What is Early Intervention in Psychosis?

Introduction

Early intervention in psychosis is a clinical approach to those experiencing symptoms of psychosis for the first time. It forms part of a new prevention paradigm for psychiatry and is leading to reform of mental health services, especially in the United Kingdom and Australia.

This approach centres on the early detection and treatment of early symptoms of psychosis during the formative years of the psychotic condition. The first three to five years are believed by some to be a critical period. The aim is to reduce the usual delays to treatment for those in their first episode of psychosis. The provision of optimal treatments in these early years is thought to prevent relapses and reduce the long-term impact of the condition. It is considered a secondary prevention strategy.

The duration of untreated psychosis (DUP) has been shown as an indicator of prognosis, with a longer DUP associated with more long-term disability.

Components of the Model

There are a number of functional components of the early psychosis model, and they can be structured as different sub-teams within early psychosis services. The emerging pattern of sub-teams are currently:

  • Early psychosis treatment teams;
  • Early detection function; and
  • Prodrome clinics.

Early Psychosis Treatment Teams

Multidisciplinary clinical teams providing an intensive case management approach for the first three to five years. The approach is similar to assertive community treatment, but with an increased focus on the engagement and treatment of this previously untreated population and the provision of evidence based, optimal interventions for clients in their first episode of psychosis. For example, the use of low-dose antipsychotic medication is promoted (“start low, go slow”), with a need for monitoring of side effects and an intensive and deliberate period of psycho-education for patients and families that are new to the mental health system. In addition, researchers in Spain showed that family intervention for psychosis (FIP) reduced relapse rates, hospitalization duration, and psychotic symptoms along with increasing functionality in first-episode psychosis (FEP) up to 24 months, according to a recent review published in Schizophrenia Bulletin. Interventions to prevent a further episodes of psychosis (a “relapse”) and strategies that encourage a return to normal vocation and social activity are a priority. There is a concept of phase specific treatment for acute, early recovery and late recovery periods in the first episode of psychosis.

Early Detection Function

Interventions aimed at avoiding late detection and engagement of those in the course of their psychotic conditions. Key tasks include being aware of early signs of psychosis and improving pathways into treatment. Teams provide information and education to the general public and assist GPs with recognition and response to those with suspected signs, for example:

  • EPPIC’s Youth Access Team (YAT) (Melbourne, Australia);
  • OPUS (Denmark);
  • TIPS (Norway);
  • REDIRECT (Birmingham, UK);
  • LEO CAT (London, UK); and
  • STEP’s Population Health approach to early detection.

The development and implementation of quantitative tools for early detection of at-risk individuals is an active research area. This includes development of risk calculators and methods for large-scale population screening.

Prodrome Clinics

Prodrome or at risk mental state clinics are specialist services for those with subclinical symptoms of psychosis or other indicators of risk of transition to psychosis. The Pace Clinic in Melbourne, Australia, is considered one of the origins of this strategy, but a number of other services and research centres have since developed. These services are able to reliably identify those at high risk of developing psychosis and are beginning to publish encouraging outcomes from randomised controlled trials that reduce the chances of becoming psychotic, including evidence that psychological therapy and high doses of fish oil have a role in the prevention of psychosis. However, a meta-analysis of five trials found that while these interventions reduced risk of psychosis after 1 year (11% conversion to psychosis in intervention groups compared to 32% in control groups), these gains were not maintained over 2-3 years of follow-up. These findings indicate that interventions delay psychosis, but do not reduce the long-term risk. There has also been debate about the ethics of using antipsychotic medication to reduce the risk of developing psychosis, because of the potential harms involved with these medications.

In 2015, the European Psychiatric Association issued guidance recommending the use of the Cognitive Disturbances scale (COGDIS), a subscale of the basic symptoms scale, to assess psychosis risk; a meta-analysis conducted for the guidance found that while rates of conversion to psychosis were similar to those who meet Ultra High Risk (UHR) criteria up to 2 years after assessment, they were significantly higher after 2 years for those patients who met the COGDIS criteria. The COGDIS criteria measure subjective symptoms, and include such symptoms as thought interference, where irrelevant and emotionally unimportant thought contents interfere with the main line of thinking; thought block, where the current train of thought halts; thought pressure, where thoughts unrelated to a common topic appear uncontrollably; referential ideation that is immediately corrected; and other characteristic disturbances of attention and the use or understanding of language.

