NorthBEAT: exploring the service needs of youth experiencing early psychosis in Northern Ontario.

Introduction: Early Psychosis Intervention (EPI) is critical for best outcomes. Among 369 diseases, psychosis is among those causing the greatest disability. Evidence-based interventions for youth in early stages of psychosis (EPI programs) have prevented chronic disability. Yet, EPI is frequently inaccessible for youth living in rural communities. Moreover, Indigenous youth often face more precipitous situations given inadequate staffing, and culturally unsafe care. The NorthBEAT (Barriers to Early Assessment and Treatment) project sought to understand the service needs of youth with psychosis in Northern Ontario. The goals were: (1) to describe the mental health of a subset of adolescents receiving EPI care; (2) examine Indigenous youth as a significant and vulnerable population; (3) to understand the barriers and facilitators for Indigenous and non-Indigenous youth receiving EPI. Methods: Mixed methods (structured and narrative interviews) included: psychometric scales interviews with youth, and narrative interviews with youth, their family, and service providers Data validation workshops were held with participants. Results: Structured interviews with 26 youth (M = 17 years) found the participants functioning moderately well with duration of untreated psychosis ranging from 1 to 96 months (M = 26 months). No significant differences were found in functioning or duration of psychosis between Indigenous and non-Indigenous youth. Narrative interviews were conducted with 18 youth, 11 family members, and 14 service providers. Identified barriers were a lack of knowledge about psychosis among service providers, a disconnected system leading to delays in treatment, help not wanted by youth, expansive geographical context. Service needs were: finding the right point of access, support for families, pre-crisis intervention, reduced stigma for youth and their families, and an EPI approach to care. Discussion: Rural and northern youth face similar barriers to accessing EPI as urban youth. However, northern youth face additional unique challenges due to expansive geographical context, limited resources and lack of knowledge about services.

Access to a regular primary care physician among young people with early psychosis in Ontario, Canada.

AIM: Access to a primary care physician in early psychosis facilitates help-seeking and engagement with psychiatric treatment. We examined access to a regular primary care physician in people with early psychosis, compared to the general population, and explored factors associated with access. METHODS: Using linked health administrative data from Ontario (Canada), we identified people aged 14-35 years with a first diagnosis of nonaffective psychotic disorder (n = 39 449; 2005-2015). We matched cases to four randomly selected general population controls based on age, sex, neighbourhood, and index date (n = 157 796). We used modified Poisson regression to estimate prevalence ratios (PR) for access to a regular primary care physician in the year prior to first diagnosis of psychotic disorder, and the sociodemographic and clinical factors associated with access. RESULTS: A larger proportion of people with early psychosis had a regular primary care physician, relative to the general population (89% vs. 68%; PR = 1.30, 95%CI = 1.30-1.31). However, this was accounted for by a higher prevalence of comorbidities among people with psychosis, and this association was no longer present after adjustment (PR = 0.97, 95%CI = 0.97, 0.98). People with early psychosis who were older, male, refugees and those residing in lower income or high residential instability neighbourhoods were less likely to have a regular primary care physician. CONCLUSION: Approximately one in ten young people with early psychosis in Ontario lack access to a regular primary care physician. Strategies to improve primary care physician access are needed for management of physical comorbidities and to ensure continuity of care.

Patient and Physician Factors Associated with First Diagnosis of Non-affective Psychotic Disorder in Primary Care.

Primary care physicians play a central role in pathways to care for first-episode psychosis, and their increased involvement in early detection could improve service-related outcomes. The aim of this study was to estimate the proportion of psychosis first diagnosed in primary care, and identify associated patient and physician factors. We used linked health administrative data to construct a retrospective cohort of people aged 14-35 years with a first diagnosis of non-affective psychosis in Ontario, Canada between 2005-2015. We restricted the sample to patients with help-seeking contacts for mental health reasons in primary care in the six months prior to first diagnosis of psychotic disorder. We used modified Poisson regression models to examine patient and physician factors associated with a first diagnosis of psychosis in primary care. Among people with early psychosis (n = 39,449), 63% had help-seeking contacts in primary care within six months prior to first diagnosis. Of those patients, 47% were diagnosed in primary care and 53% in secondary/tertiary care. Patients factors associated with lower likelihood of diagnosis in primary care included male sex, younger age, immigrant status, and comorbid psychosocial conditions. Physician factors associated with lower likelihood of diagnosis in primary care included solo practice model, urban practice setting, international medical education, and longer time since graduation. Our findings indicate that primary care is an important contact for help-seeking and diagnosis for a large proportion of people with early psychosis. For physicians less likely to diagnose psychosis in primary care, targeted resources and interventions could be provided to support them in caring for patients with early psychosis.

