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.

[Effects on the brain of effective psychological treatments for anxiety disorders: a systematic review]. / Efectos en el cerebro de los tratamientos psicológicos eficaces en los trastornos de ansiedad: una revisión sistemática.

INTRODUCTION: Psychological therapies can modify thoughts, feelings, and behaviors of people with mental disorders, but the underlying brain mechanisms remain to be clarified. Advances in neuroimaging techniques can help us to understand of how different psychotherapies change the human brain. This review has aimed to systematically investigate the brain effects of psychological therapies for adults with anxiety disorders. METHOD: Several electronic databases (Medline, PsycINFO, EMBASE and EBSCO) up to April 2010 were searched. Abstracts which appeared to fulfill the initial selection criteria (a structured psychological treatment in adults with anxiety disorders with at least one neuroimaging study performed before and after the treatment) were selected and their original articles were then retrieved. References from the selected English and Spanish language publications were also hand searched. RESULTS: Eighteen studies met the criteria for inclusion in the review. The majority of these papers reported cognitive-behavioral therapy (CBT) in specific phobia, social phobia, obsessive-compulsive disorder (OCD), posttraumatic stress disorder or panic disorder. Psychological interventions changed neural circuits involved in the pathophysiology of anxiety disorders, especially activity in frontal-striatal circuits in OCD and prefrontal areas in arachnophobia. However, the results are largely inconsistent among themselves and with the neurobiological models of anxiety, in particular as regards the changes at the limbic level. CONCLUSIONS: Despite the variety of methodological concerns, initial neuroimaging studies have showed that psychological interventions can change brain function related to anxiety disorders in the patients who respond to treatment. Neuromodulation mechanisms related to specific anxiety disorders remained to be elucidated. Future studies should delineate the process of "normalization" that occurs in the brain during a psychological treatment, helping to enrich the current neurobiological models of the origins, maintenance and treatment of anxiety disorders.

Efectos en el cerebro de los tratamientos psicológicos eficaces en los trastornos de ansiedad: una revisión sistemática / Effects on the brain of effective psychological treatments for anxiety disorders: a systematic review

Introducción: Las terapias psicológicas pueden modificar los pensamientos, emociones y conductas de las personas con trastornos mentales, pero los mecanismos cerebrales subyacentes están por esclarecer. Los avances en las técnicas de neuroimagen pueden ayudar a la comprensión de cómo las diferentes psicoterapias cambian el cerebro humano. El objetivo de esta revisión sistemática es investigar los efectos cerebrales de las terapias psicológicas en adultos con trastornos de ansiedad. Método: Se realizó una búsqueda en varias bases de datos electrónicas (Medline, PsycINFO, EMBASE y EBSCO) hasta abril 2010. Se seleccionaron los resúmenes que parecían cumplirlos criterios iniciales de inclusión (un tratamiento psicológico protocolizado en adultos con trastornos de ansiedad, al menos con un estudio de neuroimagen antes y otro después del tratamiento) y se accedió a los artículos originales. Se realizó también una búsqueda manual de las referencias de las publicaciones en inglés y español seleccionadas. Resultados: Dieciocho estudios cumplieron los criterios de inclusión. La mayoría trataban sobre la terapia cognitivo conductual (TCC) en fobia específica, fobia social, trastorno obsesivo-compulsivo (TOC), trastorno por estrés postraumático o trastorno de angustia. Las intervenciones psicológicas modificaron circuitos neuronales implicados en la patofisiología de los trastornos de ansiedad, en especial la actividad frontoestriatal en el TOC y en áreas prefrontales en la aracnofobia. Sin embargo, los resultados son en gran parte inconsistentes entre sí y con los modelos neurobiológicos de la ansiedad, en particular lo que se refiere a los cambios a nivel límbico. Conclusiones: A pesar de las diversas limitaciones metodológicas, los estudios iniciales de neuroimagen muestran que las intervenciones psicológicas pueden modificarla función cerebral asociada a los trastornos de ansiedad en aquellos pacientes que responden al tratamiento. Los mecanismos neuromoduladores vinculados con cada trastorno específico están por aclarar. Futuros estudios deberán delimitar el proceso de “normalización” que ocurre en el cerebro durante un tratamiento psicológico, contribuyendo a enriquecer los modelos neurobiológicos actuales sobre la génesis, mantenimiento y tratamiento de los trastornos de ansiedad (AU)

