Purposes
To better assess and reduce suicidal risk in first-episode psychosis (FEP), we aimed to investigate the evolution of suicidal thoughts and behaviors (STBs) and associated factors in FEP.
...Method
This systematic review (PROSPERO-CRD42020168050) meets PRISMA guidelines. PubMed, Medline, PsycINFO, Embase, EBM Reviews and references lists of relevant articles were searched (February 2020) to identify longitudinal studies, published in English or in French, that assessed the prevalence of STBs at entry to services and over follow-up, and examined factors associated with STBs among all persons with affective and non-affective FEP from a defined catchment area. Screening, data extraction and quality assessment using the adapted Newcastle Ottawa Scale were done independently by two reviewers. Results on prevalence and associated factors are presented by type of STB.
Results
Of 3,177 references, 17 studies of 11 non-overlapping samples (
n
= 14,907) with varying lengths of follow-up (1–41.7 years) were included. The prevalence of STBs decreased over follow-up. Up to 21.6% made at least one suicide attempt, 27% had suicidal ideation, and 1–4.3% died by suicide during follow-up. Of 53 factors assessed across studies, only male sex, depressive symptoms, and STBs occurring early during follow-up were associated with subsequent STBs. Early intervention for psychosis decreased STBs in the first three years. Other factors were assessed in a single study, yielded conflicting results, or were not associated with STBs.
Conclusions
The high prevalence of STBs following onset of psychosis highlights the need for early detection and intervention and ongoing assessment of suicidal risk throughout follow-up, with attention to identified risk factors. The heterogeneity of the studies precluded a meta-analysis and several factors were each assessed by a single study. Additional well-designed longitudinal studies of STBs and associated factors are warranted.
Objective:
Most studies have investigated either the singular or relative contributions of premorbid adjustment, verbal memory and symptom remission to functional outcomes in first-episode psychosis. ...Fewer studies have examined the pathways of these factors in impacting functioning. Our study addresses this gap. The objective was to determine whether the relationship between premorbid adjustment and functional outcomes was mediated by verbal memory and symptom remission.
Method:
A total of 334 first-episode psychosis participants (aged 14–35 years) were assessed on premorbid adjustment, verbal memory upon entry, and positive and negative symptom remission and functioning at multiple time points over a 2-year follow-up.
Results:
Mediation analyses showed that over the first year, the relationship between premorbid adjustment and functioning was mediated by verbal memory and positive symptom remission (β = –0.18; 95% confidence interval = –0.51, –0.04), as well as by verbal memory and negative symptom remission (β = –0.41; 95% confidence interval = –1.11, –1.03). Over 2 years, the relationship between premorbid adjustment and functioning was mediated by verbal memory and only negative symptom remission (β = –0.38; 95% confidence interval = –1.46, –0.02).
Conclusion:
Comparatively less malleable factors (premorbid adjustment and verbal memory) may contribute to functional outcomes through more malleable factors (symptoms). Promoting remission may be an important parsimonious means to achieving better functional outcomes.
Rapid progression from the first identifiable symptom to the onset of first-episode psychosis (FEP) allows less time for early intervention. The aim of this study was to examine the association ...between the first identifiable symptom and the subsequent speed of illness progression.
Data were available for 390 patients attending a catchment-based early intervention service for FEP. Exposure to non-psychotic and subthreshold psychotic symptoms was retrospectively recorded using semi-structured interviews. Outcomes following the onset of the first identifiable symptom were (1) time to onset of FEP and (2) symptom incidence rate (i.e. number of symptoms emerging per person-year until FEP onset). These outcomes were respectively analyzed with Cox proportional hazards and negative binomial regressions.
After Bonferroni correction, having a subthreshold psychotic (
non-psychotic) symptom as the first symptom was not associated with time to FEP onset hazard ratio (HR) = 1.39; 95% CI 0.94-2.04 but was associated with higher symptom incidence incidence rate ratio (IRR) = 1.92; 95% CI 1.10-3.48. A first symptom of suspiciousness was associated with shorter time to FEP onset (HR = 2.37; 95% CI 1.38-4.08) and higher symptom incidence rate (IRR = 3.20; 95% CI 1.55-7.28) compared to other first symptoms. In contrast, a first symptom of self-harm was associated with lower symptom incidence rate (IRR = 0.06; 95% CI 0.01-0.73) compared to other first symptoms. Several associations between symptoms and illness progression were moderated by the age at symptom onset.
