Introducing a New Severity Specifier for Schizophrenia: Conceptual Framework and Clinical Implications.

Schizophrenia patients represent a heterogeneous group in clinical presentation and severity. Although severity has been operationalized in different ways, mostly on a gradient between symptom severity and functional impairment, such approaches are limited in capturing real-world functioning. We suggest adopting the severity model proposed by DSM-5 for autism spectrum disorders. The model defines three levels of severity, based on the support required, directly addressing two barriers from previous models: real-world functioning and ease of implementation. Our adapted model includes three new features: First, this severity specifier is global, rather than for each symptom domain. Second, the centrality of occupational functioning is emphasized to define the level of support. Third, we propose a one-month timeframe for severity appraisal, standardizing the assessment process. Considering practical utility, we indicate how severity assessment can guide clinical practice towards rehabilitation. Additionally, we outlined operational definitions for severity and functioning in schizophrenia, aligned with the premises of our model. Finally, we acknowledge potential limitations, the most relevant being the need for empirical validation. The model is presented to foster discussion. Additional studies will follow to investigate inter-rater reliability and convergent validation with standard measures of symptom and functioning severity.

Global and risk-group stratified well-being and mental health during the COVID-19 pandemic in adults: Results from the international COH-FIT Study.

International studies measuring wellbeing/multidimensional mental health before/ during the COVID-19 pandemic, including representative samples for >2 years, identifying risk groups and coping strategies are lacking. COH-FIT is an online, international, anonymous survey measuring changes in well-being (WHO-5) and a composite psychopathology P-score, and their associations with COVID-19 deaths/restrictions, 12 a-priori defined risk individual/cumulative factors, and coping strategies during COVID-19 pandemic (26/04/2020-26/06/2022) in 30 languages (representative, weighted non-representative, adults). T-test, χ2, penalized cubic splines, linear regression, correlation analyses were conducted. Analyzing 121,066/142,364 initiated surveys, WHO-5/P-score worsened intra-pandemic by 11.1±21.1/13.2±17.9 points (effect size d=0.50/0.60) (comparable results in representative/weighted non-probability samples). Persons with WHO-5 scores indicative of depression screening (<50, 13% to 32%) and major depression (<29, 3% to 12%) significantly increased. WHO-5 worsened from those with mental disorders, female sex, COVID-19-related loss, low-income country location, physical disorders, healthcare worker occupations, large city location, COVID-19 infection, unemployment, first-generation immigration, to age=18-29 with a cumulative effect. Similar findings emerged for P-score. Changes were significantly but minimally related to COVID-19 deaths, returning to near-pre-pandemic values after >2 years. The most subjectively effective coping strategies were exercise and walking, internet use, social contacts. Identified risk groups, coping strategies and outcome trajectories can inform global public health strategies.

Association Between Juvenile Psychotic Experiences and Problematic Gaming.

Background and Hypothesis: Problematic gaming (PG) is an emerging mental health condition associated with significant adverse outcomes. Even though PG has been linked to other psychiatric disorders, its association with psychotic experiences (PEs) remains poorly explored to date. The aim of our study was to examine the association between both conditions in a large Brazilian community sample. We hypothesized that adolescents with PG were more likely to report PE compared with those without the disorder. Study Design: Our investigation was based on a cross-sectional subsample of a large Brazilian cohort (n = 1616; 13- to 21-year age range). Using the 7-item version of the Game Addiction Scale, participants were classified according to their gaming status: no PG, PG, or gaming addiction (GA). The association between PG, GA, and PE was assessed through linear regression analyses, which were adjusted for the presence of significant covariates, including other psychiatric conditions. Study Results: 9.5% (n = 154) presented PG and 2.7% (n = 43) had GA. 28.0% received any Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnosis and the mean PE score was 9.39 (SD = 4.35). Participants presenting PG had greater levels of PE, compared with participants with no PG, even controlled by sociodemographic variables and the presence of any DSM-IV diagnosis (b = 0.96, 95% CI = 0.17-1.75, P = .017). Conclusions: According to our results, PG was significantly associated with PE, even in the presence of other covariates. Although preliminary, these results suggest that PG and PE may have shared neurobiological and/or behavioral pathways.