Introduction: Psychological therapies can modify thoughts, feelings, and behaviors of people with mental disorders, but the underlying brain mechanisms remain to be clarified. Advances in neuroimaging techniques can aid to the understanding of how different psychotherapies change the human brain. This review was aimed at systematically investigating the brain effects of psychological therapies for adults with anxiety disorders. Method: Several electronic databases (Medline, PsycINFO, EMBASE and EBSCO) up to April 2010 were searched. Abstracts which appeared to fulfill the initial selection criteria (a structured psychological treatment in adults with anxiety disorders with at least one neuroimaging study performed before and after the treatment) were selected and their original articles were then retrieved. References from the selected English and Spanish language publications were also hand searched. Results: Eighteen studies met the criteria for inclusion in the review. The majority of these papers reported cognitive-behavioral therapy (CBT) in specificphobia, social phobia, obsessive-compulsive disorder(OCD), posttraumatic stress disorder or panic disorder. Psychological interventions changed neural circuits involved in the pathophysiology of anxiety disorders, especially activity in frontal-striatal circuits in OCD and prefrontal areas in arachnophobia. However, the results are largely inconsistent among themselves and with the neurobiological models of anxiety, in particular as regards the changes at the limbic level. Conclusions: Despite the variety of methodological concerns, initial neuroimaging studies have showed that psychological interventions can change brain function related to anxiety disorders in the patients who respond to treatment. Neuromodulation mechanisms related to specific anxiety disorders remained to be elucidated. Future studies should delineate the process of “normalization” that occurs in the brain during a psychological treatment, helping to enrich the current neurobiological models of the origins, maintenance and treatment of anxiety disorders (AU)

Prognostic value of cognitive functioning for global functional recovery in first-episode schizophrenia.

BACKGROUND: It has become widely accepted that cognitive deficits in schizophrenia are related to functional outcome. However, it remains to be seen whether these associations are relevant for predicting which cases will have a global functional recovery. In this study, we attempt to determine whether global functional recovery (integrating social and occupational outcomes) after first-episode schizophrenia (FES) can be predicted by cognitive variables. METHOD: A total of 131 FES patients with functional deficits (n=97) and functional recovery (n=34) as determined at 1-year follow-up were examined. Neuropsychological, sociodemographic, pre-morbid and clinical data at baseline were analysed using independent groups comparisons and a logistic regression method. RESULTS: Sustained attention and negative symptoms emerged as significant predictors of good global functional outcome. Although the model revealed a high accuracy (91%) in the classification of patients with functional deficits, it was unacceptably low (26%) in the classification of patients with global functional recovery. CONCLUSIONS: The limitations found in the prediction of a favourable global functional outcome may well be an indication for a need to address the role of other factors not commonly included in longitudinal studies of long-term outcomes in schizophrenia.

Cambios cognitivos en respuesta a la medicación antipsicótica: problemas de diseño e interpretación / Cognitive changes in response to antipsychotic medication: design and interpretation problems

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Pretreatment predictors of cognitive deficits in early psychosis.

BACKGROUND: Predicting cognitive deficits in early psychosis may well be crucial to identify those individuals most in need of receiving intensive intervention. As yet, however, the identification of potential pretreatment predictors for cognitive performance has been hampered by inconsistent findings across studies. We aimed to examine the associations of functional and clinical pretreatment variables with cognitive functioning after a first psychotic episode. METHOD: One hundred and thirty-one patients experiencing first-episode psychosis were assessed for psychopathology, pre-morbid functioning, duration of illness, age of onset, and family history of psychosis and neurocognitive functioning. Multiple regression analyses were conducted for six basic cognitive dimensions known to be affected in this population: verbal learning, verbal memory, verbal comprehensive abilities, executive functioning, motor dexterity and sustained attention. RESULTS: Pre-morbid functioning was the main predictor for five out of the six basic cognitive domains. Pre-morbid social adjustment difficulties were associated with worse performance in executive functioning, motor dexterity and sustained attention. Academic functioning was associated with verbal comprehension, and verbal learning and memory. Gender, age of onset, duration of untreated psychosis, and family history of psychosis had no or limited value as predictors of neurocognitive outcome. CONCLUSIONS: Poor pre-morbid functioning was related to a worse performance in the six basic cognitive dimensions evaluated; however, this accounted for only a small amount of the explained variance. Cognitive impairment is a prominent feature in patients with early psychosis regardless of favorable prognostic features such as short duration of illness, female gender, later age of onset, and non-family history of psychosis.

