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Smoking contributes to health inequalities for people with severe mental illness (SMI). Although smoking cessation interventions are effective in the short term, there are few long-term trial-based estimates of abstinence. The SCIMITAR trials programme includes the largest trial to date of a smoking cessation intervention for people with SMI, but this was underpowered to detect anticipated long-term quit rates. By pooling pilot and full-trial data we found that quit rates were maintained at 12 months (OR = 1.67, 95% CI 1.02–2.73, P = 0.04). Policymakers can now be confident that bespoke smoking cessation interventions produce successful short- and long-term quitting.
Better understanding of interplay among symptoms, cognition and functioning in first-episode psychosis (FEP) is crucial to promoting functional recovery. Network analysis is a promising data-driven approach to elucidating complex interactions among psychopathological variables in psychosis, but has not been applied in FEP.
This study employed network analysis to examine inter-relationships among a wide array of variables encompassing psychopathology, premorbid and onset characteristics, cognition, subjective quality-of-life and psychosocial functioning in 323 adult FEP patients in Hong Kong. Graphical Least Absolute Shrinkage and Selection Operator (LASSO) combined with extended Bayesian information criterion (BIC) model selection was used for network construction. Importance of individual nodes in a generated network was quantified by centrality analyses.
Our results showed that amotivation played the most central role and had the strongest associations with other variables in the network, as indexed by node strength. Amotivation and diminished expression displayed differential relationships with other nodes, supporting the validity of two-factor negative symptom structure. Psychosocial functioning was most strongly connected with amotivation and was weakly linked to several other variables. Within cognitive domain, digit span demonstrated the highest centrality and was connected with most of the other cognitive variables. Exploratory analysis revealed no significant gender differences in network structure and global strength.
Our results suggest the pivotal role of amotivation in psychopathology network of FEP and indicate its critical association with psychosocial functioning. Further research is required to verify the clinical significance of diminished motivation on functional outcome in the early course of psychotic illness.
The development of effective preventions for psychosis is hindered by conceptual challenges underlying diagnosis and the fact that few of the many biological risk factors identified to date are sufficiently well understood to form the basis of a targeted intervention. On the other hand, a great deal is known of the psychosocial conditions that increase the lifetime risk of most mental illnesses: surely enough to justify better resourcing of interventions focused on antenatal care and the emotional well-being of children from the early years through adolescence, where as much as a half of all mental ill health has its roots.
Early intervention in psychosis is a complex intervention, usually delivered in a specialist stand-alone setting, which aims to improve outcomes for people with psychosis. Previous studies have been criticised because the control used did not accurately reflect actual practice.
To evaluate the cost-effectiveness of early intervention by estimating the incremental net benefit (INB) of an early-intervention programme, delivered in a real-world setting. INB measures the difference in monetary terms between alternative interventions.
Two contemporaneous incidence-based cohorts presenting with first-episode psychosis, aged 18–65 years, were compared. Costs and outcomes were measured over 1 year. The main outcome was avoidance of a relapse that required admission to hospital or home-based treatment.
From the health sector perspective, the probability that early intervention was cost-effective was 0.77. The INB was €2465 per person (95% CI − €4418 to €9347) when society placed a value of €6000, the cost of an in-patient relapse, on preventing a relapse requiring admission or home care. Following adjustment, the probability that early intervention was cost-effective was 1, and the INB to the health sector was €3105 per person (95% CI −€8453 to €14 663). From a societal perspective, the adjusted probability that early intervention was cost-effective was 1, and the INB was €19 928 per person (95% CI − €2075 to €41 931).
Early intervention has a modest INB from the health sector perspective and a large INB from the societal perspective. The perspective chosen is critical when presenting results of an economic evaluation of a complex intervention.
Despite being a global problem, little is known about the relationship between severe mental illness (SMI) and homelessness in low- and middle-income countries (LMICs). Homeless people with SMI are an especially vulnerable population and face myriad health and social problems. In LMICs, low rates of treatment for mental illness, as well as differing family support systems and cultural responses to mental illness, may affect the causes and consequences of homelessness in people with SMI.
To conduct a systematic, scoping review addressing the question: what is known about the co-occurrence of homelessness and SMI among adults living in LMICs?
