The effect of the alliance on social recovery outcomes and usage in a moderated online social therapy for first-episode psychosis.

OBJECTIVES: We investigated the effect of the therapeutic alliance on both change in social recovery outcomes and usage of a moderated online social therapy platform for first-episode psychosis (FEP), Horyzons. DESIGN: Secondary analysis of a single group pilot trial. METHODS: Clients completed an alliance measure adapted for guided digital interventions at mid-treatment. A series of multi-level models evaluated change in outcomes by mid- and post-treatment assessments (relative to baseline) as a function of the overall alliance. Quasi-Poisson models evaluated the effect of the overall alliance on aggregated counts of platform usage. Exploratory analyses repeated these models in terms of the bond (human-human) or the task/goal (human-program) alliance. RESULTS: Stronger overall alliance at mid-treatment predicted lower loneliness at mid-treatment and lower social anxiety at mid- and post-treatment. It was also associated with higher completion of therapy activities and authoring of comments and reactions. A strong bond with an online therapist was associated with lower loneliness and higher perceived social support at mid-treatment, lower social anxiety at post-treatment as well as a higher number of reactions made on the social network. Stronger alliance with the platform's tasks and goals facilitated lower social anxiety at both follow-up assessments and was further associated with higher completion of therapy activities and reactions in the social network. CONCLUSIONS: The alliance may impact aspects of social recovery and usage in digital interventions for FEP. Specific aspects of the alliance (human-human and human-program relationships) should be considered in future research.

Systematic review of early warning signs of relapse and behavioural antecedents of symptom worsening in people living with schizophrenia spectrum disorders.

BACKGROUND: Identification of the early warning signs (EWS) of relapse is key to relapse prevention in schizophrenia spectrum disorders, however, limitations to their precision have been reported. Substantial methodological innovations have recently been applied to the prediction of psychotic relapse and to individual psychotic symptoms. However, there has been no systematic review that has integrated findings across these two related outcomes and no systematic review of EWS of relapse for a decade. METHOD: We conducted a systematic review of EWS of psychotic relapse and the behavioural antecedents of worsening psychotic symptoms. Traditional EWS and ecological momentary assessment/intervention studies were included. We completed meta-analyses of the pooled sensitivity and specificity of EWS in predicting relapse, and for the prediction of relapse from individual symptoms. RESULTS: Seventy two studies were identified including 6903 participants. Sleep, mood, and suspiciousness, emerged as predictors of worsening symptoms. Pooled sensitivity and specificity of EWS in predicting psychotic relapse was 71% and 64% (AUC value = 0.72). There was a large pooled-effect size for the model predicting relapse from individual symptom which did not reach statistical significance (d = 0.81, 95%CIs = -0.01, 1.63). CONCLUSIONS: Important methodological advancements in the prediction of psychotic relapse in schizophrenia spectrum disorders are evident with improvements in the precision of prediction. Further efforts are required to translate these advances into effective clinical innovations.

ENgage YOung people earlY (ENYOY): a mixed-method study design for a digital transdiagnostic clinical - and peer- moderated treatment platform for youth with beginning mental health complaints in the Netherlands.

BACKGROUND: The onset of mental disorders typically occurs between the ages of 12 and 25, and the burden of mental health problems is the most consequential for this group. Indicated prevention interventions to target individuals with subclinical symptoms to prevent the transition to clinical levels of disorders, even leading to suicide, have shown to be effective. However, the threshold to seek help appears to be high. Digital interventions could offer a solution, especially during the Covid-19 pandemic. This implementation study will investigate the digital indicated prevention intervention ENgage YOung people Early (ENYOY), the Dutch version of the original Moderated Online Social Therapy Platform (MOST+) from Australia. In addition, the relationship between stress biomarkers, symptoms and outcome measures of youth using the platform will be investigated in this study. METHODS: The MOST+ platform will be adapted, translated and developed for the situation in the Netherlands in collaboration with a Youth Panel. A prospective cohort of 125 young people (16-25 years) with beginning mental health complaints will be on the platform and followed for a year, of which 10 participants will have an additional smart watch and 10 participants will be asked to provide feedback about the platform. Data will be collected at baseline and after 3, 6 and 12 months. Outcome measures are Psychological Distress assessed with the Kessler Psychological Distress Scale (K10), Social and occupational functioning (measures by the SOFAS), positive mental health indicators measured by the Positive Health Instrument, stress biomarkers with a smart-watch, website journeys of visitors, and feedback of youth about the platform. It will be a mixed-method study design, containing qualitative and quantitative measures. DISCUSSION: This trial will specifically address young people with emerging mental health complaints, and offers a new approach for treatment in the Netherlands. Considering the waiting lists in (child and adolescent)-psychiatry and the increase in suicides among youth, early low-threshold and non-stigmatizing help to support young people with emerging psychiatric symptoms is of crucial importance. Moreover, this project aims to bridge the gap between child and adolescent and adult psychiatry. TRIAL REGISTRATION: Netherlands Trial Register ID NL8966 , retrospectively registered on the 19th of October 2020.

