Gerald Jordan

Early intervention for psychosis: a Canadian perspective.

Abstract This paper provides an overview of early intervention (EI) services for psychosis in Canada. We describe a leading Canadian EI program’s approach to enhancing access (via early case detection, open referral, and rapid response) and providing specialized phase-specific treatment. Learnings from this program’s research/evaluation indicate that EI can significantly improve service user and family engagement. Achieving and maintaining symptom remission (particularly negative symptoms) may be important for better social and occupational functioning in first-episode psychosis (FEP). Our program demonstrates the feasibility of establishing and sustaining an open referral, rapid-response system to address the chronic systemic problems of long waiting lists and barriers to access. We argue that an integrated clinical-research program based on specialized EI guidelines can significantly improve outcomes and advance FEP research.

The relative contribution of cognition and symptomatic remission to functional outcome following treatment of a first episode of psychosis.

OBJECTIVE Functional recovery remains the primary goal following treatment of a psychotic disorder, especially after a first episode. Evidence regarding relative contributions of predictors of functional outcome, including symptoms and cognition, remains equivocal. The objective of the study was to determine the relative contribution of cognition, in particular verbal memory, and symptomatic remission to social and occupational functioning while controlling for established predictors of functioning in a large sample of patients presenting with a first episode of a schizophrenia spectrum or affective psychosis. METHOD Patients (aged 14-35 years) met DSM-IV criteria for a first episode of a schizophrenia spectrum or affective psychosis and had been admitted to the Prevention and Early Intervention Program for Psychoses, Montreal, Quebec, Canada, between 2003 and 2009 for treatment and follow-up for 2 years. Established predictors (duration of untreated psychosis, medication adherence, age at onset, substance use, premorbid adjustment), verbal memory, and length of positive and negative symptom remission were regressed on functioning (using the Strauss Carpenter Scale) at 1 (n = 208) and 2 (n = 159) years. Regressions were conducted with established predictors in the first step, followed by verbal memory and consecutive months of combined positive and negative symptom remission in the third step. Regressions were then repeated with length of positive and negative symptom remission, respectively. RESULTS Length of combined positive and negative symptom remission explained the most variance in functioning at 1 (R² adjusted = 0.35, F₉,₁₂₉ = 9.33, P < .001) and 2 (R² adjusted = 0.38, F₉,₉₇ = 8.21, P < .001) years, and verbal memory contributed only slightly to such outcome. While length of remission of negative symptoms was a stronger predictor of functioning than remission of positive symptoms at 1 year, length of positive symptom remission also made a large contribution at 2 years. CONCLUSIONS These results highlight the importance of achieving and maintaining remission of both negative and positive symptoms for longer periods in patients with a first episode of a psychotic disorder and the need for effective interventions to do so.

The Relationship Between Openness to Experience and Willingness to Engage in Online Political Participation Is Influenced by News Consumption

Openness to experience is known to be an independent predictor of online political behavior, although the degree to which this relationship is influenced by other factors has not been tested. One objective of this study was to test whether the relationship between openness to experience and the propensity to engage in online political participation is mediated by internal political efficacy and hours spent consuming news. The second objective was to determine if a preference for different news sources would be related to a willingness to participate in online political behavior. University students (n = 419) were assessed on willingness to engage in online political participation, hours dedicated to news consumption, preference for different news sources, and internal political efficacy. Our results showed that openness to experience was related to a willingness to engage in online participation, and this was mediated by hours spent consuming news and internal political efficacy (95% confidence interval [CI] = [.0048, .32]). A preference for both semipublic and private news sources was related to greater internal efficacy (95% CI = [.2347, 1.4799]), which was in turn related to a greater propensity to engage in online political participation. These findings highlight the potential importance of news consumption for a propensity toward online political engagement.

An Exploratory, Open-Label, Randomized Trial Comparing Risperidone Long-Acting Injectable with Oral Antipsychotic Medication in the Treatment of Early Psychosis

Few studies have examined effectiveness and tolerability of risperidone long-acting injections (RLAI) in the early phase of a schizophrenia spectrum (SS) disorder using a randomized controlled trial (RCT) design. Eighty-five patients in early phase of an SS disorder were randomized to receive either oral second-generation antipsychotics (SGAs; n=41) or RLAI (n=44) over two years. Analyses were conducted on eligible participants (n=77) for the stabilization (maximum 18 weeks) and maintenance phases (up to Week 104) on primary outcome measures of time to stabilization and relapse, change in symptoms and safety, and comparisons made across the two groups. Both groups showed improvement on Positive and Negative Syndrome Scale (PANSS) scores and Clinical Global Impression-Severity (CGI-S) scores. There were no time X group interactions on any of the primary outcome measures. Post hoc examination revealed that the RLAI group showed greater change on CGI-S and PANSS negative symptom scores during the stabilization phase, while the oral group reached the same level of improvement during the maintenance phase. The current exploratory study suggests that-within an RCT design-RLAI and oral SGAs are equally effective and have similar safety profiles in patients in the early phase of SS disorders. Thus, RLAI offers no advantage to patients in early phase of SS disorders, but is likely to be effective and safe for those who may have problems with adherence and may either choose to take it or be prescribed under conditions of external control such as community treatment orders.

Post-traumatic growth following a first episode of psychosis: a scoping review.

A first‐episode psychosis (FEP) is a traumatic experience that can often result in great suffering. However, in addition to suffering, persons affected by FEP may also experience post‐traumatic growth (PTG) or the perception that good has followed psychosis. Although much is known concerning the negative outcomes following FEP, little attention has been given to the state of scientific knowledge on PTG following FEP. The aim of this study is to determine the state of knowledge concerning PTG following FEP to help set the stage for a full systematic review.

