European prediction of psychosis study (EPOS)

EPOS at-risk for psychosis indicators for a hazard rate of 20% for a transition to psychosis within the projects' 18-months follow-up period (EPOS group 2006), e.g. more pronounced positive psychotic symptomatology, lower levels of global functioning and premorbid adjustment. These data await further evaluation and publication. Potential end-users are governmental and non-governmental agencies and organizations, clinicians and researchers in the areas of mental health care and policy. As the main benefit, the acquired knowledge will help to implement and sustain early detection and prevention programmes adapted to European mental health care systems and the needs of the help-seeking individuals.

Multi-dimensional, i.e. clinical, sociodemographic, biographical, personality, functional, neurocognitive and biological characteristics of a sample of 246 probands putatively at risk for psychosis included into EPOS at 6 centres in 4 European regions (EPOS Group 2006). First results of ongoing data analyses comprise e.g. attenuated positive and basic symptoms being main at-risk inclusion criteria, very high rates of current co-morbid psychiatric disorders and functional impairment at intake, self-reported high levels of non-physical disabilities and low levels of quality of life both comparable to schizophrenia patients, relatively diverse numbers and kinds of contacts with mental health professionals before attending specialized care in different regional health care systems and increased prefrontal gyrification index (a measure of cortical folding) comparable to schizophrenia patients. These first results support the hypothesis that persons putatively at risk for psychosis are already in need for specialised mental health care, independently from whether or not they will actually develop a frank psychosis, and seem to indicate a biological correlate of the at risk mental state. Potential end-users are governmental and non-governmental agencies and organizations, clinicians and researchers in the areas of mental health care and policy. As the main benefit, the acquired knowledge will help to implement and sustain early detection and prevention programmes adapted to European mental health care systems and the needs of the help-seeking individuals.

The EPOS Pathways to Care (Pathways, Vazquez-Barquero J-L, Ruhrmann S, Salokangas RKR, Linszen D, Birchwood M, Schultze-Lutter F, Graf von Reventlow H, Klosterkötter J, and the EPOS Group; Santander: University of Cantabria, 2002) is an interview especially developed by EPOS for documenting in detail information on key issues related to previous contacts with the health care system, as symptoms presented with, reasons for decisions to seek care etc, and pathways to care and delays to adequate treatment. The Pathways has been developed on the basis of the WHO Encounter Form (Gater R, De Almeida E, Souza B, et al, 1991) used in research on first episode psychosis, as well as a systematic review of literature and collection of treatment settings, modalities and interventions available in the participating regions (Finland, Germany, Spain, The Netherlands, UK). Adapted and enriched according to the special requirements, the EPOS Pathways allows for the identification of obstacles leading to delayed adequate diagnosis and treatment for persons at risk for psychosis. Potential end-users are psychiatric, psychological or public health investigators engaged in early psychosis. As the main benefit, the Pathways to care provides a special assessment for psychosis prevention purposes and additionally allows to compare across different national health care systems.

The EPOS dissemination and awareness in early recognition and intervention in psychotic disorders (EPOS Group, 2001 - 2007) consisting of so far 10 EPOS major scientific symposia and a huge number of publications, workshops, individual oral presentations and posters at international, national and regional levels. At the same time, the study has significantly promoted early recognition and intervention in psychoses beyond a purely scientific scope in both European and non-European regions. About 15 new early recognition and intervention in psychosis units, most of them embedded in evolving larger national or regional networks, have been established in participating regions with more to come, similar developments in other European and non-European regions have been supported by members of the consortium. The continued dissemination of EPOS results on pathways, risk indicators, disabilities and quality of life, treatment and treatment costs etc. should possibly also largely contribute to further raising awareness for early psychosis in both, the European and non-European general public and mental health care professionals. Potential end-users are governmental and non-governmental agencies and organizations, clinicians and researchers in the areas of mental health care and policy, as well as the respective patient group, their relatives and general public. As the main benefit, the acquired know-how will help to implement and sustain early detection and prevention programmes adapted to European and non-European mental health care systems and the needs of the help-seeking individuals.

