Sociodemographic and clinical predictors of delay to and length of stay with early intervention for psychosis service: findings from the CRIS-FEP study.

PURPOSE: We investigated the influence of sociodemographic and clinical characteristics on delay to early intervention service (EIS) and the length of stay (LOS) with EIS. METHODS: We used incidence data linked to the Clinical Record Interactive Search-First Episode Psychosis (CRIS-FEP) study. We followed the patients from May 2010 to March 2016. We performed multivariable Cox regression to estimate hazard ratios of delay to EIS. Negative binomial regression was used to determine LOS with EIS by sociodemographic and clinical characteristics, controlling for confounders. RESULTS: 343 patients were eligible for an EIS, 34.1% of whom did not receive the service. Overall, the median delay to EIS was 120 days (IQR; 15-1668); and the median LOS was 130.5 days (IQR 0-663). We found that women (adj.HR 0.58; 95%C I 0.42-0.78), living alone (adj.HR: 0.63; 95% CI 0.43-0.92) and ethnicity ('Other': adj.HR 0.47; 95% CI 0.23-0.98) were associated with prolonged delay to EIS. However, family involvement in help-seeking for psychosis (adj.HR 1.37; 95% CI 1.01-1.85) was strongly associated with a shorter delay to EIS. Patients who have used mental health services previously also experienced long delays to EIS. CONCLUSIONS: Our analyses highlight the link between sociodemographic status, help-seeking behaviours, and delay to EIS. Our findings also show the vulnerability faced by those with a previous mental health problem who later develop psychosis in receiving specialist treatment for psychosis. Initiatives that ameliorate indicators of social disadvantage are urgently needed to reduce health inequalities and improve clinical outcomes.

Change in incidence rates for psychosis in different ethnic groups in south London: findings from the Clinical Record Interactive Search-First Episode Psychosis (CRIS-FEP) study.

BACKGROUND: A higher incidence of psychotic disorders has been consistently reported among black and other minority ethnic groups, particularly in northern Europe. It is unclear whether these rates have changed over time. METHODS: We identified all individuals with a first episode psychosis who presented to adult mental health services between 1 May 2010 and 30 April 2012 and who were resident in London boroughs of Lambeth and Southwark. We estimated age-and-gender standardised incidence rates overall and by ethnic group, then compared our findings to those reported in the Aetiology and Ethnicity of Schizophrenia and Other Psychoses (ÆSOP) study that we carried out in the same catchment area around 10 years earlier. RESULTS: From 9109 clinical records we identified 558 patients with first episode psychosis. Compared with ÆSOP, the overall incidence rates of psychotic disorder in southeast London have increased from 49.4 (95% confidence interval (CI) 43.6-55.3) to 63.1 (95% CI 57.3-69.0) per 100 000 person-years at risk. However, the overall incidence rate ratios (IRR) were reduced in some ethnic groups: for example, IRR (95% CI) for the black Caribbean group reduced from 6.7 (5.4-8.3) to 2.8 (2.1-3.6) and the 'mixed' group from 2.7 (1.8-4.2) to 1.4 (0.9-2.1). In the black African group, there was a negligible difference from 4.1 (3.2-5.3) to 3.5 (2.8-4.5). CONCLUSIONS: We found that incidence rates of psychosis have increased over time, and the IRR varied by the ethnic group. Future studies are needed to investigate more changes over time and determinants of change.

Ethnic variations in duration of untreated psychosis: report from the CRIS-FEP study.

OBJECTIVES: There is inconsistent evidence on the influence of ethnicity on duration of untreated psychosis (DUP). We investigated ethnic differences in DUP in a large epidemiological dataset of first episode psychosis patients in an inner city area of south London, UK. METHODS: We analysed data on 558 first episode psychosis patients at the South London and Maudsley NHS Trust, between 2010 and 2012. We performed multivariable logistic regression to estimate the odds of a short DUP (≤ 6 months) by ethnic group, controlling for confounders. RESULTS: There was no evidence that ethnicity is associated with duration of untreated psychosis. However, we found evidence that a short DUP was strongly associated with age, living circumstances, and pathways to care variables (involuntary admission, out of office hour contact, accident and emergency referral, criminal justice agency referral and family involvement in help-seeking). Conversely, a long DUP was associated with report of social isolation, living alone, being single and General Practitioner referral. CONCLUSION: Our findings suggest that indicators of social isolation were associated with long DUP. Our data also show that pathways into care characteristics play significant role in DUP. Thus, the challenge of tackling the issue of timely access to EI under the new Access and Waiting Time standard for psychosis requires a multilevel approach, including joint working with communities, public awareness of psychosis, less restrictive referral pathways and adequate resourcing of early intervention for psychosis services. These will go a long way in addressing patients' needs rather than be determined by service structures.

