Srividya Iyer

Stress and protective factors in individuals at ultra-high risk for psychosis, first episode psychosis and healthy controls

Stress-vulnerability models of schizophrenia regard psychosocial stress as an important factor in the onset and aggravation of psychotic symptoms, but such research in the early phases of psychosis is limited. Protective factors against the effects of stress might be the key to understanding some inconclusive findings and to the development of optimal psychosocial interventions. The present study compared self-reported levels of stress, self-esteem, social support and active coping in 32 patients with a first episode of psychosis (FEP), 30 individuals at ultra-high risk for psychosis (UHR) and 30 healthy controls. Associations with symptoms of psychosis were assessed in both patient groups. Individuals at UHR reported significantly higher stress levels compared to FEP patients. Both patient groups showed lower self-esteem compared to controls, and the UHR group reported lower social support and active coping than controls. These group differences could not be explained by age and dose of antipsychotic medication in the FEP group. In the UHR group, higher stress levels and lower self-esteem were associated with more severe positive and depressive symptoms on the Brief Psychiatric Rating Scale. Multiple regression analyses revealed that stress was the only significant predictor for both symptom measures and that the relationship was not moderated by self-esteem. Our findings show that individuals at UHR for psychosis experience high levels of psychosocial stress and marked deficits in protective factors. The results suggest that psychosocial interventions targeted at reducing stress levels and improving resilience in this population may be beneficial in improving outcomes.

Early intervention for psychosis: a Canadian perspective.

Abstract This paper provides an overview of early intervention (EI) services for psychosis in Canada. We describe a leading Canadian EI program’s approach to enhancing access (via early case detection, open referral, and rapid response) and providing specialized phase-specific treatment. Learnings from this program’s research/evaluation indicate that EI can significantly improve service user and family engagement. Achieving and maintaining symptom remission (particularly negative symptoms) may be important for better social and occupational functioning in first-episode psychosis (FEP). Our program demonstrates the feasibility of establishing and sustaining an open referral, rapid-response system to address the chronic systemic problems of long waiting lists and barriers to access. We argue that an integrated clinical-research program based on specialized EI guidelines can significantly improve outcomes and advance FEP research.

The relative contribution of cognition and symptomatic remission to functional outcome following treatment of a first episode of psychosis.

OBJECTIVE Functional recovery remains the primary goal following treatment of a psychotic disorder, especially after a first episode. Evidence regarding relative contributions of predictors of functional outcome, including symptoms and cognition, remains equivocal. The objective of the study was to determine the relative contribution of cognition, in particular verbal memory, and symptomatic remission to social and occupational functioning while controlling for established predictors of functioning in a large sample of patients presenting with a first episode of a schizophrenia spectrum or affective psychosis. METHOD Patients (aged 14-35 years) met DSM-IV criteria for a first episode of a schizophrenia spectrum or affective psychosis and had been admitted to the Prevention and Early Intervention Program for Psychoses, Montreal, Quebec, Canada, between 2003 and 2009 for treatment and follow-up for 2 years. Established predictors (duration of untreated psychosis, medication adherence, age at onset, substance use, premorbid adjustment), verbal memory, and length of positive and negative symptom remission were regressed on functioning (using the Strauss Carpenter Scale) at 1 (n = 208) and 2 (n = 159) years. Regressions were conducted with established predictors in the first step, followed by verbal memory and consecutive months of combined positive and negative symptom remission in the third step. Regressions were then repeated with length of positive and negative symptom remission, respectively. RESULTS Length of combined positive and negative symptom remission explained the most variance in functioning at 1 (R² adjusted = 0.35, F₉,₁₂₉ = 9.33, P < .001) and 2 (R² adjusted = 0.38, F₉,₉₇ = 8.21, P < .001) years, and verbal memory contributed only slightly to such outcome. While length of remission of negative symptoms was a stronger predictor of functioning than remission of positive symptoms at 1 year, length of positive symptom remission also made a large contribution at 2 years. CONCLUSIONS These results highlight the importance of achieving and maintaining remission of both negative and positive symptoms for longer periods in patients with a first episode of a psychotic disorder and the need for effective interventions to do so.

