Usability and Feasibility of the Antipsychotic Medication Decision Aid in a Community Program for First-Episode Psychosis.

OBJECTIVE: Although antipsychotic medications are considered first-line treatment for psychosis, rates of discontinuation and nonadherence are high, and debate persists about their use. This pilot study aimed to explore the usability, feasibility, and potential impact of a shared decision making (SDM) intervention, the Antipsychotic Medication Decision Aid (APM-DA), for decisions about use of antipsychotic medications. METHODS: A pilot randomized controlled trial was conducted with 17 participants in a first-episode psychosis program. Nine participants received the APM-DA, and eight received usual care. RESULTS: After their appointments, intervention group participants had less decisional conflict and greater satisfaction with decisions than control group participants had. Use of the APM-DA did not increase appointment length. Comparison of the intervention outcomes with the control outcomes was limited because of the small sample. CONCLUSIONS: The results support the feasibility and usability of an SDM process via the use of the APM-DA in routine community psychosis care.

Implementation of an Adapted Fidelity Scale for Pennsylvania Coordinated Specialty Care Programs for First Episode Psychosis.

Coordinated Specialty Care (CSC) is an evidence-based model for early intervention of first episode psychosis (FEP). Monitoring fidelity to CSC models is essential for proper evaluation of program outcomes and quality improvement. To address variability across CSC programs and fidelity assessment-associated burden, an adapted fidelity scale was developed and implemented statewide in Pennsylvania. This report describes the design and preliminary performance of the adapted scale. The Pennsylvania FEP Fidelity Scale (PA-FEP-FS) assesses adherence to the CSC model by focusing on essential model components of other established fidelity scales, in tandem with program evaluation data. Initial data from fourteen PA-FEP sites from 2018 to 2021 were examined as preliminary validation. Assessment-associated burdens and costs were also estimated. PA-FEP-FS captured essential components of CSC models and proved feasible for implementation across varying program structures, while minimizing burden and cost. Programs utilized annual feedback as CSC benchmarks, evidenced by increased scores over time. PA-FEP-FS provides a model for adapting CSC fidelity scales to meet state- or local-level requirements while reducing assessment burdens and costs that may be associated with existing scales.

Treatment decision-making needs among emerging adults with early psychosis.

AIM: Many emerging adults disengage from early intervention in psychosis (EIP) services prematurely. Service disengagement may be in part due to having unresolved treatment decision-making needs about use of mental health services. A basic understanding of the decision-making needs of this population is lacking. The purpose of this qualitative study was to identify the range of treatment decisions that emerging adults face during their initial engagement in an EIP program and elucidate barriers and facilitators to decision-making. METHODS: Twenty emerging adults with early psychosis were administered semistructured interviews to capture treatment decision-making experiences during the first six months after enrolment in an EIP program. Interviews were audio-recorded and transcribed verbatim. Responses were independently coded by two authors using an integrated thematic analysis approach; differences in coding were discussed to consensus. Data analysis was facilitated using NVivo 12 Plus. RESULTS: Emerging adults identified numerous decisions faced after EIP enrolment. Decisions pertaining to life and treatment goals and to starting and continuing psychiatric medication were commonly selected as the most difficult/complicated. Decision-making barriers included not having the right amount or type of information/knowledge, social factors (e.g., lacking social support, opposition/pressure), lacking internal resources (e.g., cognitive and communication skills, self-efficacy, motivation) and unappealing options. Obtaining information/knowledge, social supports (e.g., connection/trust, learning from others' experiences, encouragement), considering personal values, and time were decision-making facilitators. CONCLUSIONS: This study informs development and optimization of interventions to support decision-making among emerging adults with early psychosis, which may promote service engagement.

Facilitating treatment engagement for early psychosis through peer-delivered decision support: intervention development and protocol for pilot evaluation.

BACKGROUND: Emerging adults with early psychosis demonstrate high rates of service disengagement from critical early intervention services. Decision support interventions and peer support have both been shown to enhance service engagement but are understudied in this population. The purposes of this article are to describe the development of a novel peer-delivered decision coaching intervention for this population and to report plans for a pilot study designed to gather preliminary data about its feasibility, acceptability, and potential impact. METHODS: The intervention was developed based on formative qualitative data and in collaboration with a diverse team of researchers, key stakeholders, and expert consultants. The pilot trial will utilize a single-group (N = 20), pre-post, convergent mixed-methods design to explore whether and how the intervention addresses decision-making needs (the primary intervention target). The impact of the intervention on secondary outcomes (e.g., engagement in the program) will also be assessed. Additionally, through observation and feedback from the peer decision coach and study participants, we will evaluate the feasibility of research and intervention procedures, and the acceptability of information and support from the peer decision coach. DISCUSSION: The peer-delivered decision coaching intervention holds promise for assisting young people with making informed and values-consistent decisions about their care, and potentially enhancing service engagement within this traditionally difficult-to-engage population. If the intervention demonstrates feasibility and acceptability, and pilot data show its potential for improving treatment decision-making, our work will also lay the foundation for a new evidence base regarding roles for peer specialists on early intervention teams. TRIAL REGISTRATION: This trial was registered with ClinicalTrials.gov (Identifier: NCT04532034 ) on 28 August 2020 as Temple University Protocol Record 261047, Facilitating Engagement in Evidence-Based Treatment for Early Psychosis.

