REVIEW URRENT C OPINION
Psychosocial interventions for very early and earlyonset schizophrenia: a review of treatment efficacy Marco Armando, Maria Pontillo, and Stefano Vicari
Purpose of review Very early (VEOS) and early-onset schizophrenia (EOS) represent more severe forms of the disorder, with clear differences from adult-onset schizophrenia (AOS). However, there is a distinct lack of evidence regarding the efficacy of psychosocial interventions in this group of patients, and to date no systematic review has been conducted on the topic. The aim of this article is to review the current knowledge and evidence on the efficacy of psychosocial interventions in VEOS/EOS. Recent findings A total of eight articles were eligible for inclusion. Four studies evaluated psychoeducational and family interventions for patients with VEOS/EOS, whereas four studies focused on cognitive behavioral therapy or cognitive remediation. Overall, we found some preliminary evidence for the efficacy of psychosocial interventions in the treatment of VEOS/EOS. This evidence was strongest for cognitive remediation. Summary Heretofore, VEOS/EOS have been treated primarily with psychosocial interventions based on evidence from interventions tailored for and tested on adults. Although more conclusive studies are still needed, thanks to recent clinical trials, we now have greater evidence to support the efficacy of psychosocial interventions in EOS/VEOS. Keywords adolescent, child, early and very early-onset schizophrenia, psychosocial intervention
INTRODUCTION The incidence of schizophrenia peaks between 20 and 24 years of age [1], but, approximately, onethird of individuals develop this disorder before the age of 18 years [2]. Schizophrenia before age 18 years is commonly divided into two groups. Early-onset schizophrenia (EOS) has an onset between 13 and 17 years of age and a prevalence of, approximately, 1–2/1000, whereas very early-onset schizophrenia (VEOS) has an onset before the age of 13 years and a prevalence estimated at 1/10,000 [3]. Although VEOS/EOS are less common than adultonset schizophrenia (AOS; i.e., first episodes starting after the age of 17 years), these disorders are known to be even more severe and disabling [4–6]. Compared with individuals with AOS, those with VEOS/EOS show higher rates of premorbid abnormalities, longer duration of untreated psychosis [7], and poorer outcomes [8–10]. Moreover, VEOS/EOS are characterized by higher levels of auditory hallucinations [11], negative symptoms, bizarre behavior [7,12,13], and more severe cognitive deficits [14,15–19]. In addition, because the onset of the disorder occurs during a critical developmental period [20], www.co-psychiatry.com
individuals with VEOS/EOS are restricted in the attainment of developmental and social milestones. They are subsequently subjected to additional interruptions in education, employment, and peer relationships, which further complicated recovery [21]. Together, this body of evidence highlights that: first, VEOS/EOS represent a more severe form of the disorder than AOS; and second, there are clear neurodevelopmental, clinical, and prognostic differences between AOS and VEOS/EOS. Despite these differences, the same diagnostic criteria are applied to all groups. Several authors have recently argued that the validity of current at-risk and psychotic-onset criteria developed for Department of Neuroscience, Bambino Gesu` Children’s Hospital, IRCCS, Rome, Italy Correspondence to Marco Armando, MD, PhD, Department of Neuroscience, Children Hospital Bambino Gesu`, Piazza Sant’Onofrio 4, I-00165 Roma, Italy. Tel: +39 06 68592030; fax: +39 06 68592450; e-mail: [email protected] Curr Opin Psychiatry 2015, 28:312–323 DOI:10.1097/YCO.0000000000000165 Volume 28 Number 4 July 2015
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Psychosocial interventions for schizophrenia Armando et al.
KEY POINTS Psychosocial interventions are now recognized as important components of a comprehensive therapeutic approach in schizophrenia, improving outcomes, reducing negative symptoms, and increasing functional recovery. A relatively large number of randomized studies and reviews have investigated the efficacy of different psychosocial interventions in adult-onset schizophrenia (AOS), but there is a distinct lack of evidence regarding the efficacy of psychosocial interventions in very early (VEOS) and early-onset schizophrenia (EOS). The few existing studies show an advantage of cognitive behavioral therapy, cognitive remediation, and family intervention compared with treatment as usual in the treatment of VEOS and EOS, but the majority of these studies have low-scientific rigor and do not examine the conditions separately from AOS. Because individuals with VEOS/EOS have specific developmental issues that are very different from those of individuals with AOS, better-designed studies that are tailored to this age group and account for their developmental differences are needed in order to determine an optimal psychosocial intervention.
young adults still need to be confirmed in children and adolescents [22,23]. The lack of knowledge about appropriate diagnostic criteria is coupled with even less understanding of suitable therapeutic interventions [24]. Although antipsychotic medication represents the first-line treatment of choice in schizophrenia [2,25,26], clinical evidence from empirical studies in patients with VEOS/EOS remains limited, both in terms of efficacy and safety [27]. Moreover, pharmacological treatment alone has limited efficacy on negative symptoms and functional recovery [28,29]. Consequently, there is a growing interest in psychosocial interventions, which are now recognized as an important component of a comprehensive therapeutic approach in schizophrenia [30]. There are relatively large numbers of randomized studies on the efficacy of psychosocial interventions in AOS [31,32], and several systematic reviews have been conducted on this topic [33,34]. Nevertheless, there is a distinct lack of evidence regarding the efficacy of psychosocial interventions in VEOS/EOS, as highlighted in a recent article [28]. To date, no systematic review has been conducted on this topic. The aim of this article is to review the current knowledge and evidence supporting the efficacy of psychosocial interventions in VEOS/EOS. We have focused on the four psychosocial interventions, which have been shown to be
most effective in the treatment of schizophrenia: family intervention; psychoeducation; cognitive behavioral therapy (CBT); and cognitive remediation.
METHODS This is a systematic narrative review of the literature published between 2011 and 2014. Articles previously published were included only if particularly relevant, or in the case of lack of more recent studies on a specific psychosocial interventions discussed in the current review. A comprehensive literature search of PubMed/MEDLINE, Cochrane Library, CINHAL, and PsycINFO was carried out to identify studies on psychosocial treatments and/or symptom management interventions for people with EOS or VEOS. The search algorithm was on the basis of a combination of the terms: first, early-onset psychosis, EOS, very early-onset psychosis, VEOS, child AND psychosis/schizophrenia, adolescent psychosis/schizophrenia, and child-onset schizophrenia; second, psychosocial, family therapy/support, social skills training, cognitive therapy, cognitive behavior therapy, and cognitive remediation. Only publications in English or those with an abstract available in English were included. References from the retrieved articles and reviews on treatments for patients with VEOS/EOS were also scanned to identify potentially relevant studies. Studies were included if they tested psychosocial interventions efficacy in reducing psychotic symptoms or improving quality of life in patients with VEOS/EOS. We then excluded articles not within the field of interest of this review: review articles, editorials or letters, comments, conference proceedings, studies on treatments, and/or symptoms management interventions for people with AOS or other diagnoses (e.g., bipolar disorder and major depression with psychotic symptoms). Studies that did not demonstrate separate analysis for individuals with VEOS/EOS were also excluded. Three researchers (M.A., M.P., S.V.) independently reviewed the titles and the abstracts of the retrieved articles to apply these inclusion and exclusion criteria and then independently reviewed the full-text version of the articles to confirm eligibility for inclusion. Disagreements were resolved in a consensus meeting. Data on methodology, efficacy, acceptability, and tolerability were extracted, and these data have been presented descriptively.
RESULTS The search strategy identified 107 articles, of which 36 referred to potentially eligible studies. Of these, 28 articles were nonempirical studies, reviews,
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107 abstracts retrieved through database searching
107 abstracts screened
36 studies reviewed in full text
71 articles excluded because no direct link with the main subject
28 full text articles excluded: - Reviews editorials or letters; - Comments, conference proceedings; - Studies on adult-onset schizophrenia or mixed, but without a separate analysis for individuals with VEOS/EOS
8 studies included: - 4 studies on psychoeducational and family intervention in VEOS/EOS (Rund et al. 1994; Asarnow et al. 1994, 1999 [follow-up study]; Amminger et al. 2011; Calvo et al. 2014) - 4 studies on cognitive intervention in EOS/VEOS (Ueland and Rund 2004; Ueland and Rund 2005; Haddock et al. 2006; Puig et al. 2014)
FIGURE 1. Flow chart of literature review.
commentaries, or case reports. A total number of eight articles were included (see Fig. 1), and of these, three articles were published after 2011. Four studies are focused on CBT or cognitive remediation (listed in Table 1) and four studies on psychoeducation and family intervention for patients with VEOS/EOS (listed in Table 2). In terms of evidence-based medicine, the quality of these studies was moderate.
Cognitive behavioral therapy Considering that CBT is among the most effective psychosocial interventions in AOS is surprising that only one study investigating the efficacy of CBT in VEOS/EOS was found (see Table 1). Haddock et al. [35] evaluated outcomes by age in a randomized controlled trial (RCT) designed to test the efficacy of CBT compared with supportive counseling and treatment as usual (TAU). Seventy-one participants aged 21 years or younger and 233 participants older than 21 years with recent onset psychosis were randomly allocated to: CBT and TAU; supportive counseling and TAU; or only TAU. Outcomes were evaluated using the positive and negative symptoms scale (PANSS) [36], psychotic symptom rating scale [37], social functioning scale [38], and the California therapeutic alliance scale [39]. The psychotherapy status report [40] was used at the 3- and 18-month follow-up visits. Analysis of covariance was performed to assess the effect of treatments on symptoms and functional outcomes according to age group. Interestingly, results showed significant differences in the patterns of responses to 314
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psychological and routine treatments between younger (21 years) participants. Specifically, younger participants responded better to supportive counseling and TAU than to CBT and TAU or TAU alone, whereas older participants showed better responses to CBT and TAU than to supportive counseling and/or TAU. Although CBT did not have the greatest impact on symptoms in the younger group, its impact on insight was significantly greater than that of supportive counseling or TAU in this age group. A possible explanation is that a treatment such as CBT requires a higher level of engagement than supportive counseling. Indeed, the younger group was rated by therapists as significantly more difficult to engage in therapy. These results suggest a limited effectiveness of CBT as a psychosocial interventions for younger people with schizophrenia, particularly when there is not high engagement. Nevertheless, the small number of participants in the young group as well as the relatively high mean age (19 years old) limits the potential significance of the finding. Apart from the limited evidence on the efficacy of CBT in young patients with schizophrenia, the strongest and most interesting result of this study is the confirmation that young people may have different needs with regard to engagement in psychosocial interventions.
