Early Psychosis Intervention

Early Psychosis Intervention: A Culturally Adaptive Clinical Guide

Eric Yu-hai Chen
Helen Lee
Gloria Hoi-kei Chan
Gloria Hoi-yan Wong
Copyright Date: 2013
Pages: 416
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  • Book Info
    Early Psychosis Intervention
    Book Description:

    Taking into account cultural differences between Asian and Western patients, this book focuses on delivery of effective treatment at an early stage in psychosis, especially for young people. It pays particular attention to early intervention programmes established in Hong Kong and Singapore, and assesses recent developments in Korea, Japan and other countries. The volume covers approaches in the management of psychosis, including pathway to care, stigma and interventions. With reference to the experiences of frontline practitioners, research findings and theories, it highlights the practical needs in non-Western healthcare settings. Culturally relevant discussions on recovery, relapse, self-harm and comorbid substance abuse are discussed. It also covers case studies to illustrate challenges and strategies in managing early psychosis.

    eISBN: 978-988-8180-87-5
    Subjects: Health Sciences

Table of Contents

  1. Front Matter
    (pp. i-iv)
  2. Table of Contents
    (pp. v-viii)
  3. List of Illustrations
    (pp. ix-x)
  4. Foreword
    (pp. xi-xvi)
    Patrick McGorry

    It is now just over a decade since the first early psychosis programmes were established in Asia, representing a critical frontier in global early psychosis reform. In the intervening years an increasing number of clinical and research programmes have been developed and flourished in various Asian cities. It is inspiring to see that so many pioneering Asian psychiatrists, psychologists and academic leaders have recognized that prevention and early intervention are key potential strategies in the struggle to reduce the burden of mental illness in our rapidly changing societies and have taken effective action. Quite apart from the human cost, the...

  5. Foreword
    (pp. xvii-xviii)
    Siow Ann Chong

    An adage of modern medicine states that early detection and treatment of a disorder is the key to achieving better outcomes. However, this concept has arrived rather belatedly in mental health.

    The understanding that psychoses afflict much suffering on both individuals and their families, and exact an enormous toll in social and economic costs from lost productivity also needs little emphasis. The possibility that these losses could be ameliorated by knowledge which we already have makes the situation even more tragic.

    Fortunately, in the past two decades, much hard work has been done and much gain has been achieved in...

  6. Preface
    (pp. xix-xxii)
    Eric Yu-hai Chen, Helen Lee, Gloria Hoi-kei Chan and Gloria Hoi-yan Wong
  7. Acknowledgements
    (pp. xxiii-xxiv)
  8. List of Contributors
    (pp. xxv-xxviii)
  9. List of Abbreviations
    (pp. xxix-xxxii)
  10. Part I Early Psychosis Intervention Developments in Asia
    • 1 Development of Early Intervention Services: Introduction
      (pp. 3-16)
      Eric Yu-hai Chen

      The concept of “early intervention” is not foreign to medical practice. The idea is rooted in the recognition that many illnesses evolve as a progression over time involving the accruement of irreversible adverse processes. Consequently, the timing of intervention becomes a prime factor affecting outcomes.

      The challenge confronting the field of early psychosis is that many of these pathological processes and their interactions are not yet clearly understood. In the meantime, clinicians and patients must nevertheless manage with the best possible judgements they choose.

      One uncontroversial fact in psychosis is that the condition nearly always has negative impacts on the...

    • 2 Early Psychosis Services in an Asian Urban Setting: EASY and Other Services in Hong Kong
      (pp. 17-28)
      Dicky Wai-sau Chung and Eric Yu-hai Chen

      The first specialized early psychosis service in Hong Kong, the Early Assessment Service for Young People with Psychosis (EASY), was launched in 2001. EASY is a Hospital Authority initiative in Hong Kong. The programme consists of specialized early intervention teams providing services for young adults aged 15 to 25 years with first-episode psychosis. In 2009, an adult early psychosis service became available with the support of the Hong Kong Jockey Club Charities Trust. The Jockey Club Early Psychosis (JCEP) Project provides case management service to 1000 patients aged between 26 and 55 years under the care of the Hospital Authority....