Evaluating the feasibility of a decision aid to promote shared decision making among young adults with first-episode psychosis: protocol for a pilot study.

BACKGROUND: Young adults ages 18 to 25 with first episode psychosis (FEP) have an increased risk of discontinuation antipsychotic medications and psychiatric service disengagement that lead to symptom exacerbation and deterioration. We seek to (1) examine the feasibility, usability, and potential impact of a Shared Decision Making (SDM) Antipsychotic Medication Decision Aid (DA) on decision-making, adherence to the decision made, and service engagement among young adults with FEP and (2) understand the role of additional patient-level factors on SDM. METHODS: A randomized controlled trial is being conducted in a coordinated specialty care community program for FEP in an urban setting. Eligible patients are randomly assigned to receive an intervention, the Antipsychotic Medication Decision Aid, or treatment as usual. Patients receive their assigned intervention before their medication appointment with the psychiatrist and complete four interviews: before the appointment (T0), after the appointment (T1), and at 3- and 6-month follow-ups (T2 and T3). The study staff and participating psychiatrists are not blinded to the intervention. The data are de-identified to maintain blinding during the analysis process. The primary aims are feasibility of intervention delivery and research procedures and preliminary impact of the intervention on SDM-related outcomes, medication adherence, and service engagement. As a secondary aim, we will explore the contribution of personality and motivation variables, clinical relationships, cognitive functioning, and mental-health-related stigma to SDM. If the sample size permits, we plan to conduct parametric tests such as independent-samples t tests at T1 to compare differences in SDM, adherence, and engagement scales. In the case of a small sample size, we will use non-parametric tests and descriptive statistics. DISCUSSION: This protocol outlines the methodology for a feasibility pilot comparing the effect of a novel SDM Antipsychotic Medication encounter DA with treatment as usual on SDM, medication adherence, and service engagement in FEP care. SDM is endorsed as a framework for use in FEP and antipsychotic pharmacotherapy, but its impact on adherence and health outcomes is unclear. Understanding the potential contribution of an SDM Antipsychotic Medication DA compared with usual care in psychosis pharmacotherapy is critical. The study will help answer several key questions new to SDM research, including the contribution of personality and clinical relationships to SDM in mental health and psychosis in particular. The study will serve to gather feasibility data to inform future studies and scale-up. TRIAL REGISTRATION: Ethics approval was obtained through Temple University's institutional review board (IRB) and the City of Philadelphia's Department of Public Health IRB. The study has been retrospectively registered with ClinicalTrials.gov as NCT04373590 on 29 April 2020. https://clinicaltrials.gov/ct2/show/NCT04373590?term=NCT04373590&draw=2&rank=1.

Pennsylvania coordinated specialty care programs for first-episode psychosis: 6- and 12-month outcomes.

AIM: Pennsylvania (PA) first-episode psychosis (FEP) program evaluation is a statewide initiative, supported by the PA Office of Mental Health and Substance Abuse Services (PA-OMHSAS) and administered by PA Early Intervention Center/Heads Up, which evaluates fidelity and outcomes of PA Coordinated Specialty Care (CSC) programs. Programs participate in standard computerized measures of CSC outcomes using centralized informatics. The aims of the current report are to describe implementation of this core battery for program evaluation in PA and to present 6- and 12-month outcomes. METHODS: Participants (n = 697) from nine PA CSC programs completed the core battery at admission. The battery was re-administered at 6- and 12-month follow-up, and data were analysed for individuals (n = 230) who had completed 12-months of treatment. Domains assessed via clinician report and/or self-report included symptoms, role and social functioning, self-perceived recovery and service utilization. RESULTS: PA FEP CSC participants showed improvement over time in several domains, including decreased symptoms, higher role and social functioning, decreased hospitalizations, and improved self-perception of recovery, quality of life, and services satisfaction. Trends towards improvements were observed for participant happiness, hopelessness, and school-enrolment. Nearly all improvements were observed at 6-month follow-up, with earlier gains maintained at 12-months. CONCLUSIONS: PA FEP CSC programs demonstrate the ability to assess and improve critical outcomes of coordinated specialty care in PA. Improved outcomes by 12 months in treatment provides evidence of an effective treatment model and supports the continuation of these programs in pursuit of our goal of reducing schizophrenia disease burden on individuals and society.

