Development of an early intervention in psychosis services fidelity questionnaire.

PURPOSE: We describe the development of an online fidelity questionnaire for early intervention in psychosis (EIP) services, to be used in population-level research, and that can be completed using self-reports from EIP staff. METHODS: A review of key literature sources on the components of EIP services was used to identify those components eligible for inclusion in the questionnaire. A modified Delphi approach, using experts in EIP services, was used to select the most important components to include in the questionnaire. To pilot test the questionnaire, two EIP staff members completed one fidelity questionnaire each, and a third questionnaire was completed by an external rater. Responses from the three sources were compared and used to revise the fidelity questionnaire. RESULTS: Twenty-two experts from England and Canada responded to two Delphi rounds, identifying the top 25 most important EIP service components. Some evidence-based components were not rated as highly as some non-evidence-based components. Pilot testing showed that the EIP staff rated fidelity higher than the external rater. Several questions were removed and/or revised based on the pilot study findings. CONCLUSIONS: Fidelity instruments are limited by the available evidence and the personal experiences of experts used to develop them. As such, fidelity instruments and EIP services should continually be updated to reflect new knowledge. The online fidelity questionnaire was a simple and efficient way to collect data. Future evaluations of the fidelity questionnaire need to ensure that externally collected fidelity data are comprehensive and accurate.

Preliminary evaluation of a questionnaire for assessing fidelity of early intervention for psychosis services.

PURPOSE: Fast, easy, and cost-effective methods are needed for fidelity assessment, quality improvement initiatives, and population-based studies in Early Intervention for Psychosis (EIP) services. Having an online questionnaire assessing the fidelity of EIP services, completed by staff self-reports, and having evidence of reliability and validity, could fill that gap. We assess the reliability and validity of the Early Intervention for Psychosis Services Fidelity Questionnaire (EIPS-FQ), developed in Part I of this set of papers. METHODS: A convenience sample of 10 EIP teams in England was used. Two staff members completed online questionnaires assessing recent and past fidelity. An external rater completed the same questionnaire for the two time periods, using a random sample of patient medical records, program documentation, and interviews with staff. The intra-class correlation coefficient (ICC) was calculated to assess inter-rater reliability. Validity was assessed using Bland-Altman plots, absolute mean differences, and the ICC. RESULTS: The fidelity score measuring recent fidelity ranged from 54.2 to 82.7, out of a possible 100. The ICC assessing reliability of the fidelity score was 0.40 (95% CI: 0.0-0.81). The ICCs for the fidelity sub-category scores ranged from 0 to 0.76. Two sub-categories, comprehensive assessments and family involvement and intervention, had low ICCs, regardless of period examined. CONCLUSIONS: This first attempt at validating the EIPS-FQ has demonstrated that the reliability of the EIPS-FQ is moderate/low, and therefore requires modification prior to use. The next iteration of the fidelity questionnaire will clarify or remove items which had very low reliability and add evidence-based components not identified in the Delphi exercise.

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).

Youth Mental Health Should Be a Top Priority for Health Care in Canada.

In this article we have provided a perspective on the importance and value of youth mental health services for society and argued that advancing youth mental health services should be the number one priority of health services in Canada. Using the age period of 12-25 years for defining youth, we have provided justification for our position based on scientific evidence derived from clinical, epidemiological and neurodevelopmental studies. We have highlighted the early onset of most mental disorders and substance abuse as well as their persistence into later adulthood, the long delays experienced by most help seekers and the consequence of such delays for young people and for society in general. We have also provided a brief review of the current gross inadequacies in access and quality of care available in Canada. We have argued for the need for a different conceptual framework of youth mental disorders as well as for a transformation of the way services are provided in order not only to reduce the unmet needs but also to allow a more meaningful exploration of the nature of such problems presenting in youth and the best way to treat them. We have offered some ideas based on previous work completed in this field as well as current initiatives in Canada and elsewhere. Any transformation of youth mental health services in Canada must take into consideration the significant geographic, cultural and political diversity across the provinces, territories and indigenous peoples across this country.

Life-Course Socioeconomic Position and Hippocampal Atrophy in a Prospective Cohort of Older Adults.

