Effectiveness of a mindfulness-based intervention for persons with early psychosis: A multi-site randomized controlled trial.

BACKGROUND: The Mindfulness Ambassador Program (MAP) is a group-based, facilitated mindfulness-based intervention (MBI). We sought to determine the effectiveness of MAP on reducing negative psychotic symptoms and enhancing mindfulness skills among persons experiencing early psychosis. METHODS: We conducted a pragmatic randomized controlled trial (RCT) at three early psychosis intervention (EPI) programs in Ontario, Canada. Participants (N = 59) were randomly assigned to receive MAP (n = 29) for 1-hour weekly sessions over 3 months, or to treatment as usual (TAU, n = 30). Assessments were conducted at baseline, 3 months, and 6 months using the Self-Evaluation of Negative Symptoms (SNS) and Kentucky Inventory of Mindfulness Skills (KIMS). Linear mixed methods were used to assess the joint effects of group and time. RESULTS: At 3 months, participants who received MAP (n = 17) demonstrated greater reductions on the SNS relative to TAU (n = 15), which were clinically and statistically significant (-4.1; 95%CI -7.5, -0.7; p = 0.019). At 6 months, the difference between MAP (n = 10) and TAU (n = 13) was no longer statistically significant (-1.2; 95%CI -5.2,2.7; p = 0.54). On the KIMS, no significant effects were found at 3 months (+0.3; 95%CI -2.0,2.5; p = 0.82) or 6 months (+0.4; 95%CI -2.2,2.9; p = 0.79). CONCLUSIONS: We conducted one of the first multi-site RCTs of a MBI for early psychosis. Our findings indicated that MAP was more effective in reducing negative symptoms compared to TAU in the short term. Earlier reductions in negative psychotic symptoms may help facilitate recovery in the long term.

A pilot study of participatory video in early psychosis: Qualitative findings.

For people with psychotic disorders, developing a personal narrative about one's experiences with psychosis can help promote recovery. This pilot study examined participants' reactions to and experiences of participatory video as an intervention to help facilitate recovery-oriented narrative development in early psychosis. Outpatients of an early psychosis intervention program were recruited to participate in workshops producing short documentary-style videos of their collective and individual experiences. Six male participants completed the program and took part in a focus group upon completion and in an individual semistructured interview three months later. Themes were identified from the focus group and interviews and then summarized for descriptive purposes. Prominent themes included impacts of the videos on the participants and perceived impacts on others, fulfilment from sharing experiences and expressing oneself, value of collaboration and cohesion in a group, acquiring interpersonal and technological skills, and recommendations for future implementation. Findings of this study suggest that participatory video is an engaging means of self-definition and self-expression among young people in recovery from early psychosis.

Meaning-Centered Men's Groups: Initial Findings of an Intervention to Enhance Resiliency and Reduce Suicide Risk in Men Facing Retirement.

Objectives: To assess the preliminary effectiveness of Meaning-Centered Men's Groups (MCMG), a 12-session existentially-oriented, community-based, psychological group intervention designed to enhance psychological resiliency and prevent the onset or exacerbation of suicide ideation among men who are concerned about or struggling with the transition to retirement.Methods: We recruited 30 men (n= 10 per group), 55 years and older (M= 63.7, SD= 4.1) from community settings to participate in a course of MCMG to be delivered in a community center. Participants completed eligibility, pre-, mid-, and post-group assessments of suicide ideation and psychological risk and resiliency factors.Results: Participants experienced significant increases in attitudinal sources of meaning in life, psychological well-being, life satisfaction, retirement satisfaction, and general health, and decreases in depression, hopelessness, loneliness, and suicide ideation.Conclusions: Preliminary findings suggest that MCMG is a novel men's mental health intervention that may help to enhance psychological well-being and potentially reduce the severity or prevent the onset of symptoms of depression, hopelessness, and suicide ideation.Clinical Implications: Upstream psychological interventions may serve an important role in mental health promotion and suicide prevention with potentially vulnerable individuals facing challenging life transitions.

Youth-focused group mindfulness-based intervention in individuals with early psychosis: A randomized pilot feasibility study.

