Childhood trauma, antipsychotic medication, and symptom remission in first-episode psychosis.

BACKGROUND: To what extent psychotic symptoms in first-episode psychosis (FEP) with a history of childhood interpersonal trauma (CIT) are less responsive to antipsychotic medication is not known. In this longitudinal study, we compare symptom trajectories and remission over the first 2 years of treatment in FEP with and without CIT and examine if differences are linked to the use of antipsychotics. METHODS: FEP (N = 191) were recruited from in- and outpatient services 1997-2000, and assessed at baseline, 3 months, 1 and 2 years. Inclusion criteria were 15-65 years, actively psychotic with a DSM-IV diagnosis of psychotic disorder and no previous adequate treatment for psychosis. Antipsychotic medication is reported as defined daily dosage (DDD). CIT (<18) was assessed with the Brief Betrayal Trauma Survey, and symptomatic remission based on scores from the Positive and Negative Syndrome Scale. RESULTS: CIT (n = 63, 33%) was not associated with symptomatic remission at 2 years follow-up (71% in remission, 14% in relapse), or time to first remission (CIT 12/ no-CIT 9 weeks, p = 0.51). Those with CIT had significantly more severe positive, depressive, and excited symptoms. FEP with physical (N = 39, 20%) or emotional abuse (N = 22, 14, 7%) had higher DDD at 1 year (p < 0.05). Mean DDD did not excerpt a significant between-group effect on symptom trajectories of positive symptoms. CONCLUSION: Results indicate that antipsychotic medication is equally beneficial in the achievement of symptomatic remission in FEP after 2 years independent of CIT. Still, FEP patients with CIT had more severe positive, depressive, and excited symptoms throughout.

Lower circulating neuron-specific enolase concentrations in adults and adolescents with severe mental illness.

BACKGROUND: Both neurodegenerative and neurodevelopmental abnormalities have been suggested to be part of the etiopathology of severe mental illness (SMI). Neuron-specific enolase (NSE), mainly located in the neuronal cytoplasm, may indicate the process as it is upregulated after neuronal injury while a switch from non-neuronal enolase to NSE occurs during neuronal maturation. METHODS: We included 1132 adult patients with SMI [schizophrenia (SZ) or bipolar spectrum disorders], 903 adult healthy controls (HC), 32 adolescent patients with SMI and 67 adolescent HC. Plasma NSE concentrations were measured by enzyme immunoassay. For 842 adults and 85 adolescents, we used total grey matter volume (TGMV) based on T1-weighted magnetic resonance images processed in FreeSurfer v6.0. We explored NSE case-control differences in adults and adolescents separately. To investigate whether putative case-control differences in NSE were TGMV-dependent we controlled for TGMV. RESULTS: We found significantly lower NSE concentrations in both adult (p < 0.001) and adolescent patients with SMI (p = 0.007) compared to HC. The results remained significant after controlling for TGMV. Among adults, both patients with SZ spectrum (p < 0.001) and bipolar spectrum disorders (p = 0.005) had lower NSE than HC. In both patient subgroups, lower NSE levels were associated with increased symptom severity. Among adults (p < 0.001) and adolescents (p = 0.040), females had lower NSE concentrations than males. CONCLUSION: We found lower NSE concentrations in adult and adolescent patients with SMI compared to HC. The results suggest the lack of progressive neuronal injury, and may reflect abnormal neuronal maturation. This provides further support of a neurodevelopmental rather than a neurodegenerative mechanism in SMI.

Antidepressive Effectiveness of Amisulpride, Aripiprazole, and Olanzapine in Patients With Schizophrenia Spectrum Disorders: A Secondary Outcome Analysis of a Pragmatic, Randomized Trial (BeSt InTro).

