Systematic analysis of transdiagnostic epidemiology and clinical correlates of duration of untreated psychosis in the Cavan-Monaghan First Episode Psychosis Study (CAMFEPS)

This thesis first explores similarities and differences between numerous psychosis diagnoses using an epidemiologically based approach. Secondly, it explores relationships between duration of untreated psychosis (DUP), the less studied duration of untreated illness (DUI), developmental indices and measures of clinical, social and functional outcome, with and without controlling for confounders. Data were collected from first episode psychosis patients within a stable, rural and ethnically homogeneous population over a15-year period (1995-2010) who were incepted into the naturalistic, prospectively designed Cavan-Monaghan First Episode Psychosis Study (CAMFEPS). CAMFEPS incepts all patients aged 16 and older, with no upper age limit, who are resident in counties Cavan and Monaghan, including patients admitted to private hospitals outside of this catchment area or to the national forensic psychiatric hospital. A comprehensive range of standardised assessments was administered at inception and at 6 months to ascertain DSM-IV diagnoses and measure psychopathology, neuropsychology, neurology, quality of life and functioning in relation to DUP and DUI, with a subset of patients followed up at 6 years. Annual incidence of any DSM-IV psychotic disorder among the 432 cases incepted over the 15 years of CAMFEPS was 34.1/100,000 of population aged ≥15 years and was resolved for each of 12 DSM-IV psychotic diagnoses. Risk for psychosis was higher in males than in females for schizophrenia (3.1-fold) and substance-induced psychosis (7.0-fold) but not for any other diagnosis. Mean DUP for the cohort was 7.5 (range 0.0-192.0) months and mean DUI was 19.4 months (range 0.0-336.0) months, with these durations also resolved for individual psychotic diagnoses. While longer DUP was associated primarily with more severe negative symptoms, DUI was associated with more severe psychopathology across the positive, negative and general domains and with poorer QOL and insight. Results from this thesis suggest that psychosis, of whatever diagnosis, can emerge at any point across the life-span, in either sex, with similar extents of psychotic psychopathology, and support a dimensional rather than categorical view of psychosis. DUI revealed more robust associations with more severe psychopathology and poorer functional outcome than were evident for DUP. This suggests that DUI may be associated quantitatively with more adverse biological or psychosocial consequences than DUP and should be factored into early intervention programmes.</p

Subjective sleep complaints in patients attending a substance use disorder clinic.

This study evaluated subjective reports of sleep difficulties in patients attending a designated consultant in The Drug Treatment Centre Board (DTCB). 89 patients consented to participate representing a 51% response rate. Approximately 65% complained of sleep difficulties. All those who complained of sleep problems had multiple sleep difficulties. About 37% reported six month duration of complaints at time of assessment. There was a significant association between reports of sleep difficulties with homelessness (Pearson’s X2= 6.298, p< 0.012), cigarette smoking (Pearson’s X2=6.017, p<0.014) and day time sleep (Pearson’s X2=3.920, p<0.048). Sleep problems are common amongst patients attending our opioid replacement treatment programme. The present study suggests measures to ensure a holistic management of complaints

Violence and aggression at a substance misuse treatment clinic in Ireland.

Aims and method: To report the rates of violent and aggressive incidents at a drug treatment clinic using a newly introduced incident reporting tool (STARSWeb) and to describe the management strategies currently employed in the management of incidents at the centre. This involved the review of all completed incident reports for the year 2008 and the examination of relevant patient factors. Results: There were 276 documented incidents at the centre in 2008. The majority of incidents (72.4%) involved verbal abuse and threatening behaviours. Males were responsible for the majority of incidents. Two-thirds of the clients’ urine samples were positive for illicit substances at the time of the incidents. Clinical implications: Violent and aggressive incidents in healthcare settings continue to pose a real challenge to both service providers and service users. An accurate system of reporting of such incidents is indispensable in guiding policy development and management strategies. The STARSWeb system offers a significant improvement in incident reporting towards the attainment of these goals

Irish adults with ADHD and comorbid substance use disorder.

