The relationship between mental health literacy regarding schizophrenia and psychiatric stigma in the Republic of Ireland.

BACKGROUND: There is an unclear relationship between mental health literacy (MHL) and psychiatric stigma. MHL is associated with both positive and negative attitudes to mental illness. To our knowledge, no published peer reviewed study has examined this relationship in the Republic of Ireland. AIMS: This study was conducted to assess MHL regarding schizophrenia and the degree of psychiatric stigma displayed by the general public in the Republic of Ireland. METHOD: A face-to-face in-home omnibus survey was conducted with a representative sample of residents of the Republic of Ireland. Participants (N = 1001) were presented with a vignette depicting schizophrenia and were asked questions to determine their ability to recognise the condition and to ascertain their attitudes towards schizophrenia and mental illness. RESULTS: Among the participants, 34.1% correctly identified schizophrenia. Higher age, higher socioeconomic status, and an urban geographic location predicted identification. Those who did not correctly identify schizophrenia were significantly more optimistic about recovery and perceived people with schizophrenia as less dangerous. However, only the relationship with perceived dangerousness was considered robust. CONCLUSIONS: Participants with higher MHL displayed more negative attitudes to mental illness. Findings have implications internationally for MHL and anti-stigma campaigns.

Estimating the Cost and Effect of Early Intervention on In-Patient Admission in First Episode Psychosis.

BACKGROUND: Early intervention in psychosis is an accepted policy internationally. When 'A Vision for Change', the national blueprint for mental health policy in Ireland, was published in 2007 there was one Irish pilot service for early intervention in psychosis. The National Clinical Mental Health Programme Plan (2011) identified early intervention in psychosis as one of three areas for roll out nationally. There is limited economic evaluation in the field of mental health in Ireland to guide service development. This is in part due to lack of robust patient level data. AIMS OF THE STUDY: The aim of the study was to investigate whether the introduction of an early intervention service in psychosis resulted in any change to the number and duration of admissions in people with first-episode psychosis. METHODS: We examined two prospective epidemiological cohorts of individuals presenting with first-episode psychosis to an urban community mental health service (population 172,000). The historical cohort comprised of individuals presenting from 1995 to 1998 and received treatment as usual (n=132). The early intervention cohort presented to the same catchment area between 2008 and 2011 (n=97) following the introduction of an early intervention service in 2005. RESULTS: We found significant reductions in the rates admitted for treatment across the two time periods. Reduction in the rate of admission was larger in this catchment than the reduction in the rate of admission in the country as a whole. There were significant reductions in the duration of untreated psychosis arising from the early intervention programme. Significant reductions in length of stay were accounted for by differences in baseline age and marital status. The average cost of admission declined from 15,821 to 9,398 in the early intervention cohort. DISCUSSION AND LIMITATIONS: The comparison pre and post early intervention service showed cost savings consistent with other studies internationally. Key issues are whether changes in the admission pattern were due to the implementation of early intervention or were explained by other factors. Examination of local and national factors showed that the dominant effect was from the implementation of early intervention. Limitations are that this is a comparison with a historical cohort and analysis is limited to in-patient costs only. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: While there are cost savings, these represent opportunity cost savings, as the majority of costs associated with in-patient care are fixed. Studies such as this provide evidence that it is feasible to consider disinvestment strategies such as home care in the community. IMPLICATIONS FOR HEALTH POLICIES: It is difficult to generalize interventions shown to work in one country to other countries, as health service structures differ and there are both local and national variations in service structure and delivery. It remains important to evaluate whether a policy is applicable within its local context. IMPLICATIONS FOR FURTHER RESEARCH: Further research in this area is required to evaluate contemporaneous services and to examine whether increased costs in the community incurred through implementation of early intervention negate the savings made through reduction of admissions.

Depression and quality of life in first-episode psychosis.

