National Alliance on Mental Illness
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Research into the first episode of psychosis continues to expand, which will help to better inform service and treatment options for individuals, advocates and policymakers alike. It is important to note that different study designs in key areas of research are targeting different populations or stages in the development of an illness process and may be measuring outcomes and processes differently. Many of these studies are international in origin, and it is exciting to see how many different research groups are approaching the best ways to address people in the first episode of psychosis.
For example, the first episode of psychosis does sometime lead to an extended period of psychosis, and there are some relevant research studies from that outcome woven into this research summary—they will usually be framed as early schizophrenia.
An example of this variance in research focus can be seen by looking at a sample of recent initiatives. One is the national Recovery After Initial Schizophrenia Episode (RAISE) trial, which presumes a diagnosis of schizophrenia and looks to better understand the components that improve recovery in early stages of that illness. The Viennese fish oil study is more preventive in design, aiming to identify individuals at risk in order to prevent the development of psychosis. Marijuana research aims to target risk correlations in the development of psychosis, and to genetic variations that may raise an individual’s risk that uses marijuana. And finally, some creative and comprehensive approaches have been studied in different cultures (e.g. Open Dialogues in Western Lapland, China combination treatment and CBT in Melbourne, Australia) yet their applicability to a diverse U.S. population and culture has yet to be investigated.
Research is always being updated and developed to better understand key issues in this important field, and resources to follow this research are noted at the conclusion of this section.
RAISE: A National U.S. Clinical Trial
Recovery after an Initial Schizophrenia Episode is a National Institute of Mental Health (NIMH) funded research project. The goal of the NIMH-funded trial is to “fundamentally change the trajectory and prognosis of schizophrenia through coordinated and aggressive treatment in the earliest stages of the illness.” The study is led by John Kane, M.D. of the Feinstein Institute for Medical Research in Manhasset, N.Y., and Susan Essock, M.D., at Columbia University in New York City. There are 35 centers across the country, found in 21 states, participating in the early treatment component of the trial led by Dr. Kane. Residents of New York and Maryland may be eligible for Dr. Essock’s arm of the study. If, when contacting a local center, the trial is full or completed, ask to speak with one of the investigators of the study at your nearest local site. They may know of another investigational effort you could participate in and may know where to get the best care in your area. Results from this compelling effort will continue to emerge in the medical literature in the coming years.
For information or to learn more about enrollment, visit the RAISE website.
Fish Oil and Prevention of Progression to Psychosis
G. Paul Amminger, M.D., and his colleagues investigated the use of marine fish oil as a possible preventative agent in teens and young adults at risk for psychosis in Vienna, Austria. The study randomized 81 young people aged 13-25 who had shown some early signs of psychosis into two groups, one that received fish oil and one that received a placebo (coconut oil), each for three months. The groups also received some psychosocial interventions. After one year, 4.9 percent of the fish oil treated group progressed to psychosis while 27.5 percent progressed to psychosis in the placebo group
Amminger P., Schafer, M. et al., “Long Chain Omega-3 Fatty Acids for Indicated Prevention of Psychotic Disorders,” Archives General Psychiatry Vol 67, (No 2), Feb. 2010.
Medications with Psychosocial Intervention
In China, a randomized controlled trial led by Guo compared 1268 individuals with early-stage schizophrenia, comparing antipsychotic medications alone to antipsychotic medication plus 12 months of “psychosocial intervention consisting of psychoeducation, family intervention skills-training and cognitive behavior therapy administered during 48 group sessions.” The authors conclude that the combination group “showed lower rate of treatment discontinuation or change, lower risk of relapse and improved insight, quality of life and social functioning” and also had better work and school outcomes.
Guo et al., “Effect of Antipsychotic Medication Alone versus Combined with Psychosocial Intervention on Outcomes of Early Stage Schizophrenia,” Archives of General Psychiatry 2010: 67 (9) 895-904.
Medication Free Research in Early Episode
Bola reviewed the literature on the “question of whether short periods of medication free research in early episode schizophrenia result in demonstrably long term harm to human subjects.” There were only six studies that attempted to address this issue following subjects along for one year. He concludes, “Good quality evidence is inadequate to support a conclusion of long term harm resulting form short term postponement of medication in early episode research.”
