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Abstract

Objectives: To provide a brief overview of the development of clinical services and research for early intervention in psychotic disorders in Canada; to describe components of a comprehensive clinical/research programme for nonaffective psychotic disorders; and to present a summary of results of clinical and social outcomes achieved.

Method: This is a descriptive paper providing some details of how clinical services are being developed in Canada and concentrating on one particular early intervention programme, Prevention and Early intervention Programme for Psychoses (PEPP) London, Ontario, which is using a historical control design to evaluate the impact of an assertive approach to community case detection. Components of a phase-specific treatment programme and early case detection are described followed by results based on clinical and psychosocial data collected according to a defined protocol.

Results: One year outcome for patients treated in PEPP shows use of low dose, predominantly novel antipsychotics and high (81.5%) retention and remission (75%) rates. Highly significant improvements were also reported for self-rated quality of life and cognition. Duration of untreated psychosis (DUP) and premorbid adjustment were associated with improvement in positive and negative symptoms, respectively. Systemic changes to improve access to the service resulted in substantial increases in number of cases treated and a < 50% decline in DUP.

Conclusions: Phase-specific treatment approach and case identification strategies to reduce delay in treatment are likely to substantially improve outcome in nonaffective psychotic disorders compared with what has been reported with traditional approaches.

Keywords

early intervention psychosis first-episode

Intervening early following the onset of psychosis is not only intuitively appealing but is based on relatively robust evidence of a relationship between the length of untreated psychosis and clinical and social outcomes [1–3]. In a recent critical review, Norman and Malla [3] concluded that duration of untreated psychosis (DUP) is related to time to remission, the level of remission achieved and other measures of, at least, short-term outcome such as the level of residual positive and negative symptoms. Delay in treatment may also affect outcome on measures of social functioning and quality of life [4–6]. Patients with a first-episode of psychosis are likely to obtain the greatest benefit if treatment provided is specifically designed for this early phase of the illness in addition to these interventions being provided early following the onset of psychosis [4, 7, 8].

Following the publication of several key papers in Schizophrenia Bulletin in 1996 [4, 7, 9, 10], early intervention in psychotic disorders has attracted a significant interest in many countries. Growth of several clinical and research programmes has been observed in Australia, New Zealand, Europe and Canada. In this paper, a brief overview of the progress made in developing early intervention programmes in Canada will be presented, followed by a more detailed description of one of the Canadian clinical/research programmes and a summary of published data evaluating the effectiveness of this early intervention programme.

Nationwide Canadian early intervention initiatives

While investigations regarding first-episode psychosis have been carried out for many years in several Canadian centres, more integrated early psychosis programmes have only emerged in the last 5 years. Four such clinical/ research programmes were developed independently in Calgary, London (Ontario), Toronto and Halifax. While each of these programmes has distinct characteristics and specific research interests, they all serve mostly urban populations and provide phase-specific treatment to individuals newly diagnosed with psychosis. Brief descriptions of these programmes are available in a recent book edited by Edwards and McGorry [11].

More recently, several other programmes have been initiated or are being planned in almost all of the Canadian provinces, primarily through efforts of clinicians and advocacy on the part of families. The public policy initiatives are invariably lagging behind the enthusiasm shown by clinicians and families. Within the province of Ontario (population of 11.8 million) a working group of clinicians/researchers, consumers of service (patient and family members), self-help and other community organizations has been established in order to influence mental health policy and funding decisions. This group has been successful in obtaining research funding for tracking outcomes of first-episode psychosis (FEP) in four academic centres.

Prevention and Early Intervention Programme for Psychosis (PEPP), London, Ontario

This early intervention programme was established in 1997 following significant modifications to an earlier community-orientated programme for treatment of schizophrenia and related psychotic disorders [12]. PEPP is based on a conceptual framework that promotes a stressvulnerability hypothesis for understanding psychotic disorders and targeting nonaffective psychoses rather than a specific diagnosis of schizophrenia. The programme consists of two essential components: a phase-specific integrated medical and psychosocial assessment and treatment; and early community case detection to reduce delays in treatment.

