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Background Currently there is no first-line treatment recommended for the negative symptoms of schizophrenia. Psychosocial and behavioural interventions are widely used to reduce the burden of negative symptoms. Meta-analytic studies have summarised the evidence for specific approaches but not compared evidence quality and benefit. Aim To review and evaluate the evidence from meta-analytic studies of psychosocial and behavioural interventions for the negative symptoms of schizophrenia. Method A systematic literature search was undertaken to identify all meta-analyses evaluating psychosocial and behavioural interventions reporting on negative symptom outcomes in people with schizophrenia. Data on intervention, study characteristics, acceptability and outcome were extracted. Risk of bias was evaluated. Results were summarised descriptively, and evidence ranked on methodological quality. Results In total, 31 systematic reviews met the inclusion criteria evaluating the efficacy of negative symptom interventions on 33 141 participants. Exercise interventions showed effect sizes (reduction in negative symptoms) ranging from −0.59 to −0.24 and psychological interventions ranging from −0.65 to −0.04. Attrition ranged between 12% to 32%. Across the studies considered heterogeneity varied substantially (range 0–100). Most of the reviews were of very low to low methodological quality. Methodological quality ranking suggested that the effect size for cognitive remediation and exercise therapy may be more robust compared with other approaches. Conclusions Most of the interventions considered had a small-to-moderate effect size, good acceptability levels but very few had negative symptoms as the primary intervention target. To improve the confidence of these effect sizes being replicated in clinical settings future studies should minimise risk of bias.

The sexual health of adults with schizophrenia is poorer than the general population; however, less is known about young people experiencing a first episode of psychosis (FEP). The aim of this study was to explore the high-risk sexual behaviours and sexual well-being indicators of a cohort of young people with FEP.Data collected from young people (15-24 years) with FEP attending the EPPIC service in Melbourne and participating in a physical health intervention were analysed. Baseline trial data collected on sexual health and high-risk behaviours, psychiatric symptomology, functioning, and substance use are presented by gender. Associations between symptomology and functioning with sexual behaviour are explored.A total of 69 young people were included in this study; mean age was 19.6 years (SD±2.8), 53.6% were male, 59.6% identified as heterosexual, and 21.7% were currently in a relationship. Within the cohort, 78.3% had ever been sexually active. Of these, 44.2% consistently used a condom at last sex act and 35.7% used barrier contraception consistently, 22.5% had previously been pregnant, and 18.6% had tested positive for an STI. Finally, young people were more likely to have been sexually active if they were currently using substances.These findings suggest that high rates of high-risk sexual behaviour remain an issue for young people experiencing a first episode of psychosis. Promoting sexual well-being and communication skills between sexual partners should be targeted to ensure that high-risk sexual health outcomes are mitigated as early as possible.

Services for young people identified as having an 'at-risk mental state' (ARMS) aim to prevent transition to first-episode psychosis (FEP), in addition, early intervention services for other mental health disorders have also been developed. The aim of the current study was to determine the proportion of young people attending a specialist FEP service who had been referred via other early intervention clinics, including an ARMS clinic, and compare the characteristics to those who presented directly to the FEP service.We included young people diagnosed with FEP who received treatment at Orygen between 01.01.2012 and 31.12.2016. We examined rates of direct entry to the First Episode Psychosis service and rates from other early intervention services, specifically ARMS, personality disorders, mood disorders and a primary care youth mental health service clinics.1138 young people were diagnosed with a FEP, of whom 13.7% first attended an ARMS clinic and a further 7.6% attended other youth mental health services. Individuals who first presented to an ARMS clinic were more likely to be female, younger, and less likely to be migrants or use substances. Rates of both voluntary and involuntary hospital admissions were significantly reduced for young people who transitioned from the ARMS clinic, the personality disorder clinic or the primary care service compared to those who presented directly with FEP.A significant proportion of young people with FEP initially attended another specialist youth mental health service, and importantly, they had much lower rates of hospital admission at the time of transition to FEP.

Despite the established finding that migrants are at higher risk of developing a first-episode psychosis, they are under-represented in cohorts of young people identified as being at ultra-high risk for psychosis (UHR). Therefore, in order to determine the reasons for these conflicting findings, this study examined the pathways to care and clinical presentation of migrants attending an At-Risk Mental State clinic.This study included consecutive UHR cases identified over five years attending the PACE clinic in Melbourne, Australia. The CAARMS was used to assess the severity of attenuated psychotic symptoms. Depressive symptoms and functioning were measured using the PHQ9 and GAF, respectively.Over the five-year study period, 461 UHR young people attended the PACE clinic and 13.7% were first-generation migrants. A higher proportion of migrants were referred by community health services, such as general practitioners, than other referral sources. Australian born UHR patients were more likely to be referred via another mental health service. There was no difference in the type or severity of attenuated psychotic symptoms based on migrant status, except that there was a trend for young African migrants to have more severe unusual thought content. Depressive symptoms and poor functioning were highly prevalent across the total cohort and did not differ according to migrant status.It is not yet understood why migrants are under-represented in UHR cohorts. Qualitative interviews of migrants, who are not typically identified in the UHR stage, could provide insights into the barriers to accessing care.

Background Young people with mental ill-health have higher rates of high-risk sexual behaviour, poorer sexual health outcomes, and lower satisfaction with their sexual wellbeing compared to their peers. Ensuring good sexual health in this cohort is a public health concern, but best practice intervention in the area remains under-researched. The study aimed to co-produce a novel intervention to address the sexual health needs of young people with mental ill-health to test its effectiveness in a future trial. Methods We followed the 2022 Medical Research Council (MRC) guidelines for developing and evaluating complex interventions. This involved synthesising evidence from the 'top down' (published evidence) and 'bottom up' (stakeholder views). We combined systematic review findings with data elicited from qualitative interviews and focus groups with young people, carers, and clinicians and identified critical cultural issues. Results Existing evidence in the field of sexual health in youth mental health was limited but suggested the need to address sexual wellbeing as a concept broader than an absence of negative health outcomes. The Information-Motivation-Belief model was chosen as the theoretical Framework on which to base the intervention. Interviews/focus groups were conducted with 29 stakeholders (18 clinicians, three carers, and eight young people). Synthesis of the evidence gathered resulted in the co-design of a novel intervention consisting of an initial consultation and four 60-90-minute sessions delivered individually by a clinician with additional training in sexual health. Barriers and supports to intervention success were also identified. Conclusions Using the MRC Framework has guided the co-development of a potentially promising intervention that addresses the sexual health needs of young people with mental ill-health. The next step is to test the intervention in a one-arm feasibility trial.

Both psychotic illness and subclinical psychosis-like experiences (PLEs) have been associated with cortico-striatal dysfunction. This work has largely relied on a discrete parcellation of the striatum into distinct functional areas, but recent evidence suggests that the striatum comprises multiple overlapping and smoothly varying gradients (i.e., modes) of functional organization. Here, we investigated two of these functional connectivity modes, previously associated with variations in the topographic patterning of cortico-striatal connectivity (first-order gradient), and dopaminergic innervation of the striatum (second-order gradient), and assessed continuities in striatal function from subclinical to clinical domains. We applied connectopic mapping to resting-state fMRI data to obtain the first-order and second-order striatal connectivity modes in two distinct samples: (1) 56 antipsychotic-free patients (26 females) with first-episode psychosis (FEP) and 27 healthy controls (17 females); and (2) a community-based cohort of 377 healthy individuals (213 females) comprehensively assessed for subclinical PLEs and schizotypy. The first-order “cortico-striatal” and second-order “dopaminergic” connectivity gradients were significantly different in FEP patients compared to controls bilaterally. In the independent sample of healthy individuals, variations in the left first-order “cortico-striatal” connectivity gradient were associated with inter-individual differences in a factor capturing general schizotypy and PLE severity. The presumed cortico-striatal connectivity gradient was implicated in both subclinical and clinical cohorts, suggesting that variations in its organization may represent a neurobiological trait marker across the psychosis continuum. Disruption of the presumed dopaminergic gradient was only noticeable in patients, suggesting that neurotransmitter dysfunction may be more apparent to clinical illness.

