Patient-reported outcome measures in early psychosis: A cross-cultural, longitudinal examination of the self-reported health and self-reported mental health measures in Chennai, India and Montreal, Canada.

OBJECTIVE: Despite their acknowledged value, patient-reported outcome measures (PROMs) are infrequently used in psychosis, particularly in low-and middle-income countries. We compared ratings on two single-item PROMs, Self-Rated Health (SRH) and Self-Rated Mental Health (SRMH), of persons receiving similar early psychosis services in Chennai, India and Montreal, Canada. We hypothesized greater improvements in SRH and SRMH in the Chennai (compared to the Montreal) sample. METHODS: Participants (Chennai N = 159/168 who participated in the larger study; Montreal N = 74/165 who participated in the larger study) completed the SRH and SRMH during at least two out of three timepoints (entry, months 12 and 24). Repeated measures proportional odds logistic regressions examined the effects of time (baseline to month 24), site, and relevant baseline (e.g., gender) and time-varying covariates (i.e., symptoms) on SRH and SRMH scores. RESULTS: SRH (but not SRMH) scores significantly differed between the sites at baseline, with Chennai patients reporting poorer health (OR: 0.33; CI: 0.18, 0.63). While Chennai patients reported similar significant improvements in their SRH (OR: 7.03; CI: 3.13; 15.78) and SRMH (OR: 2.29, CI: 1.03, 5.11) over time, Montreal patients only reported significant improvements in their SRMH. Women in Chennai (but not Montreal) reported lower mental health than men. Higher anxiety and longer durations of untreated psychosis were associated with poorer SRH and SRMH, while negative symptoms were associated with SRH. CONCLUSIONS: As hypothesized, Chennai patients reported greater improvements in health and mental health. The marked differences between health and mental health in Montreal, in contrast to the overlap between the two in Chennai, aligns with previous findings of clearer distinctions between mind and body in Western societies. Cross-context (e.g., anxiety) and context-specific (e.g., gender) factors influence patients' health perceptions. Our results highlight the value of integrating simple PROMs in early psychosis.

Mental health of Canadian youth: A systematic review and meta-analysis of studies examining changes in depression, anxiety, and suicide-related outcomes during the COVID-19 pandemic.

OBJECTIVES: This systematic review and meta-analysis aims to describe Canadian youth mental health during the COVID-19 pandemic, focusing on changes in anxiety and depressive symptoms and suicidality. METHODS: We searched four databases up to February 2023 for longitudinal or repeated cross-sectional studies reporting on changes in depressive and anxiety symptoms, suicidality, or related services utilization among young people under 25 years old residing in Canada during the COVID-19 pandemic. Random-effects meta-analyses were performed for studies comparing depressive and anxiety symptoms from before to during the first, second, and third COVID-19 waves (up to June 2021), and between COVID-19 waves. Other studies were described narratively. Risk of bias was assessed using an adapted Joanna Briggs Institute Checklist. SYNTHESIS: Of the 7916 records screened, 35 articles met inclusion criteria for this review. Included studies were highly heterogeneous in design, population, and type of change investigated, and many had a high risk of bias. The meta-analyses found that depressive symptoms worsened minimally from pre-pandemic to wave 1 but returned to pre-pandemic levels by wave 2. Anxiety symptoms were broadly comparable from pre-pandemic to waves 1 and 2 but worsened from waves 1 to 3 and from pre-pandemic to wave 1 for girls. The narrative review included several studies that provided inconclusive evidence of increases in services utilization. CONCLUSION: The current evidence is limited and highly heterogeneous, making it insufficient to draw definitive conclusions regarding the short- to medium-term impact of the pandemic on youth mental health in Canada. Obtaining better mental health surveillance among Canadian youth is imperative.

