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AIM: Despite increasingly refined tools for identifying individuals at clinical high-risk for psychosis (CHR-P), less is known about the effectiveness of CHR-P interventions. The significant clinical heterogeneity among CHR-P individuals suggests that interventions may need to be personalized during this emerging illness phase. We examined longitudinal trajectories within-persons during treatment to investigate whether baseline factors predict symptomatic and functional outcomes. METHOD: A total of 36 CHR-P individuals were rated on attenuated positive symptoms and functioning at baseline and each week during CHR-P step-based treatment. RESULTS: Linear mixed-effects models revealed that attenuated positive symptoms decreased during the study period, while functioning did not significantly change. When examining baseline predictors, a significant group-by-time interaction emerged whereby CHR-P individuals with more psychiatric comorbidities at baseline (indicating greater clinical complexity) improved in functioning during the study period relative to CHR-P individuals with fewer comorbidities. CONCLUSION: Individual differences in clinical complexity may predict functional response during the early phases of CHR-P treatment.
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This study examined trajectories of suicide-risk and their relationship to symptoms, recovery, and quality of life over time. Data was obtained from the Recovery after an Initial Schizophrenia Episode Early Treatment Program (RAISE-ETP) study. 404 individuals with first-episode psychosis (FEP) completed measures of suicide-risk, depression, positive symptoms, recovery, and quality of life at baseline, 6mo, 12mo, 18mo, and 24mo. Latent class analysis was used to identify temporal trajectories of suicide-risk. General linear mixed models for repeated measures were used to examine the relationship between the latent trajectories of suicide-risk and clinical variables. Results identified three latent trajectories of suicide-risk (low-risk, worsening, and improving). The low-risk and improving classes experienced improvements in depression, positive symptoms, quality of life, and recovery over time. The worsening class experienced improvements in positive symptoms and quality of life, but no change in depression or recovery. These results suggest that some individuals with FEP are at risk for persistent depression and worsening suicide-risk during treatment despite experiencing improvements in positive symptoms and quality of life. These findings have important clinical implications, as persistent depression and worsening suicide-risk might be masked by the primary focus on positive symptoms and quality of life in most FEP clinics.
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Depresión , Trastornos Psicóticos , Calidad de Vida , Humanos , Trastornos Psicóticos/psicología , Femenino , Masculino , Adulto , Adulto Joven , Depresión/psicología , Adolescente , Suicidio/psicología , Suicidio/estadística & datos numéricos , EsquizofreniaRESUMEN
Early detection of psychotic-spectrum disorders among adolescents and young adults is crucial, as the initial years after psychotic symptom onset encompass a critical period in which psychosocial and pharmacological interventions are most effective. Moreover, clinicians and researchers in recent decades have thoroughly characterized psychosis-risk syndromes, in which youth are experiencing early warning signs indicative of heightened risk for developing a psychotic disorder. These insights have created opportunities for intervention even earlier in the illness course, ideally culminating in the prevention or mitigation of psychosis onset. However, identification and diagnosis of early signs of psychosis can be complex, as clinical presentations are heterogeneous, and psychotic symptoms exist on a continuum. When a young person presents to a clinic, it may be unclear whether they are experiencing common, mild psychotic-like symptoms, early warning signs of psychosis, overt psychotic symptoms, or symptoms better accounted for by a non-psychotic disorder. Therefore, the purpose of this review is to provide a framework for clinicians, including those who treat non-psychotic disorders and those in primary care settings, for guiding identification and diagnosis of early psychosis within the presenting clinic or via referral to a specialty clinic. We first provide descriptions and examples of first-episode psychosis (FEP) and psychosis-risk syndromes, as well as assessment tools used to diagnose these conditions. Next, we provide guidance as to the differential diagnosis of conditions which have phenotypic overlap with psychotic disorders, while considering the possibility of co-occurring symptoms in which case transdiagnostic treatments are encouraged. Finally, we conclude with an overview of early detection screening and outreach campaigns, which should be further optimized to reduce the duration of untreated psychosis among youth.
