Validating cognitive screening in young people with first-episode psychosis: The CogScreen protocol.

AIM: Cognitive impairments are a core feature of first-episode psychosis (FEP) and one of the strongest predictors of long-term psychosocial functioning. Cognition should be assessed and treated as part of routine clinical care for FEP. Cognitive screening offers the opportunity to rapidly identify and triage those in most need of cognitive support. However, there are currently no validated screening measures for young people with FEP. CogScreen is a hybrid effectiveness-implementation study which aims to evaluate the classification accuracy (relative to a neuropsychological assessment as a reference standard), test-retest reliability and acceptability of two cognitive screening tools in young people with FEP. METHODS: Participants will be 350 young people (aged 12-25) attending primary and specialist FEP treatment centres in three large metropolitan cities (Adelaide, Sydney, and Melbourne) in Australia. All participants will complete a cross-sectional assessment over two sessions including two cognitive screening tools (Screen for Cognitive Impairment in Psychiatry and Montreal Cognitive Assessment), a comprehensive neuropsychological assessment battery, psychiatric and neurodevelopmental assessments, and other supplementary clinical measures. To determine the test-retest reliability of the cognitive screening tools, a subset of 120 participants will repeat the screening measures two weeks later. RESULTS: The protocol, rationale, and hypotheses for CogScreen are presented. CONCLUSIONS: CogScreen will provide empirical evidence for the validity and reliability of two cognitive screening tools when compared to a comprehensive neuropsychological assessment. The screening measures may later be incorporated into clinical practice to assist with rapid identification and treatment of cognitive deficits commonly experienced by young people with FEP.

Brief intervention: a promising framework for child and youth mental health?

There is a discrepancy between the demand for mental health treatment amongst children, young people and their carers, and the capacity of the current service system to provide evidence based interventions. Innovative models of care are required to redress this discrepancy. One such model is the single session model, which provides a single or small number of solution focused sessions targeting one or two identified problems. Single session interventions have been trialled across a range of presenting concerns including child and youth mental health services. This paper provides a rationale for offering a brief focused intervention as part of a broader Child and Youth Mental Health Service, and introduces a model of how brief intervention fits within a broader system of care.

A randomized controlled trial of relapse prevention therapy for first-episode psychosis patients: outcome at 30-month follow-up.

The effectiveness of a novel 7-month psychosocial treatment designed to prevent the second episode of psychosis was evaluated in a randomized controlled trial at 2 specialist first-episode psychosis (FEP) programs. An individual and family cognitive behavior therapy for relapse prevention was compared with specialist FEP care. Forty-one FEP patients were randomized to the relapse prevention therapy (RPT) and 40 to specialist FEP care. Participants were assessed on an array of measures at baseline, 7- (end of therapy), 12-, 18-, 24-, and 30-month follow-up. At 12-month follow-up, the relapse rate was significantly lower in the therapy condition compared with specialized treatment alone (P = .039), and time to relapse was significantly delayed for those in the relapse therapy condition (P = .038); however, such differences were not maintained. Unexpectedly, psychosocial functioning deteriorated over time in the experimental but not in the control group; these differences were no longer statistically significant when between-group differences in medication adherence were included in the model. Further research is required to ascertain if the initial treatment effect of the RPT can be sustained. Further research is needed to investigate if medication adherence contributes to negative outcomes in functioning in FEP patients who have reached remission, or, alternatively, if a component of RPT is detrimental.

Predictors of adherence to cognitive-behavioural therapy in first-episode psychosis.

OBJECTIVE: To investigate predictors of adherence with a cognitive-behavioural intervention in first-episode psychosis (FEP) patients. METHOD: Predictors of adherence to cognitive-behavioural therapy (CBT) were longitudinally investigated in the experimental arm of a randomized controlled trial designed to evaluate the effectiveness of a CBT intervention for relapse prevention early in the course of psychosis when compared with treatment as usual within 2 high quality, youth oriented, specialist FEP programs (the EPISODE II trial). RESULTS: Longer duration of untreated psychosis (DUP) and poorer level of insight predicted poor adherence to CBT. This association remained significant after controlling for potential confounders. CONCLUSIONS: Treatment delay may decrease adherence with CBT in FEP patients. Reducing DUP and promoting insight early in the course of psychosis are likely to enhance adherence with CBT.

A randomized controlled trial of relapse prevention therapy for first-episode psychosis patients.

OBJECTIVE: Patients with first-episode psychosis are responsive to acute-phase treatments, but relapse rates are high. This study aimed to evaluate the effectiveness of a psychosocial treatment designed to prevent the second episode of psychosis compared with standardized early psychosis care. METHOD: In a randomized controlled trial, conducted at the Early Psychosis Prevention and Intervention Centre and Barwon Health, Australia, a multimodal individual and family cognitive-behavioral therapy for relapse prevention was compared with standardized case management within a specialist early psychosis service. Patients aged 15 to 25 years with a first episode of a DSM-IV psychotic disorder were recruited between November 2003 and May 2005. The main outcome measures were the number of relapses and time to first relapse. RESULTS: Forty-one first-episode psychosis patients were randomly assigned to the relapse prevention therapy (RPT) and 40 to standardized case management. At the 7-month follow up, the relapse rate was significantly lower in the therapy condition compared to treatment as usual (p = .042) and time to relapse was significantly longer for the RPT condition (p = .03). The number needed to treat was 6 over 7 months. CONCLUSIONS: Interim findings suggest that RPT provided within a specialist early psychosis program was effective in reducing relapse in early psychosis when compared with standardized early psychosis case management. TRIAL REGISTRATION: www.anzctr.org.au Identifier: ACTRN12605000514606.

Enhancing treatment fidelity in psychotherapy research: novel approach to measure the components of cognitive behavioural therapy for relapse prevention in first-episode psychosis.

OBJECTIVES: Establishing treatment fidelity is one of the most important aspects of psychotherapy research. Treatment fidelity refers to the methodological strategies used to examine and enhance the reliability and validity of psychotherapy. This study sought to develop and evaluate a measure specifically designed to assess fidelity to the different therapeutic components (i.e. therapy phases) of the individual intervention of a psychotherapy clinical trial (the EPISODE II trial). METHOD: A representative sample of sessions stratified by therapy phase was assessed using a specifically developed fidelity measure (Relapse Prevention Therapy-Fidelity Scale, RPT-FS). Each RPT-FS subscale was designed to include a different component/phase of therapy and its major therapeutic ingredients. RESULTS: The measure was found to be reliable and had good internal consistency. The RPT-FS discriminated, almost perfectly, between therapy phases. The analysis of the therapeutic strategies implemented during the intervention indicated that treatment fidelity was good throughout therapy phases. While therapists primarily engaged in interventions from the appropriate therapeutic phase, flexibility in therapy was evident. CONCLUSIONS: This study described the development of a brief, reliable and internally consistent measure to determine both treatment fidelity and the therapy components implemented throughout the intervention. This methodology can be potentially useful to determine those components related to therapeutic change.