Service evaluation of an embedded Early Intervention in Psychosis programme.

BACKGROUND: An average of 1300 adults develop First Episode Psychosis (FEP) in Ireland each year. Early Intervention in Psychosis (EIP) is now widely accepted as best practice in the treatment of conditions such as schizophrenia. A local EIP programme was established in the Dublin South Central Mental Health Service in 2012. METHODS: This is a cross-sectional study of service users presenting to the Dublin South Central Mental Health Service with FEP from 2016 to 2022 following the introduction of the EIP programme. We compared this to a previously published retrospective study of treatment as usual from 2002 to 2012. RESULTS: Most service users in this study were male, single, unemployed and living with their partner or spouse across both time periods. Cognitive Behavioural Therapy for psychosis was provided to 12% (n = 8) of service users pre-EIP as compared to 52% (n = 30) post-programme introduction (p < 0.001), and 3% (n = 2) of service users engaged with behavioural family therapy pre-EIP as opposed to 15% (n = 9) after (p < 0.01). Rates of composite baseline physical healthcare monitoring improved significantly (p < 0.001). CONCLUSION: Exclusive allocation of multidisciplinary team staff to EIP leads to improved compliance with recommended guidelines, particularly CBT-p, formal family therapy and physical health monitoring.

Neural correlates of treatment outcome in major depression.

There is a need to identify clinically useful biomarkers in major depressive disorder (MDD). In this context the functional connectivity of the orbitofrontal cortex (OFC) to other areas of the affect regulation circuit is of interest. The aim of this study was to identify neural changes during antidepressant treatment and correlates associated with the treatment outcome. In an exploratory analysis it was investigated whether functional connectivity measures moderated a response to mirtazapine and venlafaxine. Twenty-three drug-free patients with MDD were recruited from the Department of Psychiatry and Psychotherapy of the Ludwig-Maximilians University in Munich. The patients were subjected to a 4-wk randomized clinical trial with two common antidepressants, venlafaxine or mirtazapine. Functional connectivity of the OFC, derived from functional magnetic resonance imaging with an emotional face-matching task, was measured before and after the trial. Higher OFC connectivity with the left motor areas and the OFC regions prior to the trial characterized responders (p<0.05, false discovery rate). The treatment non-responders were characterized by higher OFC-cerebellum connectivity. The strength of response was positively correlated with functional coupling between left OFC and the caudate nuclei and thalami. Differences in longitudinal changes were detected between venlafaxine and mirtazapine treatment in the motor areas, cerebellum, cingulate gyrus and angular gyrus. These results indicate that OFC functional connectivity might be useful as a marker for therapy response to mirtazapine and venlafaxine and to reconstruct the differences in their mechanism of action.

Prevalence of N-Methyl-d-Aspartate Receptor antibody (NMDAR-Ab) encephalitis in patients with first episode psychosis and treatment resistant schizophrenia on clozapine, a population based study.

INTRODUCTION: N-methyl-d-aspartate receptor antibody (NMDAR-Ab) encephalitis consensus criteria has recently been defined. We aimed to examine the prevalence of NMDAR-Ab encephalitis in patients with first episode psychosis (FEP) and treatment resistant schizophrenia (TRS) on clozapine, using clinical investigations, antibody testing and to retrospectively apply diagnostic consensus criteria. METHODS: Adult (18-65 years old) cases of FEP meeting inclusion criteria were recruited over three years and assessed using the Structured Clinical Interview for DSM-IV disorders (SCID). NMDAR-Ab was identified using a live cell-based assay (L-CBA). Seropositive cases were clinically investigated for features of encephalitis including neuro-imaging, EEG and CSF where possible. Serum was retested using immunohistochemistry (IHC) as part of diagnostic criteria guidelines. A cohort of patients with TRS was also recruited. RESULTS: 112 FEP patients were recruited over 3 years. NMDAR-Ab seroprevalence was 4/112 (3.5%) cases. One case (<1%) was diagnosed with definite NMDAR-Ab encephalitis and treated with immunotherapy. One of the three other seropositive cases met criteria for probable encephalitis. However all three were ultimately diagnosed with mood disorders with psychotic features. None have developed neurological features at three year follow up. 1/100 (1%) of patients with TRS was 100 patients with TRS were recruited. One case (1%) seropositive for NMDAR-Ab but did not meet criteria for encephalitis. CONCLUSIONS: NMDAR-Ab encephalitis as defined by consensus guidelines occured rarely in psychiatric services in this study. Further studies are needed to establish pathogenicity of serum NMDAR-Ab antibodies. Psychiatric services should be aware of the clinical features of encephalitis.

Beyond the critical period: longitudinal study of 8-year outcome in first-episode non-affective psychosis.