Aims:\ud The COVID-19 pandemic forced the rapid move of mental health services to being delivered online. This included the delivery of a psychosocial recovery program (PRP) delivered in youth mental health services in Melbourne, Australia which consists of groups that address functional recovery. At the time, there was limited evidence about how this switch in service provision would be received by service users or what impact the pandemic was having on their mental health.\ud \ud Methods:\ud Young people engaged with the PRP between March and May 2020 were sent a link to complete an online survey that was co-developed by young people and clinicians. Attendance data at groups were extracted as a proximal measure of feasibility and acceptability.\ud \ud Results:\ud A total of 44 young people undertook the survey with the domains of wellbeing most impacted by lockdown being work/study, motivation and social connection. Groups provided online were generally well attended during lockdown, particularly those that had a focus on therapeutic content. Young people indicated little preference for continuing to attend groups run purely online when restrictions eased, with many expressing a preference for these to be offered face-to-face or in a combined format.\ud \ud Conclusions:\ud These findings suggest that implementation of online psychosocial groups during periods of lockdown is both feasible and acceptable. Whilst young people found accessing groups online to be of benefit at the time, they felt that continued substitution of face-to-face groups would not necessarily be preferable and clinical services should consider these preferences in their long-term service delivery.

Early intervention for psychosis services have been established worldwide and consist of specialist services for those with the At-Risk Mental State (ARMS) and a first episode of psychosis (FEP). This systematic review identified the literature on the outcomes of people who initially presented via an ARMS clinic and later transitioned to a psychotic disorder (UHR-T), compared to those who presented directly to an EI service with a FEP (FEP-D). The outcomes examined were (i) symptomatic (ii) functional, (iii) morbidity and mortality (including physical health) and (iv) service-usage.A systematic search strategy was employed using three databases: MEDLINE, PsycInfo, and EMBASE. Studies published in English and that compared any of the above outcomes in a cohort of people with a first episode of psychosis who initially presented via an ARMS clinic to those who presented directly to a FEP service were included. Meta-analysis was performed for any outcome data from at least two studies.A total of 988 unique articles were identified and of these, three studies fulfilled the inclusion criteria and these included a total of 78 UHR-T and 253 FEP-D individuals. In the one study examining remission rates, there was no difference observed after one year in the UHR-T and FEP-D groups. In the one study that examined neurocognition, no differences were observed in any of the neurocognitive domains between groups after one year. Two studies examined psychiatric admission rates within one year and one of these found that UHR-T individuals were less likely to have any psychiatric admission (46% vs 68%) and admissions were less likely to be involuntary (30% vs 74%), while the other study found no difference in admission rates. In the meta-analysis, UHR-T individuals had lower odds for any psychiatric hospital admission within one year compared to FEP-D individuals (OR = 0.54, 95% C.I. 0.32 - 0.94, p = .03). No studies examined functional outcomes or mortality and morbidity between the groups.The limited research indicates similar or superior outcomes for people with a FEP who present initially via an ARMS clinic. The reduced psychiatric admission rate is an important potential benefit of ARMS clinics that requires replication.

Dysfunction of fronto-striato-thalamic (FST) circuits is thought to contribute to dopaminergic dysfunction and symptom onset in psychosis, but it remains unclear whether this dysfunction is driven by aberrant bottom-up subcortical signalling or impaired top-down cortical regulation. We used spectral dynamic causal modelling of resting-state functional MRI to characterize the effective connectivity of dorsal and ventral FST circuits in a sample of 46 antipsychotic-naïve first-episode psychosis patients and 23 controls and an independent sample of 36 patients with established schizophrenia and 100 controls. We also investigated the association between FST effective connectivity and striatal 18F-DOPA uptake in an independent healthy cohort of 33 individuals who underwent concurrent functional MRI and PET. Using a posterior probability threshold of 0.95, we found that midbrain and thalamic connectivity were implicated as dysfunctional across both patient groups. Dysconnectivity in first-episode psychosis patients was mainly restricted to the subcortex, with positive symptom severity being associated with midbrain connectivity. Dysconnectivity between the cortex and subcortical systems was only apparent in established schizophrenia patients. In the healthy 18F-DOPA cohort, we found that striatal dopamine synthesis capacity was associated with the effective connectivity of nigrostriatal and striatothalamic pathways, implicating similar circuits to those associated with psychotic symptom severity in patients. Overall, our findings indicate that subcortical dysconnectivity is evident in the early stages of psychosis, that cortical dysfunction may emerge later in the illness, and that nigrostriatal and striatothalamic signalling are closely related to striatal dopamine synthesis capacity, which is a robust marker for psychosis.

Background Vitamin D deficiency is prevalent among people with psychosis and may play a role in the aetiology of psychotic disorders. However, its impact on clinical symptom severity has not been independently reviewed. Methods We conducted a systematic search of randomized trials and observational studies that assessed the relationship between vitamin D and symptom domains (positive and negative psychotic symptoms, total and general psychopathology, cognitive and depressive) in people with a psychotic disorder. Results 1040 articles were identified, of which 29 were eligible for inclusion: 26 observational studies and 3 randomized trials. Five studies included people with First-Episode Psychosis (FEP) and 24 included people with enduring psychosis. Most observational studies found that vitamin D was inversely associated with negative symptoms (57%; 13/23), positively associated with cognitive performance (63%; 5/8), and bore no association with positive symptoms (68%; 15/22), total psychopathology (64%; 7/11), general psychopathology (57%; 4/7) or depressive symptoms (64%; 9/14). Randomized controlled trials indicated that vitamin D supplementation improved cognitive performance (100%; 1/1) and, in some cases, reduced total psychopathology (50%; 1/2), general psychopathology (50%; 1/2) and negative symptoms (30%; 1/3), but had no effect on positive (100%; 3/3) or depressive (100%; 3/3) symptoms. Some positive associations were attenuated when controlled for potential confounders. Conclusion Low vitamin D was found to be inversely associated with more severe clinical symptoms in some, but not all symptom domains in people with psychosis. These preliminary findings warrant further exploration, particularly in regard to cognitive performance and negative symptoms.

Background Factors that contribute to the early mortality observed in psychotic disorders, specifically obesity, smoking and sedentary behaviour, occur early in the disorder. Aims We aimed to determine whether the integration of a physical health nurse in the care of young people with first-episode psychosis could prevent clinically significant weight gain (≥7% body weight). Secondary outcomes included rates of smoking, metabolic syndrome and sedentary behaviour. Method In this single-blind, randomised controlled trial, participants who had received under 4 weeks of antipsychotic medication were randomly allocated to either the intervention (addition of a physical health nurse to their care) or treatment as usual (TAU) for 12 weeks. Results Of the 77 participants, there were follow-up data for 86.8% (n = 33) of the intervention group and 82.1% (n = 32) of the TAU group. After 12 weeks, 27.3% of the intervention group experienced clinically significant weight gain compared with 34.4% of the TAU group (odds ratio 0.72, 95% CI 0.25–2.06, P = 0.54). After 6 months, 40.7% of the intervention group gained clinically significant weight compared with 44.1% of the TAU group (P = 0.79). There was no difference in mean change in weight between groups after 12 weeks (2.6 kg v. 2.9 kg, P = 0.87) or 6 months (3.6 kg v. 4.3 kg, P = 0.64). There were no differences in the rates of tobacco smoking cessation, prevalence of metabolic syndrome or physical activity levels. Conclusions This intervention failed to prevent the metabolic complications that are highly prevalent in psychotic disorders in the short to medium term, indicating that more intensive interventions are required.

Cardiovascular and metabolic diseases are the leading contributors to the early mortality associated with psychotic disorders. To date, it has not been possible to disentangle the effect of medication and non-medication factors on the physical health of people with a first episode of psychosis (FEP). This study aimed to isolate the effects of antipsychotic medication on anthropometric measurements, fasting glucose and lipids.This study utilized data from a triple-blind randomized placebo-controlled trial comparing two groups of antipsychotic-naïve young people with a FEP who were randomized to receive a second-generation antipsychotic medication (FEP-medication group) or placebo (FEP-placebo group) for 6 months. Twenty-seven control participants were also recruited.Eighty-one participants commenced the trial; 69.1% completed at least 3 months of the intervention and 33.3% completed the full 6 months. The FEP-placebo group gained a mean of 2.4 kg (±4.9) compared to 1.1 kg (±4.9) in the control participants (t = 0.76, p = .45). After controlling for multiple analyses, there was no difference in blood pressure, waist circumference or heart rate between the FEP-placebo group and controls. After 6 months, the FEP medication group had gained 4.1 kg (±4.5), higher than those receiving placebo but not statistically significant (t = 0.8, p = .44). There were no differences in fasting glucose or lipids between the FEP groups after 3 months.While limited by small numbers and high attrition, these findings indicate that some of the metabolic complications observed in psychotic disorders could be attributable to factors other than medication. This emphasizes the need to deliver physical health interventions early in the course of FEP.

