Outcomes following first-episode psychosis – Why we should intervene early in all ages, not only in youth

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Abstract

Objective:

To compare baseline demographics and 10-year outcomes of a first-episode psychosis patient incidence cohort in order to establish whether current youth-focussed age-based criteria for early intervention services are justified by patient needs. The patients in this cohort were treated prior to the establishment of early intervention services. The study aimed to test the hypothesis that those who develop psychosis at a younger age have worse outcomes than those who develop psychosis at an older age.

Methods:

Data on first-episode psychosis patients from the ÆSOP-10 longitudinal follow-up study were used to compare baseline characteristics, and 10-year clinical, functional and service use outcomes between those patients who would and would not have met age-based criteria for early intervention services, in Australia or in the United Kingdom.

Results:

In total, 58% men and 71% women with first-episode psychosis were too old to meet current Australian-early intervention age-entry criteria (χ ² = 9.1, p = 0.003), while 21% men and 34% women were too old for UK-early intervention age-entry criteria (χ ² = 11.1, p = 0.001). The 10-year clinical and functional outcomes did not differ significantly between groups by either Australian- or UK-early intervention age-entry criteria. Service use was significantly greater among the patients young enough to meet early intervention age-criteria (Australia: incidence rate ratio = 1.35 [1.19, 1.52], p < 0.001; United Kingdom: incidence rate ratio = 1.65 [1.41, 1.93], p < 0.001).

Conclusion:

Current early intervention services are gender- and age-inequitable. Large numbers of patients with first-episode psychosis will not receive early intervention care under current service provision. Illness outcomes at 10-years were no worse in first-episode psychosis patients who presented within the age range for whom early intervention has been prioritised, though these patients had greater service use. These data provide a rationale to consider extension of early intervention to all, rather than just to youth.

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Most cited references 17

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Association between duration of untreated psychosis and outcome in cohorts of first-episode patients: a systematic review.

Max Marshall, Shôn Lewis, Austin Lockwood … (2005)

Duration of untreated psychosis (DUP) is the time from manifestation of the first psychotic symptom to initiation of adequate treatment. It has been postulated that a longer DUP leads to a poorer prognosis. If so, outcome might be improved through earlier detection and treatment. To establish whether DUP is associated with prognosis and to determine whether any association is explained by confounding with premorbid adjustment. The CINAHL (Cumulative Index to Nursing and Allied Health), EMBASE, MEDLINE, and PsychLIT databases were searched from their inception dates to May 2004. Eligible studies reported the relationship between DUP and outcome in prospective cohorts recruited during their first episode of psychosis. Twenty-six eligible studies involving 4490 participants were identified from 11 458 abstracts, each screened by 2 reviewers. Data were extracted independently and were checked by double entry. Sensitivity analyses were conducted excluding studies that had follow-up rates of less than 80%, included affective psychoses, or did not use a standardized assessment of DUP. Independent meta-analyses were conducted of correlational data and of data derived from comparisons of long and short DUP groups. Most data were correlational, and these showed a significant association between DUP and several outcomes at 6 and 12 months (including total symptoms, depression/anxiety, negative symptoms, overall functioning, positive symptoms, and social functioning). Long vs short DUP data showed an association between longer DUP and worse outcome at 6 months in terms of total symptoms, overall functioning, positive symptoms, and quality of life. Patients with a long DUP were significantly less likely to achieve remission. The observed association between DUP and outcome was not explained by premorbid adjustment. There is convincing evidence of a modest association between DUP and outcome, which supports the case for clinical trials that examine the effect of reducing DUP.

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A systematic review and meta-analysis of recovery in schizophrenia.

E. Jääskeläinen, P Juola, N Hirvonen … (2013)

Our primary aims were (a) to identify the proportion of individuals with schizophrenia and related psychoses who met recovery criteria based on both clinical and social domains and (b) to examine if recovery was associated with factors such as gender, economic index of sites, and selected design features of the study. We also examined if the proportions who met our definition of recovery had changed over time. A comprehensive search strategy was used to identify potential studies, and data were extracted for those that met inclusion criteria. The proportion who met our recovery criteria (improvements in both clinical and social domains and evidence that improvements in at least 1 of these 2 domains had persisted for at least 2 years) was extracted from each study. Meta-regression techniques were used to explore the association between the recovery proportions and the selected variables. We identified 50 studies with data suitable for inclusion. The median proportion (25%-75% quantiles) who met our recovery criteria was 13.5% (8.1%-20.0%). Studies from sites in countries with poorer economic status had higher recovery proportions. However, there were no statistically significant differences when the estimates were stratified according to sex, midpoint of intake period, strictness of the diagnostic criteria, duration of follow-up, or other design features. Based on the best available data, approximately, 1 in 7 individuals with schizophrenia met our criteria for recovery. Despite major changes in treatment options in recent decades, the proportion of recovered cases has not increased.

