Sally Mustafa

Work instability and financial loss in early inflammatory arthritis.

Inflammatory arthritis is associated with a high degree of work instability and financial burden. In this study, we examine the extent of work instability and financial loss as well as their association with disease characteristics during the first 18 months of inflammatory arthritis.

Comparing three‐year extension of early intervention service to regular care following two years of early intervention service in first‐episode psychosis: a randomized single blind clinical trial

This study aimed to determine if, following two years of early intervention service for first‐episode psychosis, three‐year extension of that service was superior to three years of regular care. We conducted a randomized single blind clinical trial using an urn randomization balanced for gender and substance abuse. Participants were recruited from early intervention service clinics in Montreal. Patients (N=220), 18‐35 years old, were randomized to an extension of early intervention service (EEIS; N=110) or to regular care (N=110). EEIS included case management, family intervention, cognitive behaviour therapy and crisis intervention, while regular care involved transfer to primary (community health and social services and family physicians) or secondary care (psychiatric outpatient clinics). Cumulative length of positive and negative symptom remission was the primary outcome measure. EEIS patients had a significantly longer mean length of remission of positive symptoms (92.5 vs. 63.6 weeks, t=4.47, p<0.001), negative symptoms (73.4 vs. 59.6 weeks, t=2.84, p=0.005) and both positive and negative symptoms (66.5 vs. 56.7 weeks, t=2.25, p=0.03) compared to regular care patients. EEIS patients stayed in treatment longer than regular care patients (mean 131.7 vs. 105.3 weeks, t=3.98, p<0.001 through contact with physicians; 134.8 ± 37.7 vs. 89.8 ± 55.2, t=6.45, p<0.0001 through contact with other health care providers) and received more units of treatment (mean 74.9 vs. 39.9, t=4.21, p<0.001 from physicians, and 57.3 vs. 28.2, t=4.08, p<0.001 from other health care professionals). Length of treatment had an independent effect on the length of remission of positive symptoms (t=2.62, p=0.009), while number of units of treatment by any health care provider had an effect on length of remission of negative symptoms (t=−2.70, p=0.008) as well as total symptoms (t=−2.40, p=0.02). Post‐hoc analysis showed that patients randomized to primary care, based on their better clinical profile at randomization, maintained their better outcome, especially as to remission of negative symptoms, at the end of the study. These data suggest that extending early intervention service for three additional years has a positive impact on length of remission of positive and negative symptoms compared to regular care. This may have policy implications for extending early intervention services beyond the current two years.

Is the Clinical High-Risk State a Valid Concept? Retrospective Examination in a First-Episode Psychosis Sample

OBJECTIVE One reason for worldwide interest in the clinical high-risk (CHR) state for psychosis is its potential as a target for prevention. However, the feasibility and utility of early intervention initiatives that are focused on this stage involve an untested assumption: that most patients with a first episode of psychosis (FEP) experience earlier CHR symptoms. The objective of this study was to identify and characterize the proportion of FEP patients who had experienced such symptoms prior to the onset of their psychosis. METHODS Semistructured interviews of 351 patients and families with the Circumstances of Onset and Relapse Schedule were supplemented by chart reviews in a catchment area-based sample of FEP patients. Information was extracted regarding pathways to care and psychiatric and behavioral changes over time. Experts (N=30) working in FEP and CHR settings identified which of 27 early signs and symptoms constitute attenuated positive or subthreshold psychotic symptoms (APSPS) if they appear prior to a syndromal-level psychotic episode. RESULTS Nine early signs and symptoms were endorsed by the experts as representing APSPS. More than half of consenting patients, and two-thirds (68%) of those who completed all assessments, had experienced at least one such sign or symptom prior to their FEP. The groups with and without APSPS were similar in social, demographic, and clinical characteristics. CONCLUSIONS Most consenting patients with an FEP had experienced previous signs and symptoms consistent with a CHR state prior to the onset of threshold-level psychotic symptoms, although a substantial minority had not. This finding validates the viability of the CHR construct as a potential target for early case identification and preventive and therapeutic interventions.

Therapeutic effectiveness and tolerability of aripiprazole as initial choice of treatment in first episode psychosis in an early intervention service: A one-year outcome study

