[Show abstract][Hide abstract] ABSTRACT: Introduction
Currently, the dominant notion about cognition in schizophrenia-spectrum illnesses is that deficits are stable over the course of the illness. However, cross-sectional evidence suggests that some areas of cognition may be preserved in the early stages of psychosis, with deterioration occurring as the illness progresses. One such area of cognition is visuospatial paired associate learning (VSPA), which has been shown to be preserved in first-episode psychosis (FEP) patients, but significantly impaired in individuals with established schizophrenia. However, no study has yet investigated longitudinal change in VSPA ability following psychosis onset. Therefore, this study aimed to investigate changes in VSPA performance in a group of FEP patients in comparison with a group of matched healthy controls.
VSPA ability was assessed longitudinally in a group of 26 first-episode schizophrenia-spectrum patients (at baseline: mean age = 22.19 (3.26), 16 males; mean duration of illness = 64 (105.99) days) and 18 healthy controls (mean age at baseline = 24.44 (7.26), 14 males). The mean follow-up period was 7.29 years, with a range of 5.25 to 11.64 years. A repeated measures negative binomial regression was conducted in order to determine whether VSPA performance changed differentially between the groups. This analysis controlled for interval between assessments, IQ, and change in pattern recognition score.
A significant main effect was observed for change in pattern recognition (Wald χ2(1) = 34.97, p =<.001). There was also a significant groupxtime interaction (Wald χ2(1) = 6.94, p =.008). FEP patient’s VSPA performance deteriorated between baseline and follow-up, whereas healthy controls’ performance remained stable (FEP; mean errors at baseline = 22.57, at follow-up = 35.96: Control; mean errors at baseline = 15.73, at follow-up = 14.53).
These results suggest that, while visuospatial associative memory is unimpaired soon after psychosis onset, individuals with schizophrenia-spectrum illnesses experience deterioration in VSPA ability as the illness progresses. This deterioration may be indicative of neuroprogressive processes that are occurring over the course of psychotic illness, and are consistent with observed brain structural changes.
[Show abstract][Hide abstract] ABSTRACT: Objective
To determine mortality-related estimates and causes of death in young people with first-episode psychosis (FEP), and to identify baseline predictors of mortality.
Mortality outcomes in 723 young people presenting to an early psychosis service were prospectively ascertained up to 20 years. Predictors of all-cause and unnatural death were investigated using survival techniques.
Forty-nine participants died by study end. Most deaths (n = 41) occurred within 10 years of service entry. All-cause mortality was 5.5% at 10 years, rising to 8.0% after 20 years. Unnatural death rates at 10 and 20 years were 5.0% and 5.9%, respectively. Three risk factors consistently predicted all-cause mortality and unnatural deaths.
A substantial proportion of excess mortality was due to non-suicide unnatural death, and, later, natural deaths. This suggests that mental health services should expand their current focus on suicide to incorporate strategies to prevent accidental death and promote healthier lifestyles.
Schizophrenia Research 10/2014; 159(1). DOI:10.1016/j.schres.2014.07.042 · 3.92 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background
To explore whether poor initial insight during a first episode of mania with psychotic features was predictive of poor psychosocial and clinical outcomes at 18 months.
Secondary analysis was performed on data collected during an 8-week RCT comparing the efficacy of olanzapine versus chlorpromazine as an adjunct to lithium, and at 18-month follow-up. 74 participants were divided into three groups (no insight, partial insight, and full insight) according to the insight item from the Young Mania Rating Scale (YMRS). Differences between these three groups were examined at baseline and at 18 months on measures of symptoms (YMRS, HAMD-21, and CGI-S), and social and occupational functioning (SOFAS). Baseline differences between the three groups were determined using general linear models and chi-squared analyses. Group differences from baseline to 18-month follow-up were determined using repeated measures general linear models.
At baseline there were significant differences between the three insight groups in terms of mania and functioning, but at 18 months all groups had improved significantly in terms of psychopathology, mania, depression and social and occupational functioning. There were no significant differences between the three groups at study completion with respect to these domains.
The study was limited by the lack of availability of a more detailed rating scale for insight, and it did not account for the duration of untreated psychosis (DUI).
Poor initial insight during a first episode of mania with psychotic features does not predict poor clinical and psychosocial outcome at 18 months.
[Show abstract][Hide abstract] ABSTRACT: To compare the long-term outcome in individuals with early-onset (before age 18) and adult-onset schizophrenia spectrum disorder who were initially diagnosed and treated in the same clinical center.