Cognitive remediation We found three studies examining the efficacy of cognitive remediation in VEOS/EOS (see Table 1). In Volume 28 Number 4 July 2015
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Ueland and Rund [45]
N ¼ 26
Ueland and Rund [44]
Cognitive measure:
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N ¼ 14
Experimental group:
N ¼ 25
Spectrum or other psychotic disorder based on DSM-IV;
Criteria for schizophrenia
Symptoms and psychosocial functioning:
Behavioral functioning:
BPRS; GAS
b
(13.7)
Control: 4.4 (2.2)
Network groups
4 modules:
1–30 h of cognitive remediation:
Control: 43.3 (14.6)
Training: 37.9 (12.0)
BPRS total score:
Training: 4.6a (2.0) Milieu therapy Experimental group
WCST categories
Control: 26.2 (5.6)
Training: 25.7c (4.3)
Problem-solving sessions
Parent seminars
Psychoeducational treatment:
KRFT
Control: 49.6 (8.2)
Network groups Control group:
Training: 51.5b (7.6)
SPAN
Control: 33.3 (14.5)
Training: 40.0
GAS
Control: 14.4 (4.4)
Training: 12.7a (5.5)
BPRS-positive score
Control: 45.3 (13.2)
Training: 45.1a (11.7)
BPRS total score:
Results
Milieu therapy
Problem-solving sessions
SD: 0.7
Psychoeducational treatment:
Social perception
Memory
Attention
Cognitive differentiation
4 modules:
30 h of cognitive remediation:
Experimental group:
Focused treatment
Parent seminars
BMT; SPAN; DS-CPT; KRFT; WCST; TMT, PART B
BMT; SPAN; DS-CPT; KRFT; WCST; TMT
Cognitive measure:
CBCL
Behavioral functioning:
BPRS; GAS;
Symptoms and psychosocial functioning:
Criteria for outcome
Mean age: 15.4
N ¼ 12
Control group:
Behavioral functioning: CBCL;
SD: 1.1
Symptoms and psychosocial functioning:
Spectrum or other psychotic disorder based on DSM-IV
Schizophrenia
Criteria for
Criteria for diagnosis
BPRS; GAS;
Randomized controlled trial
Randomized controlled trial
Methods
Mean age: 15.2
N ¼ 14
Experimental group:
Sample
Study
Table 1. Randomized controlled trial of cognitive behavioural therapy and cognitive remediation for patients very early and early-onset schizophrenia
(Continued )
None
6 months
Follow-up period
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315
316
Haddock et al. [35]
Study
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Control: 49.7 (6.1)
Network groups
Control: 4.8 (1.8)
Network groups
Control group:
CBT þ treatment as usual
N ¼ 233
Group age >21 years
Alone
(F(2 197) ¼ 3.00, P ¼ 0.052),
PSYRATS delusions subscale
(F(2 210) ¼ 3.01, P ¼ 0.051)
PANSS general subscale
(F(2, 210) ¼ 3.21, P ¼ 0.043)
PANSS-positive subscale
At 3 months:
Training: 5.4 (0.8)
Milieu therapy Experimental group:
WCST
Control: 28.2 (7.9)
Parent seminars Problem-solving sessions
Training: 29.2 (4.7)
Control group: Psychoeducational treatment:
KRFT
Training: 52.1a (16.8)
SPAN
Control: 47.3 (9.3)
Training: 48.9 (11.3)
GAS
Control: 13.9 (8.4)
Training: 11.6 (4.7)
BPRS-positive score
Results
Milieu therapy
Problem-solving sessions
Parent seminars
2-Psychoeducational treatment:
Social perception
Memory
Attention
Cognitive differentiation
Focused treatment
Treatment as usual
PANSS; PSYRATS; SFS; BIS; CALPAS; PSR
BMT; SPAN; DS-CPT; KRFT; WCST; TMT
Cognitive measure:
CBCL
Criteria for outcome
SD: 1.6
PANSS; PSYRATS; SFS; BIS; CALPAS; PSR
Spectrum or other psychotic disorder based on DSM-IV
Schizophrenia
Criteria for
BMT; SPAN; DS-CPT; KRFT; WCST; TMT, PART B
Cognitive measure:
Symptoms and psychosocial functioning: BPRS; GAS
Criteria for diagnosis
Supportive Counseling þ treatment as usual
Randomized controlled trial
Methods
Mean age: 19.6
N ¼ 71
Group age ¼ 60): 28%
C-GAS
Minimal improvement (CGAS score 30–50): 28% Moderate improvement (CGAS score 50–60): 28%
Pharmacological therapy
Deteriorating course (CGAS score lower at the end of follow up than at initial): 17%
Control group: H-H:12; HL:0
Experimental group: H-H:5; H-L:7
EE changes:
Experimental group mean: 7.5 (19.7) Control group mean: 7.5 (7.9)
Total score:
GAS
Results
SAICA
K-SADS-E
Psychosocial intervention (individual e family therapy, special school programmes, day treatment)
Randomized con- Criteria for schizophrenia spectrum Symptoms and psy- EPPIC therapeutic model chosocial functiontrolled trial disorder based on DSM-III-R or ing: DSM-IV (SCID I/P or Royal Park Multidiagnostic Instrument for Psychosisa)
Symptoms and psychosocial functioning: K-SADS-E; C-GAS; PAS
Symptoms and psychosocial functioning:
Pharmacological therapy
Individual psychotherapy
Mean age: 16
Criteria for schizophrenia based on DSM-III-R (SCID II)
Pharmacological therapy Control group:
Milieu therapy
EE (Expressed Emotion): -CFI
N ¼ 12
Control group:
SD: 1.5
Symptoms and psychosocial functioning: GAS; BPRS
Symptoms and psy- Experimental group: chosocial functioning: GAS Number of relapses during treatment.
Treatment
Problem-solving sessions -Milieu therapy; Networks (rehabilitation programme)
Criteria for schizophrenia spectrum disorder based on DSM-IIIR (SCID)
Criteria for outcome
Mean age:16
Observational study
Observational study
Criteria for diagnosis
Parents seminars;
Experimental group:
Rund et al. [48]
Methods
N ¼ 12
Sample
Study
Table 2. Psychoeducation and Family Intervention for very early and early-onset schizophrenia patients
2 years
7 years
2 years
Follow-up period
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Calvo et al. && [47 ]
Randomized controlled trial
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N ¼ 55
SD:3.1
Mean age: 22.6
Age: 18–30
N ¼ 325
Adult onset:
SD: 0.8.
1 positive psychotic symptom (delusions or hallucinations) before age 18 years plus 1 diagnosis from the DSM-IV: schizophrenia, schizoaffective disorder, schizophreniform disorder, bipolar disorder, major depressive disorder with psychotic features, brief psychotic disorder, or psychosis not otherwise specified.
PANSS
Clinical questionnaire
Age: 14–17 Symptoms and psychosocial functioning: GAF; BPRS-E; Clinical questionnaire
BPRS-E
N ¼ 41
Mean age: 16.5
GAF
Early onset:
Experimental group:
PANSS Total score:
Early onset: 63.4/17.1/ 19.5 Adult onset: 43.8/15.5/ 40.7
Course of illness (Never psychotic/Episodic/Continuous):
Adjusted mean difference (95%CI): 7.5 (2.8 to 12.2)
Adult onset: 56.2
Early onset: 64.2
GAF
Total: 2.2 (5.7 to 1.3); Psychotic subscale: 1.8 (2–9 to 0.7)
Adjusted mean difference (95%CI)
Adult onset: Total: 39.0; Psychotic subscale: 8.3
Early onset: Total: 37.0; Psychotic subscale: 6.5
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(Continued )
9 months
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320
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Mean age: 16.5
N ¼ 28
Pharmacological therapy
Psychoeducational intervention
Treatment
days of hospitalization P ¼ 0.142
Pharmacological therapy
visits to the emergency department P ¼ 0.039
hospital admissions P ¼ 0.057
Control group mean: 66.31(15.23)
Experimental group mean: 73.92 (14.33)
GAF
Control group mean: 55.35(17.39)
Experimental group mean: 50.29 (19.28)
Results
Nonstructured intervention;
Number of hospital Control group: admissions, days of hospitalization, number of visits to the emergency department.
