M. Birchwood

A self‐report Insight Scale for psychosis: reliability, validity and sensitivity to change

Lack of insight is a frequent concomitant of psychosis and has traditionally been viewed as a binary, all or none phenomenon. Recent conceptualization has formulated insight as a continuum representing the juxtaposition of 3 factors – awareness of illness, need for treatment and attribution of symptoms. Measurement of insight has been exclusively based on interview; this method does not easily lend itself to frequent repeated measurement and requires interrater reliability to be established. A self‐report Insight Scale is presented, and evidence in support of its reliability, validity and sensitivity is provided that includes a sample of 30 patients monitored during recovery from an acute psychosis. The scale is a quick and acceptable measure that may find application in investigations of acute care, cognitive therapy of psychotic symptoms and as a method of augmenting clinical judgements of insight.

Psychological pathways to depression in schizophrenia: studies in acute psychosis, post psychotic depression and auditory hallucinations.

phrenia suggest that up to 50 % experience depressive symptoms (Birchwood et al. 2000). Generally, the prevalence of depression in schizophrenia (‘post psychotic depression’ -PPD) ranges from 22 % to 75 % depending upon the criteria used and the chronicity of the sample. This diversity is most commonly attributed to the numerous diagnostic criteria available to assess symptoms,the frequency of follow-up and the variations in patient environment.Furthermore, and contrary to both DSM-IV (APA 1994) and ICD-10 (WHO 1993) diagnostic criteria, Bressan Chaves, Pilowsky et al. (2002) have suggested that the requirement of a temporal link between postpsychotic depression and the immediately preceding psychotic episode is not born out by the evidence. Individual psychotic symptoms have also been linked with a raised risk of depression. Studies of the phenomenology of auditory hallucinations have revealed that between two-thirds and three-quarters of voice hearers will be at least moderately depressed and distressed by the experience (Chadwick and Birchwood 1994; Birchwood and Chadwick 1997; Trower et al. 2004). It is tempting to characterize depression as integral to psychosis and part and parcel of the accompanying loss of functioning, and it is perhaps for this reason that the pathogenesis of these emotional co-morbidities is not understood and few effective treatments are available. In order to improve our understanding of emotional dysfunction and to develop new treatments, we have argued (Birchwood 2003) that we need to make a clear distinction between three core, but not mutually exclusive pathways: depression that is intrinsic to the psychosis diathesis, a psychological reaction to it, and the product of disturbed developmental pathways resulting from developmental trauma and the childhood antecedents of psychosis. In this paper we will focus on the second pathway and present data from three studies which examine this in relation to depression in: PPD, auditory hallucinations and in acute, first episode schizophrenia. Here our emSPECIAL ISSUE

The evolution of depression and suicidality in first episode psychosis

Upthegrove R, Birchwood M, Ross K, Brunett K, McCollum R, Jones L. The evolution of depression and suicidality in first episode psychosis.

Pathways to Violent Behavior During First-Episode Psychosis: A Report From the UK National EDEN Study

IMPORTANCE Although many studies have explored the correlates of violence during first-episode psychosis (FEP), most have simply compared violent psychotic individuals with nonviolent psychotic individuals. Accumulating evidence suggests there may be subgroups within psychosis, differing in terms of developmental processes and proximal factors associated with violent behavior. OBJECTIVE To determine whether there are subgroups of psychotic individuals characterized by different developmental trajectories to violent behavior. DESIGN, SETTING, AND PARTICIPANTS The National EDEN (Evaluating the Development and Impact of Early Intervention Services in the West Midlands) Study longitudinal cohort assessed premorbid delinquency (premorbid adjustment adaptation subscale across childhood and adolescence), age at illness onset, duration of untreated psychosis, past drug use, positive symptoms, and violent behavior. Group trajectories of premorbid delinquency were estimated using latent class growth analysis, and associations with violent behavior were quantified. This study included 6 early intervention services in 5 geographical locations across England, with violent behavior information available for 670 first-episode psychosis cases. MAIN OUTCOMES AND MEASURES Violent behavior at 6 or 12 months following early intervention services entry. RESULTS Four groups of premorbid delinquency were identified: stable low, adolescent-onset high to moderate, stable moderate, and stable high. Logistic regression analysis, with stable low delinquency as the reference group, demonstrated that moderate (odds ratio, 1.97; 95% CI, 1.12-3.46) and high (odds ratio, 3.53; 95% CI, 1.85-6.73) premorbid delinquency trajectories increased the risk for violent behavior during FEP. After controlling for confounders, path analysis demonstrated that the increased risk for violence in the moderate delinquency group was indirect (ie, partially mediated by positive symptoms) (probit coefficient [β] = 0.12; P = .002); while stable high delinquency directly increased the risk for violence (β = 0.38; P = .05). CONCLUSIONS AND RELEVANCE There appear to be diverse pathways to violent behavior during FEP. Stable high premorbid delinquency from childhood onwards appears to directly increase the risk for violent behavior, independent of psychosis-related risk factors. In addition to tackling illness-related risks, treatments should directly address antisocial traits as a potent risk for violence during FEP.

Depression and Schizophrenia: Cause, Consequence or Trans-diagnostic Issue?

The presence of depression in schizophrenia has been a challenge to the Kraepelinian dichotomy, with various attempts to save the fundamental distinction including evoking and refining diagnoses such as schizoaffective disorder. But the tectonic plates are shifting. Here we put forward a summary of recent evidence regarding the prevalence, importance, possible aetiological pathways and treatment challenges that recognizing depression in schizophrenia bring. Taken together we propose that depression is more than comorbidity and that increased effective therapeutic attention to mood symptoms will be needed to improve outcomes and to support prevention.

