• Cannabis use is associated with increased psychotic symptoms and poorer psycho-social functioning in first-episode psychosis: A report from the UK National EDEN study

      Seddon, Jennifer L.; Birchwood, Max; Copello, Alex; Everard, Linda; Jones, Peter B.; Fowler, David; Amos, Tim; Freemantle, Nick; Sharma, Vimal; Marshall, Max; et al. (Oxford University Press, 2015-11-04)
      Background: The use of cannabis during the early stage of psychosis has been linked with increased psychotic symptoms. This study aimed to examine the use of cannabis in the 12 months following a first-episode psychosis (FEP) and the link with symptomatic course and outcome over one year post psychosis onset. Method: 1027 FEP patients were recruited upon inception to specialised early intervention services for psychosis in the UK. Participants completed assessments at baseline, six and twelve months. Results: The results indicate that the use of cannabis was significantly associated with increased severity of psychotic symptoms, mania, depression and poorer psycho-social functioning. Continued use of cannabis following the first episode of psychosis was prognostic of outcome at one year. These associations were significant after adjusting for age, gender, DUP, age of psychosis onset, ethnicity and other drug use. Conclusion: This is the largest cohort study of first-episode psychosis patients receiving care within early intervention services. Cannabis use, in particular continued use, is associated with poorer symptomatic and functional outcome during the first-episode of psychosis. The results highlight the need for effective and early intervention for cannabis use in FEP.
    • Comparing time use in individuals at different stages of psychosis and a non-clinical comparison group

      Hodgekins, Jo; French, Paul; Birchwood, Max; Mugford, Miranda; Christopher, Rose; Marshall, Max; Everard, Linda; Lester, Helen; Jones, Peter B.; Amos, Tim; et al. (Elsevier, 2014-12-23)
      Social functioning difficulties are a common and disabling feature of psychosis and have also been identified in the prodromal phase. However, debate exists about how such difficulties should be defined and measured. Time spent in structured activity has previously been linked to increased psychological wellbeing in non-clinical samples and may provide a useful way of assessing social functioning in clinical settings. The current study compared weekly hours in structured activity, assessed with the Time Use Survey, in three clinical groups at different stages of psychosis: individuals with at-risk mental states (N = 199), individuals with first-episode psychosis (N = 878), and individuals with delayed social recovery following the remission of psychotic symptoms (N = 77). Time use in the three clinical groups was also compared with norms from an age-matched non-clinical group (N = 5686) recruited for the Office for National Statistics UK 2000 Time Use Survey. Cut-off scores for defining social disability and recovery were examined. All three clinical groups spent significantly fewer hours per week in structured activity than individuals in the non-clinical group. Reduced activity levels were observed before the onset of psychosis in individuals with at-risk mental states. Additional reductions in activity were observed in the first-episode psychosis and delayed recovery groups compared to the at-risk mental state group. Assessing time spent in structured activity provides a useful way to assess social disability and recovery across the spectrum of psychosis.
    • Cost-effectiveness of early intervention services for psychosis and fidelity to national policy implementation guidance

      Radhakrishnan, Muralikrishnan; McCrone, Paul; Lafortune, Louise; Everard, Linda; Fowler, David; Amos, Tim; Freemantle, Nick; Singh, Swaran P.; Marshall, Max; Sharma, Vimal; et al. (Wiley, 2017-08-31)
      Introduction Early Intervention Services (EIS) for psychosis are being implemented, internationally. It is important to learn from established examples and define the components and intensity of services that provide good value for money. This study aims to assess the cost-effectiveness of EIS according to how closely they adhered to the recommendations of the English Department of Health 2001 Policy Implementation Guide (PIG). Methods EIS from the National Eden Study were assessed using a measure of fidelity to the PIG that rated the presence or absence of 64 recommended items relating to team structure and practice. EIS were then classified into three groups: those with fidelity of 75-80 %, 81%-90 %, and 91-95 %. Patient-level resource use and outcomes were measured one year following inception into the service; costs were calculated and combined with quality-adjusted life years (QALYs) gained. Results At a threshold of £20,000 per QALY, the 81-90% fidelity group had a 56.3% likelihood of being the most cost-effective option followed by 75-80% fidelity at 35.8% and 91-95% fidelity group (7.9%). Conclusions The results from England suggest that striving to maximise fidelity may not be warranted, but that dropping below a certain level of fidelity may result in inefficient use of resources.
    • The course of negative symptom in first episode psychosis and the relationship with social recovery

