Depression and functioning are important to subjective quality of life after a first episode psychosis.

BACKGROUND: Subjective quality of life (S-QoL) is an important outcome measure in first-episode psychosis, but its associations with clinical predictors may vary across the illness course. In this study we examine the association pattern, including both direct and indirect effects, between specific predefined clinical predictors (insight, depression, positive psychotic symptoms and global functioning) and S-QoL the first ten years after a first-episode psychosis. METHODS: Three hundred and one patients with a first-episode psychosis were included at first treatment, and reassessed at 3 months, 1 year, 2 years, 5 years and 10 years after inclusion. At 10-year follow-up 186 participated. S-QoL was assessed with Lehman's Quality of Life Interview. Applying a structural equation model, we investigated cross-sectional association patterns at all assessments between the predefined clinical predictors and S-QoL. RESULTS: At baseline, only depression was significantly associated with S-QoL. At all follow-up assessments, depression and functioning showed significant associations with S-QoL. Insight was not associated with S-QoL at any of the assessments. Better insight, less depressive symptoms and less positive psychotic symptoms were all associated with higher functioning at all assessments. Functioning seems to mediate a smaller indirect inverse association between positive psychotic symptoms and S-QoL. The association pattern was stable across all follow-up assessments. CONCLUSIONS: Together with depression, functioning seems to be important for S-QoL. Functioning seems to be a mediating factor between positive symptoms and S-QoL. A focus on functional outcome continues to be important.

Antipsychotic treatment: experiences of fully recovered service users.

BACKGROUND: There is lack of long-term controlled studies evaluating treatment effects of antipsychotic medication. A complete investigation should include the service user perspective. AIMS: To investigate experiences of clinically recovered service users of antipsychotic medications during and after a first episode of psychosis. METHOD: We used a thematic analytic approach within an interpretative-phenomenological framework. 20 clinically recovered service users were interviewed. RESULTS: Themes: (1) Antipsychotic drugs reduce mental chaos during the acute phase, (2) Non-stigmatizing environments were perceived to increase chances of successful use, (3) Antipsychotic drugs beyond the acute phase - considered to compromise the contribution of individual effort in recovery, (4) Prolonged use - perceived to reduce likelihood of functional recovery, (5) Antipsychotic medication was considered as a supplement to trustful relationships. CONCLUSIONS: Acute phase antipsychotic treatment was mostly perceived as advantageous by this sample, who was in clinical recovery. However, costs were often seen as outweighing benefits beyond the acute stage. Findings clearly emphasize the need for a collaborative approach to be integrated across all phases of care. This study underscores the need to investigate sub-group differences with regard to long-term antipsychotic treatment.

Is there an optimal factor structure of the Positive and Negative Syndrome Scale in patients with first-episode psychosis?

The Positive and Negative Syndrome Scale (PANSS) is the most widely used scale to assess a variety of symptoms in patients with schizophrenia and other psychoses. The factor structure of the PANSS has been examined with confirmatory factor analyses in several studies, but not in a well-defined first-episode psychosis sample. The aim of this paper is to examine the statistical fit of five different PANSS models in a first-episode, non-affective psychosis sample. Confirmatory factor analyses were performed on PANSS data (n = 588). A main criterion for best fit was defined as the Expected Cross Validation Index (ECVI). No tested model revealed an optimally satisfactory model fit index. The Wallwork/Fortgang five-factor model demonstrated the most optimal psychometric properties. The corresponding subscales of all evaluated five-factor models were strongly intercorrelated. The Wallwork/Fortgang five-factor model was found to be statistically and clinically ideal among patients with first-episode psychosis. Therefore, we recommend this model in forthcoming studies among patients with first-episode psychosis. However, to prevent the loss of clinically valuable information on an item level, we do not recommend removing any items from the original form. Our study also implies that the specific choice of model will not have a substantial effect on outcome results in studies on the course and outcome in first-episode psychosis.

A comparison of adolescent- and adult-onset first-episode, non-affective psychosis: 2-year follow-up.

