Rates and predictors of 18-months remission in an epidemiological cohort of 661 patients with first-episode psychosis.

Most first episode psychosis (FEP) outcome studies are based on patient samples enrolled through an informed consent procedure, which may induce important biases. Our aim was to study the 18-month outcome of FEP in an epidemiological sample of patients treated at the Early Psychosis Prevention and Intervention Centre (EPPIC). The files of 661 FEP patients treated for up to 18 months between 1998 and 2000 were assessed. Symptomatic remission was defined as receiving a score ≤3 on the Clinical Global Impressions (CGI) scales, and functional remission as concurrent fulfillment of occupation/employment and independent living. Predictors were analyzed using stepwise logistic regression models. At endpoint, 63% of FEP patients had reached symptomatic remission and 44% functional remission. Duration of untreated psychosis, baseline symptom intensity, time in service and decrease or remission of substance use, predicted both symptomatic and functional outcome. A history of suicide attempt or non-adherence to medication was linked to lower likelihood to reach symptomatic remission while pre-morbid GAF and employment at baseline were linked to functional outcome. The development of early intervention strategies should be pursued, in order both to provide treatment before symptoms reach a high intensity and to maintain social integration. Specific strategies need to promote engagement, facilitate adherence to medication and to create a framework where key issues such as substance abuse co-morbidity can be addressed

Risk of psychotic disorders in migrants to Australia

BACKGROUND: Certain migrant groups are at an increased risk of psychotic disorders compared to the native-born population; however, research to date has mainly been conducted in Europe. Less is known about whether migrants to other countries, with different histories and patterns of migration, such as Australia, are at an increased risk for developing a psychotic disorder. We tested this for first-generation migrants in Melbourne, Victoria. METHODS: This study included all young people aged 15-24 years, residing in a geographically-defined catchment area of north western Melbourne who presented with a first episode of psychosis (FEP) to the Early Psychosis Prevention and Intervention Centre (EPPIC) between 1 January 2011 and 31 December 2016. Data pertaining to the at-risk population were obtained from the Australian 2011 Census and incidence rate ratios were calculated and adjusted for age, sex and social deprivation. RESULTS: In total, 1220 young people presented with an FEP during the 6-year study period, of whom 24.5% were first-generation migrants. We found an increased risk for developing psychotic disorder in migrants from the following regions: Central and West Africa (adjusted incidence rate ratio [aIRR] = 3.53, 95% CI 1.58-7.92), Southern and Eastern Africa (aIRR = 3.06, 95% CI 1.99-4.70) and North Africa (aIRR = 5.03, 95% CI 3.26-7.76). Migrants from maritime South East Asia (aIRR = 0.39, 95% CI 0.23-0.65), China (aIRR = 0.25, 95% CI 0.13-0.48) and Southern Asia (aIRR = 0.44, 95% CI 0.26-0.76) had a decreased risk for developing a psychotic disorder. CONCLUSION: This clear health inequality needs to be addressed by sufficient funding and accessible mental health services for more vulnerable groups. Further research is needed to determine why migrants have an increased risk for developing psychotic disorders

Transitions of care from child and adolescent mental health services to adult mental health services (TRACK Study) : a study of protocols in Greater London

Background: Although young people's transition from Child and Adolescent Mental Health Services (CAMHS) to Adult Mental Health Services (AMHS) in England is a significant health issue for service users, commissioners and providers, there is little evidence available to guide service development. The TRACK study aims to identify factors which facilitate or impede effective transition from CAHMS to AMHS. This paper presents findings from a survey of transition protocols in Greater London. Methods: A questionnaire survey (Jan-April 2005) of Greater London CAMHS to identify transition protocols and collect data on team size, structure, transition protocols, population served and referral rates to AMHS. Identified transition protocols were subjected to content analysis. Results: Forty two of the 65 teams contacted (65%) responded to the survey. Teams varied in type (generic/targeted/in-patient), catchment area (locality-based, wider or national) and transition boundaries with AMHS. Estimated annual average number of cases considered suitable for transfer to AMHS, per CAMHS team (mean 12.3, range 0–70, SD 14.5, n = 37) was greater than the annual average number of cases actually accepted by AMHS (mean 8.3, range 0–50, SD 9.5, n = 33). In April 2005, there were 13 active and 2 draft protocols in Greater London. Protocols were largely similar in stated aims and policies, but differed in key procedural details, such as joint working between CAHMS and AMHS and whether protocols were shared at Trust or locality level. While the centrality of service users' involvement in the transition process was identified, no protocol specified how users should be prepared for transition. A major omission from protocols was procedures to ensure continuity of care for patients not accepted by AMHS. Conclusion: At least 13 transition protocols were in operation in Greater London in April 2005. Not all protocols meet all requirements set by government policy. Variation in protocol-sharing organisational units and transition process suggest that practice may vary. There is discontinuity of care provision for some patients who 'graduate' from CAMHS services but are not accepted by adult services