Feuerstein Instrumental Enrichment Program for People With Schizophrenia After the First Episode of Psychosis: Protocol for an Open-Label Intervention Study.

BACKGROUND: Schizophrenia is a disorder associated with neurocognitive deficits that adversely affect daily functioning and impose an economic burden. Cognitive rehabilitation interventions, particularly during the early phases of illness, have been shown to improve cognition, functionality, and quality of life. The Feuerstein Instrumental Enrichment (FIE) program, based on the Mediated Learning Experience and the Structural Cognitive Modifiability theory, has been applied in various disorders, but its applicability in schizophrenia has not yet been clarified. OBJECTIVE: This study aims to investigate the effects of the FIE program on the functionality of patients with first-episode schizophrenia. METHODS: In total, 17 patients will be recruited for an open-label intervention consisting of twice-weekly sessions for 10 weeks. The primary outcome measure will be changes in the Goal Achievement Scale score. Maze task performance from the Measurement and Treatment Research to Improve Cognition in Schizophrenia (MATRICS) battery will serve as a secondary outcome measure. At the same time, changes in Positive and Negative Syndrome Scale scores and other MATRICS domains will be analyzed as exploratory outcomes. Assessments will be administered before and after the intervention, with a follow-up period of 6 months. RESULTS: This trial was preregistered in The Brazilian Registry of Clinical Trials (RBR-4gzhy4s). By February 2024, 11 participants were enrolled in the training. Recruitment is expected to be completed by May 2024. Data analysis will be conducted between May and September 2024. The results are expected to be published in January 2025. CONCLUSIONS: This study may establish a protocol for the FIE program that uses mediation techniques for individuals in the early stages of schizophrenia. The results will add to the knowledge about strategies to promote cognitive skills and functional impairment in daily life. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/57031.

Childhood Anxiety Symptoms as a Predictor of Psychotic Experiences in Adolescence in a High-Risk Cohort for Psychiatric Disorders.

Background and Hypothesis: When occurring in adolescence, psychotic experiences (PE), subclinical psychotic symptoms, can be an early marker of mental illnesses. Studies with high-risk populations for psychosis show that anxiety symptoms often precede the onset of psychosis. Although anxiety symptoms are frequently experienced across the continuum of psychosis, no previous study has analyzed this association using a cross-lagged panel model (CLPM) longitudinally to identify if anxiety can be a predictor of PE over time or vice versa. The aim of the current study was to investigate whether one symptom domain predicts the other over time. Study Design: 2194 children from the Brazilian High-Risk Cohort (BHRC) were evaluated at baseline (T 0), and 76.5% completed a 3-year follow-up (T 1) interview. Childhood anxiety symptoms and PE were assessed using a standardized self-report questionnaire at both time points. Cross-lagged panel models evaluated time-lagged associations between PE and anxiety longitudinally. Study Results: Higher levels of anxiety in childhood predicted an increase in PE levels in adolescence. The cross-lagged effect of anxiety scores at T 0 on PE scores at T 1 was significant (ß = .03, SE = 0.01, P ≤ .001) and PE in childhood did not increase levels of anxiety in adolescence, when controlling for sociodemographic and clinical characteristics. Conclusions: Our findings reinforce that anxiety may represent an early marker of psychosis proneness, not a consequence of already presenting PE, which can help to develop better screening approaches. Therefore, future studies should focus on identifying biological or other clinical markers to increase prediction accuracy.

Ketamine for catatonia: A novel treatment for an old clinical challenge? A systematic review of the evidence.

