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Mission Creep: Will widening the range of ages and diagnoses in Early Intervention in Psychosis teams, without new resources, undermine their mission and dilute their methods, intensity and outcomes to the point of no difference?
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Wednesday, October 10
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Symposium Session 1
Monday, October 8, 1:00 - 2:30 pm, American Ballroom - North
Ill and idle: Exploring the nexus between functional disengagement and mental illness in adolescents and young adults
Chair: Srividya Iyer, McGill University
Speakers: Sloan Huckabee, Colm Healy, Joanna Henderson, Srividya Iyer
Though the vulnerabilities and disadvantages of youths not in employment, education or training (NEET) are widely acknowledged, little mental health research has focused on the conditions that precede youths disengaging from school or work; how and to what extent such disengagement intersects with mental illness; and how early functional disengagement impacts overall outcomes. This symposium addresses these knowledge gaps. Sloan describes the post-secondary outcomes of young adults with emotional and behavioral disorders. Using data from an American longitudinal epidemiological study, she illustrates the interplay of sociodemography, diagnoses and outcomes in youths who had psychiatric disorders by age 16. Healy presents an Irish community-based investigation of the effects of childhood psychotic experiences on global functioning. Compared to children who reported no psychotic experiences, those who did had poorer functioning that persisted into early adulthood. Notably, their underlying global vulnerability extended beyond diagnosable disorders. Henderson shows that NEET youths presenting at Canadian clinical and non-clinical services were likelier to have concurrent mental health and substance use concerns, legal troubles and crime/violence problems; be in unstable housing situations; and need welfare aid. Iyer paints a picture of NEET youths at a Canadian early psychosis program having longer prodromes characterised by unrelenting illness and plummeting premorbid adjustment. This, along with longer durations of untreated psychosis, suggests that NEET youths follow a distinct trajectory of clinical and functional decline. Finally, Cannon (discussant) will situate these findings within what is currently known about youth mental illness and functioning, and highlight their services, research and policy implications.
Talk 1 Young adult outcomes for youth with emotional and behavioral disorders with impairment by the age of 16 years
Sloan Huckabee1, William E Copeland2, Maryann Davis3; 1Transitions to Adulthood Research Center, University of Massachusetts Medical School, 2Psychiatry and Behavioral Sciences, Duke University Medical Center, 3Department of Psychiatry, University of Massachusetts Medical School
The poor post-secondary outcomes reported for students with emotional and behavioral disorders (EBDs) have included high rates of school dropout and low rates of participation in post-secondary education and post-school employment. While some studies have used longitudinal datasets to examine this group’s outcomes in youth, several questions remain. To address these, we analyzed a subset of data (collected at the 26-year mark) from the Great Smoky Mountains Study of Youth (GSMS). GSMS is an ongoing longitudinal epidemiological study of the development, need for, and use of mental health services in children in North Carolina. We calculated the sociodemographic characteristics of youths without psychiatric disorders who had emotional disturbances, behavioral disturbances, or both emotional and behavioral disturbances. We also examined the young adult outcomes of individuals identified with psychiatric disorders by age 16. The subgroup identified as having EBDs by age 16 (27.5% of GSMS participants) was broken down by type of disorder. In line with previous studies, more males than females had EBDs by 16. Low socioeconomic status, having a step parent, coming from a single-parent family and spending time in foster care were significantly related to EBD occurrence, with the latter two being particularly strong influences. There were statistically significant differences between youths with and without EBDs by age 16 in high school completion rates, working less than part-time hours, not contributing to rent and being poor at age 26. We also noted sociodemographic and outcome differences based on disorder types. These observations and their implications will be discussed.
Talk 2 Childhood psychotic experiences are associated with persistently poorer global functioning throughout adolescence and into early adulthood
Colm Healy1, Donal Campbell1, Mary Clarke1, Ian Kelleher1, Mary Cannon1; 1Department of Psychiatry, Royal College of Surgeons in Ireland, Dublin
Psychotic experiences (PEs) are commonly reported in childhood and have been associated with mental disorder and poorer global functioning. While it is understood that individuals who report PE in childhood appear susceptible to future mental disorder, little is known about the effects of childhood PEs on future functioning. We investigated the effects of childhood PEs on global functioning from childhood into early adulthood. 52 participants from a community sample completed all three waves of the ‘Adolescent Brain Development’ study (T1x̄Age:11.69, T2x̄Age:15.80 T3x̄Age:18.80). At each phases, participants completed a clinical interview assessing PEs, mental disorder and global function. Fixed-effects repeated measures models, adjusting for mental disorder and gender were used to investigate differences in current (C-GAF) and most sever past (MSP-GAF) global functioning between those with and without childhood PEs. The analyses revealed that those with history of PEs had significantly poorer C-GAF scores (p<.001) and MSP-GAF scores (p<.001) than controls. Simple-effects analysis indicated that poorer functioning was evident during childhood (C-GAF: p=.002; and MSP-GAF: p<.001), adolescence (C-GAF: p<.001; and MSP-GAF: p=.011) and early adulthood (C-GAF: p=.002; and MSP-GAF: p=.095). There was no significant effect of time or interaction. The results demonstrate that children who report PEs have persistently poorer functioning and this is evident up to at-least early adulthood. The long-term association between childhood PEs and global functioning highlights the underlying global ‘vulnerability’ in children reporting PEs which extends beyond diagnosable mental disorder. Children who report PEs should be monitored closely throughout adolescence and young adulthood.
Talk 3 Disengagement from employment, education and training in a multi-sectoral sample of service-seeking Canadian youth: Mental health and substance use profiles
Joanna Henderson1,2, Lisa D. Hawke1,2, Gloria Chaim1,2; 1Centre for Addiction and Mental Health, 2University of Toronto, Department of Psychiatry
Background. Youth who are not engaged in employment, education or training (NEET) are vulnerable to a diversity of health, economic and psychosocial challenges. While the NEET metric is widely used internationally, there is a lack of research describing Canadian NEET youth. Objective. This study explored the characteristics of NEET youth in a cross-sectoral sample of service-seeking youth in Canada, across clinical and non-clinical service sectors. Aspects examined included the proportion of NEET youth, their mental health and addictions concerns, gender differences, and other factors distinguishing them from their non-NEET peers. Method. A total of 2,576 youth were assessed using the GAIN-Short Screener and a sociodemographic information form. Results. Among youth seeking services across a diversity of sectors, 26.8% were NEET. NEET youth demonstrated a greater risk of unstable housing situations, more legal system involvement, and more reliance on government financial assistance. They were also more likely to endorse crime/violence problems, substance use problems, and concurrent mental health and substance use concerns than their non-NEET counterparts. Gender-based differences were also observed. Discussion. Since many youth presenting for services across both clinical and non-clinical sectors are NEET, youth-serving agencies within and outside of the mental health and addictions sectors should be prepared to offer a wide range of services to address their diverse needs. Further research should examine interventions and integrated models of care to address the youth’s mental health and addictions needs, their lack of engagement in employment, education and training, and their other diverse areas of need.
Talk 4 A NEET distinction: Youths not in employment, education or training follow different pathways to illness and care in psychosis
Srividya Iyer1,2,3, Sally Mustafa3, Jai Shah1,2,3, Ridha Joober1,2,3, Martin Lepage1,3, Ashok Malla1,2,3; 1Department of Psychiatry, McGill University, 2ACCESS Open Minds/Esprits ouverts, Douglas Mental Health University Institute, 3Prevention and Early Intervention Program for Psychosis (PEPP-Montreal)
Among youths presenting at specialised early intervention (SEI) services for psychosis, those Not in Employment, Education or Training (NEET) may have experienced longer periods of functional decline and mental health problems. They may also have difficulties accessing SEIs due to disadvantages associated with being NEET. These issues have not been investigated in first-episode psychosis. Our aims were therefore to document the prevalence of NEET status in a first-episode psychosis sample, and to investigate baseline differences between NEET and non-NEET groups in terms of demographics, symptomatology, pre-psychosis illness course and treatment delays. Data for 416 youths entering a catchment-based Canadian SEI service were analysed. NEET and non-NEET groups were compared on demographics (e.g. gender); symptomatology (e.g., negative symptoms); pre-psychosis course (i.e., premorbid adjustment, prodrome); and duration of untreated psychosis (DUP). NEET individuals (39% of sample) were likelier to be male, have schizophrenia-spectrum psychosis and have higher negative symptom scores than non-NEET individuals. They had longer prodromes and were likelier to remain ill after the first psychiatric change, until the onset of psychosis. Although both groups had similar premorbid adjustment earlier, the NEET group’s adjustment dropped in late adolescence. NEET youths had longer DUPs despite making more help-seeking attempts. In conclusion, NEET status was thrice as prevalent in our sample as in the Canadian populace. The NEET group followed a distinct trajectory of persistent symptoms and functional decline towards an eventual intersection of psychosis and NEET status. The systemic delays that NEET youths encounter indicate a need for better-targeted early identification efforts
Question and Answer Period
Discussant: Mary Cannon, Department of Psychiatry, Royal College of Surgeons in Ireland
Symposium Session 2
Monday, October 8, 1:00 - 2:30 pm, American Ballroom - Center
Discovering New Brain Circuits in Early Psychosis
Chair: Alan Breier, Department of Psychiatry, Indiana University School of Medicine, Indiana Psychotic Disorders Program, Prevention and Recovery Center for Early Psychosis
Speakers: Anil Malohtra, Dost Ongur, Tom Hummer, René Kahn
Disruptions in brain circuits is a primary process that appears to underlie the pathophysiology of psychotic disorders. Recent developments in connectome imaging provide powerful tools to interrogate the functional and structural integrity of circuits that exist both within and between brain networks. New information from connectome imaging has promise for elucidating new circuits, treatment approaches and genetic risk for early psychosis. This symposium will focus on new functional and structural brain circuit findings in early psychosis. Anil Malhotra will present resting state (rsfMRI) and structural data from two cohorts of first episode schizophrenia patients participating in double blind clinical trials involving the second generation antipsychotics (SGAs) aripiprazole and risperidone to identify neuroimaging predictors of treatment response. Dost Unger will focus on rsfMRI data and compare within and between network connectivity in early stage bipolar and schizophrenia. Tom Hummer will distinguish brain circuit characteristics of functional connectivity within and between distinct brain networks in patients with early-phase psychosis. Rene Kahn will examine genetic predisposition by assessing connectome organization in children at familial high risk for bipolar and schizophrenia. Together, these presentations will further illuminate the altered brain organization responsible for early psychosis.
Talk 1 Detection and Replication of Neuroimaging Biomarkers of Treatment Response in First Episode Schizophrenia
Anil Malohtra1, Philipp Homan1, Deepak Sarpal2, Miklos Argyelan1, Lauren Hanna1, Jaun Gallego3, Philip Szeszko4, Todd Lencz1, Delbert Robinson1; 1Zucker School of Medicine at Hofstra/Northwell, 2University of Pittsburgh, 3Weill Cornell Medical College, 4Icahn School of Medicine
The first episode of psychosis may be the most critical period in the life of an individual with schizophrenia, and remains the most opportune time for the study of key mechanisms that influence treatment response and outcome. We have assessed two cohorts of first episode schizophrenia patients participating in double blind clinical trials involving the second generation antipsychotics (SGAs) aripiprazole and risperidone to identify neuroimaging predictors of treatment response. For our analyses, we utilized 1) seed-based rs-fMRI analysis to examine the relationship between pretreatment functional connectivity and response to SGA treatment and 2) hierarchical linear modeling (HLM) to model individual symptom trajectories and tested for a relationship between parahippocampal thickness and treatment response. In our first analysis, a striatal connectivity index was established as a predictor of SGA treatment response in first episode patients (n=41) and replicated in a second sample (n=40). The HLM work yielded a model in which parahippocampal thickness successfully predicted response to SGA treatment in first episode patients (n=37) as well as in an independent replication data set of first episode patients treated with risperidone (n=33). As both resting state MRI measures and measures of cortical thickness significantly predicted antipsychotic drug response in discovery data sets, as well as in two independent replication cohorts, these data suggest that identification of biomarkers of antipsychotic drug response is feasible in first episode patient populations. Next steps will include combining modalities to more robustly predict response to help develop more effective intervention strategies for first episode psychosis.
Talk 2 Resting State Functional MRI Studies of Early Psychosis
Dost Ongur1; 1McLean Hospital, Harvard Medical School
Brain connectivity abnormalities have been reported in individuals with psychotic disorders both in first episode and chronic illness. But it is not clear how these abnormalities emerge and progress and how they relate to symptom formation. To address these questions, our group has been collecting resting state functional MRI (rsfMRI) data on a 3 Tesla Siemens Trio scanner from patients with first episode psychosis at McLean Hospital’s early psychosis clinic McLean OnTrack as well as from matched healthy comparison subjects. Participants are men and women between the ages of 18 and 30. We recruit patients with bipolar disorder with psychosis, schizoaffective disorder, and schizophrenia and assess them clinically and with cognitive testing at each visit. Most patients in our studies are receiving antipsychotic medications. All are scanned at baseline and at 1 and 2 years follow up. To date, we have scanned over 50 patients at baseline as well as over 30 healthy controls. 30 patients have returned for 1 year and 15 for 2 year scans. Initial analyses indicate that first episode patients show the same reduction of connectivity in the frontoparietal control network we previously reported in chronic psychosis (Baker et al JAMA Psychiatry 2014). The pattern is similar in individuals with schizophrenia and bipolar disorder. We observe a significant correlation between mania severity and reduced connectivity within the ventral attention network. In ongoing analyses, we are conducting sliding window analyses and single-subject based cortical parcellation.
Talk 3 Abnormal Functional Network Connectivity in Early Phase Psychosis
Tom Hummer1,2, Matthew Yung1,2, Joaquin Goni3, Michael Francis1,2, Susan Conroy1,2, Nikki Mehdiyoun1,2, Alan Breier1,2; 1Department of Psychiatry, Indiana University School of Medicine, 2Indiana University Psychotic Disorders Program, 3Purdue University
Characterizing dysconnectivity in psychosis patients can be advanced by understanding the interactions of functional networks. This investigation aims to distinguish network characteristics of functional connectivity in patients with early-phase psychosis (EPP) both within and between distinct brain networks. EPP subjects (n=56, within four years of treatment initiation) and matched controls (n=32) underwent resting-state fMRI. Time-series data underwent advanced processing and scrubbing methods to minimize noise. For each subject, gray matter was segmented into 278 regions, and organized into nine distinct a priori networks: visual, somatomotor, dorsal attention, ventral attention, limbic, frontoparietal, default mode, subcortical, and cerebellum networks. Network connectivity properties were defined by the mean and variance of correlations of all regions within the same network (e.g. visual-visual) and between distinct networks (e.g. visual-limbic). Connectome measures, including global efficiency and within-module z-scores, were also calculated. Global efficiency was higher in the control group, reflecting consistently stronger connectivity. The control group had higher connectivity between limbic and default mode networks and multiple other networks, but no within-network connectivity differences were found. The variance of between-network connections was generally higher in patients, particularly for connections with ventral attention network regions. In addition, patients with longer illness duration had greater variability in their network connectivity patterns. Thus, lower functional connectivity in EPP, relative to controls, was largely present between distinct networks, suggesting poor inter-network communication. Higher variance of between-network connectivity in patients suggests disorganized communication patterns that align inconsistently with typical functional networks, disruptions that may increase as the disorder progresses.
Talk 4 The Connectome in Young Offspring of Patients with Schizophrenia and Bipolar Disorder
René Kahn1,2, Guusje Collin1, Lianne Scholtens1, Manon Hillegers1,3, Martijn van den Heuvel1; 1UMC Utrecht, 2Icahn School of Medicine, 3Erasmus MC
Background: Emerging evidence suggests disruptions in the wiring organization of the brain’s network in schizophrenia and bipolar disorder. As the importance of genetic predisposition has been firmly established in these illnesses, children (offspring) of patients constitute an at-risk population. This study examines connectome organization in children at familial high risk for psychosis. Methods: Diffusion-weighted MRI scans were collected from 127 non-psychotic offspring, aged 8 to 18 years (13.5 years on average), of a parent diagnosed with schizophrenia (SZ-offspring; N = 28) or bipolar disorder (BD-offspring; N = 60), and community controls (N = 39). Resting-state fMRI scans were available for 82 subjects. Anatomical and functional brain networks were reconstructed and examined using graph theoretical analysis. Results: SZ-offspring were found to show connectivity deficits of the brain’s central rich club system relative to both controls and BD-offspring. The disruption in anatomical rich club connectivity in SZ-offspring was associated with increased modularity of the functional connectome. In addition, increased coupling between structural and functional connectivity (SC-FC coupling) of long-distance connections was observed in both SZ- and BD-offspring. Conclusions: This study shows lower levels of anatomical rich club connectivity in non-psychotic young offspring of schizophrenia patients. This finding suggests that the brain’s anatomical rich club system is affected in at-risk youths, reflecting a connectome signature of familial risk for psychotic illness. Moreover, finding no rich club deficits in offspring of bipolar disorder patients suggest a differential effect of genetic predisposition for schizophrenia versus bipolar disorder on the developmental formation of the connectome
Question and Answer Period
Discussant: Martha Shenton, Departments of Psychiatry and Radiology, Brigham & Women's Hospital, Harvard Medical School
Symposium Session 3
Monday, October 8, 1:00 - 2:30 pm, American Ballroom - South
Challenges and Opportunities in Quality of Care in Early Psychosis: Improving Outcomes at the System Level and Patient Level
Chair: Aristotle Voineskos, Centre for Addiction and Mental Health, University of Toronto
Speakers: Michael Birnbaum, Nicole Kozloff, George Foussias, Philip Tibbo
Research evidence continues to point to the need for accessible, comprehensive care for young people with psychotic disorders in order to improve their long-term trajectories. In this 90-minute symposium, we review challenges and opportunities to improve quality at various points along pathways to care for youth with psychosis. Michael Birnbaum will present on the role of the internet and social media in early identification, outreach, and engagement of youth and families in psychosis treatment. Nicole Kozloff will present on the care youth with psychosis receive following a first presentation to the emergency department, exploring factors associated with access to timely follow-up. George Foussias will present on implementation and outcomes of standardized, measurement-based care protocols in a large early psychosis intervention program, including a qualitative exploration of youth and family experiences of this style of care. Phil Tibbo will present on the development of order sets for treating early phase psychosis at the national level and their implementation. Each presenter will allow a few minutes for audience questions. Finally, John Kane, an expert in researching and implementing comprehensive care for first episode psychosis, will facilitate a group discussion on how the presentations can guide patient-, program- and system-level improvements to increase the reach and effectiveness of early psychosis intervention.
Talk 1 Factors Influencing the Duration of Untreated Psychosis: Patient and Family Perspectives
Michael Birnbaum1,2,3, Asra Rizvi1,2,3, Keren Faber1,2,3, Aristotle Voineskos4,5, John Kane1,2,3; 1The Zucker Hillside Hospital, 2The Zucker School of Medicine at Hofstra/Northwell, 3The Feinstein Institute for Medical Research, 4Centre for Addiction and Mental Health, 5University of Toronto
The emphasis on reducing the duration of untreated psychosis has highlighted the complex barriers to expeditiously accessing appropriate services. The internet and social media may prove to be critical resources for expediting help-seeking and facilitating treatment initiation in prospective patients and families with first-episode psychosis. 269 participants between the ages of 15-35 were interviewed with the Pathways to Care for Psychosis Questionnaire designed to retrospectively explore trajectories to care emphasizing online resources used to obtain information about emerging psychiatric symptoms and inform the decision to seek care. Ninety-four percent (n=253) use social media regularly and spend approximately 2 hours online daily. Social media use predates illness onset and continues throughout illness emergence. The Internet was the most used resource for information gathering while symptoms were emerging. A minority (22.9%) shared their concerns over social media. Seventy-nine percent state that they would like to receive mental health help via the internet and social media. Internet based resources are part of daily life for youth with first-episode psychosis. Information gathered online plays a role in help-seeking and may represent a proactive step towards treatment initiation. Online activity continues throughout the duration of untreated psychosis offering the prospect for earlier intervention. Youth with and without mental illness express positive attitudes towards novel internet and social media based outreach and engagement efforts.
Talk 2 Care for Youth with Psychosis following Acute Presentation: A Population-Level Study
Nicole Kozloff1,2, Binu Jacob1,3, Aristotle Voineskos1,2, Paul Kurdyak1,2,3, Nicole Kozloff; 1Centre for Addiction and Mental Health, 2University of Toronto, 3Institute of Clinical and Evaluative Sciences
Given the importance of reducing barriers to treatment for young people with psychosis, we review recent population-level data on access to care and present findings on care received by youth first presenting to acute services for psychotic disorders. We identified youth aged 16-24 across Ontario, Canada with a first emergency department (ED) presentation for psychotic disorder between 2010 and 2013. Following discharge from the ED, we examined psychiatrist visits, mental health-related primary care visits, ED revisits, and psychiatric admissions over 1 year. We modelled time to outpatient psychiatry visit using Kaplan-Meier curves and predictors of care within 30 days and 1 year using Cox proportional hazard regression. 2875 youth had a first presentation to the ED over the study period and 812 (28.2%) were discharged to the community. Among discharges, 325 (40.0%) received no outpatient mental healthcare within 30 days; factors associated with psychiatric aftercare included neighbourhood income (highest vs. lowest income, HR = 1.48, 95% CI 1.05-2.09), rural residence (HR = 0.46, 95% CI 0.31-0.70), and recent mental healthcare (outpatient psychiatrist visit: HR = 1.89, 95% CI 1.50-2.37; psychiatric admission: HR = 0.71, 95% CI 0.52-0.98). One year following first ED visit for psychosis, 105 (12.9%) youth still had not received any outpatient mental healthcare, 416 (51.2%) had returned to the ED and 334 (41.1%) had a psychiatric admission. Many youth first presenting with psychotic disorders to acute services do not receive timely mental health follow-up. These findings may guide improvements in pathways to care for youth with psychosis.
Talk 3 Standardized Measurement Based Care in Early Psychosis: Effects on Care in Hospital, Service Utilization, and Engagement
George Foussias1,2, Juveria Zaheer1,2, Janaki Joshi1, Steve Hawley1, Rebecca Metcalfe1, Dielle Miranda1, Crystal Baluyut1,2, Saima Aiwan1, Aristotle Voineskos1,2; 1Centre for Addiction and Mental Health, 2University of Toronto
Consistent delivery of comprehensive early psychosis intervention (EPI) in real-world clinical services remains a challenge despite established EPI practice standards. Across other areas of medicine, integrated care pathways (ICPs) that provide a multidisciplinary outline of coordinated measurement-based care have been associated with better patient outcomes. ICPs, however, are rarely employed in mental health services. To address this, our team developed an ICP for early psychosis that was implemented in a real-world first episode psychosis outpatient clinic (FEPC) in an academic tertiary care mental health centre. This study evaluated the implementation and effectiveness of this early psychosis ICP, as well as the experience of patients and their families of such an ICP. Of 74 patients admitted to the FEPC over a 13-month period, 55 patients (74%) received at least one ICP assessment. Significantly fewer patients dropped out of care after enrollment in the ICP compared to those patients that did not (15% versus 37%, chi2 = 4.34, p = .037). Patients enrolled in the ICP also exhibited lower emergency department presentations (9% vs 18%) and rehospitalizations (5% vs 18%) although these differences were non-significant. A qualitative exploration of patient (n=15) and family (n=8) experiences of this ICP identified a highly integrated service as a key component in engagement and recovery, and revealed positive attitudes toward scales and measures, with formalized assessment tools enabling the tracking of treatment progress. These findings suggest that such ICPs for early psychosis care are implementable and acceptable in real-world settings, and may improve EPI outcomes.
Talk 4 Adoption and Utilization of Order Sets for Early Psychosis: A National Experiment in Standardization
Philip Tibbo1, Thomas Hastings2, Andrea Bardell3, Nicola Banks4, Howard Margolese5; 1Dalhousie University, 2McMaster University, 3University of British Columbia, 4Canadian Consortium for Early Intervention in Psychosis, 5McGill University
Successful treatment of early phase psychosis (EPP) requires an organized, recovery oriented mental health system with clear standards, policies and coordinated services. The Canadian Consortium for Early Intervention in Psychosis (CCEIP), a national organization of clinicians and researchers dedicated to improving quality of care in EPP, have developed two clinician order sets based on international, national and provincial standards, guidelines and quality based procedures, to be used in outpatient or inpatient settings. Order sets are evidence-based checklists which translate the latest medical information into a structured and actionable document that clinicians can put into practice at the point of care. Using a cloud-based platform, CCEIP developed and tested order sets for: 1) Initiation of Treatment for and 2) Optimization of Treatment for Early Phase Psychotic Disorders. These order sets are aimed to improve adherence to best practice, treatment outcomes, quality of care through data tracking and feedback, consistency and efficiency of care, in addition to reducing cost of care and medical errors. A discussion around the use of order sets, presentation of the 2 developed order sets and their referenced tools, and data from a national accredited performance assessment program on use of these orders sets will be presented. This data will include dashboard results of widespread usage, quantifiable insights into EPP health care practice including real-time use data on ordering (care) trends as well as implications/assumptions.
Question and Answer Period
Discussant: John Kane, The Zucker Hillside Hospital, The Zucker School of Medicine at Hofstra/Northwell, The Feinstein Institute for Medical Research
Symposium Session 4
Monday, October 8, 1:00 - 2:30 pm, Staffordshire
Identifying patient sub-groups with specific needs within early intervention programs: developing personalized intervention on the basis of data stemming from clinical programs around the world.
Chair: Philippe Conus, Deprtment of Psychiatry, CHUV, Lausanne University, Switzerland
Co-Chair: Amal Abdel Baki, CHU Montreal, Canada
Speakers: Clairélaine Ouellet-Plamondon, Amal Abdel-Baki, Philippe Golay, Philippe Conus
There are many early intervention programs around the world and most of them aim at providing specific care for the early phase of psychotic disorders. While this is a valid focus, early psychosis samples are composed of a wide variety of patient profiles and subgroups of patients may have distinct needs. Although generic elements of early intervention programs may fit most of the patients, clinicians should adapt treatment to these specific needs and develop personalized intervention. Data stemming from clinical naturalistic prospective follow-up often provide very detailed information on which it is possible to base the identification of such cinical sub-groups of patients. In this symposium we will present the results of clinical researched based on the prospective follow up of various early intervention programs in Canada, Switzerland and Australia. These data allow the identification of subgroups of patients defined on the basis of premorbid or clinical characteristic and who have specific needs in terms of clinical intervention.
Talk 1 Interventions for comorbid addiction disorders within early psychosis program: using results from a prospective longitudinal study to improve services for specific needs
Clairélaine Ouellet-Plamondon1, Amal Abdel-Baki1; 1CHU Montreal, Canada
Background: Co-occurring substance use disorders (SUD) are very common (about 60%) in first episode psychosis and associated with poor symptomatic and functional outcomes. After 2 years of follow up in early intervention service (EIS), about a third of FEP patients have persistent SUD despite motivational and harm reduction philosophies. Homelessness history, borderline personality and the severity of SUD at baseline have been associated with persistent misuse at 2-year follow up. Methods: Based on SUD trajectories and factors associated with SUD persistence in FEP, we developed and integrated FEP-SUD program within our EIS including evidence-based interventions targeting SUD and its associated factors. Results: We will describe the different components of this ‘à la carte’ program tailored to offer interventions corresponding to each patient characteristics and needs at different time points in their trajectory. Preliminary results and pilot data of different interventions of this program (including pharmacological strategies as well as psychosocial treatments) will be presented. Outreach case management interventions, injectable antipsychotic medication, peer support, supervised housing as well as “housing first” program, manualised individual intervention (including motivational and CBT strategies) as well as group and family systemic psychotherapy and, for the more severe cases, treatment orders for mandatory inpatient therapy for SUD will be described. Conclusions: Treating comorbid SUD with FEP is challenging. However different strategies must be offered early in the course of illness to help modify their trajectory. Although it is an heterogeneous group, personalized addiction treatment plans can be built to improve FEP outcome.