An overview of the model (for details see http://www.pepp.ca)

The PEPP utilizes an assertive case management model, modified to suit the needs of mostly young people and their families [13], as its central framework (see Fig. 1). The model involves a comprehensive approach with intensive medical and psychosocial management being provided by a nurse or social worker case manager. The case manager's role includes the functions of assessment, treatment and working through the patient's recovery from psychosis. This is achieved through a close partnership with families, a strong therapeutic relationship with the patient and, whenever possible, reliance on liaisons with generic community services, educational institutions and employers to reintegrate the young person to his/her full potential over an initial 2-year follow-up period. Involvement in the direct delivery of one or more specific psychosocial group interventions and individual supportive therapy are important components of a case manager's role. The goal is to normalize the young person's environment as soon as possible, including re-establishment of peer relations. Housing through special group homes and utilization of long-term disability benefits is actively discouraged to avoid the assumption of a chronic sick role.

Figure 1.

Case management model.

Patients stay in the core programme utilizing all interventions, especially case management, for a minimum of 2 years. Patients not recovered sufficiently to assume independent functioning and/or not in remission are provided extended case management for an additional 1–3 years, while the majority (82%) graduate and are followed by their programme psychiatrist. For the latter, case management is reintroduced temporarily in case of relapse or a crisis until the crisis is resolved. All patients continue with medical management with their respective psychiatrists in the programme for at least 5 years. Most are seen every 1–3 months while stable.

Case finding and assessment

Strategies for reducing delays in treatment of psychosis

Barriers to appropriate care for individuals suffering from a first-episode of psychosis are likely to exist at different levels of a traditional referral/treatment system, but may vary across various health care systems [9]. These include the difficulty primary care physicians and other health care workers experience in identifying early signs of psychosis and often result in multiple visits before an appropriate referral is made [14]. A necessary component of an early intervention programme therefore consists of strategies that would reduce delays in new cases of psychosis receiving assessment and treatment [4, 15, 16]. We have chosen to introduce strategies for reduction of delay in treatment in two phases. The contents of the phase-specific treatment programme are being maintained unchanged throughout both phases.

Phase I (1997–1999), funded from within the clinical service funds, involved improving access through adoption of an open referral policy, provision of a prompt response with an assessment carried out within 24–48 h in the clinic or at the patient's home. All health-related referral sources in the catchment area were identified and informed through brochures describing the establishment of the programme, the nature of psychosis and the process of assessment, integrated medical and psychosocial treatments, as well as research conducted in the programme.

Phase II of the strategy for reducing delays in treatment has consisted of a community-wide case-detection programme added to the procedures already in place and funded by the Ministry as a special one time youth project. This initiative includes provision of information regarding identification of psychotic symptoms and behaviour to potential sources of referral and providing basic information regarding psychosis to all members of the community. The latter has involved community-wide campaigns using written materials (pamphlets, posters, calendars and bookmarks), the media (TV and radio) and setting up specific education programmes in all secondary schools and postsecondary institutions and providing public forums for education. The posters consist of a brief description of key symptoms of psychosis and the brochures and calendars provide a detailed description of the nature and early signs of psychosis and the advantages of early intervention. These have been placed in key locations such as shopping malls, pharmacies and the public transit system. Consumers of service (patients and families) have been involved in the planning, fundraising and wider community dissemination of information regarding psychosis. In addition, direct contact established with each educational institution and referral source has been followed by presentations, seminars and workshops.