    • 3 Overview of Early Psychosis Service Development in Singapore: The EPIP Story
      (pp. 29-36)
      Yee Huei Yong and Swapna Verma

      A study of Singaporean patients with first-episode psychosis found that the Duration of Untreated Psychosis (DUP) ranged from 0.1 to 336 months, with a mean of 32.6 months and a median of 12 months (Chong, Mythily, & Verma, 2005). A long DUP is associated with greater disabilities, long and more frequent hospitalizations, disruption in family, suicides, and higher health care costs.

      There may be several factors that contribute to a long DUP, including: ignorance, stigma, denial, lack of motivation, absence of information about early psychosis, and lack of access to appropriate intervention. In Singapore, the manifestations of psychosis are often...

    • 4 Early Psychosis Intervention in an Urban Japanese Setting: Overview of Early Psychosis Services in Japan
      (pp. 37-46)
      Masafumi Mizuno, Takahiro Nemoto and Naohisa Tsujino

      For decades, Japanese psychiatric services have been predominantly hospital-based. Many psychiatrists who are more oriented to psychosocial or integrated approaches have been struggling with this conservative system and trying to achieve a transition to community-based psychiatry. However, to date, there have few profound changes. The number of psychiatric inpatients is still large, and most admissions are long-term.

      In Japan, “mental disorder” is usually taken to mean “depression” or “adjustment disorder”. However, the real world of psychiatric conditions in this country is more serious, with the psychiatric wards having some 300,000 beds and around 30,000 suicides occurring every year. What lies...

    • 5 Overview of the Development of Services for Early Psychosis in Korea
      (pp. 47-64)
      Young-chul Chung, Guang-biao Huang and Keun-Young Oh

      An old Chinese book of traditional medicine offered the following advice to practitioners: “Do not treat a disease that has already been, treat before it starts (不治已病,治未病)”. Although well established in the context of serious physical illnesses, the strategy of early intervention has been ignored for many decades with respect to psychotic disorders due to pessimism, stigma, and neglect regarding the treatment of conditions such as schizophrenia. Recently, however, the notion of early intervention in psychotic disorders has generated significant interest and optimism in many countries. To this end, the effective identification and intervention in early psychosis require a coordinated...

  11. Part II Public Awareness and Early Detection in Cultural Context
    • 6 Factors Affecting the Duration of Untreated Psychosis in Hong Kong
      (pp. 67-74)
      Eric Yu-hai Chen

      A reduction in the duration of untreated psychosis (DUP), defined as the timelapse between onset of psychotic symptoms and initiation of treatment, is a key target of early intervention for psychotic disorders (Harrigan, McGorry, & Krstev, 2003; McGlashan & Johannessen, 1996; McGorry, 2000). Many early intervention programmes aim at DUP reduction, considering it a measurable and achievable goal (Johannessen, 1998; Malla et al., 2003).

      At present, the body of knowledge on DUP has largely been focusing on its relationship with clinical outcomes (Altamura et al., 2001; Amminger et al., 2002; Black et al., 2001). Meta-analyses have provided solid evidence for...

    • 7 Public Awareness Approaches in Early Psychosis
      (pp. 75-86)
      Gloria Hoi-yan Wong

      Psychosis is a concept surrounded by misunderstanding and stigma. Historically, mental illnesses (in particular schizophrenia) were associated with moral failure, demon-possession, and witchcraft (Miller, 2000). The fear and antipathy against psychosis continues to the present day: the media typically portray an image of a dangerous, violent person with a “split personality”. Patients are treated as social outcasts, to be avoided or made fun of.

      These misunderstandings, stigma, and discrimination add to the suffering of patients and families struggling to recover from the disease; they also pose major barriers in help-seeking, which impact adversely on patients’ outcome (Byrne, 1997). Delays in...

    • 8 Early Psychosis in the Workplace
      (pp. 87-92)
      Eric Yu-hai Chen

      For a person employed full-time and working about 40 hours a week, setting aside the time spent on daily travelling and personal care, on average spends about half of his or her waking time in the workplace. Hence, the workplace is an important setting for detecting and managing early signs of psychosis. People sharing the workplace with the concerned individual form a critical network for early detection.

      Given the fact that most people spend so much time in the workplace with a lot of intellectual and social interaction every day, it is not surprising that early signs of psychosis should...