AIM: Quality of life (QOL) has gained recognition as a valid measure of outcome in first-episode psychosis (FEP). This study aimed to determine the influence of specific groups of depressive symptoms on separate domains of subjectively appraised QOL. METHODS: We assessed 208 individuals with first-episode non-affective psychosis using measures of diagnosis (Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition), symptoms (Scale for the Assessment of Positive Symptoms, Scale for the Assessment of Negative Symptoms, and Calgary Depression Scale for Schizophrenia), functioning (Global Assessment of Functioning), insight (Birchwood Scale), duration of untreated psychosis (Beiser Scale), and QOL World Health Organisation Quality of Life Instrument (WHOQOL-Bref). We used multiple regression to determine the contribution of depressive symptoms to QOL domains while controlling for socio-demographic and other clinical characteristics. RESULTS: There were complete data for 146 individuals with FEP. Quality-of-life domains were consistently predicted by depressive symptoms including depressive mood and hopelessness rather than biological symptoms of depression with those experiencing more depressive symptoms reporting worse QOL. Those who were treated as in-patients reported improved QOL, and hospitalization was an independent predictor of most QOL domains. In-patients displayed greater levels of positive symptoms with those involuntarily detained displaying greater levels of bizarre behavior, thought disorder, and delusions. CONCLUSIONS: These findings suggest that QOL is heavily influenced by depressive symptoms at initial presentation; however, as QOL domains are also influenced by admission status with in-patients being more symptomatic in terms of positive symptoms, subjective QOL assessment may be compromised during the acute phase of illness by both positive and depressive symptom severity.

First rank symptoms in first episode psychosis and their relationship to the duration of untreated illness.

Most studies of First Rank Symptoms (FRS) are based on cross-sectional inpatient samples of people with schizophrenia at various stages of illness. We sought to examine the prevalence of FRS in a representative sample of first episode psychosis patients and compare those with and without FRS clinically and in terms of duration of untreated illness. Information was gathered from 158 consecutive cases of first episode psychosis presenting in a defined geographical region through semi-structured interview tools. Of this sample, 40.5% of cases received a diagnosis of schizophrenia. The prevalence of FRS among the entire group was 52.5%. After controlling for multiple testing, no FRS contributed significantly to predicting a diagnosis of schizophrenia. There was no significant relationship between the duration of untreated illness and FRS.

First episode psychosis and the trail to secondary care: help-seeking and health-system delays.

BACKGROUND: People experience delays in receiving effective treatment for many illnesses including psychosis. These delays have adverse consequences in heart disease and cancer, and their causes have been the subject of much research but only in recent years have pathways to care in psychosis received such attention. We sought to establish if, when and where people seek help in the early phase of psychosis in a representative sample. METHODS: One hundred and sixty-five people with first episode psychosis, referred from community-based psychiatric services and a private psychiatric facility to an early intervention service over 18 months, were interviewed with the Structured Clinical Interview for DSM-IV diagnoses. Symptoms were measured using the Schedule for the Assessment of Positive Symptoms, Schedule for the Assessment of Negative Symptoms and the Calgary Scale. Duration of untreated illness (DUI) and duration of untreated psychosis (DUP) were established using the Beiser Scale. Pathways to mental health services were systematically detailed through interviews with patients and their families. RESULTS: The final sample consisted of 142 (88M, 54F) cases after those with psychosis due to a general medical condition and those without pathway and DUP data were excluded. Less than half of participants initiated help seeking themselves. Of those who did seek help (n = 57) 25% did so during the DUI. Those who had a positive family history of mental illness and poorer premorbid adjustment were significantly less likely to seek help for themselves and those who did not seek help were more likely to require hospitalisation. Families were involved in help seeking for 50% of cases and in 1/3 of cases did so without the affected individual participating in the contact. Being younger and having more negative symptoms were associated with having one's family involved in help seeking. Delays to effective treatment from the onset of psychosis were evenly split between "help-seeking delays" and "health-system delays". Having a family member involved in help seeking and better premorbid adjustment were independently associated with shorter help-seeking delays when measured from the onset of psychosis. Being female, having better premorbid adjustment and fewer negative symptoms were associated with shorter help-seeking delays from the onset of illness. Those with a non-affective psychosis had significantly longer system delays. CONCLUSION: Many people with first episode psychosis do not initiate help-seeking for themselves particularly those with a relative affected by mental illness. Those with poor premorbid adjustment are at particular risk of longer delays. Poor premorbid adjustment compounded by long delays to effective treatment reduces the likelihood of a good outcome. Families play a vital role in hastening receipt of effective treatment.

Resilience does not mediate the association between adverse childhood experiences and later life depression. Findings from the Irish Longitudinal Study on Ageing (TILDA).