      Gee, Brioney; Hodgekins, Jo; Fowler, David; Marshall, Max; Everard, Linda; Lester, Helen; Jones, Peter B.; Amos, Tim; Singh, Swaran P.; Sharma, Vimal; et al. (Elsevier, 2016-04-28)
      AIMS: To investigate trajectories of negative symptoms during the first 12months of treatment for first episode psychosis (FEP), their predictors and relationship to social recovery. METHOD: 1006 participants were followed up for 12months following acceptance into Early Intervention in Psychosis services. Negative symptom trajectories were modelled using latent class growth analysis (LCGA) and predictors of trajectories examined using multinomial regression. Social recovery trajectories - also modelled using LCGA - of members of each negative symptom trajectory were ascertained and the relationship between negative symptom and social recovery trajectories examined. RESULTS: Four negative symptom trajectories were identified: Minimal Decreasing (63.9%), Mild Stable (13.5%), High Decreasing (17.1%) and High Stable (5.4%). Male gender and family history of non-affective psychosis predicted stably high negative symptoms. Poor premorbid adolescent adjustment, family history of non-affective psychosis and baseline depression predicted initially high but decreasing negative symptoms. Members of the Mild Stable, High Stable and High Decreasing classes were more likely to experience stably low functioning than the Minimal Decreasing class. CONCLUSIONS: Distinct negative symptom trajectories are evident in FEP. Only a small subgroup present with persistently high levels of negative symptoms. A substantial proportion of FEP patients with elevated negative symptoms at baseline will achieve remission of these symptoms within 12months. However, elevated negative symptoms at baseline, whether or not they remit, are associated with poor social recovery, suggesting targeted interventions for service users with elevated baseline negative symptoms may help improve functional outcomes.
    • The Global Mental Health Assessment Tool Primary Care and General Health Setting Version (GMHAT/PC) – Spanish version: A validity and feasibility study

      Tejada, Paola A.; Jaramillo, Luís Eduardo; Marulanda, Jefferson; Sharma, Vimal; University of Chester; National University of Colombia; Cheshire and Wirral NHS Foundation Trust (University of Zaragoza, 2016-08-31)
      The study aims to assess the feasibility of using a computer assisted diagnostic interview by GPs and to examine the level of agreement between the Spanish version GMHAT/PC diagnosis and psychiatrists' ICD-10 based clinical diagnosis. Participants in the study ranged from those who were in remission to others who had different mental illnesses. They were recruited from inpatient and outpatient mental health settings. All consecutive patients were interviewed using Spanish version of GMHAT/PC and they were assessed independently by psychiatrists to in order to get their ICD-10 based diagnosis. Two hundred ninety-nine patients participated in the study. The mean duration of interview was 12.5 minutes. There is an acceptable to good level of agreement between the GP’s (GMHAT/PC) diagnoses and the psychiatrists’ (clinical) diagnoses of any mental illness, Kappa 0.58 95% C.I (0.46, 0.72). There is good level of sensitivity (81%) and specificity (92%), with GPs correctly identifying 242 out of the 250 participants diagnosed with mental illness and 27 out of 35 of those without. The finding of the study suggest that GMHAT/PC Spanish version used by GPs detected mental disorders accurately and it was feasible to use GMHAT/PC (Spanish version) in Latin America settings.
    • Layers of listening: qualitative analysis of the impact of early intervention services for first-episode psychosis on carers’ experiences

