The role of referral pathway to early intervention services for psychosis on 2-year inpatient and emergency service use.

This study examined the relationship between terminal referral source and subsequent urgent health service use in a Canadian early intervention service (EIS) for psychosis. Administrative health record data of emergency and inpatient mental health service use over a 2-year follow up from entry to EIS were retrospectively analyzed (n = 515). Negative binomial regression models were used to assess for the relationship between referral source and care outcomes. Compared to those referred from primary care services, the rate of urgent health care use was significantly greater for individuals referred to early intervention services from urgent care services while accounting for social and occupational functioning and psychotic symptom severity. Findings suggest that those referred from urgent services may be at an increased risk for subsequent urgent health care use while attending EIS for psychosis. Further research examining this relationship while incorporating additional relevant predictors is needed.

Referral pathways to early intervention services for psychosis and their influence on perceptions of care: An interpretive phenomenological analysis.

AIM: Most young adults experiencing psychosis enter early intervention services (EIS) via inpatient and emergency departments. These experiences are suggested to negatively impact their views of treatment and engagement in EIS. However, limited research has examined the impact of young adults' prior help-seeking experiences on these outcomes. The present study aimed to explore how young adults engaged in EIS have experienced initial help-seeking and make sense of these experiences in the context of their current treatment. METHODS: Using an interpretative phenomenological analysis approach, semi-structured interviews were conducted with 12 young adults (mean age = 24.83) within their first 3-12 months of treatment in EIS. Interviews aimed to examine their experiences of help-seeking and referral to EIS as well as the impact of these experiences on their subsequent perception of, and engagement with EIS. RESULTS: 3 superordinate themes emerged: (1) Navigating the Maze of Healthcare (2) Dignity and (3) Impact of Help-Seeking and Referral Experiences. Participants with referral pathways involving urgent care services described more adversity during their referral pathway and tended to describe help-seeking experiences as contributing to negative views towards EIS and diminished engagement in treatment. CONCLUSIONS: The impact of early negative experiences with healthcare on views towards EIS and engagement is evident in participants' accounts. Sense making was further contextualized by participants' illness insight, degree of recovery, and social support throughout experiences. Emergent themes highlight the need for psychiatric services to emphasize service users' dignity and for EIS to provide opportunities for patients to process past negative mental healthcare experiences to strengthen engagement.

An Internet-Based Cognitive Behavioral Therapy Program for Anxiety and Depression (Tranquility): Adaptation Co-design and Fidelity Evaluation Study.

BACKGROUND: Internet-based cognitive behavioral therapy (iCBT) is a necessary step toward increasing the accessibility of mental health services. Yet, few iCBT programs have been evaluated for their fidelity to the therapeutic principles of cognitive behavioral therapy (CBT) or usability standards. In addition, many existing iCBT programs do not include treatments targeting both anxiety and depression, which are commonly co-occurring conditions. OBJECTIVE: This study aims to evaluate the usability of Tranquility-a novel iCBT program for anxiety-and its fidelity to CBT principles. This study also aims to engage in a co-design process to adapt Tranquility to include treatment elements for depression. METHODS: CBT experts (n=6) and mental health-informed peers (n=6) reviewed the iCBT program Tranquility. CBT experts assessed Tranquility's fidelity to CBT principles and were asked to identify necessary interventions for depression by using 2 simulated client case examples. Mental health-informed peers engaged in 2 co-design focus groups to discuss adaptations to the existing anxiety program and the integration of interventions for depression. Both groups completed web-based surveys assessing the usability of Tranquility and the likelihood that they would recommend the program. RESULTS: The CBT experts' mean rating of Tranquility's fidelity to CBT principles was 91%, indicating a high fidelity to CBT. Further, 5 out of 6 CBT experts and all mental health-informed peers (all participants: 11/12, 88%) rated Tranquility as satisfactory, indicating that they may recommend Tranquility to others, and they rated its usability highly (mean 76.56, SD 14.07). Mental health-informed peers provided suggestions on how to leverage engagement with Tranquility (eg, adding incentives and notification control). CONCLUSIONS: This preliminary study demonstrated the strong fidelity of Tranquility to CBT and usability standards. The results highlight the importance of involving stakeholders in the co-design process and future opportunities to increase engagement.