We conducted an electronic search, a manual search and we consulted with experts. Two reviewers screened titles and abstracts, assessed publications for eligibility and appraised study quality.
Of the 49 included publications, quality was generally low: they were characterised by poor or unclear methodology and reporting of results. A total of 7 publications presented the prevalence of SMI among homeless people; 12 presented the prevalence of homelessness among those with SMI. Only five publications described interventions for this population; only one included an evaluation component.
Evidence shows an association between homelessness and SMI in LMICs, however there is little information on the complex relationship and direction of causality between the phenomena. Existing programmes should undergo rigorous evaluation to identify key aspects required for individuals to achieve sustainable recovery. Respect for human rights should be paramount when conducting research with this population.
Mental health services lack a strong evidence base on the most effective interventions to reduce compulsory admissions. However, some research suggests a positive impact of crisis-planning interventions in which patients are involved in planning for their future care during a mental health crisis.
This review aimed to synthesise randomised controlled trial (RCT) evidence on the effectiveness of crisis-planning interventions (for example advance statements and joint crisis plans) in reducing rates of compulsory hospital admissions for people with psychotic illness or bipolar disorder, compared with usual care (PROSPERO registration number: CRD42018084808).
Six online databases were searched in October 2018. The primary outcome was compulsory psychiatric admissions and secondary outcomes included other psychiatric admissions, therapeutic alliance, perceived coercion and cost-effectiveness. Bias was assessed using the Cochrane collaboration tool.
The search identified 1428 studies and 5 RCTs were eligible. One study had high risk of bias because of incomplete primary outcome data. Random-effects meta-analysis showed a 25% reduction in compulsory admissions for those receiving crisis-planning interventions compared with usual care (risk ratio 0.75, 95% CI 0.61–0.93, P = 0.008; from five studies). There was no statistical evidence that the intervention reduced the risk of voluntary or combined voluntary and compulsory psychiatric admissions. Few studies assessed other secondary outcomes.
Our meta-analysis suggests that crisis-planning interventions substantially reduce the risk of compulsory admissions among individuals with psychotic illness or bipolar disorder. Despite common components, interventions varied in their content and intensity across the trials. The optimal models and implementation of these interventions require further investigation.
Declaration of interest
E.M., S.L., S.J. and B.L.-E. received funding from the National Institute for Health Research during the conduct of the study.
Concerns are recurrently expressed that the therapeutic content of in-patient care is limited and lacking clear guidance. The perspectives of patients and staff regarding therapeutic priorities for psychiatric in-patient care have been little explored and compared.
The aim of this study was to examine patient and staff perspectives on the care priorities of psychiatric in-patients with psychosis.
We recruited 12 in-patients with psychosis and 12 multidisciplinary team staff. All participants undertook a semi-structured interview examining their perspectives on the therapeutic needs of people with psychosis during admission. Interviews were transcribed verbatim and thematic analysis conducted.
Three superordinate themes arose from patient interviews: ‘the importance of considering social circumstances and trauma’, ‘managing the intra- and interpersonal impact of psychosis’ and ‘lack of control and collaboration in care’ and three from staff interviews: ‘multidisciplinary facilitators of care’, ‘treating complexity and incorporating social factors’ and ‘restrictive practices preventing quality care provision’. Comparison of patient and staff themes identified unmet needs in addressing social marginalisation, trauma and distress, and the importance of collaborative treatment process and inclusion of spirituality.
There are gaps between staff and patient perspectives on important priorities for in-patient care that may help explain persistent patient dissatisfaction with in-patient care. Findings suggest the need for coproduced work to develop and test interventions that address broader therapeutic priorities.
Schizophrenia and bipolar disorder are genetically related and their clinical features overlap. Schizophrenia is conceptualised as a neurodevelopmental disorder but the evidence for bipolar disorder is less clear. Cluster-analytic approaches reveal different cognitive profiles within bipolar disorder, possibly reflective of differing neurodevelopmental loads, which are also suggested by recent genetic and neuroimaging studies. Such studies suggest the potential utility of further clinical subcategories in bipolar disorder based on neurodevelopmental load.