      Anna, Lavis,; Lester, Helen; Everard, Linda; Freemantle, Nick; Amos, Tim; Fowler, David; Hodgekins, Jo; Jones, Peter B.; Marshall, Max; Sharma, Vimal; et al. (Cambridge University Press, 2015-08)
      Background: Early Intervention Services (EIS) comprise low-stigma youth-friendly mental health teams for young people undergoing first-episode psychosis (FEP). Engaging with the family of the young person is central to EIS policy and practice. Aims: By analysing carers’ accounts of their daily lives and affective challenges during a relative’s first-episode psychosis against the background of wider research into Early Intervention Services, this paper explores relationships between carers’ experiences and EIS. Methods: Semi-structured longitudinal interviews with 80 carers of young people with FEP treated through English EIS. Results: Our data suggest that EIS successfully aid carers to support their relatives, particularly through the provision of knowledge about psychosis and medications. However, paradoxical ramifications of these service user-focused engagements also emerge; they risk leaving carers’ emotions unacknowledged and compounding an existing lack of helpseeking. Conclusions: By focusing on EIS’s engagements with carers, this paper draws attention to an urgent broader question; as a continuing emphasis on care outside the clinic space places family members at the heart of the care of those with severe mental illness, we ask: who can, and should, support carers, and in what ways?
    • Lived experiences of negative symptoms in first-episode psychosis: A qualitative secondary analysis

      Gee, Brioney; Hodgekins, Jo; Lavis, Anna; Notley, Caitlin; Birchwood, Max; Everard, Linda; Freemantle, Nick; Jones, Peter B.; Singh, Swaran P.; Amos, Tim; et al. (Wiley, 2018-03-24)
    • Mental Health and Primary Care

      Sharma, Vimal; University of Chester (Insight Medical Publishing Group, 2017-07-21)
      Mental ill-health is a leading cause of disability and most people with mental health problems approach their primary care doctors for help. One in four consultations in primary care is mainly due to mental health related issues. Yet mental health hasn’t received due attention so far in primary care setting. The main challenges in taking mental health services at primary care level include limited mental health specialists, low priority given to mental health, Inadequate training and skills of primary care workforce, Inadequate specialists’ support to primary care workers as well as negative attitude and stigma towards metal illness. Investing in work force’s training and education in identifying and managing mental disorders at primary care is the only way forward to address the huge treatment gap exists for mental illness. The use of technology and computers may assist this process further. An example is use of a pragmatic computer assisted diagnostic and treatment tool such as GMHAT/PC. Psychiatrists and other mental health professionals need to change their mind-set to work differently by supporting primary care workers, spending more time in training front line workers and taking some leadership in keeping the mental health agenda high up in policy makers’ list.
    • Prevalence of treatment resistance and clozapine use in early intervention services.

      Stokes, Imogen; Griffiths, Siân Lowri; orcid: 0000-0003-0031-7174; Jones, Rowena; Everard, Linda; Jones, Peter B; Fowler, David; Hodgekins, Joanne; Amos, Tim; Freemantle, Nick; Sharma, Vimal; et al. (2020-09-17)
      Treatment resistance causes significant burden in psychosis. Clozapine is the only evidence-based pharmacologic intervention available for people with treatment-resistant schizophrenia; current guidelines recommend commencement after two unsuccessful trials of standard antipsychotics. This paper aims to explore the prevalence of treatment resistance and pathways to commencement of clozapine in UK early intervention in psychosis (EIP) services. Data were taken from the National Evaluation of the Development and Impact of Early Intervention Services study (N = 1027) and included demographics, medication history and psychosis symptoms measured by the Positive and Negative Syndrome Scale (PANSS) at baseline, 6 months and 12 months. Prescribing patterns and pathways to clozapine were examined. We adopted a strict criterion for treatment resistance, defined as persistent elevated positive symptoms (a PANSS positive score ≥16, equating to at least two items of at least moderate severity), across three time points. A total of 143 (18.1%) participants met the definition of treatment resistance of having continuous positive symptoms over 12 months, despite treatment in EIP services. Sixty-one (7.7%) participants were treatment resistant and eligible for clozapine, having had two trials of standard antipsychotics; however, only 25 (2.4%) were prescribed clozapine over the 12-month study period. Treatment-resistant participants were more likely to be prescribed additional antipsychotic medication and polypharmacy, instead of clozapine. Prevalent treatment resistance was observed in UK EIP services, but prescription of polypharmacy was much more common than clozapine. Significant delays in the commencement of clozapine may reflect a missed opportunity to promote recovery in this critical period.
    • Psychiatric morbidity in medically ill patients using Spanish version of GMHAT/PC