Background No biological treatment has been firmly established for the at-risk stage of psychotic disorder. In this study we aim to test if subthreshold psychotic symptoms can be effectively treated with cannabidiol (CBD), a non-psychoactive compound of the plant Cannabis sativa. The question has taken on increased importance in the wake of evidence questioning both the need and efficacy of specific pharmacological interventions in the ultra-high risk (UHR) for psychosis group. Methods Three-arm randomized controlled trial of 405 patients (135 per arm) aged 12-25 years who meet UHR for psychosis criteria. The study includes a 6-week lead-in phase during which 10% of UHR individuals are expected to experience symptom remission. Participants will receive CBD (per oral) at doses 600 or 1000 mg per day (fixed schedule) for 12 weeks. Participants in the third arm of the trial will receive matching placebo capsules. Primary outcome is severity of positive psychotic symptoms as measured by the Comprehensive Assessment of At-Risk Mental States at 12 weeks. We hypothesize that CBD will be significantly more effective than placebo in improving positive psychotic symptoms in UHR patients. All participants will also be followed up 6 months post baseline to evaluate if treatment effects are sustained. Conclusion This paper reports on the rationale and protocol of the Cannabidiol for At Risk for psychosis Youth (CanARY) study. This study will test CBD for the first time in the UHR phase of psychotic disorder.

Borderline personality disorder (BPD) is common among people diagnosed with first episode of psychosis (FEP), but is often under-recognized and under-researched. This study aimed to determine: (i) the prevalence of borderline personality pathology (subthreshold features and categorical disorder) in a FEP cohort (termed FEP + BPP); (ii) demographic and clinical factors associated with FEP + BPP; (iii) the symptomatic and functional outcomes.This study was conducted within the Early Psychosis Prevention and Intervention Centre (EPPIC) at Orygen over the 30-month period between 2014 and 2016. BPP was evaluated by using the Structured Clinical Interview for DSM-IV Axis II Personality Questionnaire BPD criteria.In a cohort of 457 young people with a FEP (mean age 19.5 years, 56% male), 18.4% had borderline personality pathology (BPP). Compared with FEP alone, young people with FEP + BPP were more likely to be female, younger, Australian-born. In addition, young people with FEP + BPP were more likely to be diagnosed with Psychosis NOS, present with more severe hallucinations, and have alcohol abuse. Young people with FEP + BPP had more relationship difficulties at presentation and they were more likely to suffer of depression and to engage in self-harm throughout the follow-up. In relation to outcome, FEP + BPP was not associated with different rates of remission or relapse, however they were less likely to be admitted to hospital at presentation or involuntarily during their episode of care.BPP is a common occurrence in psychotic disorders and is associated with more severe hallucinations and depression with higher risks of self-harm. Specific interventions need to be developed.

Purpose: Migrant and ethnic minority populations exhibit a higher incidence of psychotic disorders. The Ultra-High Risk for psychosis (UHR) paradigm provides an opportunity to explore the stage at which such factors influence the development of psychosis. In this systematic review, we collate and appraise the literature on the association between ethnicity and migrant status and the rate of identification of individuals at UHR, as well as their rate of transition to psychosis. Methods: We conducted a systematic review in the Ovid Medline, PsychINFO, Pubmed, CINAHL and EMBASE databases according to PRISMA guidelines. We included studies written in English that included an UHR cohort, provided a measure of ethnicity or migrant status, and examined the incidence, rate, or risk of UHR identification or transition to psychosis. Results: Of 2182 unique articles identified, seven fulfilled the criteria. One study found overrepresentation of UHR individuals from black ethnic groups, while another found underrepresentation. Two studies found increased rates of transition among certain ethnic groups and a further two found no association. Regarding migrant status, one study found that first-generation migrants were underrepresented in an UHR sample. Lastly, a lower transition rate in migrant populations was identified in one study, while two found no association. Conclusion: Rates of UHR identification and transition according to ethnic and migrant status were inconsistent and insufficient to conclusively explain higher incidences of psychotic disorders among these groups. We discuss the clinical implications and avenues for future research, which is required to clarify the nature of the associations.

Objectives: When presenting with a first episode of psychosis (FEP), migrants can have different demographic and clinical characteristics to the native-born population and this was examined in an Irish Early Intervention for Psychosis service. Methods: All cases of treated FEP from three local mental health services within a defined catchment area were included. Psychotic disorder diagnoses were determined using the SCID and symptom and functioning domains were measured using validated and reliable measures. Results: From a cohort of 612 people, 21.1% were first-generation migrants and there was no difference in the demographic characteristics, diagnoses, symptoms or functioning between migrants and those born in the Republic of Ireland, except that migrants from Africa presented with less insight. Of those admitted, 48.6% of admissions for migrants were involuntary compared to 37.7% for the native-born population (p = 0.09). Conclusions: First-generation migrants now make up a significant proportion of people presenting with a FEP to an Irish EI for psychosis service. Broadly the demographic and clinical characteristics of migrants and those born in the Republic of Ireland are similar, except for less insight in migrants from Africa and a trend for a higher proportion of involuntary admissions in the total migrant group.

Certain migrant groups have been identified as being at increased risk of developing a psychotic disorder, but there is limited research on the outcomes for migrants who develop a first episode of psychosis (FEP). We investigated symptomatic outcomes (remission and relapse rates), functional outcomes (occupational status and relationships) and service utilization (hospital admission and engagement). Young people, aged between 15 and 24, who presented with FEP to the Early Psychosis Prevention and Intervention Centre (EPPIC) at Orygen between 01.01.11 and 31.12.16 were included. Place of birth was recorded at the time of presentation. To determine remission, symptoms were scored at three-month intervals using the short-form Scale for the Assessment of Positive Symptoms. A total of 1220 young people presented with FEP over the six-year period (mean age = 19.6 ± 2.8). Of these, 58.1% were male and 24.0% were first-generation migrants. While there was no difference in overall rates of admission after presentation, migrants were more likely to have an involuntary admission after presentation (31.4% vs. 24.6%, aHR = 1.54, 95% CI [1.19, 2.01]) and this risk was greatest for African migrants (HR = 1.98, 95% C.I. [1.37, 2.86]. The rates of remission and relapse were similar in migrants and those born in Australia and there was no difference in functional outcomes, such as employment rates at follow-up. The outcomes for migrants who experience FEP appear to be largely similar to those for the Australian-born population. Our finding that a greater rate of involuntary admission for migrants at presentation supports existing literature and needs further exploration to improve clinical care.

BackgroundIndividuals who experience serious mental health disorders are at an increased risk of physical illness co-morbidity and early intervention is crucial. Recommendations to embed an exercise physiologist service into a mental health service have not been fully evaluated.ObjectivesThis study aimed to determine (i) demographics and clinical characteristics of the young people referred to exercise physiology, (ii) adherence to metabolic monitoring, (iii) baseline physical health and (iv) level of engagement after referral.MethodsThis is a naturalistic cohort study and included all young people referred to the exercise physiology service between 2015 and 2019 at Orygen, a specialist youth mental health service in the north-western region of Melbourne.ResultsDuring the study period of 45 months, 312 young people were referred to exercise physiology, and of those, 51.3% were male. The mean age was 19.8 years. In regard to primary diagnoses, 47.4% had a psychotic disorder and 33.7% an affective disorder. Baseline weight measurements were completed for 71.8% of young people. The proportion of young people who were classified as overweight or obese increased from 55.1% to 70.4% (p< 0.001). For those referred, 61.5% attended either an individual session or a group session. A total of 29.5% did not attend their appointment following referral.ConclusionsAs over half of young people had poor physical health at presentation, integrating an exercise physiology service into a youth mental health service is a novel and needed intervention. However, there still needs to be an emphasis on metabolic monitoring and engagement.