BACKGROUND: The critical period hypothesis proposes that deterioration occurs aggressively during the early years of psychosis, with relative stability subsequently. Thus, interventions that shorten the duration of untreated psychosis (DUP) and arrest early deterioration may have long-term benefits. AIMS: To test the critical period hypothesis by determining whether outcome in non-affective psychosis stabilises beyond the critical period and whether DUP correlates with 8-year outcome; to determine whether duration of untreated illness (DUI) has any independent effect on outcome. METHOD: We recruited 118 people consecutively referred with first-episode psychosis to a prospective, naturalistic cohort study. RESULTS: Negative and disorganised symptoms improved between 4 and 8 years. Duration of untreated psychosis predicted remission, positive symptoms and social functioning at 8 years. Continuing functional recovery between 4 and 8 years was predicted by DUI. CONCLUSIONS: These results provide qualified support for the critical period hypothesis. The critical period could be extended to include the prodrome as well as early psychosis.

Neurological signs and involuntary movements in schizophrenia: intrinsic to and informative on systems pathobiology.

While it has long been considered whether the pathobiology of schizophrenia extends beyond its defining symptoms to involve diverse domains of abnormality, in the manner of a systemic disease, studies of neuromotor dysfunction have been confounded by treatment with antipsychotic drugs. This challenge has been illuminated by a new generation of studies on first-episode schizophrenia before initiation of antipsychotic treatment and by opportunities in developing countries to study chronically ill patients who have remained antipsychotic naive due to limitations in provision of psychiatric care. Building from studies in antipsychotic-naive patients, this article reviews 2 domains of neuromotor dysfunction in schizophrenia: neurological signs and involuntary movements. The presence and characteristics of neurological signs in untreated vis-à-vis treated psychosis indicate a vulnerability marker for schizophrenia and implicate disruption to neuronal circuits linking the basal ganglia, cerebral cortex, and cerebellum. The presence and characteristics of involuntary movements in untreated vis-à-vis treated psychosis indicate an intrinsic feature of the disease process and implicate dysfunction in cortical-basal ganglia-cortical circuitry. These neuromotor disorders of schizophrenia join other markers of subtle but pervasive cerebral and extracerebral, systemic dysfunction, and complement current concepts of schizophrenia as a disorder of developmentally determined cortical-basal ganglia-thalamo-cortical/cerebellar network disconnectivity.

Suicidality in first episode psychosis.

Many studies have confirmed that the risk of suicide is high in the period after first presentation. There is relatively little information about the risk of suicide using illness onset as the starting point. We assessed suicidality in a cohort of 166 individuals from an urban catchment area during the period of untreated psychosis and at 4 year follow up. Nearly 10% of individuals attempted suicide prior to presentation. Four years later 18% had made a suicide attempt and 3% completed suicide. Suicide attempts prior to presentation were associated with a longer duration of untreated psychosis.

Diagnostic specificity and predictors of neurological soft signs in schizophrenia, bipolar disorder and other psychoses over the first 4 years of illness.

BACKGROUND: Neurological soft signs (NSS) are well described among patients with schizophrenia, the neurology of other psychoses is relatively unexplored and few comparative studies have prospectively examined these signs in first-episode patients. METHODS: We assessed neurological functioning in 242 patients presenting with a first episode of psychosis (in accordance with DSM-IV diagnosis) using the Condensed Neurological Examination (CNE). We sought to determine whether NSS were specific to patients with schizophrenia, bipolar affective disorder and other forms of psychosis. We also examined the factors associated with and predictive of neurodysfunction at first presentation and at 4 year follow-up. RESULTS: NSS were not specific to any diagnostic group. Neurological functioning was closely associated with psychopathology and mixed-handedness at first presentation. At follow-up there was a statistically significant improvement in neurological functioning. Persistent neurodysfunction at this stage was related to enduring negative symptoms and associated with poorer outcome. DISCUSSION: Schizophrenia and bipolar disorder are indistinguishable in terms of neurodysfunction at presentation. At presentation and 4 years NSS closely parallel psychopathology and mixed-handedness indicating that NSS may be a function of these factors or possibly an independent factor operates equally upon both symptoms and neurological function.

Diagnostic stability four years after a first episode of psychosis.

OBJECTIVE: The objective of this study was to determine the stability of a diagnosis of psychosis four years after the first-episode diagnosis. METHODS: The study was a prospective four-year follow-up study (1995 to 1999) of 147 patients with schizophrenia, affective disorder, and other psychoses who presented with a first episode of psychosis in an epidemiologic catchment area in Ireland. All diagnoses were made on the basis of the Structured Clinical Interview for DSM-IV. RESULTS: One quarter of the patients evidenced a change in diagnosis at follow-up. The most common change was to a diagnosis of schizophrenia. The positive predictive values of schizophrenia and bipolar affective disorder were 97 percent and 80 percent, respectively. Fewer years spent in education, lower levels of initial psychopathology, and presence of comorbid alcohol or substance abuse were associated with change in diagnosis at follow-up. CONCLUSIONS: Among the diagnoses studied, schizophrenia was the most stable diagnosis after four years. The greatest instability occurred in the categories of drug-induced psychosis and psychosis not otherwise specified.