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In this study, the authors measured and described the costs of coordinated specialty care (CSC) for first-episode psychosis in Ohio. A microcosting tool was used to estimate personnel and nonpersonnel costs of service delivery at seven CSC programs. Average annual cost per participant (N=511 participants) was estimated as $17,810 (95% CI=$9,141-$26,479). On average, 61% (95% CI=53%-69%) of annual program costs were nonbillable. Key cost drivers included facility costs, administrative tasks, and social services. Novel financing models may redress reimbursement gaps incurred by CSC programs.
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Trastornos Psicóticos , Humanos , Trastornos Psicóticos/terapia , Ohio , Servicio SocialRESUMEN
Over the past decade, significant investments have been made in coordinated specialty care (CSC) models for first episode psychosis (FEP), with the goal of promoting recovery and preventing disability. CSC programs have proliferated as a result, but financing challenges imperil their growth and sustainability. In this commentary, the authors discuss (1) entrenched and emergent challenges in behavioral health policy of consequence for CSC financing; (2) implementation realities in the home rule context of Ohio, where significant variability exists across counties; and (3) recommendations to improve both care quality and access for individuals with FEP. The authors aim to provoke careful thought about policy interventions to bridge science-to-service gaps, and in this way, advance behavioral health equity.
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Trastornos Psicóticos , Humanos , Trastornos Psicóticos/terapia , Políticas , OhioRESUMEN
Background: Metacognitive skills training (MST) is often integrated into cognitive remediation programs for psychosis. Social cognition - the mental processes underlying social perception and behavior - is robustly related to outcomes in psychosis and is increasingly addressed with targeted treatments. Though metacognition and social cognition are related constructs, little is known about how MST may influence social cognition among individuals with psychosis participating in broad-based, non-social cognitive remediation. Methods: Individuals with first-episode psychosis who completed six months of metacognitive remediation (MCR; n=12) were compared to a historical control group who received six months of computerized cognition remediation (CCR; n=10) alone (ClinicalTrials.gov Identifier NCT01570972). Results: Though individuals receiving MCR experienced gains in emotion processing and theory of mind, these changes were not significantly different when compared to individuals receiving CCR. MST did not contribute to social cognitive change in the context of CCR. Discussion: Though MST may be relevant to facilitating social cognitive gains within broader cognitive remediation programs for first-episode psychosis, these benefits are limited and may not exceed those conferred by standard cognitive remediation. Opportunities for investigation of other potential mechanisms of social cognitive response to interventions remain.
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Validated, multicomponent treatments designed to address symptoms and functioning of individuals at clinical high risk for psychosis are currently lacking. The authors report findings of a study with such individuals participating in step-based care-a program designed to provide low-intensity, non-psychosis-specific interventions and advancement to higher-intensity, psychosis-specific interventions only if an individual is not meeting criteria for a clinical response. Among individuals with symptomatic or functional concerns at enrollment, 67% met criteria for a symptomatic response (median time to response=11.1 weeks), and 64% met criteria for a functional response (median time to response=8.9 weeks).
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Individuals at clinical high-risk for psychosis (CHR-P) are at increased risk for suicide. However, the relationship between attenuated positive symptoms and suicidal ideation are not well understood, particularly as they interact over time. The current study addressed this gap in the literature. We hypothesized that greater attenuated symptoms would be concurrently and prospectively associated with suicidal ideation. Further, we hypothesized that suspiciousness and perceptual abnormalities would have the strongest relationship with suicidal ideation. Within-person variation in symptoms and suicidal ideation were examined across 24 treatment sessions for individuals at CHR-P. Attenuated positive symptoms (unusual thought content, suspiciousness, grandiose ideas, perceptual abnormalities, and disorganized communication) and suicidal ideation were assessed at each session. Logistic mixed effect models examined concurrent and time-lagged relationships between symptoms and suicidal ideation among 36 individuals at CHR-P. Results indicated that suicidal ideation was more likely during weeks when participants reported more severe total attenuated positive symptoms. Further, suspiciousness was uniquely associated with suicidal ideation, both concurrently and at the following session. Post hoc models examined the reverse direction of this relationship, demonstrating that suicidal ideation also prospectively predicted suspiciousness at the following session. These results suggest that within-person attenuated symptoms, particularly suspiciousness, are associated with suicidal ideation among individuals at CHR-P. However, the bidirectional relationship between suspiciousness and suicidal ideation raises questions about causal nature of this relationship. Further research is needed to examine the dynamic interplay of suspiciousness and suicidal ideation.
