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BACKGROUND: Identifying risk factors of individuals in a clinical-high-risk state for psychosis are vital to prevention and early intervention efforts. Among prodromal abnormalities, cognitive functioning has shown intermediate levels of impairment in CHR relative to first-episode psychosis and healthy controls, highlighting a potential role as a risk factor for transition to psychosis and other negative clinical outcomes. The current study used the AX-CPT, a brief 15-min computerized task, to determine whether cognitive control impairments in CHR at baseline could predict clinical status at 12-month follow-up. METHODS: Baseline AX-CPT data were obtained from 117 CHR individuals participating in two studies, the Early Detection, Intervention, and Prevention of Psychosis Program (EDIPPP) and the Understanding Early Psychosis Programs (EP) and used to predict clinical status at 12-month follow-up. At 12 months, 19 individuals converted to a first episode of psychosis (CHR-C), 52 remitted (CHR-R), and 46 had persistent sub-threshold symptoms (CHR-P). Binary logistic regression and multinomial logistic regression were used to test prediction models. RESULTS: Baseline AX-CPT performance (d-prime context) was less impaired in CHR-R compared to CHR-P and CHR-C patient groups. AX-CPT predictive validity was robust (0.723) for discriminating converters v. non-converters, and even greater (0.771) when predicting CHR three subgroups. CONCLUSIONS: These longitudinal outcome data indicate that cognitive control deficits as measured by AX-CPT d-prime context are a strong predictor of clinical outcome in CHR individuals. The AX-CPT is brief, easily implemented and cost-effective measure that may be valuable for large-scale prediction efforts.
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Disfunción Cognitiva/diagnóstico , Disfunción Cognitiva/psicología , Trastornos Psicóticos/diagnóstico , Trastornos Psicóticos/psicología , Adolescente , Adulto , Niño , Progresión de la Enfermedad , Femenino , Humanos , Modelos Logísticos , Estudios Longitudinales , Masculino , Pruebas Neuropsicológicas , Valor Predictivo de las Pruebas , Síntomas Prodrómicos , Riesgo , Adulto JovenRESUMEN
There is a substantial unmet need for mental health and substance abuse services in the USA. In 2009, the Institute of Medicine recommended increased early identification and intervention for young people with mental, emotional, and behavioral disorders. With the expansion of integrated models in primary care settings, we now have the chance to improve outcomes for young people with mental health conditions, just as we have by improving the early identification and treatment of other preventable and/or treatable conditions such as obesity, asthma, or HIV. This is a moment of great opportunity to fundamentally change how young people access mental health care in our country. Through strategic integration of care, we can increase access to care for those who would not seek out mental health services because of the stigma or inconvenience of reaching out to a mental health provider; we can identify those who need care earlier and reduce the impact of mental illness on individuals, family, and community through early identification and treatment; and we can purposefully embed integration into provider training programs for both primary care and mental health providers to ensure sustainability.
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Psiquiatría del Adolescente/educación , Psiquiatría Infantil/educación , Prestación Integrada de Atención de Salud/normas , Servicios de Salud Mental/normas , Servicios de Salud Escolar/normas , Adolescente , Niño , HumanosRESUMEN
Recreational cannabis use has recently gained considerable interest as an environmental risk factor that triggers the onset of psychosis. To date, however, the evidence that cannabis is associated with negative outcomes in individuals at clinical high risk (CHR) for psychosis is inconsistent. The present study tracked cannabis usage over a 2-year period and examined its associations with clinical and neurocognitive outcomes, along with medication rates. CHR youth who continuously used cannabis had higher neurocognition and social functioning over time, and decreased medication usage, relative to non-users. Surprisingly, clinical symptoms improved over time despite the medication decreases.