Since its first description in 1863, ‘hebephrenia’ has highlighted a group of patients characterised by an early onset of illness, formal thought disorder, bizarre behaviour and incongruent emotional expression. A proportion of patients with the most severe form of mental illness have a clinical presentation that is best captured by this diagnosis. Here, we outline the construct of hebephrenia and two of its core overlapping constituent parts: bizarre behaviour and the disorganisation dimension. We argue that, despite the removal of hebephrenia (disorganised schizophrenia) from DSM-5, clinicians should consider it as a differential diagnosis, particularly in suspected personality disorder.
Self-management is intended to empower individuals in their recovery by providing the skills and confidence they need to take active steps in recognising and managing their own health problems. Evidence supports such interventions in a range of long-term physical health conditions, but a recent systematic synthesis is not available for people with severe mental health problems.
To evaluate the effectiveness of self-management interventions for adults with severe mental illness (SMI).
A systematic review of randomised controlled trials was conducted. A meta-analysis of symptomatic, relapse, recovery, functioning and quality of life outcomes was conducted, using RevMan.
A total of 37 trials were included with 5790 participants. From the meta-analysis, self-management interventions conferred benefits in terms of reducing symptoms and length of admission, and improving functioning and quality of life both at the end of treatment and at follow-up. Overall the effect size was small to medium. The evidence for self-management interventions on readmissions was mixed. However, self-management did have a significant effect compared with control on subjective measures of recovery such as hope and empowerment at follow-up, and self-rated recovery and self-efficacy at both time points.
There is evidence that the provision of self-management interventions alongside standard care improves outcomes for people with SMI. Self-management interventions should form part of the standard package of care provided to people with SMI and should be prioritised in guidelines: research on best methods of implementing such interventions in routine practice is needed.
We aimed at exploring potential pathophysiological processes across psychotic disorders, applying metabolomics in a large and well-characterized sample of patients and healthy controls.
Patients with schizophrenia and bipolar disorders (N = 212) and healthy controls (N = 68) had blood sampling with subsequent metabolomics analyses using electrochemical coulometric array detection. Concentrations of 52 metabolites including tyrosine, tryptophan and purine pathways were compared between patients and controls while controlling for demographic and clinical characteristics. Significant findings were further tested in medication-free subsamples.
Significantly decreased plasma concentrations in patients compared to healthy controls were found for 3-hydroxykynurenine (3OHKY, p = 0.0008), xanthurenic acid (XANU, p = 1.5×10−5), vanillylmandelic acid (VMA, p = 4.5×10−5) and metanephrine (MN, p = 0.0001). Plasma concentration of xanthine (XAN) was increased in the patient group (p = 3.5×10−5). Differences of 3OHKY, XANU, VMA and XAN were replicated across schizophrenia spectrum disorders and bipolar disorders subsamples of medication-free individuals.
Although prone to residual confounding, the present results suggest the kynurenine pathway of tryptophan metabolism, noradrenergic and purinergic system dysfunction as trait factors in schizophrenia spectrum and bipolar disorders. Of special interest is XANU, a metabolite previously not found to be associated with bipolar disorders.
An increasing body of genetic and imaging research shows that it is becoming possible to forecast the onset of major psychiatric disorders such as depression and schizophrenia before people become ill with ever improving accuracy. Practical issues such as the optimal combination of clinical and biological variables are being addressed, but the application of predictive algorithms to individuals or in routine clinical settings have yet to be tested. The development of predictive methods in mental health comes with substantial ethical questions, including whether people wish to know their level of risk, as well as individual and societal attitudes to the potential adverse effects of data sharing, early diagnosis and treatment, which so far have been largely ignored. Preliminary data suggests that at least some people think predictive research is valuable and would take part in such studies, and some would welcome knowing the results. Future initiatives should systematically assess opinions and attitudes in conjunction with scientific and technical advances.
Declaration of interest
In the past 3 years, S.M.L. has received personal fees from Otsuaka, Sunovion and Janssen, and research grant support from Janssen and Lundbeck. A.M.M. has received research support from the Sackler Trust, Eli Lilly and Janssen. S.M.L. is part of the PSYSCAN consortium.