Bola, “Medication Free Research in Early Episode Schizophrenia: Evidence of Long Term Harm?” Schizophrenia Bulletin Vol. 32, No. 2, 2006.
Early Psychosis, Brain Changes and Medications: A Conflicting Literature
Two studies are noteworthy in this area.
Lieberman and colleagues conducted a study of 263 first episode individuals with schizophrenia in 14 sites in the U.S. and Europe, and randomized the population to either first-generation antipsychotic haloperidol or Zyprexa (olanzapine). The randomized, controlled trial showed grey matter brain loss in the haloperidol group but not in the olanzapine group. The group treated with haloperidol showed grey matter loss of about 2 percent. (Lieberman et al., American Journal of Psychiatry, 2005).
However, a different study of 211 subjects living with schizophrenia “soon after illness onset” found contradictory results. Ho and Andreason looked at these schizophrenia subjects early in treatment, followed them over seven to 14 years and concluded that “antipsychotics have a subtle but measureable influence on brain tissue loss over time, suggesting the careful risk benefit review of dosage and duration of treatment.” (Archives of General Psychiatry Vol. 68. no. 2 Feb. 2011.)
Lieberman et al, "Antispychotic Drug Effects on Brain Morphology in First Episode Psychosis" Archives General Psychiatry 2005; 62, April 2005.
Childhood Psychotic Symptoms
Polanczyk and his colleagues followed 2232 children who presented with psychosis at age 5 over 7 years in order to better understand the presentation of psychosis and how it relates to schizophrenia. They found key risk factors for early onset psychosis including “heritable risks…and urbanicity, cognitive impairments at age 5, home-rearing risk factors, behavioral emotional and educational problems at age 5 and co-morbid conditions including self harm.” They conclude that “Psychotic symptoms in childhood are often a marker of impaired developmental processes and should be actively assessed.”
Polanczyk et al., “Etiological and Clinical Features of Childhood Psychotic Symptoms,” Archives of General Psychiatry 2010, 67 (4).
Marijuana and Earlier Onset of Psychosis
A systematic review of scientific research in first episode psychosis and cannabis use was done by a team of researchers led by Large. They identified 83 studies, in English, that addressed the relationship of cannabis and possible earlier onset of psychosis. Studies that also involved alcohol were included in the review, but the conclusions related to marijuana use. The authors conclude, “The results of the meta-analysis provide evidence for a relationship between cannabis use and earlier onset of psychosis, and they support the hypothesis that cannabis plays a causal in the development in some patients.”
Large, et al., “Cannabis Use and Earlier Onset of Psychosis: A Systematic Metanalysis,” Archives of General Psychiatry 2011, 68 (6).
Course of Substance Abuse in First Episode Psychosis
A review of the published literature was done by Wisdom and her colleagues. They found that one-half of the individuals with first episode of psychosis became abstinent or significantly reduced their alcohol and drug use after a first episode of psychosis. They conclude, “Experience education treatment or other factors led many to curtail their substance use disorders after a first episode of psychosis.”
Wisdom, J., Manuel, J., and Drake, R., “Substance Abuse Disorder Among People With First Episode Psychosis A Systematic Review of Course and Treatment,” Psychiatric Services 62, Sept. 2011.
Trauma and Psychosis
Adverse or traumatic experiences have a relationship with many adult health concerns, both physical and psychiatric. The observation that many individuals who have presented with psychosis have been exposed to adverse experiences was recently reviewed looking at large survey data sets in the U.S. and England. Shevlin and his colleagues correlated the surveys finding and found a correlation with multiple adverse experiences and the later development of psychosis. They outline a clear, dose-dependent relationship between adverse experiences and the risk of later developing psychosis.
Shevlin et al, “Cumulative Traumas and Psychosis: An Analysis of the National Co morbidity Survey and the British Psychiatric Morbidity Survey,” Schizophrenia Bulletin 2008, 34 (1).
Resilience and Illness Management Strategies
Two studies are noteworthy in this area.
