Sociodemographic and clinical predictors of delay to and length of stay with early intervention for psychosis service: findings from the CRIS-FEP study.

PURPOSE: We investigated the influence of sociodemographic and clinical characteristics on delay to early intervention service (EIS) and the length of stay (LOS) with EIS. METHODS: We used incidence data linked to the Clinical Record Interactive Search-First Episode Psychosis (CRIS-FEP) study. We followed the patients from May 2010 to March 2016. We performed multivariable Cox regression to estimate hazard ratios of delay to EIS. Negative binomial regression was used to determine LOS with EIS by sociodemographic and clinical characteristics, controlling for confounders. RESULTS: 343 patients were eligible for an EIS, 34.1% of whom did not receive the service. Overall, the median delay to EIS was 120 days (IQR; 15-1668); and the median LOS was 130.5 days (IQR 0-663). We found that women (adj.HR 0.58; 95%C I 0.42-0.78), living alone (adj.HR: 0.63; 95% CI 0.43-0.92) and ethnicity ('Other': adj.HR 0.47; 95% CI 0.23-0.98) were associated with prolonged delay to EIS. However, family involvement in help-seeking for psychosis (adj.HR 1.37; 95% CI 1.01-1.85) was strongly associated with a shorter delay to EIS. Patients who have used mental health services previously also experienced long delays to EIS. CONCLUSIONS: Our analyses highlight the link between sociodemographic status, help-seeking behaviours, and delay to EIS. Our findings also show the vulnerability faced by those with a previous mental health problem who later develop psychosis in receiving specialist treatment for psychosis. Initiatives that ameliorate indicators of social disadvantage are urgently needed to reduce health inequalities and improve clinical outcomes.

Treating schizophrenia with cariprazine: from clinical research to clinical practice. Real world experiences and recommendations from an International Panel.

BACKGROUND: Management of schizophrenia is sub-optimal in many patients. Targeting negative symptoms, among the most debilitating aspects of schizophrenia, together with positive symptoms, can result in significant functional benefits and dramatically improve quality of life for patients and their carers. Cariprazine, a partial agonist of the dopamine receptors D2/D3 has demonstrated effectiveness across symptom domains in clinical trials, particularly on negative symptoms. OBJECTIVE: To obtain a broader insight from clinicians with specific experience with cariprazine, on how it affects patient populations outside the clinical trial setting. METHODS: The panel addressed a series of psychopharmacologic topics not comprehensively addressed by the evidence-based literature, including characteristics of patients treated, dosing and switching strategies, duration of therapy, role of concomitant medications and tolerability as well as recommendations on how to individualize cariprazine treatment for patients with schizophrenia. RESULTS: Patients recommended for cariprazine treatment are those with first episodes of psychosis, predominant negative symptoms (maintenance/acute phase) and significant side effects (metabolic side effects, hyperprolactinemia, sedation) with other antipsychotics. When the long-term treatment of a lifetime illness is adequately weighted, cariprazine becomes one of the first-line medications, not only for patients with predominant negative symptoms but also for those with relatively severe positive symptoms, especially if they are at the first episodes and if a specific medication is added for symptoms such as agitation or insomnia. For instance, patients with agitation may also benefit from the combination of cariprazine and a benzodiazepine or another sedating agent. Cariprazine may be prescribed as add-on to medications such as clozapine, when that medication alone is ineffective for negative symptoms, and sometimes the first may be discontinued or its dose lowered, after a period of stability, leaving the patient on a better tolerated antipsychotic regimen. CONCLUSIONS: Based on real-world clinical experience, the panel considered that cariprazine, with its distinct advantages including pharmacokinetics/pharmacodynamics, good efficacy and tolerability, represents a drug of choice in the long-term management of schizophrenia not only for patients with predominant negative symptoms but also for those with positive symptoms.

A novel method of assessing quality of postgraduate psychiatry training: experiences from a large training programme.

