The Early Youth Engagement in first episode psychosis (EYE-2) study: pragmatic cluster randomised controlled trial of implementation, effectiveness and cost-effectiveness of a team-based motivational engagement intervention to improve engagement.

BACKGROUND: Early Intervention in Psychosis (EIP) services improve health outcomes for young people with psychosis in the medium-long term, but 25% of young people disengage in the first 12 months with costs to their mental health, families, society and the NHS. This study will evaluate the effectiveness, cost-effectiveness and implementation of a team-based motivational Early Youth Engagement (EYE-2) intervention. METHOD: The study design is a cluster randomised controlled trial (RCT) with economic evaluation, comparing the EYE-2 intervention + standardised EIP service to standardised EIP service alone, with randomisation at the team level. A process evaluation will evaluate the delivery of the intervention qualitatively and quantitatively across contexts. The setting is 20 EIP teams in 5 sites: Manchester, South London, East Anglia, Thames Valley and Hampshire. Participants are young people (14-35 years) with first episode psychosis, and EIP staff. The intervention is the team-based motivational engagement (EYE-2) intervention, delivered alongside standardised EIP services, and supported by additional training, website, booklets and social groups. The comparator is the standardised EIP service. Both interventions are delivered by EIP clinicians. The primary outcome is time to disengagement (time in days from date of allocation to care coordinator to date of last contact following refusal to engage with EIP service, or lack of response to EIP contact for a consecutive 3-month period). Secondary outcomes include mental and physical health, deaths, social and occupational function, recovery, satisfaction and service use at 6, 12, 18 and 24 months. A 12-month within-trial economic evaluation will investigate cost-effectiveness from a societal perspective and from an NHS perspective. DISCUSSION: The trial will provide the first test of an engagement intervention in standardised care, with the potential for significant impact on the mental health and wellbeing of young people and their families, and economic benefits for services. The intervention will be highly scalable, supported by the toolkit including manuals, commissioning guide, training and resources, adapted to meet the needs of the diverse EIP population, and based on an in-depth process evaluation. TRIAL REGISTRATION: ISRCTN 51629746 prospectively registered 7th May 2019. Date assigned 10th May 2019.

Autism Spectrum Disorder in Early Intervention in Psychosis Services: Implementation and Findings of a 3-step Screening and Diagnostic Protocol.

Evidence indicates that autism spectrum disorder (ASD) is underidentified in populations with psychosis, but that clinical presentations of comorbid ASD and psychosis (ASD-P) and specific treatment needs that may relate to this group are not well understood. In fact, recent studies of ASD in first-episode psychosis suggest that there may be a specific clinical presentation of ASD-P. In response, the Cambridgeshire and Peterborough Early Intervention in Psychosis (EIP) service in the UK implemented and evaluated a 3-step ASD screening and diagnostic protocol, using the Autism Spectrum Disorder in Adults Screening Questionnaire (ASDASQ), case note review, and the Autism Diagnostic Observation Schedule (ADOS-2) and the Childhood Autism Spectrum Test (CAST). As a quality improvement project, the evaluation aimed to (1) establish the prevalence of patients with ASD-P, (2) describe characteristics of the clinical presentation of ASD-P and compare them to those of patients suffering from psychosis but no ASD, and (3) determine any differences in treatment between psychosis patients with and without ASD. Notably, at least 9% of the EIP service caseload met the criteria for a diagnosis of ASD-P, with half identified via the implementation of this protocol. The patients with ASD-P had specific clinical presentations and treatment needs that differed from those of patients with psychosis but no ASD. Thus, the findings from this study supported existing evidence concerning the underdetection of ASD in EIP populations. Our findings also added to emerging evidence for a clinical presentation of ASD-P with specific treatment needs. Our protocol has now been established as routine practice, and its implementation has improved the detection and treatment of patients with ASD-P within our EIP service.

Early Intervention in Psychosis Treatment Components Utilization in Patients Aged Over 35.

