Exploring Data Collection Priorities of Community Partners in Early Psychosis Care.

OBJECTIVE: Learning health care networks can significantly improve the effectiveness, consistency, and cost-effectiveness of care delivery. As part of a data harmonization process, incorporation of the perspectives of community partners to maximize the relevance and utility of the data is critical. METHODS: A mixed-methods focus group study was conducted with early psychosis program providers, leadership, service users, and family members to explore their priorities regarding data collection in early psychosis care. Focus group transcripts were analyzed through thematic analysis. RESULTS: Twenty-two focus groups comprising 178 participants were conducted across 10 early psychosis programs. Participants considered functioning, quality of life, recovery, and symptoms of psychosis as key outcomes to assess, although variation by participants' roles was also evident. Participants emphasized the clinical utility of assessing a broad range of predictors of care outcomes, favored a broad conceptualization of the constructs assessed, and indicated a preference for client-reported measures. Participants also emphasized the importance of surveys adopting a recovery-oriented, strengths-based approach. CONCLUSIONS: Large-scale aggregation of health care data collected as part of routine care offers opportunities for research and may have a positive impact on care delivery and quality improvement activities. However, these benefits are contingent on the data being both relevant and accessible to those who deliver and receive such care. This study highlights an approach that may inform the development of core assessment batteries used, optimizing the utility of such data for all community partners.

Incorporating Community Partner Perspectives on eHealth Technology Data Sharing Practices for the California Early Psychosis Intervention Network: Qualitative Focus Group Study With a User-Centered Design Approach.

BACKGROUND: Increased use of eHealth technology and user data to drive early identification and intervention algorithms in early psychosis (EP) necessitates the implementation of ethical data use practices to increase user acceptability and trust. OBJECTIVE: First, the study explored EP community partner perspectives on data sharing best practices, including beliefs, attitudes, and preferences for ethical data sharing and how best to present end-user license agreements (EULAs). Second, we present a test case of adopting a user-centered design approach to develop a EULA protocol consistent with community partner perspectives and priorities. METHODS: We conducted an exploratory, qualitative, and focus group-based study exploring mental health data sharing and privacy preferences among individuals involved in delivering or receiving EP care within the California Early Psychosis Intervention Network. Key themes were identified through a content analysis of focus group transcripts. Additionally, we conducted workshops using a user-centered design approach to develop a EULA that addresses participant priorities. RESULTS: In total, 24 participants took part in the study (14 EP providers, 6 clients, and 4 family members). Participants reported being receptive to data sharing despite being acutely aware of widespread third-party sharing across digital domains, the risk of breaches, and motives hidden in the legal language of EULAs. Consequently, they reported feeling a loss of control and a lack of protection over their data. Participants indicated these concerns could be mitigated through user-level control for data sharing with third parties and an understandable, transparent EULA, including multiple presentation modalities, text at no more than an eighth-grade reading level, and a clear definition of key terms. These findings were successfully integrated into the development of a EULA and data opt-in process that resulted in 88.1% (421/478) of clients who reviewed the video agreeing to share data. CONCLUSIONS: Many of the factors considered pertinent to informing data sharing practices in a mental health setting are consistent among clients, family members, and providers delivering or receiving EP care. These community partners' priorities can be successfully incorporated into developing EULA practices that can lead to high voluntary data sharing rates.

Effect of Technology-Enhanced Screening in Addition to Standard Targeted Clinician Education on the Duration of Untreated Psychosis: A Cluster Randomized Clinical Trial.