Questionnaire on:
Mean age: 16.4
Control group:
FES
Criteria for outcome
N ¼ 27
Criteria for diagnosis GAF
Methods
Experimental group:
Sample
Follow-up period
BPRS, Brief Psychiatric Rating Scale; BPRS-E, Brief Psychiatric Rating Scale-Expanded; CFI, Camberwell Family Interview for Childhood; C-GAS, Children’s Global Assessment Scale; FES, Family Environment Scale; GAF, Global Assessment of Functioning; GAS, Global Assessment Scale; K-SADS-E, Schedule for Affective Disorders and Schizophrenia Epidemiological version for School-Age Children; PANSS, Positive and Negative Syndrome Scale; PAS, Premorbid Adjustment Scale; SAICA, Social Adjustment Inventory for Children and Adolescents; SCID I/P, Structured Clinical Interview for DSM-IV Patient Version; SCID, the Structured Clinical Interview for DSM-III-R, a McGorry, P.D., Singh, B.S., Copolov, D.L., Kaplan, I., Dossetor, C.R., van Riel, R.J., 1990. Royal Park Multidiagnostic Instrument for Psychosis: Part II. Development, reliability, and validity. Schizophr. Bull. 16 (3), 517–536.
Study
Table 2 (Continued)
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Psychosocial interventions for schizophrenia Armando et al. &&
the most recent study, Puig et al. [41 ] performed an RCT to examine the efficacy of cognitive remediation [42] in improving cognition and functional outcomes in a sample of symptomatically stable but cognitively disabled adolescents with EOS. Fifty participants (mean age ¼ 16.7, standard deviation ¼ 1.6) were randomly assigned to receive cognitive remediation (n ¼ 25) or TAU (n ¼ 25). Clinical symptoms as well as cognitive and functional performance were assessed before and after treatment in both groups, and after 3 months in the cognitive remediation group. The primary outcomes were changes in measures of different cognitive domains and in a cognitive composite score. Secondary outcomes were functional measures, including those related to daily living skills, general adaptive functioning, and self-esteem. After cognitive remediation, significant improvements with medium-to-large effect sizes were found in verbal memory (partial h2: 0.17), executive functions (partial h2: 0.11), daily living (partial h2: 0.09), and adaptive functioning (partial h2: 0.13). The derived cognitive composite score showed a significant improvement after treatment (partial h2: 0.14). These improvements were reliable in more than two-thirds of the treated patients (66.7%) and were maintained at the 3-month follow-up. It should be highlighted that the cognitive domains that showed the most relevant improvements after cognitive remediation (i.e., verbal memory and executive functions) are known to be the best predictors of clinical and functional outcomes in both at-risk and first-episode psychosis populations [43]. Although further studies with larger sample sizes and information about the long-term efficacy are still needed, this study gives preliminary evidence on cognitive remediation as a useful tool to improve clinical and functional outcomes in VEO/EOS. Two previous consecutive studies investigated the efficacy of cognitive remediation in VEOS/EOS within the same sample population. In the first study, Ueland and Rund [44] investigated cognitive remediation as a positive supplementary treatment programme for EOS in a sample of 26 patients (14 training and 12 control; age between 12 and 18 years old) (see Table 1 for more details). The results failed to demonstrate the efficacy of cognitive remediation on any of the cognitive and functional outcome measures. Nevertheless, exploratory within-group analyses showed that only the cognitive remediation group had significant gains on early visual information processing, as well as on visual longterm memory, which has been found to be among the more impaired functions in EOS [19]. The sample was reassessed 6 months after discharge to
investigate the maintenance effects of cognitive remediation [45]. The cognitive remediation group showed significantly more improvement than the control group on early visual information processing, but no other between-group differences were evident.
Psychoeducation and family intervention Two recent studies evaluated the efficacy of psychoeducation and family intervention in VEOS/EOS [46,47 ] (see Table 2). Amminger et al. [46] compared the long-term outcome of individuals with EOS to those with AOS who were diagnosed and treated in the same clinical center. The sample of 366 patients (325 AOS, 41 EOS) was followed for an average of 7.4 years after their initial presentation. Patients were treated with a comprehensive, integrated, community-based treatment programme, which included seminars, problem-solving sessions, and an educational programme for their parents and teachers to improve integration at school. At followup, individuals with EOS reported significantly fewer positive symptoms and significantly superior global functioning than individuals with AOS. The EOS group also achieved significantly better vocational outcomes and had a more favorable course of illness, with fewer psychotic episodes over the following 2 years. Calvo et al. [47 ] performed a randomized, rater-blinded clinical trial on 55 EOS patients and either or both of their parents, in order to assess the efficacy of a structured psychoeducation group intervention as an add-on to TAU. In this trial, a psychoeducation problem-solving group intervention was compared with a nonstructured group intervention. The group interventions were conducted once every 15 days for a total length of 9 months. In total, 27 adolescents were allocated to receive the psychoeducation group intervention and 28 were allocated to receive the nonstructured group intervention. The primary outcomes used were visits to the emergency department, number of hospitalizations, and days of hospitalization. The secondary outcome measures were clinical variables and family environment. At the end of the group intervention, 15% of patients in the psychoeducation group and 39% of patients in the nonstructured group had visited the emergency department (P ¼ 0.039). A trend toward significance in favor of psychoeducation treatment was observed on the number of hospitalizations (P ¼ 0.057), whereas no differences were observed in the number of days of hospitalization (P ¼ 0.142). Regarding the secondary outcomes, the improvement in negative symptoms was more pronounced in the psychoeducation group than in the nonstructured group on the
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&&
&&
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PANSS-negative subscale (P ¼ 0.039), but no differences were detected in the PANSS total score (P ¼ 0.264) or in the Global Assessment of Functioning scale score (P ¼ 0.163). Two observational studies were performed prior to the studies described above [48–50]. These studies had a small number of participants and found only preliminary evidence of efficacy, but they were used as the basis for the hypotheses and designs of the recent clinical trials and are, thus, reported in Table 2.
CONCLUSION In this review, we examined the efficacy of psychosocial interventions in VEOS/EOS. We found preliminary evidence for the efficacy of psychosocial interventions in the treatment of VEOS/EOS. This evidence was more relevant to cognitive remediation, and less relevant to psychoeducation, family intervention, and CBT. The most critical point we noticed is that, similar to early detection tools [51,27], psychosocial interventions in VEOS/EOS are mainly developed on late adolescent/young adult samples. Most of the studies with mixed samples did not examine outcomes with regards to age group, even though it would be hypothesized that people of different ages have different therapeutic needs [47 ]. Indeed, individuals with VEOS/EOS have specific developmental and engagement issues, which are very different from those of individuals with AOS, and this needs to be accounted for when planning and delivering treatments. In this regard, Haddock et al. [35] found different patterns of response to psychological treatments between younger and older people with first-episode psychosis. Supportive counseling appeared to be of greater benefit than CBT or TAU in the younger group, whereas CBT benefited the older group over the other two treatments. In accordance with this evidence, more attention should be paid to motivating young patients to engage in therapy, and it is possible that more basic supportive approaches are more effective in providing this initially. However, it is also possible that once patients are engaged in therapy, CBT as well as other more structured interventions may be the most helpful approach. According to this hypothesis, further investigation on the efficacy of a multiple stage psychosocial interventions (i.e., a supportive approach at the beginning of the intervention to improve engagement, followed by CBT and/or cognitive remediation), which takes both age and engagement phase into account, is needed. Preliminary evidence on the efficacy of cognitive remediation in young patients [47 ] suggests &&
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that this intervention should be considered when developing psychosocial interventions for VEOS/ EOS. Indeed, an early intervention that focuses on both cognitive deficits and social skills may be even more crucial in these patients who experience psychosis when cognitive and social abilities are still under development [51] than in AOS. At the same time, assuming that family environment plays a more relevant role in children and adolescents than in adults, there is a strong rationale for the possible benefits of family intervention in VEOS/EOS. Nevertheless, we did not find definitive results on the efficacy of family intervention in VEOS/EOS. In conclusion, the different developmental stage of those with VEOS and EOS requires the development and evaluation of well designed studies targeted at psychosocial interventions specific to these age groups. Until now, adolescents and preadolescents with schizophrenia have been treated primarily with psychosocial interventions based on evidence from interventions tailored for and tested on adults. In accordance with this evidence, we hypothesize that the poorer outcomes of VEOS/EOS compared with AOS might not be intrinsic, but may at least be partially due to the lack of knowledge about psychosocial interventions specifically tailored to children and adolescents with schizophrenia. Indeed, there has been an upgrade in methodology and evidence in recent years and as a result of recent clinical trials, we now have more evidence to support psychosocial interventions in EOS/VEOS. However, we believe that highquality research is still needed and should precede definitive therapeutic choices. Acknowledgements None. Financial support and sponsorship Marco Armando was supported by a Brain and Behavior Research Foundation (formerly NARSAD) Young Investigator Award. Conflicts of interest There are no conflicts of interest.
REFERENCES AND RECOMMENDED READING Papers of particular interest, published within the annual period of review, have been highlighted as: & of special interest && of outstanding interest 1. Kirkbride JB, Fearon P, Morgan C, et al. Heterogeneity in incidence rates of schizophrenia and other psychotic syndromes: findings from the 3-center AeSOP study. Arch Gen Psychiatry 2006; 63:250–258. 2. Madaan V, Dvir Y, Wilson DR. Child and adolescent schizophrenia: pharmacological approaches. Expert Opin Pharmacother 2008; 9:2053–2068.
