The Family Psychoeducation Fidelity Scale: Psychometric Properties.

This study examined psychometric properties and feasibility of the Family Psychoeducation (FPE) Fidelity Scale. Fidelity assessors conducted reviews using the FPE fidelity scale four times over 18 months at five sites in Norway. After completing fidelity reviews, assessors rated feasibility of the fidelity review process. The FPE fidelity scale showed excellent interrater reliability (.99), interrater item agreement (88%), and internal consistency (mean = .84 across four time points). By the 18-month follow-up, all five sites increased fidelity and three reached adequate fidelity. Fidelity assessors rated feasibility as excellent. The FPE fidelity scale has good psychometric properties and is feasible for evaluating the implementation of FPE programs. Trial registration ClinicalTrials.gov Identifier: NCT03271242.

Early detection of psychosis: positive effects on 5-year outcome.

BACKGROUND: During the last decades we have seen a new focus on early treatment of psychosis. Several reviews have shown that duration of untreated psychosis (DUP) is correlated to better outcome. However, it is still unknown whether early treatment will lead to a better long-term outcome. This study reports the effects of reducing DUP on 5-year course and outcome. METHOD: During 1997-2000 a total of 281 consecutive patients aged >17 years with first episode non-affective psychosis were recruited, of which 192 participated in the 5-year follow-up. A comprehensive early detection (ED) programme with public information campaigns and low-threshold psychosis detection teams was established in one healthcare area (ED-area), but not in a comparable area (no-ED area). Both areas ran equivalent treatment programmes during the first 2 years and need-adapted treatment thereafter. RESULTS: At the start of treatment, ED-patients had shorter DUP and less symptoms than no-ED-patients. There were no significant differences in treatment (psychotherapy and medication) for the 5 years. Mixed-effects modelling showed better scores for the ED group on the Positive and Negative Syndrome Scale negative, depressive and cognitive factors and for global assessment of functioning for social functioning at 5-year follow-up. The ED group also had more contacts with friends. Regression analysis did not find that these differences could be explained by confounders. CONCLUSIONS: Early treatment had positive effects on clinical and functional status at 5-year follow-up in first episode psychosis.

Early identification of non-remission in first-episode psychosis in a two-year outcome study.

OBJECTIVE: To identify predictors of non-remission in first-episode, non-affective psychosis. METHOD: During 4 years, we recruited 301 patients consecutively. Information about first remission at 3 months was available for 299 and at 2 years for 293 cases. Symptomatic and social outcomes were assessed at 3 months, 1 and 2 years. RESULTS: One hundred and twenty-nine patients (43%) remained psychotic at 3 months and 48 patients (16.4%) remained psychotic over 2 years. When we compared premorbid and baseline data for the three groups, the non-remitted (n = 48), remitted for <6 months (n = 38) and for more than 6 months (n = 207), duration of untreated psychosis (DUP) was the only variable that significantly differentiated the groups (median DUP: 25.5, 14.4 and 6.0 weeks, respectively). Three months univariate predictors of non-remission were being single, longer DUP, core schizophrenia, and less excitative and more negative symptoms at baseline. Two-year predictors were younger age, being single and male, deteriorating premorbid social functioning, longer DUP and core schizophrenia. In multivariate analyses DUP, negative and excitative symptoms predicted non-remission at 3 months, but only DUP predicted at 2 years. CONCLUSION: Long DUP predicted both 3 month and 2-year non-remission rates in first-episode psychosis.

Are multi family groups appropriate for patients with first episode psychosis? A 5-year naturalistic follow-up study.

OBJECTIVE: To compare outcome over 5 years for patients who participated in multi family groups (MFGs) to those who refused or were not offered participation. METHOD: Of 301 first episode psychotic patients aged 15-65 years, 147 participated in MFGs. Outcome was measured by drop-out rates, positive and negative syndrome scale (PANSS) symptom scores, and duration of psychotic episodes during the follow-up period. RESULTS: Multi family group participants had a significantly lower drop-out rates at 5-year follow-up than patients who did not participate. However, the MFG participants had significantly less improvement in PANSS positive and excitative symptoms and had significantly longer duration of psychotic symptoms during the follow-up period. CONCLUSION: Multi family groups appear to increase the chance of retaining patients in a follow-up study, but adjustment of the programme may be necessary with first episode psychosis patients to meet their needs better.

