Validation francophone de la CASIG-rev ­ un outil clinique visant à soutenir le rétablissement des personnes avec un trouble psychiatrique: French validation of the CASIG-rev ­ a clinical personal recovery assessment for people with psychiatric disorders.

OBJECTIVE: There are few tools capable of measuring the personal recovery of individuals presenting with mental disorders that take into account the various dimensions of recovery. Personal recovery encompasses several objectives at the level of autonomy, positive interpersonal relationships, mental and physical health, self-acceptance, the school/professional domain, as well as developing a life project. A team of practitioners and researchers from four countries (Canada, Belgium, France, and Switzerland) adapted the Client Assessment of Strengths, Interests, and Goals (CASIG) tool to more accurately measure these different aspects of personal recovery. This study aims to validate the revised version of CASIG (CASIG-rev) in French, in terms of construct validity, test-retest reliability, convergent validity, and clinical sensitivity to change. METHOD: A total of 272 individuals were recruited across different French-speaking countries to respond to the CASIG-rev online, as well as Ryff's well-being measure, the Recovery Assessment Scale, and the WHODAS. A subgroup of 29 individuals responded again to the CASIG-rev after 1 month (for temporal stability), and 24 again at six months (for sensitivity to change). RESULTS: The confirmatory factor analysis suggests a 5-factor model, very similar to the initially proposed model of 6 factors. Convergent validity was demonstrated between the subscales of tools measuring similar concepts, and test-retest reliability was proven for the majority of scales. The CASIG-rev also appears to be sensitive to clinical or rehabilitation changes, notably at the level of the life project. CONCLUSION: This study supports the use of the CASIG-rev in French to measure the recovery of individuals presenting with mental disorders, as well as to support practitioners in the evaluation of their programs and interventions. Limitations, as well as the tool's relevance, are presented. An English validation is underway to make the CASIG-rev available in Anglo-Saxon countries.

OBJECTIF: Il existe peu d'outils capables de mesurer le rétablissement des individus présentant des troubles mentaux en tenant compte des différentes dimensions du rétablissement. Cependant, le rétablissement englobe plusieurs objectifs au niveau de l'autonomie, des relations interpersonnelles positives, de la santé mentale et physique, de l'acceptation de soi, du domaine professionnel, ainsi que de la conception d'un projet de vie. Une équipe d'intervenants et de chercheurs provenant de quatre pays (Canada, Belgique, France et Suisse) a adapté l'outil CASIG dans le but de mesurer de façon plus précise ces différents aspects du rétablissement personnel. Cette étude a pour but de valider la version révisée de la CASIG (CASIG-rev) en français. MÉTHODE: Un total de 272 individus ont été recrutés en ligne pour répondre à la CASIG-rev, ainsi qu'à la mesure du bien-être de Ryff, la Recovery Assessment Scale, et le WHODAS. Un sous-groupe a répondu de nouveau à la CASIG-rev après un mois (pour la stabilité temporelle), puis à six mois (pour la sensibilité au changement). RÉSULTATS: L'analyse factorielle confirmatoire suggère un modèle à cinq facteurs, très similaire au modèle initial proposé. La validité de convergence a été démontrée entre les sous-échelles des outils mesurant des concepts similaires, et la fidélité test-retest a été prouvée pour la majorité des échelles. La version révisée de la CASIG semble également sensible aux changements cliniques ou de rétablissement, notamment au niveau du projet de vie. CONCLUSION: Cette étude appuie l'utilisation de la CASIG-rev en français pour mesurer le rétablissement des personnes souffrant de troubles psychiques, ainsi que pour soutenir les intervenants dans l'évaluation de leurs programmes et interventions. Les limites de l'étude ainsi que la pertinence de cet outil sont aussi présentées. Une validation anglaise de l'outil est en cours.

Preferences of Young Adults With Psychosis for Cannabis-Focused Harm Reduction Interventions: A Cross-Sectional Study: Préférences des jeunes adultes souffrant de psychose pour les interventions de réduction des méfaits axées sur le cannabis : une étude transversale.

