Lockdown during the early phase of Covid-19 - effects on specialized mental health services and vocational activities for patients with psychotic disorders.

PURPOSE: People with psychotic disorders may be particularly vulnerable to adverse effects from restrictions implemented to limit the COVID-19 pandemic. Mental health professionals may also be at risk of adverse effects. The aim of this study was to investigate the impact of potential changes in accessibility, quality of care and vocational activity on people with psychotic disorders and the impact on clinicians working in these conditions. MATERIALS AND METHODS: Patients and clinicians in specialized mental health services for psychotic disorders answered questionnaires regarding changes in treatment, quality of treatment, vocational activity, and well-being. Data was analyzed with nonparametric tests. RESULTS: Inpatients appeared more influenced by the restrictions than outpatients, however, quality of treatment was regarded relatively unaffected. Clinicians seemed satisfied working under these conditions, though a larger portion of clinicians reported changes in treatment compared to patients. The patients who reported being affected by changes in vocational activity tended to report negative effects, but the majority reported being unaffected. CONCLUSION: Overall, patients and clinicians appeared to cope well with the changes they experienced in accessibility, quality of care and vocational activity during the early phases of the pandemic.

Depression and functioning are important to subjective quality of life after a first episode psychosis.

BACKGROUND: Subjective quality of life (S-QoL) is an important outcome measure in first-episode psychosis, but its associations with clinical predictors may vary across the illness course. In this study we examine the association pattern, including both direct and indirect effects, between specific predefined clinical predictors (insight, depression, positive psychotic symptoms and global functioning) and S-QoL the first ten years after a first-episode psychosis. METHODS: Three hundred and one patients with a first-episode psychosis were included at first treatment, and reassessed at 3 months, 1 year, 2 years, 5 years and 10 years after inclusion. At 10-year follow-up 186 participated. S-QoL was assessed with Lehman's Quality of Life Interview. Applying a structural equation model, we investigated cross-sectional association patterns at all assessments between the predefined clinical predictors and S-QoL. RESULTS: At baseline, only depression was significantly associated with S-QoL. At all follow-up assessments, depression and functioning showed significant associations with S-QoL. Insight was not associated with S-QoL at any of the assessments. Better insight, less depressive symptoms and less positive psychotic symptoms were all associated with higher functioning at all assessments. Functioning seems to mediate a smaller indirect inverse association between positive psychotic symptoms and S-QoL. The association pattern was stable across all follow-up assessments. CONCLUSIONS: Together with depression, functioning seems to be important for S-QoL. Functioning seems to be a mediating factor between positive symptoms and S-QoL. A focus on functional outcome continues to be important.

Exhausting, but necessary: the lived experience of participants in an intensive inpatient trauma treatment program.

Background: Intensive inpatient treatment programs have shown robust results in the treatment of post-traumatic stress disorder (PTSD). How patients experience this treatment program and what changes they experience as a result of the treatment have, however, only scarcely been explored through qualitative studies. Objective: This study aimed to explore the lived experience of participants in an intensive inpatient trauma treatment program. Our research questions were as follows: how do patients experience intensive trauma-focused treatment? How do they experience possible changes related to participating in the treatment program? Methods: Six patients diagnosed with PTSD with significant comorbidities, who recently participated in an intensive 2-week (4 + 4 days) inpatient trauma treatment program with prolonged exposure (PE), eye movement desensitization and reprocessing (EMDR), and therapist rotation (TR), were interviewed with a semi-structured qualitative interview. Transcripts were analyzed using a thematic analysis approach. Results: Our analysis resulted in five main themes: (1) the need to feel safe; (2) the benefits of many and different therapeutic encounters; (3) variable experience with elements of treatment; (4) intensity; and (5) experienced change. Our results suggest that feeling safe within the framework of the treatment program facilitated the treatment process. Many and different therapeutic encounters, both through TR and with ward staff, contributed to experienced change. All participants described the intensity as facilitative to trauma processing. However, most participants also describe often feeling too overwhelmed to benefit from all elements of the treatment program. Conclusions: Our findings suggest that participants experience the overall treatment program as beneficial and contributing to experienced change. Participants described the intensity of the program as exhausting, but necessary. Most did, however, report at times of being too overwhelmed to benefit from elements of the program. Consequently, our results prompt us to question the optimal level of intensity. Trial registration: ClinicalTrials.gov identifier: NCT05342480. Date of registration: 2022-04-22.