Brief History

Early intervention in psychosis is a preventive approach for psychosis that has evolved as contemporary recovery views of psychosis and schizophrenia have gained acceptance. It subscribes to a “post Kraepelin” concept of schizophrenia, challenging the assumptions originally promoted by Emil Kraepelin in the 19th century, that schizophrenia (“dementia praecox”) was a condition with a progressing and deteriorating course. The work of Post, whose kindling model, together with Fava and Kellner, who first adapted staging models to mental health, provided an intellectual foundation. Psychosis is now formulated within a diathesis-stress model, allowing a more hopeful view of prognosis, and expects full recovery for those with early emerging psychotic symptoms. It is more aligned with psychosis as continuum (such as with the concept of schizotypy) with multiple contributing factors, rather than schizophrenia as simply a neurobiological disease.

Within this changing view of psychosis and schizophrenia, the model has developed from a divergence of several different ideas, and from a number of sites, beginning with the closure of psychiatric institutions signalling a move toward community based care. In 1986, the Northwick Park study discovered an association between delays to treatment and disability, questioning the service provision for those with their first episode of schizophrenia. In the 1990s, evidence began to emerge that cognitive behavioural therapy was an effective treatment for delusions and hallucinations. The next step came with the development of the EPPIC early detection service in Melbourne, Australia in 1996 and the prodrome clinic led by Alison Yung. This service was an inspiration to other services, such as the West Midlands IRIS group, including the carer charity Rethink Mental Illness; the TIPS early detection randomised control trial in Norway; and the Danish OPUS trial. In 2001, the United Kingdom Department of Health called the development of early psychosis teams “a priority”. The International Early Psychosis Association, founded in 1998, issued an international consensus declaration together with the World Health Organisation in 2004. Clinical practice guidelines have been written by consensus.

Clinical Outcome Evidence

A number of studies have been carried out to see whether the early psychosis approach reduces the severity of symptoms, improves relapse rates, and decreases the use of inpatient care, in comparison to standard care. Advocates of early intervention for psychosis have been accused of selectively citing findings that support the benefits of early intervention, but ignoring findings that do not. It has been argued that the scientific reporting of evidence on early intervention in psychosis is characterised by a high prevalence of ‘spin’ and ‘bias’. An analysis of the summaries of articles found that 75% implied positive results, whereas examination of the findings with primary measures from these studies found that only 13% were positive.

Evidence on Cost

Studies have been published claiming that early psychosis services cost less than standard services, largely through reduced in-patient costs, and also save other costs to society. However, the claimed savings have been disputed. A 2012 systematic review of the evidence concluded that: “The published literature does not support the contention that early intervention for psychosis reduces costs or achieves cost-effectiveness”.

Reform of Mental Health Services

United Kingdom

The United Kingdom has made significant service reform with their adoption of early psychosis teams following the first service in Birmingham set up by Professor Max Birchwood in 1994 and used as a blueprint for national roll-out, with early psychosis now considered as an integral part of comprehensive community mental health services. The Mental Health Policy Implementation Guide outlines service specifications and forms the basis of a newly developed fidelity tool. There is a requirement for services to reduce the duration of untreated psychosis, as this has been shown to be associated with better long-term outcomes. The implementation guideline recommends:

  • 14 to 35 year age entry criteria.
  • First three years of psychotic illness.
  • Aim to reduce the duration of untreated psychosis to less than 3 months.
  • Maximum caseload ratio of 1 care coordinator to 10-15 clients.
  • For every 250,000 (depending on population characteristics), one team:
    • Total caseload 120 to 150.
    • 1.5 doctors per team.
    • Other specialist staff to provide specific evidence based interventions.

Australia and New Zealand

In Australia the EPPIC initiative provides early intervention services. In the Australian government’s 2011 budget, $222.4 million was provided to fund 12 new EPPIC centres in collaboration with the states and territories. However, there have been criticisms of the evidence base for this expansion and of the claimed cost savings.

