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Psychosis is a major mental illness with first onset in young adults. The prognosis is poor in around half of the people affected, and difficult to predict. The few tools available to predict prognosis have major weaknesses which limit their use in clinical practice. We aimed to develop and validate a risk prediction model of symptom non-remission in first-episode psychosis.
Our development cohort consisted of 1027 patients with first-episode psychosis recruited between 2005 to 2010 from 14 early intervention services across the National Health Service in England. Our validation cohort consisted of 399 patients with first-episode psychosis recruited between 2006 to 2009 from a further 11 English early intervention services. The one-year non-remission rate was 52% and 54% in the development and validation cohorts, respectively. Multivariable logistic regression was used to develop a risk prediction model for non-remission, which was externally validated.
The prediction model showed good discrimination (C-statistic of 0.74 (0.72, 0.76) and adequate calibration with intercept alpha of 0.13 (0.03, 0.23) and slope beta of 0.99 (0.87, 1.12). Our model improved the net-benefit by 16% at a risk threshold of 50%, equivalent to 16 more detected non-remitted first-episode psychosis individuals per 100 without incorrectly classifying remitted cases.
Once prospectively validated, our first episode psychosis prediction model could help identify patients at increased risk of non-remission at initial clinical contact.
Clarke and Beck rightly contend that the number sense allows us to directly perceive number. However, they unnecessarily assume a representationalist approach and incur a heavy theoretical cost by invoking “modes of presentation.” We suggest that the relevant evidence is better explained by adopting a radical enactivist approach that avoids characterizing the approximate number system (ANS) as a system for representing number.
Treatment resistance causes significant burden in psychosis. Clozapine is the only evidence-based pharmacologic intervention available for people with treatment-resistant schizophrenia; current guidelines recommend commencement after two unsuccessful trials of standard antipsychotics.
This paper aims to explore the prevalence of treatment resistance and pathways to commencement of clozapine in UK early intervention in psychosis (EIP) services.
Data were taken from the National Evaluation of the Development and Impact of Early Intervention Services study (N = 1027) and included demographics, medication history and psychosis symptoms measured by the Positive and Negative Syndrome Scale (PANSS) at baseline, 6 months and 12 months. Prescribing patterns and pathways to clozapine were examined. We adopted a strict criterion for treatment resistance, defined as persistent elevated positive symptoms (a PANSS positive score ≥16, equating to at least two items of at least moderate severity), across three time points.
A total of 143 (18.1%) participants met the definition of treatment resistance of having continuous positive symptoms over 12 months, despite treatment in EIP services. Sixty-one (7.7%) participants were treatment resistant and eligible for clozapine, having had two trials of standard antipsychotics; however, only 25 (2.4%) were prescribed clozapine over the 12-month study period. Treatment-resistant participants were more likely to be prescribed additional antipsychotic medication and polypharmacy, instead of clozapine.
Prevalent treatment resistance was observed in UK EIP services, but prescription of polypharmacy was much more common than clozapine. Significant delays in the commencement of clozapine may reflect a missed opportunity to promote recovery in this critical period.
This contribution explores how the predictive processing framework could be employed to explain imagination. At first sight, this framework seems well suited to explaining imagination, since a wide range of mental processes, such as perception and action, are seen as employing imagination-like generative processes. However, it faces problems with explaining distinctively deliberate, voluntary, and purposeful acts of imagination in which agents aim to generate content that departs from immediate reality. In order to explain imagination of this kind, more work is needed. We suggest that one clue might lie in understanding the role language plays in shaping and cueing imaginative episodes.
While we agree in broad strokes with the characterisation of rationalization as a “useful fiction,” we think that Fiery Cushman's claim remains ambiguous in two crucial respects: (1) the reality of beliefs and desires, that is, the fictional status of folk-psychological entities and (2) the degree to which they should be understood as useful. Our aim is to clarify both points and explicate the rationale of rationalization.
