Suicidality among clients in a network of coordinated specialty care (CSC) programs for first-episode psychosis: Rates, changes in rates, and their predictors.

BACKGROUND: People experiencing their first episode of psychosis have high risk of suicide, and programs specializing in early psychosis have not always achieved reduced risk. The present study analyzes patterns of suicide ideation, self-harm, and suicide attempts within the Connection Learning Healthcare System of 23 early psychosis programs in Pennsylvania and Maryland that follow the Coordinated Specialty Care treatment model. METHOD: People with first episode psychosis (n = 1101) were assessed at admission and every six months using a standardized battery that included self-reported past-month ideation and clinician-reported past-six-month ideation, self-harm, and suicide attempts. RESULTS: At admission, there were 28 % rates of self-reported past-month suicide ideation and 52 % rates clinician-reported past-six-month suicide ideation, 23 % rate of clinician-reported self-harm, and 15 % rate of attempts. After the first six months of treatment there were significantly lower rates of clinician-reported suicidality (with reductions of at least 77 %), and after the first year of treatment there was significantly lower self-reported ideation (with approximately 54 % reporting lower past-month ideation). Changes were not accounted for by differential early discharge. A range of psychosocial variables predicted within- and between-subject variability in suicidality. Social and role functioning, depressive symptom severity, and a sense of recovery were significant within-subject predictors of all four measures of suicidality. CONCLUSIONS: Compared to admission, we observed substantially lower rates of suicidality within the first year of treatment for clients with first episode psychosis in Coordinated Specialty Care. Reductions were predicted by some of the variables targeted by the treatment model.

Reasons for Discharge in a National Network of Early Psychosis Intervention Programs.

BACKGROUND: Discharge from early psychosis intervention is a critical stage of treatment that may occur for a variety of reasons. This study characterizes reasons for discharge among participants in early psychosis intervention programs participating in the Early Psychosis Intervention Network (EPINET) which comprises >100 programs in the United States organized under 8 academic hubs. STUDY DESIGN: We analyzed 1787 discharges, focusing on program completion, unilateral termination by the client/family, and lost contact with the client/family. We performed exploratory analyses of demographic, clinical, and functional predictors of discharge reason. Variables predictive of discharge type were included in multilevel logistic regressions, allowing for the estimation of predictors of discharge reason and variability in rates by program and hub. STUDY RESULTS: An estimated 20%-30% of enrolled patients completed the program. Program completion rates were higher among participants who were older on admission, had lower negative symptoms severity, spent more time in education, employment, or training, and who were covered by private insurance (a close proxy for socioeconomic status). Programs were more likely to lose contact with male participants, Black participants, and participants who were never covered by private insurance. After accounting for patient-level factors, there was substantial program-level variation in all 3 discharge outcomes, and hub-level variability in the proportion of participants who completed the program. The impact of race on program completion varied substantially by program. CONCLUSIONS: Participants were discharged from early psychosis intervention services for diverse reasons, some of which were associated with sociocultural factors. Disengagement is a widespread problem affecting all hubs.

From Rhetoric to Action: Justice, Equity, Diversity, and Inclusion in Coordinated Specialty Care for Early Psychosis.

Attention to inclusivity and equity in health research and clinical practice has grown in recent years; however, coordinated specialty care (CSC) for early psychosis lags in efforts to improve equity despite evidence of ongoing disparities and inequities in CSC care. This Open Forum argues that marginalization and disparities in early psychosis research and clinical care are interrelated, and the authors provide suggestions for paths forward. Commitment to equity and justice demands recentering the perspectives of those most affected by early psychosis services and investing in the integration of historically excluded perspectives across all aspects of practice, policy, and research.

On the proportion of patients who experience a prodrome prior to psychosis onset: A systematic review and meta-analysis.

