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.

Homocysteine level in schizophrenia patients.

OBJECTIVE: Elevated serum levels of homocysteine have been shown to be associated with schizophrenia in some studies, but the evidence is still limited and mixed. The aim of the present study was therefore to evaluate the serum homocysteine level in Chinese in schizophrenia patients and assess its association with clinical phenotypes of the disease. METHOD: A total of 250 inpatients and 250 healthy controls were identified at Kowloon Hospital and the Red Cross Blood Donation Centre, respectively. Each subject was evaluated with a structured diagnostic interview. Demographic data were collected and blood was analysed for homocysteine level. The Positive and Negative Syndrome Scale was used to grade clinical symptoms of schizophrenia. Confounding factors affecting homocysteine levels were controlled by strict exclusion criteria or statistical methods. RESULTS: Serum homocysteine level was elevated in Chinese schizophrenia patients. Both male (mean, 12.26 micromol L(-1); control, 11.40 micromol L(-1), p = 0.026) and female (mean, 9.61 micromol L(-1); control, 8.33 micromol L(-1), p < 0.001) patients had a higher serum homocysteine level than the healthy controls, and these differences persisted after controlling for age. There was no significant association between serum homocysteine level and duration of illness, clinical symptoms or age of onset of schizophrenia. CONCLUSION: The serum homocysteine levels were elevated in both male and female Chinese schizophrenia patients. The levels were not apparently related to other clinical parameters.

Dense cranial electroacupuncture stimulation for major depressive disorder--a single-blind, randomized, controlled study.

BACKGROUND: Previous studies suggest that electroacupuncture possesses therapeutic benefits for depressive disorders. The purpose of this study was to determine whether dense cranial electroacupuncture stimulation (DCEAS) could enhance the antidepressant efficacy in the early phase of selective serotonin reuptake inhibitor (SSRI) treatment of major depressive disorder (MDD). METHODS: In this single-blind, randomized, controlled study, patients with MDD were randomly assigned to 9-session DCEAS or noninvasive electroacupuncture (n-EA) control procedure in combination with fluoxetine (FLX) for 3 weeks. Clinical outcomes were measured using the 17-item Hamilton Depression Rating Scale (HAMD-17), Clinical Global Impression-severity (CGI-S), and Self-rating Depression Scale (SDS) as well as the response and remission rates. RESULTS: Seventy-three patients were randomly assigned to n-EA (n = 35) and DCEAS (n = 38), of whom 34 in n-EA and 36 in DCEAS group were analyzed. DCEAS-treated patients displayed a significantly greater reduction from baseline in HAMD-17 scores at Day 3 through Day 21 and in SDS scores at Day 3 and Day 21 compared to patients receiving n-EA. DCEAS intervention also produced a higher rate of clinically significant response compared to n-EA procedure (19.4% (7/36) vs. 8.8% (3/34)). The incidence of adverse events was similar in the two groups. CONCLUSIONS: DCEAS is a safe and effective intervention that augments the antidepressant efficacy. It can be considered as an additional therapy in the early phase of SSRI treatment of depressed patients. TRIAL REGISTRATION: Controlled-Trials.com ISRCTN88008690.

Reasons for preferring a primary care physician for care if depressed.

BACKGROUND: Most studies showed that patients would first go to their primary care physicians (PCPs) when depressed. This choice is probably due to PCP being the entry point into the health care system. We studied the general population's initial choice of mental care in Hong Kong, where patients were unclear about family medicine and free to choose doctors of any specialty. METHODS: A combined qualitative and quantitative approach was adopted. We held focus groups with participants recruited from community centers and a telephone survey with adults ages 18 or above randomly selected from the domestic telephone directory. RESULTS: Of 1,647 adults successfully interviewed, 49.0% would seek help from their regular PCP, 19.3% from psychiatrists, 4.8% from any doctors, 16.5% from non-medical resources; 6.9% would not seek any help, and 3.5% were uncertain of what to do. Those who did not seek any help were more likely to be male or without regular doctors. The focus group participants highlighted the stigmatizing effect of consulting psychiatrists and expressed strong expectation of empathic relationship, time, and communication skills from their care providers. Some participants were not aware that PCP could manage mental illness. CONCLUSIONS: Given free choice of health care service, most people would first consult their regular doctors for treatment of depression specifically because of better relationship and no stigmatization. To draw depressed patients to seek help, especially from primary care, public education of the PCPs role in mental health should be promoted, and the PCPs could demonstrate their empathy and listening skills to patients.