Early detection and specialised early intervention for people at high risk for psychotic disorders have received growing attention in the past few decades, with the aim of delaying or preventing the outbreak of explicit psychotic symptoms and improving functional outcomes. This article summarises criteria for a diagnosis of high psychosis risk, the implications for such a diagnosis and recommendations for treatment.
After reading this article you will be able to:
•recognise signs and symptoms indicating increased psychosis risk
•understand uses and limitations of screening for high psychosis risk, and interpretation of results
•recognise evidence-based treatment options for patients at clinical high risk for psychosis.
DECLARATION OF INTEREST
C.A. has received non-financial support from Sunovion and Lundbeck in the past 36 months.
Schizophrenia is a psychotic disorder that is stereotypically stigmatised as untreatable and associated with violence. Several authorities have suggested that changing the name, for example to psychosis, would reduce such stigmatisation. We aimed to compare attitudes to schizophrenia and psychosis on Twitter to see if psychosis was associated with less negative attitudes. Tweets containing the terms ‘schizophrenia’, ‘schizophrenic’, ‘psychosis’ or ‘psychotic’ were collected on www.twitter.com and were captured with NCapture. On NVivo, tweets were coded into categories based on user type, tweet content, attitude and stigma type by two independent raters. We compared the content and attitudes of tweets referring to schizophrenia/schizophrenic and psychosis/psychotic.
A total of 1120 tweets referring to schizophrenia/schizophrenic and 1080 referring to psychosis/psychotic were identified over two 7-day periods; 424 original tweets for schizophrenia and 416 original tweets for psychosis were included in the analysis. Psychosis was significantly more commonly included in tweets expressing negative attitudes (n=131, 31.5%) than schizophrenia (n=41, 9.7%) (χ² = 237.03, P < 0.0001). Of the personal opinions or dyadic interactions, 125 (53.4%) in the psychosis data set were stigmatising, compared with 33 (24.6%) of those in the schizophrenia set (χ² = 44.65, P < 0.0001).
The terms psychosis/psychotic are associated with a significantly higher number of tweets with negative content than schizophrenia/schizophrenic. Together with other evidence, this suggests that changing the name of schizophrenia to psychosis will not reduce negative attitudes toward the condition.
Declaration of interest
S.L. has received personal fees from Otsuka and Sunovion, and personal and research fees from Janssen.
Early intervention in psychosis (EIP) has been developed as an approach to improve the prognosis of people with psychotic disorders and it has been claimed to be a more efficient model of care. However, the evidence is not definitive and doubts have spread regard to the economic outcomes of EIP services amid the usually restricted mental health budget.
We aimed to review the cost-effectiveness evidence of EIP services worldwide.
We systematically reviewed the economic literature about EIP following the Preferred Reporting Items for Systematic reviews and Meta-Analyses statement guidelines. Studies were selected according to previously stated criteria and analysed with standardised critical appraisal tools for trial-based economic evaluations and modelling studies.
A total of 16 studies were selected after applying the eligibility criteria. Most of them were economic evaluations alongside clinical trials. The overall evidence was consistent in the cost-effectiveness of EIP compared with standard care for first episode of psychosis and the Clinical High Risk for Psychosis paradigm. Such evidence was replicated among different health systems, but mainly in high-income countries. The methodological quality of such evidence, however, was moderate and heterogeneity was significant across the studies.
There is consistent evidence that the implementation of EIP services might be a cost-effective alternative across different health systems. Such evidence, nevertheless, derives from heterogeneous and sometimes methodologically flawed studies, reducing the certainty of such statement. More efforts must be done to rigorously assess the value of this intervention, before expanding it among systems where mental health budgets are more constrained.
Psychiatric rehabilitation (PR) can improve functioning in people with severe mental illness (SMI), but outcomes are still suboptimal. Cognitive impairments have severe implications for functioning and might reduce the effects of PR. It has been demonstrated that performance in cognitive tests can be improved by cognitive remediation (CR). However, there is no consistent evidence that CR as a stand-alone intervention leads to improvements in real-life functioning. The present study investigated whether a combination of PR and CR enhances the effect of a stand-alone PR or CR intervention on separate domains of functioning.
A meta-analysis of randomized controlled trials of PR combined with CR in people with SMI was conducted, reporting on functioning outcomes. A multivariate meta-regression analysis was carried out to evaluate moderator effects.