EPOS early recognition and intervention infrastructure (EPOS Group, 2001 - 2006) consisting of 6 professional units with notable numbers of professionals with expertise in current standards of scientific and clinical practise and extensive regional networks in 4 European regions. This basic infrastructure is supplemented by a multi-level interfacing with other national and international specialized centres, networks, further research and health care policy lines taking into account the respective regional needs and healthcare structures. More early recognition and intervention in psychosis units have already been established in most participating regions (6 in the UK, 3 in The Netherlands, 1 in Germany), similar developments in other EU-countries (e.g. Denmark, Greece, Italy, Spain) have been supported or supervised by members of the consortium. Besides instigating further national collaborative studies in the participating regions (e.g. the Finish DEEP study, the Dutch Prediction of Psychosis Study (DUPS), the UK MRC PsyGRID network, the German 'Prevent' study), non-EU collaborations have also been fostered and maintained (e.g. with partners in Australia, Japan, Switzerland, Singapore, USA), resulting in planning for a large-scale international intervention study (NEURAPRO). Potential end-users are governmental and non-governmental agencies and organizations, clinicians and researchers in the areas of mental health care and policy. As the main benefit, the acquired know-how will help to implement and sustain early detection and prevention programmes adapted to European and non-European mental health care systems and the needs of the help-seeking individuals.

The Trauma and Distress Scale (TADS, Patterson P, Skeate A, Schultze-Lutter F, Graf von Reventlow H, Wieneke A, Ruhrmann S, Salokangas RKR; Birmingham: University of Birmingham, 2002) is a self-rating scale especially developed for recollecting and self-rating of predominantly childhood and early adulthood traumatic experiences and distress possibly contributing to the development of psychotic disorders. The TADS has been developed on the basis of a review of the respective literature. Thus, the TADS allows for the assessment of early traumatic experiences and distress in psychiatric samples. Potential end-users are psychiatric, psychological or public health investigators engaged in psychiatric research. As the main benefit, the Trauma and Distress Scale provides a condensed scale reflecting the current state in early trauma research, considering especially the clients' requirements in early recognition research.

The EPOS Client Service Receipt Inventory (EPOS-CSRI, Knapp M, Beecham J, Heinimaa M, Dingemans P, Patterson P, Graf von Reventlow H, Ruhrmann S; London: London School of Economics, 2003) is an interview for the assessment of health care service receipt, direct and indirect costs of illness, and cost-effectiveness of interventions. The EPOS-CSRI has been developed on the basis of the Client Sociodemographic and Service Receipt Inventory (CSSRI-EU, Chisholm D, Knapp M, Knudsen H, et al., BJP 2000) used in research on schizophrenia, as well as a systematic review of literature and collection of treatment settings, modalities and interventions available in the participating regions (Finland, Germany, The Netherlands, UK). Adapted and enriched according to the special requirements, the CSRI allows for the comprehensive collection of client service receipt in early recognition and intervention, especially in psychoses. Potential end-users are psychiatric, psychological or public health investigators engaged in early psychosis. As the main benefit, the EPOS CSRI provides a special assessment for psychosis prevention purposes and additionally allows cost-benefit analyses across different national health care systems.

Improvement of specialized mental health care in early stages of psychotic disorders (EPOS Group, 2001 - 2007) by - besides the impact of comprehensive up-to-date diagnostics and newly built-up or enlarged infrastructure - developing and implementing novel case finding strategies and innovative health care services for possibly prodromal patients. Clinically, this resulted in at least ameliorating the impact of beginning psychosis on those patients affected, and providing care for the high number of clinically ill at-risk patients possibly not making transition into manifest psychosis. Last but not least, high numbers of first episode patients are detected by early recognition of psychotic disorders units, thus further reducing the duration of untreated psychosis (DUP). Potential end-users are governmental and non-governmental agencies and organizations, clinicians and researchers in the areas of mental health care and policy, as well as the respective patient groups and their relatives. As the main benefit, the acquired know-how will help to implement and sustain early detection and prevention programmes adapted to European and non-European mental health care systems and the needs of the help-seeking individuals.