OBJECTIVE: Low socioeconomic position (SEP) has been linked to an increased risk of dementia and cognitive decline. However, little is known about the association between SEP and morphologic brain changes in older age. This study examines the relationships between indicators of life-course SEP with both hippocampal volume (HcV) and HcV loss in a population-based cohort of 1328 older adults aged 65 to 80 years. METHODS: Multivariable linear regression models were used to estimate the associations of SEP with baseline HcV and the annual rate of HcV atrophy according to three life-course conceptual models: the sensitive/critical periods model (which explored SEP in specific periods: in childhood [using parental education], early adulthood [based on participants' education], and midlife [based on participants' socioprofessional group]); the accumulation-of-risk model (life-course cumulative SEP), and the social mobility model (life-course SEP trajectories). RESULTS: Participants with lower midlife SEP had smaller HcV (-0.08 cm; 95% confidence interval, -0.15 to -0.01) and 0.17% (95% confidence interval, 0.04%-0.30%) faster hippocampal atrophy than participants with higher midlife SEP. Childhood and early adulthood SEPs were not related to hippocampal measures. The accumulation-of-risk and the social mobility models revealed that the accumulation of socioeconomic disadvantage and declining socioeconomic trajectories were related to faster hippocampal atrophy. CONCLUSIONS: In this cohort of older adults, lower socioprofessional attainment in midlife and disadvantageous life-course socioeconomic position were associated with faster hippocampal atrophy, a cerebral change linked to cognitive disorders. Results support the hypothesized links between socioenvironmental exposures related to stress and/or cognitive enrichment and brain/cognitive reserve capacities.

Hippocampal atrophy and subsequent depressive symptoms in older men and women: results from a 10-year prospective cohort.

Several studies have reported smaller hippocampal volume in patients with depression. However, the temporality of the association is undetermined. One hypothesis is that hippocampal atrophy might be a susceptibility factor for depression. In the present study, we assessed whether hippocampal atrophy was associated with subsequent depressive symptoms in a cohort of older French adults (n = 1,309) who were 65-80 years of age and enrolled into the study in 1999-2001 in Dijon, France. Subjects were followed for more than 10 years. Participants underwent 2 cerebral magnetic resonance imaging scans, one at baseline and one at the 4-year follow-up. We used linear mixed models to estimate the associations of hippocampal atrophy with 1) the average depressive symptom scores over follow-up (using the Center for Epidemiologic Studies-Depression scale) measured biennially over the subsequent 6 years and 2) changes in symptom scores over follow-up. In women, a 2-standard-deviation increase in annual hippocampal atrophy was associated with a 1.67-point (95% confidence interval: 0.59, 2.77) increase in the average depressive symptom score over follow-up and with a 1.97-point (95% confidence interval: 0.68, 3.24) increase in scores over the 2 subsequent years but not with later changes in symptoms. No association was detected in men. Accounting for potential selective attrition (using inverse probability weights) did not alter results. Hippocampal atrophy was associated with more subsequent depressive symptoms and with shorter-term worsening of symptoms in women.

Preoperative axillary ultrasound and fine-needle aspiration biopsy in the diagnosis of axillary metastases in patients with breast cancer: predictors of accuracy and future implications.

BACKGROUND: The utility of axillary lymph node dissection after sentinel lymph node biopsy has been called into question. We sought to determine the sensitivity, specificity, and accuracy of axillary ultrasound and fine-needle aspiration biopsy (FNAB) in the identification of axillary nodal metastasis in early breast cancer patients. METHODS: Data of patients with stage I and II breast cancer who underwent surgery and staging were reviewed. Axillary ultrasound findings were assessed and lymph node status recorded after axillary dissection. The data were cross-tabulated, and test characteristics were calculated. RESULTS: Of 235 patients, none demonstrated more than 2 positive sentinel lymph nodes. Ductal carcinoma was present in 68%, estrogen and progesterone receptors were positive in 81 and 64%, respectively, Her-2/neu was positive in 10%, and 36% were axillary node positive. The sensitivity and specificity of ultrasound alone were 55 and 88%, respectively. Predictors of abnormal ultrasound included size of metastasis, estrogen receptor and Her-2 status, tumor grade, and presence of lymphovascular invasion. Addition of FNAB increased the sensitivity and specificity to 69 and 100%. In conjunction with FNAB, the positive and negative predictive values were 100 and 54%, respectively. Ten percent of patients with nodal metastases demonstrated a positive FNAB. Patients with a positive FNAB did not harbor more nodal metastases or a greater proportion of gross extranodal disease compared to patients not subjected to FNAB. CONCLUSIONS: Axillary ultrasound with FNAB has an accuracy of >70% in this series. It is easily performed and may avoid unnecessary sentinel lymph node biopsy in a significant number of patients.

Parents' education and the risk of major depression in early adulthood.