RéSUMé: OBJECTIFS: Cette revue systématique et méta-analyse vise à décrire la santé mentale des jeunes Canadiens pendant la pandémie de COVID-19 en ce qui concerne les changements dans les symptômes d'anxiété et de dépression et la suicidalité. MéTHODES: Nous avons cherché dans quatre bases de données, jusqu'en février 2023, des études longitudinales ou transversales répétées portant sur l'évolution des symptômes dépressifs et anxieux, de la suicidalité ou de l'utilisation des services en santé mentale chez les jeunes de moins de 25 ans résidant au Canada pendant la pandémie de COVID-19. Des méta-analyses à effets aléatoires ont été réalisées pour les études comparant les symptômes dépressifs et anxieux avant et pendant les première, deuxième et troisième vagues du COVID-19 (jusqu'en juin 2021), ainsi qu'entre les vagues de COVID-19. Les autres études ont été décrites de manière narrative. Le risque de biais a été évalué à l'aide d'une liste de contrôle adaptée du Joanna Briggs Institute. SYNTHèSE: Sur les 7 916 dossiers examinés, 35 articles répondaient aux critères d'inclusion de la présente étude. Les études retenues sont très hétérogènes en termes de conception, de population et de type de changement étudié, et un grand nombre d'entre elles présentent un risque élevé de biais. Les méta-analyses révèlent que les symptômes dépressifs se sont légèrement aggravés entre la période prépandémique et la première vague, mais qu'ils sont revenus aux niveaux prépandémiques lors de la deuxième vague. Les symptômes d'anxiété sont globalement comparables entre la période prépandémique et les vagues 1 et 2, mais se sont aggravés entre les vagues 1 et 3 et entre la période prépandémique et la vague 1 pour les filles. La revue narrative porte sur plusieurs études qui ont fourni des preuves non concluantes de l'augmentation de l'utilisation des services en santé mentale. CONCLUSION: Les données actuelles sont limitées et très hétérogènes, ce qui ne permet pas de tirer des conclusions définitives quant à l'impact à court et moyen terme de la pandémie sur la santé mentale des jeunes au Canada. Il est impératif d'améliorer la surveillance de la santé mentale des jeunes Canadiens.

Similar and different? A cross-cultural comparison of the prevalence, course of and factors associated with suicidal thoughts and behaviors in first-episode psychosis in Chennai, India and Montreal, Canada.

BACKGROUND: Data from high-income countries (HICs) show a high risk of suicidal thoughts and behaviors (STBs) in first-episode psychosis (FEP). It is unknown, however, whether rates and associated factors differ in low- and middle-income countries (LMICs). AIMS: We therefore aimed to compare the 2-year course of STBs and associated factors in persons with FEP treated in two similarly structured early intervention services in Chennai, India and Montreal, Canada. METHOD: To ensure fit to the data that included persons without STBs and with varying STBs' severity, a hurdle model was conducted by site, including known predictors of STBs. The 2-year evolution of STBs was compared by site with mixed-effects ordered logistic regression. RESULTS: The study included 333 FEP patients (168 in Chennai, 165 in Montreal). A significant decrease in STBs was observed at both sites (OR = 0.87; 95% CI [0.84, 0.90]), with the greatest decline in the first 2 months of follow-up. Although three Chennai women died by suicide in the first 4 months (none in Montreal), Chennai patients had a lower risk of STBs over follow-up (OR = 0.44; 95% CI [0.23, 0.81]). Some factors (depression, history of suicide attempts) were consistently associated with STBs across contexts, while others (gender, history of suicidal ideation, relationship status) were associated at only one of the two sites. CONCLUSIONS: This is the first study to compare STBs in FEP between two distinct geo-sociocultural contexts (an HIC and an LMIC). At both sites, STBs reduced after treatment initiation, suggesting that early intervention reduces STBs across contexts. At both sites, for some patients, STBs persisted or first appeared during follow-up, indicating need for suicide prevention throughout follow-up. Our study demonstrates contextual variations in rates and factors associated with STBs. This has implications for tailoring suicide prevention and makes the case for more research on STBs in FEP in diverse contexts.

Patient-reported outcome measures in early psychosis: Evaluating the psychometric properties of the single-item self-reported health and self-reported mental health measures in Chennai, India and Montreal, Canada.

AIM: Patient-reported outcome measures (PROMs) provide valuable information and promote shared decision-making but are infrequently used in psychosis. Self-rated Health (SRH) and Self-rated Mental Health (SRMH) are single-item PROMs in which respondents rate their health and mental health from 'poor' to 'excellent'. We examined the psychometric properties of the SRH and SRMH in early psychosis services in Chennai, India and Montreal, Canada. METHODS: Assessments were completed in Tamil/English in Chennai and French/English in Montreal. Test-retest reliability included data from 59 patients in Chennai and Montreal. Criterion validity was examined against clinician-rated measures of depression, anxiety, positive and negative symptoms, and a quality-of-life PROM for 261 patients in Chennai and Montreal. RESULTS: SRH and SRMH had good to excellent test-retest reliability (ICC >0.63) at both sites and in English and Tamil (but not French). Results for criterion validity were mixed. In Montreal, low SRH was associated with not being in positive symptom remission, and poorer functioning and quality of life. SRH was associated only with functioning in Chennai. No associations were found for SRMH in Montreal. In Chennai, low SRMH was associated with not being in positive symptom remission and poorer functioning. CONCLUSIONS: Patient-reported outcome measures may perform differently across contexts as a potential function of variations in sociodemographics, illness characteristics/course, understandings of health/mental health, and so forth. More work is needed to understand if discrepancies between PROMs and CROMs indicate poor validity of PROMs or 'valid' differences between patient and clinician perceptions. Our work suggests that single-item PROMs can be feasibly integrated into clinical settings.

