Association Between Exposure to Suicidal Behaviors and Suicide Attempts Among Adolescents: The Moderating Role of Prior Psychiatric Disorders.

Theories suggest that adolescents exposed to suicide attempts and/or deaths are at higher risk of attempting suicide, themselves. However, research findings have been mixed, with most studies not accounting for psychiatric vulnerability. We examined past psychiatric diagnosis as a moderator of the association between lifetime exposure to suicide attempts and/or deaths and adolescents' suicide attempts. Adolescents (N = 518; 60% female; 45% White), ages 12-21, reported on prior suicide ideation and attempts, and mood, anxiety, and substance use disorders at baseline. Suicide attempts since baseline and exposure to suicidal behaviors were assessed 4-6 years later. Lifetime exposure to family suicide attempts and/or suicide deaths, but not to suicidal behaviors of peers/friends or others, was associated with a suicide attempt at follow-up among those with prior psychiatric disorders. Psychologically vulnerable adolescents may require additional support after exposure to suicidal behaviors of a family member to reduce their risk of attempting suicide.

Calculating individualized risk components using a mobile app-based risk calculator for clinical high risk of psychosis: findings from ShangHai At Risk for Psychosis (SHARP) program.

BACKGROUND: Only 30% or fewer of individuals at clinical high risk (CHR) convert to full psychosis within 2 years. Efforts are thus underway to refine risk identification strategies to increase their predictive power. Our objective was to develop and validate the predictive accuracy and individualized risk components of a mobile app-based psychosis risk calculator (RC) in a CHR sample from the SHARP (ShangHai At Risk for Psychosis) program. METHOD: In total, 400 CHR individuals were identified by the Chinese version of the Structured Interview for Prodromal Syndromes. In the first phase of 300 CHR individuals, 196 subjects (65.3%) who completed neurocognitive assessments and had at least a 2-year follow-up assessment were included in the construction of an RC for psychosis. In the second phase of the SHARP sample of 100 subjects, 93 with data integrity were included to validate the performance of the SHARP-RC. RESULTS: The SHARP-RC showed good discrimination of subsequent transition to psychosis with an AUC of 0.78 (p < 0.001). The individualized risk generated by the SHARP-RC provided a solid estimation of conversion in the independent validation sample, with an AUC of 0.80 (p = 0.003). A risk estimate of 20% or higher had excellent sensitivity (84%) and moderate specificity (63%) for the prediction of psychosis. The relative contribution of individual risk components can be simultaneously generated. The mobile app-based SHARP-RC was developed as a convenient tool for individualized psychosis risk appraisal. CONCLUSIONS: The SHARP-RC provides a practical tool not only for assessing the probability that an individual at CHR will develop full psychosis, but also personal risk components that might be targeted in early intervention.

First help-seeking attempt before and after psychosis onset: measures of delay and aversive pathways to care.

PURPOSE: Delay in receiving effective treatment for psychosis adversely impacts outcomes. We investigated the timing of the first help-seeking attempt in individuals with recent onset non-affective psychosis by comparing those who sought help during the prodrome to those who sought help after psychosis onset across sociodemographic and clinical characteristics, overall functioning, and occurrence of aversive events during their pathways to care. METHODS: Patients were admitted from February 1st, 2014 to January 31st, 2019 to the Program for Specialized Treatment Early in Psychosis (STEP) in New Haven, CT. Psychosis-onset date was ascertained using the Structured Interview for Psychosis-risk Syndromes. Key dates before and after psychosis onset, along with initiators and aversive events, were collected via semi-structured interview. RESULTS: Within 168 individuals, 82% had their first help-seeking episode after psychosis onset and did not differ in terms of sociodemographic characteristics from prodrome help seekers. When the first help-seeking episode started before (i.e., during prodrome) vs after psychosis onset it was mostly initiated by patients vs family members (Cramer's V = 0.23, p = 0.031) and led to a faster prescription of an antipsychotic once full-blown psychosis emerged (time to antipsychotic since psychosis onset = 21 vs 56 days, p = 0.03). No difference in aversive events before STEP enrollment was detected across groups. CONCLUSION: Help seeking during the prodrome is associated with faster initiation of antipsychotic treatment and is more likely to be self-initiated, compared to help seeking after psychosis onset. Early detection efforts that target prodromal samples may improve the length and experience of pathways to care.

