Sampling from different populations: Sociodemographic, clinical, and functional differences between samples of first episode psychosis individuals and clinical high-risk individuals who progressed to psychosis.

Over the past two decades, research and clinical resources on clinical high risk (CHR) for psychosis have both expanded, with goals to better understanding risk and protective factors on the course of illness and inform early intervention efforts. However, some studies have highlighted potential sampling bias among CHR research studies, raising questions about generalizability of findings and inequitable access to early detection and intervention. The current study sought to explore these questions by comparing 94 participants in a CHR longitudinal monitoring study across North America (NAPLS-2) who converted to syndromal psychosis over the course of the study (CHR-CV) to 171 participants who presented for treatment at a localized first-episode psychosis service (FES) after converting. CHR-CV participants were significantly more likely to be White and have a college-educated parent, while FES participants were more likely to be Black and first- or second-generation immigrants. On average, CHR-CV participants were younger at onset of attenuated positive symptoms, had a longer period of attenuated symptoms prior to conversion, and were more likely to be treated with antipsychotics prior to conversion compared to those in FES programs. After controlling for time since conversion, CHR-CV participants had higher global functioning and were less likely to have experienced recent psychiatric hospitalization. Findings suggest that CHR research and FES clinics may be sampling from different populations, although conclusions are limited by inconsistent sampling frames and methods. Integrated early detection that targets defined geographic catchments may deliver more epidemiologically representative samples to both CHR research and FES.

Reducing Delay From Referral to Admission at a U.S. First-Episode Psychosis Service: A Quality Improvement Initiative.

Duration of untreated psychosis (DUP), the period between psychosis onset and entry into care, is a time of great vulnerability. Longer DUP predicts poorer outcomes, and delayed treatment access can limit the effectiveness of coordinated specialty care (CSC) services. This column details one component of a broader early detection campaign, a quality improvement intervention focusing on reducing the delay between confirmation of eligibility and admission to care within a benchmark period of 7 days. Median delay significantly fell (from 13.5 to 3 days), and the proportion of admissions that met the benchmark increased (from 33% to 71%) over 4 years. This intervention provides a sustainable model to reduce wait times at CSC services.

Reducing the Duration of Untreated Psychosis (DUP) in a US Community: A Quasi-Experimental Trial.

Objective: Duration of Untreated Psychosis (DUP) remains unacceptably long and limits effectiveness of care. To determine whether an early detection campaign ("Mindmap") can reduce DUP in a US community setting. Methods: In this nonrandomized controlled trial, Mindmap targeted the catchment of one specialty first-episode service or FES (STEP, Greater New Haven) from 2015 to 2019, while usual detection efforts continued at a control FES (PREP, Greater Boston). Mindmap targeted diverse sources of delay through mass & social media messaging, professional outreach & detailing, and rapid enrollment of referrals. Both FES recruited 16-35 years old with psychosis onset ≤3 years. Outcome measures included DUP-Total (onset of psychosis to FES enrollment), DUP-Demand (onset of psychosis to first antipsychotic medication), and DUP-Supply (first antipsychotic medication to FES enrollment). Results: 171 subjects were recruited at STEP and 75 at PREP. Mindmap was associated with an increase in the number of referrals and in efficiency of engagement at STEP. Pre-campaign DUP (2014-2015) was equivalent, while Mindmap was associated with DUP reductions at STEP but not PREP. DUP-Total fell significantly in both the first and the second quartile (11.5 and 58.5 days reduction per campaign year, respectively). DUP-Demand and DUP-Supply fell in the third quartiles only (46.3 and 70.3 days reduction per campaign year, respectively). No reductions were detectable across all quartiles at PREP, but between site comparisons were not significant. Conclusions: This is the first controlled demonstration of community DUP reduction in the US, and can inform future early detection efforts across diverse settings.

Taking the next step: Improving care transitions from a first-episode psychosis service.

AIMS: First-episode services (FES) improve outcomes in recent onset psychosis, but there is growing concern about how patients fare after discharge from these time-limited services. METHODS: A quality improvement approach (QI) was used to improve patient engagement in the discharge planning process (disposition), and successful engagement in care 3 months after discharge from the FES (transfer). Data from 144 consecutive discharges over 62 months are presented. A planning phase was followed by recurrent Plan-Do-Study-Act cycles (PDSA) that included the introduction of proactive efforts targeting disposition planning (with patients and families) and follow-up to facilitate transfer after discharge. Fisher's exact test was used to compare disposition and transfer outcomes across the QI phases. RESULTS: This QI approach was sustained through a three-fold escalation in discharge volume. Transfer status at 3 months was significantly different between the pre- and post PDSA phases (p = .02). A greater proportion were confirmed transfers post-PDSA (54.3 vs. 37%), but of those with known status at 3 months, similar proportions were successfully transferred (76, 73%). Patients discharged post-PDSA were less likely to have unknown treatment status (26 vs. 51%). Disposition outcomes were also significantly improved post-PDSA (p = .03). Patients were more likely to engage with discharge planning (69.7 vs. 48.6%) and less likely to be lost to follow-up (13.8 vs. 25.7%), or to refuse assistance (11.0 vs. 20.0%). CONCLUSION: This QI approach offers a feasible way to improve disposition and transfer after FES and can be built upon in efforts to sustain functional gains in onward pathways.

Corrigendum to: Reducing the Duration of Untreated Psychosis (DUP) in a US Community: A Quasi-Experimental Trial.

[This corrects the article DOI: 10.1093/schizbullopen/sgab057.].

Predictive validity of conversion from the clinical high risk syndrome to frank psychosis.

Although the clinical high risk for psychosis (CHR) paradigm has become well-established over the past two decades, one key component has received surprisingly little investigative attention: the predictive validity of the criteria for conversion or transition to frank psychosis. The current study evaluates the predictive validity of the transition to psychosis as measured by the Structured Interview for Psychosis-Risk Syndromes (SIPS) in CHR individuals. Participants included 33 SIPS converters and 399 CHR non-converters both from the North American Prodromal Longitudinal Study (NAPLS-2), as well as a sample of 67 separately ascertained first-episode psychosis (FEP) patients from the STEP program. Comparisons were made at baseline and one-year follow-up on demographic, diagnostic stability (SCID), and available measurement domains relating to severity of illness (psychotropic medication, psychosocial treatment, and resource utilization). Principal findings are: 1) a large majority of cases in both SIPS converters (n = 27/33, 81.8%) and FEP (n = 57/67, 85.1%) samples met criteria for continued psychosis at one-year follow-up; 2) follow-up prescription rates for current antipsychotic medication were higher in SIPS converters (n = 17/32, 53.1%) compared to SIPS non-converters (n = 81/397, 20.4%), and similar as compared to FEP cases (n = 39/65, 60%); and 3) at follow-up, SIPS converters had higher rates of resource utilization (psychiatric hospitalizations, day hospital admissions, and ER visits) than SIPS non-converters and were similar to FEP in most categories. The results suggest that the SIPS definition of psychosis onset carries substantial predictive validity. Limitations and future directions are discussed.