Aims and Objectives 3

The third objective of this study is to determine the clinical outcome of individuals identified as experiencing a reactive psychosis. There is a range of possible ways to define outcome and, as noted in Chapter 1, there is limited consistency in defining outcome with the exception of some agreement that both symptomatic recovery and functional recovery should be considered, and others arguing for the inclusion of negative symptoms. This section will examine symptomatic recovery, whilst functional recovery will be considered in the following objective. Andreasen et al. (2005) attempted to address inconsistencies in the research field and operationalised recovery in the domains general psychopathology and negative symptoms.

The conceptualisation of reactive psychosis suggests a more favourable clinical outcome than other psychotic disorders. Specifically, it is expected that there will be a shorter duration of symptoms and a return to premorbid functioning, hence the need to examine these variables. While the reactive psychosis construct suggests a return to premorbid function, the literature does not identify a specific timepoint by which this would be expected. There is also a difficulty in establishing premorbid functioning in an adolescent population given that the illness impacts on ongoing development. However it is expected that individuals experiencing reactive psychosis will have a more favourable outcome on clinical dimensions such as duration of psychosis, recovery from positive psychotic symptoms, negative symptoms, and

general psychopathology (which includes other psychotic symptoms such as mannerisms and posturing, motor retardation, and disorientation). Since some historical accounts connected affective states with reactive psychosis, mood symptoms will also be examined both as an outcome and as a potential confound. It is noted however that affective states did not emerge among the commonalities in reactive psychosis constructs identified in Chapter 3.

In addition to examining these clinical dimensions, one of the objectives of this study is to determine whether people with a diagnosis of reactive psychosis use fewer acute and outpatient services over the course of their treatment and lastly, whether they are prescribed lower doses of antipsychotic medication and for shorter periods of time. It is expected that there will be no differences in service use and medication in the first 3 months due to comparable levels of illness acuity. However the reactive psychosis group is expected to use fewer services and medication at 9 and 15 months, consistent with shorter duration of symptoms. These variables are being used as proxy measures of remission, given that a more severely unwell patient will be more likely to use both acute and outpatient services and require more medication.

Given the exploratory nature of this study and it being one of the few studies to attempt to empirically describe the clinical characteristics of reactive psychosis in the early stages of psychosis, identified confound variables will be noted for further discussion and results interpreted with caution. Consistent with other studies, it is likely this study will find differences in distribution of gender between groups but the literature indicates no straightforward relationship between gender and outcome in first episode psychosis. The contribution of gender to outcome in reactive psychosis is beyond the scope and design of this exploratory study and will therefore not be controlled for in analyses.

Duration of untreated psychosis is likely to be different between the groups as it is related to rapid development of psychoses, which forms part of the diagnostic criteria for reactive psychosis and therefore will not be treated as a confounding variable in this design. Again any potential contribution to outcome will be noted for discussion.

The various outcome variables described above will be measured at four time points:

(1) Entry to the service

(2) 3 months of treatment (recovery/stabilisation phase) (3) 9 month follow up

(4) 15 month follow up.

Hypothesis 3a: The reactive psychosis group will have a significantly shorter duration of psychosis and experience higher rates of remission from their psychotic episode at the 3-month follow up point than the non reactive psychosis group.

Hypothesis 3b: The reactive psychosis group will have significantly less severe general psychopathological symptoms than the non reactive psychosis group at 3, 6 and 15 month follow up points.

Hypothesis 3c: The reactive psychosis group will have significantly less severe positive psychotic symptoms than the non reactive psychosis group at 3, 6 and 15 month follow up points.

Hypothesis 3d: The reactive psychosis group will have significantly less severe negative symptoms than the non reactive psychosis group at 3, 6 and 15 month follow up points.

Hypotheses 3e: There will be no differences between the reactive psychosis and non reactive psychosis group on the severity of depressive and manic symptoms at 3, 6 and 15 month follow up points.

Hypothesis 3f: There will be no significant differences between groups in the degree of outpatient service use during the acute phase (first 3 months).

Hypothesis 3g: The reactive psychosis group will use outpatient services significantly less than the non reactive psychosis group at 9 and 15 month follow up.

Hypothesis 3h: There will be no significant differences between groups in the degree of acute service use (YAT and inpatient unit) during the acute phase (first 3 months).

Hypothesis 3i: The reactive psychosis group will use acute services (YAT and inpatient unit) significantly less than the non reactive psychosis group at 9 and 15 month follow up.

Hypothesis 3j: There will be no significant differences between groups in the dose or likelihood of being prescribed an antipsychotic medication during the acute phase (first 3 months).

Hypothesis 3k: The reactive psychosis group will have significantly lower doses and be less likely to be prescribed an antipsychotic medication than the non reactive psychosis group at 9 and 15 month follow up.