Clinical subtypes that predict conversion to psychosis: A canonical correlation analysis study from the ShangHai At Risk for Psychosis program.

OBJECTIVE: Since only 30% or fewer of individuals at clinical high risk convert to psychosis within 2 years, efforts are underway to refine risk identification strategies to increase their predictive power. The clinical high risk is a heterogeneous syndrome presenting with highly variable clinical symptoms and cognitive dysfunctions. This study investigated whether subtypes defined by baseline clinical and cognitive features improve the prediction of psychosis. METHOD: Four hundred clinical high-risk subjects from the ongoing ShangHai At Risk for Psychosis program were enrolled in a prospective cohort study. Canonical correlation analysis was applied to 289 clinical high-risk subjects with completed Structured Interview for Prodromal Syndromes and cognitive battery tests at baseline, and at least 1-year follow-up. Canonical variates were generated by canonical correlation analysis and then used for hierarchical cluster analysis to produce subtypes. Kaplan-Meier survival curves were constructed from the three subtypes to test their utility further in predicting psychosis. RESULTS: Canonical correlation analysis determined two linear combinations: (1) negative symptom and functional deterioration-related cognitive features, and (2) Positive symptoms and emotional disorganization-related cognitive features. Cluster analysis revealed three subtypes defined by distinct and relatively homogeneous patterns along two dimensions, comprising 14.2% (subtype 1, n = 41), 37.4% (subtype 2, n = 108) and 48.4% (subtype 3, n = 140) of the sample, and each with distinctive features of clinical and cognitive performance. Those with subtype 1, which is characterized by extensive negative symptoms and cognitive deficits, appear to have the highest risk for psychosis. The conversion risk for subtypes 1-3 are 39.0%, 11.1% and 18.6%, respectively. CONCLUSION: Our results define important subtypes within clinical high-risk syndromes that highlight clinical symptoms and cognitive features that transcend current diagnostic boundaries. The three different subtypes reflect significant differences in clinical and cognitive characteristics as well as in the risk of conversion to psychosis.

A comparison of neurocognition and functioning in first episode psychosis populations: do research samples reflect the real world?

PURPOSE: The current study evaluates the demographic, clinical, and neurocognitive characteristics of a recruited FEP research sample, a research control group, and a FEP clinic sample that were assessed and treated within the same center and time period. METHODS: This study utilized data collected through an observational study and a retrospective chart review. Samples were ascertained in the Longitudinal Assessment and Monitoring of Clinical Status and Brain Function in Adolescents and Adults study and the Prevention and Recovery in Early Psychosis clinic. FEP clinic patients (n = 77), FEP research participants (n = 44), and age-matched controls (n = 38) were assessed using the MATRICS consensus cognitive battery and global functioning social and role scales. Between-group differences were assessed via one-way ANOVA and Chi-square analyses. RESULTS: No significant differences were observed between groups with regard to age and gender. The FEP research sample had a higher proportion of white participants, better social and role functioning, and better neurocognitive performance when compared with the FEP clinical population. The clinic sample also had more diagnostic variability and higher prevalence of substance use disorders relative to the FEP research sample. CONCLUSIONS: Researchers should be aware of how study design and recruitment practices may impact the representativeness of samples, with particular concern for equal representation of racial minorities and patients with more severe illness. Studies should be designed to minimize burden to promote a wider range of participation.

Childhood dyspraxia predicts adult-onset nonaffective-psychosis-spectrum disorder.