On 19 August 2011, Patrick McGorry, South Australian Social Inclusion Commissioner David Cappo AO and Frank Quinlan, CEO of the Mental Health Council of Australia, addressed a meeting of the Council of Australian Governments (COAG), chaired by Prime Minister Julia Gillard, on the future direction of mental health policy and the need for priority funding for early intervention. The invitation, an initiative of South Australian Premier Mike Rann, followed the release of Cappo’s “Stepping Up” report, supported by the Rann Government, which recommended a major overhaul of mental health in South Australia, including stepped levels of care and early intervention.

New Zealand has operated significant early psychosis teams for more than 20 years, following the inclusion of early psychosis in a mental health policy document in 1997. There is a national early psychosis professional group, New Zealand Early Intervention for Psychosis Society (NZEIPS), organising a biannual training event, advocating for evidenced based service reform and supporting production of local resources.

Scandinavia

Early psychosis programmes have continued to develop from the original TIPS services in Norway and the OPUS randomised trial in Denmark.

North America

Canada has extensive coverage across most provinces, including established clinical services and comprehensive academic research in British Columbia (Vancouver), Alberta (EPT in Calgary), Quebec (PEPP-Montreal), and Ontario (PEPP, FEPP).

In the United States, the Early Assessment Support Alliance (EASA) is implementing early psychosis intervention throughout the state of Oregon.

In the United States, the implementation of Coordinated Specialty Care (CSC), as a recovery-oriented treatment program for people with first episode psychosis (FEP), has become a US health policy priority. CSC promotes shared decision making and uses a team of specialists who work with the client to create a personal treatment plan. The specialists offer psychotherapy, medication management geared to individuals with FEP, family education and support, case management, and work or education support, depending on the individual’s needs and preferences. The client and the team work together to make treatment decisions, involving family members as much as possible. The goal is to link the individual with a CSC team as soon as possible after psychotic symptoms begin because a longer period of unchecked and untreated illness might be associated with poorer outcomes.

Asia

The first meeting of the Asian Network of Early Psychosis (ANEP) was held in 2004. There are now established services in Singapore, Hong Kong and South Korea.

Is Neuroanalysis a Useful Method for Brain-Related Neuroscientific Diagnosis of Mental Disorders?

Research Paper Title

Neuroanalysis: a method for brain-related neuroscientific diagnosis of mental disorders.

Background

As an Ancient Chinese proverb says “The beginning of wisdom is to call things by their right names” thus we must start calling mental disorders by the names of their underlying brain disturbances. Without knowledge of the causes of mental disorders, their cures will remain elusive.

Methods

Neuroanalysis is a literature-based re-conceptualisation of mental disorders as disturbances of brain organisation. Psychosis and schizophrenia can be re-conceptualised as disturbances to connectivity and hierarchical dynamics in the brain; mood disorders can be re-conceptualised as disturbances to optimization dynamics and free energy in the brain, and finally personality disorders can be re-conceptualised as disordered default-mode networks in the brain.

Results and Conclusions

Knowledge and awareness of the disease algorithms of mental disorders will become critical because powerful technologies for controlling brain activity are developing and becoming available. The time will soon come when psychiatrists will be asked to define the exact ‘algorithms’ of disturbances in their psychiatric patients. Neuroanalysis can be a starting point for the response to that challenge.

Reference

Peled, A. (2020) Neuroanalysis: a method for brain-related neuroscientific diagnosis of mental disorders. Medical Hypotheses. 78(5), pp.636-640. doi: 10.1016/j.mehy.2012.01.043. Epub 2012 Feb 18.

Qigong and its Role in Mental Disorders

Research Paper Title

Qigong-induced mental disorders: a review.

Background

This review article aims to explore current opinions on Qigong-induced mental disorders, an entity which is unfamiliar to Western psychiatrists.

Method

Relevant literature published in Chinese and English is reviewed.

Results

The review is divided into three sections:

  • First, there is brief consideration of the historical development of Qigong in traditional Chinese medicine and its role in psychiatry;
  • Second, there is a review of the literature published on Qigong deviations and Qigong-induced mental disorders; and
  • Third, there is a discussion on the aetiological role of Qigong in these conditions.