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Personal agency-a key element of recovery from psychotic disorders-is formed and maintained in large part through interactions with others. Interactions with caregivers are particularly important in first-episode psychosis (FEP), as these interactions form the foundations for lifelong caregiving relationships. The present study examined shared understandings of agency (operationalized as efficacy to manage symptoms and social behaviors) within families affected by FEP. Individuals with FEP (n = 46) completed the Self-Efficacy Scale for Schizophrenia (SESS) and measures of symptom severity, social functioning, social quality of life, stigma, and discrimination. Caregivers (n = 42) completed a caregiver version of the SESS assessing perceptions of their affected relative's self-efficacy. Self-rated efficacy was higher than caregiver-rated efficacy in all domains (positive symptoms, negative symptoms, and social behavior). Self- and caregiver-rated efficacy correlated only in the social behavior domain. Self-rated efficacy was most associated with lower depression and stigmatization, whereas caregiver-rated efficacy was most associated with better social functioning. Psychotic symptoms did not relate to self- or caregiver-rated efficacy. Individuals with FEP and caregivers have discrepant perceptions of personal agency, perhaps because they base perceptions of agency on different sources of information. These findings highlight specific targets for psychoeducation, social skills training, and assertiveness training to develop shared understandings of agency and facilitate functional recovery.
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Trastornos Psicóticos , Esquizofrenia , Humanos , Cuidadores , Calidad de Vida , Trastornos Psicóticos/diagnóstico , Estigma SocialRESUMEN
AIM: Suicide risk is elevated among individuals at clinical high risk for psychosis (CHR-P). The current study examined variability in suicidal ideation during treatment for individuals at CHR-P. METHODS: A retrospective chart review was used to examine the course of suicidal ideation during 16 sessions of individual psychotherapy for 25 individuals at CHR-P. RESULTS: Suicidal ideation was reported by 24% of participants at session 1 and 16% at session 16, with minimal within-subject change in the presence of suicidal ideation across the two time points. However, a more fine-grained investigation at each session indicated that 60% of individuals at CHR-P experienced suicidal ideation at least once during treatment. Additionally, there was great variability in suicidal ideation both within and between participants over the course of the 16 sessions. CONCLUSIONS: These findings highlight the importance of repeated assessment when examining suicidal ideation as a treatment outcome for individuals at CHR-P.
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Trastornos Psicóticos , Ideación Suicida , Humanos , Estudios Retrospectivos , Trastornos Psicóticos/diagnóstico , Trastornos Psicóticos/terapia , Psicoterapia , Resultado del Tratamiento , Factores de RiesgoRESUMEN
Recent COVID-19-related federal legislation has resulted in time-limited increases in Mental Health Block Grant (MHBG) set-aside dollars for coordinated specialty care (CSC) throughout the United States. The state of Ohio has opted to apply these funds to establish a learning health network of Ohio CSC teams, promote efforts to expand access to CSC, and quantify the operating costs and rates of reimbursement from private and public payers for these CSC teams. These efforts may provide other states with a model through which they can apply increased MHBG funds to support the success of their own CSC programs.
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COVID-19 , Humanos , Estados Unidos , Ohio , Costos y Análisis de Costo , Salud Mental , Grupo de Atención al PacienteRESUMEN
Objective: There is emerging evidence that greater cognition is associated with increased risk for suicide among individuals with psychosis. Given this association, concerns have been raised that cognitive interventions might actually increase risk for suicide in this population. Therefore, the present study investigated the cross-sectional and longitudinal relationship between cognition and suicide risk among individuals with first-episode psychosis. Method: Sixty-five participants completed measures of suicide risk, depression, and cognition at baseline and 6 months. Within-subject mediation analysis was used to examine the indirect effect of cognition on suicide risk. Within-subject moderation analysis was used to examine whether participation in cognitive enhancing intervention (e.g., computerized drill-and-practice cognitive remediation and metacognitive remediation therapy) moderated changes in suicide risk. Results: Consistent with prior studies, our cross-sectional results suggest that greater cognition is associated with increased risk for suicide. However, this effect was limited in scope, as we found that verbal learning was the only cognitive domain associated with suicide risk in our sample. Results from our longitudinal analyses show that changes in depressive symptoms, but not changes verbal learning, mediate changes in suicide risk during the first 6 months of treatment. In addition, participation in cognitive enhancing interventions did not moderate changes in suicide risk. Conclusions and Implications for Practice: Our results suggest that cognition is a correlate, or a proxy risk factor, rather than a causal risk factor for suicide. Although these findings contradict previously raised concerns that cognitive interventions might unintentionally increase risk for suicide, ongoing assessment is warranted and additional research is needed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).
