Role of Executive Function in Response to a Problem Solving Based Psychoeducational Intervention in Adolescents with Psychosis: The PIENSA Trial Revisited.

An improvement in negative symptoms and a reduction in the number of visits to the emergency department have been reported in a problem solving based psychoeducational group intervention (PE) for adolescents with psychosis relative to a nonstructured group (NS). One of the factors that may play a role on the response to PE treatment is executive function (EF), a crucial cognitive domain for problem-solving performance. We aimed to examine the role of EF in response to PE treatment versus an NS group. We examined the associations between changes in cognition and in clinical/functional variables within each treatment group using Spearman-ranked and partial correlation analyses. A total of 22 individuals (mean age: 16.3) were randomized to PE (N = 10) and NS (N = 12). We found an association between improvements in EF performance and a reduction in positive symptoms (rs = -0.756, p = 0.030 for semantic fluency), reduction in negative symptoms (r = 0.758, p = 0.029 for semantic; rs = -0,733, p = 0.025 for verbal fluency), and reduction in the number of visits to the emergency department (r = -0,743, p = 0.035 for semantic fluency) in the PE group. No associations were found in the NS group. Our results suggest that EF may play a role in the specific improvements observed in the PE group. This may have implications in the development of new areas of clinical intervention focusing on the role of cognitive functioning in response to psychosocial treatments in psychosis.

Psychoeducational Group Intervention for Adolescents With Psychosis and Their Families: A Two-Year Follow-Up.

OBJECTIVE: To investigate whether the beneficial effects of a structured, psychoeducational, parallel-group program for adolescents with early-onset psychosis and their families observed immediately after the intervention were maintained 2 years later. METHOD: The present study examines the longitudinal efficacy of a randomized controlled trial based on a psychoeducational, problem-solving, structured group intervention for adolescents with early-onset psychosis and their families (PE) and compares it with that of a nonstructured group intervention (NS) after a 2-year follow-up. We analyzed whether the differences between PE and NS found after the intervention persisted 2 years later. Intergroup differences in number and duration of hospitalizations, symptoms, and functioning were also assessed. RESULTS: After 2 years of follow-up, we were able to reassess 89% of patients. In the PE group, 13% of patients had visited the emergency department, compared with 50% in the NS group (p = .019). However, no statistically significant differences were found between the groups for negative symptoms or number and duration of hospitalizations. A significant improvement in Positive and Negative Syndrome Scale (PANSS) general symptoms was observed in the PE group. CONCLUSION: Our psychoeducational group intervention showed sustained effects by diminishing the number of visits to emergency departments 2 years after the intervention. Our findings indicate that this psychoeducational intervention could provide patients with long-lasting resources to manage crises more effectively. Clinical trial registration information-Intervention Module AGES (AGES-CM); http://clinicaltrials.gov/; NCT02101372.

Intervention for adolescents with early-onset psychosis and their families: a randomized controlled trial.

OBJECTIVE: The present study aims to assess the efficacy of a structured psychoeducational group intervention for adolescents with early-onset psychosis and their families. The intervention was implemented in parallel in 2 separate groups by focusing specifically on problem-solving strategies and structured psychosis-related information to manage daily life difficulties associated with the disease, to mitigate crises, and to prevent relapses. METHOD: We performed a 9-month, randomized, rater-blinded clinical trial involving 55 adolescent patients with early-onset psychosis and either or both of their parents. A psychoeducational problem-solving group intervention (n = 27) was compared with a nonstructured group intervention (n = 28). The primary outcomes were number of hospitalizations, days of hospitalization, and visits to the emergency department. The secondary outcome measures were clinical variables and family environment. RESULTS: Assessments were performed before and after the intervention. At the end of the group intervention, 15% of patients in the psychoeducational group and 39% patients in the nonstructured group had visited the emergency department (χ² = 3.62, df = 1, p = .039). The improvement in negative symptoms was more pronounced in the psychoeducational group (12.84 [7.87]) than in the nonstructured group (15.81 [6.37]) (p = .039). CONCLUSION: A parallel psychoeducational group intervention providing written instructions in a structured manner could help adolescents with early-onset psychosis and their parents to manage crises by implementing problem-solving strategies within the family, thus reducing the number of visits to the emergency department. Negative symptoms improved in adolescents in the psychoeducational group. Clinical trial registration information--Intervention Module AGES (AGES-CM); http://clinicaltrials.gov/; NCT02101372. [corrected].