AIM: To assess the feasibility of a randomized pilot trial that evaluated the acceptability and potential clinical utility of the Mindfulness Ambassador Program (MAP), a unique, standardized 12-session facilitated group mindfulness-based intervention (MBI) for youth experiencing early psychosis. METHODS: Twenty-one patients of an early psychosis intervention program were randomized to receive MAP (n = 11) or treatment as usual (n = 10). Acceptability was measured by group attendance rate and client satisfaction; feasibility of the study design was measured by the recruitment and retention rate. The means, standard deviations, and 95% confidence intervals were described for outcomes of interest. RESULTS: MAP is associated with a high degree of acceptability and has beneficial effects for depression and fatigue. The randomized trial design is feasible. CONCLUSIONS: This study provides important pilot data supporting a larger randomized trial of effectiveness for MAP as a group MBI for early psychosis. Details of MAP and study limitations are discussed.

Understanding the role of the family physician in early psychosis intervention.

BACKGROUND: The family physician is key to facilitating access to psychiatric treatment for young people with first-episode psychosis, and this involvement can reduce aversive events in pathways to care. Those who seek help from primary care tend to have longer intervals to psychiatric care, and some people receive ongoing psychiatric treatment from the family physician. AIMS: Our objective is to understand the role of the family physician in help-seeking, recognition and ongoing management of first-episode psychosis. METHOD: We will use a mixed-methods approach, incorporating health administrative data, electronic medical records (EMRs) and qualitative methodologies to study the role of the family physician at three points on the pathway to care. First, help-seeking: we will use health administrative data to examine access to a family physician and patterns of primary care use preceding the first diagnosis of psychosis; second, recognition: we will identify first-onset cases of psychosis in health administrative data, and look back at linked EMRs from primary care to define a risk profile for undetected cases; and third, management: we will examine service provision to identified patients through EMR data, including patterns of contacts, prescriptions and referrals to specialised care. We will then conduct qualitative interviews and focus groups with key stakeholders to better understand the trends observed in the quantitative data. DISCUSSION: These findings will provide an in-depth description of first-episode psychosis in primary care, informing strategies to build linkages between family physicians and psychiatric services to improve transitions of care during the crucial early stages of psychosis. DECLARATION OF INTEREST: None.

An examination of components of recovery after five years of treatment in an early intervention program for psychosis.

Recovery from psychotic disorders includes both symptomatic and functional components. Progress in understanding recovery requires careful replication and extension of findings using comparable measures. In the current paper, we present a study of five year recovery rates in an early intervention program in London, Canada with the same operational criteria as those used in a previous report from the OPUS cohort in Denmark. Our analysis extends the OPUS reports by including additional potential predictors of overall recovery, such as cognitive functioning, adherence to medication and early social support, and examining rates and predictors of individual components of recovery at five year follow-up. Consistent with reports from OPUS, we found younger age of onset and lower initial severity of negative symptoms to predict greater likelihood of overall recovery. Different patterns of predictors emerge when we examine individual components of recovery. Adherence to medication during the first year was the sole independent predictor of remission of positive symptoms, while early social adjustment and social support were more likely to predict negative symptom and functional aspects of recovery at five years. Cognitive functioning, as represented by IQ, did not predict any aspects of recovery. Our findings suggest the importance of examining the predictors of individual components in the quest to improve overall recovery.

Untreated illness and recovery in clients of an early psychosis intervention program: a 10-year prospective cohort study.