Conclusions

Qigong remained veiled in secrecy and available only to the elite until the early 1980s. Despite the widespread use of Qigong, there is a conspicuous lack of controlled data regarding its effects on mental health.

Qigong, when practised inappropriately, may induce abnormal psychosomatic responses and even mental disorders. However, the ties between Qigong and mental disorders are manifold, and a causal relationship is difficult to establish.

Many so-called ‘Qigong-induced psychoses’ may be more appropriately labelled ‘Qigong-precipitated psychoses’, where the practice of Qigong acts as a stressor in vulnerable individuals.

Reference

Ng, B.Y. (2020) Qigong-induced mental disorders: a review. The Australian and New Zealand Journal of Psychiatry. 33(2), pp.197-206. doi: 10.1046/j.1440-1614.1999.00536.x.

What is Qigong?

Qigong, which is sometimes spelled Chi-Kung (and pronounced chee-gung), is the study and practice of cultivating vital life-force through various techniques, including:

  • Breathing techniques.
  • Postures.
  • Meditations.
  • Guided imagery.

Qi means “breath” or “air” and is considered the “vital-life-force” or “life-force energy.” Qigong practitioners believe that this vital-life-force penetrates and permeates everything in the universe. It corresponds to the Greek “pneuma,” the Sanskrit “prana,” or the Western medical conception of “bioelectricity.”

Gong means “work” or “effort” and is the commitment an individual puts into any practice or skill that requires time, patience, and repetition to perfect.

Through study, the individual aims to develop the ability to manipulate Qi in order to promote self-healing, prevent disease, and increase longevity.

Book: Social Cognition in Psychosis

Book Title:

Social Cognition in Psychosis.

Author(s): Kathryn Eve Lewandowski and Ahmed A. Moustafa (Editors).

Year: 2019.

Edition: First (1st).

Publisher: Academic Press.

Type(s): Paperback and Kindle.

Synopsis:

Social Cognition in Psychosis combines current research on phenotypes, neurobiology, and existing evidence on the assessment and treatment of various forms of psychoses.

The book presents various treatment options, including assessment approaches, tools and training methods that aid in the rehabilitation of patients with psychotic disorders.

Social cognition is a set of psychological processes related to understanding, recognising, processing and appropriately using social stimuli in one’s environment.

Individuals with psychotic disorders consistently exhibit impairments in social cognition. As a result, social cognition has been an important target for intervention, with recent efforts trying to enhance early recovery among individuals with psychotic disorders.

Book: Out of My Mind

Book Title:

Out of My Mind: A Psychologist’s Descent into Madness and Back.

Author(s): Shalom Camenietzki.

Year: 2020.

Edition: First (1st).

Publisher: University of Regina Press.

Type(s): Hardcover and Kindle.

Synopsis:

On paper, psychologist Dr. Shalom Camenietzski seemed to have it all – a beautiful family, a thriving practice, and supportive friends and colleagues.

But in reality, he lived a life of turmoil – obsessive daydreams of taking his life, flamboyant periods of mania, disturbing acts of violence against his wife and son, and various episodes of psychosis, one of which would see him speeding his car the wrong way up Toronto’s Gardiner Expressway.

Able to understand the clinical profile of his bipolar disorder, he was nonetheless powerless to stop it.

A fascinating account of a “”mentally disordered healer,”” Out of My Mind reveals the strengths and fallibilities of traditional psychotherapies and shows how Dr. Camenietzki finally obtained a symptom-free life.

Book: The End of Mental Illness

Book Title:

The End of Mental Illness: How Neuroscience Is Transforming Psychiatry and Helping Prevent or Reverse Mood and Anxiety Disorders, ADHD, Addictions, PTSD, Psychosis, Personality Disorders, and More.

Author(s): Daniel G. Amen.

Year: 2020.

Edition: First (1st), Illustrated Edition.

Publisher: Tyndale Momentum.

Type(s): Hardcover, Paperback, Audiobook, and Kindle.

