Effectiveness and optimal duration of early intervention treatment in adult-onset psychosis: a randomized clinical trial.

BACKGROUND: Contrasting the well-described effects of early intervention (EI) services for youth-onset psychosis, the potential benefits of the intervention for adult-onset psychosis are uncertain. This paper aims to examine the effectiveness of EI on functioning and symptomatic improvement in adult-onset psychosis, and the optimal duration of the intervention. METHODS: 360 psychosis patients aged 26-55 years were randomized to receive either standard care (SC, n = 120), or case management for two (2-year EI, n = 120) or 4 years (4-year EI, n = 120) in a 4-year rater-masked, parallel-group, superiority, randomized controlled trial of treatment effectiveness (Clinicaltrials.gov: NCT00919620). Primary (i.e. social and occupational functioning) and secondary outcomes (i.e. positive and negative symptoms, and quality of life) were assessed at baseline, 6-month, and yearly for 4 years. RESULTS: Compared with SC, patients with 4-year EI had better Role Functioning Scale (RFS) immediate [interaction estimate = 0.008, 95% confidence interval (CI) = 0.001-0.014, p = 0.02] and extended social network (interaction estimate = 0.011, 95% CI = 0.004-0.018, p = 0.003) scores. Specifically, these improvements were observed in the first 2 years. Compared with the 2-year EI group, the 4-year EI group had better RFS total (p = 0.01), immediate (p = 0.01), and extended social network (p = 0.05) scores at the fourth year. Meanwhile, the 4-year (p = 0.02) and 2-year EI (p = 0.004) group had less severe symptoms than the SC group at the first year. CONCLUSIONS: Specialized EI treatment for psychosis patients aged 26-55 should be provided for at least the initial 2 years of illness. Further treatment up to 4 years confers little benefits in this age range over the course of the study.

The role of symptoms and insight in mediating cognition and functioning in first episode psychosis.

INTRODUCTION: Achieving functional recovery in patients with psychosis is a challenge in clinical practice. Investigating the complex interplay between cognition, symptoms, insight and functional outcome in first episode psychosis will be crucial to understanding the factors leading to better functioning. METHODS: In this 12-month prospective follow-up study, we investigated how cognition, clinical symptoms, and insight into illness affected overall functioning in 160 patients with first episode psychosis recruited from the Early Assessment Service for Young People with Psychosis (EASY) in Hong Kong from July 1, 2014 to June 30, 2016. Cognition was assessed at baseline while symptoms, insight, and functioning were assessed at 12-month follow-up. Structural equation modelling was used to examine the direct and indirect relationships between functioning and other latent constructs. RESULTS: Symptoms (negative symptoms and general psychopathology) and insight were shown to be significant mediators between cognition and functioning. The significant direct relationship between cognition and functioning (ß = 0.387; p < 0.001) became insignificant (ß = 0.079; p = 0.578) after including symptoms and insight in the model. Symptoms and insight were significantly associated with cognition (symptoms, ß = -0.469; p < 0.001; insight, ß = -0.372; p < 0.001) and predicted functioning (symptoms, ß = -0.558; p < 0.001; insight, ß = -0.264; p < 0.01). CONCLUSION: Symptoms and insight mediated the effects of cognition on functioning. Interventions for improving functioning in patients with first episode psychosis should target not only cognition but also symptoms and insight.

Metacognitive training for delusions (MCTd): effectiveness on data-gathering and belief flexibility in a Chinese sample.

