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.

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.

A Scoping Review of Measures Used in Early Intervention Services for Psychosis.

OBJECTIVE: The early intervention service (EIS) model for psychosis has been implemented with increasing frequency; yet, improving outcomes across domains for all patients remains challenging. Measurement-based care can strengthen outcomes by optimizing interventions and promoting alignment with standards, but it is still not widely deployed in EIS. The authors conducted a scoping review by systematically identifying and synthesizing measures used in EIS related to purpose (i.e., to assess patients, families, and programs), domains (e.g., symptoms, quality of life), and reporting perspectives (of patients, families, and clinicians). METHODS: EMBASE, MEDLINE, PsycINFO, CINAHL, and Cochrane Library databases were searched for pertinent literature published between 2000 and 2020. Two reviewers independently screened titles, abstracts, and full texts and extracted data. Measures were classified as clinician-reported outcome measures (CROMs), patient-reported outcome or experience measures (PROMs/PREMs), or family-reported outcome or experience measures (FROMs/FREMs). RESULTS: In total, 172 measures of 27 domains were identified from 115 articles. Nineteen measures had been used to assess programs on fidelity, service engagement, and satisfaction; 136 to assess patients on duration of untreated psychosis, symptoms, functioning, quality of life, and others; and 17 to assess families on coping and burden, background, and others. Sixty percent were CROMs, 30% were PROMs/PREMs, and 10% were FROMs/FREMs. CONCLUSIONS: Greater inclusion of PROMs and FROMs is needed because they align with the EIS philosophy of patient and family engagement and may improve shared decision making and outcomes. A comprehensive, meaningfully synthesized archive of measures can advance measurement-based care, services research, and data harmonization in early psychosis.

Fit for purpose: Conception and psychometric evaluation of developmentally appropriate measures to assess functional recovery in first-episode psychosis across geo-cultural contexts.

OBJECTIVE: Given the paucity of functional recovery measures for young people with psychosis, we developed and conducted psychometric testing of the Functional Outcomes Interview (FOI) and the Roles and Aspirations Among Youth scale (RAY; a much-needed patient-reported outcome measure). METHOD: Both measures were developed in English, Tamil, and French through discussions with professionals, participants, and families at early psychosis programs in Canada and India. The FOI assesses the number and tenure of functional roles and allows the nuanced assessment of each role in terms of performance, need for support, and quality of social contacts. The roles include work, school, household responsibilities, parenting/caregiving, and efforts to return to work/school. The RAY is a self-report of current roles and future aspirations. Test-retest reliability, internal consistency, factorial validity, and concurrent validity for the RAY; and inter-rater reliability (IRR), internal consistency, and concurrent validity for the FOI were assessed. RESULTS: The RAY had adequate internal consistency and temporal stability and was unidimensional in factor analysis. The FOI had acceptable IRR and internal consistency, as evinced by comparable performance ratings across functional roles. Significant associations between our novel measures and well-established measures of functioning and negative symptoms indicate concurrent validity. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: The FOI and RAY were designed to be youth friendly, assess aspirations, and acknowledge individuals as desiring and holding multiple roles. They thus represent a significant advancement in assessing functional recovery in first-episode psychosis. Having been tested in two distinct settings, these measures show promise for wider deployment across geo-cultural contexts. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Adapting, updating and translating the Social Functioning Scale to assess social, recreational and independent functioning among youth with psychosis in diverse sociocultural contexts.

AIM: To compare social, recreational and independent functioning among persons with psychosis across two geo-cultural contexts, we adapted the well-established Social Functioning Scale (SFS) and translated it into French and Tamil. We present the development and psychometric testing of this adaptation, the SFS-Early Intervention. METHODS: Sixteen items were added to reflect contemporary youth activities (e.g., online games) and 31 items adapted to enhance applicability and/or include context-specific examples (e.g., 'church activity' replaced with 'religious/spiritual activity'). Psychometric properties and participant feedback were evaluated. RESULTS: Test-retest reliability (ICCs) ranged from 0.813 to 0.964. Internal consistency (Cronbach's α) ranged from .749 to .936 across sites and languages. Correlations with original subscales were high. The scale was rated easy to complete and understand. CONCLUSIONS: The SFS-Early Intervention is a promising patient-reported measure of social, recreational and independent functioning. Our approach shows that conceptually sound existing measures are adaptable to different times and contexts.