Early Intervention in Psychosis (EIP) services have been youth-focused since their inception. In England, recent National Institute for Health and Care Excellence (NICE) guidelines and new National Health Service (NHS) Standards for EIP recommend the expansion of the age acceptability criterion from 14-35 to 14-65. In the Cambridgeshire and Peterborough EIP service (CAMEO), we ran a service evaluation to assess the initial impact of this policy change. It aimed to elicit EIP treatment components utilization by patients with first-episode psychosis (FEP) aged over 35, in comparison with those under 35. We found that the over-35s required more contacts from EIP healthcare professionals, especially from care coordinators (coefficient = .239; Robust SE = .102; Z = 6.42; p = 0.019) and social workers (coefficient = 18.462; Robust SE = .692; Z = .016; p < 0.001). These findings indicate that FEP patients aged over 35 may present with more complex and sustained clinical/social needs. This may have implications for EIP service development and commissioning.

Towards a Multi-Level Phenomenology of Delusional Disorder: The Dissociative Thought-Script.

Delusional disorder (DD) is still considered a diagnosis of exclusion for a difficult-to-treat condition characterised by the presence of delusional beliefs in the absence of other psychiatric symptoms. Attempts to contextualise psychological processes recognised since the earliest observations of this disorder have had very limited impact on improving some fixed beliefs. In the Cambridge Early Intervention in Psychosis Service we have observed a particular phenomenon, often categorised as a delusional idea in the context of DD, which manifests through highly repetitive belief expression that fails to respond to pharmacological and psychological treatments. Key aspects of this phenomenon are similar to those observed in dissociative (functional neurological) presentations. Drawing on the Integrative Cognitive Model of functional neurological disorders, we developed a successful psychological intervention that places less emphasis on challenging delusional content and focuses more on dismantling dissociation and underlying affective factors associated with the activation of the fixed belief. Our initial findings reinforce the need to continue developing a multi-level phenomenological approach to define a variety of symptoms traditionally grouped under the concept of "delusion."

The over-35s: early intervention in psychosis services entering uncharted territory.

Aims and methodFollowing the introduction of new standards for early intervention in psychosis (EIP) in England, EIP services are accepting referrals for people aged 35-65. The Cambridgeshire and Peterborough EIP service (CAMEO) aimed to explore the immediate implications for the service, especially with regards to referral numbers and sources. Data were collected from April 2016 to June 2017. RESULTS: Referrals for over-35s represented 25.7% of all new referrals. Fifty per cent of referrals for over-35s were accepted onto caseload (40.2% for under-35s). The over-35s were more likely to be referred from acute and secondary mental health services (P < 0.01) and had longer durations of untreated psychosis than the under-35s (P = 0.02).Clinical implicationsCAMEO has received a significantly higher number of referrals as a result of age inclusivity, with an increased proportion of patients suffering from severe, acute psychotic presentations and existing mental health difficulties. This has implications for service planning.Declaration of interestNone.

Social reasoning, emotion and empathy in frontotemporal dementia.

INTRODUCTION: Social cognition is crucial for human interaction, and is markedly impaired in the frontal variant of frontotemporal dementia (fvFTD). The relationship of various aspects of social functioning, however, remains controversial in this group. METHODS: Patients with fvFTD (n = 18), and matched controls (n = 13), were tested using tasks designed to assess their Theory of Mind (ToM), moral reasoning, emotion recognition and executive function. Caregivers documented changes in empathy compared to premorbid functioning. RESULTS: We found marked impairments in the abilities of fvFTD patients, relative to controls, in ability to mentalise (ToM), which was evident on a cartoon test, but not on a story-based ToM task. Knowledge of social rules was intact, but moral reasoning was defective, and was due, in part, to an inability to rate the seriousness of moral and conventional transgressions appropriately. Executive function was impaired in this group, and compromised aspects of moral reasoning, but ToM performance was independent of this. Emotion recognition was globally impaired in fvFTD, but was particularly so for anger and disgust which may partly explain the difficulty these patients have with identifying social violations. Empathy, as rated by carers, was also shown to be abnormal. CONCLUSION: It appears that social reasoning is disrupted in a number of ways in fvFTD, and the findings provide a basis for the understanding and further study of abnormal behaviour in this disease. The results are discussed in light of neuroimaging findings in studies of social cognition and the locus of pathology in fvFTD.