OBJECTIVES: Cannabis use is common in people with early-phase psychosis (EP) and is associated with worse treatment outcomes. Few targeted interventions for cannabis use behaviour in this population exist, most focusing on abstinence, none focusing on harm reduction. Many people with EP will not seek treatment for their cannabis use with current therapeutic options. Understanding preferences for cannabis-focused harm reduction interventions may be key to improving outcomes. This study aimed to determine preferences of young adults with EP who use cannabis for cannabis-focused harm reduction interventions. METHODS: Eighty-nine young adults across Canada with EP interested in reducing cannabis-related harms were recruited. An online questionnaire combining conventional survey methodology and two unique discrete choice experiments (DCEs) was administered. One DCE focused on attributes of core harm reduction interventions (DCE 1) and the second on attributes of boosters (DCE 2). We analysed these using mixed ranked-ordered logistic regression models. Preference questions using conventional survey methodology were analysed using summary statistics. RESULTS: Preferred characteristics for cannabis-focused harm reduction interventions (DCE 1) were: shorter sessions (60 min vs. 10 min, odds ratio (OR): 0.72; P < 0.001); less frequent sessions (daily vs. monthly, OR: 0.68; P < 0.001); shorter interventions (3 months vs. 1 month, OR: 0.80; P < 0.01); technology-based interventions (vs. in-person, OR: 1.17; P < 0.05). Preferences for post-intervention boosters (DCE 2) included opting into boosters (vs. opting out, OR: 3.53; P < 0.001) and having shorter boosters (3 months vs. 1 month, OR: 0.79; P < 0.01). Nearly half of the participants preferred to reduce cannabis use as a principal intervention goal (vs. using in less harmful ways or avoiding risky situations). CONCLUSIONS: Further research is required to see if technology-based harm reduction interventions for cannabis featuring these preferences translate into greater engagement and improved outcomes in EP patients.

Manualized group cognitive behavioral therapy for social anxiety in first-episode psychosis: a randomized controlled trial.

BACKGROUND: Social anxiety (SA), a prevalent comorbid condition in psychotic disorders with a negative impact on functioning, requires adequate intervention relatively early. Using a randomized controlled trial, we tested the efficacy of a group cognitive-behavioral therapy intervention for SA (CBT-SA) that we developed for youth who experienced the first episode of psychosis (FEP). For our primary outcome, we hypothesized that compared to the active control of group cognitive remediation (CR), the CBT-SA group would show a reduction in SA that would be maintained at 3- and 6-month follow-ups. For secondary outcomes, it was hypothesized that the CBT-SA group would show a reduction of positive and negative symptoms and improvements in recovery and functioning. METHOD: Ninety-six patients with an FEP and SA, recruited from five different FEP programs in the Montreal area, were randomized to 13 weekly group sessions of either CBT-SA or CR intervention. RESULTS: Linear mixed models revealed that multiple measures of SA significantly reduced over time, but with no significant group differences. Positive and negative symptoms, as well as functioning improved over time, with negative symptoms and functioning exhibiting a greater reduction in the CBT-SA group. CONCLUSIONS: While SA decreased over time with both interventions, a positive effect of the CBT-SA intervention on measures of negative symptoms, functioning, and self-reported recovery at follow-up suggests that our intervention had a positive effect that extended beyond symptoms specific to SA.ClinicalTrials.gov identifier: NCT02294409.

Problem gambling among people with first-episode psychosis: protocol for a prospective multicenter cohort study.

BACKGROUND: The limited available data suggest that the prevalence of problem gambling is increased among young adults with first-episode psychosis, possibly due in part to several risk factors for problem gambling that are common in this population. Aripiprazole, a widely used antipsychotic drug, has also been linked to cases of problem gambling, but causality remains uncertain. Although the consequences of problem gambling further hinder the recovery of people with first-episode psychosis, there is a paucity of research about this comorbidity and its risk factors. Additionally, to our knowledge, no screening instrument for problem gambling tailored to these individuals exists, contributing to its under-recognition. Further, treatment approaches for problem gambling adapted to this population are at an embryonic stage, while existing treatments effectiveness remains to be documented. Using an innovative screening and assessment procedure for problem gambling, this study aims to identify risk factors for problem gambling among people with first-episode psychosis and to document the effectiveness of standard treatment approaches. METHODS: This is a multicenter prospective cohort study conducted in two first-episode psychosis clinics, including all patients admitted between November 1st, 2019, and November 1st, 2023, followed for up to 3 years until May 1st, 2024. These 2 clinics admit approximately 200 patients annually, for an expected sample size of 800 individuals. The primary outcome is the occurrence of a DSM-5 diagnosis of gambling disorder. All patients are screened and evaluated for problem gambling using a systematic procedure at admission, and every 6 months thereafter. Socio-demographic and clinical variables are prospectively extracted from the patients' medical records. The nature and effectiveness of treatments for problem gambling offered to affected individuals are also documented from medical records. Survival analyses with Cox regression models will be used to identify potential risk factors for problem gambling. Descriptive statistics will document the effectiveness of treatments for problem gambling in this population. DISCUSSION: A better understanding of potential risk factors for problem gambling among people with first-episode psychosis will allow for better prevention and detection of this neglected comorbidity. Results of this study will also hopefully raise clinicians' and researchers' awareness and serve as the basis to adapted treatments that will better support recovery. TRIAL REGISTRATION: ClinicalTrials.gov, NCT05686772. Retrospectively registered, 9 January 2023.

Community Treatment Orders use Among Persons With a First Episode of Psychosis in Quebec.

