From Rhetoric to Action: Justice, Equity, Diversity, and Inclusion in Coordinated Specialty Care for Early Psychosis.

Attention to inclusivity and equity in health research and clinical practice has grown in recent years; however, coordinated specialty care (CSC) for early psychosis lags in efforts to improve equity despite evidence of ongoing disparities and inequities in CSC care. This Open Forum argues that marginalization and disparities in early psychosis research and clinical care are interrelated, and the authors provide suggestions for paths forward. Commitment to equity and justice demands recentering the perspectives of those most affected by early psychosis services and investing in the integration of historically excluded perspectives across all aspects of practice, policy, and research.

A reduction in cigarette smoking improves health-related quality of life and does not worsen psychiatric symptoms in individuals with serious mental illness.

INTRODUCTION: Individuals with serious mental illness (SMI) smoke cigarettes at a much higher rate than the general population, increasing their risk for medical illnesses and mortality. However, individuals with SMI do not get enough support to quit smoking, partially because of concerns from medical providers that reducing smoking may worsen their symptoms or quality of life. METHODS: Veterans with SMI and nicotine dependence (n = 178) completed a 12-week smoking cessation trial (parent trial dates: 2010-2014) including assessments of smoking status, psychiatric symptoms (Brief Psychiatric Rating Scale), and quality of life (Lehman Quality of Life Interview-Short Version) at up to four time points: baseline, post-treatment, three-month follow-up, and 9-month follow-up. Bayesian multilevel modeling estimated the impact of changes in the self-reported number of cigarettes per day in the past seven days on psychiatric symptoms and quality of life. RESULTS: Between subjects, each additional pack of cigarettes smoked per day was associated with a 0.83 point higher score (95%CI: 0.03 to 1.7) on a negative symptoms scale ranging from 0 to 35. Within subjects, each one-pack reduction in the number of cigarettes smoked per day was associated with an improvement of 0.32 (95%CI = 0.12 to 0.54) on the health-related quality of life scale, which ranges from 0 to 7 points. There were no other significant between- or within-subjects effects of smoking on psychiatric symptoms or quality of life. CONCLUSIONS: Individuals with SMI and their providers should pursue smoking cessation without fear of worsening psychiatric symptoms or quality of life.

Research on Youth Suicide and Sexual Orientation is Impacted by High Rates of Missingness in National Surveillance Systems.

OBJECTIVE: The sexual orientation of youth who die by suicide in the United States is usually unknown. This study assessed how observed patterns of unknown sexual orientation are likely to affect research findings. METHODS: We analyzed the National Violent Death Reporting System (NVDRS) Restricted Access Dataset to assess whether sexual orientation among youth suicide decedents is disproportionately known for different demographics. We then assessed the degree to which estimated sexual minority rates would be affected if researchers were to assume either (a) that sexual orientation data is missing completely at random, or (b) that orientation information is missing at random after accounting for observed demographic patterns. RESULTS: <10% of the sample had known sexual orientation. Sexual orientation was more frequently known for females, white people, and older people, and missingness varied by geography. The choice between modeling the data as missing completely at random versus at random conditional upon demographics had a > 2-fold impact on estimated sexual minority rates among youth suicide decedents. CONCLUSION: Research on sexual orientation and youth suicide is strongly impacted by how researchers account (or do not account) for missingness.

Predictors of attendance in health and wellness treatment groups for people with serious mental illness.

OBJECTIVE: People with serious mental illness have dramatically reduced life expectancy that is largely attributed to elevated rates of chronic medical conditions. Several group interventions have been developed and implemented in recent years to improve health and wellness among people with mental health conditions. Unfortunately, attendance in these interventions is often low, and there is limited understanding of factors that influence patient engagement in this treatment modality. METHOD: Participants (N = 242) were enrolled in 1 of 2 group-based health and wellness treatment programs. Using descriptive statistics and regression, we assessed treatment attendance and a range of potential predictors of attendance. RESULTS: We found lower attendance among people who were younger, people with more medical conditions, and people with more emergency room visits in the 6 months prior to the beginning of treatment. Younger age was a particularly strong predictor of low attendance and was the only variable significantly associated with attending zero treatment sessions. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: These results highlight the need for strategies to improve engagement of patients with poorer objective indicators of medical health and patients with younger age. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Evidence for Differential Predictive Performance of the Prime Screen Between Black and White Help-Seeking Youths.