Feasibility and acceptability of a volunteer peer fidelity assessment model in early psychosis intervention programmes in Ontario: Results from a pilot study.

AIM: Fidelity monitoring can support high-quality service delivery but is resource-intensive to implement. A fidelity assessment model utilizing volunteer assessors was trialled as a low-cost strategy for conducting fidelity assessments. This article reports on the acceptability and feasibility of this model. METHODS: Twenty volunteer assessors were trained to conduct fidelity assessments in nine Early Psychosis Intervention programmes across Ontario, Canada. Assessments were conducted using the First-Episode Psychosis Services Fidelity Scale based on a 2-day site visit, during which assessors interviewed staff, clients and families; reviewed charts; observed a team meeting and reviewed programme materials. The model was evaluated based on assessor focus groups, programme interviews, consensus meeting data and time-tracking logs. General inductive analysis was used to code and synthesize qualitative data. Quantitative data were aggregated and summarized. RESULTS: Participant feedback was positive and indicated that use of peer assessors and the in-person site visit added value to the process. The model was perceived to provide valuable information to support internal quality improvement efforts. Assessors reported direct benefits from participating, including networking and learning opportunities. Key challenges were the high time demand on assessors and turnover in the assessor team. CONCLUSIONS: The volunteer peer fidelity model was perceived to be a valuable improvement process by participants, but the high cost and reliance on ongoing volunteerism makes its sustainability uncertain. Next steps may include exploring remote assessment strategies or direct payments, although these strategies risk reducing the acceptability, and therefore uptake, of the assessment.

International application of standards for health care quality, access and evaluation of services for early intervention in psychotic disorders.

AIM: Standards for health care quality, access and evaluation of early intervention in psychosis services are required to assess implementation, provide accountability to service users and funders and support quality assurance. The aim of this article is to review the application of standards in Europe and North America. METHODS: Descriptive methods will be used to illustrate the organizational context in which standards are being applied and used, specific measures being applied and results so far. RESULTS: Both fidelity scales and quality indicators of health care are being used. Fidelity scales are being applied in Australia, Canada, Denmark, Italy and United States. In England, quality indicators derived from the National Institute for Health and Care Excellence guidance are being used. CONCLUSION: In the last 4 years, significant progress has been made in the development and application of measures that assess quality and access to evidence-based practices for early intervention in psychosis services. This represents an important step towards providing accountability, improving outcomes and service user experience. The methods used allow for comparison between the services that are assessed with the same methods, but there is a need to compare the different methods. Further research is also required to explore links between quality of care and outcomes for community mental health services that deliver early intervention in psychotic disorders.

Using Fidelity Measurement to Assess Quality of Early Psychosis Intervention Services in Ontario.

OBJECTIVES: The First Episode Psychosis Services Fidelity Scale (FEPS-FS) is a validated measure of program delivery in relation to international standards. This study assessed fidelity in Ontario programs and the utility of the FEPS-FS for program improvement. METHODS: Assessments were conducted in a volunteer sample of nine early psychosis intervention (EPI) programs. Thirty components of care were each rated on a 5-point scale; a rating of 4 indicates satisfactory performance. Trained assessor teams conducted site visits, and ratings were made by consensus. RESULTS: Program mean fidelity ratings ranged from 3.1 to 4.4 and exceeded 4 in five programs. Across the programs, item mean fidelity ratings ranged from 2.1 to 5 and exceeded 4 for 14 of 30 items. CONCLUSIONS: The FEPS-FS captured variation in program implementation and provided a baseline for measuring change. Additions to the scale are planned to address components of the Ontario EPI standards not covered by the FEPS-FS.