Process, outcome and experience of transition from child to adult mental healthcare : multiperspective study

Background Many adolescents with mental health problems experience transition of care from child and adolescent mental health services (CAMHS) to adult mental health services (AMHS). Aims As part of the TRACK study we evaluated the process, outcomes and user and carer experience of transition from CAMHS to AMHS. Method We identified a cohort of service users crossing the CAMHS/AMHS boundary over 1 year across six mental health trusts in England. We tracked their journey to determine predictors of optimal transition and conducted qualitative interviews with a subsample of users, their carers and clinicians on how transition was experienced. Results Of 154 individuals who crossed the transition boundary in 1 year, 90 were actual referrals (i.e. they made a transition to AMHS), and 64 were potential referrals (i.e. were either not referred to AMHS or not accepted by AMHS). Individuals with a history of severe mental illness, being on medication or having been admitted were more likely to make a transition than those with neurodevelopmental disorders, emotional/neurotic disorders and emerging personality disorder. Optimal transition, defined as adequate transition planning, good information transfer across teams, joint working between teams and continuity of care following transition, was experienced by less than 5% of those who made a transition. Following transition, most service users stayed engaged with AMHS and reported improvement in their mental health. Conclusions For the vast majority of service users, transition from CAMHS to AMHS is poorly planned, poorly executed and poorly experienced. The transition process accentuates pre-existing barriers between CAMHS and AMH

Examining a staging model for anorexia nervosa: empirical exploration of a four stage model of severity.

Background: An illness staging model for anorexia nervosa (AN) has received increasing attention, but assessing the merits of this concept is dependent on empirically examining a model in clinical samples. Building on preliminary findings regarding the reliability and validity of the Clinician Administered Staging Instrument for Anorexia Nervosa (CASIAN), the current study explores operationalising CASIAN severity scores into stages and assesses their relationship with other clinical features. Method: In women with DSM-IV-R AN and sub-threshold AN (all met AN criteria using DSM 5), receiver operating curve (ROC) analysis (n = 67) assessed the relationship between the sensitivity and specificity of each stage of the CASIAN. Thereafter chi-square and post-hoc adjusted residual analysis provided a preliminary assessment of the validity of the stages comparing the relationship between stage and treatment intensity and AN sub-types, and explored movement between stages after six months (Time 3) in a larger cohort (n = 171). Results: The CASIAN significantly distinguished between milder stages of illness (Stage 1 and 2) versus more severe stages of illness (Stages 3 and 4), and approached statistical significance in distinguishing each of the four stages from one other. CASIAN Stages were significantly associated with treatment modality and primary diagnosis, and CASIAN Stage at Time 1 was significantly associated with Stage at 6 month follow-up. Conclusions: Provisional support is provided for a staging model in AN. Larger studies with longer follow-up of cases are now needed to replicate and extend these findings and evaluate the overall utility of staging as well as optimal staging models

Clinical and service implications of a cognitive analytic therapy model of psychosis

Cognitive analytic therapy (CAT) is an integrative, interpersonal model of therapy predicated on a radically social concept of self, developed over recent years in the UK by Anthony Ryle. A CAT-based model of psychotic disorder has been developed much more recently based on encouraging early experience in this area. The model describes and accounts for many psychotic experiences and symptoms in terms of distorted, amplified or muddled enactments of normal or ‘neurotic’ reciprocal role procedures (RRPs) and of damage at a meta-procedural level to the structures of the self. Reciprocal role procedures are understood in CAT to represent the outcome of the process of internalization of early, sign-mediated, interpersonal experience and to constitute the basis for all mental activity, normal or otherwise. Enactments of maladaptive RRPs generated by early interpersonal stress are seen in this model to constitute a form of ‘internal expressed emotion’. Joint description of these RRPs and their enactments (both internally and externally) and their subsequent revision is central to the practice of CAT during which they are mapped out through written and diagrammatic reformulations. This model may usefully complement and extend existing approaches, notably recent CBT-based interventions, particularly with ‘difficult’ patients, and generate meaningful and helpful understandings of these disorders for both patients and their treating teams. We suggest that use of a coherent and robust model such as CAT could have important clinical and service implications in terms of developing and researching models of these disorders as well as for the training of multidisciplinary teams in their effective treatment