Several neurological variables have been investigated as premorbid biomarkers of vulnerability for schizophrenia and other related disorders. The current study examined whether childhood dyspraxia predicted later adult nonaffective-psychosis-spectrum disorders. From a standardized neurological examination performed with children (aged 10-13) at genetic high risk of schizophrenia and controls, several measures of dyspraxia were used to create a scale composed of face/head dyspraxia, oral articulation, ideomotor dyspraxia (clumsiness), and dressing dyspraxia (n = 244). Multinomial logistic regression showed higher scores on the dyspraxia scale predict nonaffective-psychosis-spectrum disorders relative to other psychiatric disorders and no mental illness outcomes, even after controlling for genetic risk, χ2 (4, 244) = 18.61, p < .001. Findings that symptoms of dyspraxia in childhood (reflecting abnormalities spanning functionally distinct brain networks) specifically predict adult nonaffective-psychosis-spectrum disorders are consistent with a theory of abnormal connectivity, and they highlight a marked early-stage vulnerability in the pathophysiology of nonaffective-psychosis-spectrum disorders.

Reinforcement Learning Performance and Risk for Psychosis in Youth.

Early identification efforts for psychosis have thus far yielded many more individuals "at risk" than actually develop psychotic illness. Here, we test whether measures of reinforcement learning (RL), known to be impaired in chronic schizophrenia, are related to the severity of clinical risk symptoms. Because of the reliance of RL on dopamine-rich frontostriatal systems and evidence of dopamine system dysfunction in the psychosis prodrome, RL measures are of specific interest in this clinical population. The current study examines relationships between psychosis risk symptoms and RL task performance in a sample of adolescents and young adults (n = 70) receiving mental health services. We observed significant correlations between multiple measures of RL performance and measures of both positive and negative symptoms. These results suggest that RL measures may provide a psychosis risk signal in treatment-seeking youth. Further research is necessary to understand the potential predictive role of RL measures for conversion to psychosis.

Outcomes of a Family Peer Education Program for Families of Youth and Adults with Mental Illness.

Family members of consumers with mental illness often play important roles in initiating and supporting treatment. Self-help programs such as the National Alliance on Mental Illness (NAMI) Family-to-Family Education Program (FTF) have been shown to provide a variety of benefits for family members. Despite recognizing the benefits of FTF, little is known about who may benefit most, and in what ways they might benefit. One group of interest is family members of younger consumers, a group shown to report more negative caregiving experiences and more depression and anxiety than caregivers of older consumers. The current study assesses whether relatives of youth (ages 8-18) differ in their response to FTF as opposed to relatives of adults (19 years and older). Results suggest that all members benefit from FTF. Family members of youth in FTF, however, reported gains more pronounced on their depressive symptoms, and negative perceptions and experiences, relative to family members of adults. The importance of peer support programs is discussed, as well as the specific usefulness of these programs to effectively address concerns of relatives of youth with serious mental health concerns.

First episode psychosis caregiver perspectives on motivational interviewing for loved ones training: A qualitative study.

BACKGROUND: Past research has found that family involvement in psychosis treatment leads to better patient outcomes. Thus, caregiver communication skills training can be a viable approach to reducing caregiver stress and increasing self-efficacy and communication. AIM: The purpose of this qualitative study was to describe family caregivers' perceptions of changes in themselves and their family member with psychosis following their participation in Motivational Interviewing in Loved Ones (MILO), a brief four to five-hour psychoeducational intervention for caregivers. METHODS: Sixty-three participants in the MILO trials provided written qualitative responses to the prompt, "Since learning the ideas and techniques in this course, what is the most significant change you noticed in yourself, your family, or your relationships?" Responses were collected immediately following MILO participation and 12 weeks later. Qualitative themes were identified through an iterative consensus process. RESULTS: Most participants reported positive changes in multiple domains of their lives. Major themes included: (1) Changes in Self, (2) Changes in Relationships, (3) Changes in Mindset, (4) Use of MILO Skills, and (5) Challenges. CONCLUSION: Qualitative results support and add context to the previously reported quantitative results from this study. MILO is a promising family intervention that positively influenced family environment and communication in pilot trials. Adaptations of MILO for families outside of a highly educated North American context should be considered.