OBJECTIVES: Specialized early intervention for psychosis can reduce the duration of untreated psychosis and improve clinical and functional outcomes. However, poor adherence to treatment is frequent. The literature on community treatment orders (CTOs) use in first-episode psychosis (FEP) as a means to improve treatment adherence is limited. In the context of early intervention for psychosis services (EIS), this study aims to describe (1) the frequency of CTOs utilisation, (2) the trend of CTOs use over time, (3) the timing and reasons for requesting CTOs and (4) the baseline characteristics of FEP patients on CTOs compared to those who were not. METHOD: A 5-year prospective longitudinal study describing the use of CTOs among persons with FEP admitted to two urban EIS in Montreal, Quebec, from 2005 to 2013. At admission, and then annually for 5 years, CTOs data were collected through chart review. Baseline characteristics, assessed by patient interviews, standardized questionnaires and chart review, included socio-demographic data, illness severity, functioning and alcohol and substance use. Descriptive analyses were performed, and FEP patients on CTOs during follow-up and those who were not were compared using analyses of variance, chi-square test and multivariate logistic regression. RESULTS: Among 567 FEP patients, 19.2% were placed on CTOs. The main reasons for requesting CTOs were to prevent further deterioration in mental state, social functioning, harmful behaviours to self and others and homelessness. FEP patients on CTOs had poorer premorbid and baseline functioning, more severe symptoms and social dysfunction at admission, including legal problems and homelessness. CONCLUSIONS: CTOs can be a tool to improve adherence to treatment, which is crucial for relapse prevention in FEP. However, since it is a coercive method that limits a person's fundamental rights, further research is warranted to assess its impact on patients' lives, clinical and functional outcomes, as well as patients' and carers' perception.

Heterogeneity in the Course of Suicidal Ideation and its Relation to Suicide Attempts in First-Episode Psychosis: A 5-Year Prospective Study.

OBJECTIVES: Although the risk of suicide is high in first-episode psychosis (FEP), little is known about the course of suicidal ideation and its relation to suicide attempts. Therefore, we aimed to identify 5-year trajectories of suicidal ideation and associated factors in FEP and compare how suicide attempts were distributed across these identified trajectories. METHOD: This 5-year prospective study assessed suicidal ideation, suicide attempts and potentially associated factors through research interviews, chart review and coroners' reports in 382 FEP patients [mean age = 23.53 (SD = 3.61)] admitted to 2 5-year early psychosis services in Montreal, Canada. Trajectories were identified using a semiparametric mixture model, and associated factors with multinomial logistic regression. RESULTS: Three suicidal ideation trajectories were identified: low and decreasing (n = 325, 85.08%); early decline, then increasing (n = 30, 7.85%), and persistent suicidal ideation (n = 27, 7.07%). Suicidal ideation prior to admission (OR = 2.85, 95% CI, 1.23 to 6.63, P < 0.05) and cocaine use disorder (OR = 6.78, 95% CI, 1.08 to 42.75, P < 0.05) were associated with the early decline, then increasing suicidal ideation trajectory. Persons with prior suicide ideation (OR = 4.33, 95% CI, 1.66 to 11.29, P < 0.05) and attempts (OR = 8.18, 95% CI, 2.39 to 27.97, P < 0.001) and alcohol use disorder (OR = 3.63, 95% CI, 1.4 to 9.42, P < 0.05) were more likely to belong to the persistent suicidal ideation trajectory, and to attempt suicide during follow-up. CONCLUSIONS: Our study highlights heterogeneity in the course of suicidal ideation over 5 years and the importance of ongoing assessment of suicidal risk in FEP patients, particularly for patients who persistently report suicidal ideation, as they are likelier to engage in suicide attempts. Patients with factors associated with increasing or persistent suicidal ideation trajectories should be targeted for suicide prevention interventions from the early phase of follow-up. Given the small number of persons in these trajectories and the wide CIs for some factors, larger studies are however needed to further characterize who belongs in each group.

Impact of early use of long-acting injectable antipsychotics on functional outcome in first episode psychosis: a 3-year longitudinal study.

OBJECTIVES: To describe, in a naturalistic setting, the impact of the early use of LAI-AP on functional outcomes of early psychosis patients as compared to oral antipsychotics (OAP). METHODS: Longitudinal prospective 3-year naturalistic study of all consecutive admissions (n = 416) to two Early intervention services (EIS) for psychosis comparing baseline characteristics and the evolution of global functioning, occupation (work and studies), and living arrangements autonomy according to the route of administration of the antipsychotic medication. The cohort was divided into four groups: LAI-AP first (started on LAI-AP and later received OAP), OAP first, LAI-AP only, and OAP only. RESULTS: Global assessment of functioning (GAF) improved in all groups, but our mixed-effect model did not show any significant association between the route of administration and the GAF outcome. The LAI-AP only group was significantly less likely to have extreme residential instability at 3 years than the other groups despite its highest proportion of homeless youth and their poor prognostic factors at baseline. CONCLUSIONS: Our naturalistic study suggests a significant protective effect of LAI-AP on extreme residential instability for the most vulnerable patients, but no impact of the first AP administration route on other functional outcomes was observed at 3 years of follow-up. Key pointsLong-acting injectable antipsychotics seem promising to avoid extreme residential instability in early psychosis.Global assessment of functioning (GAF) improved in all groups.There was no significant association between the first route of administration and global functionning.