      Tejada, Paola A.; Jaramillo, Luís Eduardo; Polo, Gilberto; Sharma, Vimal; University of Chester (Taylor and Francis, 2016-12-14)
      The study aimed to assess psychiatric morbidity in medically ill patients and to examine the use of GMHAT/PC Spanish version in a general health setting. We recruited patients who were hospitalized at the services of Internal Medicine, Surgery and G/O during a period of 1 month for each service. The diagnosis of a medical illness was supported by specialists in each service. A trained GP conducted a psychiatric assessment of all the participants using GMHAT/PC. The interview was carried out at patients’ bedside. Of 455 medically ill patients, 4.8% had a mental illness identified by GMHAT/PC interview. Anxiety, depression and organic disorders were the most frequently identified mental disorders in internal medicine and surgery. Cancer had a significantly higher prevalence of comorbid mental illness. In this study the proportion of medically ill with mental disorders was less compared to other studies. The GMHAT/PC is more close to identifying clinical cases of mental illness and also patients who need help. The GMHAT is more a diagnostic instrument than a screening instrument. Physicians and practitioners can be trained to identify mental illness using computer-assisted tools such as GMHAT/PC. A holistic approach of providing care to such patients may improve their overall outcome and quality of life.
    • Social recovery therapy in combination with early intervention services for enhancement of social recovery in patients with first-episode psychosis (SUPEREDEN3): a single-blind, randomised controlled trial

      Fowler, David; Hodgekins, Jo; French, Paul; Marshall, Max; Freemantle, Nick; McCrone, Paul; Everard, Linda; Lavis, Anna; Jones, Peter B.; Amos, Tim; et al. (Elsevier, 2017-12-11)
      Background - Provision of early intervention services has increased the rate of social recovery in patients with first episode psychosis; however, many individuals have continuing severe and persistent problems with social functioning. We aimed to assess the efficacy of early intervention services augmented with social recovery therapy in patients with first-episode psychosis. The primary hypothesis was that social recovery therapy plus early intervention services would lead to improvements in social recovery. Methods - We did this single-blind, phase 2, randomised controlled trial (SUPEREDEN3) at four specialist early intervention services in the UK. We included participants who were aged 16–35 years, had non-affective psychosis, had been clients of early intervention services for 12–30 months, and had persistent and severe social disability, defined as engagement in less than 30 h per week of structured activity. Participants were randomly assigned (1:1), via computer-generated randomisation with permuted blocks (sizes of four to six), to receive social recovery therapy plus early intervention services or early intervention services alone. Randomisation was stratified by sex and recruitment centre (Norfolk, Birmingham, Lancashire, and Sussex). By necessity, participants were not masked to group allocation, but allocation was concealed from outcome assessors. The primary outcome was time spent in structured activity at 9 months, as measured by the Time Use Survey. Analysis was by intention to treat. This trial is registered with ISRCTN, number ISRCTN61621571. Findings Between Oct 1, 2012, and June 20, 2014, we randomly assigned 155 participants to receive social recovery therapy plus early intervention services (n=76) or early intervention services alone (n=79); the intention-to-treat population comprised 154 patients. At 9 months, 143 (93%) participants had data for the primary outcome. Social recovery therapy plus early intervention services was associated with an increase in structured activity of 8·1 h (95% CI 2·5–13·6; p=0·0050) compared with early intervention services alone. No adverse events were deemed attributable to study therapy. Interpretation - Our findings show a clinically important benefit of enhanced social recovery on structured activity in patients with first-episode psychosis who received social recovery therapy plus early intervention services. Social recovery therapy might be useful in improving functional outcomes in people with first-episode psychosis, particularly in individuals not motivated to engage in existing psychosocial interventions targeting functioning, or who have comorbid difficulties preventing them from doing so.