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Staging and stratification are two diagnostic approaches that have introduced a more dynamic outlook on the development of diseases, thus participating in blurring the line between the normal and the pathological. First, diagnostic staging, aiming to capture how diseases evolve in time and/or space through identifiable and gradually more severe stages, may be said to lean on an underlying assumption of "temporal determinism". Stratification, on the other hand, allows for the identification of various prognostic or predictive subgroups based on specific markers, relying on a more "mechanistic" or "statistical" form of determinism. There are two medical fields in which these developments have played a significant role and have given rise to sometimes profound nosological transformations: oncology and psychiatry. Drawing on examples from these two fields, this paper aims to provide much needed conceptual clarifications on both staging and stratification in order to outline how several epistemological and ethical issues may, in turn, arise. We argue that diagnostic staging ought to be detached from the assumption of temporal determinism, though it should still play an essential role in adapting interventions to stage. In doing so, it would help counterbalance stratification's own epistemological and ethical shortcomings. In this sense, the reflections and propositions developed in psychiatry can offer invaluable insights regarding how adopting a more transdiagnostic and cross-cutting perspective on temporality and disease dynamics may help combine both staging and stratification in clinical practice., (© 2024. The Author(s), under exclusive licence to Springer Nature B.V.)

Background: Early‐onset (EO) major depressive disorder (MDD) patients experience more depressive episodes and an increased risk of relapse. Thus, on a neurobiological level, adult EO patients might display brain structure and function different from adult‐onset (AO) patients. Methods: A total of 103 patients (66 females) underwent magnetic resonance imaging. Structural measures of gray matter volume (GMV) and functional connectivity networks during resting state were compared between EO (≤19 years) and AO groups. Four residual major depression symptoms, mood, anxiety, insomnia, and somatic symptoms, were correlated with GMV between groups. Results: We found comparatively increased GMV in the EO group, namely the medial prefrontal and insular cortex, as well as the anterior hippocampus. Functional networks in EO patients showed a comparatively weaker synchronization of the left hippocampus with the adjacent amygdala, and a stronger integration with nodes in the contralateral prefrontal cortex and supramarginal gyrus. Volumetric analysis of depression symptoms associated the caudate nuclei with symptoms of insomnia, and persisting mood symptoms with the right amygdala, while finding no significant clusters for somatic and anxiety symptoms. Conclusions: The study highlights the important role of the hippocampus and the prefrontal cortex in EO patients as part of emotion‐regulation networks. Results in EO patients demonstrated subcortical volume changes irrespective of sleep and mood symptom recovery, which substantiates adolescence as a pivotal developmental phase for MDD. Longitudinal studies are needed to differentiate neural recovery trajectories while accounting for age of onset. [ABSTRACT FROM AUTHOR]

The authors discuss a paper by M. Fielding and D. Marwede on the anatomy of a neurological image in an applied onto-psychiatry. They list the aims of the paper that motivate the authors' efforts which include developing tools for the development of knowledge representational systems that can be used by clinicians to diagnose and treat psychiatric illnesses. Providing an ontological description of specific types of images used in the domain of medical research and practice is also included.

The article presents abstracts on psychiatry which include early recognition and early intervention of psychosis, current evidence and future perspectives on psychological treatments in schizophrenia and research and perspectives on pharmacogenetics of schizophrenia.

BackgroundThe ACE project involved 62 participants with a first episode of psychosis randomly assigned to either a cognitive behaviour therapy (CBT) intervention known as Active Cognitive Therapy for Early Psychosis (ACE) or a control condition known as Befriending. The study hypotheses were that: (1) treating participants with ACE in the acute phase would lead to faster reductions in positive and negative symptoms and more rapid improvement in functioning than Befriending; (2) these improvements in symptoms and functioning would be sustained at a 1-year follow-up; and (3) ACE would lead to fewer hospitalizations than Befriending as assessed at the 1-year follow-up.MethodTwo therapists treated the participants across both conditions. Participants could not receive any more than 20 sessions within 14 weeks. Participants were assessed by independent raters on four primary outcome measures of symptoms and functioning: at pretreatment, the middle of treatment, the end of treatment and at 1-year follow-up. An independent pair of raters assessed treatment integrity.ResultsBoth groups improved significantly over time. ACE significantly outperformed Befriending by improving functioning at mid-treatment, but it did not improve positive or negative symptoms. Past the mid-treatment assessment, Befriending caught up with the ACE group and there were no significant differences in any outcome measure and in hospital admissions at follow-up.ConclusionsThere is some preliminary evidence that ACE promotes better early recovery in functioning and this finding needs to be replicated in other independent research centres with larger samples. [ABSTRACT FROM AUTHOR]

Although the underlying neurobiology of emerging psychotic disorders is not well understood, evidence from structural imaging and other studies support the notion that schizophrenia arises as a consequence of both an 'early neurodevelopmental' disturbance, as well as 'late neurodevelopmental' changes occurring during the initial stages of a psychotic illness, including around the time of transition to illness. In line with this, our longitudinal MRI findings in individuals at ultra-high risk for developing a psychotic illness show that there are excessive neuroanatomical changes in those who convert to psychosis. These aberrant changes are observed most prominently in medial temporal and prefrontal lobe regions. In a further series of longitudinal studies in first-episode psychosis, we have identified changes in prefrontal regions that indicate an accelerated loss of grey matter in patients compared to healthy control subjects. We suggest that the available evidence is consistent with the presence of subtle regionally and temporally specific neurobiological changes through the course of psychosis (Pantelis et al., 2005), including: (1) evidence for early (pre- and peri-natal) neurodevelopmental anomalies, (2) evidence for progressive grey matter loss involving medial temporal and orbital prefrontal regions around the time of transition to illness, and (3) evidence of late (post-pubertal) neurodevelopmental changes soon after the onset of psychosis, involving an acceleration of normal brain maturational processes, associated with significant loss of grey matter in dorsal prefrontal regions. The pathological processes underlying such changes remain unclear and may reflect anomalies in genetic and/or other endogenous mechanisms responsible for brain maturation, the adverse effects of intense or prolonged stress, or other environmental factors. These findings suggest that early markers of impending illness may prove difficult to define, and that brain changes in psychosis may better be conceptualized as anomalous trajectories of brain development. Further, active changes during transition to illness may present the potential to intervene and ameliorate these changes with potential benefit clinically. [ABSTRACT FROM AUTHOR]