An Examination of the Community Participation Interests of Young Adults with Serious Mental Illnesses.

Participation in various aspects of community life (e.g., education, employment) plays a critical role in fostering young adult development and health. To support behavioral health services in addressing a broader array of meaningful community participation areas, the current study examined the participation interests of young adults with serious mental illnesses via a literature review and focus groups interviews. Literature review results revealed a range of community participation areas of interest to these individuals, including employment, education, religion and spirituality, social networking (e.g., using social media), volunteering activities, socializing, and civic and artistic participation (e.g., attending a political event, playing music). Focus group participants named many of these same areas, but also mentioned unique areas of participation that have not been the focus of previous research (i.e., playing games, sports, exploration of other communities (e.g., traveling), hanging out, and nature-based participation). Implications for future research and behavioral health practice are discussed.

A 10-minute measure of global cognition: Validation of the Brief Cognitive Assessment Tool for Schizophrenia (B-CATS).

INTRODUCTION: Schizophrenia is marked by a global cognitive impairment that contributes significantly to chronic disability and unemployment. As new treatments are developed for cognition in schizophrenia, clinicians require easily administered instruments to assess cognition. We previously developed a very brief cognitive battery (Bell et al., 2005). The Brief Cognitive Assessment Tool for Schizophrenia (B-CATS) was developed specifically to provide clinicians with a way to assess cognition in their patients with schizophrenia. Here, we report the results of a validity study comparing B-CATS to a larger neurocognitive battery, the Measurement and Treatment Research to Improve Cognition in Schizophrenia (MATRICS) battery. METHODS: Outpatients with schizophrenia (N=91) were administered the B-CATS and the non-overlapping tests of the MATRICS battery at two time points separated by 1month. They were also administered the UCSD Performance-based Skills Assessment-Brief (UPSA-B), a measure of functional capacity. RESULT: The B-CATS has an administration time of approximately 10min. It demonstrates good test-retest reliability and internal consistency. It correlates 0.76 (p<0.01) with the MATRICS battery. The shorter B-CATS and the MATRICS battery correlate with the UPSA-B at 0.50 and 0.58 respectively. CONCLUSION: A 10-minute version of the B-CATS correlates highly with the "gold standard" neurocognitive battery that has an administration time of over 60min. Both measures correlate moderately with a measure of functional capacity. This brief battery was designed to allow clinicians to monitor cognitive change and better inform treatment decisions.

Recurrent Idiopathic Catatonia: Implications beyond the Diagnostic and Statistical Manual of Mental Disorders 5th Edition.

We describe a case of recurrent, life-threatening, catatonic stupor, without evidence of any associated medical, toxic or mental disorder. This case provides support for the inclusion of a separate category of "unspecified catatonia" in the Diagnostic and Statistical Manual of Mental Disorders 5th edition (DSM-5) to be used to classify idiopathic cases, which appears to be consistent with Kahlbaum's concept of catatonia as a distinct disease state. But beyond the limited, cross-sectional, syndromal approach adopted in DSM-5, this case more importantly illustrates the prognostic and therapeutic significance of the longitudinal course of illness in differentiating cases of catatonia, which is better defined in the Wernicke-Kleist-Leonhard classification system. The importance of differentiating cases of catatonia is further supported by the efficacy of antipsychotics in treatment of this case, contrary to conventional guidelines.

Is prevention a realistic goal for schizophrenia?

Over the past 2 decades, increased efforts have focused on identifying those at genetic or clinical risk for psychosis and promoting interventions that may alter the onset or trajectory of schizophrenia. We review studies published between 2010-2013 that: (1) investigate at-risk states for psychosis in larger epidemiological studies; (2) identify causes of certain clinical presentations of the schizophrenia phenotype and (3) investigate focused and multidisciplinary approaches to treat early clinical symptoms. The article places these recent studies within the context of prior research and the concept of potential measures to prevent or ameliorate the onset of psychosis.

The Cognitive Assessment Interview (CAI): reliability and validity of a brief interview-based measure of cognition.