BACKGROUND: Resilience has been found to moderate the association between childhood trauma and later depression. We examined whether resilience mediates the association between Adverse Childhood Experiences (ACEs) and later life depression among older adults. METHODS: Data were from The Irish Longitudinal Study on Ageing (TILDA), a prospective study of 8,500 community-dwelling adults aged ≥ 50 years. Negative binomial regressions were used to examine the relationships between ACEs, resilience, and depression and path analysis was conducted to test the potential mediating effect of resilience on the association between ACEs and depressive symptoms. RESULTS: Mean CES-D8 depression score was 3.3 from a maximum of 24. The average resilience score from a maximum of 15 was 8.9. 26.0% of participants had experienced at least one ACE before the age of 18. A history of ACEs was associated with increased depressive symptomology. The strongest association was between physical abuse and depressive symptoms followed by sexual abuse, parental drug or alcohol use, and childhood poverty. Our path analyses showed that there was no evidence that resilience mediated the association between ACEs and depressive symptoms among this cohort. LIMITATIONS: Information on ACEs was collected retrospectively. The resilience measure depended on experience of stressful life events in the last five years and therefore some participants were excluded. CONCLUSIONS: ACEs were associated with an increased likelihood of late-life depressive symptoms. Higher resilience was associated with decreased likelihood of late-life depressive symptoms. A history of ACEs is associated with lower resilience. The association between ACEs and late-life depressive symptoms is not mediated by resilience.

Perspectives on paid work among men and women with schizophrenia: The results of a two study comparison in Ireland.

BACKGROUND: While research indicates that people with serious mental health conditions want to work, few studies have examined motivation and concerns associated with employment. OBJECTIVES: This study examined the work attitudes among two samples of Irish people with psychotic conditions, primarily schizophrenia. METHODS: Data gathered through two work related research projects was used. A self-report instrument, the work motivation scale (WMS), gathered data in two separate studies. It was possible to examine participants' motives and concerns due to the two factor structure, positive and negative, of this scale. Descriptive statistical analysis was conducted for each of the two samples individually. A sub-analysis by gender was also conducted. RESULTS: Across the two samples, analysis showed the consistent motivators were increased coping ability, improved self-identity, and enhanced self-worth. Men particularly wanted others to see them as good workers. On the other hand, women regarded a job as a means to forget about having a mental illness. A sizeable minority in both samples expressed apprehensions such as work being boring and an expectation from others that they should work rather than them being personally motivated to do so. CONCLUSIONS: While caution must be exercised in interpreting the results due to the small sample size, this study has extended our understanding in this under-researched but important topic.

Employment status amongst those with psychosis at first presentation.

INTRODUCTION: Employment is generally beneficial to health and quality of life. Despite many advances in the treatment of psychosis there are continuing reports of high levels of unemployment. In most studies of first episode psychosis (FEP) only rudimentary rates of employment are provided. We sought to establish the prevalence of employment amongst those with FEP from a geographically defined area, to compare employment categories for differences in demographical and clinical characteristics and finally, to examine factors associated with employment. METHODS: All cases of FEP were assessed from a defined suburban area with a structured clinical interview for DSM-III-R diagnosis and a standardised assessment protocol. Employment status was divided into employed, non-labour force work and unemployed. RESULTS: Of 162 cases of psychosis, those employed (46%) were indistinguishable from those in non-labour force work (21%). Those unemployed (33%) had significantly longer DUP, more negative symptoms and lower quality of life than those engaged in non-labour force work or those employed. Having a non-affective psychosis (chi(2) = 0.05, OR = 1.2; 95% CI 1.0, 1.4) was associated with being unemployed at presentation. Better (beta = -0.2, P = 0.00) academic premorbid adjustment was associated with being employed at presentation. CONCLUSIONS: Although 67% of those with FEP from a geographically defined area are engaged in purposeful work, the rate of unemployment is nine times the local rate. Longer DUP and negative symptoms are associated with unemployment at presentation. Standardised reporting of employment status would greatly assist research in this area.

Is the duration of untreated psychosis temporally stable?