Is loneliness a feasible treatment target in psychosis?

PURPOSE: Loneliness is a challenge for individuals with psychosis; however, interventions rarely target loneliness in this group. METHOD: We developed a pilot positive psychology group intervention designed to reduce loneliness in psychosis and examined its feasibility and acceptability. RESULTS: Sixteen participants attended 5.38 (SD = 0.70) out of six sessions, with a dropout rate of 10%. Participants were significantly less lonely at post-treatment (p < 0.001, d = 1.51), and maintained their improvements from post-treatment to follow-up (p = 0.81, d = 0.07). CONCLUSIONS: Loneliness may be a feasible and acceptable treatment target within psychosocial treatments.

Enhancing social functioning in young people at Ultra High Risk (UHR) for psychosis: A pilot study of a novel strengths and mindfulness-based online social therapy.

BACKGROUND: Psychological and pharmacological treatments have been shown to reduce rates of transition to psychosis in Ultra High Risk (UHR) young people. However, social functioning deficits have been unresponsive to current treatments. AIMS: The study aims were to: i) describe the theoretical basis and therapeutic targets of a novel intervention targeting social functioning in UHR young people; and ii) examine its acceptability, safety and preliminary effect on social functioning. METHODS: An international, multidisciplinary team developed a new intervention (MOMENTUM) to improve social functioning in UHR young people. MOMENTUM blends two novel approaches to social recovery: strengths and mindfulness-based intervention embedded within a social media environment, and application of the self-determination theory of motivation. The acceptability and safety of MOMENTUM were tested through a 2-month pilot study with 14 UHR participants. RESULTS: System usage was high, with over 70% of users being actively engaged over the trial. All participants reported a positive experience using MOMENTUM, considered it safe and would recommend it to others. 93% reported it to be helpful. There were large, reliable improvements in social functioning (d = 1.83, p < 0.001) and subjective wellbeing (d = 0.75, p = 0.03) at follow-up. There were significant increases in the mechanisms targeted by the intervention including strengths usage (d = 0.70, p = 0.03), mindfulness skills (d = 0.66, p = 0.04) and components of social support. Social functioning improvement was significantly correlated with indicators of system usage. CONCLUSION: MOMENTUM is engaging and safe. MOMENTUM appeared to engage the hypothesized mechanisms and showed promise as a new avenue to improve social functioning in UHR young people.

Beyond Clinical Remission in First Episode Psychosis: Thoughts on Antipsychotic Maintenance vs. Guided Discontinuation in the Functional Recovery Era.