BACKGROUND: Preventing or delaying the onset of psychosis requires identification of those at risk for developing psychosis. For predictive purposes, the prodrome - a constellation of symptoms which may occur before the onset of psychosis - has been increasingly recognized as having utility. However, it is unclear what proportion of patients experience a prodrome or how this varies based on the multiple definitions used. METHODS: We conducted a systematic review and meta-analysis of studies of patients with psychosis with the objective of determining the proportion of patients who experienced a prodrome prior to psychosis onset. Inclusion criteria included a consistent prodrome definition and reporting the proportion of patients who experienced a prodrome. We excluded studies of only patients with a prodrome or solely substance-induced psychosis, qualitative studies without prevalence data, conference abstracts, and case reports/case series. We searched Ovid MEDLINE, Embase (Ovid), APA PsycInfo (Ovid), Web of Science Core Collection (Clarivate), Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, APA PsycBooks (Ovid), ProQuest Dissertation & Thesis, on March 3, 2021. Studies were assessed for quality using the Critical Appraisal Checklist for Prevalence Studies. Narrative synthesis and proportion meta-analysis were used to estimate prodrome prevalence. I2 and predictive interval were used to assess heterogeneity. Subgroup analyses were used to probe sources of heterogeneity. (PROSPERO ID: CRD42021239797). RESULTS: Seventy-one articles were included, representing 13,774 patients. Studies varied significantly in terms of methodology and prodrome definition used. The random effects proportion meta-analysis estimate for prodrome prevalence was 78.3% (95% CI = 72.8-83.2); heterogeneity was high (I2 97.98% [95% CI = 97.71-98.22]); and the prediction interval was wide (95% PI = 0.411-0.936). There were no meaningful differences in prevalence between grouped prodrome definitions, and subgroup analyses failed to reveal a consistent source of heterogeneity. CONCLUSIONS: This is the first meta-analysis on the prevalence of a prodrome prior to the onset of first episode psychosis. The majority of patients (78.3%) were found to have experienced a prodrome prior to psychosis onset. However, findings are highly heterogenous across study and no definitive source of heterogeneity was found despite extensive subgroup analyses. As most studies were retrospective in nature, recall bias likely affects these results. While the large majority of patients with psychosis experience a prodrome in some form, it is unclear if the remainder of patients experience no prodrome, or if ascertainment methods employed in the studies were not sensitive to their experiences. Given widespread investment in indicated prevention of psychosis through prospective identification and intervention during the prodrome, a resolution of this question as well as a consensus definition of the prodrome is much needed in order to effectively direct and organize services, and may be accomplished through novel, densely sampled and phenotyped prospective cohort studies that aim for representative sampling across multiple settings.

A reduction in cigarette smoking improves health-related quality of life and does not worsen psychiatric symptoms in individuals with serious mental illness.

INTRODUCTION: Individuals with serious mental illness (SMI) smoke cigarettes at a much higher rate than the general population, increasing their risk for medical illnesses and mortality. However, individuals with SMI do not get enough support to quit smoking, partially because of concerns from medical providers that reducing smoking may worsen their symptoms or quality of life. METHODS: Veterans with SMI and nicotine dependence (n = 178) completed a 12-week smoking cessation trial (parent trial dates: 2010-2014) including assessments of smoking status, psychiatric symptoms (Brief Psychiatric Rating Scale), and quality of life (Lehman Quality of Life Interview-Short Version) at up to four time points: baseline, post-treatment, three-month follow-up, and 9-month follow-up. Bayesian multilevel modeling estimated the impact of changes in the self-reported number of cigarettes per day in the past seven days on psychiatric symptoms and quality of life. RESULTS: Between subjects, each additional pack of cigarettes smoked per day was associated with a 0.83 point higher score (95%CI: 0.03 to 1.7) on a negative symptoms scale ranging from 0 to 35. Within subjects, each one-pack reduction in the number of cigarettes smoked per day was associated with an improvement of 0.32 (95%CI = 0.12 to 0.54) on the health-related quality of life scale, which ranges from 0 to 7 points. There were no other significant between- or within-subjects effects of smoking on psychiatric symptoms or quality of life. CONCLUSIONS: Individuals with SMI and their providers should pursue smoking cessation without fear of worsening psychiatric symptoms or quality of life.

