Mary Verdi

Neuropsychological Profiles in Individuals at Clinical High Risk for Psychosis: Relationship to Psychosis and Intelligence

BACKGROUND Characterizing neuropsychological (NP) functioning of individuals at clinical high risk (CHR) for psychosis may be useful for prediction of psychosis and understanding functional outcome. The degree to which NP impairments are associated with general cognitive ability and/or later emergence of full psychosis in CHR samples requires study with well-matched controls. METHODS We assessed NP functioning across eight cognitive domains in a sample of 73 CHR youth, 13 of whom developed psychotic-level symptoms after baseline assessment, and 34 healthy comparison (HC) subjects. Groups were matched on age, sex, ethnicity, handedness, subject and parent grade attainment, and median family income, and were comparable on WRAT-3 Reading, an estimate of premorbid IQ. Profile analysis was used to examine group differences and the role of IQ in profile shape. RESULTS The CHR sample demonstrated a significant difference in overall magnitude of NP impairment but only a small and nearly significant difference in profile shape, primarily due to a large impairment in olfactory identification. Individuals who subsequently developed psychotic-level symptoms demonstrated large impairments in verbal IQ, verbal memory and olfactory identification comparable in magnitude to first episode samples. CONCLUSIONS CHR status may be associated with moderate generalized cognitive impairments marked by some degree of selective impairment in olfaction and verbal memory. Impairments were greatest in those who later developed psychotic symptoms. Future study of olfaction in CHR samples may enhance early detection and specification of neurodevelopmental mechanisms of risk.

Clinical and Functional Outcomes After 2 Years in the Early Detection and Intervention for the Prevention of Psychosis Multisite Effectiveness Trial

Objective: To test effectiveness of the Early Detection, Intervention, and Prevention of Psychosis Program in preventing the onset of severe psychosis and improving functioning in a national sample of at-risk youth. Methods: In a risk-based allocation study design, 337 youth (age 12–25) at risk of psychosis were assigned to treatment groups based on severity of positive symptoms. Those at clinically higher risk (CHR) or having an early first episode of psychosis (EFEP) were assigned to receive Family-aided Assertive Community Treatment (FACT); those at clinically lower risk (CLR) were assigned to receive community care. Between-groups differences on outcome variables were adjusted statistically according to regression-discontinuity procedures and evaluated using the Global Test Procedure that combined all symptom and functional measures. Results: A total of 337 young people (mean age: 16.6) were assigned to the treatment group (CHR + EFEP, n = 250) or comparison group (CLR, n = 87). On the primary variable, positive symptoms, after 2 years FACT, were superior to community care (2 df, p < .0001) for both CHR (p = .0034) and EFEP (p < .0001) subgroups. Rates of conversion (6.3% CHR vs 2.3% CLR) and first negative event (25% CHR vs 22% CLR) were low but did not differ. FACT was superior in the Global Test (p = .0007; p = .024 for CHR and p = .0002 for EFEP, vs CLR) and in improvement in participation in work and school (p = .025). Conclusion: FACT is effective in improving positive, negative, disorganized and general symptoms, Global Assessment of Functioning, work and school participation and global outcome in youth at risk for, or experiencing very early, psychosis.

Change in neuropsychological functioning over one year in youth at clinical high risk for psychosis.

Schizophrenia and related psychotic disorders are associated with significant neuropsychological (NP) impairments. Yet the onset and developmental evolution of these impairments remains incompletely characterized. This study examined NP functioning over one year in a sample of youth at clinical high risk (CHR) for psychosis participating in a treatment study. We assessed functioning across six cognitive domains at two time points in a sample of 53 CHR and 32 healthy comparison (HC) subjects. Linear regression of HC one-year scores was used to predict one-year performance for CHR from baseline scores and relevant demographic variables. We used raw scores and MANOVAs of the standardized residuals to test for progressive impairment over time. NP functioning of CHR at one year fell significantly below predicted levels. Effects were largest and most consistent for a failure of normative improvement on tests of executive function. CHR who reached the highest positive symptom rating (6, severe and psychotic) on the Structured Interview of Prodromal Syndromes after the baseline assessment (n = 10/53) demonstrated a particularly large (d = -1.89), although non-significant, discrepancy between observed and predicted one-year verbal memory test performance. Findings suggest that, although much of the cognitive impairment associated with psychosis is present prior to the full expression of the psychotic syndrome, some progressive NP impairments may accompany risk for psychosis and be greatest for those who develop psychotic level symptoms.

Reduction in Incidence of Hospitalizations for Psychotic Episodes Through Early Identification and Intervention

OBJECTIVE This study examined whether the incidence of hospitalization for psychosis was reduced by a communitywide system of early identification and intervention to prevent onset of psychosis. METHODS The Portland Identification and Early Referral program (PIER) was initiated in 2001. Youths and young adults ages 12-35 were identified by professionals in a wide variety of educational, health, and mental health settings. PIER program staff assessed, confirmed risk of psychosis, and provided treatment for 24 months to eligible and consenting young people (N=148). The monthly rate of first hospital admission for psychosis was the outcome measure for efficacy of identification and intervention. Admission rates before and after the program began accepting referrals were compared, both in the experimental area (Greater Portland) and in aggregated urban areas of Maine (control areas). Autoregressive integrated moving-average (ARIMA) models were used to assess the effect. RESULTS On the basis of ARIMA models, the rate of first hospital admission for psychosis decreased significantly by 26% (95% confidence interval [CI]=-64% to -11%) in the Greater Portland area. The rate increased by 8% (CI=-5% to 36%) in the control areas. Taking into account the increase in the control areas, the actual percentage reduction in Greater Portland during the intervention period was 34% (26% plus 8%). The reduction in admissions was largest for individuals with nonaffective nonschizophrenic psychosis. CONCLUSIONS PIER has demonstrated that populationwide early identification is feasible. Preventive intervention can reduce rates of initial hospitalizations for psychosis in a midsized city.

Sleep Problems and Their Relationship to Maladaptive Behavior Severity in Psychiatrically Hospitalized Children with Autism Spectrum Disorder (ASD)

We examined the relationship between sleep duration and awakenings to Aberrant Behavior Checklist-Community (ABC-C) and Autism Diagnostic Observation Schedule (ADOS-2) scores in hospitalized youth with ASD and behavioral disturbance. Participants included 106 patients with a stay of at least 10 nights. Sleep in the hospital was recorded by staff observation. Higher scores on the ABC-C (irritability, stereotypy, and hyperactivity subscales) at admission were significantly associated with fewer minutes slept during the last five nights of hospitalization. There was no association between total awakenings and ABC-C scores or ADOS-2 comparison scores. Improved understanding of the relationship between sleep quality and maladaptive behavior in this challenging cohort of patients with ASD is vital to the definition and design of future effective interventions.