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BACKGROUND: As efforts intensify to intervene early among those at risk for psychosis, examination of the relationship between presenting psychopathology and long-term functional outcome may guide treatment decision-making and offer a means to prevent or reduce chronic disability. METHODS: Data were collected through the Early Detection and Intervention for the Prevention of Psychosis Program (EDIPPP), a multisite national trial testing the efficacy of an early intervention for youth at risk of developing psychosis. Participants were followed prospectively and completed comprehensive evaluations at 6, 12, and 24â¯months, including the Structured Interview for Prodromal Syndromes (SIPS) and the Global Social and Role Functioning Scales. The present analyses included 327 participants and examined the relationships between baseline symptoms and longitudinal global social and role functioning using a linear mixed modeling approach. RESULTS: Higher baseline negative symptoms and deteriorated thought process predicted worse social and role functioning in the follow-up period. The effect of negative symptoms on social functioning, however, was moderated by positive symptoms, and the relationship between positive symptoms and social functioning changed over time. Baseline positive symptoms, distress, and level of symptom severity were not predictors of either social or role functioning. CONCLUSIONS: Baseline negative symptoms and thought disorder appear to predict functional outcome for up to two years among adolescents and young adults at risk for psychosis. Developing effective interventions to target these symptoms may be critical to promote functional recovery among those experiencing attenuated symptoms or a first episode of psychosis.
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Intervención Médica Temprana , Evaluación de Resultado en la Atención de Salud , Trastornos Psicóticos/fisiopatología , Trastornos Psicóticos/terapia , Adolescente , Adulto , Susceptibilidad a Enfermedades , Femenino , Estudios de Seguimiento , Humanos , Estudios Longitudinales , Masculino , Riesgo , Adulto JovenRESUMEN
Cognitive deficits have an important role in the neurodevelopment of schizophrenia and other psychotic disorders. However, there is a continuing debate as to whether cognitive impairments in the psychosis prodrome are stable predictors of eventual psychosis or undergo a decline due to the onset of psychosis. In the present study, to determine how cognition changes as illness emerges, we examined baseline neurocognitive performance in a large sample of helping-seeking youth ranging in clinical state from low-risk for psychosis through individuals at clinical high-risk (CHR) for illness to early first-episode patients (EFEP). At baseline, the MATRICS Cognitive Consensus battery was administered to 322 individuals (205 CHRs, 28 EFEPs, and 89 help-seeking controls, HSC) that were part of the larger Early Detection, Intervention and Prevention of Psychosis Program study. CHR individuals were further divided into those who did (CHR-T; n = 12, 6.8%) and did not (CHR-NT, n = 163) convert to psychosis over follow-up (Mean = 99.20 weeks, SD = 21.54). ANCOVAs revealed that there were significant overall group differences (CHR, EFEP, HSC) in processing speed, verbal learning, and overall neurocognition, relative to healthy controls (CNTL). In addition, the CHR-NTs performed similarly to the HSC group, with mild to moderate cognitive deficits relative to the CTRL group. The CHR-Ts mirrored the EFEP group, with large deficits in processing speed, working memory, attention/vigilance, and verbal learning (>1 SD below CNTLs). Interestingly, only verbal learning impairments predicted transition to psychosis, when adjusting for age, education, symptoms, antipsychotic medication, and neurocognitive performance in the other domains. Our findings suggest that large neurocognitive deficits are present prior to illness onset and represent vulnerability markers for psychosis. The results of this study further reinforce that verbal learning should be specifically targeted for preventive intervention for psychosis.
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Cognición , Trastornos Psicóticos/psicología , Adolescente , Antidepresivos/uso terapéutico , Antipsicóticos/uso terapéutico , Disfunción Cognitiva , Progresión de la Enfermedad , Femenino , Estudios de Seguimiento , Humanos , Masculino , Análisis Multivariante , Pruebas Neuropsicológicas , Aceptación de la Atención de Salud , Síntomas Prodrómicos , Modelos de Riesgos Proporcionales , Trastornos Psicóticos/terapia , Riesgo , Esquizofrenia/terapia , Psicología del EsquizofrénicoRESUMEN
The New Freedom Commission has called for a transformation in the delivery of mental health services in this country. The commission's report and recommendations have highlighted the role of school mental health services in transforming mental health care for children and adolescents. This article examines the intersection of school mental health programs and the commission's recommendations in order to highlight the role of school mental health in the transformation of the child and adolescent mental health system. Schools are uniquely positioned to play a central role in improving access to child mental health services and in supporting mental health and wellness as well as academic functioning of youths. The New Freedom Commission report articulated several goals related to school mental health: reducing stigma, preventing suicide, improving screening and treating co-occurring disorders, and expanding school mental health programs. The authors suggest strategies for change, including demonstrating relevance to schools, developing consensus among stakeholders, enhancing community mental health-school connections, building quality assessment and improvement, and considering the organizational context of schools.