Treatment guidelines for first episode psychosis (FEP) recommend at least 1 year of antipsychotic treatment following remission; however, in light of some recent research and the preference of some individuals to discontinue their medication sooner, this recommendation can be questioned. The aim of this article is to appraise the current discontinuation studies given our views on how this field should progress. We conducted a review of randomized controlled trials investigating dose-reduction/medication discontinuation compared with treatment maintenance in clinically remitted FEP patients. Seven trials were identified, and these reported a higher rate of relapse in the dose reduction or discontinuation groups. Relapse rates were higher when a lower threshold for relapse was utilized. However, only three studies specified that concurrent psychosocial interventions were also provided, despite an evidence base for these interventions in reducing symptom severity and relapse. Length of follow-up may also be important, as the study with the longest follow-up (7 years), albeit with some methodological shortcomings, found greater functional recovery in the dose-reduction group and that relapse rates between the two groups (dose-reduction vs. maintenance) were equal after 3 years. Finally, in addition to discontinuation or dose reduction, a diagnosis of schizophrenia, a longer duration of illness, and poor premorbid functioning were associated with a greater risk of relapse. Further trials are needed in this area to establish the long-term risk-benefit ratio of antipsychotic medication in FEP. Meanwhile, young people with FEP who do not fulfil criteria for a diagnosis of a schizophrenia disorder, achieve clinical remission for at least 3 months, attain early functional recovery, and have good social support may be possible candidates for discontinuation of antipsychotic medication bolstered by effective psychosocial interventions provided in the context of a specialized FEP service.

Longitudinal relationship between expressed emotion and cannabis misuse in young people with first-episode psychosis.

Carers' expressed emotion (EE) and patients' cannabis misuse are two of the most robust predictors of psychotic relapse. We aimed to examine the temporal relationship between EE and cannabis misuse. Sixty-three key carers of young people with first-episode psychosis (FEP) were assessed at baseline and 7-month follow-up. EE was measured in carers using the Family Questionnaire (FQ) and cannabis misuse in patients using the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST). Correlational and hierarchical logistic regression analyses were conducted to examine the temporal relationship between EE components (i.e. criticism and emotional over involvement) and cannabis misuse. Carers' criticism at baseline significantly predicted cannabis misuse according to the ASSIST at 7-month follow-up. The association remained significant after controlling for baseline symptom severity and social functioning (B=0.15, P=.02). Conversely, baseline cannabis misuse was not associated with carers' criticism at 7-month follow-up. Patients in families with high criticism showed a tendency to increase cannabis misuse over time whereas the opposite trend was observed in those with carers with low criticism. A family environment characterized by high criticism may become a key risk factor for worsening cannabis misuse over time in young people with FEP. Further studies should investigate the potential mechanisms (e.g., patient's anxiety or perceived stress) through which criticism increases cannabis misuse in FEP.

Online, social media and mobile technologies for psychosis treatment: a systematic review on novel user-led interventions.

BACKGROUND: Internet and mobile-based interventions provide a unique opportunity to deliver cost-effective, accessible, time-unlimited support to people with psychosis. The aims of this study were to systematically compile and analyze the evidence on the acceptability, feasibility, safety and benefits of online and mobile-based interventions for psychosis. METHODS: Systematic review of peer-reviewed studies examining the usability, acceptability, feasibility, safety or efficacy of user-led, Internet or mobile-based interventions, with at least 80% of participants diagnosed with schizophrenia-spectrum disorders. RESULTS: Of 38 potentially relevant articles, 12 were eligible for inclusion. Interventions included web-based psycho-education; web-based psycho-education plus moderated forums for patients and supporters; integrated web-based therapy, social networking and peer and expert moderation; web-based CBT; personalized advice based on clinical monitoring; and text messaging interventions. Results showed that 74-86% of patients used the web-based interventions efficiently, 75-92% perceived them as positive and useful, and 70-86% completed or were engaged with the interventions over the follow-up. Preliminary evidence indicated that online and mobile-based interventions show promise in improving positive psychotic symptoms, hospital admissions, socialization, social connectedness, depression and medication adherence. CONCLUSIONS: Internet and mobile-based interventions for psychosis seem to be acceptable and feasible and have the potential to improve clinical and social outcomes. The heterogeneity, poor quality and early state of current research precludes any definite conclusions. Future research should investigate the efficacy of online and mobile interventions through controlled, well-powered studies, which investigate intervention and patient factors associated with take-up and intervention effects.

Coping strategies in carers of young people with a first episode of psychosis.