Understanding the role of the family physician in early psychosis intervention.

BACKGROUND: The family physician is key to facilitating access to psychiatric treatment for young people with first-episode psychosis, and this involvement can reduce aversive events in pathways to care. Those who seek help from primary care tend to have longer intervals to psychiatric care, and some people receive ongoing psychiatric treatment from the family physician. AIMS: Our objective is to understand the role of the family physician in help-seeking, recognition and ongoing management of first-episode psychosis. METHOD: We will use a mixed-methods approach, incorporating health administrative data, electronic medical records (EMRs) and qualitative methodologies to study the role of the family physician at three points on the pathway to care. First, help-seeking: we will use health administrative data to examine access to a family physician and patterns of primary care use preceding the first diagnosis of psychosis; second, recognition: we will identify first-onset cases of psychosis in health administrative data, and look back at linked EMRs from primary care to define a risk profile for undetected cases; and third, management: we will examine service provision to identified patients through EMR data, including patterns of contacts, prescriptions and referrals to specialised care. We will then conduct qualitative interviews and focus groups with key stakeholders to better understand the trends observed in the quantitative data. DISCUSSION: These findings will provide an in-depth description of first-episode psychosis in primary care, informing strategies to build linkages between family physicians and psychiatric services to improve transitions of care during the crucial early stages of psychosis. DECLARATION OF INTEREST: None.

Potential Effects of the Choice of Costing Perspective on Cost Estimates: An Example Based on 6 Early Psychosis Intervention Programs.

OBJECTIVE: Because health care resources are constrained, decision-making processes often require clarifying the potential costs and savings associated with different options. This involves calculating a program's costs. The chosen costing perspective defines the costs to be considered and can ultimately influence decisions. Yet reviews of the literature suggest little attention has been paid to the perspective in economic evaluations. This article's purpose is to explore how the costing perspective can affect cost estimates. METHOD: As a vehicle for our discussion, we use service use data for clients enrolled in 6 Ontario early psychosis intervention programs. Governmental and nongovernmental payer costing perspectives are considered. We examine annual costs associated with early psychosis intervention clients enrolled for ≤12 months versus those enrolled for >12 months. This also allows for an assessment of the impact that choice of time horizon can make on the results. RESULTS: The difference in total between group cost for hospital, emergency room, and physicians is $2499; the >12-month group has relatively higher mean costs. When all governmental and nongovernmental costs are considered, there is a mean between-group cost difference of $1272, with lower mean costs for the >12-month group. CONCLUSIONS: Although the Ministry of Health bears a large proportion of costs, other governmental agencies and the private sector can incur a sizeable share. This example demonstrates the potential importance of including other cost perspectives with the hospital sector in analyses as well as the impact of time horizon on cost estimates.

Implementation and evaluation of a quality improvement project: carepaths for Early Psychosis Intervention Programmes in Northeastern Ontario.

AIM: This study aims to describe the implementation and evaluation of a quality improvement project, which aimed to standardize services and documentation across several district Early Psychosis Intervention Programmes in a rural region of Canada (Northeastern Ontario). METHOD: A Carepath for early psychosis intervention (EPI), which outlined best practice EPI care pathways, was implemented across 12 EPI programme sites. It was hypothesized that the proportion of best practice interventions provided across the district programmes would increase after the implementation of the Carepath initiative and that documentation would be standardized. Pre-Carepath and post-Carepath chart audits evaluated the provision and documentation of EPI best practices that were specified in the Carepath. RESULTS: Pre-audits and post-audits were completed on 110 and 108 client files, respectively. Chi-squared tests revealed that the post-audit frequencies were significantly higher than the pre-audit frequencies for two of the 12 EPI best practices that were evaluated (i.e. assessed impact on family and assessment of substance use). Standardization of documentation did not improve significantly. CONCLUSIONS: The results are discussed in the context of barriers to implementing and evaluating the Carepaths. Various individual and agency level barriers are identified (e.g. staff resistance, resources and agency documentation parameters), and strategies to overcome them are discussed. It is concluded that, despite barriers to implementation and evaluation, Carepaths can be a useful tool for standardizing services and documentation across a network of EPI programmes and guiding programme evaluation and quality assurance.