    • 9 Enhancing Psychosis Detection through Gatekeepers
      (pp. 93-100)
      Chi-wing Law

      One of the most significant challenges in running an early assessment and intervention programme for psychosis is how readily people with untreated psychosis can get in touch with services. According to the annual statistics of the Early Assessment and Services for Young People with Psychosis (EASY) in Hong Kong, schools and youth services social workers and counsellors contributed to more than 10% of all referrals, with the vast majority of cases assessed and managed on an outpatient basis. Looking into details of the pathway to care, more than 20% of all clients had had contact with social workers at some...

    • 10 Initial Screening and Assessment: A Phone-Based Two-Stage Screening
      (pp. 101-110)
      Sherry Kit-wa Chan, Dana Yuk-yee Chun and Kin-sheung Wong

      One of the core objectives of early psychosis intervention service is to encourage potential clients to seek medical help as soon as possible in order to reduce the duration of untreated psychosis (DUP) (Bertolote & McGorry, 2005). To achieve this, a fast and easy access point for potential clients and their relatives for information and possible referral at the same time becomes essential. The referring system of early psychosis intervention service should therefore be open, direct, simple, accessible, flexible, and user-friendly. In Hong Kong, the Early Assessment Service for Young People with Psychosis (EASY) adopts a two-staged assessment and referral...

    • 11 The Diagnostic Interview in Early Psychosis
      (pp. 111-122)
      Wing-chung Chang and Yip-chau Wong

      Accurate diagnosis of psychosis in an early phase is important, as case formulation and management can be more confidently determined on this basis. Nevertheless, making a definitive psychiatric diagnosis during the initial interviews can be one of the most challenging aspects in early intervention services. The difficulties, to a certain extent, can be accounted for by the characteristics of young patients and the ambiguous and variable clinical pictures at this early phase. In this chapter, the challenges in ascertaining a definitive diagnosis of early psychosis are described. The approach to the patients presenting with a first-episode psychosis is also outlined....

    • 12 Handling At-Risk Mental State
      (pp. 123-134)
      May Mei-ling Lam, Chi-chiu Lee, Wing-chung Chang and Se-fong Hung

      Various studies have demonstrated that schizophrenia is often preceded by a prodromal phase. It is suggested that the earlier the treatment begins, the faster the recovery and the better the overall outcome. The rationale for early intervention in psychosis has been extensively discussed in recent years (Corcoran, Malaspina, & Hercher, 2005; Larsen et al., 2001; Malla & Norman, 2002; McGorry et al., 2000; McGorry, Yung, & Phillips, 2001; Verdoux & Cougnard, 2003), and it is generally acknowledged that most psychosocial impairment develops in the prodromal and onset phase (Hafner et al., 1995).

      Research on the prodrome has a long tradition...

  12. Part III Culturally Relevant Psychosocial Case Intervention
    • 13 Implementing Psychological Intervention Programmes in Early Psychosis (PIPE)
      (pp. 137-158)
      Suzanne Ho-wai So

      Over the past five decades or so, antipsychotic treatment has been and remains the mainstay of treatment for psychosis (Kapur & Mamo, 2003). Abundant evidence supports its efficacy in reducing the severity of psychotic symptoms such as hallucinations and delusions (see reviews by Miyamoto et al., 2005; Miyamoto et al., 2003). However, approximately 20%–50% of patients demonstrate persistent symptoms despite active antipsychotic treatment (Craig et al., 2004; Kane, 1996; Lieberman et al., 2005; Marder, 1996; Kane, 1999).

      In the past two decades, there has been a surge of psychological interventions targeting psychotic symptoms and functional deterioration. Examples include cognitive-behavioural...

    • 14 The PASTE that Binds: Culturally Relevant Psychological Interventions for First-Episode Psychosis Individuals in Singapore
      (pp. 159-174)
      Eugene Puay Chong Tay and Lyn Chua

      Unlike people with other disorders, individuals who are afflicted with psychosis are most likely to experience disturbances in their perception and cognition. Compounded with the psychotic experiences and the presence of symptoms, their ability to engage in fruitful social interactions and usual role functioning are often impaired. Moreover, individuals may experience comorbid conditions and must be closely monitored for related emotional reactions of social anxiety, depression and suicidality, hostility or trauma, so as to incorporate interventions that help them function optimally.

      Besides the use of antipsychotic medication, which is the mainstay of treatment, psychological interventions have been identified as the...