Compulsory admission at first presentation to services for psychosis: does ethnicity still matter? Findings from two population-based studies of first episode psychosis.

OBJECTIVES: Compared with the majority population, those from minority ethnic groups in the UK are more likely to be admitted compulsorily during a first episode of psychosis (FEP). We investigated whether these disparities in pathways in to care continue. METHODS: We analysed data from two first episode psychosis studies, conducted in the same geographical area in south London 15 years apart: the Aetiology and Ethnicity in Schizophrenia and Other Psychosis (AESOP) and the Clinical Record Interactive Search-First Episode Psychosis (CRIS-FEP) studies. The inclusion/exclusion criteria for case ascertainment for first episode psychosis were identical across the two studies. We performed multivariable logistic regression to estimate odds of compulsory admission by ethnic group, controlling for confounders. PARTICIPANTS: Two hundred sixty-six patients with first episode psychosis, aged 18-64 years, who presented to mental health services in south London in 1997-1999 and 446 with FEP who presented in 2010-2012. RESULTS: When the two samples  were compared, ethnic differences in compulsory admission appear to have remained the same for black African patients, i.e. three times higher than white British in both samples: AESOP (adj. OR = 3.96; 95% CI = 1.80-8.71) vs. CRIS-FEP (adj. OR = 3.12; 95% CI = 1.52-6.35). Black Caribbean patients were three times more likely to be compulsorily admitted in AESOP (adj. OR = 3.20; 95% CI = 1.56-6.54). This was lower in the CRIS-FEP sample (adj. OR = 1.68; 95% CI = 0.71-3.98) and did not meet conventional levels for statistical significance. CONCLUSION: Ethnicity is strongly associated with compulsory admissions at first presentation for psychosis with evidence of heterogeneity across groups, which deserves further research.

Predicting psychiatric inpatient costs.

PURPOSE: A large proportion of mental health costs is inpatient care but little is known about their variation between patients. The aim of this study was to measure and identify the predictors of costs of staff contacts and activities on inpatient wards. METHOD: Inpatients from psychiatric hospital wards in south London were interviewed in 2008 and 2009 and staff contacts and use of activities recorded over a week and costs calculated. Regression analyses identified predictors. RESULTS: Of 334 participants, 78% used activities and 90% had staff contacts. However, 41% reported no nurse contact. Mean staff contact and activity costs were £197 and £30 per week, respectively. Staff contact costs were inversely related to age, and activity costs were higher for patients with higher levels of education. Patient satisfaction was positively associated with both costs. CONCLUSIONS: The costs of self-reported staff contacts and use of activities account for a small amount of total inpatient costs. Patients with higher costs appeared to have higher levels of satisfaction.

Acute mental health service use by patients with severe mental illness after discharge to primary care in South London.

BACKGROUND: To return the patients to primary care is arguably the desired service outcome for community mental health teams (CMHTs). AIMS: To assess acute mental health service use (hospitalisation or Home Treatment Team) by people with severe mental illness following discharge to primary care. METHOD: Retrospective cohort study comparing receipt and duration of acute care by 98 patients in the two years following discharge to primary care from CMHT, with a cohort of 92 patients transferred to another CMHT. RESULTS: The discharged group was significantly more stable on clinical measures. Fifty-seven (58.2%) patients were re-referred after median 39 weeks, with 35 (60.3%) in crisis. The difference in acute service use between discharged patients (27.9 days/patient) and transferred patients (31.7 days/patient) was not significant. Hospitalisation in the two years prior to discharge or transfer increased the odds of re-referral (OR 3.93, 95% CI 1.44-14.55), subsequent acute service use (OR 1.02, 95% CI 1.01-1.03) and duration of input (0.45 extra days/patient, 95% CI 0.22-0.68). CONCLUSIONS: The majority of the discharged patients were re-referred to mental health services. Although these were more stable, there was no difference from the transferred group on acute service use. Further support may be required in primary care to maintain stability.

