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Upthegrove R, Birchwood M, Ross K, Brunett K, McCollum R, Jones L. The evolution of depression and suicidality in first episode psychosis. Objective: To have a clearer understanding of the ebb and flow of depression and suicidal thinking in the early phase of psychosis, whether these events are predictable and how they relate to the early course of psychotic symptoms. Method: Ninety-two patients with first episode psychosis (FEP) completed measures of depression, including prodromal depression, self-harm and duration of untreated psychosis. Follow-up took place over 12 months. Results: Depression occurred in 80% of patients at one or more phases of FEP; a combination of depression and suicidal thinking was present in 63%. Depression in the prodromal phase was the most significant predictor of future depression and acts of self-harm. Conclusion: Depression early in the emergence of a psychosis is fundamental to the development of future depression and suicidal thinking. Efforts to predict and reduce depression and deliberate self-harm in psychosis may need to target this early phase to reduce later risk. [ABSTRACT FROM AUTHOR]

The article presents a study which discusses the use of evidence-based health care in the early intervention in psychosis. It mentions that the research focuses on the early stage of the disorder which identifies the two classes of patients which include those who have an essentially trivial problem and the other who have a hard time coping up with the disease despite treatments. It affirms that the creation of early psychosis models has been a significant factor in the treatment of the disease.

Background: In paper I we reported that depression in the acute stage remitted in line with the psychosis and that 36% of patients developed post-psychotic depression (PPD).Aims: We apply our cognitive framework to PPD and chart the appraisal of self and psychosis and their link with the later emergence of PPD.Method: Patients with ICD-10 schizophrenia (n=105) were followed up over 12 months following the acute episode, taking measures of depression, working self-concept, cognitive vulnerability, insight and appraisals of psychosis.Results: Before developing PPD, these patients felt greater loss, humiliation and entrapment by their illness than those who relapsed or did not become depressed, and were more likely to see their future selves in 'lower status' roles. Upon becoming depressed, participants developed greater insight, lower self-esteem and a worsening of their appraisals of psychosis.Conclusions: Depression in psychosis arises from the individual's appraisal of psychosis and its implications for his/her perceived social identity, position and 'group fit'. Patients developing PPD feel forced to accept a subordinate role without opportunity for escape. Implications for treatment are discussed. [ABSTRACT FROM AUTHOR]

Background: Depression in schizophrenia is a rather neglected field of study, perhaps because of its confused nosological status. Three course patterns of depression in schizophrenia, including post-psychotic depression (PPD), are proposed.Aims: We chart the ontogeny of depression and psychotic symptoms from the acute psychotic episode over a 12-month period and test the validity of the proposed course patterns.Method: One hundred and five patients with ICD-10 schizophrenia were followed up on five occasions over 12 months following the acute episode, taking measures of depression, positive symptoms, negative symptoms, neuroleptic exposure and side-effects.Results: Depression accompanied acute psychosis in 70% of cases and remitted in line with the psychosis; 36% developed PPD without a concomitant increase in psychotic symptoms.Conclusions: The results provided support for the validity of two of the three course patterns of depression in schizophrenia, including PPD. Post-psychotic depression occurs de novo without concomitant change in positive or negative symptoms. [ABSTRACT FROM AUTHOR]

The article proposes three key elements of an early therapeutic strategy for patients with schizophrenia. These elements include early detection of at-risk or prodromal mental states, early treatment of the first psychotic episode and interventions targeted during the early phase of psychosis. The following are the three elements of intervention of early psychosis: relapse prevention, psychosocial recovery and treatment resistance.

Background: A trial of CT in acute psychosis conducted by the authors has shown a significant impact on the rate and degree of recovery of positive symptoms, the focus of the intervention. This paper seeks to determine whether these effects generalise to other features of acute psychosis including dysphoria, insight and "low level' psychotic thinking which were not directly targeted.Method: Measures of dysphoria, insight and psychotic thinking were taken over a six-month period following presentation for acute psychosis. Using survival analysis, time to recovery from psychosis using three definitions of increasing stringency was compared between the CT and control group.Results: CT was associated with a 25-50% reduction in recovery time depending on the definition used.Conclusion: The impact of the CT intervention extended beyond positive symptoms to include insight, dysphoria and "low level' psychotic thinking. Nevertheless this kind of "clinical' recovery required a median of 20 weeks to complete. Implications for clinical models of acute care are discussed. [ABSTRACT FROM AUTHOR]