Trust of patients and families in mental healthcare providers and institutions: a cross-cultural study in Chennai, India, and Montreal, Canada.

PURPOSE: Cross-cultural psychosis research has typically focused on a limited number of outcomes (generally symptom-related). It is unknown if the purported superior outcomes for psychosis in some low- and middle-income countries extend to fundamental treatment processes like trust. Addressing this gap, we studied two similar first-episode psychosis programs in Montreal, Canada, and Chennai, India. We hypothesized higher trust in healthcare institutions and providers among patients and families in Chennai at baseline and over follow-up. METHODS: Upon treatment entry and at months 3, 12 and 24, trust in healthcare providers was measured using the Wake Forest Trust scale and trust in the healthcare and mental healthcare systems using two single items. Nonparametric tests were performed to compare trust levels across sites and mixed-effects linear regression models to investigate predictors of trust in healthcare providers. RESULTS: The study included 333 patients (Montreal = 165, Chennai = 168) and 324 family members (Montreal = 128, Chennai = 168). Across all timepoints, Chennai patients and families had higher trust in healthcare providers and the healthcare and mental healthcare systems. The effect of site on trust in healthcare providers was significant after controlling for sociodemographic characteristics known to impact trust. Patients' trust in doctors increased over follow-up. CONCLUSION: This study uniquely focuses on trust as an outcome in psychosis, via a comparative longitudinal analysis of different trust dimensions and predictors, across two geographical settings. The consistent differences in trust levels between sites may be attributable to local cultural values and institutional structures and processes and underpin cross-cultural variations in treatment engagement and outcomes.

Combinations and Temporal Associations Among Precursor Symptoms Before a First Episode of Psychosis.

BACKGROUND AND HYPOTHESIS: Symptoms that precede a first episode of psychosis (FEP) can ideally be targeted by early intervention services with the aim of preventing or delaying psychosis onset. However, these precursor symptoms emerge in combinations and sequences that do not rest fully within traditional diagnostic categories. To advance our understanding of illness trajectories preceding FEP, we aimed to investigate combinations and temporal associations among precursor symptoms. STUDY DESIGN: Participants were from PEPP-Montréal, a catchment-based early intervention program for FEP. Through semistructured interviews, collateral from relatives, and a review of health and social records, we retrospectively measured the presence or absence of 29 precursor symptoms, including 9 subthreshold psychotic and 20 nonpsychotic symptoms. Sequences of symptoms were derived from the timing of the first precursor symptom relative to the onset of FEP. STUDY RESULTS: The sample included 390 participants (68% men; age range: 14-35 years). Combinations of precursor symptoms most frequently featured depression, anxiety, and substance use. Of 256 possible pairs of initial and subsequent precursor symptoms, many had asymmetrical associations: eg, when the first symptom was suspiciousness, the incidence rate ratio (IRR) of subsequent anxiety was 3.40 (95% confidence interval [CI]: 1.79, 6.46), but when the first symptom was anxiety, the IRR of subsequent suspiciousness was 1.15 (95% CI: 0.77, 1.73). CONCLUSIONS: A detailed examination of precursor symptoms reveals diverse clinical profiles that cut across diagnostic categories and evolve longitudinally prior to FEP. Their identification may contribute to risk assessments and provide insights into the mechanisms of illness progression.

[Peer support for recovery in early intervention for psychosis: Issues surrounding its implementation in Quebec and the French-speaking world]. / La pair-aidance pour soutenir le rétablissement en intervention précoce pour la psychose : enjeux autour de son implantation au Québec et dans la francophonie.