BACKGROUND: Depressive symptoms are frequent in schizophrenia and associated with a poorer outcome. Currently, the optimal treatment for depressive symptoms in schizophrenia remains undetermined. Amisulpride, aripiprazole, and olanzapine all have antidepressive pharmacodynamic properties, ranging from serotonergic affinities to limbic dopaminergic selectivity. Consequently, in a 12-month pragmatic, randomized clinical trial, we aimed to investigate differences in antidepressive effectiveness among amisulpride, aripiprazole, and olanzapine as a secondary outcome, measured by change in the Calgary Depression Scale for Schizophrenia sum score in patients within the schizophrenia spectrum. METHODS: Psychotic patients within the schizophrenia spectrum were included, and effectiveness was analyzed with latent growth curve modeling. RESULTS: Of the 144 patients, 51 (35%) were women, the mean age was 31.7 (SD 12.7), and 39% were antipsychotic naive. At inclusion, 68 (47%) participants had a Calgary Depression Scale for Schizophrenia sum score >6, indicating severe depressive symptoms. Across the 12-month follow-up, there was a depressive symptom reduction in all medication groups, but no statistically significant differences between the study drugs. Separate analyses of the subcohort with elevated depressive symptoms at inclusion also failed to find differences in depressive symptom reduction between study drugs. The reduction in depressive symptoms mainly occurred within 6 weeks after randomization. CONCLUSIONS: There was a reduction in depressive symptoms under treatment with amisulpride, aripiprazole, and olanzapine in acutely psychotic patients with schizophrenia spectrum disorder, but no differences between the drugs.

Exploring key determinants of health among individuals with serious mental Illness: qualitative insights from a first episode psychosis cohort, 20 years postdiagnosis.

BACKGROUND: Individuals with serious mental illness (SMI) are more likely to experience functional decline, low well-being, comorbidities, shorter lifespan, and diminished quality of life than the general population. This qualitative study explores determinants of health that individuals with SMI perceive as important to their health, well-being, and ability to live a meaningful life. METHOD: We conducted interviews with 13 individuals with early detected first episode psychosis as part of a 20-year follow-up study of a larger cohort. Interview data were analyzed using qualitative content analysis. RESULTS: Analysis identified two themes comprising eight categories representing determinants of health. The first theme reflected management of mental and physical health. Categories in this theme were: access to mental healthcare adapted to individual needs, strategies during deterioration, use of psychotropic medication, maintenance of physical health and lifestyle. The second theme reflected social health determinants in coping with mental illness and comprised three categories: family and friends, engaging in meaningful hobbies and activities, and the influence of employment on mental health. CONCLUSIONS: Individuals with SMI outlined mental, physical, and social determinants of health that were important for their health, well-being, and ability to live a meaningful life. In future clinical practice, coordinated care addressing the complexity of health determinants will be important.

Increased circulating IL-18 levels in severe mental disorders indicate systemic inflammasome activation.

BACKGROUND: Schizophrenia (SCZ) and bipolar disorder (BD) are severe mental illnesses (SMI) that are part of a psychosis continuum, and dysregulated innate immune responses have been suggested to be involved in their pathophysiology. However, disease-specific immune mechanisms in SMI are not known yet. Recently, dyslipidemia has been linked to systemic inflammasome activation, and elevated atherogenic lipid ratios have been shown to correlate with circulating levels of inflammatory biomarkers in SMI. It is, however, not yet known if increased systemic cholesterol load leads to inflammasome activation in these patients. METHODS: We tested the hypothesis that patients with SCZ and BD display higher circulating levels compared to healthy individuals of key members of the IL-18 system using a large patient cohort (n = 1632; including 737 SCZ and 895 BD), and healthy controls (CTRL; n = 1070). In addition, we assessed associations with coronary artery disease risk factors in SMI, focusing on relevant inflammasome-related, neuroendocrine, and lipid markers. RESULTS: We report higher baseline levels of circulating IL-18 system components (IL-18, IL-18BPA, IL-18R1), and increased expression of inflammasome-related genes (NLRP3 and NLRC4) in the blood of patients relative to CTRL. We demonstrate a cholesterol dyslipidemia pattern in psychotic disorders, and report correlations between levels of blood cholesterol types and the expression of inflammasome system elements in SMI. CONCLUSIONS: Based on these results, we suggest a role for inflammasome activation/dysregulation in SMI. Our findings further the understanding of possible underlying inflammatory mechanisms and may expose important therapeutic targets in SMI.

Psychiatric patients' attitudes towards being hospitalized: a national multicentre study in Norway.