Cognitive efficacy of quetiapine and olanzapine in early-onset first-episode psychosis.

The primary purpose of this study was to compare changes in cognition in early-onset psychosis after 6-months treatment with quetiapine or olanzapine. This is a randomized, single-blind, 6-month study in 50 adolescents with a diagnosis of early-onset psychosis. Patients were randomized to quetiapine (n = 24) or olanzapine (n =26). A thorough neuropsychological battery was administered at baseline and after 6-month treatment. Out of the total sample included in the study, 32 patients completed at least 6-months treatment with the assigned medication (quetiapine, n =16; olanzapine, n = 16). No changes were observed in cognitive performance after 6-month treatment with quetiapine or olanzapine. Although some trends toward cognitive improvement were observed for the olanzapine group after 6-month treatment, neither group showed statistically significant gains. Furthermore, there was no evidence of any differential efficacy of olanzapine or quetiapine on cognitive improvement in this sample of adolescents with psychosis.

Olanzapine compared to quetiapine in adolescents with a first psychotic episode.

OBJECTIVE: To compare the efficacy, safety, and tolerability of olanzapine and quetiapine in adolescents with first episode psychosis. METHOD: Fifty adolescents (age 16 +/- 1.25) with a first episode of psychosis were randomized to quetiapine or olanzapine in a 6-month open label study. Efficacy and side effect scales, as well as vital signs and laboratory data were recorded at baseline, 7, 15, 30, 90, and 180 days (end of study). RESULTS: Out of the total sample included in the study, 32 patients completed the trial (quetiapine n = 16, olanzapine n = 16). Patients in both treatment groups had a significant reduction in all clinical scales with the exception of the negative scale of the Positive and Negative Symptom Scale (PANSS) for olanzapine and the general psychopathology scale of the PANSS for quetiapine. The only difference between treatment arms on the clinical scales was observed on the patients' strength and difficulties questionnaire (SDQ) scale, with greater improvement for olanzapine. Patients on olanzapine gained 15.5 kg and patients on quetiapine gained 5.5 kg. CONCLUSION: Olanzapine and quetiapine reduced psychotic symptoms in this adolescent sample. Patients on olanzapine gained significantly more weight. Side effects with both drugs seemed to be more prevalent than those reported in adult studies.

Neurological soft signs in adolescents with first episode psychosis: two-year followup.

Neurological soft signs were assessed in 24 first episodes of early onset psychosis and 30 healthy adolescents over a 2-year period. Patients presented more neurological soft signs than controls and showed a significant decrease in some Neurological Evaluation Scale scores over the followup period. This decrease in the patient group was influenced by changes in symptomatology.

Metabolic and hormonal side effects in children and adolescents treated with second-generation antipsychotics.

OBJECTIVE: The aim of this study was to evaluate metabolic and hormonal side effects in children and adolescents after 6 months of treatment with 3 different second-generation antipsychotics (SGAs). METHOD: 66 children and adolescents (44 male [66.7%], mean +/- SD age = 15.2 +/- 2.9 years) treated for 6 months with risperidone (N = 22), olanzapine (N = 20), or quetiapine (N = 24) composed the study sample. 34 patients (51.5%) suffered from schizophrenia or other psychosis (according to DSM-IV criteria). Patients were consecutively attending different programs from March 2005 to October 2006. Prior to enrollment in the study, patients were either antipsychotic-naive (37.9%, N = 25) or had been taking an antipsychotic drug for fewer than 30 days. Significant weight gain was defined as a > or = 0.5 increase in body mass index (BMI) z score (adjusted for age and gender) at 6 months. Based on recent criteria for pediatric populations, patients were considered "at risk for adverse health outcome" if they met at least 1 of the following criteria: (1) > or = 85th BMI percentile plus presence of 1 or more negative weight-related clinical outcomes, or (2) > or = 95th BMI percentile. RESULTS: After the 6 months, BMI z scores increased significantly in patients receiving olanzapine and risperidone. At the 6-month follow-up, 33 patients (50.0%) showed significant weight gain. The number of patients at risk for adverse health outcome increased from 11 (16.7%) to 25 (37.9%) (p = .018). The latter increase was significant only in the olanzapine group (p = .012). Total cholesterol levels increased significantly in patients receiving olanzapine (p = .047) and quetiapine (p = .016). Treatment with quetiapine was associated with a significant decrease in free thyroxin (p = .011). CONCLUSION: Metabolic and hormonal side effects of SGAs in children and adolescents should be carefully monitored when prescribing these drugs.

