Current Psychiatry Reviews - Volume 12, Issue 4, 2016

Available research has clearly demonstrated that individuals with longstanding psychotic disorders have deficits in cognitive functioning that (i) have deleterious effects on their everyday functioning and (ii) can be partially ameliorated via available treatment options. Despite the fact that the cognitive deficits that accompany psychotic disorders are largely present by the time of the first-episode of psychosis, the nature of these associations in first-episode psychosis is less clear. Data are mixed with regard to a possible association between neurocognition and real-world functioning among individuals with first-episode psychosis, possibly due in part to methodological limitations of available studies. Although cognitive remediation has shown promise in ameliorating cognitive and functional deficits among individuals with longstanding psychotic disorder, these associations are not as robust for individuals with first-episode psychosis. With regard to pharmacological treatment, available data suggest that antipsychotic medications do not produce meaningful gains in cognitive functioning. Data in support of other pro-cognitive pharmacological agents are also limited. Ultimately, further research using methodologically sound approaches is needed to clarify the role of cognitive deficits in the disability that accompanies first-episode psychosis and to identify the most effective interventions with which to ameliorate these cognitive deficits.

Psychotic disorders are devastating illnesses that impact countless people worldwide, and a mounting body of empirical evidence promotes the importance of early intervention in psychosis for improving outcomes for young people living with these disorders. In particular, studies aimed at understanding the interactions between symptoms, functioning, and recovery amongst those early in the course of illness (i.e., first-episode psychosis) have become more prevalent. Despite these efforts, there is still much we don’t understand about the underpinnings of psychotic disorders. Though traditional approaches to the study of psychiatric disorders have focused primarily on symptoms and behavioral indicators of functioning (e.g., vocational status, social activities), an increasing number of researchers are adopting phenomenological approaches in order to understand how experiential aspects of psychosis may improve our understanding of these disorders. An accumulating literature suggests that anomalies in the sense of self that accompany psychosis provide a particularly important source of clinical information. Despite this insight, research on anomalies of self in psychotic disorders - and particularly first-episode psychosis - remains relatively limited, likely due in part to the inherent difficulties of assessing subjective constructs in empirical designs. In this review, theoretical models of self relevant to the understanding of anomalies of self in psychosis are discussed and the available literature is reviewed within this framework. Implications for the treatment of psychotic disorders as well as suggestions for future research are also discussed.

Despite evidence that individuals with schizophrenia are disproportionately affected by cardiovascular and cerebrovascular diseases, it is unclear if individuals with schizophrenia have an underlying liability to cardiovascular diseases or if these diseases are a consequence of psychotic illness (e.g., antipsychotic medications, sedentary lifestyle). To resolve this, we must study cardiovascular disease risk factors in individuals in the early stages of illness with limited exposure to antipsychotic medications (i.e., individuals with first-episode psychosis) and in unaffected relatives of individuals with schizophrenia. Here we review evidence of cardiovascular risk in individuals with first-episode psychosis and in unaffected relatives of individuals with schizophrenia. We identify a gap in research on cardiovascular risk in these populations, namely the lack of studies that directly visualize the vasculature, and we introduce a novel technology, retinal imaging, that may be useful for directly visualizing the vasculature and clarifying pathophysiological mechanisms that underlie both schizophrenia and cardiovascular disease. We conclude with suggestions for priorities in future research using retinal imaging.

Abnormalities in basic sensory perception are frequently found in individuals with schizophrenia. However, the literature on basic sensory perception in the clinical high-risk and firstepisode psychosis populations has been less extensive. This article summarizes research on sensory perception in clinical high-risk and first-episode psychosis for the auditory, visual, olfactory, and bodycentered senses. It then highlights the uncertainty of whether sensory perception abnormalities and psychotic symptoms are concurrent results of disruption in normal brain development, or whether abnormal basic sensory experiences play a causal role in the development of psychotic symptoms. Finally, potential directions for future research are discussed.

