Paul Roy

A multi‐site Canadian perspective: examining the functional outcome from first‐episode psychosis

Objective:  To examine factors contributing to variance in functional outcome in first‐episode psychosis (FEP) following 1 year of treatment.

A multisite Canadian study of outcome of first-episode psychosis treated in publicly funded early intervention services.

Objective: The aim of this study was to determine 1-year symptomatic outcome and its predictors in patients with first-episode psychosis (FEP) treated at 3 different publicly funded sites. Method: We evaluated FEP patients (n = 172) treated in specialized programs in 2 medium-sized centres and 1 large urban centre with an identical protocol for demographic variables, diagnosis, and duration of untreated psychosis (DUP) at entry, and positive, negative, and general psychopathology symptoms at entry, 6 months, and 1 year. We used a mixed model analysis of variance, with time and centre and interaction between time and centre as fixed effects and sex and DUP as covariates, to analyze data. Results: A significant effect of time and time x centre interaction on positive, negative, and general symptom outcome was shown after controlling for ethnicity, education, and diagnosis. Patients showed significantly better outcome on all dimensions of symptoms in the 2 medium-sized centres, compared with the 1 large urban centre. Sex had a significant effect on negative and general symptoms, while DUP had no effect on any outcome measure. Conclusions: Similarly enriched early intervention services may produce different outcomes, even within a relatively homogeneous mental health system.

A randomised controlled trial of a group intervention to reduce engulfment and self-stigmatisation in first episode schizophrenia

Abstract Young people coping with first episode schizophrenia may be predisposed to illness engulfment whereby the illness entirely defines self-concept. They require psychosocial intervention to preserve an identity distinct from illness, promote hopefulness, and minimise the impact of stigma, enabling them to embrace a healthy sense of self and an optimistic future. The purpose of this study was to evaluate a group intervention designed to promote healthy self-concepts by reducing self-stigmatisation and engulfment among young adults recovering from first episode schizophrenia. Participants at two first episode psychosis clinics, one in Toronto and one in Ottawa, were assigned to one of two groups: intervention plus treatment as usual, or a control with only treatment as usual. A repeated measures analysis revealed that immediately post-intervention, the treatment group significantly improved on engulfment, hope, and quality of life measures compared with the control. No improvement was observed in self-concept, self-esteem, self-efficacy, and stigma. Intervening early in the course of the illness to address engulfment and self-stigmatisation may enable young people to acquire positive attitudes toward themselves and the future. Future longitudinal data are needed to determine whether this intervention will prevent the development of chronicity and demoralisation over time.

The International Study on General Practitioners and Early Psychosis (IGPS)

BACKGROUND In much of the world, general practitioners (GPs) are the health professionals most frequently initially contacted when a young person is developing psychosis. However little is known about their expertise in assessing psychosis and its risk. METHODS To assess the diagnostic patterns and treatment practices related to psychosis of GPs working in a range of health care systems, questionnaires were mailed to 12,516 randomly selected GPs in seven countries: Canada, Australia, New Zealand, England, Norway, Austria and the Czech Republic. Sites were defined as gatekeeping or non-gatekeeping, based on the primary care health system in effect at each site. A gatekeeping system (GK) is one which mandates that patients see a GP before in order to be referred to a specialist. By contrast, in a non-gatekeeping (nGK) system, individuals can seek help directly from specialists without authorization by a GP. RESULTS Twenty-two percent (n=2784) GPs responded to the mailed questionnaire. They reported low prevalence of early psychosis seen in general practice. Using awareness of functional decline as a prognostic sign as a proxy, gatekeeping (GK) GPs were found to be superior in their knowledge of the signs and symptoms of early psychosis than were non-gatekeeping GPs. GPs with less knowledge as to early psychosis were more likely to refer individuals with suspected psychosis to specialists. GPs reported a preference for access to specialized outpatient services as compared with obtaining continuous medical education relevant to early psychosis. The duration of maintenance treatment recommended by GPs was less than that recommended in international guidelines. GPs also underestimated the risk for relapse after a first episode of psychosis. CONCLUSIONS As GPs were largely unaware of features of early psychosis, such as functional decline, this should be the target of educational programs for GPs. However, the incidence of psychosis is low and GPs express a preference for access to appropriate referral over continuing medical education. Therefore, the development of specialized services for the assessment and care of patients who are in the early stages of developing schizophrenia may be warranted.