Assessment and engagement

Following direct contact with the source of referral an assessment clinician conducts a brief screening to ensure that the patient may have psychotic symptoms or be at high or imminent risk for psychosis followed by a formal initial assessment carried out within a maximum of 48 h (depending on the urgency) by an experienced clinician (a nurse) either in the clinic setting or at the patient's home. A full assessment of the patient with a psychiatrist is carried out following a review of the initial assessment, in order to confirm the presence of a nonaffective psychosis followed later by a Structured Clinical Interview (SCID-IV) to confirm DSM-IV diagnosis of a psychotic disorder. For clinical purposes, only a generic diagnosis of psychosis is made at this stage, to be reviewed 1 year later. Patients (16–50 years old) who meet criteria of a nonaffective psychosis, live in the defined catchment area (population 360 000 urban and 30 000 rural) and have not received antipsychotic treatment for a period greater than 1 month are asked to sign a consent for assessment and treatment. Patients presenting other diagnoses are referred to respective treatment programmes. However, approximately 10% of patients still receive a diagnosis of affective psychosis following completion of the SCID-IV at 1 year. Patients who do not meet criteria for diagnosis of a psychotic disorder but are judged to meet criteria for ‘at risk mental state’, a state of pre-psychosis as defined by the PACE clinic [17, 18] are followed-up regularly by individual clinicians and their mental state monitored to gauge transition to psychosis or recovery.

Following admission to the programme an assessment of the patient's quality of life (client, provider and family versions of the Wisconsin Quality of Life scale [19]), and cognition is conducted as early as clinically feasible. The cognitive assessment encompasses several areas of functioning: intellectual (premorbid and current), executive, attention, working memory, speed of processing, learning and short-term and long-term/auditory and visual memory, self-reported cognition and emotional functioning [20]. Symptom and side-effect assessments are repeated at regular intervals with standard instruments while cognitive and quality of life assessments are repeated at the end of 1 and 2 years.

Treatment

Medication management

While specific treatment for psychosis begins with the initiation of antipsychotic medication, patients who initially refuse drug therapy are provided support and education along with their families. This may extend for weeks and, occasionally, several months. The choice of antipsychotic medication is established through a treatment protocol (see Fig. 2) that is explained to the patient and family by the psychiatrist. Patients are started on a dosage as low as 0.5 mg to 1 mg of risperidone, 5 mg of olanzapine or, less frequently, 50–100 mg of quetiapine and increased over several days to 2, 10 and 300 mg a day, respectively. If needed, the dose of the medication is increased to a maximum tolerated dose up to 6 mg, 20 mg and 900 mg, respectively. While side-effects are monitored closely by all clinical staff involved, standard ratings of movement disorders and sexual dysfunction are carried out by the treating physician biweekly for the first month, on a monthly basis for the subsequent three months and every three months thereafter over the 2-year period of follow-up. Failure of treatment to adequate trials with two novel antipsychotics results in the discussion of clozapine therapy with the patient and the family. Typical antipsychotic medications are used only as depot preparations when adherence to oral medications becomes problematic.

Figure 2.

Medication protocol guide

Specific psychosocial interventions

Family intervention: This consists of several components: three evening educational workshops delivered on a rotational basis on the nature of psychosis, drug treatment and side-effects, and psychosocial issues and their impact on outcome; individual family intervention provided by the social worker and/or case manager and the psychiatrist; a parent support group operated by families, and multiple family group intervention [21] for patients who have not recovered completely at the end of 2 years. In addition, three sets of new video and accompanying written modules are presented that have been designed for families to work initially with clinical staff and later on their own. These modules address 14 different concerns often encountered by families with a first-episode of psychosis, using live scenarios to demonstrate the nature of the problem and some guidelines to deal with them. These include coping with diagnosis, dealing with stigma, substance abuse, returning to work/school, intimacy/sexual relationships, etc. (details can be obtained from the principal author). A family support group initiated by parents of young patients functions as an active partner in treatment, providing additional support and education to new families, participating in disseminating information to the community and acting as both an effective advocate for the programme and its clients, as well as a watchdog for the performance of the programme through participation in the programme's community advisory committee.

Group interventions: Following group interventions are provided to address patients' needs specific to each stage of recovery.

(a) Recovery through Activity and Participation (RAP): RAP provides simple low-stress activities designed to enhance daily functioning, increase structure and work towards personal goals for in- and outpatients still experiencing psychotic symptoms and/or having difficulties with attention and thinking. It is a transitional activity-based group conducted twice a week, for a maximum of 12 weeks, in an outpatient setting. It assists in monitoring individuals in their early stages of recovery and provides a link to the community for those who receive their initial treatment as inpatients. The activities, chosen by the group members, are graded to meet their current needs and may include cooking, games, sports, painting and sculpting, guest speakers or community field trips.