OBJECTIVE: Self-report screening instruments for emerging psychosis have the potential to improve early detection efforts by increasing the number of true positives among persons deemed to be at "clinical high risk" of the disorder, but their practical utility depends on their validity across race. This study sought to examine whether a commonly used self-report screening tool for psychosis risk performed equally among black and white youths in its ability to predict clinical high-risk status. METHODS: Black (N=58) and white (N=50) help-seeking individuals ages 12-25 (61% female) were assessed with the Prime Screen and the Structured Interview for Psychosis-Risk Syndromes (SIPS). A logistic regression model estimated race differences in the strength of the relation between Prime Screen scores and SIPS-defined risk status. RESULTS: Higher Prime Screen scores significantly predicted clinical high-risk status among white (p<.01) but not black participants. Among black youths without clinical high risk, self-reported Prime Screen scores more closely resembled scores for youths (black or white) with clinical high risk than scores of white peers who were also without clinical high risk. CONCLUSIONS: Results suggest that consideration of race or ethnicity and associated cultural factors is important when screening for clinical high-risk status. Findings support the need to develop culturally valid early psychosis screening tools to promote appropriately tailored early intervention efforts.

Firearm Ownership and Domestic Versus Nondomestic Homicide in the U.S.

INTRODUCTION: Gun ownership is associated with firearm mortality, although this association differs across victim-offender relationships. This study examines the relationship between gun ownership and domestic versus nondomestic homicide rates by victim sex. METHODS: Several sources of state-level panel data from 1990 through 2016 were merged from each of the 50 states to model domestic (i.e., family and intimate partners) and nondomestic firearm homicide as a function of state-level household firearm ownership. Firearm ownership was examined using a validated proxy measure and homicide rates came from the Supplemental Homicide Reports of the Federal Bureau of Investigation's Uniform Crime Reports. Negative binomial regression with fixed effects was used to model the outcomes and employed generalized estimating equations to account for clustering within states. Statistical analyses were completed in 2018. RESULTS: State-level firearm ownership was uniquely associated with domestic (incidence rate ratio=1.013, 95% CI=1.008, 1.018) but not nondomestic (incidence rate ratio=1.002, 95% CI=0.996, 1.008) firearm homicide rates, and this pattern held for both male and female victims. States in the top quartile of firearm ownership had a 64.6% (p<0.001) higher incidence rate of domestic firearm homicide than states in the lowest quartile; however, states in the top quartile did not differ significantly from states in the lowest quartile of firearm ownership in observed incidence rates of nondomestic firearm homicide. CONCLUSIONS: State-level firearm ownership rates are related to rates of domestic but not nondomestic firearm homicide.

The impact of age on the validity of psychosis-risk screening in a sample of help-seeking youth.

Self-report screening instruments offer promise in furthering early identification of at-risk youth, yet current efforts are limited by false positive rates. Identifying moderators of accuracy is a potential step towards improving identification and prevention efforts. We investigated the moderating effect of age on self-reported attenuated positive symptoms from the Prime Screen and clinician diagnosed clinical high-risk/early psychosis (CHR/EP) status. Participants (N = 134) were racially diverse, lower-income, help-seeking adolescents and young adults from a primarily urban community. The overall model predicting CHR/EP status was significant, with results suggesting the presence of a trending interaction between age and Prime Screen symptoms. Analyses indicated that number of items endorsed to predict CHR/EP decreased with age (youngest group [M = 12.99] cut off = 6 items; middle age group [M = 14.97] cut off = 3; oldest age group [M = 18.40] cut off = 1). Although younger participants endorsed more risk items on average, follow up analyses suggested that the Prime Screen was a more accurate predictor of clinician-diagnosed-risk among older participants relative to their younger peers. The current study builds on the literature identifying moderators of psychosis-risk screening measure accuracy, highlighting potential limitations of CHR/EP screening tools in younger populations.

Validity of a two-item screen for early psychosis.