This study aimed to compare 2-year outcome among individuals with early-onset (EO; <18 years) versus adult-onset (AO) first-episode, non-affective psychosis. We compared clinical and treatment characteristics of 43 EO and 189 AO patients 2 years after their inclusion in a clinical epidemiologic population-based cohort study of first-episode psychosis. Outcome variables included symptom severity, remission status, drug abuse, treatment utilization, cognition and social functioning. At baseline, EO patients were more symptomatically compromised. However, these initial baseline differences were no longer significant at the 2-year follow-up. This study challenges the findings of a larger and older literature base consisting primarily of non-comparative studies concluding that teenage onset indicates a poor outcome. Our results indicate that adolescent-onset and adult-onset psychosis have similar prognostic trajectories, although both may predict a qualitatively different course from childhood-onset psychosis.

Associations between symptom and neurocognitive dimensions in clinical high risk for psychosis.

Introduction: Clinical high risk for psychosis (CHR) is associated with mild cognitive impairments. Symptoms are clustered into positive, negative and disorganization symptoms. The association between specific symptom dimensions and cognitive functions remains unclear. The aim of this study was to investigate the associations between cognitive functions and positive, negative, and disorganization symptoms. Method: 53 CHR subjects fulfilling criteria for attenuated psychotic syndrome in the Structural Interview for Prodromal Syndromes (SIPS) were assessed for cognitive function. Five cognitive domain z-scores were defined by contrasting with observed scores of a group of healthy controls (n = 40). Principal Components Analyses were performed to construct general cognitive composite scores; one using all subtests and one using the cognitive domains. Associations between cognitive functions and symptoms are presented as Spearman's rank correlations and partial Spearman's rank correlations adjusted for age and gender. Results: Positive symptoms were negatively associated with executive functions and verbal memory, and disorganization symptoms with poorer verbal fluency. Negative symptoms were associated with better executive functioning. There were no significant associations between the general cognitive composites and any of the symptom domains, except for a trend for positive symptoms. Conclusion: In line with previous research, data indicated associations between positive symptoms and poorer executive functioning. Negative symptoms may not be related to executive functions in CHR the same way as in psychosis. Our results could indicate that attenuated positive symptoms are more related to cognitive deficits in CHR than positive symptoms in schizophrenia and FEP.

Reduced Expression of Emotion: A Red Flag Signalling Conversion to Psychosis in Clinical High Risk for Psychosis (CHR-P) Populations.

Objective: In this hypothesis-testing study, which is based on findings from a previous atheoretical machine-learning study, we test the predictive power of baseline "reduced expression of emotion" for psychosis.Method: Study participants (N = 96, mean age 16.55 years) were recruited from the Prevention of Psychosis Study in Rogaland, Norway. The Structured Interview for Prodromal Syndromes (SIPS) was conducted 13 times over two years. Reduced expression of emotion was added to positive symptoms at baseline (P1-P5) as a predictor of psychosis onset over a two-year period using logistic regression.Results: Participants with a score above zero on expression of emotion had over eight times the odds of conversion (OR = 8.69, p < .001). Data indicated a significant dose-response association. A model including reduced expression of emotion at baseline together with the positive symptoms of the SIPS rendered the latter statistically insignificant.Conclusions: The study findings confirm findings from the previous machine-learning study, indicating that observing reduced expression of emotion may serve two purposes: first, it may add predictive value to psychosis conversion, and second, it is readily observable. This may facilitate detection of those most at risk within the clinical high risk of psychosis population, as well as those at clinical high risk. A next step could be including this symptom within current high-risk criteria. Future research should consolidate these findings.

Exploring specific predictors of psychosis onset over a 2-year period: A decision-tree model.