Importance: Reducing the duration of untreated psychosis (DUP) is essential to improving outcomes for people with first-episode psychosis (FEP). Current US approaches are insufficient to reduce DUP to international standards of less than 90 days. Objective: To determine whether population-based electronic screening in addition to standard targeted clinician education increases early detection of psychosis and decreases DUP, compared with clinician education alone. Design, Setting, and Participants: This cluster randomized clinical trial included individuals aged 12 to 30 years presenting for services between March 2015 and September 2017 at participating sites that included community mental health clinics and school support and special education services. Eligible participants were referred to the Early Diagnosis and Preventative Treatment (EDAPT) Clinic. Data analyses were performed in September and October 2019 for the primary and secondary analyses, with the exploratory subgroup analyses completed in May 2021. Interventions: All sites in both groups received targeted education about early psychosis for health care professionals. In the active screening group, clients also completed the Prodromal Questionnaire-Brief using tablets at intake; referrals were based on those scores and clinical judgment. In the group receiving treatment as usual (TAU), referrals were based on clinical judgment alone. Main Outcomes and Measures: Primary outcomes included DUP, defined as the period from full psychosis onset to the date of the EDAPT diagnostic telephone interview, and the number of individuals identified with FEP or a psychosis spectrum disorder. Exploratory analyses examined differences by site type, completion rates between conditions, and days from service entry to telephone interview. Results: Twenty-four sites agreed to participate, and 12 sites were randomized to either the active screening or TAU group. However, only 10 community clinics and 4 school sites were able to fully implement population screening and were included in the final analysis. The total potentially eligible population size within each study group was similar, with 2432 individuals entering at active screening group sites and 2455 at TAU group sites. A total of 303 diagnostic telephone interviews were completed (178 [58.7%] female individuals; mean [SD] age, 17.09 years [4.57]). Active screening sites reported a significantly higher detection rate of psychosis spectrum disorders (136 cases [5.6%], relative to 65 [2.6%]; P < .001) and referred a higher proportion of individuals with FEP and DUP less than 90 days (13 cases, relative to 4; odds ratio, 0.30; 95% CI, 0.10-0.93; P = .03). There was no difference in mean (SD) DUP between groups (active screening group, 239.0 days [207.4]; TAU group 262.3 days [170.2]). Conclusions and Relevance: In this cluster trial, population-based technology-enhanced screening across community settings detected more than twice as many individuals with psychosis spectrum disorders compared with clinical judgment alone but did not reduce DUP. Screening could identify people undetected in US mental health services. Significant DUP reduction may require interventions to reduce time to the first mental health contact. Trial Registration: ClinicalTrials.gov Identifier: NCT02841956.

Risk and Resilience Factors for Youth Homelessness in Western Countries: A Systematic Review.

OBJECTIVES: The experience of homelessness for young people can affect social, emotional, and physical development, resulting in poorer physical and mental health outcomes. To reduce rates of youth homelessness, a better understanding of both risk and resilience is needed to inform future intervention development. This article presents a systematic review of published research reporting risk or resilience factors related to homelessness among young people in Western countries. METHODS: After thorough examination for inclusion criteria, 665 abstracts of peer-reviewed quantitative studies of risk or resilience factors for homelessness among young people (ages 0-25) that included an adequate comparison group (e.g., not homeless) were selected. After abstract and full-text screening, 16 articles were reviewed. A primary prevention framework was used to create an explanatory model for the onset of homelessness using risk and resilience factors. RESULTS: Common risk factors for youth homelessness included difficulties with family, mental health or substance use problems, a history of problem behaviors, a history of foster care, homelessness as a child, and running away. Common protective factors included a supportive family, a college education, and high socioeconomic status. Findings were integrated into a provisional developmental model of youth homelessness risk. Clinical implications of the model for service development are discussed, and a model for monitoring homelessness risk and resilience factors is proposed. CONCLUSIONS: Factors affecting homelessness risk among youths and adults differ, with family, foster care, and schooling playing a much more important role among youths. Findings highlight opportunities for youth homelessness prevention strategies and monitoring.

Links Between Human and Animal Models of Trauma and Psychosis: A Narrative Review.

Traumatic experiences during development are associated with an increased risk of developing psychosis. Individuals with psychosis also report a higher rate of past trauma than healthy control subjects and worse outcomes than those who do not have these experiences. It is thought that traumatic experiences negatively impact specific neurobiological processes to confer this increased risk, and that systems affected by trauma are similarly changed in individuals with psychosis. Examining animal models of psychosis and the shared neurobiological changes in response to stressors can offer valuable insight into biological mechanisms that mediate symptoms and targets for intervention. This targeted review highlights a subset of models of psychosis across humans and animals, examines the similarities with the brain's response to stress and traumatic events, and discusses how these models may interact. Suggestions for future research are described.

Suicide behavior is associated with childhood emotion dysregulation but not trait impulsivity in first episode psychosis.