Evaluating outcomes of rehabilitation for severe mental illness

Improving the quality of life of individuals with severe mental illness has been the focus of considerable research. With advances in treatments for severe mental illness, particularly in psychiatric rehabilitation, evaluating outcomes has become increasingly important. Given the complex and multidimensional nature of severe mental illness, outcome evaluation of psychiatric rehabilitation is particularly difficult. This article addresses issues in evaluating psychiatric rehabilitation outcomes, including key outcome domains, selection of methods and measures, and meaningful use of results. Continuing conceptual and methodological issues are discussed. Also, future directions are explored, including evaluating multidimensional treatment effects and interactions and building an integrated understanding of all of the outcomes involved in psychiatric rehabilitation. More than 8% of individuals 18 years of age or older in the United States, or approximately 17.5 million people, have a severe mental illness resulting in significant functional impairment in their daily lives (Substance Abuse & Mental Health Services Administration, 2003). The social and economic costs of these illnesses are high. Needless to say, the suffering of affected individuals and their families is immeasurable. The Global Burden of Disease Study (Murray & Lopez, 1996) identified mental illness as one of the leading burdens, second only to cardiovascular conditions, in market economies such as the United States. Although individuals with severe mental illness represent a small proportion of all individuals having a mental illness, they account for a significant proportion of the economic burden. Reducing the costs of and improving the quality of life of individuals with severe mental illness have thus been the foci of considerable research during the past three decades. Severe mental illness (also labeled severe and persistent, serious, disabling, or chronic mental illness) encompasses a group of

Long-acting injectable antipsychotics: evidence of effectiveness and use.

Objective To review the evidence for the role of long-acting injectable (LAI) antipsychotics (APs), especially the second-generation AP (SGA) LAIs, in the treatment of schizophrenia and to discuss the use rates of LAIs in Canada. Method A search of online medical databases was conducted of the published literature (1995–2012) of the effects of LAIs on the domains of remission, adherence, relapse, and hospitalization. Results obtained from randomized controlled trials (RCTs), systematic reviews, meta-analyses, and large-scale observational studies were included. Expert consensus data were also solicited on LAI use within a Canadian context. Results While the efficacy of LAIs, compared with placebo, is well established, the evidence from RCTs is equivocal for any specific advantage for SGA LAIs, compared with oral medications, probably owing to challenges in conducting such RCTs. Evidence from methodologically less rigorous studies and from clinical practice suggests some advantages in achieving and maintaining remission, risk of relapse, and hospitalization. The rate of LAI (first-generation AP and SGA) use from published outpatient studies is low at 6.3% in Canada, compared with 15% to 80% worldwide. However, there is a relatively high rate of use in specific early psychosis programs and in conjunction with community treatment orders in Canada. Conclusions LAIs are at least as effective as oral APs in the treatment of psychotic disorders. The former may have specific advantages for patients who demonstrate covert nonadherence. The underuse of LAIs in Canada needs to be better understood and addressed.

Long-acting injectable antipsychotics: recommendations for clinicians.

A major source of limitation to the real effectiveness of antipsychotics is the high rate of patient nonadherence or, more frequently, partial adherence. using long-acting injectable (LAI) formulations is likely to reduce the impact of such adherence problems. Conversely, the use of LAIs in Canada remains low relative to many other jurisdictions. Based on effectiveness data from randomized control trials and other, less rigorous, studies, as well as our 2 qualitative studies exploring numerous issues around the use of LAIs, including their low use, we put forward 10 different recommendations for consideration by clinicians. These are also based on the experience of many clinicians and clinician scientists. These recommendations address mostly clinical challenges associated with the use of LAIs. Their application in clinical settings is illustrated in our report through several case examples highlighting the large variation across patients and different phases of illness. It is recommended that LAIs should be considered as a treatment option for psychotic disorders across all phases, including the first 2 to 5 critical years.

An examination of patient‐identified goals for treatment in a first‐episode programme in Chennai, India

Aim: Our objective was to describe the goals identified by patients upon entering a specialized programme for treatment of first‐episode psychosis (FEP) in Chennai, India.