BACKGROUND: Early-life low socioeconomic position (SEP) increases the risk of adult major depression; however, associations vary according to the measure of SEP and adults' life stage. Although maternal education often predicts offspring health better than other SEP indicators, including paternal education, it is unclear how maternal and paternal education differentially influence early-adult depression, and how early-life and adult risk factors may mediate the association. METHODS: Longitudinal data come from the Canadian National Population Health Survey from 1994/1995 to 2006/2007, restricted to a sample (N = 1,267) that was aged 12-24 years in 1994/1995. Past-year major depressive episode (MDE) was assessed in 2004/2005 and 2006/2007 using the Composite International Diagnostic Interview Short Form for Major Depression. Logistic regression models were used to estimate odds ratios (OR) and 95 % confidence intervals (CI) for the association between both maternal and paternal education and MDE, adjusting for respondent's demographics, early-life adversities, adult SEP, psychosocial factors, and physical health. RESULTS: Offsprings of mothers with less than secondary school education had higher odds of MDE (adjusted OR 2.04, 95 % CI 1.25-3.32) relative to those whose mothers had more education. Paternal education was not associated with MDE. Although adult income, student status, psychosocial stress, and several early-life adversities remained associated with MDE in the fully adjusted model, the estimate for maternal education was not reduced. CONCLUSIONS: Maternal education was associated with MDE in early adulthood, independent of paternal education and other early-life and early-adult risk factors.

Determinants of negative pathways to care and their impact on service disengagement in first-episode psychosis.

PURPOSE: Although there have been numerous studies on pathways to care in first-episode psychosis (FEP), few have examined the determinants of the pathway to care and its impact on subsequent engagement with mental health services. METHODS: Using a sample of 324 FEP patients from a catchment area-based early intervention (EI) program in Montréal, we estimated the association of several socio-demographic, clinical, and service-level factors with negative pathways to care and treatment delay. We also assessed the impact of the pathway to care on time to disengagement from EI services. RESULTS: Few socio-demographic or clinical factors were predictive of negative pathways to care. Rather, service-level factors, such as contact with primary care providers, have a stronger impact on patterns of health service use across multiple indicators. Patients who were in contact with primary care had a reduced likelihood of negative pathways to care, but also had longer referral delays to EI services. Socio-demographic and clinical factors were more relevant for predicting subsequent engagement with EI services, and indicators of negative pathways to care were not associated with service disengagement. CONCLUSIONS: Primary care providers may be an efficacious target for interventions aimed at reducing overall treatment delay. Increasing the uptake of primary care services may also reduce the likelihood of negative pathways to care. Our findings draw attention to the need for further investigations of the role that the primary care system plays in early intervention for FEP, and strategies for supporting service providers in this role.

Patterns of health services use prior to a first diagnosis of psychosis: the importance of primary care.

PURPOSE: The observed association between treatment delay and poor outcomes in first-episode psychosis has led to an interest in the topography of symptom development preceding the onset of psychosis and associated help-seeking behaviors. We estimated the extent to which socio-demographic, clinical, and health service indicators are associated with patterns of service use for mental health reasons preceding a first diagnosis of psychosis. METHODS: Population-based administrative data from physician billings, hospitalizations, and public health clinics were used to identify incident cases of schizophrenia-spectrum psychosis among individuals aged 14-25 years in Montréal. Mental health contacts in the 4 years preceding the index diagnosis were analyzed. RESULTS: Thirty-two percent of cases had no contact with services for a mental health reason preceding the index diagnosis, and nearly 50% received the index diagnosis of psychosis in the emergency department. Individuals in contact with primary care had a reduced likelihood of contact with the emergency department and inpatient services (OR = 0.15, 0.06-0.39) and of receiving the index diagnosis in the emergency department (OR = 0.36, 0.24-0.54), but also had a longer time to contact with a psychiatrist (HR = 0.32, 0.23-0.45). CONCLUSIONS: Improving access to primary care may reduce the burden on emergency departments and inpatient units; however, primary care providers may need additional training in the symptoms of early psychosis and referral protocols. Given the limitations associated with using clinical samples from specialized services, population-based administrative data are an important source of information for understanding patterns of health services use preceding a first diagnosis of psychosis.

"There are too many steps before you get to where you need to be": help-seeking by patients with first-episode psychosis.

BACKGROUND: There has been substantial research on pathways to care in first-episode psychosis (FEP); however, few studies have used a qualitative research paradigm or have been done from the perspective of the person experiencing the psychotic episode. OBJECTIVE: We sought to describe the experiences of patients with FEP on their pathway to care and to identify factors that help or hinder help-seeking efforts. METHODS: Using a qualitative descriptive approach, we conducted semi-structured interviews with 16 patients recruited from an early intervention program. Data were analyzed using content analysis to organize the findings into themes. FINDINGS: Self-stigma and a pervasive lack of knowledge regarding the symptoms of psychosis and availability of services were barriers to help-seeking. Participants highlighted the crucial role of significant others in initiating the help-seeking process. Participants typically described a complex series of contacts along the pathway to care which resulted in feelings of being misunderstood and losing control, but many individuals identified unexpected benefits of their experience. CONCLUSIONS: Our findings suggest a shift in the philosophy and orientation of service delivery towards the creation of services that address these concerns and are relevant to the young people who utilize them.