INTRODUCTION: Catatonia, documented since the 19th century, remains a significant challenge in terms of recognition and treatment. Over the last two decades, ketamine has brought new perspectives to psychiatry, sparking widespread interest. Concurrently, catatonia has attracted heightened scientific attention. Preliminary evidence suggests the therapeutic potential of ketamine for catatonia. METHODS: We systematically searched Medline/PubMed, Embase, PsycINFO, Lilacs, and Cochrane Library databases, as well as Google Scholar, for studies with ketamine or its enantiomers as intervention for catatonia, with no restrictions to underlying diagnosis, date, language, or study design. RESULTS: Twenty articles were included, encompassing a total of 25 catatonic patients receiving ketamine or esketamine. Predominantly female (61.9 %), with a mean age of 44.4 years, patients mostly exhibited manifestations compatible with the retarded subtype of catatonia. Mood disorders were the most prevalent underlying diagnoses. Ketamine was primarily administered intravenously over a 40-minute period and in multiple-dosing schemes. Mean response and remission rates of catatonic manifestations for the whole sample were 80 % and 44 %, respectively, with no reports of worsening catatonic features or psychotic symptoms. Only one patient discontinued treatment due to intolerable dissociative effects. CONCLUSION: Challenging the conventional contraindication of ketamine in psychotic disorders, current evidence highlights its potential efficacy, particularly in treating catatonia. Pending further research, we advocate reevaluating this contraindication, as it may offer a promising therapeutic option, especially for challenging cases. Preliminary evidence suggests potentially greater benefits for catatonic patients with underlying mood disorders compared to primary psychotic disorders.

A hybrid model for predicting response to risperidone after first episode of psychosis.

Patient response to antipsychotic drugs varies and may be related to clinical and genetic heterogeneity. This study aimed to determine the performance of clinical, genetic, and hybrid models to predict the response of first episode of psychosis (FEP). patients to the antipsychotic risperidone. We evaluated 141 antipsychotic-naïve FEP patients before and after 10 weeks of risperidone treatment. Patients who had a response rate equal to or higher than 50% on the Positive and Negative Syndrome Scale were considered responders (n = 72; 51%). Analyses were performed using a support vector machine (SVM), k-nearest neighbors (kNN), and random forests (RF). Clinical and genetic (with single-nucleotide variants [SNVs]) models were created separately. Hybrid models (clinical+genetic factors) with and without feature selection were created. Clinical models presented greater balanced accuracy 63.3% (confidence interval [CI] 0.46-0.69) with the SVM algorithm than the genetic models (balanced accuracy: 58.5% [CI 0.41-0.76] - kNN algorithm). The hybrid model, which included duration of untreated psychosis, Clinical Global Impression-Severity scale scores, age, cannabis use, and 406 SNVs, showed the best performance (balanced accuracy: 72.9% [CI 0.62-0.84] - RF algorithm). A hybrid model, including clinical and genetic predictors, can provide enhanced predictions of response to antipsychotic treatment.

Increased COVID-19 mortality in patients with schizophrenia: A retrospective study in Brazil.

The risk that COVID-19 poses for mortality risk in individuals with schizophrenia in low- and middle-income countries has only been the subject of a few studies. In this retrospective study, we examined the standardized mortality ratio (SMR), by age group and sex, in a cohort of patients diagnosed with schizophrenia (n = 20,417), with second-generation antipsychotics, in a South Brazilian State database (Paraná-Brazil). We performed a linkage with the Brazilian Mortality Information System database between 2020 and 2021. We also assessed in a logistic regression how clozapine could affect COVID-19 mortality controlling by sex, age, and presence of obesity. A secondary analysis was to compare mortality with SMR due to COVID-19 in individuals with and without obesity. Compared to the State population (8,850,682 individuals), those with schizophrenia had more than two times greater risk of dying from COVID-19 (SMR = 2.21, 95 % CI: 1.90-2.55). Between the ages of 16 and 29, their risk is more than ten times higher than the state population (SMR = 10.18, 95 % CI: 4.73-19.33). Obesity showed an almost twofold risk of dying from COVID-19 in the patient's group (OR = 1.89, 95 % CI: 1.39-2.57). Clozapine was not found as a protector or a risk factor for COVID-19 mortality. In Brazil, a middle-income nation, people with schizophrenia are more likely to die prematurely from COVID-19. The burden of schizophrenia is higher in younger and in patients with obesity.