INTRODUCTION Aripiprazole has been associated with a low prevalence of metabolic side effects as compared to other second generation antipsychotic (SGA) medications mostly in patients with long standing illness. The purpose of the present study was to assess specifically the effectiveness and safety of aripiprazole as a first choice for antipsychotic therapy for young patients presenting with a previously untreated first episode of a psychotic disorder (FEP). METHODS Seventy-three patients presenting with a FEP and with minimal prior exposure to antipsychotic medications were recruited to be part of an open label naturalistic outcome study using aripiprazole as the first choice of antipsychotic medication. Data on positive, negative and total symptom severity including general psychopathological symptoms, level of functioning and metabolic indices were collected prospectively over a one-year period. RESULTS As compared to baseline, patients treated with aripiprazole (mean dose 9.6mg) improved significantly on measures of positive (p<0.001), negative (p<0.001) and total severity-general psychopathology symptoms (p<0.001) and level of functioning (p<0.001). Seventy two percent of the participants achieved positive symptom remission and 50% achieved total remission (positive and negative) at one year of follow up. Unlike reports on patients with longer standing illness, significant weight gain (p<0.001) was observed, with 44% of participants experiencing >7% increase in body weight. CONCLUSION FEP patients starting treatment with aripiprazole improved on symptoms and social and occupational functioning. Aripiprazole was well tolerated except for a significant weight gain.

History of depressive episodes as a risk factor for illness severity in early inflammatory arthritis.

OBJECTIVE Psychosocial research in arthritis consistently demonstrates a relationship between depression and disease characteristics such as severity of illness and physical disability. In this study, we examine how a history of clinical depression identified through diagnostic interviews influences disease outcome measures in patients with early inflammatory arthritis (EIA) in the absence of current depression. METHODS Patients in the early phase (more than 6-weeks, less than 1-year duration) of inflammatory arthritis were recruited from a larger EIA registry, which recorded sociodemographic data, current depressive symptoms and measures of disease severity. Current and history of major depression was assessed by a structured clinical interview. Eighty-one patients without current major depression were divided into two groups: 28 with and 53 without a history of depression. RESULTS There were no significant differences between the two groups in age, sex, education, income, or level of current depressive symptoms. Compared with patients with no history of major depression, those with a history of depressive episodes had higher self-ratings of disease activity and were assessed as having more severe disease and poorer physical functioning by their physicians. CONCLUSION This study indicates that a history of major depression represents a risk factor for disease severity in EIA. This may reflect an enduring physiological effect of depression that influences subsequent inflammatory arthritis or an underlying shared process between these two disease entities.

Effectiveness of Community Treatment Order in Patients with a First Episode of Psychosis: A Mirror-Image Study:

Objective: Poor adherence to antipsychotic medications is strongly associated with psychotic relapses and hospitalizations. This may hinder patients’ ability to function, particularly in a first episode of psychosis (FEP). Poor adherence to treatment may be due to poor insight that can alter the capacity to consent to care, including pharmacotherapy. When patients are judged legally lacking the capacity to consent to care, treatment can be mandated through community treatment orders (CTOs). This naturalistic study examines the effects of CTOs in FEP patients. Method: This study examines 38 FEP patients legally deemed unable to consent to care during their follow-up. Using a naturalistic mirror-image approach, we compare clinical (Scale for the Assessment of Positive Symptoms [SAPS], Scale for the Assessment of Negative Symptoms [SANS]), functional (Global Assessment of Functioning Scale [GAF], Social and Occupational Functioning Assessment Scale [SOFAS]), and service use (number of emergency room visits, length of hospitalizations) indicators before and after CTO. Results: After the CTO, 37 of 38 patients complied with treatment. Statistically significant improvements in clinical (▵SAPS = –6.3; 95% CI, 4.5 to 8.1 and ▵SANS = –2.2; 95% CI, 0.9 to 3.4, P < 0.01) and functional (▵GAF = +15.0; 95% CI, 8.4 to 21.6, ▵SOFAS = +18.6; 95% CI, 12.8 to 24.4, P < 0.01) outcomes were observed. Significant reduction in emergency room visits (P = 0.016) and days of hospitalization per month in acute care units (P < 0.05) were identified with no difference in hospital days per month in short-stay units. Moreover, encounters with case managers (P = 0.008) and attendance of cognitive therapy sessions (P = 0.031) were significantly higher. However, patients’ weight significantly increased after CTO (▵weight = +8.0 kg, P < 0.01). Conclusions: In FEP patients, CTOs improve compliance to treatment, which contributes to reducing positive and negative symptoms, shortening hospital stays, and improving functioning.

Predictors of ‘all-cause discontinuation’ of initial oral antipsychotic medication in first episode psychosis