A multiple baseline trial of adapted prolonged exposure psychotherapy for individuals with early phase psychosis, comorbid substance misuse, and a history of adversity: A study protocol.

Background: Adversity is prevalent among people with psychotic disorders, especially those within the first 5 years of a psychotic disorder, called early phase psychosis. Although adversity can lead to many negative outcomes (e.g., posttraumatic stress symptoms), very few treatments for adversity-related sequelae have been tested with individuals with psychotic disorders, and even fewer studies have specifically tested interventions for people in early phase psychosis. Furthermore, people who misuse substances are commonly excluded from adversity treatment trials, which is problematic given that individuals with early phase psychosis have high rates of substance misuse. For the first time, this trial will examine the outcomes of an adapted 15-session prolonged exposure protocol (i.e., PE+) to observe whether reductions in adversity-related psychopathology occurs among people with early phase psychosis and comorbid substance misuse. Methods: This study will use a multiple-baseline design with randomization of participants to treatment start time. Participants will complete baseline appointments prior to therapy, engage in assessments between each of the five therapy modules, and complete a series of follow-up appointments 2 months after the completion of therapy. Primary hypothesized outcomes include clinically significant reductions in (1) negative psychotic symptoms measured using the Positive and Negative Syndrome Scale, (2) adversity-related sequelae measured using the Trauma Symptom Checklist-40, and (3) substance use frequency and overall risk score measured with the Alcohol, Smoking, and Substance Involvement Screening Test. We also anticipate that clinically significant reductions in hopelessness and experiential avoidance, measured with the Beck Hopelessness Scale and Brief Experiential Avoidance Questionnaire, the theorized mechanisms of change of PE+, will also be observed. A secondary outcome is a hypothesized improvement in functioning, measured using the Clinical Global Impression and Social and Occupational Functioning Assessment scales. Discussion: The results of this treatment trial will contribute to the advancement of treatment research for individuals in early phase psychosis who have current substance misuse and a history of adversity, and the findings may provide evidence supporting the use of hopelessness and experiential avoidance as mechanisms of change for this treatment. Clinical trial registration: Clinicaltrials.gov, NCT04546178; registered August 28, 2020, https://clinicaltrials.gov/ct2/show/NCT04546178?term=NCT04546178&draw=2&rank=1.

Youth Experience Tracker Instrument: A self-report measure of developmental antecedents to severe mental illness.

AIM: We sought to examine the structure, internal consistency, convergent and criterion validity of the Youth Experience Tracker Instrument (YETI), a new brief self-report measure designed to facilitate early identification of risk for severe forms of mental illness, including major depressive disorder, bipolar disorder, and schizophrenia. METHODS: We collected 716 YETIs from 315 individuals aged 8 to 27 with and without familial risk of severe mental illness. The YETI measures six developmental antecedents that precede and predict serious forms of mental illness: affective lability, anxiety, basic symptoms, depressive symptoms, psychotic-like experiences, and sleep. A battery of concurrent questionnaires and interviews measured the same constructs. RESULTS: The best-fitting bifactor model supported the validity of both total score and antecedent-specific subscales. Internal consistency was high for the total score (ω = 0.94) and subscales (ω = 0.80-0.92; ρ = 0.72). The total score captured the majority of information from the 26 YETI items (hierarchical omega ωh = 0.74). Correlations of YETI subscales with established measures of the same constructs (r = 0.45-0.80) suggested adequate convergent validity. We propose cut-offs with high negative predictive values to facilitate efficient risk screening. CONCLUSION: The YETI, a brief self-report measure of antecedents, provides an alternative to using multiple longer instruments. Future research may examine the predictive validity of the YETI for the onset of major mood and psychotic disorders.

Outcome of a first episode of psychosis in adolescence: a 2-year follow-up.

