First Psychotic Episode: Organizational Aspects and Effectiveness of Services

I. Y. Gurovich, A. B. Shmukler, A. S. Dorodnova, L. G. Movina, Y. S. Zaitseva

Moscow Research Institute of Psychiatry of the Russian Ministry of Health

A recent innovation in mental health has been development of 'first episode' clinics to give intensive treatment and support to individuals, usually on an 'outpatient' basis, when they first experience a psychotic episode such as schizophrenia. This article reviews the adaptation of this idea to Russia, and presents data on a control study of the program's effectiveness where the 'treatment' group received both pharmacological and psychosocial treatments, and the control group received advanced pharmacological treatment alone. The combination of pharmacological and psychosocial interventions contributed to significantly better outcomes than use of advanced pharmacological treatment alone both as measured in clinical symptoms and in social functioning. Finally, an evaluation of the first episode clinic results with comparable clients treated in conventional psychiatric services revealed a significant advantage for the first episode clinic treatment approach.

Provision of service to people with early manifestations of psychotic conditions has acquired increased importance in recent years. It has been demonstrated that early intervention contributes to achieving earlier remissions and allows for decrease in extent of social loss. Early intervention also renders an opportunity to begin neurocognitive treatment in the initial stages of the disease, which can reduce the manifestation of neurocognitive changes that are characteristic for persons with schizophrenia and, as a result, contribute to the patients' social recovery, improve their long term prognosis, and promote the secondary prevention of relapses and chronic conditions. In the long term, it can decrease the number of hospital admissions and duration of hospital stay, which can lead to the reduction of service costs (Birchwood et al., 1998; Breier, 1999; De Haan et al, 2003; Gleeson et al, 2003; Gurovich et al, 2001; Harrigan et al, 2003; Keshavan & Schooler, 1992; Lehtinen et al, 1996; Magomedova, 2003; Malla et al, 2002, 2004; Marshall & Lockwood, 2004; McGlashan, 1998; McGorry et al, 1996, 2002; Norman et al, 2005; Oosthuizen et al, 2001).

First Psychotic Episode Clinics (FPEC) that provide specific service programs to this particular target group of patients have been established in Australia (Early Psychosis Prevention and Intervention Centre), Canada (the Early Psychosis Treatment and Prevention Program in Calgary), Finland (the Multicentre National Project) and other countries. The first such clinic in Russia opened in November 2000 at the Moscow Research Institute of Psychiatry (MRIP). To date, FPEC programs consistent with the MRIP model have been established in 20 regions across Russia.

The established organizational service model for patients with early psychotic episode is represented by specialized clinics that utilize a standard set of strategies aimed at improving functional outcomes of schizophrenia. However, there is a need for the further study of the evidence and content of this model's advantages. As such, no data are available in literature concerning differential approaches to utilizing various forms of psychosocial treatment. The patterns of subjective evaluation of mental disorder by patients and their family members and their reactions to the unfolding of the disease are also insufficiently represented in literature.

Basic Principles

The FPEC at the Moscow Research Institute of Psychiatry has developed a comprehensive therapeutic intervention program based on the following major principles:

1. Services within the least restrictive approach, both in the in-patient settings and at the following treatment stages.

2. Primary use of atypical neuroleptics as pharmacotherapy of first choice

3. Combining biological treatments with the consistent program of psychosocial interventions at the earliest possible stages of treatment.

4. Long-term follow up with individualized case management and comprehensive maintenance therapy.

5. Polyprofessional team services (including psychiatrist, psychotherapist, psychologist, and nurses).

Admission criteria for the FPEC include the diagnosis of schizophrenia or other schizophrenia spectrum disorders, according to ICD-10 (World Health Organization, 1992), with the duration of the illness less than 5 years since the first manifestation, and not more than three relapses since the onset of the condition. Upon the referral to the clinic, decision on the possibility of admission for each patient was made according to the established service policy for day hospitals (Gurovich & Sarkisyan, 1979; Gurovich et al, 1984). Persons with sub-acute psychotic conditions were accepted for the program, and in cases of acute psychotic manifestations patients were admitted after controlling the acute symptoms through inpatient treatment in a psychiatric hospital.