The future of academic psychiatry may be social.

The past 30 years have produced no discoveries leading to major changes in psychiatric practice. The rules regulating research and a dominant neurobiological paradigm may both have stifled creativity. Embracing a social paradigm could generate real progress and, simultaneously, make the profession more attractive.

Promoting recovery-oriented practice in mental health services: a quasi-experimental mixed-methods study.

BACKGROUND: Recovery has become an increasingly prominent concept in mental health policy internationally. However, there is a lack of guidance regarding organisational transformation towards a recovery orientation. This study evaluated the implementation of recovery-orientated practice through training across a system of mental health services. METHODS: The intervention comprised four full-day workshops and an in-team half-day session on supporting recovery. It was offered to 383 staff in 22 multidisciplinary community and rehabilitation teams providing mental health services across two contiguous regions. A quasi-experimental design was used for evaluation, comparing behavioural intent with staff from a third contiguous region. Behavioural intent was rated by coding points of action on the care plans of a random sample of 700 patients (400 intervention, 300 control), before and three months after the intervention. Action points were coded for (a) focus of action, using predetermined categories of care; and (b) responsibility for action. Qualitative inquiry was used to explore staff understanding of recovery, implementation in services and the wider system, and the perceived impact of the intervention. Semi-structured interviews were conducted with 16 intervention group team leaders post-training and an inductive thematic analysis undertaken. RESULTS: A total of 342 (89%) staff received the intervention. Care plans of patients in the intervention group had significantly more changes with evidence of change in the content of patient's care plans (OR 10.94. 95% CI 7.01-17.07) and the attributed responsibility for the actions detailed (OR 2.95, 95% CI 1.68-5.18). Nine themes emerged from the qualitative analysis split into two superordinate categories. 'Recovery, individual and practice', describes the perception and provision of recovery orientated care by individuals and at a team level. It includes themes on care provision, the role of hope, language of recovery, ownership and multidisciplinarity. 'Systemic implementation', describes organizational implementation and includes themes on hierarchy and role definition, training approaches, measures of recovery and resources. CONCLUSIONS: Training can provide an important mechanism for instigating change in promoting recovery-orientated practice. However, the challenge of systemically implementing recovery approaches requires further consideration of the conceptual elements of recovery, its measurement, and maximising and demonstrating organizational commitment.

Perceived emotional support in remission: results from an 18-month follow-up of patients with early episode psychosis.

PURPOSE: Serious mental illness is known for the damage that it inflicts on the social network and social support of patients. Although many studies have used relapse and rehospitalisation as outcomes, recent research has emphasized the importance of a fuller definition of recovery that includes social function. In this study, our goal is to investigate the association of social support with sustained remission in patients with early episode psychosis. METHODS: A secondary analysis of remission and social support was performed with 123 of 144 patients enrolled in the Lambeth Early Onset randomized clinical trial who ever achieved symptom-free status in 18 months of follow-up. Social support was measured by hours of family contact, perceived support, and network size at 6 months into an early intervention treatment program. Consensus judgments made by clinicians on symptom status at each of 18 months of follow-up were analyzed for consecutive months spent in remission. Direct and mediated effects of social support on remission were calculated using Poisson regression and path analysis, respectively. RESULTS: 114 of 123 patients achieved remission after about 7 months on average [mean 6.81 (SD 4.17)]. In univariate models, perceived emotional support predicted longer time spent in remission, while moderate family contact predicted shorter remission duration. Perceived practical support was not associated with remission. Perceived emotional support mediated the association between family contact and remission and between network size and remission. These results are not totally attributable to a specialized early intervention treatment. CONCLUSION: Structural measures of support probably contribute to the maintenance of remission through the patient's perception of emotional support.

Multidimensional and intergenerational impact of Severe Mental Disorders.