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Servicios de Salud Mental/organización & administración , Servicios de Salud Escolar , Adolescente , Comités Consultivos , Niño , Humanos , Trastornos Mentales/diagnóstico , Trastornos Mentales/prevención & control , Trastornos Mentales/terapia , Innovación Organizacional , Estados Unidos , Prevención del SuicidioRESUMEN
OBJECTIVE: The purpose of this study was to understand stakeholder perspectives on school mental health and the mental health system as they relate to the goals identified by the President's New Freedom Commission on Mental Health. METHODS: A total of 11 focus groups were held in Maryland, Ohio, and New Mexico with groups of parents, youths, school- and community-based providers and staff, and child and school mental health advocates and leaders. Across the three sites, 105 individuals participated in the focus groups. RESULTS: The stakeholders provided several important recommendations to advance the field of mental health. They included addressing stigma, implementing culturally competent care, providing mental health training to school staff, and increasing collaboration between community providers. CONCLUSIONS: Obtaining the views of key stakeholders is critical to transforming the mental health system and expanding the focus on mental health in schools.
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Comités Consultivos , Directrices para la Planificación en Salud , Servicios de Salud Mental/organización & administración , Instituciones Académicas , Adolescente , Niño , Grupos Focales , Humanos , Estados UnidosRESUMEN
This column describes the first year of efforts in New Mexico to reform the behavioral health system. The process, guided by principles of cultural exchange theory, seeks to establish a "collaborative culture" among all stakeholders involved, including state agencies, consumers, families, advocates, and providers. Challenges have included inadequate system funding; insufficient development of skill sets among state personnel; underestimation of time and labor needed to address complex tasks; varying federal statutory and funder requirements for individual agencies; lack of a solid infrastructure for data collection, management, and dissemination; and clear definitions of the roles and relationships of local stakeholders to the state leadership group.
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Medicina de la Conducta , Reforma de la Atención de Salud/organización & administración , Diversidad Cultural , Humanos , New Mexico , Salud PúblicaRESUMEN
BACKGROUND: This article discusses the importance of screening students in schools for emotional/behavioral problems. METHODS: Elements relevant to planning and implementing effective mental health screening in schools are considered. Screening in schools is linked to a broader national agenda to improve the mental health of children and adolescents. Strategies for systematic planning for mental health screening in schools are presented. RESULTS: Mental health screening in schools is a very important, yet sensitive, agenda that is in its very early stages. Careful planning and implementation of mental health screening in schools offers a number of benefits including enhancing outreach and help to youth in need, and mobilizing school and community efforts to promote student mental health while reducing barriers to their learning. CONCLUSIONS: When implemented with appropriate family, school, and community involvement, mental health screening in schools has the potential to be a cornerstone of a transformed mental health system. Screening, as part of a coordinated and comprehensive school mental health program, complements the mission of schools, identifies youth in need, links them to effective services, and contributes to positive educational outcomes valued by families, schools, and communities.