Historically, research on suicide behavior has not included those experiencing first episode psychosis (FEP), hindering prevention efforts for this population. Emotion dysregulation and impulsivity represent two mechanisms that contribute to suicide, but these have not been examined in FEP. We hypothesize that the combination of trait impulsivity and childhood emotion dysregulation are associated with suicide behavior (SB) and ideation (SI) in those experiencing FEP. Participants were recruited from an Early Psychosis Program (N=80, ages 12-32, 65% male). Clinician ratings of symptoms and history of SI and SB were obtained at baseline. Participants also completed self-report measures of childhood emotion dysregulation and trait impulsivity. Regression analyses examined whether childhood emotion dysregulation and trait impulsivity individually or in combination were associated with SI and SB, and the severity of SI and SB. Childhood emotion dysregulation was significantly associated with a history of SB and its severity, but not SI. Attention impulsivity was associated with the severity of SI. However, other impulsivity types, and interactions were not associated with a history of SI or SB. This suggests childhood emotion dysregulation is a potential target for prevention of SB in FEP, while trait impulsivity may be less important in this effort.

Loss of Sensitivity to Rewards by Dopamine Neurons May Underlie Age-Related Increased Probability Discounting.

Normative aging is known to affect how decisions are made in risky situations. Although important individual variability exists, on average, aging is accompanied by greater risk aversion. Here the behavioral and neural mechanisms of greater risk aversion were examined in young and old rats trained on an instrumental probability discounting task. Consistent with the literature, old rats showed greater discounting of reward value when the probability of obtaining rewards dropped below 100%. Behaviorally, reward magnitude discrimination was the same between young and old rats, and yet these same rats exhibited reduced sensitivity to positive, but not negative, choice outcomes. The latter behavioral result was congruent with additional findings that the aged ventral tegmental neurons (including dopamine cells) were less responsive to rewards when compared to the same cell types recorded from young animals. In sum, it appears that reduced responses of dopamine neurons to rewards contribute to aging-related changes in risky decisions.

A History of Trauma is Associated with Aggression, Depression, Non-Suicidal Self-Injury Behavior, and Suicide Ideation in First-Episode Psychosis.

The association between trauma and psychosis outcomes is well-established, and yet the impact of trauma on comorbid clinical symptoms-such as aggression, non-suicidal self-injury behavior (NSSIB), suicide ideation, and suicide behavior-for those with psychosis is unclear. To effectively treat those with first-episode psychosis (FEP) and a history of trauma, we need to understand the impact of trauma on their whole presentation. FEP participants were recruited from an Early Psychosis Program (N = 187, ages 12-35, 72.2% male). Clinicians gathered history of trauma, aggression, and suicide data, and rated current symptom severity and functioning. Data was coded using clinician rated measures, self-report measures, and retrospective clinical chart review. Regression analyses examined whether trauma was associated with a history of aggression, suicidal ideation, suicide behavior, NSSIB, symptoms, and functioning. Trauma was associated with aggression, aggression severity and type of aggression (aggression towards others). Trauma was also associated with depression severity, suicide ideation, most severe suicide ideation, and NSSIB. Trauma was not associated with suicide behavior, severity of suicide behavior or psychosocial functioning. Integrating trauma treatment into FEP care could reduce rates of depression, aggression, suicide ideation, and NSSIB for those with a history of trauma. To reduce suicide attempt occurrence and improve functioning, more research is needed.

Hippocampal neural activity reflects the economy of choices during goal-directed navigation.

Distinguishing spatial contexts is likely essential for the well-known role of the hippocampus in episodic memory. We studied whether types of hippocampal neural organization thought to underlie context discrimination are impacted by learned economic considerations of choice behavior. Hippocampal place cells and theta activity were recorded as rats performed a maze-based probability discounting task that involved choosing between a small certain reward or a large probabilistic reward. Different spatial distributions of place fields were observed in response to changes in probability, the outcome of the rats' choice, and whether or not rats were free to make that choice. The degree to which the reward location was represented by place cells scaled with the expected probability of rewards. Theta power increased around the goal location also in proportion to the expected probability of signaled rewards. Furthermore, theta power dynamically varied as specific econometric information was obtained "on the fly" during task performance. Such an economic perspective of memory processing by hippocampal place cells expands our view of the nature of context memories retrieved by hippocampus during adaptive navigation.