Client and key worker ratings of need in first-episode psychosis early intervention programmes.

AIM: The aim of this study was to fill a gap in the literature by examining agreement on need as rated by clients and their key workers from first-episode psychosis early intervention programmes. Compared with adult populations and more chronic courses of illness, these clients may have unique needs given the onset of their illness in adolescence or early adulthood. METHODS: Needs agreement between clients and key workers was assessed using the Camberwell Assessment of Need in a sample of 188 client-key worker pairs recruited from six early intervention programmes in Ontario, Canada. Ratings were assessed with percentage agreement and prevalence-adjusted Cohen's kappa. RESULTS: At the aggregate level, both clients and key workers rated a mean of 2.6 unmet needs. Compared with other diagnoses, key workers rated significantly more unmet need in clients with primary psychotic disorders. Agreement between individual client and key worker ratings was highest (adjusted κ > 0.85) in the domains of telephone, risk to others, child care and accommodation. Lowest agreement (adjusted κ < 0.4) was found in the domains of psychological distress, sexual expression, company, daytime activities and intimate relationships. CONCLUSIONS: While congruence is present in concrete domains, there is substantial variability in how clients and their key workers perceive need in more personal areas. The initial focus of care may necessarily be on needs such as shelter, food and treatment; however, subsequent care should incorporate a shared assessment of need to support strong relationships with providers and ongoing engagement in treatment.

A first step in system improvement: a survey of Early Psychosis Intervention Programmes in Ontario.

AIM: Ontario, Canada is a large province with a geographically dispersed population. Early psychosis intervention (EPI) programmes are available province-wide, with delivery approaches adapted to context. This study examined EPI programme delivery in relation to recently released provincial EPI Program Standards, and variations based on geographic context. METHODS: The data source was a province-wide key informant survey of early psychosis programmes conducted after release of the Standards. Chi-squared tests compared large- and small-area programmes on selected programme structural features and perceived adherence to 19 service components. RESULTS: Responses were obtained from 52 programme sites, including 21 small-area programmes with 1 to 2 staff. In general, frequency of EPI delivery was highest for individual assessment and treatment components, and moderate for social supports and family support. Implementation was lowest for public education, early detection and recovery planning. Small-area programmes reported lower implementation for over half of the components, with differences statistically significant for psychiatric assessment and physical health monitoring. CONCLUSION: Since the release of the Standards, the Ontario Ministry of Health has partnered with a provincial network of EPI stakeholders to support practice improvement. This survey identified components where more implementation support is needed, overall and for rural area delivery. Ultimately, systematic monitoring of programme fidelity and measuring client outcomes are key to advancing the quality of EPI programme delivery.

Arfaptin-1 negatively regulates Arl1-mediated retrograde transport.

The small GTPase Arf-like protein 1 (Arl1) is well known for its role in intracellular vesicular transport at the trans-Golgi network (TGN). In this study, we used differential affinity chromatography combined with mass spectrometry to identify Arf-interacting protein 1b (arfaptin-1b) as an Arl1-interacting protein and characterized a novel function for arfaptin-1 (including the arfaptin-1a and 1b isoforms) in Arl1-mediated retrograde transport. Using a Shiga-toxin subunit B (STxB) transportation assay, we demonstrated that knockdown of arfaptin-1 accelerated the retrograde transport of STxB from the endosome to the Golgi apparatus, whereas Arl1 knockdown inhibited STxB transport compared with control cells. Arfaptin-1 overexpression, but not an Arl1 binding-defective mutant (arfaptin-1b-F317A), consistently inhibited STxB transport. Exogenous arfaptin-1 expression did not interfere with the localization of the Arl1-interacting proteins golgin-97 and golgin-245 to the TGN and vice versa. Moreover, we found that the N-terminal region of arfaptin-1 was involved in the regulation of retrograde transport. Our results show that arfaptin-1 acts as a negative regulator in Arl1-mediated retrograde transport and suggest that different functional complexes containing Arl1 form in distinct microdomains and are responsible for different functions.

Rural and remote early psychosis intervention services: the Gordian knot of early intervention.