    • 15 Cultural Issues in Early Psychosis Management
      (pp. 175-188)
      K. Pushpa

      Singapore is a multi-religious country due to its diverse ethnic mix of peoples from various origins. Most of the key religious denominations are represented in Singapore (see Figure 15.1) and the government promotes religious tolerance. In 2000, Singapore had a population of about 4 million. It is comprised mainly of Chinese (76.8%), the majority of whom are Buddhist or atheists; Malays (13.9%), who are generally Muslim; and Indians (7.9%), who are mostly Hindus; another 1.4% is of other ethnicities (Statistics Singapore, 2007).

      These statistics are relevant and of high importance in understanding the explanatory model of patients afflicted by mental...

    • 16 Engagement and Outreach in Early Psychosis Management
      (pp. 189-198)
      Kai-tai Chan and Gloria Hoi-kei Chan

      According to the Oxford Advanced Learner’s Dictionary, engagement means “locking together, fitting into; of part of a machine, etc.” (Hornby, 2005). Yet, in psychology or psychiatry literature, there is little consensus on the definition and measurement of engagement or disengagement (see reviews by O’Brien, Fahmy, & Singh, 2009; Tetley et al., 2011) and this construct is often conflated with concepts related to the treatment progression or therapeutic alliance. Despite this, it is well recognized that therapeutic engagement is important for patients to receive appropriate help and achieve better outcomes.

      Engagement is especially important in first-episode psychosis. First of all, failure...

    • 17 Experience of Stigma in Early Psychosis Patients and Caregivers
      (pp. 199-208)
      Desiree Yan Wong, Dicky Wai-sau Chung and May Mei-ling Lam

      Psychotic disorders often emerge in late adolescence and young adulthood with a prolonged delay between onset of symptoms and the first effective treatment. Such delays affect symptom severity, treatment response, relapses, and quality of life. The stigma associated with psychosis may be one of the major factors associated with delays in seeking medical help. For diagnosed patients and their family members, the negative stigma attached to psychotic disorders also often cause psychosocial repercussions. This chapter discusses some concepts of stigma in psychosis, with reference to the subjective experience of stigma and reactions to the diagnosis among patients and caregivers in...

    • 18 The Phase-Specific Progress Supervision Model for Case Managers
      (pp. 209-220)
      Helen Lee

      Case managers, who form a part of an allied healthcare professional specialty and those working in specialized fields such as mental health, are faced with a multitude of challenges and responsibilities of providing brokerage, assessments, and therapeutic roles to their patients. Delivering psychoeducation, coordinating services, providing supportive counselling, and formulating care plans are some of the general duties of case managers. In the Early Psychosis Intervention Programme (EPIP) in Singapore, patients are followed up by a designated case manager for a three-year period, during which a good working relationship is forged between both parties. A three-year period is a considerable...

  13. Part IV Support Programmes in the Community
    • 19 Community Psychosocial Intervention in Early Psychosis
      (pp. 223-234)

      First-episode psychosis—in the main, schizophrenia—arises often during the developmental stages of early adolescence and early adulthood (Rinaldi et al., 2010). It is also during these development stages that education, employment, self-identity, and formation of relationships tend to occur (Basset et al., 2001). Due to the impact of the illness, adolescents with early psychosis commonly experience social exclusion, low self-esteem, and decreased social and occupational functioning (Cotton et al., 2011).

      The three essential elements in managing early psychosis are early recognition and assistance, initial assessment and treatment, and promoting recovery (McGorry, 2002). Programmes have to be comprehensive in supporting...

    • 20 The Peer Support Programme in Early Psychosis Intervention Programme (EPIP)
      (pp. 235-246)
      Suying Ang

      The diagnosis of early psychosis can be a lonely experience for a young person. The illness typically strikes at the developmental stage of heightened yearnings for affiliation and intimacy. Yet, the stigma and shame of having a mental illness often results in them shunning their social support systems. Further marginalization is inadvertently caused by the medical model of diagnostic labels, which imposes a role of “mental patient”, leaving a sense of otherness and disconnectedness in their lives (Mead, Hilton, & Curtis, 2001).

      The provision of psychosocial interventions such as case management attempts to address this isolation through working closely with...