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Psychosocial interventions for schizophrenia Armando et al. 3. McClennan J. Early onset schizophrenia. In: Sadock BJ, Sadock VA, editors. Comprehensive Textbook of Psychiatry. 8th edition, Vol. 2. Philadelphia: Lippincott Williams & Wilkins; 2005. pp. 3257–3261. 4. Hafner H, Nowotny B. Epidemiology of early-onset schizophrenia. Eur Arch Psychiatry Clin Neurosci 1995; 245:80–92. 5. Rabinowitz J, Levine SZ, Hafner H. A population based elaboration of the role of age of onset on the course of schizophrenia. Schizophr Res 2006; 88:96– 101. 6. Reichert A, Kreiker S, Mehler-Wex C, Warnke A. The psychopathological and psychosocial outcome of early-onset schizophrenia: preliminary data of a 13-year follow-up. Child Adolesc Psychiatry Ment Health 2008; 2:6. 7. Ballageer T, Malla A, Manchanda R, et al. Is adolescent-onset first-episode psychosis different from adult onset? J Am Acad Child Adolesc Psychiatry 2005; 44:782–789. 8. Hollis C. Adult outcomes of child- and adolescent-onset schizophrenia: diagnostic stability and predictive validity. Am J Psychiatry 2000; 157:1652–1659. 9. Lay B, Blanz B, Hartmann M, Schmidt MH. The psychosocial outcome of adolescent-onset schizophrenia: a 12-year followup. Schizophr Bull 2000; 26:801–816. 10. Hassan GA, Taha GR. Long term functioning in early onset psychosis: two years prospective follow-up study. Behav Brain Funct 2011; 7:28. 11. David CN, Greenstein D, Clasen L, et al. Childhood onset schizophrenia: high rate of visual hallucinations. J Am Acad Child Adolesc Psychiatry 2011; 50:681–686. 12. Kao YC, Liu YP. Effects of age of onset on clinical characteristics in schizophrenia spectrum disorders. BMC Psychiatry 2010; 10:63. 13. Schothorst PF, Emck C, van Engeland H. Characteristics of early psychosis. Compr Psychiatry 2006; 47:438–442. 14. Tuulio-Henriksson A, Partonen T, Suvisaari J, et al. Age at onset and cognitive functioning in schizophrenia. Br J Psychiatry 2004; 185:215–219. 15. Asarnow RF, Asamen J, Granholm E, et al. Cognitive/neuropsychological studies of children with a schizophrenic disorder. Schizophr Bull 1994; 20:647–669. 16. Kumra S, Wiggs E, Bedwell J, et al. Neuropsychological deficits in pediatric patients with childhood-onset schizophrenia and psychotic disorder not otherwise specified. Schizophr Res 2000; 42:135–144. 17. Kenny JT, Friedman L, Findling RL, et al. Cognitive impairment in adolescents with schizophrenia. Am J Psychiatry 1997; 154:1613–1615. 18. Kravariti E, Morris RG, Rabe-Hesketh S, et al. The Maudsley early onset schizophrenia study: cognitive function in adolescents with recent onset schizophrenia. Schizophr Res 2003; 61:137–148. 19. Oie M, Rund BR. Neuropsychological deficits in adolescent-onset schizophrenia compared with attention deficit hyperactivity disorder. Am J Psychiatry 1999; 156:1216–1222. 20. Breier A, Schreiber JL, Dyer J, Pickar D. National Institute of Mental Health longitudinal study of chronic schizophrenia. Prognosis and predictors of outcome. Arch Gen Psychiatry 1991; 48:239–246. 21. Hafner H. Onset and early course as determinants of the further course of schizophrenia. Acta Psychiatr Scand Suppl 2000; 407:44–48. 22. Schultze-Lutter F, Ruhrmann S, Fusar-Poli P, et al. Basic symptoms and the prediction of first-episode psychosis. Curr Pharm Des 2012; 18:351–357. 23. Fiori Nastro P, Schimmelmann BG, Gebhardt E, et al. Challenges in the early detection of psychosis in children and adolescents. Riv Psichiatr 2012; 47:116–125. 24. Masi G, Liboni F. Management of schizophrenia in children and adolescents: focus on pharmacotherapy. Drugs 2011; 71:179–208. 25. Kumra S, Oberstar JV, Sikich L, et al. Efficacy and tolerability of secondgeneration antipsychotics in children and adolescents with schizophrenia. Schizophr Bull 2008; 34:60–71. 26. Fraguas D, Correll CU, Merchan-Naranjo J, et al. Efficacy and safety of second-generation antipsychotics in children and adolescents with psychotic and bipolar spectrum disorders: comprehensive review of prospective headto-head and placebo-controlled comparisons. Eur Neuropsychopharmacol 2011; 21:621–645. 27. Schimmelmann BG, Schmidt SJ, Carbon M, Correll CU. Treatment of adolescents with early-onset schizophrenia spectrum disorders: in search of a rational, evidence-informed approach. Curr Opin Psychiatry 2013; 26:219–230. 28. Hollis C, Kendall T, Birchwood M, et al. Psychosis and schizophrenia in children and young people. Clinical Guideline 155. London: National Institute for Health and Clinical Excellence; 2013. pp. 1–51. 29. Liberman RP, Van Putten T, Marshall BD, et al. Optimal drug and behavior therapy for treatment-refractory schizophrenic patients. Am J Psychiatry 1994; 151:756–759. 30. Severs M, Pearson C. Learning to manage health informations: a theme for clinical education. Enabling People Programme. London: National Health Service Executive. pp. 3–15.
31. Bechdolf A, Kohn D, Knost B, et al. A randomized comparison of group cognitive-behavioural therapy and group psychoeducation in acute patients with schizophrenia: outcome at 24 months. Acta Psychiatr Scand 2005; 112:173–179. 32. Morrison AP, Hutton P, Wardle M, et al. Cognitive therapy for people with a schizophrenia spectrum diagnosis not taking antipsychotic medication: an exploratory trial. Psychol Med 2012; 42:1049–1056. 33. Pilling S, Bebbington P, Kuipers E, et al. Psychological treatments in schizophrenia: I. Meta-analysis of family intervention and cognitive behaviour therapy. Psychol Med 2002; 32:763–782. 34. Tarrier N, Haddock G, Barrowclough C, Wykes T. Are all psychological treatments for psychosis equal? The need for CBT in the treatment of psychosis and not for psychodynamic psychotherapy. Psychol Psychother 2002; 75:365–374; discussion 375-9.. 35. Haddock G, Lewis S, Bentall R, et al. Influence of age on outcome of psychological treatments in first-episode psychosis. Br J Psychiatry 2006; 188:250–254. 36. Kay SR, Opler LA, Lindenmayer JP. The Positive and Negative Syndrome Scale (PANSS): rationale and standardisation. Br J Psychiatry Suppl 1989; 7:59–67. 37. Haddock G, McCarron J, Tarrier N, Faragher EB. Scales to measure dimensions of hallucinations and delusions: the psychotic symptom rating scales (PSYRATS). Psychol Med 1999; 29:879–889. 38. Birchwood M, Smith J, Cochrane R, et al. The Social Functioning Scale. The development and validation of a new scale of social adjustment for use in family intervention programmes with schizophrenic patients. Br J Psychiatry 1990; 157:853–859. 39. Gaston L. Reliability and criterion-related validity of the California Psychotherapy Alliance Scales—patient version. Psychol Assess 1991; 3: 68–74. 40. Frank AF, Gunderson JG. The role of the therapeutic alliance in the treatment of schizophrenia. Relationship to course and outcome. Arch Gen Psychiatry 1990; 47:228–236. 41. Puig O, Penades R, Baeza I, et al. Cognitive remediation therapy in adoles&& cents with early-onset schizophrenia: a randomized controlled trial. J Am Acad Child Adolesc Psychiatry 2014; 53:859–868. This is the first controlled study to demonstrate the efficacy of cognitive remediation in improving several measures of cognition and functional outcome in a sample (n ¼ 50) of adolescents with stabilized EOS spectrum disorders. The findings show that cognitive remediation induced significant, reliable, medium-to-large cognitive improvements (especially on verbal memory and executive functions) and significant functional gains in adolescents with EOS. 42. Wykes T, Reeder C. Cognitive Remediation Therapy for Schizophrenia. London: Routledge; 2005. 43. Lin A, Wood SJ, Nelson B, et al. Neurocognitive predictors of functional outcome two to 13 years after identification as ultra-high risk for psychosis. Schizophr Res 2011; 132:1–7. 44. Ueland T, Rund BR. A controlled randomized treatment study: the effects of a cognitive remediation program on adolescents with early onset psychosis. Acta Psychiatr Scand 2004; 109:70–74. 45. Ueland T, Rund BR. Cognitive remediation for adolescents with early onset psychosis: a 1-year follow-up study. Acta Psychiatr Scand 2005; 111:193– 201. 46. Amminger GP, Henry LP, Harrigan SM, et al. Outcome in early-onset schizophrenia revisited: findings from the Early Psychosis Prevention and Intervention Centre long-term follow-up study. Schizophr Res 2011; 131:112–119. 47. Calvo A, Moreno M, Ruiz-Sancho A, et al. Intervention for adolescents with && early-onset psychosis and their families: a randomized controlled trial. J Am Acad Child Adolesc Psychiatry 2014; 53:688–696. This study shows that the short-term outcome of early-onset psychosis was improved by implementing a comprehensive psychoeducational programme early in the course of the disease. The results shows that patients enrolled in the psychoeducational problem-solving group intervention (n ¼ 27) had fewer visits to the emergency department, and a reduction in the number and intensity of negative symptoms than patients in the nonstructured group intervention. 48. Rund BR, Moe L, Sollien T, et al. The Psychosis Project: outcome and costeffectiveness of a psychoeducational treatment programme for schizophrenic adolescents. Acta Psychiatr Scand 1994; 89:211–218. 49. Asarnow JR, Tompson MC, Goldstein MJ. Childhood-onset schizophrenia: a follow-up study. Schizophr Bull 1994; 20:599–617. 50. Asarnow JR, Tompson MC. Childhood-onset schizophrenia: a follow-up study. Eur Child Adolesc Psychiatry 1999; 8 (Suppl 1):I9–12. 51. Schimmelmann BG, Schultze-Lutter F. Early detection and intervention of psychosis in children and adolescents: urgent need for studies. Eur Child Adolesc Psychiatry 2012; 21:239–241.