(b) Youth Education and Support (YES) Group: This more intensive group intervention, consisting of eight 2-hour weekly sessions, forms an essential component of treatment for the young client (16–25 years). The main objective of the group is to assist young patients in the process of recovery through prevention of relapse and resumption of roles relevant to the individual's level of psychosocial development. Each of the eight sessions addresses a specific theme paired with relevant information using multiple media and pedagogic techniques (e.g. film, games, humour). The paired themes include: selfidentity and what is psychosis; peer pressure and drug and alcohol use; relationships and medications; stigma and strategies; social skills and recovery; and return to school/work and early warning signs.

(c) Cognitively Oriented Skills Training (COST): Cognitive deficits [22], frequently present even at first presentation [23–25], are reported to have important implications for the community functioning (education and employment) of individuals with psychotic disorders, independent of clinical symptoms [26, 27]. Research supports the efficacy of interventions such as the adaptation of the physical and social environment [28, 29] and compensatory cognitive and behavioural strategies in group settings, rather than trying to rehabilitate targeted deficits [30, 31]. The COST group is designed to address deficits in functioning that relate to academic performance through the instruction of cognitive and behavioural compensatory strategies for specific domains of cognition. The main objectives are to increase the use and effectiveness of study strategies, decrease the frequency of cognitive complaints, improve attention and concentration, increase the use of learning and memory strategies and improve academic performance. This intervention consists of 10 weekly sessions (each 2 hours) conducted in a didactic format mirroring that of a classroom setting with 6–8 participants and is facilitated by two co-therapists.

Individual therapies: All patients receive individual supportive psychotherapy from their respective case managers. In addition, patients demonstrating anxiety or mild to moderate depression during the recovery and follow-up period are offered cognitive behavioural therapy with or without supplementary medications. Patients who are able to achieve only a partial remission of their psychotic symptoms despite adequate pharmacological interventions are also provided cognitive therapy specifically to reduce the impact of psychotic symptoms [32].

Evaluation

While there is substantial evidence of a relationship between DUP and, at least, short-term outcome, it remains unclear whether the improved outcome reported from early intervention [4] is related to improved treatment specifically designed for this phase of the illness or to intervening early or both. There is some suggestion that phase-specific treatment, if provided within a crucial period following onset of psychosis, produces the greatest benefit [33]. The PEPP project is designed to evaluate the relative effect of assertive community early case detection on 1 and 2 year outcomes as distinct from any improvement achieved through phase-specific treatment. The content of such treatment is being kept constant before and after the introduction of the case detection initiative. Here we will summarize findings from the first phase regarding outcome on clinical, quality of life and cognitive measures, and the impact of the first phase of systemic strategies on rates of treated incidence and reduction in DUP. These findings have been published in greater detail in several papers [34–36].

Sample

Over the first two and a half years a total of 201 patients were assessed and 130 met criteria for a first-episode of psychosis. Of these, 106 (81.5%) completed 1 year of treatment and complete data were available on 88 (68% of total) patients. At the time of initial assessment 60% of these met criteria for schizophrenia spectrum psychosis and 20% psychosis not otherwise specified (NOS) and the rest had diagnosis of affective psychosis (8%), substance-induced psychosis (9.7%) and delusional disorder (2.3%). At 1 year, 81% met criteria for schizophrenia spectrum psychosis, 8% affective psychosis, 6% psychosis NOS and 5% had substanceinduced psychosis or delusional disorder.

Treatment

At 1 year the vast majority (83%) were treated with novel antipsychotics including clozapine (2.4%). Typical antipsychotics (depot) were received by 7.2% of participants; 3.6% were participating in double-blind trial with a novel and a typical antipsychotic and 6% refused to take any medication regularly. The distribution of DUP was positively skewed with a mean of 44 weeks and a median of 22 weeks. Three-quarters of patients were in remission (all SAPS global item scores 2 or <) at 1 year. Of those not in remission, the majority (n = 18) had only moderate positive symptoms (global SAPS item scores 3), and only four showed moderately severe or severe symptoms (SAPS global item scores 4 or 5) at 1 year. Eleven unremitted patients agreed to take clozapine, of which nine responded.

