Effects of Group Cognitive-Behavioral Therapy in Young Patients in the Early Stage of Psychosis

OBJECTIVE: To develop a model of group cognitive-behavioral therapy (CBT) for Korean patients with early psychosis. METHODS: The group CBT utilized in the present study consisted of metacognitive training, cognitive restructuring, and lifestyle managements. The Subjective Well-being Under Neuroleptics (SWN-K), Ambiguous Intentions Hostility Questionnaire (AIHQ), Drug Attitude Inventory (DAI), Beck Depression Inventory (BDI), Perceived Stress Scale (PSS), and Clinical Global Impression (CGI) were administered prior to and after CBT sessions. The participants were categorized into two groups according to the median duration of untreated psychosis (DUP; 4 months). RESULTS: A total of 34 patients were included in this analysis. From pre- to post-therapy, there were significant increases in the SWN-K and DAI scores and significant decreases in the hostility subscale of the AIHQ, PSS, and CGI scores. Significant time × DUP interaction effects were observed for the SWN-K, DAI, and BDI scores, such that there were significant changes in patients with a short DUP but not in those with a long DUP. CONCLUSION: The group CBT program had a positive effect on subjective wellbeing, attitude toward treatment, perceived stress, and suspiciousness of young Korean patients with early psychosis. These effects were particularly significant in patients with a short DUP.

Symptom Remission Related to Increased Drug Response after Conversion Into Schizophrenia in Early Psychosis : A Case Report / 대한정신분열병학회지

In recent years, early intervention is the paradigm in psychosis treatment. The logic of early intervention paradigm is based on the view that the earliest possible detection and intervention for psychosis will deliver the best outcome for patients. Therefore, in recent decades, most of studies focused on indentifying people with psychosis as early as possible, reducing the duration of untreated psychosis. However, while there are well documented and sometimes serious side effects associated with antipsychotic medication in the short-term, the iatrogenic risks of atypical antipsychotic medication are underscored. Furthermore, against this paradigm, the recent of longitudinal studies of schizophrenia suggest a new paradigm shift in treatment timing of psychosis. In this respect, this case which showed symptom remission after conversion into schizophrenia in early psychosis suggests wondering about the time of treatment. Similar cases have not been reported. And review of the effects of timing, in fact, has yet to be done. If similar cases would be reported in the future more, treatment timing may be the next paradigm shift in the therapeutics of early psychosis.

The Analysis of Community-Based Identification, Assessment and Allocation System for Early Psychosis / 대한정신분열병학회지

OBJECTIVES: The purpose of this study was to make empirical evidence of community based detection, assessment and allocation system for early psychosis. METHODS: We analysed 222 youths who were referred to Seoul Early Management and Improvement Services (SEMIS) for early psychosis during six years from 2007 to 2012. RESULTS: 44% of referrals were from suicide hotline, 23% from web-based SEMIS assessment program, 20% from other service areas such as military services and 11% were self referred. Among 222 youths, 139 (62.6%) were completed Structured Interview for Prodromal Syndrome (SIPS). After SIPS, 23% had untreated or early psychosis, another 17% were found to be at high risk of psychosis and 18% of completed SIPS were found to have other mental illness such as depression, yielding an efficiency ratio of 58%. 70% of youths who were categorized as psychosis or high risk of psychosis or other mental illness were referred to psychiatric hospital or case management services. CONCLUSION: This study shows the effectiveness and limitations of community-based assessment and intervention system for early psychosis. Integrated community program is necessary to improve the efficiency of early intervention and for the better outcomes.

