis

a Department of Psychiatry, The University of Hong Kong, Queen Mary Hospital, Hong Kong b State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong, Hong Kong c Department of Psychiatry, Queen Mary Hospital, Hong Kong d Department of Psychiatry, Pamela Youde Nethersole Eastern Hospital, Hong Kong e Department of Psychiatry, Kwai Chung Hospital, Hong Kong f Department of Psychiatry, Kowloon Hospital, Hong Kong g Department of Psychiatry, United Christian Hospital, Hong Kong h Department of Psychiatry, Tai Po Hospital, Hong Kong i Department of Psychiatry, Alice Ho Miu Ling Nethersole Hospital, Hong Kong j Department of Psychiatry, Castle Peak Hospital, Hong Kong

Prediction of motivational impairment: 12-month follow-up of the randomized-controlled trial on extended early intervention for first-episode psychosis

BACKGROUND Amotivation is prevalent in first-episode psychosis (FEP) patients and is a major determinant of functional outcome. Prediction of amotivation in the early stage of psychosis, however, is under-studied. We aimed to prospectively examine predictors of amotivation in FEP patients in a randomized-controlled trial comparing a 1-year extension of early intervention (Extended EI, 3-year EI) with step-down psychiatric care (SC, 2-year EI). METHODS One hundred sixty Chinese patents were recruited from a specialized EI program for FEP in Hong Kong after they have completed this 2-year EI service, randomly allocated to Extended EI or SC, and followed up for 12 months. Assessments on premorbid adjustment, onset profiles, baseline symptom severity and treatment characteristics were conducted. Data analysis was based on 156 subjects who completed follow-up assessments. RESULTS Amotivation at 12-month follow-up was associated with premorbid adjustment, allocated treatment condition, and levels of positive symptoms, disorganization, amotivation, diminished expression (DE) and depression at study intake. Hierarchical multiple regression analysis revealed that Extended EI and lower levels of DE independently predicted better outcome on 12-month amotivation. CONCLUSION Our findings indicate a potentially critical therapeutic role of an extended specialized EI on alleviating motivational impairment in FEP patients. The longer-term effect of Extended EI on amotivation merits further investigation.

Determinants of subjective quality of life in first-episode psychosis patients receiving specialized early intervention service in Hong Kong

IEPA 10th International Conference on Early Intervention in Mental Health – “Looking Back, Moving Forward” Milan, Italy, 20th – 22nd October 2016

EPA-0752 – Spirituality in schizophrenia: do patients and healthcare professionals have similar understanding

Background The special mental states such as hallucination and confusion in schizophrenia have been creating obstacles in research in spirituality in this population. Although primary treatment should focus on symptom management, psychosocial and spiritual care should not be neglected. This study aimed to understand spirituality from the perspectives of both the patients and the healthcare professionals and its role in different stages of disease and rehabilitation. Method Schizophrenic patients (n=22) and healthcare professionals including psychiatric doctors, nurses, and social workers (n=19) were recruited from an out-patient clinic of a hospital and a mental health rehabilitation complex. Semi-structured interviews on the meaning and experiences of spirituality, and its role in rehabilitation were conducted, with follow-up interviews when further clarification was needed. Interviews were transcribed into verbatim and analyzed with the assistance of computer software based on Ground theory. Trustworthiness was assured through member checking and peer scrutiny. Results Both patients and professionals regarded spirituality as an inherent part of the patients’ well-being. Spirituality could be a practice, a way of thinking, sense of peace and fulfillment, and connectedness towards oneself, others, and a higher power. Spiritual experiences were helpful in the rehabilitation phase. However, some patients considered spirituality as apparitional experiences, thus hindered their recovery. Conclusion This study demonstrated that the spirituality played a part in patients’ lives and rehabilitation. Findings suggest the importance of spiritual care in this population and provide insights and roadmap for developing spiritual assessments and holistic care in psychiatric context. This study is supported by RGCGRF / HKU745511H .