A prototype software framework for transparent, reusable and updatable computational health economic models

Most health economic analyses are undertaken with the aid of computers. However, the ethical dimensions of implementing health economic models as software (or computational health economic models (CHEMs)) are poorly understood. We propose that developers and funders of CHEMs share ethical responsibilities to (i) establish socially acceptable user requirements and design specifications; (ii) ensure fitness for purpose; and (iii) support socially beneficial use. We further propose that a transparent (T), reusable (R) and updatable (U) CHEM is suggestive of a project team that has largely fulfilled these responsibilities. We propose six criteria for assessing CHEMs: (T1) software files are open access; (T2) project team contributions and judgments are easily identified; (R1) programming practices promote generalisability and transferability; (R2) licenses restrict only unethical reuse; (U1) maintenance infrastructure is in place; and (U2) new releases are systematically retested and appropriately deprecated. To facilitate CHEMs that meet TRU criteria, we have developed a prototype software framework in the open-source programming language R. The framework comprises six code libraries for authoring CHEMs, supplying CHEMs with data and undertaking analyses with CHEMs. The prototype software framework integrates with services for software development and research data archiving. We determine that an initial set of youth mental health CHEMs we developed with the prototype software framework wholly meet criteria T1-2, R1-2 and U1 and partially meet criterion U2. Our assessment criteria and prototype software framework can help inform and improve ethical implementation of CHEMs. Resource barriers to ethical CHEM practice should be addressed by research funders.Comment: 17 pages, 4 tables, 1 figur

The 'At-risk mental state' for psychosis in adolescents : clinical presentation, transition and remission.

Despite increased efforts over the last decade to prospectively identify individuals at ultra-high risk of developing a psychotic illness, limited attention has been specifically directed towards adolescent populations (<18 years). In order to evaluate how those under 18 fulfilling the operationalised criteria for an At-Risk Mental State (ARMS) present and fare over time, we conducted an observational study. Participants (N = 30) generally reported a high degree of functional disability and frequent and distressing perceptual disturbance, mainly in the form of auditory hallucinations. Seventy percent (21/30) were found to fulfil the criteria for a co-morbid ICD-10 listed mental health disorder, with mood (affective; 13/30) disorders being most prevalent. Overall transition rates to psychosis were low at 24 months follow-up (2/28; 7.1 %) whilst many participants demonstrated a significant reduction in psychotic-like symptoms. The generalisation of these findings may be limited due to the small sample size and require replication in a larger sample

Reduced parahippocampal cortical thickness in subjects at ultra-high risk for psychosis

Background Grey matter volume and cortical thickness represent two complementary aspects of brain structure. Several studies have described reductions in grey matter volume in people at ultra-high risk (UHR) of psychosis; however, little is known about cortical thickness in this group. The aim of the present study was to investigate cortical thickness alterations in UHR subjects and compare individuals who subsequently did and did not develop psychosis. Method We examined magnetic resonance imaging data collected at four different scanning sites. The UHR subjects were followed up for at least 2 years. Subsequent to scanning, 50 UHR subjects developed psychosis and 117 did not. Cortical thickness was examined in regions previously identified as sites of neuroanatomical alterations in UHR subjects, using voxel-based cortical thickness. Results At baseline UHR subjects, compared with controls, showed reduced cortical thickness in the right parahippocampal gyrus (p<0.05, familywise error corrected). There were no significant differences in cortical thickness between the UHR subjects who later developed psychosis and those who did not. Conclusions These data suggest that UHR symptomatology is characterized by alterations in the thickness of the medial temporal cortex. We did not find evidence that the later progression to psychosis was linked to additional alterations in cortical thickness, although we cannot exclude the possibility that the study lacked sufficient power to detect such difference