BACKGROUND: Severe Mental Disorders (SMDs) affect multiple generations although this is poorly studied. The aim of this study was to investigate the intergenerational and multidimensional impacts of SMD in rural Ethiopia. METHODS: This comparative study was nested within an existing population-based cohort study. We collected data from a total 5762 family members of 532 households (266 households with at least one family member with SMD and 266 sex and age matched mentally well controls from the neighborhood) in 2019. The main outcomes were multidimensional poverty, mortality, food insecurity, and family satisfaction. FINDINGS: Multidimensional poverty Index was higher in the households of persons with SMD (74·44%) than the comparison households (38·35%). School attendance was lower in children of people with SMD (63·28%) than children of the comparisons (78·08%). The median years of schooling was also lower among children of people with SMD than the controls. This lower attendance was also true among siblings of people with SMD (35·52%) than the comparisons (49·33%). Over the course of 20 years, family members who have a person with SMD in their household had 23% increased risk of death compared to family members who did not have a person with SMD in their household. Severe food insecurity was also higher in the SMD households (20·68%) than the comparison (13·53%) while family satisfaction was lower. INTERPRETATION: Families of people with SMD experience pervasive multidimensional and intergenerational impacts. Interventions should consider the broader family social and healthcare needs of the broader family.

Side-effect monitoring of continuing LAI antipsychotic medication in UK adult mental health services.

BACKGROUND: Long-acting injectable (LAI) antipsychotic medications are used to optimise treatment outcomes in schizophrenia. Guaranteed medication delivery increases the responsibility of prescribers to monitor and manage adverse effects. METHODS: In the context of a quality improvement programme conducted by the Prescribing Observatory for Mental Health, a clinical audit addressed documented side-effect monitoring in patients prescribed continuing LAI antipsychotic medication under the care of United Kingdom adult mental health services. RESULTS: A total of 62 mental health services submitted data on 5169 patients prescribed LAI antipsychotic medication for more than a year. An assessment of side effects had been documented in the past year in 2304 (45%) cases. Post hoc analysis showed that extrapyramidal side effects were more likely to have been assessed and found to be present in those patients prescribed LAI haloperidol, flupentixol or zuclopenthixol. There was little other targeting of assessments to the known side effects profiles of individual LAI antipsychotic medications, but when dysphoria had been assessed it was most commonly found with LAI haloperidol treatment and when weight gain, sexual and prolactin-related side effects had been assessed, they were more often identified with LAI paliperidone. CONCLUSION: The data suggest a relatively low frequency of side-effect assessments, largely untargeted. This is likely to result in many adverse effects going unrecognised and unmanaged, thus failing to tackle their potential to confound mental state assessment and adversely affect physical health and adherence. Patients receiving LAI antipsychotic medication have regular contact with a healthcare professional who administers the medication, which provides an opportunity to potentially remedy this situation.

Cost-effectiveness of an early intervention service for people with psychosis.

BACKGROUND: There is concern that delaying treatment for psychosis may have a negative impact on its long-term course. A number of countries have developed early intervention teams but there is limited evidence regarding their cost-effectiveness. AIMS: To compare the costs and cost-effectiveness of an early intervention service in London with standard care. METHOD: Individuals in their first episode of psychosis (or those who had previously discontinued treatment) were recruited to the study. Clinical variables and costs were measured at baseline and then at 6- and 18-month follow-up. Information on quality of life and vocational outcomes were combined with costs to assess cost-effectiveness. RESULTS: A total of 144 people were randomised. Total mean costs were 11,685 pounds sterling in the early intervention group and 14,062 pounds sterling in the standard care group, with the difference not being significant (95% CI -8128 pounds sterling to 3326 pounds sterling). When costs were combined with improved vocational and quality of life outcomes it was shown that early intervention would have a very high likelihood of being cost-effective. CONCLUSIONS: Early intervention did not increase costs and was highly likely to be cost-effective when compared with standard care.

Effect of early intervention on 5-year outcome in non-affective psychosis.

BACKGROUND: Early specialised care may improve short-term outcome in first-episode non-affective psychosis, but it is unclear if these benefits endure. AIMS: To assess the long-term effect of early intervention in psychosis. METHOD: Individuals with first-episode psychosis were randomised to specialised care or care as usual (trial number: ISRCTN73679874). Outcome after 5 years was assessed by case-note review. RESULTS: There were no significant differences in the admission rate (coefficient 0.096, 95% CI -0.550 to 0.742, P = 0.770) or the mean number of bed days (coefficient 6.344, 95% CI -46 to 58.7, P = 0.810). CONCLUSIONS: These findings that specialist intervention did not markedly improved outcome at 5 years accord with those from a larger OPUS study. The sample size of this study was small and these results should be generalised with caution. More research is needed.