Treatment response to olanzapine and haloperidol and its association with dopamine D2 receptor occupancy in first-episode psychosis

Objective: Response to typical antipsychotic medication has been associated with achieving a level of striatal dopamine D2 receptor occupancy in the range of 65% to 70%. We undertook this study to determine whether response to the atypical antipsychotic olanzapine occurs at lower levels of D2 receptor occupancy. Method: Eighteen patients who presented with a first episode of psychosis were randomized to receive olanzapine 5 mg daily or haloperidol 2 mg daily in a double-blind design. We acquired positron emission tomography (PET) scans using the D2 ligand [11C]raclopride within the first 15 days of treatment to determine the percentage of D2 receptors occupied by the medication. According to response, dosage was then adjusted to a maximum dosage of 20 mg daily of either drug. PET scans were repeated after 10 to 12 weeks of treatment. Results: At the first PET scan, the 8 olanzapine-treated patients had significantly lower D2 receptor occupancies (mean 63.4%, SD 7.3) than those observed in the 10 patients treated with haloperidol (mean 73.0%, SD 6.1). When patients were rescanned following dosage adjustment, mean D2 receptor occupancies were greater than 70% in both groups. D2 receptor occupancies did not differ significantly between the olanzapine-treated group (mean 72.0%, SD 5.7) and the haloperidol-treated group (mean 78.7%, SD 7.6). Conclusions: These results suggest that, in patients being treated for a first episode of psychosis, olanzapine has its antipsychotic effect at approximately the same levels of D2 receptor occupancy as are achieved with low dosages of haloperidol.

Compensatory cognitive training for people with first-episode schizophrenia: Results from a pilot randomized controlled trial

Cognitive training or remediation now has multiple studies and meta-analyses supporting its efficacy in improving cognition and functioning in people with schizophrenia. However, relatively little is known about cognitive training outcomes in early psychosis. We conducted a pilot randomized controlled trial of Compensatory Cognitive Training (CCT) compared to Treatment as Usual (TAU) in 27 participants with first-episode psychosis who had received treatment for psychosis for less than six months. Assessments of cognition (MATRICS Consensus Cognitive Battery; MCCB) and functional capacity (UCSD Performance-Based Skills Assessment-Brief; UPSA-B) were administered at baseline and following the 12-week treatment. The CCT condition, compared to TAU, was associated with significant improvements on the MCCB composite score, as well as MCCB subtests measuring processing speed (Trail Making) and social cognition (Mayer-Salovey-Caruso Emotional Intelligence Test), with large effects on these three outcome measures. There were no significant CCT-associated effects on the UPSA-B or on positive, negative, or depressive symptoms. CCT treatment of cognitive impairments in first-episode schizophrenia is feasible and can result in large effect size improvements in global cognition, processing speed, and social cognition.

0223 SUBSTANCE USE AND ABUSE IN FIRST EPISODE PSYCHOSIS: PREVALENCE BEFORE AND AFTER EARLY INTERVENTION

UNLABELLED Despite the high prevalence of substance abuse among first-episode psychosis (FEP) populations, few studies examine whether early intervention (EI) improves substance abuse. OBJECTIVE To examine the prevalence and pattern of substance use and abuse among an FEP sample over 12 months. METHODS All the participants were diagnosed with a first episode of a schizophrenia spectrum disorder. The participants were followed prospectively. The prevalence rates of substance use and abuse from this sample were compared before and after 12 months of EI services and were compared with rates observed in a sample from the general population. RESULTS A total of 200 participants (80.0% males; mean age 24 years) entered the study: 183 participants completed all the assessments at baseline, 131 participants completed all the assessments at 12 months. At baseline, the findings showed similar prevalence rates between the FEP sample and the general sample for lifetime cannabis use (60% vs 55%, respectively) and hazardous alcohol use (26% vs 21%) but significantly different prevalence rates for lifetime hallucinogen (29% vs 15%; P < .001) and cocaine use (20% vs 14%; P < .001). At 12 months, the prevalence rates for drug abuse (P < .01), hazardous alcohol use (P < .01), and concurrent drug abuse and hazardous alcohol use (P < .05) were significantly lower than at baseline. CONCLUSION Substance use and abuse decreased significantly after 12 months of EI services; EI services may be able to detect and to reduce substance use among FEP patients before it becomes a more serious disorder.