Gomis, O., Palma, C., Farriols, N.

Domiciliary intervention in psychosis: a systematic review

BACKGROUND: This theoretical study reviews the main findings and research on home-based treatment for psychosis. The principal purpose was to analyze the various types of home-based service and make recommendations for a service that would meet the needs of both first-episode and resistant patients. We compare the Early Intervention Service, which aims to reduce the range of untreated psychosis (DUP) with other types of home-care and similar interventions that have already been implemented: crisis resolution home teams (CRHTs), Open Dialogue Approach (ODA), social skills training (SST) and foster homes.\rMETHOD: We searched electronic bibliographic databases including PubMed, PsycINFO, and Discovery for relevant publications appearing between 2005 and 2015. Ninetythree publications were deemed eligible for inclusion; 9 of these were systematic reviews and the rest were scientific papers or books.\rDISCUSSION: We describe in this review the most widely used home-based interventions, including individual and family therapy. Multidisciplinary teams carry out all the interventions discussed. There does not appear to be a form of psychotherapy, which is effective in treating resistant patients.\rCONCLUSIONS: Home-based interventions improve adherence to treatment, everyday living and social skills and also have a beneficial impact on family conflicts and other social conflicts. As a whole result, the number of incomes is reduced, patients' quality of life and autonomy are increased and inclusion and community living are improved.

Actas Espanolas De Psiquiatria, 45(6) : 290-302

Barbato, M., Buchy, L., Bray, S., MacMaster, F., Deighton, S., Addington, J.

Testing the feasibility of a computerized facial affect recognition training in early psychosis

Schizophrenia Research, 190 : 180- 181

Robinson, D. G.

Randomized comparison of comprehensive versus usual community care for first-episode psychosis: The RAISE-ETP study [Conference abstract]

Objectives: The RAISE-ETP (Recovery After an Initial Schizophrenia Episode Early Treatment Program) study compared NAVIGATE, a comprehensive, multidisciplinary, team-based treatment approach for first-episode psychosis (FEP) to clinician-choice community care (CC). The primary outcome was quality of life; secondary outcomes included symptoms and work and school participation. Methods: Thirty-four community treatment clinics in 21 states were randomly assigned to provide either NAVIGATE or CC care. NAVIGATE treatment included four core interventions: 1) personalized medication management (assisted by COMPASS, a web-based decision support system developed for RAISE-ETP); 2) family psychoeducation; 3) resilience-focused individual therapy; and 4) supported employment and education. Diagnosis, duration of untreated psychosis (DUP), and clinical outcomes were assessed live and remotely by two-way video of centralized raters masked to treatment allocation. Participants (N = 404; mean age 23 years, 13.6% 18 years or younger; 37.4% 20 years or younger), with schizophrenia spectrum disorders and lifetime treatment for antipsychosis (<6 months), were enrolled and followed for at least two years. The primary outcome measure was the total score of the Heinrichs-Carpenter Quality of Life Scale (QLS). Results: Over the first two years, the 223 participants at NAVIGATE sites remained in treatment longer (P < 0.004); experienced greater improvement in quality of life (P < 0.02 for QLS total score) and psychopathology (P < 0.02 for PANSS total scores; P < 0.04 for Calgary Depression Scale for Schizophrenia scores); and more involvement in work or school (P < 0.05) compared with the 181 participants at CC sites. The sample median DUP was 74 weeks. NAVIGATE participants with DUP of 74 weeks or less had greater improvement on quality of life and psychopathology compared with those with DUP greater than 74 weeks. Subgroup analysis of outcomes for younger participants in the trial will be presented at the meeting. Conclusions: Comprehensive care for FEP can be implemented at community mental health clinics, with associated improvement in functional and clinical outcomes. Effects are more pronounced for those with shorter DUP. Attention to strategies to reduce DUP could improve outcomes for patients early in the course of illness.

Journal of the American Academy of Child and Adolescent Psychiatry, 56 (10) : S340

Albert, N., Melau, M., Jensen, H., Emborg, C., Jepsen, J. R., Fagerlund, B., Gluud, C., Mors, O., Hjorthoj, C., Nordentoft, M.