GAPi: A description of the initiative for early psychosis intervention in Latin America and the short- to medium-term outcomes in early psychosis patients.

INTRODUCTION: Schizophrenia is a debilitating disorder that affects a significant proportion of the population and leads to impaired functionality and long-term challenges. The first episode of psychosis (FEP) is a critical intervention stage for improving long-term outcomes. The GAPi program was established in São Paulo, Brazil to provide early intervention services and evaluate biomarkers in individuals with FEP. This article delineates the objectives of the GAPi program, detailing its innovative research protocol, examining the clinical outcomes achieved, and discussing the operational challenges encountered during its initial decade of operation. METHODS: The study comprised a prospective cohort of antipsychotic-naïve individuals with first-episode psychosis aged between 16 and 35 years. Participants were recruited from a public psychiatric facility in São Paulo. Emphasizing the initiative's commitment to early intervention, clinical assessments were systematically conducted at baseline and at two months, one year, two years, and five years of treatment to capture both short- and medium-term outcomes. Various assessment tools were utilized, including structured interviews, symptom scales, the Addiction Severity Index, and functional assessments. RESULTS: A total of 232 patients were enrolled in the cohort. Among them, 65.95 % completed the 2-month follow-up. Most patients presented with schizophrenia spectrum disorders, followed by bipolar disorder and major depressive disorder with psychotic features. Treatment response rates and remission rates were evaluated at different time points, with promising outcomes observed. The program also assessed socio-demographic factors, substance use, family history, and genetic and biomarker profiles, providing valuable data for research. DISCUSSION: The GAPi program has emerged as the largest ongoing cohort of antipsychotic-naïve first-episode psychosis in Latin America, contributing to the understanding of early psychosis in low- and middle-income countries. Despite operational challenges, the program has demonstrated efficacy in reducing the duration of untreated psychosis and in improving clinical outcomes. A multidisciplinary approach, including pharmacological treatment, psychosocial interventions, and family involvement, has been instrumental in enhancing treatment adherence and long-term prognosis. CONCLUSION: The GAPi program represents a valuable model for early intervention in first-episode psychosis and provides insights into the pathophysiology, treatment, and long-term outcomes of individuals with schizophrenia and related disorders. Continued research and resource allocation are essential for addressing operational challenges and expanding early intervention services in low- and middle-income countries.

Is waiting for rewards good for you? No association between impulsive choice, psychopathology, and functional outcomes in a large cohort sample.

Background: A stronger preference for immediate rewards has been reported in individuals with ADHD and other disorders. However, the consistency of the associations between this preference and psychiatric conditions as well as functional outcomes have been questioned. Research on its association with longitudinal outcomes is scarce. Methods: The current study used data on a choice delay task (CDT) from a school-based cohort of Brazilian children with those at higher risk for psychiatric disorders over-sampled (n = 1917). The sample included typically developing children (n = 1379), those with ADHD (n = 213), and other disorders. The frequency of the trials where children chose a larger later reward versus a smaller sooner reward was compared for those with ADHD and typically developing children. Cross-sectionally and longitudinally, the study also evaluated whether children's preference for larger delayed rewards at baseline predicted the presence of psychiatric disorders and functional life outcomes (academic performance, alcohol use, early pregnancy, criminal conviction, BMI). Results: Children with ADHD and their typically developing peers performed similarly on the CDT. Their baseline task performance was not related to psychiatric conditions or life outcomes. Conclusions: The current results raise questions regarding the use of the CDT with diverse populations and whether a preference for larger delayed rewards is predictive of positive long-term outcomes as widely assumed.

The S20 Brazilian Mental Health Report for Building a Just World and a Sustainable Planet: Part II.

