The association between mental health stigma and face emotion recognition in individuals at risk for psychosis.

Self-stigma has been associated with reduced accuracy of face emotion recognition in individuals at clinical high risk for psychosis (CHR). Stigma may also relate to slowing of performance during cognitive tasks for which a negative stereotype is relevant. This study aimed to investigate the association of mental illness stigma with face emotion recognition among CHR individuals. Participants were 143 CHR individuals identified using the Structured Interview for Psychosis-Risk Syndromes (SIPS). Face emotion recognition was assessed using the Penn Emotion Recognition Task (ER-40). Stigma was assessed using discrimination, stereotype awareness, and stereotype agreement subscales of the Mental Health Attitudes Interview for CHR. We tested associations of ER-40 accuracy and response times with these stigma variables, including the role of clinical and demographic factors. Racial/ethnic minoritized participants had higher attenuated positive symptoms than non-minoritized participants. Longer ER-40 response times were correlated with greater stereotype agreement (r=.17, p=.045) and discrimination (r=.22, p=.012). A regression model predicting ER-40 response times revealed an interaction of stereotype agreement with minoritized status (p=.008), with slower response times for minoritized participants as stereotype agreement increased. Greater disorganized symptoms and male gender also predicted longer response times. ER-40 accuracy was not associated with stigma. Overall, minoritized CHR individuals with greater internalized stigma took longer to identify face emotions. Future research is needed to assess whether slower response times are specific to social cues, and if internalized stigma interferes with performance in real-world social situations. Reducing stigma may be an important target for interventions that aim to improve social skills.

Emotional and stigma-related experiences relative to being told one is at risk for psychosis.

OBJECTIVE: Despite the appeal of early intervention in psychosis, there is concern that identifying youth as having high psychosis risk (PR) may trigger stigma. This study employed a pre-post design to measure change in PR participants' emotions about PR upon being told of their PR status and according to whether this was the first time receiving this information. METHODS: Participants (n = 54) identified as at PR via structured interview rated their emotions about PR before and after being told they were at PR. Qualitative analyses explored the valence of participant reflections on being given this information. RESULTS: Participants reported significantly less negative emotion after being told of their PR status (p < .001), regardless of whether they were hearing this for the first time (p = .72). There was no change in positive emotions or the predominant belief that they should keep their PR status private. Most participants commented positively about the process of feedback but negatively about its impact on their self-perceptions and/or expectations of others' perceptions of them. CONCLUSION: This is the first study to collect pre-post data related to being told one is at PR and to examine quantitative and qualitative responses across and within individuals. For a majority of participants, clinical feedback stimulated negative stereotypes even as it relieved some distress. To actively address internalized stigma, clinicians providing feedback to PR youth must attend to the positive and negative impacts on how youth think about themselves as well as how they feel.

Impact of "psychosis risk" identification: Examining predictors of how youth view themselves.

BACKGROUND: Identifying young people as at clinical high-risk (CHR) for psychosis affords opportunities for intervention to possibly prevent psychosis onset. Yet such CHR identification could plausibly increase stigma. We do not know whether these youth already perceive themselves to be at psychosis-risk (PR) or how their being told they are at PR might impact how they think about themselves. METHODS: 148 CHR youth were asked about labels they had been given by others (labeling by others) or with which they personally identified (self-labeling). They were then asked which had the greatest impact on how they thought about themselves. We evaluated whether being told vs. thinking they were at PR had stronger effects. FINDINGS: The majority identified nonpsychotic disorders rather than PR labels as having the greatest impact on sense of self (67.6% vs. 27.7%). However, participants who identified themselves as at PR had an 8.8 (95% CI = 2.0-39.1) increase in the odds of the PR label having the greatest impact (p < 0.01). Additionally, having been told by others that they were at PR was associated with a 4.0 increase in odds (95% CI = 1.1-15.0) that the PR label had the most impact (p < 0.05). INTERPRETATION: Nonpsychotic disorder labels appear to have a greater impact on CHR youth than psychosis-risk labels. However, thinking they are at PR, and, secondarily, being told they are at PR, appears to increase the relative impact of the PR label. Understanding self- and other-labeling may be important to how young people think of themselves, and may inform early intervention strategies.

Sensory characteristics of youth at clinical high risk for psychosis.

AIM: To identify and compare the sensory characteristics of young people at clinical high risk (CHR) for psychosis to those of peers at clinical low risk (CLR), and to national normative data. CHR and CLR participants were recruited from 6 US regions. METHOD: A descriptive cohort design was used to analyse baseline data collected as part of the Early Detection and Intervention for the Prevention of Psychosis Program (EDIPPP). Raw scores on the Adolescent/Adult Sensory Profile (AASP) were analysed for 205 young people with CHR and 87 with CLR in 2 age groups: 12 to 17 years (N = 203) and 18 to 25 years (N = 89). ANOVA procedures were used to determine whether differences in AASP scores existed across CLR, CHR, and normative groups by age group. RESULTS: CHR participants differed significantly from the normative group for all 4 AASP quadrant scores (Low Registration, Sensory Seeking, Sensory Sensitivity and Sensory Avoiding) in both age groups. CLR participants were similar to norms, except for Sensory Seeking scores that were significantly lower than norms in both age ranges. CONCLUSION: Young people with CHR demonstrate active avoidance, heightened sensitivity, reduced seeking, and reduced registration of sensations in everyday life compared to typical peers. This pattern of differences may be a valuable marker for identifying individuals who are at high risk for developing a psychotic illness, and may also inform interventions designed to prevent or minimize the illness process and accompanying dysfunction.