Five years of specialised early intervention versus two years of specialised early intervention followed by three years of standard treatment for patients with a first episode psychosis: randomised, superiority, parallel group trial in Denmark (OPUS II)

OBJECTIVE: To compare the effects of five years of specialised early intervention (SEI) treatment for first episode schizophrenia spectrum disorder with the standard two years of SEI plus three years of treatment as usual.\rDESIGN: Randomised, superiority, parallel group trial with blinded outcome assessment. Randomisation was centralised and computerised with concealed randomisation sequence carried out at an external site.\rSETTING: Participants were recruited from six OPUS teams in Denmark between 2009 and 2012. OPUS teams provide SEI treatment to all patients diagnosed with a schizophrenia spectrum disorder in Denmark.\rPARTICIPANTS: 400 participants (51% women) with a mean age of 25.6 (standard deviation 4.3) were randomised to five years of SEI (experimental intervention; n=197) or to two years of SEI plus three years of treatment as usual (control; n=203).\rINTERVENTIONS: OPUS treatment consists of three core elements-modified assertive community treatment, family involvement, and social skill training-with a patient-case manager ratio of no more than 12:1. For participants randomised to five years of OPUS treatment, the treatment was largely unchanged. Participants randomised to the control group were mostly referred to community health centres after two years of SEI treatment.\rMAIN OUTCOMES: Follow-up assessments were conducted five years after start of OPUS treatment. Primary outcome was negative symptoms measured on the scale for assessment of negative symptoms (avolition-apathy, anhedonia, alogia, and affective blunting). Secondary outcomes were remission of both negative and psychotic symptoms, psychotic symptoms, suicidal ideation, substance abuse, compliance with medical treatment, adherence with treatment, client satisfaction, days in hospital care, and labour market affiliation. \rRESULTS: Levels of negative symptoms did not differ between the intervention group and control group (1.72 v 1.81 points; estimated mean difference -0.10 (95% confidence interval 0.33 to 0.13), P=0.39). Participants receiving five years of OPUS treatment were more likely to remain in contact with specialised mental health services (90.4% v 55.6%, P<0.001), had higher client satisfaction (estimated mean difference 2.57 points (95% confidence interval 1.36 to 3.79), P<0.001), and had a stronger working alliance (estimated mean difference 5.56 points (95% confidence interval 2.30 to 8.82), P=0.001) than the control group.\rCONCLUSIONS: This trial tests SEI treatment for up to five years for patients with first episode schizophrenia spectrum disorder; previous trials have found treatment effects for programmes lasting from one to three years. The prolonged SEI treatment had few effects, which could be due to the high level of treatment provided to control participants and the late start of specialised treatment.Trial registration Clinicaltrial.gov NCT00914238.\rCopyright Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

BMJ, 356 : i6681

Bechdolf, A., Muller, H., Stutzer, H., Lambert, M., Karow, A., Zink, M., Lautenschlager, M., Heinz, A., De-Millas, W., Janssen, B., Gaebel, W., Schneider, F., Juckel, G., Kruger-Ozgurdal, S., Wobrock, T., Wagner, M., Maier, W., Klosterkotter, J.

Prevent: A randomized controlled trial for the prevention of first-episode psychosis comparing cognitive-behavior therapy (CBT), clinical management, and aripiprazole combined and clinical management and placebo combined [conference abstract]