PURPOSE: To investigate whether duration of untreated psychosis (DUP) and duration of untreated illness (DUI) are associated with measures of both subjective and objective recovery 10 years after a first episode of psychosis. METHODS: A cohort of 65 clients from an early psychosis intervention program completed a battery of outcome measures 10 years following initial treatment for first-episode psychosis (FEP). The outcomes of interest were self-perceived recovery scores (Maryland Assessment of Recovery in People with Serious Mental Illness Scale) and occupational activity, defined as engagement in work and/or school on a full/part-time basis. Multiple linear and logistic regression analyses were used to estimate the associations between DUP and DUI with each measure of recovery, adjusting for potential confounding factors. RESULTS: We did not find a statistically significant association between DUP and either occupational activity (OR = 1.26, 95% CI 0.81-1.95) or self-perceived recovery score (ß = - 0.73, 95% CI - 2.42 to 0.97). However, we found a significant negative association between DUI and self-perceived recovery score (ß = - 0.52, 95% CI - 0.87 to - 0.16). CONCLUSIONS: Our findings suggest that DUI may have a stronger influence than DUP on recovery from FEP at 10-year follow-up. This suggests the potential value in targeted interventions for people with a long DUI to increase the likelihood of achieving recovery after the first episode of psychosis.

Stability of outcomes after 5 years of treatment in an early intervention programme.

AIM: It has been hypothesized that the first 5 years are critical in determining long-term recovery from psychotic disorders. We examine stability in recovery indices after 5 years for 56 patients treated in an early intervention programme for psychosis. METHODS: Assessments of symptom remission and functional recovery were carried out 5 and 10 years after initiation of treatment. RESULTS: Although overall rates of recovery were comparable at both times, there were significant changes for individuals reflecting both improvement and deterioration. CONCLUSIONS: Evidence concerning the critical period hypothesis should examine stability in individuals rather than relying on cumulative indices.

The differential effects of a focus on symptoms versus recovery in reducing stigma of schizophrenia.

PURPOSE: We extend investigations of the impact of the content of video contact with an individual with schizophrenia on stigma reduction. We examine whether differential impacts persist over a 2-week period and the extent to which they are mediated by perceived similarity and feelings of empathy and/or sympathy. METHOD: We used a randomized control trial wherein participants were exposed to a video in which an individual described his recovery from schizophrenia, or the same person described acute symptoms of schizophrenia, or a no-video control condition. Outcomes included impressions of and preferred social distance to the person in the video and people in general with schizophrenia and well as perceptions of similarity and feelings of sympathy and empathy. We also measured an overt behaviour, seating distance, at 2-week follow-up. RESULTS: The recovery-focused material was generally more effective in improving impressions and reducing preferred level of social distance. Although the symptom-focused video resulted in great sympathy for the person, this did not translate into positive impressions or reduced social distance. Mediational analyses yielded findings consistent with the benefits of the recovery video being mediated by increased perceptions of similarity and lower feelings of sympathy. Exposure to the recovery-focused video resulted in less anxiety in anticipation of meeting the person in the video relative to the control condition. CONCLUSIONS: Video contact emphasizing potential for recovery from schizophrenia was more effective in reducing stigmatizing responses than contact highlighting acute symptoms. Increased sympathy does not necessarily translate into reductions in stigma.

Determinants of self-esteem in early psychosis: The role of perceived social dominance.

Self-esteem plays a role in the formation and maintenance of symptoms and in the recovery from psychotic illness. This study examines the relative contribution of perceived social dominance and other known predictors in determining self-esteem in 102 individuals in an early intervention program for psychosis. Regression analysis demonstrated that scores on the Perceived Relational Evaluation Scale (PRES), depressed mood, social dominance, gender and positive symptoms significantly contributed to the prediction of scores on the Rosenberg Self-esteem Scale (RSES), whereas self-stigma and negative symptoms did not. Our study suggests that low self-esteem in early psychosis can be understood in part as a reflection of low levels of perceived social value and status.

Prevention and Early Intervention Program for Psychoses (PEPP).

The Prevention and Early Intervention Program for Psychoses (PEPP) was established in 1997 for individuals with first-episode non-affective psychotic disorder. The objectives of PEPP are to improve outcomes for clients by providing a prompt, comprehensive, coordinated and effective treatment program as well as to advance research concerning early intervention for psychotic disorders. This article describes the clinical and research program and the lessons learned.

The course of negative symptoms over the first five years of treatment: Data from an early intervention program for psychosis.

