We aimed to enhance the clinical governance of medical input to patients within Brighton Early Intervention in Psychosis (EIP) service. The Service Standard Operational Policy indicates that patients should be medically reviewed every 6 months as part of the Care Programme Approach (CPA) and include review of: diagnosis, service eligibility, medication positive and negative effect, clinical improvement, risk assessment and physical health.

The EIP caseload on a specific date was reviewed to explore if a medical CPA review had taken place. A detailed medical letter evidenced this. A meeting was convened between team doctors to identify from electronic records when the last medical CPA had taken place. General characteristics of the delayed review group were identified. An excel spreadsheet was used to create a system to autogenerate when a next review is required.

142 patients were identified on the EIP caseload. 21 patients had been discharged so were excluded. 121 patients were eligible for this audit, including 8 inpatients. 46 (38%) patients were identified as having an overdue CPA review.

Those with overdue CPA reviews were found to be overall clinically stable, on the caseload for over a year and those who had had a recent change in Lead Practitioner (LP) who were not aware of service operational policy due to high staff turnover linked with the COVID-19 pandemic. Some duplications of routine medical reviews were identified between team doctors within the 6 months.

This service was not achieving CPA standards of the operational policy. A spreadsheet was set up to proactively alert the LP when patients required a 6 month review. Policy information sessions were set up for the team and will be specifically included in new worker induction training. A full audit cycle will be completed by implementing the change made and re-auditing to see if there is an improvement. Duplications of routine medical reviews will be explored in more detail.

Identification of a psychosis risk syndrome to aid reduction of transition to a FEP is an important focus of worldwide research. ARMS for psychosis was defined by Yung and McGorry in 1996. UK EIP services were mandated to identify and ‘treat’ ARMS in the ‘Implementing the Early Intervention in Psychosis Access and Waiting Time Standard: Guidance' 2016. Sussex EIP services developed such an ARMS service with a 1-year pathway of assessment, intervention as indicated, and monitoring from 2017. Sussex serves a population of approximately 1.4 million, including areas with both low and high social deprivation indices. Transition rates from ARMS to FEP in recent studies have suggested widely varying rates of 8–17% of transition in a two-year period, notably less than initially identified by Yung et al. We aimed to establish the rate of transition to FEP within 12 months from identification of ARMS in Sussex EIP services.

A retrospective study was conducted on all patients on the ARMS pathway, across five EIP services in Sussex, between Jan 2017-Oct 2021. The primary outcome measure was operationally defined transition to FEP; secondary outcome measures included clinical features and use of clinical services.

71 cases were identified as meeting ARMS criteria, with mean age 21.4yo; range 14–35, from a total new caseload of 447 over this period.

ARMS subcategories identified 4 state/trait, 55 attenuated psychosis and 12 BLIPS. Comorbidity was more common than not; mood disorders were identified in 17 cases. 23 cases met not in education, employment or training (NEET) criteria.

All cases received full care coordination by lead practitioners. 19 cases were prescribed atypical antipsychotics. 18 cases received formal CBT.

4 of the 71 cases transitioned to FEP within 12 months at mean time 35 weeks; range 28–45 weeks. 2 had attenuated symptoms and 2 experienced BLIPS. 3 were initially NEET.

We report a very low transition rate to FEP of 6% in this service, consistent with other such UK services. Whilst the ARMS sample is low in number, a clear impact on EIP service case management is identified. Risk saturation is arguably required to justify continuing this ARMS pathway, achievable by primary focus on the BLIPS subgroup. Wider review of UK ARMS services is required to reduce dilution of EIP service models and reduction of their well evidenced effectiveness.

Prompt treatment with medication and intensive psychosocial support are interventions that have been shown to improve function and prognosis in patients with First Episode Psychosis. NICE guidelines state that patients with a first episode of Psychosis should remain on an antipsychotic medication for 1–2 years to reduce risk of relapse, yet most patients stop long before 2 years. This systematic review explores the comparative time to all cause discontinuation of antipsychotics, often used as a marker of real-world treatment effectiveness, in First Episode Psychosis patients.