Pathways of care, a set of specific steps taken in the care of a particular disorder, are rarely employed in mental health. The Early Psychosis Intervention (EPI) Programme has taken up the challenge of developing care pathways for the treatment of early psychosis. The EPI Programme provides services to clients across several communities through a team of community-based mental health clinicians and psychiatrists. The current pathway focuses on care provided by the clinicians. The goals for the pathway include: (a) providing a practical 'best practices' guide to care, (b) standardizing care, (c) providing a method for evaluating and improving quality of care and (d) improving client outcome. Prior to developing the pathway, clinical practice was assessed through random chart audits and interviews with the clinicians. A pathway was then developed incorporating both outcome measurement and a documentation system utilizing a series of checklists detailing currently recognized bestpractice in early psychosis, organized according to phase ofrecovery. The pathway was piloted and revised before fullimplementation. Extension of the pathway to early psychosis inpatient treatment and psychiatric care is currently underway. [ABSTRACT FROM AUTHOR]

In November 1997 a new, world first model of service delivery to young people suffering from psychiatric disorders was implemented, the Youth Access Team (YAT). YAT is the only youth orientated crisis team that specifically targets first presentation psychosis as well as adolescents in psychiatric crisis, and also provides an after hours triage service for children under 12. YAT is a multidisciplinary mobile crisis, assessment and treatment team, operating 24 h a day, 7 days a week. YAT provides excellence in care to young people experiencing initial mental health problems. The principal goal of YAT is secondary prevention in first episode psychosis, with the dual aims of attenuating the period of untreated psychosis and reducing the secondary morbidity associated with becoming engaged with psychiatric services. Other important goals of YAT are early detection and engagement in treatment with a client-centred focus. [ABSTRACT FROM AUTHOR]

In order to give youngsters with severe psychological impairment a stronger psycological support in our public practice, we treated seven adolescents simultaneously with a psychoanalitic open group psychotherapy and an individual psychological treatment. All of them, five boys and two girls, were outpatients of our the Adolescent Unit of our public health institution. The youngest was 16, the oldest 21. They had presented important psychiatric symptoms ranging from brief psychotic reactions to important depressive states, one of them had experienced one of this symptoms after occasional marijuana assumption. Two other girls participated in the group psychotherapy without receiving regular individual support. Many of them received also pharmacological treatment and occasional familial support. We noticed that the contemporary experience of individual and group psychotherapy offered some advantages: the group allowed us to have a wider field ofobservation and understand earlier the structure of our patients' personality; the confrontation with two different settings seemed to stimulate a faster improvement in insight and reflection abilities and an easier recover. [ABSTRACT FROM AUTHOR]

Within the UK, it is envisaged that Early Intervention Services will be developed nation-wide by 2004 and these are expected to adhere to a strict model of service structure and provision. This uniform approach seems to lack the flexibility required to cater for local needs. Therefore, it would appear more appropriate to develop Early Intervention Services based on assessments of first-episode psychosis (FEP) within the context of the local mental health economy and current service provision. A survey of FEP cases within South and West London revealed that existing mental health services were unable to adequately provide specialist care to this client group. As a result, it was decided to set up a tertiary service to provide comprehensive care to FEP patients based within the community. This package comprises assertive engagement, intensive keyworker support, atypical antipsychotics, psychosocial interventions, specialist psychological treatments, occupational therapy and educational/vocational rehabilitation. An ongoing evaluation of this specially tailored service is being conducted, focussing on patient characteristics, pathways to care, service delivery, patient outcomes and patient, carer and referrer satisfaction. [ABSTRACT FROM AUTHOR]

Primary Mental Health Teams are a state-wide initiative of the government of Victoria to address identified gaps in mental health service delivery namely early intervention for psychosis and mental health services for high prevalence disorders. This poster will outline this dynamic community based approach to supporting and enhancing services for clients with mental health issues that are currently provided by the primary care sector. Specifically, the poster will focus on the development of a local cross sectorial approach to early psychosis with the dual aims of decreasing the duration of untreated psychosis and adopting best practice guidelines for improved outcomes for this high risk population. [ABSTRACT FROM AUTHOR]

The realization of early detection and intervention programs needs to combine the preexisting mental health servicesorganization on the territory with modalities specific for professionals' competence, setting, procedures and attitude. Actually, services mostly function with current standard practices and professionals having different backgrounds: then they could be operatively and culturally revitalized by the link with a more focused, outreaching and research-oriented working style. The authors describe the organizational strategies to overcome the problems of connecting an ad hoc early detection and intervention Service, set up on a STAR-SHAPED MODEL, the core of which is a team acquired by counselling contracts, with the existing network of Psychiatric Services (4 CMHC, 2 Psychiatric Wards, 1 day Centre, 2 Residential Facilities) and Agencies of the area (GPs, Child Neuropsychiatry, Schools, etc.). In the next 3-year period (2002-2005) the increase of cases and the enlargement of the catchment area, making the system more complex, will require further adaptation and improvement of the model. [ABSTRACT FROM AUTHOR]