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Aim Service disengagement is a challenge in young individuals struggling with psychosis. Combining cognitive behavioural therapy for psychosis (CBTp) with virtual reality (VR) has proven acceptable and potentially effective for symptoms and social functioning in adults with psychosis. However, studies focusing on young adolescents are lacking. The aim of the present study was to investigate the acceptability of VR-assisted CBTp among adolescents with psychosis. Methods A qualitative study investigating the acceptability of VR during exposure-based social training among adolescents with early onset psychosis. Thematic analysis was used to identify, analyse, interpret and report patterns from the qualitative interviews. Results A total of 27 adolescents with psychosis were invited to participate, 11 declined and 16 were enrolled (59%), and all completed the study. The participants were from 13 until 18 years old, mean age 16 years. None of them had previous experience with use of VR in therapy, but 10 out of 16 participants had prior experience with VR from playing video games. Regarding acceptability, 14 out of 16 had positive expectations towards using VR in CBTp, and they would prefer using VR during exposure-based social training to real-life training only. Conclusions VR-assisted CBTp can be an acceptable intervention for adolescents with psychosis, given their comfort with technology and the opportunity to confront their fears in less threatening virtual social settings with fewer social risks. The present study yields support to continue developing VR-assisted therapy for adolescents, and focusing on VR-interventions for early onset psychosis. publishedVersion

Objective: In this hypothesis-testing study, which is based on findings from a previous atheoretical machine-learning study, we test the predictive power of baseline “reduced expression of emotion” for psychosis. Method: Study participants (N = 96, mean age 16.55 years) were recruited from the Prevention of Psychosis Study in Rogaland, Norway. The Structured Interview for Prodromal Syndromes (SIPS) was conducted 13 times over two years. Reduced expression of emotion was added to positive symptoms at baseline (P1–P5) as a predictor of psychosis onset over a two-year period using logistic regression. Results: Participants with a score above zero on expression of emotion had over eight times the odds of conversion (OR = 8.69, p < .001). Data indicated a significant dose–response association. A model including reduced expression of emotion at baseline together with the positive symptoms of the SIPS rendered the latter statistically insignificant. Conclusions: The study findings confirm findings from the previous machine-learning study, indicating that observing reduced expression of emotion may serve two purposes: first, it may add predictive value to psychosis conversion, and second, it is readily observable. This may facilitate detection of those most at risk within the clinical high risk of psychosis population, as well as those at clinical high risk. A next step could be including this symptom within current high-risk criteria. Future research should consolidate these findings.

Aim The fluctuating symptoms of clinical high risk for psychosis hamper conversion prediction models. Exploring specific symptoms using machine-learning has proven fruitful in accommodating this challenge. The aim of this study is to explore specific predictors and generate atheoretical hypotheses of onset using a close-monitoring, machine-learning approach. Methods Study participants, N = 96, mean age 16.55 years, male to female ratio 46:54%, were recruited from the Prevention of Psychosis Study in Rogaland, Norway. Participants were assessed using the Structured Interview for Psychosis Risk Syndromes (SIPS) at 13 separate assessment time points across 2 years, yielding 247 specific scores. A machine-learning decision-tree analysis (i) examined potential SIPS predictors of psychosis conversion and (ii) hierarchically ranked predictors of psychosis conversion. Results Four out of 247 specific SIPS symptom scores were significant: (i) reduced expression of emotion at baseline, (ii) experience of emotions and self at 5 months, (iii) perceptual abnormalities/hallucinations at 3 months and (iv) ideational richness at 6 months. No SIPS symptom scores obtained after 6 months of follow-up predicted psychosis. Conclusions Study findings suggest that early negative symptoms, particularly those observable by peers and arguably a risk factor for social exclusion, were predictive of psychosis. Self-expression and social behaviour might prove relevant entry points for early intervention in psychosis and psychosis risk. Testing study results in larger samples and at other sites is warranted.

Jorunn Nærland Skjærpe,1 Inge Joa,1,2 Elisabeth Willumsen,1 Wenche ten Velden Hegelstad,2,3 Tatiana Aleksandrovna Iakovleva,4 Marianne Storm1,5 1Department of Public Health, Faculty of Health Science, University of Stavanger, Stavanger, Norway; 2TIPS Centre for Clinical Research in Psychosis, Stavanger University Hospital, Stavanger, Norway; 3Department of Social Studies, Faculty of Social Science, University of Stavanger, Stavanger, Norway; 4Stavanger Business School, University of Stavanger, Stavanger, Norway; 5Faculty of Health Sciences and Social Care, Molde University College, Molde, NorwayCorrespondence: Jorunn Nærland Skjærpe, University of Stavanger, Postbox 8600 FORUS, Stavanger, NO-4036, Norway, Tel +4797767039, Email jorunn.n.skjerpe@uis.noPurpose: Individuals with serious mental illness (SMI) might require coordinated health services to meet their healthcare needs. The overall aim of this study was to describe the perspectives of professionals (registered nurses, medical doctors, social educators, and social workers) on care coordination and measures to ensure proper and coordinated follow-up of the healthcare needs of individuals with SMI. More specifically, we investigated which measures are taken by employees in municipal health and care services to prevent the deterioration of health conditions and which measures are taken in cases where deterioration occurs despite preventive efforts.Method: The study comprised individual qualitative interviews with professionals employed in municipal health and care services in two Norwegian municipalities. The interview material was analyzed using systematic text condensation.Results: Three categories and seven subcategories were created in the data analysis: 1) Maintain a stable and meaningful home life, including ensuring proper housing and access to services and assistance in receiving healthcare; 2) Measures to prevent deterioration of the health condition, including close monitoring of symptoms, emergency psychiatric care plans and emergency room calls and visits; and 3) Inpatient care to stabilize acute and severe symptoms, including municipal inpatient care, returning home after inpatient care and a need for shared responsibility for treatment and care.Conclusion: Professionals employed in municipal health and care services coordinate health services to ensure proper and coordinated follow-up of the healthcare needs of individuals with SMI by ensuring housing services and access to the required healthcare. Measures taken when deterioration occurs include monitoring symptoms, use of emergency psychiatric care plans, emergency room contacts, or inpatient care.Keywords: care coordination, service integration, qualitative interviews, chronic medical condition, physical health