A prospective follow-up study of 723 consecutive first-episode psychosis patients (age range 14 to 30 years) on average 7.4 years after initial presentation to an early psychosis service, the Early Psychosis Prevention and Intervention Centre in Melbourne, Australia. The outcome measures included the Brief Psychiatric Rating Scale, the Schedule for the Assessment of Negative Symptoms, the Beck Depression Inventory, the Global Assessment of Functioning Scale, the Social and Occupational Functioning Assessment Scale, and the Quality of Life Scale.
Follow-up interviews were conducted on 66.9% (484/723) individuals, of whom 75.6% (366/484) received a schizophrenia spectrum disorder diagnosis at baseline. Early-onset schizophrenia spectrum disorder was observed in 11.2% (41/366). At follow-up, individuals with early-onset reported significantly fewer positive symptoms and were characterised by significantly superior functioning on measures assessing global functioning, social-occupational functioning, and community functioning than individuals with adult-onset. The early-onset group also achieved significantly better vocational outcomes and had a more favourable course of illness with fewer psychotic episodes over the last two years prior to follow-up. Finally, when investigated as a continuous variable, younger age at onset significantly correlated with better symptomatic and functional outcomes.
These results question the assumption that early-onset schizophrenia typically has a poor outcome. Early detection and specialised treatment for the first psychotic episode appear to be more effective at improving long-term functional outcomes in people with early-onset schizophrenia as in those with adult-onset schizophrenia. This possibility and the reasons for it need further investigation.
Schizophrenia Research 09/2011; 131(1-3):112-9. DOI:10.1016/j.schres.2011.06.009 · 3.92 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In recent years there has been increasing interest in functional recovery in the early phase of schizophrenia. Concurrently, new remission criteria have been proposed and several studies have examined their clinical relevance for prediction of functional outcome in first-episode psychosis (FEP). However, the longitudinal interrelationship between full functional recovery (FFR) and symptom remission has not yet been investigated. This study sought to: (1) examine the relationships between FFR and symptom remission in FEP over 7.5 years; (2) test two different models of the interaction between both variables.
Altogether, 209 FEP patients treated at a specialized early psychosis service were assessed at baseline, 8 months, 14 months and 7.5 years to determine their remission of positive and negative symptoms and functional recovery. Multivariate logistic regression and path analysis were employed to test the hypothesized relationships between symptom remission and FFR.
Remission of both positive and negative symptoms at 8-month follow-up predicted functional recovery at 14-month follow-up, but had limited value for the prediction of FFR at 7.5 years. Functional recovery at 14-month follow-up significantly predicted both FFR and remission of negative symptoms at 7.5 years, irrespective of whether remission criteria were simultaneously met. The association remained significant after controlling for baseline prognostic indicators.
These findings provided support for the hypothesis that early functional and vocational recovery plays a pivotal role in preventing the development of chronic negative symptoms and disability. This underlines the need for interventions that specifically address early psychosocial recovery.
Psychological Medicine 08/2011; 42(3):595-606. DOI:10.1017/S0033291711001504 · 5.94 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This paper will describe the rationale for, and importance of, psychological interventions for young people early in the course of bipolar disorder.
Emerging literature in this field will be discussed in addition to describing specific clinical challenges and opportunities with this population.
In order to be more developmentally appropriate for young people with bipolar disorder, eight aspects of clinical work which may require modification were identified.
The evidence base for the effectiveness of psychological interventions for people diagnosed with bipolar disorder is growing. However, some aspects relating to working with adults with bipolar disorder require modification to be effective in working with young people early in the course of the disorder.