While significant improvement occurred in both positive and negative symptoms, 40% of patients showed no change in negative symptoms compared to 11% for positive symptoms at the end of 1 year. Patients with a DUP of less than 6 months were significantly more likely to remit (83% vs 65%, χ² 3.9, p < 0.05) than those with DUP of greater than 22 weeks (median split). The level of positive symptoms at 1 year was associated with DUP and premorbid adjustment during adolescence which together with length of the prodrome accounted for 14% of explained variance. Negative symptoms were predicted by premorbid adjustment during adolescence, which together with gender and diagnosis of schizophrenia versus other psychoses accounted for 16% of explained variance. Residual symptoms of disorganization were associated with early age of onset, premorbid adjustment during early adolescence, gender and length of prodrome, accounting for 13.5% of explained variance. The lack of association between outcome and childhood adjustment and likely contiguity of adolescent adjustment with prodromal period may suggest a deteriorating process that does not begin until early adolescence. These findings could argue against the significant impact of early neurodevelopment on the course of the illness.

Nearly half of the patients were initially treated as outpatients. The initial venue of treatment did not influence later utilization of inpatient resources during the follow-up period of 1 year. Significant improvements have also been observed in several cognitive domains [37] and indicators of social relations and community functioning after 1 year of treatment [36, 38]. The results reported are comparable to more recent investigations of effectiveness of a phase-specific approach to treating FEP [4, 39] but better than that with traditional approaches [40, 41].

Impact of strategies to reduce delays in treatment

Previous reports have detailed strategies for reducing delays in treatment and their impact on such delays [42]. The first phase of the programme to reduce delay in treatment, involving primarily systemic changes, produced a substantial increase in new cases seen in the second year (from 44 to 62). Based on the number of positive cases identified, PEPP's annual treated incidence rates were 20.8, 30 and 24.7 for 1997, 1998 and 1999 for population at risk (age 16–50). Not withstanding variations in estimation of the yearly incidence of new cases of schizophrenia has been reported to range from 7 to 28 per 100 000 [43]. The rates may be underestimated compared to those in other programmes (e.g. EPPIC) and may reflect exclusion of affective psychosis and criterion of a narrow time frame for exposure to antipsychotic treatment for entry to the programme. There was a significant difference in median DUP over the three years (p = 0.02). From 1997 to 1998 the median DUP decreased slightly from 26.6 to 24.0 weeks, followed by a decrease to 11.6 weeks in 1999 [44]. The second phase of active case detection has been underway for 2 years and data are being collected.

Conclusion

Early intervention in psychosis is gaining momentum in Canada, largely as a result of mounting evidence as well as enthusiasm generated by clinicians, researchers and families. Improved access appears to reduce delay in treatment.

References

Loebel

A D

Lieberman

J A

Alvir

J MJ

Mayerhoff

D I

Geisler

S H

Szymanski

S R

Duration of untreated psychosis and outcome in first episode schizophrenia

American Journal of Psychiatry 1992 149: 1183–1188.

Wyatt

R J

Neuroleptics and the natural course of schizophrenia

Schizophrenia Bulletin 1991 17: 325–351.

Norman

R MG

Malla

A K

Duration of untreated psychosis: a critical examination of the concept and its importance

Psychological Medicine 2001 31: 381–400.

McGorry

P D

Edwards

Mihalopoulos

Harrigan

S M

Jackson

H J

EPPIC: an evolving system of early detection and optimal management

Schizophrenia Bulletin 1996 22: 305–326.

Edwards

Maude

McGorry

P D

Harrigan

S M

Cocks

J T

Prolonged recovery in first episode psychosis

British Journal of Psychiatry 1998 172 (Suppl. 33) 107–116.