BACKGROUND: Most assessments of the quality of postgraduate training are based on anonymised questionnaires of trainees. We report a comprehensive assessment of the quality of training at a large postgraduate psychiatry training institute using non-anonymised face-to-face interviews with trainees and their trainers. METHODS: Two consultant psychiatrists interviewed 99 trainees and 109 trainers. Scoring of interview responses was determined by using a pre-defined criteria. Additional comments were recorded as free text. Interviews covered 13 domains, including: Clinical, teaching, research and management opportunities, clinical environment, clinical supervision, adequacy of job description, absence of bullying and job satisfaction. Multiple interview domain scores were combined, generating a 'Combined' score for each post. RESULTS: The interview response rate was 97% for trainers 88% for trainees. There was a significant correlation between trainee and trainer scores for the same interview domains (Pearson's r = 0.968, p< 0.001). Overall scores were significantly higher for specialist psychiatry posts as compared to general adult psychiatry posts (Two tailed t-test, p < 0.001, 95% CI: -0.398 to -0.132), and significantly higher for liaison psychiatry as compared to other specialist psychiatry posts (t-test: p = 0.038, 95% CI: -0.3901, -0.0118). Job satisfaction scores of year 1 to year 3 core trainees showed a significant increase with increasing seniority (Linear regression coefficient = 0.273, 95% CI: 0.033 to 0.513, ANOVA p= 0.026). CONCLUSIONS: This in-depth examination of the quality of training on a large psychiatry training programme successfully elicited strengths and weakness of our programme. Such an interview scheme could be easily implemented in smaller schemes and may well provide important information to allow for targeted improvement of training. Additionally, trends in quality of training and job satisfaction amongst various psychiatric specialities were identified; specifically speciality posts and liaison posts in psychiatry were revealed to be the most popular with trainees.

Cariprazine as a treatment for negative psychotic symptoms in first-episode psychosis: case series.

Negative psychotic symptoms are among the most disabling features of schizophrenia, and are strongly associated with relatively poor clinical and functional outcomes. However, there are no effective treatments for negative symptoms, and this represents a major unmet clinical need. Recent research has shown that negative symptoms are already present in many patients at illness onset. There is evidence that cariprazine may improve negative symptoms in patients with chronic schizophrenia. However, its utility in treating negative symptoms in the early stage of the disorder is unclear. Here, we report six cases of patients with first-episode psychosis who were treated with cariprazine.

Association Between Specific Childhood Adversities and Symptom Dimensions in People With Psychosis: Systematic Review and Meta-Analysis.

Despite the accepted link between childhood abuse and positive psychotic symptoms, findings between other adversities, such as neglect, and the remaining dimensions in people with psychosis have been inconsistent, with evidence not yet reviewed quantitatively. The aim of this study was to systematically examine quantitatively the association between broadly defined childhood adversity (CA), abuse (sexual/physical/emotional), and neglect (physical/emotional) subtypes, with positive, negative, depressive, manic, and disorganized dimensions in those with psychosis. A search was conducted across EMBASE, MEDLINE, PsychINFO, and Cochrane Libraries using search terms related to psychosis population, CA, and psychopathological dimensions. After reviewing for relevance, data were extracted, synthesized, and meta-analyzed. Forty-seven papers were identified, including 7379 cases across 40 studies examining positive, 37 negative, 20 depressive, 9 disorganized, and 13 manic dimensions. After adjustment for publication bias, general adversity was positively associated with all dimensions (ranging from r = 0.08 to r = 0.24). Most forms of abuse were associated with depressive (ranging from r = 0.16 to r = 0.32), positive (ranging from r = 0.14 to r = 0.16), manic (r = 0.13), and negative dimensions (ranging from r = 0.05 to r = 0.09), while neglect was only associated with negative (r = 0.13) and depressive dimensions (ranging from r = 0.16 to r = 0.20). When heterogeneity was found, it tended to be explained by one specific study. The depressive dimension was influenced by percentage of women (ranging from r = 0.83 to r = 1.36) and poor-quality scores (ranging from r = -0.21 and r = -0.059). Quality was judged as fair overall. Broadly defined adversity and forms of abuse increase transdimensional severity. Being exposed to neglect during childhood seems to be exclusively related to negative and depressive dimensions suggesting specific effects.

Early Intervention Services for First Episode of Psychosis in South London and the Maudsley (SLaM): 20 Years of Care and Research for Young People.