AIM: One of the basic challenges of Early Psychosis Intervention (EPI) programs for rural populations is translating best practice which developed for urban high-population density areas to rural and remote settings. This paper presents data from two different models (hub and spoke and specialist outreach) of rural EPI practice in Ontario, Canada. METHODS: This cross-sectional study used a convenience sample of clients from two rural EPI programs between 2005 and 2007. Data about client outcomes specific to general functioning, admissions to hospital and emergency room (ER) visits were collected. For all dichotomous variables, chi-square tests were used to test differences between two groups. RESULTS: The total clients served in hub and spoke were 457 compared to 91 in specialist outreach. Although not statistically significant, the hub and spoke group showed better functioning in the community. There was a significant difference between the two groups with regard to hospital admissions. Although not significant, there was a greater percentage (58.3%) of specialist outreach clients who visited the ER in the previous 12 months as compared to clients serviced by the hub and spoke model (34.9%). CONCLUSIONS: The observed data from these two rural models suggest that there may be differing outcomes. There are limitations to this study, and this paper does not address why there are differences. Future work needs to continue to further explore why differences exist and whether they persist so we can provide equity and quality care for rural and remote populations.

Psychosis 101: evaluating a training programme for northern and remote youth mental health service providers.

BACKGROUND: Most of the early psychosis intervention (EPI) training has focused on family physicians participants. In Northern Ontario, there is a shortage of primary care. This paper will present evaluation results of a pilot training programme for rural and remote youth mental health service providers. METHOD: A mixed methods approach was used. We evaluated a 2-day workshop about EPI for non-medical mental health workers delivered onsite and simultaneously by videoconferencing. There were 19 participants across four agencies. Seven were onsite and 12 were offsite. Participants' knowledge was measured using a validated questionnaire at pre-intervention and at 3-, 6- and 9-month follow up. A repeated measures ANOVA was used to evaluate knowledge acquisition between the two modes of training. At 6 months, focus group interviews were conducted to explore their experiences of the mode of intervention delivery and evaluation. Emerging themes were iteratively derived through a series of discussions involving independent coders. RESULTS: Only 15 complete datasets were available of the 19 original participants. Differences in knowledge acquisition between the two groups did not reach statistical difference. Six-month focus group data indicated that participants improved their relationship with EPI services and they were part of a strengthened network with other providers in the region. Post-intervention, the accuracy of referrals from participating agencies increased dramatically, with an increase in proportion of referrals who were eligible for EPI services. The follow-up process engaged participants in learning and re-engaged them with the material taught during the training session. CONCLUSIONS: The results about developing service partnerships and relationship with specialist services are encouraging for policy and service decision-makers to address mental health service needs in northern and remote areas.

Substance abuse and smoking among a Canadian cohort of first episode psychosis patients.

Individuals experiencing their first psychotic episode report rates of substance and tobacco use that are higher than observed in the general population. In this sample of individuals diagnosed with first episode psychosis, rural/non-rural variations in substance use and smoking behaviour were evaluated. Analyses were performed utilizing data from a sample of individuals enrolled in early intervention programs located throughout the province of Ontario. Based upon population density, two geographical regions were developed: rural and non-rural. Illicit drug use, alcohol consumption, and smoking behaviour were assessed. The total sample consisted of 152 individuals experiencing their first episode of psychosis. Of these individuals, 82 and 70 resided in rural and non-rural areas, respectively. Rural vs non-rural residence was not significantly associated with substance or tobacco use. Regardless of geographical location, early intervention programs for individuals experiencing their first psychotic episode need to incorporate interventions that address substance use.

Examining the factors associated with paid employment of clients enrolled in first episode of psychosis programs.

Schizophrenia is one of the most debilitating mental disorders. For a significant portion of individuals who suffer from this disorder, onset occurs in young adulthood, arresting important social and educational development that is necessary for future successful labor force participation. The purpose of this paper is to contribute to the literature about clients enrolled in first episode psychosis programs and psychosocial outcomes by examining the factors associated with paid employment among young adults who have experienced their first psychotic episodes. In this paper, we consider the association of socioeconomic factors to employment. Our results suggest that in addition to treatment, socioeconomic factors such as receipt of public disability benefits and educational attainment are associated with employment status. These results can help to inform future directions for the enhancement of psychosocial programs in FEP models to promote paid employment.