Wellness Recovery Action Plan (WRAP)
WRAP, developed by Mary Ellen Copeland, was studied in six Ohio Counties in a randomized controlled study led by Cook. The 519 subjects were randomized to an eight-week, peer-led course or a wait list. The results showed improvements in symptoms, quality of life and hopefulness. This study was not done on a first episode population. Outcomes were measured at the end of the course and at six months. This is a strong design with a large number of subjects and builds scientific evidence to the first hand experience of people who have benefitted from WRAP.
Cook et al., “Results of a Randomized Controlled Trial of Mental Illness Self Management using Wellness Recovery Action Planning,” Schizophrenia Bulletin 10, March 2011.
Illness Management and Recovery
In a Swedish study, Fardig and his colleagues looked at an illness self-management tool for individuals with schizophrenia and compared it to treatment as usual. One of the approaches to promoting recovery and self-management in the field is called Illness Management and Recovery (IMR) and this has been the best-studied to-date. IMR in this study was done in a randomized, controlled trial of a small number (41) of individuals diagnosed with schizophrenia or schizoaffective disorder in community settings. Better results in coping and reduced suicidal ideation were key findings in the IMR group.
Fardig et al, "A Randomized Controlled Trial of Illness Management and Recovery in Person with Schizophrenia" Psychiatric Services 62, June 2011.
Open Dialogues: A Comprehensive Approach in Finland
Western Lapland is a rural homogenous community in Finland of about 70,000 people. A group of community psychiatrists in this area have developed a comprehensive community-based approach called Open Dialogue for individuals, their families and communities and have followed the outcomes. The team is rapid-continuous (inpatient and outpatient), uses all natural supports and focuses on family understanding as well as individual understanding. They conclude that after two years “81 percent of patients did not have any residual psychotic symptoms. And 84 percent has returned to full time employment or studies. Only 33 percent had used neuroleptics medication.” They also report a decrease in the incidence of schizophrenia using these interventions.
Seikkula, Alakare and Asltonen, “The Comprehensive Open Dialogue Approach in Western Lapland: II Long-term Stability of Acute Psychosis Outcomes in Advanced Community Care,” Psychosis 2011, 1-13 First article.
Family Psychoeducation: NAMI Family-to-Family
Dixon and her colleagues studied NAMI’s signature Family-to-Family education program in the greater Baltimore and surrounding Maryland areas. The randomized design included 318 family members who either took the course when they called for it or were asked to wait three months or more. The difference in the two groups was studied and gains in coping and empowerment were found in the active group that got Family-to-Family over the wait-list group. This design helps to explain that time passing alone was not the key ingredient in the improvement.
Dixon et al., “Outcomes of a Randomized Study of a Peer Taught Family-to-Family Education Program for Mental Illness,” Psychiatric Services 62, June 2011.
Cognitive Enhancement Therapy and Early SchizophreniaThe researchers used Cognitive Enhancement Therapy (CET) in outpatients early in the course of schizophrenia. They randomized a small group of subjects (58) to receive CET or a similarly intensive nonspecific support. The results showed a clear advantage in employment, earnings and cognition for the CET group. They conclude, “CET can help facilitate employment in early schizophrenia by addressing the cognitive impairments that limit functioning in the disorder.” Eack, Hogarty, et al., “Effects on Cognitive Enhancement Therapy on Employment Outcomes in Early Schizophrenia Results from a Two-year, Randomized Trial,” Social Work Practice, 21 (1) 2011.
Cognitive Behavior Therapy
The EPPIC Centre in Melbourne, Australia Psychosis Early Prevention and Intervention Centre Origen Youth Health
There are many resources to review from this leading center on Cognitive Behavior Therapy (CBT) and other psychosocial approaches. The best way to review this work is to go to the EPPIC Center website and to review what they have tried and learned in their system of care. This has led research in the use of CBT in the early episode of psychosis, but this summary alone does not do the center’s integrated and creative efforts justice.
Places to Watch for More Research
This important research work is happening in many countries each with its own delivery system, funding streams, culture and care models. For this reason, looking internationally to understand possible models and solutions is essential.
The International Society for Early Psychosis Association pulls together many of these international resources that are doing creative work in different cultural and system of delivery environments. Their eighth annual conference is in September 2012 in San Francisco.
Additional information on mental illness research can be found by visiting NIMH and NAMI’s Research section, which includes information on additional mental illness research opportunities, protection of research volunteers and more.