Early intervention in psychosis: Concepts, evidence and future directions

ORYGEN Research Centre and Department of Psychiatry, and.
World psychiatry: official journal of the World Psychiatric Association (WPA) (Impact Factor: 14.23). 11/2008; 7(3):148-56. DOI: 10.1002/j.2051-5545.2008.tb00182.x
Source: PubMed


The rise of the early intervention paradigm in psychotic disorders represents a maturing of the therapeutic approach in psychiatry, as it embraces practical preventive strategies which are firmly established in mainstream health care. Early intervention means better access and systematic early delivery of existing and incremental improvements in knowledge rather than necessarily requiring dramatic and elusive breakthroughs. A clinical staging model has proven useful and may have wider utility in psychiatry. The earliest clinical stages of psychotic disorder are non-specific and multidimensional and overlap phenotypically with the initial stages of other disorders. This implies that treatment should proceed in a stepwise fashion depending upon safety, response and progression. Withholding treatment until severe and less reversible symptomatic and functional impairment have become entrenched represents a failure of care. While early intervention in psychosis has developed strongly in recent years, many countries have made no progress at all, and others have achieved only sparse coverage. The reform process has been substantially evidence-based, arguably more so than other system reforms in mental health. However, while evidence is necessary, it is insufficient. It is also a by-product as well as a catalyst of reform. In early psychosis, we have also seen the evidence-based paradigm misused to frustrate overdue reform. Mental disorders are the chronic diseases of the young, with their onset and maximum impact in late adolescence and early adult life. A broader focus for early intervention would solve many of the second order issues raised by the early psychosis reform process, such as diagnostic uncertainty despite a clear-cut need for care, stigma and engagement, and should be more effective in mobilizing community support. Early intervention represents a vital and challenging project for early adopters in global psychiatry to consider.

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Available from: Eoin Killackey, Mar 08, 2015
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    • "Research findings support a number of key elements of early intervention programs, yet there is variability in their implementation (Catts et al., 2010; Ghio et al., 2012; McGorry et al., 2008; Srihari et al., 2012). Some programs stress the importance of case management, while others focus on medication or social and functional recovery (Garety et al., 2006; Spencer et al., 2001). "
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    ABSTRACT: Programs providing interventions for early psychosis are becoming commonplace in the United States (U.S.); however, the characteristics of existing services remain undocumented. We examined program characteristics, clinical services, and program eligibility criteria for outpatient early intervention programs across the U.S. using a semi-structured telephone interview. Content analysis was used to identify the presence or absence of program components, based in part on a recent list of essential evidence-based components recommended for early intervention programs (Addington, MacKenzie, Norman, Wang and Bond, 2013) as well as program characteristics, including eligibility criteria. A total of 34 eligible programs were identified; 31 (91.2%) program representatives agreed to be interviewed. Of the examined components, the most prevalent were individual psychoeducation and outcomes tracking; the least prevalent were outreach services and communication with inpatient units. The populations served by US programs were most frequently defined by restrictions on the duration of psychosis and age. This study provides critical feedback on services for the early psychosis population and identifies research to practice gaps and areas for future improvement. Copyright © 2015 Elsevier B.V. All rights reserved.
    Schizophrenia Research 08/2015; 168(1). DOI:10.1016/j.schres.2015.08.020 · 3.92 Impact Factor
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    • "Corstens & Longden, 2013). One promising approach (Read et al. 2003) is combining trauma-focused therapeutic models (e.g., Herman, 1992; Ross & Halpern, 2009; Bacon & Kennedy, 2014) with treatments that have established effectiveness in alleviating psychotic symptoms (e. g., acceptance and commitment therapy (Gaudiano & Herbert, 2006), cognitive therapy (Morrison et al. 2014), compassion-focused therapy (Braehler et al. 2013), early intervention strategies (McGorry et al. 2008) and Open Dialogue (Seikkula et al. 2011)). "
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    ABSTRACT: This study examines relationships between childhood adversity and the presence of characteristic symptoms of schizophrenia. It was hypothesised that total adversity exposures would be significantly higher in individuals exhibiting these symptoms relative to patients without. Recent proposals that differential associations exist between specific psychotic symptoms and specific adversities was also tested, namely: sexual abuse and hallucinations, physical abuse and delusions, and fostering/adoption and delusions. Data were collected through auditing 251 randomly selected medical records, drawn from adult patients in New Zealand community mental health centres. Information was extracted on presence and subtype of psychotic symptoms and exposure to ten types of childhood adversity, including five types of abuse and neglect. Adversity exposure was significantly higher in patients experiencing hallucinations in general, voice hearing, command hallucinations, visions, delusions in general, paranoid delusions and negative symptoms than in patients without these symptoms. There was no difference in adversity exposure in patients with and without tactile/olfactory hallucinations, grandiose delusions or thought disorder. Indication of a dose-response relationship was detected, in that total number of adversities significantly predicted total number of psychotic symptoms. Although fostering/adoption was associated with paranoid delusions, the hypothesised specificity between sexual abuse and hallucinations, and physical abuse and delusions, was not found. The two adversities showing the largest number of associations with psychotic symptoms were poverty and being fostered/adopted. The current data are consistent with a model of global and cumulative adversity, in which multiple exposures may intensify psychosis risk beyond the impact of single events. Implications for clinical intervention are discussed.
    Epidemiology and Psychiatric Sciences 07/2015; -1:1-11. DOI:10.1017/S204579601500044X · 3.91 Impact Factor
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    • "Targeting treatments to the first 2–5 years of illness may optimize achieving desirable outcomes [McGorry et al. 2008]. In addition, data from two observational studies reported that patients with recently diagnosed schizophrenia (⩽3 years) might be more responsive to treatment than those with more long-standing disease [Dubois et al. 2014]. "
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    ABSTRACT: This study was designed to explore the efficacy and tolerability of oral paliperidone extended release (ER) in a sample of patients who were switched to flexible doses within the crucial first 5 years after receiving a diagnosis of schizophrenia. Patients were recruited from 23 countries. Adults with nonacute but symptomatic schizophrenia, previously unsuccessfully treated with other oral antipsychotics, were transitioned to paliperidone ER (3-12 mg/day) and prospectively treated for up to 6 months. The primary efficacy outcome for patients switching for the main reason of lack of efficacy with their previous antipsychotic was at least 20% improvement in Positive and Negative Syndrome Scale (PANSS) total scores. For patients switching for other main reasons, such as lack of tolerability, compliance or 'other', the primary outcome was non-inferiority in efficacy compared with the previous oral antipsychotic. For patients switching for the main reason of lack of efficacy, 63.1% achieved an improvement of at least 20% in PANSS total scores from baseline to endpoint. For each reason for switching other than lack of efficacy, efficacy maintenance after switching to paliperidone ER was confirmed. Statistically significant improvement in patient functioning from baseline to endpoint, as assessed by the Personal and Social Performance scale, was observed (p < 0.0001). Treatment satisfaction with prior antipsychotic treatment at baseline was rated 'good' to 'very good' by 16.8% of patients, and at endpoint by 66.0% of patients treated with paliperidone ER. Paliperidone ER was generally well tolerated, with frequently reported treatment-emergent adverse events being insomnia, anxiety and somnolence. Flexibly dosed paliperidone ER was associated with clinically relevant symptomatic and functional improvement in recently diagnosed patients with non-acute schizophrenia previously unsuccessfully treated with other oral antipsychotics.
    Therapeutic Advances in Psychopharmacology 05/2015; 5(4). DOI:10.1177/2045125315584870 · 1.53 Impact Factor
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