Objectives To describe the different issues surrounding the integration of peer support workers (PSW) and family peer support workers (FPSW) into early intervention for psychosis services (EIS): their roles, the impacts of these interventions for patients, their families, and treatment teams, as well as the challenges and facilitators of this process. Method This article, co-authored with PSW and FPSW, presents a description and discussion of the experience of implementing peer support and family peer support in EIS in Québec, supported by a perspective of a review of the scientific and grey literature published in French or English in the last twenty years. Results Eight of the 36 scientific articles and two of the 14 grey literature publications selected were specific to early intervention for psychosis; the remainder were on mental health intervention. These publications put into context the experience described by clinicians, PSW and FPSW, and illustrated by clinical vignettes. Different modalities of peer support have demonstrated a positive impact on young people with early psychosis: it contributes to the improvement of self-esteem, quality of life, emotional well-being and can facilitate the rehabilitation process and reduce hospitalizations. Family peer support can reduce the stigma surrounding mental health problems, foster hope and a sense of belonging, increase knowledge of the illness and its treatment, and promote better coping strategies by family members. Nevertheless, many challenges have been identified during the integration of peer support and family peer support within clinical teams: planning and funding the implementation of services, defining their roles in EIS, training, clinical supervision, etc. These challenges need to be identified and addressed quickly in order to optimize care for youth and their families. Various strategies have been proposed for the successful implementation of peer support in EIS, which remains limited in Quebec and in the French-speaking world. It requires the participation and support of all stakeholders, including health professionals, managers and decision makers. Conclusion Peer support and family peer support emphasizes lived experience as expertise, recognizing the contribution of people with psychosis and their families as sources of support and models for recovery. This perspective fits well with the philosophy advocated by EIS. This promising intervention, which has been put forward by various national policies or guides, would benefit from being rapidly implemented on a larger scale in Quebec EIS and in the French-speaking world. This would make it possible to study the positive impacts described for service users and their families with more rigorous research designs and larger samples.

Subjective quality of life among first-episode psychosis patients in Chennai, India and Montreal, Canada.

Differences in subjective quality of life among persons receiving early intervention for psychosis in varying geo-sociocultural contexts have rarely been examined. Our prospective longitudinal study compared the quality of life of persons with first-episode psychosis receiving two years of similar early intervention in Chennai, India and Montreal, Canada. We hypothesized that general life satisfaction would be higher in Chennai compared to Montreal, and that social relations (a specific quality of life component) would also be higher in Chennai and positively contribute to general life satisfaction. Participants completed the general satisfaction and social relations domains of the Wisconsin Quality of Life Index at baseline, months 12 and 24. Baseline weighted mean general satisfaction and social relations scores were in the low to moderate range. Generalized estimating equation analyses showed that general satisfaction scores increased with time [Wald χ2 (1) = 125.28, p < 0.001] and were higher in Chennai than in Montreal [Wald χ2 (1) = 7.50, p = 0.006]. Social relations scores showed the highest association with general satisfaction scores (B = 0.52), followed by positive symptom remission (B = 0.24) and gender (B = 0.18) with Chennai males having the highest general satisfaction scores. Social relations weighted mean scores increased with time [Wald χ2 (1) = 87.30, p < 0.001] and were positively associated with years of education [Wald χ2 (1) = 4.76, p = 0.029] and early negative symptom remission [Wald χ2 (1) = 7.38, p = 0.007]. Our results suggest that subjective quality of life may improve following early intervention for psychosis across contexts. Our findings advance knowledge about the role of sociocultural (e.g., gender) and clinical factors in influencing subjective outcomes in psychosis, and point to social support networks and symptom remission as avenues to boost quality of life.

Engaging with care in an early intervention for psychosis program: The role of language, communication, and culture.

Language is an important aspect of communication and language status is known to impact healthcare accessibility, its perceived suitability, and outcomes. However, its influence on treatment engagement and/or disengagement is unknown. Our study therefore sought to investigate the impact of language on service disengagement in an early intervention psychosis program in Montreal, Quebec (a province with French as the official language). We aimed to compare service disengagement between a linguistic minority group (i.e., English) vis-à-vis those whose preferred language was French and to explore the role of language in service engagement. Using a mixed methods sequential design, we tested preferred language and several sociodemographic characteristics associated with service disengagement in a time-to-event analysis with Cox proportional hazards regression models (N = 338). We then conducted two focus groups with English (seven patients) and French speakers (five patients) to further explore differences between the two linguistic groups. Overall, 24% (n = 82) disengaged from the service before the two-year mark. Those whose preferred language was English were more likely to disengage (n = 47, 31.5%) than those whose preferred language was French (n = 35, 18.5%; χ2 = 9.11, p < .01). This remained significant in the multivariate regression. In focus groups, participants identified language as one aspect of a complex communication process between patients and clinicians and highlighted the importance of culture in the clinical encounter. Language status of patients plays an important role in their engagement with early psychosis services. Our findings underscore the value of establishing communication and cultural understanding in creating clinical/therapeutic alliance.

Heterogeneity in the Course of Suicidal Ideation and its Relation to Suicide Attempts in First-Episode Psychosis: A 5-Year Prospective Study.