BACKGROUND: The aim of the study was to explore patients' attitudes towards voluntary and involuntary hospitalization in Norway, and predictors for involuntary patients who wanted admission. METHODS: A multi-centre study of consecutively admitted patients to emergency psychiatric wards over a 3 months period in 2005-06. Data included demographics, admission status (voluntary / involuntary), symptom levels, and whether the patients expressed a wish to be admitted regardless of judicial status. To analyse predictors of wanting admission (binary variable), a generalized linear mixed modelling was conducted, using random intercepts for the site, and fixed effects for all variables, with logit link-function. RESULTS: The sample comprised of 3.051 patients of witch 1.232 (40.4%) were being involuntary hospitalised. As expected 96.5% of the voluntary admitted patients wanted admission, while as many as 29.7% of the involuntary patients stated that they wanted the same. The involuntary patients wanting admission were less likely to be transported by police, had less aggression, hallucinations and delusions, more depressed mood, less use of drugs, less suicidality before admission, better social functioning and were less often referred by general practitioners compared with involuntary patients who did not want admission. In a multivariate analysis, predictors for involuntary hospitalization and wanting admission were, not being transported by police, less aggression and less use of drugs. CONCLUSIONS: Almost a third of the involuntary admitted patients stated that they actually wanted to be hospitalized. It thus seems to be important to thoroughly address patients' preferences, both before and after admission, regarding whether they wish to be hospitalized or not.

Can systematic implementation support improve programme fidelity by improving care providers' perceptions of implementation factors? A cluster randomized trial.

BACKGROUND: Investigations of implementation factors (e.g., collegial support and sense of coherence) are recommended to better understand and address inadequate implementation outcomes. Little is known about the relationship between implementation factors and outcomes, especially in later phases of an implementation effort. The aims of this study were to assess the association between implementation success (measured by programme fidelity) and care providers' perceptions of implementation factors during an implementation process and to investigate whether these perceptions are affected by systematic implementation support. METHODS: Using a cluster-randomized design, mental health clinics were drawn to receive implementation support for one (intervention) and not for another (control) of four evidence-based practices. Programme fidelity and care providers' perceptions (Implementation Process Assessment Tool questionnaire) were scored for both intervention and control groups at baseline, 6-, 12- and 18-months. Associations and group differences were tested by means of descriptive statistics (mean, standard deviation and confidence interval) and linear mixed effect analysis. RESULTS: Including 33 mental health centres or wards, we found care providers' perceptions of a set of implementation factors to be associated with fidelity but not at baseline. After 18 months of implementation effort, fidelity and care providers' perceptions were strongly correlated (B (95% CI) = .7 (.2, 1.1), p = .004). Care providers perceived implementation factors more positively when implementation support was provided than when it was not (t (140) = 2.22, p = .028). CONCLUSIONS: Implementation support can facilitate positive perceptions among care providers, which is associated with higher programme fidelity. To improve implementation success, we should pay more attention to how care providers constantly perceive implementation factors during all phases of the implementation effort. Further research is needed to investigate the validity of our findings in other settings and to improve our understanding of ongoing decision-making among care providers, i.e., the mechanisms of sustaining the high fidelity of recommended practices. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03271242 (registration date: 05.09.2017).

Differential Effectiveness of Atypical Antipsychotics on Hallucinations: A Pragmatic Randomized Controlled Trial.

BACKGROUND: Most studies investigating antipsychotic effectiveness report either total psychopathology or symptom cluster findings. Studies focusing on a separate symptom, such as hallucinations, a hallmark symptom in schizophrenia, are scarce.Therefore, the current study aims to compare the antihallucinatory effectiveness of 3 pharmacologically different antipsychotics: olanzapine, amisulpride, and aripiprazole. METHODS: The present study is part of the Bergen-Stavanger-Innsbruck-Trondheim study, a 12-month prospective, randomized, pragmatic antipsychotic drug trial in active-phase schizophrenia spectrum disorders. The primary outcome of the present study was change of hallucinations as measured by item P3 (hallucinatory behavior) from the Positive and Negative Syndrome Scale in the subgroup with hallucinations at baseline. Primary analyses were intention to treat. RESULTS: A total of 144 participants were included in the study, where 105 (72%) had a score of 3 or more on the Positive and Negative Syndrome Scale P3 item at baseline, indicating the presence of hallucinations (HALL subgroup).In the HALL subgroup, a significantly less reduction of hallucinations was revealed for participants using olanzapine in weeks 12, 26, 39, and 52 when compared with amisulpride and in weeks 26 and 52 when compared with aripiprazole. In subanalyses for participants never exposed to antipsychotic drugs (antipsychotic-naive) and those who had used antipsychotics before entering the study, antihallucinatory differences were revealed only in the latter group. CONCLUSIONS: A differential antihallucinatory effect of the 3 study drugs was present. The inferior effect of olanzapine seems to be driven by the subgroup of participants exposed to antipsychotic treatment before entering the study.