Early Intervention in Mental Health for Adolescents and Young Adults: A Systematic Review.

OBJECTIVE: The purpose of this systematic review was to describe the evidence for the effectiveness of early intervention to improve and maintain performance in occupations for youths with or at risk for serious mental illness (SMI). METHOD: Titles and abstracts of 670 articles were reviewed, 234 were retrieved for full review, and 30 met inclusion criteria. RESULTS: Moderate to strong evidence supports cognitive remediation (CR) and mixed evidence supports cognitive-behavioral therapy (CBT) as an adjunct modality to improve general functioning. Moderate to strong evidence supports use of supported employment and supported education (SE/E) to improve social and occupational outcomes in employment and academics. Strong evidence supports family psychoeducation (FPE) to prevent relapse and rehospitalization and improve problem-solving skills and general functioning. CONCLUSION: Occupational therapy practitioners should integrate CR, SE/E, and FPE into early intervention with youth with or at risk for SMI. In addition, CBT is an effective modality for use with this population.

Early Detection, Intervention and Prevention of Psychosis Program: Community Outreach and Early Identification at Six U.S. Sites.

OBJECTIVE: This study assessed the effects of a community outreach and education model implemented as part of the Early Detection, Intervention and Prevention of Psychosis Program (EDIPPP), a national multisite study in six U.S. regions. METHODS: EDIPPP's model was designed to generate rapid referrals of youths at clinical high risk of psychosis by creating a network of professionals and community members trained to identify signs of early psychosis. Qualitative and quantitative data were gathered through an evaluation of outreach efforts at five sites over a two-year period and through interviews with staff at all six sites. All outreach activities to groups (educational, medical, and mental health professionals; community groups; media; youth and parent groups; and multicultural communities) were counted for the six sites to determine correlations with total referrals and enrollments. RESULTS: During the study period (May 2007-May 2010), 848 formal presentations were made to 22,840 attendees and 145 informal presentations were made to 11,528 attendees at all six sites. These presentations led to 1,652 phone referrals. A total of 520 (31%) of these individuals were offered in-person orientation, and 392 (75%) of those were assessed for eligibility. A total of 337 individuals (86% of those assessed) met criteria for assignment to the EDIPPP study. CONCLUSIONS: EDIPPP's outreach and education model demonstrated the effectiveness of following a protocol-defined outreach strategy combined with flexibility to reach culturally diverse audiences or initially inaccessible systems. All EDIPPP sites yielded appropriate referrals of youths at risk of psychosis.

Recent developments in family psychoeducation as an evidence-based practice.

Among potential resources for people with serious mental illnesses (SMI) and their families, professionally delivered family psychoeducation (FPE) is designed to engage, inform, and educate family members, so that they can assist the person with SMI in managing their illness. In this article, we review research regarding FPE outcomes and implementation since 2001, updating the previous review in this journal (McFarlane, Dixon, Lukens, & Lucksted, Journal of Marital and Family Therapy 2003; 29, 223). Research on a range of FPE variations continues to return mostly positive effects for adults with schizophrenia and increasingly, bipolar disorder. More recent studies include functional outcomes as well as the more common relapse and hospitalization. FPE research involving adults with other diagnoses is increasing, as is FPE research outside the United States In both cases, uneven methodologies and multiple FPE variations make drawing conclusions difficult, although the core utility of access to information, skill building, problem solving, and social support often shines though. Since the previous review, several FPE programs for parents of children or youth with mood disorders have also been developed, with limited research showing more positive than null results. Similarly, we review the developing inquiry into early intervention and FPE, short-form FPE, and cost studies involving FPE. The second half of the article updates the paradox of FPE's evidence base versus its persistently low use, via recent implementation efforts. Multiple challenges and facilitating factors across healthcare systems and financing, individual programs and providers, family members, and consumers shape this issue, and we conclude with discussion of the need for empirical evaluation of implementation strategies and models.

Portland identification and early referral: a community-based system for identifying and treating youths at high risk of psychosis.

OBJECTIVE: The Portland [Maine] Identification and Early Referral (PIER) program was established in 2000 as a prevention system for identifying and treating youths at high risk of an initial psychotic episode. METHODS: During six years, 7,270 professionals from the educational, medical, and mental health sectors were provided information on prodromal symptoms and means for rapid referral of at-risk youths, which resulted in referral of 780 youths who met eligibility criteria. RESULTS: After screening, 37% of the community referrals were found to be at high risk of psychosis, and another 20% had untreated or early psychosis, yielding an efficiency ratio of 57%. Prodromal cases identified were 46% of the expected incidence of psychosis in the catchment area. Community educational presentations were significantly associated with referrals about six months later; half of referrals were from outside the mental health system. CONCLUSIONS: Community-based identification is an efficient public health strategy, offering the opportunity for preventive intervention.

Partnering with families: multiple family group psychoeducation for schizophrenia.

Family psychoeducation (FPE) is one of six evidence-based practices endorsed by the Center for Mental Health Services for individuals suffering from chronic mental illnesses. Multiple family group psychoeducation (MFG) has been shown to be an effective component of FPE in reducing symptom relapses and rehospitalizations for individuals with schizophrenia. It is especially effective when family members participate on a consistent basis, which allows them to increase their understanding of the biology of the disorder, learn ways to be supportive, reduce stress in the environment and in their own lives, and develop a broader social network. When used in conjunction with medication, MFG can help an individual with schizophrenia progress towards the rehabilitation phase of recovery. A case illustration describes the engagement of a chronically ill, mid-thirties male in MFG and how his family's participation for 2 years benefits all members, in spite of the longevity of his illness.