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Trastornos Psicóticos , Prevención del Suicidio , Cognición , Estudios Transversales , Estudios de Seguimiento , Humanos , Trastornos Psicóticos/psicología , Factores de RiesgoRESUMEN
AIM: Metacognitive remediation therapy (MCR) has been shown to help individuals with first-episode psychosis experience improvements in cognition, social functioning, vocational/educational functioning and quality of life. The theoretical model underlying MCR has yet to be empirically validated. METHODS: Seventy-three individuals with first-episode psychosis completed measures of metacognition and cognition at enrollment and after 6-months of care at a specialized clinical program for individuals with first-episode psychosis. Among this group, we compared changes in these variables between the 21 individuals who opted to participate in MCR and the 52 individuals who did not participate in MCR. RESULTS: Improvements in metacognition were moderated by MCR treatment participation. Consistent with the MCR theoretical model of change, increases in metacognition mediated the relationship between treatment and longitudinal changes in cognition. CONCLUSIONS: Our findings suggest that the benefits of MCR on cognitive functioning may stem, in part, from the ability of MCR to produce improvements in metacognitive functioning.
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Metacognición , Trastornos Psicóticos , Cognición , Humanos , Trastornos Psicóticos/psicología , Trastornos Psicóticos/terapia , Calidad de Vida , Ajuste SocialRESUMEN
Social functioning is diminished among people early in the course of psychotic illnesses, and is likely influenced by the negative symptoms that accompany these disorders, including changes in motivation and experience of pleasure. Though social impairments have a deleterious impact on functioning, socialization is a multifaceted behavior and little is known about how the various aspects may influence social functioning and social quality of life among people with first-episode psychosis. In the present study, we investigated the associations of specific aspects of social motivation and behavior with social functioning and social quality of life in a group of 54 young people (aged 15 to 35) with first-episode psychosis. Though different aspects of social motivation and behavior correlated positively with one another, social motivation for peer interactions was uniquely associated with social functioning and social quality of life - including when a broad measure of negative symptoms was considered within the same model. When these same associations were examined longitudinally, social motivation for peer interactions again emerged as a unique predictor of change in social functioning over 6 months. Our results suggest that the unique contribution of aspects of social motivation has implications for treatment, including the importance of developmentally-informed interventions to improve peer socialization in youth and young adults with psychosis.
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Trastornos Psicóticos , Calidad de Vida , Adolescente , Adulto , Humanos , Motivación , Trastornos Psicóticos/terapia , Conducta Social , Interacción Social , Adulto JovenRESUMEN
INTRODUCTION: Individuals with psychotic-spectrum disorders may smoke due to the ameliorating effect of nicotine on the cognitive deficits that accompany these illnesses. Metacognitive remediation therapy (MCR) has been shown to produce improvements in cognitive functioning among individuals with psychotic-spectrum disorders and provides a foundation for a novel smoking cessation intervention for this population. AIMS: To complete an open investigation of pharmacotherapy and a modified version of MCR [MCR to Quit (MCR-Q)] in promoting smoking cessation among individuals with psychotic-spectrum disorders. METHODS: Forty-nine individuals with a psychotic-spectrum disorder and who currently smoke cigarettes participated in MCR-Q while also receiving evidence-based smoking cessation pharmacotherapy. Tobacco use was assessed as follows: (i) prior to MCR-Q, (ii) immediately after completing MCR-Q, and (iii) six weeks after completion of MCR-Q. RESULTS: /Findings. During participation in MCR-Q, nearly 80% of participants made a 24-hour quit attempt. Following the completion of MCR-Q, participants experienced reductions in level of nicotine dependency and exhaled carbon monoxide, with reductions in nicotine dependency sustained six weeks after completion of MCR-Q. Over the course of their participation in MCR-Q, participants reported strong therapeutic alliance with their MCR-Q therapist and high levels of intrinsic motivation with regard to completing MCR-Q exercises. CONCLUSIONS: The results from the current study suggest cautious optimism with regard to the use of MCR-Q in combination with medication for individuals with psychotic-spectrum disorders who want to quit smoking.