"It takes time to see the whole picture": patients' views on improvement in cognitive behavioral therapy and psychodynamic therapy after three years.

Introduction: There is a lack of qualitative research that retrospectively explores how patients with major depressive disorder view their improvement in psychotherapy. Methods: Fifteen patients who received short-term cognitive behavioral therapy and psychodynamic therapy were individually interviewed approximately three years after completing therapy. Results: Some patients had altered their views on therapy, especially those who initially were uncertain of how helpful therapy had been. They said they did not realize the extent and importance of their improvement in therapy before some time had passed, which can be explained by the surprising cumulative effects of seemingly small changes. Discussion: This should make retrospective qualitative research an important part of future psychotherapy research.

COPSYC-19: The impact of early phase lockdown on mental health among people with psychotic disorders.

PURPOSE: On March 12th 2020 extensive measures were implemented to prevent spread of the coronavirus disease-19 (COVID-19). These measures were commonly referred to as "lockdown". In this study we investigate the psychological impact associated with living under these circumstances among patients with psychotic disorders receiving care from specialized mental health services in Norway. METHOD: During early phases of lockdown, patients and clinicians receiving and providing mental health care for psychotic disorders in specialized health services at Oslo University Hospital were asked to fill out questionnaires developed for the study. 129 participants from outpatient clinics (91 patients and 38 clinicians) and 89 from inpatient wards (15 patients and 74 clinicians) were recruited. Data regarding mental health and related symptoms were analysed using Wilcoxon signed rank tests and standard multiple regression. RESULTS: Outpatients reported significantly less extensive worrying, loneliness and hallucinatory experiences during early phase lockdown compared to the two weeks prior. Reductions in loneliness were predictive of experienced improvement in subjective mental health. However, the majority of clinicians from outpatient clinics believed their patients were experiencing more worrying and loneliness. CONCLUSION: The result of this study suggests that many patients with psychosis experienced less loneliness, excessive worrying and hallucinations during the first phase of lockdown. This contrasts the clinicians' perceptions, as the patients show signs of resilience during times of uncertainty. The limitation in the study timeframe should be noted.

Contrasting monosymptomatic patients with hallucinations and delusions in first-episode psychosis patients: a five-year longitudinal follow-up study.

BACKGROUND: The main aim of this study was to identify subgroups of patients characterized by having hallucinations only or delusions only and to examine whether these groups differed with regard to demographic characteristics, clinical characteristics and outcome factors, including suicidality. METHODS: Out of 301 consecutively admitted patients with first-episode psychosis, individuals with delusions only (D) and hallucinations only (H) were identified based on Positive and Negative Syndrome Scale (PANSS) items P1 (delusions) and P3 (hallucinations) scores at baseline and through 4 follow-up interviews over 5 years. The subgroups were compared with regard to demographic data, premorbid functioning, duration of untreated psychosis, clinical variables, time to remission and suicidality. RESULTS: Two groups of patients were identified; H (n = 16) and D (n = 106). 179 patients experienced both hallucinations and delusions (dual symptom group). The H group was significantly younger, had a longer duration of untreated psychosis, poorer premorbid function and better insight than the D group. Notably, the H group scored higher on measures of suicidality, and at 5 years follow-up a significantly higher proportion of patients was lost to suicide in this group. The dual symptom group was closer to the D group on significant parameters, including suicidality and suicide rate. CONCLUSIONS: Patients with hallucinations only can be separated from patients with delusions only and the subgroups differ with regard to demographical data, clinical variables and notably with regard to suicidality. These findings suggest distinctions in the underlying biological and psychological processes involved in hallucinations and in delusions.

The Synergistic Process of Improvement in Cognitive Behavioral Therapy for Major Depression.