Background Earlier engagement in risk-taking behaviors has been associated with more severe mental health problems across development. However, sex differences in risk-outcome relationships remain underexplored and mental health outcomes spanning both ends of the internalizing and externalizing spectra are rarely considered within the same sample. The present study examined associations between age at initiation of alcohol use, illicit drug use, and sexual intercourse, and symptoms of internalizing, externalizing, depression and self-harm, for males and females. Methods The present study analyzed self-report survey data from a nationally representative sample of Australian adolescents (N=2,950). Logistic regression models were conducted separately for males and females to test the association of early (age 15 or younger) and concurrent (age 16–17) initiation of alcohol use, illicit drug use and sexual behavior with symptoms of internalizing, externalizing, depression and self-harm at age 16–17. Results Risk-taking behaviors were associated with all mental health outcomes. Generally, earlier initiation of risk-taking behaviors demonstrated stronger associations with mental health outcomes than concurrent initiation. Associations between risk-taking behaviors and mental health outcomes varied by participant sex and mental health outcome. Limitations Mechanisms underlying the relationship between risk-taking behaviors and mental health problems were not tested and the sample had not yet reached early adulthood. Conclusions Risk-taking behaviors, particularly when initiated early, share links with multiple mental health problems in adolescence. Public health strategies to delay the onset of risk-taking behaviors may therefore incur multiple benefits as might an integrated approach to mental health prevention programs for youth.

OBJECTIVE: Young adults with serious mental illness (SMI) are reported to be socially excluded, but social inclusion measures are untested in this population. The aim of this study was to test the Filia Social Inclusion Measure (F-SIM) in this population. METHOD: Categorical principal components analysis of F-SIM data from N = 159 young adults with SMI aged 18-25 was conducted. Cronbach's alpha (α) examined internal consistency. Intraclass Correlation Coefficients (ICC3,2) examined 2-week test-retest reliability. Spearman's rho correlation coefficients (rs) examined construct validity. RESULTS: Cronbach's alpha was .94 for Dimension 1 (Interpersonal Connections), .87 for Dimension 2 (Vocational and Financial Security), and .82 for Dimension 3 (Healthy Independent Lifestyle). ICC3,2 coefficients ranged from .20-.99. Dimension 1 scores correlated with measures of social inclusion (rs = .69, p < .01), Quality of Life (QoL [rs = .63, p < .01]), hours of social/leisure activities last week (rs = .32, p < .01), loneliness (rs = -.76, p < .01), and psychological distress (rs = -.42, p < .01). Dimension 2 scores correlated with measures of social inclusion (rs = .27, p < .01) and hours working (rs = .67, p < .01) and studying last week (rs = .47, p < .01). Dimension 3 scores correlated with measures of social inclusion (rs = .25, p < .01), QoL (rs = .40, p < .01), psychological distress (rs = -.33, p < .01), and loneliness (rs = -.26, p < .01). CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: The F-SIM demonstrated excellent reliability and validity among young adults aged 18-25 with SMI. This represents a preliminary step toward evidence-based assessment and intervention to help increase social inclusion for this vulnerable population. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

In the last three decades, early intervention for psychosis (EIP) services have been established worldwide and have resulted in superior symptomatic and functional outcomes for people affected by psychotic disorders. These improved outcomes are a result of reducing delays to treatment and the provision of specialised, holistic interventions. The COVID-19 pandemic poses significant challenges to the delivery of these services, such as undetected cases or long delays to treatment. Furthermore, the COVID-19 pandemic will likely increase the mental health needs of communities, including the incidence of psychotic disorders. In this perspective piece, we provide suggestions as to how EIP services can adapt within this environment, such as utilising novel technologies. Finally, we argue that despite the economic consequences of the pandemic, the funding for mental health services, including EI services, should be increased in line with the need for these services during and beyond the pandemic.

IntroductionTobacco smoking is a leading cause of preventable death and disease worldwide. Adults with mental ill-health smoke tobacco at substantially higher rates than other adults, with public health approaches effective in the population overall having less impact on those with mental ill-health. However, less is known about the tobacco smoking behaviours, attitudes and knowledge of young people with mental ill-health, despite this being the peak period of onset for both mental illness and cigarette smoking.MethodsYoung people attending a youth mental health centre (providing both primary and specialist care) in Melbourne, Australia were approached by youth peer researchers and asked to complete a survey about smoking behaviours, attitudes and knowledge. We examined smoking and associated attitudes in the sample overall, and as a function of the services accessed.ResultsIn total, 114 young people completed the survey, with 56.3% reporting lifetime cigarette smoking, 42.0% smoking in the last 12 months and 28.6% in the past week. Of current regular smokers, 75.0% acknowledged they should quit in the future; however, only 23.5% planned to do so in the next month, with 44.4% confident that they could quit. Participants lacked knowledge about interactions between tobacco smoking, mental and physical health.ConclusionsYouth presenting for mental ill-health had high rates of cigarette smoking relative to population rates. Presentation at youth mental health services may represent a critical window for early intervention to reduce the lifetime impacts of cigarette smoking in mental ill-health. Interventions to support smoking cessation in this group are urgently needed.

Aim Phenomena within the psychosis continuum that varies in frequency/duration/intensity have been increasingly identified. Different terms describe these phenomena, however there is no standardization within the terminology. This review evaluated the definitions and assessment tools of seven terms - (i) 'psychotic experiences'; (ii) 'psychotic-like experiences'; (iii) 'psychotic-like symptoms'; (iv) 'attenuated psychotic symptoms'; (v) 'prodromal psychotic symptoms'; (vi) 'psychotic symptomatology'; and (vii) 'psychotic symptoms'. Methods EMBASE, MEDLINE, and CINAHL were searched during February-March 2019. Inclusion criteria included 1989-2019, full text, human, and English. Papers with no explicit definition or assessment tool, duplicates, conference abstracts, systematic reviews, meta-analyses, or no access were excluded. Results A total of 2238 papers were identified and of these, 627 were included. Definitions and assessment tools varied, but some trends were found. Psychotic experiences and psychotic-like experiences were transient and mild, found in the general population and those at-risk. Psychotic-like symptoms were subthreshold and among at-risk populations and non-psychotic mental disorders. Attenuated psychotic symptoms were subthreshold but associated with distress, risk, and help-seeking. Prodromal psychotic symptoms referred to the prodrome of psychotic disorders. Psychotic symptomatology included delusions and hallucinations within psychotic disorders. Psychotic symptoms was the broadest term, encompassing a range of populations but most commonly involving hallucinations, delusions, thought disorder, and disorganization. Discussion A model for conceptualizing the required terms is proposed and future directions needed to advance this field of research are discussed.

Background: There is a higher incidence of psychotic disorders in neighbourhoods of greater social deprivation. However, it is not known whether this represents a causal relationship, as the stage at which social deprivation exerts its influence on the development of psychotic disorders is yet to be elucidated. We aimed to investigate the association between neighbourhood-level social deprivation and the rate of identification of individuals at Ultra-High Risk for psychosis (UHR), as well as the risk of transition to psychosis in UHR individuals. Methods: The cohort included all young people aged 15 to 24 identified as UHR attending an Early Intervention clinic in northwestern Melbourne over a 5-year period (2012–2016). Australian census data were used to obtain the at-risk population and social deprivation information according to the postcode of residence. Levels of social deprivation were arranged into quartiles. Poisson regression was used to calculate rate ratios and Cox regression analysis determined hazard ratios. Results: Of the 461 young people identified as UHR, 11.1% ( n = 49) lived in the most affluent neighbourhoods (Quartile 1) compared to 36.7% ( n = 162) in the most deprived neighbourhoods (Quartile 4). There was a 35% higher rate of identification of young people who were UHR from the most deprived neighbourhoods (aIRR = 1.35, 95% CI [0.98, 1.86]). Over a median follow-up of approximately 10 months (308 days (IQR: 188–557), 17.5% ( n = 77) were known to have transitioned to a full-threshold psychotic disorder. Residing in a neighbourhood of above average deprivation had a hazard ratio of 2.05 (95% CI [0.88, 4.80]) for risk of transition, when controlling for age, sex and substance use. Conclusions: These findings provide more support that EI services should be funded as per the expected incidence of psychotic disorders.