Prospective relationship of duration of untreated psychosis to psychopathology and functional outcome over 12 years.

BACKGROUND: The duration of untreated psychosis is well recognised as an independent predictor of symptomatic and functional outcome in the short term and has facilitated the development of worldwide early intervention programmes. However, the extent and mechanisms by which it might influence prognosis beyond a decade remain poorly understood. METHODS: The authors examined the relationship between duration of untreated psychosis and outcome 12years after a first episode of psychosis and assessed whether its relationship with function is affected by symptoms in a prospective, 12-year follow-up of an epidemiologically-based inception cohort. RESULTS: Longer duration of untreated psychosis predicted poorer remission status, more severe positive and negative symptoms, and greater impairment in general functioning, social functioning and quality of life at 12years on standardised measures, independent of other factors at baseline. It was not associated with gainful employment, for which education was the only predictor, or independent living, for which age was the only predictor. The relationship between duration of untreated psychosis and functional outcome was mediated by concurrent psychopathology, particularly negative symptoms. CONCLUSIONS: These results provide qualified support for the potential long-term benefit of reduction in the duration of untreated psychosis in terms of improvement in symptoms and functional outcome. Its failure to predict real-life outcomes such as independent living and gainful employment could reflect the importance of pre-existing socio-cultural factors such as individual opportunity. The relationship between duration of untreated psychosis and negative symptoms was largely responsible for its effect on function, suggesting a possible long-term protective mechanism against disability.

Two-year study of the use of neuroimaging in a psychiatric inpatients unit.

OBJECTIVES: Neuroimaging is being used increasingly in the investigation of psychiatric disorders. Previous studies have found abnormalities in about two-thirds of all scans done in psychiatry. The aim of our study was to investigate the use of CT and MRI in the management of inpatients in psychiatry department Adelaide & Meath hospital, Tallaght and to examine the relationship between diagnosis and abnormalities seen on scans. METHOD: We did a two-year retrospective study of all inpatient referrals for CT scans/MRI scans. A case note review of bio-demographic data, diagnosis, relevant medical history, substance misuse history, indication for tests and results of scans was done. We found that 66 CTs and MRI scans were done over the study period. RESULTS: Fourteen (21%) of the scans had abnormal results which were mostly atrophic changes. Of the 14 abnormal scans, seven had abnormal findings on neurological examination. We found a lower number of abnormal scans compared to previous studies. CONCLUSIONS: Radiological abnormalities were not disease specific. We wish to propose guidelines on the indications for using neuroimaging in psychiatric patients.

Combined antipsychotic use in a community rehabilitation psychiatric service.

OBJECTIVES: Despite the clinical guidelines regarding the use of combined antipsychotics and the limited evidence for its benefits, use remains high in psychiatric practice. The aim of this study was to examine prescribing practices and investigate reasons for initiating and continuing combined antipsychotics in stable psychiatric illnesses. METHOD: A cross-sectional case record survey of antipsychotic prescribing practices in a community psychiatric rehabilitation service. A total sample (n = 75) of patients with chronic and enduring psychiatric illnesses was studied. The age, gender, diagnosis and prescribed antipsychotics were examined. The proportional prevalence and documented reasons for combined antipsychotic prescribing were analysed. RESULTS: Seventy-three of the 75 patients were prescribed antipsychotic mediations. Of these, 44 (60%) received a combination of two or more antipsychotics. The most common reason for combined prescribing was a switch of antipsychotic (n = 18; 41%). No reason was documented in 19 cases (43%). CONCLUSIONS: In this study, slow cross-tapering or incomplete switch process of antipsychotics contributed to the prolonged period of combined antipsychotics treatment. Adequate documentation regarding indication and review of medications cannot be overemphasized.

Tardive dyskinesia on low dose risperidone.

Tardive dyskinesia is a neurological disorder characterised by involuntary and purposeless movements affecting any part of the body. These movements typically occur in the oro-facial area and the patient is usually unaware of them. There are inconsistent findings in the literature on the risk factors for developing tardive dyskinesia. Nevertheless, previous reports indicate that tardive dyskinesia is more common in female patients, patients with a history of alcohol and substance misuse, affective disorders, and intellectual disability. The dose, class and duration of antipsychotic nmedication may also be independent risk factors. We report on the case of a patient who developed tardive dyskinesia on a low dose of the second generation antipsychotic risperidone.