Background: Although there are encouraging results from clinical trials focusing on second generation antipsychotics, omega-3-fatty acids or psychotherapy for the prevention of psychosis, their empirical evidence remains uncertain and it is unknown whether these interventions are com-parable in reducing the risk of conversion to psychosis in persons at clinical high risk (CHR). Therefore, the present multicenter, prospective, randomized, blinded trial with three parallel groups (PREVENT) was designed to explore the differential preventive effcacy of two approaches 1. cognitive behavioral therapy (CBT) and 2. Aripiprazole (ARI) + clinical management (CM) to 3. placebo (PL) + CM. Methods: Individuals aged 18-49 identifed as CHR by Ultra-High-Risk and/or basic symptoms COGDIS criteria were assessed at baseline, 28 and 52 weeks. The primary outcome was progression to psychosis including transition to psychosis or conversion from early initial prodromal state (defned by COGDIS or decline of functioning in combination with family risk factors or schizotypal disorder) to late initial prodromal state (defned by the presence of attenuated positive symptoms or brief limited intermittent psychotic symptoms). Secondary outcome was transition to psychosis. Results: Of 611 eligible individuals 280 were randomized. The Full analy-sis set comprised 216 individuals [mean age 24.4 (5.1) years; about 66 % male]. In terms of the primary outcome, there was a clinical relevant difference between the three treatment arms (CBT: 19.2 %; AR+CM: 26.8 %; PL+CM: 30.0 %), but no statistical difference (P >.05). Pairwise comparisons showed a statistical trend in favor of CBT compared with CM + PL. With respect to the secondary outcome, there was a reduction in favor of CBT compared to CM + ARI also on a statistical trend level. Drop-out rates differed between the arms over time (P <.05), with indications for more premature terminations in ARI + CM and PL + CM compared to CBT. Conclusion: Pairwise comparisons showed a clinically relevant reduction regarding the primary (about 30%) and secondary outcome (about 40%) in favor of CBT. Lower drop-out rates in CBT could be interpreted as higher adherence and acceptance of psychotherapy within this trial.

Schizophrenia Bulletin, 43(Suppl 1) : S56-S57

Biagianti, B., Roach, B., Fisher, M., Loewy, R., Ford, J., Vinogradov, S.

Auditory mismatch negativity impairments predict response to cognitive training in individuals with early illness schizophrenia [conference abstract]

Objective: Schizophrenia patients have heterogeneous impairments of the auditory system that mediate differences in the cognitive gains induced by cognitive training (CT). Mismatch negativity (MMN) is an event-related potential, and its amplitude reduction in schizophrenia has been linked to cognitive deficits. Therefore, MMN may predict an attenuated response to CT or, alternatively, identify schizophrenia patients who benefit the most from CT. Furthermore, to the extent that CT strengthens auditory processing, MMN may also serve as a readout of the underlying auditory system changes induced by CT. Methods: Fifty-six individuals with early illness schizophrenia (ESZ) were randomly assigned to 40 h of CT or computer games (CG). Cognitive assessments and EEG recordings were obtained before and after CT and CG. Changes in these measures were compared between the treatment groups. Baseline and trait-like MMN data were evaluated as predictors of treatment response. MMN data collected from 102 healthy controls (HC) were compared to baseline MMN data from the ESZ group. Results: Compared to HC, ESZ showed significant MMN reductions at baseline (p = .003). Reduced Double-Deviant MMN was associated with greater general cognitive impairment in ESZ individuals (p = .020). Neither ESZ intervention group showed significant change in MMN. We found high correlations in all MMN deviant types (rs = .59-.68, all ps<.001) between baseline and post-training amplitudes irrespective of treatment group, suggesting trait- like stability of the MMN signal. Greater deficits in trait-like Double-Deviant MMN predicted greater cognitive improvements in the CT group (p = .02), but not in CG group. Conclusion: In ESZ, baseline MMN was significantly reduced relative to HC, and associated with general cognitive impairment. MMN did not show changes after CT and exhibited trait-like stability (see Fig. 12). Greater deficits in the Double-Deviant MMN trait predicted greater gains in general cognition in response to CT, suggesting that MMN identifies individuals who stand to gain the most from CT. (Figure Presented).

European Archives of Psychiatry and Clinical Neuroscience, 267(1 (Suppl 1)) : S91-S92

Biagianti, B., Roach, B. J., Fisher, M., Loewy, R., Ford, J. M., Vinogradov, S., Mathalon, D. H.