From early intervention in psychosis to youth mental health reform: a review of the evolution and transformation of mental health services for young people

AbstractPurpose The objective of this review is to report on recent developments in youth mental health incorporating all levels of severity of mental disorders encouraged by progress in the field of early intervention in psychotic disorders, research in deficiencies in the current system and social advocacy.MethodsThe authors have briefly reviewed the relevant current state of knowledge, challenges and the service and research response across four countries (Australia, Ireland, the UK and Canada) currently active in the youth mental health field. ResultsHere we present information on response to principal challenges associated with improving youth mental services in each country. Australia has developed a model comprised of a distinct front-line youth mental health service (Headspace) to be implemented across the country and initially stimulated by success in early intervention in psychosis; in Ireland, Headstrong has been driven primarily through advocacy and philanthropy resulting in front-line services (Jigsaw) which are being implemented across different jurisdictions; in the UK, a limited regional response has addressed mostly problems with transition from child–adolescent to adult mental health services; and in Canada, a national multi-site research initiative involving transformation of youth mental health services has been launched with public and philanthropic funding, with the expectation that results of this study will inform implementation of a transformed model of service across the country including indigenous peoples.ConclusionsThere is evidence that several countries are now engaged in transformation of youth mental health services and in evaluation of these initiatives.

Preliminary findings from a study of first-episode psychosis in Montreal, Canada and Chennai, India: Comparison of outcomes

BACKGROUND This article reports preliminary findings from a multi-year investigation of onset and course of previously untreated first-episode psychosis in two similarly structured treatment programs in Canada and India. Specifically, the aim of this study was to examine whether one year clinical and functional outcomes of first-episode psychosis varied between these two programs. METHOD Patients with first-episode non-affective psychosis receiving similar treatment in Chennai, India (N=61) and in Montreal, Canada (N=88) were evaluated for demographic variables, duration of untreated psychosis, and baseline diagnosis, and for positive, negative, and general psychopathology symptoms and overall functioning at baseline and one year. RESULTS At both sites, there was a significant improvement in symptoms and functioning over the one year course of treatment. There was also a significant time-by-site interaction on negative symptoms and functioning, after controlling for age, sex, and marital status. On these domains, patients in India showed greater improvement over time than their Canadian counterparts. The time-by-site interactions were not significant for positive symptoms and general psychopathology. CONCLUSION First-episode patients in the Indian program demonstrated higher rates of improvement at one year in negative symptoms and functioning than patients receiving similar treatment in Canada. There was no difference in improvement between the sites on positive symptoms and general psychopathology. These results suggest that the sociocultural context of treatment can influence outcomes early in the course of psychotic disorders. Further, outcomes are not uniformly better or worse in one sociocultural context compared to another, but seem to vary from one outcome domain to another.

Investigating cognitive deficits and symptomatology across pre-morbid adjustment patterns in first-episode psychosis

BACKGROUND Cognitive deficits in schizophrenia are well established and are known to be present during the first episode of a psychotic disorder. In addition, consistent heterogeneity within these impairments remains unexplained. One potential source of variability may be the level of pre-morbid adjustment prior to the onset of first-episode psychosis (FEP). METHOD Ninety-four FEP patients and 32 healthy controls were assessed at baseline on several neuropsychological tests comprising six cognitive domains (verbal memory, visual memory, working memory, processing speed, reasoning/problem-solving and attention) and an abbreviated version of the full IQ. A global neurocognitive domain was also computed. Pre-morbid adjustment patterns were divided into three distinct groups: stable-poor, stable-good and deteriorating course. RESULTS Based on a cut-off of 0.8 for effect size, the stable-poor pre-morbid adjustment group was significantly more impaired on most cognitive domains and full IQ compared to the deteriorating group, who were more severely impaired on all measures compared to the stable-good group. The type of cognitive deficit within each subgroup did not differ and the results indicate that a global neurocognition measure may reliably reflect the severity of cognitive impairment within each subgroup. CONCLUSIONS Pre-morbid adjustment patterns prior to onset of psychosis are associated with severity but not type of cognitive impairment. Patients in the stable-poor group are generally more impaired compared to the deteriorating group, who are, in turn, more impaired than the stable-good group.