Fentanyl Exposure and Detection Strategies Utilized by Clinical Trial Participants Seeking Linkage to Opioid Use Disorder Treatment at a Syringe Service Program.

INTRODUCTION: The USA continues to face a fentanyl-driven overdose epidemic. Prior research has demonstrated users of illicit opioids are concerned about fentanyl exposure and overdose, but the strategies they report using to detect fentanyl's presence lack empirical support. This study compares self-report and biologically detected fentanyl use and investigates overdose risk and risk reduction behaviors among a sample of high-risk people who use opioids. METHODS: Structured enrollment interviews conducted as part of a larger clinical trial assessed self-reported fentanyl exposure as well as strategies used to determine believed fentanyl exposure and prevent overdose among 240 participants enrolled at a Chicago, IL syringe service program. Urinalysis measured actual fentanyl exposure. RESULTS: Most participants identified as African American (66.7%) and had considerable overdose experience (76.7% lifetime and 48% in the past year). Most also tested positive for fentanyl (93.75%) despite reporting no past year use of fentanyl or fentanyl-adulterated drugs (64.17%). The most utilized approaches reported for identifying fentanyl exposure were stronger effects of the drug (60.7%), sight or taste (46.9%), and being told by someone using the same drugs (34.2%). Few participants (14%) reported using fentanyl test strips. No significant associations were identified between self-report and urinalysis measures or urinalysis results and risk reduction strategies. CONCLUSION: This study adds to prior fentanyl exposure risk research. The disconnect between participants' fentanyl detection methods and reported overdose experiences supports the need for more research to identify and understand factors driving access and use of overdose prevention resources and strategies.

Latent class analysis of emergency department patients engaged in telehealth peer recovery support services and associations of identified classes with post-discharge outcomes.

BACKGROUND: People with substance use disorders (SUDs) frequently use emergency department (ED) services. Despite evidence demonstrating that post-discharge SUD treatment linkage effectively reduces the number of ED re-presentations, relatively few hospitals have implemented interventions to identify and connect patients with SUDs to appropriate care. ED-based peer recovery support specialist (PRSS) interventions have emerged as a promising approach for hospitals, but more research is needed to understand the extent to which these interventions meet the needs of patients who present to the ED for different reasons and with various underlying concerns. METHOD: A retrospective cohort analysis used data from a telehealth PRSS program in 15 EDs within one Indiana hospital system. The study included 2950 ED patients who engaged with telehealth PRSS services between September 2018 and September 2021. Latent class analysis identified patterns of patient characteristics associated with post-discharge PRSS engagement and ED re-presentations. Covariate predictors and distal outcomes were assessed to examine the associations between class membership, demographic factors, and patient outcomes. RESULTS: The study team selected a six-class model as the best fit for the data. Class 1, representing patients with opioid use disorder and mental health diagnoses who presented to the ED for an opioid overdose, was used as the reference class for all other statistical tests. Multinomial logistic regression analysis demonstrated significant associations between covariate predictors, outcomes, and class membership. Regression results also demonstrate PRSSs had greater success contacting patients with prior year ED use and patients with a successful post-discharge PRSS contact were less likely to re-present to the ED. CONCLUSION: Results highlight the heterogeneity of patients with SUDs and emphasize the need for tailored interventions to address patient-specific needs more effectively. They also provide support for the perceived utility of PRSS engagement for ED patients.

Emotional distress and dysregulation as treatment targets to reduce suicide in psychosis: a scoping review.

There is a pressing need for effective treatments that address the high rate of suicide observed among people with psychosis. In this scoping review we highlight two suicidogenic treatment targets that have been relatively neglected in people with psychotic disorders: emotional distress and emotion dysregulation. We review the research on these constructs in psychosis and their relationship to suicide in this population, and then make clinical recommendations based on research findings. Emotional distress and emotional dysregulation may be promising treatment targets for suicide among people with psychosis.