Background: The application of cognitive therapy (CT) to psychosis is currently being developed in the UK. This paper reports a trial of CT in acute psychosis with the objective of hastening the resolution of positive symptoms and reducing residual symptoms.Method: Of 117 patients with acute non-affective psychosis, 69 satisfied inclusion criteria and 40 proceeded to stratified randomisation. The experimental intervention involving individual and group CT was compared with a group receiving matched hours of therapist input providing structured activities and informal support; routine pharmacotherapy was provided by clinicians blind to group allocation. Patients were monitored weekly using self-report and mental state assessments during admission and over the subsequent nine months.Results: Both groups showed a decline in positive symptoms but this was more marked in the CT group (P < 0.001). At 9 months 5% of the CT group, v.56% of the control group, showed moderate or severe residual symptoms.Conclusion: CT appears to be a potent adjunct to pharmacotherapy and standard care for acute psychosis. Issues concerning internal and external validity of the study and opportunities for further research are discussed. [ABSTRACT FROM AUTHOR]

"This paper reviews the recent empirical studies on psychosocial family intervention in schizophrenia. Six family educational intervention studies and five more intensive family work studies with 2-year follow-up have been included. A series of questions is asked relating to the effects of such interventions, the efficacy of the different educational models, the active ingredients of these multi-component treatment packages, and the contribution of this new generation of studies to our understanding of the mechanisms through which these interventions work. Suggestions for further research are made. Finally, from the published manuals, the common components of these diverse, multi-component treatment packages of different family-intervention studies are identified." [ABSTRACT FROM AUTHOR]

A clearer understanding of the ebb and flow of depression and suicidal thinking in the early phase of psychosis, and how this relates to other symptom dimensions, is essential for developing interventions to reduce risk. The studies presented here investigate whether depression and suicidal thinking are predictable, how they relate to the early course of psychotic symptoms and develop over time. 92 patients with first episode psychosis recruited from the Birmingham Early Intervention Service completed measures of depression, including an prodromal depression, psotove and negative symptoms, self-harm, duration of untreated psychosis, insight and illness appraisals. Follow up took place over 12 months. Depression occurred in 80% of patients at one or more phase of illness; a combination of depression and suicidal thinking was present in 63%. Depression in the prodromal phase was the most significant predictor of future depression and acts of selfharm. Post psychotic depression unheralded by previous depressive episodes was rare. Depression and suicidal thinking in the acute and post psychotic phases is associated with higher levels of loss and shame, and subordination to persecutors and malevolent voices. Depression early in the emergence of a psychosis is fundamental to the development of future depression and suicidal thinking, and related to the personal significance and impact of positive symptom dimensions. Efforts to predict and reduce depression and self-harm in psychosis may need to target this early phase to reduce later risk. [Copyright &y& Elsevier]

EPOS presented a unique opportunity to document all ''treatments as usual'' offered and received in the participating centres to help-seeking patients who fulfilled criteria for UHR status. The EPOS centres were drawn from very different healthcare systems, employing different treatment concepts and using different methods of ascertainment. EPOS ascertained n=245 UHR patients who were then followed up at 9 and 18 months, taking repeat measures of prodromal symptoms (SIPS), PANSS and depression. In this paper I will describe the different treatments offered in each EPOS centre and the impact of each treatment class on the course of symptoms over time, including ‘transition’ to psychosis. These data will have important bearing on the misnomer of the ‘false positive’ in high risk research and on the other risks and outcomes linked to the UHR/PACE paradigm and their treatment. [Copyright &y& Elsevier]

Aim: Evidence from long-term follow-up studies of schizophrenia and from the ‘new epidemiology’ of psychoses has forced us to rewrite the textbooks and challenge accepted wisdom. In this paper I aim to review the concept of my ‘Critical Period’ in the long-term trajectory of schizophrenia. Method: I will review long-term follow-up studies of first episode psychosis. Results: Studies suggest that: [a.] the course of the psychoses is very variable; [b.] much of this variability is laid down during the ‘prodromal’ and first 3 - 5 years following the first episode; [c.] the ‘disability’ plateaus quickly, much of it occuring before the positive symptoms develop (the ‘symptom-disability gap’) but [d.] the psychosocial and ecological risk factors that have now been uncovered, suggest a more protean, malleable process in the development of psychosis, as witnessed, for example by the considerable number of ‘at risk’ individuals with low-level, but disabling psychotic symptoms, who escape psychosis (the misnomer of the ‘false positive’). Conclusion: This picture presents a fresh take on my concept of the ‘critical period’ with implications for public health and prevention. [Copyright &y& Elsevier]