Background: Migration is a robust risk factor for developing a psychotic disorder, yet there is a paucity of research on the outcomes of migrants who develop a psychotic disorder. Identifying sub-groups within FEP cohorts who have a poorer outcome, could assist in the development and delivery of more targeted interventions. Aims: There is a paucity of research on the outcomes of migrants who develop a psychotic disorder. This study aimed to evaluate a broad range of outcomes for those with a FEP who migrated to the Republic of Ireland, including: (i) symptomatic; (ii) functional; (iii) hospitalisation and (iv) engagement with psychosocial services. Methods: All individuals with a FEP aged 18 to 65 who presented between 01.02.2006 and 01.07.2014 were included. Structured and validated instruments were used to measure positive, negative, depressive symptoms and insight. Results: Of the 573 individuals with a FEP, 22.3% were first-generation migrants and 63.4% ( n = 363) were followed up at 1 year. At this time, 72.4% of migrants were in remission of positive psychotic symptoms compared to 78.5% of the Irish born ( OR = 0.84, 95% CI [0.50–1.41], p = .51). In relation to negative symptoms, 60.5% of migrants were in remission compared to 67.2% of the Irish born ( OR = 0.75, 95% CI [0.44–1.27], p = .283). There was no difference in the severity of positive, negative or depressive symptoms between groups and there was a trend for the Irish born to have better insight ( p = .056). The functional outcomes were similar across groups. One third of migrants were admitted to hospital compared to 28.7% of the Irish born ( OR = 1.24, 95% CI [0.73–2.13], p = .426). Just over half of both groups attended CBT and 46.2% of caregivers for migrants attended the psychoeducation programme, compared to 39.7% for the Irish born ( OR = 1.30, 95% CI [0.79–2.16], p = .306). Conclusions: These findings demonstrate that migrants have broadly similar outcomes to the native-born populations, however there is still considerable scope for the outcomes for all individuals affected by psychotic disorders to be improved.

Objectives The field of early psychosis has undergone considerable expansion over the last few decades and has a strong evidence base of effectiveness. Like all areas of healthcare, however, early psychosis services need to more consistently deliver higher quality care to achieve better outcomes for patients and families. A national clinical research infrastructure is urgently required to enable the sector to deliver the highest quality care and expand and translate evidence more quickly and efficiently. This paper describes the establishment of the Australian Early Psychosis Collaborative Consortium (AEPCC) that aims to achieve this. Conclusion AEPCC is the first of its kind in Australia (and internationally). It will deliver the required clinical research infrastructure through the implementation of a clinical quality registry, clinical trials and translation network, and lived experience network. AEPCC will provide a critical resource to better understand the state of early psychosis care, and trial new interventions on a scale that has not previously been possible in Australia.

Objective: Early intervention for psychosis services result in superior outcomes in the domains of symptomatic and functional recovery, hospitalisation and employment compared to standard services; however, the optimal duration of care with these services is unknown. Knowledge on the discharge destinations, specifically the proportion discharged to high- and low-intensity services, could provide insights into the proportion of who may require a longer tenure of care. This study aimed to determine (1) the discharge destinations from early intervention for psychosis services and (2) baseline and intra-episode factors associated with discharge to the secondary care/adult mental health service. Methodology: This study was conducted at the Early Psychosis Prevention and Intervention Centre in Melbourne and included all young people treated by the service with a first episode of psychosis over a 6-year period. Discharge destinations were categorised according to high-intensity services, namely, secondary mental health care, or lower intensity services, such as private practitioners or primary care. Results: A total of 1101 young people with a first episode of psychosis were included in the study, of whom 58.8% were male and the median age was 20.0 years (interquartile range: 17–22). After a median of 95.4 weeks (interquartile range: 66.7–105.7), 36.6% were discharged to the adult mental health services, which was associated with being not in employment, education or training at presentation (odds ratio = 1.71, 95% confidence interval [1.23, 2.37]); experiencing a relapse (odds ratio = 1.76, 95% confidence interval [1.24, 2.49]); and being admitted to a mental health unit (odds ratio = 3.98, 95% confidence interval [2.61, 6.09]). Young people who lived with their parents were less likely to be discharged to secondary care services (odds ratio = 0.52, 95% confidence interval [0.37, 0.73]), as were those who were achieving symptomatic remission within 12 weeks (odds ratio = 0.60, 95% confidence interval [0.43, 0.83]). Migrant status and the duration of untreated psychosis were not associated with discharge destination. Conclusion: These findings indicate that there is a sizable, identifiable minority who may benefit from a longer episode of care with early intervention for psychosis services.

ObjectiveCognitive impairment occurs in antipsychotic-naïve first-episode psychosis (FEP), but antipsychotics confound interpretation of the longitudinal course of cognition. The primary aim was to disentangle the effects of illness from antipsychotics on cognition over the first 6-months of FEP treatment.MethodsRandomised, triple-blind placebo-controlled trial (Staged Treatment and Acceptability Guidelines in Early Psychosis; STAGES), where cognition was a secondary outcome. Antipsychotic-naïve FEP patients were allocated to receive risperidone/paliperidone (N=38) or placebo (N=40) in addition to intensive psychosocial therapy for 6-months. A healthy control group (N=42) was also recruited. A cognitive battery assessing attention, working memory, processing speed, verbal fluency, cognitive control and verbal paired-associate learning and memory was administered at baseline and 6-months. Twelve- and 24-month follow-up was also conducted.ResultsOver the 6-month trial period, cognitive performance remained stable (working memory, verbal fluency) or improved (attention, processing speed, cognitive control), with no group-by-time interaction evident. The exception was for verbal paired-associate learning and memory, where a significant group-by-time interaction was observed. The placebo and healthy control groups improved, and the medication group deteriorated on immediate paired-associate recall (p=0.039) and delayed cued recall (p=0.005); effect sizes were medium-to-large. Findings were similar when only trial completers were included in the analysis.ConclusionsRisperidone/paliperidone may cause progression of memory impairment in the early months of FEP. Replication is needed in confirmatory trials. The findings support the need for careful consideration of the risks and benefits of various antipsychotics and the importance of accounting for their cognitive effects in longitudinal research.Trial registrationAustralian New Zealand Clinical Trials Registry (http://www.anzctr.org.au/ ACTRN12607000608460).

Objective: Understanding the pathways to care for migrants experiencing a first episode of psychosis is important, as they are more likely to experience longer delays to treatment and negative experiences, such as involuntary treatment. Despite the increased risk of developing a psychotic illness and barriers associated with pathways to care, there are limited studies exploring pathways to care in migrants in Australia. This study seeks to examine pathways to care for young people with a first episode of psychosis to a publicly funded youth mental health service. Methods: This study included all young people aged 15–24 years who presented with a first episode of psychosis to the Early Psychosis Prevention and Intervention Centre (EPPIC) between 1 February 2011 and 31 December 2016. Referral sources and place of birth were recorded at the time of presentation. The severity of psychotic symptoms was rated at baseline. Results: A total of 1220 young people presented with a first episode of psychosis during the study period, including 293 (24.5%) first-generation migrants. First-generation migrants with a first episode of psychosis were more likely to be admitted to hospital than Australian-born youth (odds ratio = 1.67, 95% confidence interval = [1.27, 2.18], p Conclusion: First-generation migrants who develop a psychotic disorder are at greater risk of experiencing negative pathways to care than the Australian-born population. Further research is needed to identify the factors that lead to migrants being involuntarily admitted to hospital for first episode of psychosis.