Research on Youth Suicide and Sexual Orientation is Impacted by High Rates of Missingness in National Surveillance Systems.

OBJECTIVE: The sexual orientation of youth who die by suicide in the United States is usually unknown. This study assessed how observed patterns of unknown sexual orientation are likely to affect research findings. METHODS: We analyzed the National Violent Death Reporting System (NVDRS) Restricted Access Dataset to assess whether sexual orientation among youth suicide decedents is disproportionately known for different demographics. We then assessed the degree to which estimated sexual minority rates would be affected if researchers were to assume either (a) that sexual orientation data is missing completely at random, or (b) that orientation information is missing at random after accounting for observed demographic patterns. RESULTS: <10% of the sample had known sexual orientation. Sexual orientation was more frequently known for females, white people, and older people, and missingness varied by geography. The choice between modeling the data as missing completely at random versus at random conditional upon demographics had a > 2-fold impact on estimated sexual minority rates among youth suicide decedents. CONCLUSION: Research on sexual orientation and youth suicide is strongly impacted by how researchers account (or do not account) for missingness.

Evaluation of post-discharge engagement for emergency department patients with opioid use history who received telehealth recovery coaching services.

BACKGROUND: In recent years, emergency departments (EDs) across the nation have implemented peer recovery coach (PRC) services to support patients who use opioids. The majority of such interventions discussed in the literature follow an in-person modality where PRCs engage patients directly at the ED bedside. However, the use of telehealth services in EDs is becoming more popular. These services connect PRCs with ED patients in real-time via secure communications technology, and very little is known about the service- and clinical-based outcomes with which they are associated. The current study sought to assess factors associated with successful post-discharge follow-up of patients with a history of opioid use who received PRC telehealth services while in the ED. METHOD: Data come from records for 917 patients who engaged with a telehealth PRC one or more times (1208 total engagements) at 1 of 13 EDs within the same health system. A multilevel Poisson regression model was used to assess the degree to which variables predicted successful post-discharge follow-up, defined as the number of times a PRC successfully spoke with the patient each month after ED discharge. RESULTS: At least one follow-up was successfully completed by a PRC for 23% of enrolled patients. Significant predictors of successful follow-up included patient employment at baseline (Incidence Rate Ratio [IRR]: 2.8, CI: 2.05-3.9), living in a rural area (IRR: 1.8, CI: 1.04-3.2), PRC provision of referrals (IRR: 1.7, CI: 1.2-2.2), number of ED encounters in the previous 365 days (IRR: 0.99, CI: 0.98-0.99), and duration of the initial PRC telehealth interaction (IRR: 0.87, CI: 0.85-0.88). CONCLUSION: Given that relationship development is a key tool in the PRC profession, understanding successful follow-up associated with telehealth engagement has unique importance. The results have potential utility for planning and implementing peer telehealth services in EDs and other locations, which is needed for the development of the PRC profession and the likely expansion of peer telehealth services.

Description of a Dialectical Behavior Therapy program in a Veterans Affairs Health Care System.

A comprehensive Dialectical Behavior Therapy (DBT) program was created within a VA Health Care System for patients with recent psychiatric hospitalization, suicidality and/or significant emotion dysregulation. The program was notable for being one of a relatively small number of comprehensive DBT programs in the VA system, and for including patients with psychosis and psychotic disorder, with a majority of patients (58%) having a documented history of psychosis or endorsing psychotic symptoms in assessments. We describe the process of creating this program at a VA medical center and present preliminary program evaluation data. All patients completed assessments of suicidality (C-SSRS), emotion dysregulation (DERS), skills use and dysfunctional coping (DBT-WCCL), borderline symptomatology (BSL-23), and depression (PHQ-9) at program entry and subsequently every 6-8 weeks through program completion. Suicide attempts and hospitalizations were also tracked. Twelve patients completed multiple (up to six) assessment timepoints, allowing for evaluation of change during treatment. Patients demonstrated improvements on most measures and no hospitalizations or suicide attempts during active treatment, and the subsample with psychosis showed average improvements on every outcome measure. Eleven of 12 patients completed a full six-month rotation.

