Pathways to care in at-risk mental states: a systematic review

Aim: Pathways to care are well studied in the First Episode Psychosis field, but less attention has been given to At‐Risk Mental States or prodromal psychosis. This is important because accessing appropriate help at the earliest opportunity is likely to improve outcomes, particularly for those who make transition to psychosis. The present systematic review aimed to synthesize the available literature on pathways to care in ARMS or prodromal psychosis, and investigate the barriers and facilitators to receiving care for ARMS. Methods: The CINAHL Complete, EMBASE, Medline Complete, PsycINFO and PubMED databases were searched. Studies were included if they were published in English between 1985 and 2019, where reported data came exclusively from an At‐Risk Mental State population, and the study described or related to pathways to care. Results: Ten studies met the inclusion criteria, of which 8 were quantitative. Screening tools and pathways to care instruments varied. Mental health professionals, and general practitioners played a key role in help seeking. Family involvement was also found to be an important factor. Conclusions: Pathways to care research in At‐Risk Mental States are more scarce than in the field of First Episode Psychosis. More research is warranted, especially concerning the role of patient‐level characteristics on pathways to care. A validated measure of pathways to care may also be of benefit

The effectiveness of public health interventions, initiatives, and campaigns designed to improve pathways to care for individuals with psychotic disorders: A systematic review

Purpose: Lengthy duration of untreated psychosis (DUP) and duration of untreated illness (DUI) in people at clinical high-risk for psychosis (CHR-P) and first episode psychosis (FEP) is associated with poorer outcomes. However, individuals with FEP often experience negative pathways to care involving contacts with police, crisis services and requiring compulsory admissions, and evidence suggests individuals with both FEP and CHR-P often experience lengthy delays to treatment. Early detection interventions, such as public health interventions, may be one way to reduce delays. This systematic review aimed to synthesise the available evidence on such interventions. Methods: The EMBASE, PsychINFO, CINAHL, and MEDLINE databases were searched. Studies were included if they compared an intervention designed to improve timely access to treatment for individuals with FEP or CHR-P to standard treatment provision. Interventions may be targeted at potential patients, their families, the general public, or non-healthcare professionals. Outcomes of interest were DUP or DUI, and/or characteristics of pathways to care. Results: Nineteen studies met the inclusion criteria. All consisted of FEP populations, none of CHR-P populations. Employing narrative synthesis, we found mixed results about the effectiveness of interventions at reducing DUP and interventions appeared to differentially impact groups. Pathways to care information was limited and mixed. Conclusion: Findings on the effectiveness of interventions designed to improve timely access to treatment were inconclusive. More research is warranted to better understand where delays occur and factors which may influence this for both FEP and CHR-P populations which may help to develop targeted interventions to address delays

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

REalist Synthesis Of non-pharmacologicaL interVEntions for antipsychotic-induced weight gain (RESOLVE) in people living with Severe Mental Illness (SMI)

Background: People with severe mental illnesses (SMI) such as schizophrenia die on average 15 to 20 years earlier than everyone else. Two-thirds of these deaths are from preventable physical illnesses such as hypertension, cardiovascular disease, and diabetes, which are worsened by weight gain. Antipsychotics are associated with significant weight gain. In RESOLVE, a realist synthesis, combining primary and secondary data, will be used to understand and explain how, why, for whom, and in what contexts nonpharmacological interventions can help service users to manage antipsychotic-induced weight gain. Methods: A five-step approach will be used to develop guidance: 1. Developing the initial programme theory An initial (candidate) programme theory, which sets out how and why outcomes occur within an intervention, will be developed. 2. Developing the search: The initial programme theory will be refined using academic and grey literature. The proposed initial sampling frame is: Context: people living with SMI, taking antipsychotics, different types of SMI. Intervention: non-pharmacological interventions. Mechanisms: triggered by the intervention. Outcomes e.g. weight, metabolic adverse events, quality of life, adherence, burden, economic. Searching for relevant documents will continue until sufficient data is found to conclude that the refined programme theory is coherent and plausible. Lived Experience (service users) and Stakeholder (practitioners) groups will provide feedback. 3. Selection, appraisal, data extraction: Documents will be screened against inclusion and exclusion criteria. Text extracted from these documents will be coded as contexts, mechanisms and their relationships to outcomes. 4. Primary Data Collection: Realist interviews with up to 30 service users and informal carers, and 20 practitioners will gather data to support, refute or refine the programme theory. 5. Data Analysis: A realist logic of analysis will be used to develop and refine the programme theory from secondary and primary data. The analysis will aim to identify practical intervention strategies to change contexts so that key mechanisms are triggered to produce desired outcomes. Guidance will be produced based on these strategies. Discussion: This realist synthesis aims to develop guidance for service users and practitioners on the most appropriate interventional strategies to manage and limit antipsychotic weight gain

A realist review of medication optimisation of community dwelling service users with serious mental illness