Decision-makers need readily accessible tools to understand the potential impacts of alternative policies on forest cover and greenhouse gas (GHG) emissions and to develop effective policies to meet national and international targets for biodiversity conservation, sustainable development and climate change mitigation. Land change modelling can support policy decisions by demonstrating potential impacts of policies on future deforestation and GHG emissions. We modelled land change to explore the potential impacts of expert-informed scenarios on deforestation and GHG emissions, specifically CO2 emissions, in the Ankeniheny–Zahamena Corridor in eastern Madagascar. We considered four scenarios: business as usual; effective conservation of protected areas; investment in infrastructure; and agricultural intensification. Our results highlight that effective forest conservation could deliver substantial emissions reductions, while infrastructure development will likely cause forest loss in new areas. Agricultural intensification could prevent additional forest loss if it reduced the need to clear more land while improving food security. Our study demonstrates how available land change modelling tools and scenario analyses can inform land-use policies, helping countries reconcile economic development with forest conservation and climate change mitigation commitments.
We report three-dimensional imaging of a rare finding of Ebstein’s anomaly of the tricuspid valve in a patient with hypoplastic left heart syndrome, which has been previously reported only by two-dimensional echocardiography. A fetal echocardiogram was performed at 19 weeks that showed a moderately hypoplastic left ventricle, severely hypoplastic mitral valve, a severely hypoplastic aortic valve, and a dysplastic tricuspid valve. Post Caesarean delivery at 40 weeks of gestation, a transthoracic echocardiogram confirmed the findings seen on the fetal echocardiogram. A three-dimensional echocardiogram was then performed, which demonstrated an Ebstein tricuspid valve with apical displacement of the septal leaflet, chordal attachments of the valve to the right ventricular outflow tract, and moderate tricuspid regurgitation. The patient underwent a successful heart transplantation.
Professor Jay Spencer Birnbrauer peacefully passed away on November 1, 2017, aged 83, in Perth, Western Australia. Known to his friends and colleagues in Australia as ‘Birny’, he was a pioneer of applied behaviour analysis on both the Australian and world stage. He contributed to the development of behaviour-analytic technology for children with intellectual and developmental disabilities in the 1960s and played a central part in the formation of the Australian Behaviour Modification Association (known today as the Australian Association for Cognitive and Behaviour Therapy) in the 1970s. He was a purist in the field of applied behaviour analysis (ABA) and was relentless in his efforts to see ABA being provided to children with a developmental disability and their families. Birny's influence in Australia, and particularly Western Australia, was mainly imparted through his role with the Master of Applied Psychology program at Murdoch University. His most widely known piece of work, the Murdoch Early Intervention Program, was an early and important replication of Lovaas's evaluation of early intensive behavioural intervention for children with autism. Birny contributed significantly to our field and to many people's lives. He is remembered often and fondly by his many friends and colleagues.
Social disability is a hallmark of severe mental illness yet individual
differences and factors predicting outcome are largely unknown.
To explore trajectories and predictors of social recovery following a
first episode of psychosis (FEP).
A sample of 764 individuals with FEP were assessed on entry into early
intervention in psychosis (EIP) services and followed up over 12 months.
Social recovery profiles were examined using latent class growth
Three types of social recovery profile were identified: Low Stable (66%),
Moderate-Increasing (27%), and High-Decreasing (7%). Poor social recovery
was predicted by male gender, ethnic minority status, younger age at
onset of psychosis, increased negative symptoms, and poor premorbid
Social disability is prevalent in FEP, although distinct recovery
profiles are evident. Where social disability is present on entry into
EIP services it can remain stable, highlighting a need for targeted
The prospect of improving “noncognitive” skills through intervention increases the need to understand how to represent them in evaluations. Economic assessment of such efforts rarely incorporates these factors, especially when a benefit-cost approach is employed. Programs targeting such skills are more likely to be assessed through approaches that do not monetize noncognitive ability (e.g., using cost-effectiveness analysis). This could lead to ineffective policy formulations in situations where policy is swayed toward programs that can show monetized effects. Benefit-cost analyses (BCAs) that are employed for programs that target noncognitive competencies currently may underestimate the true economic impact if such skills are left out of the equation. The limitations in valuing these skills impede thorough economic assessment for important and effective programs that target noncognitive competencies. This is especially the case for programs for younger children where readily monetized outcomes are few. The targeted outcomes in programs for children are often noncognitive skills, skills that are perceived as vital to healthy human development and valued by parents, teachers, and educators.