OBJECTIVE: To obtain Food and Drug Administration approval for the treatment of cognitive impairments associated with schizophrenia, a drug will need to demonstrate benefits beyond those that may be documented on objective cognitive tests. Interview-based measures of cognition such as the Cognitive Assessment Interview (CAI) are candidate coprimary outcome measures. METHODS: Psychiatrically stable schizophrenia outpatients (n=150) were studied using the CAI to obtain information about cognitive functioning from both the patient and an informant. Patients also received objective assessments of neurocognition, functional capacity, functional outcome, and symptoms, at baseline and 1 month later. RESULTS: The CAI had good internal consistency (Cronbach's alpha=.92) and good test-retest reliability (r=.83). The CAI was moderately correlated with objective neurocognitive test scores (r's=-.39 to -.41) and moderately correlated with social functioning (r=-.38), work functioning (r=-.48), and overall functional outcome (r=-.49). The correlations of CAI scores with external validity indicators did not differ significantly by source of information (patient alone ratings were valid). Overall functional outcome correlated more strongly with patient CAI scores (r=-.50) than with objective neurocognitive test scores (r=.29) or functional capacity (r=.29). CONCLUSIONS: Field testing of the CAI produced reliable ratings of cognitive functioning that were correlated with functional outcome. Patient ratings alone yielded scores with reliability and validity values appropriate for use in clinical trials. The CAI appears to provide useful complementary information and possesses practical advantages for rating cognitive functioning including an interview-based method of administration, brief assessment time (15 min for the patient assessment), little or no practice effects, and ease of scoring.

Movement disorders induced by antipsychotic drugs: implications of the CATIE schizophrenia trial.

Drug-induced movement disorders have dramatically declined with the widespread use of second-generation antipsychotics, but remain important in clinical practice and for understanding antipsychotic pharmacology. The diagnosis and management of dystonia, parkinsonism, akathisia, catatonia, neuroleptic malignant syndrome, and tardive dyskinesia are reviewed in relation to the decreased liability of the second-generation antipsychotics contrasted with evidence from the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) Schizophrenia Trial. Data from the CATIE trial imply that advantages of second-generation antipsychotics in significantly reducing extrapyramidal side effects compared with haloperidol may be diminished when compared with modest doses of lower-potency first-generation drugs.

A brief cognitive assessment tool for schizophrenia: construction of a tool for clinicians.

Cognitive impairment in schizophrenia is often severe, enduring, and contributes significantly to chronic disability. But clinicians have difficulty in assessing cognition due to a lack of brief instruments. We evaluated whether a brief battery of cognitive tests derived from larger batteries could generate a summary score representing global cognitive function. Using data from 3 previously published trials, we calculated the corrected item-total correlations (CITCs) or the correlation of each test with the battery total score. We computed the proportion of variance that each test shares with the global score excluding that test (R(t)(2)=CITC(2)) and the variance explained per minute of administration time for each test (R(t)(2)/min). The 3 tests with the highest R(t)(2)/min were selected for the brief battery. The composite score from the trail making test B, category fluency, and digit symbol correlated .86 with the global score of the larger battery in 2 of the studies and correlated between .73 and .82 with the total battery scores excluding these 3 tests. A Brief Cognitive Assessment Tool for Schizophrenia (B-CATS) using the above 3 tests can be administered in 10-11 min. The full batteries of the larger studies have administration times ranging from 90 to 210 min. Given prior research suggesting that a single factor of global cognition best explains the pattern of cognitive deficit in schizophrenia, an instrument like B-CATS can provide clinicians with meaningful data regarding their patients' cognitive function. It can also serve researchers who want an estimate of global cognitive function without requiring a full neuropsychological battery.

Neurocognition in schizophrenia.

Neuropsychological deficits among schizophrenia patients have been consistently documented in research over the past 20 years and are reviewed in this chapter. Discussion of general abilities is presented as a background and is followed by analysis of functioning in specific cognitive domains. Overall intellectual deficits are indicated by results from both general intelligence tests and composite test battery scores. Within specific cognitive domains, effect size differences are noted in numerous areas, including attention, with indications that working memory is affected more severely than simple attention, likely due to inclusion of an executive component in such tasks. There is also evidence of slowed processing speed among schizophrenia patients, likely contributing to deficits in other domains which rely on rapid and efficient assimilation of information. Executive impairments have been found on tests assessing set-shifting abilities, selective attention, and inhibition of inappropriate responses. Learning and memory deficits have been demonstrated extensively, with some evidence that recall of verbal material is more affected than recall of visual information, and that recognition abilities are comparatively less impaired than recall for both modalities. Receptive and expressive language abilities are compromised in schizophrenia patients, as well as visual perceptual, constructional, and fine motor skills. Social cognition is an area of particular importance due to its relevance to functional outcome. Deficits in expression and recognition of facial and prosodic affect have been demonstrated, although subjective experience of emotion appears to be relatively well preserved. Neuropsychological deficits described in this review appear to generally remain stable throughout adulthood, supporting neurodevelopmental, rather than neurodegenerative, models of the illness. Finally, cognitive deficits are increasingly used as endophenotypes, which is likely an important direction of future research.