The Recognition and Management of Early Psychosis: A Preventive Approach

Cover......Page 1
Half-title......Page 3
Title......Page 5
Copyright......Page 6
Dedication......Page 7
Contents......Page 9
Contributors......Page 13
Foreword......Page 19
Acknowledgements......Page 21
Section 1 Introduction......Page 23
Book overview......Page 25
The early psychosis mission......Page 36
References......Page 37
Introduction......Page 39
Diagnosis of psychosis: issues of validity......Page 40
The staging model and its application to early psychosis......Page 42
Stages 1a–1b: ultra-high risk or prodromal phase......Page 45
Research implications......Page 46
References......Page 47
Section 2 Risk and vulnerability......Page 51
Introduction......Page 53
The phenotype called schizophrenia......Page 54
Linkage studies......Page 55
Dysbindin......Page 56
Regulator of G-protein signalling-4......Page 57
The ‘disrupted in schizophrenia’ genes......Page 58
Brain-derived neurotrophic factor......Page 59
Intermediate phenotypes (endophenotypes)......Page 60
Discussion......Page 61
References......Page 63
Gene–environment relationships......Page 69
First-generation gene–environment interaction studies in psychosis......Page 70
Studies using psychometric psychosis liability approach......Page 71
Studies of environmental impact on DNA sequence and methylation......Page 72
Second-generation gene–environment interaction studies in psychosis......Page 76
Discussion......Page 78
References......Page 79
Background......Page 83
High-risk strategies......Page 84
Neuropsychological studies......Page 85
Psychophysiological studies: event-related potentials......Page 87
Functional neuroimaging studies......Page 89
Structural neuroimaging studies......Page 90
Conclusions......Page 93
References......Page 94
Section 3 At-risk mental state......Page 103
Background: the prodrome of psychotic disorders......Page 105
Rationale: why focus on the prodrome?......Page 106
Ultra-high-risk criteria: the Melbourne PACE approach......Page 107
Basic symptoms criteria......Page 110
Disadvantages of ‘prodromal’ identification......Page 114
Negative symptoms......Page 115
Poor functioning......Page 116
Neurocognitive variables......Page 117
Neurobiological variables......Page 118
Intervention......Page 119
Appendix: Short definition of basic symptoms included in the two basic symptom criteria of the initial prodrome, COPER and COGDIS......Page 120
References......Page 122
Introduction......Page 129
The case supporting antipsychotic medication......Page 130
The case against antipsychotic medication......Page 132
The case supporting psychological interventions......Page 133
The case against psychological interventions......Page 134
No intervention......Page 135
Summary......Page 136
The UK Early Detection and Intervention Team......Page 137
Cologne Early Recognition and Intervention Centre for mental crisis......Page 138
Conclusions and recommendations......Page 139
Section 4 Access and reducing delay to treatment: reducing the duration of untreated psychosis......Page 145
Defining the onset and offset of untreated psychosis......Page 147
Discrepancies between the accounts of patients and carers......Page 149
Failure to use standardized assessment instruments......Page 150
Duration of untreated psychosis and outcome......Page 151
Methods of measuring duration of untreated psychosis......Page 152
Data extraction......Page 154
Cohort characteristics......Page 155
Effect of premorbid adjustment......Page 158
Sensitivity analysis......Page 160
Discussion......Page 161
References......Page 165
Recognition of psychosis......Page 169
First aid skills......Page 170
Beliefs about mental health professionals......Page 171
Beliefs about treatments......Page 172
Contrast between public and professional beliefs......Page 173
Community campaigns......Page 175
School-based programmes......Page 177
Individual training programmes......Page 179
References......Page 180
Introduction......Page 183
Help-seeking is often initiated for reasons other than psychotic symptoms......Page 184
Primary healthcare providers such as family physicians are often the first points of contact in accessing treatment......Page 185
Once help is sought, there is considerable variation in how readily it is provided......Page 186
Accessing the right service does not automatically mean immediate treatment......Page 187
Demographic and personal circumstances......Page 188
Aspects of illness onset......Page 189
Interventions to reduce treatment delay for psychotic disorders......Page 190
Conclusions: what have we learned?......Page 192
References......Page 193
Section 5 The first episode......Page 197
Engagement and development of a therapeutic alliance......Page 199
Treatment of behavioural disturbances......Page 200
Formulation of an integrated treatment plan......Page 201
Clinical and personal history......Page 202
Assessment of comorbid disorders......Page 204
Risk assessment......Page 205
Neuropsychological assessment......Page 206
Reduction of treatment delay improves antipsychotic response......Page 207
Medication side effects should be avoided or treated early to promote response and future adherence......Page 209
Adaptation of pharmacotherapy according to diagnostic shift is needed......Page 210
Pharmacotherapy of acute first-episode non-affective psychosis......Page 211
Pharmacotherapy in psychiatric emergencies......Page 213
Management of adverse events and medical disorders......Page 215
Extrapyramidal motor symptoms and tardive dyskinesia......Page 216
Endocrine and sexual side effects......Page 217
References......Page 218
Introduction......Page 223
Early recovery phase: pharmacological treatments......Page 224
Long-acting novel antipsychotic drugs......Page 225
Psychoeducation......Page 226
Cognitive–behaviour therapy......Page 227
Interventions focusing on vocation......Page 228
Incomplete recovery 3 months after the acute episode......Page 229
Social deficits......Page 230
Stage 1: dealing with outcome confounders......Page 231
Adequacy of psychosocial interventions......Page 233
Adherence......Page 234
Stage 2: dealing with impaired adherence......Page 235
Treatment approaches for incomplete recovery......Page 236
Individual therapy......Page 237
References......Page 238