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Tamizaje Masivo , Trastornos Mentales/diagnóstico , Servicios de Salud Mental , Servicios de Salud Escolar , Adolescente , Niño , Consejo , Humanos , Trastornos Mentales/prevención & control , Evaluación de Programas y Proyectos de Salud , Estados UnidosRESUMEN
AIM: The Scale of Prodromal Symptoms (SOPS) was developed to identify individuals experiencing early signs of psychosis, a critical first step towards early intervention. Preliminary dimension reduction analyses suggested that psychosis-risk symptoms may deviate from the traditional symptom structure of schizophrenia, but findings have been inconsistent. This study investigated the phenomenology of psychosis risk symptoms in a large sample from a multi-site, national study using rigorous factor analysis procedure. METHODS: Participants were 334 help-seeking youth (age: 17.0 ± 3.3) from the Early Detection and Intervention for the Prevention of Psychosis Program, consisting of 203 participants at clinically higher risk (sum of P scores ≥ 7), 87 with clinically lower risk (sum of P scores < 7) and 44 in very early first-episode psychosis (<30 days of positive symptoms). Baseline SOPS data were subjected to principal axis factoring (PAF), estimating factors based on shared variance, with Oblimin rotation. RESULTS: PAF yielded four latent factors explaining 36.1% of total variance: positive symptoms; distress; negative symptoms; and deteriorated thought process. They showed reasonable internal consistency and good convergence validity, and were not orthogonal. CONCLUSIONS: The empirical factors of the SOPS showed similarities and notable differences compared with the existing SOPS structure. Regrouping the symptoms based on the empirical symptom dimensions may improve the diagnostic validity of the SOPS. Relative prominence of the factors and symptom frequency support early identification strategies focusing on positive symptoms and distress. Future investigation of long-term functional implications of these symptom factors may further inform intervention strategies.
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Diagnóstico Precoz , Intervención Médica Temprana , Síntomas Prodrómicos , Escalas de Valoración Psiquiátrica/estadística & datos numéricos , Trastornos Psicóticos/diagnóstico , Trastornos Psicóticos/terapia , Adolescente , Femenino , Humanos , Masculino , Aceptación de la Atención de Salud , Psicometría/estadística & datos numéricos , Trastornos Psicóticos/prevención & control , Reproducibilidad de los Resultados , Adulto JovenRESUMEN
OBJECTIVE: This study assessed the effects of a community outreach and education model implemented as part of the Early Detection, Intervention and Prevention of Psychosis Program (EDIPPP), a national multisite study in six U.S. regions. METHODS: EDIPPP's model was designed to generate rapid referrals of youths at clinical high risk of psychosis by creating a network of professionals and community members trained to identify signs of early psychosis. Qualitative and quantitative data were gathered through an evaluation of outreach efforts at five sites over a two-year period and through interviews with staff at all six sites. All outreach activities to groups (educational, medical, and mental health professionals; community groups; media; youth and parent groups; and multicultural communities) were counted for the six sites to determine correlations with total referrals and enrollments. RESULTS: During the study period (May 2007-May 2010), 848 formal presentations were made to 22,840 attendees and 145 informal presentations were made to 11,528 attendees at all six sites. These presentations led to 1,652 phone referrals. A total of 520 (31%) of these individuals were offered in-person orientation, and 392 (75%) of those were assessed for eligibility. A total of 337 individuals (86% of those assessed) met criteria for assignment to the EDIPPP study. CONCLUSIONS: EDIPPP's outreach and education model demonstrated the effectiveness of following a protocol-defined outreach strategy combined with flexibility to reach culturally diverse audiences or initially inaccessible systems. All EDIPPP sites yielded appropriate referrals of youths at risk of psychosis.
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Relaciones Comunidad-Institución , Diagnóstico Precoz , Trastornos Psicóticos/diagnóstico , Trastornos Psicóticos/prevención & control , Trastornos Psicóticos/terapia , Derivación y Consulta/estadística & datos numéricos , Adolescente , Adulto , Educación en Salud , Humanos , Masculino , Evaluación de Programas y Proyectos de Salud , Medición de Riesgo , Estados Unidos , Adulto JovenRESUMEN
OBJECTIVE: As part of the second phase of the North American Prodrome Longitudinal Study (NAPLS-2), Cannon and colleagues report, concurrently with the present article, on a risk calculator for the individualized prediction of a psychotic disorder in a 2-year period. The present study represents an external validation of the NAPLS-2 psychosis risk calculator using an independent sample of patients at clinical high risk for psychosis collected as part of the Early Detection, Intervention, and Prevention of Psychosis Program (EDIPPP). METHOD: Of the total EDIPPP sample of 210 subjects rated as being at clinical high risk based on the Structured Interview for Prodromal Syndromes, 176 had at least one follow-up assessment and were included in the construction of a new prediction model with six predictor variables in the NAPLS-2 psychosis risk calculator (unusual thoughts and suspiciousness, symbol coding test performance, verbal learning test performance, decline in social functioning, baseline age, and family history). Discrimination performance was assessed with the area under the receiver operating characteristic curve (AUC). The NAPLS-2 risk calculator was then used to generate a psychosis risk estimate for each case in the external validation sample. RESULTS: The external validation model showed good discrimination, with an AUC of 0.790 (95% CI=0.644-0.937). In addition, the personalized risk generated by the risk calculator provided a solid estimation of the actual conversion outcome in the validation sample. CONCLUSIONS: Two independent samples of clinical high-risk patients converge to validate the NAPLS-2 psychosis risk calculator. This prediction calculator represents a meaningful step toward early intervention and the personalized treatment of psychotic disorders.