Unfinished business: Functional outcomes in a randomized controlled trial of a three-year extension of early intervention versus regular care following two years of early intervention for psychosis.

OBJECTIVE: To investigate whether first-episode psychosis patients receiving extended early intervention had better functional outcomes than those in regular care and to examine the predictors of functional outcomes. METHODS: This is a randomized controlled single-blind trial of 220 patients randomized after 2 years of early intervention to receive early intervention or regular care for the subsequent 3 years. Outcomes included cumulative time in functional recovery during the 3-year trial assessed using the Social and Occupational Functioning Assessment Scale (SOFAS); and employment/education at last assessment which were, respectively, analyzed using multiple linear regression and logistic regression, accounting for well-known predictors. Linear mixed and generalized linear models were also used to examine the course of SOFAS and employment/education over the 3-year period. RESULTS: The extended early intervention and regular care groups did not differ on time in functional recovery (mean = 50.17 weeks, SD = 46.62 vs. mean = 46.18 weeks, SD = 51.54); percent employed/in school (60.4% vs. 68.8%) or change in SOFAS or employment/education status over time. SOFAS scores were stable between years 2 and 5. Individuals with longer periods of total symptom remission experienced significantly longer periods of functional recovery and were likelier to be employed/in school. Those who had completed high school were nine times likelier to be employed/studying. CONCLUSION: Most individuals maintained functional gains accrued from 2 years of early intervention with no further improvement whether in extended early intervention or regular care. There was a gap between symptomatic and functional recovery, and one-third were unemployed/not in school at year 5. The lack of additional progress even in extended early intervention suggests that specific interventions addressing functional roles need to be provided beyond the first 2 years of early intervention. Sustaining symptom remission and high-school completion may be additional avenues for targeting functional recovery.

The Impact of Policy Changes, Dedicated Funding and Implementation Support on Early Intervention Programs for Psychosis.

INTRODUCTION: Early intervention services for psychosis (EIS) are associated with improved clinical and economic outcomes. In Quebec, clinicians led the development of EIS from the late 1980s until 2017 when the provincial government announced EIS-specific funding, implementation support and provincial standards. This provides an interesting context to understand the impacts of policy commitments on EIS. Our primary objective was to describe the implementation of EIS three years after this increased political involvement. METHODS: This cross-sectional descriptive study was conducted in 2020 through a 161-question online survey, modeled after our team's earlier surveys, on the following themes: program characteristics, accessibility, program operations, clinical services, training/supervision, and quality assurance. Descriptive statistics were performed. When relevant, we compared data on programs founded before and after 2017. RESULTS: Twenty-eight of 33 existing EIS completed the survey. Between 2016 and 2020, the proportion of Quebec's population having access to EIS rose from 46% to 88%; >1,300 yearly admissions were reported by surveyed EIS, surpassing governments' epidemiological estimates. Most programs set accessibility targets; adopted inclusive intake criteria and an open referral policy; engaged in education of referral sources. A wide range of biopsychosocial interventions and assertive outreach were offered by interdisciplinary teams. Administrative/organisational components were less widely implemented, such as clinical/administrative data collection, respecting recommended patient-to-case manager ratios and quality assurance. CONCLUSION: Increased governmental implementation support including dedicated funding led to widespread implementation of good-quality, accessible EIS. Though some differences were found between programs founded before and after 2017, there was no overall discernible impact of year of implementation. Persisting challenges to collecting data may impede monitoring, data-informed decision-making, and quality improvement. Maintaining fidelity and meeting provincial standards may prove challenging as programs mature and adapt to their catchment area's specificities and as caseloads increase. Governmental incidence estimates may need recalculation considering recent epidemiological data.

Economic Evaluation of Early Psychosis Interventions From A Canadian Perspective.