The Bonn Scale for the Assessment of Basic Symptoms - Prediction List (BSABS-P, Schultze-Lutter F, Klosterkötter J; Cologne: University of Cologne, 2002) is an interview for evaluating a unique European approach, the basic symptom cluster 'cognitive disturbances' as high risk criterion and to assess self-experienced cognitive, perceptual and motor disturbances found to be predictive for a transition to psychosis. Adapted from the Schizophrenia prediction instrument, adult version - SPI-A (Schultze-Lutter F, Klosterkötter, J; Department of Psychiatry and Psychotherapy, University of Cologne, 2004, the BSABS-P allows for the focussed assessment of the presence and severity of Basic Symptoms with especially high predictive validity. Potential end-users are psychiatric, psychological or public health investigators engaged in early psychosis. As the main benefit, the BSABS-P provides a particular early recognition of a prodromal phase of psychoses.

The EPOS Assessment Scale of Life Events (EPOS Life Events, Hambrecht M: Cologne: University of Cologne, 2001) is an interview for reviewing and evaluating life events prior to inclusion or in between follow-up periods in a short form chart adapted from the Munich Life Event List (Maier-Dewald M, Wittchen H-U, Hecht H, Werner Eilert K; München: Max-Planck-Institut für Psychiatrie, 1983). As add-on, this chart also includes an assessment of the appraisal of the event and degree of subjective burden. Thus, the EPOS Life Events allows for the fast and comprehensive collection of major life events and their felt impact in psychiatric research. Potential end-users are psychiatric, psychological or public health investigators engaged in psychosis research. As the main benefit, the EPOS Assessment Scale of Life Events provides the brief, concise and time-efficient assessment of life events and their appraisal.

The Basic Data Form (BDF, Salokangas RKR, Suomela T; Turku: University of Turku 2002) is an interview especially developed by EPOS for briefly reviewing the probands sociodemographic background, physical health, obstetric complications, as well as premorbid adjustment, social functioning and impairment by psychiatric symptoms. For the latter, the Premorbid Adjustment Scale (PAS, Cannon-Spoor H, Potkin G, Wyatt J, 1982) and the Prognostic Scale (S& C PS, Strauss JS, Carpenter WT jr, 1974) were incorporated into the Basic data Form. Thus, instead of having numerous collections of partly differing characteristics in various instruments, the BDF allows for the focused collection of data needed to generally characterize psychosis research samples including developmental and functional aspects. The predictive value of the BDF data in terms of early recognition and course of prodrome-like states is currently further evaluated. Potential end-users are psychiatric, psychological or public health investigators engaged in psychosis research. As the main benefit, the Basic Data Form provides a time-efficient assessment of essential sample data for various types of psychosis studies.

The Treatment Documentation Sheet (TDS-EPOS, Patterson P, Birchwood M, Skeate A; Birmingham: University of Birmingham, 2002) is an interview especially developed by EPOS for documenting in detail all contacts with health care agencies related to mental health problems, i.e. hours of psychological intervention, number of contacts with health care professionals, dosage of psychopharmacological treatments etc. The TDS has been developed on the basis of a systematic review of literature and collection of treatment settings, modalities and interventions available in the participating regions (Finland, Germany, Spain, The Netherlands, UK). Thus, the TDS allows for the fast and comprehensive collection of treatment data in psychiatric samples, especially in psychosis research. Potential end-users are psychiatric, psychological or public health investigators engaged in psychosis research. As the main benefit, the Treatment Documentation Sheet provides a concise and time-efficient assessment of treatments, and clients compliance and appraisals in naturalistic studies.