Attitude toward antipsychotic medication as a predictor of antipsychotic treatment discontinuation in first-episode early-onset psychosis.

BACKGROUND: Antipsychotic drug discontinuation is a key risk factor in psychotic relapses. Clinical relapse is related to poor outcome, especially in the earlier stages of psychotic illness. The attitude toward treatment during the acute phase of a first episode of psychosis has been proposed as one of the main determinants of treatment discontinuation. However, the relationship between attitude toward antipsychotic medication and treatment discontinuation in the adolescent population has not been properly assessed. METHODS: Adolescents, aged 12-18 years old, consecutively admitted to an adolescent unit with a first lifetime admission for a first episode of psychosis were asked to participate in a randomized, flexible-dose, 6-month controlled trial of olanzapine vs. quetiapine. Attitude toward antipsychotic medication was assessed using the 10-item Drug Attitude Inventory (DAI). The outcome variable was all-cause treatment discontinuation over the 6-month follow- up. The study sample was composed of 42 patients [34 boys (82.9%), eight girls (17.1%), mean age ± SD: 16.1±1.3]. RESULTS: Of the 42 patients, only 29 (69%) continued the medication throughout the entire 6-month follow-up, while 13 (31%) discontinued the medication. DAI scores were greater than zero at all assessments, indicating that the general attitude of the patients toward medication was positive. Higher DAI scores at baseline were related to lower all-cause treatment discontinuation [adjusted hazard ratio (HR) = 0.81 (95% CI: 0.68-0.96), P=0.016], while DAI scores at 15 days were unrelated to treatment discontinuation [adjusted HR=1.0 (95% CI: 0.82-1.23), P=0.998]. CONCLUSIONS: A better attitude toward antipsychotic medication at a first lifetime psychiatric admission for a first early-onset psychotic episode was significantly related to lower all-cause antipsychotic treatment discontinuation.

Is attempted suicide different in adolescent and adults?

Attempted suicide may be a different phenomenon in adolescents than in adults. To our knowledge, direct comparisons between these two populations are very scarce. The aim of this study is to analyze the differences between adolescents and adults in methods of attempted suicide, accompanying certainty of death, and intentionality. All cases admitted to one adult (n=173) and one adolescent (n=104) inpatient unit who attempted suicide in the period from January 2003 through October 2005 were included in a prospective, common, national register, with data on methods, circumstances, and intentionality. The methodology followed that of the WHO/Euro Multicenter Study on Parasuicide. A stratified analysis was performed using the Mantel-Haenszel procedure in order to control for the effects of gender and diagnosis. Adolescents used significantly more over-the-counter medicines. Adults were significantly more certain of the possible fatal outcome of their attempt and had a significantly more severe intention when harming themselves. Individuals appear to use the methods that are available to them to attempt suicide. Adolescents may display more impulsive and less lethal directed behavior than adults or, alternatively, they are more frequently admitted for less severe attempts.

Antipsychotic-related abnormal involuntary movements and metabolic and endocrine side effects in children and adolescents.

There has been a remarkable increase in prescription rates of antipsychotics in children and adolescents in recent years. Their side effects are a neglected area of research in this population, despite its vulnerability. In this cross-sectional study, we compared the presence of side effects in 60 children and adolescents who had taken antipsychotic medication for less than 1 month and 66 who had been receiving treatment with antipsychotics for more than 12 months. Mean age for the total sample was 15.62 years (SD 1.85). Groups did not differ in age, gender, or diagnosis. A total of 21.7% of short-term treatment group patients and 37.9% of longer-term treatment group patients presented mild dyskinetic movements (p = 0.004). Hyperprolactinemia was present in 78.6% and 48.5% in the short-term and longer-term treatment groups, respectively. Body mass index (p < 0.001), cholesterol levels (p < 0.001), and low-density lipoprotein-cholesterol (LDL-C) (p = 0.018) were higher in the longer-term treatment group. The use of these drugs in these populations merits careful scrutiny.