Introduction: Early Intervention for a first episode of Psychosis (EI) is essential to improve outcomes. There is limited research describing real-world implementation of EI services. Method: Analysis of service characteristics, outcomes (described through a retrospective 2007-2017 Electronic Health Record (EHR) cohort study) and clinical research relating to the first 20 years of implementation of EI services in South London and Maudsley (SLaM) Trust. Results: SLaM EI are standalone services serving 443,050 young individuals in South-London, where (2017) incidence of psychosis (58.3-71.9 cases per 100,000 person-years) is greater than the national average. From 2007-2017 (when the EHR was established), 1,200 individuals (62.67% male, mean age 24.38 years, 88.17% single; two-thirds of non-white ethnicity) received NICE-compliant EI care. Pathways to EI services came mainly (75.26%) through inpatient (39.83%) or community (19.33%) mental health services or Accident and Emergency departments (A&E) (16%). At 6 year follow-up 34.92% of patients were still being prescribed antipsychotics. The 3 month and 6 year cumulative proportions of those receiving clozapine were 0.75 and 7.33%; those compulsorily admitted to psychiatric hospitals 26.92 and 57.25%; those admitted to physical health hospitals 6.83 and 31.17%, respectively. Average 3 months and 6 year days spent in hospital were 0.82 and 1.85, respectively; mean 6 year attendance at A&E was 3.01. SLaM EI clinical research attracted £58 million grant income and numerous high-impact scientific publications. Conclusions: SLaM EI services represent one of the largest, most established services of its kind, and are a leading model for development of similar services in the UK and worldwide.

The Lambeth Early Onset Crisis Assessment Team Study: general practitioner education and access to an early detection team in first-episode psychosis.

BACKGROUND: There are few evaluations of strategies to improve rates of early detection and treatment of patients with first-episode psychosis. AIMS: To evaluate the effectiveness of a general practitioner (GP) education programme and an early detection assessment team (the Lambeth Early Onset Crisis Assessment Team; LEO CAT) in reducing delays in accessing treatment for first-episode psychosis patients. METHOD: 46 clusters of GP practices randomised to GP education in early detection with direct access to LEO CAT v. care as usual. Primary outcome measures were GP referral rates, duration of untreated psychosis (DUP) and delays in receiving treatment. RESULTS: 150 patients with first-episode psychosis were recruited; 113 were registered with the study GPs, who referred 54 (47.7%) directly to mental health services. Significantly more intervention group GPs (86.1% v. 65.7%) referred their patients directly to mental health services and fewer patients experienced long delays in receiving treatment. However, their overall DUP was unaffected. CONCLUSIONS: Educating GPs improves detection and referral rates of first-episode psychosis patients. An early detection team reduces the long delays in initial assessment and treatment. However, these only impact on the later phases of the DUP. Broader measures, such as public health education, are needed to reduce the earlier delays in DUP.

Psychosis and identity: Alteration or loss?

The onset of psychotic disorders often brings major changes to an individual, which, for some, are never fully reversed and remain a dominant force. Despite such changes, the individual still experiences themselves as a continuous person and must find some way to assimilate these shifts into their self-concept. From a philosophical perspective, the various models of continuing identity all depend upon some notion of fundamental stability, which seems a poor fit for the trajectory associated with psychotic disorders. This article will explore, in more depth, how the transitions that accompany psychotic disorders present a challenge to conventional and philosophical notions of selfhood. If we are not simply to judge psychotic disorders as bringing about a loss of selfhood, we will need an alternative model of identity to use in this context.

Impact of crime victimization on initial presentation to an early intervention for psychosis service and 18-month outcomes.

AIM: To investigate the clinical and social correlates of a lifetime history of crime victimization among first-episode psychosis patients at entry to an Early Intervention Service and following 18 months of specialist care. METHODS: Face-to-face interviews were conducted with 149 individuals who presented to an Early Intervention Service for the first time with psychosis in the London borough of Lambeth, UK. A range of demographic and clinical measures were completed including self-reported history of victimization along with the type of crime and its subjective effect on the patient. Clinical and functional outcomes at 18-month follow up were ascertained from clinical case notes by a psychiatrist. RESULTS: A large proportion of patients (n = 64, 43%) reported a history of crime victimization. This was associated with significantly higher levels of depression and substance misuse at initial presentation. Being a victim of a crime was not significantly associated with poorer clinical or functional outcomes after 18 months of specialist care. However, non-significant differences were found for those who reported crime victimization in terms of their increased use of illegal substances or having assaulted someone else during the follow-up period. CONCLUSION: Past experience of being a victim of crime appears to be common in patients presenting for the first time with psychosis and is associated with increased likelihood of comorbidity. Thus, Early Intervention Services should consider screening for past victimization and be prepared to deal with comorbid problems. The impact of crime victimization on clinical and functional outcomes requires investigation over a longer period of time.

