What happens after a first episode of psychosis?

There has been much research focused on understanding and ultimately trying to improve outcomes for those with a first episode of psychosis. Lally et al (pp. ) consider rates of remission and recovery following a first episode, in a systematic review and meta-analysis which includes 79 studies and almost 20 000 individuals. The pooled rate of remission was 58% (mean follow-up of 5.5 years) and the pooled prevalence of recovery was found to be 38% (mean follow-up of 7.2 years). The authors noted that more recent studies reported higher remission rates while recovery rates were higher in North American samples. The authors note that the prognosis following first-episode psychosis may be better than previously reported but that specialised services may not be having a sufficient impact on longer-term recovery. In a linked editorial, Power (pp. ) highlights the need for individualised treatment approaches for first-episode psychosis and calls for a broader understanding of outcomes, including recovery, following onset of psychosis.

Beyond remission and recovery, another outcome of concern following onset of a psychotic illness is development of physical ill health, particularly in the form of cardiometabolic ill health. In a systematic review and meta-analysis of cholesterol and triglyceride levels in first-episode psychosis patients compared with controls, Pillinger et al (pp. ) identified 20 case-control studies and found that both total cholesterol and LDL cholesterol levels were decreased in patients. Triglyceride levels were significantly increased in the patient group while HDL cholesterol and leptin levels did not differ. The authors comment on the likelihood that the hypercholesterolaemia seen in psychosis is secondary and thus preventable. Raised triglyceride levels, however, can be seen as indicating an existing risk for subsequent development of diabetes which is present at the first episode of psychosis even when individuals have had little or no exposure to antipsychotic medication.

Sequelae of trauma

Traumatic events are well known to be associated with psychosis but the direction of causality is not clear. McGrath et al (pp. ) used data from the World Mental Health Survey and found that those reporting traumatic events had three times the odds of subsequently developing psychotic experiences compared with other respondents. There was a dose-response relationship found between the number of reported traumatic events and the odds of psychotic experiences, and the strength of association varied by the type of event reported. Dr Marcus Tan discusses this paper further in the December Mental Elf blog at: https://slefi.sh/bjp-me10.

If traumatic events can increase risk of subsequent onset of mental illness, are there particular developmental periods during which individuals are particularly vulnerable to the effects of trauma? Dunn et al (pp. ) used cross-sectional data from the US National Comorbidity Survey Replication – Adolescent Supplement (NCS-A) to examine the role of developmental timing of first exposure to interpersonal violence and risk for psychopathology. While exposure to interpersonal violence at any age doubled the risk of psychiatric disorder, age at first exposure was largely unassociated with such risk. The authors call for further work, particularly from population-based samples, focused on understanding the role of potentially sensitive developmental periods for risk exposure.

In an editorial in the BJPsych this month, Brooker & Forrester (pp. ) also address traumatic experiences among those with mental illness, in this case in a prison context. The authors are specifically concerned about the possible failure of prison mental health in-reach services to adhere to Care Programme Approach requirements for enquiries to be made about an individual's experience of sexual abuse or sexual violence. They also note, however, that enquiry of this type is far from routine even in the community. The authors conclude that there is a need to determine what interventions prisoners are receiving from services and what outcomes are achieved.

Cognitive functioning – at high and low levels

Roux et al (pp. ) explored the relationship between residual depressive symptoms, cognition and functioning in a multicentre sample of adults with euthymic bipolar disorder. A path analysis used to perform a mediation analysis revealed that cognition and residual depressive symptoms independently influenced functioning. The authors recommend to clinicians that impairment in either domain is identified and addressed specifically in order to improve functional recovery for individuals between bipolar episodes.

Rommelse et al (pp. ) have considered the widely debated possibility that high intelligence may be associated with disadvantages as well as positive outcomes. In a Dutch population-based study of children and adolescents, they confirmed a relationship between IQ and fewer attention problems, evidence against the hypothesis that higher IQ might increase risk of ADHD-like problems. However, some support for the notion that ADHD traits might be less situationally pervasive among those with high IQ was found based on parent-teacher discrepancy rates for attentional problems.