Esquire trial: efficacy and adverse effects of quetiapine versus risperidone in first-episode schizophrenia.

OBJECTIVE: To compare the efficacy and adverse effect profiles of 2 widely used atypical antipsychotics in the short-term phase of first-episode schizophrenia in patients who were treatment-naive. A secondary objective was to establish the effective dose of these drugs in this context. METHODS: A total of 72 patients with a first episode of schizophreniform psychosis (schizophrenia spectrum disorder) with less than 2 weeks of exposure to antipsychotic medication were randomized to quetiapine or risperidone in a single-blind 12-week controlled trial. Psychopathologic diagnoses and adverse effects were assessed by blinded raters at 4 weekly intervals. Medication was administered by a specialized clinical team following dosing guidelines. Data were analyzed using an intention-to-treat paradigm. RESULTS: Both quetiapine and risperidone were associated with a reduction in immediate symptoms and relatively few adverse effects other than weight gain. There was no statistically significant difference between the 2 compounds in adverse effects, relative efficacies, or adherence to treatment. The median (SD) time to cessation for patients randomized to quetiapine was 65.3 (41.85) days and that for risperidone was 82.5 (44.88) days. There was no statistically significant difference between time to discontinuation for the 2 compounds. The mean daily doses prescribed were 375 mg of quetiapine and 2.72 mg of risperidone. CONCLUSIONS: Quetiapine and risperidone are both effective treatments in first-episode schizophrenia at doses lower than those used in patients with long-term schizophrenia and are similar in efficacy and the incidence of adverse effects.

Self-esteem in remitted bipolar disorder patients: a meta-analysis.

OBJECTIVES: Low self-esteem has been found to be a risk factor for depression in major depressive disorder (MDD). In contrast, the role of self-esteem in bipolar disorder (BD) is still uncertain. In order to examine the characteristics of self-esteem in BD, we synthesized studies comparing self-esteem in BD patients with self-esteem in MDD patients and in normal controls. METHODS: Database searches and identification of studies were conducted by two of the authors independently. Remission of BD and MDD was a major selection criterion. The results were generated through meta-analyses. RESULTS: Random-effects models of 19 between-group comparisons (N= 1,838) suggested that the self-esteem of remitted BD patients was significantly lower than that of normal controls (Cohen's d= -0.83), while significantly higher than that of remitted MDD patients (Cohen's d= 0.54). Fail-safe numbers and tests for funnel plot asymmetry indicated that the results were robust and unlikely to reflect publication biases. Additional studies indicated that self-esteem may take a fluctuating course during remission of BD. CONCLUSIONS: By revealing that BD patients do experience low self-esteem, the findings implicate a need for further understanding the causes and therapeutic impact of such abnormality in BD.

AVATAR Therapy for Distressing Voices: A Comprehensive Account of Therapeutic Targets.

AVATAR therapy represents an effective new way of working with distressing voices based on face-to-face dialogue between the person and a digital representation (avatar) of their persecutory voice. To date, there has been no complete account of AVATAR therapy delivery. This article presents, for the first time, the full range of therapeutic targets along with information on acceptability and potential side effects. Interest in the approach is growing rapidly and this report acts as a necessary touchstone for future development.

Multidimensional impact of severe mental illness on family members: systematic review.

OBJECTIVE: The impact of severe mental illnesses (SMIs) is not limited to the person with the illness but extends to their family members and the community where the patient comes from. In this review, we systematically analyse the available evidence of impacts of SMI on family members, including parents, grandparents, siblings, spouses and children. DATA SOURCES: PubMed, PsycINFO, Embase and Global Index Medicus were searched from the inception of each database up to 9 November 2019. We also did manual searches of grey literature. ELIGIBILITY CRITERIA: We included studies that assessed the impacts of SMI on any family member. We excluded studies in admitted clinics and acute wards to rule out the acute effect of hospitalisation. DATA EXTRACTION: Two reviewers extracted data independently using the Cochrane handbook guideline for systematic reviews and agreed on the final inclusion of identified studies. RISK OF BIAS: The quality of the included studies was assessed using effective public health practice project quality assessment tool for quantitative studies.The review protocol was registered in the PROSPERO database. RESULTS: We screened a total of 12 107 duplicate free articles and included 39 articles in the review. The multidimensional impact of SMI included physical health problems (sleeplessness, headache and extreme tiredness.), psychological difficulties (depression and other psychological problems) and socioeconomic drift (less likely to marry and higher divorce rate and greater food insecurity). Impacts on children included higher mortality, poor school performance and nutritional problems. However, the quality of one in five studies was considered weak. CONCLUSIONS: Our review indicated a high level of multidimensional impact across multiple generations. The serious nature of the impact calls for interventions to address the multidimensional and multigenerational impact of SMI, particularly in low/middle-income countries. Given the relatively high number of studies rated methodologically weak, more robust studies are indicated. PROSPERO REGISTRATION NUMBER: CRD42018064123.