Target Patient Group

From its inception through the year 2004 a total of 115 people were admitted to the program. Of these, 76 persons were diagnosed with schizophrenia (66.1%), 31 with schizoaffective disorder (27.0%) and 8 with schizotypal disorder (7.0%). Of those with schizophrenia, most often it was the paranoid type (58 persons) with episodic course and progressive (32 persons) or stable (22 persons) deficit. Four patients had continuous course of schizophrenia.

More than half had family history of the disorder. Early childhood development had features of dysontogenesis in 23.3% of patients. Only 11.7% were characterized as harmonious personality. The majority of patients had specific pre-morbid personality traits, most often of schizoid (53.3%), cyclothymic (12.5%), hyperthymic (10.0%), anxious (8.33%), and explosive (4.17%) types.

The prodromal period was characterized by unstable affect, personality shifts, various neurotic-like complaints, behavioral and thought disorders, as well as subjectively over-valued conceptual constructs, unusual ideation with empty metaphysical reasoning, and dysmorphophobic fears with distorted body image and self perception. In some patients, pathological fantasies were observed in the prodromal period. In addition, some patients demonstrated transitory sub-psychotic episodes and unstable ideas of reference. As a consequence of these disturbances, the prodromal period was associated with social losses. Many did not work (30.4% or 35 persons), lost their initial professional qualification (3.5% or 4 persons), had temporary, unstable employment (4.3% or 5 persons), or dropped out of school (17.4% or 20 persons). Many patients experienced significant disturbances in their social networks (47% or 54 persons), losing their friendships and professional connections. A few experienced family breakdown (1.7% or 2 persons). On the positive side, 55.8% of patients admitted to the FPEC maintained their previous social status (i.e., continued to work in their profession or remained in school).

The structure of the manifest psychotic episodes was represented by hallucinatory-delusional (37.4% or 43 persons), affective-delusional (32.2% or 37 persons) and polymorphous (25.2% or 29 persons) disorders. In 5.2% cases (6 persons) oneiroid-catatonic psychoses were observed. The average scores on the Positive and Negative Syndrome Scale (PANSS) (Kay et al, 1987) among all patients admitted to the FPEC was 77.9+15.0.

Treatments and Interventions: Program Organization and Content

Basic principles of pharmacological treatment at the FPEC included the following: primary use of atypical neuroleptics as first-choice medication (Bradford et al, 2003; Correl et al, 2004; Meltzer, 2003); using minimum effective doses; and on-going dose adjustment based on thorough observation of changes in the patients' condition.

Psychosocial treatment included psycho-education with the elements of problem solving techniques and social skills training, individualised family intervention, and support therapy. Psychosocial treatment in FPEC began at the earliest possible stage of treatment after controlling the acute psychotic manifestations. Various types of psychosocial treatment were prescribed to patients according to the indications. Each intervention was planned with the consideration of relevant goals and with the indication of appropriate timelines for achieving these goals.

From the time of admission in the program to the moment of achieving remission (most often 3 to 4 weeks), the main objective of psychosocial treatment was establishing a therapeutic alliance with the patient.

During the period of remission (from the time when the acute psychotic symptoms were controlled to the time of the discharge from the program, most often 6 to 8 weeks), group methods of intervention were actively used, in particular group psycho-education sessions. Group formation process, indication and contraindications for patients' participation in groups, group facilitation methods, and the content of sessions were based on recommendations reflected in literature (Gurovich et al, 2002; Salnikova et al, 2002). In total, 49 patients with schizophrenia and other schizophrenia spectrum disorders we included in these groups. The number of participants in each group varied from 6 to 8 persons, with one-hour sessions running 2 or 3 times per week. Each full cycle of group sessions included 10 to 12 sessions, depending on particular patients' needs and their cognitive capacities.