Talk 2 Homeless first episode psychosis youth may benefit from a specialised assertive community intervention team
Amal Abdel-Baki1, Virginie Doré-Gauthier1, Isabelle-Sarah Lévesque1; 1CHU Montreal, Canada
Background: Psychosis is associated with homelessness and conversely homelessness increases psychosis risk, the young being at higher risk. In Montreal inner city early intervention service (EIS), 29% of the first episode psychosis (FEP) cohort experienced homelessness. Non-affective psychosis, male gender, lower education, drug abuse and cluster B personality disorder were associated with homelessness. Homeless participants had worse symptomatic and functional outcomes, longer hospitalisations and were more likely to use emergency services despite regular EIS services. The Centre Hospitalier de l’Université de Montréal created in 2012, an intensive assertive community intervention team (AICIT) offering specialized care for homeless FEP (HFEP), aiming to offer to this clientele, individualized treatment integrating specialized and intensive care for early psychosis, housing support as well as substance use disorder (SUD) and outreach interventions. Objectives: Explore the impact of the addition of an IACIT to an EIS. Methods: 2 years-longitudinal study comparing the outcome of HFEP followed by both the EIS and IACIT since 2012 to a historical cohort of HFEP followed only by the EIS between 2005 and 2011. Results: HFEP followed by the EIS+IACIT attained housing stability more quickly and spent less time hospitalised than HFEP followed only by the EIS (RR 2.38, p=0.017). HFEP with cocaine misuse were less likely to attain housing stability (RR 0.25, p=0.04). Symptomatic, functional and SUD outcomes between the two groups were similar. Conclusion: HFEP outcome may be improved by the addition of IACIT to EIS as they have special expertise in quitting homelessness in collaboration with community organisations.
Talk 3 Migration in patients with early psychosis is a two-sided coin: findings from a three year prospective study
Philippe Golay1, Philipp Baumann1, Laure Jaton1, Romeo Restellini1, Nadir Mebdouhi1, Philippe Conus1; 1TIPP program, Département de Psychiatrie CHUV, Lausanne University, Switzerland
Aim: Most early psychosis programs treat high ratios of migrants, given they display higher rates of psychosis than the indigenous population. There are however limited studies on this topic in early psychosis programs (EP) and less is known about outcomes. The aim of this study was to compare the premorbid, baseline and outcome profile of patients according to migration (M) and migration in psychosocial adversity (MIA) in order to explore if there were differences suggesting particular needs in terms of treatment in these patients group. Methods: 257 early psychosis patients aged 18-35 years old were followed-up prospectively over 36 months. MIA (29.6%) and M (17.9%) were compared to patients who were born in Switzerland (NM). Results: The profile of MIA was characterized by lower socio-economical level for equal level of education, higher unemployment and forensic history rates, high prevalence of trauma and worse functioning at baseline. MIA patients also had lower global functioning during the follow-up. M patients had a better premorbid adjustment and experienced similar outcomes as the NM group. Conclusions: Results are compatible with the hypothesis that migration in adversity is a potential determinant of functional impairment in early psychosis. The fact that patients who migrated in other contexts have a better outcome is consistent with evidence showing that some migrants are more resilient. Patients who experienced migration in adversity may have specific needs in terms of intervention considering they are more vulnerable, less integrated and have a higher likelihood to have been exposed to trauma.
Talk 4 Personality disorder among youth with first episode psychotic mania: An important target for specific treatment?
Philippe Conus1,2, Melissa Hasty2, Craig Macneil2, Sue M Cotton2, Michael Berk3, Linda Kader2, Aswin Ratheesh2, Andrew Chanen2,4; 1Treatment and Early Intervention in Psychosis Program (TIPP), Service of General Psychiatry, Department of Psychiatry CHUV, Lausanne University, Switzerland, 2Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, Australia, 3Deakin University, IMPACT Strategic Research Centre, School of Medicine, Barwon Health, Geelong, 4Centre for Youth Mental Health, The University of Melbourne, Parkville, Victoria, Australia
Objectives: Personality disorder (PD) comorbidity is common among patients with bipolar disorder and has been shown to negatively impact on outcome. However, little is known about this comorbidity in the early phases of BD. We aimed to examine the prevalence and impact of PD comorbidity on outcome in a cohort of youth with first episode mania (FEM) with psychotic features. Methods: Seventy-one patients with FEM aged 15 to 29 and treated at the Early Psychosis Prevention and Intervention Centre (EPPIC) in Melbourne, Australia, were assessed at baseline, 6, 12, and 18 months as part of a randomized controlled trial of olanzapine and chlorpromazine as add-on to lithium in FEM with psychotic features. This study involved secondary analysis of trial data. Results: A comorbid clinical PD diagnosis was made in 16.9% of patients, antisocial and narcissistic PD being the most common sub-types. Patients with PD comorbidity had higher rates of readmission to hospital, lower rates of symptomatic recovery and poorer functional levels at 6 months, but these differences were not maintained after 12 and 18 months. Conclusions: In the early phase of bipolar disorders, patients with PD comorbidity display a delay in reaching symptomatic and functional recovery and are more likely to need hospital readmissions. These observations suggest specific intervention might be needed in order to improve short-term treatment efficacy in this subgroup.
Symposium Session 5
Monday, October 8, 2:45 - 4:15 pm, American Ballroom - North
Treatment for Youth at Clinical High Risk for Psychosis: What next?
Chair: Jean Addington, University of Calgary
Co-Chair: Matcheri Keshevan, Harvard University
Speakers: Jean Addington, Kristin Cadenhead, Michelle Friedman-Yakoobian, Scott Woods
The main focus of treatment for youth at clinical high risk (CHR) of psychosis has been to prevent transition to full-blown psychosis. However, there are other targets that have been considered less often such as attenuated psychotic symptoms, negative symptoms, social functioning, and cognition. Although the literature is promising there are many areas that are not impacted by current treatments in particular social functioning which is of concern since many of these young people continue to have poorer social functioning even when they do not make the transition to psychosis and attenuated psychotic symptoms have remitted. The first presentation (Addington) will present a critical overview of some of the promising areas of psychosocial treatment (such as cognitive behavior therapy, social skills training, cognitive remediation, and family focused therapy) and pharmacotherapy. The other three presentations will review the most recent research, highlight the features of the interventions and describe future goals for making the intervention more effective. The second presentation (Cadenhead) will focus on group-based CBT and social skills training to address social functioning. The use of cognitive remediation will be addressed in the third presentation (Friedman-Yakoobian). The fourth presentation will offer a critical examination of the current use of antidepressants in the CHR population (Woods). Finally, the discussant (Keshavan) will summarize the extant findings and propose a potential treatment algorithm for CHR.
Talk 1 Meta-analytic Review of Treatment Options for CHR youth
Jean Addington1, Daniel Devoe1; 1University of Calgary
The main focus of psychological treatment for youth at clinical high risk (CHR) of psychosis has been to prevent transition to full-blown psychosis and less often attenuated psychotic symptoms. However, in addition to the attenuated psychotic symptoms, these young people often present with negative symptoms, as well as other comorbid disorders. They typically have cognitive difficulties that are intermediate to healthy controls and individuals with full-blown psychosis. Many have poor social and role functioning. Through a series of network and pairwise meta-analyses this presentation reviews all treatment studies to date including cognitive behavior therapy (CBT), family intervention, cognitive remediation, integrated psychological treatment and a range of pharmacotherapies and includes outcomes such as transition, attenuated psychotic symptoms, negative symptoms, cognition and social and role functioning. There are some positive results in support of CBT in preventing transition to psychosis and reducing attenuated psychotic symptoms. None of the treatments reviewed appear to have an impact on negative symptoms or social functioning, which is of concern since many of these young people continue to have poorer social functioning even when they do not make the transition to psychosis and attenuated psychotic symptoms have remitted
Talk 2 Cognitive Behavioral Social Skills Training for Youth at Clinical High Risk for Psychosis: Recovery Through Group (ReGroup)
Kristin Cadenhead1, Jean Addington2, Barbara Cornblatt3; 1University of California at San Diego, 2University of Calgary, 3Zucker Hillside Hospital, New York
The majority of youth at clinical high-risk (CHR) for psychosis do not develop a psychotic syndrome but rather continue to have fluctuating subthreshold symptoms, poor social and role functioning. There are no specific treatments for these functional difficulties. However, Cognitive Behavioral and Social Skills Training (CBSST) significantly increases the frequency of social functioning activities compared to treatment as usual or supportive therapy in chronic schizophrenia. The ReGroup study is a three-site, longitudinal study aimed at testing the effectiveness and feasibility as well as mediators and mechanisms of action of a manualized CBSST intervention targeting functional difficulties associated with CHR for psychosis. The goals of the study are 1) to examine whether CBSST compared to a psychoeducation improves functioning and 2) to determine whether reduction in defeatist beliefs and improvement in social competence mediate change in psychosocial functioning. Participants are randomized to: CBSST, an 18-week group comprised of three modules; 1) Cognitive Skills; 2) Social Skills; 3) Problem Solving, or a psychoeducation group. We have demonstrated the feasibility of CBSST treatment in CHR youth and determined that it is easy to train therapists and assure reliability of the intervention through weekly supervision. Participants enjoy the intervention and are less likely to drop out of the study after starting group. CBSST can be readily disseminated to clinical community practice with proper training and supervision. This study will provide insights into approaches to halt or mitigate the pathological process and advance our understanding of risk prediction
Talk 3 Cognitive Remediation for Youth at Clinical High Risk for Psychosis
Michelle Friedman-Yakoobian1; 1Harvard University
Cognitive difficulties, including deficits in psychomotor speed, memory, attention, reasoning, and social cognition are key rate-limiting factors to functional recovery from psychotic disorders. These deficits appear to be present, in milder form, in children and adolescents who later go on to develop schizophrenia, as well as in individuals who are identified as being at clinical high risk (CHR) for psychosis. Compelling evidence for effectiveness of psychosocial approaches to cognitive remediation in schizophrenia gives rise to the question of whether these approaches could be useful in ameliorating and/or preventing cognitive deficits in youth at CHR for psychosis. To date, a handful of studies using various cognitive remediation approaches in individuals at CHR have begun. This talk will provide an overview of extant literature in this area and will discuss current and future directions for the role of cognitive remediation in treatment for youth at CHR.
Talk 4 Antidepressant Medication Use in Attenuated Psychosis Syndrome: Community Selection and Outcome
Scott Woods1, Jean Addington2, Carrie Bearden3, Kristin Cadenhead4, Tyrone Cannon1, Barbara Cornblatt5, Daniel Mathalon6, Diana Perkins7, Larry Seidman8, Ming Tsuang4, Elaine Walker9, McGlashan Thomas1; 1Yale University, 2University of Calgary, 3UCLA, 4UCSD, 5Zucker Hillside Hospital, 6UCSF, 7UNC, 8Harvard University, 9Emory University
Antidepressants (ADs) are commonly used in DSM-5 Attenuated Psychosis Syndrome (APS) and other clinical high-risk syndrome (CHR) patients (Woods et al Schizophr Res 2013), but there is a dearth of efficacy data. The observational NAPLS-2 study offered an opportunity to investigate outcomes of community practice in this population. NAPLS-2 CHR patients were evaluated at baseline and six-monthly intervals with the Scale Of Psychosis-risk Symptoms (SOPS), SCID, the Calgary Depression Scale for Schizophrenia (CDSS), and the Global Assessment of Functioning (GAF). Six-month outcomes were described according to a “course specifier” classification (Woods et al Schizophr Res 2014). 360 CHR patients enrolled in the first half of NAPLS-2; 106 met APS criteria, were AD-naive at baseline, and completed 6-month assessment. 27 of these began AD during the first six months; average AD duration was 3.1±2.5 months. AD starters had higher baseline scores on CDSS (p<0.001) and were somewhat more likely to have comorbid current major depression (p=0.105). Six-month outcomes for AD starters vs nonstarters were: psychosis 4 vs 10%, progression 52 vs 53%, persistence 30 vs 19%, and remission 15 vs 18% (gamma=0.134, p=0.466). CDSS change did not differ between groups (F=0.1, p=0.806), nor did SOPS or GAF scores. Available data from the full NAPLS-2 and partial NAPLS-3 samples will be presented. Community selection of APS patients to begin AD medication appeared driven by depression severity and diagnosis, but AD starts seemed to confer little benefit. Randomized studies are needed.
Question and Answer Period
Discussant: Matcheri Keshevan, Harvard University
Symposium Session 6
Monday, October 8, 2:45 - 4:15 pm, American Ballroom - Center
From Static to Dynamic Models of the Onset of Mental Disorder
Chair: Barnaby Nelson, Orygen, The National Centre of Excellence in Youth Mental Health
Co-Chair: Jessica Hartmann, Orygen, The National Centre of Excellence in Youth Mental Health
Speakers: Hok Pan Yuen, Marieke Wichers, Jessica Hartmann, Johanna Wigman
Prediction studies in early psychosis and related research has generally relied on one-off sampling of cross-sectional data (i.e., a "snapshot" of clinical state and other risk markers at study entry). A new approach is emerging based on the view that psychopathology is an evolving, dynamic picture, particularly in the early stages of disorder, and that predictive modelling may therefore be maximised by taking these temporal changes into account. This approach to prediction research in psychopathology draws on cross-disciplinary models of complex systems and advances in statistical modelling. This symposium consists of presentations illustrating this emerging paradigm in prediction research, consistent with the “broadening the scope” theme of the conference. Hok Pan Yuen will present joint modeling analysis of longitudinal clinical variables in an ultra high risk for psychosis cohort. Dr Wichers will present novel empirical support for the presence of early warning signals in anticipation of critical transitions in depressive symptomatology. Dr Hartmann will present data relating to early warning signals (psychopathology and circadian activity) from a cohort study of young people at risk of a range of mental disorders. Dr Wigman will present findings from a new diary study (daily recordings of psychopathology) mapping individual symptom networks and the predictive value of these for course/outcome. This next generation of prediction studies may more accurately identify people at highest risk of disorder progression or relapse, which clearly has important treatment implications, such as stratifying patients to particular treatments and introducing methods for identifying early warning signs of mental state deterioration.
Talk 1 A Novel Approach to Developing A Prediction Model of Transition to Psychosis: Dynamic Prediction Using Joint Modelling
Hok Pan Yuen1, Andrew Mackinnon2, Patrick McGorry1, G. Paul Amminger1, Jessica Hartmann1, Miriam Schäfer 1, Connie Markulev1, Suzie Lavoie1, Barnaby Nelson1; 1Orygen, The National Centre of Excellence in Youth Mental Health, University of Melbourne, 2Centre for Mental Health, Melbourne School of Population and Global Health, University of Melbourne
Introduction Joint modelling (JM) is a promising new statistical methodology which can use data from both study entry and subsequent follow-up assessments to develop prediction models of psychosis onset in ultra-high risk (UHR) individuals. The practical implication is that the prediction provided by these models could be updated as new information about patients’ clinical state is obtained and appropriate treatment could be implemented accordingly. This study aimed to test the potential benefits of joint modelling to dynamically predict the onset of psychosis in UHR individuals. Method Data from the NEURAPRO intervention study was used. This study was a multi-centre placebo-controlled randomized trial of the effect of omega-3 polyunsaturated fatty acids on risk of transition to psychotic disorder in UHR individuals. The sample size was 304. Study assessments were conducted monthly during the first 6 months and then at months 9 and 12. There were in total 40 known cases of transition to psychosis. Candidate predictor variables consisted of demographic characteristics assessed at intake as well as repeated measurements of clinical variables. Results Compared with the conventional approach of using only baseline data for prediction of psychosis, JM prediction showed significantly better sensitivity, specificity and likelihood ratios. The JM approach yielded sensitivity of 82.8%/specificity 72.4%, whereas the baseline-data only model yielded sensitivity of 69.0%/specificity 73.8%. Conclusions Incorporating time-dependent variables into predictive models has the potential to improve the prediction of onset of psychosis and hence to help in providing timely and personalized treatment to patients.
Talk 2 Can we obtain personalized early warnings for symptom transitions? Novel empirical support for a complex system approach in psychopathology.
Marieke Wichers1, Marieke Schreuder1, Arnout Smit1, Evelien Snippe1; 1Interdisciplinary Center Psychopathology and Emotion regulation (ICPE), Department of Psychiatry, University Medical Centre Groningen (UMCG), Groningen, The Netherlands
Introduction: Clinically, it is highly relevant to be able to foresee sudden rises in psychopathology. However, person-specific symptom transitions are extremely difficult to predict. Complex system theory offers a novel possibility to estimate the likelihood of such transitions and expects the presence of rising early warning signals (EWS) in anticipation of sudden symptom transitions. We aimed to replicate the first study1 that revealed empirical support for this and, second, to further translate this idea to personalized models. Methods: Adolescent participants were recruited via the East Flanders Twin register. This novel sample consisted of 239 participants with SCL-90 baseline and follow-up measures. At baseline they underwent experience sampling (ESM). Second, a set of ESM case-studies were conducted in patients tapering their antidepressant medication. These were followed for > 4 months with >5 measurements per day to capture possible sudden transitions in symptoms and the precise period before those transitions. Results: We replicated the results of the first group-level study1. The level of EWS in ESM items on depressed mood states was associated with follow-up increases in symptom severity (down: β=0.10, SEβ=0.03, p<0.001; listless: β=0.09, SEβ=0.04, p<0.001). Furthermore, in the individual time-series cases, rising EWS were observed in anticipation of sudden transitions. Conclusions: The current group-level and individual-level studies supported the hypothesis that critical transitions in psychopathology can be foreseen by observing changes in EWS, also in individual time-series of data. This has major relevance for applications in clinical practice. 1 Leemput, Wichers et al. Proc Natl Acad Sci USA 111(1):87–92.
Talk 3 Tipping points – predicting transitions to mental illness and remission in at-risk young people
Jessica Hartmann1, Marieke Wichers2, Patrick McGorry1, Barnaby Nelson1; 1Orygen, the National Centre of Excellence in Youth Mental Health, University of Melbourne, 2Interdisciplinary Center Psychopathology and Emotion regulation (ICPE), Department of Psychiatry, University Medical Centre Groningen (UMCG), Groningen, The Netherlands
With more than half of mental disorders emerging by the age of 24, it is of utmost importance to be able to predict which help-seeking young people are at greatest risk of mental health deterioration. Mental health has increasingly been conceptualised as a complex system characterised by phase transitions, preceded by early warning signals. The aim of the current study is to predict ‘tipping points’ in mental health in at-risk young people by means of an early warning signal called ‘critical slowing down’. Using ecological momentary assessment in combination with actigraphy, N=10 help-seeking young people aged 12-24 are followed for four months to capture transitions to full-threshold disorder in real-time. The young people, part of a larger cohort study, are at pluripotential risk for developing full-threshold disorder (depression, psychosis, mania and borderline personality disorder) within a short (12-month) time frame. We present on this ongoing pilot study investigating critical slowing down in psychopathology (mood states and attenuated psychotic symptoms) and actigraphy preceding transitions from at-risk state (stage 1b) to full-threshold state (stage 2) or to remission (State 0). We expect to find an increase in temporal autocorrelation at-lag-1, variance and skewness in mood states and circadian activity prior to a transition. Data collection is expected to be completed by time of presentation. This new framework may represent a paradigm shift from static prediction approaches to dynamic, individualised models of psychosis prediction and may inform the development of new clinical identification tools and early and individualised interventions to prevent such transitions.
Talk 4 Mirorr Mirorr on the wall, who’s the most ‘at risk’ of all?
Johanna Wigman1, Sanne Booij1; 1Interdisciplinary Center Psychopathology and Emotion regulation (ICPE), Department of Psychiatry, University Medical Centre Groningen (UMCG), Groningen, The Netherlands
Background: Course and outcome of early psychotic symptoms are difficult to predict, hampering timely intervention. Research relies heavily on diagnostic categories, group-level comparisons and assessment of static symptom levels. However, symptoms may wax, wane, change individually or cross diagnostic borders. Adding a more personalized as well as a more transdiagnostic dimension to the model may provide a valuable step forwards. Methods: The new Mirorr study investigates this. Mirorr follows N=100 individuals (age 18-35), divided over four subgroups with increasing psychopathological severity (i.e. subsequent clinical stages). Mirorr is a diary study, assessing a broad range of transdiagnostic symptoms for 90 consecutive days that are then mapped into individual networks of interacting symptoms. Comparison of these networks across different stages as well as within-person comparison of symptom networks over time are investigated. Network characteristics will be used to predict clinical and functional outcome after one, two and three years. Mirorr is currently running and results of the study so far will be presented. Results: Preliminary results indicate differences in symptom networks between subgroups. Characteristics of these symptom networks of individuals in different clinical stages will be presented, and associations with psychopathology and functioning. Of particular interest are structure (e.g. density) of the symptom networks, differences therein and the specific role of psychotic experiences. Discussion: Research and clinical practice may benefit from a more personalized, dynamic, transdiagnostic perspective. Mirorr exemplifies how this may help to capture the complex nature of psychopathology and its development.
Question and Answer Period
Discussant: Barnaby Nelson, Orygen, The National Centre of Excellence in Youth Mental Health
Symposium Session 7
Monday, October 8, 2:45 - 4:15 pm, American Ballroom - South
Findings on Strategies for Reducing the Duration of Untreated Psychosis in the United States
Chair: Susan T. Azrin, National Institute of Mental Health, Bethesda, MD, USA
Speakers: Steven R. Lopez, Vinod H. Srihari, Cameron S. Carter, Leslie Marino
The World Health Organization recommends that treatment for psychosis begin within 3 months of symptom onset. However, dozens of studies worldwide have observed an average delay of 2 years between appearance of psychotic symptoms and treatment initiation. Two meta-analyses and the U.S. Recovery After an Initial Schizophrenia Episode-Early Treatment Program have established that duration of untreated psychosis (DUP)—the time from psychosis onset to treatment initiation—is correlated with poor clinical and functional outcomes. Early psychosis treatment programs are increasingly available in the U.S., but many in need are missing this critical opportunity. Accordingly, the National Institute of Mental Health (NIMH) launched a research program to identify sources of early psychosis treatment delay and test practical and innovative strategies for reducing DUP in the U.S. This symposium features findings from a selection of these studies. Steven Lopez will report on the impact of a community-based, multi-level, bilingual psychosis communication campaign for U.S. Latinos on help seeking, DUP and treatment continuation. Vinod Srihari will report findings from the trial of Mindmap—a population-based, multi-element, early psychosis detection campaign—on help seeking and DUP. Cameron Carter will present results from his trial assessing whether adding a novel, technology-enhanced early psychosis screening tool to standard provider education for early psychosis increases early psychosis identification and reduces DUP. Leslie Marino will present findings on a comprehensive set of DUP predictors for nearly 800 individuals enrolled in early psychosis treatment programs. Susan Azrin will discuss these findings and implications for developing practical DUP reduction strategies.
Talk 1 Towards Decreasing the Duration of Untreated Psychosis in a Minority Community: The Case of US Latinos
Steven R. Lopez1, Alex Kopelowicz2, Jodie Ullman3, Maria Santos1, Maya Kratzer1; 1University of Southern California, 2University of California Los Angeles, 3California State University San Bernardino
We conducted a 2-year, multifaceted bilingual communication campaign for US Latinos regarding psychosis. We assessed whether the duration of untreated psychosis (DUP) decreased during the campaign more than during the 15-month historical control condition preceding the campaign. Patients with first episode psychosis were recruited from a public outpatient and inpatient mental health unit in the Los Angeles area. Inclusion criteria were: ages 16-65, having a psychotic disorder not due to a medical condition or substance use, and self-identifying as Latino. Exclusion criteria were: having taken antipsychotic medication for more than a year or not understanding the informed consent procedures. Three DUPs were measured: onset to first seeking any services for the disorder (DUP1), first prescription for antipsychotic medication (DUP2), and taking medication for at least 3 months (DUP3). The DUPs were highly skewed; therefore, analyses were conducted on transformed measures. We found no significant mean differences between the campaign condition (n=57) and the control condition (n=46) for the DUP measures. Significant differences in the variance of DUP1, but not for DUP2/DUP3, were found. There was a significantly smaller variance for the campaign than for the control. The variance of DUP1 was also smaller for those residing within the targeted community than in surrounding communities, and for those born in the US versus Latin America. That the variance differed for DUP1 but not DUP2/DUP3 suggests that the campaign influenced families’ contribution to DUP but not professional networks. Recommendations to increase the impact of DUP reduction campaigns for minority communities are discussed.
Talk 2 Mindmap – A Quasi-Experimental Test of Early Detection of Psychosis in the U.S.
Vinod H. Srihari1,2, Maria Ferrara1,2, Fangyong Li3, Shadie Burke1,2, Emily Kline4,5, Jessica M. Pollard1,2, John D. Cahill1,2, Sinan Guloksuz6, Glen McDermott7, Scott W. Woods1, Larry Seidman4,5, Matcheri Keshavan4,5; 1Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA, 2Program for Specialized Treatment Early in Psychosis (STEP), New Haven, CT, USA, 3Yale Center for Analytical Sciences, Yale School of Public Health, 4Harvard Medical School, 5Program for Prevention and Recovery in Early Psychosis (PREP), Boston, MA, USA, 6Department of Psychiatry and Psychology, Maastricht University Medical Centre, Maastricht, the Netherlands, 7Red Rock Branding, New Haven, CT, USA
BACKGROUND: The Specialized Treatment Early in Psychosis (STEP) program has delivered coordinated team-based first-episode services (FES) since 2006 in New Haven. In 2015, STEP launched a 4-year early detection (ED) campaign (Mindmap), adapted from the Scandinavian TIPS approach, to shorten Duration of Untreated Psychosis (DUP) in a 10-town catchment (population 400,000). METHODS: Mindmap’s social-ecological model targets demand (delays in identifying illness and help-seeking) and supply (delays in referring to and providing FES) side constituents of DUP. Mindmap uses mass and social media messaging, professional detailing, and rapid triage of referrals. DUP is classified as the time between the onset of psychosis and initiation of antipsychotic treatment (DUP1) and FES care (DUP2). A control FES (PREP, Boston) supports the quasi-experimental design. The campaign was launched in 2015, after a one-year baseline. A selective interim analysis follows. RESULTS: The number of help-seeking attempts (HSAs) varied between 1-24, without a statistically significant reduction at STEP: median (Quartile 1- Quartile 3): 2 (1-3) at baseline vs. 1 (1-2) at 32mos (p=0.19). DUP1 trended downward at STEP: median (Q1-Q3): 153 (17 – 339) days at baseline to 40 (15-141) days at 32mos (p=0.06). No significant reduction in DUP2 at STEP is yet evident: median (Q1-Q3): 332 (52 – 521) days at baseline to 184 (62-470) days at 32mos (p=0.70). At PREP both DUP1 & DUP2 remain unchanged and comparable to baseline levels at STEP. CONCLUSION: Mindmap has shown promise in reducing delays to care. Additional measures of impact with comparisons across sites will be presented.
Talk 3 A Technology-enhanced Intervention to Reduce the Duration of Untreated Psychosis through Rapid Identification & Engagement
Cameron S. Carter1, Tara A. Niendam1, Rachel Loewy2, Mark Savill2, Monet Meyer1, Adi Rosenthal1, Kevin Delucchi2, Tyler A. Lesh1, Haley Skymba1, Daniel Ragland1, Howard H. Goldman3, Richard L. Kravitz4; 1Department of Psychiatry, University of California, Davis School of Medicine, Sacramento, CA, USA, 2Department of Psychiatry, Weill Institute for Neurosciences, University of California San Francisco, CA, USA, 3Department of Psychiatry, University of Maryland School of Medicine, USA, 4Department of Internal Medicine, University of California, Davis School of Medicine, Sacramento, CA, USA
The present cluster-randomized controlled trial assesses whether adding a novel technology-enhanced screening using the Prodromal Questionnaire-Brief version (PQ-B) to standard provider education identifies more individuals with first episode psychosis (FEP), earlier in their illness. Twenty-two sites were randomized within 3 strata [community mental health, CMH (N=10), middle/high schools, SCH (N=8), primary care, PC (N=4)] to an Education alone (TAU) vs Education + Electronic Screening (Active)]. Active sites screened individuals ages 12-30 referred those who passed a liberal PQ-B cut off score for phone evaluation. TAU sites referred individuals for phone evaluation based on clinician judgment. Phone evaluations assessed eligibility for FEP services and duration of untreated psychosis (DUP). Active sites effectively implemented electronic screening. Of the 822 individuals screened at Active sites between June 2015 and July 2017, 43.2% scored above the cutoff (mean ±SD PQ-B score=21.25±20.75). One in 8 individuals who completed the tablet were identified with threshold psychosis. Across Active and TAU sites, 511 individuals were identified, 422 agreed to be referred, and 319 completed a phone interview: 33.23% reported attenuated and 36.68% fully psychotic symptoms. Active sites identified significantly more individuals with threshold psychosis (p<.001) than TAU. DUP was relatively short in both groups (186 days in Active and 195 days in TAU). No difference in days of DUP was observed across arms. Preliminary results show the feasibility of electronic screening across various community settings and a 3.5 times higher identification rate for electronic screening of self-reported psychosis spectrum symptoms than clinician-based identification alone.