Parental maltreatment and proximal risk factors using the Childhood Experience of Care & Abuse (CECA) instrument: a life-course study of adult chronic depression - 5.

BACKGROUND: This is the final paper of a series concerning parental maltreatment and chronic depression in women. It extends the scope of the analysis to take account of proximal risk factors, present within at most six months of an onset. It deals with the contribution of factors influencing onset of a depressive episode as well as those related to whether this takes a chronic course. Once a two-stage model dealing with both sets of risk factors has been developed we explore how far distal factors (more than at least one year earlier) influence each stage. METHODS: Three studies are employed. All take account of parental maltreatment. Two prospective studies deal with proximal risk factors, and a retrospective one with distal and proximal factors. RESULTS: For the first stage of the model concerning onset the influence of parental maltreatment and its correlated risk factors (e.g. conduct problems) are almost entirely mediated by proximal factors (e.g. quality of core relationships). However, for the second stage concerning course parental maltreatment makes a direct contribution that is independent of all other risk factors. LIMITATIONS: The retrospective nature of some of the data may introduce bias (But see the second paper in the present series [Brown, G.W., Craig, T.K.J., Harris, T.O., Handley, R.V., Harvey, A.L., 2007b. Validity of retrospective measures of early maltreatment and depressive episodes using the Childhood Experience of Care & Abuse (CECA) instrument - a life-course study of adult chronic depression - 2. J. Affect. Dis., 103, 217-224]). Only females have been considered. CONCLUSIONS: The influence of parental maltreatment on the onset of adult depression is largely indirect and the mechanisms involved are reasonably clear. However, the mechanisms involved in the substantial direct contribution of maltreatment to course are as yet unclear. Some interplay of maltreatment and early brain development is one of a number of interesting possibilities.

Parental maltreatment and adulthood cohabiting partnerships: a life-course study of adult chronic depression--4.

BACKGROUND: This fourth paper of a series of five concerning depression in women considers: i. why parental maltreatment increases risk of highly aversive ('very poor') partnerships, and ii. how far these relationships explain the link of such maltreatment with adult chronic depression. METHODS: Data was collected retrospectively by semi-structured interviews and only women living at some point with a partner included. RESULTS: Parental maltreatment was indirectly linked to chronic depression via highly aversive partnerships. This was partly mediated by childhood conduct problems. However, a broader range of behaviour in late adolescence and early adulthood such as early risky sexual behaviour among those without conduct problems was also involved. In addition parental maltreatment was directly linked to chronic depression, judged by a substantial remaining association when other risk factors were controlled. Highly aversive partnerships were less common by the late 20s while this was matched by an increase of 'very poor' circumstances among those no longer living with a partner. This increase often involved lone motherhood, an established risk factor for chronic depression. LIMITATIONS: These findings should be seen as tentative given the retrospective nature of many of the measures (But see the second paper in the present series [Brown, G.W., Craig, T.K.J., Harris, T.O., Handley, R.V., & Harvey, A.L. (2007b). Validity of retrospective measures of early maltreatment and depressive episodes using CECA (Childhood Experience of Care & Abuse)--A life-course study of adult chronic depression--2. J. Affect. Disord., 103, 217-224]. Only women were studied. CONCLUSIONS: Parental maltreatment relates indirectly to adult chronic episodes of depression with highly aversive partnerships playing an important mediating role. Parental maltreatment also has a direct link. While these results are broadly consistent with earlier research a more complete understanding of the mechanisms acting across the life-course requires an assessment of a wider range of factors around the time of an onset of depression. This is the task of our next and final paper.