Trait aspects of auditory mismatch negativity predict response to auditory training in individuals with early illness schizophrenia

BACKGROUND: Individuals with schizophrenia have heterogeneous impairments of the auditory processing system that likely mediate differences in the cognitive gains induced by auditory training (AT). Mismatch negativity (MMN) is an event-related potential component reflecting auditory echoic memory, and its amplitude reduction in schizophrenia has been linked to cognitive deficits. Therefore, MMN may predict response to AT and identify individuals with schizophrenia who have the most to gain from AT. Furthermore, to the extent that AT strengthens auditory deviance processing, MMN may also serve as a readout of the underlying changes in the auditory system induced by AT.\rMETHODS: Fifty-six individuals early in the course of a schizophrenia-spectrum illness (ESZ) were randomly assigned to 40 h of AT or Computer Games (CG). Cognitive assessments and EEG recordings during a multi-deviant MMN paradigm were obtained before and after AT and CG. Changes in these measures were compared between the treatment groups. Baseline and trait-like MMN data were evaluated as predictors of treatment response. MMN data collected with the same paradigm from a sample of Healthy Controls (HC; n = 105) were compared to baseline MMN data from the ESZ group.\rRESULTS: Compared to HC, ESZ individuals showed significant MMN reductions at baseline (p = .003). Reduced Double-Deviant MMN was associated with greater general cognitive impairment in ESZ individuals (p = .020). Neither ESZ intervention group showed significant change in MMN. We found high correlations in all MMN deviant types (rs = .59-.68, all ps < .001) between baseline and post- intervention amplitudes irrespective of treatment group, suggesting trait-like stability of the MMN signal. Greater deficits in trait-like Double- Deviant MMN predicted greater cognitive improvements in the AT group (p = .02), but not in the CG group.\rCONCLUSIONS: In this sample of ESZ individuals, AT had no effect on auditory deviance processing as assessed by MMN. In ESZ individuals, baseline MMN was significantly reduced relative to HCs, and associated with global cognitive impairment. MMN did not show changes after AT and exhibited trait-like stability. Greater deficits in the trait aspects of Double-Deviant MMN predicted greater gains in global cognition in response to AT, suggesting that MMN may identify individuals who stand to gain the most from AT.\rTRIAL REGISTRATION: NCT00694889. Registered 1 August 2007.

Neuropsychiatric Electrophysiology, 3(2) :

Cadenhead, K., Addington, J., Bearden, C., Cannon, T., Cornblatt, B., Mathalon, D., McGlashan, T., Perkins, D., Seidman, L., Walker, E., Woods, S., Yao, J.

Dietary omega 3 and erythrocyte omega 3 are associated with symptoms, functioning and psychotic conversion in a clinical high risk population [conference abstract]

Background: Omega-3 Fatty Acids (FAs), EPA (eicosapentaenoic acid) and DHA (Docosahexaenoic acid), are essential for normal brain development and may also have neuroprotective properties. Abnormal FA metabolism may play a role in the etiology of psychiatric illness. Reductions in Red Blood Cell (RBC) membrane Polyunsaturated Fatty Acids (PUFAs) have been reported in both chronic patients and unmedicated first episode patients with schizophrenia. Dietary supplementation of EPA and DHA may have beneficial effects in both somatic and mental illness. Studies of Omega 3 supplementation in Clinical High Risk (CHR) populations have had mixed results. One study (Amminger et al) found reduced conversion to psychosis along with improvement in symptoms and functioning in the Omega 3 versus the Placebo group while two studies (McGorry et al and Cadenhead et al unpublished) have failed to replicate these findings. In the current study, we assessed the relationship of dietary Omega 3 and RBC PUFA levels to symptoms, functioning and conversion to psychosis in a sample of CHR subjects participating in a trial of Omega 3 FA versus Placebo. Methods: As part of a 24-week, randomized, double-blind, placebo, fixed dose-controlled study of Omega-3FA versus placebo in 127 CHR subjects, baseline diet was assessed using a systematic checklist of Omega-3FA foods and fasting RBC PUFA composition was assessed. Regular assessments of symptoms and functioning were performed throughout the study. We investigated the relationship between reported Omega 3 FA consumption, RBC PUFA levels and outcome measures as part of this trial. Results: Of the 127 CHR subjects recruited into the trial, 118 completed baseline assessment and 70 completed the 6 month trial. Ten percent of subjects converted to psychosis during the 24 months. The rate of psychotic conversion did not differ in the Omega-3FA (13%) versus Placebo (8%) samples. However, conversion to psychosis was predicted by lower levels of EPA (24-month conversion 16.2% low EPA vs 2.6% high EPA) in the RBC membrane (Wald Statistic 3.72, p<0.05). Greater levels of negative symptoms and low GAF scores were associated with a diet consisting of few Omega 3 fatty acid rich foods and corresponding low EPA in the RBC membrane. The self-reported Omega 3 fatty acids in the diet were significantly correlated with a number of the RBC PUFA composition variables and measures of oxidative stress. Conclusions: The finding of a significant association between baseline diet low in Omega-3FA rich foods and outcome raises the question of whether it is possible to influence both physical and mental health with lifestyle choices including diet. These findings reinforce that early detection of food insecurity is crucial since this factor is modifiable with the potential for significant gains in terms of quality of life, physical and mental health. Longitudinal follow-up will provide insight into whether these indices are risk factors for future psychosis and functional outcome.