BACKGROUND: Carers of young people with first episode psychosis (FEP) often face burden. Understanding ways in which carers cope is not only important for providing support to them but might maximise patient outcomes. The aim of this study was to examine strategies carers use to cope with the burden of caring for a young person with FEP. METHODS: The study was part of a randomized controlled trial focusing on the effectiveness of a problem-solving bibliotherapy intervention for carers of FEP patients, in terms of promoting coping and reducing psychological distress. Baseline data on the Ways of Coping (WOC) scale was available for 124 carers aged between 18 and 66 years. Principal component analysis with PROMAX rotation was used to determine the number of factors that could be used to characterise coping behaviour. Regression analyses were used to determine how the factors were related to carers' demographics, burden, psychological well-being and expressed emotion. RESULTS: Approximately half of the carers reported that they frequently use positive coping techniques such as self-talk, active problem solving, and positive reframing. The factor analysis yielded five factors: (i) cognitive-escape coping; (ii) optimistic coping; (iii) seeking connections; (iv) tension reduction; and (v) distancing. The relationships between these factors and demographic characteristics, carers' perception of burden, expressed emotion, and psychological distress are reported. CONCLUSIONS: Avoidance coping strategies are related to psychological distress, emotional over-involvement, and increased carer burden. Interventions facilitating the use of adaptive problem solving and positive re-appraisal will promote carer coping and reduce psychological distress.

Differences between first episode schizophrenia and schizoaffective disorder.

BACKGROUND: The diagnostic and clinical overlap between schizophrenia and schizoaffective disorder is an important nosological issue in psychiatry that is yet to be resolved. The aim of this study was to compare the clinical and functional characteristics of an epidemiological treated cohort of first episode patients with an 18-month discharge diagnosis of schizophrenia (FES) or schizoaffective disorder (FESA). METHODS: This study was part of the larger First Episode Psychosis Outcome Study (FEPOS) which involved a medical file audit study of all 786 patients treated at the Early Psychosis Prevention and Intervention Centre between 1998 and 2000. Of this cohort, 283 patients had an 18-month discharge diagnosis of FES and 64 had a diagnosis of FESA. DSM-IV diagnoses and clinical and functional ratings were derived and validated by two consultant psychiatrists. RESULTS: Compared to FES patients, those with FESA were significantly more likely to have a later age of onset (p=.004), longer prodrome (p=.020), and a longer duration of untreated psychosis (p<.001). At service entry, FESA patients presented with a higher illness severity (p=.020), largely due to the presence of more severe manic symptoms (p<.001). FESA patients also had a greater number of subsequent inpatient admissions (p=.017), had more severe depressive symptoms (p=.011), and higher levels of functioning at discharge. DISCUSSION: The findings support the notion that these might be considered two discernable disorders; however, further research is required to ascertain the ways and extent to which these disorders are discriminable at presentation and over time.

On the HORYZON: moderated online social therapy for long-term recovery in first episode psychosis.

BACKGROUND: Early intervention services have demonstrated improved outcomes in first episode psychosis (FEP); however, recent evidence shows that treatment benefits may not be sustainable over time. These findings have resulted in repeated recommendations for the implementation of longer term treatment programs. An Internet-based intervention specifically designed for young people with psychosis may provide a cost-effective alternative to prevent loss of treatment benefits from early intervention. METHODS: Our multi-disciplinary team has developed a highly novel online intervention (HORYZONS) in regular consultation with stakeholders within a specialist early psychosis program. HORYZONS integrates: i) peer-to-peer social networking, ii) individually tailored interactive psychosocial interventions, and iii) expert interdisciplinary and peer-moderation in a coherent platform designed to improve long-term outcomes in FEP. The acceptability, safety and initial clinical benefits of HORYZONS were examined through a 1-month pilot study with 20 participants with FEP. RESULTS: There were no dropouts during the pilot study. Seventy per cent of participants utilised the system for at least 3weeks, 95% used the social networking features, and 60% completed at least 3 therapy modules. System usage was high during the study. There were no incidents and the majority of participants reported feeling safe, empowered and more socially connected using HORYZONS. Analysis revealed a significant reduction in depressive symptoms at follow-up. CONCLUSIONS: Our results indicate that HORYZONS is feasible, engaging and safe and may augment social connectedness and empowerment in FEP. These findings have significant implications for the enhancement of specialist FEP services. The potential of HORYZONS to improve long-term recovery is worthy of further investigation.

Risk factors for relapse following treatment for first episode psychosis: a systematic review and meta-analysis of longitudinal studies.