Abstract: Aim: Our previous study suggested that the subjective experience of negative attitude of others (NAO) towards oneself is an early indicator of psychotic development. The aim of this prospective follow-up study was to test this hypothesis. Methods: A total of 55 young psychiatric outpatients assessed as being at current risk of psychosis (CROP) were followed for up to 60 months and rates of transition to psychosis (TTP) identified. CROP was assessed employing the Bonn Scale for assessment of basic symptoms and the Structured Interview for prodromal symptoms . TTP was defined by a psychotic episode lasting for more than one week. Associations between NAO at baseline and TTP were analyzed by a Cox regression survival analysis. Results: Eight (14.5%) TTP were identified: four (57.1%) within seven NAO patients and four (8.7%) within forty-six non-NAO patients. In the multivariate Cox regression analysis, NAO at baseline significantly (P =0.007) predicted TTP. Conclusion: The prospective follow-up results support our hypothesis that subjective experience of NAO is an early indicator of psychotic in development. [Copyright &y& Elsevier]

The ultra-high risk state of developing a psychosis is mainly characterized by attenuated or transient full-blown psychotic symptoms. It can be assessed with the structured interview for prodromal symptoms (SIPS), comprising four domains: positive, negative, disorganization and general symptoms. As the scores of the SOPS sub-domains are regularly used to perform domain-related analyses the stability of the suggested domain structure and item composition is of major interest. Method: SIPS (version 3.0) data from n=243 participants of the European Prediction of Psychosis Study (EPOS) were used for the current analysis. Inclusion criteria comprised ultra-high risk criteria and the basic symptom criterion COGDIS. The EPOS investigators received extensive training by one of the scale''s authors (Tandy J. Miller, PhD). Pairwise interrater concordance for SIPS was 77%, which was determined acceptable by the training team. A principal component analysis was performed (Eigenvalues > 1, varimax rotation). Results: A five factor solution emerged. Factor 1 was primarily defined by a loss of intentionality, functioning and stress tolerance, factor 2 by anhedonia and affective blunting, factor 3 by cognitive and behavioural disorganization, factor 4 by delusions. Sleep disturbances and perceptual abnormalities/hallucinations have both been associated with dopaminergic disturbances, this may explain their common appearance on factor 5. Discussion: The originally suggested structure of the SIPS proofed not to be stable and was replaced by a five-factor solution. Our results suggest considering a different item and factor structure in future SIPS based data analyses. [Copyright &y& Elsevier]

Introduction: A considerable part of clinical high-risk samples does not convert to psychosis within the studies'' limited observation periods. A part of these ‘non-converters’ shows a remission of symptoms (with unknown future course). Another part, however, maintains the risk state during follow-up. Objectives: Persistence of indicators for an increased risk of psychosis. Aims: To investigate, if persistence of attenuated (APS) or brief limited intermittent psychotic symptoms (BLIPS), the core syndromes of ultra-high risk (UHR) criteria, can be predicted clinically. Methods: N = 129 participants of the European Prediction of Psychosis (EPOS) Study were included into the current analysis. Persistent Risk Symptoms (pRS) were defined as an at-least ‘moderate’ level (SIPS) of at least one positive symptom at all visits (symptom had to remain the same). Functional significance was defined by a GAF-M score ≤60 at 18-month follow-up (T2). Results: 23.3% displayed persistent risk symptoms throughout follow-up. Most frequent pRS were ‘unusual thought contents’, ‘ideas of persecution’ and ‘perceptual disturbances’. In 90% of the pRS subjects, but only in 25.3% of the non-pRS subjects, GAF scores at T2 were below 60 points (p<0.01). Logistic regression analysis revealed that the presence of the pRS syndrome at T2 was predictable by the early course of attenuated positive symptoms with maximum accuracy when the number of at least ‘moderate’ symptoms was considered. Conclusions: A considerable number of subjects at risk showed persistent attenuated positive symptoms associated with long-lasting functional impairments, irrespective of conversion within the foreseeable future. [Copyright &y& Elsevier]