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BACKGROUND: Although effective treatments are available to address the cognitive deficits experienced by individuals with first-episode psychosis, provision of such treatments within Coordinated Specialty Care (CSC) programs is rare. One factor that may contribute to this is uncertainty about the cost implications of providing cognitive-enhancing treatments within the American mental healthcare system. The aim of this study is to complete a naturalistic evaluation of the cost utility of incorporating two different cognitive-enhancing interventions within an American CSC program. METHODS: Participants included 66, predominately white (75.38%), individuals with first-episode psychosis (19 women and 47 men) with a mean age of 22.71 years. Quality adjusted life years (QALYs) and cost of care were tracked among these individuals during their participation in a CSC program. These data were compared among three groups of participants during their first six months of care: (i) individuals who participated in metacognitive remediation therapy (MCR), (ii) individuals who participated in computerized cognitive remediation (CCR), and (iii) individuals who participated in no cognitive-enhancing intervention. RESULTS: Participation in MCR, but not CCR, was associated with larger gains in QALYs than participation in no cognitive-enhancing intervention within a CSC program. Moreover, data support the cost utility of MCR as compared to CCR or no-cognitive enhancing intervention within a CSC program. Conversely, CCR did not appear to be a cost-effective addition to CSC services. CONCLUSIONS: Our results highlight the potential cost utility of incorporating MCR within CSC programs for individuals with first-episode psychosis. However, given study limitations, these results should be interpreted cautiously until replicated by large, randomized controlled trials. Trial Registration ClinicalTrials.gov Identifier NCT01570972, registered April 4, 2012, Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT01570972?term=breitborde&draw=2&rank=6 .
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Individuals diagnosed with psychosis have high rates of smoking-related morbidity and early mortality. Only a small proportion of these smokers will attempt to quit, and many existing cessation interventions have limited effectiveness. To explore the unique and potentially unmet cessation needs of individuals with psychosis, we sought first-person experiences with smoking cessation and reactions to a proposed intervention. Twenty-four smokers with psychosis participated in focus group interviews. Multiple participants reported previous quit attempts using pharmacotherapy or behavioral methods, but few indicated they had previously tried cessation counseling. Though some individuals reported modest success with cessation, most participants tended to express negative perceptions of many available cessation approaches. When informed about the development of a novel smoking cessation intervention, participants had mixed but generally positive perceptions. Smokers diagnosed with psychosis are interested in sustained, individualized delivery of cessation services as part of their broader mental health care.
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Trastornos Psicóticos , Cese del Hábito de Fumar , Humanos , Percepción , Intervención Psicosocial , FumarRESUMEN
Objective: Psychotic disorders are serious illnesses that are most amenable to early intervention. Though inpatient units are typically the first care setting for young people with psychosis, almost all early intervention work has been limited to outpatient settings. Social difficulties are a core feature of psychotic illnesses, and despite need for empirically supported social-skills treatments there are few interventions intended specifically for the developmental phase during which psychosis manifests (i.e., late teenage to early adult years). Method: Our group implemented an adapted social-skills training intervention (SST) designed for young adults on a psychiatric inpatient unit. Nineteen young adult inpatients (aged 18-35) with psychosis participated. Psychiatric symptoms and aspects of social functioning, including reported social self-efficacy and performance on social skills role-plays, were assessed before and after SST participation. Results: Preliminary data demonstrate improvements in both self-report and performance-based measures of social functioning after SST participation. Conclusions and Implications for Practice: These findings, though preliminary, support additional, larger-scale investigations of this SST among young adults with psychosis. Further, multidisciplinary collaborations are valuable in providing specialized care for young adults with psychosis who are receiving inpatient psychiatric care. (PsycInfo Database Record (c) 2021 APA, all rights reserved).