The Application of the Cognitive Behavioral Therapy in Schizophrenia / 신경정신의학

OBJECTIVES: Cognitive behavioral therapy for treatment of schizophrenia was designed as a psychological therapy for treatment of drug resistant patients with schizophrenia. This therapy is currently being widely applied from early psychosis to chronic condition. The aim of this article is to review the main results of research articles on cognitive behavioral therapy of schizophrenia and prompt practicing the therapy in Korean mental health services. METHODS: The important original and review articles were referred in order to understand the main results of research from published international books, and the English website Pubmed was searched in order to update recent findings. This article reviewed the results of four areas of different phases and types of cognitive behavioral therapy for treatment of schizophrenia: drug resistant chronic patients, acute psychotic state, prodromal phase, and group cognitive behavioral therapy. RESULTS: Cognitive behavioral therapy for treatment of drug resistant patients with schizophrenia can attenuate the positive and general symptoms more than that for patients who receive supportive psychotherapy or treatment as usual. However, the effect appears to be less than previously expected, small to moderate. Cognitive behavioral therapy for patients of acute psychotic state can reduce the time of recovery from acute psychotic symptoms by approximately 25%. The result of cognitive behavioral therapy for patients of prodromal phase shows that the therapy can reduce the rate of transition to schizophrenia by up to one third. Group behavioral therapy has recently been tested. Group therapists have suggested that the therapy should be applied through the way of groups with relatively homogenous symptoms. However, whether the therapy can reduce the severity of hallucination in the voice hearer group is inconclusive. CONCLUSION: Alongside pharmacotherapy for treatment of schizophrenia, cognitive behavioral therapy is a distinct psychological therapy for attenuation of psychotic symptoms. The effect of cognitive behavioral therapy appears to last for one year and requires additional therapeutic sessions after one year. The effect is not still clear in group cognitive behavioral therapy for treatment of schizophrenia. Cognitive behavioral therapy for treatment of schizophrenia should be practiced widely in the Korean mental health system.

The need-adapted integrated treatment in Sant Pere Claver-Early Psychosis Program (SPC-EPP) in Barcelona, Spain / El tratamiento integrado y adaptado a las necesidades del Programa de Psicosis Incipiente-Sant Pere Claver (PPI-SPC) en Barcelona, España

International interest has grown over the past 15 years in the prognostic potential of early identification and intervention in the prodromal and first-episode phases of psychosis. This focus is associated with increasing optimism about the benefits of implementing treatment as early as possible in the course of psychosis, at least to help improve the course of illness, reducing its long-term impact. A clearer framework for guiding, designing, and evaluating preventive interventions in mental disorders has been developed. As a consequence, a series of research projects and real-world services systems are currently emerging. Additionally, several influential international figures and research groups have developed and cooperated in disseminating a more optimistic set of ideas concerning early intervention in psychosis. The early psychosis programs developed worldwide have a number of common elements and goals: a) early detection of new cases, b) reducing the duration of untreated psychosis (DUP), and c) providing better and continued treatment during the <

Los trastornos del espectro psicótico presentan un curso crónico y episódico que provoca alteraciones en todas las áreas de la vida, generando importantes grados de discapacidad, pérdida de funciones psicosociales, grandes costes económicos, una comorbilidad considerable y sufrimiento tanto para los pacientes como para sus familias. A pesar de que el tratamiento farmacológico y psicosocial ha ayudado a aliviar los síntomas y mejorar la calidad de vida, en muy pocas ocasiones se logra una recuperación satisfactoria en los niveles psicológico y funcional. Durante los últimos 15 años, el optimismo creciente sobre la posibilidad de mejorar el pronóstico de la psicosis y alterar con ello el tradicional curso negativo de la enfermedad, ha producido una reforma sustancial en la práctica clínica y en el desarrollo de estrategias de intervención temprana en muchos países. De esta manera, el desplazamiento del foco de atención desde las fases estables o residuales de la psicosis hacia los inicios de la misma está suponiendo una serie de innovaciones y avances, tanto en la evaluación y diagnóstico, como en las modalidades terapéuticas y en la consiguiente reordenación de los servicios asistenciales. Cada vez existen más grupos en todo el mundo que establecen programas clínicos e iniciativas de investigación centradas en la psicosis temprana. Cada uno de estos programas tiene características particulares y rasgos propios en cuanto a las modalidades de tratamiento o los instrumentos de evaluación, pero la mayoría comparte una serie de elementos y objetivos en común: a) detectar de forma precoz nuevos casos; b) reducir el periodo de tiempo desde que el paciente presenta una sintomatología claramente psicótica hasta que recibe un tratamiento adecuado (duración de la psicosis no tratada); y c) proporcionar un mejor y continuo tratamiento en el <

Rationale and state of the art in early detection and intervention in psychosis / Justificación y estado de la cuestión en la detección e intervención temprana en psicosis