BACKGROUND: There is a substantial lack of qualitative research concerning individual cognitive behavioral therapy (CBT) for patients with major depressive disorder (MDD). In the present study, we wanted to explore how patients suffering from MDD experience improvement in CBT. METHOD: Patients with MDD (N = 10) were interviewed at therapy termination with semi-structured qualitative interviews. The transcripts were analyzed using a thematic analysis approach. RESULTS: We identified three elements that were relevant to the process of improvement for all patients: the therapeutic relationship, the therapeutic interventions and increased insight. There is a dynamic interrelationship and synergy between these elements that may explain why patients considered the same elements as helpful, but often in different ways and at different stages of therapy. CONCLUSIONS: Highlighting the synergies and interrelationship between the elements that patients experience as helpful, may help therapists to learn from and utilize these experiences. This is a reminder of the importance of always being attentive to the individual processes of patients.

A 10-year follow-up study of violent victimization in first episode psychosis: Risk and protective factors.

Violent victimization in persons with severe mental illness has long-term adverse consequences. Little is known about the long-term prevalence of victimization in first episode psychosis, or about factors affecting victimization throughout the course of illness. To assess the prevalence of violent victimization during a 10-year follow-up period in a group of first episode psychosis (FEP) patients, and to identify early predictors and risk factors for victimization. A prospective design was used with comprehensive assessments of violent victimization, treatment variables and functioning at baseline and during 10-year follow-up. A clinical epidemiological sample of FEP patients (n = 298) was studied. FEP patients in our study were at a 3.5 times greater risk of victimization as compared to the normal population. During the 10-year follow-up period, 23% of subjects fell victim to one or more violent assaults. Victimized patients were younger and reported less occupational activity. At 10-year follow-up, victimization was associated with more concomitant drug use, alcohol misuse and violent behavior, but not with a worse clinical or functional outcome. Treatment programs should focus on risk factors for victimization and develop behavioral alternatives to mitigate risk in FEP patients.

Relation between premorbid adjustment, duration of untreated psychosis and close interpersonal trauma in first-episode psychosis.

AIM: Interpersonal traumas are highly prevalent in patients with psychotic disorders. Trauma caused by those close to the patient might have a more profound impact than other types of trauma and may influence early life social functioning. The aim is to investigate the associations between different types of trauma, in particular close interpersonal traumas experienced before the age of 18, premorbid factors and baseline clinical characteristics in a sample of first-episode psychosis patients. METHODS: A total of 191 patients from the 'TIPS' cohort completed assessment with the Brief Betrayal Trauma Survey at their 5 years follow-up interview. RESULTS: Half of the patients reported that they had experienced interpersonal trauma and one-third reported having experienced close interpersonal trauma before the age of 18. Women reported more sexual abuse, physical attacks and emotional and physical maltreatment than men. There were significant associations between early interpersonal trauma and premorbid adjustment and duration of untreated psychosis, but no significant associations with length of education, comorbid substance use or baseline clinical symptomatology. CONCLUSIONS: Close interpersonal trauma before the age of 18 is associated with poorer premorbid adjustment and a longer duration of untreated psychosis. This may indicate that traumatic experiences delay help-seeking behaviour.

Is going into stable symptomatic remission associated with a more positive development of life satisfaction? A 10-year follow-up study of first episode psychosis.

BACKGROUND: Quality of life is an important outcome measure for patients with psychosis. We investigated whether going into stable symptomatic remission is associated with a more positive development of subjective quality of life (S-QoL) and if different patient characteristics are associated with S-QoL depending on remission status. METHODS: Three hundred and one patients with a first-episode psychosis were included at baseline. At 10-year follow-up 186 were reassessed. QoL was assessed by Lehman's Quality of Life Interview. Remission was defined according to criteria proposed by the Remission in Schizophrenia Working Group. One-way ANOVA, mixed model analysis, bivariate correlations and multiple regression analyses were performed. RESULTS: Patients going into stable symptomatic remission showed a more positive S-QoL-development over the follow-up period and reported higher life satisfaction at 10-year follow-up compared to non-remission. At 10-year follow-up, depressive symptoms and alcohol abuse or dependence explained a significant amount of variance in S-QoL among patients in remission. Among patients in non-remission, PANSS excitative component explained a significant amount of variance in S-QoL. All significant effects were negative. CONCLUSIONS: Stable symptomatic remission is associated with a more positive development of overall life satisfaction. Furthermore, different symptoms influence life satisfaction depending on status of remission. This has important clinical implications. While patients in remission might need treatment for depressive symptoms to increase S-QoL, in non-remission measures aiming to decrease hostility and uncooperativeness should be part of the treatment approach. Alcohol problems should be treated regardless of remission status.