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Psychosocial interventions for very early and earlyonset schizophrenia: a review of treatment efficacy Marco Armando, Maria Pontillo, and Stefano Vicari
Purpose of review Very early (VEOS) and early-onset schizophrenia (EOS) represent more severe forms of the disorder, with clear differences from adult-onset schizophrenia (AOS). However, there is a distinct lack of evidence regarding the efficacy of psychosocial interventions in this group of patients, and to date no systematic review has been conducted on the topic. The aim of this article is to review the current knowledge and evidence on the efficacy of psychosocial interventions in VEOS/EOS. Recent findings A total of eight articles were eligible for inclusion. Four studies evaluated psychoeducational and family interventions for patients with VEOS/EOS, whereas four studies focused on cognitive behavioral therapy or cognitive remediation. Overall, we found some preliminary evidence for the efficacy of psychosocial interventions in the treatment of VEOS/EOS. This evidence was strongest for cognitive remediation. Summary Heretofore, VEOS/EOS have been treated primarily with psychosocial interventions based on evidence from interventions tailored for and tested on adults. Although more conclusive studies are still needed, thanks to recent clinical trials, we now have greater evidence to support the efficacy of psychosocial interventions in EOS/VEOS. Keywords adolescent, child, early and very early-onset schizophrenia, psychosocial intervention
INTRODUCTION The incidence of schizophrenia peaks between 20 and 24 years of age [1], but, approximately, onethird of individuals develop this disorder before the age of 18 years [2]. Schizophrenia before age 18 years is commonly divided into two groups. Early-onset schizophrenia (EOS) has an onset between 13 and 17 years of age and a prevalence of, approximately, 1–2/1000, whereas very early-onset schizophrenia (VEOS) has an onset before the age of 13 years and a prevalence estimated at 1/10,000 [3]. Although VEOS/EOS are less common than adultonset schizophrenia (AOS; i.e., first episodes starting after the age of 17 years), these disorders are known to be even more severe and disabling [4–6]. Compared with individuals with AOS, those with VEOS/EOS show higher rates of premorbid abnormalities, longer duration of untreated psychosis [7], and poorer outcomes [8–10]. Moreover, VEOS/EOS are characterized by higher levels of auditory hallucinations [11], negative symptoms, bizarre behavior [7,12,13], and more severe cognitive deficits [14,15–19]. In addition, because the onset of the disorder occurs during a critical developmental period [20], www.co-psychiatry.com
individuals with VEOS/EOS are restricted in the attainment of developmental and social milestones. They are subsequently subjected to additional interruptions in education, employment, and peer relationships, which further complicated recovery [21]. Together, this body of evidence highlights that: first, VEOS/EOS represent a more severe form of the disorder than AOS; and second, there are clear neurodevelopmental, clinical, and prognostic differences between AOS and VEOS/EOS. Despite these differences, the same diagnostic criteria are applied to all groups. Several authors have recently argued that the validity of current at-risk and psychotic-onset criteria developed for Department of Neuroscience, Bambino Gesu` Children’s Hospital, IRCCS, Rome, Italy Correspondence to Marco Armando, MD, PhD, Department of Neuroscience, Children Hospital Bambino Gesu`, Piazza Sant’Onofrio 4, I-00165 Roma, Italy. Tel: +39 06 68592030; fax: +39 06 68592450; e-mail: [email protected] Curr Opin Psychiatry 2015, 28:312–323 DOI:10.1097/YCO.0000000000000165 Volume 28 Number 4 July 2015
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Psychosocial interventions for schizophrenia Armando et al.
KEY POINTS Psychosocial interventions are now recognized as important components of a comprehensive therapeutic approach in schizophrenia, improving outcomes, reducing negative symptoms, and increasing functional recovery. A relatively large number of randomized studies and reviews have investigated the efficacy of different psychosocial interventions in adult-onset schizophrenia (AOS), but there is a distinct lack of evidence regarding the efficacy of psychosocial interventions in very early (VEOS) and early-onset schizophrenia (EOS). The few existing studies show an advantage of cognitive behavioral therapy, cognitive remediation, and family intervention compared with treatment as usual in the treatment of VEOS and EOS, but the majority of these studies have low-scientific rigor and do not examine the conditions separately from AOS. Because individuals with VEOS/EOS have specific developmental issues that are very different from those of individuals with AOS, better-designed studies that are tailored to this age group and account for their developmental differences are needed in order to determine an optimal psychosocial intervention.
young adults still need to be confirmed in children and adolescents [22,23]. The lack of knowledge about appropriate diagnostic criteria is coupled with even less understanding of suitable therapeutic interventions [24]. Although antipsychotic medication represents the first-line treatment of choice in schizophrenia [2,25,26], clinical evidence from empirical studies in patients with VEOS/EOS remains limited, both in terms of efficacy and safety [27]. Moreover, pharmacological treatment alone has limited efficacy on negative symptoms and functional recovery [28,29]. Consequently, there is a growing interest in psychosocial interventions, which are now recognized as an important component of a comprehensive therapeutic approach in schizophrenia [30]. There are relatively large numbers of randomized studies on the efficacy of psychosocial interventions in AOS [31,32], and several systematic reviews have been conducted on this topic [33,34]. Nevertheless, there is a distinct lack of evidence regarding the efficacy of psychosocial interventions in VEOS/EOS, as highlighted in a recent article [28]. To date, no systematic review has been conducted on this topic. The aim of this article is to review the current knowledge and evidence supporting the efficacy of psychosocial interventions in VEOS/EOS. We have focused on the four psychosocial interventions, which have been shown to be
most effective in the treatment of schizophrenia: family intervention; psychoeducation; cognitive behavioral therapy (CBT); and cognitive remediation.
METHODS This is a systematic narrative review of the literature published between 2011 and 2014. Articles previously published were included only if particularly relevant, or in the case of lack of more recent studies on a specific psychosocial interventions discussed in the current review. A comprehensive literature search of PubMed/MEDLINE, Cochrane Library, CINHAL, and PsycINFO was carried out to identify studies on psychosocial treatments and/or symptom management interventions for people with EOS or VEOS. The search algorithm was on the basis of a combination of the terms: first, early-onset psychosis, EOS, very early-onset psychosis, VEOS, child AND psychosis/schizophrenia, adolescent psychosis/schizophrenia, and child-onset schizophrenia; second, psychosocial, family therapy/support, social skills training, cognitive therapy, cognitive behavior therapy, and cognitive remediation. Only publications in English or those with an abstract available in English were included. References from the retrieved articles and reviews on treatments for patients with VEOS/EOS were also scanned to identify potentially relevant studies. Studies were included if they tested psychosocial interventions efficacy in reducing psychotic symptoms or improving quality of life in patients with VEOS/EOS. We then excluded articles not within the field of interest of this review: review articles, editorials or letters, comments, conference proceedings, studies on treatments, and/or symptoms management interventions for people with AOS or other diagnoses (e.g., bipolar disorder and major depression with psychotic symptoms). Studies that did not demonstrate separate analysis for individuals with VEOS/EOS were also excluded. Three researchers (M.A., M.P., S.V.) independently reviewed the titles and the abstracts of the retrieved articles to apply these inclusion and exclusion criteria and then independently reviewed the full-text version of the articles to confirm eligibility for inclusion. Disagreements were resolved in a consensus meeting. Data on methodology, efficacy, acceptability, and tolerability were extracted, and these data have been presented descriptively.
RESULTS The search strategy identified 107 articles, of which 36 referred to potentially eligible studies. Of these, 28 articles were nonempirical studies, reviews,
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313
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107 abstracts retrieved through database searching
107 abstracts screened
36 studies reviewed in full text
71 articles excluded because no direct link with the main subject
28 full text articles excluded: - Reviews editorials or letters; - Comments, conference proceedings; - Studies on adult-onset schizophrenia or mixed, but without a separate analysis for individuals with VEOS/EOS
8 studies included: - 4 studies on psychoeducational and family intervention in VEOS/EOS (Rund et al. 1994; Asarnow et al. 1994, 1999 [follow-up study]; Amminger et al. 2011; Calvo et al. 2014) - 4 studies on cognitive intervention in EOS/VEOS (Ueland and Rund 2004; Ueland and Rund 2005; Haddock et al. 2006; Puig et al. 2014)
FIGURE 1. Flow chart of literature review.
commentaries, or case reports. A total number of eight articles were included (see Fig. 1), and of these, three articles were published after 2011. Four studies are focused on CBT or cognitive remediation (listed in Table 1) and four studies on psychoeducation and family intervention for patients with VEOS/EOS (listed in Table 2). In terms of evidence-based medicine, the quality of these studies was moderate.
Cognitive behavioral therapy Considering that CBT is among the most effective psychosocial interventions in AOS is surprising that only one study investigating the efficacy of CBT in VEOS/EOS was found (see Table 1). Haddock et al. [35] evaluated outcomes by age in a randomized controlled trial (RCT) designed to test the efficacy of CBT compared with supportive counseling and treatment as usual (TAU). Seventy-one participants aged 21 years or younger and 233 participants older than 21 years with recent onset psychosis were randomly allocated to: CBT and TAU; supportive counseling and TAU; or only TAU. Outcomes were evaluated using the positive and negative symptoms scale (PANSS) [36], psychotic symptom rating scale [37], social functioning scale [38], and the California therapeutic alliance scale [39]. The psychotherapy status report [40] was used at the 3- and 18-month follow-up visits. Analysis of covariance was performed to assess the effect of treatments on symptoms and functional outcomes according to age group. Interestingly, results showed significant differences in the patterns of responses to 314
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psychological and routine treatments between younger (21 years) participants. Specifically, younger participants responded better to supportive counseling and TAU than to CBT and TAU or TAU alone, whereas older participants showed better responses to CBT and TAU than to supportive counseling and/or TAU. Although CBT did not have the greatest impact on symptoms in the younger group, its impact on insight was significantly greater than that of supportive counseling or TAU in this age group. A possible explanation is that a treatment such as CBT requires a higher level of engagement than supportive counseling. Indeed, the younger group was rated by therapists as significantly more difficult to engage in therapy. These results suggest a limited effectiveness of CBT as a psychosocial interventions for younger people with schizophrenia, particularly when there is not high engagement. Nevertheless, the small number of participants in the young group as well as the relatively high mean age (19 years old) limits the potential significance of the finding. Apart from the limited evidence on the efficacy of CBT in young patients with schizophrenia, the strongest and most interesting result of this study is the confirmation that young people may have different needs with regard to engagement in psychosocial interventions.