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Symptomatic and functional recovery from a first episode of schizophrenia or schizoaffective disorder.

Delbert G Robinson, Margaret G Woerner, Marjorie McMeniman … (2004)

Follow-up studies have found that a substantial number of patients with schizophrenia achieve full recovery (i.e., sustained improvement in both symptoms and social/vocational functioning) when examined decades after an index admission. This study addressed recovery during the crucial early course of the illness. Subjects in their first episode of schizophrenia or schizoaffective disorder (N=118) were assessed at baseline and then treated according to a medication algorithm. Full recovery required concurrent remission of positive and negative symptoms and adequate social/vocational functioning (fulfillment of age-appropriate role expectations, performance of daily living tasks without supervision, and engagement in social interactions). After 5 years, 47.2% (95% CI=36.0%-58.4%) of the subjects achieved symptom remission, and 25.5% (95% CI=16.1%-34.7%) had adequate social functioning for 2 years or more. Only 13.7% (95% CI=6.4%-20.9%) of subjects met full recovery criteria for 2 years or longer. Better cognitive functioning at stabilization was associated with full recovery, adequate social/vocational functioning, and symptom remission. Shorter duration of psychosis before study entry predicted both full recovery and symptom remission. More cerebral asymmetry was associated with full recovery and adequate social/vocational functioning; a schizoaffective diagnosis predicted symptom remission. Although some patients with first-episode schizophrenia can achieve sustained symptomatic and functional recovery, the overall rate of recovery during the early years of the illness is low.

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Author and article information

Journal

Journal ID (nlm-ta): Aust N Z J Psychiatry

Journal ID (iso-abbrev): Aust N Z J Psychiatry

Journal ID (publisher-id): ANP

Journal ID (hwp): spanp

Title: The Australian and New Zealand Journal of Psychiatry

Publisher: SAGE Publications (Sage UK: London, England )

ISSN (Print): 0004-8674

ISSN (Electronic): 1440-1614

Publication date (Electronic): 22 October 2016

Publication date (Print): November 2016

Volume: 50

Issue: 11

Pages: 1055-1063

Affiliations

[1 ]School of Psychiatry, University of New South Wales, Sydney, NSW, Australia

[2 ]Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK

[3 ]Department of Psychiatry, University of Cambridge, Cambridge, UK

[4 ]Department of Psychiatry, The University of Nottingham, Nottingham, UK

[5 ]School of Nursing and Health Sciences University of Dundee, Dundee, UK

[6 ]Nottingham University Hospitals NHS Trust, The University of Nottingham, Nottingham, UK

[7 ]Department of Psychiatry, Trinity College Dublin, Dublin, Ireland

Author notes

[*]Julia M Lappin, School of Psychiatry, Black Dog Institute, Hospital Road, Randwick, NSW 2031, Australia. Email: j.lappin@ 123456unsw.edu.au

[*]

Joint first authors

Article

Publisher ID: 10.1177_0004867416673454

DOI: 10.1177/0004867416673454

PMC ID: 5316960

PubMed ID: 27756771

SO-VID: 9df79095-1d87-4e75-9f0d-80dee429dbba

License:

This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 3.0 License ( http://www.creativecommons.org/licenses/by-nc/3.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access page ( https://us.sagepub.com/en-us/nam/open-access-at-sage).

Outcomes following first-episode psychosis – Why we should intervene early in all ages, not only in youth

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Abstract

Objective:

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Most cited references 17

Association between duration of untreated psychosis and outcome in cohorts of first-episode patients: a systematic review.

A systematic review and meta-analysis of recovery in schizophrenia.

Symptomatic and functional recovery from a first episode of schizophrenia or schizoaffective disorder.

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