Jan Olav Johannessen

Early detection strategies for untreated first-episode psychosis

Some studies in first-episode schizophrenia correlate shorter duration of untreated psychosis (DUP) with better prognosis, suggesting that timing of treatment may be important. A three-site prospective clinical trial in Norway and Denmark is underway to investigate the effect of the timing of treatment in first-episode psychosis. One health care sector (Rogaland, Norway) is experimental and has developed an early detection (ED) system to reduce DUP. Two other sectors (Ullevål, Norway, and Roskilde, Denmark) are comparison sectors and rely on existing detection and referral systems for first-episode cases. The study ultimately will compare early detected with usual detected patients. This paper describes the studys major independent intervention variable, i.e. a comprehensive education and detection system to change DUP in first onset psychosis. System variables and first results from the four-year inclusion period (1997-2000) are described. It includes targeted information towards the general public, health professionals and schools, and ED teams to recruit appropriate patients into treatment as soon as possible. This plus easy access to psychiatric services via ED teams systematically changed referral patterns of first-episode schizophrenia. DUP was reduced by 1.5 years (mean) from before the time the ED system was instituted (to 0.5 years). The ED strategies appear to be effective and to influence directly the communitys help-seeking behaviour.

Early detection and intervention in first-episode schizophrenia: a critical review

Objective: To review the literature on early intervention in psychosis and to evaluate relevant studies.

Premorbid functioning versus duration of untreated psychosis in 1 year outcome in first-episode psychosis

OBJECTIVE This study examines 1year outcome in patients having first-episode non-affective psychosis, with emphasis on Duration of Untreated Psychosis (DUP) and premorbid functioning, in order to clarify how these factors interact. METHOD Forty-three consecutively admitted patients were all rated on the Positive and Negative Syndrome Scale (PANSS) and the Global Assessment of Functioning Scale (GAF), both upon hospitalization and at 1year follow-up. In addition, premorbid functioning, DUP, duration of hospitalization, and social functioning were rated. RESULTS Fifty-six per cent were in remission, 18% suffered multiple relapses and 26% were continuously psychotic at 1 year follow-up. Both poor premorbid functioning and long DUP are significantly correlated with more negative symptoms and poorer global functioning at follow-up. Long DUP is also significantly correlated with more positive symptoms. Even when we control for other factors, including premorbid functioning and gender, DUP is a strong predictor of outcome. To a limited degree premorbid functioning and DUP interact, but DUP has an independent influence on outcome. CONCLUSIONS these findings strengthen the rationale for establishing health service programs for early detection and treatment of first-onset psychosis

The course of neurocognitive functioning in first-episode psychosis and its relation to premorbid adjustment, duration of untreated psychosis, and relapse

The aim was to determine the post-onset longitudinal course of cognitive functioning in first-episode psychoses and to examine how premorbid adjustment, duration of untreated psychosis (DUP), and clinical variables such as relapse are associated with that course. Consecutive patients with a DSM-IV diagnosis of non-organic psychosis coming to their first treatment in the health care areas under study were included. Ultimately, 207 patients were assessed neuropsychologically at baseline, 138 were reassessed one year later, and 111 two years later. Five dimensions were identified through principal component analysis of eight neuropsychological (NP) test results: Working Memory (WM), Executive Function (EF), Verbal Learning (VL), Impulsivity (Im), and Motor Speed (MS). No major changes were found in the level of neurocognitive functioning from baseline to the 1-year and 2-year follow-ups. Patients with good initial levels of premorbid academic functioning had consistently better scores on WM at all three time points. No association was found between DUP and the longitudinal course of neurocognitive function. Significant associations occurred between better WM and VL at 1 and 2 years and fewer relapses during the first year, but not the second. Most NP deficits are in place by onset of psychosis and are stable over two years. Milder WM deficits are associated with higher premorbid academic functioning. More severe deficits in WM and VL are associated with more relapses during the first year. It is unclear whether NP deficits cause relapse, relapse causes NP deficits, or both are manifestations of a third deteriorative process.

Methodological pitfalls in early detection studies: the NAPE Lecture 2002

Objective: To identify and discuss methodological pitfalls that may help explain why many questions around early detection (ED) and duration of untreated psychosis (DUP) are still unsolved.

Early detection of psychosis: positive effects on 5-year outcome

BACKGROUND During the last decades we have seen a new focus on early treatment of psychosis. Several reviews have shown that duration of untreated psychosis (DUP) is correlated to better outcome. However, it is still unknown whether early treatment will lead to a better long-term outcome. This study reports the effects of reducing DUP on 5-year course and outcome. METHOD During 1997-2000 a total of 281 consecutive patients aged >17 years with first episode non-affective psychosis were recruited, of which 192 participated in the 5-year follow-up. A comprehensive early detection (ED) programme with public information campaigns and low-threshold psychosis detection teams was established in one healthcare area (ED-area), but not in a comparable area (no-ED area). Both areas ran equivalent treatment programmes during the first 2 years and need-adapted treatment thereafter. RESULTS At the start of treatment, ED-patients had shorter DUP and less symptoms than no-ED-patients. There were no significant differences in treatment (psychotherapy and medication) for the 5 years. Mixed-effects modelling showed better scores for the ED group on the Positive and Negative Syndrome Scale negative, depressive and cognitive factors and for global assessment of functioning for social functioning at 5-year follow-up. The ED group also had more contacts with friends. Regression analysis did not find that these differences could be explained by confounders. CONCLUSIONS Early treatment had positive effects on clinical and functional status at 5-year follow-up in first episode psychosis.