Appreciating the content and timing of early symptoms can identify windows and treatment targets for early interventions in psychosis.
Abstract
Background and Hypothesis
Symptoms that precede a first episode of psychosis (FEP) can ideally be targeted by early intervention services with the aim of preventing or delaying psychosis ...onset. However, these precursor symptoms emerge in combinations and sequences that do not rest fully within traditional diagnostic categories. To advance our understanding of illness trajectories preceding FEP, we aimed to investigate combinations and temporal associations among precursor symptoms.
Study Design
Participants were from PEPP-Montréal, a catchment-based early intervention program for FEP. Through semistructured interviews, collateral from relatives, and a review of health and social records, we retrospectively measured the presence or absence of 29 precursor symptoms, including 9 subthreshold psychotic and 20 nonpsychotic symptoms. Sequences of symptoms were derived from the timing of the first precursor symptom relative to the onset of FEP.
Study Results
The sample included 390 participants (68% men; age range: 14–35 years). Combinations of precursor symptoms most frequently featured depression, anxiety, and substance use. Of 256 possible pairs of initial and subsequent precursor symptoms, many had asymmetrical associations: eg, when the first symptom was suspiciousness, the incidence rate ratio (IRR) of subsequent anxiety was 3.40 (95% confidence interval CI: 1.79, 6.46), but when the first symptom was anxiety, the IRR of subsequent suspiciousness was 1.15 (95% CI: 0.77, 1.73).
Conclusions
A detailed examination of precursor symptoms reveals diverse clinical profiles that cut across diagnostic categories and evolve longitudinally prior to FEP. Their identification may contribute to risk assessments and provide insights into the mechanisms of illness progression.
Differences in subjective quality of life among persons receiving early intervention for psychosis in varying geo-sociocultural contexts have rarely been examined. Our prospective longitudinal study ...compared the quality of life of persons with first-episode psychosis receiving two years of similar early intervention in Chennai, India and Montreal, Canada. We hypothesized that general life satisfaction would be higher in Chennai compared to Montreal, and that social relations (a specific quality of life component) would also be higher in Chennai and positively contribute to general life satisfaction. Participants completed the general satisfaction and social relations domains of the Wisconsin Quality of Life Index at baseline, months 12 and 24. Baseline weighted mean general satisfaction and social relations scores were in the low to moderate range. Generalized estimating equation analyses showed that general satisfaction scores increased with time Wald χ2 (1) = 125.28, p < 0.001 and were higher in Chennai than in Montreal Wald χ2 (1) = 7.50, p = 0.006. Social relations scores showed the highest association with general satisfaction scores (B = 0.52), followed by positive symptom remission (B = 0.24) and gender (B = 0.18) with Chennai males having the highest general satisfaction scores. Social relations weighted mean scores increased with time Wald χ2 (1) = 87.30, p < 0.001 and were positively associated with years of education Wald χ2 (1) = 4.76, p = 0.029 and early negative symptom remission Wald χ2 (1) = 7.38, p = 0.007. Our results suggest that subjective quality of life may improve following early intervention for psychosis across contexts. Our findings advance knowledge about the role of sociocultural (e.g., gender) and clinical factors in influencing subjective outcomes in psychosis, and point to social support networks and symptom remission as avenues to boost quality of life.
Purported superior outcomes for treatment of psychosis in low- and middle-income (LMICs) compared with high-income (HICs) countries have not been examined in the context of early intervention ...services (EIS).
To compare 2-year clinical outcomes in first-episode psychosis (FEP) treated in EIS in Chennai (LMIC) and Montreal (HIC) using a similar EIS treatment protocol and to identify factors associated with any outcome differences.
Patients with FEP treated in EIS in Chennai (n = 168) and Montreal (n = 165) were compared on change in level of symptoms and rate and duration of positive and negative symptom remission over a 2-year period. Repeated-measures analysis of variance, and logistic and linear regression analyses were conducted.