The impact of early detection (ED) campaigns on care presentations: Beyond DUP reduction.

We examined the effects of an early detection (ED) campaign (Mindmap), that successfully shortened the duration of untreated psychosis (DUP), on patient presentation profiles at two receiving coordinated specialty care (CSC) services. Data were collected between 2015 and 2019 during a test of ED delivered at one CSC (STEP, n = 147) compared to usual detection at another CSC (PREP, n = 63). Regression models were used to test the effects of ED and DUP on presentation. Before the launch of ED, there were no differences in presentation between STEP and PREP. However, the ED changed the profile of presentations to STEP such that patients were admitted with better negative and total symptoms scores, but worse GAF current and GAF social and with a greater decline in function over the prior year (GAF-Δ). Site-by-time interaction effects were not significant. During the campaign years, STEP vs. PREP recruited patients with better negative and total symptoms, GAF role, and pre-morbid adjustment scores but with worse positive symptoms, GAF current, and GAF-Δ. Nonetheless, mediation analysis revealed that DUP reduction accounted for very little (<8 %) of these differences in presentation. Early detection campaigns while successfully reducing access delays, can have salutary effects on presentation independent of DUP reduction.

The role of borderline personality disorder traits in predicting longitudinal variability of major depressive symptoms among a sample of depressed adults.

BACKGROUND: Major depressive disorder (MDD) and borderline personality disorder (BPD) often co-occur, with 20 % of adults with MDD meeting criteria for BPD. While MDD is typically diagnosed by symptoms persisting for several weeks, research suggests a dynamic pattern of symptom changes occurring over shorter durations. Given the diagnostic focus on affective states in MDD and BPD, with BPD characterized by instability, we expected heightened instability of MDD symptoms among depressed adults with BPD traits. The current study examined whether BPD symptoms predicted instability in depression symptoms, measured by ecological momentary assessments (EMAs). METHODS: The sample included 207 adults with MDD (76 % White, 82 % women) recruited from across the United States. At the start of the study, participants completed a battery of mental health screens including BPD severity and neuroticism. Participants completed EMAs tracking their depression symptoms three times a day over a 90-day period. RESULTS: Using self-report scores assessing borderline personality disorder (BPD) traits along with neuroticism scores and sociodemographic data, Bayesian and frequentist linear regression models consistently indicated that BPD severity was not associated with depression symptom change through time. LIMITATIONS: Diagnostic sensitivity and specificity may be restricted by use of a self-report screening tool for capturing BPD severity. Additionally, this clinical sample of depressed adults lacks a comparison group to determine whether subclinical depressive symptoms present differently among individuals with BPD only. CONCLUSIONS: The unexpected findings shed light on the interplay between these disorders, emphasizing the need for further research to understand their association.

Clinical insights: Preventing psychosis treatment disengagement.

Many patients with schizophrenia spectrum disorders disengage from treatment, with negative impacts on prognosis and recovery. This commentary provides an overview of common reasons underlying treatment dropout and strategies for overcoming obstacles and enhancing patient engagement. Basic clinical skills such as open-ended questions and reflective listening can be powerful tools in unmasking structural and attitudinal barriers to psychosis care.

Development of the motivational interviewing for loved ones skills assessment (MILO-SA).