BACKGROUND: Cross-sectional studies suggest that negative symptoms are constituted by separable domains of reduced expressiveness and reduced motivation, but there is little data on the longitudinal course of these symptoms. We examined evidence for differences in the course and correlates of these two domains in a prospective study of patients presenting with a first episode of psychosis. METHODS: Of 132 patients who were followed up for five years, it was possible to monitor reduced expressiveness and motivation on a weekly basis for 127. Information on treatment delay, premorbid adjustment, intellectual functioning, anxiety, depression and psychosocial functioning were also collected. RESULTS: Over the five year follow-up, symptoms of reduced motivation occurred in 95.3% of patients and reduced expressiveness in 68.5%; and deficits in motivation were more likely to be unremitting (15.7%) than expressive deficits (5.5%). There were differences in the correlates of the proportion of time each patient experienced symptoms of each domain. Depression, weeks of full time occupation and weeks on a disability pension were associated with both domains. Anxiety was associated only with diminished motivation. Lower performance IQ; extrapyramidal symptoms (EPS) and dysrhythmic EEG were associated only with proportion of time showing reduced expressiveness. CONCLUSIONS: The prospective data support previous cross-sectional findings that, while these domains of negative symptoms are correlated, they do show differences in prevalence over time and in their correlates.

Negative future self as a mediator in the relationship between insight and depression in psychotic disorders.

Awareness of illness in psychotic disorders is associated with better clinical outcomes, but also poorer psychological well-being. This is known as "The Insight Paradox". Understanding of the paradox has focused on the role of self-stigma. This study examines possible future self as a mediator in the relationship between insight and depression in 102 individuals in an early intervention program for psychosis. Mediation analysis demonstrated that negative possible self was the sole significant independent mediator in a model which included self-stigma. Our study shows that awareness of mental illness and perception that it will negatively impact future self increases likelihood of depression.

Cognition and the prediction of functioning in patients with a first treated episode of psychosis: a prospective study.

Past research on the role of cognitive performance in predicting later psychosocial functioning for individuals with first treated episode of a psychotic disorder has yielded inconsistent results. Several factors have been suggested as determining the strength of any such relationship including the type of functioning measured, time of the cognitive assessment, covariates included and the use of global versus specific measures of cognitive functioning. In the current study, we examined the importance of these factors in a five year prospective study of individuals with first episode psychotic disorders. Just over 80% of the sample had a schizophrenia spectrum disorder. Cognitive assessments were carried out after initiation of treatment on 113 patients, and at one year for 79 patients. There was evidence that cognition predicted occupational functioning and use of a disability pension, but not a summary index of functioning or use of supervised housing, at follow-up. Overall I.Q. was a more consistent predictor than measures of specific cognitive functions, and there was evidence that cognition assessed after presentation for treatment, particularly after a year of treatment, was more predictive of later functioning than premorbid I.Q. Cognitive functioning, however, did not add to the prediction of outcomes beyond the level possible using past educational achievement or academic premorbid adjustment.

The prognostic significance of early remission of positive symptoms in first treated psychosis.

We examine the relationship between achieving remission of positive symptoms within 3 months in first episode psychosis and outcomes 5 years later. Time to remission of positive symptoms, other early characteristics and 5 year outcomes were assessed in a prospective study of 132 patients being treated for the first time for a psychotic disorder. Just under 60% of patients showed remission of positive symptoms within 3 months. In comparison to later remitters, they showed lower levels of positive symptoms, greater likelihood of competitive employment and less likelihood of collecting a disability pension at 5 years. Earlier remission of positive symptoms may have prognostic significance for longer term outcomes.

Research experience in psychiatry residency programs across Canada: current status.