Early Intervention in Psychiatry 05/2011; 5(2):100-7. DOI:10.1111/j.1751-7893.2011.00273.x · 1.95 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This study aims to identify correlates of vocational functioning in a first episode psychosis (FEP) sample 7.5 years after presentation at a specialized early psychosis treatment service. The study involved a prospective, naturalistic follow-up of FEP patients commencing treatment with the Early Psychosis Prevention & Intervention Centre (EPPIC) in Melbourne, Australia, between 1995 and 1997. At treatment entry the Royal Park Multidiagnostic Instrument for Psychosis was used to assess duration of untreated psychosis (DUP), age at onset of psychotic disorder, and premorbid work/social functioning. At 7.5-year follow-up measures included the Brief Psychiatric Rating Scale (Thinking Disturbance subscale), Scale for the Assessment of Negative Symptoms (Alogia subscale), WHO Life Chart Schedule (to assess course of illness, treatment history, and duration of receipt of a disability support pension (DSP)), and the Structured Clinical Interview for DSM-IV (to derive Axis I diagnoses). Analyses involved 180 participants. Univariate and multivariate logistic regression analyses were used to estimate the effects of demographic, clinical and treatment variables on two outcomes: current employment; and durable employment (employment for more than 6 months in the past 2 years). The sample was primarily male (72%), with a mean age at follow-up of 29 years (sd=3.4). 45% reported current participation in competitive employment at 7.5 year follow-up (28% full-time, 17% part-time), and 53% reported recent durable employment. Multivariate analyses showed that, after controlling for other variables (including positive and negative thought disorder, premorbid functioning, and recent psychiatric treatment), current employment was negatively associated with continuous or episodic illness course characterized by worsening trajectory or incomplete remissions, disrupted education, and receiving a DSP for longer than 2 years. Lifetime diagnosis of schizophrenia, receipt of a DSP (regardless of duration) and disrupted education were negatively associated with durable employment. Educational attainment appears to be an important predictor of vocational outcome in the Australian labor market, although its relationship with premorbid functioning requires further investigation. The inverse relationship between DSP and employment, after controlling for symptom levels and course of illness, supports evidence from US studies that such payments may act as a disincentive to employment.
[Show abstract][Hide abstract] ABSTRACT: The objective of this paper is to provide a rationale and description of the EPPIC 800 FEP 6- to 8-year follow-up study and provide the context for the following data-driven papers in the symposium. The study assembled a cohort of 800 FEP patients recruited from the pre-EPPIC and EPPIC (Early Psychosis Prevention and Intervention Centre) services from 1989 to 1997. The pre-EPPIC cohort constituted consecutive admissions of 200 patients to the Aubrey Lewis Unit, Royal Park Psychiatric Hospital from 1989 to 1992. The EPPIC service was founded in 1992 and the remaining cohort of 600 were recruited from 1992 to 1997. The study design is a naturalistic, prospective, longitudinal, 6- to 8-year follow-up study on a treated incidence cohort of representative patients with FEP, from a strictly defined catchment’s area of Melbourne, Australia, with multiple follow-up time points. The cohort have been prospectively followed-up over a number of years with careful record keeping, structured and reliable protocols in terms of psychopathology, risk factors, premorbid functioning and functional and psychosocial outcome.
[Show abstract][Hide abstract] ABSTRACT: Despite considerable interest and investment in early psychosis services over the past 1-2 decades, scant attention has been paid to the economic evaluation of such services.A one-year evaluation of the costeffectiveness of the Early Psychosis Prevention&Intervention Centre (EPPIC) model in Melbourne, Australia, concluded that EPPIC was a dominant intervention compared to historical care in that itwas cheaper and more effective, however no published studies have evaluated the longer term effects of a model of early intervention in terms of both outcomes and costs. This study examined whether the cost savings and benefits associated with EPPIC persist beyond the one year timeframe. The study used a historical control design.Asample of 51 participants who presented to EPPIC in 1993 was individually matched (on age, sex, diagnosis, premorbid adjustment and marital status) with 51 participants admitted to the precursor service (the ‘pre-EPPIC’ service) between 1989 and 1992. Participants were followed up at one year, then again approximately 8 years after inception.Arepresentative subsample of 65 participants was interviewed at 8-year follow-up. Data describing psychiatric service use, medication type, duration and dosage were collected via interviews with patients and informants, electronic databases, and medical records. Standard economic methods will be used to assess the costs, benefits and incremental cost-effectiveness ratios of the two interventions. The economic perspective will be that of the health sector. The previous cost-effectiveness analysis found that the EPPIC sample incurred lower health service costs (largely due to reduced use of inpatient services) and had better outcomes (improvements on measures of symptomatology and quality of life) compared to the pre-EPPIC control group. This study will help answer whether the EPPIC model of care maintains ‘value for money’ over a longer period. The longer time frame of the current study will also help to resolve some of the methodological issues of historical matching faced by the first study in that the both the service use and outcome data of the two samples were collected over distinctly different periods of time, therefore issues of confounding and bias could not be unequivocally dismissed. During the longer term follow-up a significant proportion of service use in both cohorts will have occurred over a similar time frame, therefore reducing the potential effects of bias and confounding.