Lifetime history of substance misuse in first-episode psychosis: prevalence and its influence on psychopathology and onset of psychotic symptoms.

INTRODUCTION: Substance misuse (SM) (drug/alcohol dependence or abuse) in psychotic illness is an increasingly recognized problem. We aimed to estimate the prevalence and examine the influence of SM on age at onset of psychosis and psychopathology among patients with first-episode psychosis. METHOD: One hundred seventy-one consecutive patients with first-episode psychosis were assessed. SM, age of onset of psychosis and psychopathology were determined using valid instruments. RESULTS: Seventy-seven (46%) patients had a lifetime history of SM and were predominately males, had more positive symptoms, and in the majority of cases (84%), started misusing substances before the onset of psychosis (SM-BP). There was no difference in age of onset between patients with SM-BP and the rest of the sample. CONCLUSION: Lifetime history of SM is common and may influence psychopathology, but does not appear to influence or bring forward the age at onset of psychotic symptoms.

Violence and aggression in the Drug Treatment Centre Board.

OBJECTIVES: We sought to determine the prevalence of and the factors associated with violent and aggressive incidents among clients attending an out-patient methadone stabilisation and detoxification programme in Dublin. METHODS: We retrospectively examined all incident report forms over a two-year period. We also obtained information on demographics, main drug of abuse, timing and location of the incident as well as psychiatric and physical comorbidity among the perpetrators from case note review. RESULTS: Two hundred and ninety-five incidents occurred over the study period. The overall rate of violence and aggression was 85 per 1,000 clients attending the centre per year. Most incidents involved verbal abuse. Females were significantly more likely to be involved in assaults compared to males. A high proportion of clients (80%) who were physically aggressive tested positive for benzodiazepine medication. CONCLUSIONS: Levels of recorded violence have remained stable however racial abuse has increased in recent years. The relatively low overall rate of violence suggests that existing measures have helped reduce the number of aggressive and violent incidents in the centre. Most of the victims were either doctors, nursing staff or general assistants. This finding reflected their respective roles in the centre, which included limit setting and dealing with positive drug screens among clients.

Delusions or obsessions: the same only different? A case report.

The phenomenological distinction between delusions and obsessions has been the subject of much debate in psychiatry. Some authors feel these symptoms are distinct nosological entities, while others argue that they reflect manifestations of the same symptom and are distinguishable on the basis of the level of insight a patient displays. In this report we describe the case history of a lady who presented with an obsessional disorder. The symptom was resistant to standard treatments and subsequently became more delusional in nature. We review the literature in terms of the classification of obsessions and delusions and offer assistance to clinicians in terms of the diagnosis and treatment of cases where the distinction between these phenomena is not clear and offer alternative means of classifying these symptoms based on insight.

Untreated illness and outcome of psychosis.

BACKGROUND: There has been controversy as to whether early intervention in psychosis can improve the outcome of the disorder. AIMS: To establish if there is an association between duration of untreated psychosis and the 4-year outcome of persons with a first episode of psychosis. METHOD: Prospective naturalistic follow-up study of the outcome of consecutive first presentations with DSM-IV psychosis attending a community-based psychiatric service. RESULTS: A longer duration of untreated psychosis was associated with a significantly poorer functional and symptomatic outcome 4 years later. For schizophrenia and schizophreniform disorder, each increment in duration of untreated psychosis was associated with a 7.8 point decrease in global functioning and an increase in positive symptoms scores by 1.9 points. CONCLUSIONS: This study extends the findings of short-term follow-up studies by confirming an association between duration of untreated psychosis and 'mid-term' outcome.

Mental illness in migrants: diagnostic and therapeutic challenges.

We describe the case of a 30 year old Chinese woman who presented to an Irish psychiatric service with a five-month history of somatic delusions, auditory hallucinations and denial of lineage. We utilise this case to illustrate the significant cultural influences on psychopathology. We discuss the increasingly frequent diagnostic and therapeutic challenges presented by migrants with mental illness.

Systematic comparison of subjective and objective measures of quality of life at 4-year follow-up subsequent to a first episode of psychosis.

There is enduring debate about the validity of subjective measures of quality of life derived from people with psychiatric disorders and particularly from those with psychosis. We evaluated patients with established psychosis 4 years after their first episode. We compared subjective and objective measures of quality of life and evaluated the influence of insight on the individual's interpretation of their quality of life. Subjective measures of quality of life were derived using the World Health Organization Quality of Life Scale-Brief Version, and objective measures of quality of life were derived using the Quality of Life Scale by Heinrichs et al. We measured Insight using the Insight Scale. There were robust correlations between subjective and objective assessments of quality of life. This was most marked for psychological symptoms. Self-report measures are valid and should form part of the overall assessment of quality of life among patients with psychotic disorders.