Neuropsychopharmacology, 43(Suppl 1) : S422- S423

Cechnicki, A., Bielanska, A.

The influence of early psychosocial intervention on the long-term clinical outcomes of people suffering from schizophrenia

Aim: To compare the treatment outcomes of DSM-IV-TR schizophrenia patients in either a Community Treatment Program or an Individual Treatment Program (CTP vs. ITP). The assessment was made after the first hospitalization, and then after three and twelve years. Method: Participants were randomly assigned to CTP (experimental) and ITP (traditional) group, with 40 people in each group. 67 people (84%) participated in all three assessments. The socio-demographic and clinical indicators were the same for both groups. In the first three years only the CTP group participated in day-care treatment, patient and family psychoeducation and community treatment. Later, both groups received this treatment. The following tools were used: Anamnestic and Catamnestic Questionnaire, the GAF scale, the BPRS LA and Lehman's Quality of Life Interview. Results: It was only after twelve years that there was a significant beneficial improvement in the mean GAF score in the CTP group (p = 0.036), which was comparable with the results obtained by Watt and Shepherd for the course of the illness in favorable remission cases (p = 0.038). The difference in the number of relapses was also significantly in favor of the CTP group only after 12 years (p = 0.045), as was the difference in the number of rehospitalizations (p = 0.013). The general severity of symptoms was found to be significantly lower for the CPT group after 3 (p = 0.008) and 12 years (p = 0.030), whereas it was significantly lower in the case of positive syndrome only after 3 years (p = 0.044). Conclusions: 1. A greater number of favorable differences were identified for the CTP group at the twelve-year point than at the conclusion of the experiment. 2. The three- year delay in introducing psycho-social treatment was associated with a poorer long-term outcome for the clinical course of schizophrenia. (PsycINFO Database Record (c) 2017 APA, all rights reserved)

Psychiatria Polska, 51(1) : 45- 61

Chang, W., Kwong, V., Chan, G., Jim, O., Lau, E., Hui, C., Chan, S., Lee, E., Chen, E.

Prediction of motivational impairment: 12-month follow-up of the randomized-controlled trial on extended early intervention for first-episode psychosis

Background: Amotivation is prevalent in first-episode psychosis (FEP) patients and is a major determinant of functional outcome. Prediction of amotivation in the early stage of psychosis, however, is under-studied. We aimed to prospectively examine predictors of amotivation in FEP patients in a randomized-controlled trial comparing a 1-year extension of early intervention (Extended EI, 3-year EI) with step-down psychiatric care (SC, 2-year EI). Methods: One hundred sixty Chinese patents were recruited from a specialized EI program for FEP in Hong Kong after they have completed this 2-year EI service, randomly allocated to Extended EI or SC, and followed up for 12 months. Assessments on premorbid adjustment, onset profiles, baseline symptom severity and treatment characteristics were conducted. Data analysis was based on 156 subjects who completed follow-up assessments. Results: Amotivation at 12-month follow-up was associated with premorbid adjustment, allocated treatment condition, and levels of positive symptoms, disorganization, amotivation, diminished expression (DE) and depression at study intake. Hierarchical multiple regression analysis revealed that Extended EI and lower levels of DE independently predicted better outcome on 12-month amotivation. Conclusion: Our findings indicate a potentially critical therapeutic role of an extended specialized EI on alleviating motivational impairment in FEP patients. The longer-term effect of Extended EI on amotivation merits further investigation. (PsycINFO Database Record (c) 2017 APA, all rights reserved)