Repeated job strain and the risk of depression: longitudinal analyses from the Whitehall II study.

OBJECTIVES: We addressed whether repeated job strain and low work social support increase the risk of major depressive disorder (MDD). METHODS: We used work characteristics from Karasek's Job Strain model, measured on 3 occasions over 10 years in a cohort of 7732 British civil servants, to predict subsequent onset of MDD with the Composite International Diagnostic Interview. RESULTS: Repeated job strain was associated with increased risk of MDD (odds ratio [OR] = 2.19; 95% confidence interval [CI] = 1.48, 3.26; high job strain on 2 of 3 occasions vs none) in a fully adjusted model. Repeated low work social support was associated with MDD (OR = 1.61; 95% CI = 1.10, 2.37; low work social support on 2 of 3 occasions vs none). Repeated job strain remained associated with MDD after adjustment for earlier psychological distress. CONCLUSIONS: Demonstration of an increased association for repeated job strain adds to the evidence that job strain is a risk factor for depression. Recognition and alleviation of job strain through work reorganization and staff training could reduce depression in employees.

The incidence of first-episode schizophrenia-spectrum psychosis in adolescents and young adults in montreal: an estimate from an administrative claims database.

OBJECTIVE: There has been increasing interest in the psychiatric literature on research and service delivery focused on first-episode psychosis (FEP), and accurate information on the incidence of FEP is crucial for the development of services targeting patients in the early stages of illness. We sought to obtain a population-based estimate of the incidence of first-episode schizophrenia-spectrum psychosis (SSP) among adolescents and young adults in Montreal. METHODS: Population-based administrative data from physician billings, hospitalizations, pharmacies, and public health clinics were used to estimate the incidence of first-episode SSP in Montreal. A 3-year period (2004-2006) was used to identify patients with SSP aged 14 to 25 years. We used a 4- to 6-year clearance period to remove patients with a history of any psychotic disorder or prescription for an antipsychotic. RESULTS: We identified 456 patients with SSP, yielding a standardized annual incidence of 82.9 per 100 000 for males (95% CI 73.7 to 92.1), and 32.2 per 100 000 for females (95% CI 26.7 to 37.8). Using ecologic indicators of material and social deprivation, we found a higher-incidence proportion of SSP among people living in the most deprived areas, relative to people living in the least deprived areas. CONCLUSIONS: Clinical samples obtained from psychiatric services are unlikely to capture all treatment-seeking patients, and epidemiologic surveys have resource-intensive constraints, making this approach challenging for rare forms of psychopathology; therefore, population-based administrative data may be a useful tool for studying the frequency of psychotic disorders.

Impact of common mental disorders on sickness absence in an occupational cohort study.

OBJECTIVES: Common mental disorders are associated with impaired functioning and sickness absence. We examine whether sub-clinical as well as clinical psychiatric morbidity predict long spells of sickness absence for both psychiatric and non-psychiatric illness. We also examine whether recent common mental disorders and those present on two occasions have a stronger association with sickness absence than less recent and single episodes of disorder. METHODS: Common mental disorders measured by the General Health Questionnaire were linked with long spells of sickness absence in 5104 civil servants from the longitudinal Whitehall II Study. Negative binomial models were used to estimate rate ratios for long spells of sickness absence with and without a psychiatric diagnosis (mean follow-up 5.3 years). RESULTS: Clinical but not sub-threshold common mental disorders were associated with increased risk of long spells of psychiatric sickness absence for men, but not for women, after adjusting for covariates (rate ratios (RR) 1.67, 95% CI 1.13 to 2.46). Risk of psychiatric sickness absence was associated with recent common mental disorders (RR 2.08, 95% CI 1.29 to 3.35) and disorder present on two occasions (RR 1.65, 95% CI 0.98 to 2.71) for men only. Common mental disorders were not associated with increased risk of non-psychiatric sickness absence after adjustment for covariates. CONCLUSIONS: Identification and treatment of common mental disorders may reduce the economic burden of long term psychiatric sickness absence. Our results suggest that public health and clinical services should focus on the identification of workers with elevated mental health symptoms. Studies are needed of the efficacy of early identification and management of mental health symptoms for the prevention of long spells of sickness absence.