Talk 4 Pathways to Care for Young Adults with First Episode Psychosis in a Coordinated Specialty Care Program
Leslie Marino1,2, Melanie Wall1,2, Jennifer Scodes1,2, Hong Ngo1,2, Ilana Nossel1,2, Iruma Bello1,2, Thomas Smith1,2, Lisa Dixon1,2; 1Columbia University Medical Center, 2New York State Psychiatric Institute
PURPOSE: Substantial research has demonstrated that a longer duration of untreated psychosis (DUP) is associated with poorer outcomes among young adults with early non-affective psychosis. As federal funding has expanded access to evidence-based coordinated specialty care (CSC) in the US, little is known about factors influencing the pathway to care and DUP in non-research treatment settings. This study explores the pathway to care and predictors of time to OnTrackNY, New York state’s CSC program. METHODS: The sample includes 779 individuals ages 16-30 within two years of onset of non-affective psychosis enrolled in OnTrackNY at 19 sites as of September 2017. Multivariate analyses tested the association between the primary outcome of time from onset of psychosis to intervention (OnTrackNY) and a comprehensive list of predictors within the admission assessment domains of demographic and clinical characteristics; social and occupational functioning; suicidality/violence/legal problems; service utilization; family characteristics; and prior mental health contacts. RESULTS: The mean time to treatment was 231.18 days (SD=187.66) with a median of 169 days (5.63 months). In multivariate analyses, current school participation (p=.005) and at least one psychiatric hospitalization (p<.001) were associated with shorter time to intervention, whereas when first service contact is hospitalization (p=.006) or an outpatient visit (p<.001), compared to ER visit, time to intervention is longer. CONCLUSIONS: Engagement in school and the early mental health service contacts can predict the pathway to care and time to early intervention services in a cohort of young adults with early psychosis. This has implications for efforts to reduce DUP.
Question and Answer Period
Discussant: Susan T. Azrin, National Institute of Mental Health, Bethesda, MD, USA
Symposium Session 8
Monday, October 8, 2:45 - 4:15 pm, American Ballroom - North
Early Intervention in Bipolar Disorder
Chair: Craig A Macneil, EPPIC, Orygen Youth Health, Melbourne, Australia
Speakers: Aswin Ratheesh, Philippe Conus, Craig Macneil, Sue Cotton
Bipolar Disorder can be a serious, ongoing and recurrent mental health difficulty that can impact considerably on individuals, families and society. This symposium will focus on some of the challenges presented while working with individuals that have this diagnosis, while focussing also on the significant potential opportunities of early intervention with this population. Specific challenges to early intervention work in bipolar disorder include; lack of guidelines for early intervention, difficulties in the development of engagement and insight, and limitations to the evidence base for psychosocial therapies for this population. However, the symposium will also discuss the development of guidelines for early intervention in bipolar disorder, techniques to improve insight and engagement, and the development of RECOVER, a randomised controlled trial of a specialised psychological intervention for bipolar disorder.
Talk 1 Does guideline concordant care improve the outcomes for youth with early stage bipolar disorders?
Aswin Ratheesh1,2, Ming Fang, Christopher Davey, Michael Berk3, Patrick McGorry, Sue Cotton2; 1Orygen Youth Health, 2Orygen, the National Centre of Excellence in Youth Mental Health, 3Deakin University
Background: Youth with early stage Bipolar Disorders (BD) typically receive care in generic mental health services or youth early psychosis services. The lack of specific guidelines for their care could lead to heterogeneous and non-standardised care. We aimed to examine whether concordance with available guidelines was associated with better outcomes over 10-24 months of prospective follow-up. Methods: We conducted a file-audit study of all participants aged 15-25 years with BD I or II referred to a tertiary youth mental health service in Melbourne, Australia between 01/01/2014 and 30/06/2015. Concordance with three guidelines were established using a checklist developed for this purpose. All items relating to youth, early stage BD and care within an early intervention service were selected. A guideline concordance score was developed for each file. The primary outcome selected was the Global Assessment of Functioning scale score at the point of discharge (10-24 months from initial referral). We propose to examine the relationship between the discharge GAF scores and guideline concordance scores using linear regressions, controlling for a) age, b) gender, c) baseline illness severity, d) baseline GAF score and e) type of BD diagnosis. Results: Of the 90 participants selected, half had a BD I diagnosis and were treated in the early psychosis clinic, while the remaining had a BD II diagnosis and received care from the mood disorders clinic. Results from the regression analyses will be presented. The results could have implications for the development of a specific guideline for youth with early stage BD.
Talk 2 The Challenges of Engagement and Insight in Bipolar Disorder: Data and Recommendations
Philippe Conus1; 1Centre Hospitalier Universitaire Vaudois, Switzerland
Over the last 20 years, numerous programs for early intervention in psychosis have developed. Although their structure may differ according to the context in which they are implanted, mental health professionals working in these setting are usually faced with very similar challenges. There are globally 2 main issues to be resolved. The first one is to engage young patients, including those with a diagnosis of bipolar disorder, who are often reluctant to receive treatment. We suggest that this this can be assisted though organizational strategies, specific engagement techniques, and by providing interventions that target factors known to be linked with increased risk of disengagement. The second is to promote the development of insight, which is not only an aim but also a subtle therapeutic process. In this talk we will describe these various strategies through the example of TIPP, an early intervention program implanted in Lausanne, Switzerland in 2004. TIPP has treated more than 600 patients, over a three-year treatment period, many of whom have experienced mania, having achieved a disengagement rate of less than 5%.
Talk 3 Early Intervention for Bipolar Disorder: The Role of Psychological Interventions
Craig Macneil1, Melissa Hasty1, Kate Filia2, Aswin Ratheesh1, Philippe Conus3, Michael Berk4, Sue Cotton2,5; 1Early Psychosis Prevention & Intervention Centre, Orygen Youth Health, 35 Poplar Road, Parkville, VIC 3052, Melbourne, Australia, 2Orygen, The National Centre of Excellence in Youth Mental Health, Parkville, Victoria, Australia, 3Treatment & Early Intervention in Psychosis Program (TIPP), Département de Psychiatrie CHUV, Université de Lausanne, Clinique de Cery, 1008 Prilly, Switzerland, 4IMPACT Strategic Research Centre, School of Medicine, Deakin University, 1 Gheringhap Street, Geelong, Victoria, 3220, Australia, 5Centre for Youth Mental Health, The University of Melbourne, Victoria, Australia, 3052
Bipolar disorder generally has its onset when an individual is in their late teens, a critical developmental phase. While the research evidence often suggests that outcomes can be poor in bipolar disorder, some emerging evidence indicates that psychological interventions may be at their most effective early in the course of the disorder. This paper will report on the limited evidence base for early intervention in bipolar disorder, and describe the development of a specialised psychosocial intervention designed for young people following a first manic episode. This intervention is currently being tested in a National Health & Medical Research Council-funded, randomised controlled trail (RECOVER). Specifically, RECOVER aims to examine the efficacy of a six month, manualised psychological intervention on symptomatic and functional outcomes of young people immediately following a first manic episode. It focusses on engagement, shared formulation, balancing sleep and activity, engaging families, and supporting functioning, while also attending specifically to unhelpful schema that may maintain bipolar symptoms. Challenges in working with this population, and developmental modifications that may be required will be discussed, while acknowledging the strengths and opportunities presented when working with young people early in the course of bipolar disorder.
Talk 4 RECOVER: a randomised controlled trial of a tailored psychological intervention for first episode bipolar disorder
Sue Cotton1,2, Craig Macneil1,2,3, Henry Jackson4, Greg Murray5, Aswin Ratheesh1,2,3, Michael Berk1,2,6,7,8, Andrew Chanen1,2,3, Kate Filia1,2, Melissa Hasty1,2,3, Christopher Davey1,2,3, Barnaby Nelson1,2,3; 1Centre for Youth Mental Health, The University of Melbourne, 2Orygen, The National Centre of Excellence in Youth Mental Health, Parkville, Australia, 3Orygen Youth Health, Parkville, Australia, 4Melbourne School of Psychological Sciences, The University of Melbourne, Parkville, Australia, 5Department of Psychological Sciences, Swinburne University of Technology, Hawthorn, Australia, 6School of Medicine, Deakin University and Barwon Health, Geelong, Australia, 7The Florey Institute of Neuroscience and Mental Health, Parkville Australia, 8Department of Psychiatry, The University of Melbourne, Parkville Australia
Background: People with bipolar disorder too commonly experience deficits in functional recovery, despite symptomatic recovery and exemplary school performance. The outcome of this is poor long-term functional outcomes. Applying psychological therapies alongside pharmacology may be useful in improving functional outcomes. Our group has led growing international interest in a staged approach to understanding illness trajectories of bipolar disorder with different psychological and pharmacological therapies required for the different stages of illness. Intervention in the early stages may potentially reduce the burden and risk associated with the disorder, and mitigate its impact on normal developmental trajectories. To date, however, there is a limited evidence base psychological therapies available to young people with early BD. Methods: RECOVER is an RCT of a refined existing psychological intervention, to be delivered in addition to treatment as usual at two specialist early intervention services in Melbourne. 122 young people in the early stages of BD-I will be recruited. The RECOVER intervention will be delivered over a 6 month period. Assessments will be conducted at baseline, 3, 6, 9, 12, 15, and 18 months. Results: The trial design will be discussed in depth. Conclusion: To date, there is a limited evidence base for psychological therapies available to young people with early BD. Therefore, the findings of this project will provide definitive evidence that early psychological intervention in the course of BD can reduce the symptomatic, vocational, relationship and psychological impact that is seen in entrenched disorder.
Symposium Session 9
Monday, October 8, 4:30 - 6:00 pm, American Ballroom - Center
Youth at Risk for Serious Mental illness: The Canadian Psychiatric Risk and Outcome Study (PROCAN)
Chair: Olga Santesteban-Echarri, University of Calgary, Calgary, Alberta, Canada
Co-Chair: Paul Metzak, University of Calgary, Calgary, Alberta, Canada
Speakers: Kali Brummitt, Jean Addington, Olga Santesteban-Echarri, Paul Metzak
In the early psychosis field there has been a major focus on those at clinical high risk for psychosis. Despite the fact that the majority of mental illnesses arise in youth, and early treatment of mental health issues is vital to reducing poor outcomes, less attention has been paid to understanding the risk for serious mental illness (SMI), which includes psychotic disorders, bipolar disorder and recurrent major depression. The Canadian Psychiatric Risk and Outcome Study (PROCAN) is a longitudinal study investigating the clinical, social, and neurobiological factors that may lead to SMI in youth, with the aim of developing an algorithm that can predict which youth will move from undifferentiated symptoms to a diagnosable mental illness. PROCAN is currently following 243 young people (aged 12-25) who may be at risk for the later development of SMI. This symposium will present various aspects of PROCAN. The first talk presents the staging model developed by McGorry and Hickie, used in PROCAN and the recruitment and retention strategies to identify these young at-risk individuals. The second talk presents the baseline differences in clinical symptomatology, neurocognition and social and role functioning between youth in the different stages and how they compare to healthy controls. The third talk discusses the impact of familial relationship styles on mental health and examines the stage-related differences in family functioning and communication. The fourth talk outlines the functional brain imaging measures that have been used in PROCAN and presents data outlining differences in brain activity at baseline.
Talk 1 Overview of and Referral Pathways to the Canadian Psychiatric Risk and Outcome Study (PROCAN)
Kali Brummitt1, Jean Addington1; 1University of Calgary, Calgary, Alberta, Canada
This presentation will first present the clinical staging model used in PROCAN. Secondly, an overview of the study which includes demographics of the sample and measures used will be given. Since the project is focused on adolescents and young adults who may be presenting with mixed symptom patterns or brief or undifferentiated symptoms several months or even years before the development of a diagnosable mental illness, it is important to find ways to identify these young people early so that we can learn more about the factors that may predict later mental illness and offer early intervention. Studies in the clinical high risk for psychosis population have identified strategies on recruitment, but there is little to help with a more general at-risk population. Thus, thirdly, we will present tracking data of the referral sources of all PROCAN participants and compare them by age and by the clinical stage. Referrals were evenly split by gender and age. Most referrals, however, were in stage 1b, individuals who met criteria for an attenuated syndrome, the majority of which were referred by community mental health services. In contrast stage 1a participants with distress, mild anxiety and depression were more often self- or family referred. Implications of referral pathways for identifying youth at risk will be discussed.
Talk 2 Clinical Symptoms and Functioning of Youth at Risk for Serious Mental Illness
Jean Addington1; 1University of Calgary, Calgary, Alberta, Canada
In the Canadian Psychiatric Risk and Outcome Study (PROCAN), using McGorry and Hickie’s clinical staging model, our sample included 42 healthy controls (HCs), 41 youth with a family risk of mental illness (stage 0), 52 distressed youth with mild depression and anxiety and 108 with attenuated psychiatric syndromes, the majority of whom met criteria for being at clinical high risk for psychosis. In order to determine if the criteria for these different stages were useful and made sense, the groups were first compared on a range of clinical measures and secondly on social, and neurocognitive functioning. Stage 0 participants did not differ from healthy controls on any clinical measure. Stage 1a differed from HCs and Stage 0 in anxiety, depression, rumination, anhedonia, negative symptoms and negative beliefs about the self. Stage 1b participants presented with significantly more severe symptoms than all other groups in anxiety, depression, anhedonia, attenuated psychotic symptoms, negative symptoms and negative beliefs about the self and from HCS and stage 0 in anhedonia and rumination. These results suggest that the clinical staging of our sample was a good fit. In terms of social functioning, Stage 1a and 1b participants both differed from the HCs and stage 0 participants. Interestingly, in examining neurocognition, only the stage 1b group differed significantly from the HCs and stage 0 participants in IQ and in the speed of processing, attention, working memory domains from the MATRICS. Thus, the staging model is further supported with neurocognitive and social functioning performance.
Talk 3 Family Communication and Family Functioning in Youth at Risk for Serious Mental Illness
Olga Santesteban-Echarri1; 1University of Calgary, Calgary, Alberta, Canada
Family flexibility and cohesion are at times impaired in families of first-episode psychosis patients compared to healthy controls (HCs). Furthermore, family functioning may be important even before the onset of illness. A positive family environment may be related to a decrease in symptoms and improved functioning in youth at clinical high-risk for psychosis. However, little is known about earlier stages of risk and the importance of the family environment for youth at-risk for serious mental illness (SMI).In the PROCAN study, we examined family functioning from the Circumplex Model of Family Systems in a large sample of youth at-risk for SMI. Family functioning was evaluated with the Family Adaptability and Cohesion Evaluation Scales-IV (FACES-IV) for 41 youth with a family history of SMI (Stage 0), 52 distressed youth with early mood and anxiety symptoms (Stage 1a), 105 youth with subthreshold psychotic symptoms (Stage 1b), and 42 HCs. Results from multivariate linear regression analyses showed that participants in Stage 1a and Stage 1b significantly differ from HCs in all the family functioning scales. Furthermore, participants in Stage 0 differed from participants in Stage 1b; and similarly, participants in Stage 1a differed in all the scales from participants in Stage 0. Therefore, family functioning appears to be impaired in youth at-risk for SMI who present with early signs of mood, anxiety or subthreshold psychotic symptoms.
Talk 4 Overview of the Functional Neuroimaging Measures in the PROCAN Study
Paul Metzak1, Signe Bray1, Glenda MacQueen1; 1University of Calgary, Calgary, Alberta, Canada
Although the onset of serious mental illness (SMI) primarily occurs in youth, there have been few studies examining the neurobiological correlates of SMI prior to a formal diagnosis. In the PROCAN study we have employed McGorry and Hickie’s clinical staging model as the basis for assessing changes in brain activity in youth at risk for SMI. As SMI is a broad category encompassing multiple discrete illnesses, the functional MRI tasks that we have selected activate multiple brain networks that are known to be impacted in psychiatric illness. The three tasks selected were: 1) a monetary incentive delay task, which targets reward networks, 2) an N-back working memory task, which targets cognitive control and dorsal attention networks, and 3) an emotional Go-NoGo task, which targets emotional and inhibitory control networks. Participants also underwent a resting state scan, which enables a task free assessment of multiple brain networks. Each participant performs these tasks upon recruitment, twelve months after recruitment, and upon conversion to a diagnosable SMI. Preliminary results from the Anhedonia task indicate that symptomatic participants display differences in basal ganglia activity relative to healthy volunteers and those at familial high risk.
Symposium Session 10
Monday, October 8, 4:30 - 6:00 pm, American Ballroom - South
Career Development: Key for Recovery in Young People with First Episode Psychosis But Can an Integrated IPS Model of Supported Education and Employment Work?
Chair: Luana R Turner, Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, UCLA, Los Angeles, USA, The UCLA Aftercare Research Program, Los Angeles, USA
Co-Chair: Wenche ten Velden Hegelstad, TIPS Clinical Research in Psychosis, Stavanger University Hospital, Stavanger, Norway
Speakers: Wenche ten Velden Hegelstad, Daniëlle van Duin, Nanna Briem, Eóin Killackey
The exploration of career goals is a natural part of youth development, yet this period is often delayed and even bypassed for many young people who experience psychosis. Further, how can a career come to fruition without the corresponding educational attainment? Thus, focusing on supported education (Sed), as part of career development and recovery is an essential next step in early intervention. The Individual Placement and Support (IPS) Model is the most evidenced-based model of supported employment. Accordingly, testing the integration of Sed within this model has merit. At IEPA 10 in Milan, Italy an international pilot study was formed to assess the feasibility and validity of an integrated fidelity scale for supported employment and education (SEE) using the current IPS fidelity scale. This symposium will, first, report on the preliminary results of this collaboration including the successes and challenges. Second, it will report on potential reasons for poorer outcomes using IPS for Sed, validity issues regarding the adapted integrated scale, and possibilities for improving validity. Third, it will describe the coordination of the international collaboration between Norway, The Netherlands, Australia, Iceland, the U. K., Germany, Chile and the U. S. while navigating different public policy and regulations. Finally, this symposium aims to highlight the importance of collaboration to improve career outcomes and recovery in first episode psychosis. To conclude, there will be a discussant period at the end exploring future directions of Sed and relevant clinical needs to help youth effectively reach their career goals.
Talk 1 School-and JobPrescription: An Approach Integrating IPS for Employment and Education for People with First Episode Psychosis
Wenche ten Velden Hegelstad1, Inge Joa1,2, Lena Heitmann3, Jan Olav Johannessen1,2, Johannes Langeveld1; 1TIPS Clinical Research in Psychosis, Stavanger University Hospital, Stavanger, Norway, 2Network for Medical Sciences, University of Stavanger, Stavanger, Norway, 3School and JobPrescription, Stavanger University Hospital, Stavanger, Norway
Background: Individual Placement and Support (IPS) is an effective intervention for supported employment (SE), however, less so for education (Sed). School and JobPrescription in Norway are part of an international collaborative adapting the original IPS intervention and fidelity scale to include Sed. Method: This study was a quasi-experimental historical matched controls (N=33+33) study with a one–year intervention and two-year follow-up. The IPS-team was trained in educational facilities, curriculums, regulations, and financial resources and was rated on fidelity (April 2016, October 2017). Primary outcomes were hours enrolled in employment or education. Results: Thirty participants completed the intervention. SE scores remained stable (99 and 98 of 125) whilst Sed scores dropped (102 and 99 of 125). Fourteen participants (47%) attained competitive employment >20hrs/week post intervention, compared to 2 in the control group. Fifteen (50%)were in education >20hrs/week compared to 5 (17%) in the control group. However, 1-year post termination differences had waned. The control group had attained the same level of education, however had missed one year. Conclusion: Time-unlimited support was restricted due to funding. This may explain why results waned over time.
Talk 2 Does Cognitive Remediation Enhance the Vocational Recovery of Young People with First Episode Psychosis Using Individual Placement and Support? Results of the CREW Study: A Multisite Randomized Controlled Trial in The Netherlands
Daniëlle van Duin1,2,3, Hans Kroon2,3, Wim Veling4, Jaap van Weeghel1,3; 1Phrenos Center of Expertise, 2Trimbos Institute, 3Tilburg University, 4University of Groningen, University Medical Center Groningen
Background: Young people with psychosis have similar vocational ambitions as their healthy peers. However, psychosis and related problems make their vocational participation lower (Hendriksen et al, 2012). Individual Placement and Support (IPS) can improve vocational functioning in this group. However, 40-50% motivated to participate vocationally cannot succeed when offered IPS. Cognitive impairments may be one obstacle (McGurk et al., 2004). Cognitive remediation (CR) has demonstrated improvement in cognitive functioning for first episode psychosis (FEP). Some studies also indicate the efficacy of CR in daily functioning, provided that CR is combined with psychiatric rehabilitation to boost effects (Wykes et al, 2011; McGurk et al, 2007). The present multisite-study investigated whether CR can enhance the effect of vocational rehabilitation using IPS in competitive employment and mainstream education for FEP. Method: Seventy-three people with FEP either received IPS-enhanced with computerized CR (Circuits), or IPS in combination with an active control intervention (computer games). Follow-up assessments were conducted at 6 and 18 months to see whether patients improved vocationally (hours worked in regular employment or education), in cognitive functioning, symptoms, empowerment and self-stigma. Results: Preliminary results of the study will be presented.
Talk 3 Individual Placement and Support In ICELAND: Collaboration Between Landspitali University Hospital and VIRK Vocational Rehabilitation Fund
Nanna Briem1, Hlynur Jónasson2, Hildur Ævarsdóttir1, Halldora Jonsdottir1; 1Landspitali University Hospital, Reykjavik, Iceland, 2VIRK Vocational Rehabilitation Fund, Reykjavik, Iceland
Background: In 2012 a project began to implement the Individual Placement & Support (IPS) model into vocational rehabilitation for young people with psychosis in Reykjavik. The study was a collaborative project between Laugarasinn; a specialized unit for early intervention in psychosis and VIRK-Vocational Rehabilitation Fund, a private foundation where all the major unions and employers of the Iceland labor market are members. In November 2013 the first client began competitive employment via IPS and the project has gradually developed into one of the most important aspects of the rehabilitation-program for young people with first onset psychosis. In the last year the project has expanded to an inpatient psychosis unit and a dual diagnosis program. Method: Eighty-seven clients have received IPS services with an IPS team of three IPS workers from VIRK and IPS supervisors from three teams at Landspitali University Hospital. Integration of supported education (Sed) services is currently underway using the original IPS fidelity scale adapted for Sed. Results: Fifty-three of 103 clients (50%) are currently receiving IPS services and preliminary results regarding outcomes from the project will be presented.
Talk 4 Solid Foundations for Career: IPS, Education and Youth Mental Health
Eóin Killackey1,2, Kelly Allott1,2, Gina Woodhead4, Judy Ring3; 1Orygen, The National Centre of Excellence in Youth Mental Health, Parkville, Victoria, 2Centre for Youth Mental Health, The University of Melbourne, Parkville, Victoria, 3Travencore School, Department of Education and Training, Parkville, Victoria, 4Orygen Youth Health, Parkville, Victoria
Background: Individual Placement and Support (IPS) is a proven intervention in helping people with psychotic illness return to, or enter into, work. In applying IPS to younger populations with First Episode Psychosis (FEP), education was seen as an equally valid outcome. However, educational outcomes were not significantly better in IPS groups compared to controls. This has been confirmed in meta-analyses of IPS in FEP. Hence, we conducted a pilot study of IPS adapted so as to have only education as a focus (IPSed). Method: 19 young people attending Orygen Youth Health in Melbourne were recruited and given access to IPSed. Results: 18 of the 19 participants had a positive outcome and either completed their course or completed prerequisite units to continue to the next level of their course. Conclusion: IPS has not been superior for education. There are a number of possible reasons for this. Firstly, that IPS was designed as an employment intervention and the IPS Fidelity scale reinforces this. Secondly, IPS workers often come from employment backgrounds and may not have the expertise to address educational goals. Finally, it may be that youth mental health services have historically included education as part of their developmental world-view, and so finding an effect above this is difficult. Results of our pilot study suggest that a singular focus on education may produce excellent outcomes. This result needs to be replicated but also raises questions about IPS for education in populations of young people with mental illness.
Question and Answer Period
Discussant: Jaap van Weeghel, Phrenos Center of Expertise, Tilburg University
Symposium Session 11
Tuesday, October 9, 1:00 - 2:30 pm, American Ballroom - North
How can we prevent psychosis? An examination of primary vs secondary approaches to prevention
Chair: Mary Cannon, Royal College of Surgeons in Ireland, Dublin, Ireland
Co-Chair: Olesya Ajnakina, Institute of Psychiatry, Psychology and Neuroscience, Kings College London
Speakers: Hannah Jongsma, Olesya Ajnakina, Kristine Engemann Jensen, Robin Murray
Mental health has lagged behind physical health in terms of focus on prevention. To date, the emphasis has been on secondary approaches to prevention of psychosis using early detection and early intervention models. But is this really the most effective approach? It may be time to move to a primary or population-based prevention focus. This symposium will present new data relating to both primary (population-based) and secondary (early intervention) approaches to prevention of psychosis. Data will be presented from epidemiological studies of first episode psychosis and large population-based and register-based studies. Hannah Jongsma will present data from the EU-GEI study showing an association between greater owner-occupancy levels and lower incidence of psychosis and increased risk for psychosis among minority groups. Hannah also will show that risk for psychosis incidence extends beyond young adulthood. Olesya Ajnakina will show that “At risk mental state” approach may not be as useful for prevention of psychosis as had been originally hoped. Kristine Engemann Jensen will report that childhood exposure to green space is a novel protective factor for psychosis, showing the importance of the built environment for mental health. Sir Robin Murray argues that we should harness public health and political measures to prevent psychosis. He shows that 24% of psychosis cases could theoretically be prevented by eliminating use of high-potency cannabis use in the population. Professor Andreas Meyer-Lindenberg will draw on these findings, and insights from his own work, in discussing how we can develop a new prevention-focused paradigm of research on psychosis.
Talk 1 Preventing psychosis: what can we learn from a large multicentre European incidence study?
Hannah Jongsma1, Craig Morgan2, Peter Jones1, James Kirkbride3; 1Department of Psychiatry University of Cambridge, 2Society and Mental Health Research Group, Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK, 3PsyLife Group, Division of Psychiatry, University College London
The incidence of psychotic disorders varies across social and environmental gradients at both an individual and a population level. However, the factors underpinning this are unclear. We conducted a population-based study of the incidence of non-organic adult ICD-10 psychotic disorders across the 17 catchment areas in the six countries (England, France, Italy, Netherlands, Spain, Brazil). Crude incidence rates were standardised to the 2011 England and Wales Census population to account for population differences in age, sex and ethnicity. Multilevel Poisson regression was carried out to investigate variance in incidence between catchment areas by latitude, population density, and percentage of unemployment, owner-occupied houses and single-person households. We identified a total of 2,774 cases over 12.94 million person-years at risk, leading to a crude incidence of 21.4 per 100,000 person-years (95%CI=19.4-23.4). By age 35, 68% of male cases had presented to services, compared with 51% of female cases. Poisson regression revealed higher rates of all psychotic disorders in minority groups (IRR=1.6, 95%CI=1.5-1.7), and an association between greater catchment area-level owner-occupancy and lower incidence (IRR for a 10% increase: 0.8, 95%CI=0.7-0.8). A higher population density was associated with an increased incidence of psychosis in England (IRR=1.2, 95%CI=1.1-1.2) and Netherlands (IRR=1.9, 95%CI=1.4-2.6), and was associated with a lower incidence in Italy (IRR=0.7, 95%CI=0.6-0.8). Services focused on early intervention should not have an upper age limit as half of all female (and 32% of male) cases present after age 35; future examinations of variance should be locally informed and take socioenvironmental risk factors into account.
Talk 2 Is the At Risk Mental State approach an effective method of preventing psychosis onset? A retrospective study of a UK mental health programme
Olesya Ajnakina1, Craig Morgan2, Charlotte Gayer-Anderson2, Sherifat Oduola3, François Bourque2, James MacCabe1, Paola Dazzan1, Robin Murray1, Anthony David1; 1Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK, 2Society and Mental Health Research Group, Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK, 3David Goldberg Building, Institute of Psychiatry, Psychology & Neuroscience, Kings College London
Little is known about patients with a first episode of psychosis (FEP) who had first presented to prodromal services with an “at risk mental state” (ARMS) before making the transition to psychosis. We set out to identify the proportion of patients with a FEP who had first presented to the prodromal services in the ARMS state. We further sought to compare FEP patients with and without prior contact with prodromal services. In this study 338 patients aged ≤37 years who presented to mental health services between 2010 and 2012 with a FEP were employed. The data on pathways to care, clinical and socio-demographic characteristics were extracted from the Biomedical Research Council Case Register for South London and Maudsley NHS Trust. Over 2 years, 55 (16.3% of 338) young adults presented with FEP and had been seen previously by the prodromal services. Of these, 14 (4.1% of 338) had met criteria for the ARMS when seen in a prodromal service and 41 (12.1% of 338) were already psychotic. The true ARMS patients were more likely to enter their pathway to care via referral from General Practice, be born in the UK and to have had an insidious mode of illness onset than FEP patients without prior contact with the prodromal services. In the current pathways to care configuration, prodromal services are likely to prevent only a few at-risk individuals from transitioning to psychosis even if effective preventative treatments become available.