Substance abuse in first-episode non-affective psychosis.

Abuse of alcohol and drugs is an important and clinically challenging aspect of first-episode psychosis. Only a few studies have been carried out on large-sized and reliably characterized samples. These are reviewed, and the results are compared with a sample of 300 first-episode psychosis patients recruited for the TIPS (Early Treatment and Identification of Psychosis) study from Norway and Denmark. Prevalence rates from the literature vary from 6% to 44% for drugs and 3% to 35% for alcohol. In our sample, 23% abused drugs and 15% abused alcohol during the last 6 months. When compared to non-abusers, the drug-abusing group is characterized by the following: male gender, younger age, better premorbid social, poor premorbid academic functioning, and more contact with friends in the last year before onset. Alcohol abusers were the oldest group and they had the least contact with friends. A group of patients abusing both drugs and alcohol had poor premorbid academic functioning from early childhood. Overall, drug and alcohol abuse are highly prevalent in contemporary first-episode psychosis samples. In our study, substance abuse comorbidity did not generate differences on diagnosis, duration of untreated psychosis, psychiatric symptoms, or global functioning at onset/baseline. The premorbid profiles of the substance abusers were clearly different from the non-abusers. Drug abusers, in particular, were more socially active both premorbidly and during the year preceding the start of treatment.

Clinical epidemiologic first-episode psychosis : 1-year outcome and predictors

Objective:  To describe 1‐year outcome in a large clinical epidemiologic sample of first‐episode psychosis and its predictors.

Apathy in first episode psychosis patients: a ten year longitudinal follow-up study.

BACKGROUND Apathy is a common symptom in first episode psychosis (FEP), and is associated with poor functioning. Prevalence and correlates of apathy 10 years after the first psychotic episode remain unexplored. OBJECTIVE The aims of the study were twofold: 1) to examine prevalence and predictors of apathy at 10 years, and 2) to examine the relationship between apathy at 10 years and concurrent symptoms, functioning and outcome, including subjective quality of life. METHODS Three-hundred-and-one patients with FEP were included at baseline, 186 participated in the 10 year follow-up. Of these, 178 patients completed the Apathy Evaluation Scale (AES-S-Apathy). Patients were classified as having apathy (AES-S-Apathy≥27) or not. The relationship between apathy and baseline variables (Demographics, Diagnosis, Duration of Untreated Psychosis), measures of symptomatology (Positive and Negative Syndrome Scale, Calgary Depression Scale for Schizophrenia), functioning (Global Assessment of Functioning Scale, Strauss Carpenter Level of Functioning Scale) and subjective quality of life (Lehmans Quality of Life Interview) were estimated through correlation analyses and blockwise multiple hierarchical regression analysis. RESULTS Nearly 30% of patients met the threshold for being apathetic at follow-up. No baseline variables predicted apathy significantly at 10 years. Apathy was found to contribute independently to functioning and subjective quality of life, even when controlling for other significant correlates. CONCLUSIONS Apathy is a common symptom in a FEP cohort 10 years after illness debut, and its presence relates to impaired functioning and poorer subjective quality of life.

First-Episode Psychosis: Diagnostic Stability over One and Two Years

Background: Diagnostic stability is important for daily clinical work and planning of treatment. The aims of this study were to measure diagnostic stability in a clinical epidemiologic sample and to identify markers of change in diagnosis. Sampling and Methods: Diagnostic stability and change were measured in a sample of 301 patients with first-episode psychosis from four national health care sectors in Norway and Denmark at baseline, 1 and 2 years. Results: Diagnostic stabilities were high for schizophrenia and schizoaffective disorder (85–99%), low for schizophreniform disorder (16–19%), and intermediate for other diagnoses. Diagnostic change from schizophreniform to schizophrenia was frequent in year 1 (72%). Characteristics discriminating schizophreniform patients keeping their diagnosis (i.e. having recovered within 6 months with no relapse) from those developing schizophrenia at 1 year were female gender, better childhood premorbid functioning, shorter duration of untreated psychosis and more severe general psychotic symptoms, especially excitation. Conclusions: Findings provide validation for the DSM-IV categories within the schizophrenic spectrum. The limitations of the study were: the raters were not blind to baseline assessments; patients with longer duration of untreated psychosis were more likely to refuse participation; not all patients were assessed at 1- and 2-year follow-up, but the attrition was rather low.