Synopsis:

Though incidence of these conditions is skyrocketing, for the past four decades standard treatment hasn’t much changed, and success rates in treating them have barely improved, either. Meanwhile, the stigma of the “mental illness” label—damaging and devastating on its own—can often prevent sufferers from getting the help they need.

Brain specialist and bestselling author Dr. Daniel Amen is on the forefront of a new movement within medicine and related disciplines that aims to change all that. In The End of Mental Illness, Dr. Amen draws on the latest findings of neuroscience to challenge an outdated psychiatric paradigm and help readers take control and improve the health of their own brain, minimising or reversing conditions that may be preventing them from living a full and emotionally healthy life.

The End of Mental Illness will help you discover:

  • Why labeling someone as having a “mental illness” is not only inaccurate but harmful.
  • Why standard treatment may not have helped you or a loved one – and why diagnosing and treating you based on your symptoms alone so often misses the true cause of those symptoms and results in poor outcomes.
  • At least 100 simple things you can do yourself to heal your brain and prevent or reverse the problems that are making you feel sad, mad, or bad.
  • How to identify your “brain type” and what you can do to optimise your particular type.
  • Where to find the kind of health provider who understands and uses the new paradigm of brain health.

Trying to Understand the Link between Socioeconomic Deprivation, Blood Lipids, Pyschosis, & Cardiovascular Risk

Research Paper Title

Socioeconomic deprivation and blood lipids in first-episode psychosis patients with minimal antipsychotic exposure: Implications for cardiovascular risk.

Background

The influence of socioeconomic deprivation on the cardiovascular health of patients with psychosis-spectrum disorders (PSD) has not been investigated despite the growing recognition of social factors as determinants of health, and the disproportionate rates of cardiovascular mortality observed in PSD.

Discordant results have been documented when studying dyslipidemia -a core cardiovascular risk factor- in first-episode psychosis (FEP), before chronic exposure to antipsychotic medications.

The objective of the present study is to determine the extent to which socioeconomic deprivation affects blood lipids in patients with FEP, and examine its implications for cardiovascular risk in PSD.

Methods

Linear regression models, controlling for age, sex, exposure to pharmacotherapy, and physical anergia, were used to test the association between area-based measures of material and social deprivation and blood lipid levels in a sample of FEP patients (n = 208).

Results

Social, but not material deprivation, was associated with lower levels of total and HDL cholesterol.

This effect was statistically significant in patients with affective psychoses, but not in schizophrenia-spectrum disorders.

Conclusions

Contrary to other reports from the literature, the relationship between socioeconomic disadvantage and blood lipid levels was contingent on the social rather than the material aspects of deprivation.

Furthermore, this association also depended on the main diagnostic category of psychosis, suggesting a complex interaction between the environment, psychopathology, and physical health.

Future studies exploring health issues in psychosis might benefit from taking these associations into consideration.

A better understanding of the biology of blood lipids in this context is necessary.

Reference

Veru-Lesmes, F., Rho, A., Joober, R., Iyer, S. & Malla, A. (2020) Socioeconomic deprivation and blood lipids in first-episode psychosis patients with minimal antipsychotic exposure: Implications for cardiovascular risk. Schizophrenia Research. pii: S0920-9964(19)30589-4. doi: 10.1016/j.schres.2019.12.019. [Epub ahead of print].

Inflammatory Response & Treatment-Resistant Mental Disorders

Research Paper Title

Inflammatory Response and Treatment-Resistant Mental Disorders: Should Immunotherapy Be Added to Pharmacotherapy?

Abstract

Treatment resistance continues to challenge and frustrate mental health clinicians and provoke psychiatric researchers to seek additional explanatory theories for psychopathology.

Because the inflammatory process activates symptoms of depression, anxiety, and psychosis, it is a reasonable route to follow for primary and/or indirect contribution to mental disorders.

The current article reviews the research literature regarding the role the inflammatory process and immune system play in mental disorders as well as novel treatments under investigation for resistant depression, anxiety, substance use, and psychotic disorders.

Reference

Limandri, B.J. (2020) Inflammatory Response and Treatment-Resistant Mental Disorders: Should Immunotherapy Be Added to Pharmacotherapy? Journal of Psychosocial Nursing and Mental Health Services. 58(1), pp.11-16. doi: 10.3928/02793695-20191218-03.