OBJECTIVES: Although the risk of suicide is high in first-episode psychosis (FEP), little is known about the course of suicidal ideation and its relation to suicide attempts. Therefore, we aimed to identify 5-year trajectories of suicidal ideation and associated factors in FEP and compare how suicide attempts were distributed across these identified trajectories. METHOD: This 5-year prospective study assessed suicidal ideation, suicide attempts and potentially associated factors through research interviews, chart review and coroners' reports in 382 FEP patients [mean age = 23.53 (SD = 3.61)] admitted to 2 5-year early psychosis services in Montreal, Canada. Trajectories were identified using a semiparametric mixture model, and associated factors with multinomial logistic regression. RESULTS: Three suicidal ideation trajectories were identified: low and decreasing (n = 325, 85.08%); early decline, then increasing (n = 30, 7.85%), and persistent suicidal ideation (n = 27, 7.07%). Suicidal ideation prior to admission (OR = 2.85, 95% CI, 1.23 to 6.63, P < 0.05) and cocaine use disorder (OR = 6.78, 95% CI, 1.08 to 42.75, P < 0.05) were associated with the early decline, then increasing suicidal ideation trajectory. Persons with prior suicide ideation (OR = 4.33, 95% CI, 1.66 to 11.29, P < 0.05) and attempts (OR = 8.18, 95% CI, 2.39 to 27.97, P < 0.001) and alcohol use disorder (OR = 3.63, 95% CI, 1.4 to 9.42, P < 0.05) were more likely to belong to the persistent suicidal ideation trajectory, and to attempt suicide during follow-up. CONCLUSIONS: Our study highlights heterogeneity in the course of suicidal ideation over 5 years and the importance of ongoing assessment of suicidal risk in FEP patients, particularly for patients who persistently report suicidal ideation, as they are likelier to engage in suicide attempts. Patients with factors associated with increasing or persistent suicidal ideation trajectories should be targeted for suicide prevention interventions from the early phase of follow-up. Given the small number of persons in these trajectories and the wide CIs for some factors, larger studies are however needed to further characterize who belongs in each group.

Return on investment from service transformation for young people experiencing mental health problems: Approach to economic evaluations in ACCESS Open Minds (Esprits ouverts), a multi-site pan-Canadian youth mental health project.

Introduction: Mental health problems are common globally, and typically have their onset in adolescence and early adulthood-making youth (aged 11-25) an optimal target for prevention and early intervention efforts. While increasing numbers of youth mental health (YMH) initiatives are now underway, thus far few have been subject to economic evaluations. Here we describe an approach to determining the return on investment of YMH service transformation via the pan-Canadian ACCESS Open Minds (AOM) project, for which a key focus is on improving access to mental health care and reducing unmet need in community settings. Approach: As a complex intervention package, it is hoped that the AOM transformation will: (i) enable early intervention through accessible, community-based services; (ii) shift care away toward these primary/community settings and away from acute hospital and emergency services; and (iii) offset at least some of the increased costs of primary care/community-based mental health services with reductions in the volume of more resource-intensive acute, emergency, hospital or specialist services utilized. Co-designed with three diverse sites that represent different Canadian contexts, a return on investment analysis will (separately at each site) compare the costs generated by the intervention, including volumes and expenditures associated with the AOM service transformation and any contemporaneous changes in acute, emergency, hospital or service utilization (vs. historical or parallel comparators). Available data from health system partners are being mobilized to assess these hypotheses. Anticipated results: Across urban, semi-urban and Indigenous sites, the additional costs of the AOM transformation and its implementation in community settings are expected to be at least partially offset by a reduction in the need for acute, emergency, hospital or specialist care. Discussion: Complex interventions such as AOM aim to shift care "upstream": away from acute, emergency, hospital and specialist services and toward community-based programming which is more easily accessible, often more appropriate for early-stage presentations, and more resource-efficient. Carrying out economic evaluations of such interventions is challenging given the constraints of available data and health system organization. Nonetheless, such analyses can advance knowledge, strengthen stakeholder engagement, and further implementation of this public health priority.

Using dimensionality-reduction techniques to understand the organization of psychotic symptoms in persistent psychotic illness and first episode psychosis.