This is the second part of the Brazilian S20 mental health report. The mental health working group is dedicated to leveraging scientific insights to foster innovation and propose actionable recommendations for implementation in Brazil and participating countries. In addressing the heightened mental health challenges in a post-pandemic world, strategies should encompass several key elements. This second part of the S20 Brazilian Mental Health Report will delve into some of these elements, including: the impact of climate change on mental health, the influence of environmental factors on neurodevelopmental disorders, the intersection of serious mental illness and precision psychiatry, the co-occurrence of physical and mental disorders, advancements in biomarkers for mental disorders, the utilization of digital health in mental healthcare, the implementation of interventional psychiatry, and the design of innovative mental health systems integrating principles of innovation and human rights. Reassessing the treatment settings for psychiatric patients within general hospitals, where their mental health and physical needs are addressed should be prioritized in mental health policy. As the S20 countries prepare for the future, we need principles that stand to advance innovation, uphold human rights, and strive for the highest standards in mental health care.

The interplay between ADHD and school shift on educational outcomes in children and adolescents: A cross-sectional and longitudinal analysis.

Many countries implement a double-shift schooling system, offering morning or afternoon shifts, driven by diverse factors. Young people with ADHD may face educational problems attending morning shifts compared to afternoon shifts. To investigate this, we used data from a Brazilian school-based cohort (n = 2.240, 6-14 years old, 45.6% female; 50.2% in the morning shift; 11.2% with ADHD). ADHD was determined by child psychiatrists using semi-structured interview. Educational outcomes were measured cross-sectionally and three years later (80% retention) and included reading and writing ability, performance in school subjects, and any negative school events (repetition, suspension, or dropout). Generalized regression models tested the interaction between ADHD and school shift and were adjusted for age, sex, race/ethnicity, intelligence, parental education, socioeconomic status, and site. Attrition was adjusted with inverse probability weights. We used two dimensional measures of attentional problems as sensitivity analysis. ADHD and morning shift were independently associated with lower reading and writing ability and with higher odds for negative school events cross sectionally. ADHD independently predicted lower performance in school subjects and higher negative school events at follow-up. Interaction was found only at the cross-sectional level in a way that those studying in the afternoon present better educational outcomes compared with those studying in the morning only if they have lower ADHD symptom. Thus, ADHD was not associated with poorer educational outcomes among those studying in the morning. However, participants studying in the afternoon with lower levels of attentional problems presented better educational, despite these associations fade away over time.

Perinatal and neonatal factors and mental disorders in children and adolescents: looking for the contributions of the early environment to common and dissociable aspects of psychopathology.

High rates of co-occurrence of mental disorders have been hypothesized to represent a result of common susceptibility to overall psychopathology. The purpose of this study is to test the hypothesis that commonalities among psychiatric disorders might be partially driven by sharable perinatal and neonatal environmental factors for mental disorders. Participants were 6-14 years of age children and their parents. Primary caregivers provided data on perinatal and neonatal information assessed retrospectively (n = 2231). Psychiatric disorders diagnoses were assessed using the Development and Well Being Behavior Assessment (DAWBA). We used bifactor models to disentangle common from dissociable aspects of psychopathology. These models allow modeling psychiatric disorders as the result of a common domain of psychopathology (p-factor) and three dissociable domains (fear, distress, and externalizing symptoms). Associations were tested using linear and tobit regression models. The p-factor was associated with male sex, low socioeconomic status, gestational smoking, gestational drinking, low levels of maternal education and presence of mental disorder in the mother. Associations with specific factors also emerged suggesting some risk factors might also have some role for fear, distress and externalizing factors. Our study supports the hypothesis that overall susceptibility to psychopathology might be partially driven by sharable perinatal and neonatal factors.

Comparing mental health semi-structured diagnostic interviews and symptom checklists to predict poor life outcomes: an 8-year cohort study from childhood to young adulthood in Brazil.