A 2-year follow-up of involuntary admission's influence upon adherence and outcome in first-episode psychosis.

OBJECTIVE: To see, if voluntary admission for treatment in first-episode psychosis results in better adherence to treatment and more favourable outcome than involuntary admission. METHOD: We compared consecutively first-admitted, hospitalised patients from a voluntary (n = 91) with an involuntary (n = 126) group as to psychopathology and functioning using Positive and Negative Syndrome Scale and Global Assessment of Functioning Scales at baseline, after 3 months and at 2 year follow-up. Moreover, duration of supportive psychotherapy, medication and number of hospitalisations during the 2 years were measured. RESULTS: More women than men were admitted involuntarily. Voluntary patients had less psychopathology and better functioning than involuntary patients at baseline. No significant difference as to duration of psychotherapy and medication between groups was found. No significant difference was found as to psychopathology and functioning between voluntarily and involuntarily admitted patients at follow-up. CONCLUSION: Legal admission status per se did not seem to influence treatment adherence and outcome.

Baseline profiles of adolescent vs. adult-onset first-episode psychosis in an early detection program.

OBJECTIVE: Psychotic disorders often start in adolescence. We aim to investigate premorbid and baseline differences characterizing patients with an onset of psychosis in adolescence versus adulthood. METHOD: We compare first-episode, DSM-IV non-affective psychosis with onset before (n = 43) and after (n = 189) 18 years on duration of untreated psychosis (DUP), level of symptoms, suicidal behaviour, and other baseline clinical and demographic characteristics. RESULTS: Adolescent onset patients had poorer premorbid functioning, a longer DUP, higher suicidality, and more depressive symptoms. They also had better cognition, fewer psychotic symptoms, and were more likely to be treated on an out-patient basis. CONCLUSION: Adolescents with first-episode psychosis may have a slower and more silent, i.e. insidious onset, and are at risk of experiencing longer treatment delays than adults. They fit the description of what used to be labeled process (versus reactive) schizophrenia.

Clinical epidemiologic first-episode psychosis: 1-year outcome and predictors.

OBJECTIVE: To describe 1-year outcome in a large clinical epidemiologic sample of first-episode psychosis and its predictors. METHOD: A total of 301 patients with first-episode psychosis from four healthcare sectors in Norway and Denmark receiving common assessments and standardized treatment were evaluated at baseline, at 3 months, and at 1 year. RESULTS: Substantial clinical and social improvements occurred within the first 3 months. At 1-year 66% were in remission, 11% in relapse, and 23% continuously psychotic. Female gender and better premorbid functioning were predictive of less severe negative symptoms. Shorter DUP was predictive for shorter time to remission, stable remission, less severe positive symptoms, and better social functioning. Female gender, better premorbid social functioning and more education also contributed to a better social functioning. CONCLUSION: This first-episode sample, being well treated, may be typical of the early course of schizophrenia in contemporary centers.

Reducing the duration of untreated first-episode psychosis -- effects on baseline social functioning and quality of life.

OBJECTIVE: Long duration of untreated psychosis (DUP) is associated with poorer outcome. The TIPS study demonstrated that DUP can be reduced through early detection (ED). As quality of life (QoL) is associated with DUP it is expected that reduction of DUP leads to better QoL. METHOD: Consecutive first-episode patients with a DSM-IV diagnosis of non-organic, non-affective psychosis were included, 281 patients gave informed consent and 263 completed a full evaluation of QoL. RESULTS: There were no differences in subjective QoL between ED and No-ED groups attributable to reduction in DUP. There were significant bivariate differences in frequency of family and social contacts in favor of the ED group, but multivariate analyses indicated that these differences were based on differences in sample characteristics. CONCLUSION: Deterioration in QoL may precede overt symptom formation. Focus on functional loss in ED educational campaigns may identify risk subjects earlier in the course of the disorder.