In this paper, we review the state of valuation of key noncognitive skills that are often targeted in social policy intervention directed toward children in youth. We examine the state of valuation of noncognitive skills through a summary of the frameworks in research for characterizing noncognitive ability and by considering the measurement approaches for noncognitive skills in terms of origin (interpersonal versus intrapersonal) and measurement type (observed versus assessed). We review examples of recent BCAs that have employed shadow prices for certain noncognitive skills. Finally, we consider what research is necessary to facilitate valuation in BCA in the future. Shadow price methodology should be carried out in a rigorous manner that recognizes uncertainty in cost projections. Improved methodologies in this area will increase the potential for more comprehensive BCA in evaluations of programs for children and youth.
Early intervention services (EIS) comprise low-stigma, youth-friendly mental health teams for young people undergoing first-episode psychosis (FEP). Engaging with the family of the young person is central to EIS policy and practice.
By analysing carers' accounts of their daily lives and affective challenges during a relative's FEP against the background of wider research into EIS, this paper explores relationships between carers' experiences and EIS.
Semi-structured longitudinal interviews with 80 carers of young people with FEP treated through English EIS.
Our data suggest that EIS successfully aid carers to support their relatives, particularly through the provision of knowledge about psychosis and medications. However, paradoxical ramifications of these user-focused engagements also emerge; they risk leaving carers' emotions unacknowledged and compounding an existing lack of help-seeking.
By focusing on EIS's engagements with carers, this paper draws attention to an urgent broader question: as a continuing emphasis on care outside the clinic space places family members at the heart of the care of those with severe mental illness, we ask: who can, and should, support carers, and in what ways?
Internalised stigma in young people meeting criteria for at-risk mental states (ARMS) has been highlighted as an important issue, and it has been suggested that provision of cognitive therapy may increase such stigma.
To investigate the effects of cognitive therapy on internalised stigma using a secondary analysis of data from the EDIE-2 trial.
Participants meeting criteria for ARMS were recruited as part of a multisite randomised controlled trial of cognitive therapy for prevention and amelioration of psychosis. Participants were assessed at baseline and at 6, 12, 18 and 24 months using measures of psychotic experiences, symptoms and internalised stigma.
Negative appraisals of experiences were significantly reduced in the group assigned to cognitive therapy (estimated difference at 12 months was −1.36 (95% Cl −2.69 to −0.02), P = 0.047). There was no difference in social acceptability of experiences (estimated difference at 12 months was 0.46, 95% Cl −0.05 to 0.98, P = 0.079).
These findings suggest that, rather than increasing internalised stigma, cognitive therapy decreases negative appraisals of unusual experiences in young people at risk of psychosis; as such, it is a non-stigmatising intervention for this population.
Interventions to reduce treatment delay in first-episode psychosis have met with mixed results. Systematic reviews highlight the need for greater understanding of delays within the care pathway if successful strategies are to be developed.
To document the care-pathway components of duration of untreated psychosis (DUP) and their link with delays in accessing specialised early intervention services (EIS). To model the likely impact on efforts to reduce DUP of targeted changes in the care pathway.
Data for 343 individuals from the Birmingham, UK, lead site of the National EDEN cohort study were analysed.
A third of the cohort had a DUP exceeding 6 months. The greatest contribution to DUP for the whole cohort came from delays within mental health services, followed by help-seeking delays. It was found that delay in reaching EIS was strongly correlated with longer DUP.
Community education and awareness campaigns to reduce DUP may be constrained by later delays within mental health services, especially access to EIS. Our methodology, based on analysis of care pathways, will have international application when devising strategies to reduce DUP.
In order to improve the methodology for growing and maintaining corals in captivity, a consortium of European zoos, aquaria and academia executed a four-year public/private collaborative research and innovation project (CORALZOO) on the breeding and husbandry of stony corals. CORALZOO comprised the following topics: (1) sexual and asexual breeding of corals in captivity, including techniques for propagation, feeding and induction of natural coral colony morphogenesis; and (2) coral husbandry: development of generic bioassays to evaluate biotic and abiotic husbandry parameters and to monitor coral health, elaboration of methods for identification and treatment of coral diseases and optimization of transport and acclimation procedures. The results of this project are reviewed.