Motivational impairment predicts functional remission in first-episode psychosis: 3-Year follow-up of the randomized controlled trial on extended early intervention.

OBJECTIVE: Functional remission represents an intermediate functional milestone toward recovery. Differential relationships of negative symptom sub-domains with functional remission in first-episode psychosis are understudied. We aimed to examine rate and predictors of functional remission in people with first-episode psychosis in the context of a 3-year follow-up of a randomized controlled trial comparing 1-year extension of early intervention (i.e. 3-year early intervention) with step-down psychiatric care (i.e. 2-year early intervention). METHOD: A total of 160 participants were recruited upon completion of a 2-year specialized early intervention program for first-episode psychosis in Hong Kong and underwent a 1-year randomized controlled trial comparing 1-year extended early intervention with step-down care. Participants were followed up and reassessed 3 years after inclusion to the trial (i.e. 3-year follow-up). Functional remission was operationalized as simultaneous fulfillment of attaining adequate functioning (measured by Social and Occupational Functioning Scale and Role Functioning Scale) at 3-year follow-up and sustained employment in the last 6 months of 3-year study period. Negative symptom measure was delineated into amotivation (i.e. motivational impairment) and diminished expression (i.e. reduced affect and speech output). Data analysis was based on 143 participants who completed follow-up functional assessments. RESULTS: A total of 31 (21.7%) participants achieved functional remission status at 3-year follow-up. Multivariate regression analysis showed that lower levels of amotivation (p = 0.010) and better functioning at study intake (p = 0.004) independently predicted functional remission (Final model: Nagelkerke R2 = 0.40, χ2 = 42.9, p < 0.001). Extended early intervention, duration of untreated psychosis and diminished expression did not predict functional remission. CONCLUSION: Only approximately one-fifths of early psychosis patients were found to achieve functional remission. Functional impairment remains an unmet treatment need in the early stage of psychotic illness. Our results further suggest that amotivation may represent a critical therapeutic target for functional remission attainment in early psychosis.

Sustainability of treatment effect of a 3-year early intervention programme for first-episode psychosis.

BackgroundEvidence indicates that the positive effects of 2-year early intervention services for psychosis are not maintained after service withdrawal. Optimal duration of early intervention in sustaining initial improved outcomes remains to be determined.AimsTo examine the sustainability of the positive effects of an extended, 3-year, early intervention programme for patients with first-episode psychosis (FEP) after transition to standard care.MethodA total of 160 patients, who had received a 2-year early intervention programme for FEP, were enrolled to a 12-month randomised-controlled trial (ClinicalTrials.gov: NCT01202357) comparing a 1-year extension of the early intervention (3-year specialised treatment) with step-down care (2-year specialised treatment). Participants were followed up and reassessed 2 and 3 years after inclusion to the trial.ResultsThere were no significant differences between the treatment groups in outcomes on functioning, symptom severity and service use during the post-trial follow-up period.ConclusionsThe therapeutic benefits achieved by the extended, 3-year early intervention were not sustainable after termination of the specialised service.

Optimal duration of an early intervention programme for first-episode psychosis: randomised controlled trial.

BACKGROUND: Numerous early intervention services targeting young people with psychosis have been established, based on the premise that reducing treatment delay and providing intensive treatment in the initial phase of psychosis can improve long-term outcome. AIMS: To establish the effect of extending a specialised early intervention treatment for first-episode psychosis by 1 year. METHOD: A randomised, single-blind controlled trial (NCT01202357) compared a 1-year extension of specialised early intervention with step-down care in patients who had all received a 2-year intensive early intervention programme for first-episode psychosis. RESULTS: Patients receiving an additional year of specialised intervention had better outcomes in functioning, negative and depressive symptoms and treatment default rate than those managed by step-down psychiatric care. CONCLUSIONS: Extending the period of specialised early intervention is clinically desirable but may not be feasible in lower-income countries.

Prediction of self-stigma in early psychosis: 3-Year follow-up of the randomized-controlled trial on extended early intervention.

BACKGROUND: Self-stigma represents a major barrier to recovery in people with psychotic disorders but is understudied in early illness stage. Longitudinal investigation of prediction for self-stigma is scarce and none is conducted in early psychosis. We aimed to prospectively examine baseline predictors of self-stigma in early psychosis patients in the context of a 3-year follow-up of a randomized-controlled trial (RCT) comparing 1-year extension of early intervention (EI) with step-down psychiatric care for first-episode psychosis (FEP). METHOD: One hundred sixty Chinese patients were recruited from a specialized EI program for FEP in Hong Kong after they had completed this 2-year EI service, and underwent a 12-month RCT. Participants were followed up and reassessed 3years after inclusion to the trial. Comprehensive evaluation encompassing clinical, functional, subjective quality of life and treatment-related variables were conducted. Data analysis was based on 136 participants who completed self-stigma assessment at 3-year follow-up. RESULTS: Fifty patients (36.8%) had moderate to high levels of self-stigma at 3-year follow-up. Multivariate regression analysis revealed that female gender, prior psychiatric hospitalization, longer duration of untreated psychosis and greater positive symptom severity at study intake independently predicted self-stigma at the end of 3-year study period. CONCLUSION: Our results of more than one-third of early psychosis patients experienced significant self-stigma underscore the clinical needs for early identification and intervention of self-stigmatization in the initial years of psychotic illness. Further research is warranted to clarify prediction profile and longitudinal course of self-stigma in the early illness phase.