INTRODUCTION Discontinuation of the initial oral antipsychotic prescribed for a first episode of psychosis (FEP) can derail outcome. Our objective was to examine the rate of and time to all-cause discontinuation of the first antipsychotic prescribed and the factors influencing such discontinuation. METHODS In a sample of 390 FEP patients, we estimated the rate of and time to discontinuation of the initial antipsychotic over a one-year period. The effects of a number of putative predictors of discontinuation were estimated using regression analyses. RESULTS Rate of discontinuation of the first antipsychotic was 72%, with no difference between the 3 investigated antipsychotics (olanzapine (73%), risperidone (68%) and aripiprazole (75%)), (χ2 (2) = 1.89, p = 0.388). Mean time to discontinuation was 7.2 (4.6) months and was not different among the three antipsychotics (Log-rank χ2 (2) = 0.257, p = 0.879). Binary logistic regression showed that higher positive and negative symptoms remission and baseline functioning were associated with lower rates of discontinuation (Nagelkerke R2 = 0.36, χ2 (10) = 66.9, p < 0.001). Multiple linear regression showed the same predictors, in addition to male gender and less weight gain per month of exposure to the initial antipsychotic, to be associated with longer time to discontinuation (adjusted R2 = 0.336, F (9, 219) = 13.8, p < 0.001). CONCLUSION Discontinuation of the initial antipsychotic is a major concern in the course of treating FEP. Symptom relief, better functioning and lower side effects appear to be the major factors associated with continuing an antipsychotic medication.

Association of Pre-onset Subthreshold Psychotic Symptoms With Longitudinal Outcomes During Treatment of a First Episode of Psychosis

Importance The clinical high-risk state in psychosis is most often characterized by subthreshold psychotic symptoms (STPS) and represents a target for psychosis prevention. However, evidence suggests that between 30% and 50% of patients with a first episode of psychosis (FEP) report no prior history of STPS, indicating that not all patients with FEP experience a previous clinical high-risk phase. As with other early characteristics of illness onset, this diversity in the early course of symptoms may offer prognostic value for subsequent clinical trajectories. Objective To determine whether a history of pre-onset STPS is associated with differential 1-year treatment outcomes in an early intervention service for FEP. Design, Setting, and Participants Data on 195 patients 15 to 35 years of age who were recruited between January 17, 2003, and October 17, 2013, were collected from a catchment-based specialized early intervention service for FEP. Patients who reported experiencing at least 1 STPS prior to the onset of FEP were identified as STPS present (STPSp; n = 135); those who reported no such history were identified as STPS absent (STPSa; n = 60). Statistical analysis was conducted from December 15, 2016, to February 15, 2018. Main Outcomes and Measures Summary scores on the Scale for the Assessment of Positive Symptoms and the Scale for the Assessment of Negative Symptoms, Calgary Depression Scale for Schizophrenia, Hamilton Anxiety Rating Scale, Global Assessment of Functioning scores, and Social and Occupational Functioning Assessment Scale scores at baseline and after 1 year of treatment were analyzed to evaluate 1-year outcomes. Results Individuals in the STPSp group (39 female and 96 male participants; mean [SD] age, 23.4 [4.2] years) and the STPSa group (20 female and 40 male participants; mean [SD] age, 23.9 [5.1] years) did not differ in symptom severity or functioning at baseline. Although both groups improved by 1 year of treatment, mixed analyses of covariance (controlling for duration of untreated psychosis) revealed group-by-time interactions for scores on the Scale for the Assessment of Negative Symptoms (F1,192 = 6.17; P = .01), the Global Assessment of Functioning (F1,188 = 7.54; P = .006), and the Social and Occupational Functioning Assessment Scale (F1,192 = 3.79; P = .05). Mixed analyses of covariance also revealed a group effect for scores on the Scale for the Assessment of Positive Symptoms (F1,192 = 5.31; P = .02). After controlling for multiple comparisons, all significant results indicate poorer 1-year outcomes for patients with STPSp compared with patients with STPSa. Conclusions and Relevance A history of pre-onset STPS consistent with a prior clinical high-risk state is associated with poorer outcomes in psychotic symptoms and global functioning for patients after 1 year of treatment for FEP. The presence or absence of pre-onset STPS therefore has prognostic value for treatment outcomes, even during a later stage of psychotic illness.

Role overload, pain and physical dysfunction in early rheumatoid or undifferentiated inflammatory arthritis in Canada

BackgroundInflammatory arthritis impairs participation in societal roles. Role overload arises when the demands by a given role set exceed the resources; time and energy, to carry out the required tasks. The present study examines the association between role overload and disease outcomes in early inflammatory arthritis (EIA).MethodsPatients (n = 104) of 7.61 months mean duration of inflammatory arthritis completed self-report questionnaires on sociodemographics, disease characteristics and role overload. Pain was assessed using the Short Form McGill Pain Questionnaire (MPQ) and physical functioning was measured with the Medical Outcomes Study Short Form 36 (SF-36) physical functioning score. Role overload was measured by the Role Overload Scale. Patients indicated the number of social roles they occupied from a total of the three typical roles; marital, parental and paid work.ResultsParticipants’ mean age was 56 years and 70.2% were female. Role overload was not correlated to the number of social roles, however, it was positively associated with pain (p = 0.004) and negatively associated with physical functioning (p = 0.001). On multivariate analysis, role overload was negatively associated with physical functioning after controlling for the relevant sociodemographic variables.ConclusionThis study identifies a possible reciprocal relationship between role overload and physical functioning in patients with EIA.