Incidence of treated first episode psychosis from an Australian early intervention service and its association with neighbourhood characteristics.

OBJECTIVES: Psychotic disorder incidence varies geographically and is associated with neighbourhood characteristics, including social deprivation, population density, unemployment, social capital or social fragmentation. Yet it is not known whether these findings are applicable to Australia's unique geography. This study aimed to determine whether the incidence of first episode psychosis (FEP) varies according to neighbourhood characteristics in an Australian cohort. METHOD: This study included all young people, aged 15 to 24, with an FEP who attended Orygen Youth Health in Melbourne, from a geographically defined catchment area encompassing Northern and Western Melbourne, over a 44-month period. Neighbourhood demographic data was collected from the 2011 Australian National Census. Negative binomial regression was used to determine incidence rate ratios controlled for age, sex and migrant status. RESULTS: A total of 747 young people had an FEP during the 44-month study period and 722 were included in this study. Of these, 58.0% were males and 67.9% had a non-affective psychotic disorder; the mean age of the cohort was 19.1 years. The incidence of FEP in young people aged 15 to 24 in the catchment area was 123.2 per 100,000 person-years. There was a higher incidence of FEP in neighbourhoods of greatest social deprivation (IRR = 1.65, CI = 1.06-2.51, p = .02), highest unemployment (IRR = 1.56, CI = 1.04-2.35, p = .03) and above average social fragmentation (IRR = 1.42, CI = 1.02-1.97, p = .04), when controlled for age, sex and migrant status. CONCLUSIONS: This study highlights variation in psychotic disorder incidence and the need for this disparity to be reflected in appropriate resource allocation.

Rates, determinants and outcomes associated with the use of community treatment orders in young people experiencing first episode psychosis.

BACKGROUND: Community treatment orders (CTOs) are a controversial form of involuntary treatment for individuals affected by mental health disorders and yet little is known about the use of CTOs in first presentations. Therefore, this study aimed to determine the rates, determinants and outcomes associated with the use of CTOs in young people with a first episode of psychosis (FEP). METHODS: This epidemiological cohort study included all individuals aged 15-24 who presented with a FEP to the Early Psychosis Prevention and Intervention Centre (EPPIC) in Melbourne between 01.01.2011 and 31.12.13. RESULTS: A total of 544 young people presented with a FEP during the study period and of these, 93 (17.3%) were subject to a CTO during their episode of care. A total of 69.7% of CTOs were commenced after the first three months of treatment and the median duration of CTOs was 168.5 days. Males, a diagnosis of a schizophrenia spectrum disorder and a concurrent substance abuse disorder were associated with the use of CTOs. Additionally, young people with more severe positive psychotic symptoms were more likely to be subject to a CTO. At the time of discharge, only 38.7% of those subject to a CTO were in education or employment compared to 65.4% of those who had not been subject to a CTO. CONCLUSIONS: The majority of CTOs are commenced after at least three months of treatment, however the optimal timing of CTO implementation needs to be determined. The poor functioning of young people on a CTO should be the focus of future interventional studies.

Delays and barriers to the commencement of clozapine in eligible people with a psychotic disorder: A literature review.

AIM: While the majority of individuals with a first episode of psychosis (FEP) achieve symptomatic remission with the appropriate treatment, there is a small but significant proportion who do not achieve remission of symptoms despite adequate treatment with at least two antipsychotic medications (termed treatment resistance). Clozapine is indicated in individuals who fulfil the criteria for treatment-resistant schizophrenia, however, despite it being the most effective antipsychotic medication, there can be delays in the commencement of clozapine in eligible patients. METHODS: A systematic search was performed to identify articles reporting either the time taken to commence clozapine (or delays) in eligible individuals or articles reporting barriers to the commencement of clozapine. The initial search generated 5588 articles and of these, 18 were eligible. RESULTS: 13 studies described delays in commencing clozapine and five studies reported on the barriers to the commencement of clozapine. The duration of delay from when an individual was deemed eligible for clozapine treatment to the time of clozapine commencement ranged from 19.3 weeks to 5.5 years. In addition, the duration of illness prior to clozapine initiation ranged from 1.1 to 9.7 years. It was found that some clinicians were more inclined to prescribe antipsychotic polypharmacy or doses higher than recommended than to prescribe clozapine. CONCLUSIONS: Delays in commencing clozapine have been consistently demonstrated. Early intervention for psychosis services are the ideal settings to identify individuals with persistent positive psychotic symptoms and commence clozapine if indicated.

Clozapine use in early psychosis.

BACKGROUND: The superior efficacy of clozapine in treatment resistant schizophrenia has been clearly demonstrated, yet there are often delays in the commencement of clozapine. In this study, we aimed to determine; the proportion of young people with a first episode of psychosis (FEP) who would be considered eligible for clozapine treatment, the theoretical delay in commencing clozapine and to compare the outcomes of those treated with clozapine to those who were eligible but not treated with clozapine. METHODS: This study was conducted at Orygen Youth Health (OYH), a youth mental health service for young people aged 15-24. All clients who were treated at the Early Psychosis Prevention and Intervention Centre (EPPIC) clinic between 01.01.2011 and 31.12.2013 were included. RESULTS: 544 young people presented with a FEP in the study period and 9.4% (N = 51) subsequently fulfilled criteria for treatment-resistant schizophrenia. Of these individuals, thirty (58.8%) were commenced on clozapine, in addition to a further eleven. The median delay to the commencement of clozapine was 42 weeks (I.Q.R. = 7.5-64). Of those commenced on clozapine, 76.6% achieved remission of positive psychotic symptoms and 50% were in employment or education by the time of discharge or transfer to the adult mental health services. The rate of discontinuation of clozapine was 24.4% and 60.0% of discontinuations were due to cardiac complications and the remainder were due to non-compliance. CONCLUSIONS: These findings suggest that early intervention for psychosis services have a crucial role in ensuring timely initiation of clozapine in individuals with a diagnosis of treatment-resistant schizophrenia.

Rates and predictors of relapse following discontinuation of antipsychotic medication after a first episode of psychosis.

BACKGROUND: There is uncertainty about the required duration of long-term antipsychotic maintenance medication after a first episode of psychosis. Robust predictors of relapse after discontinuation are yet to be identified. The present study aimed to determine the proportion of young people who discontinue their antipsychotic medication after a first episode of psychosis, the proportion who experience relapse, and predictors of relapse. METHODS: A retrospective study of all individuals presenting to the Early Psychosis Prevention and Intervention Centre between 01/01/11 and 31/12/13 was conducted. A Cox regression analysis was conducted to identify predictors of relapse. RESULTS: A total of 544 young people with a FEP were included. A trial of discontinuation was undertaken by 61% of the cohort. Median duration of antipsychotic medication prior to first trial of discontinuation was 174.50days. Amongst those trialing discontinuation, 149 (45.8%) experienced relapse in a median follow-up time post discontinuation of 372days. On multivariate analysis, predictors of relapse were a diagnosis of cannabis abuse disorder (HR: 1.40), and longer duration of antipsychotic medication (HR: 1.05). CONCLUSION: Antipsychotic discontinuation frequently occurs earlier than guidelines recommend. Individuals with a diagnosis of cannabis abuse are more likely to experience relapse and addressing this substance abuse prior to discontinuation could possibly reduce relapse rates.