Clinical and treatment-related determinants of subjective quality of life in patients with first-episode psychosis.

Subjective quality of life (SQoL) has been increasingly studied in first-episode psychosis (FEP). Prior research primarily examined the impact of psychiatric symptoms on SQoL. Relationship between treatment-related factors and SQoL is under-studied. In this study, 159 Chinese patients who had completed 2-year treatment from early intervention service in Hong Kong were recruited. Assessments on premorbid adjustment, clinical profiles including social anxiety measure, functioning, antipsychotic-induced extrapyramidal side-effects and attitude toward medication treatment were conducted. SQoL was evaluated by Chinese version SF36 which generated mental and physical component summary (MCS and PCS) scores for analysis. Our results showed that more severe positive symptoms, higher level of depression, greater social anxiety, more negative attitude toward antipsychotic medications and greater degree of akathisia independently predicted lower MCS score. Higher social anxiety level and poorer functioning predicted lower PCS score. Our results indicate that affective and positive symptoms, functioning, and treatment-related variables are critical determinants of SQoL in FEP patients. These identified factors thus represent potentially malleable therapeutic targets for early detection and prompt intervention to promote enhancement of SQoL in the early stage of illness.

Three-year clinical and functional outcome comparison between first-episode mania with psychotic features and first-episode schizophrenia.

BACKGROUND: The early course of first-episode mania with psychotic features (FEMP) is under-studied. Accumulating evidence suggests that FEMP is associated with substantial functional impairment. Very few studies were conducted to directly compare clinical and functional outcomes between FEMP and first-episode schizophrenia (FES). METHODS: Four-hundred-twenty patients aged 15-25 years who presented with FEMP or FES to a territory-wide early intervention service in Hong Kong from July 2001 to August 2003 and completed 3-year follow-up were studied. Baseline and follow-up variables were collected via systematic medial file review. Functional remission was operationalized as attaining sustained employment, and Social and Occupational Functioning Assessment Scale (SOFAS) score >60 in the last 12 months of follow-up. RESULTS: At baseline, FEMP patients were younger, more likely to be hospitalized, had shorter duration of untreated psychosis, more severe positive symptoms and lower SOFAS score than FES patients. By the end of 3-year follow-up, FEMP patients had significantly milder positive symptom severity, higher SOFAS score, and higher rates of sustained employment (45.7%) and functional remission (36.9%) than FES patients. Regression analyses showed that diagnostic group membership of FEMP (vs. FES) independently predicted better clinical and functional outcomes. CONCLUSION: Our results indicate that FEMP patients had better clinical and functional outcomes than FES patients in the initial 3 years of treatment. Yet, only approximately 37% of FEMP patients attained functional remission at 3 years. This underscores the need to develop specialized early intervention for FEMP populations to promote functional recovery in the early stage of illness.

Prediction of functional remission in first-episode psychosis: 12-month follow-up of the randomized-controlled trial on extended early intervention in Hong Kong.

BACKGROUND: Functional remission (FR) is an intermediate and necessary step toward recovery, but is understudied in first-episode psychosis (FEP). We aimed to examine the rate and predictors of FR in FEP patients in the context of a randomized-controlled trial (RCT) comparing a 1-year extension of early intervention (Extended EI, 3-year EI) with step-down psychiatric care (SC, 2-year EI). METHODS: One hundred sixty Chinese patients were recruited from a specialized EI program for FEP in Hong Kong after they have completed this 2-year EI service, randomly allocated to Extended EI or SC, and followed up for 12 months. Assessments on premorbid adjustment and personality, clinical profiles, functioning, and treatment characteristics were conducted. FR was operationalized as simultaneous fulfillment of attaining adequate functional levels (measured by Social and Occupational Functioning Scale and Role Functioning Scale) and competitive employment at 6 and 12 months. Data analysis was based on 156 subjects who completed follow-up functional assessments. RESULTS: Thirty-one (19.9%) patients achieved FR status. Multivariate binary regression analysis showed that female gender, lower degrees of premorbid schizoid-schizotypal traits, Extended EI treatment condition, lower levels of positive symptoms at intake, and better baseline functioning independently predicted FR. CONCLUSION: This is the first RCT providing supportive evidence to an extension of EI service beyond 2-year treatment duration on further enhancing the likelihood of FR attainment in FEP. Our findings that only approximately 20% of patients achieved FR indicate an unmet therapeutic need for promoting sustained adequate functional improvement in the early stage of psychotic illness.