The meta-analysis included 23 studies with 1819 patients. Enhancing PR with CR had significant beneficial effects on vocational outcomes (e.g. employment rate: SMD = 0.41), and social skills (SMD = 0.24). No significant effects were found on relationships and outcomes of community functioning. Effects on vocational outcomes were moderated by years of education, intensity of the intervention, type of CR approach and integration of treatment goals for PR and CR. Type of PR was no significant moderator.
Augmenting PR by adding cognitive training can improve vocational and social functioning in patients with SMI more than a stand-alone PR intervention. First indications exist that a synergetic mechanism also works the other way around, with beneficial effects of the combined intervention compared with a stand-alone CR intervention.
Mismatch negativity (MMN) is an event-related potential (ERP) component reflecting auditory predictive coding. Repeated standard tones evoke increasing positivity (‘repetition positivity’; RP), reflecting strengthening of the standard's memory trace and the prediction it will recur. Likewise, deviant tones preceded by more standard repetitions evoke greater negativity (‘deviant negativity’; DN), reflecting stronger prediction error signaling. These memory trace effects are also evident in MMN difference wave. Here, we assess group differences and test-retest reliability of these indices in schizophrenia patients (SZ) and healthy controls (HC).
Electroencephalography was recorded twice, 2 weeks apart, from 43 SZ and 30 HC, during a roving standard paradigm. We examined ERPs to the third, eighth, and 33rd standards (RP), immediately subsequent deviants (DN), and the corresponding MMN. Memory trace effects were assessed by comparing amplitudes associated with the three standard repetition trains.
Compared with controls, SZ showed reduced MMNs and DNs, but normal RPs. Both groups showed memory trace effects for RP, MMN, and DN, with a trend for attenuated DNs in SZ. Intraclass correlations obtained via this paradigm indicated good-to-moderate reliabilities for overall MMN, DN and RP, but moderate to poor reliabilities for components associated with short, intermediate, and long standard trains, and poor reliability of their memory trace effects.
MMN deficits in SZ reflected attenuated prediction error signaling (DN), with relatively intact predictive code formation (RP) and memory trace effects. This roving standard MMN paradigm requires additional development/validation to obtain suitable levels of reliability for use in clinical trials.
There is currently debate about when a clinician should consider neuroimaging for patients with a known psychiatric illness. We consider this topic and propose a set of ‘red flags’ to use to aid decision-making.
We assessed whether the risk of various psychotic disorders and non-psychotic bipolar disorder (including mania) varied by migrant status, a region of origin, or age-at-migration, hypothesizing that risk would only be elevated for psychotic disorders.
We established a prospective cohort of 1 796 257 Swedish residents born between 1982 and 1996, followed from their 15th birthday, or immigration to Sweden after age 15, until diagnosis, emigration, death, or end of 2011. Cox proportional hazards models were used to model hazard ratios by migration-related factors, adjusted for covariates.
All psychotic disorders were elevated among migrants and their children compared with Swedish-born individuals, including schizophrenia and schizoaffective disorder (adjusted hazard ratio [aHR]migrants: 2.20, 95% CI 1.96–2.47; aHRchildren : 2.00, 95% CI 1.79–2.25), affective psychotic disorders (aHRmigrant1.42, 95% CI 1.25–1.63; aHRchildren: 1.22 95% CI 1.07–1.40), and other non-affective psychotic disorders (aHRmigrant: 1.97, 95% CI 1.81–2.14; aHRchildren: 1.68, 95% CI 1.54–1.83). For all psychotic disorders, risks were generally highest in migrants from Africa (i.e. aHRschizophrenia: 5.24, 95% CI 4.26–6.45) and elevated at most ages-of-migration. By contrast, risk of non-psychotic bipolar disorders was lower for migrants (aHR: 0.58, 95% CI 0.52–0.64) overall, and across all ages-of-migration except infancy (aHR: 1.20; 95% CI 1.01–1.42), while risk for their children was similar to the Swedish-born population (aHR: 1.00, 95% CI 0.93–1.08).
Increased risk of psychiatric disorders associated with migration and minority status may be specific to psychotic disorders, with exact risk dependent on the region of origin.