Cognitive remediation We found three studies examining the efficacy of cognitive remediation in VEOS/EOS (see Table 1). In Volume 28 Number 4 July 2015
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Ueland and Rund [45]
N ¼ 26
Ueland and Rund [44]
Cognitive measure:
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N ¼ 14
Experimental group:
N ¼ 25
Spectrum or other psychotic disorder based on DSM-IV;
Criteria for schizophrenia
Symptoms and psychosocial functioning:
Behavioral functioning:
BPRS; GAS
b
(13.7)
Control: 4.4 (2.2)
Network groups
4 modules:
1–30 h of cognitive remediation:
Control: 43.3 (14.6)
Training: 37.9 (12.0)
BPRS total score:
Training: 4.6a (2.0) Milieu therapy Experimental group
WCST categories
Control: 26.2 (5.6)
Training: 25.7c (4.3)
Problem-solving sessions
Parent seminars
Psychoeducational treatment:
KRFT
Control: 49.6 (8.2)
Network groups Control group:
Training: 51.5b (7.6)
SPAN
Control: 33.3 (14.5)
Training: 40.0
GAS
Control: 14.4 (4.4)
Training: 12.7a (5.5)
BPRS-positive score
Control: 45.3 (13.2)
Training: 45.1a (11.7)
BPRS total score:
Results
Milieu therapy
Problem-solving sessions
SD: 0.7
Psychoeducational treatment:
Social perception
Memory
Attention
Cognitive differentiation
4 modules:
30 h of cognitive remediation:
Experimental group:
Focused treatment
Parent seminars
BMT; SPAN; DS-CPT; KRFT; WCST; TMT, PART B
BMT; SPAN; DS-CPT; KRFT; WCST; TMT
Cognitive measure:
CBCL
Behavioral functioning:
BPRS; GAS;
Symptoms and psychosocial functioning:
Criteria for outcome
Mean age: 15.4
N ¼ 12
Control group:
Behavioral functioning: CBCL;
SD: 1.1
Symptoms and psychosocial functioning:
Spectrum or other psychotic disorder based on DSM-IV
Schizophrenia
Criteria for
Criteria for diagnosis
BPRS; GAS;
Randomized controlled trial
Randomized controlled trial
Methods
Mean age: 15.2
N ¼ 14
Experimental group:
Sample
Study
Table 1. Randomized controlled trial of cognitive behavioural therapy and cognitive remediation for patients very early and early-onset schizophrenia
(Continued )
None
6 months
Follow-up period
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315
316
Haddock et al. [35]
Study
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Control: 49.7 (6.1)
Network groups
Control: 4.8 (1.8)
Network groups
Control group:
CBT þ treatment as usual
N ¼ 233
Group age >21 years
Alone
(F(2 197) ¼ 3.00, P ¼ 0.052),
PSYRATS delusions subscale
(F(2 210) ¼ 3.01, P ¼ 0.051)
PANSS general subscale
(F(2, 210) ¼ 3.21, P ¼ 0.043)
PANSS-positive subscale
At 3 months:
Training: 5.4 (0.8)
Milieu therapy Experimental group:
WCST
Control: 28.2 (7.9)
Parent seminars Problem-solving sessions
Training: 29.2 (4.7)
Control group: Psychoeducational treatment:
KRFT
Training: 52.1a (16.8)
SPAN
Control: 47.3 (9.3)
Training: 48.9 (11.3)
GAS
Control: 13.9 (8.4)
Training: 11.6 (4.7)
BPRS-positive score
Results
Milieu therapy
Problem-solving sessions
Parent seminars
2-Psychoeducational treatment:
Social perception
Memory
Attention
Cognitive differentiation
Focused treatment
Treatment as usual
PANSS; PSYRATS; SFS; BIS; CALPAS; PSR
BMT; SPAN; DS-CPT; KRFT; WCST; TMT
Cognitive measure:
CBCL
Criteria for outcome
SD: 1.6
PANSS; PSYRATS; SFS; BIS; CALPAS; PSR
Spectrum or other psychotic disorder based on DSM-IV
Schizophrenia
Criteria for
BMT; SPAN; DS-CPT; KRFT; WCST; TMT, PART B
Cognitive measure:
Symptoms and psychosocial functioning: BPRS; GAS
Criteria for diagnosis
Supportive Counseling þ treatment as usual
Randomized controlled trial
Methods
Mean age: 19.6
N ¼ 71
Group age ¼ 60): 28%
C-GAS
Minimal improvement (CGAS score 30–50): 28% Moderate improvement (CGAS score 50–60): 28%
Pharmacological therapy
Deteriorating course (CGAS score lower at the end of follow up than at initial): 17%
Control group: H-H:12; HL:0
Experimental group: H-H:5; H-L:7
EE changes:
Experimental group mean: 7.5 (19.7) Control group mean: 7.5 (7.9)
Total score:
GAS
Results
SAICA
K-SADS-E
Psychosocial intervention (individual e family therapy, special school programmes, day treatment)
Randomized con- Criteria for schizophrenia spectrum Symptoms and psy- EPPIC therapeutic model chosocial functiontrolled trial disorder based on DSM-III-R or ing: DSM-IV (SCID I/P or Royal Park Multidiagnostic Instrument for Psychosisa)
Symptoms and psychosocial functioning: K-SADS-E; C-GAS; PAS
Symptoms and psychosocial functioning:
Pharmacological therapy
Individual psychotherapy
Mean age: 16
Criteria for schizophrenia based on DSM-III-R (SCID II)
Pharmacological therapy Control group:
Milieu therapy
EE (Expressed Emotion): -CFI
N ¼ 12
Control group:
SD: 1.5
Symptoms and psychosocial functioning: GAS; BPRS
Symptoms and psy- Experimental group: chosocial functioning: GAS Number of relapses during treatment.
Treatment
Problem-solving sessions -Milieu therapy; Networks (rehabilitation programme)
Criteria for schizophrenia spectrum disorder based on DSM-IIIR (SCID)
Criteria for outcome
Mean age:16
Observational study
Observational study
Criteria for diagnosis
Parents seminars;
Experimental group:
Rund et al. [48]
Methods
N ¼ 12
Sample
Study
Table 2. Psychoeducation and Family Intervention for very early and early-onset schizophrenia patients
2 years
7 years
2 years
Follow-up period
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Calvo et al. && [47 ]
Randomized controlled trial
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N ¼ 55
SD:3.1
Mean age: 22.6
Age: 18–30
N ¼ 325
Adult onset:
SD: 0.8.
1 positive psychotic symptom (delusions or hallucinations) before age 18 years plus 1 diagnosis from the DSM-IV: schizophrenia, schizoaffective disorder, schizophreniform disorder, bipolar disorder, major depressive disorder with psychotic features, brief psychotic disorder, or psychosis not otherwise specified.
PANSS
Clinical questionnaire
Age: 14–17 Symptoms and psychosocial functioning: GAF; BPRS-E; Clinical questionnaire
BPRS-E
N ¼ 41
Mean age: 16.5
GAF
Early onset:
Experimental group:
PANSS Total score:
Early onset: 63.4/17.1/ 19.5 Adult onset: 43.8/15.5/ 40.7
Course of illness (Never psychotic/Episodic/Continuous):
Adjusted mean difference (95%CI): 7.5 (2.8 to 12.2)
Adult onset: 56.2
Early onset: 64.2
GAF
Total: 2.2 (5.7 to 1.3); Psychotic subscale: 1.8 (2–9 to 0.7)
Adjusted mean difference (95%CI)
Adult onset: Total: 39.0; Psychotic subscale: 8.3
Early onset: Total: 37.0; Psychotic subscale: 6.5
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(Continued )
9 months
Psychosocial interventions for schizophrenia Armando et al.
319
320
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Mean age: 16.5
N ¼ 28
Pharmacological therapy
Psychoeducational intervention
Treatment
days of hospitalization P ¼ 0.142
Pharmacological therapy
visits to the emergency department P ¼ 0.039
hospital admissions P ¼ 0.057
Control group mean: 66.31(15.23)
Experimental group mean: 73.92 (14.33)
GAF
Control group mean: 55.35(17.39)
Experimental group mean: 50.29 (19.28)
Results
Nonstructured intervention;
Number of hospital Control group: admissions, days of hospitalization, number of visits to the emergency department.