Talk 3 Experiencing childhood closer to green space is linked to lower schizophrenia risk
Kristine Engemann Jensen1,2, Carsten Pedersen2,3,4, Constantinos Tsirogiannis5, Preben Bo Mortensen2,3,4, Jens-Christian Svenning1; 1Section for Ecoinformatics & Biodiversity, Department of Bioscience, Aarhus University, Denmark, 2Centre for Integrated Register-based Research, CIRRAU, Aarhus University, Fuglsangs Alle 4, 8210 Aarhus V, Denmark, 3National Centre for Register-based Research, Aarhus BSS, Department of Economics and Business Economics, Aarhus University, Fuglsangs Alle 4, 8210 Aarhus V, Denmark, 4The Lundbeck Foundation Iniative for Integrative Psychiatric Research, iPSYCH, Aarhus University, Fuglsangs Alle 4, 8210 Aarhus V, Denmark, 5Center for Massive Data Algorithmics, MADALGO, Aarhus University, Department of Computer Science, Aarhus University, The IT-park, Åbogade 34, DK-8200 Aarhus N, Denmark
Background Less green space in urbanized areas, where schizophrenia risk is high, could point to green space as an important factor. Green space is hypothesized to positively influence mental health and could mediate schizophrenia risk through noise and particle pollution removal, stress relief or other unknown mechanisms. However, the effect of green space on schizophrenia risk has not been disentangled from that of urbanization and it is unclear if different measures of green space associate differently with risk. Methods We used satellite data from the Landsat program to quantify green space for Denmark in 30×30m resolution for the years 1985-2013. The effect of quantity and heterogeneity of green space and urbanization at place of residence on schizophrenia risk was estimated using cox regression from a longitudinal population-based sample of the Danish population (943027 persons). Schizophrenia risk was controlled for age, sex, parental education, salary, and employment status. Results Living at the lowest amount of green space was associated with a 1.52-fold increased risk of developing schizophrenia compared to persons living at the highest level of green space. The strongest protective association was observed during the earliest childhood years and closest to place of residence. Conclusion Green space decreases schizophrenia risk independent of urbanization - consequently pointing to green space as a new environmental risk factor for schizophrenia. This study supports findings from other studies highlighting the natural environment as an important factor for human health, and points to a new methodological framework that combines epidemiological studies with big data approaches.
Talk 4 It is time to take a Public Health Approach to Prevention of Psychosis
Robin Murray1, Marta Di Forti2, Evangelos Vassos2, Harriet Quicgley1, Antonella Trotta2, Diego Quattrone2, Victoria Rodrigues1, Craig Morgan; 1Institute of Psychiatry, Psychology and Neuroscience, De Crespigny Park, London, 2MRC Social, Genetic & Developmental Psychiatry Centre, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, De Crespigny Park, London, 3Society and Mental Health Research Group, Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
Background The main attempt to prevent the development of psychosis has been through clinics for people at clinical high risk. Such an approach is useful for research but can never reach the majority of individuals who will become psychotic. Biological markers could be used to identify individuals with unusual vulnerabilities e.g. those with copy number variations. However, identifying those with such markers is unlikely to impact on the majority of cases, and as yet no useful interventions are available. How therefore to prevent psychosis? Methods Data will be presented from 3 studies of first onset psychosis which used similar methods of ascertainment and assessment of cases and controls across 16 sites in 5 European countries. Results The polygenic risk score accounted for the greatest variance in caseness; those with scores in the highest quintile were 7 times more likely to be a psychotic case than those in those lowest quintile. Attributable fraction analyses indicated that if no one was exposed to child abuse and use of high potency cannabis, then 16% and 24% respectively of psychosis in South-London could be prevented. There are differences in the incidence of psychosis between Northern and Southern Europe. Conclusions Similarly to preventive approaches for hypertension or obesity where members of the general population are encouraged to take exercise and reduce their calorie intake, attempts should be made to influence society’s patterns of consumption of high-potency cannabis and educate them on impact of childhood abuse in a bid to prevent development of psychosis.
Question and Answer Period
Discussant: Andreas Meyer-Lindenberg, Central Institute for Mental Health, Mannheim, Germany
Symposium Session 12
Tuesday, October 9, 1:00 - 2:30 pm, American Ballroom - Center
Trauma and psychosis: What we know and how to move forward
Chair: David van den Berg, Parnassia Psychiatric Institute, The Hague, The Netherlands
Co-Chair: Amy Hardy, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, U.K.
Speakers: Sandra Bucci, David van den Berg, Mark van der Gaag, Amy Hardy
Childhood adversities are associated with psychosis, and empirical evidence investigating the causal mechanisms underlying this association is accruing (Bentall et al, 2014; Gibson et al, 2016; Hardy, 2017; Varese et al, 2012). People with psychosis are at an increased risk of revictimisation and are more likely to experience a range of post-traumatic stress difficulties, which negatively influences functional and clinical outcomes. In line with these findings, best practice guidelines recommend trauma and PTSD are routinely assessed in psychosis services, including Early Intervention, and that therapy is offered when indicated. Unfortunately, it is rare for trauma and PTSD to be recognised in psychosis services, preventing access to psychological treatments. The challenge is to effectively disseminate trauma-informed practice within frontline EIP services to ensure people’s needs are met. This symposium will reflect on progress and challenges in the area, illustrating our current theoretical understanding, clinical trial evidence, and routine service developments. Sandra Bucci will provide an overview of research highlighting the complex and multiple pathways from trauma to psychosis. David van den Berg will present the long-term results of a randomised controlled trial of trauma-focused treatment (TFT) for PTSD in psychosis. Mark van der Gaag will present on cost-effectiveness of TFT in psychosis. Amy Hardy will describe initiatives aiming to implement and build on these research findings in the early intervention in psychosis services of a National Health Service Trust in inner city London. The discussion will focus on how to move forward into the realm of early intervention and prevention.
Talk 1 Psychological mediators of the association between childhood adversities and psychosis
Sandra Bucci1, Jessica Williams1, Filippo Varese1, Katherine Berry1; 1Division of Psychology and Mental Health, University of Manchester, U.K.
Background: Risk for psychosis has been linked to a range of adverse life experiences and circumstances. Particular interest has been given to the relationship between psychosis and exposure to potentially traumatic life events in childhood to identify the impact of socio-environmental precursors to psychosis. This talk will report on a series of studies our group have conducted exploring psychological mediators of the relationship between childhood adversities and psychosis. Methods: We present findings from a systematic review, which identified 36 papers, comprising 9,057 participants with psychotic disorders and 58,782 non-clinical participants. Results: Despite great variation in the mediators considered and the methodological and analytic quality of the primary studies, our synthesis suggests the relationship between childhood adversity and psychosis is mediated by a several “families” of mediating variables including post-traumatic sequelae (e.g. dissociation, PTSD symptoms), affective dysfunction and dysregulation, and maladaptive cognitive factors (e.g. self-esteem and beliefs and concepts about the self and others; and miscellaneous (neuroticism and mastery; mindfulness; proximal life stressors). We have also conducted a series of studies investigating mechanisms involved in explaining the trauma-psychosis link, including attachment, particularly the role of disorganised attachment, and dissociative processes, and present findings from these studies in this talk. Discussion: The importance of the five different (but not independent or mutually exclusive) families of mediators considered in our work should be examined by future research employing appropriate modelling methods to better disentangle the contribution of these different processes.
Talk 2 Long-term outcomes of long overdue trauma-focused treatment in psychosis
David van den Berg1, Paul de Bont2, Berber van der Vleugel3, Carlijn de Roos4, Ad de Jongh5,6, Agnes van Minnen7,8, Mark van der Gaag1,9; 1Parnassia Psychiatric Institute, The Hague, Netherlands, 2Mental Health Organisation GGZ Oost Brabant, The Netherlands, 3Community Mental Health Service GGZ Noord-Holland Noord, 4Mental Health Organisation Rivierduinen, Leiden, The Netherlands, 5Department of Behavioral Sciences, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and VU University Amsterdam, 6School of Health Sciences, Salford University, Manchester, UK, 7Radboud University Nijmegen, Behavioural Science Institute, NijCare, The Netherlands, 8PSYTREC Psychotrauma Expertise Center, Bilthoven, The Netherlands, 9VU University Amsterdam and EMGO Institute for Health and Care Research, Department of Clinical Psychology,
Background: Both childhood trauma and posttraumatic stress increase the odds of developing psychosis. Trauma focused treatments were found to reduce PTSD at 6-month follow-up in individuals who had, on average, been suffering from psychosis for 17.7 years and from PTSD for 21 years (van den Berg et al, 2015). In this RCT, participants in the control condition received their TFT of choice after the 6-month follow-up assessment. The prolonged exposure (PE) and eye movement desensitization and reprocessing (EMDR) groups were also assessed at 12-month follow-up. Methods: we compared the long-term outcomes for PE and EMDR with the 6-month outcomes to test whether the effects endured on the long term (n=85, = 78.8%). Results: Positive effects of both PE and EMDR on clinician-rated PTSD, self-rated PTSD, depression, paranoid-referential thinking, and remission from schizophrenia were maintained up to 12-month follow-up. Negative posttraumatic cognitions declined further in PE and were stable in EMDR. A significant decline in social functioning was found, whereas reductions in the interference of PTSD symptoms with social functioning were maintained. Discussion: Treating posttraumatic stress symptoms after 21 years is feasible and has long-term neutral to positive side-effects on symptoms of psychosis. Many factors other than PTSD, influence social functioning in this group and 8 sessions of therapy are not enough to enhance social recovery. A next step is to attend to symptoms of posttraumatic stress in young people with emerging symptoms of psychosis. As societies, we should invest more in the primary prevention of childhood trauma.
Talk 3 Cost-effectiveness and cost-utility for treating trauma in psychosis
Mark van der Gaag1,2, Paul de Bont3, Berber van der Vleugel4, Carlijn de Roos5, Ad de Jongh6,7, Agnes van Minnen8,9, David van den Berg2; 1VU University Amsterdam and EMGO Institute for Health and Care Research, Department of Clinical Psychology,, 2Parnassia Psychiatric Institute, Den Haag, The Netherlands, 3Mental Health Organization (MHO) GGZ Oost Brabant, The Netherlands, 4Community Mental Health Service GGZ Noord-Holland Noord, 5MHO Rivierduinen, Leiden, The Netherlands, 6Department of Behavioral Sciences, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and VU University Amsterdam, 7School of Health Sciences, Salford University, Manchester, UK, 8Radboud University Nijmegen, Behavioural Science Institute, NijCare, The Netherlands, 9PSYTREC Psychotrauma Expertise Center, Bilthoven, The Netherlands
Background: The treatment of posttraumatic stress disorder (PTSD) in patients with a psychotic disorder is feasible, effective and safe. But the costs and benefits of trauma-focused treatment (Eye Movement and Desensitization Reprocessing therapy (EMDR) or Prolonged Exposure (PE) therapy) from a health economics and a societal perspective are unknown. Methods: All costs were recorded and both therapy conditions EMDR and PE were compared to the waiting list condition on “losing the classification of PTSD” according to DSM-IV-TR and on “gaining one Quality Adjusted Life Year (QALY)”. Results: Both therapies are cost-saving in losing the diagnosis of PTSD and in gaining one QALY. This is true for the health care costs and for the societal costs. Detailed outcomes will be presented at the conference. Discussion: The treatment of PTSD in people with psychosis has now been recommended in guidelines as being effective and safe. Policymakers, health care providers and insurance companies are encouraged to implement the therapies as they are also cost-saving in most cases, even in the short term of six months.
Talk 4 The ‘Talking Trauma’ project: Implementation of trauma-informed care in Early Intervention in Psychosis services
Amy Hardy1,2, Sarah Swan2, Jonathan Bradley2, Claire Thompson2, Suzanne Jolley1,2; 1Institute of Psychiatry, Psychology & Neuroscience, King's College London, 2South London & Maudsley NHS Foundation Trust
Background: The United Kingdom’s National Institute for Health and Care Excellence guidelines for psychosis and schizophrenia recommend that trauma and PTSD should be routinely assessed in Early Intervention for Psychosis services and, when indicated, therapies for posttraumatic stress disorder and other reactions to trauma provided (NICE, 2014). This is based on research indicating higher rates of trauma and posttraumatic stress reactions in this clinical group compared to the general population, and emerging evidence of the effectiveness of trauma-focused talking treatments (de Bont et al, 2015; van den Berg et al, 2015). However, effective implementation of the guidance is dependent on addressing barriers and opportunities from a range of stakeholder perspectives, multidisciplinary staff training and supervision, and an audit cycle to evaluate trauma-informed practice. Methods: The ‘Talking Trauma’ audit aims to address these needs, using interviews and surveys with service users and staff, together with case note review, and is being conducted across the psychosis services of a National Health Service Trust in inner city London. Results: A summary of the audit findings to date will be provided, followed by plans for further service development. Discussion: Implementation in early intervention in psychosis services is challenging but feasible. Attention needs to be directed towards establishing and maintaining a culture of trauma-informed care, to support effective case management and access to trauma-focused therapy.
Question and Answer Period
Discussant: Lucia Valmaggia, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, U.K.
Symposium Session 13
Tuesday, October 9, 1:00 - 2:30 pm, American Ballroom - South
Specialized early intervention services and duration of untreated psychosis – is there an interaction?
Chair: Nikolai Albert, Mental Health Centre Copenhagen, Copenhagen University
Co-Chair: Merete Nordentoft, Mental Health Centre Copenhagen, Copenhagen University
Speakers: Nikolai Albert, Robert Heinssen, Eric YH Chen, Ashok Malla
The focus of the early intervention services developed across the globe has been to improve the treatment and outcome of patients with a first episode of psychosis. There are ideally two complementary strategies for achieving this, I.e, providing a comprehensive phase specific specialized treatment and actively reducing duration of untreated psychosis through multiple systemic interventions. Unfortunately only a few programs have been able to do both while for majority of jurisdictions have failed to integrate the two components. As a result patients in areas that have concentrated on reduction of DUP may still be treated in community health centers and patients in areas where specialized early intervention teams are operating are still experiencing a long DUP prior to treatment. Logically it should be possible to integrate the two components of EI; however, systemic barriers may be difficult to break down. In this symposium we will explore if there might be a positive mediating effect on the effect of the specialized early treatment by DUP reduction. The early intervention hypothesis suggested that the early years of illness were especially receptive to interventions, and in this symposium we want to explore if this hypothesis is supported by examining the role of DUP as a moderator of treatment effect. This symposium will bring together an international field of experts presenting data from some of the largest trials in the world. • JCEP, Prof. Eric Chen • PEPP-Montréal, Prof. Ashok Malla • RAISE prof. Robert Heinssen • OPUS II Ph.D. Nikolai Albert
Talk 1 The Effect of Duration of Untreated Psychosis and Treatment Delay on the Outcomes of Prolonged Early Intervention in Psychotic Disorders - a subgroup analysis of the OPUS II trial
Nikolai Albert1, Marianne Melau1, Heidi Jensen1, Lene Halling Hastrup2, Carsten Hjorthøj1, Merete Nordentoft1,3; 1Copenhagen Mental Health Centre, 2Psychiatric Research Unit, Region Zealand, 3University of Copenhagen
The duration of untreated psychosis (DUP) has been shown to have an effect on outcome after first episode psychosis. The premise of specialized early intervention (SEI) services is that intervention in the early years of illness can affect long-term outcomes. In this study we investigate whether DUP affects treatment response after 5 years of SEI treatment compared to 2 years of SEI treatment. As part of a randomized controlled trial testing the effect of prolonged SEI treatment 400 participants diagnosed within the schizophrenia spectrum were recruited. In the main trial, we did not find an effect on the main outcome, negative symptoms, of prolonging the SEI treatment from 2 to 5 years. In this post-hoc analysis, participants were dichotomized based on DUP, treatment delay and time from first symptom until start of SEI treatment. The participants with a short DUP (< 3 months) showed a tendency to respond better to the prolonged treatment with regards to disorganized and negative dimension. For participants with short duration from first symptom until start of SEI treatment (<6 months) there was a significant difference on the negative dimension favoring the prolonged OPUS treatment. The finding of an effect of prolonged treatment for participants with a short total treatment delay could mean that prolonged SEI treatment is more beneficial than treatment as usual so long as it is provided in the early years of illness and not just in the early years after diagnosis.
Talk 2 Duration of Untreated Psychosis Moderates Clinical Outcomes and Cost-Effectiveness in First Episode Psychosis Treatment Programs
Robert Heinssen1; 1National Institute of Mental Health
The Recovery After an Initial Schizophrenia Episode initiative evaluated the feasibility, effectiveness, and scalability of a multi-element, team-based approach to first episode psychosis care in the United States. The Early Treatment Program comparative effectiveness trial (RAISE-ETP) enrolled 404 participants from 34 community centers in 21 states; clinics were randomly assigned to provide specialized early intervention services (NAVIGATE; N=17) or usual community care (N=17). The median duration of untreated psychosis (DUP) among participants was 74 weeks. After 24 months, NAVIGATE recipients experienced greater improvements in quality of life, psychopathology, and involvement in work or school compared with patients in community care. In addition, NAVIGATE was more cost-effective than typical treatment. Median DUP was a significant moderator of treatment effects on quality of life and overall symptoms, but not on employment or school attendance. Patients with shorter DUP derived substantially more benefit from NAVIGATE compared to those with longer DUP, and participants in community care. For NAVIGATE patients with DUP <74 weeks, average annual treatment costs were 15 percent lower compared to the annual cost of typical care. Together these findings underscore the importance of complementary approaches for improving FEP outcomes. In 2013, the National Institute of Mental Health launched research initiatives to test feasible strategies for reducing DUP and achieving rapid referral of persons with FEP to specialized treatment programs. The focus, methods, and preliminary findings from 10 funded projects will be presented, along with implications for reducing DUP in ~200 specialized early intervention clinics now established in the United States.
Talk 3 4-year outcome of a specialized early intervention treatment for adult onset psychosis (JCEP): a randomized controlled trial
Eric YH Chen1, Christy LM Hui1, Sherry KW Chan1, WC Chang1, Edwin HM Lee1; 1Department of Psychiatry, The University of Hong Kong, Hong Kong
Despite advances in treatment of psychotic disorders, functional decline remains a prominent obstacle in the recovery pathway. Early intervention (EI) services worldwide have focused timely treatment on the first few years (i.e. critical period) of the disorder to prevent patients from developing long-term disabilities. However, the optimal intervention model and length remain unknown. The Jockey Club Early Psychosis (JCEP) Project delivered a specialized EI service for adult-onset first-episode psychosis patients aged 26 and 55 in Hong Kong. Using a randomized controlled trial, 360 patients were randomly assigned to receive either 4-year of EI treatment (n=120), 2-year of EI treatment (n=120), or 4-year of standard care (n=120). Clinical, functional and neurocognitive assessments were conducted at baseline, 6 months, and yearly until 4 years. By 4 years, it was found that the 4-year EI group had better cognitive outcome than the standard care group; and also better functional and cognitive outcome than the 2-year EI group. Subgroup analysis revealed that patients with longer duration of untreated psychosis (DUP) (≥94 days) benefited substantially more from 4-year EI, compared to 2-year EI. Patients with longer DUP who received 4-year EI had better functioning and cognitive outcome, while no additional benefit was observed in patients who had shorter treatment delay. JCEP evaluated the impact of EI by extending its duration to the entire 4 years. The consequence and implication of prolonged treatment to cover a longer hypothesized critical period will be discussed in this presentation.
Talk 4 Delay in initial treatment may limit the benefit of even extended early intervention service: results from a RCT
Ashok Malla1,2, Jai Shah1,2, Manish Dama1,2, Srividya Iyer1,2, Ridha Joober1,2, Amal Abdel-Baki3,4, Sherezad Abadi2; 1McGill University, 2Douglas Mental Health University Institute, 3Université de Montréal, 4Centre Hospitalier Universtaire de Montréal
Longer duration of untreated psychosis (DUP) has a negative influence on short and long term outcome in first episode psychosis (FEP) and may limit benefits of specialized early intervention services. It is not clear if this effect would persist even when the early intervention service is extended beyond the initial two years. We report here post-hoc analysis of the results of a large RCT comparing effectiveness of an extended early intervention service (EEIS) to Regular Care, following two years of initial EIS. The results of the principal analyses on the primary outcome (length of positive, negative and total remission) favoured the EEIS. Using a DUP ≤ 12 weeks (as per the literature) cut-off 217 patients were split into two groups and examined if longer remission in patients randomized to an EEIS was associated with shorter DUP. Patients with DUP ≤ 12 weeks (median for the sample), treated in an extended EIS experienced significantly longer remission for positive (β = 0.35; p <0.01), negative (β = 0.38; p <0.01), and total symptoms (β = 0.36; p = 0.01) compared to regular care. However, for patients with DUP > 12 weeks, no such difference emerged between the two treatment conditions. For those with DUP between 12-24 weeks, only length of remission for positive symptoms (but not negative) showed a borderline significance (β = 0.37; p = 0.05). These findings suggest that reducing DUP may be essential to getting the most benefit from a specialized EI service even in an extended EI service.
Question and Answer Period
Discussant: Jan Olav Johannessen, Stavanger University Hospital
Symposium Session 14
Tuesday, October 9, 1:00 - 2:30 pm, Staffordshire
Computer-aided diagnostic and prognostic tools in the early recognition of psychosis: findings from the multi-site European PRONIA study
Chair: Stephen Wood, Orygen, University of Melbourne
Co-Chair: Nikos Koutsouleris, Ludwig-Maximilians University Munich
Speakers: Lana Ilankovic-Kambeitz, John Gillam, Rachel Upthegrove, Paolo Brambilla
Despite five decades of quantitative research into early phases of psychoses, early recognition still depends on a human expert. Unfortunately, the availability of clinical services that provide this expert knowledge is not the only limitation. Early recognition is also a unique clinical challenge - accurately estimating the risk profile of an individual with diverse, frequently nonspecific psychopathology, leading to biased reasoning given different clinical traditions and gut feeling. Recently, opportunities to address the clincial challenge have emerged with machine learning, multi-site prospective study designs and international collaborations merging into a powerful methodology for precision psychiatry. Previous studies have provided preliminary evidence regarding the feasibility of stratifying at-risk and first-episode patients according to the odds of adverse outcomes by extracting candidate predictive models from diverse data. Candidate models are under further validation and analysis based on multi-site datasets collected within the NAPLS, PRONIA, PsySCAN and PNC projects. Should candidate markers generalize well, the outcomes would translate into significant increases in predictive and prognostic certainty. Such progress would allow for individualized risk-based stratification of patients and clinical trials, novel targets for drug development and tools for individualized neuromonitoring of preventive treatments. The symposium will present new data from the PRONIA project which has collected clinical, neurocognitive, blood-based and MRI data from 1600 persons in at-risk and early stages of psychoses and mood disorders, and healthy controls. PRONIA is currently generating machine-learning markers intended to predict clinically relevant outcomes, identify vulnerable subgroups and combine data for diagnosis and prediction across heterogeneous domains.
Talk 1 Using neuroimaging data to predict functional outcome in early spectrum psychosis
Lana Ilankovic-Kambeitz1; 1Ludwig-Maximilian-University
The growing knowledge about enduring functional impairment and disability in psychosis and in high risk (CHR) patients encouraged us to search for prognostic biomarkers to individually predict functional and clinical outcome independent of a subsequent transition to full-blown psychosis or remission of symptoms after psychosis. We aim to elucidate structural and functional brain determinants and potential modifiers of functional outcome trajectories in early stages of psychosis. We have employed Multivariate Pattern Analysis (MVPA) in the PRONIA discovery sample to predict functional outcomes of recent onset psychosis (ROP) patients and CHR patients after 12 months of naturalistic treatment, based on the patients' structural neuroimaging measures. The Global Functioning: Social and Role scale (GF:S, GF:R) were used to determine good or poor outcome status at the follow up examination. Volume-based pattern classification predicted good vs. poor outcome status at follow-up in CHR patients with accuracy levels of up to 77% as determined by leave-site out cross-validation. The neuroanatomical prediction signature mapped to volume increments in cortical areas pertaining to the default-mode and central executive network whereas volume reductions were located in hub regions of the salience network and the temporal cortices. The detection of CHR and psychosis individuals with specific brain alterations associated with poorer outcome at follow-up may help identifying a critical group of at-risk persons, who irrespective of diagnostic thresholds require clinical treatment and therapeutic support. In the next step, we are planning to employ functional resting state (rs) analysis to predict functional outcome in the same group of patients.
Talk 2 Data fusion and prediction of outcome in early psychosis
John Gillam1,2; 1Orygen, 2University of Melbourne
In order to extract the most powerful predictive models from data collected within the PRONIA study, diverse information sources must be combined. For each subject, neurocognitive, neuroimaging and clinically observed data has been collected that is intended to provided the basis for the development of predictive models for use in individualised diagnosis and prediction. While a number of approaches may be considered in the combination of data from a diverse range of sources, here, we investigate a two-stage learning approach. An initial step produces a single (probabilistic) outcome for each modality and a second step combines these outcomes to generate a final estimate of the target class. Neurocognitive and neuroimaging data, collected as part of PRONIA, were considered as features for prediction of clinically observed global function, measured at the same time-point. Each neurocognitive test was considered as an independent modality, as were each of a range of MRI-based neuroimaging measures. Using the same target-class (a global assessment of function score less than 65), different approaches to model generation were conducted for each modality using repeated, nested, cross-validation in both stages in order ensure robust estimates of generalisation. The framework of the two-stage learning process is described, and initial results are presented for each approach to classifier-learning considered for both the first and second layer of learning outcomes. An exploration of the contribution to the final prediction from each of the input data streams is discussed and the extension of this approach to structured data-fusion and prediction is considered.
Talk 3 Specificity of depression phenomenology, and neurobiology, in clinical high-risk and first episode psychosis
Rachel Upthegrove1,2; 1University of Birmingham, 2Forward Thinking Birmingham & Birmingham and Solihull Mental Health Foundation Trust
Major depressive disorder (MDD) is one of the most common mental disorders and is also the most common co-morbidity seen with other mental disorders. In schizophrenia the prevalence of depressive disorder is around 40%, reaching over 50% in groups at clinical high risk (CHR) for psychosis. It is unclear whether these expressions of depression are distinct from MDD without co-morbidity. To further understand the symptom profile of depression in emerging mental disorders, we present data from the PRONIA study (an EUFP7 funded 8 centre study; n=716) to compare CHR, recent onset psychosis (ROP), and recent onset depression (ROD). Using clinical, demographic, and neuroimaging data, and machine learning with Neurominer®, we attempted to classify participants on the basis of their depressive presentation. Data from BDI-II symptom endorsement suggests a 'classical depression phenotype' corresponding to Becks 'cognitive triad'; "life is pointless, future hopeless, self as worthless" may separate depression in ROD from that seen in ROP. Data will also be presented on the CHR group, together with analysis of structural MRI examining correlates with highly weighted classifying symptoms in and across all three groups. When given early in the course of illness, interventions have the greatest potential impact, and characterization and accurate diagnosis of depression in emerging mental disorders is an important goal. This study suggests it may be possible to accurately identify depression in different diagnostic categories, including major depressive disorder, psychosis and clinical high risk, and that neuroimaging holds potential to add to diagnostic accuracy in complex co-morbid disorders.