Although there is some evidence that duration of untreated psychosis (DUP) is geographically stable, few have examined whether the phenomenon is temporally stable. We examined DUP in two cohorts within two discrete time periods (1995-1999 and 2003-2005) spanning a decade in the same geographically defined community psychiatric service with no early intervention programme. Patients were diagnosed by Structured Clinical Interview for DSM (SCID) and we determined the DUP using the Beiser Scale. The DUP of the 240 participants did not differ significantly between study periods.

Feasibility of a psychosis information intervention to improve mental health literacy for professional groups in contact with young people.

The aim of this study was to assess the feasibility of a psychosis information intervention for professionals in contact with young people in Ireland. A quasi-experimental pre- and post-intervention design was used. One thousand and thirty-two professionals received an information intervention designed to improve mental health literacy (MHL) and confidence in providing help to people with psychosis. Seven hundred and fifty-five participants completed the Psychosis Information and Confidence Questionnaire pre- and post-intervention. The information intervention significantly improved participants': (1) knowledge of psychosis; (2) ability to recognize signs and symptoms of psychosis; (3) awareness of how to access services; and (4) confidence in providing help to people experiencing psychosis. Findings provide promising support for the intervention's feasibility and acceptability. The intervention enhanced MHL regarding psychosis among professionals in contact with young people. Further research assessing if such improvements translate to the facilitation of appropriate help seeking, the enhanced early detection of psychosis and a reduction of the duration of untreated psychosis is required.

The hidden stories within census data.

Census data plays an important role in informing a Government's policies and priorities. In the Republic of Ireland census data from 1986 onwards is available online. For this article variables pertaining to work, specifically the non-labour force variable, were analysed. While we found a linear decline from 47.16% in 1986 to 38.14% in 2011 this had not occurred in all categories of non-labour force work; the "unable to work due to permanent sickness or disability" group increased from 6.84% to 11.41%, a 66% rise. This occurred in spite of legislation and services being put in place to assist people with disabilities to re-enter the workforce. US data also indicates a rise in the number of people with disabilities in the non-labour force work category. Why this is occurring is a complex question, determining if similar trends are evident within census data in other countries would assist in answering it.

An exploratory study of the extent of social inclusion among people with psychosis and psychotic-related conditions.

BACKGROUND: Understanding social inclusion among at-risk populations will deepen our understanding of their specific needs. AIM: This study explored the level of social inclusion among people with psychotic-related conditions using a standardised interview. METHOD: The Social Inclusion Interview Schedule was used in two research projects. People with psychosis participated in both studies and had been recruited as part of an Irish programme of research on psychotic conditions. Descriptive statistics were used to quantify participants' level of social exclusion. RESULTS: Data from 71 participants were available, 38 in one cohort and 33 in the other. The smaller cohort had a shorter mean duration of illness. Participants' mean age was 40. The majority lived in the community and were satisfied with their living arrangements. In each cohort, the same two areas of community integration emerged as problematic - having something productive to do and being close to someone in the community. There was a higher level of perceived stigma among the cohort with the longer duration of illness. DISCUSSION/CONCLUSION: While evidence of social inclusion was found among participants, there were areas of concern particularly with regard to integration into work and social connectedness.

Subjective and objective quality of life at first presentation with psychosis.

AIM: Quality of life (QOL) in first-episode psychosis (FEP) is impaired when compared to non-clinical controls and several clinical factors including symptoms and untreated psychosis have been linked with poorer QOL. Measurement methods are varied, however, resulting in inconsistent findings and there is a need to simultaneously combine subjective and objective measures of QOL. METHODS: We examined both subjective (n = 128) and objective QOL (n = 178) in a catchment area cohort of individuals with FEP (n = 222) to determine correspondence between patient satisfaction and clinician-rated functional domains. We also examined the contribution of sociodemographic and clinical characteristics to both subjective and objective QOL. RESULTS: There were complex relationships between subjective and objective QOL domains in that patient's assessments of health status (psychological well-being, symptoms/outlook, physical health) were not correlated with clinicians but there were strong correlations between social functioning domains (occupation, social relations, financial status and activities of daily living) assessed by patients and clinicians. Longer duration of untreated psychosis, being treated as an inpatient, higher positive symptoms and poorer social functioning in client-rated QOL domains predicted poorer objective QOL. CONCLUSION: We found that both subjective and objective assessments of QOL displayed a degree of clinical utility demonstrated by relationships between clinical factors and both QOL perspectives. Moreover, the lack of association between patient characteristics and QOL shows some potential malleability of QOL outcomes through intervention as there were several clinical factors linked with both subjective and objective QOL.