Improving quality at the hospital psychiatric ward level through the use of the EFQM model.

OBJECTIVE: To describe the implementation of the European Foundation for Quality Management (EFQM) model as a quality framework for improving a psychiatric hospital ward. METHODOGY: Two self-assessments were conducted using the EFQM model. The self-assessment methods combined two approaches proposed by the EFQM: the award simulation approach and the questionnaire approach. Work groups were set up to improve the areas for improvement identified on the self-assessment. RESULTS: The EFQM was a useful framework for self-assessment at the ward level and a good system for identifying areas for improvement. Only one of the 32 sub-criteria did not apply at the ward level. The self-assessment score was 209 points in 2003 and 311 points 2 years later (an increase of 48.8% from the initial score). DISCUSSION: The main difficulties were ensuring that clinical personnel understood the EFQM model, the extra effort demanded by the initial phase and the lack of decision-making capacity in certain relevant areas. Adapting the self-assessment methodology to the specific context facilitated the process, as did a high level of involvement of the part of manager and staff. CONCLUSIONS: It is possible to implement the EFQM model at the hospital was level and it has a positive influence on staff communication and involvement. It is important, when working at this level, to adequately focus the scope of the project on improving quality in those areas where there is decision-making capacity.

The child and adolescent first-episode psychosis study (CAFEPS): design and baseline results.

OBJECTIVE: The child and adolescent first-episode psychosis study (CAFEPS) is a multicenter, two-year, longitudinal project aiming to evaluate different clinical, neuropsychological, neuroimaging, biochemical, immunological, and genetic variables and treatment and prognostic factors in these patients. This paper describes the methods and rationale behind the study and the general characteristics of the sample. METHOD: At six different centers, from March 2003 through November 2005, we consecutively recruited 110 patients, ages 9-17 years, who presented with a first psychotic episode. Controls were recruited from the same geographic areas and were matched for gender and age. RESULTS: Patients had lower socioeconomic status (SES) (p=0.018) and parental years of education (p<0.001) than controls. The percentage of patients recruited increased with age (p<0.001) and there was a higher percentage of males (p<0.001). The total mean PANSS score was 89.03+/-20.1, the positive score 23.8+/-6.5 and the negative score 20.02+/-8.8. There were no significant differences between the genders with respect to age, parental years of education, SES, or scores in premorbid adjustment or general functioning. There were statistically significant positive correlations between age and positive symptoms and between all PANSS subscales and the Disability Assessment Schedule, and negative correlations between positive symptoms and global functioning. Diagnoses after the baseline evaluation were: psychotic disorder not otherwise specified (NOS) 35.5%, schizophreniform disorder 24.5%, mood disorder with psychotic symptoms 22.7%, schizophrenia 10%, schizoaffective disorder 2.7%, and other psychotic disorders 4.5%. Patients had worse premorbid adjustment (p<0.001) and global functioning (p<0.001) than controls after controlling for SES. CONCLUSIONS: Infancy and adolescence adjustment and global functioning are lower in children and adolescents with psychotic disorders than in controls, severity of symptoms are related to general disability, and the most frequent diagnoses are psychotic disorders NOS.

Neurological soft signs in adolescents with first episode psychosis.

The purpose of this study is to determine the decrease of neurological soft signs (NSS) during adolescence and to compare this evolutionary process in two groups of adolescents with first episode psychosis: a) schizophrenia and b) non-schizophrenia patients. The structured neurological evaluation scale (NES) was administered to 24 adolescents with first episode psychosis. The number of NSS, the total and subscales scores were correlated with age in patients and in 39 healthy controls. Adolescents with first-episode psychosis had a higher prevalence of NSS than healthy controls; the schizophrenia patients (N=9) scored higher than non-schizophrenia patients (N=15). The number of NSS, total score and the scores on three of the four NES subscales correlated inversely with age in the healthy control group. No correlation was found for the schizophrenia group. For the non-schizophrenia group, a significant negative correlation was found only in one subscale. The decrease of NSS during adolescence in the healthy population but not in the patient groups with psychosis may be an indicator of a disturbance of brain processes that occurs during development. We did not find a clear pattern of NSS that distinguished schizophrenia from other psychoses.