BACKGROUND: Semi-structured diagnostic interviews and symptom checklists present similar internal reliability. We aim to investigate whether they differ in predicting poor life outcomes in the transition from childhood to young adulthood. METHODS: For this longitudinal study, we used data from the Brazilian High Risk Cohort Study for Childhood Mental Health Conditions. Eligible participants were aged 6-14 years on the day of study enrolment (January to February, 2010) and were enrolled in public schools by a biological parent in Porto Alegre and São Paulo, Brazil. 2511 young people and their caregivers were assessed at baseline in 2010-11, and 1917 were assessed 8 years later (2018-19; 76·3% retention). Clinical thresholds were derived using semi-structured parent-report interview based on the Diagnostic and Statistical Manual of Mental Disorders, according to the Developmental and Well-being Assessment (DAWBA), and clinical scores as defined by the Child Behavior Checklist (CBCL; T-score ≥70 considered positive caseness). At 8 years, participants were assessed for a composite life-threatening outcome (a composite of death, suicide attempts, severe self-harm, psychiatric inpatient admission, or emergency department visits) and a composite poor life chances outcome (a composite of any criminal conviction, substance misuse, or school dropout). We evaluated the accuracy of DAWBA and CBCL to predict these outcomes. Logistic regression models were adjusted for age, sex, race or ethnicity, study site, and socioeconomic class. FINDINGS: DAWBA and CBCL had similar sensitivity, specificity, predictive values, and test accuracy for both composite outcomes and their components. Any mental health problem, as classified by DAWBA and CBCL, was independently associated with the composite life-threatening outcome (DAWBA adjusted odds ratio 1·62, 95% CI 1·20-2·18; CBCL 1·66, 1·19-2·30), but only CBCL independently predicted poor life chances (1·56, 1·19-2·04). Participants classified by both approaches did not have higher odds of the life-threatening outcome when compared with participants classified by DAWBA or CBCL alone, nor for the poor life chances outcome when compared with those classified by CBCL alone. INTERPRETATION: Classifying children and adolescents based on a semi-structured diagnostic interview was not statistically different to symptom checklist in terms of test accuracy and predictive validity for relevant life outcomes. Classification based on symptom checklist might be a valid alternative to costly and time-consuming methods to identify young people at risk for poor life outcomes. FUNDING: Conselho Nacional de Desenvolvimento Científico e Tecnológico; Fundação de Amparo à Pesquisa do Estado de São Paulo; and Medical Research Council, European Research Council. TRANSLATION: For the Portuguese translation of the abstract see Supplementary Materials section.

Treatment resistance in schizophrenia: a meta-analysis of prevalence and correlates

Objectives: To determine the prevalence and correlates of treatment-resistant schizophrenia (TRS) through a systematic review and meta-analysis. Methods: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria, an electronic search was performed in PubMed and Embase through May 17, 2022. All study designs that assessed a minimum of 20 schizophrenia-spectrum patients and provided data on TRS prevalence or allowed its calculation were included. Estimates were produced using a random-effects model meta-analysis. Results: The TRS prevalence across 50 studies (n = 29,390) was 36.7% (95%CI 33.1-40.5, p < 0.0001). The prevalence ranged from 22% (95%CI 18.4-25.8) in first-episode to 39.5% (95%CI 32.2-47.0) in multiple-episode samples (Q = 18.27, p < 0.0001). Primary treatment resistance, defined as no response from the first episode, was 23.6% (95%CI 20.5-26.8) vs. 9.3% (95%CI 6.8-12.2) for later-onset/secondary (≥ 6 months after initial treatment response). Longer illness duration and recruitment from long-term hospitals or clozapine clinics were associated with higher prevalence estimates. In meta-regression analyses, older age and poor functioning predicted greater TRS. When including only studies with lower bias risk, the TRS prevalence was 28.4%. Conclusion: Different study designs and recruitment strategies accounted for most of the observed heterogeneity in TRS prevalence rates. The results point to early-onset and later-onset TRS as two separate disease pathways requiring clinical attention. Registration number: PROSPERO CRD42018092033.

Treatment resistance in schizophrenia: a meta-analysis of prevalence and correlates.