IMPORTANCE The ENIGMA clinical high risk (CHR) for psychosis initiative, the largest pooled neuroimaging sample of individuals at CHR to date, aims to discover robust neurobiological markers of psychosis risk.OBJECTIVE To investigate baseline structural neuroimaging differences between individuals at CHR and healthy controls as well as between participants at CHR who later developed a psychotic disorder (CHR-PS+) and those who did not (CHR-PS-).DESIGN, SETTING, AND PARTICIPANTS In this case-control study, baseline T1-weighted magnetic resonance imaging (MRI) data were pooled from 31 international sites participating in the ENIGMA Clinical High Risk for Psychosis Working Group. CHR status was assessed using the Comprehensive Assessment of At-Risk Mental States or Structured Interview for Prodromal Syndromes. MRI scans were processed using harmonized protocols and analyzed within a mega-analysis and meta-analysis framework from January to October 2020.MAIN OUTCOMES AND MEASURES Measures of regional cortical thickness (CT), surface area, and subcortical volumes were extracted from T1-weighted MRI scans. Independent variables were group (CHR group vs control group) and conversion status (CHR-PS+ group vs CHR-PS- group vs control group).RESULTS Of the 3169 included participants, 1428 (45.1%) were female, and the mean (SD; range) age was 21.1 (4.9; 9.5-39.9) years. This study included 1792 individuals at CHR and 1377 healthy controls. Using longitudinal clinical information, 253 in the CHR-PS+ group, 1234 in the CHR-PS- group, and 305 at CHR without follow-up data were identified. Compared with healthy controls, individuals at CHR exhibited widespread lower CT measures (mean [range] Cohen d = -0.13 [-0.17 to -0.09]), but not surface area or subcortical volume. Lower CT measures in the fusiform, superior temporal, and paracentral regions were associated with psychosis conversion (mean Cohen d = -0.22; 95% CI, -0.35 to 0.10). Among healthy controls, compared with those in the CHR-PS+ group, age showed a stronger negative association with left fusiform CT measures (F = 9.8; P < .001; q < .001) and left paracentral CT measures (F = 5.9; P = .005; q = .02). Effect sizes representing lower CT associated with psychosis conversion resembled patterns of CT differences observed in ENIGMA studies of schizophrenia (rho = 0.35; 95% CI, 0.12 to 0.55; P = .004) and individuals with 22q11.2 microdeletion syndrome and a psychotic disorder diagnosis (rho = 0.43; 95% CI, 0.20 to 0.61; P = .001).CONCLUSIONS AND RELEVANCE This study provides evidence for widespread subtle, lower CT measures in individuals at CHR. The pattern of CT measure differences in those in the CHR-PS+ group was similar to those reported in other large-scale investigations of psychosis. Additionally, a subset of these regions displayed abnormal age associations. Widespread disruptions in CT coupled with abnormal age associations in those at CHR may point to disruptions in postnatal brain developmental processes.Question How are brain morphometric features associated with later psychosis conversion in individuals at clinical high risk (CHR) for developing psychosis?Findings In this case-control study including 3169 participants, lower cortical thickness, but not cortical surface area or subcortical volume, was more pronounced in individuals at CHR in a manner highly consistent with thinner cortex in individuals with established psychosis. Regions that displayed lower cortical thickness in individuals at CHR who later developed a psychotic disorder additionally displayed abnormal associations with age.Meaning In this study, CHR status and later transition to psychosis was robustly associated with lower cortical thickness; abnormal age associations and specificity to cortical thickness may point to aberrant postnatal brain development in individuals at CHR, including pruning and myelination.This case-control study investigates baseline structural magnetic resonance imaging (MRI) differences between individuals at clinical high risk and healthy controls as well as between participants at clinical high risk who later developed a psychotic disorder and those who did not.

Background Childhood interpersonal trauma (CIT) and premorbid adjustment are both associated with poor outcome in psychosis. In this study we investigate the relative impact of CIT and premorbid adjustment on symptom remission in first episode psychosis (FEP) over two years. Method A total of 232 participants with FEP were recruited through the early detection program of the The early detection and Intervention in Psychosis (TIPS)-2 study and followed up after two years. Symptom remission was according to consensus criteria. CIT was assessed with the semi-structured interview Freyd Goldberg Brief Betrayal Trauma Survey, and premorbid adjustment with the Premorbid Adjustment Scale. Generalized estimating equations and multivariate models were used to analyze the associations between remission, symptom levels over time, CIT and premorbid adjustment; and a path analysis of mediation effects of CIT through premorbid adjustment on remission. Results In this sample with 57% males and a mean age of 26.6 years (SD 10.2), a third of participants had experienced CIT. The participants with CIT had poorer premorbid adjustment compared to those without. Statistical analyses found independent effects of CIT and an interaction effect of CIT with premorbid adjustment on remission after two years, suggesting that CIT moderates the effect of premorbid adjustment. However contrary to expectations, premorbid adjustment did not mediate the effect of CIT. Conclusion Our findings indicate a complex interplay between effects of interpersonal trauma and premorbid social adjustment on remission in psychosis. CIT appeared to moderate the effect of premorbid adjustment such that individuals with CIT and who had poor social functioning in childhood are at greater risk of non-remission. Findings indicate that better premorbid social relations could provide a buffer for the effects of trauma on symptom course.