Schizophrenia-spectrum disorders have a chronic and episodic course that results in impairment of all life domains. Pharmacological and psychosocial treatments provide symptom relief, but there is not a cure for schizophrenia and many patients suffer chronic impairment. In addition, it is expensive both in economical terms and also in terms of personal costs for both patients and their families. International interest has grown over the past 15 years in the prognostic potential of early identification and intervention in the prodromal and first-episode phases of psychotic illness. This focus is associated with increasing optimism about the benefits of implementing treatment as early as possible in the course of psychosis at least to help improve the course of illness, reducing its long-term impact. The most recent epidemiological studies have shown that patients with longer duration of untreated psychosis (DUP) have worse short-term outcomes in terms of treatment response, positive symptoms, negative symptoms, and global functioning. Neuroimaging studies have also indicated that prolonged untreated illness is associated with more pronounced structural brain abnormalities, while this is less prominent earlier in the course of the disorder. Therefore, early detection aims to reduce treatment delay in the hope of improving prognosis and reducing illness severity. Early intervention in psychotic disorders has gained momentum in the last decades, and there is now an estimated 200 centers worldwide offering specialized services for young people experiencing their first episode of psychosis. Each of these programs has unique characteristics and distinctive features in terms of treatment modalities and assessment tools, but most have a number of common elements and goals: a) early detection of new cases, b) reducing DUP, and c) providing better and continued treatment during the «critical period¼ of the early years of the disease. Moreover, the role of family work in early psychosis can be crucial given that relatives are the main informal caretakers of persons with mental health problems. Family interventions in early psychosis usually offer psychoeducation and/or individual and group family therapy, communication and problem solving training, which can help to develop coping strategies and reduce distress and burden. Intervention programs in early psychosis are usually composed by interdisciplinary teams, providing a wide range of integrated services that typically include psychoeducation, clinical case management, and group interventions. Specific interventions generally include pharmacotherapy, stress management, relapse prevention, social and employment rehabilitation support, and cognitive and family therapy. Given the complex etiology and clinical manifestation of psychosis, treatment packages for people experiencing early psychosis need to be individually tailored to specific needs rather than applied homogenously across early psychosis patients. The current challenge in the implementation of psychological interventions in the early stages of psychosis are: 1. to adapt treatment modalities that have been proven effective in stable and residual stages of the disease to its early stages; 2. to develop new forms of therapy tailored to the specific characteristics of these early stages of psychosis (prodromal and ultra high-risk phase, onset and first episode psychosis, and «critical period¼ or post-crisis psychosis); and 3. treatment packages need to be individually tailored to their specific needs rather than applied homogenously across a group of patients. The aims of this paper are: 1. to present the basic concepts, rationale and state of the art of the early detection and intervention paradigm; 2. to review and present the main detection and intervention programs in early psychosis and 3. to provide an overview of the current psychotherapeutic approaches in early psychosis.