Analysis of morphine-induced changes in the activity of periaqueductal gray neurons in the intact rat.

Microinjection of morphine into the periaqueductal gray (PAG) produces antinociception. In vitro slice recordings indicate that all PAG neurons are sensitive to morphine either by direct inhibition or indirect disinhibition. We tested the hypothesis that all PAG neurons respond to opioids in vivo by examining the extracellular activity of PAG neurons recorded in lightly anesthetized and awake rats. Spontaneous activity was less than 1Hz in most neurons. Noxious stimuli (heat, pinch) caused an increase in activity in 57% and 75% of the neurons recorded in anesthetized and awake rats, respectively. The same noxious stimuli caused a decrease in activity in only 17% and 6% of neurons recorded in anesthetized and awake rats. Systemic administration of morphine caused approximately equal numbers of neurons to increase, decrease, or show no change in activity in lightly anesthetized rats. In contrast, administration of morphine caused an increase in the activity of 22 of the 27 neurons recorded in awake rats. No change in activity was evident in the remaining five neurons. Changes in activity caused by morphine were surprisingly modest (a median increase from 0.7 to 1.3Hz). The small inconsistent effects of morphine are in stark contrast to the large changes produced by morphine on the activity of rostral ventromedial medulla (RVM) neurons or the widespread inhibition and excitation of PAG neurons treated with opioids in in vitro slice experiments. The relatively modest effects of morphine in the present study suggest that morphine produces antinociception by causing small changes in the activity of many PAG neurons.

Integrative hippocampal and decision-making neurocircuitry during goal-relevant predictions and encoding.

It has become clear that the hippocampus plays a critical role in the identification of new contexts and for the detection of changes in familiar contexts. The hippocampus accomplishes these goals through a continual process of comparing predicted features of a context or situation to those actually experienced. A mismatch between expected and experienced context expectations is thought to lead to the generation of a context prediction error (Mizumori, 2013) that functionally alerts connected brain areas to alter subsequent decision making and response selection. Little is understood about how hippocampal context analyses impact downstream decision processes. This issue is evaluated here first by comparing the nature of the information represented in hippocampus and decision-related midbrain-striatal structures, while rats perform a hippocampal-dependent spatial memory task in which rewards of different value are found at different locations. In contrast to place-specific and egocentric neural representations, neural representations of goal information are broadly distributed in hippocampal and decision neural circuitry, but they appear in different forms for different brain structures. It is suggested that further researching on how goal information processing occurs in hippocampus and decision neural circuitry may reveal insights into the nature of the interaction between memory and decision systems. The second part of this review describes neural pathways by which hippocampal context information might arrive within the decision circuit. The third section presents a hypothesis that the nature of the interactions between hippocampal and midbrain-striatal circuitry is regulated by the prefrontal cortex.

Magnetic field polarity fails to influence the directional signal carried by the head direction cell network and the behavior of rats in a task requiring magnetic field orientation.

Many different species of animals including mole rats, pigeons, and sea turtles are thought to use the magnetic field of the earth for navigational guidance. While laboratory rats are commonly used for navigational research, and brain networks have been described in these animals that presumably mediate accurate spatial navigation, little has been done to determine the role of the geomagnetic field in these brain networks and in the navigational behavior of these animals. In Experiment 1, anterior thalamic head direction (HD) cells were recorded in female Long-Evans rats while they foraged in an environment subjected to an experimentally generated magnetic field of earth-strength intensity, the polarity of which could be shifted from one session to another. Despite previous work that has shown that the preferred direction of HD cells can be controlled by the position of familiar landmarks in a recording environment, the directional signal of HD cells was not influenced by the polarity of the magnetic field in the enclosure. Because this finding could be attributed to the animal being insensitive or inattentive to the magnetic field, in Experiment 2, rats were trained in a choice maze task dependent on the ability of the animals to sense the polarity of the experimentally controlled magnetic field. Over the course of 28 days of training, performance failed to improve to a level above chance, providing evidence that the spatial behavior of laboratory rats (and the associated HD network) is insensitive to the polarity of the geomagnetic field.