European Psychiatry, 41 : 37- 41

Chang, W., Kwong, V., Lau, E., So, H., Wong, C., Chan, G., Jim, O., Hui, C., Chan, S., Ming Lee, E., Chen, E.

Sustainability of treatment effect of a 3-year early intervention programme for first-episode psychosis

Background: Evidence indicates that the positive effects of 2-year early intervention services for psychosis are not maintained after service withdrawal. Optimal duration of early intervention in sustaining initial improved outcomes remains to be determined. Aims: To examine the sustainability of the positive effects of an extended, 3-year, early intervention programme for patients with first-episode psychosis (FEP) after transition to standard care. Method: A total of 160 patients, who had received a 2-year early intervention programme for FEP, were enrolled to a 12-month randomised-controlled trial (ClinicalTrials.gov: NCT01202357) comparing a 1-year extension of the early intervention (3-year specialised treatment) with step-down care (2-year specialised treatment). Participants were followed up and reassessed 2 and 3 years after inclusion to the trial. Results: There were no significant differences between the treatment groups in outcomes on functioning, symptom severity and service use during the post-trial follow-up period. Conclusions: The therapeutic benefits achieved by the extended, 3-year early intervention were not sustainable after termination of the specialised service. (PsycINFO Database Record (c) 2017 APA, all rights reserved)

British Journal of Psychiatry, 211(1) : 37-44

Chen, E. Y. H., Hui, C. L. M., Lee, E. H. M., Chang, W. C., Chan, S. K. W., Honer, W. G.

Maintenance discontinuation after first episode psychosis may increase treatment non- responsiveness: 10-year follow-up of an RCT [conference abstract]

Background: Clinical decision to discontinue antipsychotics in patients remitted from frst-episode psychosis is important. Existing short-term evidence suggests that patients who discontinued antipsychotics had more relapses. Data on long-term outcomes are lacking; with only one open-label study suggesting better long-term recovery outcome in patients who had early medication discontinuation. We compared the long-term clinical and functional outcomes at 10 years of remitted frst-episode psychosis patients who had either discontinued or continued their antipsychotic medications in the early stage of the illness under a randomized controlled trial (RCT). Methods: We followed up 178 frst-episode psychosis patients who participated in a 1-year RCT on medication discontinuation. In the RCT, patients were randomized into receiving either a medication maintenance group (MT) or a placebo discontinuation group (PL). In this follow-up study, 142 subjects were successfully traced and assessed at 10 years on their clinical, functional and cognitive outcomes. Results: There were no differences between patients who were included (n = 142) and excluded (n = 36) from the study with regard to their baseline demographics, clinical and functioning. At 10 years, patients in the PL group had more residual delusion as defned using PANSS P1 item score (15%) than those in the MT group (4%; P =.028). PL group also had more treatment refractory (as defned using residual delusion or on clozapine; 24%) than the MT group (8%; P =.011). Specifcally, PL started to take clo-zapine signifcantly earlier than MT during the follow-up period (P =.04). We found no signifcant differences between MT and PL in terms of func-tioning, cognitive functioning, quality of life, and medication taken after 10 years. Conclusion: This is the frst study to examine the long-term impacts of med-ication discontinuation during early phase of psychotic disorders. Our fnd-ings show that early decision to stop medication in remitted frst-episode psychosis may result in less symptomatic remission and more treatment nonresponsiveness. The decision to discontinue medication during the early phase of psychosis should be considered carefully.

Schizophrenia Bulletin, 43(Suppl 1) : S78- S79