BACKGROUND: Preventing relapse is an essential element of early intervention in psychosis, but relevant risk factors and precise relapse rates remain to be clarified. The aim of this study was to systematically compile and analyse risk factors for and rates of relapse in the early course of psychosis. METHODS: Systematic review and meta-analysis of English and non-English language, peer-reviewed, longitudinal studies, with a minimum 12-month follow-up and at least 80% of participants diagnosed with a first episode of psychosis (FEP) that reported risk factors for relapse. RESULTS: Of 153 potentially relevant articles, 29 were included in the study. Pooled prevalence of relapse of positive symptoms was 28% (range=12-47%), 43% (35-54%), 54% (40-63%) at 1, 1.5-2, and 3 years follow-up, in that order. A total of 109 predictors were analysed, with 24 being assessed in at least 3 studies. Of those, 20 predictors could be extracted for meta-analysis. Medication non-adherence, persistent substance use disorder, carers' critical comments (but not overall expressed emotion) and poorer premorbid adjustment, increased the risk for relapse 4-fold, 3-fold, 2.3-fold and 2.2-fold, respectively. CONCLUSIONS: Clinical variables and general demographic variables have little impact on relapse rates. Conversely, non-adherence with medication, persistent substance use disorder, carers' criticism and poorer premorbid adjustment significantly increase the risk for relapse in FEP. Future studies need to address the methodological limitations of the extant research (e.g. definition of relapse), focus on the identification of protective factors and evaluate theoretically derived models of relapse.

Road to full recovery: longitudinal relationship between symptomatic remission and psychosocial recovery in first-episode psychosis over 7.5 years.

BACKGROUND: In recent years there has been increasing interest in functional recovery in the early phase of schizophrenia. Concurrently, new remission criteria have been proposed and several studies have examined their clinical relevance for prediction of functional outcome in first-episode psychosis (FEP). However, the longitudinal interrelationship between full functional recovery (FFR) and symptom remission has not yet been investigated. This study sought to: (1) examine the relationships between FFR and symptom remission in FEP over 7.5 years; (2) test two different models of the interaction between both variables. METHOD: Altogether, 209 FEP patients treated at a specialized early psychosis service were assessed at baseline, 8 months, 14 months and 7.5 years to determine their remission of positive and negative symptoms and functional recovery. Multivariate logistic regression and path analysis were employed to test the hypothesized relationships between symptom remission and FFR. RESULTS: Remission of both positive and negative symptoms at 8-month follow-up predicted functional recovery at 14-month follow-up, but had limited value for the prediction of FFR at 7.5 years. Functional recovery at 14-month follow-up significantly predicted both FFR and remission of negative symptoms at 7.5 years, irrespective of whether remission criteria were simultaneously met. The association remained significant after controlling for baseline prognostic indicators. CONCLUSIONS: These findings provided support for the hypothesis that early functional and vocational recovery plays a pivotal role in preventing the development of chronic negative symptoms and disability. This underlines the need for interventions that specifically address early psychosocial recovery.

Depressive symptoms in first episode schizophrenia spectrum disorder.

BACKGROUND: Depressive symptoms in 'non-affective' first episode schizophrenia spectrum disorders (FES) are common, but poorly understood, resulting in a range of conceptual and clinical management issues. This study had three aims: (i) to determine the prevalence of moderate to severe depressive symptoms (defined as a Clinical Global Impressions Scale-Bipolar Disorder (CGI-BP depression) score >3) in a large representative sample of FES patients; (ii) to compare the clinical and functional characteristics of FES patients with and without these depressive symptoms at service entry; and (iii) to compare the characteristics of FES patients with and without persistent depressive symptoms. METHODS: Medical file audit methodology was employed to collect information on 405 patients with FES treated at the Early Psychosis Prevention and Intervention Centre (EPPIC), Melbourne, Australia. RESULTS: 26.2% (n=106) of the patients had moderate to severe depression at service entry. At service entry and at discharge, those with depressive symptoms had greater insight into their illness but did not differ from those without depressive symptoms in terms of severity of overall psychopathology. Substance use was significantly less common in those with depressive symptoms at service entry and at discharge. Of those who were depressed at baseline, 14.2% (n=15) continued to have moderate to severe depressive symptoms at discharge. DISCUSSION: Depressive symptoms are common in patients with FES. Understanding the nature and characteristics of depression in FES has important clinical implications for both early intervention and treatment.