ImportanceThe ENIGMA clinical high risk for psychosis (CHR) initiative, the largest pooled CHR-neuroimaging sample to date, aims to discover robust neurobiological markers of psychosis risk in a sample with known heterogeneous outcomes.ObjectiveWe investigated baseline structural neuroimaging differences between CHR subjects and healthy controls (HC), and between CHR participants who later developed a psychotic disorder (CHR-PS+) and those who did not (CHR-PS-). We assessed associations with age by group and conversion status, and similarities between the patterns of effect size maps for psychosis conversion and those found in other large-scale psychosis studies.Design, Setting, and ParticipantsBaseline T1-weighted MRI data were pooled from 31 international sites participating in the ENIGMA CHR Working Group. MRI scans were processed using harmonized protocols and analyzed within a mega- and meta-analysis framework from January-October 2020.Main Outcome(s) and Measure(s)Measures of regional cortical thickness (CT), surface area (SA), and subcortical volumes were extracted from T1-weighted MRI scans. Independent variables were group (CHR, HC) and conversion status (CHR-PS+, CHR-PS-, HC).ResultsThe final dataset consisted of 3,169 participants (CHR=1,792, HC=1,377, age range: 9.5 to 39.8 years, 45% female). Using longitudinal clinical information, we identified CHR-PS+ (N=253) and CHR-PS- (N=1,234). CHR exhibited widespread thinner cortex compared to HC (average d=-0.125, range: -0.09 to -0.17), but not SA or subcortical volume. Thinner cortex in the fusiform, superior temporal, and paracentral regions was associated with psychosis conversion (average d=-0.22). Age showed a stronger negative association with left fusiform and left paracentral CT in HC, compared to CHR-PS+. Regional CT psychosis conversion effect sizes resembled patterns of CT alterations observed in other ENIGMA studies of psychosis.Conclusions and RelevanceWe provide evidence for widespread subtle CT reductions in CHR. The pattern of regions displaying greater CT alterations in CHR-PS+ were similar to those reported in other large-scale investigations of psychosis. Additionally, a subset of these regions displayed abnormal age associations. Widespread CT disruptions coupled with abnormal age associations in CHR may point to disruptions in postnatal brain developmental processes.Key PointsQuestionHow do baseline brain morphometric features relate to later psychosis conversion in individuals at clinical high risk (CHR)?FindingsIn the largest coordinated international analysis to date, reduced baseline cortical thickness, but not cortical surface area or subcortical volume, was more pronounced in CHR, in a manner highly consistent with thinner cortex in established psychosis. Regions that displayed greater cortical thinning in future psychosis converters additionally displayed abnormal associations with age.MeaningCHR status and later transition to psychosis is robustly associated with reduced cortical thickness. Abnormal age associations and specificity to cortical thickness may point to aberrant postnatal brain development in CHR, including pruning and myelination.

Background Clinical High Risk (CHS) for psychosis is a state in which positive symptoms are predominant but do not reach a level of severity that fulfils the criteria for a psychotic episode. The aim of this study has been to investigate whether cognition in subjects with newly detected CHR affects the longitudinal development of positive symptoms. Methods Fifty-three CHR individuals fulfilling the criteria for attenuated positive syndrome in the Structural Interview for Prodromal Syndromes (SIPS) were included. At inclusion, all participants completed a neurocognitive battery consisting of tests measuring attention, verbal memory, verbal fluency, executive functions and general intelligence. Cognitive domain z-scores were defined by contrasting with observed scores of a group of matched healthy controls (n = 40). Associations between cognitive performance at inclusion and longitudinal measures of positive symptoms were assessed by using generalised linear models including non-linear effects of time. All regression models were adjusted for age and gender. Results Overall, SIPS positive symptoms declined over the time period, with a steeper decline during the first six months. Deficits in executive functions were assossiated witn a higher load of positive symptoms at baseline (p=0.006), but also to a faster improvement (p=0.030), wheras those with poor verbal fluency improved more slowly (p=0.018). Conclusion To our knowledge, this is the first study that follows CHR subjects by means of frequent clinical interviews over a sustained period of time. The study provides evidence of an association between executive functions, including verbal fluency, with the evolvement of positive symptoms.

BackgroundTo what extent psychotic symptoms in first-episode psychosis (FEP) with a history of childhood interpersonal trauma (CIT) are less responsive to antipsychotic medication is not known. In this longitudinal study, we compare symptom trajectories and remission over the first 2 years of treatment in FEP with and without CIT and examine if differences are linked to the use of antipsychotics.MethodsFEP (N = 191) were recruited from in- and outpatient services 1997–2000, and assessed at baseline, 3 months, 1 and 2 years. Inclusion criteria were 15–65 years, actively psychotic with a DSM-IV diagnosis of psychotic disorder and no previous adequate treatment for psychosis. Antipsychotic medication is reported as defined daily dosage (DDD). CIT (ResultsCIT (n = 63, 33%) was not associated with symptomatic remission at 2 years follow-up (71% in remission, 14% in relapse), or time to first remission (CIT 12/ no-CIT 9 weeks, p = 0.51). Those with CIT had significantly more severe positive, depressive, and excited symptoms. FEP with physical (N = 39, 20%) or emotional abuse (N = 22, 14, 7%) had higher DDD at 1 year (p < 0.05). Mean DDD did not excerpt a significant between-group effect on symptom trajectories of positive symptoms.ConclusionResults indicate that antipsychotic medication is equally beneficial in the achievement of symptomatic remission in FEP after 2 years independent of CIT. Still, FEP patients with CIT had more severe positive, depressive, and excited symptoms throughout.

