Susan Harrigan

Preventing progression to first-episode psychosis in early initial prodromal states.

BACKGROUND Young people with self-experienced cognitive thought and perception deficits (basic symptoms) may present with an early initial prodromal state (EIPS) of psychosis in which most of the disability and neurobiological deficits of schizophrenia have not yet occurred. AIMS To investigate the effects of an integrated psychological intervention (IPI), combining individual cognitive-behavioural therapy, group skills training, cognitive remediation and multifamily psychoeducation, on the prevention of psychosis in the EIPS. METHOD A randomised controlled, multicentre, parallel group trial of 12 months of IPI v. supportive counselling (trial registration number: NCT00204087). Primary outcome was progression to psychosis at 12- and 24-month follow-up. RESULTS A total of 128 help-seeking out-patients in an EIPS were randomised. Integrated psychological intervention was superior to supportive counselling in preventing progression to psychosis at 12-month follow-up (3.2% v. 16.9%; P = 0.008) and at 24-month follow-up (6.3% v. 20.0%; P = 0.019). CONCLUSIONS Integrated psychological intervention appears effective in delaying the onset of psychosis over a 24-month time period in people in an EIPS.

Comparing correlated kappas by resampling: Is one level of agreement significantly different from another?

Researchers comparing diagnostic systems or screening tests frequently need to compare indices of agreement such as the kappa coefficient. While asymptotic methods exist for comparing kappas derived from independent samples, no satisfactory approach exists for comparing kappas derived from the same or related samples. Resampling methods for comparing kappa coefficients obtained from the same sample are presented. Easily undertaken using readily available software, these methods are illustrated by application to a small sample of psychiatric data, as well as to several thousand samples of simulated data. An acceptable type I error rate was exhibited. Resampling techniques-easily implemented and making few assumptions-deserve wider application in psychiatric research.

Recovery style and outcome in first-episode psychosis

Our study aimed to investigate how recovery styles influence 12-month clinical outcome in first-episode psychosis patients. We hypothesised that patients who use an integrative recovery style would have better outcome than those who seal over. A total of 196 first-episode psychosis patients from the Early Psychosis Intervention Centre (EPPIC) participated in the study. Each patient was interviewed at stabilization of their acute psychotic episode, and then again 12 months later, using an Integration/Sealing-over measure. Our results suggest that recovery style may be a useful predictor of outcome. Integrative patients had better outcome and functioning at 12 months. These results were influenced by diagnosis and, unlike previous studies, recovery style changed over time, suggesting it was not a stable trait. The capacity for recovery style to change challenges the suggestion it is a personality trait and raises the need for psychoeducation and other psychological interventions that could improve outcome.

Prediction of a single psychotic episode: A 7.5-year, prospective study in first-episode psychosis

BACKGROUND Around 20% of patients who suffer from psychosis will experience a single psychotic episode (SPE), but relatively little is known about the characteristics and predictors for this group of patients. This study sought to: 1) characterise the subgroup of first-episode psychosis (FEP) patients who experienced a SPE over a 7.5-year follow-up; and 2) to identify significant predictors for this subgroup independent of potential confounders. METHODS A representative sample of 413 FEP patients treated at a specialist early psychosis service were assessed at baseline and followed-up for 7.5 years. Binary logistic regression models were employed to investigate univariate and adjusted associations between baseline predictors and experiencing a SPE. Results were adjusted for the influence of known prognostic factors for psychosis. RESULTS Follow-up data was available for 274 participants. Forty-six (16.5%) achieved clinical remission and experienced no recurrence over the follow-up period. Duration of untreated psychosis (DUP) shorter than 60 days (OR=3.89, p=0.007), more rapid response to antipsychotic treatment (OR=0.33, p=0.019) and no parental loss (OR=5.25, p=0.045) significantly predicted a SPE. The association remained significant after controlling for potential confounders. CONCLUSIONS Early treatment (within two months of onset of psychotic symptoms) and social support significantly reduce vulnerability to subsequent psychotic episodes. Future studies need to investigate the interplay between biological factors (i.e. sensitized dopaminergic system), environmental variables (i.e. exposure to trauma, stigma and discrimination), and psychological attributes (i.e. cognitive schemata) in order to elucidate the processes underlying the vulnerability to recurrent psychotic episodes.

The Credibility and Acceptability of Befriending as a Control Therapy in a Randomized Controlled Trial of Cognitive Behaviour Therapy for Acute First Episode Psychosis

There is increasing evidence that cognitive behavioural therapy (CBT) is efficacious in treating psychosis. However, very little attention has been paid to the nature of the control treatments used in studies of this. Befriending has been used as a control treatment in several randomized control trials (RCTs) of CBT for psychosis as it is simple to learn and administer. The aim of the present study was to examine whether Befriending controlled for important non-specific aspects of therapy when compared to CBT in a RCT for acute first episode psychosis (FEP). These non-specific factors included time in, expectancy created by, and acceptability of therapy. Expectations and enjoyment of therapy were measured by questionnaire. Time in therapy and the number of drop-outs were also recorded. Results showed that Befriending was comparable to CBT on measures of expectancy, enjoyment of therapy and drop-out rate, but significantly different with regard to time in therapy. This suggests that Befriending is a credible and acceptable control therapy for FEP with modification to increase time in therapy sessions. Methodological issues are raised, and suggestions for future research are made regarding control treatments.