The early impact of therapeutic alliance in brief psychodynamic psychotherapy.

INTRODUCTION: Therapeutic alliance is a key component of the psychotherapeutic process. This study estimated the impact of the therapeutic alliance as measured by CALPAS-P in an individual brief psychodynamic psychotherapy program. METHODS: To study the impact of the therapeutic alliance patients in psychotherapy answered to the CALPAS-P at the first and third session and to the Self-report Questionnaire (SRQ-20), to the Beck Depression Inventory (BDI) and to the Hamilton Anxiety Scale at the beginning and at the end of psychotherapy. RESULTS: The study of the impact of the therapeutic alliance in brief psychodynamic psychotherapy showed that higher TUI scores in the first session were significantly associated to the improvement on the BDI. Patients with best scores in the working alliance, measured at the third PWC session had also significant symptomatic changes. DISCUSSION: The study of the impact of the therapeutic alliance in brief psychotherapy indicated that patients who perceived that their therapists had the best capability to understand and to be involved in their issues had best results in reducing depressive symptoms and patients with higher capability to form the working alliance reached the best psychotherapy outcomes.

Lambeth Early Onset (LEO) and Outreach & Support in South London (OASIS) service.

AIM: To establish a comprehensive phase-oriented early intervention service for young people with early psychosis in south London and to evaluate its effectiveness in delivering user friendly interventions and better outcomes. METHODS: The Lambeth Early Onset (LEO) and Outreach & Support in South London (OASIS) service has been developed incrementally over the last 6 years into 4 teams each addressing one of the phases of early psychosis: (i) prodrome/ultra-high risk (ii) untreated psychosis (c) acute inpatient treatment and (d) recovery/ relapse prevention phases. Research and evaluation have been integral to each team's development with three of the teams configured as Randomised Controlled Trials. RESULTS: During the first 6 years, 1255 young people in Lambeth were referred for assessment (963 to LEO and 292 to OASIS). Of them 578 were diagnosed as suffering from first episode psychosis (some before or after they presented to OASIS), 450 have been followed up in Lambeth by the LEO Community Team and 40% discharged back to GPs in remission at the end of their two years of follow-up. Compared to standard service, patients' delays in accessing treatment are less, and outcomes at 18 months are better. CONCLUSIONS: The LEO and OASIS service now provide most of the mental health service requirements for young people with early psychosis in Lambeth. It represents good value for money and improved outcomes for clients. Further interventions are planned and ultimately it will be possible to evaluate the impact of each incremental step in the service's development.

Tradução e validação para português brasileiro da Escala de Autoavaliação do Funcionamento Ocupacional: [revisão] / Traducción y validación al portugués brasileño de la Escala de Autoevaluación del Funcionamiento Ocupacional: [revisión] / Tanslation and validation to brazilian portuguese of Self Assessment of Occupational Functioning Scale: [review]

O artigo apresenta a tradução para a língua portuguesa, a adaptação transcultural e a validação do instrumento SAOF – Self Assessment of Occupational Functioning, uma escala de autoavaliação do funcionamento ocupacional, para uso na população brasileira. Foram realizadas as etapas de equivalência semântica e conceitual tanto na etapa da tradução como na etapa da adaptação transcultural. A adaptação do SAOF disponibiliza para uso um instrumento de utilização prática para terapeutas ocupacionais e a reprodutibilidade para os 23 componentes e para as 7 áreas foi considerada significante e altamente satisfatória sugerindo a indicação da utilização desta versão adaptada.