[Show abstract][Hide abstract] ABSTRACT: The study purpose is to examine the 8-year functional and symptomatic outcome of a FEP cohort of 800 patients in addition to the course patterns of psychosis over time. The design is a naturalistic, prospective, longitudinal, 8-year follow-up study with multiple follow- up time points, on a representative multidiagnostic cohort of 800 patients with FEP from the Early Psychosis Prevention and Intervention Centre, which is a frontline public mental health service and its precursor service in Melbourne, Australia. Recruitment is ongoing. The preliminary results which follow concern the 470 subjects who have been interviewed to date. At 8-year outcome, analyses indicate that 74% remain unmarried, 54% are either working, studying or are homemakers. Mean scores on quality of life and social functioning measures indicate functioning in the good range. 75% are currently receiving psychiatric treatment, however 45% of these were being treated in the private health sector suggesting less severe illness and better functioning. Those taking an antipsychotic were on a CPZ equivalent mean low dose of 303mg. In terms of psychiatric hospital admission, 60% have not been admitted in the most recent two years and the mean number of admissions over the 8-year period was two. 47% have not been psychotic in the most recent 2 years and one quarter never had another psychotic episode after recovering from their first episode. Mean scores on psychopathology measures indicate minimal to low levels of current psychopathology. Comparison of these findings with the existing outcome literature of similar follow- up duration should be made with caution as the majority are of first episode schizophrenia. However our data concerning course type over the most recent two years is consistent with the findings of Mason et al. (1995) and Robinson et al. (2004). However our findings concerning the never psychotic course type over the entire follow- up period differs to that found by Thara et al. (1994). Our study reported a higher percentage (24%) than Thara et al. (1994) (17%) who had not been psychotic during the intervening years and over half of this group had completely remitted. Over half of our cohort was fully occupationally engaged compared with 19% reported by the Scottish Schizophrenia Research Group (1992). The findings from this study suggest patients with psychotic disorders can achieve symptomatic remission and good social and occupational functioning 8-years post FEP.
[Show abstract][Hide abstract] ABSTRACT: OBJECTIVE: This study aims to investigate the impact of tobacco smoking on longer-term outcomes following a first episode of psychosis. METHODS: Data on 193 individuals were collected as part of a prospective follow-up visit of a cohort of patients after a mean of 7.5 years (SD = 0.8) after first treatment presentation. Primary outcome measures were positive and negative psychotic symptoms, depressive symptoms, quality of life, and global functioning at the 7.5 year follow-up. RESULTS: Using unadjusted analyses, smoking status was linked to male gender, longer duration of untreated psychosis, more problem illicit drug use, and problem alcohol use. After adjustment for these potential confounders, smoking at baseline was not associated with poorer long-term outcomes on the primary outcome variables of interest but was associated with drug and alcohol abuse or dependence. CONCLUSIONS: These findings suggest that smoking does not appear to be associated with worse clinical and functional outcomes in psychosis. (Journal of Dual Diagnosis, 6:212-234, 2010).
[Show abstract][Hide abstract] ABSTRACT: 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.
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.
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.
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.
Schizophrenia Research 11/2010; 125(2-3):236-46. DOI:10.1016/j.schres.2010.10.020 · 3.92 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To describe the longer-term clinical and functional outcome of a large, epidemiologic representative cohort of individuals experiencing a first episode of psychosis.
A naturalistic, prospective follow-up of an epidemiologic sample of 723 consecutive first-episode psychosis patients, followed between January 1998 and April 2005, at a median of 7.4 years after initial presentation to the Early Psychosis Prevention and Intervention Centre (EPPIC) in Melbourne, Australia. EPPIC is a frontline public mental health early psychosis program, servicing a geographically defined catchment area with a population of about 800,000 people. The main outcome measures included the Brief Psychiatric Rating Scale, the Schedule for the Assessment of Negative Symptoms, the Beck Depression Inventory, the Global Assessment of Functioning Scale, the Social and Occupational Functioning Assessment Scale, the Quality of Life Scale, and the remission criteria developed by the Remission in Schizophrenia Working Group.
Follow-up information was collected on up to 90.0% (n = 651) of the baseline cohort of 723 participants, with 66.9% (n = 484) interviewed. In the last 2 years, 57% of individuals with schizophrenia/schizophreniform, 54% with schizoaffective disorder, 62% with affective psychosis, and 68% with other psychotic disorders reported some paid employment. Depending upon the criteria applied, symptomatic remission at follow-up was observed in 37%-59% of the cohort. Social/vocational recovery was observed in 31% of the cohort. Approximately a quarter achieved both symptomatic remission and social/vocational recovery.
The relatively positive outcomes are consistent with a beneficial effect of specialized early intervention programs; however it is premature to draw firm conclusions. There was no control group and there are many differences between the relevant comparison studies and the present one. Although difficult to conduct, large scale controlled health services research trials are required to definitively determine the impact and optimal duration of specialized early psychosis programs.