The Effect of Substance Use on 10-Year Outcome in First-Episode Psychosis.

Substance use is common in first-episode psychosis (FEP) and has been linked to poorer outcomes with more severe psychopathology and higher relapse rates. Early substance discontinuation appears to improve symptoms and function. However, studies vary widely in their methodology, and few have examined patients longitudinally, making it difficult to draw conclusions for practice and treatment. We aimed to investigate the relationship between substance use and early abstinence and the long-term course of illness in a representative sample of FEP patients. Out of 301 included patients, 266 could be divided into 4 groups based on substance use patterns during the first 2 years of treatment: persistent users, episodic users, stop-users and nonusers. Differences in clinical and functional measures during the follow-up period were assessed using linear mixed effects models for the analysis of repeated measures data. Patients who stopped using substances within the first 2 years after diagnosis had outcomes similar to those who had never used with fewer symptoms than episodic or persistent users. Both episodic and persistent users had lower rates of symptom remission than nonusers, and persistent users also had more negative symptoms than those who stopped using. Our findings emerge from one of very few long-term longitudinal studies examining substance use cessation in FEP with 10-year follow-up. The results convey hope that the detrimental effects of substance abuse on mental health may be significantly reversed if one stops the abuse in time. This can help patients who struggle with addiction with their motivation to embrace abstinence.

Preventing Poor Vocational Functioning in Psychosis Through Early Intervention.

OBJECTIVE: This study tested the hypothesis that early detection of psychosis improves long-term vocational functioning through the prevention of negative symptom development. METHODS: Generalized estimating equations and mediation analysis were conducted to examine the association between employment and negative symptoms over ten years among patients in geographic areas characterized by usual detection (N=140) or early detection (N=141) of psychosis. RESULTS: Improved vocational outcome after ten years among patients in the early-detection area was mediated by lower levels of negative symptoms during the first five years. Regardless of symptoms, rates of full-time employment or study were lower among patients in the usual-detection versus the early-detection area. CONCLUSIONS: Patients from an early-detection area attained lower negative symptom levels earlier compared with patients from a usual-detection area, which seemed to have facilitated vocational careers.

Early Predictors of Ten-Year Course in First-Episode Psychosis.

OBJECTIVE: Identifying patients at risk of poor outcome at an early stage of illness can aid in treatment planning. This study sought to create a best-fit statistical model of known baseline and early-course risk factors to predict time in psychosis during a ten-year follow-up period after a first psychotic episode. METHODS: Between 1997 and 2000, 301 patients with DSM-IV nonorganic, nonaffective first-episode psychosis were recruited consecutively from catchment area-based sectors in Norway and Denmark. Specialized mental health personnel evaluated patients at baseline, three months, and one, two, five, and ten years (N=186 at ten years). Time in psychosis was defined as time with scores ≥4 on any of the Positive and Negative Syndrome Scale items P1, P3, P5, P6, and G9. Evaluations were retrospective, based on clinical interviews and all available clinical information. During the first two years, patients were also evaluated by their clinicians at least biweekly. Baseline and early-course predictors of long-term course were identified with linear mixed-model analyses. RESULTS: Four variables provided significant, additive predictions of longer time in psychosis during the ten-year follow-up: deterioration in premorbid social functioning, duration of untreated psychosis (DUP) of ≥26 weeks, core schizophrenia spectrum disorder, and no remission within three months. CONCLUSIONS: First-episode psychosis patients should be followed carefully after the start of treatment. If symptoms do not remit within three months with adequate treatment, there is a considerable risk of a poor long-term outcome, particularly for patients with a deterioration in premorbid social functioning, a DUP of at least half a year, and a diagnosis within the core schizophrenia spectrum.