Family intervention format was individualized in each case. Particular attention was paid to communication skills in families, developing collaborative relationships with mental health services, and elements of training aimed at overcoming disturbed communication styles within families.

Many researchers have stressed the importance and severity of reactions experienced by patients and their families with the first manifestation and diagnosis of the illness (Barrelet, et al, 1990; Mari & Streinger, 1994; McCay & Ryan, 2002), but these reactions have not been studied differentially. However, the great significance of these reactions for overcoming the illness and for the consequent adaptation is indisputable (Hatfield & Lefly, 1993; McGorry et al, 1996; Strauss, 1989; Thompson et al, 2003). It is important to consider these factors in the process of developing psychosocial interventions.

At Moscow FPEC, the types of patients' reaction to the unfolding of the disease were identified, and the emphasis was made accordingly on different aspects of psychosocial interventions. For example, when patients and their families tended to minimize evident problems, the emphasis in psycho-education was on instability of the achieved improvement, the need for clearer awareness about the impact of the disorder, high risk of a relapse under the influence of stress, and possible negative consequences of premature discontinuation of treatment and reoccurring psychoses. In contrast, when patients and their families tended to exaggerate the severity of the illness, the emphasis was on emotional support, encouraging hope, and communicating information about possible patterns of the disease course. When we worked with patients and their families who were prone to rationalize the symptoms and relate them to ordinary personal experiences, we emphasised the risk of deterioration of the condition as a consequence of rejecting the adequate treatment. For patients who had accepted their illness, we made an accent not on fighting the disease, but rather on coping strategies through alleviating the severity of symptoms, emphasising personal strengths, improving social functioning, and promoting autonomy. For patients who interpreted their psychopathological symptoms as personality traits, or denied the pathological nature of their psychotic behaviours, the effective strategy involved stressing those manifestations which were acceptable to the patients, such as low mood or sleep disturbances, and to include these patients in social skills training sessions. The most effective psycho-education tactics with families of such patients involved primary emphasis on information about the strategies of communicating with their loved ones and planning their future.

At the stage of complete or partial recovery, interventions provided to patients and their families were aimed at maintaining compliance, preventing relapses, timely recognition of reoccurring symptoms, patients' readiness to seek timely treatment in the future, and reducing the risk of suicide.

After the discharge, patients were provided with a follow up treatment based on the principles of case management. Patients continued to live in their natural environment, and communication was maintained with each of the patients and their families. During the first 2 months after the discharge, home visits were paid twice a month, then monthly or more often if needed. Patients' condition was assessed and their maintenance pharmacological treatment was adjusted accordingly, as well as their maintenance psychosocial treatment that was provided either individually or in a group setting.

A clinical study of treatment effectiveness and outcomes was conducted on people admitted to the first 3 years of the Moscow FPEC, involving nearly the total patient population (112 of 115 persons described above). From the beginning of the FPEC patients were assigned to one of two types of treatment, according to their and their families' choice. One group (the treatment group, 71 persons) received a full comprehensive treatment program that included a combination of pharmacological and psychosocial interventions. The second group (the control group, 41 persons) received similar advanced pharmacological treatment, but this was not combined with psychosocial interventions. The effectiveness of these two intervention approaches was evaluated by measuring clinical, organizational, psychopathological, social, and psychological parameters, and comparing the results achieved in the treatment and control groups during a 2-year follow-up period.

According to the data collected during follow-up, more than half of the treatment group achieved complete remission by the end of the 2nd year of observation (61.1%) as opposed to 39.3% in the control group (p=0.06), with significantly lower frequency of delusional behavior (5.6% and 29.3% respectively, p<0.001). Follow-up assessment showed PANSS scores of severity of psychopathological symptoms were significantly lower in the treatment group than in the control group (p<0.001), though there had been no statistically significant difference between these scores in the two groups of patients at the time of the initial admission or at the time of the discharge (Figure 1).