OBJECTIVES: To determine the prevalence and correlates of treatment-resistant schizophrenia (TRS) through a systematic review and meta-analysis. METHODS: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria, an electronic search was performed in PubMed and Embase through May 17, 2022. All study designs that assessed a minimum of 20 schizophrenia-spectrum patients and provided data on TRS prevalence or allowed its calculation were included. Estimates were produced using a random-effects model meta-analysis. RESULTS: The TRS prevalence across 50 studies (n = 29,390) was 36.7% (95%CI 33.1-40.5, p < 0.0001). The prevalence ranged from 22% (95%CI 18.4-25.8) in first-episode to 39.5% (95%CI 32.2-47.0) in multiple-episode samples (Q = 18.27, p < 0.0001). Primary treatment resistance, defined as no response from the first episode, was 23.6% (95%CI 20.5-26.8) vs. 9.3% (95%CI 6.8-12.2) for later-onset/secondary (≥ 6 months after initial treatment response). Longer illness duration and recruitment from long-term hospitals or clozapine clinics were associated with higher prevalence estimates. In meta-regression analyses, older age and poor functioning predicted greater TRS. When including only studies with lower bias risk, the TRS prevalence was 28.4%. CONCLUSION: Different study designs and recruitment strategies accounted for most of the observed heterogeneity in TRS prevalence rates. The results point to early-onset and later-onset TRS as two separate disease pathways requiring clinical attention.

Urban distance to mental healthcare units and public transport increases duration of untreated psychosis in first-episode patients.

BACKGROUND: There is a growing interest in environmental and social determinants of mental health. However, how distance to healthcare and public transportation affect illness is neglected in schizophrenia research. Here, we are interested in how the availability of mental healthcare and the ways to reach it may be associated with psychosis. AIMS: We aim to investigate the association between distances to healthcare units and subway stations and duration of untreated psychosis (DUP) and greater initial severity in an antipsychotic-naïve first episode of psychosis (FEP) sample. METHOD: Using 212 untreated FEP patients' data, we calculated the distances from their residences to the places of interest. Diagnoses comprehended schizophrenia spectrum disorders, depressive and bipolar affective disorders, and substance-induced disorders. Linear regressions were performed with distances as independent variables, DUP and Positive and Negative Syndrome Scale (PANSS) scores as dependent variables. RESULTS: Longer distance to emergency mental healthcare was related to longer DUP (95% CI: p = .034, B = 0.152) and higher total PANSS (95% CI: p = .007, B = 0.0189); longer distance to community mental healthcare units was related to longer DUP (95% CI: p = .004, B = 0.0204) and higher total PANSS (95% CI: p = .030, B = 0.152). Moreover, a longer distance to the closest subway station predicted longer DUP (95% CI: p = .019, B = 0.170). CONCLUSION: Our results indicate that poor healthcare access is related to longer DUP and higher initial PANSS scores. Future research should investigate how investments in mental health access and actions to improve public transport access could impact DUP and treatment outcomes in psychosis patients.

Identifying Depression Early in Adolescence: assessing the performance of a risk score for future onset of depression in an independent Brazilian sample.

OBJECTIVE: The Identifying Depression Early in Adolescence Risk Score (IDEA-RS) was recently developed in Brazil using data from the Pelotas 1993 Birth Cohort to estimate the individualized probability of developing depression in adolescence. This model includes 11 sociodemographic variables and has been assessed in longitudinal studies from four other countries. We aimed to test the performance of IDEA-RS in an independent, community-based, school-attending sample within the same country: the Brazilian High-Risk Cohort. METHODS: Standard external validation, refitted, and case mix-corrected models were used to predict depression among 1442 youth followed from a mean age of 13.5 years at baseline to 17.7 years at follow-up, using probabilities calculated with IDEA-RS coefficients. RESULTS: The area under the curve was 0.65 for standard external validation, 0.70 for the case mix-corrected model, and 0.69 for the refitted model, with discrimination consistently above chance for predicting depression in the new dataset. There was some degree of miscalibration, corrected by model refitting (calibration-in-the-large reduced from 0.77 to 0). CONCLUSION: IDEA-RS was able to parse individuals with higher or lower probability of developing depression beyond chance in an independent Brazilian sample. Further steps should include model improvements and additional studies in populations with high levels of subclinical symptoms to improve clinical decision making.