    • 21 Family Work in Early Psychosis
      (pp. 247-254)
      Christopher Loh

      Psychosis is a major psychiatric illness that has debilitating impact on patients and their families. Providing care for patients in their home environment can be physically and emotionally demanding for the families. Numerous studies have shown caregivers of patients with psychosis experience distress and burnout (Addington et al., 2003; Barrowclough, Tarrier, & Johnston, 1996; Chen et al., 2004). Evidence suggests that some families need considerable support to prevent further deterioration in family functioning, especially when the patient is admitted to hospital (Seng & Bentelspacher, 2001).

      Bowen (1978) describes the impact of serious emotional events as the “emotional shock wave”, which...

    • 22 Working with Non-Governmental Organizations in Early Psychosis
      (pp. 255-260)
      Steve Tso and Simon Sai-yu Lui

      The Early Assessment Service for Young People with Psychosis (EASY) in Hong Kong emphasizes close links with non-governmental organizations (NGOs) involved in providing mental healthcare to the community. In Hong Kong, NGOs provide a wide range of services. Many youth and community centres are run by NGOs where people in the local community meet and join activities. Staff members of NGOs are usually trained social workers.

      NGOs are key suppliers of mental healthcare for people with early psychosis, as they:

      1. refer many suspected cases of psychosis;

      2. facilitate detection and identification of people with untreated psychosis in the community;...

  14. Part V Medication and Adherence Issues
    • 23 Pharmacological Intervention in Early Psychosis
      (pp. 263-272)
      Phyllis Kwok-ling Chan and Edwin Ho-ming Lee

      Questions on pharmacotherapy are frequently asked by patients and their caregivers in the treatment of early psychosis, reflecting their concern for this topic. Doctors and nurses often face questions on the following issues during psychoeducation:

      Do I need to take medication? When should it be started?

      How effective is the drug treatment? What kind of symptoms is it useful for?

      What kind of drugs should I take?

      What are the immediate and long-term side-effects?

      How to choose between the old and new drugs?

      Why do I have to continue taking drugs even when I have no symptoms?

      What are the...

    • 24 Medication Adherence: Specific Issues in Early Psychosis in Asia
      (pp. 273-280)
      Christy Lai-ming Hui

      In psychotic disorders including schizophrenia, the risk of relapse increases five-fold upon discontinuation of treatment. This chapter discusses issues related to medication adherence in psychosis, paying particular attention to patients in the early stage of illness.

      With regard to medication adherence in psychosis, a variety of challenges are involved at different stages of the illness. At first presentation to clinic, most first-episode psychosis patients are experiencing full-blown hallucinations and/or delusions. During this period, things or people in the environment may carry special meanings or appear absurd to the patients, including the antipsychotic medication given to them. It is therefore not...

  15. Part VI Handling Specific Challenges
    • 25 Relapse Intervention and Related Issues
      (pp. 283-290)
      Christy Lai-ming Hui

      Having a psychotic disease is unlike other illnesses in the sense that it significantly alters a person’s normal experience. As the metaphor “fish is the last to discover water” goes, the ability to perceive reality is so basic a process that seems effortless and unnoticeable to most of us. Thus, it is hard to imagine how a person functions when this ability is disturbed.

      This chapter explores an important aftermath of psychosis, namely relapse after a first episode of psychosis. Special attention will be given to relapse rates, relapse predictors, and maintenance medication to prevent relapse. Local prospective data of...

    • 26 Suicide and Self-Harm Behaviour in Early Psychosis
      (pp. 291-300)
      Edwin Pui-fai Pang

      Suicide has a strong association with psychosis and contributes to its high mortality. In a meta-analysis conducted in 1997, Harris and Barraclough (1997) showed that the overall suicide risk for schizophrenia was 8.5 times that of the general population. As with other disorders, precise identification of risk factors may assist clinicians in managing suicide risk among patients with psychosis. For this purpose, researchers have been looking into the risk factors, using a broad array of methodological designs of various scientific rigours. Hawton et al. (2005) conducted a systematic review of cohort and case-control studies to provide valid estimates of risk...

    • 27 Comorbid Substance Abuse in Early Psychosis
      (pp. 301-310)
      Sherry Kit-wa Chan and Kathy Po-man Chan

      Substance misuse is prevalent among clients suffering from first-episode psychosis. Figures from the West have shown prevalence ranging from 20% to 53% (Addington & Addington, 2007; Barnett et al., 2007; Cantwell et al., 1999; Hambrecht & Hafner, 1996; Wade et al., 2006). Although less common among first-episode clients in Hong Kong, a significant proportion of the clients suffer from comorbid substance abuse. Based on the cohort of clients from the Early Assessment Service for Young People with Psychosis (EASY) programme, about 12% of clients have recently used illicit substances prior to their contact with EASY. This habit presents particular problems...