Background and Objective: Goal-directed behavior is a central feature of human functioning. It requires goal appraisal and implicit cost-benefit analyses, i.e., how much effort to invest in the pursuit of a certain goal, against its value and a confidence judgment regarding the chance of attainment. Persons with severe mental illness such as psychosis often struggle with reaching goals. Cognitive deficits, positive symptoms restricting balanced judgment, and negative symptoms such as anhedonia and avolition may compromise goal attainment. The objective of this study was to investigate to what degree symptom severity is related to cognitive abilities, metacognition, and effort-based decision-making in a visual search task. Methods: Two studies were conducted: study 1: N = 52 (healthy controls), and study 2: N = 46 (23 patients with psychosis/23 matched healthy controls). Symptoms were measured by the CAPE-42 (study 1) and the PANSS (study 2). By using a visual search task, we concomitantly measured (a) accuracy in short-term memory, (b) perceived accuracy by participants making a capture area or confidence interval, and (c) effort by measuring how long one searched for the target. Perseverance was assessed in trials in which the target was omitted and search had to be abandoned. Results: Higher levels of positive symptoms, and having a diagnosis of psychosis, were associated with larger errors in memory. Participants adjusted both their capture area and their search investment to the error of their memory. Perseverance was associated with negative symptoms in study 1 but not in study 2. Conclusion: By simultaneously assessing error and confidence in one’s memory, as well as effort in search, we found that memory was affected by positive, not negative, symptoms in healthy controls, and was reduced in patients with psychosis. However, impaired memory did not concur with overconfidence or less effort in search, i.e., goal directed behavior was unrelated to symptoms or diagnosis. Metacognition and motivation were neither affected by cognitive abilities nor by negative symptoms. Clinically, this could indicate that struggles with goal directed behavior in psychosis may not solely be dependent on primary illness factors. Copyright © 2020 Hegelstad, Kreis, Tjelmeland and Pfuhl. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

Background Remission in schizophrenia is difficult to achieve. Antipsychotic drugs are critical in the treatment of schizophrenia. International guidelines for the pharmacological treatment of schizophrenia recommend a 3-step algorithm with clozapine being the third-line antipsychotic agent. This study investigated the 1-year outcome and the application of the guidelines for the pharmacological treatment of nonremitted first-episode schizophrenia (FES) patients during the first year of follow-up. Methods A sample of 78 FES patients from the Norwegian TIPS (Early Treatment and Intervention in Psychosis) 2 study was assessed at the end of the first year of follow-up. The symptom remission criteria were those defined by the Remission in Schizophrenia Working Group. The adherence to the pharmacological guidelines was assessed by reading the medical files and by a digital search of the words “clozapine,” “klozapin,” and “Leponex” in the hospital electronic data system. Results The majority (n = 53, 67.9%) of the patients included were nonremitted at the 1-year follow-up. The majority of the nonremitted patients received either none (7.5%), one (56.6%), or 2 types (15.1%) of antipsychotic drugs during the first year of follow-up. Only 2 (3.8%) received treatment with clozapine, and 3 (5.7%) in total were offered it. Conclusions For our FES sample, there was a low 1-year remission rate and a poor adherence to the pharmacological guidelines. Higher adherence to treatment guidelines with a more intensified antipsychotic treatment, which in some cases will include clozapine, will enhance the quality of treatment and may enhance the rates of remission for schizophrenia. publishedVersion

Background Subjective quality of life (S-QoL) is an important outcome measure in first-episode psychosis, but its associations with clinical predictors may vary across the illness course. In this study we examine the association pattern, including both direct and indirect effects, between specific predefined clinical predictors (insight, depression, positive psychotic symptoms and global functioning) and S-QoL the first ten years after a first-episode psychosis. Methods Three hundred and one patients with a first-episode psychosis were included at first treatment, and reassessed at 3 months, 1 year, 2 years, 5 years and 10 years after inclusion. At 10-year follow-up 186 participated. S-QoL was assessed with Lehman's Quality of Life Interview. Applying a structural equation model, we investigated cross-sectional association patterns at all assessments between the predefined clinical predictors and S-QoL. Results At baseline, only depression was significantly associated with S-QoL. At all follow-up assessments, depression and functioning showed significant associations with S-QoL. Insight was not associated with S-QoL at any of the assessments. Better insight, less depressive symptoms and less positive psychotic symptoms were all associated with higher functioning at all assessments. Functioning seems to mediate a smaller indirect inverse association between positive psychotic symptoms and S-QoL. The association pattern was stable across all follow-up assessments. Conclusions Together with depression, functioning seems to be important for S-QoL. Functioning seems to be a mediating factor between positive symptoms and S-QoL. A focus on functional outcome continues to be important.

AIM Individual placement and support (IPS) for first episode psychosis (FEP) has proven effective for employment and education, but yields differing results across geographical regions. Local adaptations may be necessary for various reasons, such as regional differences in employment- and welfare services; in educational opportunities and job markets. The aim of this study was to investigate the efficacy of an adapted Norwegian intervention offering early IPS for education and employment to persons with FEP. METHOD Matched control (N = 66) study with a 1-year early IPS intervention and a 2-year follow up. A rating of fidelity to the IPS model was conducted. RESULTS Fidelity was "good." Adaptations to the model included the use of internships and flexible combinations of education and employment. Thirty out of 33 participants completed the intervention. Fourteen were in competitive employment >20 h/wk post intervention, compared to 2 in the control group. Fifteen participants were enrolled in education >20 h/wk, 10 of whom also had employment >20 h/wk and 3 < 20 h/wk, compared to 5 in the control group, with 2 having employment