Objectives: To examine the literature for drug treatment of attention deficit hyperactivity disorder (ADHD) in adolescents with co-occurring substance use disorder (SUD), the challenges posed by this, and make recommendations taking into account current trends in ireland

Prevalence of Major Depressive Disorder and Correlates of Thoughts of Death, Suicidal Behaviour, and Death by Suicide in the Geriatric Population—A General Review of Literature

Background: There has been an increase in deaths by suicide in old age in the last decade. Depression and suicide in the elderly, 60 years and above, is a major global public health concern. Determining the prevalence of depression, and correlates of death by suicide in the geriatric population, is an important first step toward addressing this public health concern. This literature review aims to determine the prevalence of major depressive disorders and the correlates of death by suicide in the geriatric population. Methods: This general review of the literature was performed using relevant search terms to determine both the prevalence of depression and the correlates of death by suicide among the geriatric population. Databases such as MEDLINE, PsycINFO, CINAHL, and PubMed were searched. Relevant and current articles were extracted, reviewed, and analyzed. The elderly population was defined as individuals 60 years and above. Only full texts articles in English were reviewed. Findings: The prevalence estimates of major depressive disorder in the elderly ranged from 5.37 to 56%. Adults aged 60 years and older have a high risk of depression that exposes them to suicide. Moreover, elderly women are more likely to experience depression than elderly men, but successful suicide is more common in men. Depression and other mental health conditions (schizophrenia, anxiety disorders) and perceived stress were found to be predictors of suicide in the elderly. Other predictors included physical illnesses such as malignancies, financial constraints, cuckoldry, and sexual dysfunction, and also social factors like living alone triggers depressive symptoms and increases suicidal risk in the elderly. Hanging was found to be the most common method of death by suicide for both sexes. While elderly women preferred poisoning, elderly men in Western countries preferred firearms. Differences in gender, the aging process and social issues were also contributing factors to methods used for suicide. Conclusions: Depression and debilitating physical illnesses were identified as significant contributors to suicide risk in the elderly population, and emphasis should be placed on identifying these factors early and treating them. Recognizing and addressing factors that predict suicide in the elderly will help to improve the mental wellbeing of the elderly

Schizophrenia vis-à-vis dimensional-spectrum concepts of psychotic illness: Has an answer been ‘hiding in plain sight’?

As our field debates schizophrenia as a construct, vis-à-vis dimensional-spectrum concepts of psychotic illness (Guloksuz and van Os, 2018; Tamminga et al., 2021), answers may be hiding in the ‘plain sight’ of previous studies. Notions of ‘unitary psychosis’ date back to 19th century anatomo-clinical models of disease (Berrios and Markova, 2021). Notably, during this period ventricular enlargement in psychotic illness, the prototypical pathobiological finding, was first described long before any concept of schizophrenia as a diagnosis (Haslam, 1809; see Waddington, 1984) or the seminal neuroimaging report (Johnstone et al., 1976). On this background, 40 years ago (1982) Johnstone and colleagues embarked on the Northwick Park Functional Psychosis Study of 120 subjects experiencing first episode psychosis (FEP) or acute psychotic relapse, without diagnosis other than exclusion of organic illness. Initially (Johnstone et al., 1988), subjects were randomized to four treatment groups: pimozide plus placebo; placebo plus lithium; pimozide plus lithium; placebo plus placebo. Pimozide reduced psychotic symptoms but was without effect on mood, while lithium reduced mood swings but was without effect on psychotic symptoms. DSM-III criteria were then applied post hoc to resolve psychotic diagnoses [including schizophrenia, schizoaffective disorder, bipolar disorder and major depressive disorder with psychotic features]; both the antipsychotic effect of pimozide and the mood stabilizing effect of lithium were independent of diagnosis. Subsequently (Johnstone et al., 1992), all subjects were followed up after 2.5 years, with DSM-III diagnoses again derived post hoc; lack of clear diagnostic distinction in acute treatment response was evident also in clinical and functional outcome, particularly cognitive impairment.</p

Schizophrenia vis-à-vis dimensional-spectrum concepts of psychotic illness: Has an answer been ‘hiding in plain sight’?