Does duration of untreated psychosis bias study samples of first-episode psychosis?

OBJECTIVE: While findings are contradictory, many studies report that long Duration of Untreated Psychosis (DUP) correlates with poorer outcome in first episode psychosis. In an outcome study of first-episode psychosis, we compared the patients who refused to participate in a follow-along with those who consented to estimate the importance of this factor in sample recruitment bias. Our questions were: (i) What is the percentage of refusers? (ii) Are there systematic differences between refusers and consenters on DUP and/or other admission variables? (iii) What is the risk of refusal for different values of DUP? METHOD: In an unselected group of consecutively admitted patients we compared follow-along refusers and consenters on the following admission variables: sex, age, diagnostic group, substance abuse, being in-patient, coming from an early detection site and DUP. We conducted a logistic regression analysis with refusal as the outcome variable. RESULTS: Ninety-three of 397 patients (23%) were refusers. In univariate analyses the only significant difference was found for DUP. The median DUP for consenters was 10 weeks and for refusers 32 weeks. DUP remained significant when all independent variables were controlled for. CONCLUSION: DUP was significantly related to risk for refusal. For tests of the impact of DUP on outcome, this may introduce a type II error bias.

Methodological pitfalls in early detection studies - the NAPE Lecture 2002. Nordic Association for Psychiatric Epidemiology.

OBJECTIVE: To identify and discuss methodological pitfalls that may help explain why many questions around early detection (ED) and duration of untreated psychosis (DUP) are still unsolved. METHOD: This paper concentrates on pitfalls in the following areas: sampling, measurement and data analyses. RESULTS: The main problems seem to be: SAMPLING: Referral bias, exclusion of patients, patient refusal, and patients lost to follow-up. MEASUREMENT: Reliability, which is particularly cogent for multisite investigations, and validity, which includes: Start of illness, start of psychosis, diagnoses, start of treatment, the relationship between ED and DUP and choice of outcome measures. Data Analyses: Overlooking threshold effects of DUP, improper control for baseline scores, and lack of control for confounders. CONCLUSION: Methodological pitfalls may bias ED studies. Several pitfalls are unavoidable, but proper design and quality assurance can reduce their impact. Researchers ought to identify the pitfalls, and to estimate and discuss their influence.

Shortened duration of untreated first episode of psychosis: changes in patient characteristics at treatment.

OBJECTIVE: This study examined whether duration of untreated psychosis can be shortened in patients with first episodes of DSM-IV schizophrenia spectrum disorders and whether shorted duration alters patient appearance at treatment. METHOD: Two study groups were ascertained in the same Norwegian health care sector: one from 1993-1994 with usual detection methods and one from 1997-1998 with early detection strategies that included education about psychosis. RESULTS: Patients with early detection had a shorter median duration of untreated psychosis by 21.5 weeks than patients with usual detection. The number with psychosis was greater in the early detection group; the number with schizophrenia was less. Early detection patients had more substance abuse and were younger, better adjusted premorbidly, and less ill. CONCLUSIONS: Early detection can shorten duration of untreated psychosis and help more patients when they are less severely ill. Given the devastation of psychosis, this is a significant treatment advance.

Early detection strategies for untreated first-episode psychosis.

Some studies in first-episode schizophrenia correlate shorter duration of untreated psychosis (DUP) with better prognosis, suggesting that timing of treatment may be important. A three-site prospective clinical trial in Norway and Denmark is underway to investigate the effect of the timing of treatment in first-episode psychosis. One health care sector (Rogaland, Norway) is experimental and has developed an early detection (ED) system to reduce DUP. Two other sectors (Ullevål, Norway, and Roskilde, Denmark) are comparison sectors and rely on existing detection and referral systems for first-episode cases. The study ultimately will compare early detected with usual detected patients. This paper describes the study's major independent intervention variable, i.e. a comprehensive education and detection system to change DUP in first onset psychosis. System variables and first results from the four-year inclusion period (1997-2000) are described. It includes targeted information towards the general public, health professionals and schools, and ED teams to recruit appropriate patients into treatment as soon as possible. This plus easy access to psychiatric services via ED teams systematically changed referral patterns of first-episode schizophrenia. DUP was reduced by 1.5 years (mean) from before the time the ED system was instituted (to 0.5 years). The ED strategies appear to be effective and to influence directly the community's help-seeking behaviour.