AIM: The fluctuating symptoms of clinical high risk for psychosis hamper conversion prediction models. Exploring specific symptoms using machine-learning has proven fruitful in accommodating this challenge. The aim of this study is to explore specific predictors and generate atheoretical hypotheses of onset using a close-monitoring, machine-learning approach. METHODS: Study participants, N = 96, mean age 16.55 years, male to female ratio 46:54%, were recruited from the Prevention of Psychosis Study in Rogaland, Norway. Participants were assessed using the Structured Interview for Psychosis Risk Syndromes (SIPS) at 13 separate assessment time points across 2 years, yielding 247 specific scores. A machine-learning decision-tree analysis (i) examined potential SIPS predictors of psychosis conversion and (ii) hierarchically ranked predictors of psychosis conversion. RESULTS: Four out of 247 specific SIPS symptom scores were significant: (i) reduced expression of emotion at baseline, (ii) experience of emotions and self at 5 months, (iii) perceptual abnormalities/hallucinations at 3 months and (iv) ideational richness at 6 months. No SIPS symptom scores obtained after 6 months of follow-up predicted psychosis. CONCLUSIONS: Study findings suggest that early negative symptoms, particularly those observable by peers and arguably a risk factor for social exclusion, were predictive of psychosis. Self-expression and social behaviour might prove relevant entry points for early intervention in psychosis and psychosis risk. Testing study results in larger samples and at other sites is warranted.

Psychometric properties of the Inventory of Interpersonal Problems (IIP-C) used with a clinical sample of adolescents: a preliminary study.

Background: Interpersonal problems are consistently identified with psychopathology that often has its onset in adolescence. Most of the commonly used instruments in child and adolescent psychiatry target non-interpersonal problems. The Inventory of Interpersonal Problems (IIP) is a widely studied and utilized instrument in the adult mental health field. Aims: This study aimed to examine the psychometric properties of the IIP (circumplex version) used with a clinical adolescent population. Method: Sixty-two adolescents (13-17 years) who received treatment in a child and adolescent mental health clinic (CAMHS) were included in the study. To establish reliability and validity, we conducted confirmatory factor analyses, internal consistency, and validity analyses. Results: Confirmatory analyses did not show optimal model fit. However, other indices like CFI and TLI were promising. The reliability of the eight scales was in the same range as previous studies and acceptable. There were expected significant correlations between IIP-C scales and the broadband scales of Youth Self-report (YSR). Conclusion: The pioneer nature and its clinical focus are strengths however, there is a need for more research. The promising results are encouraging, and future research could also explore how best to bring the instrument into the digital age.

Cognitive predictors of longitudinal positive symptom course in clinical high risk for psychosis.

BACKGROUND: Clinical High Risk (CHS) for psychosis is a state in which positive symptoms are predominant but do not reach a level of severity that fulfils the criteria for a psychotic episode. The aim of this study has been to investigate whether cognition in subjects with newly detected CHR affects the longitudinal development of positive symptoms. METHODS: Fifty-three CHR individuals fulfilling the criteria for attenuated positive syndrome in the Structural Interview for Prodromal Syndromes (SIPS) were included. At inclusion, all participants completed a neurocognitive battery consisting of tests measuring attention, verbal memory, verbal fluency, executive functions and general intelligence. Cognitive domain z-scores were defined by contrasting with observed scores of a group of matched healthy controls (n = 40). Associations between cognitive performance at inclusion and longitudinal measures of positive symptoms were assessed by using generalised linear models including non-linear effects of time. All regression models were adjusted for age and gender. RESULTS: Overall, SIPS positive symptoms declined over the time period, with a steeper decline during the first six months. Deficits in executive functions were assossiated witn a higher load of positive symptoms at baseline (p=0.006), but also to a faster improvement (p=0.030), wheras those with poor verbal fluency improved more slowly (p=0.018). CONCLUSION: To our knowledge, this is the first study that follows CHR subjects by means of frequent clinical interviews over a sustained period of time. The study provides evidence of an association between executive functions, including verbal fluency, with the evolvement of positive symptoms.

Early Detection of Ultra High Risk for Psychosis in a Norwegian Catchment Area: The Two Year Follow-Up of the Prevention of Psychosis Study.