AIM: Expressed emotion of family members is a key target for intervention for bettering psychosocial outcomes for transitional-age youth experiencing mental health crises. Motivational Interviewing for Loved Ones (MILO) seeks to reduce expressed emotion by teaching parents motivational interviewing skills such as taking a non-judgmental stance, exploring their loved one's thoughts and feelings, expressing optimism and confidence, and avoiding taking an expert role. This report details the creation of the Motivational Interviewing for Loved Ones- Skills Assessment (MILO-SA), its psychometric properties, and convergent validity with other measures of motivational interviewing adeptness. METHODS: Our sample (n = 54) consisted of baseline assessments from parents participating in a pilot study of MILO. Parents were assessed for baseline knowledge of motivational interviewing as well as MILO skills with the MILO-SA and a traditional assessment clinician application of motivational interviewing skills. RESULTS: We found that the MILO-SA displayed high interrater reliability (k = 0.81), and convergent validity with motivational interviewing knowledge (r = 0.32) as well as traditional assessments of clinician adeptness applying motivational interviewing skills (r = 0.67). CONCLUSIONS: Our findings suggest that the MILO-SA has strong psychometric properties and is a useful tool for assessing parent acquisition of motivational interviewing skills. Specifically, the MILO-SA can be used in future studies focused on teaching non-clinicians motivational interviewing skills.

The School of Hard Talks: A telehealth parent training group for caregivers of adolescents and young adults.

AIM: A large body of evidence demonstrates the importance of the family environment in the developmental trajectory of mental illness in young people. Caregiver communication skills training represents a potential model for influencing the outcomes of adolescents and young adults struggling with emerging mental health and behavioural difficulties. The aim of the current study is to describe the development of a telehealth group training intervention for caregivers of adolescents and young adults, and to report the results of a pilot feasibility-effectiveness study that took place in 2020-2021. METHODS: The "School of Hard Talks" intervention consisted of 8 h of training in communication skills consistent with motivational interviewing techniques. All pilot study participants were assigned to receive the intervention. Outcomes of interest were family conflict, caregiver stress, caregiver self-efficacy and expressed emotion (EE). Participants were assessed three times: prior to the intervention, after the intervention and 12 weeks later. RESULTS: A total of 62 participants enrolled in the study, of whom 49 completed the intervention. Large, significant improvements were observed over time in all four domains of interest. Qualitative feedback from parents was very positive and added context to quantitative observations. CONCLUSIONS: The School of Hard Talks was a feasible and effective intervention targeting both caregiver wellbeing as well as important mechanisms of risk for youth psychopathology, namely family conflict and EE. Further research involving a larger sample and a control condition are needed to confirm these findings.

Association between cannabis use and symptom dimensions in schizophrenia spectrum disorders: an individual participant data meta-analysis on 3053 individuals.

Background: The association between cannabis use and positive symptoms in schizophrenia spectrum disorders is well documented, especially via meta-analyses. Yet, findings are inconsistent regarding negative symptoms, while other dimensions such as disorganization, depression, and excitement, have not been investigated. In addition, meta-analyses use aggregated data discarding important confounding variables which is a source of bias. Methods: PubMed, ScienceDirect and PsycINFO were used to search for publications from inception to September 27, 2022. We contacted the authors of relevant studies to extract raw datasets and perform an Individual Participant Data meta-analysis (IPDMA). Inclusion criteria were: psychopathology of individuals with schizophrenia spectrum disorders assessed by the Positive and Negative Syndrome Scale (PANSS); cannabis-users had to either have a diagnosis of cannabis use disorder or use cannabis at least twice a week. The main outcomes were the PANSS subscores extracted via the 3-factor (positive, negative and general) and 5-factor (positive, negative, disorganization, depression, excitement) structures. Preregistration is accessible via Prospero: ID CRD42022329172. Findings: Among the 1149 identified studies, 65 were eligible and 21 datasets were shared, totaling 3677 IPD and 3053 complete cases. The adjusted multivariate analysis revealed that relative to non-use, cannabis use was associated with higher severity of positive dimension (3-factor: Adjusted Mean Difference, aMD = 0.34, 95% Confidence Interval, CI = [0.03; 0.66]; 5-factor: aMD = 0.38, 95% CI = [0.08; 0.63]), lower severity of negative dimension (3-factor: aMD = -0.49, 95% CI [-0.90; -0.09]; 5-factor: aMD = -0.50, 95% CI = [-0.91; -0.08]), higher severity of excitement dimension (aMD = 0.16, 95% CI = [0.03; 0.28]). No association was found between cannabis use and disorganization (aMD = -0.13, 95% CI = [-0.42; 0.17]) or depression (aMD = -0.14, 95% CI = [-0.34; 0.06]). Interpretation: No causal relationship can be inferred from the current results. The findings could be in favor of both a detrimental and beneficial effect of cannabis on positive and negative symptoms, respectively. Longitudinal designs are needed to understand the role of cannabis is this association. The reported effect sizes are small and CIs are wide, the interpretation of findings should be taken with caution. Funding: This research did not receive any specific grant or funding. Primary financial support for authors was provided by Le Vinatier Psychiatric Hospital.