Four patients died in Chennai compared with none in Montreal. Family support was higher for Chennai patients (F = 14.05, d.f. = 1, P < 0.001, ƞp2 = 0.061) and increased over time at both sites (F = 7.0, d.f. = 1.915, P < 0.001, ƞp2 = 0.03). Negative symptom outcomes were significantly better in Chennai for level of symptoms (time × site interaction F = 7.36, d.f. = 1.49, P = 0.002, ƞp2 = 0.03), duration of remission (mean 16.1 v. 9.78 months, t = -7.35, d.f. = 331, P < 0.001, Cohen's d = 0.80) and the proportion of patients in remission (81.5% v. 60.3%, χ2 = 16.12, d.f. = 1, P < 0.001). The site differences in outcome remained robust after adjusting for inter-site differences in other characteristics. Early remission and family support facilitated better outcome on negative symptoms. No significant differences were observed in positive symptom outcomes.
Patients with FEP treated in EIS in LMIC contexts are likely to show better outcome on negative symptoms compared with those in HIC contexts. Early remission and family support may benefit patients across both contexts.
Objective:Given the benefits of early intervention for psychosis and the social disengagement of youths not in education, employment, or training (NEET), this study sought to examine how being ...vocationally inactive (NEET) affects engagement in early intervention services. Both baseline vocational status and vocational trajectory in the first year of treatment were analyzed.Methods:Data from 394 patients of a Canadian early intervention service were analyzed using time-to-event and Cox proportional hazards regression analyses. Two-year disengagement rates were compared between patients who were vocationally inactive and active at baseline and between those who remained vocationally inactive until month 12 and those who were vocationally inactive only at baseline. Pertinent sociodemographic (age, sex, visible minority status, social and material deprivation indices, and family involvement), and clinical (duration of untreated psychosis, substance use disorder, medication nonadherence, and baseline positive and negative symptoms) factors were considered.Results:There was no statistically significant difference between the disengagement rates of those who were vocationally inactive (N=154) and those who were vocationally active (N=240) at baseline. Those who remained vocationally inactive at month 12 (N=77) were likelier to disengage in the second year than those who were vocationally inactive only at baseline (N=48) (χ2=5.44, df=1, p<0.05). This comparison remained significant in the regression analysis (hazard ratio HR=8.52, 95% confidence interval 95% CI=1.54–47.1). The association of disengagement from services with lack of family contact with the treatment team (HR=3.91, 95% CI=0.98–15.6) and with greater material deprivation (HR=1.03, 95% CI=1.00–1.07) trended toward significance.Conclusions:The functional recovery of youths who are vocationally inactive when they enter services can affect their long-term service engagement and merits targeting by evidence-based interventions.
•Treatment delays may be a means by which childhood trauma worsens psychosis outcomes.•Childhood trauma was associated with delays in help-seeking and system's response.•Each unit increase in ...childhood trauma increased treatment delay in psychosis by 25%.
Apart from increasing risk for psychotic disorders, childhood adversity has been associated with worse outcomes. One way in which childhood adversity may worsen outcomes is by lengthening treatment delays, which are associated with negative impacts. We tested the influence of childhood trauma on treatment delays, measured as the duration of untreated psychosis (DUP), and its help-seeking and referral components, in a first-episode psychosis cohort (N = 203). We accounted for pertinent social (e.g., migrant status) and other determinants (i.e., age at onset, diagnosis, symptoms) of treatment delays. Multiple linear regression analyses revealed that for a one-unit increase in Childhood Trauma Questionnaire (CTQ) scores, average overall DUP increased by 25%. Higher CTQ scores also significantly predicted help-seeking and referral DUPs. Patients with schizophrenia-spectrum psychosis had longer help-seeking and total DUPs than those with affective psychosis. More severe positive symptoms predicted longer help-seeking DUPs, while more severe negative symptoms predicted longer referral DUPs. Indicators of social disadvantage did not affect DUP. Our results show that childhood trauma increases DUP by prolonging the help-seeking process and delaying access to mental healthcare even after help is sought. Early identification of psychosis among populations with trauma histories seems warranted and can likely positively impact outcomes.
The current mental health services system in Canada is fragmented and transitions between the youth and adult mental health systems have been identified as needing significant improvement. Integrated ...Youth Services (IYS) are designed to be adaptable and developmentally appropriate as well as to promote seamless transitions, including during emerging adulthood. This article provides an overview of recent developments in Canadian mental health system transformation to promote the integration of services and the holistic promotion of youth well-being. We offer an overview of the current state of knowledge related to best practices in IYS in Canada and highlight areas for future development. We also introduce Frayme, a Canadian-based international knowledge translation platform designed to connect organizations working in the youth services system to accelerate the implementation of IYS.
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