Rationale for early intervention in bipolar disorders......Page 245
Are targets for early intervention in psychotic disorders relevant to bipolar disorders?......Page 247
Consequences of delayed diagnosis......Page 248
Current guidelines......Page 249
Treatment adherence......Page 250
Defining targets for early intervention in bipolar disorders......Page 251
Initial prodrome to bipolar disorder......Page 252
Improved identification of first-episode mania......Page 253
Identification of the initial prodrome to bipolar disorders......Page 254
Pharmacological treatment......Page 255
Psychological approaches......Page 256
Conclusions......Page 257
References......Page 258
Section 6 The critical period: other psychopathology and comorbidity......Page 263
Rate and patterns......Page 265
Correlates and consequences of substance misuse......Page 266
Substance use causes psychosis......Page 267
Common risk factors for psychosis and substance misuse......Page 268
Studies of psychological interventions for substance misuse in psychosis......Page 269
Initial assessment......Page 271
Motivation to address substance misuse......Page 272
Psychoeducation......Page 273
Cognitive–behavioural therapy......Page 274
References......Page 275
Introduction......Page 279
During the non-psychotic state......Page 280
During the psychotic state......Page 281
First-episode acute phase......Page 282
Recovery phase......Page 284
The initial suicide risk assessment......Page 285
The initial risk formulation and provisional risk management plan......Page 287
Chronic illnesses......Page 288
Wider family, social and cultural risk factors......Page 289
Service and treatment risk factors......Page 290
Routine risk monitoring......Page 291
Examples of systems of risk monitoring......Page 292
Acute suicide risk containment......Page 294
Psychological interventions......Page 295
Self-help......Page 296
Models of mental health service provision......Page 297
The future of suicide prevention in psychosis......Page 298
References......Page 299
Emotion and psychosis......Page 305
Emotional dysfunction in the prodromal phase......Page 306
Depression......Page 307
Content of delusions/hallucinations as a reflection of the content of emotional disorders......Page 308
Similar maintenance processes in delusions, hallucinations and emotion......Page 309
Shared developmental pathways......Page 310
Social anxiety and the shame and stigma of mental illness......Page 311
A cognitive model of social anxiety in psychosis......Page 312
Implications for cognitive–behaviour therapy of early psychosis......Page 313
Cognitive–behaviour therapy for (emotional dysfunction in) psychosis......Page 314
Borderline personality disorder: a neglected issue in first-episode psychosis......Page 315
The prevalence of comorbidity......Page 316
Cognitive analytic therapy......Page 317
Cognitive analytic therapy in psychosis......Page 318
References......Page 319
Section 7 The critical period: specific interventions......Page 325
Families and the course of psychotic disorder......Page 327
The impact of expressed emotion: its predictive validity in formal and informal carers......Page 328
Expressed emotion and first-episode psychosis and ultra-high-risk patients......Page 329
Why is the link between expressed emotion and outcome less consistently detected in first-episode psychosis?......Page 330
The caregiving experience: how distressed are caregivers?......Page 334
Specific issues in the literature on first-episode psychosis and ultra-high-risk groups......Page 335
Family interventions in first-episode psychosis......Page 337
Stage models of family interventions......Page 338
Key components and guidelines for family services in first episode......Page 342
Supportive interventions......Page 343
Coping strategies......Page 344
Future directions......Page 345
References......Page 346
Introduction......Page 353
Unemployment and its consequences in psychotic illness......Page 354
Social firms......Page 356
The Clubhouse model......Page 357
Clubhouse studies......Page 358
Studies on individual placement and support initiatives......Page 360
Vocational interventions in first-episode psychosis......Page 361
Vocational intervention at the Early Psychosis and Prevention Centre, Melbourne, Australia......Page 362
The University of California at Los Angeles Aftercare Research Programme: combining individual placement and support with Workplace Fundamentals Module training......Page 364
The Norfolk Early Intervention Service, UK......Page 365
References......Page 367
Introduction......Page 371
Defining and assessing psychotic relapse......Page 372
Factors associated with the risk for relapse......Page 373
Medication non-adherence......Page 374
Expressed emotion......Page 375
Stress and life events......Page 376
Cognitive deficits......Page 377
Relapse and antipsychotic medication......Page 378
Family interventions for relapse prevention......Page 379
Recommendations regarding relapse prevention in first-episode psychosis......Page 380
Rerferences......Page 382
Schizophrenia and schizoaffective disorder......Page 387
Major depressive disorder......Page 388
Major depressive disorder......Page 389
Service prerequisites......Page 390
Early detection of treatment resistance......Page 392
Schizophrenia and schizoaffective disorder......Page 393
Treatment-resistant bipolar mania or mixed episodes......Page 395
Major depressive disorder......Page 396
Schizophrenia and schizoaffective disorder......Page 397
Major depressive disorder......Page 398
Conclusions......Page 399
References......Page 400
Section 8 Service models......Page 405
Overview......Page 407
Clinical subprogrammes......Page 408
Inpatient care......Page 409
An integrated clinical and research programme......Page 410
Introduction and historical context......Page 411
Inpatient care......Page 412
Research and evaluation......Page 413
Inpatient service......Page 414
The Home Intervention Programme for Psychosis......Page 415
Referral criteria and service pathways......Page 416
The Calgary Early Psychosis Treatment Service......Page 417
Approach to programme evaluation......Page 418
Effectiveness research......Page 419
Overview of the service......Page 420
Assertive community treatment......Page 421
Conclusions......Page 422
References......Page 424
Index......Page 427