Social cognitive mechanisms between psychological maltreatment and adolescent suicide ideation: Race/ethnicity and gender as moderators.

Childhood psychological maltreatment is a well-studied predictor of adolescent suicide ideation, while social support is a protective factor, but little is known about social-cognitive mechanisms that may link psychological maltreatment to suicide ideation. Further, given the impact that culture, race/ethnicity, and gender can have on social relationships and suicide-related risk factors, these mechanisms may differ across demographic groups. Objective: The current study examined whether psychological maltreatment predicts suicide ideation through self-perception of social competence, and whether this relationship differs depending on race/ethnicity and gender. Method: We analyzed a racially diverse, longitudinal sample of adolescents at risk for maltreatment (N = 765). Self-report measures of lifetime maltreatment were completed at age 12 and combined with data from Child Protective Services. Youth also completed measures of perceived social competence at age 12. Indicators of suicide ideation were taken at ages 8, 12, 16, and 18. Results: Perceived social competence scores differed significantly between children who were psychologically maltreated and those who were not, but these differences were nonsignificant for physical and sexual abuse. Self-perception of social competence fully mediated the relationship between childhood psychological maltreatment and suicide ideation for White girls and boys. Conclusions: Our findings suggest that poor perceived social competence is uniquely associated with psychological maltreatment, and White adolescents may develop suicide ideation through specific mechanisms involving social cognition. Certain youth may benefit from interventions improving social cognitions and promoting healthy relationships to prevent suicide ideation during adolescence.

Timing of cannabis exposure relative to prodrome and psychosis onset in a community-based first episode psychosis sample.

Cannabis has been implicated as both a potential cause and adverse prognostic factor in psychotic disorders. Investigating the contributory role of cannabis toward the overall burden of psychotic illnesses may represent an important step toward psychosis prevention and treatment. The current study samples consecutive admissions (N = 246) to two community based first-episode psychosis services to characterize timing of cannabis use relative to psychosis and attenuated symptom onset, differences between those with and without cannabis exposure, and the association of age at first cannabis exposure with clinical and demographic variables. Both cannabis exposure (78%) and cannabis use disorders (47%) were highly prevalent at admission. In 94% of participants, cannabis use preceded the onset of both attenuated and full-threshold psychosis symptoms by several years. Earlier age at first exposure to cannabis was associated with younger age at prodrome and psychosis onset, worse premorbid functioning, and greater severity of cannabis use disorder at admission. The timing of first exposure to cannabis may have individual prognostic as well as public health significance. Documenting the prevalence and impact of cannabis use in early psychosis samples, as well as the overall incidence of psychotic disorders, will be of vital public health significance as the United States enacts cannabis legalization and cannabis products become more widely available.

Motivational interviewing for loved ones: Randomized controlled trial of brief training for first episode psychosis caregivers.