The Clinic for Assessment of Youth at Risk (CAYR): 10 years of service delivery and research targeting the prevention of psychosis in Montreal, Canada.

AIM: In the context of an increasing focus on indicated prevention of psychotic disorders, we describe the operation of the Clinic for Assessment of Youth at Risk (CAYR) over 10 years, a specialized service for identification, monitoring and treatment of young individuals who meet ultra-high risk (UHR) criteria for psychosis, and its integration within the Prevention and Early Intervention Program for Psychosis (PEPP) in Montreal, Canada. METHODS: We outline rationale, development, inclusion and exclusion criteria, assessment, services offered, community outreach and liaison with potential referral sites, and our research focus on risk and protective factors related to the neural diathesis-stress model of psychosis. RESULTS: Between January 2005 and December 2014, CAYR has received 370 referrals and accepted 177 patients who met UHR criteria based on the Comprehensive Assessment for At Risk Mental States. Conversion rates to a first episode of psychosis were 11%. Our research findings point to high subjective stress levels, poor self-esteem, social support and coping skills, and a dysregulation of the hypothalamus-pituitary-adrenal axis during the high-risk phase. CONCLUSIONS: Our efforts at community outreach have resulted in increasing numbers of referrals and patients accepted to CAYR, highlighting the relevance of and need for a high-risk programme in the Montreal area. Patients with psychotic symptoms can be immediately assigned to the first-episode psychosis clinic within PEPP, which has likely contributed to the low conversion rates observed in the UHR group. Our research findings on stress and protective factors emphasize the importance of psychosocial interventions for high-risk patients.

Mode of entry to an early intervention service for psychotic disorders: determinants and impact on outcome.

OBJECTIVE: Specialized early intervention services for first-episode psychosis should treat a proportion of patients without using inpatient beds. This study compared such service users by their initial mode of treatment before entry-inpatient (N=157) or outpatient (N=102). METHODS: On entry to a Montreal early intervention service, the groups were compared on baseline clinical and functional variables and on hospitalizations during two years of treatment. RESULTS: Initial presentation at an emergency service, shorter duration of untreated psychosis, lower functioning level, and aggressive and bizarre behavior were associated with the inpatient entry mode to early intervention services. During follow-up, individuals entering as inpatients spent more days hospitalized than those entering as outpatients, and their time to rehospitalization was shorter. CONCLUSIONS: Results suggest that entry into early intervention services via the hospital emergency department and presentation with behavioral and functional disturbances were more predictive than core psychotic symptoms of hospital inpatient status on referral to an early intervention service.

Childhood trauma and dissociation in first-episode psychosis, chronic schizophrenia and community controls.

Increasing evidence supports the role of childhood trauma in the etiology of psychosis but underlying mechanisms are poorly understood. Early maltreatment has been linked to dissociative symptoms in psychosis patients. We explored associations between childhood trauma (Childhood Trauma Questionnaire) and dissociation (Dissociative Experiences Scale) in first-episode psychotic patients (n=62), chronic psychotic patients (n=43), and non-psychotic community controls (n=66). Multivariate analyses of covariance were used to test associations between childhood trauma and dissociation by group while controlling for sex. Chronic patients reported the highest level of dissociation. More severe childhood trauma was associated with greater dissociative symptoms in all groups although most strongly in chronic patients. Emotional abuse showed the strongest associations with dissociation, with these being strongest for chronic patients, followed by first-episode patients--and least for controls. Men showed a stronger association between physical neglect and dissociation than women, irrespective of group. There were no significant group by sex interactions. Our findings replicate the strong association between childhood trauma and dissociative symptoms in chronic and first-episode psychotic patients relative to non-psychotic control subjects. We also demonstrate the salience of emotional abuse in explaining variance in dissociation, especially in chronic patients.