Objectives: Most individuals experience a relatively long period of sub-clinical psychotic like symptoms, known as the ultra high risk (UHR) or at risk mental states (ARMS), prior to a first episode of psychosis. Approximately 95% of individuals who will later develop psychosis are not referred to specialized clinical services and assessed during the UHR phase. The study aimed to investigate whether a systematic early detection program, modeled after the successful early detection of psychosis program TIPS, would improve the detection of help-seeking UHR individuals. The secondary aim was to examine the rates and predictors of conversion to psychosis after 2 years. Method: The overall study design was a prospective (2012-2018), follow- up study of individuals fulfilling UHR inclusion criteria as assessed by the structural interview for prodromal syndromes (SIPS). Help-seeking UHR individuals were recruited through systematic early detection strategies in a Norwegian catchment area and treated in the public mental health services. Results: In the study period 141 UHR help-seeking individuals were identified. This averages an incidence of 7 per 100,000 people per year. The baseline assessment was completed by 99 of these and the 2 year psychosis conversion rate was 20%. A linear mixed-model regression analysis found that the significant predictors of conversion were the course of positive (0.038) and negative symptoms (0.017). Age was also a significant predictor and showed an interaction with female gender (<0.000). Conclusion: We managed to detect a proportion of UHR individuals in the upper range of the expected prediction by the population statistics and further case enrichment would improve this rate. Negative symptoms were significant predictors. As a risk factor for adverse functional outcomes and social marginalization, this could offer opportunities for earlier psychosocial intervention.

Parental relations and referral of adolescents to Norwegian mental health clinics.

OBJECTIVE: Many youngsters with mental health problems are not referred to mental health clinics. Parents play an important role in the referral process of youngster to mental health clinics. The main aim of this study was to explore the role of the parent-child relation for referral of adolescents to outpatient psychiatric clinics. METHOD: Employing a cross-sectional design, we compared a referred sample of 39 adolescents in outpatient psychiatric treatment with a non-referred matched control sample of 39 adolescents. The Parental Bonding Instrument and Youth Self-Report were employed to assess the characteristics of these two population groups. RESULTS: Adolescents referred to Norwegian mental health clinics for mental health problems report more perceived care from mothers and a trend of more care from fathers compared with non-referred controls matched on level of mental health problems, age and gender. Implications of the finding for the role of parents on referral of adolescents to mental health clinics and for treatment compliance are discussed.

Job- and schoolprescription: A local adaptation to individual placement and support for first episode psychosis.

AIM: Individual placement and support (IPS) for first episode psychosis (FEP) has proven effective for employment and education, but yields differing results across geographical regions. Local adaptations may be necessary for various reasons, such as regional differences in employment- and welfare services; in educational opportunities and job markets. The aim of this study was to investigate the efficacy of an adapted Norwegian intervention offering early IPS for education and employment to persons with FEP. METHOD: Matched control (N = 66) study with a 1-year early IPS intervention and a 2-year follow up. A rating of fidelity to the IPS model was conducted. RESULTS: Fidelity was "good." Adaptations to the model included the use of internships and flexible combinations of education and employment. Thirty out of 33 participants completed the intervention. Fourteen were in competitive employment >20 h/wk post intervention, compared to 2 in the control group. Fifteen participants were enrolled in education >20 h/wk, 10 of whom also had employment >20 h/wk and 3 < 20 h/wk, compared to 5 in the control group, with 2 having employment <20 h/wk on the side. Symptom levels did not predict outcome. CONCLUSION: The School- and JobPrescription adaptation of IPS, allowing for temporary internships as a step towards obtaining the goal of paid competitive employment and facilitating flexible combinations of employment and education, showed encouraging results. These were however not sustained after closure of the intervention. At the 2-year follow up, Job- and SchoolPrescription advantages had waned, underscoring the point in IPS that support should be time-unlimited.

A 10-year follow-up study of violent victimization in first episode psychosis: Risk and protective factors.

Violent victimization in persons with severe mental illness has long-term adverse consequences. Little is known about the long-term prevalence of victimization in first episode psychosis, or about factors affecting victimization throughout the course of illness. To assess the prevalence of violent victimization during a 10-year follow-up period in a group of first episode psychosis (FEP) patients, and to identify early predictors and risk factors for victimization. A prospective design was used with comprehensive assessments of violent victimization, treatment variables and functioning at baseline and during 10-year follow-up. A clinical epidemiological sample of FEP patients (n = 298) was studied. FEP patients in our study were at a 3.5 times greater risk of victimization as compared to the normal population. During the 10-year follow-up period, 23% of subjects fell victim to one or more violent assaults. Victimized patients were younger and reported less occupational activity. At 10-year follow-up, victimization was associated with more concomitant drug use, alcohol misuse and violent behavior, but not with a worse clinical or functional outcome. Treatment programs should focus on risk factors for victimization and develop behavioral alternatives to mitigate risk in FEP patients.