The Effect of Intensive Implementation Support on Fidelity for Four Evidence-Based Psychosis Treatments: A Cluster Randomized Trial.

PURPOSE: Service providers need effective strategies to implement evidence-based practices (EBPs) with high fidelity. This study aimed to evaluate an intensive implementation support strategy to increase fidelity to EBP standards in treatment of patients with psychosis. METHODS: The study used a cluster randomized design with pairwise assignment of practices within each of 39 Norwegian mental health clinics. Each site chose two of four practices for implementation: physical health care, antipsychotic medication management, family psychoeducation, illness management and recovery. One practice was assigned to the experimental condition (toolkits, clinical training, implementation facilitation, data-based feedback) and the other to the control condition (manual only). The outcome measure was fidelity to the EBP, measured at baseline and after 6, 12, and 18 months, analyzed using linear mixed models and effect sizes. RESULTS: The increase in fidelity scores (within a range 1-5) from baseline to 18 months was significantly greater for experimental sites than for control sites for the combined four practices, with mean difference in change of 0.86 with 95% CI (0.21; 1.50), p = 0.009). Effect sizes for increase in group difference of mean fidelity scores were 2.24 for illness management and recovery, 0.68 for physical health care, 0.71 for antipsychotic medication management, and 0.27 for family psychoeducation. Most improvements occurred during the first 12 months. CONCLUSIONS: Intensive implementation strategies (toolkits, clinical training, implementation facilitation, data-based feedback) over 12 months can facilitate the implementation of EBPs for psychosis treatment. The approach may be more effective for some practices than for others.

One-Year Outcome and Adherence to Pharmacological Guidelines in First-Episode Schizophrenia: Results From a Consecutive Cohort Study.

BACKGROUND: Remission in schizophrenia is difficult to achieve. Antipsychotic drugs are critical in the treatment of schizophrenia. International guidelines for the pharmacological treatment of schizophrenia recommend a 3-step algorithm with clozapine being the third-line antipsychotic agent. This study investigated the 1-year outcome and the application of the guidelines for the pharmacological treatment of nonremitted first-episode schizophrenia (FES) patients during the first year of follow-up. METHODS: A sample of 78 FES patients from the Norwegian TIPS (Early Treatment and Intervention in Psychosis) 2 study was assessed at the end of the first year of follow-up. The symptom remission criteria were those defined by the Remission in Schizophrenia Working Group. The adherence to the pharmacological guidelines was assessed by reading the medical files and by a digital search of the words "clozapine," "klozapin," and "Leponex" in the hospital electronic data system. RESULTS: The majority (n = 53, 67.9%) of the patients included were nonremitted at the 1-year follow-up. The majority of the nonremitted patients received either none (7.5%), one (56.6%), or 2 types (15.1%) of antipsychotic drugs during the first year of follow-up. Only 2 (3.8%) received treatment with clozapine, and 3 (5.7%) in total were offered it. CONCLUSIONS: For our FES sample, there was a low 1-year remission rate and a poor adherence to the pharmacological guidelines. Higher adherence to treatment guidelines with a more intensified antipsychotic treatment, which in some cases will include clozapine, will enhance the quality of treatment and may enhance the rates of remission for schizophrenia.

Psychometric Properties of the General Organizational Index (GOI): A Measure of Individualization and Quality Improvement to Complement Program Fidelity.

To assess the implementation of effective practices, mental health programs need standardized measures. The General Organizational Index (GOI), although widely used for this purpose, has received minimal psychometric research. For this study, we assessed psychometric properties of the GOI scale administered four times over 18 months during the implementation of a new program in 11 sites. The GOI scale demonstrated high levels of interrater reliability (.97), agreement between assessors on item ratings (86% overall), internal consistency (.77-.80 at three time points), sensitivity to change, and feasibility. We conclude that the GOI scale has acceptable psychometric properties, and its use may enhance implementation and research on evidence-based mental health practices.Trial registration: REK2015/2169. ClinicalTrials.gov Identifier: NCT03271242.