Cannabis abuse is associated with decision-making impairment among first-episode patients with schizophrenia-spectrum psychosis.

BACKGROUND: Cannabis use appears to be a risk factor for schizophrenia. Moreover, cannabis abusers show impaired decision-making capacities, linked to the orbitofrontal cortex (OFC). Although there is substantial evidence that first-episode schizophrenia patients show impairments in cognitive tasks associated with the dorsolateral prefrontal cortex (DLPFC), it is not clear whether decision making is impaired at schizophrenia onset. In this study, we examined the association between antecedents of cannabis abuse and cognitive impairment in cognitive tasks associated with the DLPFC and the OFC in a sample of first-episode patients with schizophrenia-spectrum disorders. METHOD: One hundred and thirty-two patients experiencing their first episode of a schizophrenia-spectrum psychosis were assessed with a cognitive battery including DLPFC-related tasks [backward digits, verbal fluency (FAS) and the Trail Making Test (TMT)] and an OFC-related task [the Iowa Gambling Task (GT)]. Performance on these tasks was compared between patients who had and had not abused cannabis before their psychosis onset. RESULTS: No differences were observed between the two groups on the performance of any of the DLPFC-related tasks. However, patients who had abused cannabis before their psychosis onset showed a poorer total performance on the gambling task and a lower improvement on the performance of the task compared to no-abusers. CONCLUSIONS: Pre-psychotic cannabis abuse is associated with decision-making impairment, but not working memory and executive function impairment, among first-episode patients with a schizophrenia-spectrum psychosis. Further studies are needed to examine the direction of causality of this impairment; that is, does the impairment make the patients abuse cannabis, or does cannabis abuse cause the impairment?

Cognitive therapy in early psychosis and "at risk mental state".

Evidence suggests that the early course of psychosis might be important in the long term outcome of the disease. Moreover, pharmacological treatment has important limitations in this population which has increased the interest in the combination of psychological and biological treatments. Recently, cognitive therapy has been modified and applied to the field of psychosis. For decades several studies have shown its effectiveness in the treatment of psychotic symptoms which has led to formulate new and more comprehensive cognitive treatments for early psychosis. These new cognitive approaches have been assessed in clinical trials. In the same way, the study of the pre-psychotic phase and prevention of illness is becoming important. Two aspects are especially relevant in this regards: the possibility of prospective detection of patients at risk of developing psychosis and the search for adequate treatments in this phase. Recent studies concerning early and pre-onset psychosis cognitive treatment are reviewed by the authors.

Terapia cognitiva en psicosis de inicio reciente y "estado mental de riesgo" / Cognitive therapy in early psychosis and "at risk mental state"

Diferentes investigaciones sugieren que las fases tempranas de las psicosis pueden tener una influencia decisiva en el curso posterior de la enfermedad. Además, el tratamiento farmacológico plantea importantes limitaciones en esta población, aspecto que ha favorecido el interés por la combinación de tratamientos psicológicos y biológicos. La terapia cognitiva ha sido adaptada y aplicada al campo de la psicosis. La evidencia que sugiere desde hace décadas su eficacia en el tratamiento de síntomas psicóticos ha llevado al desarrollo de modelos de tratamiento cognitivo más complejos, de variado enfoque terapéutico y a la evaluación de su eficacia en estudios controlados. Este interés también se ha extendido al estudio de las fases prepsicóticas y a la posibilidad de prevención de la enfermedad. Dos aspectos adquieren especial relevancia en este ámbito: la posibilidad de detección prospectiva de individuos en estado de riesgo de desarrollar psicosis y la provisión de tratamientos adecuados en estas circunstancias. Los autores revisan la literatura reciente relativa al tratamiento cognitivo de fases tempranas de las psicosis y estado mental de riesgo

Evidence suggests that the early course of psychosis might be important in the long term outcome of the disease. Moreover, pharmacological treatment has important limitations in this population which has increased the interest in the combination of psychological and biological treatments. Recently, cognitive therapy has been modified and applied to the field of psychosis. For decades several studies have shown its effectiveness in the treatment of psychotic symptoms which has led to formulate new and more comprehensive cognitive treatments for early psychosis. These new cognitive approaches have been assessed in clinical trials. In the same way, the study of the pre-psychotic phase and prevention of illness is becoming important. Two aspects are especially relevant in this regards: the possibility of prospective detection of patients at risk of developing psychosis and the search for adequate treatments in this phase. Recent studies concerning early and pre-onset psychosis cognitive treatment are reviewed by the authors