Creating a curriculum on psychosis: a pilot training programme with youth workers.

AIMS: Public education may constitute an effective early intervention strategy to reduce delays in the treatment of psychotic disorders and thereby improve outcome. The purpose of this project was to design, implement and validate a curriculum on early intervention in psychosis for youth workers. METHOD: A training intervention on early intervention in psychosis was designed and delivered through 1-day workshops. Objective and self-perceived competencies were measured before and after the intervention and at 3-month follow up. An additional question was added to assess social distancing from subjects with psychosis. RESULTS: Compared with baseline, the training programme resulted in an improvement in problem identification and symptom recognition skills for vignettes on psychosis (P < 0.05), and in advice on help-seeking behaviour (P < 0.001) and in self-perceived competencies (P < 0.001). Additionally, there was a reduction in social distancing (P < 0.001). These desired outcomes were found to be sustained over a 3-month period. CONCLUSIONS: The training course improved case recognition skills and advice on help-seeking behaviour and resulted in reduction in social distancing in this cohort of youth workers.

Environmental factors and the age at onset in first episode psychosis.

OBJECTIVE: Factors that influence the age at onset in psychotic disorders could provide valuable insights into precipitating or causative factors of the disorder. Despite being established risk factors, it is not yet known whether migration status, place of birth, social class at birth and season of birth influence the age at onset of psychotic disorders. This study aimed to determine whether these environmental factors, in addition to cannabis abuse and obstetric complications, influence the age at onset. Additionally, we investigated whether environmental factors could have a cumulative effect on the age at onset. METHOD: Data was obtained from two first episode of psychosis (FEP) cohort studies. Diagnosis was established using the Structured Clinical Interview for DSM IV diagnoses. RESULTS: The age at onset was determined for 555 individuals with a FEP and the median age at onset was 27.3years. Individuals with a history of cannabis abuse had an earlier age at onset by nearly six years. There was a trend for a history of obstetric complications to be associated with a younger age at onset by 2.7years and this was significant in the subgroup with a family history of psychosis. Social class at birth, migration status, place of birth and season of birth were not associated with the age at onset. Exposure to a higher number of environmental factors was associated with an earlier age at onset. CONCLUSIONS: Cannabis and obstetric complications are associated with an earlier age at onset and there appears to be a cumulative effect of exposure to multiple environmental factors.

Social class at birth and risk of psychosis.

BACKGROUND: Individuals with psychotic disorders are represented more in the lower social classes, yet there is conflicting evidence to whether these individuals drift into the lower social classes or whether lower social class is a risk factor for developing psychosis. The aim of this study was to examine whether the social class at birth is a risk factor for developing psychosis. METHODS: We included individuals with a first episode of psychosis (FEP) whose social class at birth was determined from birth records. We employed a case-control study design and also compared the distribution of the social classes at birth of the cases to that of the general population. RESULTS: A total of 380 individuals with an FEP and 760 controls were included in the case-control study. The odds ratio for developing an FEP associated with social class (low vs high) was .62 (95% confidence interval (CI): .46-.85, p < .001), indicating that individuals from a lower social class at birth have a reduced risk of psychosis. Individuals born between 1961 and 1980 with an FEP were more likely to be from a higher social class at birth compared to the general population (60.8% vs 36.7%, χ(2) = 60.85, df = 1, p < .001). However, this association was not observed for those born between 1981 and 1990. CONCLUSION: A higher social class at birth is associated with a greater risk for developing a psychotic disorder; however, this effect may show temporal variation.

Negative symptom domain prevalence across diagnostic boundaries: The relevance of diagnostic shifts.