BACKGROUND: Severe mental illness (SMI) incorporates schizophrenia, bipolar disorder, non-organic psychosis, personality disorder or any other severe and enduring mental health illness. Medication, particularly antipsychotics and mood stabilisers are the main treatment options. Medication optimisation is a hallmark of medication safety, characterised by the use of collaborative, person-centred approaches. There is very little published research describing medication optimisation with people living with SMI. OBJECTIVE: Published literature and two stakeholder groups were employed to answer: What works for whom and in what circumstances to optimise medication use with people living with SMI in the community? METHODS: A five-stage realist review was co-conducted with a lived experience group of individuals living with SMI and a practitioner group caring for individuals with SMI. An initial programme theory was developed. A formal literature search was conducted across eight bibliographic databases, and literature were screened for relevance to programme theory refinement. In total 60 papers contributed to the review. 42 papers were from the original database search with 18 papers identified from additional database searches and citation searches conducted based on stakeholder recommendations. RESULTS: Our programme theory represents a continuum from a service user's initial diagnosis of SMI to therapeutic alliance development with practitioners, followed by mutual exchange of information, shared decision-making and medication optimisation. Accompanying the programme theory are 11 context-mechanism-outcome configurations that propose evidence-informed contextual factors and mechanisms that either facilitate or impede medication optimisation. Two mid-range theories highlighted in this review are supported decision-making and trust formation. CONCLUSIONS: Supported decision-making and trust are foundational to overcoming stigma and establishing 'safety' and comfort between service users and practitioners. Avenues for future research include the influence of stigma and equity across cultural and ethnic groups with individuals with SMI; and use of trained supports, such as peer support workers. PROSPERO REGISTRATION NUMBER: CRD42021280980

Finishing the euchromatic sequence of the human genome

The sequence of the human genome encodes the genetic instructions for human physiology, as well as rich information about human evolution. In 2001, the International Human Genome Sequencing Consortium reported a draft sequence of the euchromatic portion of the human genome. Since then, the international collaboration has worked to convert this draft into a genome sequence with high accuracy and nearly complete coverage. Here, we report the result of this finishing process. The current genome sequence (Build 35) contains 2.85 billion nucleotides interrupted by only 341 gaps. It covers ∼99% of the euchromatic genome and is accurate to an error rate of ∼1 event per 100,000 bases. Many of the remaining euchromatic gaps are associated with segmental duplications and will require focused work with new methods. The near-complete sequence, the first for a vertebrate, greatly improves the precision of biological analyses of the human genome including studies of gene number, birth and death. Notably, the human enome seems to encode only 20,000-25,000 protein-coding genes. The genome sequence reported here should serve as a firm foundation for biomedical research in the decades ahead

Demographic and Clinical Predictors of Duration of Untreated Psychosis

Background: A shorter duration of untreated psychosis (DUP) is associated with better outcomes following first-episode psychosis (FEP; Power et al., 2007; Birchwood et al., 2013; McGorry et al., 2008). However, the evidence on social and clinical factors that may predict to DUP is inconsistent. Aims: To investigate the association between DUP and social and clinical factors. Methods: A retrospective incidence study design was employed, using the Biomedical Research Centre (BRC) clinical record interactive search (CRIS) system. In brief, CRIS is a regional case register based in South London containing a large data set of anonymous clinical data of over 250 000 patient records derived from the South London and Maudsley NHS Foundation Trust (SLaM) electronic health record system. All patients presenting to SLaM adult mental health services for the first time with a psychotic disorder between May 2010 and April 2012 and in the catchment area served by SLaM were screened for inclusion. Data relating to DUP, sociodemographic characteristics, mode of contact, and source of referral were collated from clinical records. Individuals were included as cases if they were: resident in the London boroughs of Lambeth or Southwark (served by SLaM); aged 18–64 years (inclusive), experienced psychotic symptoms of at least one day duration, and were making their first contact for psychosis with mental health services. Results: A total of 558 individuals with first-episode psychosis were identified. Individuals who were unemployed (68.5%) experienced longer DUP (median = 119; interquartile range= 28–492) compared to people who were employed (19.6%; median =45; interquartile range= 6–426, P < .001). Living alone (29.7%) was also associated with longer DUP (median = 116; interquartile range = 30–531) compared to living with family/relative (median = 90; interquartile range = 14–370, P = .04). Further, an insidious mode of onset of psychosis (37.5%) was associated with longer DUP (median = 608; interquartile range = 360–1918) compared to acute onset (20.7%; median = 4; interquartile range = 2–6.5, P < .001). Similarly, individuals accessing care via accident and emergency departments (A&E 38.9%) experienced shorter DUP (median = 41; interquartile range = 6–295) compared with those referred by their general practitioner (GP 35.1%; Median=184.5; interquartile range = 46.5–821.5, P < .001). Conclusion: Findings from this sample of FEP patients suggest that indicators of social isolation were associated with DUP. Clinically, pathways into care were also strongly associated with DUP prior to help seeking. Our results are consistent with previous findings