Adolescent vs. adult onset of a first episode psychosis: Impact on remission of positive and negative symptoms

OBJECTIVE Adolescent-onset psychosis has traditionally been characterized as a more severe form of psychosis with a poorer prognosis. However, it is still unclear if patients with an adolescent-onset have worse symptom remission outcomes. Symptom remission is the principal clinical outcome known to predict quality of life and social functioning in the long term. The goal of this study is to clarify the influence of age of onset of psychosis on symptom remission in a sample of first-episode psychosis patients. METHOD A total of 246 first-episode psychosis patients were recruited from a specialized early intervention program serving a defined epidemiological catchment area. Age of onset of psychosis (adolescence vs. adulthood) was used as the main predictor, and duration of untreated psychosis (DUP), baseline symptoms, baseline functioning, substance abuse diagnosis, medication adherence and gender were used as covariates in hierarchical regression models predicting the following positive and negative symptom remission outcomes: maximum continuous months in remission and early remission (i.e., occurring in the first three months of follow-up). RESULTS After controlling for other variables, onset of psychosis in adulthood and shorter DUP predicted early remission of positive symptoms. This effect was stronger in patients with a diagnosis of a schizophrenia-spectrum disorder. Remission of negative symptoms did not depend on age of onset, and was only predicted by baseline negative symptoms. CONCLUSION Patients with onset of psychosis during adulthood are more likely to achieve early positive symptom remission than those with adolescent onset. This effect might be stronger in patients with a diagnosis of a schizophrenia-spectrum disorder.

Outcome in patients converting to psychosis following a treated clinical high risk state

We explored 2‐year outcomes in a sample of clinical high risk (CHR) patients who converted to psychosis despite receiving interventions.

Baby or bathwater? Referrals of “non-cases” in a targeted early identification intervention for psychosis

PurposeTo explore the unintended impact of a targeted case identification (TCI) campaign for first episode psychosis (FEP) on people not experiencing FEP (“non-cases”) with respect to referral patterns and reasons for being a non-case.MethodsSources of referral, reasons for being a non-case, and subsequent referral destinations of non-cases were examined before and after a TCI.ResultsFollowing the TCI, a greater proportion of non-cases lived outside the study catchment area. A smaller proportion was referred by the parent hospital’s emergency room or had a substance-induced psychosis.ConclusionsTCIs for FEP may have unintended effects, with implications for early case identification and early intervention services.

Pathways to functional outcomes following a first episode of psychosis: The roles of premorbid adjustment, verbal memory and symptom remission

Objective: Most studies have investigated either the singular or relative contributions of premorbid adjustment, verbal memory and symptom remission to functional outcomes in first-episode psychosis. Fewer studies have examined the pathways of these factors in impacting functioning. Our study addresses this gap. The objective was to determine whether the relationship between premorbid adjustment and functional outcomes was mediated by verbal memory and symptom remission. Method: A total of 334 first-episode psychosis participants (aged 14–35 years) were assessed on premorbid adjustment, verbal memory upon entry, and positive and negative symptom remission and functioning at multiple time points over a 2-year follow-up. Results: Mediation analyses showed that over the first year, the relationship between premorbid adjustment and functioning was mediated by verbal memory and positive symptom remission (β = –0.18; 95% confidence interval = [–0.51, –0.04]), as well as by verbal memory and negative symptom remission (β = –0.41; 95% confidence interval = [–1.11, –1.03]). Over 2 years, the relationship between premorbid adjustment and functioning was mediated by verbal memory and only negative symptom remission (β = –0.38; 95% confidence interval = [–1.46, –0.02]). Conclusion: Comparatively less malleable factors (premorbid adjustment and verbal memory) may contribute to functional outcomes through more malleable factors (symptoms). Promoting remission may be an important parsimonious means to achieving better functional outcomes.

Posttraumatic growth following a first episode of psychosis: a mixed methods research protocol using a convergent design

BackgroundThe suffering people experience following a first episode of psychosis is great, and has been well-investigated. Conversely, potential positive outcomes following a first episode of psychosis have been under-investigated. One such outcome that may result from a first episode of psychosis is posttraumatic growth, or a positive aftermath following the trauma of a first psychotic episode. While posttraumatic growth has been described following other physical and mental illnesses, posttraumatic growth has received very little attention following a first episode of psychosis. To address this research gap, we will conduct a mixed methods study aimed at answering two research questions: 1) How do people experience posttraumatic growth following a first episode of psychosis? 2) What predicts, or facilitates, posttraumatic growth following a first episode of psychosis?Methods/designThe research questions will be investigated using a mixed methods convergent design. All participants will be service-users being offered treatment for a first episode of psychosis at a specialized early intervention service for young people with psychosis, as well as their case managers.. A qualitative descriptive methodology will guide data-collection through semi-structured interviews with service-users. Service-users and case managers will complete questionnaires related to posttraumatic growth and its potential predictors using quantitative methods. These predictors include the impact a first episode of psychosis on service-users’ lives, the coping strategies they use; the level of social support they enjoy; and their experiences of resilience and recovery. Qualitative data will be subject to thematic analysis, quantitative data will be subject to multiple regression analyses, and results from both methods will be combined to answer the research questions in a holistic way.DiscussionFindings from this study are expected to show that in addition to suffering, people with a first episode of psychosis may experience positive changes. This study will be one of few to have investigated posttraumatic growth following a first episode of psychosis, and will be the first to do so with a mixed methods approach.