Case manager- and patient-rated alliance as a predictor of medication adherence in first-episode psychosis.

OBJECTIVE: The objective of this study was to evaluate the association between adherence to antipsychotic medication and working alliance (WA) ratings as reported separately by case manager (CM) and patient in first-episode psychosis (FEP) and to identify whether other factors previously related to adherence influence this relationship. METHODS: Adherence was evaluated every month in 81 participants who met criteria for a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, psychotic disorder (affective or nonaffective) and were treated in a specialized early intervention program. Adherence was measured, taking into account information from patient and clinician reports and pill counting. The WA, as assessed by both CM and patient, was assessed using the Working Alliance Inventory. RESULTS: The WA was stable during the course of the study as rated by both patient and CM. The "task" domain of WA was the subdomain most significantly correlated to adherence in cross-sectional analysis. The WA as measured by CM at study baseline was a significant predictor of the number of subsequent months with "good" adherence independently of other variables, including adherence at treatment onset (ß = 0.011; P = 0.020; 95% confidence interval, 0.002-0.020). However, the WA as measured by patients was not similarly predictive of subsequent adherence (ß = 0.003; P = 0.31; 95% confidence interval, -0.003 to 0.010). CONCLUSIONS: The CM-rated WA is a significant predictor of future medication adherence in FEP, suggesting that good alliance can improve adherence in this population.

Medication-adherent first-episode psychosis patients also relapse: why?

OBJECTIVE: Poor adherence to medication is a major determinant of relapse following treatment of first-episode psychosis (FEP). However, medication-adherent patients also relapse. We examined what factors influence the risk of relapse after controlling for adherence. METHOD: We selected a sample of fully adherent patients (n = 65) who had achieved remission at one point. We then compared patients who relapsed, using 2 different definitions of relapse, to those who did not relapse by 12 months on age, sex, premorbid adjustment, duration of untreated psychosis, length of prodrome, and substance abuse. RESULTS: Among the 65 medication-adherent patients in remission, 9 (14%) relapsed according to criteria for relapse requiring a change in medication. These patients differed from those who remained in remission only in the pattern of premorbid adjustment (greater proportion with deteriorating pattern), although this was not independent of other variables. No differences were found on any other variable. Using a more commonly used metric for relapse, based on symptom ratings alone, an additional 14 (21.5%) patients relapsed. Substance abuse significantly predicted relapse, with substance abusers having more than 25 times the odds of relapsing by 12 months (OR 25.6; 95% CI 2.4 to 278.1, P = 0.008). CONCLUSION: Using a more conservative definition of relapse in this adherent-to-medication population, we find a very low rate of relapse associated, at least partially, with poor premorbid adjustment. As substance abuse was a significant predictor of symptomatic relapse, this would suggest that there should be a greater emphasis on interventions focused on reducing substance abuse in FEP.

Concerns reported by family members of individuals with first-episode psychosis.

AIM: Our aim was to examine the concerns reported by family members and other caregivers of individuals with first-episode psychosis (FEP). METHODS: Family members who attended group psychoeducation selected their top two concerns from a list of nine concerns: stigma, medication, substance abuse, social behaviour, stressful situations, self-esteem and identity, sexuality and intimacy, early warning signs, and resources and support. RESULTS: Parents, particularly mothers, were a significant majority of those who attended psychoeducation sessions. In order of frequency of endorsement, the concerns endorsed were self-esteem and identity, social behaviour, substance abuse, medications, stressful situations, early warning signs, resources and support, stigma, and sexuality and intimacy. CONCLUSION: Families were most concerned about the self-esteem and identity of their young relatives with FEP. Our findings suggest that early intervention programmes should specifically address issues of self-esteem and identity. Further research on the concerns shared by families of individuals with FEP is needed.

Prevalence of psychotic and non-psychotic disorders in relatives of patients with a first episode psychosis.