Los trastornos del espectro psicótico presentan un curso crónico y episódico que provoca alteraciones en todas las áreas de la vida, generando importantes grados de discapacidad, pérdida de funciones psicosociales, grandes costos económicos, una comorbilidad considerable y sufrimiento tanto para los pacientes como para sus familias. A pesar de que los tratamientos farmacológicos y psicosociales han ayudado a aliviar los síntomas y mejorar la calidad de vida, en muy pocas ocasiones se logra una recuperación satisfactoria a nivel psicológico y funcional. Durante los últimos 15 años, el optimismo creciente sobre la posibilidad de mejorar el pronóstico de la psicosis y alterar con ello el tradicional curso negativo de la enfermedad ha producido una reforma sustancial en la práctica clínica y en el desarrollo de estrategias de intervención temprana en muchos países. De esta manera, el desplazamiento del foco de atención desde las fases estables o residuales de la psicosis hacia los inicios de la misma está suponiendo una serie de innovaciones y avances, tanto en la evaluación y diagnóstico como en las modalidades terapéuticas y en la consiguiente reordenación de los servicios asistenciales. Los estudios epidemiológicos más recientes han mostrado que los pacientes con mayor duración de la psicosis no tratada tienen peor respuesta al tratamiento farmacológico, mayor gravedad de síntomas positivos, síntomas negativos y peor funcionamiento global. Por otra parte, los estudios de neuroimagen también indican que un periodo prolongado de enfermedad no tratada produce anormalidades estructurales cerebrales más pronunciadas. Es por esto que la detección temprana en psicosis tiene como objetivo reducir la demora del tratamiento para mejorar el pronóstico y reducir la gravedad del trastorno. La detección temprana y la aplicación del tratamiento específico más eficaz para cada fase inicial del trastorno son dos elementos que diferencian la intervención temprana de las formas habituales de asistencia actuales. Cada vez existen más grupos en todo el mundo dedicados a establecer programas clínicos e iniciativas de investigación centradas en la psicosis temprana. Cada uno de estos programas tiene características particulares y rasgos propios en cuanto a las modalidades de tratamiento o los instrumentos de evaluación, pero la mayoría tiene una serie de elementos y objetivos en común: a) detectar de forma precoz nuevos casos; b) reducir el periodo de tiempo desde que el paciente presenta una sintomatología claramente psicótica hasta que recibe un tratamiento adecuado y c) proporcionar un mejor y continuo tratamiento en el «periodo crítico¼ de los primeros años de la enfermedad. En el contexto de la prevención e intervención temprana, el trabajo con la familia puede ser crucial, ya que los familiares son los principales cuidadores informales y son una parte fundamental para la recuperación del paciente. La mayoría de las intervenciones familiares ofrecen psicoeducación y/o terapia familiar que ayudan a desarrollar estrategias de adaptación y afrontamiento, disminuir el estrés y la carga a largo plazo, así como mejorar la comunicación y la resolución de problemas. Los programas de intervención en la psicosis temprana están habitualmente formados por equipos interdisciplinarios que proporcionan una amplia serie de servicios integrados que suelen incluir psicoeducación, manejo clínico de casos e intervenciones grupales. Las intervenciones específicas incluyen generalmente farmacoterapia, manejo de estrés, prevención de recaídas, apoyo y rehabilitación social y laboral, así como terapia cognitiva y familiar. Dada la compleja etiología y manifestación clínica de la psicosis, los tratamientos para personas con psicosis incipiente deben ser adaptados individualmente a las necesidades específicas en lugar de aplicarlos homogéneamente a todos los pacientes por igual. El desafío actual en la aplicación de intervenciones en la psicosis temprana consiste en: 1. conseguir adaptar aquellas modalidades de tratamiento que ya han demostrado su eficacia en las fases estables y residuales de la enfermedad a los inicios de la misma; 2. integrar y desarrollar nuevas formas de terapia que se adapten a las características específicas de cada una de las fases iniciales de la psicosis (fase prodrómica o de alto riesgo, inicio de la psicosis o primer episodio de psicosis y «fase crítica¼ o poscrisis) y 3. adecuar los tratamientos de manera individual en vez de aplicarlos de forma homogénea. Los objetivos del presente artículo son: 1. presentar los conceptos básicos, la justificación y el estado de la cuestión del paradigma de detección e intervención temprana en psicosis; 2. hacer una revisión y presentar los principales programas de detección e intervención temprana en psicosis y 3. proporcionar una visión general de los enfoques psicoterapéuticos actuales en psicosis incipiente.

Primeiro episódio psicótico: uma janela de oportunidade para tratamento? / First episode psychosis: a window of treatment opportunity?

CONTEXTO: Programas específicos para a pesquisa e assistência ao primeiro episódio psicótico foram desenvolvidos ao redor do mundo cujos pressupostos básicos são: identificação precoce do episódio psicótico, tratamento intensivo da crise e prevenção de recaídas. OBJETIVO: Este artigo pretende dar uma visão sobre a abordagem atual do paciente no primeiro episódio psicótico. MÉTODO: Revisão de pesquisas sobre primeiro episódio psicótico em centros internacionais e nacionais. RESULTADOS: Programas para identificação precoce do episódio psicótico podem diminuir o tempo de psicose não tratada e intervenções intensivas no primeiro episódio psicótico devem incluir tratamento intensivo do paciente e de seus familiares. CONCLUSÃO: Em alguns países os serviços já foram incorporados à rede de saúde pública. Existem poucas pesquisas e serviços especializados para primeiro episódio em nosso meio mostrando a necessidade de desenvolvimento de novas pesquisas nessa área.

BACKGROUND: Specific first episode programs were developed around the world aiming to: early detection, intensive crises care and relapse prevention. OBJECTIVE: This article intends to outline this new first episode psychosis approach. METHOD: To review study findings from international and national centers. RESULTS: Early education programs can lower the duration of untreated psychosis and interventions in first episode psychosis should include patient and family intensive care. CONCLUSION: In some countries these services have already been incorporated in the health system. There are few research and services in our country, showing the need to develop research in this area.