Depressive symptoms in first-episode psychosis: a 10-year follow-up study.

AIMS: The present study examined if any patient characteristics at baseline predicted depressive symptoms at 10 years and whether patients prone to depressive symptoms in the first year of treatment had a different prognosis in the following years. METHOD: A total of 299 first-episode psychosis (FEP) patients with schizophrenia spectrum disorders were assessed for depressive symptoms with PANSS depression item (g6) at baseline, and 1, 2, 5 and 10 years of follow up. At 10 years, depressive symptoms were also assessed with Calgary Depression Scale for Schizophrenia (CDSS). A PANSS g6 ≥ 4 and CDSS score ≥ 6 were used as a cut-off score for depression. RESULTS: A total of 122 (41%) patients were scored as depressed at baseline, 75 (28%) at 1 year, 50 (20%) at 2 years, 33 (16%) at 5 years, and 35 (19%) at 10 years of follow up. Poor childhood social functioning and alcohol use at baseline predicted depression at 10 years of follow up. Thirty-eight patients were depressed at both baseline and 1 year follow up. This group had poorer symptomatic and functional outcome in the follow-up period compared to a group of patients with no depression in the first year of treatment. CONCLUSION: Depressive symptoms are frequent among FEP patients at baseline but decrease after treatment because their general symptoms have been initiated. Patients with poor social functioning in childhood and alcohol use at baseline are more prone to have depressive symptoms at 10 years of follow up. Patients struggling with depressive symptoms in the first year of treatment should be identified as having poorer long-term prognosis.

Neurocognition and Duration of Psychosis: A 10-year Follow-up of First-Episode Patients.

A substantial proportion of schizophrenia-spectrum patients exhibit a cognitive impairment at illness onset. However, the long-term course of neurocognition and a possible neurotoxic effect of time spent in active psychosis, is a topic of controversy. Furthermore, it is of importance to find out what predicts the long-term course of neurocognition. Duration of untreated psychosis (DUP), accumulated time in psychosis the first year after start of treatment, relapse rates and symptoms are potential predictors of the long-term course. In this study, 261 first-episode psychosis patients were assessed neuropsychologically on one or more occasions. Patients were tested after remission of psychotic symptoms and reassessed 1, 2, 5, and 10 years after inclusion. The neurocognitive battery consisted of California Verbal Learning Test, Wisconsin Card Sorting Test, Controlled Oral Word Association Task, Trail Making A and B, and Finger Tapping. We calculated a composite score by adding the z-scores of 4 tests that were only moderately inter-correlated, not including Finger Tapping. Data were analyzed by a linear mixed model. The composite score was stable over 10 years. No significant relationship between psychosis before (DUP) or after start of treatment and the composite score was found, providing no support for the neurotoxicity hypothesis, and indicating that psychosis before start of treatment has no significant impact on the course and outcome in psychosis. We found no association between symptoms and the neurocognitive trajectory. Stable remission during the first year predicted neurocognitive functioning, suggesting that the early clinical course is a good predictor for the long-term course.

Subjective quality of life in first-episode psychosis. A ten year follow-up study.

UNLABELLED: Subjective quality of life (S-QoL) is an important outcome measure in first episode psychosis (FEP). The aims of this study were to describe S-QoL-development the first 10-years in FEP patients and to identify predictors of this development. METHODS: A representative sample of 272 patients with a first episode psychotic disorder was included from 1997 through 2000. At 10 year follow-up 186 patients participated. QoL was measured by the Lehman's Quality of Life Interview. Linear mixed model analyses were performed to investigate longitudinal effects of baseline psychiatric symptoms and socio-economic variables and the effects of changes in the same variables on S-QoL-development. RESULTS: S-QoL improved significantly over the follow-up period. More contact with family and a better financial situation at baseline had a positive and longstanding effect on S-QoL-development, but changes in these variables were not associated with S-QoL-development. Higher depressive symptoms and less daily activities at baseline both had a negative independent effect, but a positive interaction effect with time on S-QoL-development indicating that the independent negative effect diminished over time. In the change analysis, increased daily activities and a decrease in depressive symptoms were associated with a positive S-QoL-development. CONCLUSIONS: Treatment of depressive symptoms and measures aimed at increasing daily activities seem important to improve S-QoL in patients with psychosis. More contact with family and a better financial situation at baseline have a long-standing effect on S-QoL-development in FEP patients.