Relation between premorbid adjustment, duration of untreated psychosis and close interpersonal trauma in first-episode psychosis.

AIM: Interpersonal traumas are highly prevalent in patients with psychotic disorders. Trauma caused by those close to the patient might have a more profound impact than other types of trauma and may influence early life social functioning. The aim is to investigate the associations between different types of trauma, in particular close interpersonal traumas experienced before the age of 18, premorbid factors and baseline clinical characteristics in a sample of first-episode psychosis patients. METHODS: A total of 191 patients from the 'TIPS' cohort completed assessment with the Brief Betrayal Trauma Survey at their 5 years follow-up interview. RESULTS: Half of the patients reported that they had experienced interpersonal trauma and one-third reported having experienced close interpersonal trauma before the age of 18. Women reported more sexual abuse, physical attacks and emotional and physical maltreatment than men. There were significant associations between early interpersonal trauma and premorbid adjustment and duration of untreated psychosis, but no significant associations with length of education, comorbid substance use or baseline clinical symptomatology. CONCLUSIONS: Close interpersonal trauma before the age of 18 is associated with poorer premorbid adjustment and a longer duration of untreated psychosis. This may indicate that traumatic experiences delay help-seeking behaviour.

Is going into stable symptomatic remission associated with a more positive development of life satisfaction? A 10-year follow-up study of first episode psychosis.

BACKGROUND: Quality of life is an important outcome measure for patients with psychosis. We investigated whether going into stable symptomatic remission is associated with a more positive development of subjective quality of life (S-QoL) and if different patient characteristics are associated with S-QoL depending on remission status. METHODS: Three hundred and one patients with a first-episode psychosis were included at baseline. At 10-year follow-up 186 were reassessed. QoL was assessed by Lehman's Quality of Life Interview. Remission was defined according to criteria proposed by the Remission in Schizophrenia Working Group. One-way ANOVA, mixed model analysis, bivariate correlations and multiple regression analyses were performed. RESULTS: Patients going into stable symptomatic remission showed a more positive S-QoL-development over the follow-up period and reported higher life satisfaction at 10-year follow-up compared to non-remission. At 10-year follow-up, depressive symptoms and alcohol abuse or dependence explained a significant amount of variance in S-QoL among patients in remission. Among patients in non-remission, PANSS excitative component explained a significant amount of variance in S-QoL. All significant effects were negative. CONCLUSIONS: Stable symptomatic remission is associated with a more positive development of overall life satisfaction. Furthermore, different symptoms influence life satisfaction depending on status of remission. This has important clinical implications. While patients in remission might need treatment for depressive symptoms to increase S-QoL, in non-remission measures aiming to decrease hostility and uncooperativeness should be part of the treatment approach. Alcohol problems should be treated regardless of remission status.

Public attitudes towards involuntary admission and treatment by mental health services in Norway.