The article presents the translation to the Portuguese language, the transcultural adaptation and the validation of Self Assessment of Occupational Functioning Scale for using with the Brazilian population. We did the stages of semantic and conceptual equivalence both in translation and in transcultural adaptation procedures. The adapted scale is a practical instrument for occupational therapists with reproductibility for the 23 (twenty three) component and the 7 (seven) areas. The scale was considered significant and highly satisfactory, suggesting the indication of the use of this suitable version.

El artículo presenta la traducción a la lengua portuguesa, la adaptación transcultural y la validación de la escala de autoevaluación del funcionamiento y ocupacional para uso con la población brasileña. Hicimos las etapas de la equivalencia semántica y conceptual en la traducción y en los procedimientos transculturales de la adaptación. La escala adaptada es un instrumento práctico para los terapeutas ocupacionales con reproducibilidad para los 23 (veintitrés) componentes y las 7 (siete) áreas. La escala fue considerada significativa y extremadamente satisfactoria, sugiriendo la indicación del uso de esta versión conveniente.

Metodological issues in measuring the detection of emotional disorders by primary care physicians: a review of the literature

A series of studies in the field of Epidemiological Psychiatry have been performed over the last two decades, and these focused on the ability of primary care physicians to detevt emotional disorders in the patients that attend their practices. The scientific methodology utilized in these studies is the subject of this review, which contains a discussion concerning: a) interviewer awareness bias; b) accuracy of of the instruments and c) medical and psychological concepts involved in defining minor emotional disorders. Suggestions for change in the methodology are made in each of the sections of the review

The early impact of therapeutic alliance in brief psychodynamic psychotherapy

INTRODCTION: Therapeutic alliance is a key component of the psychotherapeutic process. This study estimated the impact of the therapeutic alliance as measured by CALPAS-P in an individual brief psychodynamic psychotherapy program. METHODS: To study the impact of the therapeutic alliance patients in psychotherapy answered to the CALPAS-P at the first and third session and to the Self-report Questionnaire (SRQ-20), to the Beck Depression Inventory (BDI) and to the Hamilton Anxiety Scale at the beginning and at the end of psychotherapy. RESULTS: The study of the impact of the therapeutic alliance in brief psychodynamic psychotherapy showed that higher TUI scores in the first session were significantly associated to the improvement on the BDI. Patients with best scores in the working alliance, measured at the third PWC session had also significant symptomatic changes. DISCUSSION: The study of the impact of the therapeutic alliance in brief psychotherapy indicated that patients who perceived that their therapists had the best capability to understand and to be involved in their issues had best results in reducing depressive symptoms and patients with higher capability to form the working alliance reached the best psychotherapy outcomes

Escala de Aliança Psicoterápica da Califórnia na versäo do paciente / California Psychotherapy Alliance Scale as the patient version

Objetivo: A aliança terapêutica corresponde a um conceito central do processo psicoterápico. Este estudo produziu a traduçäo para o português e examinou a confiabilidade da Calpas-P (Escala de Aliança Psicoterápica da Califórnia - versäo do paciente). Métodos: Para a traduçäo, foi adotada a técnica da retrotraduçäo, realizada por indivíduos bilíngues. Para o estudo de confiabilidade, uma amostra de profissionais de saúde mental, atendidos em psicoterapia individual foi convidada para responder a versäo em português da Calpas-P. Resultados: Um total de 83 questionários foi devolvido. As médias das quatro escalas da Calpas-P foram: 5,66 para a PC; 5,20 para PWC; 6,10 para a TUI; e 5,99 para a WSC. As escalas mostraram uma alta correlaçäo entre si, com valores variando de 0,57 a 0,74. O Alpha de cronbach para a Calpas-P também foi alto: 0,90 para todos os itens; 0,71 para a PC; 0,56 para a PWC; 0,71 para a TUI; e 0,84 para a WSC. Conclusäo: Esses coeficientes apresentaram índices superiores, quando comparados àqueles do estudo original, na versäo em inglês. A presente investigaçäo, que tornou disponível a versäo em português da Calpas-P e algumas de suas características psicométricas, pode contribuir para uma mensuraçäo mais cuidadosa da aliança terapêutica por meio de sua inclusäo em pesquisas futuras na psicoterapia

Validade e confiabilidade da versão brasileira de um inventário de avaliação de relações objetais / Validity and reliability of the Brazilian version of an inventory for the evaluation of object relations