Inflammatory markers are altered in severe mental disorders independent of comorbid cardiometabolic disease risk factors.

BACKGROUND: Inflammation and immune activation have been implicated in the pathogenesis of severe mental disorders and cardiovascular disease (CVD). Despite high level of comorbidity, many studies of the immune system in severe mental disorders have not systematically taken cardiometabolic risk factors into account. METHODS: We investigated if inflammatory markers were increased in schizophrenia (SCZ) and affective (AFF) disorders independently of comorbid CVD risk factors. Cardiometabolic risk factors (blood lipids, body mass index and glucose) and CVD-related inflammatory markers CXCL16, soluble interleukin-2 receptor (sIL-2R), soluble CD14 (sCD14), macrophage inhibitory factor and activated leukocyte cell adhesion molecule (ALCAM) were measured in n = 992 patients (SCZ, AFF), and n = 647 healthy controls. We analyzed the inflammatory markers before and after controlling for comorbid cardiometabolic risk factors, and tested for association with psychotropic medication and symptom levels. RESULTS: CXCL16 (p = 0.03) and sIL-2R (p = 7.8 × 10-5) were higher, while sCD14 (p = 0.05) were lower in patients compared to controls after controlling for confounders, with significant differences in SCZ for CXCL16 (p = 0.04) and sIL-2R (p = 1.1 × 10-5). After adjustment for cardiometabolic risk factors higher levels of sIL-2R (p = 0.001) and lower sCD14 (p = 0.002) remained, also in SCZ (sIL-2R, p = 3.0 × 10-4 and sCD14, p = 0.01). The adjustment revealed lower ALCAM levels (p = 0.03) in patients. We found no significant associations with psychotropic medication or symptom levels. CONCLUSION: The results indicate that inflammation, in particular enhanced T cell activation and impaired monocyte activation, are associated with severe mental disorders independent of comorbid cardiometabolic risk factors. This suggests a role of novel pathophysiological mechanisms in severe mental disorders, particularly SCZ.

Social Media and Social Functioning in Psychosis: A Systematic Review.

BACKGROUND: Individuals with psychosis are heavy consumers of social media. It is unknown to what degree measures of social functioning include measures of online social activity. OBJECTIVE: To examine the inclusion of social media activity in measures of social functioning in psychosis and ultrahigh risk (UHR) for psychosis. METHODS: Two independent authors conducted a search using the following electronic databases: Epistemonikos, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, MEDLINE, Embase, and PsycINFO. The included articles were required to meet all of the following criteria: (1) an empirical study published in the English language in a peer-reviewed journal; (2) the study included a measure of objective or subjective offline (ie, non-Web-mediated contact) and/or online social functioning (ie, Web-mediated contact); (3) the social functioning measure had to be used in samples meeting criteria (ie, Diagnostic and Statistical Manual of Mental Disorders or International Classification of Diseases) for a psychotic disorder or UHR for psychosis; and (4) the study was published between January 2004 and February 2019. Facebook was launched as the first large-scale social media platform in 2004 and, therefore, it is highly improbable that studies conducted prior to 2004 would have included measures of social media activity. RESULTS: The electronic search resulted in 11,844 distinct articles. Full-text evaluation was conducted on 719 articles, of which 597 articles met inclusion criteria. A total of 58 social functioning measures were identified. With some exceptions, reports on reliability and validity were scarce, and only one measure integrated social media social activity. CONCLUSIONS: The ecological validity of social functioning measures is challenged by the lack of assessment of social media activity, as it fails to reflect an important aspect of the current social reality of persons with psychosis. Measures should be revised to include social media activity and thus avoid the clinical consequences of inadequate assessment of social functioning. TRIAL REGISTRATION: International Prospective Register of Systematic Reviews (PROSPERO) CRD42017058514; http://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42017058514.

Attitudes toward standardized assessment tools and their use among clinicians in a public mental health service.