The inter-rater and test-retest reliabilities of prodromal symptoms in first-episode psychosis.

Objective: As part of the DSM-IV field trial for psychotic disorders, the authors endeavoured to determine the reliability of the DSM-IV prodromal features for schizophrenia in a first-episode sample. Method: Fifty first-episode psychotic patients were assessed using a semi-structured instrument to determine the presence/absence of nine prodromal symptoms. Inter-rater reliability data were calculated for 25 of the patients, and test-retest data were calculated for the remaining 25 patients. Results: Levels of reliability were poor. Conclusions: The results lend some support to American Psychiatric Association and World Health Organization decisions to omit specific criteria for prodromal features from their respective nosologies.

Admissions of elderly patients from English-speaking and non-English-speaking backgrounds to an inpatient psychogeriatric unit

Objective: The aim of this study was to compare differences between elderly patients from non-English-speaking backgrounds (NESB) and English-speaking backgrounds (ESB) admitted to an acute psychogeriatric unit. Method: Sociodemographic and clinical variables were collated from inpatient files for a 12-month period and analysed according to NESB and ESB status. The 1996 Australian Census data were used for comparison of catchment area representation of different ethnic groups. Results: With a few exceptions, admission rates for elderly patients from NESB reflected the representation of that ethnic group in the catchment area population figures. No significant differences were found between the two groups for mean age, length of stay and previous admissions to the unit. Patients from NESB were less likely to be admitted voluntarily and less likely to be diagnosed with affective disorder. These differences were more marked for males, who were more likely to be diagnosed with dementia. Conclusions: These findings suggest that further investigation is required into the accessibility of psychiatric hospitalisation for elderly patients from NESB. Under recognition of disorders such as depression and reluctance to accept necessary inpatient management are two possible factors that should concern mental health service providers for the ethnic elderly. A subsequent analysis will examine if differences also exist between elderly patients from NESB and ESB who receive community-based psychiatric treatment. Implications for mental health service provision for the elderly from NESB are discussed.

Predictors of adherence to atypical antipsychotics (risperidone or olanzapine) in older patients with schizophrenia: an open study of 3½ years duration

Although the evidence base for the use of antipsychotics in older people with schizophrenia is generally of low quality, it tends to support the use of atypical antipsychotics. Only limited information regarding longer term adherence to these apparently more effective drugs is available. The aim of this study was to determine predictors of adherence to risperidone or olanzapine in patients over 60.

Characteristics of aggressive subjects in Australian (Melbourne) nursing homes

BACKGROUND Aggressive behavior is common in nursing homes for the elderly. It causes distress to carers and can lead to hospitalization, overmedication, and physical restraint. METHOD A 6-month prospective study examining the characteristics of aggressive subjects in 11 nursing homes in Melbourne using validated, reliable instruments. RESULTS During the study, 121 and 143 subjects were rated aggressive on the Rating Scale for Aggressive Behavior in the Elderly and the Staff Observation Aggression Scale, respectively. Aggressive behavior was associated with younger age, men, subsequent mortality, and prescription of psychotropic drugs including neuroleptics, antidepressants, and benzodiazepines. CONCLUSIONS Educational programs in the use of psychotropic drugs directed at staff involved in the care of nursing home residents may be of value because these drugs have modest efficacy, have significant side effects, and may simply sedate the patient rather than treat aggressive behavior.

Randomized Controlled Trial of Clozapine and CBT for First-Episode Psychosis with Enduring Positive Symptoms: A Pilot Study

Here we report the results of a pilot study investigating the relative and combined effects of a 12 week course of clozapine and CBT in first-episode psychosis patients with prominent ongoing positive symptoms following their initial treatment. Patients from our early psychosis service who met the inclusion criteria (n = 48) were randomized to one of four treatment groups: clozapine, clozapine plus CBT, thioridazine, or thioridazine plus CBT. The degree of psychopathology and functionality of all participants was measured at baseline then again at 6, 12 and 24 weeks, and the treatment outcomes for each group determined by statistical analysis. A substantial proportion (52%) of those treated with clozapine achieved symptomatic remission, as compared to 35% of those who were treated with thioridazine. Overall, those who received clozapine responded more rapidly to treatment than those receiving the alternative treatments. Interestingly, during the early treatment phase CBT appeared to reduce the intensity of both positive and negative symptoms and thus the time taken to respond to treatment, as well having as a stabilizing effect over time.