10 year course of IQ in first-episode psychosis: relationship between duration of psychosis and long-term intellectual trajectories.

A substantial proportion of patients suffering from schizophrenia-spectrum disorders (SSDs) exhibit a general intellectual impairment at illness onset, but the subsequent intellectual course remains unclear. Relationships between accumulated time in psychosis and long-term intellectual functioning are largely uninvestigated, but may identify subgroups with different intellectual trajectories. Eighty-nine first-episode psychosis patients were investigated on IQ at baseline and at 10-years follow-up. Total time in psychosis was defined as two separate variables; Duration of psychosis before start of treatment (i.e. duration of untreated psychosis: DUP), and duration of psychosis after start of treatment (DAT). The sample was divided in three equal groups based on DUP and DAT, respectively. To investigate if diagnosis could separate IQ-trajectories beyond that of psychotic duration, two diagnostic categories were defined: core versus non-core SSDs. No significant change in IQ was found for the total sample. Intellectual course was not related to DUP or stringency of diagnostic category. However, a subgroup with long DAT demonstrated a significant intellectual decline, mainly associated with a weaker performance on test of immediate verbal recall/working memory (WAIS-R Digit Span). This indicates a relationship between accumulated duration of psychosis and long-term intellectual course, irrespective of diagnostic category, in a significant subgroup of patients.

Variation in duration of untreated psychosis in an 18-year perspective.

AIM: The Scandinavian TIPS project engineered an early detection of psychosis programme that sought to reduce the duration of untreated psychosis (DUP) through early detection teams and extensive information campaigns since 1997. In 1997-2000, DUP was reduced from 26 to 4.5 weeks median. The programme was continued beyond the initial project in modified forms for over 13 years. The aim of this study was to track the vicissitudes of DUP over an 18-year period (1993-2010) with differing early detection efforts in a defined catchment area. METHOD: The DUP of all patients meeting criteria for first episode psychosis was measured 1993-1994 and from 1997 to 2010 in a naturalistic long-term study. DUP values of all patients were included, irrespective of patients' participation in a clinical follow-up study, yielding a highly representative sample. RESULTS: DUP varied across studies with differing information campaign intensity and content. These variations will be described and explored. CONCLUSIONS: Early detection campaigns should have a stable focus and high intensity level. Future research should further elucidate pathways to care in order to establish principal targets for information campaigns.

Treatment and violent behavior in persons with first episode psychosis during a 10-year prospective follow-up study.

BACKGROUND: First episode psychosis (FEP) patients have an increased risk for violence and criminal activity prior to initial treatment. However, little is known about the prevalence of criminality and acts of violence many years after implementation of treatment for a first episode psychosis. AIM: To assess the prevalence of criminal and violent behaviors during a 10-year follow-up period after the debut of a first psychosis episode, and to identify early predictors and concomitant risk factors of violent behavior. METHOD: A prospective design was used with comprehensive assessments of criminal behavior, drug abuse, clinical, social and treatment variables at baseline, five, and 10-year follow-up. Additionally, threatening and violent behavior was assessed at 10-year follow-up. A clinical epidemiological sample of first-episode psychosis patients (n=178) was studied. RESULTS: During the 10-year follow-up period, 20% of subjects had been apprehended or incarcerated. At 10-year follow-up, 15% of subjects had exposed others to threats or violence during the year before assessment. Illegal drug use at baseline and five-year follow-up, and a longer duration of psychotic symptoms were found to be predictive of violent behavior during the year preceding the 10-year follow-up. CONCLUSION: After treatment initiation, the overall prevalence of violence in psychotic patients drops gradually to rates close to those of the general population. However, persistent illicit drug abuse is a serious risk factor for violent behavior, even long after the start of treatment. Achieving remission early and reducing substance abuse may contribute to a lower long-term risk for violent behavior in FEP patients.