Patients who received psychosocial treatment demonstrated improved compliance. They adhered to on-going follow up contacts with professionals significantly more often than patients in the control group (90.1% and 51.2% respectively, p<0.0001), took their maintenance pharmacological treatment more regularly (74.1% and 50.0% respectively, p<0.05), and discontinued their treatment less often (14.8% and 35.7% respectively, p<0.05). In case of relapses, these patients significantly more often received day hospital treatment than patients of the control group (73.8% and 35.0% respectively, p<0.01), as opposed to in-patient hospital admissions (11.9% and 45.0% respectively, p<0.01). During the first year of follow up observation, there were no in-patient hospital admissions among the patients of the treatment group, and their average duration of stay in day hospital programs was significantly shorter than in the control group (42.8+31.2 and 65.7+39.4 days, p=0.05).

Figure 1. The dynamics of change in severity of psychopathological symptoms in patients of the treatment and control groups, measured through PANSS

Social outcomes in the treatment group were superior to those in the control group: upon the completion of treatment, a higher percent of patients in the treatment group obtained employment (33.8% as opposed to 14.6% in the control group, p<0.05), continued their education (49.3% as opposed to 26.8%, p<0.05), and successfully maintained their family roles (56.3% as opposed to 31.7%, p<0.05). Conversely, a larger portion of patients in the control group did not work or study (26.8% as opposed to 5.6% in the treatment group, p<0.05) and had a dependent status in their families (68.3% as opposed to 43.7%, p<0.05). The number of patients who succeeded in maintaining their previous social networks was approximately equal in both treatment and control groups. However, among those patients whose social networks were damaged as a result of the illness, patients of the treatment group more often experienced narrowing their networks rather than its complete destruction (in 43.7% and 14.1% of cases respectively), while in the control group the situation was reverse: only 19.5% of patients experienced the narrowing of their social networks, and 43.9% of patients completely lost their social connections (p<0.01).

Their awareness about the condition and knowledge of early signs of a relapse were significantly higher in the main group: the difference between the two groups in answers to almost all items of the original questionnaire (Salnikova & Movina, 2002) was significant (p<0,05-0,001).

Psychosocial treatment contributed to achieving higher levels of social functioning and quality of life. Upon the completion of the program, patients of the treatment group demonstrated significant improvement of most indicators (Table 1). These patients demonstrated the growth of trusting relationships with others (upon the completion of the program, 93.4% of patients in the treatment group chose the maximum scores on the scale of trusting relationships with others, p<0.001). They also reported high evaluation of perceived level of support from their reference group (the scores of perceived emotional support in patients who received psychosocial treatment were 32.1+7.1 as opposed to 27.8+9.2 in the control group, p<0.05). Finally, psychosocial treatment contributed to the alleviating of family burden (Table 2).

Table 1: Social functioning and quality of life indicators in treatment and control groups upon completion of the Program

* Indicators were measured on the scale from 4 to 0: the lower the average scores, the closer the indicator to normal.

** The percentage of patients who expressed satisfaction with their mental condition and with their life in general (items 3 and 4 of the related sections of the questionnaire)

Table 2. Family burden indicators in treatment and control groups upon completion of the Program

Thus, individual and in group psychosocial interventions, in combination with psychopharmacological treatment, represent an essential element of the comprehensive treatment program provided at the FPEC to persons with schizophrenia and other schizophrenic spectrum disorders. The tactics and content of psychosocial interventions must meet the needs of patients with early psychotic manifestations and their families, with the consideration of their subjective evaluation of the condition and the specifics of their individual reactions to symptoms. The positive impact of psychosocial interventions on the compliance of patients with first psychotic episode is particularly important, because this impact indirectly contributes to achieving higher quality of remissions and timely recognition of recurring psychotic manifestations, broadens the patient's ability to receive services in least restrictive environment, and prevents social loss.

The effectiveness of the FPEC as an innovative mental health service model was evaluated in two stages. First, the Institute's research team compared service outcomes in two groups of patients, one which received treatment in the conventional mental health system and the second at FPEC. Second, researchers conducted a specific comparison study between two purposefully selected groups of patients during 3 years of follow up after treatment.