Early detection and intervention in first-episode schizophrenia: a critical review.

OBJECTIVE: To review the literature on early intervention in psychosis and to evaluate relevant studies. METHOD: Early intervention was defined as intervention in the prodromal phase (primary prevention) and intervention after the onset of psychosis, i.e. shortening of duration of untreated psychosis (DUP) (secondary prevention). RESULTS: We found few studies aimed at early intervention, but many papers discussing the idea at a more general level. We identified no studies that prove that intervention in the prodromal phase is possible without a high risk for treating false positives. We identified some studies aimed at reducing DUP, but the results are ambiguous and, until now, no follow-up data showing a positive effect on prognosis have been presented. CONCLUSION: Early intervention in psychosis is a difficult and important challenge for the psychiatric health services. At the time being reduction of DUP seems to be the most promising strategy. Intervention in the prodromal phase is more ethically and conceptually problematic.

[Relapse as quality indicator in psychiatric treatment]. / Tilbakefallsprosent som kvalitetsmål i psykiatrisk behandling.

BACKGROUND: Efficiency and productivity expressed by length of hospitalisation, number of admissions, treated patients per time unit, and cost in NOK are incomplete measures for quality in a medical context. These measures should be supplemented by measures of results based on the course of illness for specific diagnostic categories. Few psychiatric institutions, including outpatient units, record the course of illness on a regular basis. MATERIAL AND METHODS: A review of the literature shows that rough measures of results, for instance readmission rates, often form the basis for evaluation of course/treatment results. The article gives examples of measures like readmission rates and more scientific measures such as Positive and negative syndrome scale (PANSS) used to measure results in a Norwegian psychiatric hospital. RESULTS: Of all first time admitted patients to Rogaland Psychiatric Hospital in 1985 and 1990, 40% of patients diagnosed with schizophrenia were readmitted after one year. For first time admitted patients from 1993 and 1994, the remission rate was 56% measured by PANSS. INTERPRETATION: The results of the treatment of first time admitted patients with a schizophrenia diagnosis were poorer than what is suggested possible through studies of optimal treatment, where the remission percentage is estimated to be 80% after one year. Rough measures of results, like readmission, do not seem to differ considerably from the results measured by PANSS. Norwegian psychiatric institutes are recommended to monitor the quality of treatment through a systematic recording of relapse among patients with a first time schizophrenia diagnosis.

Premorbid functioning versus duration of untreated psychosis in 1 year outcome in first-episode psychosis.

OBJECTIVE: This study examines 1year outcome in patients having first-episode non-affective psychosis, with emphasis on Duration of Untreated Psychosis (DUP) and premorbid functioning, in order to clarify how these factors interact. METHOD: Forty-three consecutively admitted patients were all rated on the Positive and Negative Syndrome Scale (PANSS) and the Global Assessment of Functioning Scale (GAF), both upon hospitalization and at 1year follow-up. In addition, premorbid functioning, DUP, duration of hospitalization, and social functioning were rated. RESULTS: Fifty-six per cent were in remission, 18% suffered multiple relapses and 26% were continuously psychotic at 1 year follow-up. Both poor premorbid functioning and long DUP are significantly correlated with more negative symptoms and poorer global functioning at follow-up. Long DUP is also significantly correlated with more positive symptoms. Even when we control for other factors, including premorbid functioning and gender, DUP is a strong predictor of outcome. To a limited degree premorbid functioning and DUP interact, but DUP has an independent influence on outcome. CONCLUSIONS: these findings strengthen the rationale for establishing health service programs for early detection and treatment of first-onset psychosis

Early intervention and prevention in schizophrenia--experiences from a study in Stavanger, Norway.