Prevalence of psychotic-like experiences in young adults with social anxiety disorder and correlation with affective dysregulation

Abstract Social anxiety disorder (SAD) is associated with psychotic-like experiences (PLEs) and is a frequent diagnosis in the prodromal phases of psychosis. We investigated whether psychopathological factors could discriminate which subjects with SAD are more likely to develop PLEs. A sample of 128 young adults with SAD was split into two subsamples according to the presence of clinically relevant PLEs. Correlations between PLEs and other psychopathological markers were explored. The SAD with PLEs group showed higher level of anxiety, depression, and intolerance of uncertainty (IU) compared with the SAD without PLEs group. A limitation of this study is that the cross-sectional design precluded the analysis of causality. In our sample, the presence of PLEs is related to higher levels of depression, anxiety, and IU. The current findings are consistent with hypotheses suggesting that cognitive disturbances, together with social anxiety, may result in PLEs.

Core outcome sets for use in effectiveness trials involving people with bipolar and schizophrenia in a community-based setting (PARTNERS2): study protocol for the development of two core outcome sets

BackgroundIn the general population the prevalence of bipolar and schizophrenia is 0.24% and 1.4% respectively. People with schizophrenia and bipolar disorder have a significantly reduced life expectancy, increased rates of unemployment and a fear of stigma leading to reduced self-confidence. A core outcome set is a standardised collection of items that should be reported in all controlled trials within a research area. There are currently no core outcome sets available for use in effectiveness trials involving bipolar or schizophrenia service users managed in a community setting.MethodsA three-step approach is to be used to concurrently develop two core outcome sets, one for bipolar and one for schizophrenia. First, a comprehensive list of outcomes will be compiled through qualitative research and systematic searching of trial databases. Focus groups and one-to-one interviews will be completed with service users, carers and healthcare professionals. Second, a Delphi study will be used to reduce the lists to a core set. The three-round Delphi study will ask service users to score the outcome list for relevance. In round two stakeholders will only see the results of their group, while in round three stakeholders will see the results of all stakeholder group by stakeholder group. Third, a consensus meeting with stakeholders will be used to confirm outcomes to be included in the core set. Following the development of the core set a systematic literature review of existing measures will allow recommendations for how the core outcomes should be measured and a stated preference survey will explore the strength of people’s preferences and estimate weights for the outcomes that comprise the core set.DiscussionA core outcome set represents the minimum measurement requirement for a research area. We aim to develop core outcome sets for use in research involving service users with schizophrenia or bipolar managed in a community setting. This will inform the wider PARTNERS2 study aims and objectives of developing an innovative primary care-based model of collaborative care for people with a diagnosis of bipolar or schizophrenia.

Seeking help for first-episode psychosis: a family narrative

Delayed help‐seeking can have serious consequences for young people with first‐episode psychosis (FEP), in terms of treatment response and outcome. Young peoples narratives about help‐seeking are important to understand why delays occur; however, as the majority of help‐seeking is initiated by family members, through a general practitioner (GP), family narratives are also of interest. The aim of this study was to explore help‐seeking for FEP, including first contact with a GP.

Usefulness of EQ-5D for evaluation of health-related quality of life in young adults with first-episode psychosis

PurposeTo evaluate the psychometric properties of the EQ-5D and the usefulness of this instrument in psychiatric practice as a measure of health-related quality of life (HRQoL) in a sample of young adults with first-episode psychosis.MethodsThe validity of individual questionnaire items is studied using an Item Response/Latent Trait Theory modeling approach. Sensitivity of response patterns on EQ-5D items to particular diagnostic subtypes of psychosis is investigated using a finite mixture modeling approach through latent class analysis. Finally, a structural equation modeling framework is used to study differential item functioning via a multigroup approach.ResultsResults suggest that the data closely correspond to the Rasch Rating Scale Model, and therefore that EQ-5D latent scores are equal interval measures. Despite comprising relatively few items, the instrument yields reliable measures of HRQoL for group comparisons and cost-effectiveness evaluation, but EQ-5D score is too imprecise for the assessment of HRQoL for clinical purposes at the individual level. A significant relationship was found between EQ-5D responses and type of psychosis due to inclusion of item anxiety/depression in EQ-5D. Two items (anxiety/depression, functioning in usual activities) showed an ethnicity bias.ConclusionsPsychometric evidence confirmed the EQ-5D to be a valid, interval measure that is scalable according to Rasch principles.

Don’t turn your back on the symptoms of psychosis: a proof-of-principle, quasi-experimental public health trial to reduce the duration of untreated psychosis in Birmingham, UK

BackgroundReducing the duration of untreated psychosis (DUP) is an aspiration of international guidelines for first episode psychosis; however, public health initiatives have met with mixed results. Systematic reviews suggest that greater focus on the sources of delay within care pathways, (which will vary between healthcare settings) is needed to achieve sustainable reductions in DUP (BJP 198: 256-263; 2011).Methods/DesignA quasi-experimental trial, comparing a targeted intervention area with a ‘detection as usual’ area in the same city. A proof-of–principle trial, no a priori assumptions are made regarding effect size; key outcome will be an estimate of the potential effect size for a definitive trial. DUP and number of new cases will be collected over an 18-month period in target and control areas and compared; historical data on DUP collected in both areas over the previous three years, will serve as a benchmark. The intervention will focus on reducing two significant DUP component delays within the overall care pathway: delays within the mental health service and help-seeking delay.DiscussionThis pragmatic trial will be the first to target known delays within the care pathway for those with a first episode of psychosis. If successful, this will provide a generalizable methodology that can be implemented in a variety of healthcare contexts with differing sources of delay.Trial registrationhttp://www.controlled-trials.com/ISRCTN45058713