BACKGROUND: Family members of individuals with schizophrenia suffer from elevated rates of schizophrenia-spectrum disorders (SSD) and other forms of psychopathology. However, few studies have examined familial psychopathology in probands with a first episode of psychosis (FEP). We systematically evaluated family history in patients experiencing an affective or non-affective FEP. METHODS: The Family Interview for Genetic Studies was used to obtain diagnostic information on all first- and second-degree relatives of probands admitted to a specialized FEP program. Probands were 94 previously untreated patients suffering from a first-episode of affective or schizophrenia spectrum psychosis, aged 14 to 30. The interview ascertained diagnoses of psychotic disorders, affective disorders, substance-use disorders (SUD), and schizophrenia-related personality disorders. RESULTS: One in five probands (19.1%) had a history of psychosis among their first-degree relatives, while 34.0% had any relative with psychosis. Fewer probands had a family history of SSD (7.4% with a first-degree history and 18.1% with a history among any relatives). Over half (53.2%) of probands had a first-degree relative with Major Depressive Disorder, and 38.3% had a first-degree relative with a SUD. Overall, 69.9% of probands had a first-degree relative with a mental disorder. The proportion of probands with a family history of any of these diagnoses did not vary by proband diagnosis (affective or SS Psychosis), though probands with co-morbid SUD were more likely to have a family history of substance abuse. CONCLUSIONS: Diverse psychopathology is commonly present in families of FEP patients and may imply a generalized vulnerability to psychiatric disorders to be greater in such families compared to specific vulnerability to SS or affective psychosis. These findings may also have implications for provision of care for the probands.

Validation of the English and French versions of the Community Assessment of Psychic Experiences (CAPE) with a Montreal community sample.

OBJECTIVE: The aim of this study was to examine the reliability, validity and factor structure of the Community Assessment of Psychic Experiences (CAPE), a 42-item self-report questionnaire. We analyzed the internal consistency of the CAPE to determine whether the 3-factor structure (positive, negative and depressive symptoms) found by the CAPE authors would also be found in our sample. METHOD: A sample of 2275 individuals from the general community in the Montreal area completed the questionnaire in either French or English. RESULTS: The internal consistencies of the original three subscales were good and the confirmatory factor models had a good fit. The exploratory factor analysis suggested a 3-5-factor solution, without improving the alternative factor structures. The 4-factor solution separated positive symptoms into factors we called 'bizarre positive symptoms' and 'social delusions', and the 5-factor solution separated positive symptoms further and included a 'popular psychic beliefs' factor. Results suggest that the scalability might be improved by shortening the original questionnaire to 23 items with the same 3 original scales. CONCLUSION: We support the internal consistency of the CAPE. Although alternative scaling (4 and 5 factors) did not improve the model fit, researchers interested in distinguishing 3 factors of positive symptoms could find utility in these two new scales. Finally, reducing the number of CAPE items could be useful for shorter surveys. Future studies should test the implications of these suggestions.

Measuring patient quality of life: is the health utility index useful?

The purpose of this paper is to report Health Utility Index Mark 3 (HUI3) scores, at baseline and at one year, for patients with psychotic disorders. Eighty two randomly selected outpatients from a Montreal teaching hospital completed the HUI3 and other measures of symptoms and side-effects. At baseline, the average Global Utility score was 0.64, which is rated in the "dysfunctional" health status range. Improvements were seen at one year follow-up in the Global, Dexterity, Cognition, and Pain Utility scores. The proportion of individuals rated in the "healthy" health status range improved by 32% from baseline to one year. HUI3 scores were negatively related to measures of psychotic symptoms and side-effects. We propose that the HUI3 should be used to assess health-related quality of life (HRQOL) in patients with psychotic disorders. Scores could be compared with other populations affected with chronic conditions (e.g., Alzheimer dementia, cancer, arthritis, etc.).

Qualitative assessment of mental health service satisfaction: strengths and limitations of a self-administered procedure.