OBJECTIVE: To determine the current status of research experience in psychiatry residency programs across Canada. METHOD: Coordinators of Psychiatric Education (COPE) resident representatives from all 17 psychiatry residency programs in Canada were asked to complete a survey regarding research training requirements in their programs. RESULTS: Among the 17 COPE representatives, 15 completed the survey, representing 88% of the Canadian medical schools that have a psychiatry residency program. Among the 15 programs, 11 (73%) require residents to conduct a scholarly activity to complete residency. Some of these programs incorporated such a requirement in the past 5 years. Ten respondents (67%) reported availability of official policy and (or) guidelines on resident research requirements. Among the 11 programs that have a research requirement, 10 (91%) require residents to complete 1 scholarly activity; 1 requires completion of 2 scholarly activities. Eight (53%) residency programs reported having a separate research track. All of the programs have a research coordinator and 14 (93%) programs provide protected time to residents for conducting research. The 3 most common types of scholarly activities that qualify for the mandatory research requirement are a full independent project (10 programs), a quality improvement project (8 programs), and assisting in a faculty project (8 programs). Six programs expect their residents to present their final work in a departmental forum. None of the residency programs require publication of residents' final work. CONCLUSIONS: The current status of the research experience during psychiatry residency in Canada is encouraging but there is heterogeneity across the programs.

Are the effects of duration of untreated psychosis socially mediated?

Investigation of possible mechanisms by which longer duration of untreated psychosis (DUP) could influence treatment outcomes has focused primarily on evidence for neurotoxic effects. It is also possible that longer DUP has psychosocial effects, which could mediate its impact on outcomes. The evidence of relevance to such socially toxic effects is reviewed, with particular reference to the possible role of social support. There is no definite evidence for social support as a mediator of the influence of DUP, but further investigation of this issue is warranted.

The significance of possible selves in patients of an early intervention programme for psychotic disorders.

AIMS: To assess the possible importance of patients' perceptions of possible future selves in determining self-esteem and mood. METHODS: One hundred and two patients of an early intervention programme for psychotic disorders completed measures of perceived positive and negative current and possible future selves, as well as indices of self-esteem and mood. RESULTS: Measures of current and possible selves generally showed bivariate correlations with self-esteem, depression and anger/hostility. Perceived negative possible self was the most important independent predictor of self-esteem, depression and anger/hostility. CONCLUSIONS: Perceptions of possible negative future selves may be a particularly important determinant of self-esteem and negative mood states. Addressing fears about possible future self is likely to be an important aspect of recovery from psychotic disorders.

Admixture analysis of age at onset in schizophrenia: evidence of three subgroups in a first-episode sample.

OBJECTIVE: The objective was to assess the presence of different subgroups, via age-at-onset (AAO) analysis, in a schizophrenia population consecutively recruited through an Early Psychosis Service in London, Canada. METHOD: Admixture analysis was applied in order to identify a model of separate normal distribution of AAO characterized by different means, variances and population proportions to allow for evaluation of different subgroups in a sample of 187 unrelated patients with a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, diagnosis of schizophrenia. RESULTS: The best-fitting model suggested three subgroups with means and standard deviations of 16.8 ± 1.9, 22.3 ± 2.1 and 32.7 ± 5.9 years comprising 41%, 30% and 29% of the schizophrenia sample, respectively. These three subgroups were categorized as early, intermediate and late onset with cutoffs determined by admixture analysis to be 19 and 26 years of age, respectively. In our investigation, the definition of early-onset schizophrenia is the main outcome. We considered the clinical variables mainly related to the heritability and neurobiology of schizophrenia. Single status was strongly associated with early onset (P<.001). The male gender (P=.023), as well as a history of drug abuse (P=.004), was significantly associated with early onset. Interestingly, lower academic achievement was also associated with early-onset schizophrenia (P<.001). CONCLUSION: Overall, our study showed that a typical early-onset schizophrenia patient is more likely to be a single male, with a history of drug abuse and birth complications, and lower academic achievement as compared to the late-onset subgroup.

A qualitative analysis of influences on recovery following a first episode of psychosis.

BACKGROUND: Understanding perceived influences on recovery following a first episode of psychosis could help improve services. MATERIAL: Thematic analysis was used to examine important influences on early recovery identified by 30 individuals receiving services in an early intervention programme. DISCUSSION: Social support, medication, meaningful activities and lifestyle modification were identified as helpful, and stigma, substance abuse and medication side effects as harmful. Perceptions of benefits of social support and the negative effects of stigma were particularly prominent. CONCLUSIONS: Results suggest the importance of assistance with engagement in valued activities and relationships, and provision of messages of worth and hope for recovery.