Negative symptoms are included in diagnostic manuals as part of criteria for schizophrenia spectrum psychoses only, however some studies have found their presence in other diagnoses. This study sought to clarify negative symptom domain prevalence across diagnostic categories, while investigating whether negative symptoms predicted diagnostic shift over time. Scale for the Assessment of Negative Symptoms (SANS) data were collected at first presentation in 197 individuals presenting with first episode psychosis and again at one year follow-up assessment. Negative symptoms were highest among individuals with schizophrenia and among those whose diagnosis shifted from non-schizophrenia spectrum at baseline to schizophrenia spectrum at follow-up. In a non-schizophrenia spectrum group negative symptoms at baseline were not a significant predictor of diagnostic shift to schizophrenia spectrum diagnoses. The study suggests negative symptoms can present among individuals with non-schizophrenia spectrum diagnoses, although this is most relevant for individuals following diagnostic shift from non-schizophrenia spectrum to schizophrenia spectrum diagnoses. The findings support introduction of a negative symptom dimension when describing a range of psychotic illnesses, and indicate that further research investigating the evolution of negative symptoms in non-schizophrenia diagnoses is needed.

Work life after psychosis: A detailed examination.

BACKGROUND: Conducting research on the work outcomes of first episode psychosis (FEP) samples may extend our understanding of the factors associated with the work outcome of people with schizophrenia and other psychotic illnesses. OBJECTIVE: To conduct a detailed study of the work outcome of an FEP sample. METHODS: Members of a FEP cohort, who had completed a 12-year clinical outcome assessment, were invited to participate in an adjunctive work outcome study. Engagement in paid and non-paid work was first established and the relationship with potentially influential baseline characteristics investigated. Subsequently the influence of work outcome to participants' level of quality of life, mental health, recovery, and social inclusion were examined. RESULTS: Among the 38 participants the mean percentage of time spent in work was 62% of which 50% was in paid work and 12% was in non-paid work. Being employed at inception was the only independent predictor of the duration of the follow-up period spent in work. Relationships between work outcome and all measures of wellbeing were found. CONCLUSION: The paid and non-paid work attained by people affected by a psychotic illness played an important role in the extent of their wellbeing, recovery, and social inclusion.

First-episode psychosis and disengagement from treatment: a systematic review.

OBJECTIVES: This review examined rates and definitions of disengagement among services for first-episode psychosis (FEP) and identified the most relevant demographic and clinical predictors of disengagement. METHODS: A comprehensive search for and review of published studies that reported rates and predictors of disengagement within FEP services were conducted. The databases PubMed (1966-2012) and PsycINFO (1882-2012) were searched. Relevant terms were used to search the Internet and the reference sections of relevant papers for other pertinent studies. Independent searches for recent publications by leading researchers in the field were also conducted. RESULTS: Ten articles were included in the review. There was a lack of consensus on a clear definition of engagement and disengagement. However, despite differences in definitions and study settings, the evidence reviewed indicates that approximately 30% of individuals with FEP disengage from services. Variables that were consistently found to exert an influence on disengagement across studies were duration of untreated psychosis, symptom severity at baseline, insight, substance abuse and dependence, and involvement of a family member. CONCLUSIONS: Given the importance of continuity of care for FEP, there is a need for a clearly defined and agreed measurement of service engagement and disengagement across FEP services. In particular, those who enter an FEP program without family involvement and support as well as those who maintain persistent substance abuse are at higher risk of disengagement. Early identification of such individuals and the development of approaches to reduce risk of service disengagement are likely to increase the effectiveness of these services.

Putting television's portrayal of schizophrenia into reverse: an evaluation of the impact on public opinion.

AIM: We examined whether it is possible to use a television programme to improve mental health literacy about schizophrenia by investigating the impact of the introduction of a realistic portrayal of schizophrenia into a popular television soap opera. METHOD: A population level omnibus survey method was used. A market research company conducted face-to-face interviews with a representative sample of the Irish population (n = 993). A specifically developed questionnaire was used which included a question on the extent to which the relevant television programme was watched. A grouping variable 'viewers/non-viewers' was then created. Groups were subsequently compared for differences in demographic characteristics, mental health literacy and attitudes towards schizophrenia. RESULTS: Of the sample, 370 were regarded as viewers. When compared, viewers and non-viewers did not differ on demographic characteristics but there were significant differences between the groups in both knowledge and attitudes regarding schizophrenia. Viewers were better informed on where to go for help and were more optimistic regarding the likelihood of recovery. However, on a question regarding willingness to have an intimate relationship with someone with a previous history of mental illness, viewers had greater concerns than non-viewers. CONCLUSION: It is possible to use television dramas to educate the public about mental illnesses. Piloting of the educational material may offer an opportunity to refine the storyline so that the relevant messages are clearly communicated.