What are the Comorbidity Rates of Depression & Anxiety in First Episode Psychosis?

Research Paper Title

Comorbidity rates of depression and anxiety in first episode psychosis: A systematic review and meta-analysis.

Background

Anxiety and depression symptoms are frequently experienced by individuals with psychosis, although prevalence rates have not been reviewed in first-episode psychosis (FEP).

The aim of this systematic review was to focus on the prevalence rates for both anxiety and depression, comparing the rates within the same study population.

Methods

A systematic review and meta-analysis was completed for all studies measuring both anxiety and depression in FEP at baseline.

The search identified 6040 citations, of which n = 10 met inclusion criteria.

These reported 1265 patients (age 28.3 ± 9.1, females: 39.9%) with diagnosed FEP.

Studies which used diagnosis to define comorbidity count were included in separate meta-analyses for anxiety and depression, although the heterogeneity was high limiting interpretation of separate prevalence rates.

A random-effects meta-analysis also compared the mean difference between anxiety and depression within the same studies.

Results

The researchers show that anxiety and depression co-occur at a similar rate within FEP, although the exact rates are not reliable due to the heterogeneity between the small number of studies.

Conclusions

Future research in FEP should consider routinely measuring anxiety and depression using continuous self-report measures of symptoms.

Clinically, the researchers recommend that both anxiety and depression are equally targeted during psychological intervention in FEP, together with the psychotic symptoms.

Reference

Wilson, R.S., Yung, A.R. & Morrison, A.P. (2019) Comorbidity rates of depression and anxiety in first episode psychosis: A systematic review and meta-analysis. Schizophrenia Research. pii: S0920-9964(19)30542-0. doi: 10.1016/j.schres.2019.11.035. [Epub ahead of print].

Can Brain Changes Reflected by Alterations in Functional Connectivity be a Useful for Outcome Prediction in the Prodromal Stage?

Research Paper Title

Brain functional connectivity data enhance prediction of clinical outcome in youth at risk for psychosis.

Background

The first episode of psychosis is typically preceded by a prodromal phase with subthreshold symptoms and functional decline.

Improved outcome prediction in this stage is needed to allow targeted early intervention.

This study assesses a combined clinical and resting-state fMRI prediction model in 137 adolescents and young adults at Clinical High Risk (CHR) for psychosis from the Shanghai At Risk for Psychosis (SHARP) programme.

Methods

Based on outcome at one-year follow-up, participants were separated into three outcome categories including:

  • Good outcome (symptom remission, N = 71);
  • Intermediate outcome (ongoing CHR symptoms, N = 30); and
  • Poor outcome (conversion to psychosis or treatment-refractory, N = 36).

Validated clinical predictors from the psychosis-risk calculator were combined with measures of resting-state functional connectivity.

Results

Using multinomial logistic regression analysis and leave-one-out cross-validation, a clinical-only prediction model did not achieve a significant level of outcome prediction (F1 = 0.32, p = .154).

An imaging-only model yielded a significant prediction model (F1 = 0.41, p = .016), but a combined model including both clinical and connectivity measures showed the best performance (F1 = 0.46, p < .001).

Influential predictors in this model included functional decline, verbal learning performance, a family history of psychosis, default-mode and frontoparietal within-network connectivity, and between-network connectivity among language, salience, dorsal attention, sensorimotor, and cerebellar networks.

Conclusions

These findings suggest that brain changes reflected by alterations in functional connectivity may be useful for outcome prediction in the prodromal stage.

Reference

Collin, G., Nieto-Castanon, A., Shenton, M.E., Pasternak, O., Kelly, S., Keshavan, M.S., Seidman, L.J., McCarley, R.W., Niznikiewicz, M.A., Li, H., Zhang, T., Tang, Y., Stone, W.S., Wang, J. & Whitfield-Gabrieli, S. (2019) Brain functional connectivity data enhance prediction of clinical outcome in youth at risk for psychosis. NeuroImage Clinical. doi: 10.1016/j.nicl.2019.102108. [Epub ahead of print].