Evaluation Results, Stage I

1. Data from conventional psychiatric services. Patients who received treatment in the conventional psychiatric system were recruited from two different groups: persons who were dispensary outpatients and persons whose first psychotic episodes had been managed in an inpatient setting at the Moscow Psychiatric Hospital (PH) # 4. Patients in both groups were diagnosed with a first psychotic episode of schizophrenia or other disorders of schizophrenia spectrum. The data from a 2-year follow up study with these two groups of patients in the conventional system demonstrated a fairly low percent of persons who continued to attend their appointments at the dispensary or who adhered to maintenance of their pharmacological treatment (35% and 23.6% in two groups, respectively). Results also demonstrated an increase of the number of relapses during the 2-year follow-up period, with the usage of in-patient services increasing (39.4% and 91.0% of relapses respectively were managed in a PH). The group of patients who adhered to therapy involved the same persons in both groups throughout the time of follow-up, but the total number of these individuals decreased by the 2nd year (by 13.3% and 7.4% respectively). By the end of the follow-up period, the percentage of incomplete (as opposed to complete) remissions increased, with the prevalence of personality changes in 30% and 45% of such remissions. The patients' social functioning, according to the follow up assessment, not only did not return to the prodromal period levels, but continued to deteriorate: the number of patients who maintained job positions at their previous professional qualification level decreased (by 5% and 16.2%), the portion of patients who were unemployed increased (5% and 3.9% of patients lost their jobs, and the number of patients who dropped out of school doubled). The follow-up assessment revealed a high percentage of disability among these patients (21.6% and 11%). The consequences of the psychosis also affected the patients' friendships and professional connections, which remained intact only in a small portion of cases (21.6% and 18%).

2. FPEC data. In comparison with the outcomes of patients who received conventional treatment, the 2-year follow up outcome evaluation of FPEC patients rendered results that were significantly different. During 2 years of observation, the number of patients who achieved complete remission increased by 16.3% (from 39.0% in the 1st year to 55.3% by the end of the 2nd year). Almost all patients continued to take their maintenance pharmacological treatment (95.6% of patients in the 1st year and 88.2% in the 2nd year). The average number of relapses during the follow up period was 0.86+1.12, and the occurrence of relapses was not associated with the discontinuation of pharmacological treatment (R=0.12; p>0.05). When relapses occurred, they were controlled through outpatient services in 80.5% of patients (48.8% of relapses were treated at the FPEC day program, and the remaining 32.9% in the community). These results were partially credited to the patients' ability to recognize the early signs of reoccurring psychosis, when they experienced a relapse. This enabled patients to prevent the full unfolding of psychotic manifestation. The patients were able to restore the social loss that they had incurred during the prodromal period of psychosis; moreover, they were able to increase their social functioning levels. The number of patients who were employed doubled, and the number of patients enrolled in school increased in 1.2 times, with 10.4% of students also working within their future vocational field. Only 4.3% of patients had an officially registered disability (were eligible for disability benefits).

3. Discussion This outcome evaluation revealed many advantages of treatment provided by FPEC in comparison with the traditional treatment programs, particularly in the area of social recovery. However, appraising the evidence of effectiveness of this innovative service model represents a complex task.

The most reliable strategy of evaluation would involve the comparison of service outcomes in large, representative cohorts that include all patients identified among the entire populations residing in each of the compared territories. Because such data are unavailable, the reliability of evidence-based research should be rooted in the comparison of outcomes in two groups of patients who received services in two different settings described above, with consideration of not only demographic, but also other important clinical characteristics, such as the ratio of diagnostic categories within groups, age of onset, pace of the development and patterns of the of course of the disorder, syndromal characteristics of psychotic episodes, and patterns of the consequent course of the condition.

If sufficient diversity is achieved among patients included in the compared groups, considering the above clinical and demographic characteristics, research results can render important evidence of differences between the effectiveness of given service models.