Symptomatic and functional outcome and cognitive functioning were examined in adolescents experiencing their first episode of psychosis. The adolescents (n=69) were assessed and compared with adults (n=69), all presenting for treatment for the first time to a specialized Early Psychosis Program. Assessments were conducted at the initial presentation, and at 1- and 2-year follow-ups. Assessments included positive and negative symptoms, depression, number of relapses, substance use, cognitive functioning, age-appropriate productivity (employment or being in school) and quality of life. Adolescents showed both symptomatic and functional improvement over 2 years of optimal treatment. Positive and negative symptoms predicted outcome at 2 years. Compared with adults, the adolescents had similar clinical and functional outcomes but used more cannabis and had an increased number of relapses. These adolescents are doing relatively well following their first episode and reinforce the need to address cannabis use as an integral part of a comprehensive treatment program.

Models of substance use in adolescents with and without psychosis.

INTRODUCTION: The use of substances is a major concern with adolescents with psychotic disorders, as it can have detrimental effects on psychotic symptoms and other aspects of functioning. The purpose of this study is to increase our understanding of the association between substance use and psychosis in adolescents by testing three models of substance use: the normative development model, the deviance-prone model, and the affect regulation model. METHODS: Participants were 35 adolescents with a psychotic disorder, and 35 typically developing adolescents. Measures used: Personal Experience Screening Questionnaire, Youth Self-Report, Beck Depression Inventory, and the Beck Anxiety Inventory. RESULTS: The normative development model, hypothesizing that mild substance use leads to better socio-emotional adjustment, was not supported for either group. The deviance-prone model was supported for both groups, indicating that rule-breaking behaviour and aggression significantly predicted substance use. The affect-regulation model was supported for adolescents with psychosis only, indicating that negative affect significantly predicted substance use. CONCLUSIONS: The treatment of substance misuse in adolescents with psychosis may be complicated by a number of factors including deviant behaviour and negative affective symptoms. Thus, the current results point to the importance of integrated treatments to help reduce substance misuse and associated problems.

Reasons for using substances in adolescents with and without psychosis.

AIM: To increase our understanding of substance use among adolescents with psychosis by comparing their reasons for use with those of typically developing adolescents. METHODS: Participants were 35 outpatient adolescents, recently admitted for a first episode of psychosis to an early psychosis programme, and 35 typically developing adolescents. Measures used included the Personal Experience Screening Questionnaire and Reasons for Use Scale. RESULTS: Adolescents with psychosis used significantly more substances than adolescents without psychosis (P<0.01). Reasons for use in the two groups were similar. CONCLUSIONS: Although adolescents with psychosis report using substances for the same reasons as other adolescents, they may also use to self-medicate secondary morbidity associated with psychosis. These results have a number of implications for prevention and treatment.

Substance use and cognition in early psychosis.

OBJECTIVE: To determine the relation between substance use and cognition in individuals experiencing their first episode of psychosis. DESIGN: Prospective cross-sectional and longitudinal study. SETTING: An Early Psychosis Treatment and Prevention Program, an outpatient clinic in a psychiatry department at a university-affiliated hospital. PARTICIPANTS: Individuals with a psychotic illness who were admitted to an Early Psychosis Program; 266 patients were assessed at initial presentation, 159 at 1 year and 90 at 2 years. Most were outpatients. MEASURES: The effects of substance use (alcohol, cannabis, hallucinogens, cocaine, stimulants) on cognition were assessed. Substance use was determined by DSM-IV criteria, and the Case Manager Rating Scale was used to determine the level of substance use. A comprehensive cognitive battery of tests was used, and the Positive and Negative Syndrome Scale for schizophrenia was administered to all subjects to determine levels of positive and negative symptoms. RESULTS: Overall, both cross-sectionally and longitudinally, there were no significant associations between cognitive functioning and the use of various substances. Substance use was associated with higher positive symptoms. CONCLUSIONS: Individuals with psychotic disorders who show mild-to-moderate abuse of substances, in particular alcohol and cannabis, do not exhibit more cognitive impairment than those who do not do use the substances. However, substance use may have other detrimental effects on the process of the psychotic illness.