PURPOSE: The role of compulsory treatment of serious mental disorders has been the topic of ongoing public debate involving among others mental health professionals, service providers, service user advocates, relatives of service users, media commentators and politicians. However, relatively little is known about general public attitudes towards involuntary admission and compulsory treatment of people with various mental disorders. This article examines the attitudes in a representative sample of Norway's population towards the use of involuntary admission and treatment, and under which circumstances does the general public consider compulsory treatment to be justified in the Norwegian mental health care services. METHOD: Data were collected from a representative sample of the population in Norway aged 18 and older. The sample was stratified for gender, geographical region and age distribution (n=2001). The survey was performed in the months of May 2009 (n=1000) and May 2011 (n=1001), using Computer Assisted Telephone Interviews (CATI) by an independent polling company. All respondents were provided a general definition of coercive intervention before the interview was conducted. ANALYSIS: Univariate descriptions and bivariate analyses were performed by means of cross-tabulation, analysis of variance (one-way ANOVA) and comparing of group of means. Cohen's d was used as the measure for effect size. RESULTS: Between 87% and 97% of those surveyed expressed strong or partial agreement with the use of involuntary admissions or compulsory treatment related to specified cases and situations. The majority of interviewees (56%) expressed the opinion that overall, current levels are acceptable. A further, 34% were of the opinion that current levels are too low, while only 9.9% of respondents supported a reduction in the level of involuntary treatment. Lower levels of education were associated with a more positive attitude towards involuntary admission and treatment. There was stronger support for admission to prevent suicide than the possibility of violence by the mentally ill. CONCLUSION: The Norwegian adult population largely supports current legislation and practices regarding involuntary admission and compulsory treatment in the mental health services.

Preventing Poor Vocational Functioning in Psychosis Through Early Intervention.

OBJECTIVE: This study tested the hypothesis that early detection of psychosis improves long-term vocational functioning through the prevention of negative symptom development. METHODS: Generalized estimating equations and mediation analysis were conducted to examine the association between employment and negative symptoms over ten years among patients in geographic areas characterized by usual detection (N=140) or early detection (N=141) of psychosis. RESULTS: Improved vocational outcome after ten years among patients in the early-detection area was mediated by lower levels of negative symptoms during the first five years. Regardless of symptoms, rates of full-time employment or study were lower among patients in the usual-detection versus the early-detection area. CONCLUSIONS: Patients from an early-detection area attained lower negative symptom levels earlier compared with patients from a usual-detection area, which seemed to have facilitated vocational careers.

Visual Hallucinations in First-Episode Psychosis: Association with Childhood Trauma.

BACKGROUND: Hallucinations are a core diagnostic criterion for psychotic disorders and have been investigated with regard to its association with childhood trauma in first-episode psychosis samples. Research has largely focused on auditory hallucinations, while specific investigations of visual hallucinations in first-episode psychosis remain scarce. OBJECTIVES: The aims of this study were to describe the prevalence of visual hallucinations, and to explore the association between visual hallucination and childhood trauma in a first-episode psychosis sample. METHODS: Subjects were included from TIPS-2, a first episode psychosis study in south Rogaland, Norway. Based on the medical journal descriptions of the Positive and Negative Symptoms Scale (PANSS), a separate score for visual and auditory hallucinations was created (N = 204). Patients were grouped according to hallucination severity (none, mild, and psychotic hallucinations) and multinomial logistic regression was performed to identify factors associated with visual hallucination group. RESULTS: Visual hallucinations of a psychotic nature were reported by 26.5% of patients. The experience of childhood interpersonal trauma increased the likelihood of having psychotic visual hallucinations. CONCLUSION: Visual hallucinations are common in first-episode psychosis, and are related to childhood interpersonal trauma.

"Everyone Needs a Friend Sometimes" - Social Predictors of Long-Term Remission In First Episode Psychosis.

Background: Predictors of long-term symptomatic remission are crucial to the successful tailoring of treatment in first episode psychosis. There is lack of studies distinguishing the predictive effects of different social factors. This prevents a valid evaluating of their independent effects. Objectives: To test specific social baseline predictors of long-term remission. We hypothesized that first, satisfaction with social relations predicts remission; second, that frequency of social interaction predicts remission; and third, that the effect of friend relationship satisfaction and frequency will be greater than that of family relations satisfaction and frequency. Material and Methods: A sample of first episode psychosis (n = 186) completed baseline measures of social functioning, as well as clinical assessments. We compared groups of remitted and non-remitted individuals using generalized estimating equations analyses. Results: Frequency of social interaction with friends was a significant positive predictor of remission over a two-year period. Neither global perceived social satisfaction nor frequency of family interaction showed significant effects. Conclusions: The study findings are of particular clinical importance since frequency of friendship interaction is a possibly malleable factor. Frequency of interaction could be affected through behavioral modification and therapy already from an early stage in the course, and thus increase remission rates.