Talk 4 Prediction of functioning using neurocognitive features in subjects with clinical high risk (CHR), recent onset psychosis (ROP) and recent onset depression (ROD)
Paolo Brambilla1,2; 1University of Milan, 2The University of Texas Health Science Center at Houston
In this work, a relationship between functioning and neurocognitive evaluations has been investigated using machine learning. The analyses were carried out on the neuropsychological scores in 707 subjects with clinical high risk (CHR), recent onset psychosis (ROP), recent onset depres-sion (ROD) and healthy controls (HC). Subjects were not divided in classes but the prediction has been considered as dealing with a continuum in terms of global functioning. Subjects with incomplete data were excluded from the analysis. The measures of Global Functioning (GF) social and role, which quantify how effectively the person is functioning in their everyday life, were used to predict the difference in functioning at baseline (T0) and at 9 months follow up (T1) in respect to lifetime. Then, 38 features drawn from the PRONIA cognitive battery (PCB) on the basis of a priori knowledge were entered into a model that was evaluated with machine learning methods implemented with Neurominer. The non-informative features were pruned and the data were scaled. The model under-went 10x10 cycles of internal cross-validation (CV1) and 10x10 cycles of cross-validation against an outer portion of the sample (CV2) that, at each cycle, did not enter the CV1. The results showed that the model could reliably predict a drop in social and role functioning at T0 with respect to both life and past year (p<0.01), and GF social could be predicted (p=0.03).
Question and Answer Period
Discussant: Paola Dazzan, Institute of Psychology Psychiatry & Neuroscience, Kings College London
Symposium Session 15
Tuesday, October 9, 2:45 - 4:15 pm, American Ballroom - North
Electrophysiological markers of psychosis risk and conversion: A view from the North American Prodrome Longitudinal Study (NAPLS 2)
Chair: Susanna Fryer, University of California - San Francisco, San Francisco VA Healthcare System
Co-Chair: Ricardo Carrion, Hofstra Northwell School of Medicine
Speakers: Susanna L. Fryer, Ricardo E. Carrión, Sylvia B Guillory, Margaret Niznikiewicz
Identifying biologically-based predictors and mechanisms related to the development of psychosis is critical to early detection and disability prevention efforts. The multi-site North American Prodrome Longitudinal Study combined baseline neurobiological assessment with longitudinal clinical follow-up of adolescents and young adults identified as clinical high risk (CHR) for developing psychosis. This session will present data on electrophysiology studies from the NAPLS 2 cohort with a focus on highlighting baseline electrophysiological markers that relate to 24-month clinical outcomes including, but not limited to, transition to psychotic spectrum disorders. Dr. Fryer from the University of California, San Francisco (UCSF) will present data from the mismatch negativity (MMN) paradigm, focusing on the relationship between measures of predictive coding at baseline and clinical outcomes 24 months later. Dr. Carrión from Hofstra Northwell School of Medicine will present a study on the functional impact of these MMN deficits by discussing interrelationships among MMN, negative symptoms, and cognitive and social functioning. Dr. Guillory from the Ichan School of Medicine at Mount Sinai will present a study comparing MMN and P300 functioning in CHR individuals with and without comorbid autism spectrum diagnoses including the extent to which this comorbidity influences biomarker relationships to conversion status. Dr. Niznikiewicz from Harvard Medical School will present findings on the gamma-band auditory steady-state response in youth at CHR for psychosis compared to healthy controls and conversion-based analyses within CHR. Dr. Mathalon from UCSF is the electrophysiology lead for NAPLS and will serve as the session’s discussant.
Talk 1 Experience-dependent strengthening of auditory prediction signals in youth at clinical high risk for psychosis: Effects of clinical outcome and conversion
Susanna L. Fryer1,2, Peter Bachman3, Aysenil Belger4, Ricardo Carrión5, Erica Duncan6, Jason Johannesen7, Margaret Niznikiewicz8, Brian Roach2, Jean Addington9, Kristin Cadenhead10, NAPLS Consortium, Daniel H. Mathalon1,2; 1University of California, San Francisco, 2San Francisco VA Healthcare System, 3University of Pittsburgh, 4University of North Carolina, 5Zucker Hillside Hospital, 6Emory University, 7Yale University, 8Harvard Medical School, 9University of Calgary, 10University of California, San Diego
The mismatch negativity (MMN) event-related potential (ERP) is an auditory prediction error signal elicited by the violation of the expectation that a standard, frequent sound will repeat. Repetitions of standards strengthen this prediction signal, and produce an increasing electrophysiological signature, the “repetition positivity” (RP). The RP reflects strengthening of experience-dependent short-term plasticity. Here, we examine the RP elicited by a MMN paradigm in youth at clinical high risk for psychosis (CHR; n=450) and healthy controls (HC; n=241) from the North American Prodromal Longitudinal Study-2. After 24 months of clinical follow-up, CHR participants (n=244) were categorized by clinical outcome status into subgroups that: i) transitioned to psychosis (CHR-Transition, n = 54), ii) did not transition but remained symptomatic (CHR-Symptomatic, n = 112), and iii) did not transition and reached symptom remission (CHR-Remission, n = 78). The RP (100-200 ms post-stimulus) to successive standards (2, 3, 4-5, 6-7, 8-10, >10 repetitions) was assessed at baseline. Significant group differences in RP amplitude were detected based on clinical outcome (Group*Standard interaction, p <.001). Follow-up tests revealed CHR-Transition had significantly smaller baseline RPs to late standards (>10 repetitions), relative to HC and CHR-Remission participants, who did not differ from each other. Similarly, the CHR-Symptomatic group, which did not differ from the CHR-Transition group, had smaller baseline RPs to late standards relative to HC and CHR-Remission groups (all follow-up p’s <.05, FDR-corrected for multiple comparisons). These results implicate deficits in short-term auditory cortex plasticity as a risk factor for psychosis that is sensitive to clinical outcome.
Talk 2 Determinants of Poor Social Functioning in Individuals at Clinical High Risk for Psychosis: Modeling the impact of Early Auditory Processing Deficits, Neurocognition, Social Cognition, and Negative Symptoms
Ricardo E. Carrión1, Barbara A. Cornblatt1, Peter Bachman2, Aysenil Belger3, Erica Duncan4, Jason Johannesen5, Margaret Niznikiewicz6, Brian J. Roach7, Jean Addington8, Kristin Cadenhead9, NAPLS Consortium, Daniel H. Mathalon7,10; 1Zucker Hillside Hospital, 2University of Pittsburgh, 3University of North Carolina, 4Emory University, 5Yale University, 6Harvard Medical School, 7San Francisco VA Healthcare System, 8University of Calgary, 9University of California, San Diego, 10University of California, San Francisco
Recent research in patients with schizophrenia has demonstrated complex relationships between early auditory processing deficits, neurocognition, social cognition, negative symptoms, and social functioning. However, the interrelationships and impact of these variables on social (i.e., interpersonal relationships) functioning impairments prior to the onset of the illness is unclear. The present study used a structural equation modeling (SEM) approach to integrate these factors to determine the specific determinants and pathways that lead to poor functioning in a large sample of treatment-seeking individuals at clinical high-risk (CHR) for psychosis. Participants were 765 CHR individuals enrolled and prospectively followed in the North American Prodrome Longitudinal Study (NAPLS2). We evaluated several theoretically based models with pathways starting from mismatch negativity (MMN) deficits to functioning. The intervening variables included neurocognitive performance, social cognition, and negative symptom levels. Social functioning was assessed with the GF:Social scale. Prodromal symptoms were assessed using the Scale of Prodromal Symptoms (SIPS/SOPS). Model estimation was performed using AMOS v16. A final trimmed model revealed that early auditory information processing (MMN) had a direct effect on neurocognition, neurocognition had a direct effect on negative symptoms, and both neurocognition and negative symptoms had direct effects on social functioning. The direct effect from social cognition to functioning was not significant. Our findings reveal a complex relationship between MMN reductions, neurocognition, negative symptoms and social outcomes in individuals at CHR for psychosis. These results may have implications for early intervention strategies that aim to improve functional trajectories in young individuals at high risk of developing psychosis.
Talk 3 Atypical P300, but not MMN, amplitude differentiates conversion patterns in psychosis prodrome with versus without comorbid autism spectrum disorder
Sylvia B Guillory1, Eva Velthorst1, Peter Bachman2, Aysenil Belger3, Ricardo Carrión4, Erica Duncan5, Jason Johannesen6, Margaret Niznikiewicz7, Kristin Cadenhead8, Jennifer Foss-Feig1, NAPLS Consortium, Daniel H. Mathalon9; 1Icahn School of Medicine at Mount Sinai, 2University of Pittsburgh, 3University of North Carolina, 4Zucker Hillside Hospital, 5Emory University, 6Yale University, 7Harvard Medical School, 8University of California, San Diego, 9University of California, San Francisco
Autism spectrum disorder (ASD) and schizophrenia are distinct disorders. However, atypical sensory and attentional processing characterizes both, and psychosis symptoms exist disproportionally in ASD. Electrophysiological markers that characterize schizophrenia, including P300 and mismatch negativity (MMN) amplitude reductions, are present in individuals at clinical high-risk (CHR) for psychosis. Whether these markers are: present in ASD individuals showing CHR profiles and/or predictive of conversion is unknown. We investigated P300 and MMN response and sensitivity to psychosis conversion across CHR groups with (CHR/ASD+) and without(CHR/ASD−) comorbid ASD. Electrophysiological data were analyzed from 305 NAPLS-2 CHR patients (14 CHR/ASD+; 291 CHR/ASD−). We examined P300 amplitude to infrequent Target(10%) and Novel distractor(10%) stimuli from visual and auditory oddball tasks, and MMN response for duration(5%), frequency(5%), and duration+frequency(5%) deviants. P300 amplitude to Novel visual stimuli was smaller in CHR/ASD− converters(n=71) than CHR/ASD− non-converters(n=220), but larger in CHR/ASD+ converters(n=4) than CHR/ASD+ non-converters(n=10) (Modality×ASD×Converter Interaction, F=3.57;p=.06). For auditory and visual Target stimuli, whereas P300 amplitude was similar for CHR/ASD+ non-converters and all CHR/ASD− individuals, CHR/ASD+ converters had larger P300 amplitudes (ASD×Converter interaction, F=12.12;p=.001). For MMN, there were no significant amplitude differences between groups (Conversion,p=0.31; ASD,p=0.57) or deviant type (p=0.56). Results revealed dissociable P300 amplitude profiles to visual and auditory target and novel stimuli in CHR patients that differentially predicted conversion to psychosis, depending on ASD status. MMN did not differ by ASD status. These findings suggest attentional orienting is differentially affected in CHR patients with ASD, whereas pre-attentive sensory memory is similar in CHR with and without ASD.
Talk 4 40 Hz-centered ASSR measures distinguish between healthy control and clinical high risk individuals in the NAPLS sample
Margaret Niznikiewicz1,2, Peter Bachman3, Aysenil Belger4, Ricardo Carrión5, Erica Duncan6, Jason Johannesen7, Brian J. Roach8, Jean Addington9, Kristin Cadenhead10, NAPLS Consortium, Daniel H. Mathalon8,11; 1VA Boston Healthcare System, 2Harvard Medical School, 3University of Pittsburgh, 4University of North Carolina, 5Zucker Hillside Hospital, 6Emory University, 7Yale University, 8San Francisco VA Healthcare System, 9University of Calgary, 10University of California, San Diego, 11Univeristy of California, San Francisco
Purpose: Abnormalities in gamma-band auditory steady-state response (ASSR) are an index of dysfunction in neural oscillations associated with GABAergic interneuron function and related to cognitive dysfunction in schizophrenia (SZ). A robust finding in SZ, they are regarded as one of its biomarkers. However, it is not clear if this abnormality is present already in individuals at clinical high risk for psychosis (CHR) and whether it distinguishes between those who will convert to schizophrenia and those who will not. As part of the NAPLS study we examined ASSR at both baseline and post-stimulus time-windows to address this important question. Materials and Methods. 439 CHR and 236 healthy controls (HC) were tested on the ASSR paradigm using 20, 30, and 40 Hz click-trains. Baseline power was examined within -200-0 msec window. The inter-trial phase coherence (ITC) was examined within 1. 0-200 msec post-stimulus latency window to interrogate early gamma-band response and 2. 200-500 msec post-stimulus window, to interrogate late gamma-band response. Results: For 40Hz click stimulation but not for 20 or 30 Hz, the baseline power was larger in CHR than in HC at both Fz (p=.04) and Cz (p=.04). In contrast, reduced ITC was observed for 40 Hz click-trains for latency windows of 200-300 msec (p=0.006), 300-400 msec (p=0.023) and 400-500 (p=0.34), (i.e., late gamma-band response). No measure distinguished between CHR-converters and non-converters. Conclusions: These results suggest that measures of baseline power and of ITC at 40 Hz distinguish between HC and CHR but are not sensitive to the conversion status.
Question and Answer Period
Discussant: Daniel Mathalon, University of California - San Francisco, San Francisco VA Healthcare System
Symposium Session 16
Tuesday, October 9, 2:45 - 4:15 pm, American Ballroom - Center
Cultural Influences on Care for First Episode Psychosis in Yogyakarta, Indonesia
Chair: Byron J. Good, Harvard Medical School
Speakers: Byron J. Good, M. A. Subandi, Nida Ul Hassanat, Carla Raymondaleas Marchira
This panel grows out of two decades of collaboration between researchers from Harvard Medical School and Gadjah Mada University in Yogyakarta, Indonesia, focusing on first episode psychotic illness. Studies range from epidemiological research on the incidence and nature of onset of first episode/first contact psychoses; intensive ethnographic studies of individual cases followed over time, family responses and care for illness, and interaction with traditional healers; clinical studies, linking cultural phenomenology with clinical rating scales, and intervention studies focused on developing, evaluating, then scaling up psycho-educational interventions for families caring for a person with psychotic illness. Rather than addressing individual studies, this panel will provide a brief overview of the context and history of this program of research, followed by four presentations examining specific issues, drawing from the larger body of research: 1) the social and cultural influences on onset and long-term outcomes of illness, with a particular focus comparing very rapid and slow onset psychoses; 2) cultural phenomenology and care-seeking, providing both case studies and quantitative data; 3) the social course of illness, based on intensive longitudinal studies; and 4) evaluation of psycho-educational interventions for families of persons with psychotic illness, designed for the local social and cultural setting, and preliminary efforts to scale up such interventions through the primary health care system. The panel thus links studies of cultural phenomenology and psychosocial interventions of first episode psychosis. Though not generalizable to all of Indonesia, this research provides important data from Indonesia, the world’s fourth most populous nation.
Talk 1 The Place of Acute Onset in the Cultural Patterning of First Episode Psychosis in Java
Byron J. Good1, M. A. Subandi2, Carla Marchira2, Mary-Jo DelVecchio Good1; 1Harvard Medical School, 2Gadjah Mada University
From the beginning of our ethnographic and clinical research in 1996, the Yogyakarta team began identifying very rapid onset psychoses as unexpectedly common. This led to a series of studies investigating their cultural phenomenology, prevalence, the nature of prodromal features, and eventually to the relationship between acuteness of onset and long-term outcomes. Purpose: The overall aim of paper will be to present data about the nature and prevalence of acute onset illness among first episode first contact psychoses in Java, and to ask how the nature of onset relates to care-seeking and long-term course of illness. Methods: Data are drawn from ethnographic studies, an epidemiological study (of 304 first episode psychoses appearing for treatment in Yogyakarta in 6 months), an intensive set of 30 in-depth interviews with individuals and their care providers, and a 12 year follow-up of the 30 intensive cases. All data are retrospective studies of persons in first episode who have already contacted services. Findings: Our findings indicate that this is a real phenomenon, that as many as 36% of cases escalate from first appearance of psychotic symptoms to acute psychosis in a two week period, and that rapidity of seeking treatment is directly related to rapidity of onset. Small case studies indicate diversity in outcomes on follow-up. A 12 year follow-up of 30 intensive cases will be reported. Conclusion: Relevance of these studies for diagnostic issues, for studies of DUP and outcomes, and for the importance of cross-cultural research will be discussed.
Talk 2 Cultural Understandings of Illness and Care-Seeking Behavior among Caregivers of First Episode Psychosis in Java, Indonesia
M. A. Subandi1, Carla Marchira1, Mary-Jo DelVecchio Good2, Byron J Good2; 1Gadjah Mada University, 2Harvard Medical School
The cultural understanding of illness among caregivers of first episode psychotic persons is a crucial issue. Not only does it influences caregivers’ care-seeking behavior and length of time until receiving medical treatment (known as DUP, the Duration of Untreated Psychosis), but also in turn predicts outcome of illness. Purpose: This paper aims to explore cultural understanding and care-seeking behavior among caregivers of psychotic patients in Java Indonesia. Methods: Data for this paper were taken from several studies conducted by our research group in Yogyakarta, Indonesia. Methods of data collection include an epidemiological survey, ethnographic fieldwork, in depth interviews, and an intervention program. Findings: Results of analyses within and across studies indicate that caregivers employed diverse cultural explanatory model in understanding psychotic illness. Local cultural understandings, including possession and forms of black magic, were among the most common initial concepts used by family members in relation to psychosis. This echoes broader cultural beliefs in Java. However, it was not uncommon that caregivers also understood illness in psychological terms (frustration, dissapointment, and stress) and using medical explanations. Caregivers’ understanding of illness also changed over time, following the changing course of illness. Both models of illness and rapidity of care-seeking is also related to acuteness of onset. Conclusion: It is important for mental health providers, as well as those designing systems of care, to understand the diversity and changing nature of caregivers cultural understandings of psychotic illness.
Talk 3 The “Social Course” of the Early Phase of Psychotic Illness in Yogyakarta, Indonesia
Nida Ul Hassanat1, Mahana Sofiati Utami1, Carla Marchira1, M. A. Subandi1, Mary-Jo DelVecchio Good2, Byron J. Good2; 1Gadjah Mada University, 2Harvard Medical School
The concept “course of illness” for schizophrenia has primarily focused on clinical course. Social experience and cultural interpretations are also critical to understanding the course of schizophrenia. Purpose: This paper introduces the concept of “social course of illness,” as distinct from clinical course, to focus attention on what factors influence the development over time of the experience of psychotic illness, social functioning and social impairment, and family experiences, and uses the concept to explore the diverse courses of illness of a small cohort of persons with first episode psychosis in Yogyakarta, a center of Javanese culture in Indonesia. Methods: Eight patients with first-episode psychosis were interviewed approximately eight times each over three years, beginning 2001. Narrative data about illness experiences and care-seeking, cultural understandings of the illness, clinical ratings, data on social functioning, and qualitative data on stigma and social response, were all recorded. A follow-up study of these patients is currently underway. Results: Data from this study suggest that clinical symptoms and social processes influence each other, and that "clinical course” and “social course” may follow different patterns. It also suggested that both clinical course and social course vary widely from one individual to another, and that clinical impairment and social impairment are not always directly related. Conclusion: This research suggests the importance of reconceptualizing the early course of schizophrenic illnesses, and that culturally sophisticated social interventions should accompany clinical interventions to limit social impairment associated with psychotic illness and contribute to recovery.
Talk 4 The Effectiveness of a Brief Interactive Psychoeducational Intervention for Persons Living with First Episode Psychosis and Family Caregivers in Yogyakarta, Indonesia
Carla Raymondaleas Marchira1, Iran Suprianto1, M. A. Subandi1, Mary-Jo DelVecchio Good2, Byron J. Good2; 1Gadjah Mada University, 2Harvard Medical School
Psychoeducation of persons living with psychotic illness and their family caregivers is a long-standing and effective means of providing information and support that benefits both families and those living with illness. However, cultural adaptation of psychoeducation and integration into routine care in settings with very low mental health resources is rare. Purpose: This presentation aims to describe outcomes of an investigation of the effectiveness of a culturally-adapted, brief interactive psychoeducation intervention for family caregivers in Java, and to study the feasibility of integrating such interventions into routine mental health services provided by primary health care providers. Methods: An experimental study was conducted with pre-test and post-test assessments with 100 persons living with first episode psychotic illness and their family caregivers. Families were randomly assigned to intervention and control groups, and psychiatric residents were trained to administer 4 weekly interactive psychoeducation sessions with modules adapted for the local cultural setting. When the intervention was found to be feasible and effective, a program was developed to train staff in three primary health centers to provide a similar intervention for individuals and families registered with the primary health care center. Findings: The initial intervention was found to be feasible and effective, particularly in increasing Knowledge of Schizophrenia of family members and reducing rehospitalization. Training of primary health care workers was found to be feasible and effective. Conclusion: Adapting psychoeducation for individuals with psychotic illness and family caregivers is feasible and can be integrated into primary health services in low resource settings.
Question and Answer Period
Discussant: Eric Y H Chen, Dept of Psychiatry, Hong Kong University
Symposium Session 17
Tuesday, October 9, 2:45 - 4:15 pm, American Ballroom - South
International application of fidelity scales for first episode psychosis services
Chair: Donald Addington, University of Calgary
Speakers: Marianne Melau, Ilana Nossel, Janet Durbin, Eóin Killackey
First episode psychosis services have been shown to be effective in several large randomized controlled studies in different health care systems. There is a growing consensus as to the essential components of such services and fidelity scales have been developed to assess the degree to which services deliver the essential evidence based components. Fidelity scales can be used for assessing implementation of new programs, ensuring quality of existing programs and by funders for setting standards. The international health challenge is now to broaden access to first episode psychosis services and to ensure that existing services continue to deliver evidence based care. Fidelity scales are one of the tools that can be used to support access to quality services, but their application is challenging. Several fidelity scales are now available, and are being applied in the United States, Italy, Canada, Denmark, and Australia. In this symposium we will examine the challenges of large scale application of fidelity scales. Speakers will illustrate how these challenges are being overcome and fidelity scales are being applied in the United States, Canada, Australia, and Denmark. Mental health services have been slower to measure access and quality of services than other health services. Developing the systems required to support evidence based quality assessment for first episode psychosis services can lead to broader application in other aspects of mental health services.
Talk 1 Introducing program fidelity scales for Specialized Early Intervention in Denmark.
Marianne Melau1, Nikolai Albert1, Merete Nordentoft1; 1Mental Health Centre Copenhagen, Copenhagen University Hospital, Denmark
The evidence-based Specialized Early Intervention (SEI) has in Denmark grown to be a nationwide service for young adults’ experiencing a first episode psychosis. The implementation of the program was carried out without the use of fidelity measures. To rectify this, we developed and tested out a Danish fidelity scale for SEI teams, and for the first time we did a nationwide assessment of the quality and program fidelity of the SEI teams in Denmark. We found the fidelity scale to be a feasible and easy manageable tool for collecting fidelity data, and by using a multimodal approach we got a good understanding of how multidisciplinary teams interact and manage various aspects of a patient's treatment. Totally 96% (n = 22) of the SEI teams participated and all in all 59 % (n = 13) fulfilled the criteria for program fidelity in a satisfactory level. We found that there was high variability between SEI teams according to the structural domain of the fidelity scale. By contrast, we found great homogeneity between the teams in terms of item referring to treatment. This mapping of SEI teams’ program fidelity in Denmark makes it obvious that at a national level, there is an urgent need for a more systematic approach to training and supervision, with a centralized development of educational material, provision of training and organization of supervision. The study revealed a fragile organization of the educational activities. Models for implementation of continuous fidelity measurements will be discussed
Talk 2 Assessing Fidelity to the OnTrackNY Coordinated Specialty Care Model
Ilana Nossel1, Sarah Piscitelli,1, Susan Essock2, Franco Mascayano2, Lisa Dixon1; 1New Yoirk State Psychiatric Institute, 2Columbia University
OnTrackNY, New York State’s coordinated specialty care (CSC) program, has grown rapidly to 22 sites, highlighting the importance of scalable fidelity assessments. Our approach evolved in phases, using three information sources. We first relied on findings from high-touch training activities. Second, we used client- and program-level data on care processes and outcomes solicited quarterly from teams which are tabulated centrally, generating reports that teams receive. Third, building on Addington’s FEP Fidelity Scale, we added site visits, including chart reviews, team meeting observation and staff, participant and family member interviews. Our scale has 25 domains, comprised of 94 sub-items, 48 from data and 46 from site visit. Each domain includes one “critical sub-item” essential for fidelity. We completed a pilot study (2 sites) focusing on assessing the incremental value of site visits. Both programs had high fidelity, meeting expectations in 23/25 domains. Data items addressed team functioning and outcomes over the past year. Raters identified items that were sub-threshold, required clarification, or had gaps; these were validated and supplemented with information from the site visit. Ten domains were heavily or solely scored based on site visit including assertive outreach, treatment planning, client preferences/ shared decision making, and trauma. Eligibility and enrollment, crisis services, care processes, metabolic monitoring, and peer services had critical items that relied on site visit. Final scores reflect all information sources; raters discussed discrepancies between sources and reached consensus. Conclusion: Site visits can be a useful adjunct to regular summaries of administrative data used to monitor implementation fidelity.
Talk 3 Conducting Fidelity Assessments in Ontario Early Psychosis Intervention Programs: Evaluation of a Pilot Implementation Initiative
Janet Durbin1, Avra Selick1, Gordon Langill2, Donald Addington3, Chiachen Cheng4; 1Centre for Addiction and Mental Health, 2Canadian Mental Health Association, 3University of Calgary, 4Northern Ontario School of Medicine
Ontario Canada is home to about 50 Early Psychosis Intervention (EPI) programs, and a sector wide network of providers (EPION - Early Psychosis Intervention Ontario Network) who work collaboratively to improve quality of care. Ontario released EPI program standards in 2011 but adherence is unknown. In the fall of 2016, EPION partnered with Centre for Addiction and Mental Health (CAMH) to pilot a novel fidelity review process using the First Episode Psychosis Fidelity Scale (FEPS-FS). Three-person assessor teams of volunteer EPI staff (2) and CAMH implementation specialists (1) conducted 2-day site visits to assess fidelity. Assessor teams were supported through training, tailored data collection tools and post-visit rating consensus meetings with an expert. Fidelity reports included quality improvement suggestions as well as fidelity ratings and related explanations. Nine programs were reviewed. Qualitative data were collected from assessors and sites to assess value, feasibility, and quality of this fidelity assessment process. Overall feedback was positive. Assessor team members brought complimentary skills to the process. Programs valued having front line assessors who understood the clinical experience, and assessors valued learning about and from peer programs. The process required a steep learning curve, but assessor confidence increased with their second review. Using a validated, standardized scale gave weight to the assessment although some adaptations may be needed for Ontario context. Some rating challenges were encountered, and the time commitment was greater than expected. In our presentation we will further discuss Ontario-specific challenges and explore feasibility of continuing this approach.
Talk 4 Challenges, initial outcomes and results from the application of a fidelity model to first episode psychosis services in Australia
Eóin Killackey1, Kristi van der El1, Heather Stavely1, Patrick McGorry1; 1Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, Australia
Background: In the 2010 Australian Federal Budget funding was committed to establish a first episode psychosis (FEP) service system based on the EPPIC model. This system was established by 2016. A fidelity scale, the EPPIC Model Integrity Tool (EMIT), was developed to measure the adherence to the model of the 6 clusters delivering the FEP services. Method: The EMIT is an 80-item assessment tool that maps onto the 16 core components of the EPPIC model. The tool is administered via on-site interviews with staff and young people as well as accessing documents, policies and data around client flow and service. Results: The first two rounds of fidelity assessments occurred in June/July and September/October 2017. Brief results around these assessments will be presented. These data give an initial snapshot of the adherence of the sites to the EPPIC model. The implementation of the tool cast light on a number of challenges that need to be addressed and these will also be discussed. The utility of the feedback from assessment as a means to identify areas in need of improvement will also be discussed. Conclusions: Model fidelity is an increasingly recognised way to ensure that programs based on evidence continue to deliver high quality outcomes, and avoid drift from the model. This presentation will demonstrate the outcomes from the first two rounds of application of the EMIT, associated challenges and ways in which fidelity testing can help services to improve their support of young people with early psychosis.
Symposium Session 18
Tuesday, October 9, 2:45 - 4:15 pm, Staffordshire
Implementation and integration of digital therapies in secondary care mental health services
Chair: Sandra Bucci, University of Manchester
Speakers: Sandra Bucci, Shon Lewis, Andrew Gumley, John Torous
The acceptability of digital tools in secondary mental healthcare appears acceptable, with promising results regarding efficacy. However, implementation of digital tools within mental health services is problematic. Without considering issues around implementation during the early stages of the development and delivery of digital tools, it is unlikely that these approaches will be disseminated beyond research studies and into mental healthcare services. This symposium brings together some of the world’s key research centres currently engaged in research evaluating integration of digital tools into secondary care mental health services. Bucci will present findings from qualitative and quantitative work regarding mental health staff and service user views on the facilitators and barriers to implementing digital tools into secondary care services. Lewis will then present findings from the ClinTouch/CareLoop trial, a smartphone software system built into the electronic care records of two large UK NHS Trusts targeting active symptom monitoring, symptom self-management and early detection of relapse in early psychosis. When built into clinical management workflows to enable personalised alerts of symptom deterioration, the system has the potential to promote earlier intervention for relapse. Gumley will present the protocol for EMPOWER, an end-to-end self-management system for psychosis being trialled in the UK and Australia. Gumley will discuss issues regarding medical device registration and engaging clinical teams in using the self-management system. Finally, using normalisation process theory, Lobban will report on a study identifying critical factors impacting on the implementation of an online peer supported self-management intervention for relatives of people with SMI.