ImportancePsychotic illness is associated with anatomically distributed grey matter reductions that can worsen with illness progression, but the mechanisms underlying the specific spatial patterning of these changes is unknown.ObjectiveTo test the hypothesis that brain network architecture constrains cross-sectional and longitudinal grey matter alterations across different stages of psychotic illness and to identify whether certain brain regions act as putative epicentres from which volume loss spreads.Design, Settings, ParticipantsThis study included 534 individuals from 4 cohorts, spanning early and late stages of psychotic illness. Early-stage cohorts included patients with antipsychotic-naïve first episode psychosis (N=59) and a group of medicated patients within 3 years of psychosis onset (N=121). Late-stage cohorts comprised two independent samples of people with established schizophrenia (N=136 in total). Each patient group had a corresponding matched control group (N=218 in total). A further independent sample of healthy adults (N=346) was used to derive representative structural and functional brain networks for modelling of network-based spreading processes. We additionally examined longitudinal illness-related and antipsychotic-related grey matter changes over 3 and 12 months using a triple-blind randomised placebo-control MRI study of the antipsychotic-naïve patients. All data were collected between April 2008 and January 2020, and analyses were performed between March 2021 and January 2023.Main Outcomes and MeasuresWe used coordinated deformation models to predict the extent of grey matter volume change in each of 332 parcellated areas by the volume changes observed in areas to which they were structurally or functionally coupled. To identify putative epicentres of volume loss, we used a network diffusion model to simulate the spread of pathology from different seed regions. Correlations between predicted and empirical spatial patterns of grey matter volume alterations were used to quantify model performance.ResultsIn both early and late stages of illness, spatial patterns of cross-sectional volume differences between patients and controls were more accurately predicted by coordinated deformation models constrained by structural, rather than functional, network architecture (. 46 52;p< .001) and antipsychotic exposure (r> .50;p< .001). Diffusion modelling consistently identified, across all four datasets, the anterior hippocampus as a putative epicentre of pathological spread in psychosis (all p< .05). Epicentres of longitudinal grey matter loss were apparent posteriorly early in the illness and shifted anteriorly to prefrontal cortex with illness progression.Conclusion and RelevanceOur findings highlight a robust and central role for white matter fibres as conduits for the spread of pathology across different stages of psychotic illness, mirroring findings reported in neurodegenerative conditions. The structural connectome thus represents a fundamental constraint on brain changes in psychosis, regardless of whether these changes are caused by illness or medication. Moreover, the anterior hippocampus represents a putative epicentre of early brain pathology from which dysfunction may spread to affect connected areas.Key pointsQuestionAre grey matter changes across the psychosis continuum constrained by brain network architecture and are certain regions epicentres of volume loss?FindingsAcross four independent samples spanning different stages of psychotic illness, grey matter alterations are strongly constrained by the underlying architecture of the brain’s axonal pathways and the hippocampus is consistently identified as a putative source from which volume-loss may spread to connected regions.MeaningWhite matter fibres may act as conduits for the spread of pathology across all stages of psychotic illness and medial temporal regions play a critical role in the origins of grey matter reductions.

Objective: The COVID-19 pandemic has had a profound effect on global mental health, with one-third of infected individuals developing a psychiatric or neurological disorder 6 months after infection. The risk of infection and the associated restrictions introduced to reduce the spread of the virus have also impacted help-seeking behaviours. Therefore, this study aimed to determine whether there was a difference during the COVID-19 pandemic in the treated incidence of psychotic disorders and rates of admission to hospital for psychosis (including involuntary admission). Methods: Incident cases of first-episode psychosis in young people, aged 15 to 24, at an early intervention service in Melbourne from an 8-month period before the pandemic were compared with rates during the pandemic. Hospital admission rates for these periods were also compared. Results: Before the pandemic, the annual incidence of first-episode psychosis was 104.5 cases per 100,000 at-risk population, and during the pandemic it was 121.9 (incidence rate ratio = 1.14, 95% confidence interval = [0.92, 1.42], p = 0.24). Immediately after the implementation of restrictions, there was a non-significant reduction in the treated incidence (incidence rate ratio = 0.80, 95% confidence interval = [0.58, 1.09]), which was followed by a significant increase in the treated incidence in later months (incidence rate ratio = 1.94, 95% confidence interval = [1.52, 2.49]; incidence rate ratio = 1.64, 95% confidence interval = [1.25, 2.16]). Before the pandemic, 37.3% of young people with first-episode psychosis were admitted to hospital, compared to 61.7% during the pandemic (odds ratio = 2.71, 95% confidence interval = [1.73, 4.24]). Concerning the legal status of the admissions, before the pandemic, 27.3% were admitted involuntarily to hospital, compared to 42.5% during the pandemic (odds ratio = 1.97, 95% confidence interval = [1.23, 3.14]). Conclusion: There was a mild increase, which did not reach statistical significance, in the overall incidence of first-episode psychosis; however, the pattern of presentations changed significantly, with nearly twice as many cases presenting in the later months of the restrictions. There was a significant increase in both voluntary and involuntary admissions, and the possible explanations for these findings are discussed.

Objectives:Clozapine is the most effective antipsychotic medication, but it has the highest propensity for metabolic side effects. A clozapine clinic was established within an early intervention for psychosis service to facilitate the timely commencement of clozapine and to manage the associated adverse effects. This study describes the changes in the weight, body mass index (BMI), waist circumference and blood pressure after 6 months in young people commenced on clozapine.Method:This was a prospective cohort study of all young people, aged 15–24 years, commenced on clozapine within an early intervention service in Melbourne, Australia, between 01.04.2016 and 30.06.2018. Continuous data were analyzed with paired t-test and categorical with Wilcoxon signed-rank test.Results:Twenty-six young people received 6 months of treatment with clozapine, of whom the mean age was 19.8 years (s.d. ±3.1) and 66.7% were male. After 6 months, the mean weight gain was 5.1 kg (s.d. ±10.1 kg) and over half (53.8%) gained clinically significant weight. The proportion of young people classified as either overweight or obese rose from 69.2% to 88.5% (p = 0.006). The proportion of young people with a waist circumference above the recommended parameters increased from 57.9% to 78.9% (p = 0.008). Hypertension was present in 30%, and after 6 months, 45% had hypertension (p = 0.64). Metformin was prescribed to 34.6%, typically to those with the greatest and most rapid weight gain.Conclusion:Among young people with treatment resistant psychosis, clozapine is associated with significant metabolic side effects in the early stages of commencement. More interventions aimed at attenuating this weight gain are needed.

BACKGROUND: Certain migrant groups are more likely to develop a psychotic disorder compared to the native-born populations, and a younger age at migration is associated with greater risk. However, it is not known at which stage migration has an effect on the development of psychotic disorders. We examined whether migrants were more likely to be identified as ultra-high risk for psychosis (UHR) compared to native-born young people and whether migrant status was associated with the risk of transition to a full-threshold psychotic disorder. METHODS: The cohort included all young people aged 15-24 who were identified as UHR at a specialist clinic over a five-year period (2012-16). Australian census data were used to obtain the at-risk population. Poisson regression was used to calculate rate ratios and Cox regression analysis determined hazard ratios. RESULTS: 467 young people were identified as UHR, of which 13.5% (n = 63) were born overseas. First-generation migrants were 2.6-fold less likely to be identified as UHR compared to Australian-born young people (IRR = 0.39, 95% CI [0.30, 0.51], P

Aims: Young adults with serious mental illness (SMI) are thought to be socially excluded. However, psychometric measures of social inclusion have not been employed to examine group differences relative to peers from the general community. The aim of this study was to employ such a measure to determine differences in social inclusion between young adults with SMI and peers from the general community. Methods: A cross-sectional hierarchical logistic regression was conducted to identify which dimensions and individual indicators from the Filia Social Inclusion Measure (F-SIM) discriminated between n = 152 young adults aged 18–25 from the general community ( M = 21.36, SD = 2.16) and n = 159 young adults aged 18–25 with SMI ( M = 21.13, SD = 2.21). Results: Group membership was accounted for by Interpersonal Connections (Nagelkerke R2 = .32), Vocational & Financial Security (Nagelkerke R2 = .32) and Healthy Independent Lifestyle (Nagelkerke R2 = .08) dimensions of the F-SIM. Relative to young adults from the general community, those with SMI were five times less likely to feel they had friends who would call on them in a crisis, odds ratio (OR) = .19 (95%CI = .04, .53), p = .04, almost five times more likely to live with their parents, OR = 4.79 (95%CI = 1.98,11.15), p = .004, almost four times less likely to have worked/studied any time over the past 12 months, OR = .27 (95%CI = .11,.64), p Conclusion: Young adults with SMI are socially excluded relative to peers from the general community in terms of interpersonal connections, vocational engagement, autonomy/independence and housing stability. In addition to the well-established focus on vocational engagement, interventions to improve social inclusion in this population must promote reciprocity within social relationships and healthy autonomy/independence (including stable housing).