BACKGROUND: Compared to treatment as usual (TAU), early psychosis intervention programs (EPI) have been shown to reduce mortality, hospitalizations and days of assisted living while improving employment status. AIMS: The study aim was to conduct a cost-benefit analysis (CBA) and a cost-effectiveness analysis (CEA) to compare EPI and TAU in Canada. METHODS: A decision-analytic model was used to estimate the 5-year costs and benefits of treating patients with a first episode of psychosis with EPI or TAU. EPI benefits were derived from randomized controlled trials (RCTs) and Canadian administrative data. The cost of EPI was based on a published survey of 52 EPI centers in Canada while hospitalizations, employment and days of assisted living were valued using Canadian unit costs. The outcomes of the CBA and CEA were expressed in terms of net benefit (NB) and incremental cost per life year gained (LYG), respectively. Scenario analyses were conducted to examine the impact of key assumptions. Costs are reported in 2019 Canadian dollars. RESULTS: Base case results indicated that EPI had a NB of $85,441 (95% CI: $41,140; $126,386) compared to TAU while the incremental cost per LYG was $26,366 (95% CI: EPI dominates TAU (less costs, more life years); $102,269). In all sensitivity analyses the NB of EPI remained positive and the incremental cost per LYG was less than $50,000. CONCLUSIONS: In addition to EPI demonstrated clinical benefits, our results suggest that large-scale implementation of EPI in Canada would be desirable from an economic point of view .

Long term course and outcome of first episode schizophrenia: a 27-to-31-year follow-up.

PURPOSE: To describe long term clinical and functional outcomes of schizophrenia in a developed country. METHOD: Long term longitudinal study of clinical and functional outcomes of incidence cohort of all consecutive admissions for a first hospitalization for schizophrenia between 1983 and 1987 in Montreal, Canada (n = 142). Data collection was conducted at admission, 5 years, 10-16 years and 27-31 years follow-up by reviewing hospital charts and government linked health administrative databases. RESULTS: One fifth of patients were never re-hospitalized and 35% were still in contact with the same catchment area psychiatric services. Thirty-four (24%) died on average at 45.5 years. Fourteen (9.9%) died by suicide; half of them did so 10 years after their first hospitalization. Over 20% were exposed to clozapine and nearly 50% to long-acting injectable antipsychotic medication. There were no inmates; an estimated one fifth might be inferred to be living in supervised residential settings and the rest lived alone or with family. Approximately three quarters of the patients under 65 were receiving social assistance benefits at study's end. From 15 to 25% might have been employed (supported or competitive employment). CONCLUSION: This study confirms that the long-term course of schizophrenia is heterogenous and mostly positive with most patients living in the community, although a significant proportion need long term support and an important proportion experience premature death. To mitigate the persistent suicide risk and to respond to their need for support, continuous mental health professional's involvement is required for many.

Suicidality Over the First 5 Years of Psychosis: Does Extending Early Intervention Have Benefits?

OBJECTIVE: We aimed to investigate whether individuals with first-episode psychosis (FEP) receiving extended early intervention (EI) were less likely to experience suicidal ideation and behaviors than those transferred to regular care after 2 years of EI. Another objective was to examine the 5-year course of suicidality in FEP. METHODS: We conducted a secondary analysis of a randomized controlled trial where 220 patients were randomized after 2 years of EI to receive extended EI or regular care for the subsequent 3 years. Suicidality was rated using the Brief Psychiatric Rating Scale. Linear mixed model analysis was used to study time and group effects on suicidality. RESULTS: Extended EI and regular care groups did not differ on suicidality. There was a small decrease in suicidality over time, F(7, 1038) = 1.84, P = 0.077, with an immediate sharp decline within a month of treatment, followed by stability over the remaining 5 years. Patients who endorsed suicidality at entry (46.6%) had higher baseline positive, negative, and depressive symptoms. The 5-year course fell in 3 groups: never endorsed suicidality (33.9%), endorsed suicidality at low-risk levels (43.1%), and endorsed high-risk levels (23.0%). The high-risk group had a higher proportion of affective versus nonaffective psychosis diagnosis; higher baseline positive and depressive symptoms; higher 5-year mean depression scores, and fewer weeks of positive symptom remission over the 5-year course. CONCLUSIONS: The first month of treatment is a critical period for suicide risk in FEP. Although early reductions in suicidality are often maintained, our findings make the case for sustained monitoring for suicide risk management.

A systematic review of longitudinal studies of suicidal thoughts and behaviors in first-episode psychosis: course and associated factors.

PURPOSES: To better assess and reduce suicidal risk in first-episode psychosis (FEP), we aimed to investigate the evolution of suicidal thoughts and behaviors (STBs) and associated factors in FEP. METHOD: This systematic review (PROSPERO-CRD42020168050) meets PRISMA guidelines. PubMed, Medline, PsycINFO, Embase, EBM Reviews and references lists of relevant articles were searched (February 2020) to identify longitudinal studies, published in English or in French, that assessed the prevalence of STBs at entry to services and over follow-up, and examined factors associated with STBs among all persons with affective and non-affective FEP from a defined catchment area. Screening, data extraction and quality assessment using the adapted Newcastle Ottawa Scale were done independently by two reviewers. Results on prevalence and associated factors are presented by type of STB. RESULTS: Of 3,177 references, 17 studies of 11 non-overlapping samples (n = 14,907) with varying lengths of follow-up (1-41.7 years) were included. The prevalence of STBs decreased over follow-up. Up to 21.6% made at least one suicide attempt, 27% had suicidal ideation, and 1-4.3% died by suicide during follow-up. Of 53 factors assessed across studies, only male sex, depressive symptoms, and STBs occurring early during follow-up were associated with subsequent STBs. Early intervention for psychosis decreased STBs in the first three years. Other factors were assessed in a single study, yielded conflicting results, or were not associated with STBs. CONCLUSIONS: The high prevalence of STBs following onset of psychosis highlights the need for early detection and intervention and ongoing assessment of suicidal risk throughout follow-up, with attention to identified risk factors. The heterogeneity of the studies precluded a meta-analysis and several factors were each assessed by a single study. Additional well-designed longitudinal studies of STBs and associated factors are warranted.