Prediction of a single psychotic episode: a 7.5-year, prospective study in first-episode psychosis.

BACKGROUND: Around 20% of patients who suffer from psychosis will experience a single psychotic episode (SPE), but relatively little is known about the characteristics and predictors for this group of patients. This study sought to: 1) characterise the subgroup of first-episode psychosis (FEP) patients who experienced a SPE over a 7.5-year follow-up; and 2) to identify significant predictors for this subgroup independent of potential confounders. METHODS: A representative sample of 413 FEP patients treated at a specialist early psychosis service were assessed at baseline and followed-up for 7.5 years. Binary logistic regression models were employed to investigate univariate and adjusted associations between baseline predictors and experiencing a SPE. Results were adjusted for the influence of known prognostic factors for psychosis. RESULTS: Follow-up data was available for 274 participants. Forty-six (16.5%) achieved clinical remission and experienced no recurrence over the follow-up period. Duration of untreated psychosis (DUP) shorter than 60 days (OR=3.89, p=0.007), more rapid response to antipsychotic treatment (OR=0.33, p=0.019) and no parental loss (OR=5.25, p=0.045) significantly predicted a SPE. The association remained significant after controlling for potential confounders. CONCLUSIONS: Early treatment (within two months of onset of psychotic symptoms) and social support significantly reduce vulnerability to subsequent psychotic episodes. Future studies need to investigate the interplay between biological factors (i.e. sensitized dopaminergic system), environmental variables (i.e. exposure to trauma, stigma and discrimination), and psychological attributes (i.e. cognitive schemata) in order to elucidate the processes underlying the vulnerability to recurrent psychotic episodes.

Quality of life in patients who have remitted from their first episode of psychosis.

BACKGROUND: Quality of life (QoL) in first-episode psychosis (FEP) is strongly related to levels of psychopathology and may vary as a function of illness phase. QoL remains poorly understood in FEP. AIM: Characterise the nature and predictors of QoL in patients who have remitted from their first-episode of psychosis. METHOD: Demographic characteristics, diagnoses, and psychopathology were assessed in 81 FEP patients. The World Health Organization Quality of Life Scale-Bref (WHOQoL-Bref) was used to assess QoL in these patients. Carer-related variables (expressed emotion and burden of care) were ascertained from 63 relatives. RESULTS: Poorer QoL was associated with personality disorder, depression, mild psychotic positive symptoms, and impaired functioning. Carer-related factors such as emotional overinvolvement and burden of care were also associated with a reduction in patients' QoL. CONCLUSIONS: Depression, functioning and family variables impacted on QoL, and need to be considered in terms of ongoing patient management.

Differential predictors of critical comments and emotional over-involvement in first-episode psychosis.

BACKGROUND: Little research has focused on delineating the specific predictors of emotional over-involvement (EOI) and critical comments (CC) in the early course of psychosis. The purpose of this study was to investigate the differential relationships of EOI and CC with relevant predictors in relatives of first-episode psychosis (FEP) patients. METHOD: Baseline patient-related factors including psychotic symptoms, depression and duration of untreated psychosis (DUP) and carer attributes comprising CC, EOI, burden of care and carers' stress and depression were assessed in a cohort of 63 remitted FEP patients and their relatives. Carers were reassessed at 7 months follow-up. RESULTS: Baseline analysis showed that EOI was more strongly correlated with family stress compared with CC, whereas CC yielded a stronger association with DUP than EOI. Carers' CC at follow-up was not significantly predicted by either baseline family stress, burden of care or patient-related variables. Conversely, baseline EOI predicted both family stress and burden of care at 7 months follow-up. Finally, family burden of care at follow-up was a function of baseline EOI and patients' depressive symptoms. CONCLUSIONS: This study provides preliminary support to the postulate that EOI and CC may be influenced by separate factors early in the course of psychosis and warrant future research and therapeutic interventions as separate constructs. Implications for family interventions in the early phase of psychosis and the prevention of CC and EOI are discussed.