Individuals affected by psychotic disorders frequently disengage from mental health services, although reports of this rate in the literature have ranged from 6 to 60%. One of the potential explanations for the large variation is that studies have adopted different definitions. Without a universal definition it is challenging to compare rates and factors leading to disengagement across studies. This systematic review aims to identify and compare how disengagement from psychosis services has been defined, measured and operationalised in the literature to date. A systemic literature search of the PubMed, PsycINFO and CINAHL databases was completed following the PRISMA guidelines for systematic reviews. 1506 Studies were identified, of which 30 were eligible to be included. It was found that disengagement was operationalized as either a categorical or continuous variable across studies, with 18 studies classifying it as a categorical, binary variable. Only four studies applied a time period over which disengagement was said to occur, and only four studies used an instrument to measure or predict disengagement. Few studies considered similar factors in their definition, when this occurred it was because the papers came from the same research group. To truly understand the phenomenon of disengagement, studies need to have a comparable outcome variable. The need for consensus on a gold standard definition of disengagement that considers the full breadth of its complexity remains. A potential process for establishing a definition that includes set parameters, agreed upon terminology and time periods of assessment is discussed.

Objectives Psychotic disorder incidence varies geographically and is associated with neighbourhood characteristics, including social deprivation, population density, unemployment, social capital or social fragmentation. Yet it is not known whether these findings are applicable to Australia's unique geography. This study aimed to determine whether the incidence of first episode psychosis (FEP) varies according to neighbourhood characteristics in an Australian cohort. Method This study included all young people, aged 15 to 24, with an FEP who attended Orygen Youth Health in Melbourne, from a geographically defined catchment area encompassing Northern and Western Melbourne, over a 44-month period. Neighbourhood demographic data was collected from the 2011 Australian National Census. Negative binomial regression was used to determine incidence rate ratios controlled for age, sex and migrant status. Results A total of 747 young people had an FEP during the 44-month study period and 722 were included in this study. Of these, 58.0% were males and 67.9% had a non-affective psychotic disorder; the mean age of the cohort was 19.1 years. The incidence of FEP in young people aged 15 to 24 in the catchment area was 123.2 per 100,000 person-years. There was a higher incidence of FEP in neighbourhoods of greatest social deprivation (IRR = 1.65, CI = 1.06–2.51, p = .02), highest unemployment (IRR = 1.56, CI = 1.04–2.35, p = .03) and above average social fragmentation (IRR = 1.42, CI = 1.02–1.97, p = .04), when controlled for age, sex and migrant status. Conclusions This study highlights variation in psychotic disorder incidence and the need for this disparity to be reflected in appropriate resource allocation.

Purpose: Migrant status is one of the most replicated and robust risk factors for developing a psychotic disorder. This study aimed to determine whether migrant status in people identified as Ultra-High Risk for Psychosis (UHR) was associated with risk of transitioning to a full-threshold psychotic disorder.Methods: Hazard ratios for the risk of transition were calculated from five large UHR cohorts (n = 2166) and were used to conduct a meta-analysis using the generic inverse-variance method using a random-effects model.Results: 2166 UHR young people, with a mean age of 19.1 years (SD ± 4.5) were included, of whom 221 (10.7%) were first-generation migrants. A total of 357 young people transitioned to psychosis over a median follow-up time of 417 days (I.Q.R.147–756 days), representing 17.0% of the cohort. The risk of transition to a full-threshold disorder was not increased for first-generation migrants, (HR = 1.08, 95% CI 0.62–1.89); however, there was a high level of heterogeneity between studies The hazard ratio for second-generation migrants to transition to a full-threshold psychotic disorder compared to the remainder of the native-born population was 1.03 (95% CI 0.70–1.51).Conclusions: This meta-analysis did not find a statistically significant association between migrant status and an increased risk for transition to a full-threshold psychotic disorder; however, several methodological issues could explain this finding. Further research should focus on examining the risk of specific migrant groups and also ensuring that migrant populations are adequately represented within UHR clinics.

Cognitive impairments are a core feature of first-episode psychosis (FEP), arising before illness onset and antipsychotic exposure. Individuals with chronic psychosis experience poorer physical health while taking antipsychotic medication, but health disparities may be evident at FEP onset, prior to antipsychotic exposure. Given the links between cognition and physical health in healthy populations, the aim was to explore whether cognition and physical health are associated in FEP, which could inform early physical health interventions for cognition in FEP. Participants were aged 15 to 25 and included 86 individuals experiencing FEP with limited antipsychotic exposure and duration of untreated psychosis of ≤six months, and 43 age- and sex-matched controls. Individuals with FEP performed significantly poorer than controls in most cognitive domains (Cohen's d = 0.38 to 1.59). Groups were similar in metabolic health measures, excluding a significantly faster heart rate in FEP (d = 0.68). Through hierarchical regression analyses, we found that in the overall sample, BMI was negatively related to current IQ after controlling for education and group (FEP/control). Relationships between BMI and cognition were consistent across the FEP and healthy control groups. In FEP, current IQ and working memory were negatively correlated with lipid profiles. Findings suggest that in FEP, impaired cognition is exhibited earlier than physical health problems, and that compared to controls, similar relationships with cognition are demonstrated. Causal pathways and trajectories of relationships between health and cognition in FEP require investigation, especially as antipsychotic medications are introduced. The findings have implications for cognitive and health interventions.

Background Migration is an established risk factor for developing a psychotic disorder in countries with a long history of migration. Less is known for countries with only a recent history of migration. This study aimed to determine the risk for developing a psychotic disorder in migrants to the Republic of Ireland. Methods We included all presentations of first-episode psychosis over 8.5 years to the DETECT Early Intervention for psychosis service in the Republic of Ireland (573 individuals aged 18–65, of whom 22% were first-generation migrants). Psychotic disorder diagnosis relied on SCID. The at-risk population was calculated using census data, and negative binomial regression was used to estimate incidence rate ratios. Results The annual crude incidence rate for a first-episode psychotic disorder in the total cohort was 25.62 per 100000 population at risk. Migrants from Africa had a nearly twofold increased risk for developing a psychotic disorder compared to those born in the Republic of Ireland (IRR = 1.83, 95% CI 1.11–3.02, p = 0.02). In contrast, migrants from certain Asian countries had a reduced risk, specifically those from China, India, Philippines, Pakistan, Malaysia, Bangladesh and Hong Kong (aIRR = 0.36, 95% CI 0.16–0.81, p = 0.01). Conclusions Further research into the reasons for this inflated risk in specific migrant groups could produce insights into the aetiology of psychotic disorders. This information should also be used, alongside other data on environmental risk factors that can be determined from census data, to predict the incidence of psychotic disorders and thereby resource services appropriately.

BackgroundAltered functional connectivity (FC) is a common finding in resting-state functional Magnetic Resonance Imaging (rs-fMRI) studies of people with psychosis, yet how FC disturbances evolve in the early stages of illness, and how antipsychotics may influence the temporal evolution of these disturbances, remains unclear. Here, we scanned first episode psychosis (FEP) patients who were and were not exposed to antipsychotic medication during the first six months of illness at baseline, three months, and 12 months, to characterize how FC changes over time and in relation to medication use.MethodsSixty-two antipsychotic-naïve patients with FEP received either an atypical antipsychotic or a placebo pill over a treatment period of 6 months. Both FEP groups received intensive psychosocial therapy. A healthy control group (n=27) was also recruited. A total of 202 rs-fMRI scans were obtained across three timepoints: baseline, 3-months and 12-months. Our primary aim was to differentiate patterns of FC in antipsychotic-treated and antipsychotic-naive patients within the first 3 months of treatment, and to examine associations with clinical and functional outcomes. A secondary aim was to investigate long-term effects at the 12-month timepoint.ResultsAt baseline, FEP patients showed widespread functional dysconnectivity in comparison to controls, with reductions predominantly affecting interactions between the default mode network (DMN), limbic systems, and the rest of the brain. From baseline to 3 months, patients receiving placebo showed increased FC principally within the same systems, and some of these changes correlated with improved clinical outcomes. Antipsychotic exposure was associated with increased FC primarily between the thalamus and the rest of the brain. At the 12-month follow-up, antipsychotic treatment was associated with a prolonged increase of FC primarily in the DMN and limbic systems.Conclusions and RelevanceAntipsychotic-naïve FEP patients show widespread functional dysconnectivity at baseline, followed by an early normalization of DMN and paralimbic dysfunction in patients receiving a psychosocial intervention only. Antipsychotic exposure is associated with distinct FC changes, principally concentrated on thalamo-cortical and limbic networks.