Psychotic disorders are highly heterogeneous. Understanding relationships between symptoms will be relevant to their underlying pathophysiology. We apply dimensionality-reduction methods across two unique samples to characterize the patterns of symptom organization. We analyzed publicly-available data from 153 participants diagnosed with schizophrenia or schizoaffective disorder (fBIRN Data Repository and the Consortium for Neuropsychiatric Phenomics), as well as 636 first-episode psychosis (FEP) participants from the Prevention and Early Intervention Program for Psychosis (PEPP-Montreal). In all participants, the Scale for the Assessment of Positive Symptoms (SAPS) and Scale for the Assessment of Negative Symptoms (SANS) were collected. Multidimensional scaling (MDS) combined with cluster analysis was applied to SAPS and SANS scores across these two groups of participants. MDS revealed relationships between items of SAPS and SANS. Our application of cluster analysis to these results identified: 1 cluster of disorganization symptoms, 2 clusters of hallucinations/delusions, and 2 SANS clusters (asocial and apathy, speech and affect). Those reality distortion items which were furthest from auditory hallucinations had very weak to no relationship with hallucination severity. Despite being at an earlier stage of illness, symptoms in FEP presentations were similarly organized. While hallucinations and delusions commonly co-occur, we found that their specific themes and content sometimes travel together and sometimes do not. This has important implications, not only for treatment, but also for research-particularly efforts to understand the neurocomputational and pathophysiological mechanism underlying delusions and hallucinations.

Differential Trajectories of Delusional Content and Severity Over 2 Years of Early Intervention for Psychosis: Comparison Between Chennai, India, and Montréal, Canada.

BACKGROUND: There exist few direct studies of delusional content in psychosis across geo-cultural contexts, especially those in which treatment protocols and measures are comparable. To directly examine an illness outcome that is potentially culturally mediated, this study investigated the baseline presentation and longitudinal trajectory of delusions in first-episode psychosis (FEP) across 2 similar treatment settings in Montréal (Canada) and Chennai (India). STUDY DESIGN: Patients entering an early intervention program for FEP in Chennai (N = 168) and Montréal (N = 165) were compared on site-level differences in the presentation of delusions across specific time points over 2 years of treatment. Delusions were measured using the Scale for Assessment of Positive Symptoms. Chi-square and regression analyses were conducted. STUDY RESULTS: At baseline, delusions were more frequent in Montréal than in Chennai (93% vs 80%, respectively; X2(1) = 12.36, P < .001). Thematically, delusions of grandiosity, religiosity, and mind reading were more common in Montréal than in Chennai (all P < .001); however, these baseline differences did not persist over time. Regression revealed a significant time-by-site interaction in the longitudinal course of delusions, which differs from the trajectory of other FEP-positive symptom domains. CONCLUSIONS: To the best of our knowledge, this is the first direct comparison of delusions in similar programs for FEP across 2 different geo-cultural contexts. Our findings support the notion that delusion themes follow consistent ordinal patterns across continents. Future work is needed to unpack the differences in severity that present at baseline and minor differences in content.

Context and Expectations Matter: Social, Recreational, and Independent Functioning among Youth with Psychosis in Chennai, India and Montreal, Canada.

OBJECTIVES: Most cross-cultural psychosis research has focused on a limited number of outcomes (generally symptom-related) and perspectives (often clinician-/observer-rated). It is unknown if the purported superior outcomes for psychosis in some low- and middle-income countries extend to patient-reported measures of social, recreational, and independent functioning. Addressing this gap, this study aimed to compare these outcomes in first-episode psychosis at a high-income site and a lower middle-income site. METHODS: Patients receiving similarly designed early intervention for psychosis in Chennai, India (N = 164) and Montreal, Canada (N = 140) completed the self-reported Social Functioning Scale-Early Intervention, which measures prosocial, recreation, and independence-performance functioning. Their case managers rated expected independence-performance functioning. Both sets of assessments were done at entry and Months 6, 18, and 24. Linear mixed model analyses of differences between sites and over time were conducted, accounting for other pertinent variables, especially negative symptoms. RESULTS: Linear mixed models showed that prosocial, recreation, and independence-performance functioning scores were significantly higher in Montreal than Chennai and did not change over time. Expected independence-performance was also higher in Montreal and increased over time. Negative symptoms and education independently predicted prosocial, recreation, and expected independence-performance functioning. When added to the model, expected independence-performance predicted actual independence-performance and site was no longer significant. At both sites, prosocial and recreation scores were consistently lower (<40%) than independence-performance (40-65%). CONCLUSION: This is the first cross-cultural investigation of prosocial, recreation, and independent functioning in early psychosis. It demonstrates that these outcomes differ by socio-cultural context. Differing levels of expectations about patients, themselves shaped by cultural, illness, and social determinants, may contribute to cross-cultural variations in functional outcomes. At both sites, social, recreational, and independent functioning were in the low-to-moderate range and there was no improvement over time, underscoring the need for effective interventions specifically designed to impact these outcomes.

Trust of patients and families in mental healthcare providers and institutions: A cross-cultural study in Chennai, India and Montreal, Canada.