Talk 1 Staff and service user perspectives of digital technology for early psychosis
Sandra Bucci1, Rohan Morris1, Christine Barrowclough1, Natalie Berry1, Gillian Haddock1, Shon Lewis1, Dawn Edge1; 1Division of Psychology and Mental Health, University of Manchester
Digital technology has the potential to transform the way people engage with mental health services. Findings from trials suggest that digital tools are feasible, with promising findings regards efficacy. However, research to date has largely ignored stakeholder and service user perspectives of these systems. Our group has explored both early psychosis service users' and staff subjective views of the use of mobile technology in the mental health setting. Framework analysis revealed a variety of barriers and facilitators to implementation of digital tools into the secondary care setting, including issues regarding the acceptability of technology in mental health, technology increasing access to, and augmenting, mental health support, issues around data protection, privacy and security of information, whether digital interventions are used as an adjunct to, or replacement for, usual care, and factors related to digital tools affording greater empowerment, control and choice than routine care. More specifically, service users' views said digital tools could enhance access to care by extending the reach of services to one’s natural environment and facilitating open and honest communication. Digital systems were also viewed as progressive, modern and relevant and potentially de-stigmatising. Digital tools were perceived as facilitating empowerment, affording patients meaningful choice and the opportunity to take active control of their healthcare. While staff share some of these views, they expressed more concerns around data security, risk management and workload flows. This talk will conclude with findings on the acceptability of a randomised controlled trial of a smartphone app used within UK early intervention services.
Talk 2 Smartphone-enhanced symptom management and relapse prevention: A randomised controlled trial
Shon Lewis1, Paolo Fraccaro1, Matthew Machin1, Richard Hopkins1, Caroline Sanders1, Zhimin He2, Charlotte Stockton-Powdrell1, John Ainsworth1, Pauline Whelan1, Til Wykes2; 1Division of Psychology and Mental Health, University of Manchester, 2Institute of Psychiatry, Psychology & Neuroscience
Improving recovery from acute symptoms and preventing relapse are two major challenges in psychosis. We previously developed a smartphone-based personalised technology to monitor symptoms in real time, which showed good acceptability, reliability and validity for active remote monitoring of symptoms. We now report an RCT testing its efficacy when embedded into the ICT systems of mental health services. Participants with early psychosis/SMI received a semi-random beep 2-4 times per day on their smartphone app and answer 14 key symptom rating items using a touchscreen slider. Responses are uploaded wirelessly in real time to a central server and build into a graphical readout on the handset. This was built into an end-to-end system in two NHS Hospital Trusts to stream data into ECRs and enable detection by the clinical team of SMI EWS when key symptoms exceeded a personalised severity threshold. 81 people were randomised to either active symptom monitoring or TAU. PANSS positive subscale score showed a significant mean reduction in treatment over 12 weeks in the early psychosis group. EWS alerts generated by the system occurred in 92% of cases and blind comparison with electronic case record data suggested good sensitivity and lower specificity, with clear indications of how to adjust the gain of the system to improve future event-detection efficiency. When the symptom-monitoring system was built into clinical management workflows to enable personalised alerts of symptom deterioration, it was shown to have potential use in promoting earlier intervention for relapse.
Talk 3 Implementation of a digital software system for recovery from psychosis early signs
Andrew Gumley1, Simon Bradstreet1, Stephanie Allan1, John Farhall2, John Gleeson3, Matthew Machin4, Maria Lambrou2; 1Institute of Health and Wellbeing, University of Glasgow, 2La Trobe University, Melbourne, Australia, 3Australian Catholic University, School of Psychology, Melbourne, Australia, 4University of Manchester
The detection and prevention of relapse in people who experience psychosis is important. EMPOWER is a complex intervention which is harnessing digital technology to identify risk of relapse in psychosis, and establish a pathway towards relapse prevention. This talk will report on findings from three stakeholder groups. Staff across Community Mental Health services in NHS Greater Glasgow and Clyde, UK and NorthWestern Area Mental Health, Melbourne, Australia were invited to participate, as well as service users with experience of psychosis and families and carers. The constructivist grounded theory approach was utilised to address the aims of the study. In total we conducted 25 Focus Groups (7 with service users, 5 with carers and 13 with staff). These Focus Groups comprised 23 service users, 38 carers and 86 mental health staff. All three groups reported the utility of early warning signs as a tool towards relapse prevention. However, each group differed in their conceptualisation of risk and their relative power to manage perceived risk. These perceptions of risk were closely linked to their roles and relationships with each other. Barriers and facilitators to implementation were conceptualised as existing at the level of service provision (e.g. staffing levels), fit with existing practice (e.g. potential relationships changes) and personal level of acceptability and making sense (e.g. access to one's own wellbeing data is useful). Results suggest several important factors for consideration when implementing self-monitoring via mobile phones for psychosis.
Talk 4 Integrating smartphone tools into clinical care: evolving regulatory, legal, and clinical workflow issues
John Torous1, Luis Sandoval1, Matcheri Keshavan1; 1Harvard Medical School, Boston, Massachusetts, USA
While efforts to improve the engagement and efficacy of smartphone app and sensors for psychosis patients continue to increase their clinical utility and validity, real world uptake remains lows. Drawing upon recent literature searches, consultation with attorneys, monitoring of healthcare legislation, and our team’s experience piloting smartphone apps for early course psychosis patients, this session will explore current barriers and opportunities to increase uptake of these digital tools in clinical care. While a review of United States case law reveals no legal precedent for mental health app liability, recent federal legislation offers insights into new means to certify apps as healthcare devices and differentiate clinical apps from a plethora of general wellness apps. Reviewing qualitative feedback our team’s three-month pilot of smartphone monitoring for patients with psychosis, we will discuss the resulting consensus on a need for better integration of app data with electronic medical records, better clinical summaries of data, and further education on mobile health technologies. Reviewing recent survey data from 100 patients with psychosis, we will also discuss the views and concerns of service users regarding privacy and safety for smartphone apps. Finally, we will review our team's smartphone ongoing research and integration efforts that aim to incorporate the principles discussed in this talk.
Question and Answer Period
Discussant: Amy Hardy, Institute of Psychology, Psychiatry and Neuroscience, Kings College London
Symposium Session 19
Tuesday, October 9, 4:30 - 6:00 pm, American Ballroom - North
New Directions for Cognitive Remediation in Early Psychosis
Chair: Michelle Friedman-Yakoobian, Center for Early Detection, Assessment and Response to Risk, Beth Israel Deaconess Medical Center, Massachusetts Mental Health Center, Harvard Medical School
Co-Chair: Shaun Eack, School of Social Work and Department of Psychiatry University of Pittsburgh
Speakers: Joseph Ventura, Christopher Bowie, Shaun Eack, Michelle Friedman-Yakoobian
Cognitive impairments begin early in the high risk period for psychosis and persist throughout the course of illness, leading to significant functional disability. Literature on interventions targeting neurocognition and social cognition in early course psychosis is growing and showing promising results. Effectiveness, predictors, mechanisms, and moderators of these interventions and how they relate to the pathophysiology of early course psychotic disorders is just beginning to be explored. Presenters will share emerging data on novel interventions designed to improve neurocognition and social cognition in patients with early psychosis or those at clinical high risk. Christopher Bowie will present on efficacy and effectiveness of cognitive remediation in patients with early versus long-term psychotic illness. Joseph Ventura will present data on the impact of cognitive remediation on social functioning, and negative and positive symptoms in first episode schizophrenia. Shaun Eack will present on 10-year follow-up data on cognitive enhancement therapy for early course schizophrenia. Michelle Friedman-Yakoobian will describe an adaptation of cognitive enhancement therapy for individuals at clinical high risk for psychosis. Sophia Vinogradov will be the discussant for this symposium and will comment on current progress and future directions for this work.
Talk 1 Cognitive Remediation Can Improve Negative Symptoms and Social Functioning in First-Episode Schizophrenia: A Randomized Controlled Trial
Joseph Ventura1, Kenneth Subotnik1, Denise Gretchen-Doorly1, Laurie Casaus1, Michael , Boucher1, Gerhard Hellemann1, Keith Nuechterlein1,2; 1Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, 2Department of Psychology, University of California, Los Angeles
Background: Meta-analyses have reported that the effects of cognitive remediation might go beyond improvement in cognition to include additional benefits for schizophrenia patients such as negative and positive symptom reduction and improvements in functioning. Method: A RCT compared Cognitive Remediation (CR) to Healthy Behaviors Training (HBT) in 80 patients (78% male) with a mean age of 21.9 years and mean education of 12.3 years who had a first psychotic episode within two years of study entry. Participants were trained using CR programs or received HBT involving 50 sessions over 6 months and then booster sessions over the next 6 months. The SANS and BPRS were used to assess symptoms. The UCLA Social Attainment Survey assessed social functioning. Results: Using GLMM, improvements over 12 months were found favoring CR for SANS Expressive Symptoms (p<.01), which was composed of Affective Flattening (p<.01) and Alogia (p=.04), and for SANS Experiential Symptoms (p<.01), composed of Avolition /Apathy (p=.04) and Anhedonia / Asociality (p<.01). Improvements were also found for the BPRS Positive Symptom Factor (p=.04) composed mostly of reality distortion (p<.01). CR was associated with improvements in social functioning (p=.05) as compared to HBT. Discussion: We confirmed that the beneficial effects of CR appear to extend beyond cognition to improvements in negative and positive symptoms, and social functioning in early course schizophrenia patients. These results suggest that cognitive remediation might have an impact at an early point in the illness when the reduction of risk factors for chronicity is most critical for promoting recovery.
Talk 2 Training Cognition in Psychosis: Effects of Perceptual Training and Executive Functioning Training Methods as a Function of Age
Christopher Bowie1, Michael Best1; 1Queen’s University
Several approaches to enhancing cognition have been used during the evolution of cognitive remediation for psychosis. The cognitive target of training differs across studies, from targeted to broad. Targeted training of perceptual skills has replicated effects on brain function, but less support for broader generalization than training of executive skills. Few studies have directly compared training across these dimensions. In this study, patients with psychosis were randomized to receive either perceptual skills training or executive functioning training, three sessions per week for three weeks with a therapist, and daily for 12 weeks with independent at-home training. Pre- and post-treatment measures included neurophysiological functioning, cognitive abilities, functional competence, and everyday functioning outcomes. Data from 70 patients with psychosis, including a subgroup with first-episode psychosis, will be compared both across training modalities and length of illness. At the time of the abstract, all participants have been enrolled in the trial with a last assessment date in March 2018.
Talk 3 Ten Year Durability Effects of Cognitive Enhancement Therapy in Early Course Schizophrenia
Shaun Eack1, Jessica Wojtalik1, Matcheri Keshavan2; 1School of Social Work and Department of Psychiatry University of Pittsburgh, 2Beth Israel Deaconess Medical Center, Massachusetts Mental Health Center, Harvard Medical School
Background: The purpose of this investigation was to examine the long-term trajectories of cognitive, functional, and clinical outcomes following Cognitive Enhancement Therapy (CET) in early course schizophrenia. Methods: Schizophrenia outpatients from a 2-year randomized clinical trial of CET applied in the early course of the illness are completing a 10-year post-treatment follow-up study. Participants from the original trial have completed a comprehensive battery of cognitive, functional, and clinical assessments identical to those in the original trial. Composite indexes were calculated for processing speed, neurocognition, social cognition, functioning, and symptomatology. Linear growth curve models were used to examine longitudinal durability differences in these five domains 10-years following treatment with either CET or an Enriched Supportive Therapy (EST) comparison treatment. Results: Social-cognitive ability favoring CET was stable across the 10-year follow-up period, with continued evidence of group separation and little evidence of erosion of efficacy. Some reduction in functioning was observed in both groups after completing treatment (all p < .001), but after 10 years patients in CET retained a higher level of functioning over the follow-up period. Finally, group separation favoring CET in symptomatology continued to persist relative to EST over the course of 10-year follow-up. Conclusions: Although these data are considered preliminary, the results suggest that CET is an effective treatment that contributes to long-term and stable improvements in cognition and functional outcome in people with schizophrenia treated in the early course of the illness.
Talk 4 Cognition for Learning and Understanding Everyday Social Situations (CLUES) for Youth at Clinical High Risk for Psychosis
Michelle Friedman-Yakoobian1, Matcheri Keshavan1; 1Center for Early Detection, Assessment and Response to Risk (CEDAR), Beth Israel Deaconess Medical Center, Massachusetts Mental Health Center, Harvard Medical School
Cognitive remediation approaches, especially those that are accompanied by intensive psychosocial rehabilitation, have shown promise for improving cognition and functional outcomes in individuals with schizophrenia. The movement of the field towards earlier detection and treatment of those at risk for psychosis has prompted questions about whether these approaches, when applied to youth at risk for psychosis, may have the capacity to reduce or prevent cognitive decline and associated functional disability. One approach that has shown promise for improving cognition and functioning in individuals with schizophrenia is cognitive enhancement therapy (CET), which is an intensive, individualized program that combines drill and practice cognitive training with group based skills training for enhancing neuro and social cognitive functioning. CET has been associated with improved cognition and role functioning in clients with chronic and early course schizophrenia. This talk will describe a modification of CET aimed for youth at clinical high risk (CHR) for psychosis. This program, named CLUES (Cognition for Learning and for Understanding Everyday Social Situations), has been modified to meet the unique developmental needs of a younger population of individuals at CHR. An overview of CLUES will be provided and data from an initial feasibility and small RCT will be shared and discussed.
Question and Answer Period
Discussant: Sophia Vinogradov, University of Minnesota Medical School
Symposium Session 20
Tuesday, October 9, 4:30 - 6:00 pm, American Ballroom - Center
Using Serious Games and Virtual Reality to prevent and treat mental health problems in young people
Chair: Lucia Valmaggia, King's College London, Institute of Psychiatry, Psychology & Neuroscience
Speakers: Sophie Browning, Charlotte Gayer-Anderson, Merete Nordentoft, Gary O' Reilly
Being online has become an integral part of our daily life, and the majority of young people spend large part of their time interacting with new technologies, whether it is at school, to play games, to communicate with each other, or to relax. In this symposium, we explore how new technologies can be applied for the prevention and in the treatment of mental health problems. CUES-ED combines traditional teaching methods with new interactive technologies to build resilience in 7-10 years olds school children. The REACH study and the Danish High Risk study, have integrated Virtual Reality in the assessment of mental health problems to measure the real-time response to social interactions and to identify liability and resilience factors to emerging mental health problems in children and teenagers. To conclude we will present Pesky gNATs, a computer based intervention which integrates CBT with serious games to help children and young people experiencing anxiety and depression.
Talk 1 CUES-Ed: A universal early intervention programme for primary school children to promote wellbeing and resilience and to de-stigmatise mental health problems
Sophie Browning1, Debbie Plant1, Anna Redfern1, Karen Bracegirdle1, Suzanne Jolley2; 1South London and Maudsley NHS Foundation Trust, 2King's College London, Institute of Psychiatry, Psychology & Neuroscience
Difficulties meeting the need for mental health care amongst children and adolescents has led to increasing interest in resilience-building programmes delivered in public health settings. CUES-Ed is a universal clinician-led, school classroom-based programme for 7-10 year olds, rooted in cognitive behavioural therapy (CBT) and models. The central theme is ‘keeping our brains amazing’ by looking after our physical wellbeing; learning that thoughts, feelings and behaviour are interconnected; and building practical skills to help children manage life’s ups and downs. Uniquely, CUES-Ed also includes a focus on unusual perceptual experiences which have been associated with a range of adverse mental health outcomes. Sessions are delivered in a highly active and engaging way and the programme creatively utilises a range of innovative new technologies that help make abstract concepts more concrete and memorable. Our visually strong and recognisable branding and characters also help promote mental health in a positive way. Routine service evaluation has yielded promising findings in terms of pre-post improvements in general wellbeing, and in emotional and behavioural difficulties for those children scoring in the borderline or clinical ranges. Children self-reported an increased repertoire of coping strategies. Feedback from children, parents and teachers indicates that CUES-Ed is acceptable and subjectively helpful. Future developments include incorporating elements from our CUES (Coping with Unusual ExperienceS for Children) CBT manual, to adapt CUES-Ed for a clinical CAMHS population.
Talk 2 Validation of self-reported paranoid thoughts amongst adolescents using Virtual Reality
Charlotte Gayer-Anderson1, Gemma Knowles1, Stephanie Beards1, Maria Rus-Calafell1, Craig Morgan1, Lucia Valmaggia1,2; 1King's College London, Institute of Psychiatry, Psychology and Neursocience, 2South London and Maudsley NHS Foundation Trust
Background: Studies of suspiciousness about others in early adolescence have relied almost exclusively on self-report measures, with high resulting prevalence estimates (~30-45%). Virtual reality (VR) has successfully been used in adult samples to discriminate more precisely between potentially rational perceptions of threat, and unfounded paranoia. Using the first laboratory method for capturing the experience amongst adolescents, we are assessing the extent of agreement between self-report and interview measures of paranoia and low-level paranoia towards neutral avatars in a VR environment. Methods: Self-report and interview data on low-level paranoia are being collected from adolescents as part of a new cohort study, REACH (Resilience, Ethnicity and AdolesCent mental Health). Around 200 adolescents from REACH will be invited to enter a VR school canteen populated by neutral characters, and will be assessed on positive, neutral, and negative thoughts about the avatars. Results: Current pilot data (n=29) provides suggestive evidence that higher levels of negative thoughts towards the neutral characters was associated with feeling lonely (β 4.04, p 0.045), generalized anxiety (β 8.04, p 0.001), and depression (β 6.45, p 0.001). There was no association between VR-rated paranoid thoughts and self-report paranoia (β 0.27, p 0.851). Additional data will be available at the time of the conference. Conclusions: There is a need for simple and effective methods to accurately identify those with paranoia since these experiences are associated with increased distress and poor functioning in the short-term, and a range of severe mental health problems in the long-term. VR could be one such method.
Talk 3 Use of Virtual Reality to identify liability to social anxiety and paranoid ideas in the Danish High Risk and Resilience study
Merete Nordentoft1,2, Anne Søndergaard1,2, Maja Gregersen1,2, Nicoline Hemager1,2, Kerstin Jessica Plessen2,3, Niels Ole Mors2,4, Anne A. E. Thorup1,2,3; 1Mental Health Center Copenhagen, Psychiatric Research Unit, Mental Health Services, Capital Region of Denmark, University of Copenhagen, 2The Lundbeck Foundation Initiative for Integrative Psychiatric Research (iPSYCH), 3Child and Adolescent Mental Health Center, Research Unit, Mental Health Services, Capital Region of Denmark,& University of Copenhagen, 4Research Department P, Aarhus University Hospital, Risskov, Denmark
The Danish High Risk and Resilience Study - VIA7 is a representative nationwide cohort study of 522 7-year old children of parents with schizophrenia, bipolar disorder or neither of these disorders. The children and their parents were thoroughly examined, when the children were seven years old. We are now reassessing all the children at age 11 and their families. In self-reports, high risk children more often report being bullied, but it is uncertain whether this is a sad fact or a marker of aberrant attributional style. A standardized social situation in a virtual reality scenario will help us to identify any liability to social anxiety and paranoid ideas. Therefore, we have developed a Virtual Reality (VR) scenario, which is a sensitive, standardised and direct measure of liability to anxiety, and paranoid ideas, which can be subtle signs of emerging mental disorders. VR can increase validity of assessments, by standardizing the exposure. Preliminary results from the first 200 children will be presented This VR format has the potential to become a crucial element in cognitive behavioural treatment of phobia, PTSD, social withdrawal and paranoid ideas, because exposure is considered as a very valuable element in cognitive behavioural therapy. However, exposure in real life can be hard to organize, and the VR animation allows exposure to challenging situations in an immersive, but also protected and controlled environment. The difficulty of the exposure can be changed, e.g. patients can be exposed to more hostility or higher levels of laughter.
Talk 4 Pesky gNATs! A CBT Computer Game and App for Young People with Anxiety or Depression.
Gary O' Reilly1; 1School of Psychology, University College Dublin.
This paper will describe Pesky gNATs, a computer assisted Cognitive Behaviour Therapy (CBT) intervention for young people aged 9 years or older experiencing anxiety or low mood. Pesky gNATs is designed to assist mental health professionals to deliver a CBT intervention filtered through the ideas of developmental psychology and learning theory, packaged within a computer game, played within the supportive context of a therapeutic relationship. Pesky gNATs has three components: (1). A computer game that delivers a child friendly CBT intervention. The game is played in session by a young person along-side a mental health professional. The game has seven levels, each delivering a single component of a customized developmentally appropriate CBT intervention, designed to be the equivalent of a standard treatment session in length to play. The CBT concepts in each game level are related and build on each other over the course of the programme. (2). A mobile app - freely available to any young person playing the game to download to their smartphone or tablet. The Pesky gNATs App supports the young person’s application of the CBT ideas they learn in session to their everyday life at home and school. (3). An on-line training suite for mental health professionals allowing them to train to use our programme and download it to their work computer. This paper will also describe the evidence supporting Pesky gNATs and our plans for its future development.
Symposium Session 21
Tuesday, October 9, 4:30 - 6:00 pm, American Ballroom - South
Youth/Peer Participation and Leadership in Early Intervention Services & Research: Towards the Future
Chair: Nev Jones, University of South Florida
Speakers: Sascha DuBrul, Vanessa Klodnick, Stephanie Allen, Tamara Sale
Across mental health services research, increasing emphasis has been placed on the importance of involving youth and young adults with lived experience across the areas of program development, service implementation and research. Both peer-led research and research on peer or youth-led service components in early intervention nevertheless remain under-researched and under-represented in both the scientific literature and academic conferences. The goal of this symposium is to showcase four exemplary peer-led and/or peer-involvement focused projects from the US and UK in order to increase the visibility of youth/peer research leadership and its transformative potential. These presentations span research on the underlying mechanisms of peer support for young adults (DuBrul), emerging best practices in young adult peer supervision (Klodnick), the role of service user involvement in addressing implementation gaps in early intervention services (Allen) and in seeding innovation (EASA Young Adult Leadership Council). The symposium chair will begin with a brief overview of the international landscape of peer involvement in research and program development, followed by the four presentations, and concluding with a group Q & A.
Talk 1 What Makes a 'Peer'? Deconstructing Young People's Perceptions of Shared Experiences & Identities to Inform Peer Support in Early Intervention
Sascha DuBrul1; 1New York State Psychiatric Institute, NY, NY, USA
Purpose: In both the peer support literature and in practice, it is generally assumed that shared experience of specific diagnoses, mental health challenges and/or treatment are the primary basis for a shared "peer" identity and that these shared experiences in turn serve as primary drivers of the effectiveness of peer support. The goal of the service user led project described in this presentation was to investigate the extent to which both young adult service users and peer specialists working in early intervention (EI) settings in fact center shared mental health experiences versus other potentially salient aspects of shared identity including age, shared interests, background adversity, race/ethnicity and sexual orientation or gender identity. Methods: We conducted a mixed methods research project including a survey (n = 50) and interviews (n = 15) with both young adult current/former service users and peer specialists working in EI. Results: Our data suggest that there are a wide range of views on the perceived subjective importance of shared treatment or diagnostic experiences among young adults, with some interview participants expressing strong disidentification with their diagnoses or identities as a "service user" and a preference for relationships and mutual support premised on other (non mental health related) categories. Conclusion: We will discuss implications of our findings including the potential for mutual support interventions that foreground shared experiences, identities and/or interests unrelated to diagnosis, symptoms or treatment and propose next steps vis-a-vis both service development and research.
Talk 2 Developing Effective Supervision Practices & Processes for Young Adult Peer Mentors in Massachusetts
Vanessa Klodnick1; 1Thresholds Research, Chicago, IL, USA
Purpose: To boost engagement and ensure services are young person-informed, peer support is becoming increasingly common in transition-age youth mental health programs. Supervision is key for young adult peer support on-the-job success. However, what supervision looks like for young adult peers varies widely. Methods: Massachusetts successfully integrated Young Adult Peer Mentoring (a Medicaid reimbursable service) statewide for 14-21 year olds with mental health challenges. Through a partnership with the University of Massachusetts Transitions to Adulthood Center for Research and Thresholds in Chicago, supervision principles, practices, online and in-person trainings, and a guidebook were developed for Young Adult Peer Mentor supervisors. Results: Over 100 supervisors participated in on-line webinars, in-person trainings, and community of practice calls between 2015 and 2017. Participant feedback was exceedingly positive, calling for additional tools, which led to the development of a Young Adult Peer Supervision Guidebook. The trainings and guidebook help supervisors to effectively use the working alliance, reflective supervision, strategic use of self, and self-care in order to provide culturally attuned, developmentally focused supervision to peers. The trainings and guidebook are available at: http://www.cbhknowledge.center/yapm-supervisor-tool-kit. Conclusions: Advances in young adult peer supervision theory, practice, and processes in Massachusetts have implications for child and adult serving systems and providers. Research is needed to evaluate the impact of supervisor development initiatives within transition-age youth serving programs in Massachusetts and beyond.
Talk 3 Addressing the Research to Practice Gap through Co-Production & Service User Leadership in Early Psychosis Intervention Research
Stephanie Allen1; 1University of Glasgow, Glasgow, United Kingdom
Purpose: Digital technologies offer much promise in delivering psychosocial interventions for early psychosis. However, many interventions that appear to work within the context of a clinical trial fail to become part of everyday practice. This failure to implement seemingly successful interventions into routine practice wastes money and time, and also raises concerns that people are unable to access interventions that could improve their wellbeing. Implementation can be more successful if we take greater account of users' experience and engage in collaborative practice (Gillard et al., 2016). Collaborating with service users and valuing their experiential knowledge can help anticipate structural implementation barriers relevant to service users alongside those experienced by staff. Methods: EMPOWER is a digital intervention which aims to enhance control and promote recovery for people with psychosis (including those using early intervention services) through the early identification of potential relapse. Service user involvement has been key to the development of the intervention. Implementation of EMPOWER is also supported by peer support workers. In addition, a service user researcher is evaluating the implementation process as part of an ongoing cluster randomised controlled trial. Findings: This talk will offer reflections from the service user evaluator on how direct user involvement can not only make interventions more relevant for people with psychosis but also potentially develop a more valid understanding of the implementation process. Conclusions: Service user involvement in early intervention research and development has the potential to significantly impact the form interventions take and the questions we ask in evaluating them.
Talk 4 From Participatory Leadership to Participatory Research: Integrating Lived Experience into the Evidence Base for Early Intervention
Tamara Sale1; 1Early Assessment and Support Alliance (EASA) Center for Excellence, Oregon Health Sciences University, Portland, OR, USA
Purpose: Responding to the need to increase the meaningful involvement of youth/young adults, the EASA Young Adult Leadership Council (YALC) was created in 2013 to provide direction and feedback to Oregon’s statewide early psychosis dissemination effort. Methods: YALC members have prioritized improving rapid identification and early engagement in EASA, and used their own experiences to inform policy development, research, clinical training and practice. YALC's interest in reducing early drop-out and increasing initial engagement led to the EASA Connections research study in which EASA graduates and participants worked with researchers and EASA clinicians to design and develop a peer-oriented web resource and investigate its impact on new individuals entering the EASA program. Findings: EASA Connections is in the final stages of testing. The iterative process in which YALC generated priorities informed by data and understanding of the EASA program, launched a separate participatory research process, and participated in the development and implementation of the research, provides a template for similar bodies in other programs. In addition, the Leadership Council has spearheaded the use of iterative feedback to develop policy recommendations and feedback for practice guidelines, written materials and trainings, in a fashion which may begin to inform the field about how such leadership groups can integrate lived experience, quality improvement, research and policy advocacy to maximize the impact and effectiveness of early psychosis efforts. Conclusion: EASA's experiences underscore the impact of young adult leadership and the importance of incorporating such mechanisms in EI.
Symposium Session 22
Tuesday, October 9, 4:30 - 6:00 pm, Staffordshire
Mission Creep: Will widening the range of ages and diagnoses in Early Intervention in Psychosis teams, without new resources, undermine their mission and dilute their methods, intensity and outcomes to the point of no difference?