Où en sommes-nous? An Overview of Successes and Challenges after 30 Years of Early Intervention Services for Psychosis in Quebec: Où en sommes-nous? Un aperçu des réussites et des problèmes après 30 ans de services d'intervention précoce pour la psychose au Québec.

INTRODUCTION: Over the last 30 years, early intervention services (EIS) for first-episode psychosis (FEP) were gradually implemented in the province of Quebec. Such implementation occurred without provincial standards/guidelines and policy commitment to EIS until 2017. Although the literature highlights essential elements for EIS, studies conducted elsewhere reveal that important EIS components are often missing. No thorough review of Quebec EIS practices has ever been conducted, a gap we sought to address. METHODS: Adopting a cross-sectional descriptive study design, an online survey was distributed to 18 EIS that existed in Quebec in 2016 to collect data on clinical, administrative, training, and research variables. Survey responses were compared with existing EIS service delivery recommendations. RESULTS: Half of Quebec's population had access to EIS, with some regions having no programs. Most programs adhered to essential components of EIS. However, divergence from expert recommendations occurred with respect to variables such as open referral processes and patient-clinician ratio. Nonurban EIS encountered additional challenges related to their geography and lower population densities, which impacted their team size/composition and intensity of follow-up. CONCLUSIONS: Most Quebec EIS offer adequate services but lack resources and organizational support to adhere to some core components. Recently, the provincial government has created EIS guidelines, invested in the development of new programs and offered implementation support from the National Centre of Excellence in Mental Health. These changes, along with continued mentoring and networking of clinicians and researchers, can help all Quebec EIS to attain and maintain recommended quality standards.

A Promising Route Towards Improvement of Homeless Young People's Access to Mental Health Services: The Creation and Evolution of an Outreach Service Network in Montréal.

Youth homelessness is a complex phenomenon as well as an important public health issue often compounded by mental illness of varying severity, in turn creating numerous deleterious consequences. While emergency health services usage remains high, access to mental health services is arduous and conventional interventions often fall short on providing integrated care and seldom lead to sustained positive outcomes for this group. From this observation, clinicians in Montreal, Canada, initiated collaborative meetings, eventually attended by a growing number of institutional and community stakeholders working with homeless youth. Acknowledging the unique needs of this population, the Réseau d'intervention de proximité auprès des Jeunes de la Rue (RIPAJ) or Montreal Homeless Youth Network was created to engage and seamlessly connect youth with the right resources within the network including mental health services amongst others. The genesis, philosophy and unique features of RIPAJ that allow for effective and cohesive interventions as well as future directions are discussed.

Do Mental Health Professionals Promote a Healthy Lifestyle among Individuals Experiencing Serious Mental Illness?

Purpose: While a healthy lifestyle would be an asset to people experiencing psychotic disorders, not all mental health professionals provide counselling regarding healthy behaviours, such as physical activity, healthy nutrition, and tobacco cessation. Therefore, the objective of the present study was to investigate the factors associated with health promotion practice (HPP) among mental health professionals.Methods: Cross-sectional survey including mental health professionals across the Province of Quebec (Canada). The promotion of health behaviour and the "Exercise in Mental Illness Questionnaire - Health Practitioner Version" and its adaptation for nutrition improvement and tobacco cessation were used to evaluate knowledge, beliefs, promotion behaviours, and barriers to HPP.Results: One hundred mental health professionals, most being nurses (29%) and medical doctors/psychiatrists (20%) were recruited throughout the province of Quebec (Canada). The rate of formal training among professionals was 11% for physical activity, 26% for nutrition, and 21% for tobacco cessation. Approximately 60% were promoting physical activity, 49% good nutrition, and 41% tobacco cessation. Professionals promoting healthy behaviours had a higher level of self-efficacy in HPP, were more likely to value physical health, and less likely to endorse barriers to HPP.Conclusion: Rates of formal training in lifestyle habits and health promotion (aiming at improving a healthy lifestyle in patients experiencing psychotic disorders) among mental health professionals are currently low in the Province of Quebec and need to be improved. In addition, the level of confidence and barriers that endorse healthy behaviours appear to be key factors in HPP among mental health professionals.

