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Spot psychosis early – but how?

Since the Recovery After an Initial Schizophrenia Episode (RAISE) study identified the crucial 74 week window of opportunity to treat first episode psychosis (FEP), reducing the duration of untreated psychosis (DUP) has become the rosetta stone of schizophrenia management. Everyone knows that it tells us something important but translating that information to those who can best benefit from it – mainly young men - is challenging. Here strategies to reduce DUP are described.

Social media – friends first

As John Kane, New York, USA, explained, one means of accessing young people is through social media. Amazingly, retrospective investigation of young patients’ social media postings was permitted to researchers! What was immediately apparent was that their first port of call with mental health concerns was their friends. Interestingly, young patients said they would be happy to receive reactive postings offering helpful advice. Studies are ongoing to determine whether this is the case. Currently, of the 207 participants recruited, 72% said they would be interested in getting help and their average reach out time to family and/or friends was 16 weeks. So a promising start.

Big hits – poor response

However, an anonymous email survey of mental health sent to 100,000 college students was less positive. Of the just 833 respondents, 22% were at high risk of psychosis. Disappointingly, only a single student responded when offered help.

In an attempt to understand this poor response, high-school interns were tasked with devising online and social media postings that would be attractive to their peers, including those with possible mental health issues. The results of their endeavours can be viewed at https://friendsofmind.com/

Clearly the challenge of reaching at risk people is huge, as Birnbaum et al. discovered. In their study of Google, Facebook and Twitter hits in response to potential questions such as ‘Am I going mad?’, the top 5 hits were not to sites encouraging youths to seek help. Instead, unmonitored chat-lines that either promote stigma or normalise psychotic behaviour predominated.

Connecticut – and STEP-ED

Vinod Srihari described the STEP-ED initiative – a Connecticut-based programme designed to make young people, their friends and carers aware of the need to seek early help for psychosis. Dr Srihari called it a ‘kitchen-sink’ approach as it targeted all relevant concerned parties.

3 million web-site hits – and still they won’t come

Yet despite a huge concerted effort and co-ordinated programme of community-wide promotional activities and initiatives, like the efforts described by Dr Kane, few young people approached for help. It appears than even 3 million visits to their site doesn’t guarantee direct action. Targeting family and friends appears more fruitful and maybe it’s to these more attention should be given.

Care enough in early psychosis

Christoph Correll, New York, USA, described a meta-analysis conducted to see whether specialised care interventions in early psychosis offered real benefits compared to standard care.

Google, Facebook and Twitter hits found unmonitored chat-lines that promote stigma and normalise psychotic behaviour predominated.

A total of 2,056 patients were included. Their mean age was 27 years and 63% were men. Specialised care varied widely between the studies included but there were overlaps in the treatments offered.

Is standard care just too good?

A 29% reduction in risk of drop out from therapy and a 23% fall in risk relapse were seen with specialised care compared to standard care. However, hospitalization, the real driver of cost, was not statistically significantly different between groups and the other benefits gained were small. It may be that standard care is becoming just too good for any benefit to be seen.

Online - the way forward?

Everyone has a phone, including the majority of patients with schizophrenia, so why not use it. This was the message from Dr Dror Ben-Zeev, New Hampshire, USA. He explained the feasibility of mobile behaviour sensing in out- and in-patient clinics. Leveraging the Global Positioning System and specific apps available on mobile phones, daily functioning data can be captured and analysed for patterns of behaviour. Of particular interest are patterns that occur just prior to a psychotic episode. Should these patterns arise again, patients and their carers can be alerted to the possibility of a repeat episode and potentially prevent it.

Phone for help

Importantly, patients are amenable to use of such devices and are keen to gain feedback if it helps them. A pilot study is currently underway. As Dr Ben-Zeev said, people have chosen to have these devices so we should ensure they have the best tools available to help them.

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