Metacognitive training (MCT) was developed to promote awareness of reasoning biases among patients with schizophrenia. While MCT has been translated into 31 languages, most MCT studies were conducted in Europe, including newer evidence recommending an individualized approach of delivery. As reasoning biases covered in MCT are separable processes and are associated with different symptoms, testing the effect of selected MCT modules would help to develop a targeted and cost-effective intervention for specific symptoms and associated mechanisms. This study tested the efficacy of a four-session metacognitive training for delusions, MCTd (in Traditional Chinese with cultural adaptations, provided individually), as an adjunct to antipsychotics in reducing severity and conviction of delusions, jumping to conclusions (JTC) bias and belief inflexibility. Forty-four patients with delusions were randomized into the MCTd or the wait-list control condition. Patients on wait-list received the same MCTd after 4 weeks of treatment as usual (TAU). Assessment interviews took place before and after the treatment, and at 4-week follow-up. There was an additional baseline assessment for the controls. JTC and belief flexibility were measured by the beads tasks and the Maudsley Assessment of Delusions Scale. Attendance rate of the MCTd was satisfactory (84.5%). Compared to TAU, there was a greater reduction in psychotic symptoms, delusional severity and conviction following MCTd. There was a large treatment effect size in improvement in belief flexibility. Improvement in reaction to hypothetical contradiction predicted treatment effect in positive symptoms and delusions. JTC bias was reduced following MCTd, although the treatment effect was not significantly larger than TAU. Our results support the use of process-based interventions that target psychological mechanisms underlying specific psychotic symptoms as adjuncts to more conventional approaches.

Duration of untreated psychosis: relationship with baseline characteristics and three-year outcome in first-episode psychosis.

Duration of untreated psychosis (DUP) has been considered as one of the few potentially malleable prognostic factors in psychotic illness. The literature demonstrated that prolonged DUP predicted the level of positive symptoms, but its relationships with negative symptoms and functional outcome were less clear-cut. Thus far, most first-episode studies have been conducted in western countries. Yet, it is known that illness outcome might be modified by socio-cultural factors. In this study, we aimed to examine the impact of DUP on baseline characteristics, clinical and vocational outcomes over 3 years in 700 Chinese young people who presented with first-episode psychosis to a specialized early intervention service in Hong Kong. Our results showed that prolonged DUP was associated with male sex, younger age of onset, schizophrenia-spectrum diagnosis, insidious development of psychosis, fewer baseline positive symptoms and less likelihood of hospitalization at intake. Regression analyses revealed that prolonged DUP was significantly predictive of outcome on positive symptoms, recovery and sustained full-time employment in our first-episode psychosis cohort. Taken together, our study provided further supportive evidence regarding the prognostic value of DUP on illness outcome. Additionally, it suggested that an adverse impact of treatment delay for psychosis may likely be applied across regions of various ethno-cultural backgrounds.

Five-year stability of ICD-10 diagnoses among Chinese patients presented with first-episode psychosis in Hong Kong.

BACKGROUND: Diagnostic stability is one measure of predictive validity for psychiatric syndromes. It is an under-studied area in functional psychosis despite its clinical and research implications. We aimed at evaluating the stability of ICD-10 diagnoses in a sample of young people with first-episode psychosis. METHOD: One hundred and sixty-six Hong Kong Chinese enrolled in a regional first-episode psychosis treatment program were studied. Subjects' baseline and final 5-year consensus diagnoses were established via systematic medical records' review to determine diagnostic stability and to identify predictors of diagnostic shift towards schizophrenia spectrum. RESULTS: The overall diagnostic consistency was 80.7%. Bipolar affective disorder and schizophrenia were the most stable diagnostic categories over 5 years with prospective consistency of 100% and 95.8% respectively. The least stable baseline diagnoses were unspecified non-organic psychosis, acute and transient psychotic disorders and delusional disorder. Around one-fifth (19.3%) of subjects had diagnostic revision in 5 years. The predominant pattern of diagnostic shift was towards schizophrenia spectrum disorder. Family history of psychosis and longer duration of untreated psychosis were associated with diagnostic transition towards schizophrenia spectrum. CONCLUSIONS: Schizophrenia and bipolar affective disorder were diagnostically stable and could be reliably classified at intake in a Chinese first-episode psychosis sample using the ICD-10 criteria. Diagnostic instability in the least prevalent categories of functional psychosis highlights the limitations of current taxonomies and calls for ongoing revision of diagnostic criteria. In the absence of biological marker, longitudinal validation across consecutive episodes is necessary for accurate diagnostic ascertainment.