Other EPOS scientific results (EPOS Group, 2006) over a broad range from epidemiology (e.g. annual vulnerability to psychosis of 11.6/10000 and risk for psychosis of 6.6/10000 on basis of an estimated rate of vulnerability to psychosis of 26% and risk to psychosis 15% in Finish psychiatric outpatients in Finish catchment area), to treatment receipt (e.g. similar overall rates of prescription of medication and notably diverse rates of applied psychotherapy in the participating European regions). These data await further evaluation and publication, e.g. on pathways to care, disability, and health economical aspects, as well as results regarding present and past psychopathology, personality, alcohol and drug abuse, expressed emotions, life events, childhood trauma, neuropsychology, neurophysiology, structural MRI. Potential end-users are governmental and non-governmental agencies and organizations, clinicians and researchers in the areas of mental health care and policy. As the main benefit, the acquired knowledge will help to implement and sustain early detection and prevention programmes adapted to European mental health care systems and the needs of the help-seeking individuals.

EPOS data set (EPOS Group, 2007) for 246 probands putatively at risk for psychosis included into the EPOS baseline (t0-) database, 188 probands at the 9-month (1st-) follow-up, and 148 probands at the 18-month (2nd-)follow-up time point, respectively. The data set includes data on pathways to care, socio-demography and premorbid adjustment, special, past and present psychopathology, personality traits and disorders, social functioning, disability, and quality of life, neuropsychology, neurophysiology, structural magnetic resonance imaging, additional factors possibly contributing to the 'at risk' state, as well as data on treatment, service receipt and costs. Special psychopathological indicators on 39 probands having undergone transition to psychosis, so far. The EPOS baseline, 1st follow-up and 2nd-follow-up data collected have been stored and computed at the participating centres within SPSS 10.0 data-file sets especially designed for the study. Together with an early optimisation at an individual site level, a most elaborate multi-phased quality assurance procedure including study visits has been applied on the data set. Potential end-users are psychiatric, psychological or public health investigators engaged in mental health research, especially early psychosis studies. As the main benefit, the EPOS data set provides a hitherto unique basis of prospectively collected knowledge on potential clinical, environmental and biological risk factors and indicators for prevention of psychosis and its health economics.

A comprehensive, most up-to-date EPOS assessment battery (EPOS Group, 2003) of more than 30 individual instruments and paradigms designed for the multi-level assessment of factors possibly contributing to clarifying the studies' research objectives. These efforts included the development and/or adaptation of the EPOS inclusion and exclusion criteria (e.g. first simultaneous evaluation of Basic Symptom and Ultra-High Risk approach), screening procedures (e.g. EPOS screening module, PROD-screen in Finland), questionnaires and self-rating scales (EPOS Basic Data Form (BDF), Treatment Documentation Sheet (TDS), EPOS Scale of Life Events (Life Events), EPOS Trauma and Distress Scale (TADS), Pathways to care (Pathways), EPOS Client Service Receipt Inventory (EPOS CSRI), Structured Clinical Interview for DSM IV (SCID), Substance Abuse Module of the Composite International Diagnostic Interview (CIDI-SAM), Beck Depression Inventory (BDI), Interview for the Retrospective Assessment of the Onset of Schizophrenia (IRAOS), Scale of Prodromal Symptoms (SOPS 3.0), Positive and Negative Syndromes Scale (PANSS), Revised Bonn Scale for the Assessment of Basic Symptoms (BSABS-P), Personality Disorder Questionnaire (PDQ-R), Schizotypal Personality Questionnaire (SPQ), Global Assessment of Functioning Scale (GAF-M), Disability Assessment Schedule - Second version (WHO-DAS II), Modular System for Quality of life (MSLQ-R), Level of Expressed Emotions Scale (LEE), common neuropsychological paradigms (Continuous Performance Test (CPT), Verbal Fluency Test (VFT), Verbal Learning and Memory Test (VLMT), Finger Tapping Test (FTT), Spatial Working Memory Test (SWMT), and Verbal IQ Test (standard tests in the respective languages), neurophysiological parameters (P300 and Mismatch Negativity, MMN), and structural magnetic resonance imaging (MRI) procedures with respect to the methodological limits given by different scanners etc. Potential end-users are psychiatric, psychological or public health investigators engaged in mental health research, especially early psychosis studies. As the main benefit, the EPOS Assessment Battery provides the most comprehensive prospective multi-level approach so far to prediction, treatment and health care system related research in early psychosis.

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