Categorical versus dimensional models of early psychosis.

AIM: Early psychosis is typically operationalized as a categorical construct by dividing people into one of three diagnostic statuses: low-risk, clinical high-risk, and first episode psychosis. We empirically assess whether an alternative dimensional approach focused on observed symptom severity may be more desirable for clinical and research purposes. METHODS: Participants were 152 help-seeking youths ages 12-22 years old. Structured interview for psychosis risk syndromes interviews were used to obtain dimensional psychosis symptom severity ratings, and to classify participants by categorical psychosis risk status. Twenty-five participants were classified as having a diagnosable psychotic disorder, 52 participants as clinical high-risk, and 75 participants as help-seeking controls. We assessed the relation between categorical and dimensional measurements of psychosis severity, and then compared categorical versus dimensional psychosis severity in their ability to predict social and role functioning. RESULTS: On average, dimensional psychosis symptom severity increased along with categorical risk status (help-seeking control < clinical high-risk < diagnosable psychotic disorder). There was, however, considerable overlap between categories, with people at clinical high-risk being particularly hard to distinguish from people with diagnosable psychotic disorders on the basis of symptom severity. Dimensional symptom severity was more predictive of functioning than categorical risk status. CONCLUSIONS: Categorical risk status and psychosis symptom severity are related but not interchangeable, and dimensional models of psychosis may be more predictive of functional outcomes. Adopting a dimensional rather than categorical approach to the psychosis risk spectrum may facilitate better predictive models and a richer theoretical understanding of early psychosis.

Lived Experience, Research Leadership, and the Transformation of Mental Health Services: Building a Researcher Pipeline.

In recent years, investment in participatory research methods within mental health services research has grown. Participatory efforts are often limited in scope, however, and attention to research leadership is largely absent from discourse about stakeholder involvement in the United States. This Open Forum calls for investment in building a pipeline of researchers with significant psychiatric disabilities and intersecting lived experiences frequently studied in public sector services research, including homelessness, incarceration, comorbid health problems, structural racism, and poverty. A series of concrete steps are described that faculty and research leadership can take now.

Peer and Non-Peer Co-Facilitation of a Health and Wellness Intervention for Adults with Serious Mental Illness.

Peer specialists, or individuals with lived experience of mental health conditions who support the mental health recovery of others, often work side-by-side with traditional providers (non-peers) in the delivery of treatment groups. The present study aimed to examine group participant and peer provider experiences with peer and non-peer group co-facilitation. Data from a randomized controlled trial of Living Well, a peer and non-peer co-facilitated intervention for medical illness management for adults with serious mental illness, were utilized. A subset of Living Well participants (n = 16) and all peer facilitators (n = 3) completed qualitative interviews. Transcripts were coded and analyzed using a general inductive approach and thematic analysis. The complementary perspectives of the facilitators, teamwork between them, skillful group pacing, and peer facilitator self-disclosure contributed to a warm, respectful, and interactive group atmosphere, which created an environment conducive to social learning. Guidelines for successful co-facilitation emerging from this work are described.

Adolescent Suicide, Household Firearm Ownership, and the Effects of Child Access Prevention Laws.