Chair: Alan Rosen, Brain & Mind Centre, University of Sydney, Institute of Mental Health,University of Wollongong, Australia
Co-Chair: Patrick McGorry, Orygen Youth Mental Health Centre, University of Melbourne, Australia
Speakers: Alan Rosen, Katherine Boydell, Peter Byrne, Patrick McGorry
Does the evidence support having Early Intervention (EI) teams which cover wider diagnoses and age groups, or does it still only squarely support having discrete early intervention teams for young people with first episodes of psychosis? Meanwhile, triage and initial counselling services as a "one-stop-shop" or "clearing house" for assessing and assisting with all mental health disorders in young people, or exploratory programs for EI's of other disorders and other age-groups may be promising. However, they require further evaluation at this stage, for evidence of better outcomes. Should we enhance and resource EIP teams for young people to allocate a minority of extra places (say 10-15%) for severe high intensity disorders of a wider spectrum of psychiatric diagnoses which require a similar approach (as for psychosis) whether in ultra high risk states, acute early episodes requiring intensive mobile community care and assertive rehabilitative/recovery work? eg major affective disorders, disabling anxiety states, and severe eating disorders. This would not denature the clinical and functional teamwork protocols, and therefore should not diminish outcomes for first episode psychoses. Further, should trauma specific care be provided in common to most severe disorders? These approaches are consistent with Rosen, McGorry, Byrne and Goldstone chapter in Tasman A et al, eds, “Psychiatry” current 4th edition textbook, Wiley, 2016, on early Intervention across multiple disorders and age-groups, Byrne & Rosen, eds, "Early Intervention in Psychiatry : EI of nearly everything for better mental health" Blackwell-Wiley, 2014, and McGorry, EI: Mission Cramp Vs Mission Creep, ANZJP, 50, 11:1033-1035.
Talk 1 Will widening the range of ages and diagnoses in Early Intervention in Psychosis teams dilute their methods and outcomes? How specific, how focussed, how intensive, and how pure in diagnosis, purpose and age-group criteria do these teams need to be to achieve consistently better outcomes?
Alan Rosen1,2; 1Brain & Mind Centre, University of Sydney, Australia, 2Illawarra Institute of Mental Health, University of Wollongong, Australia
Does the evidence support having Early Intervention (EI) teams which cover wider diagnoses and age groups, or at this stage does it still only squarely supports having discrete teams for early intervention teams for young people with first episodes of psychosis? Meanwhile, triage and initial counselling services as a "one-stop-shop" or "clearing house" for assessing and assisting with all mental health disorders in young people, or exploratory programs for EI's of other disorders and other age-groups may be promising. However, they require further evaluation at this stage, for evidence of better outcomes. At the same time, perhaps we should consider EIP teams for young people reserving a minority of places (say 10-20%) for severe high intensity disorders of a wider spectrum of psychiatric diagnoses which require a similar approach (as for psychosis) whether in ultra high risk states, acute early episodes requiring intensive mobile community care and assertive rehabilitative/recovery work. eg post-traumatic, major affective disorders, disabling anxiety states, and severe eating disorders.This would not denature the clinical and functional teamwork protocols and therefore should result in equivalent outcomes as for first episode psychoses. Training, working and supervising to evolving fidelity criteria for evidence based early interventions and service delivery systems, as well as contextual considerations, like agegroup specific and friendly facilities and practices, and home visits and social system intervention to engage, educate and elicit collaboration with both individuals and families, may be more crucial to success than procedural purity.
Talk 2 Women over 25+ years with first episode psychosis: A rationale for extending early intervention in psychosis services [or should we provide specific FEP teams for this age-group]?
Katherine Boydell1,2; 1Black Dog Institute, School of Psychiatry, University of New South Wales, Australia, 2Child Health Evaluative Sciences, The Hospital for Sick Children, Department of Psychiatry, University of Toronto, Canada
Psychotic disorders are serious mental disorders resulting in significant human and economic impact. Early intervention for individuals with psychosis is effective in enabling better clinical and functional outcomes, however, most specialist services in early intervention in New South Wales, Australia work within an upper age limit of 25 years. We identify the need to explore help-seeking (pathways to care) and care-receiving narratives (experiences of services/supports) of 70% of women (in NSW, Australia) who experience a first episode of psychosis (FEP) when over 25 years of age and who are, therefore, frequently excluded from specialist early intervention. There is little research on this group and consequent lack of an evidence-base to inform service design and delivery. What is clear is that: 1) a significant proportion of women experiencing FEP are excluded from specialist early intervention services as they are over the arbitrary age limit, 2) these women’s specific needs are not addressed by general or youth services, and 3) the failure to provide specialist treatment has deleterious effects for them and their children. We provide an overview of the need to examine these women’s help-seeking and care-receiving experiences via mixed methods in order to understand how to best support women at home, school/work, and within their community, and inform practices in mental health, education/employment and welfare service settings. Specific evidence-based knowledge translation strategies will be suggested to ensure that findings meaningfully impact stakeholders and influence health-care practices and policy and redress the inequity of healthcare experienced by this group of women.
Talk 3 Whither and Where Next for Early Intervention Teams in the UK?
Peter Byrne1,2,3; 1Royal London Hospital, East London NHS Foundation Trust, England, 2Royal College of Psychiatrists, UK, 3Centre for Health Policy, University of Strathclyde, UK
Many London EI teams are now seeing adults into their 30s. I have come across some females (late 30s and 50+) who had psychotic depression and were complex, They had great results thanks to flexible EI team working; but can this work continue to be extended without more resources? What about working with vulnerable infants and young children? On the other hand does this trend represent the potential serial diluting of the EIP model in the NHS, England, by extending the scope of the EIP teams to cope with both wider age groups (beginning with teams stretching to 18-36 and some to 18-65) and all mental health diagnoses and all high risk states. This presentation will explore the pro's and con's of these developments, and review their impacts so far. In addition, there are new requirements to meet intake deadlines and comprehensive delivery requirements in return for nominal new enhancements for their trusts based on the National Access & Waiting Time Policy Standard. Is this resulting in real stabilization and further constructive development of EI teams, or is this an acceptance of an offer of a Faustian Pact under pressure, or resignation to having to comply with an unpalatable deal that they can’t refuse? Firstly, will this enhancement really come back to EI teams? ? In reality are they just being asked to do more, more superficially with less resource? Secondly will it denature the culture & skills of a service which is vulnerable young-person friendly & developmentally focussed?
Talk 4 Has Mission Creep crept into Early Intervention? Beware a reversion to the former status quo of superficial and unfocussed services.
Patrick McGorry1,2; 1Orygen Youth Mental Health Centre, University of Melbourne, Australia, 2International Association for Youth Mental Health, Australia
Dementia Praecox was named thus for a reason. Most cases appear in young people though a minority of cases do present later in life, some after youth onsets with very long DUPs. The AESOP study data, which seems to have prompted the unfortunate move of inducing early intervention services in some countries to fall for the “3 card trick” of adding in older patients without more resources. Instead of creating a developmentally appropriate model for this subgroup, the successful and cost effective EI model has been undermined in a reversion to the status quo. Much more sensible would have been adding resources and making the EI model available to a range of complex syndromes where working intensively to EI protocols and specialist expertise are required. This would build a specialist youth mental health model to integrate horizontally with EIP services and vertically with youth friendly primary care and also with acute youth mental health care including inpatient services. While over-relying on the AESOP study which is out of kilter with most of the literature, and possibly over-estimating the proportion of disabling FEP’s emerging in older age groups, Lappin et al (2016) legitimately argue for EI provision for FEP’s starting over 25 or even 35. They also suffer from delayed access and outcomes that are equally as poor as in younger individuals with FEP, which are likely to be improved by more intensive and sustained EIP care. The question is how to do it, without disrupting clearly evidence-based EIP youth-friendly services.
Question and Answer Period
Discussant: Peter Jones, Professor of Psychiatry, University of Cambridge UK, President IEPA
Symposium Session 23
Wednesday, October 10, 1:00 - 2:30 pm, American Ballroom - North
Active and Passive Data from Daily Life: Applications at Different Levels of Analysis for Prediction and Early Intervention
Chair: Kristen A Woodberry, Beth Israel Deaconess Medical School, Harvard Medical School
Co-Chair: John Torous, Beth Israel Deaconess Medical School, Harvard Medical School
Speakers: Sarah Lynch, Kristen A Woodberry, Zuzana Kasanova, John Torous
The proliferation of smartphones has launched a new era of research providing insight into the dynamics and underlying mechanisms of mental health and mental illness. In this symposium, we will illustrate the potential of different types of digital data and levels of analysis for predicting and intervening in symptom patterns, risk, phenotypes, and trajectories. Sarah Lynch, MSW, will present the clinician’s perspective, illustrating how time-lagged analysis of daily affect and psychosis ratings can inform clinical intervention, from psychoeducation to psychopharmacology. Kristen Woodberry, MSW, Ph.D., will expand on this, examining how symptom dynamics may improve on static predictors in the early stages of mood and psychotic disorders. Preliminary experience sampling data from youth ages 15-25 with psychotic spectrum disorders will illustrate different patterns of affect and psychosis variability. Zuzana Kasanova, Ph.D., will discuss the association of reward-oriented behavior in daily life and striatal reward-related dopamine release in the lab using data collected in healthy volunteers and first degree relatives of patients with psychosis. John Torous, M.D., will illustrate how a combination of smartphone active data (surveys and voice samples) as well as passive data (geolocation, accelerometer, call/text logs) can be combined to create a digital phenotype of early psychosis. Using freely available and open source research apps, the talk will feature examples and discuss the ethics, implementation, and analysis of digital phenotyping data. Finally, Inez Myin-Germeys, Ph.D., will discuss the overall implications of different digital data and levels of analyses for the science of early intervention.
Talk 1 Using daily diary data to guide differential treatment of affect and psychosis in early course psychotic disorders
Sarah Lynch1; 1Maine Medical Center
Background: The interplay between affect and psychosis is often complex during the first years of a psychotic illness, particularly in adolescents and young adults. Determining the primary target of treatment can be challenging, particularly with weekly or less frequent self-report. Methods: Participants of a specialized first episode psychosis program rated affective and psychotic symptoms on a daily basis over multiple weeks of treatment. Auto-, cross-lagged, and between symptom correlations are calculated. Results: Statistical correlations augment visual graphs to illustrate periods of stability, instability, and temporal sequencing in affect and psychosis. Clinical examples will highlight the use of these data in patient or family psychoeducation, clinical problem solving, and the selection of primary and secondary treatment targets. Discussion: Individual tracking of symptoms within and across multiple days can highlight predictive shifts, not only in levels of affect or psychosis, but also in the degree to which they vary and relate. Temporal analyses of symptom dynamics could help individuals and their clinicians recognize early warning signs and alter treatment targets, priorities, or strategies to improve symptom management and clinical outcomes over time.
Talk 2 Within and between day variability of affect and psychotic-spectrum symptoms in psychotic-spectrum and healthy youth
Kristen A Woodberry1,2, Kelsey Johnson1, Sarah Lynch3, Anna Cloutier3, Douglas Robbins3, Kristen Woodberry; 1Beth Israel Deaconess Medical Center, 2Harvard Medical School, 3Maine Medical Center
The majority of major mental illnesses emerge between ages 15 and 24. Yet initial symptoms, typically subtle disruptions of both affect and thought, are precursors of a range of serious disorders including schizophrenia spectrum, bipolar, borderline personality disorders, and severe depression and anxiety. There have been efforts to identify specific symptoms or combinations of symptoms, demographic variables, and biomarkers predictive of later disorder, particularly schizophrenia. However, there has been little research capturing the temporal sequence or variability of affect and unusual thoughts during the early phases of mental illness and across different trajectories. Preliminary experience sampling data from youth ages 15-25 with and without psychotic spectrum disorders will illustrate different patterns of variability in affect and psychosis within and across days and weeks. The author will highlight the potential relevance of different measures of variability (e.g., intensity and valence, positive to negative affect shifts), temporal variations (moment-to-moment, day-to-day, week-to-week), periods of stability and instability, and the temporal sequencing and relationships of affect and psychosis over time. Improving on static predictors of mood and psychotic disorders, dynamic data could transform clinical formulation and treatment planning with high risk youth, leveraging digital data for personalized medicine approaches to early intervention.
Talk 3 Striatal Dopaminergic Modulation of Reward Learning Predicts Daily-Life Reward-Oriented Behavior in Individuals at a Familiar Risk for Psychotic Disorder
Zuzana Kasanova1; 1Leuven University
Abnormalities in reward learning in psychotic disorders have been proposed to be linked to dysregulated subcortical dopaminergic (DA) neurotransmission, which in turn is a suspected mechanism for predisposition to psychosis. We therefore explored the striatal dopaminergic modulation of reward processing and its behavioral correlates in individuals at familial risk for psychosis. We performed a DA D2/3 receptor [18F]fallypride PET scan during a probabilistic reinforcement learning task in 16 healthy first-degree relatives of patients with psychosis and 16 healthy volunteers, followed by a six-day ecological momentary assessment study capturing reward-oriented behavior in the everyday life. We detected significant reward-induced DA release in bilateral caudate, putamen and ventral striatum of both groups, with no group differences in its magnitude nor spatial extent. In both groups alike, greater extent of reward-induced DA release in all ROIs was associated with better performance in the task, as well as in greater tendency to be engaged in reward-oriented behavior in the daily life. These findings suggest intact striatal dopaminergic modulation of reinforcement learning and reward-oriented behavior in individuals with familial predisposition to psychosis. Furthermore, this study points towards a key link between striatal reward-related DA release and pursuit of ecologically relevant rewards out in the real world.
Talk 4 Towards Digital Phenotyping for Relapse Prediction in Schizophrenia
John Torous1,2, Ian Barnett3, Patrick Staples3, Luis Sandoval1, JP Onella3, Matcheri Keshavan1,2; 1Beth Israel Deaconess Medical Center, 2Harvard Medical School, 3Harvard School of Public Health
The SMART study is a pilot investigation into digital phenotyping for schizophrenia and related psychotic disorder. Utilizing the Beiwe platform that runs on patients' personal smartphones, the app can collect active data in the form of surveys and passive data in the form of real time GPS, accelerometer, anonymized call/text logs, screen use time, power status, and other features. The goal of the SMART study was to 1) assess feasibility of this method of data collection in participants with schizophrenia and 2) collect pilot data regarding the utility of digital phenotyping to aid in relapse prediction in schizophrenia Patients in active treatment and with a diagnosis of schizophrenia or a related psychotic disorder were recruited and asked to use the Beiwe app for up to 3 months. We used anomaly detection methods to calculate relapse risk based on the smartphone passive data as well as survey responses. 17 research participants used the smartphone app for up to 3 months. Three research participants experienced a clinical relapse that was recorded by the app. No participants experienced any adverse event or negative outcomes during the course of the study related to app use. While these pilot results preclude reporting on the sensitivity and specificity of digital phenotyping in relapse prediction, they do suggest this method is acceptable to patients with schizophrenia and related disorders. Our group is currently conducting a larger scale study to better characterize this method of relapse prediction.
Question and Answer Period
Discussant: Inez Myin-Germeys, Leuven University
Symposium Session 24
Wednesday, October 10, 1:00 - 2:30 pm, American Ballroom - Center
The need of effective interventions for first episode psychosis in adolescents and young adults
Chair: Celso Arango, Department of Psychiatry, Hospital Universitario Gregorio Marañón, Universidad Complutense, CIBERSAM
Speakers: Celso Arango, Brian O’Donoghue, Olga Puig, Sophia Vinogradov
For the last few decades, clinical research has focused on improving early detection and treatment for young people with psychosis. Finding effective psychosocial treatments, designed to improve coping and assist in stress reduction, has been a crucial goal in this context. In particular, current evidence supports the effectiveness of two kinds of interventions: psychotherapy (mainly CBT, Family Therapy, and Psychoeducation) and cognitive remediation. However, some controversial questions still remain: Within psychotherapy, there is some debate about the differential effectiveness of discrete psychological interventions as compared with early intervention services. In contrast, within cognitive remediation, the debate revolves around the different methods of work, fundamentally the classic ones (paper-and-pencil task/top down) vs. other more basic ones (bottom-up processing). The differential effectiveness of these interventions in different age groups (e.g., adolescents vs. adults) also remains unclear. This symposium aims to provide a global vision of the different psychotherapeutic approaches for the young population with psychosis. We will present data from a discrete psychoeducational intervention (the PIENSA program), exploring its long-term benefits; from a specialized clinical center “the Early Psychosis Prevention and Intervention Centre (EPPIC),” searching for the differential therapeutic needs in adolescents vs. young adults; and from two discrete, methodologically different cognitive remediation therapies (one top-down and one bottom-up), exploring their effects on both cognition and functioning in adolescents and young people with early-onset psychosis.
Talk 1 LONG-TERM EFFECTS OF AN INTERVENTION FOR ADOLESCENTS WITH EARLY ONSET PSYCHOSIS AND THEIR FAMILIES. THE PIENSA PROGRAM
Celso Arango1, María Mayoral1; 1Hospital Universitario Gregorio Marañón, Universidad Complutense, CIBERSAM
Early specialized care may improve short-term outcomes in first-episode psychosis. We implemented a psychoeducational group program (PIENSA) and showed that it helped adolescent patients and their families manage crises, improved patients’ negative symptoms, and increased their involvement in social activities in the short-term. However, it was unclear whether the benefits persist over time. Objective: To investigate whether the beneficial effects of a structured psychoeducational group program for adolescents with early-onset psychosis and their families, observed immediately after the intervention, were maintained two years later. Method: The current study examines the two-year longitudinal efficacy of a randomized controlled trial based on a structured psychoeducational problem-solving group intervention for adolescents with early-onset psychosis and their families (PE) compared with a non-structured group intervention (NS). We analyzed whether the differences found between PE and NS after the intervention persisted two years later. Results: At the two-year follow-up, 89% of patients were able to be reassessed. In the PE group, 13% of patients visited the Emergency Department as compared with 50% in the NS group (p=0.019). However, no statistically significant differences were found between the two groups in terms of negative symptoms or number and duration of hospitalizations. Conclusions: A psychoeducational group intervention showed sustained effects on diminishing the number of Emergency Department visits two years after the intervention. However, improvement in negative symptoms is not maintained. We will present the new actions implemented by the PIENSA team in order to enhance the long-term effects of our intervention.
Talk 2 SYMPTOMATIC AND FUNCTIONAL OUTCOMES OF YOUNG PEOPLE WITH AN EARLY ONSET PSYCHOTIC DISORDER
Brian O’Donoghue1,2,3, Patrick McGorry1,2; 1Orygen, the National Centre of Excellence in Youth Mental Health, Melbourne, Australia, 2Centre for Youth Mental Health, University of Melbourne, Australia, 3Orygen Youth Health, 35 Poplar rd, Parkville, VIC 3052, Australia
It has been suggested that early onset psychosis (before the age of 18) may represent a more severe variant of the disorder as a number of studies have indicated a poorer outcome in this sub-group. However more recent evidence has suggested that those with early onset have a more favourable course of illness and outcome. Methods: This study was conducted at the Early Psychosis Prevention and Intervention Centre (EPPIC) and included all young people aged 15 to 24 who presented with a first episode of psychosis (FEP) in a defined catchment in Melbourne between 01/01/11 and 31/12/13. The management at EPPIC includes psychopharmacology, cognitive behavioural therapy and psychosocial interventions. Results: A total of 544 young people presented with a FEP during the three year period and 37.1% had an onset before the age of 18. Young people with an early onset psychotic disorder were more likely to be female, be born in Australia, have a diagnosis of Psychosis NOS and less likely to have a concurrent substance abuse disorder. 42% of young people with early onset psychotic disorder experienced a relapse following symptomatic remission, which was comparable to those with a later onset. Functional outcomes were superior in those with an early onset, with 60% returning to either school or work by the time of discharge, compared to 50% of those with a later onset. Conclusions: These results indicate that with the appropriate management, young people with an early onset of a psychotic disorder can have positive outcomes.
Talk 3 TREATMENT OF COGNITIVE IMPAIRMENT IN ADOLESCENTS WITH EARLY-ONSET SCHIZOPHRENIA THROUGHT COGNITIVE REMEDIATION THERAPY
Olga Puig1; 1Department of Child and Adolescent Psychiatry and Psychology, Institute of Neuroscience, Hospital Clínic of Barcelona, 2014SGR489. Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Spain.
Early-onset schizophrenia (EOS), defined as the manifestation of psychotic symptoms prior to 18 years of age, is a less common and phenotypically more severe form of the disorder, and implies generalized neurocognitive impairment. Cognitive remediation therapy (CRT) is a strategy-learning approach targeting cognitive deficits with the ultimate goal of improving functional outcome. The height neural plasticity during childhood and adolescence suggests that they may be "sensitive periods" to treatment effects but it is also possible that having EOS may confer damage that reduces the ability of the brain to benefit from CRT. Objetive: To examine the efficacy of CRT in improving cognition and functional outcomes in a sample of symptomatically stable but cognitively disabled adolescents with EOS. Methods: Randomized, controlled trial of individually delivered CRT plus treatment-as-usual (n=25) compared with treatment-as-usual (TAU, n=25). Clinical symptoms and cognitive and functional performance were assessed before and after treatment in both groups and after 3 months in the CRT group. Results: After CRT, significant improvements were found in verbal memory and executive functions. The derived cognitive composite score showed an improvement after the treatment and this change was reliable in more than two-thirds of the treated patients. Improvements were also found after CRT in daily living and adaptive functioning, and in family burden. Cognitive but not functional changes were maintained after 3 months. Conclusion: Cognitive and functional improvements can be achieved through CRT in adolescents with EOS but additional strategies may be needed to enhance the durability of functional gains.
Talk 4 Neuroscience-informed Cognitive Training in Early Phases of Schizophrenia Using Mobile Devices
Sophia Vinogradov1, Ian Ramsay1, Bruno Biagianti2, Rachel Loewy3, Melissa Fisher1, Dan Mathalon3, Sisi Ma1, Dan Ragland4, Tara Niendam4, Cam Carter4; 1Department of Psychiatry, University of Minnesota, 2Department of Psychiatry, UCSF, and Positscience, Inc, San Francisco, 3Dept of Psychiatry, UCSF, 4Dept of Psychiatry, UC Davis
The cognitive deficits that characterize patients with schizophrenia are present in the prodrome, worsen as the illness progresses, and predict functional outcome. Cognitive dysfunction thus must be a primary target for aggressive early intervention in in early phases of schizophrenia. We report on behavioral and imaging data from a randomized controlled trial of targeted auditory-system training (AT) in participants with recent onset schizophrenia (N=144, mean age 21 years). These findings begin to point to personalized psychiatry approaches. 1. Auditory training subjects demonstrated significant improvements in Global Cognition, Verbal Memory, and Problem-solving compared to computer games control subjects. Training-induced cognitive gains at 40 hours showed significant associations with improved auditory processing speed at 20 hours. 2. Global Cognition showed durable improvements at 6-month follow-up. Within the AT group, Global Cognition improvement after training was significantly correlated with positive symptom improvement at 6-month follow-up. 3. Baseline auditory MMN was significantly reduced in participants and associated with worse Global Cognition. MMN did not show changes after AT and exhibited trait-like stability. Greater deficits in double-deviant MMN predicted greater gains in Global Cognition in response to AT. 4. Change in Global Cognition was significantly related to change in left thalamus volume in the AT group. Greater symptom severity at baseline reduced the likelihood of response to AT both with respect to improved cognition and change in thalamic volume. 5. A model selection and regression analytic approach (LASSO) identified baseline Global Cognition, education, and gender in a model predictive of improvement on cognition following AT.
Symposium Session 25
Wednesday, October 10, 1:00 - 2:30 pm, American Ballroom - South
Comprehensive coordinated care programs in Asia and Brazil: Short-term outcome results
Chair: Young Chul Chung, Chonbuk National University Medical School, Jeonju, Korea
Co-Chair: Rodrigo Bressan, PRISMA Clinic - Universidade Federal de São Paulo (UNIFESP)
Speakers: Lee Helen, Ary Gadelha, Tomoyuki Funatogawa, Sung Wan Kim
Young people with psychosis suffer from diverse psychosocial difficulties such as impaired social relationships, low self-esteem, unemployed or poor academic performance, financial difficulties, etc. To help them recover psychosocial impairments, Western countries had developed coordinated special care programs consisting of multidisciplinary teams. These special programs can not be provided adequately in routine psychiatric service in Asia and Brazil. However, there has been emerging interest in early psychosis in Asia and Brazil recently, and several initiating programs have been launched: ILBOSCO in Japan, MindLink in Korea, Program for Recognition and Intervention in Individuals in At-Risk Mental States (PRISMA) in Brazil, and --- in Singapore. We have encouraging short-term results on outcome after delivering coordinated programs in each country. The implications of these findings will be shared and discussed in terms of implementing optimal strategies targeting young people with psychosis.
Talk 1 The Effectiveness of Case Management Service in the Singapore Early Psychosis Intervention Programme (EPIP)
Lee Helen1, Verma Swapna1, Wong Peter1; 1Early Psychosis Intervention Programme, Institute of Mental Health, Singapore.
EPIP was the first clinical service to start psychiatric case management in Singapore. In the beginning, our case management model was adopted from other developed countries, but gradually our care model has evolved with the changing healthcare landscape and resources’ allocation and taking into account our users’ literacy in mental health. We have moved away from emphasizing medication compliance and adherence to doctors’ appointments to focusing more on identification of clients’ strengths and empowering them to be active participants of their own recovery. Our clients’ satisfaction rate has been consistently good and 75% of our clients returned to school or are gainfully employed upon discharge from our programme (Verma, et al., 2012). Recently we conducted a qualitative study to explore the perspectives of clients and caregivers on case management with the intent to understand the salient aspects of case management from their perspective. Focus group discussions (FGD) were conducted with 47 clients and 19 caregivers. The main themes that emerged were: therapeutic alliance, holistic monitoring, collaborative role with other care providers, counselling and guidance, crisis management, client empowerment and strength building, education on illness, support and problem solving. A second phase quantitative study is currently underway that looks at validating a scale on the quality of case management in an Early Intervention service.
Talk 2 Prevention and the opportunity to transform mental health care in Brazil – The history of PRISMA clinic
Ary Gadelha1, Rodrigo Bressan1, Graccielle Cunha1, André Zugman1; 1PRISMA Clinic - Universidade Federal de São Paulo (UNIFESP)
Almost ten years ago, prevention in mental health was rarely debated in Brazil. A group of volunteers and young researchers of Federal University of São Paulo (UNIFESP) created a research program to deliver an intervention at public schools aimed at foster identification of subjects at-risk for psychosis. This research demanded to structure a service to provide care to subjects at-risk identified at schools. In 10 years, the PRISMA clinic screened around 300 subjects, identified 40 subjects at-risk for psychosis or bipolar disorder, with a conversion rate of 10% over two years. Besides research, PRISMA became part of the psychiatry residency program at UNIFESP, allowing new psychiatrists the opportunity to get In contact with the prevention paradigm. Recently, PRISMA became part of the National Centre for Prevention In Mental Health to test pilot interventions for at-risk subjects and allow later implementation in other parts of Brazil.
Talk 3 Integrated approach to mental health among Adolescents and Young Adults generation.
Tomoyuki Funatogawa1, Naoyuki Katagiri1, Takahiro Nemoto1, Masafumi Mizuno1; 1Toho University Department of Neuropsychiatry, Tokyo, Japan
The Toho University Omori Medical Center is located in Ota, a city with a population of about 700,000 located in the southern area of the Tokyo Metropolitan region. In 2007, we established a comprehensive treatment center for young people with psychiatric problems, consisting of a Youth Clinic, which specialises in the treatment of young people with an at-risk mental state for psychosis (ARMS), a Child and Adolescent Clinic, which specialises in the treatment of developmental disorders and school-age problems, and Il Bosco, which is a special day-care service for individuals with early psychosis. Il Bosco aims to provide early intervention to prevent the development of full-blown psychosis in individuals with ARMS and to provide intensive rehabilitation to enable patients with first-episode psychosis (FEP) to return to school and community life. So far, 247 patients with a mean age of 21.2 years and a mean GAF score of 48.2 at the baseline have used this facility. The contents of the daily programs are specifically designed for promoting the brain plasticity of young patients and providing them with an environment where they can obtain relief and support without the stigma of psychiatric disease. About two-thirds of the patients have already achieved their own goals to ‘restart’ their lives after attending the one-year program. The drop-out rate was quite low (16.8%). At present, we provide the same programs for ARMS and FEP patients at Il Bosco. However, we propose to start more phase-specific and need-specific services which are indispensable for early psychiatric interventions in the future.