Three-year outcome of phase-specific early intervention for first-episode psychosis: a cohort study in Hong Kong.

AIM: Although phase-specific early intervention for first-episode psychosis has been implemented in many different parts of the world, limited medium-term outcome data are available in non-Western populations with relatively low mental health resources. The study aimed to determine the effectiveness of phase-specific early intervention in first-episode psychosis. METHOD: In this cohort study, we compared the 3-year outcome of 700 first-episode psychosis patients who received phase-specific early intervention with that of 700 patients matched for age, sex and diagnosis who received standard psychiatric care prior to early intervention. Using a structured data acquisition procedure, we determined functional outcome, symptom levels, relapse, recovery, suicidal behaviour and service utilization from clinical records. RESULTS: Patients in the early intervention group had longer full-time employment or study (P<0.001), fewer days of hospitalization (P<0.001), less severe positive symptoms (P=0.006), less severe negative symptoms (P =0.001), fewer suicides (P=0.009) and fewer disengagements (P=0.002) than the historical control group. Additionally, more patients in the early intervention group experienced a period of recovery (P=0.001), but the two groups had similar rates of relapse (P=0.08) and durations of untreated psychosis (P=0.72). CONCLUSIONS: The 3-year outcome in phase-specific early intervention compared favourably with that of standard psychiatric care, particularly with respect to functional outcome and reduction in hospitalizations, suicides and disengagements. However, intervention did not appear to reduce the rate of relapse.

How do patients choose their doctors for primary care in a free market?

AIMS: A recent trend in health care system is to provide more choices to the patients. This study surveyed the general public's choices for primary care in Hong Kong which has the setting of free choices for private or public service and also direct access to specialists. METHODS: We used a combined qualitative and quantitative approach. We held five focus group interviews with participants of different socio-economic categories. Information from the focus groups helped to design a questionnaire for random telephone interviews with members of the public aged 18 or above. RESULTS: There were 37 participants in the focus groups and 1647 respondents in the telephone survey. The most important factor for choosing a doctor was proximity to home or workplace, followed by quick relief from the illness. Once continuity of care had been established, distance was of less importance but comprehensive care was valued. Nearly 70% of the public had regular doctors. About 93% of the public would consult specialists directly when they thought they needed a specialist's opinion. Nearly 30% chose specialists for any medical care and 38% preferred specialists to also look after their primary care problems. CONCLUSION: Convenient accessibility was the most important factor for the initial choice of primary care doctors by the general public. The perceived clinical proficiency of the doctor determined future continuity of care. Patients liked to have direct access to specialists. Though some chose to see the specialists even for primary care problems, most people had regular doctors who were likely to have the attributes of family doctors.

The effectiveness and safety of acupuncture therapy in depressive disorders: systematic review and meta-analysis.

BACKGROUND: Although acupuncture has been used as an alternative treatment for depressive disorders, its effectiveness and safety are not well defined. The purpose of this systematic review with meta-analysis was to evaluate the effectiveness of acupuncture as monotherapy and as an additional therapy in treating various depressive conditions, particularly major depressive disorder (MDD) and post-stroke depression (PSD). METHODS: Following systematic review, meta-analysis was conducted on high-quality randomized controlled trials (RCTs). RESULTS: Of 207 clinical studies of acupuncture for various depression retrieved, 113 (54.6%) were on MDD and 76 (36.7%) on PSD. Twenty RCTs of MDD (n=1998) and 15 of PSD (n=1680) identified for high-quality protocol (Jadad score >or=3) were included for meta-analysis. The efficacy of acupuncture as monotherapy was comparable to antidepressants alone in improving clinical response and alleviating symptom severity of MDD, but not different from sham acupuncture. No sufficient evidence favored the expectation that acupuncture combined with antidepressants could yield better outcomes than antidepressants alone in treating MDD. Acupuncture was superior to antidepressants and waitlist controls in improving both response and symptom severity of PSD. The incidence of adverse events in acupuncture intervention was significantly lower than antidepressants. CONCLUSIONS: Acupuncture therapy is safe and effective in treating MDD and PSD, and could be considered an alternative option for the two disorders. The efficacy in other forms of depression remains to be further determined.