Purpose: Cross-cultural psychosis research has typically focused on a limited number of outcomes (generally symptom-related). It is unknown if the purported superior outcomes for psychosis in some low- and middle-income countries extend to fundamental treatment processes like trust. Addressing this gap, we studied two similar first-episode psychosis programs in Montreal, Canada and Chennai, India. We hypothesized higher trust in healthcare institutions and providers among patients and families in Chennai at baseline and over follow-up. Methods: Upon treatment entry and at months 3, 12 and 24, trust in healthcare providers was measured using the Wake Forest Trust scale and trust in the healthcare and mental healthcare systems using two single items. Non-parametric tests were performed to compare trust levels across sites and mixed-effects linear regression models to investigate predictors of trust in healthcare providers. Results: The study included 333 patients (Montreal=165, Chennai=168) and 324 family members (Montreal=128, Chennai=168). Across all timepoints, Chennai patients and families had higher trust in healthcare providers and the healthcare and mental healthcare systems. The effect of site on trust in healthcare providers was significant after controlling for sociodemographic characteristics known to impact trust. Patients' trust in doctors increased over follow-up. Conclusion: This study uniquely focuses on trust as an outcome in psychosis, via a comparative longitudinal analysis of different trust dimensions and predictors, across two geographical settings. The consistent differences in trust levels between sites may be attributable to local cultural values and institutional structures and processes and underpin cross-cultural variations in treatment engagement and outcomes.

Transsyndromic trajectories from pre-onset self-harm and subthreshold psychosis to the first episode of psychosis: A longitudinal study.

Across subthreshold psychotic and nonpsychotic syndromes, symptoms experienced before the onset of a first episode of psychosis (FEP) may index distinct illness trajectories. We aimed to examine the associations between three types of pre-onset symptoms (self-harm, suicide attempts, and subthreshold psychotic) and outcome trajectories during FEP. Participants with FEP were recruited from PEPP-Montreal, a catchment-based early intervention service. Pre-onset symptoms were systematically assessed through interviews with participants (and their relatives) and reviews of health and social records. Over 2 years of follow-up at PEPP-Montreal, 3-8 repeated measures were collected for positive, negative, depressive, and anxiety symptoms, as well as functioning. We applied linear mixed models to examine associations between pre-onset symptoms and outcome trajectories. We found that on average over follow-up, participants with pre-onset self-harm had more severe positive, depressive, and anxiety symptoms compared with other participants (standardized mean differences: 0.32-0.76), while differences in negative symptoms and functioning were not significant. Associations did not differ by gender and remained similar after adjusting for the duration of untreated psychosis, substance use disorder, or baseline diagnosis of affective psychosis. Over time, depressive and anxiety symptoms improved among individuals with pre-onset self-harm, such that they converged with other individuals by the end of the follow-up. Similarly, pre-onset suicide attempts were associated with elevated depressive symptoms that improved over time. Pre-onset subthreshold psychotic symptoms were not associated with outcomes, except for a slightly different trajectory of functioning. Individuals with pre-onset self-harm or suicide attempts may benefit from early interventions that target their transsyndromic trajectories. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Pathways to care in first-episode psychosis in low-resource settings: Implications for policy and practice.

OBJECTIVE: Developing countries such as India face a major mental health care gap. Delayed or inadequate care can have a profound impact on treatment outcomes. We compared pathways to care in first episode psychosis (FEP) between North and South India to inform solutions to bridge the treatment gap. METHODS: Cross-sectional observation study of 'untreated' FEP patients (n = 177) visiting a psychiatry department in two sites in India (AIIMS, New Delhi and SCARF, Chennai). We compared duration of untreated psychosis (DUP), first service encounters, illness attributions and socio-demographic factors between patients from North and South India. Correlates of DUP were explored using logistic regression analysis (DUP ≥ 6 months) and generalised linear models (DUP in weeks). RESULTS: Patients in North India had experienced longer DUP than patients in South India (ß = 17.68, p < 0.05). The most common first encounter in North India was with a faith healer (45.7%), however, this contact was not significantly associated with longer DUP. Visiting a faith healer was the second most common first contact in South India (23.6%) and was significantly associated with longer DUP (Odds Ratio: 6.84; 95% Confidence Interval: 1.77, 26.49). Being in paid employment was significantly associated with shorter DUP across both sites. CONCLUSIONS: Implementing early intervention strategies in a diverse country like India requires careful attention to local population demographics; one size may not fit all. A collaborative relationship between faith healers and mental health professionals could help with educational initiatives and to provide more accessible care.