The aim of the present study was to investigate the use and attitudes toward standardized assessment tools among clinicians in a public mental health service in Norway. A total of 606 clinicians provided feedback on their use and attitudes regarding psychometric qualities of such tools, their practicality, and their benefit over clinical judgment alone using the Attitudes toward Standardized Assessment (ASA) Scales. Clinicians working in the adult mental health field scored significantly higher on use of diagnostic interviews, pre-post evaluations, and ongoing evaluations, whereas clinicians working in the child/adolescent mental health field scored significantly higher on use of screening instruments and held more positive attitudes towards using standardized assessment tools. Attitudes toward standardized assessment tools predicted use of such tools, and results were found to be similar to a study on US clinicians. Whereas the US study only found attitudes regarding the practicality of using such instrument as an independent predictor of assessment use, the current study found that attitudes regarding psychometric qualities of such tools, their practicality, and their benefit over clinical judgment alone were independent predictors of use.

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.

Experiences of antipsychotic use in patients with early psychosis: a two-year follow-up study.

BACKGROUND: Non-adherence is a major public health problem despite treatment advances. Poor drug adherence in patients with psychosis is associated with more frequent relapse, re-hospitalization, increased consumption of health services and poor outcomes on a variety of measures. Adherence rate in patients with first episode psychosis have been found to vary from 40 to 60%. However, most previous studies have addressed the consequences of non-adherence rather than its potential causes. The purpose of this study was, therefore, to investigate experiential factors which may affect adherence to medication in adults with psychotic disorders, during the 24-month period after the onset of treatment. METHODS: Twenty first episode patients (7 male, 13 female) were included in our qualitative sub-study from the ongoing TIPS2 (Early Intervention in Psychosis study). Each person participated in semi-structured interviews at 2-year follow-up. All had used antipsychotics, with some still using them. Data were analyzed within an interpretative-phenomenological framework using an established meaning condensation procedure. RESULTS: The textual analysis revealed four main themes that affected adherence largely: 1) Positive experiences of admission, 2) Sufficient timely information, 3) Shared decision-making and 4) Changed attitudes to antipsychotics due to their beneficial effects and improved insight into illness. CONCLUSION: Patients reported several factors to have a prominent impact on adherence to their antipsychotics. The patients do not independently choose to jeopardize their medication regime. Health care staff play an important role in maintaining good adherence by being empathetic and supportive in the admission phase, giving tailored information according to patients' condition and involving patients when making treatment decisions.

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.

Primary prevention of psychosis through interventions in the symptomatic prodromal phase, a pragmatic Norwegian Ultra High Risk study.

BACKGROUND: Evidence has been accumulating that it may be possible to achieve prevention in psychotic disorders. The aim of the Prevention Of Psychosis (POP) study is to reduce the annual incidence of psychotic disorders in a catchment area population through detection and intervention in the prodromal phase of disorder. Prodromal patients will be recruited through information campaigns modelled on the Scandinavian early Treatment and Intervention in Psychosis (TIPS) study and assessed by low-threshold detection teams. METHODS/DESIGN: The study will use a parallel control design comparing the incidence of first episode psychotic disorders between two Norwegian catchment areas with prodromal detection and treatment (Stavanger and Fonna) with two catchment areas without a prodromal intervention program (Bergen and Østfold). The primary aim of the current study is to test the effect of a Prodromal Detection and Treatment program at the health care systems level. The study will investigate: 1) If the combination of information campaigns and detection teams modelled will help in identifying individuals (age 13-65, fulfilling study inclusion criteria) at high risk of developing psychosis early, and 2) If a graded, multi-modal treatment program will reduce rates of conversion compared to the rates seen in follow-along assessments. DISCUSSION: Positive results could potentially revolutionize therapy by treating risk earlier rather than disorder later and could open a new era of early detection and intervention in psychosis. Negative results will suggest that the potential for psychosis is determined early in life and that research should focus more on genetically linked neurodevelopmental processes. If we can identify people about to become psychotic with high accuracy, we can track them to understand more about how psychosis unfolds. Appropriate intervention at this stage could also prevent or delay the onset of psychosis and/or subsequent deterioration, i.e., social and instrumental disability, suicide, aggressive behavior, affective- and cognitive deficits. TRIAL REGISTRATION: Current Controlled Trials ISRCTN20328848 . Registered 02 November 2014.