OBJECTIVE: This study has 3 objectives: to examine the association between state-level firearm ownership and suicide among adolescents of high school age; to compare the strength of the firearm ownership-suicide association among adolescents relative to adults; and to evaluate the relationship between 11 child access prevention (CAP) laws and suicide. METHOD: Using an ecological time series cross-sectional design, we modeled suicide rates from January 1, 1991, to December 31, 2017, as a function of household firearm ownership and states' implementation of CAP provisions using fixed effect negative binomial models. RESULTS: There were 37,652 suicides among adolescents between the ages of 14 and 18 years during the study period, and more than half of all suicides (51.5%, n = 19,402) involved firearms. Each 10 percentage-point increase in states' firearm ownership was associated with a 39.3% (35.1%-43.5%) increase in firearm suicide, which in turn contributed a 6.8% (2.5%-11.1%) increase in all-cause suicide. The association between firearm ownership and suicide was approximately 2 times stronger among adolescents relative to adults. Policies mandating locks and safe storage were associated with a 13.1% (2.7%-22.3%) reduction in adolescent firearm suicide and an unexplained 8.7% (1.2%-15.7%) reduction in non-firearm suicide. CAP provisions were associated with reduced firearm suicide across the lifespan, but effects were stronger among adolescents. CONCLUSION: There is an increased risk of adolescent suicide associated with household firearm ownership, and safe storage provisions are associated with decreased adolescent firearm suicide.

Baltimore Ceasefire 365: Estimated Impact of a Recurring Community-Led Ceasefire on Gun Violence.

Objectives. To estimate the impact of recurring community-led, weekend-long ceasefires on gun violence in the City of Baltimore, Maryland.Methods. The City of Baltimore releases detailed data on all crimes occurring in the city. We compiled daily counts of fatal and nonfatal shootings occurring between January 2012 and July 2019 and fit a Bayesian model to estimate the impact of the ceasefires on gun violence during designated weekends after accounting for yearly seasonality, day of the week, calendar days, and overall time trends. We also looked at the 3-day periods following each 3-day ceasefire weekend to test for a possible postponement effect.Results. There was an estimated 52% (95% credible interval [CI] = 33%, 67%) reduction in gun violence during ceasefire days and no evidence of a postponement effect on either the next 3 days or the next 3-day weekend following each ceasefire weekend (incidence rate ratio = 0.88; 95% CI = 0.72, 1.06).Conclusions. The Baltimore Ceasefire weekends may be an effective short-term intervention for reducing gun violence. Future research should aim to understand the key components and transferability of the intervention.

Cognitive impairment and depression symptoms are independently associated with suicidal ideation in US Veterans.

Depression is associated with cognitive impairment and suicidality. The independent association between cognitive impairment and suicidality is less clear. We examined the relationship between suicidal ideation and cognitive impairment in a sample of 50 veterans with depressive disorder diagnoses. Using zero-inflated Poisson regression, the severity of suicidal ideation was negatively associated with attention (incidence rate ratio [IRR] = 0.78, p < .001), memory (IRR = 0.87, p < .001), and total cognition (IRR = 0.90, p = .007) index scores as measured by the Dementia Rating Scale 2 (DRS-2). These three indices continued to significantly predict suicidal ideation severity once depression symptoms were controlled for.

Metacognitive Capacity Is Related to Self-Reported Social Functioning and May Moderate the Effects of Symptoms on Interpersonal Behavior.

Impairments in metacognition or the ability to form integrated senses of self and others have been linked to deficits in laboratory-based measures of social functioning in schizophrenia. This study examined whether self-reported social functioning was related to metacognition in 88 adults in a nonacute phase of schizophrenia. Concurrent assessments were made of metacognition with the Metacognition Assessment Scale-Abbreviated, social functioning with the Social Functioning Scale, symptoms with the Positive and Negative Syndrome Scale, and neurocognition with the Wisconsin Card Sorting Task. Univariate correlations revealed that self-reported social functioning was related to metacognition. Symptom severity was linked to interpersonal relationships, and overall metacognition was found to significantly moderate that relationship such that the effects of symptoms on function grew less as metacognitive capacity was stronger, independent of the effects of neurocognition. This may suggest the potential of metacognitive interventions to titrate the negative effects of symptoms on social function.