Questionnaire on:
Mean age: 16.4
Control group:
FES
Criteria for outcome
N ¼ 27
Criteria for diagnosis GAF
Methods
Experimental group:
Sample
Follow-up period
BPRS, Brief Psychiatric Rating Scale; BPRS-E, Brief Psychiatric Rating Scale-Expanded; CFI, Camberwell Family Interview for Childhood; C-GAS, Children’s Global Assessment Scale; FES, Family Environment Scale; GAF, Global Assessment of Functioning; GAS, Global Assessment Scale; K-SADS-E, Schedule for Affective Disorders and Schizophrenia Epidemiological version for School-Age Children; PANSS, Positive and Negative Syndrome Scale; PAS, Premorbid Adjustment Scale; SAICA, Social Adjustment Inventory for Children and Adolescents; SCID I/P, Structured Clinical Interview for DSM-IV Patient Version; SCID, the Structured Clinical Interview for DSM-III-R, a McGorry, P.D., Singh, B.S., Copolov, D.L., Kaplan, I., Dossetor, C.R., van Riel, R.J., 1990. Royal Park Multidiagnostic Instrument for Psychosis: Part II. Development, reliability, and validity. Schizophr. Bull. 16 (3), 517–536.
Study
Table 2 (Continued)
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Psychosocial interventions for schizophrenia Armando et al. &&
the most recent study, Puig et al. [41 ] performed an RCT to examine the efficacy of cognitive remediation [42] in improving cognition and functional outcomes in a sample of symptomatically stable but cognitively disabled adolescents with EOS. Fifty participants (mean age ¼ 16.7, standard deviation ¼ 1.6) were randomly assigned to receive cognitive remediation (n ¼ 25) or TAU (n ¼ 25). Clinical symptoms as well as cognitive and functional performance were assessed before and after treatment in both groups, and after 3 months in the cognitive remediation group. The primary outcomes were changes in measures of different cognitive domains and in a cognitive composite score. Secondary outcomes were functional measures, including those related to daily living skills, general adaptive functioning, and self-esteem. After cognitive remediation, significant improvements with medium-to-large effect sizes were found in verbal memory (partial h2: 0.17), executive functions (partial h2: 0.11), daily living (partial h2: 0.09), and adaptive functioning (partial h2: 0.13). The derived cognitive composite score showed a significant improvement after treatment (partial h2: 0.14). These improvements were reliable in more than two-thirds of the treated patients (66.7%) and were maintained at the 3-month follow-up. It should be highlighted that the cognitive domains that showed the most relevant improvements after cognitive remediation (i.e., verbal memory and executive functions) are known to be the best predictors of clinical and functional outcomes in both at-risk and first-episode psychosis populations [43]. Although further studies with larger sample sizes and information about the long-term efficacy are still needed, this study gives preliminary evidence on cognitive remediation as a useful tool to improve clinical and functional outcomes in VEO/EOS. Two previous consecutive studies investigated the efficacy of cognitive remediation in VEOS/EOS within the same sample population. In the first study, Ueland and Rund [44] investigated cognitive remediation as a positive supplementary treatment programme for EOS in a sample of 26 patients (14 training and 12 control; age between 12 and 18 years old) (see Table 1 for more details). The results failed to demonstrate the efficacy of cognitive remediation on any of the cognitive and functional outcome measures. Nevertheless, exploratory within-group analyses showed that only the cognitive remediation group had significant gains on early visual information processing, as well as on visual longterm memory, which has been found to be among the more impaired functions in EOS [19]. The sample was reassessed 6 months after discharge to
investigate the maintenance effects of cognitive remediation [45]. The cognitive remediation group showed significantly more improvement than the control group on early visual information processing, but no other between-group differences were evident.
Psychoeducation and family intervention Two recent studies evaluated the efficacy of psychoeducation and family intervention in VEOS/EOS [46,47 ] (see Table 2). Amminger et al. [46] compared the long-term outcome of individuals with EOS to those with AOS who were diagnosed and treated in the same clinical center. The sample of 366 patients (325 AOS, 41 EOS) was followed for an average of 7.4 years after their initial presentation. Patients were treated with a comprehensive, integrated, community-based treatment programme, which included seminars, problem-solving sessions, and an educational programme for their parents and teachers to improve integration at school. At followup, individuals with EOS reported significantly fewer positive symptoms and significantly superior global functioning than individuals with AOS. The EOS group also achieved significantly better vocational outcomes and had a more favorable course of illness, with fewer psychotic episodes over the following 2 years. Calvo et al. [47 ] performed a randomized, rater-blinded clinical trial on 55 EOS patients and either or both of their parents, in order to assess the efficacy of a structured psychoeducation group intervention as an add-on to TAU. In this trial, a psychoeducation problem-solving group intervention was compared with a nonstructured group intervention. The group interventions were conducted once every 15 days for a total length of 9 months. In total, 27 adolescents were allocated to receive the psychoeducation group intervention and 28 were allocated to receive the nonstructured group intervention. The primary outcomes used were visits to the emergency department, number of hospitalizations, and days of hospitalization. The secondary outcome measures were clinical variables and family environment. At the end of the group intervention, 15% of patients in the psychoeducation group and 39% of patients in the nonstructured group had visited the emergency department (P ¼ 0.039). A trend toward significance in favor of psychoeducation treatment was observed on the number of hospitalizations (P ¼ 0.057), whereas no differences were observed in the number of days of hospitalization (P ¼ 0.142). Regarding the secondary outcomes, the improvement in negative symptoms was more pronounced in the psychoeducation group than in the nonstructured group on the
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PANSS-negative subscale (P ¼ 0.039), but no differences were detected in the PANSS total score (P ¼ 0.264) or in the Global Assessment of Functioning scale score (P ¼ 0.163). Two observational studies were performed prior to the studies described above [48–50]. These studies had a small number of participants and found only preliminary evidence of efficacy, but they were used as the basis for the hypotheses and designs of the recent clinical trials and are, thus, reported in Table 2.
CONCLUSION In this review, we examined the efficacy of psychosocial interventions in VEOS/EOS. We found preliminary evidence for the efficacy of psychosocial interventions in the treatment of VEOS/EOS. This evidence was more relevant to cognitive remediation, and less relevant to psychoeducation, family intervention, and CBT. The most critical point we noticed is that, similar to early detection tools [51,27], psychosocial interventions in VEOS/EOS are mainly developed on late adolescent/young adult samples. Most of the studies with mixed samples did not examine outcomes with regards to age group, even though it would be hypothesized that people of different ages have different therapeutic needs [47 ]. Indeed, individuals with VEOS/EOS have specific developmental and engagement issues, which are very different from those of individuals with AOS, and this needs to be accounted for when planning and delivering treatments. In this regard, Haddock et al. [35] found different patterns of response to psychological treatments between younger and older people with first-episode psychosis. Supportive counseling appeared to be of greater benefit than CBT or TAU in the younger group, whereas CBT benefited the older group over the other two treatments. In accordance with this evidence, more attention should be paid to motivating young patients to engage in therapy, and it is possible that more basic supportive approaches are more effective in providing this initially. However, it is also possible that once patients are engaged in therapy, CBT as well as other more structured interventions may be the most helpful approach. According to this hypothesis, further investigation on the efficacy of a multiple stage psychosocial interventions (i.e., a supportive approach at the beginning of the intervention to improve engagement, followed by CBT and/or cognitive remediation), which takes both age and engagement phase into account, is needed. Preliminary evidence on the efficacy of cognitive remediation in young patients [47 ] suggests &&
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that this intervention should be considered when developing psychosocial interventions for VEOS/ EOS. Indeed, an early intervention that focuses on both cognitive deficits and social skills may be even more crucial in these patients who experience psychosis when cognitive and social abilities are still under development [51] than in AOS. At the same time, assuming that family environment plays a more relevant role in children and adolescents than in adults, there is a strong rationale for the possible benefits of family intervention in VEOS/EOS. Nevertheless, we did not find definitive results on the efficacy of family intervention in VEOS/EOS. In conclusion, the different developmental stage of those with VEOS and EOS requires the development and evaluation of well designed studies targeted at psychosocial interventions specific to these age groups. Until now, adolescents and preadolescents with schizophrenia have been treated primarily with psychosocial interventions based on evidence from interventions tailored for and tested on adults. In accordance with this evidence, we hypothesize that the poorer outcomes of VEOS/EOS compared with AOS might not be intrinsic, but may at least be partially due to the lack of knowledge about psychosocial interventions specifically tailored to children and adolescents with schizophrenia. Indeed, there has been an upgrade in methodology and evidence in recent years and as a result of recent clinical trials, we now have more evidence to support psychosocial interventions in EOS/VEOS. However, we believe that highquality research is still needed and should precede definitive therapeutic choices. Acknowledgements None. Financial support and sponsorship Marco Armando was supported by a Brain and Behavior Research Foundation (formerly NARSAD) Young Investigator Award. Conflicts of interest There are no conflicts of interest.
REFERENCES AND RECOMMENDED READING Papers of particular interest, published within the annual period of review, have been highlighted as: & of special interest && of outstanding interest 1. Kirkbride JB, Fearon P, Morgan C, et al. Heterogeneity in incidence rates of schizophrenia and other psychotic syndromes: findings from the 3-center AeSOP study. Arch Gen Psychiatry 2006; 63:250–258. 2. Madaan V, Dvir Y, Wilson DR. Child and adolescent schizophrenia: pharmacological approaches. Expert Opin Pharmacother 2008; 9:2053–2068.