Evaluation Results, Stage II

With the purpose of achieving reliable evidence, in the second stage of the evaluation researchers selected two groups of 35 patients in each, with pairing similar patients for outcome comparison. The treatment group included patients who received treatment at FPEC, and the control group included patients who received conventional mental health services. The comparison of long-term outcomes was based on three sets of data: after 1 year (35 pairs of patients - 70 persons), after 2 years (27 pairs of patients - 54 persons), and after 3 (three) full years of treatment (9 pairs of patients - 18 persons). The pairs of patients were purposefully selected, so that the patients whose outcomes were compared had same diagnosis, age of onset of the condition, course type, level of the disease progression, and similar psychopathological structure of the first psychotic manifestation (p>0.05). Age and gender differences were minor and not statistically significant (p>0.05). The results are presented in Table 3.

Table 3. The results of follow-up observation in two comparison groups

As demonstrated in Table 3, psychotic symptoms of patients treated at FPEC (the treatment group) were controlled within shorter time than in patients served within conventional mental health care services. People in the treatment group were less frequently admitted to a hospital when their condition was aggravated or relapsed, and more often received services in outpatient or day treatment settings. They adhered to their prescribed maintenance treatment for a longer time during follow up observation, demonstrated better compliance and, as a result, achieved higher quality remissions in that delusional behavior occurred in their remissions with significantly lower frequency than in the control group. An indicator of high compliance in the treatment group was their early referral for treatment in case of relapse: the time between the beginning of reoccurring symptoms and the patients' seeking of help was significantly shorter (half as long) than that of the control group. The early help-seeking behaviour seemed to enable treatment group members to prevent the full unfolding of psychotic symptoms and to allow them to control their condition in least restrictive situation, without hospitalization. As a result, the patients' condition improved within a shorter time, and they were able to resume their regular activities sooner.

Evaluation results also indicated significant differences between social indicators in the two groups. Outcome indicators signifying a person's ability to maintain her/his pre-morbid social status were twice as high in the treatment group as in the control group. Conversely, the portion of people who lost their pre-morbid social achievements in the control group clearly prevailed with the ratio 2.4:1 when contrasted with the treatment group. In addition, in the number of control group members who were registered with the State as having a disability was 8 times greater than this number in the treatment group.

The results of a three-year outcome evaluation with comparable groups of patients demonstrated significant advantages of the innovative service model - the First Psychotic Episode Clinic - in comparison with traditional mental health services. These advantages are represented by improving the quality of remissions, maintaining treatment compliance, reducing the number of reoccurring relapses and hospital admissions, and reducing the duration of time needed for controlling psychotic manifestations. The innovative model is also superior to the traditional services in achieving higher social outcome indicators, such as minimizing social loss and maintaining the patients' pre-existing social status.

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Contributors:

Isaac Gurovich, MD, PhD, Professor
Deputy Director of Moscow Research Institute of Psychiatry
Head of the Department of Outpatient Psychiatry and Mental Health Services Organization
Moscow, Russia

Email: isaac.gurovich@gmail.com

A. B. Shmukler, MD, PhD, Professor
Leading Researcher, Moscow Research Institute of Psychiatry, the Department of Outpatient Psychiatry and Mental Health Services Organization, Moscow, Russia

Email: ashmukler@yandex.ru

A. S. Dorodnova, MD, PhD
Head of First Psychotic Episode Clinic (Day Program), Moscow Research Institute of Psychiatry, Moscow, Russia

L. G. Movina, MD, PhD, Senior Researcher
Moscow Research Institute of Psychiatry, the Department of Outpatient Psychiatry and Mental Health Services Organization, Moscow, Russia

Y. S. Zaitseva, MD
Graduate Student, Moscow Research Institute of Psychiatry, the Department of Outpatient Psychiatry and Mental Health Services Organization, Moscow, Russia

Translation:

Translated from Russian by

Svetlana Shklarov, MD, PhD Candidate
Interdisciplinary Graduate Program
Community Rehabilitation and Disability Studies Program
University of Calgary
Canada

Email: shklarov@ucalgary.ca

International Journal of Disability, Community & Rehabilitation
Volume 6, No. 2
www.ijdcr.ca
ISSN 1703-3381