A literature search was performed across multiple healthcare databases from 1980 to present day in the English Language. Inclusion criteria covered patients with a First Episode of Psychosis aged 14 years and over, and studies that were randomised controlled trials or observational in nature. The primary outcome measure was time to discontinuation of antipsychotic medication. Bias was assessed using the GRADE approach.

11 studies and 3840 patients were included in the review. Seven studies were randomised clinical trials; three were blinded, and four open-label. The remaining four were observational studies. All but one of the studies had a minimum follow-up period of one year (with a maximum of three years). Due to significant methodological heterogeneity across studies, it was not possible to perform meta-analysis. Narrative analysis of the results showed that Olanzapine performed ranked best, and wasbeing taken for the longest time period by patients, followed by Risperidone.

Multiple reviews exist on the efficacy of antipsychotics in First Episode Psychosis, but this is the first one to focus on time to discontinuation as a distinct outcome measure. The review encompasses a large sample size across North America, Eastern Asia and Europe. The interaction of time to discontinuation of antipsychotics with associated symptom levels and medication doses remains an area for further research. The review highlighted the significant differences in statistical methodology across studies in this emerging field, and the need for standardisation in ongoing research. Whilst effectiveness may therefore be greatest for olanzapine, this is outweighed in current guidance by its least favourable metabolic adverse effects profile.

One year of antipsychotic treatment from symptom remission is recommended following a first episode of psychosis (FEP).

To investigate the effectiveness of commonly used antipsychotic medications in FEP.

A retrospective cohort study of naturalistic treatment of patients (N = 460) accepted by FEP services across seven UK sites. Treatment initiation to all-cause discontinuation determined from case files.

Risk of treatment discontinuation is greatest within 3 months of treatment initiation. Risperidone had longest median survival time. No significant differences were observed in time to discontinuation between commonly used antipsychotics on multivariable Cox regression analysis. Poor adherence and efficacy failure were the most common reasons for discontinuation.

Effectiveness differences appear not to be a current reason for antipsychotic choice in FEP. Adherence strategies and weighing up likely adverse effects should be the clinical focus.

Neuroendocrine studies of brain serotonin (5-HT) function in depression generally show evidence of impaired 5-HT function but it is disputed whether or not this impairment resolves with clinical recovery.

To use the endocrine response to the selective 5-HTreuptake inhibitor, citalopram, to study brain 5-HT function in acute and recovered depressed subjects relative to healthy controls.

We used a double-blind, placebo-controlled design to measure the prolactin and cortisol responses to citalopram (10 mg intravenously) in patients with major depression, in unmedicated subjects recovered from depression and in healthy controls.

The prolactin responses to citalopram were blunted similarly in both acutely depressed and recovered subjects. The cortisol responses were blunted in the acutely depressed patients but not in the recovered subjects.

Our data support the proposal that some aspects of impaired 5-HT neurotransmission may be trait markers of vulnerability to depression. The recovery of the cortisol response to citalopram may indicate resolution of hypothalamic – pituitary-adrenal axis dysfunction.

Brain serotonin (5-HT) function is abnormal in major depression, but the involvement of different 5-HT receptor subtypes has been little studied. The availability of selective ligands now makes it possible to test the sensitivity of 5-HT1D receptors in patients with depression.

The aim of the study was to use the 5-HT1D receptor agonist, zolmitriptan, to test the sensitivity of 5-HT1D receptors in patients with depression before and after treatment with selective serotonin reuptake inhibitors (SSRIs).

We measured the growth hormone response to zolmitriptan (5 mg orally) in patients with major depression before and after SSRI treatment. A matched sample of healthy subjects acted as a control group.

The growth hormone response to zolmitriptan was blunted in patients with a melancholic depressive syndrome. SSRI treatment produced a marked reduction in zolmitriptan-induced growth hormone release.

Patients with melancholic depression have impaired sensitivity of the post-synaptic 5-HT1D receptors that mediate growth hormone release. The reduction in 5-HT1D receptor sensitivity following SSRI treatment is probably an adaptive response to increased levels of synaptic 5-HT.