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Modelos Psicológicos , Valor Predictivo de las Pruebas , Síntomas Prodrómicos , Trastornos Psicóticos/diagnóstico , Adolescente , Adulto , Niño , Diagnóstico Precoz , Femenino , Humanos , Estudios Longitudinales , Masculino , Escalas de Valoración Psiquiátrica , Factores de Riesgo , Adulto JovenRESUMEN
OBJECTIVE: To test effectiveness of the Early Detection, Intervention, and Prevention of Psychosis Program in preventing the onset of severe psychosis and improving functioning in a national sample of at-risk youth. METHODS: In a risk-based allocation study design, 337 youth (age 12-25) at risk of psychosis were assigned to treatment groups based on severity of positive symptoms. Those at clinically higher risk (CHR) or having an early first episode of psychosis (EFEP) were assigned to receive Family-aided Assertive Community Treatment (FACT); those at clinically lower risk (CLR) were assigned to receive community care. Between-groups differences on outcome variables were adjusted statistically according to regression-discontinuity procedures and evaluated using the Global Test Procedure that combined all symptom and functional measures. RESULTS: A total of 337 young people (mean age: 16.6) were assigned to the treatment group (CHR + EFEP, n = 250) or comparison group (CLR, n = 87). On the primary variable, positive symptoms, after 2 years FACT, were superior to community care (2 df, p < .0001) for both CHR (p = .0034) and EFEP (p < .0001) subgroups. Rates of conversion (6.3% CHR vs 2.3% CLR) and first negative event (25% CHR vs 22% CLR) were low but did not differ. FACT was superior in the Global Test (p = .0007; p = .024 for CHR and p = .0002 for EFEP, vs CLR) and in improvement in participation in work and school (p = .025). CONCLUSION: FACT is effective in improving positive, negative, disorganized and general symptoms, Global Assessment of Functioning, work and school participation and global outcome in youth at risk for, or experiencing very early, psychosis.
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Antipsicóticos/uso terapéutico , Servicios Comunitarios de Salud Mental/métodos , Terapia Familiar/métodos , Trastornos Psicóticos/prevención & control , Adolescente , Adulto , Ansiolíticos/uso terapéutico , Antidepresivos/uso terapéutico , Antimaníacos/uso terapéutico , Trastornos de Ansiedad/tratamiento farmacológico , Trastornos de Ansiedad/psicología , Niño , Diagnóstico Precoz , Intervención Médica Temprana , Empleos Subvencionados , Femenino , Humanos , Estudios Longitudinales , Masculino , Trastornos del Humor/tratamiento farmacológico , Trastornos del Humor/psicología , Trastornos Psicóticos/psicología , Índice de Severidad de la Enfermedad , Resultado del Tratamiento , Adulto JovenRESUMEN
As the size of functional and structural MRI datasets expands, it becomes increasingly important to establish a baseline from which diagnostic relevance may be determined, a processing strategy that efficiently prepares data for analysis, and a statistical approach that identifies important effects in a manner that is both robust and reproducible. In this paper, we introduce a multivariate analytic approach that optimizes sensitivity and reduces unnecessary testing. We demonstrate the utility of this mega-analytic approach by identifying the effects of age and gender on the resting-state networks (RSNs) of 603 healthy adolescents and adults (mean age: 23.4 years, range: 12-71 years). Data were collected on the same scanner, preprocessed using an automated analysis pipeline based in SPM, and studied using group independent component analysis. RSNs were identified and evaluated in terms of three primary outcome measures: time course spectral power, spatial map intensity, and functional network connectivity. Results revealed robust effects of age on all three outcome measures, largely indicating decreases in network coherence and connectivity with increasing age. Gender effects were of smaller magnitude but suggested stronger intra-network connectivity in females and more inter-network connectivity in males, particularly with regard to sensorimotor networks. These findings, along with the analysis approach and statistical framework described here, provide a useful baseline for future investigations of brain networks in health and disease.