A minimum evaluation protocol and stepped-wedge cluster randomized trial of ACCESS Open Minds, a large Canadian youth mental health services transformation project.

BACKGROUND: Many Canadian adolescents and young adults with mental health problems face delayed detection, long waiting lists, poorly accessible services, care of inconsistent quality and abrupt or absent inter-service transitions. To address these issues, ACCESS Open Minds, a multi-stakeholder network, is implementing and systematically evaluating a transformation of mental health services for youth aged 11 to 25 at 14 sites across Canada. The transformation plan has five key foci: early identification, rapid access, appropriate care, the elimination of age-based transitions between services, and the engagement of youth and families. METHODS: The ACCESS Open Minds Research Protocol has multiple components including a minimum evaluation protocol and a stepped-wedge cluster randomized trial, that are detailed in this paper. Additional components include qualitative methods and cost-effectiveness analyses. The services transformation is being evaluated at all sites via a minimum evaluation protocol. Six sites are participating in the stepped-wedge trial whereby the intervention (a service transformation along the key foci) was rolled out in three waves, each commencing six months apart. Two sites, one high-population and one low-population, were randomly assigned to each of the three waves, i.e., randomization was stratified by population size. Our primary hypotheses pertain to increased referral numbers, and reduced wait times to initial assessment and to the commencement of appropriate care. Secondary hypotheses pertain to simplified pathways to care; improved clinical, functional and subjective outcomes; and increased satisfaction among youth and families. Quantitative measures addressing these hypotheses are being used to determine the effectiveness of the intervention. DISCUSSION: Data from our overall research strategy will help test the effectiveness of the ACCESS Open Minds transformation, refine it further, and inform its scale-up. The process by which our research strategy was developed has implications for the practice of research itself in that it highlights the need to actively engage all stakeholder groups and address unique considerations in designing evaluations of complex healthcare interventions in multiple, diverse contexts. Our approach will generate both concrete evidence and nuanced insights, including about the challenges of conducting research in real-world settings. More such innovative approaches are needed to advance youth mental health services research. TRIAL REGISTRATION NUMBER: Clinicaltrials.gov, ISRCTN23349893 (Retrospectively registered: 16/02/2017).

[Long-acting antipsychotics: The QAAPAPLE algorithm review]. / Antipsychotiques à Action Prolongée: Révision de l'algorithme QAAPAPLE.

BACKGROUND: Eight years ago, a committee of experts from 4 Quebec university psychiatry departments has provided the QAAPAPLE algorithm in order to guide clinicians in their use of long-acting antipsychotics (LAAP) for patients with psychotic disorders. OBJECTIVE: Update the QAAPAPLE algorithm. METHODS: Using a qualitative and selective literature review, the experts have focused on several aspects related to the use of LAAP and the relevance of modifying the algorithm: 1) new data on LAAP (including polypharmacy and co-prescription with clozapine, dose frequency/interval); 2) perception and attitude regarding algorithms and evidence; 3) difficulties in implementing algorithms; 4) polypharmacy involving LAAP and co-prescriptions with clozapine; 5) partner patients perspective on the algorithm. RESULTS: Thirteen meta-analysis were published and completed observational studies (including those on national registries), confirming the LAAP benefits. Literature adds specifications about using some drug associations as well as dose frequency and interval. Therefore, scientific advances have been considered to modify the algorithm. CONCLUSION: Interacting with Quebec psychiatrists, we have examined changes in prescription and literature to better understand the use of algorithm. The committee has updated the QAAPAPLE algorithm to guide clinicians in using LAAP along the path of patients with psychosis as early as the first episode and through different clinical settings (including treatment resistance) in order to have a more flexible and user-friendly treatment.