Stigma as a barrier to early intervention among youth seeking mental health services in Ontario, Canada: a qualitative study.

BACKGROUND: Stigma associated with mental health challenges is a major barrier to service seeking among youth. Understanding how stigma impacts service-seeking decisions from the perspectives of youth remains underexplored. Such research is necessary to inform effective stigma reduction. OBJECTIVE: This study aims to understand how stigma influences service seeking among youth with mental health challenges. METHODS: Qualitative inquiry was taken using youth engagement, underpinned by pragmatism. Data were collected via 4 virtual focus groups with 22 purposively selected youth participants with lived experience of mental health challenges in Ontario, Canada. Focus group guides were developed collaboratively among research team members, including youth co-researchers. Data were analyzed inductively using reflexive thematic analysis. RESULTS: Three main themes were constructed from the data: point of entry into the system, being biomedicalized or trivialized, and paving the way for non-stigmatizing services. Initial contact with the mental healthcare system was seen to be affected by stigma, causing participants to delay contact or be refused services if they do not fit with an expected profile. Participants described a constant negotiation between feeling 'sick enough' and 'not sick enough' to receive services. Once participants accessed services, they perceived the biomedicalization or trivialization of their challenges to be driven by stigma. Lastly, participants reflected on changes needed to reduce stigma's effects on seeking and obtaining services. CONCLUSION: A constant negotiation between being 'sick enough' or 'not sick enough' is a key component of stigma from the perspectives of youth. This tension influences youth decisions about whether to seek services, but also service provider decisions about whether to offer services. Building awareness around the invisibility of mental health challenges and the continuum of wellness to illness may help to break down stigma's impact as a barrier to service seeking. Early intervention models of care that propose services across the spectrum of challenges may prevent the sense of stigma that deters youth from accessing and continuing to access services.

Implications of time and space factors related with youth substance use prevention: a conceptual review and case study of the Icelandic Prevention Model being implemented in the context of the COVID-19 pandemic.

PURPOSE: This research examines the implementation of the Icelandic Prevention Model (IPM) in Canada to identify opportunities revealed by the COVID-19 pandemic to re-design our social eco-system to promote wellbeing. This paper has two objectives: 1) to provide a conceptual review of research that applies the bioecological model to youth substance use prevention with a focus on the concepts of time and physical space use and 2) to describe a case study that examines the implementation of the IPM in Canada within the context of the COVID-19 pandemic. METHOD: Study data were collected through semi-structured qualitative interviews with key stakeholders involved in implementing the IPM. RESULTS: Findings are organized within three over-arching themes derived from a thematic analysis: 1) Issues that influence time and space use patterns and youth substance use, 2) Family and community cohesion and influences on developmental context and time use and 3) Opportunities presented by the pandemic that can promote youth wellbeing. CONCLUSION: We apply the findings to research on the IPM as well as the pandemic to examine opportunities that may support primary prevention and overall youth wellbeing. We use the concepts of time and space as a foundation to discuss implications for policy and practice going forward.

Comparing treatment delays and pathways to early intervention services for psychosis in urban settings in India and Canada.

INTRODUCTION: Although extensively studied in high-income countries (HICs) and less so in low- and middle-income countries (LMICs), pathways to care and treatment delays in early psychosis have not been compared across contexts. We compared pathways to early intervention for psychosis in an HIC (Montreal, Canada) and an LMIC (Chennai, India). We hypothesised that the duration of untreated psychosis (DUP) would be longer in Chennai. METHODS: The number of contacts preceding early intervention, referral sources, first contacts, and DUP and its referral and help-seeking components of first-episode psychosis patients at both sites were similarly measured and compared using chi-square analyses and t tests/one-way ANOVAs. RESULTS: Overall and help-seeking DUPs of Chennai (N = 168) and Montreal (N = 165) participants were not significantly different. However, Chennai patients had shorter referral DUPs [mean = 12.0 ± 34.1 weeks vs. Montreal mean = 13.2 ± 28.7 weeks; t(302.57) = 4.40; p < 0.001] as the early intervention service was the first contact for 44% of them (vs. 5% in Montreal). Faith healers comprised 25% of first contacts in Chennai. Those seeing faith healers had significantly shorter help-seeking but longer referral DUPs. As predicted, most (93%) Montreal referrals came from medical sources. Those seeing psychologists/counsellors/social workers as their first contact had longer DUPs. CONCLUSION: Differences in cultural views about mental illnesses and organizational structures shape pathways to care and their associations with treatment delays across contexts. Both formal and informal sources need to be targeted to reduce delays. Early intervention services being the first portal where help is sought can reduce DUP especially if accessed early on in the illness course.