Highlights of this issue

Improving vocational and physical health outcomes in schizophrenia

Onset of psychosis can have a dramatic impact on educational and employment trajectories, one from which recovery can be very difficult. Killackey et al (pp. 76–82) have completed a randomised controlled trial in participants with first-episode psychosis of an intervention for improving vocational recovery previously shown to be effective for those with chronic psychosis – individual placement and support (IPS). Those in the intervention group had higher rates of employment over the 6 months of IPS compared with those receiving treatment as usual alone (71.2% v. 48.0%) but the difference was not sustained at the 12-month and 18-month follow-up points. Neither duration of employment nor level of educational engagement differed between the groups at any point. The authors comment on the unusually high rate of employment achieved in the control group, perhaps related to the skills and experience of staff in the specialist clinical service setting of the study. They also suggest that IPS might be more effective in the subgroup of those with first-episode psychosis who have failed to gain employment, rather than as a universally delivered intervention.

In addition to adverse vocational trajectories, poor physical health outcomes, linked to lifestyle-related risk factors, have been well documented in people with psychosis. Holt et al (pp. 63–73) conducted a randomised controlled trial of a group-based structured lifestyle education intervention for individuals with psychosis (STEPWISE), with weight reduction the key aim. Although the trial recruitment and retention strategies were effective and the intervention was well received, no differences in weight reduction, physical activity, dietary intake or biochemical measures were found between the intervention and control groups at 12 months. The authors comment on the need to consider interventions for weight reduction beyond lifestyle education and on the likelihood that approaches need to be tailored to individual needs.

In a linked commentary, Coventry et al (pp. 74–75) also point to the need to consider tailoring interventions at an individual level, an important omission in much of the current guidance focused on reducing risk factors for physical illness among those with serious mental illness. The authors argue that scaling up lifestyle interventions for the general population will likely see a widening in health inequalities for people with serious mental illness if these challenges are not addressed. The role of antipsychotic prescribing in limiting the potential for weight reduction is also raised.

Clozapine, one of the worse antipsychotic offenders in relation to weight gain, is the subject of another paper in the Journal this month. The association between clozapine and neutropenia is well established; however, the known increase in risk of pneumonia is not well understood. Ponsford et al (pp. 83–89) found that immunoglobulin (IG) levels (IgG, IgA, IgM and specific IgG antibodies to haemophilus influenzae type b, tetanus and IgG, IgA and IgM to pneumococcus) were all significantly reduced in a sample of patients taking clozapine, compared with a control group of clozapine-naive patients treated with other antipsychotics. The authors also identified an association between clozapine use and risk of taking more than five courses of antibiotics in the preceding year. The merits of including antibody testing in routine clozapine monitoring programmes are considered.

Schizophrenia – genetic overlap and social cognition

Schizophrenia polygenic risk scores have been shown in clinical samples to be associated with psychiatric disorders beyond schizophrenia. Richards et al (pp. 96–102) have examined the extent to which such associations persist in two population-based samples with data available on psychopathology in adulthood (from New Zealand and the UK). Schizophrenia polygenic risk scores were found to be associated with the total number of adulthood anxiety disorders and with generalised anxiety disorder and panic disorder specifically in the former sample, while an association was found with manic/hypomanic episodes in both samples. The authors call for their research findings to be replicated in other larger population-based samples with measures of adult psychopathology.

In a meta-analytic review of studies testing the association between social cognition and symptoms of thought disorder and disorganisation in schizophrenia spectrum disorders de Sousa et al (pp. 103–112) identified 123 studies. Their main analyses provided evidence for moderate associations between the target symptoms and social cognition. In subanalyses, moderate associations were also found with theory of mind and emotion recognition, whereas smaller associations were identified for social perception, emotion regulation and attributional biases. The authors highlight the extent of heterogeneity found and discuss the complexity likely underlying the identified associations. They comment on the results of trials of socio-cognitive training and recommend that interventions focus on emotion recognition and perspective-taking in communication for those with psychosis characterised by persistent thought disorder.

Stigma reduction in rural India

The treatment-gap for common mental disorders identified in low- and middle-income settings, such as in rural India, has been the target of a trial of a complex intervention involving task sharing, a multimedia anti-stigma campaign and the use of technology-based decision-support tools in primary care (the SMART or Systematic Medical Appraisal, Referral and Treatment, Mental Health intervention). Maulik et al (pp. 90–95) found that most measures of knowledge, attitude and behaviour towards mental health improved over three time points (before and after the anti-stigma campaign, and after the health services delivery intervention component). Stigma perceptions related to help-seeking also improved. In an editorial in the Journal, also focused on mental healthcare developments in India, Duffy & Kelly (pp. 59–60) highlight the recent granting of a legally binding right to mental healthcare arising from the implementation of the Mental Healthcare Act 2017. The authors note that, although other countries have also ratified the Convention on the Rights of Persons with Disabilities, only India has gone beyond ratification to introduce such important legislative reform.