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Psychosocial interventions for schizophrenia Armando et al. 3. McClennan J. Early onset schizophrenia. In: Sadock BJ, Sadock VA, editors. Comprehensive Textbook of Psychiatry. 8th edition, Vol. 2. Philadelphia: Lippincott Williams & Wilkins; 2005. pp. 3257–3261. 4. Hafner H, Nowotny B. Epidemiology of early-onset schizophrenia. Eur Arch Psychiatry Clin Neurosci 1995; 245:80–92. 5. Rabinowitz J, Levine SZ, Hafner H. A population based elaboration of the role of age of onset on the course of schizophrenia. Schizophr Res 2006; 88:96– 101. 6. Reichert A, Kreiker S, Mehler-Wex C, Warnke A. The psychopathological and psychosocial outcome of early-onset schizophrenia: preliminary data of a 13-year follow-up. Child Adolesc Psychiatry Ment Health 2008; 2:6. 7. Ballageer T, Malla A, Manchanda R, et al. Is adolescent-onset first-episode psychosis different from adult onset? J Am Acad Child Adolesc Psychiatry 2005; 44:782–789. 8. Hollis C. Adult outcomes of child- and adolescent-onset schizophrenia: diagnostic stability and predictive validity. Am J Psychiatry 2000; 157:1652–1659. 9. Lay B, Blanz B, Hartmann M, Schmidt MH. The psychosocial outcome of adolescent-onset schizophrenia: a 12-year followup. Schizophr Bull 2000; 26:801–816. 10. Hassan GA, Taha GR. Long term functioning in early onset psychosis: two years prospective follow-up study. Behav Brain Funct 2011; 7:28. 11. David CN, Greenstein D, Clasen L, et al. Childhood onset schizophrenia: high rate of visual hallucinations. J Am Acad Child Adolesc Psychiatry 2011; 50:681–686. 12. Kao YC, Liu YP. Effects of age of onset on clinical characteristics in schizophrenia spectrum disorders. BMC Psychiatry 2010; 10:63. 13. Schothorst PF, Emck C, van Engeland H. Characteristics of early psychosis. Compr Psychiatry 2006; 47:438–442. 14. Tuulio-Henriksson A, Partonen T, Suvisaari J, et al. Age at onset and cognitive functioning in schizophrenia. Br J Psychiatry 2004; 185:215–219. 15. Asarnow RF, Asamen J, Granholm E, et al. Cognitive/neuropsychological studies of children with a schizophrenic disorder. Schizophr Bull 1994; 20:647–669. 16. Kumra S, Wiggs E, Bedwell J, et al. Neuropsychological deficits in pediatric patients with childhood-onset schizophrenia and psychotic disorder not otherwise specified. Schizophr Res 2000; 42:135–144. 17. Kenny JT, Friedman L, Findling RL, et al. Cognitive impairment in adolescents with schizophrenia. Am J Psychiatry 1997; 154:1613–1615. 18. Kravariti E, Morris RG, Rabe-Hesketh S, et al. The Maudsley early onset schizophrenia study: cognitive function in adolescents with recent onset schizophrenia. Schizophr Res 2003; 61:137–148. 19. Oie M, Rund BR. Neuropsychological deficits in adolescent-onset schizophrenia compared with attention deficit hyperactivity disorder. Am J Psychiatry 1999; 156:1216–1222. 20. Breier A, Schreiber JL, Dyer J, Pickar D. National Institute of Mental Health longitudinal study of chronic schizophrenia. Prognosis and predictors of outcome. Arch Gen Psychiatry 1991; 48:239–246. 21. Hafner H. Onset and early course as determinants of the further course of schizophrenia. Acta Psychiatr Scand Suppl 2000; 407:44–48. 22. Schultze-Lutter F, Ruhrmann S, Fusar-Poli P, et al. Basic symptoms and the prediction of first-episode psychosis. Curr Pharm Des 2012; 18:351–357. 23. Fiori Nastro P, Schimmelmann BG, Gebhardt E, et al. Challenges in the early detection of psychosis in children and adolescents. Riv Psichiatr 2012; 47:116–125. 24. Masi G, Liboni F. Management of schizophrenia in children and adolescents: focus on pharmacotherapy. Drugs 2011; 71:179–208. 25. Kumra S, Oberstar JV, Sikich L, et al. Efficacy and tolerability of secondgeneration antipsychotics in children and adolescents with schizophrenia. Schizophr Bull 2008; 34:60–71. 26. Fraguas D, Correll CU, Merchan-Naranjo J, et al. Efficacy and safety of second-generation antipsychotics in children and adolescents with psychotic and bipolar spectrum disorders: comprehensive review of prospective headto-head and placebo-controlled comparisons. Eur Neuropsychopharmacol 2011; 21:621–645. 27. Schimmelmann BG, Schmidt SJ, Carbon M, Correll CU. Treatment of adolescents with early-onset schizophrenia spectrum disorders: in search of a rational, evidence-informed approach. Curr Opin Psychiatry 2013; 26:219–230. 28. Hollis C, Kendall T, Birchwood M, et al. Psychosis and schizophrenia in children and young people. Clinical Guideline 155. London: National Institute for Health and Clinical Excellence; 2013. pp. 1–51. 29. Liberman RP, Van Putten T, Marshall BD, et al. Optimal drug and behavior therapy for treatment-refractory schizophrenic patients. Am J Psychiatry 1994; 151:756–759. 30. Severs M, Pearson C. Learning to manage health informations: a theme for clinical education. Enabling People Programme. London: National Health Service Executive. pp. 3–15.
31. Bechdolf A, Kohn D, Knost B, et al. A randomized comparison of group cognitive-behavioural therapy and group psychoeducation in acute patients with schizophrenia: outcome at 24 months. Acta Psychiatr Scand 2005; 112:173–179. 32. Morrison AP, Hutton P, Wardle M, et al. Cognitive therapy for people with a schizophrenia spectrum diagnosis not taking antipsychotic medication: an exploratory trial. Psychol Med 2012; 42:1049–1056. 33. Pilling S, Bebbington P, Kuipers E, et al. Psychological treatments in schizophrenia: I. Meta-analysis of family intervention and cognitive behaviour therapy. Psychol Med 2002; 32:763–782. 34. Tarrier N, Haddock G, Barrowclough C, Wykes T. Are all psychological treatments for psychosis equal? The need for CBT in the treatment of psychosis and not for psychodynamic psychotherapy. Psychol Psychother 2002; 75:365–374; discussion 375-9.. 35. Haddock G, Lewis S, Bentall R, et al. Influence of age on outcome of psychological treatments in first-episode psychosis. Br J Psychiatry 2006; 188:250–254. 36. Kay SR, Opler LA, Lindenmayer JP. The Positive and Negative Syndrome Scale (PANSS): rationale and standardisation. Br J Psychiatry Suppl 1989; 7:59–67. 37. Haddock G, McCarron J, Tarrier N, Faragher EB. Scales to measure dimensions of hallucinations and delusions: the psychotic symptom rating scales (PSYRATS). Psychol Med 1999; 29:879–889. 38. Birchwood M, Smith J, Cochrane R, et al. The Social Functioning Scale. The development and validation of a new scale of social adjustment for use in family intervention programmes with schizophrenic patients. Br J Psychiatry 1990; 157:853–859. 39. Gaston L. Reliability and criterion-related validity of the California Psychotherapy Alliance Scales—patient version. Psychol Assess 1991; 3: 68–74. 40. Frank AF, Gunderson JG. The role of the therapeutic alliance in the treatment of schizophrenia. Relationship to course and outcome. Arch Gen Psychiatry 1990; 47:228–236. 41. Puig O, Penades R, Baeza I, et al. Cognitive remediation therapy in adoles&& cents with early-onset schizophrenia: a randomized controlled trial. J Am Acad Child Adolesc Psychiatry 2014; 53:859–868. This is the first controlled study to demonstrate the efficacy of cognitive remediation in improving several measures of cognition and functional outcome in a sample (n ¼ 50) of adolescents with stabilized EOS spectrum disorders. The findings show that cognitive remediation induced significant, reliable, medium-to-large cognitive improvements (especially on verbal memory and executive functions) and significant functional gains in adolescents with EOS. 42. Wykes T, Reeder C. Cognitive Remediation Therapy for Schizophrenia. London: Routledge; 2005. 43. Lin A, Wood SJ, Nelson B, et al. Neurocognitive predictors of functional outcome two to 13 years after identification as ultra-high risk for psychosis. Schizophr Res 2011; 132:1–7. 44. Ueland T, Rund BR. A controlled randomized treatment study: the effects of a cognitive remediation program on adolescents with early onset psychosis. Acta Psychiatr Scand 2004; 109:70–74. 45. Ueland T, Rund BR. Cognitive remediation for adolescents with early onset psychosis: a 1-year follow-up study. Acta Psychiatr Scand 2005; 111:193– 201. 46. Amminger GP, Henry LP, Harrigan SM, et al. Outcome in early-onset schizophrenia revisited: findings from the Early Psychosis Prevention and Intervention Centre long-term follow-up study. Schizophr Res 2011; 131:112–119. 47. Calvo A, Moreno M, Ruiz-Sancho A, et al. Intervention for adolescents with && early-onset psychosis and their families: a randomized controlled trial. J Am Acad Child Adolesc Psychiatry 2014; 53:688–696. This study shows that the short-term outcome of early-onset psychosis was improved by implementing a comprehensive psychoeducational programme early in the course of the disease. The results shows that patients enrolled in the psychoeducational problem-solving group intervention (n ¼ 27) had fewer visits to the emergency department, and a reduction in the number and intensity of negative symptoms than patients in the nonstructured group intervention. 48. Rund BR, Moe L, Sollien T, et al. The Psychosis Project: outcome and costeffectiveness of a psychoeducational treatment programme for schizophrenic adolescents. Acta Psychiatr Scand 1994; 89:211–218. 49. Asarnow JR, Tompson MC, Goldstein MJ. Childhood-onset schizophrenia: a follow-up study. Schizophr Bull 1994; 20:599–617. 50. Asarnow JR, Tompson MC. Childhood-onset schizophrenia: a follow-up study. Eur Child Adolesc Psychiatry 1999; 8 (Suppl 1):I9–12. 51. Schimmelmann BG, Schultze-Lutter F. Early detection and intervention of psychosis in children and adolescents: urgent need for studies. Eur Child Adolesc Psychiatry 2012; 21:239–241.
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