A 10-year outcome study of an early intervention program for psychosis in Hong Kong (EASY) compared with standard care service

This journal suppl. contain Abstracts for the 14th International Congress on Schizophrenia ResearchBackground: Adverse social circumstances in childhood and adolescence increase vulnerability for adult psychotic disorders. Children who have psychotic- like experiences (PLEs) are at higher risk to develop psychotic disorders later in life. If PLEs are considered potential precursors of psychotic disorders and the risk for psychotic disorders develops in early life, PLEs in childhood should be related to indicators of social disadvantage. Methods: A self-report study assessing a sample of 1545 schoolchildren (45% Dutch, 26% Moroccan, 11% Turkish, 5% Western and 13% other non-Western) was conducted in the Netherlands (age range: 9-16). PLEs were measured with 8 items from the psychosis section of the K-SADS. Additional questions addressed impact of the PLEs. Measures of parental socio-economic status, neighborhood deprivation, perceived discrimination, parental separation, housing stability and degree of urbanization were used as indicators of social disadvantage, based on which a cumulative index of social disadvantage was created (low, medium, high). Results: The overall prevalence of any PLE with high impact was 6% (N = 93). Neighborhood deprivation, perceived discrimination and an unstable housing situation were associated with risk for PLEs. Age- and sex-adjusted Odds Ratios for any PLE with high impact were 1.83 (95% CI, 0.92-3.69) for medium and 2.28 (1.11-4.69) for high cumulative social disadvantage, compared to low social disadvantage. The risk was higher for ethnic minority youth compared to Dutch (Odds Ratio = 2.6; 95% CI, 1.6-4.3). The increased risk remained after adjusting for social disadvantage. Conclusion: The risk for PLEs with high impact was associated with indicators of social disadvantage. PLEs with high impact were more prevalent in ethnic minority youth than in Dutch youth. The increased risk was not explained by cumulative social disadvantage.Background: The risk for psychotic disorders is increased for many immigrant groups in several countries, particularly for those who migrated in early life and for second-generation immigrants. Social factors are likely to contribute to this increase, but biological pathways have hardly been explored. Since immune activation has been associated both with schizophrenia and social stress in early life, it may be involved in the pathway of migration, ethnic minority status and psychosis. Methods: Case-control study of 11 Dutch and 14 immigrant patients with first episode psychosis, and 14 Dutch and 10 immigrant healthy controls. Quantitative polymerase chain reaction (Q-PCR) techniques were used to measure mRNA levels of 97 genes in isolated monocytes. These genes were selected for their association with schizophrenia, bipolar disorder, autoimmune or inflammatory disorders in previous genome wide association studies. Results: Compared to Dutch controls, 29 genes in monocytes of Dutch cases were upregulated (fold changes more than two standard deviations (sd)) and statistical significance was reached for 13 genes. Most of these genes are involved in inflammation pathways, including coding for the pro-inflammatory cytokines IL-8, IL-1 beta and IL-6. Immigrant cases had a similar gene expression profile to Dutch cases. Twenty-four of the upregulated genes in patients had an increased expression in immigrant controls as well. The fold changes of an additional 14 genes was more than two sd for immigrant controls compared with Dutch controls. Conclusion: Inflammatory genes in monocytes were upregulated both in Dutch and in immigrant patients with first episode psychosis. Immigrant controls showed similar inflammatory gene expression to both patient groups and differed from Dutch controls. The findings suggest that childhood migration and second generation immigrant status may result in a shift of the distribution of immune activation in immigrant populations, which may contribute to the higher rates of psychotic disorders in these groups.Background: Many people with schizophrenia (50-80%) demonstrate impaired insight. A number of interventions aiming to improve insight have been proposed and evaluated, for example cognitive behavioral therapy and psycho-education. Results of these interventions leave room for improvement. Therefore, we propose a new intervention to improve insight in people with schizophrenia (REFLEX). REFLEX focuses on insight in ones functioning in everyday life and changes in general functioning after psychosis by improving metacognitive acts necessary for insight (selfreflectiveness, idiosyncratic self-certainty) and reducing stigma-sensitivity. Methods: The primary objective is to improve insight. By improving insight, we hope to improve functional outcome and symptoms. Results: 120 patients diagnosed with schizophrenia with poor insight and sensitive are included in a randomized controlled trial): REFLEX was compared to an active control condition consisting of group wise drill and practice cognitive remediation training. Preliminary analysis show that while clinical insight measures with the SAI-E remains unchanged, while cognitive insight measured with the BCIS improves in the REFLEX condition (F 1,85 4,9, p