Background Ensuring young people experience good sexual health is a key public health concern. Yet, some vulnerable groups of young people are at higher risk of poor sexual health, and consequently require additional support to achieve good sexual health. Therefore, the aim of this systematic review was to identify and assess the evidence base for behavioural and psychosocial interventions to improve sexual health for young people with additional vulnerabilities.Methods We searched for randomised controlled trials of interventions aimed at promoting sexual health, with any non-pharmacological comparator (e.g., waitlist control). Key outcomes of interest were indicators of sexual health (e.g., condom use, attitudes to contraception, knowledge of risk). Participants in eligible trials were under 25 years old and in a high-risk group (alcohol and other drug use; justice-involved; homeless; LGBTQI+; mental ill-health; ethnic minority, or out-of-home care). The final literature searches were performed on 16 September 2020, on MEDLINE, PsycINFO, EMBASE, CENTRAL, Web of Science, Scopus and clinical trial registries. Meta-analyses were conducted where possible.Results Forty-seven papers from 46 trials of the 5213 identified met inclusion criteria, with all but one of the included trials conducted in North America. Three focused predominantly on AOD, six on juvenile justice, two on homelessness, five on young men who have sex with men (YMSM), 26 on ethnic minorities, two on mental ill-health, three on out-of-home care, however no trials were identified in LGBTQI + groups outside of YMSM. The 47 included papers had a combined total of 21,543 participants. The vast majority (26/46) of trials were conducted with ethnic minority groups, with most of the interventions delivered as group therapy, and some involving parents and caregivers. Condom use was the most frequently reported outcome measure. In trials targeting ethnic minorities, the meta-analysis found a medium effect size (0.62, p = 0.0004) of the intervention on condom use.Conclusions There remains a dearth of research undertaken outside of North America, and in high-risk groups other than ethnic minorities. Future interventions should address sexual health more broadly than just the absence of negative biological outcomes with LGBTQI+, homeless and mental ill-health populations targeted for such work.This review was registered at Prospero (ref. 149810) and at osf.io/ukva9.

BACKGROUND: Anxiety is common in young people with early psychosis and treatment options for this co-morbidity remain limited. Yoga is a promising adjunct intervention that has been shown to reduce anxiety for adults with schizophrenia, therefore this pilot study evaluated the acceptability and potential effectiveness of yoga for anxiety in early psychosis. METHODS: A prospective single arm pilot study of a yoga intervention was conducted within an Early Intervention for psychosis service. Rates of attendance, as well as symptoms of anxiety pre and post yoga session were measured. RESULTS: A total of 14 young people participated in the study and over 70% attended half or more of the yoga sessions offered. Significant transient reduction in state anxiety after a single session of yoga was observed (p

People affected by severe mental health disorders have a greatly reduced life expectancy compared to their non-affected peers. Cardiovascular disease is the main contributor to this early mortality, caused by higher rates of smoking, physical inactivity, unhealthy diet, sleep disturbance, excessive alcohol use or substance abuse and medication side effects. Therefore, we need to take a preventative approach and translate effective interventions for physical health into routine clinical practice. These interventions should be delivered across all stages of mental health disorders and could also have the added benefit of leading to improvements in mental health. Furthermore, we need to advocate to ensure that people affected by severe mental health disorders receive the appropriate medical assessments and treatments when indicated. This themed issue highlights that physical health is now an urgent priority for funding and development in mental health services. The widespread implementation of evidence-based interventions into routine clinical practice is an essential need for consideration by clinicians and policymakers.

Dysfunction of fronto-striato-thalamic (FST) circuits is thought to contribute to dopaminergic dysfunction and symptom onset in psychosis, but it remains unclear whether this dysfunction is driven by aberrant bottom-up subcortical signaling or impaired top-down cortical regulation. Here, we used spectral dynamic causal modelling (DCM) of resting-state functional magnetic resonance imaging (fMRI) to characterize the effective connectivity of dorsal and ventral FST circuits in a sample of 46 antipsychotic-naïve first-episode psychosis (FEP) patients and 23 controls and an independent sample of 36 patients with established schizophrenia (SCZ) patients and 100 controls. We found that midbrain and thalamic connectivity were implicated across both patient groups. Dysconnectivity in FEP patients was mainly restricted to the subcortex, with positive symptom severity being associated with midbrain connectivity. Dysconnectivity between the cortex and subcortical systems was only apparent in SCZ patients. In another independent sample of 33 healthy individuals who underwent concurrent fMRI and [18F]DOPA positron emission tomography, we found that striatal dopamine synthesis capacity was associated with the effective connectivity of nigrostriatal and striatothalamic pathways, implicating similar circuits as those associated with psychotic symptom severity in patients. Our findings thus indicate that subcortical dysconnectivity is salient in the early stages of psychosis, that cortical dysfunction may emerge later in the illness, and that nigrostriatal and striatothalamic signaling are closely related to striatal dopamine synthesis capacity, which is a robust risk marker for psychosis.

Background: Ensuring young people experience good sexual health is a key public health concern, yet some vulnerable groups of young people remain at higher risk of poor sexual health. These individuals require additional support to achieve good sexual health but the best way to provide this remains needs to be better understood. Methods: We searched for randomised controlled trials of behavioural and psychosocial interventions aimed at promoting sexual health in high-risk young populations. Outcomes of interest were indicators of sexual health (e.g., condom use, attitudes to contraception, knowledge of risk). Participants were under 25 years old and in one of the following high-risk groups: alcohol and other drug use; ethnic minority; homeless; justice-involved; LGBTQI+; mental ill-health; or out-of-home care. Results: Twenty-eight papers from 26 trials met our inclusion criteria, with all but one conducted in North America. Condom use was the most frequently reported outcome measure along with knowledge and attitudes towards sexual health but considerable differences in measures used made comparisons across studies difficult. Change in knowledge and attitudes did not consistently result in long-term change in behaviours. Conclusions: There remains a dearth of research undertaken outside of North America across all high-risk groups of young people. Future interventions should address sexual health more broadly than just the absence of negative biological outcomes, with LGBTQI+, homeless and mental ill-health populations targeted for such work. An international consensus on outcome measures would support the research field going forward, making future meta-analyses possible.

Objective: Young people affected by mental health disorders have greater sexual health needs compared to their peers. Less is known about this need across illness severity. Method: A cross-sectional survey of the sexual health of those attending outpatients or inpatients within a youth mental health service was conducted. Statistical differences between groups were explored. Results: One hundred and seven young people (18–25 years) participated and of these, 37.7% were inpatients who had more severe psychiatric symptoms than outpatients. While inpatients were as likely to be sexually active as outpatients, they were significantly less likely to have a regular sexual partner (25% vs 64.5%). Additionally, they used amphetamines more frequently during sex (28.6% vs 5.8%). Sexual dysfunction was experienced by 55.6% of inpatients and 37.9% of outpatients. Conclusions: High-risk sexual behaviours and sexual dysfunction were highly prevalent in both groups. For some behaviours and dysfunction, this prevalence was higher in the inpatient population. Holistic clinical services that address the mental, physical and sexual health needs of consumers are needed both within inpatient and outpatient settings.

Changes in brain volume are a common finding in Magnetic Resonance Imaging (MRI) studies of people with psychosis and numerous longitudinal studies suggest that volume deficits progress with illness duration. However, a major unresolved question concerns whether these changes are driven by the underlying illness or represent iatrogenic effects of antipsychotic medication. In this study, 62 antipsychotic-naïve patients with first-episode psychosis (FEP) received either a second-generation antipsychotic (risperidone or paliperidone) or a placebo pill over a treatment period of 6 months. Both FEP groups received intensive psychosocial therapy. A healthy control group (n = 27) was also recruited. Structural MRI scans were obtained at baseline, 3 months and 12 months. Our primary aim was to differentiate illness-related brain volume changes from medication-related changes within the first 3 months of treatment. We secondarily investigated long-term effects at the 12-month timepoint. From baseline to 3 months, we observed a significant group x time interaction in the pallidum (p