BACKGROUND: Individuals with psychosis are heavy consumers of social media. It is unknown to what degree measures of social functioning include measures of online social activity. OBJECTIVE: To examine the inclusion of social media activity in measures of social functioning in psychosis and ultrahigh risk (UHR) for psychosis. METHODS: Two independent authors conducted a search using the following electronic databases: Epistemonikos, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, MEDLINE, Embase, and PsycINFO. The included articles were required to meet all of the following criteria: (1) an empirical study published in the English language in a peer-reviewed journal; (2) the study included a measure of objective or subjective offline (ie, non-Web-mediated contact) and/or online social functioning (ie, Web-mediated contact); (3) the social functioning measure had to be used in samples meeting criteria (ie, Diagnostic and Statistical Manual of Mental Disorders or International Classification of Diseases) for a psychotic disorder or UHR for psychosis; and (4) the study was published between January 2004 and February 2019. Facebook was launched as the first large-scale social media platform in 2004 and, therefore, it is highly improbable that studies conducted prior to 2004 would have included measures of social media activity. RESULTS: The electronic search resulted in 11,844 distinct articles. Full-text evaluation was conducted on 719 articles, of which 597 articles met inclusion criteria. A total of 58 social functioning measures were identified. With some exceptions, reports on reliability and validity were scarce, and only one measure integrated social media social activity. CONCLUSIONS: The ecological validity of social functioning measures is challenged by the lack of assessment of social media activity, as it fails to reflect an important aspect of the current social reality of persons with psychosis. Measures should be revised to include social media activity and thus avoid the clinical consequences of inadequate assessment of social functioning. TRIAL REGISTRATION: International Prospective Register of Systematic Reviews (PROSPERO) CRD42017058514; http://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42017058514.

BACKGROUND: Social functioning impairment is a core predictor of outcome in psychosis and a main target for interventions. Assessments reflecting social reality are thus essential. After the 2004 advent of Facebook, social networking platforms have become integral to young peoples’ social life and yet it is unclear whether this is being assessed. The aim of this systematic review is to examine the inclusion of social media activity in measures of social functioning in psychosis and ultra-high-risk for psychosis. METHODS: Design: Systematic review. Data sources: Epistemonikos, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effect (DARE), MEDLINE, EMBASE and PsycINFO. Eligibility criteria for study selection: Empirical study published in English language in peer reviewed journals, with a sample meeting criteria (DSM/ICD) for a psychotic disorder or ultra-high risk for psychosis, and including a measure of social functioning. Papers published between January 2004 and April 2018 were included. Data extraction: The electronic search resulted in 10,575 distinct articles. Full-text evaluation was conducted on 690 articles of which 573 articles met inclusion criteria. RESULTS: 58 social functioning measures were identified. With some exceptions, reports on reliability and validity were scarce and only one measures integrated social media social activity. DISCUSSION: The ecological validity of social functioning measures is challenged by the lack of assessment of social media activity as it fails to reflect an important aspect of the current social reality of persons with psychosis. Measures should be revised to include social media activity and thus avoid the clinical consequences of inadequate assessment of social functioning.

BACKGROUND Individuals with psychosis are heavy consumers of social media. It is unknown to what degree measures of social functioning include measures of online social activity. OBJECTIVE To examine the inclusion of social media activity in measures of social functioning in psychosis and ultrahigh risk (UHR) for psychosis. METHODS Two independent authors conducted a search using the following electronic databases: Epistemonikos, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, MEDLINE, Embase, and PsycINFO. The included articles were required to meet all of the following criteria: (1) an empirical study published in the English language in a peer-reviewed journal; (2) the study included a measure of objective or subjective offline (ie, non-Web-mediated contact) and/or online social functioning (ie, Web-mediated contact); (3) the social functioning measure had to be used in samples meeting criteria (ie, Diagnostic and Statistical Manual of Mental Disorders or International Classification of Diseases) for a psychotic disorder or UHR for psychosis; and (4) the study was published between January 2004 and February 2019. Facebook was launched as the first large-scale social media platform in 2004 and, therefore, it is highly improbable that studies conducted prior to 2004 would have included measures of social media activity. RESULTS The electronic search resulted in 11,844 distinct articles. Full-text evaluation was conducted on 719 articles, of which 597 articles met inclusion criteria. A total of 58 social functioning measures were identified. With some exceptions, reports on reliability and validity were scarce, and only one measure integrated social media social activity. CONCLUSIONS The ecological validity of social functioning measures is challenged by the lack of assessment of social media activity, as it fails to reflect an important aspect of the current social reality of persons with psychosis. Measures should be revised to include social media activity and thus avoid the clinical consequences of inadequate assessment of social functioning. CLINICALTRIAL International Prospective Register of Systematic Reviews (PROSPERO) CRD42017058514; http://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42017058514

Purpose: While there is accumulating evidence for clinical recovery in a significant proportion of people experiencing a first episode psychosis, the mechanisms facilitating this form of recovery are less well known. Thus, the aim of this study is to investigate mechanisms of recovery after a first-episode psychosis as perceived by clinically recovered service users.Methods: Thematic analytic approach within an interpretative–phenomenological framework. Twenty clinically recovered service users were interviewed. Analysis followed an established meaning condensation procedure.Results: Main theme: Establishment of subjective self-agency. Subordinate themes: (1) Environmental support and gentle pressure, (2) Individually tailored assistance, (3) Antipsychotic medication: relinquishing personal responsibility, and considerable side effects.Conclusions: We suggest that an increase in sense of personal agency is a core mechanism driving recovery for participants in the study sample. Findings indicate th...

Identifying patients at risk of poor outcome at an early stage of illness can aid in treatment planning. This study sought to create a best-fit statistical model of known baseline and early-course risk factors to predict time in psychosis during a ten-year follow-up period after a first psychotic episode.Between 1997 and 2000, 301 patients with DSM-IV nonorganic, nonaffective first-episode psychosis were recruited consecutively from catchment area-based sectors in Norway and Denmark. Specialized mental health personnel evaluated patients at baseline, three months, and one, two, five, and ten years (N=186 at ten years). Time in psychosis was defined as time with scores ≥4 on any of the Positive and Negative Syndrome Scale items P1, P3, P5, P6, and G9. Evaluations were retrospective, based on clinical interviews and all available clinical information. During the first two years, patients were also evaluated by their clinicians at least biweekly. Baseline and early-course predictors of long-term course were identified with linear mixed-model analyses.Four variables provided significant, additive predictions of longer time in psychosis during the ten-year follow-up: deterioration in premorbid social functioning, duration of untreated psychosis (DUP) of ≥26 weeks, core schizophrenia spectrum disorder, and no remission within three months.First-episode psychosis patients should be followed carefully after the start of treatment. If symptoms do not remit within three months with adequate treatment, there is a considerable risk of a poor long-term outcome, particularly for patients with a deterioration in premorbid social functioning, a DUP of at least half a year, and a diagnosis within the core schizophrenia spectrum.