Drake

R J

Haley

C J

Akhar

Lewis

Causes and consequences of duration of untreated psychosis in schizophrenia

British Journal of Psychiatry 2000 177: 511–515.

McGlashan

Early detection and intervention in schizophrenia: research

Schizophrenia Bulletin 1996 22: 327–345.

Malla

A K

Norman

R MG

Voruganti

L P

Improving outcome in schizophrenia: the case for early intervention

Canadian Medical Association Journal 1999 160: 843–846.

Vaglum

Early detection and intervention in schizophrenia: unsolved questions

Schizophrenia Bulletin 1996 22: 347–351.

10.

Yung

A R

McGorry

P D

The prodromal phase of first episode psychosis: past and current conceptualizations

Schizophrenia Bulletin 1996 22: 353–370.

11.

Edwards

McGorry

P D

. Implementing early intervention in psychosis: a guide to establishing early psychosis services. Martin Dunitz, London 2002.

12.

Malla

A K

Norman

R MG

McLean

T S

An integrated medical and psychosocial treatment program for psychotic disorders: patient characteristics and outcome

Canadian Journal of Psychiatry 1998 43: 698–705.

13.

Malla

A K

Norman

R MG

Facing the challenges of intervening early in psychosis

Annales Royal College of Physicians and Surgeons of Canada 1999 32: 394–397.

14.

Lincoln

C V

McGorry

Who cares? Pathways to psychiatric care for young people experiencing a first episode of psychosis

Psychiatric Services 1995 11: 1166–1171.

15.

Jorgensen

Nordentoft

Abel

M B

Gouliaev

Jeppesen

Kassow

Early detection and assertive community treatment of young psychotics: the Opus Study

Social Psychiatry and Psychiatric Epidemiology 2000 35: 283–287.

16.

Johannessen

J O

McGlashan

T H

Larson

T K

Early detection strategies for untreated first-episode psychosis

Schizophrenia Research 2001 51: 39–46.

17.

Yung

A R

McGorry

P D

McFarlane

C A

Jackson

J H

Patton

G C

Rakkar

Monitoring and care of young people at incipient risk of psychosis

Schizophrenia Bulletin 1996 22: 283–303.

18.

Phillips

L J

McGorry

P D

Yung

A R

The development of preventive interventions for early psychosis: early findings and directions for the future

Schizophrenia Research 1999 36: 331–332.

19.

Becker

Diamond

Sainfort

A new patient focused index for measuring quality of life in persons with severe and persistent mental illness

Quality Life Research 1993 2: 239–251.

20.

Townsend

L A

Malla

A K

Norman

R MG

Cognitive functioning in stabilized first-episode psychosis patients

Psychiatry Research 2001 104: 119–131.

21.

McFarlane

W R

Dunne

Family psychoeducation and multifamily groups in the treatment of schizophrenia

Directions in Psychology 1991 11: 2–7.

22.

Heinrichs

R W

Zakzanis

K K

Neurocognitive deficit in schizophrenia: a quantitative review of the evidence

Neuropsychology 1998 12: 426–445.

23.

Saykin

A J

Gur

R C

Gur

R E

Neuropsychological function in schizophrenia: selective impairment in memory and learning

Archives of General Psychiatry 1991 51: 124–131.

24.

Mohamed

Paulsen

J S

O'Leary

Arndt

Andreasen

Generalized cognitive deficits in schizophrenia

Archives of General Psychiatry 1999 56: 749–754.

25.

Binder

Albus

Hubman

Neuropsychological impairment and psychopathology in first-episode schizophrenic patients related to the early course of illness

European Archives of Psychiatry and Clinical Neurosciences 1998 248: 70–77.

26.

Green

M F

What are the functional consequences of neurocognitive deficits in schizophrenia?

American Journal of Psychiatry 1996 153: 321–330.

27.

Green

A F

Kern

R S

Braff

D L

Mintz

Neurocognitive deficits and functional outcome in schizophrenia: are we measuring the ‘right stuff’?