Talk 4 Comprehensive early intervention services for young individuals with psychosis in Korea
Sung Wan Kim1; 1Chonnam National University Medical School; Mindlink, Gwangju Bukgu Community Mental Health Center
In Korea, mental health services are typically characterized by low accessibility to psychiatric treatment, high caseloads, and a relatively large incidence of inpatient care. The duration of untreated psychosis (DUP), which is related to a poor prognosis for patients with schizophrenia, is comparatively long in Korea relative to that of Western countries and may be attributed to the high level of stigma associated with psychosis and psychiatric treatment. Recently, early intervention services for young individuals with psychotic disorders have begun in Gwangju, Korea. We developed a Korean version of group CBT consisting of metacognitive training, cognitive restructuring, life style modification, and stress management. In addition, we developed and launched a smartphone application for cognitive–behavioral case management and symptom monitoring. Group CBT had a positive effect on the quality of life, attitude toward treatment, perceived stress, and suspiciousness of patients with early psychosis. These effects were particularly significant in patients with a short DUP. A smartphone application for case management was useful for young individuals with early psychosis. Furthermore, mean number of admissions and bed days were decreased after use of special early intervention service. This study may contribute to the development of a youth- and customer-friendly case management system for individuals with early psychosis in Asian countries.
Symposium Session 26
Wednesday, October 10, 2:45 - 4:15 pm, American Ballroom - North
The Neurobiology of Conversion to Psychosis – Emerging Findings from the SHARP Study
Chair: Margaret Niznikiewicz, VA Boston Healthcare System, Harvard Medical School
Co-Chair: Guusje Collin, 1. Beth Israel Deaconess Medical Center, Harvard Medical School
Speakers: Elisabetta C. Del Re, Ofer Pasternak, Guusjie Collin, Yingying Tang
The Clinical High Risk (CHR) phase of schizophrenia is the period of imminent risk for psychosis when cognitive and social functioning begin to decline. The CHR phase typically occurs during adolescence extending into young adulthood, a time period when major changes in the brain’s structural and functional organization support cognitive and behavioral development. Disruptions in these processes may give rise to brain and neurocognitive abnormalities and, ultimately, conversion to psychosis. In this symposium, we examine the neurobiology of conversion using multimodal imaging data from a unique sample of medication-naïve adolescents and young adults who meet criteria for CHR, and age- and gender-matched healthy controls (HC). This sample was acquired as part of the SHARP (Shanghai At-Risk for Psychosis) study, a longitudinal NIMH-funded research program developed at the Shanghai Mental Health Center in collaboration with a multidisciplinary Harvard/MIT research team. In four presentations, we will report on different imaging data acquired in the SHARP sample, including structural MRI, diffusion-weighted MRI, resting-state fMRI, and event related potentials. Together, the findings provide important preliminary insights into the neurobiology of conversion as documented by structural, functional and neurophysiological brain changes in CHR relative to HC, with some changes occurring in CHRs who converted to psychosis but not in those who did not. Discussant Martha Shenton, a leading international expert on neuroimaging in schizophrenia, will conclude the session by interpreting the findings presented in our symposium into the broader schizophrenia literature and moderating a discussion on brain changes taking place in the transition to psychosis.
Talk 1 Morphometric Analyses of SHARP Clinical High Risk for Psychosis Subjects
Elisabetta C. Del Re1,2, William S. Stone3, Yingying Tang4, Tianhong Zang4, Susan Whitfield-Gabrieli5, Jijun Wang4, Larry J. Seidman3,6, Nikos Makris6, Margaret A Niznikiewicz2, Robert W McCarley2, Martha E. Shenton1,2; 1Brigham and Women's Hospital, Harvard Medical School, 2Veterans Affairs Boston Healthcare System, 3Beth Israel Deaconess Medical Center, Harvard Medical School, 4Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, 5McGovern Institute for Brain Research, Massachusetts Institute of Technology, 6Massachusetts General Hospital, Harvard Medical School
Purpose: Frontal and temporal lobes are often affected in schizophrenia. Here we hypothesized that cortical thickness (CT) and/or surface area (SA) and integrity of several white matter tracts related to frontal and temporal lobes, alone or in aggregate, distinguish CHR converters (CHR-C) from CHR non-converters (CHR-NC). Materials and methods: Magnetic resonance images and clinical/cognitive data were acquired in 92 healthy controls (HC), 130 CHR-NC and 22 CHR-C at the Shanghai Mental Health Center, China, as part of the NIMH-funded SHARP research program. Assessment of 9 temporal and 11 frontal regions from the two lobes in both hemispheres, as well as the superior longitudinal (SLF), arcuate (AF), extreme capsule (ECFS), and uncinate (UF) white matter tracts was carried out by using an internal pipeline developed at the Psychiatry Neuroimaging Laboratory (PNL), Brigham and Women's Hospital, HMS. Results: Temporal lobe: The posterior region of superior temporal sulcus and Heschl’s gyrus CT were smaller in CHR-C compared to CHR-NC (p=0.027) and NC (p=0.002). Middle temporal gyrus (MTG) CT was also smaller in CHR-C than HC (p=0.004) with trend level findings for CHR-NC (p=0.098). Frontal lobe: The pars triangularis CT was smaller in CHR-C vs CHR-NC (p=0.02) and HC (p=0.012). In CHR-C, CT of MTG correlated with Verbal Learning (rho=0.64; p=0.002) and Visual Memory Tests (rho=0.6, p=0.004). These correlations were not present in HC or CHR-NC. Analyses of tractography data are in progress. Conclusion: Results indicate that language circuits are among the earliest regions affected in schizophrenia and distinguish CHR-C from CHR-NC.
Talk 2 Microstructural White Matter Alterations in Clinical High Risk Subjects from the SHARP Project
Ofer Pasternak1, Yingying Tang1,2, Marek Kubicki1, Yogesh Rathi1, Tianhong Zhang2, Zhenying Qian2, William S Stone3, Susan Whitfield-Gabrieli4, Robert W McCarley5, Martha E. Shenton1,5, Jijun Wang2; 11. Brigham and Women’s Hospital, Harvard Medical School, 2Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, 3Beth Israel Deaconess Medical Center, Harvard Medical School, 4McGovern Institute for Brain Research, Massachusetts Institute of Technology, 5Veterans Affairs Boston Healthcare System
Purpose: Recent free-water diffusion MRI studies suggest co-occurring extracellular changes, measured by free-water (FW), and microstructural cellular changes, measured by fractional anisotropy of tissue (FAt). The extracellular changes reveal a widespread extent during first psychotic episode, and lower levels during chronic stages of the illness. Cellular changes were limited in the first episode stage, and were more widespread in the chronic stage. These findings led to the hypothesis that FW increases may reflect an acute brain response to psychosis, while FAt may reflect a continuous process of accumulating damage. What is not yet clear is the presentation of these abnormalities prior to the onset of psychosis. Materials and methods: Using 3T diffusion MRI data from the SHARP study we explored white matter alterations in 50 individuals at clinical high risk (CHR) for psychosis who were largely medication-naïve, and 50 matching healthy controls (HC). Results: CHR subjects showed significantly reduced FAt (p=0.020), but no changes in FW (p=0.137). FAt was positively correlated with age (p=0.018) in HC, but not in CHR (p=0.290). Conclusion: Our findings suggest that cellular changes precede the onset of psychosis and may reflect altered neurodevelopmental processes in CHR. As no differences in FW were observed, we predict that FW increases will emerge as an acute response in this CHR sample, closer to the onset of psychosis. We therefore plan to follow-up on these findings in longitudinal analyses to investigate both FW and FAt between individuals who convert to psychosis compared to those who do not convert.
Talk 3 Abnormal Modular Organization of the Functional Connectome Predicts Conversion to Psychosis in Clinical High Risk Youth
Guusjie Collin1,2,3, Larry J. Seidman1,4, Matcheri S. Keshevan1, Zhenghan Qi5, William S. Stone1, Tianhong Zhang6, Margaret A Niznikiewicz7, Martha E Shenton3,7, Jijun Wang6, Susan Whitfield-Gabrieli2; 1Beth Israel Deaconess Medical Center, Harvard Medical School, 2McGovern Institute for Brain Research, Massachusetts Institute of Technology, 3Brigham and Women’s Hospital, Harvard Medical School, 4Massachusetts General Hospital, Harvard Medical School, 5University of Delaware, 6Shanghai Mental Health Center, Shanghai Jaio Tong University School of Medicine, 7Veterans Affairs Boston Healthcare System
Purpose: Prodromal symptoms progressing into psychosis may involve a functional reorganization of the connectome. In this study, we performed a functional connectome analysis in a large group of adolescents and young adults at Clinical High Risk (CHR) for psychosis. We aimed to assess whether, and if so how, baseline connectome organization distinguishes CHRs that go on to develop psychosis. Materials and methods: A total of 251 subjects, including 158 CHRs and 93 matched healthy controls (HCs), participated in this study. Prodromal symptoms and cognition were assessed using validated procedures. MRI scans were processed with Freesurfer v6.0 and CONN v17.d software to produce functional connectome maps that were analyzed using Louvain community detection. For each CHR, we assessed how similar their modular organization was relative to a group-averaged HC network using the rand similarity coefficient. Results: Modular connectome organization of CHRs who developed psychosis was significantly less similar to HCs than CHRs who did not convert (F(1,154) = 7.14, p = 0.008). Superior and medial temporal and ventromedial prefrontal regions were most abnormal in terms of modular assignment. Furthermore, Kaplan-Meier analysis showed reduced psychosis-free survival in CHRs with abnormal baseline connectome organization, with an approximately 3-fold risk of conversion to psychosis. Cox regression analysis indicated that modular connectome organization, gender, and IQ predicted time to conversion. Conclusion: Abnormal functional connectome organization precedes the onset of psychosis and is associated with increased conversion rates in CHRs. Our results suggest that a reorganization of the functional connectome may accompany the manifestation of psychosis.
Talk 4 Abnormal Mismatch Negativity Duration at Baseline Distinguishing Remitted from Ron-remitted Clinical High Risk for Psychosis Individuals
Yingying Tang1, Tianhong Zhang1, Junjie Wang1, Lihua Xu1, Zhenying Qian1, Matcheri S. Keshavan2, Susan Whitfield-Gabrieli3, Martha E Shenton4,5, William S. Stone2, Margaret A. Niznikiewicz4, Jijun Wang1; 11. Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, 2Beth Israel Deaconess Medical Center, Harvard Medical School, 3McGovern Institute for Brain Research, Massachusetts Institute of Technology, 4Veterans Affairs Boston Healthcare System, 5Brigham and Women's Hospital, Harvard Medical School
Purpose: Mismatch negativity (MMN) indexing pre-attentive sensory processes has been considered a candidate biomarker for predicting transition to psychosis in clinical high risk for psychosis (CHR) individuals. However, in Asian CHR population, the MMN association with psychosis has been less explored. The present study, a part of the Shanghai At-Risk for Psychosis (SHARP) program, examined whether the MMN duration amplitude at baseline can distinguish between remitted non-converters (those who got better) and non-remitted individuals (who included those who converted to psychosis (i.e., converters) and those who remained symptomatic) a year later. Materials and Methods: 104 CHR subjects meeting the Structural Interview for Prodromal Syndromes criteria (Chinese version) and 90 healthy controls (HCs) were tested on the auditory MMN duration paradigm. CHR subjects were grouped into 53 remitted individuals defined as getting clinically better and 51 non-remitted individuals defined as remaining symptomatic, or converting to psychosis, based on their clinical symptoms and functional scores at one-year follow-up. MMN amplitude was analyzed using an ANOVA at midline (Fz, Fcz) with a between-factor of group (remitted CHR, non-remitted CHR and HCs). Results: Group differences were significant (p=0.004) with non-remitted CHR showing less negative MMN amplitude than HC (p=0.0029) and remitted CHR not different from HC (p=0.88) Non-remitters had significantly reduced MMN amplitude relative to remitters (p=0.007). Conclusions: These results suggest that MMN duration amplitude is not only abnormal at baseline in the CHR phase in non-remitters but also distinguishes between CHRs who remitted and those who did not remit one year later.
Question and Answer Period
Discussant: Martha Shenton, 3. Brigham and Women’s Hospital, Harvard Medical School, VA Boston Healthcare System
Symposium Session 27
Wednesday, October 10, 2:45 - 4:15 pm, American Ballroom - Center
The relationship between relapse and medication discontinuation on long-term outcome in first episode psychosis
Chair: Eric YH Chen, University of Hong Kong
Speakers: Lex Wunderink, Christy Hui, Sherry Chan, Swapna Verma
Psychotic disorders are characterized by a relapsing course of illness, poor recovery and even treatment resistance. Although maintenance treatment can help prevent relapse, the long-term use of antipsychotics carries substantial side effects. Without much empirical data on the long-term effects of medication discontinuation and relapse, the decision to discontinue or continue medication in first-episode psychosis (FEP) patients who have been free of positive symptoms for a period of time poses a clinical dilemma. Using long-term follow-up data in patients with FEP from The Netherlands and Hong Kong, important questions on factors leading to poor outcome will be examined. The first speaker will discuss what predicted relapse; the relationship of relapse and 7-year outcome; and if negative symptoms predicted relapse, whether medication strategies would make a difference in reducing relapse rates, in FEP involved in a dose-reduction/discontinuation trial. The second speaker will investigate the effect of early medication discontinuation on 10-year clinical outcome in FEP who were previously involved in a medication discontinuation (placebo) trial. The role of early relapse in mediating discontinuation and outcome will also be discussed. Using a case-control first episode cohort followed up for 12 years, the third speaker will examine how the early clinical characteristics such as early relapse and planned medication discontinuation would affect the long-term outcome of recovery, treatment resistance, and suicide. The last speaker will present data from a survey in Singapore, looking at clinicians’ views on medication discontinuation in remitted FEP.
Talk 1 Predicting Relapse and Outcome in First Episode Psychosis: Impact of Negative Symptoms, and Personalized Low Dose versus Maintenance Antipsychotic Treatment
Lex Wunderink1,2, Jan van Bebber2, Sjoerd Sytema2, Nynke Boonstra1, Rob Meijer3, Hanneke Wigman2; 1Friesland Mental Health Services, Leeuwarden, The Netherlands, 2University Medical Center Groningen, University of Groningen, Groningen, The Netherlands, 3Dept of Psychometrics and Statistics, University of Groningen, Groningen, The Netherlands
Relapse of psychosis indicates worse functional outcome. The aim of current treatment strategies is relapse-prevention, though neither predictors of relapse nor causation of functional decline have been established. If relapse were a consequence of a decline-related confounder, preventing relapse might only partly impact upon decline. We hypothesized baseline negative symptoms to predict both functional deficits and relapse risk. Analyzing 7-years follow-up data of a first episode cohort involved in a dose-reduction/discontinuation trial, we examined: 1) what predicted relapse, 2) what predicted functional outcome and 3) if baseline negative symptoms (BNS) predicted relapse, whether medication strategies would make a difference reducing relapse rates. Relapse was predicted by baseline negative symptoms and duration of untreated psychosis. The more relapses, the less recovery. No relapses yielded recovery in 18/36 patients, 1 relapse: 8/32, 2 relapses: 4/21 and ≥3 relapses: 0/14. However, baseline negative symptoms were a better predictor of functional outcome (pseudo partial correlation [pr]=.90) than number of relapses (pr=.64) or treatment strategy (pr=.57), although all predictors had unique contributions. Within maintenance treatment more negative symptoms showed higher relapse rates. Within high or low negative symptom groups, relapse rates were equal across both treatment strategies. Negative symptoms not only predicted non-recovery, but also relapses during 7-years follow-up. Apparent consequences of relapse, mainly non-recovery, have to be partially attributed to baseline negative symptoms. Relapse prevention by (low-dose) maintenance treatment does not seem effective, since relapse rates were equal across arms and mainly dependent on negative symptoms.
Talk 2 The 10-year clinical outcome of early medication discontinuation in remitted first episode psychosis
Christy Hui1, William Honer2, Edwin Lee1, Sherry Chan1, Wing Chung Chang1, Eric Chen1; 1University of Hong Kong, Hong Kong, 2University of British Columbia, Vancouver, Canada
Whether to discontinue or continue antipsychotics medication in remitted first-episode psychosis is a difficult clinical decision. Consistent short-term evidence suggests that maintenance medication is effective in relapse prevention. However, long-term outcome data are lacking; with only one open-label study suggesting better recovery outcome in patients who had early dose reduction/discontinuation. We examined the long-term effect of early medication discontinuation in a remitted first-episode psychosis cohort in Hong Kong. We followed-up 178 first-episode psychosis patients who had previously participated in a 12-month randomized controlled trial on medication discontinuation (placebo) or continuation (quetiapine). Following the trial, all patients received usual psychiatric care. Poor clinical outcome was defined as a composite of persistent psychotic symptoms, a requirement for clozapine, or suicide at 10 years. We found no significant differences between patients who were successfully traced after 10 years (n=142) and those who were not (n=36) in terms of their basic demographics, symptoms and functioning at baseline. At 10 years, more patients in the early discontinuation group (35 of 89, 39%) had poor clinical outcome than patients in the maintenance group (19 of 89, 21%) (P<0.01). Relapse during the randomized trial had partly mediated the significant relationship between early medication discontinuation and poor outcome (P=0.003). In first episode psychosis with a full initial response to antipsychotic treatment, continued need for maintenance medication is important for the first three years after starting treatment, so as to prevent relapse, and to decrease the risk for a poor long-term outcome.
Talk 3 Predictors of long-term outcomes of first episode schizophrenia-spectrum disorders
Sherry Chan1, Christy Hui1, Edwin Lee1, Wing Chung Chang1, Eric Chen1; 1University of Hong Kong, Hong Kong
Despite of the improvement in intervention, long term outcomes of patients with schizophrenia has not improved much. Early clinical characteristics has been suggested to predict the long-term outcomes. The current study is to look at predictors of early clinical characteristics including relapse and planned discontinuation of antipsychotic medications to long-term outcomes including suicide, treatment resistance and recovery in patients with schizophrenia-spectrum disorders. Apart from basic demographics, information of baseline clinical condition including positive and negative symptoms, duration of untreated psychosis (DUP), suicidal attempts during DUP; clinical characteristics during the first three years including number of relapse, number hospitalization, compliance, suicidal attempts, planned discontinuation of antipsychotic medications were obtained from clinical record review. The review was conducted at monthly basis with standardized entry form with operational definitions. Suicide information was obtained at 12-year follow up of 1400 patients. Results suggested number of relapse, premorbid functional impairment and compliance predicted suicide in year 4 to 12 (p=0.002), whereas suicide attempts in DUP and first three years predicted suicide in year 1-3(p=0.004). Among the 1400 patients, 165 patients were considered treatment resistant by 12-year follow up. Use case-control study approach with control patients who were randomly identified among the 1400 patients matched with diagnosis of patients with treatment resistance. A total of 290 patient control was identified. Results suggested patients with treatment resistant had younger age of onset, lower years of education, poorer premorbid adjustment, more number of hospitalization and relapse during the initial three years of treatment than the patient control.
Talk 4 Perception towards medication discontinuation in remitted first-episode psychosis among clinicians
Swapna Verma1, Chun Ting Chan1, Christy Hui2, Eric Chen2; 1Institute of Mental Health, Singapore, 2University of Hong Kong, Hong Kong
Aim: A survey was carried out in 4 countries across Asia (Hong Kong, Singapore, Japan, and Korea) to investigate the views of clinicians towards the issue of medication discontinuation in remitted patients with first episode psychosis (FEP).The current presentation will be from the results from Singapore. Methods: An online questionnaire was sent to clinicians (Psychiatrists, Psychologists, Case Managers) in Singapore. The questionnaire contained three sections: direct questions probing at views on medication discontinuation in remitted FEP patients, case vignettes to assess decision-making in applied situations, and a checklist of criteria for discontinuing medication. Results: 82 participants of whom 70.6% were Psychiatrists completed the questionnaire. We found that majority believed that (i) 21-40% of remitted first episode psychosis patients can discontinue medication, (ii) patients should remain on medication for 1-2 years following absence of psychotic symptoms, and (iii) the monitoring process after discontinuing medication should be for 12-24 months. 47.6% of clinicians were unsure about whether quality of life is better in those symptom-free patients who remain on antipsychotics versus those who stop. “Having good social support” and “able to cope with stressful situations” were considered the most important criteria when making a decision about medication discontinuation. Conclusions: The results reflect the ambiguity in clinicians about medication discontinuation in patients with FEP arising mainly from lack of clear guidelines on one hand, and patients’ desire to stop medication on the other.
Symposium Session 28
Wednesday, October 10, 2:45 - 4:15 pm, American Ballroom - South
Transdiagnostic approaches to distinguishing between various stages and types of psychopathology in adolescents
Chair: Marieke Schreuder, University Medical Center Groningen
Co-Chair: Robin Groen, University Medical Center Groningen
Speakers: Robin Groen, Jessica Hartmann, Lars Pieper, Marieke Schreuder
The progression from early psychopathological symptoms to severe disorders is typically heterogeneous. For instance, adolescents who initially report similar symptoms might later meet the criteria of qualitatively distinct disorders and vice versa. Insight in the route from prodromal symptoms to severe disorders is crucial for early diagnosis and treatment. The course of symptoms over time is best captured by designs that involve time series data in adolescents, who are by definition vulnerable for first-onset complaints. Since symptom trajectories tend to transcend diagnostic boundaries, such designs require a transdiagnostic approach. The current symposium includes four studies that all fulfilled these criteria and adopted innovative methods in order to improve our understanding in the characteristics of different stages of psychopathology (e.g. increased risk, mild symptoms and severe symptoms). Robin Groen presents findings on whether patterns of symptom co-occurrence differ across varying levels of symptom severity, using a transdiagnostic network approach. Jessica Hartmann will complement these findings by introducing CHARMS (Clinical High At-Risk Mental State) criteria that aim to distinguish between different stages of disorders. Moreover, the potential of ecological momentary assessments (EMA) to signal adolescents’ current symptom severity and their vulnerability for future psychopathological symptoms will be outlined. Lars Pieper will discuss how EMA-based symptom clusters may improve the early identification of disorders. Finally, Marieke Schreuder will show that specific mood dynamics might reveal the nature of upcoming symptoms. This work will outline how a complex dynamic system’s approach to psychopathology may allow us to anticipate the emergence of certain symptom clusters.
Talk 1 Continuity in patterns of co-occurring symptoms across psychopathology severity levels
Robin Groen1, Johanna Wigman1, Marieke Wichers1, Catharina Hartman1; 1University Medical Center Groningen, Department of Psychiatry, Interdisciplinary Center Psychopathology and Emotion Regulation, Groningen, the Netherlands
Early stages of psychopathology frequently manifest as a ‘mixed bag of symptoms’, which may develop into increasingly specific symptom patterns over time as mental ill-health progresses. However, high comorbidity rates in diagnosed individuals do not support this notion of specificity. Using a transdiagnostic, network approach, we investigated symptom co-occurrence in groups with increasing psychopathology severity. As such, we aimed to address the question whether there is continuity in heterogeneous symptom patterns across severity of psychopathology. For that purpose network connectivity and communities were examined in psychopathology symptoms across groups of different severity. Four groups were derived based on a diagnostic interview conducted at age 19 (n=1933; TRAILS cohort). For each group a separate symptom network was estimated. Symptoms were measured by items of the Adult Self Report (ASR). Pairwise comparisons across groups showed a significant difference (p = 0.014) in overall network structure between the two lowest severity groups, but no other differences between the groups. Although minor differences existed in the types of network communities, most community structures replicated across groups. The consistency between groups in overall network strength, and in number and type of communities suggests that patterns of co-occurring symptoms across various levels of severity are more similar than different from each other. Hence we tentatively conclude that continuity in the patterns of symptom combinations exist across severity levels. This contrasts with the idea of increasing specificity in symptom combinations as psychopathology gets more severe.
Talk 2 Broadening the scope: A pluripotential at-risk mental state
Jessica Hartmann1, Barnaby Nelson1, Rachael Spooner1, G. Paul Amminger1, Andrew Chanen1, Aswin Ratheesh1, Christopher Davey1, Patrick McGorry1; 1The National Centre of Excellence in Youth Mental Health, Orygen, Australia
Similar to cancer staging in general medicine, the clinical staging model in psychiatry aims to define current stage of disorder development and assist in treatment selection. Clinical stages range from a pre-symptomatic at-risk state (Stage 0) to severe, unremitted illness (Stage 4). The CHARMS criteria (Clinical High At-Risk Mental State) aim to identify young people at pluripotential risk (Stage 1b) of a range of full-threshold (Stage 2) disorders, including severe depression, psychosis, mania, and borderline personality disorder. The CHARMS study is an ongoing cohort study of help-seeking young people aged 12-25 attending youth mental health services in Melbourne, Australia. New referrals meeting the CHARMS criteria are allocated to CHARMS+ (Stage 1b); referrals under CHARMS threshold are allocated to CHARMS- (Stage 0-1a). Transition status and clinical/functional outcomes are re-assessed at 6 and 12 months. To date, a sample of N=73 participants has been recruited: N=49 (67%) met CHARMS criteria at baseline. At 6 months, 32% of CHARMS+ have transitioned to Stage 2 with a slight increase to 37% at 12 months follow-up. There were no transitions in the CHARMS- group. Our initial results indicate that the CHARMS criteria can be applied in the context of a youth mental health service and may validly identify help-seeking young people at risk of progressing to serious mental disorder. This study is the first to introduce and validate a set of clinical criteria to identify a broader ‘at risk’ patient population, and represents an important advance from the UHR for psychosis approach.
Talk 3 Symptom Expression of Depression and Anxiety in Daily Life: Results of the BeMIND Study
Lars Pieper1, John Venz1, Catharina Voss1, Katja Beesdo-Baum1; 1Behavioral Epidemiology, Institute of Clinical Psychology and Psychotherapy, Technische Universität Dresden, Germany
Mental problems and illnesses represent an enormous personal, social and societal burden, as they frequently emerge in late childhood/early adolescence and are often unrecognized or inadequately treated. So, for example, depression and anxiety can affect every area of life, including but not limited to health, physical activity, sleep, eating behaviors and social relationships. This contribution aims to describe (1) how DSM-5 depression and anxiety reflect in daily life mood and behaviour and (2) how different pattern of symptom expressions in daily life can predict future depression and anxiety episodes. Analyses base on data from the Dresden BeMIND study, an epidemiological cross-sectional and prospective-longitudinal study on the development of psychopathology. Among other assessments, a community sample of 1180 adolescents and young adults (age 14-21 years) from Dresden (Germany) completed a clinical diagnostic interview and took part in a four day ecological momentary assessment study including measures of current affective states (e.g. symptoms of depression and anxiety, energetic arousal, valence, calmness, positive/negative mood), social interactions, eating and sleeping behaviour and objective/subjective measures of physical activity. One year follow-up data on psychopathology is available from approximately 800 participants. Data show for example that depressive study-participants engaged more often in online social interactions and not in real life. Quality of social interactions decreased with depression severity. Depressed people were less physical active in their spare time. It will be discussed how the identification of symptom clusters can help to improve early recognition of mental disorders and lead to preventive action at an early stage.
Talk 4 Anticipating the direction of future shifts in psychopathology using early warning signals
Marieke Schreuder1, Johanna Wigman1, Catharina Hartman1, Marieke Wichers1; 1University Medical Center Groningen, Department of Psychiatry, Interdisciplinary Center Psychopathology and Emotion Regulation, Groningen, the Netherlands
Recent studies revealed that shifts from mild to severe psychopathological symptoms are preceded by particular mood dynamics (EWS). The present study aimed to extend earlier findings by examining whether EWS may reveal not only the likelihood of psychopathological shifts but also their direction. In other words, do EWS predict the symptom cluster (e.g. depression, psychosis, etc.) that will develop? We analysed transdiagnostic time series data retrieved from the TWINS-scan study, which included adolescent twins from the general population. EWS were inferred from daily mood ratings acquired through the experience sampling method (ESM). We selected adolescents who reported higher symptom severity at one year follow-up compared to baseline in at least one of the domains of interest (depression, anxiety, paranoid ideation and somatization). This resulted in four subsamples (N=166-192). Multilevel models confirmed that EWS in mood states predict the direction of upcoming shifts in psychopathological symptoms in all domains except for somatization. For instance, the association between EWS in mood states and shifts towards depression was most pronounced for feeling down (β=0.10, p<0.001) and listless (β=0.09, p<0.001). Similarly, shifts towards anxiety and paranoid ideation were preceded by EWS in feeling anxious (β=0.09, p<0.01) and insecure (β=0.08, p<0.01) mood states, respectively. EWS thus not only revealed the likelihood of future distress, but also indicated the domain involved in this distress. EWS might therefore considerably contribute to early diagnosis and treatment. Such clinical applications of EWS however require replication of the above findings on an intra-individual level, which is currently in progress.