Subjective quality of life (S-QoL) is an important outcome measure in first episode psychosis (FEP). The aims of this study were to describe S-QoL-development the first 10-years in FEP patients and to identify predictors of this development. Methods A representative sample of 272 patients with a first episode psychotic disorder was included from 1997 through 2000. At 10 year follow-up 186 patients participated. QoL was measured by the Lehman's Quality of Life Interview. Linear mixed model analyses were performed to investigate longitudinal effects of baseline psychiatric symptoms and socio-economic variables and the effects of changes in the same variables on S-QoL-development. Results S-QoL improved significantly over the follow-up period. More contact with family and a better financial situation at baseline had a positive and longstanding effect on S-QoL-development, but changes in these variables were not associated with S-QoL-development. Higher depressive symptoms and less daily activities at baseline both had a negative independent effect, but a positive interaction effect with time on S-QoL-development indicating that the independent negative effect diminished over time. In the change analysis, increased daily activities and a decrease in depressive symptoms were associated with a positive S-QoL-development. Conclusions Treatment of depressive symptoms and measures aimed at increasing daily activities seem important to improve S-QoL in patients with psychosis. More contact with family and a better financial situation at baseline have a long-standing effect on S-QoL-development in FEP patients.

Aim Interpersonal traumas are highly prevalent in patients with psychotic disorders. Trauma caused by those close to the patient might have a more profound impact than other types of trauma and may influence early life social functioning. The aim is to investigate the associations between different types of trauma, in particular close interpersonal traumas experienced before the age of 18, premorbid factors and baseline clinical characteristics in a sample of first-episode psychosis patients. Methods A total of 191 patients from the 'TIPS' cohort completed assessment with the Brief Betrayal Trauma Survey at their 5 years follow-up interview. Results Half of the patients reported that they had experienced interpersonal trauma and one-third reported having experienced close interpersonal trauma before the age of 18. Women reported more sexual abuse, physical attacks and emotional and physical maltreatment than men. There were significant associations between early interpersonal trauma and premorbid adjustment and duration of untreated psychosis, but no significant associations with length of education, comorbid substance use or baseline clinical symptomatology. Conclusions Close interpersonal trauma before the age of 18 is associated with poorer premorbid adjustment and a longer duration of untreated psychosis. This may indicate that traumatic experiences delay help-seeking behaviour.

Background Patients with schizophrenia spectrum disorders and substance use may have an earlier onset of illness compared to those without substance use. Most previous studies have, however, too small samples to control for confounding variables and the effect of specific types of substances. The present study aimed to examine the relationship between substance use and age at onset, in addition to the influence of possible confounders and specific substances, in a large and heterogeneous multisite sample of patients with schizophrenia spectrum disorders. Methods The patients (N = 1119) were recruited from catchment areas in Oslo, Stavanger and Bergen, Norway, diagnosed according to DSM-IV and screened for substance use history. Linear regression analysis was used to examine the relationship between substance use and age at onset of illness. Results Patients with substance use (n = 627) had about 3 years earlier age at onset (23.0 years; SD 7.1) than the abstinent group (n = 492; 25.9 years; SD 9.7). Only cannabis use was statistically significantly related to earlier age at onset. Gender or family history of psychosis did not influence the results. Conclusion Cannabis use is associated with 3 years earlier onset of psychosis.

Background: Despite the evidence of the importance of including service users’ views on psychotherapy after psychosis, there is a paucity of research investigating impact on full recovery. Objectives: To explore what fully recovered service users found to be the working ingredients of psychotherapy in the recovery process after psychosis. Materials and Methods: The study was designed as a phenomenological investigation with thematic analysis as the practical tool for analysis. Twenty fully recovered service users were interviewed. Results: Themes: (1) Help with the basics, (2) Having a companion when moving through chaotic turf, (3) Creating a common language, (4) Putting psychosis in brackets and cultivate all that is healthy, and (5) Building a bridge from the psychotic state to the outside world. Conclusion: Therapeutic approaches sensitive to stage specific functional challenges seemed crucial for counteracting social isolation and achieving full recovery. Findings indicate that psychotherapy focusing on early readjustment to everyday activities, to what are perceived as meaningful and recovery-oriented, seems to be what is preferred and called for by service users. publishedVersion

Background Quality of life is an important outcome measure for patients with psychosis. We investigated whether going into stable symptomatic remission is associated with a more positive development of subjective quality of life (S-QoL) and if different patient characteristics are associated with S-QoL depending on remission status. Methods Three hundred and one patients with a first-episode psychosis were included at baseline. At 10-year follow-up 186 were reassessed. QoL was assessed by Lehman's Quality of Life Interview. Remission was defined according to criteria proposed by the Remission in Schizophrenia Working Group. One-way ANOVA, mixed model analysis, bivariate correlations and multiple regression analyses were performed. Results Patients going into stable symptomatic remission showed a more positive S-QoL-development over the follow-up period and reported higher life satisfaction at 10-year follow-up compared to non-remission. At 10-year follow-up, depressive symptoms and alcohol abuse or dependence explained a significant amount of variance in S-QoL among patients in remission. Among patients in non-remission, PANSS excitative component explained a significant amount of variance in S-QoL. All significant effects were negative. Conclusions Stable symptomatic remission is associated with a more positive development of overall life satisfaction. Furthermore, different symptoms influence life satisfaction depending on status of remission. This has important clinical implications. While patients in remission might need treatment for depressive symptoms to increase S-QoL, in non-remission measures aiming to decrease hostility and uncooperativeness should be part of the treatment approach. Alcohol problems should be treated regardless of remission status.