CONTEXTE: Il y a 8 ans, un comité d'experts issus des 4 départements de psychiatrie universitaires québécois a proposé l'algorithme QAAPAPLE visant à guider les cliniciens à l'égard de l'utilisation des APAP pour les patients atteints de troubles psychotiques. OBJECTIF: Faire une mise à jour de l'algorithme QAAPAPLE. MÉTHODES: Grâce à une revue qualitative et sélective de la littérature, les experts se sont intéressés à plusieurs aspects en lien avec l'utilisation des APAP et sur la pertinence de modifier l'algorithme: 1) données nouvelles sur les APAP (incluant polypharmacie et co-prescription avec clozapine, fréquence et intervalle d'administration); 2) perception et attitude sur des algorithmes et données probantes; 3) difficultés d'application des algorithmes; 4) polypharmacie impliquant les APAP et co-prescriptions avec clozapine; 5) avis des patients partenaires sur l'algorithme. RÉSULTATS: 13 méta-analyses ont été publiées et complètent les études observationnelles (incluant celles sur des registres nationaux) confirmant les avantages des APAP. La littérature apporte des précisions quant à l'utilisation de certaines associations médicamenteuses, fréquence et intervalle d'administration. L'algorithme a donc été modifié en tenant compte des avancées scientifiques. CONCLUSION: En interaction avec les psychiatres québécois, nous avons examiné les changements des prescriptions, la littérature, pour mieux comprendre l'utilisation de l'algorithme. Le comité a actualisé l'algorithme QAAPAPLE, pour mieux guider les cliniciens dans l'utilisation des APAP dans la trajectoire des patients atteints de psychoses dès le premier épisode et à travers les différents contextes cliniques (incluant la résistance au traitement) afin de le rendre plus flexible et convivial. IMPLICATIONS CLINIQUES: Les études observationnelles (naturalistes) montrent que les APAP réduisent les rechutes, les ré-hospitalisations et la surmortalité. La palette de fréquence d'injection permet des intervalles de deux semaines à trois mois, ce qui permet un ajustement aux besoins du patient en termes de stabilité clinique et de fréquence des contacts. Les APAP restent une modalité thérapeutique sous-utilisée, un algorithme peut aider à se repérer et donc en faciliter l'utilisation. LIMITES: Le comité a produit une revue de la littérature narrative et systématique, plutôt que quantitative; toutefois, il s'est complètement basé sur les conclusions des méta-analyses. La participation aux sondages reliés à ce projet demeure sous optimale. Le comité n'a pas examiné la littérature concernant les aspects spécifiques reliés à la prescription d'APAP chez les personnes âgées ou les enfants.

Early Intervention for Psychosis in Canada: What Is the State of Affairs?

OBJECTIVE: Early intervention services (EIS) for psychosis have been developed in several countries, including Canada. There is some agreement about the program elements considered essential for improving the long-term outcomes for patients in the early phase of psychotic disorders. In the absence of national standards, the current state of EIS for psychosis in Canada needs to be examined in relation to expert recommendations currently available. METHOD: A detailed online benchmark survey was developed and administered to 11 Canadian academic EIS programs covering administrative, clinical, education, and research domains. In addition, an electronic database and Internet search was conducted to find existing guidelines for EIS. Survey results were then compared with the existing expert recommendations. RESULTS: Most of the surveyed programs offer similar services, in line with published expert recommendations (i.e., easy and rapid access, intensive follow-up through case management with emphasis on patient engagement and continuity of care, and a range of integrated evidence-based psychosocial interventions). However, differences are observed among programs in admission and discharge criteria, services for patients at ultra high risk (UHR) for psychosis, patient to clinician ratios, accessibility of services, and existence of specific inpatient units. These seem to diverge from expert recommendations. CONCLUSIONS: Although Canadian programs are following most expert recommendations on clinical components of care, some programs lack administrative and organizational elements considered essential. Continued mentoring and networking of clinicians through organizations such as the Canadian Consortium for Early Intervention in Psychosis (CCEIP), as well as the development of a fidelity scale through further research, could possibly help programs attain and maintain the best standards of early intervention. However, simply making clinical guidelines available to care providers is not sufficient for changing practices; this will need to be accompanied by adequate funding and support from organizations and policy makers.

Running for your life: A review of physical activity and cardiovascular disease risk reduction in individuals with schizophrenia.

Individuals with schizophrenia have a greater risk for cardiometabolic risk factors (e.g. central obesity, insulin resistance, hypertension and dyslipidaemia), cardiovascular diseases and mortality. This risky profile may be explained by the adverse effects of antipsychotic medications and an unhealthy lifestyle (e.g. smoking, poor nutrition and low physical activity). In the general population, physical activity has been shown to be the optimal strategy to improve both cardiometabolic parameters and cardiorespiratory fitness levels. Accordingly, an emerging literature of non-pharmacological interventions (e.g. cognitive behavioural therapy, diet and physical activity) has been studied in individuals with schizophrenia. Therefore, the purpose of this review was 1) to conduct a critical literature review of non-pharmacological interventions that included some kind of physical activity (including supervised and unsupervised exercise training) and target cardiometabolic risk factors in individuals with schizophrenia. 2) To describe the contribution of physical activity alone by reviewing trials of supervised exercise training programmes only. A literature review via systematic keyword search for publications in Medline, PubMed, Embase and PsycINFO was performed. Many non-pharmacological interventions are efficient in reducing cardiovascular disease risk factors when combined with physical activity. Supervised physical activity has been successful in decreasing cardiovascular disease risk, and aerobic interval training appears to provide more benefits by specifically targeting cardiorespiratory fitness levels. In conclusion, physical activity is an effective strategy for addressing cardiovascular disease risk in individuals with schizophrenia. Long-term studies are needed to evaluate the feasibility and impact of exercise training programmes in individuals with schizophrenia.