Objective The primary aim was to compare the impact of NAVIGATE, a comprehensive, multidisciplinary, team-based treatment approach for first episode psychosis designed for implementation in the U.S. healthcare system, to Community Care on quality of life. Methods Thirty-four clinics in 21 states were randomly assigned to NAVIGATE or Community Care. Diagnosis, duration of untreated psychosis and clinical outcomes were assessed via live, two-way video by remote, centralized raters masked to study design and treatment. Participants (mean age 23) with schizophrenia and related disorders and ≤6 months antipsychotic treatment (N=404) were enrolled and followed for ≥2 years. The primary outcome was the Total Score of the Heinrichs-Carpenter Quality of Life Scale, a measure that includes sense of purpose, motivation, emotional and social interactions, role functioning and engagement in regular activities. Results 223 NAVIGATE recipients remained in treatment longer, experienced greater improvement in quality of life, psychopathology and involvement in work/school compared to 181 Community Care participants. The median duration of untreated psychosis=74 weeks. NAVIGATE participants with duration of untreated psychosis <74 weeks had greater improvement in quality of life and psychopathology compared with those with longer duration of untreated psychosis and those in Community Care. Rates of hospitalization were relatively low compared to other first episode psychosis clinical trials and did not differ between groups. Conclusions Comprehensive care for first episode psychosis can be implemented in U.S. community clinics. and improves functional and clinical outcomes. Effects are more pronounced for those with shorter duration of untreated psychosis.
Forced expiratory flows (FEF) can be measured in infants from lung volumes initiated near total lung capacity. In order to establish reference values and to evaluate lung growth, we obtained measurements in 155 healthy subjects between 3 and 149 wk of age. Forced vital capacity (FVC) was highly correlated with body length; however, after accounting for length, age was also significant. When subjects were divided at the median age (40 wk) younger compared with older subjects had a significantly larger slope for length (3.7 versus 2.8; p = 0.002). The flow parameters (FEF(50), FEF(75), FEF(85), and FEF(25-75)) were highly correlated with length, and those infants whose mothers smoked had lower flows. For FEF(75), male subjects had lower flows than female subjects. The relationship between FEF and volume was assessed using FEV(0.5)/FVC, which decreased with increasing length. Smaller subjects emptied their lung volume proportionately faster. We conclude that our study provides reference values for this age group and demonstrates that smoke-exposed infants and male subjects have decreased FEF. In addition, our findings indicate that lung volume increases most rapidly during the first year of life and that airways are large relative to lung volume very early in life.
IMPORTANCEThe fact that individuals with schizophrenia have high cardiovascular morbidity and mortality is well established. However, risk status and moderators or mediators in the earliest stages of illness are less clear.OBJECTIVE To assess cardiometabolic risk in first-episode schizophrenia spectrum disorders (FES) and its relationship to illness duration, antipsychotic treatment duration and type, sex, and race/ethnicity. DESIGN, SETTING, AND PARTICIPANTS Baseline results of the Recovery After an Initial Schizophrenia Episode (RAISE) study, collected between July 22, 2010, and July 5, 2012, from 34 community mental health facilities without major research, teaching, or clinical FES programs. Patients were aged 15 to 40 years, had research-confirmed diagnoses of FES, and had less than 6 months of lifetime antipsychotic treatment. EXPOSURE Prebaseline antipsychotic treatment was based on the community clinician's and/or patient's decision. MAIN OUTCOMES AND MEASURES Body composition and fasting lipid, glucose, and insulin parameters. RESULTS In 394 of 404 patients with cardiometabolic data (mean [SD] age, 23.6 [5.0] years; mean [SD] lifetime antipsychotic treatment, 47.3 [46.1] days), 48.3% were obese or overweight, 50.8% smoked, 56.5% had dyslipidemia, 39.9% had prehypertension, 10.0% had hypertension, and 13.2% had metabolic syndrome. Prediabetes (glucose based, 4.0%; hemoglobin A 1c based, 15.4%) and diabetes (glucose based, 3.0%; hemoglobin A 1c based, 2.9%) were less frequent. Total psychiatric illness duration correlated significantly with higher body mass index, fat mass, fat percentage, and waist circumference (all P < .01) but not elevated metabolic parameters (except triglycerides to HDL-C ratio [P = .04]). Conversely, antipsychotic treatment duration correlated significantly with higher non-HDL-C, triglycerides, and triglycerides to HDL-C ratio and lower HDL-C and systolic blood pressure (all P Յ .01). Olanzapine was significantly associated with higher triglycerides, insulin, and insulin resistance, whereas quetiapine fumarate was associated with significantly higher triglycerides to HDL-C ratio (all P Յ .02). CONCLUSIONS AND RELEVANCEIn patients with FES, cardiometabolic risk factors and abnormalities are present early in the illness and likely related to the underlying illness, unhealthy lifestyle, and antipsychotic medications, which interact with each other. Prevention of and early interventions for psychiatric illness and treatment with lower-risk agents, routine antipsychotic adverse effect monitoring, and smoking cessation interventions are needed from the earliest illness phases.
Importance Suicide is a leading cause of deaths in the U.S. Although the emergency department (ED) is an opportune setting for initiating suicide prevention efforts, ED-initiated suicide prevention interventions remain underdeveloped. Objective To determine if an ED-initiated intervention reduces subsequent suicidal behavior. Design This multicenter study was composed of three sequential phases: 1) Treatment as Usual (TAU) (August 2010–December 2011), 2) Universal Screening (Screening) (September 2011–December 2012, and 3) Universal Screening + Intervention (Intervention)(July 2012-November 2013. Setting Eight EDs in the United States Participants Adults with a recent suicidal attempt or ideation were enrolled. Intervention Universal Screening consisted of universal suicide risk screening. The Intervention phase consisted of universal screening plus an intervention which included secondary suicide risk screening by the ED physician, discharge resources, and post-ED telephone calls focused on reducing suicide risk. Main Outcomes The primary outcome was suicide attempts (non-fatal and fatal) over the 52-week follow-up. The proportion and total number of attempts were analyzed. Results 1,376 participants (56% female, median age 36 years) were recruited. 288 participants (21%) made at least one suicide attempt. There were 548 total suicide attempts among participants. There were no significant differences in risk reduction between the TAU and Screening phases (23% vs. 22%). However, when compared to the TAU Phase, subjects in the Intervention phase showed a 5 % absolute reduction in suicide attempt risk (23% vs. 18%) with a relative risk reduction of 20%. Participants in the Intervention Phase had 30% fewer total suicide attempts than participants in the TAU Phase. Negative binomial regression analysis indicated that the participants in the Intervention Phase had significantly fewer total suicide attempts than participants in the TAU Phase (IRR, 0.72, 95%CI 0.52–1.00, P=0.05), but no differences between the TAU and Screening phases (IRR, 1, 95%CI 0.71–1.41, P=0.99). Conclusions Among at-risk patients in the ED, a combination of brief interventions administered both during and after the ED visit decreased post-ED suicidal behavior.
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