There is lack of long-term controlled studies evaluating treatment effects of antipsychotic medication. A complete investigation should include the service user perspective.To investigate experiences of clinically recovered service users of antipsychotic medications during and after a first episode of psychosis.We used a thematic analytic approach within an interpretative-phenomenological framework. 20 clinically recovered service users were interviewed.Themes: (1) Antipsychotic drugs reduce mental chaos during the acute phase, (2) Non-stigmatizing environments were perceived to increase chances of successful use, (3) Antipsychotic drugs beyond the acute phase - considered to compromise the contribution of individual effort in recovery, (4) Prolonged use - perceived to reduce likelihood of functional recovery, (5) Antipsychotic medication was considered as a supplement to trustful relationships.Acute phase antipsychotic treatment was mostly perceived as advantageous by this sample, who was in clinical recovery. However, costs were often seen as outweighing benefits beyond the acute stage. Findings clearly emphasize the need for a collaborative approach to be integrated across all phases of care. This study underscores the need to investigate sub-group differences with regard to long-term antipsychotic treatment.

Background: Social functioning is a conglomerate of factors central to clinical recovery after a first-episode psychosis. There is a lack of studies investigating the relative impact of factors related to social interaction. Disentangling these could facilitate improvement of psychosocial interventions. This study aims to investigate the impact of social interactions on two-year clinical recovery in first-episode psychosis, by examining frequency and satisfaction of relationships with family and friends.

Substance use is common in first-episode psychosis (FEP) and has been linked to poorer outcomes with more severe psychopathology and higher relapse rates. Early substance discontinuation appears to improve symptoms and function. However, studies vary widely in their methodology, and few have examined patients longitudinally, making it difficult to draw conclusions for practice and treatment. We aimed to investigate the relationship between substance use and early abstinence and the long-term course of illness in a representative sample of FEP patients. Out of 301 included patients, 266 could be divided into 4 groups based on substance use patterns during the first 2 years of treatment: persistent users, episodic users, stop-users and nonusers. Differences in clinical and functional measures during the follow-up period were assessed using linear mixed effects models for the analysis of repeated measures data. Patients who stopped using substances within the first 2 years after diagnosis had outcomes similar to those who had never used with fewer symptoms than episodic or persistent users. Both episodic and persistent users had lower rates of symptom remission than nonusers, and persistent users also had more negative symptoms than those who stopped using. Our findings emerge from one of very few long-term longitudinal studies examining substance use cessation in FEP with 10-year follow-up. The results convey hope that the detrimental effects of substance abuse on mental health may be significantly reversed if one stops the abuse in time. This can help patients who struggle with addiction with their motivation to embrace abstinence.

Aims The present study examined if any patient characteristics at baseline predicted depressive symptoms at 10 years and whether patients prone to depressive symptoms in the first year of treatment had a different prognosis in the following years. Method A total of 299 first-episode psychosis (FEP) patients with schizophrenia spectrum disorders were assessed for depressive symptoms with PANSS depression item (g6) at baseline, and 1, 2, 5 and 10 years of follow up. At 10 years, depressive symptoms were also assessed with Calgary Depression Scale for Schizophrenia (CDSS). A PANSS g6 ≥ 4 and CDSS score ≥ 6 were used as a cut-off score for depression. Results A total of 122 (41%) patients were scored as depressed at baseline, 75 (28%) at 1 year, 50 (20%) at 2 years, 33 (16%) at 5 years, and 35 (19%) at 10 years of follow up. Poor childhood social functioning and alcohol use at baseline predicted depression at 10 years of follow up. Thirty-eight patients were depressed at both baseline and 1 year follow up. This group had poorer symptomatic and functional outcome in the follow-up period compared to a group of patients with no depression in the first year of treatment. Conclusion Depressive symptoms are frequent among FEP patients at baseline but decrease after treatment because their general symptoms have been initiated. Patients with poor social functioning in childhood and alcohol use at baseline are more prone to have depressive symptoms at 10 years of follow up. Patients struggling with depressive symptoms in the first year of treatment should be identified as having poorer long-term prognosis.

Background Auditory verbal hallucinations are a characteristic symptom in schizophrenia. Recent causal models of auditory verbal hallucinations propose that cognitive mechanisms involving verbal working memory are involved in the genesis of auditory verbal hallucinations. Thus, in the present study, we investigate the hypothesis that verbal working memory is a specific factor behind auditory verbal hallucinations. Methods In the present study, we investigated the association between verbal working memory manipulation (Backward Digit Span and Letter–Number Sequencing) and auditory verbal hallucinations in a population study (N = 52) of first episode psychosis. The degree of auditory verbal hallucination as reported in the P3-subscale of the PANSS interview was included as dependent variable using sequential multiple regression, while controlling for age, psychosis symptom severity, executive cognitive functions and simple auditory working memory span. Results Multiple sequential regression analyses revealed verbal working memory manipulation to be the only significant predictor of verbal hallucination severity. Conclusions Consistent with cognitive data from auditory verbal hallucinations in healthy individuals, the present results suggest a specific association between auditory verbal hallucinations, and cognitive processes involving the manipulation of phonological representations during a verbal working memory task.