As our field debates schizophrenia as a construct, vis-à-vis dimensional-spectrum concepts of psychotic illness (Guloksuz and van Os, 2018; Tamminga et al., 2021), answers may be hiding in the ‘plain sight’ of previous studies. Notions of ‘unitary psychosis’ date back to 19th century anatomo-clinical models of disease (Berrios and Markova, 2021). Notably, during this period ventricular enlargement in psychotic illness, the prototypical pathobiological finding, was first described long before any concept of schizophrenia as a diagnosis (Haslam, 1809; see Waddington, 1984) or the seminal neuroimaging report (Johnstone et al., 1976). On this background, 40 years ago (1982) Johnstone and colleagues embarked on the Northwick Park Functional Psychosis Study of 120 subjects experiencing first episode psychosis (FEP) or acute psychotic relapse, without diagnosis other than exclusion of organic illness. Initially (Johnstone et al., 1988), subjects were randomized to four treatment groups: pimozide plus placebo; placebo plus lithium; pimozide plus lithium; placebo plus placebo. Pimozide reduced psychotic symptoms but was without effect on mood, while lithium reduced mood swings but was without effect on psychotic symptoms. DSM-III criteria were then applied post hoc to resolve psychotic diagnoses [including schizophrenia, schizoaffective disorder, bipolar disorder and major depressive disorder with psychotic features]; both the antipsychotic effect of pimozide and the mood stabilizing effect of lithium were independent of diagnosis. Subsequently (Johnstone et al., 1992), all subjects were followed up after 2.5 years, with DSM-III diagnoses again derived post hoc; lack of clear diagnostic distinction in acute treatment response was evident also in clinical and functional outcome, particularly cognitive impairment.</p

Duration of the psychosis prodrome and its relationship to duration of untreated psychosis across all 12 DSM-IV psychotic diagnoses: evidence for a trans-diagnostic process associated with resilience.

While duration of the psychosis prodrome (DPP) attracts attention in relation to the developmental trajectory of psychotic illness and service models, fundamental issues endure in the context of dimensional-spectrum models of psychosis. Among 205 epidemiologically representative subjects in the Cavan-Monaghan First Episode Psychosis Study, DPP was systematically quantified and compared, for the first time, across all 12 DSM-IV psychotic diagnoses. DPP was also compared with duration of untreated psychosis (DUP) and each was then analysed in relation to premorbid features across three age ranges: </p

Readmission of Patients to Acute Psychiatric Hospitals: Influential Factors and Interventions to Reduce Psychiatric Readmission Rates

Background: Appropriate and adequate treatment of psychiatric conditions in the community or at first presentation to the hospital may prevent rehospitalization. Information about hospital readmission factors may help to reduce readmission rates. This scoping review sought to examine the readmission of patients to acute psychiatric hospitals to determine predictors and interventions to reduce psychiatric readmission rates. Method: A scoping review was conducted in eleven bibliographic databases to identify the relevant peer-reviewed studies. Two reviewers independently assessed full-text articles, and a screening process was undertaken to identify studies for inclusion in the review. PRISMA checklist was adopted, and with the Covidence software, 75 articles were eligible for review. Data extraction was conducted, collated, summarized, and findings reported. Result: 75 articles were analyzed. The review shows that learning disabilities, developmental delays, alcohol, drug, and substance abuse, were crucial factors that increased the risk of readmission. Greater access to mental health services in residential treatment and improved crisis intervention in congregate care settings were indicated as factors that reduce the risk of readmission. Conclusion: High rates of readmission may adversely impact healthcare spending. This study suggests a need for focused health policies to address readmission factors and improve community-based care

DUP redux: observations vs. experiments in early intervention (Letter to the Editor in reply to Srihari and Li)

Before even the earliest concepts of dementia praecox/schizophrenia, Kesteven (1881) wrote: “To recognise disorder of the mind in its early phases, places it within our reach at the most opportune season for checking or arresting its progress. The first signs of alienation, if duly appreciated, should afford warnings to have recourse, without delay, to the means of cutting it short. The consequences of overlooking or neglecting these timely indications may soon become irreparable … we must surely, in any one or all such cases, look for the accession of mental disorder, hallucinations, illusions, delusions”. Now, more than 140 year later, our field still struggles to verify through contemporary rigour what Kesteven first articulated on the basis of his clinical observations: “Plus ça change …”? We thank Srihari and Li (2022) for their Commentary on our study (Nkire et al., 2022), in which they correctly emphasise the limitations of observational studies in interpreting the statistical relationship between DUP and outcome vis-à-vis rigorous, controlled intervention studies. Several issues are worthy of further consideration.</p