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Because the majority of children with mental health needs are most likely to receive treatment in a school setting, there is a long history of linking child and adolescent psychiatrists to schools. Psychiatrists traditionally have been involved in assessing, diagnosing, and treating the severely mentally ill or consulting with school-based providers. With no end in sight to the dearth of child and adolescent psychiatrists, not to mention child and adolescent behavioral health providers in other disciplines, this role has been broadened in recent years by several programs in which the child and adolescent psychiatrist provides flexible, population-based, systemic, and context-specific approaches to working in schools. In this article, the authors first review some of the traditional roles for child and adolescent psychiatrists working in school mental health settings. Then 2 national programs are highlighted, which successfully integrate psychiatrist trainees into comprehensive school mental health programs. The theoretical approach to a specific community-oriented, strengths-based model for school mental health support used in New Mexico by the University of New Mexico (UNM) Psychiatry Department's Center for Rural and Community Behavioral Health school telepsychiatry program, which supports rural and frontier school mental health programs and school-based health centers, is discussed in detail. The UNM model involves a strength-and resiliency-based collaboration between the child and adolescent psychiatrist, students, families, educators, and those who support them. The psychiatrist co-creates a "community of concern" and support for students, including not only customary participants such as parents, educators, and health care providers but also peers, families of choice, lay professionals, community gatekeepers, and others identified by the student as critical to his or her well-being. The advantages for child and adolescent psychiatry trainees being exposed to a wider variety of potential roles working with schools are also discussed.
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Psiquiatría del Adolescente/tendencias , Psiquiatría Infantil/tendencias , Servicios Comunitarios de Salud Mental/tendencias , Liderazgo , Rol del Médico , Servicios de Salud Escolar/tendencias , Adolescente , Psiquiatría del Adolescente/educación , Niño , Psiquiatría Infantil/educación , Conducta Cooperativa , Curriculum/tendencias , Predicción , Humanos , Comunicación Interdisciplinaria , Internado y Residencia/tendencias , Derivación y Consulta/tendenciasRESUMEN
OBJECTIVE: To determine changes in psychotropic medication use before and after juvenile justice incarceration, contrasting stays in long-stay commitment facilities and short-stay detention facilities. DESIGN: Statewide administrative data (July 1, 1998, through June 30, 2003) from the Florida Department of Juvenile Justice and Florida Medicaid. Medication prescriptions filled before entry and after release from facilities were determined based on paid claims. Psychotropic medication was categorized by drug class based on the National Drug Code. SETTING: General community services. PARTICIPANTS: All of the Medicaid-enrolled youth aged 11 to 17 years identified as having a stay in a juvenile justice facility. The total sample included 67 819 detention stays and 59 918 commitment stays. Main Exposure Incarceration in juvenile commitment and detention facilities. Main Outcome Measure Filled prescriptions for psychotropic medication by class 30 and 90 days before and after incarceration. RESULTS: Ninety days prior to detention, 3666 youth (5.4%) had psychotropic drug claims. Among these, 2296 (62.6%) had any psychotropic medication claims in the 30 days after release. Among commitment cases, 29.6% continued medication use after release. Onset of medication use after release from detention and commitment facilities was relatively uncommon (1.7% and 1.9%, respectively). Youth in commitment facilities were less likely than youth in detention facilities to resume their medication use across drug classes after 30 days (chi(2)(3) = 6.28; P = .04) and after 90 days (chi(2)(2) = 7.62; P = .02). CONCLUSIONS: The results find greater support for a disruption effect than a discovery effect from incarceration. The findings suggest several areas for further investigation and improvement of services for incarcerated youth.