Schizophrenia Bulletin 2000 26: 119–136.

28.

Cassidy

J J

Easton

Capelli

Cognitive remediation of persons with severe and persistent mental illness

Psychiatric Quarterly 1996 67: 313–321.

29.

Sohlberg

M M

Mateer

C A

. Introduction to cognitive rehabilitation. Guilford, New York 1989.

30.

Ballack

A S

Cognitive rehabilitation for schizophrenia: is it possible? Is it necessary?

Schizophrenia Bulletin 1992 18: 43–50.

31.

Benedict

R HB

Harris

A E

Markow

McCormick

J A

Nuechterlein

K H

Asarnow

R F

Effects of attention training on information processing in schizophrenia

Schizophrenia Bulletin 1994 20: 537–546.

32.

Norman

R MG

Townsend

Cognitive-behavioural therapy for psychosis: a status report

Canadian Journal of Psychiatry 1999 44: 245–252.

33.

Carbone

Harrigan

McGorry

Curry

Elkins

Duration of untreated psychosis and 12 month outcome in first episode psychosis: the impact of treatment approach

Acta Psychiatrica Scandinavica 1999 100: 96–104.

34.

Malla

A K

Norman

Manchanda

Status of patients with first-episode psychosis after one year of phase-specific community-oriented treatment

Psychiatric Services 2002 53: 458–463.

35.

Malla

Norman

Manchanda

One year outcome in first episode psychosis. influence of DUP and other predictors

Schizophrenic Research 2002 54: 231–242.

36.

Malla

Norman

R MG

Manchanda

Townsend

Symptoms, cognition, treatment adherence and functional outcome in first episode psychosis

Psychological Medicine 2002 32: 1109–1119.

37.

Townsend

Norman

R M

Malla

A K

Rychlo

Ahmed

Changes in cognitive functioning following comprehensive treatment for first episode patients with schizophrenia spectrum disorders

Psychiatry Research 2002 113: 69–81.

38.

Malla

A K

Norman

R MG

McLean

T S

McIntosh

Impact of phase-specific treatment of first episode of psychosis on Wisconsin Quality of Life Index (client version)

Acta Psychiatrica Scandinavica 2001 103: 355–361.

39.

Power

Elkins

Adlard

Curry

McGorry

Harrigan

Analysis of the initial treatment phase in first-episode psychosis

British Journal of Psychiatry 1998 172 (Suppl. 33) 71–76.

40.

Rabiner

C J

Wagner

J T

Kane

J M

Outcome study of first-episode psychosis: I. Relapse rates after 1 year

American Journal of Psychiatry 1986 143: 1155–1158.

41.

Scottish Schizophrenia Research Group

The Scottish first episode schizophrenia study V: one-year follow-up

British Journal of Psychiatry 1988 152: 470–476.

42.

Johannsen

J O

Larsen

T K

Horneland

Strategies for reducing duration of untreated psychosis

Schizophrenia Research 1999 361: 342–343.

43.

Jablensky

Sartorius

Ernberg

Schizophrenia: manifestations, incidence and course in different cultures. A World Health Organization ten-country study

Psychological Medicine 1992 20 (Monograph Supplement) 1–97.

44.

Scholten

D J

Malla

A K

Norman

R M

McLean

T S

McIntosh

E M

Early intervention in psychosis: the impact of a novel approach to early case detection. Presented at International Congress of Schizophrenia Research, British Columbia, April 28–May 2, 2001

Schizophrenia Research 2001 49 (Suppl. 1–2) 41.

A Canadian Programme for Early Intervention in Non-Affective Psychotic Disorders

Abstract

Keywords

Nationwide Canadian early intervention initiatives

Prevention and Early Intervention Programme for Psychosis (PEPP), London, Ontario

An overview of the model (for details see http://www.pepp.ca)

Case finding and assessment

Strategies for reducing delays in treatment of psychosis

Assessment and engagement

Treatment

Medication management

Specific psychosocial interventions

Evaluation

Sample

Treatment

Impact of strategies to reduce delays in treatment

Conclusion

References