Background Prolonged duration of untreated psychosis (DUP) is associated with poor outcome. The Scandinavian TIPS study deployed an early detection (ED) campaign to halve DUP. However, while reducing DUP will improve outcomes for most patients, there are some for whom prolonged DUP is a byproduct of an insidiously illness rather than a modifiable prognostic factor. It is also unclear whether the success of an ED program relies on targeting those with longer or shorter DUP. Previously, we demonstrated that quantile regression (QR) can both manage skewed distributions and allow analysis for meaningful heterogeneity in DUP. The current study aims to investigate the utility of QR to analyze the impact of an ED campaign across the DUP distribution, using data from the TIPS study. We hypothesized the effectiveness of TIPS’s ED campaign will vary across different quantiles of DUP. Methods Between 1997 and 2000, a comprehensive early detection (ED) program with public information campaigns and low-threshold psychosis detection teams was established in one health-care area (ED-area), but not in a comparable area (No-ED area). Users with DSM IV non-organic non-affective first episode psychosis were consecutively recruited. Demographic, social and clinical characteristics of people enrolled in an ED area were compared to those coming from a No-ED area. Quantile regression can model the relationship between conditional quantiles of response and independent variables. Unlike ordinary least-squares regression that focuses on conditional mean response, QR estimates the heterogeneous effects of ED across different quantiles of DUP, rather than presuming a uniform mean effect. It is particularly useful when the differential effect of predictors on lower or upper quantile of outcome are of interest. In this study, we examined the impact of ED across the entire quantiles of DUP, particularly on Q1, Q2, Q3, dividing data into four quartiles. A post hoc analysis of the effect of gender, marital status, premorbid adjustment social level, and social cluster on quartiles of DUP was also conducted. Results The total sample included 301 subjects, of which 161 belonged to an early detection (ED) area. If compared to users from No-ED area, ED users were younger (mean age 25 vs 31), and mainly unmarried (80% vs 62%). QR highlighted that ED had no effect on the first quartile (Q1) of DUP, with very short DUP, even in the No-ED area. ED was significantly associated with a reduction in the second quartile of DUP (median) (11 weeks reduction, p

Background The pre-TIPS study in 1994–95 showed that the duration of untreated psychosis (DUP) was long in our region with a mean value of 2.1 years, and median 26 weeks. This set the stage for the TIPS-study (1997–2000), reducing DUP through information campaigns targeted to the general population and other referral agents (GP’s, schools and others) in Rogaland County (Norway). The information campaigns were launched together with a low threshold organization with direct access to an early detection team, for a diagnostic interview and help. No referral other than a phone call needed, and a guarantee of assessment within 24 hours if there was suspicion of psychotic symptoms. The hypothesis was that this could change help seeking behavior, awareness towards psychosis and thus reduce the DUP. The information campaigns and the early detection team were introduced in an early detection(ED) area (Rogaland county, Norway) comparing DUP with two usual-detection control sites in Oslo (Norway) and Roskilde (Denmark). As a result, DUP in the early detection area was reduced from 26 weeks median to 4 weeks median. All patients with First Episode Psychosis in the early detection area have been followed for ten years, and a twenty-year follow-up is to take place shortly. Symptom and function advantages of early detection and DUP reduction have been demonstrated as being significant throughout the follow-up period. Social and functional outcome have been increasingly emphasized as being key parameters, as these contribute to both quality of life and to financial costs in society. Substance use is common in first-episode psychosis (FEP) and has been linked to poorer outcomes with more severe psychopathology and higher relapse rates. Early substance discontinuation appears to improve symptoms and function. However, studies vary widely in their methodology, and few have examined patients longitudinally, making it difficult to draw conclusions for practice and treatment. Methods We aimed to investigate the relationship between substance use and early abstinence and the long-term course of illness in a representative sample of FEP patients. Out of 301 included patients, 266 could be divided into four groups based on substance use patterns during the first two years of treatment: persistent users, episodic users, stop-users and non-users. Differences in clinical and functional during the follow-up period were assessed using linear mixed effects (lme) models for the analysis of repeated measures data. Results Patients who stopped using substances within the first two years after diagnosis had outcomes similar to those who had never used with less symptoms than episodic or persistent users. Both episodic and persistent users had lower rates of symptom remission than non-users, and persistent users also had more negative symptoms than those who stopped using. Discussion Our findings emerge from one of very few long-term longitudinal studies examining substance use cessation in FEP with 10-year follow-up. The results convey hope that the detrimental effects of substance abuse on mental health may be significantly reversed if one stops the abuse in time. This can help patients who struggle with addiction with their motivation to embrace abstinence.

Background: Prolonged duration of untreated psychosis (DUP) is associated with poor outcomes. The TIPS study halved DUP with an early detection (ED) campaign; however, conventional statistical analyses, focused on mean estimates, failed to reveal the effects of ED across the full DUP distribution, restricting inferences about ED's effectiveness. Utilizing a novel quantile regression based analysis, we examined the differential impact of ED across DUP. Secondary analysis explored possible predictors of DUP, and moderators of the effect of the campaign.Methods: The TIPS ED campaign was conducted in two health care sectors in Norway, with two equivalent health care sectors serving as controls. Quantile regression analysis was performed to analyze ED campaign's effect.Results: 281 patients with first episode psychosis were recruited, including 141 from the ED area. ED had no effect on the first quartile (Q1) of DUP, whereas a significant reduction in Q2 (11 weeks), and Q3 (41 weeks) of DUP was observed. The effect of ED was significantly stronger on reducing Q3 than Q1 or Q2, suggesting that the campaign was more effective in longerDUP samples. Male gender and single status predicted longerDUP inQ3: by 38 and 27 weeks, respectively. Single status, but not gender, emerged as a significant moderator of ED campaign effect.Conclusions: Quantile regression provided in depth information about the non-uniformity, and moderators, of TIPS's ED effort across the full distribution of DUP, demonstrating the value of this analytic approach to re-examine prior, and plan analyses for future, early detection efforts. (C) 2019 Published by Elsevier B.V.