In schizophrenia, social cognition is a strong predictor of functional outcome, and researchers have developed a range of interventions with the aim of improving functional outcome by way of improved social cognition. This article summarizes the literature on social cognitive dysfunction and social cognitive treatment approaches in first episode psychosis (FEP). Although the literature in FEP is relatively small, findings parallel those in chronic schizophrenia. Specifically, FEP individuals exhibit social cognitive dysfunction across a range of subdomains, this dysfunction is relatively stable over time, predicts social functioning, and mediates the relationship between neurocognition and social functioning. As in chronic schizophrenia, psychosocial interventions targeting social cognition in FEP appear to be feasible and acceptable to patients. These interventions show promising initial indicators that they may improve both social cognition and social functioning in FEP. Although several interventions have been designed or adapted to meet the age- and phase-specific needs of FEP individuals, there is no data as yet to assess whether these interventions are more acceptable to FEP patients than traditional social cognitive interventions. Computer-assisted treatments for social cognition are being tested in FEP. More research is needed to determine whether the potential benefits of computer approaches in terms of patient engagement and skill rehearsal outweigh the disadvantage of these interventions not involving actual social interaction.

Recent developments in the U.S. healthcare policy signal a growing commitment to early intervention for psychotic disorders. A growing international and U.S. research database supports the effectiveness of specialty team-based models adapted to care for young individuals with recent onset psychosis. The RAISE (Recovery After an Initial Schizophrenia Episode) initiative, sponsored by the NIMH (National Institute of Mental Health), has defined such Coordinated Specialty Care (CSC) services as a new benchmark for care across the U.S., and published a variety of resources to support dissemination. Funding initiatives led by the center for Substance Abuse and Mental Health Services (SAMHSA), and support from other national organizations, have catalyzed interest in community agencies across the country. We offer guidance to such early adopters and supplement extant resources with a focus on the process of setting up such programs. Adopters have numerous decisions to make. These include determining admission criteria, structuring care processes to maximize impact, choosing from several empirically based interventions, and resourcing workforce development. We provide a guide to salient resources, and lessons learned from a decade old CSC, to aid in these complex decisions. We end with a discussion of limitations in the current knowledge base, and the need for responsive research. Early intervention services can engender application of demonstrably effective treatment, while also providing platforms for research to improve and develop new treatments. Collaborations between a wide variety of government, academic and commercial stakeholders will be essential to realize the transformative public health impact of early intervention for psychotic disorders.

Growing research has highlighted that the first few years of psychotic illnesses constitute a “critical period” in which (i) the majority of the functional deterioration that accompanies these illnesses occurs, and (ii) individuals are most responsive to both pharmacological and psychosocial treatments for psychosis and its deleterious sequelae. Clinical interest in intervening earlier in psychotic episodes, and what early intervention might mean for a person’s symptom reduction and social functioning, has emerged within a decades-long history of social science research on the concept of recovery. In this article, we describe the intersection between that long-standing interest in recovery and the more recent attention to first-episode psychosis to explore conundrums that may arise as clinicians engage with their clients following a first episode of psychosis. We suggest ways of addressing these situations by highlighting several complementary or alternative approaches to traditional psychiatric treatment and conclude with a call to rethink ways of doing research on recovery in first-episode psychosis.

In the context of contemporary psychiatry, most patients live in their family’s home, which leads to cohabitation of brothers and sisters with the schizophrenic sibling. Having briefly alluded to the change in the role granted to the families of patients in psychiatric care, the present article reveals the intrapsychic and interpersonal issues involved in this cohabitation. Discussion turns around clinical practice with the brothers and sisters of schizophrenic patients and on research work (questionnaires filled in by 600 people who are brothers and sisters of schizophrenic patients and qualitative research covering the relations inside the group of siblings). The results lead to recommending, for preventive and curative ends, greater consideration for what the siblings experience within the families of origin that include a schizophrenic child. A merely educational and informative response is not adequate if it is not integrated within a more global approach to provide support for the relation.

Adversity in early life has been associated with consequent altered behaviors or mental disorders during adulthood. Similar observations occur in the intrauterine environment that can disturb the neurodevelopment of the fetus. A particular example of this phenomenon is seen in infants of mothers who experience depression during pregnancy, who seem to be more prone to have emotional disturbances throughout life. The interaction between environmental factors and a genetic predisposition could be an explanation to the association between perinatal depression and psychological symptoms in the offspring. In this regard, it is essential to consider the epigenetic changes that occur in the complex interaction between environment, genetic factors and mood disorders during pre-natal life. It has been observed that epigenetic modifications play a central role as a mediator in the fetal programming of adult health. The aim of our study is to present an updated review of the data regarding epigenetic modifications in specific regions of candidate genes for perinatal depression.