Background: Ultra-high risk (UHR) criteria are defined by attenuated and/or transient full-blown psychotic symptoms and/or a combination of genetic risk factor and deterioration of functioning. To achieve a higher predictive specificity and a clear threshold of clinical importance, functional impairment has been considered as an obligate part of all UHR criteria. Method: In the European Prediction of Psychosis Study (EPOS)N=37 participants converted to psychosis, n=146 completed the whole 18-month follow-up period without conversion. Assessed by the Global Assessment of Functioning Scale, modified version (GAF-M), the following functional states were considered: Considered GAF-M: ≤30%/≤10% reduction of baseline scores related to highest scores in the previous year; scores ≤70/≤60. Results: The GAF reduction criteria led to a very unfavorable loss of sensitivity, even, if only 10% were demanded. This was accompanied by correspondingly unfavorable accuracy measures. Introducing functional impairment criteria defined by the current state reported to be predictive for psychiatric caseness (score ≤ 70) or to define serious impairment (score ≤ 60) (Kessler et al., 2002, 2003) kept sensitivity at a perfectly high level, yet did not produce any gain of specificity. Discussion: These results were certainly be caused by the fact that the whole group showed already low GAF-M scores in the previous year. Thus, a functional impairment criterion proved not to be useful to improve prediction. However, a combination of APS or BLIPS with a ‘clinical status’ criterion of GAF-M ≤ 70 may be considerable to demonstrate a strong need for intervention. [ABSTRACT FROM AUTHOR]

Introduction: A considerable number of patients at clinical high risk of psychosis (CHR) are found to meet criteria for co-morbid clinical psychiatric disorders. Objectives: It is not known how clinical diagnoses correspond to transitions to psychosis (TTP). Aims: We aimed to examine distributions of life-time and current Axis I diagnoses, and their association with TTP in CHR patients. Methods: In the European Prediction of Psychosis Study project, 245 young help-seeking CHR patients were examined, and their baseline and life-time diagnoses were assessed by the Structured Clinical Interview for DSM-IV (SCID-I). TTP was defined by continuation of BLIPS for more than seven days. Results: Altogether, 71 % of the CHR patients had one or more life-time and 62 % one or more current SCID-I diagnosis; about a half in each category received a diagnosis of life-time depressive and anxiety disorder. Currently, 34 % suffered from depressive, 39 % from anxiety disorder, 4 % from bipolar and 6.5 % from somatoform disorder. During follow-up, 37 (15.1 %) TTPs were identified. In multivariate Cox regression analyses, current bipolar disorder, somatoform and unipolar depressive disorders associated positively, and anxiety disorders negatively, with TTP. Conclusions: Both life-time and current mood and anxiety disorders are highly prevalent among help-seeking CHR patients and need to be carefully evaluated. Among them, occurrence of bipolar, somatoform and depressive disorders seem to predict TTP, while anxiety disorder may predict non-transition to psychosis. Treatment of bipolar, somatoform and depressive disorders may prevent CHR patients from developing full-blown psychotic disorders. [ABSTRACT FROM AUTHOR]

Introduction: Research on at-risk states of psychosis has mainly aimed to predict conversion. Yet as a considerable number of patients does not to progress to this outcome during the investigated observation periods, the course of these non-converters (NC) is of major interest, particularly with regard to preventive interventions and treatment. Aims: To analyze the psychopathological and functional in 18-month non-converters. Methods: Data were derived from the prospective multicenter European Prediction of Psychosis Study with an 18-month follow-up period. Participants had to fulfill ultra-high risk criteria and/or the COGDIS criterion, which is based on a set of cognitive basic symptoms. Psychopathology was assessed with the Structure Interview for Prodromal Syndromes (SIPS), including the Global Assessment of Functioning Scale (GAF) and a short version of the Schizophrenia Proneness Instrument (SPI-A). Results: All total and subscale scores improved significantly during follow-up. However, a more detailed analysis revealed that a considerable part of the patients showed no improvement or even a worsening of psychopathology and function. Conclusions: Our first analysis of course on non-converters shows that a high proportion of patients improved. In the light of results from retrospective studies, however, this improvement has to be interpreted with caution, as the observation period does not allow to determine the proportion of outpost syndromes, i.e. precursors of a later prodrome. Furthermore, a considerable portion of our sample worsened functionally and/or symptomatically. With regard to retrospective schizophrenia related results, very long observation periods may be needed to characterize the patterns of course in subpsychotic syndromes. [ABSTRACT FROM AUTHOR]