    • 28 Handling Patients with Negative Symptoms
      (pp. 311-320)
      Wing-chung Chang and Cindy Pui-yu Chiu

      People suffering from first-episode psychosis are often bewildered by the extraordinary experiences evolving around them, being helplessly entwined by events, which often bring turmoil into their lives. Positive psychotic symptoms may be readily understood by patients and caregivers as symptoms of an illness, whereas negative symptoms (including blunted affect, poverty of speech, avolition, apathy, and lack of social drive) are usually less easily accepted as part of the pathological process.

      When positive symptoms subside with treatment, some patients may be left with a residual state or deficit state where negative symptoms predominate. In fact, negative symptoms have long been regarded...

  16. Part VII Recovering from Early Psychosis
    • 29 Recovery from Psychosis
      (pp. 323-334)
      Chi-wing Law

      The development of antipsychotics in the 1950s marked the turning point in the treatment of psychosis. Since then, there has been a progressive increase in expectations for treatment outcomes in psychotic disorders. In the pre-1960s era, the goal of treatment was simply “improvement in self-care and reduction in aggression and self-injury”. With time, this goal has changed to “deinstitutionalization” in the 1960s and 1970s, and to “reduction of recidivism and minimization of positive symptoms” in the 1980s. From the 1990s onward, the ultimate goal of the treatment of psychosis has advanced to the “increase in periods of stabilization, minimization of...

    • 30 Concepts of Recovery in Early Psychosis: A Cognitive Linguistic Approach
      (pp. 335-344)
      Eric Yu-hai Chen

      The concepts of “recovery” and “remission” are often differentiated in the literature. While remission has a more stringent definition and emphasizes symptoms, the concept of recovery is broader with more demanding criteria. This chapter will first discuss some definitions of recovery and remission commonly used in clinical and research settings, and then explore subjective ideas of recovery and the potential use of a tool to reconcile differences. Thirdly, the cognitive linguistic approach to the concept of recovery will be considered before a review of some experiential aspects of psychosis including reality judgement, sealing over and integration approaches.

      Based on the...

    • 31 Experiential Aspects of Recovery in Early Psychosis: Focus Group Findings
      (pp. 345-356)
      May Mei-ling Lam

      Young people who have suffered from a first episode of psychosis have high rates of remission if treated adequately and comprehensively. Despite this, more than 33% of clients are readmitted to the hospital within six months, 55% within two years and 80% within five years following the treatment of their first episode of psychosis. Given these alarming relapse rates, it is important to develop ways of intervention during the initial recovery period in order to reduce the risk of recurrence. This cannot be achieved without understanding the complex issues associated with increased risk of relapse. These include poor adherence to...

  17. Part VIII Evaluation and Research
    • 32 Database Design and Management
      (pp. 359-366)
      Kin-sheung Wong

      Healthcare is one of the most information-intensive and information-demanding industries. Healthcare workers, including doctors, nurses, and other allied health workers, require large amounts of information about their clients in order to make clinical decisions and select appropriate care for clients. At the same time, healthcare planners need comprehensive service data to evaluate existing services and to implement new service strategies. The application of information technology to healthcare industries is therefore an essential element to ensure that timely and up-to-date client information is maintained and accessible when necessary.

      In Hong Kong’s Early Assessment Service for Young People with Psychosis (EASY), case...

    • 33 Research and Outcome Evaluation in Early Psychosis
      (pp. 367-374)
      Eric Yu-hai Chen

      One of the major characteristics distinguishing early psychosis from some other mental health arenas is that research forms an integral part of the early psychosis initiative.

      In the last two decades, research in schizophrenia has witnessed a growing emphasis on first-episode studies. Researchers started to identify patient samples with a first onset of psychotic illness and performed various clinical, cognitive, and biological measurements. Some of these observations (particularly those focusing on biological or neurocognitive markers of the disease) were potentially affected by the patients’ medication. In attempts to rule out medication effects, researchers measured these markers among first-episode patients, especially...

  18. Index
    (pp. 375-382)