A qualitative procedure based on self-administered open-ended questions was assessed in three psychiatric outpatient clinics in Montreal. Acceptability to clients, mode of administration and convergent validity were evaluated. Comparison with findings from personal interviews demonstrates a lower frequency in responses but similar patterns in sources of satisfaction/dissatisfaction. Scores generated by quantification of responses to one of the open-ended questions presented a significant correlation with a standardized questionnaire (OQOS) administered to 242 psychiatric outpatients. Findings suggest that a self-administered procedure based on open-ended questions could be practical and useful for both formative evaluation and monitoring in environments with limited resources.

The role of relatives in discharge planning from psychiatric hospitals: the perspective of patients and their relatives.

This study prospectively assessed the preferences and satisfaction of 98 psychiatric inpatients and 40 of their relatives with family involvement in discharge planning. Preferences questionnaires were administered during hospitalization. Satisfaction questionnaires were completed 3 months later. Preferences noted by most participants included information concerning patient health status, ways to prevent further hospitalizations, services for relatives, and signs of patient decompensation. More relatives than patients felt that post-discharge residence and activities were important areas to be involved in. Most participants were satisfied if relatives were involved in discharge planning. However, up to 89% of patients, and 84% of relatives, reported no communication between clinical staff and relatives regarding discharge. When this was the case, satisfaction rates dropped sharply, especially for relatives. The need for increased communication between clinicians and relatives regarding discharge planning remains a problem.

Stakeholder perspectives on psychiatric foster homes: residents, families, caregivers, and professionals.

Eight focus groups were conducted with the stakeholders involved in psychiatric foster homes: people with psychiatric disabilities, families, caregivers, and professionals. Four content dimensions emerged as important: 1) foster home environment, 2) caregiver characteristics, 3) community integration, and 4) stakeholder relationships. Findings revealed different perspectives among stakeholders. Caregivers and professionals differed in their views on rehabilitation. Families wanted stricter controls within homes; residents appreciated more autonomy. While residents and caregivers focussed on integration within the foster home, professionals criticized the lack of community integration. These findings demonstrate the need to examine the perspectives of multiple stakeholders in order to present a complete view of psychiatric foster homes.

Conventional, atypical, and combination antipsychotic prescriptions: a 2-year comparison.

BACKGROUND: The purpose of this study was to determine if there is a relationship between the type of antipsychotic prescribed (conventional, atypical, or a combination) and patients' use of psychiatric services and prescription of adjuvant medications. METHOD: A chart review of 83 outpatients with long-term psychiatric disorders recorded the type and dosage of psychiatric medications prescribed in 1997-1998 (T1) and 2 years later, in 1999-2000 (T2). Psychiatric service use was also noted during the 2-year follow-up. RESULTS: Atypical prescriptions increased from 27% (N = 22) to 45% (N = 37) 2 years later. At T2, 35% of patients (N = 29) were prescribed conventionals, and 19% (N = 16) were prescribed a combination of conventionals and atypicals. The mean antipsychotic dosage in chlorpromazine equivalents (546.5 mg/day) increased significantly (p <.05). There was no difference between the 3 groups in their use of psychiatric services or the prescription of adjuvant medications, with the exception of less common prescription of anticholinergics. There was also no difference in psychiatric service use between patients who remained on treatment with combined antipsychotics at T1 and T2 (11%; N = 9) and the rest of the sample. Patients who were switched from one type of antipsychotic to another made more use of psychiatric services, however. CONCLUSION: Contrary to our expectations, patients prescribed combined antipsychotic types did not make more use of psychiatric services or use more adjuvant medications. The high percentage of patients prescribed a combination may be due to antipsychotic polypharmacy preferences and may represent a very slow crossover from one antipsychotic to another.

Satisfaction with clinical case management services of patients with long-term psychoses.

Outpatients with long-term psychotic disorders from two clinical case management programs were interviewed one-on-one to determine their satisfaction with specific aspects of such services. Patients answered standardized questionnaires and two open-ended satisfaction questions. The close follow-up provided by these programs led us to expect high patient satisfaction, and most patients were very satisfied with their clinical case managers. Lower functioning patients, followed by more intensive clinical case management, were equally satisfied to those followed by a less intensive program. However, many patients revealed dissatisfaction with explanations about clinical treatment and services.