The paper gives an overview of current literature and research that makes the foundation and rationale for early intervention in functional psychosis, i.e. schizophrenia. The duration of untreated psychosis (DUP) and its practical implications are demonstrated. An outline of the prerequisites of the psychiatric services and the societal preconditions for effective early intervention strategies is given. The development of working clinical treatment programmes within the county of Rogaland, Norway, is described, as well as strategies towards enhancing the knowledge of serious psychiatric disorders among the population and thus making the foundation for effective and early help-seeking. The different resistance factors in relation to early intervention are introduced. Preliminary results of an early intervention is presented, indicating that it is possible to shorten DUP (from 114 to 20 weeks), and showing that DUP is the single most important predictor for poor prognosis.

First-episode schizophrenia with long duration of untreated psychosis. Pathways to care.

BACKGROUND: The early course of illness in first-episode schizophrenia was examined with special emphasis on the duration of untreated psychosis and pathways to care. METHOD: The consecutively admitted individuals (n = 34) were assessed on premorbid functioning, duration of untreated psychosis, global functioning, symptoms and social network. To clarify the obstacles for receiving earlier treatment, 17 case histories with long duration of untreated psychosis were intensively studied. RESULTS: The duration of untreated psychosis was on average very long (130 weeks), the median value was 54 weeks. The long duration of untreated psychosis group (> 54 weeks) had greater deterioration in the premorbid phase, a weaker social network and were more withdrawn than the short duration of untreated psychosis group (< 54 weeks). The main obstacles for receiving treatment were withdrawal and poor social network. CONCLUSIONS: In order to identify people earlier, a system of detection must be mobile, easily accessible and attentive to early symptoms of psychosis. It seems to be important to educate the social network related to the individual about the importance of early treatment.

Early detection and intervention with schizophrenia: rationale.

This article explores the rationale for early detection and intervention in schizophrenia. The most compelling reason is the disorder's severity and chronicity and our knowledge that, while many treatments for schizophrenia are effective, they are also limited and palliative. This state of affairs suggests that researchers pay closer attention to schizophrenia's premorbid and onset phases, when the vulnerability to psychosis becomes expressed and the neurobiological deficit processes driving symptom formation appear to be the most active. We review the evidence that brain plasticity can be retained or reversed despite deficit processes. This evidence includes the putative attenuation of the severity of schizophrenia throughout the 20th century, retrospective and prospective linkage of earlier neuroleptic treatment and better long-term outcome, and data from a program designed to intervene in the prodromal phase of disorder. While the evidence to date does not demonstrate that early intervention with known treatments can change the natural history of schizophrenia, it is suggestive enough (for both biological and psychosocial treatment) to support further investigation. Focusing on the early course of schizophrenia also offers the possibility of identifying potential patients long before onset using vulnerability markers and of making more feasible primary prevention efforts. Finally, studies of untreated psychosis in first-episode cases have revealed that patients are often actively psychotic for a very long time before they get help. Bringing treatment more rapidly to a person who has been psychotic is in itself enough to justify early detection efforts.

First-episode schizophrenia: II. Premorbid patterns by gender.

This article describes the application of the Premorbid Adjustment Scale to Norwegian subjects with first-episode schizophrenia. The scale measures premorbid functioning from several perspectives: functioning at different developmental periods, change of functioning over time, and distinctive patterns of functioning over time. Gender differences were striking, with males scoring poorer and deteriorating faster than females, especially closer to onset. While the duration of untreated psychosis (DUP) was significantly longer in males, correlations between DUP and premorbid functioning within gender were largely nonsignificant, as were the analyses of premorbid functioning and age at onset. On the other hand, we replicated studies that found associations between poorer premorbid functioning and insidious onset and negative symptoms. Overall, our premorbid patterns suggest that a process of asymptomatic premorbid deficit formation precedes onset by some period, especially among males. The patterns also suggest that active symptom formation does not always precede this deteriorative process.

[Neuroleptic malignant syndrome]. / Malignt neuroleptikasyndrom.

Neuroleptic malignant syndrome is a rare but often serious complication of treatment with antipsychotic drugs. The syndrome is characterized by hyperthermia, altered state of consciousness, muscular rigidity and autonomous dysfunction. The article reviews the syndrome and presents a case-history.