Well-validated screening tools have been developed to identify people at high risk for psychosis, but these are rarely used outside of specialty clinics or research settings. The development of extremely brief and simple screening tools could increase dissemination, especially in settings with low buy-in such as those with low base rates of psychosis and/or time constraints. We sought to identify such a brief measure by modeling participant responses to three psychosis screening questionnaires (Prime Screen; Prodromal Questionnaire-Brief; Youth Psychosis At Risk Questionnaire) in a sample of 139 help-seeking individuals and 335 college students (age range: 12-25). Two screening questions with especially strong information characteristics were identified: "Do you see things that others can't or don't see?" and "Have you ever felt that someone was playing with your mind?" (Alternative two-item screens with similarly strong properties were also identified and validated using uncertainty quantified through Bayesian modeling.) The resulting measure was validated against clinician ratings of psychosis. The screen performed with a sensitivity of 53% and specificity 98% for clinically significant hallucinations or delusions, and sensitivity of 32% and specificity 99% for identifying people in an early phase of psychosis (clinical high risk or first episode psychosis).

Firearm Legislation and Fatal Police Shootings in the United States.

OBJECTIVES: To examine whether stricter firearm legislation is associated with rates of fatal police shootings. METHODS: We used a cross-sectional, state-level design to evaluate the effect of state-level firearm legislation on rates of fatal police shootings from January 1, 2015, through October 31, 2016. We measured state-level variation in firearm laws with legislative scorecards from the Brady Center, and for fatal police shootings we used The Counted, an online database maintained by The Guardian. RESULTS: State-level firearm legislation was significantly associated with lower rates of fatal police shootings (incidence rate ratio = 0.961; 95% confidence interval = 0.939, 0.984). When we controlled for sociodemographic factors, states in the top quartile of legislative strength had a 51% lower incidence rate than did states in the lowest quartile. Laws aimed at strengthening background checks, promoting safe storage, and reducing gun trafficking were associated with fewer fatal police shootings. CONCLUSIONS: Legislative restrictions on firearms are associated with reductions in fatal police shootings. Public Health Implications. Although further research is necessary to determine causality and potential mechanisms, firearm legislation is a potential policy solution for reducing fatal police shootings in the United States.

Aspects of Theory of Mind that attenuate the relationship between persecutory delusions and social functioning in schizophrenia spectrum disorders.

BACKGROUND AND OBJECTIVES: Despite the apparent relevance of persecutory delusions to social relationships, evidence linking these beliefs to social functioning has been inconsistent. In this study, we examined the hypothesis that theory of mind moderates the relationship between persecutory delusions and social functioning. METHODS: 88 adults with schizophrenia or schizoaffective disorder were assessed concurrently for social functioning, severity of persecutory delusions, and two components of theory of mind: mental state decoding and mental state reasoning. Mental state decoding was assessed using the Eyes Test, mental state reasoning using the Hinting Task, and social functioning assessed with the Social Functioning Scale. Moderation effects were evaluated using linear models and the Johnson-Neyman procedure. RESULTS: Mental state reasoning was found to moderate the relationship between persecutory delusions and social functioning, controlling for overall psychopathology. For participants with reasoning scores in the bottom 78th percentile, persecutory delusions showed a significant negative relationship with social functioning. However, for those participants with mental state reasoning scores in the top 22nd percentile, more severe persecutory delusions were not significantly associated with worse social functioning. Mental state decoding was not a statistically significant moderator. LIMITATIONS: Generalizability is limited as participants were generally men in later phases of illness. CONCLUSIONS: Mental state reasoning abilities may buffer the impact of persecutory delusions on social functioning, possibly by helping individuals avoid applying global beliefs of persecution to specific individuals or by allowing for the correction of paranoid inferences.

The relationship between cognitive insight and quality of life in schizophrenia spectrum disorders: Symptom severity as potential moderator.

Cognitive insight is implicated in the formation and maintenance of hallucinations and delusions. However, it is not yet known whether cognitive insight relates to broader outcome measures like quality of life. In the current study, we investigated whether the component elements of cognitive insight-self-certainty and self-reflectiveness-were related to quality of life for 43 outpatients with schizophrenia or schizoaffective disorder. Cognitive insight was assessed using the Beck Cognitive Insight Scale (BCIS) while quality of life was assessed with Quality of Life Scale (QLS). We tested whether this relationship was moderated by clinical insight and symptom severity using the Scale to Assess Unawareness of Mental Disorder (SUMD) and the Positive and Negative Syndrome Scale (PANSS). We found that self- reflectiveness had an unmoderated positive relationship with quality of life. Self-certainty was associated with better quality of life for people with more severe symptoms. Theoretical and clinical implications of these findings are discussed and areas of future research are proposed.