Introdução: Relação objetal tem sido um conceito fértil para a psicanálise e para a psiquiatria. O reconhecimento crescente do valor diagnóstico do conceito de relação objetal nos transtornos psiquiátricos tem levado ao desenvolvimento de várias escalas que pretendem mensurá-lo. O estudo teve o propósito de produzir os índices de validade e confiabilidade da versão em português de um instrumento amplamente usado, planejado para avaliar relações objetais, o Bell Object Relations and Reality Testing Inventory (BORRTI - Form 0). Métodos: A amostra foi composta de 218 estudantes de graduação de psicologia. Uma análise fatorial exploratória obteve, com sucesso, as quatro dimensões descritas nos estudos originais. Resultados: Estas dimensões demonstraram boa correlação dos escores quando comparadas às respectivas dimensões da versão em inglês do BORRTI - Forma 0 (0,62 para alienação, 0,82 para vinculação insegura, 0,83 para egocentrismo e 0,78 para incapacidade social). Os escores de confiabilidade também foram aceitáveis, com um valor alpha de Cronbach para todos os itens de 0,59 e confiabilidade split-half Spearman-Brown de 0,63. Conclusões: Tornando estes índices disponíveis, o estudo pode contribuir para a escolha adequada de escalas que investiguem relações objetais no Brasil.

Estudo de fidedignidade inter-avaliadores de uma escala para a avaliação da interação mãe-bebê / An inter-rater reliability study of a scale to assess mother-infant interaction

OBJETIVO: Realizar um estudo de concordância entre examinadores da versão adaptada de uma escala para a avaliação de interação mãe-bebê (Brown e colaboradores - 1975) MÉTODO: Quatorze puérperas e seus recém-nascidos participaram deste estudo. As observações, que duravam quinze minutos, foram filmadas na maternidade no segundo dia após o nascimento do bebê, durante a amamentação. Num momento sucessivo e isoladamente, dois avaliadores atribuíram escores para cada item de interação estabelecida entre a mãe e o recém nascido. Para tal fim, foi utilizada e submetida ao estudo de fidedignidade uma versão adaptada da escala de Brown e colaboradores.³ (1975). RESULTADOS: Nove entre os dez itens pertencentes à escala adaptada do estudo de Brown e colaboradores³ (1975) revelaram uma concordância excelente, o coeficiente Kappa acima de 0,85. O único item que apresentou uma concordância moderada (K= 0,59) foi 'mãe segura o bebê'.Os resultados obtidos indicam a estabilidade da escala adaptada e aplicada em ambiente hospitalar destinado às mães de baixa renda. CONCLUSÕES: Os dados trazidos por este estudo indicam que a utilização das categorias é um parâmetro fidedigno na avaliação da interação mãe-bebê.

Detection of psychiatric morbidity in the primary medical care setting in Brazil

Objetivou-se avaliar a habilidade de clínicos gerais em diagnosticar distúrbios emocionais na assistência primária, e investigar a possibilidade de se introduzir um questionário de "screening" para auxiliar o diagnóstico de doenças psiquiátricas. O estudo foi realizado em dois centros de saúde e um ambulatório de clínica geral na cidade de Säo Paulo (Brasil), por um período de 6 meses. Uma amostra representativa de pacientes adultos (16 anos) atendidos por clínico geral preencheu um questionário de "screening" para distúrbios psiquiátricos menores. Uma sub-amostra foi selecionada para entrevista psiquiátrica semi-estruturada, segundo a versäo brasileira da "Clinical Interview Schedule" (CIS). No final da consulta os clínicos gerais avaliaram, através de uma escala padronizada, se o paciente apresentava ou näo um distúrbio psiquiátrico e a severidade do mesmo. Considerável número de pacientes que apresentavam distúrbios psiquiátricos menores näo foram identificados pelos clínicos gerais (de 22% a 79%), sendo que o questionário de "screening" contribuiria sobremaneira na identificaçäo desses distúrbios. Säo apresentadas quatro estratégias que podem ser consideradas na adoçäo do "screening", e discutidas as conseqüências clínicas que circunscrevem a aplicaçäo desse instrumental