Quantitative proteomics reveals regulation of karyopherin subunit alpha-2 (KPNA2) and its potential novel cargo proteins in nonsmall cell lung cancer.

The process of nucleocytoplasmic shuttling is mediated by karyopherins. Dysregulated expression of karyopherins may trigger oncogenesis through aberrant distribution of cargo proteins. Karyopherin subunit alpha-2 (KPNA2) was previously identified as a potential biomarker for nonsmall cell lung cancer by integration of the cancer cell secretome and tissue transcriptome data sets. Knockdown of KPNA2 suppressed the proliferation and migration abilities of lung cancer cells. However, the precise molecular mechanisms underlying KPNA2 activity in cancer remain to be established. In the current study, we applied gene knockdown, subcellular fractionation, and stable isotope labeling by amino acids in cell culture-based quantitative proteomic strategies to systematically analyze the KPNA2-regulating protein profiles in an adenocarcinoma cell line. Interaction network analysis revealed that several KPNA2-regulating proteins are involved in the cell cycle, DNA metabolic process, cellular component movements and cell migration. Importantly, E2F1 was identified as a potential novel cargo of KPNA2 in the nuclear proteome. The mRNA levels of potential effectors of E2F1 measured using quantitative PCR indicated that E2F1 is one of the "master molecule" responses to KPNA2 knockdown. Immunofluorescence staining and immunoprecipitation assays disclosed co-localization and association between E2F1 and KPNA2. An in vitro protein binding assay further demonstrated that E2F1 interacts directly with KPNA2. Moreover, knockdown of KPNA2 led to subcellular redistribution of E2F1 in lung cancer cells. Our results collectively demonstrate the utility of quantitative proteomic approaches and provide a fundamental platform to further explore the biological roles of KPNA2 in nonsmall cell lung cancer.

Effective lifestyle interventions to improve type II diabetes self-management for those with schizophrenia or schizoaffective disorder: a systematic review.

BACKGROUND: The prevalence of type II diabetes among individuals suffering from schizophrenia or schizoaffective disorders is more than double that of the general population. By 2005, North American professional medical associations of Psychiatry, Diabetes, and Endocrinology responded by recommending continuous metabolic monitoring for this population to control complications from obesity and diabetes. However, these recommendations do not identify the types of effective treatment for people with schizophrenia who have type II diabetes. To fill this gap, this systematic evidence review identifies effective lifestyle interventions that enhance quality care in individuals who are suffering from type II diabetes and schizophrenia or other schizoaffective disorders. METHODS: A systematic search from Medline, CINAHL, PsycINFO, and ISI Web of Science was conducted. Of the 1810 unique papers that were retrieved, four met the inclusion/exclusion criteria and were analyzed. RESULTS: The results indicate that diabetes education is effective when it incorporates diet and exercise components, while using a design that addresses challenges such as cognition, motivation, and weight gain that may result from antipsychotics. CONCLUSIONS: This paper begins to point to effective interventions that will improve type II diabetes management for people with schizophrenia or other schizoaffective disorders.

Lessons from a Canadian province: examining collaborations between the mental health and justice sectors.

OBJECTIVE: The objective of this paper was to identify the factors that program developers perceived as important to the successful collaboration between the mental health and justice sectors in seven Ontario, Canada, post-booking programs. METHODS: Semi-structured telephone interviews with developers of the programs in each region were conducted. Key informants were identified using a snowball technique. All transcripts were analyzed using a modified grounded theory approach. RESULTS: The primary themes identified involved partnership development, adjustment to broader mandates and addressing ongoing challenges. Conclusions were validated through member checking. CONCLUSIONS: The findings highlight important considerations for cross-ministerial enterprises. If partnerships are constructed within the existing parameters of systems, the system with the most flexibility will be required to work around its partner's constraints. The role of the adapter could be acknowledged by having the funding flow through the adapter's system. Program development will involve a significant time investment including activities to become part of both systems' culture through education, establishing a presence and identifying boundary spanners. Long-run implications for both systems should also be considered.