The Journal of Clinical Psychiatry 06/2010; 71(6):716-28. DOI:10.4088/JCP.08m04846yel · 5.50 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To review the evidence that supports early intervention in the treatment of bipolar disorder.
Bipolar disorder is a pleomorphic condition, with varying manifestations that are determined by a number of complex factors including the "stage" of illness. It is consequently a notoriously difficult illness to diagnose and as a corollary is associated with lengthy delays in recognition and the initiation of suitable treatment.
A literature search was conducted using MEDLINE augmented by a manual search.
Emerging neuroimaging data suggests that, in contrast to schizophrenia, where at the time of a first-episode of illness there is already discernible volume loss, in bipolar disorder, gross brain structure is relatively preserved, and it is only with recurrences that there is a sequential, but marked loss of brain volume. Recent evidence suggests that both pharmacotherapy and psychotherapy are more effective if instituted early in the course of bipolar disorder, and that with multiple episodes and disease progression there is a noticeable decline in treatment response.
Such data supports the notion of clinical staging, and the tailored implementation of treatments according to the stage of illness. The progressive nature of bipolar disorder further supports the concept that the first episode is a period that requires energetic broad-based treatment, with the hope that this could alter the temporal trajectory of the illness. It also raises hope that prompt treatment may be neuroprotective and that this perhaps attenuates or even prevents the neurostructural and neurocognitive changes seen to emerge with chronicity. This highlights the need for early identification at a population level and the necessity of implementing treatments and services at a stage of the illness where prognosis is optimal.
Journal of Mental Health 04/2010; 19(2):113-26. DOI:10.3109/09638230903469111 · 1.01 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Individuals with first-episode psychosis demonstrate high rates of suicide attempt (SA).
1) To examine the prevalence of, and risk factors for, SA in a first-episode psychosis (FEP) cohort over a 7.4 year follow-up period. 2) To investigate differences between single versus multiple suicide attempters.
This study reports baseline and follow-up data from a naturalistic, prospective follow-up of 413 FEP patients treated at a specialist early psychosis centre. Assessments were conducted at treatment entry, initial symptom remission or stabilization, and long term follow-up. Binary logistic regression models were used to assess unadjusted and adjusted associations between early illness and sociodemographic characteristics and two outcome measures: any SA during follow-up; and multiple SAs.
Follow-up data were available for 282 participants. Sixty-one (21.6%) made a suicide attempt over the follow-up period, including 12 successful suicides. The following baseline risk factors increased the risk of any SA: history of self-harm (OR=4.27; p<0.001), suicidal tendencies (OR=2.30; p=0.022), being depressed for >50% of the initial psychotic episode (OR=2.49; p=0.045), and hopelessness (OR=2.03; p=0.030). History of problem alcohol use increased the risk of multiple SAs (OR=4.43; 95% CI (1.05-18.7); p=0.043).
The prevalence of suicide attempt in this study exceeds reports from short-term FEP studies but is comparable to longer term follow-up studies, indicating that risk remains elevated for at least 7 years following commencement of treatment. The key predictor of future suicide attempt was previous self-harm, indicating that interventions for self-harm are required.
Schizophrenia Research 10/2009; 116(1):1-8. DOI:10.1016/j.schres.2009.10.009 · 3.92 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This study assesses the long-term cost-effectiveness of a comprehensive model of mental health care for first-episode psychosis. The study is an extension of a previous economic evaluation of the Early Psychosis Prevention and Intervention Centre (EPPIC) that assessed the first-year costs and outcomes of treatment.
The current study used a matched, historical control group design with a follow-up of approximately 8 years. Complete follow-up data were available for 65 of the original 102 participants. Direct public mental health service costs incurred subsequent to the first year of treatment and symptomatic and functional outcomes of 32 participants initially treated for up to 2 years at EPPIC were compared with a matched cohort of 33 participants initially treated by generic mental health services. Treatment-related resource use was measured and valued using Australian published prices.
Almost 8 years after initial treatment, EPPIC subjects displayed lower levels of positive psychotic symptoms (P = .007), were more likely to be in remission (P = .008), and had a more favorable course of illness (P = .011) than the controls. Fifty-six percent of the EPPIC cohort were in paid employment over the last 2 years compared with 33% of controls (P = .083). Each EPPIC patient costs on average A$3445 per annum to treat compared with controls, who each costs A$9503 per annum.
Specialized early psychosis programs can deliver a higher recovery rate at one-third the cost of standard public mental health services. Residual methodological limitations and limited sample size indicate that further research is required to verify this finding.