BACKGROUND: Research shows that family involvement in psychosis treatment leads to better patient outcomes. Interventions that involve and counsel family members may improve patient outcomes by addressing barriers to treatment adherence and lowering family expressed emotion, thereby creating a less stressful and more supportive home environment. Learning to use motivational interviewing communication skills may help caregivers to decrease conflict and expressed emotion and improve treatment adherence. METHODS: The current study is a pilot randomized controlled trial testing the impact of "Motivational Interviewing for Loved Ones" (MILO), a brief five-hour psychoeducational intervention for caregivers, in a sample of family members of individuals with early course psychosis (N = 40). Using a randomized crossover design, caregivers were randomized to either immediate MILO or a six-week waitlist control condition; all participants eventually received the intervention. RESULTS: Caregiver participants experienced large (d = 1.08-1.43) and significant improvements in caregiver wellbeing, caregiver self-efficacy, family conflict, and expressed emotion. There was no change over time in caregiver-reported patient treatment adherence. Relative to waitlist, MILO had significant effects on family conflict and expressed emotion, a trending effect on perceived stress, and no effect on parenting self-efficacy or treatment adherence. CONCLUSIONS: MILO showed benefits for caregivers of FEP patients in this small, controlled trial. Further testing in a larger randomized controlled trial is warranted to better characterize MILO's effects for caregivers and patients across a range of diagnoses.

Changes in community providers' screening behaviours, referral practices, and clinical confidence following participation in an early psychosis educational campaign.

AIM: Successful delivery of care to individuals with early psychosis depends on the ability of community providers to identify and refer appropriate candidates for services. Although specialty centres commonly rely upon education and outreach campaigns to building bridges with community providers, few studies have examined the effectiveness of these campaigns or the mechanisms by which they may achieve their intended effects. METHODS: We surveyed community clinicians (N = 39) about their screening behaviours, referral practices, and confidence in managing early psychosis just before and 3-6 months after attending an educational event designed to promote recognition and quality treatment of early psychosis. RESULTS: Three to six months following attendance, providers reported screening a greater proportion of clients for early psychosis, referring a greater number of clients to specialty services, and feeling more confident in their ability to respond to clients with early psychosis. Increases in confidence following attendance were associated with corresponding increases in screening behaviour. CONCLUSIONS: The results suggest that outreach campaigns designed to enhance community providers' knowledge about early psychosis assessment and resources may be effective in promoting screening, referrals, and confidence in managing psychosis. Gains in provider confidence may contribute to increases in screening. Given the lack of control group and relatively short follow-up period, more research is needed to determine the effects of early psychosis educational events and the mechanisms by which they may promote successful treatment delivery for young people in need.

Granular analysis of pathways to care and durations of untreated psychosis: A marginal delay model.

OBJECTIVE: An extensive international literature demonstrates that understanding pathways to care (PTC) is essential for efforts to reduce community Duration of Untreated Psychosis (DUP). However, knowledge from these studies is difficult to translate to new settings. We present a novel approach to characterize and analyze PTC and demonstrate its value for the design and implementation of early detection efforts. METHODS: Type and date of every encounter, or node, along the PTC were encoded for 156 participants enrolled in the clinic for Specialized Treatment Early in Psychosis (STEP), within the context of an early detection campaign. Marginal-delay, or the portion of overall delay attributable to a specific node, was computed as the number of days between the start dates of contiguous nodes on the PTC. Sources of delay within the network of care were quantified and patient characteristic (sex, age, race, income, insurance, living, education, employment, and function) influences on such delays were analyzed via bivariate and mixed model testing. RESULTS: The period from psychosis onset to antipsychotic prescription was significantly longer (52 vs. 20.5 days, [p = 0.004]), involved more interactions (3 vs. 1 nodes, [p<0.001]), and was predominated by encounters with non-clinical nodes while the period from antipsychotic to STEP enrollment was shorter and predominated by clinical nodes. Outpatient programs were the greatest contributor of marginal delays on both before antipsychotic prescription (median [IQR] of 36.5 [1.3-132.8] days) and (median [IQR] of 56 [15-210.5] days). Sharper functional declines in the year before enrollment correlated significantly with longer DUP (p<0.001), while those with higher functioning moved significantly faster through nodes (p<0.001). No other associations were found with patient characteristics and PTCs. CONCLUSIONS: The conceptual model and analytic approach outlined in this study give first episode services tools to measure, analyze, and inform strategies to reduce untreated psychosis.