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We retrospectively evaluated the effectiveness of trauma-focused psychotherapy (TF-P) versus stabilization and waiting in a civilian cohort of patients with an 11th version of the international classification of disease (ICD-11) diagnosis of complex post-traumatic stress disorder (CPTSD).
We identified patients with CPTSD treated at a specialist trauma service over a 3-year period by triangulating evidence from self-report questionnaires, file review, and expert-clinician opinion. Patients completed a phase-based treatment: stabilization consisting of symptom management and establishing safety, followed by waiting for treatment (phase 1); individual TF-P in the form of trauma-focused cognitive behavioral therapy (TF-CBT), or eye movement desensitization and reprocessing (EMDR) or TF-CBT plus EMDR (phase 2). Our primary outcome was PTSD symptoms during phase 2 versus phase 1. Secondary outcomes included depressive symptoms, functional impairment, and a proxy CPTSD measure. Exploratory analysis compared outcomes between treatments. Adverse outcomes were recorded.
Fifty-nine patients were included. Compared to receiving only phase 1, patients completing TF-P showed statistically significant reductions in PTSD [t(58) = −3.99, p < 0.001], depressive symptoms [t(58) = −4.41, p < 0.001], functional impairment [t(58) = −2.26, p = 0.028], and proxy scores for CPTSD [t(58) = 4.69, p < 0.001]. There were no significant differences in outcomes between different treatments offered during phase 2. Baseline depressive symptoms were associated with higher PTSD symptoms and functional impairment.
This study suggests that TF-P effectively improves symptoms of CPTSD. However, prospective research with validated measurements is necessary to evaluate current and new treatments and identify personal markers of treatment effectiveness for CPTSD.
There is strong evidence from systematic reviews and meta-analyses that cannabis use is related to an elevated risk of developing a subsequent psychotic illness. It is less clear if the length of cannabis abstinence is related to the risk of developing a psychotic episode. We explore the relationship between length of cannabis abstinence and subsequent risk of a psychotic episode.
We included patients aged 18–64 years who presented to psychiatric services in 11 sites across Europe and Brazil with first-episode psychosis and recruited controls representative of the local populations. We excluded all patients who reported no past history of cannabis use. We carried out hierarchical survival analyses on probability weighted data to examine the relative hazards of cessation of cannabis abstinence between cases and controls. Data on cannabis abstinence were collected retrospectively by participant recollection. We controlled for ethnicity, age, length of education and history of cigarette smoking. Proportionality assumptions were verified using Kaplan Meier plots, log-log plots and scaled Schoenfeld residuals. There was some evidence of non-proportional hazards and the assumptions of proportionality were relaxed by introducing caseness as a time varying co-variate with time specified as its natural log.
We included 506 cases and 482 controls with a mean age of 30.12 years (sd = 9.97). Cases had an elevated hazard ratio of cannabis use versus cannabis abstinence in controls (HR = 6.11 [SE = 1.43; p = <0.001]). There was no evidence of a difference associated with ethnicity (p = 0.198) but there were statistically significant differences at the 5% level between age groups. Ages 23–27 had a hazard ratio of 0.528 (SE = 0.064; p <0.001) versus those 18–22 years old. For ages 28–32, 33–44 and 43 to 64, the hazards ratios were 0.311, 0.110 and 0.100 (all statistically significant; p<-0.001) respectively.
Abstinence of cannabis use is related to a reduced hazard of having a subsequent psychotic episode. The magnitude of the hazards for a subsequent psychotic illness is highest in those 18–22 years old and decreases with increasing age. Cannabis cessation maintenance therapies may have greater impact if targeting younger rather than older cannabis users who are at an elevated risk of developing a psychotic illness.
Clozapine is indicated for the treatment of patients intolerant of conventional antipsychotic agents. It is often used to treat those patients who have developed movement disorders while on conventional antipsychotics. We report three cases of dyskinesia associated with clozapine induction. We suggest a mechanism that might explain an underlying dopaminergic hypersensitivity during this transitional period. Further, we identify groups that might be at high risk of developing dyskinesia and suggest strategies to reduce risk especially in these groups.
While recent research points to the potential benefits of clinical intervention before the first episode of psychosis, the logistical feasibility of this is unclear.
To assess the feasibility of providing a clinical service for people with prodromal symptoms in an inner city area where engagement with mental health services is generally poor.
Following a period of liaison with local agencies to promote the service, referrals were assessed and managed in a primary care setting. Activity of the service was audited over 30 months.
People with prodromal symptoms were referred by a range of community agencies and seen at their local primary care physician practice. Over 30 months, 180 clients were referred; 58 (32.2%) met criteria for an at risk mental state, most of whom (67.2%) had attenuated psychotic symptoms. Almost 30% were excluded due to current or previous psychotic illness, of which two-thirds were in the first episode of psychosis. The socio-demographic composition of the 'at risk' group reflected that of the local population, with an over-representation of clients from an ethnic minority. Over 90% of suitable clients remained engaged with the service after 1 year.
It is feasible to provide a clinical service for people with prodromal symptoms in a deprived inner city area with a large ethnic minority population.
Early specialised care may improve short-term outcome in first-episode non-affective psychosis, but it is unclear if these benefits endure.
To assess the long-term effect of early intervention in psychosis.
Individuals with first-episode psychosis were randomised to specialised care or care as usual (trial number: ISRCTN73679874). Outcome after 5 years was assessed by case-note review.
There were no significant differences in the admission rate (coefficient 0.096, 95% CI −0.550 to 0.742, P = 0.770) or the mean number of bed days (coefficient 6.344, 95% CI −46 to 58.7, P = 0.810).
These findings that specialist intervention did not markedly improved outcome at 5 years accord with those from a larger OPUS study. The sample size of this study was small and these results should be generalised with caution. More research is needed.
Aunque la investigatión recieñte senala los beneficios potenciales de la interventión clínica antes del primer episodio de psicosis, la viabilidad logística de esto no esta clara.
Evaluar la viabilidad de proporcionar un servicio clínico para personas con síntomas prodrómicos en un área urbana deprimida donde el compromiso con los servicios de salud mental es malo por lo general.
Después de un periodo de enlace con agencias locales para promover el servicio, se evaluó y trató las derivaciones en un entomo de atención primaria. La actividad del servicio se auditó durante 30 meses.
Diversas agencias comunitarias derivaron a las personas con síntomas prodrómicos. Se vio a estas personas en la consulta de su médico de atención primaria local. Durante 30 meses, derivaron a 180 clientes; 50 (32,%) cumplían los criterios para estado mental de riesgo, teniendo la mayoría de ellos (67,2%) síntomas psicóticos atenuados. Se excluyó casi al 30% debido a enfermedad psicótica actual o anterior; dos tercios de ellos estaban en el primer episodio de psicosis. La compositión sociodemográfica del grupo “en situation de riesgo” reflejaba la de la población local, con una sobre-representación de clientes de una minoría étnica. Más del 90% de los clients apropiados mantenía el compromiso con el servicio después de 1 año.
Es posible proporcionar un servicio clínico para personas con síntomas pródromicos en un área urbana deprimida deficitaria con una gran población de minoría ertnica.
La clozapina está indicada para el tratamiento de pacientes que no toleran los agentes antipsicóticos convencionales. Se utiliza a menudo para tratar a los pacientes que han desarrollado trastornos del movimiento mientras están con antipsicóticos convencionales. Informamos de tres casos de discinesia asociados con la iniciación de la clozapina. Proponemos un mecanismo que podría explicar una hipersensibilidad dopaminérgica subyacente durante este periodo de transición. Además, identificamos grupos que podrían tener un riesgo alto de desarrollar discinesia y proponemos estrategias para reducir el riesgo especialmente en esos grupos.
A case of venlafaxine associated visual hallucinations is described. The underlying neurochemical pathophysiology is explored and recommendations for management of patients who experience this side effect are discussed.
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