Engaging with care in an early intervention for psychosis program: The role of language, communication, and culture.

Language is an important aspect of communication and language status is known to impact healthcare accessibility, its perceived suitability, and outcomes. However, its influence on treatment engagement and/or disengagement is unknown. Our study therefore sought to investigate the impact of language on service disengagement in an early intervention psychosis program in Montreal, Quebec (a province with French as the official language). We aimed to compare service disengagement between a linguistic minority group (i.e., English) vis-à-vis those whose preferred language was French and to explore the role of language in service engagement. Using a mixed methods sequential design, we tested preferred language and several sociodemographic characteristics associated with service disengagement in a time-to-event analysis with Cox proportional hazards regression models (N = 338). We then conducted two focus groups with English (seven patients) and French speakers (five patients) to further explore differences between the two linguistic groups. Overall, 24% (n = 82) disengaged from the service before the two-year mark. Those whose preferred language was English were more likely to disengage (n = 47, 31.5%) than those whose preferred language was French (n = 35, 18.5%; χ2 = 9.11, p < .01). This remained significant in the multivariate regression. In focus groups, participants identified language as one aspect of a complex communication process between patients and clinicians and highlighted the importance of culture in the clinical encounter. Language status of patients plays an important role in their engagement with early psychosis services. Our findings underscore the value of establishing communication and cultural understanding in creating clinical/therapeutic alliance.

Sex Modifies the Associations of APOEɛ4 with Neuropsychiatric Symptom Burden in Both At-Risk and Clinical Cohorts of Alzheimer's Disease.

BACKGROUND: Recent work suggests that APOEɛ4/4 females with Alzheimer's disease (AD) are more susceptible to developing neuropsychiatric symptoms (NPS). OBJECTIVE: To examine the interaction of sex and APOEɛ4 status on NPS burden using two independent cohorts: 1) patients at risk for AD with mild cognitive impairment and/or major depressive disorder (n = 252) and 2) patients with probable AD (n = 7,261). METHODS: Regression models examined the interactive effects of sex and APOEɛ4 on the number of NPS experienced and NPS Severity. APOEɛ3/4 and APOEɛ4/4 were pooled in the at-risk cohort due to the sample size. RESULTS: In the at-risk cohort, there was a significant sex*APOEɛ4 interaction (p = 0.007) such that the association of APOEɛ4 with NPS was greater in females than in males (incident rate ratio (IRR) = 2.0). APOEɛ4/4 females had the most NPS (mean = 1.9) and the highest severity scores (mean = 3.5) of any subgroup. In the clinical cohort, APOEɛ4/4 females had significantly more NPS (IRR = 1.1, p = 0.001, mean = 3.1) and higher severity scores (b = 0.31, p = 0.015, mean = 3.7) than APOEɛ3/3 females (meanNPS = 2.9, meanSeverity = 3.3). No association was found in males. CONCLUSION: Our study suggests that sex modifies the association of APOEɛ4 on NPS burden. APOEɛ4/4 females may be particularly susceptible to increased NPS burden among individuals with AD and among individuals at risk for AD. Further investigation into the mechanisms behind these associations are needed.

Context and contact: a comparison of patient and family engagement with early intervention services for psychosis in India and Canada.

BACKGROUND: It is unknown whether patient disengagement from early intervention services for psychosis is as prevalent in low- and middle-income countries (LMICs) like India, as it is in high-income countries (HICs). Addressing this gap, we studied two first-episode psychosis programs in Montreal, Canada and Chennai, India. We hypothesized lower service disengagement among patients and higher engagement among families in Chennai, and that family engagement would mediate cross-site differences in patient disengagement. METHODS: Sites were compared on their 2-year patient disengagement and family engagement rates conducting time-to-event analyses and independent samples t tests on monthly contact data. Along with site and family involvement, Cox proportional hazards regression included known predictors of patient disengagement (e.g. gender). RESULTS: The study included data about 333 patients (165 in Montreal, 168 in Chennai) and their family members (156 in Montreal, 168 in Chennai). More Montreal patients (19%) disengaged before 24 months than Chennai patients (1%), χ2(1, N = 333) = 28.87, p < 0.001. Chennai families had more contact with clinicians throughout treatment (Cohen's d = -1.28). Family contact significantly predicted patient disengagement in Montreal (HR = 0.87, 95% CI 0.81-0.93). Unlike in Chennai, family contact declined over time in Montreal, with clinicians perceiving such contact as not necessary (Cohen's d = 1.73). CONCLUSIONS: This is the first investigation of early psychosis service engagement across a HIC and an LMIC. Patient and family engagement was strikingly higher in Chennai. Maintaining family contact may benefit patient engagement, irrespective of context. Findings also suggest that differential service utilization may underpin cross-cultural variations in psychosis outcomes.

Towards Understanding the Relationship Between Psychosocial Factors and Ego Resilience Among Primary School Children in a Kenyan Setting: A Pilot Feasibility Study.

Ego resilience in childhood is linked to positive mental health outcomes but varies across cultures. Kenya presents a unique context in which children are vulnerable to adversity. We therefore hypothesized that Ego resilience traits are found in Kenya. We aimed to: (i) demonstrate Ego resilience in Kenya, (ii) determine associated social-demographic and psychological factors in a non-clinical population of primary school going children, (iii) contribute to the global data base with Kenyan data and (iv) lay the grounds for informed future and more focused studies in Kenya. We used a socio-demographic questionnaire, Ego Resilience scale (ER-89) and the Youth Self Report (YSR). Multivariate analyses showed the only independent predictors of Ego resilience were female gender (p < 0.001) and peri-urban region (p < 0.001). We did not find any association between Ego resilience and YSR syndrome scores in this non-clinical population study. We achieved our aims.

Caught in the "NEET Trap": The Intersection Between Vocational Inactivity and Disengagement From an Early Intervention Service for Psychosis.

OBJECTIVE: Given the benefits of early intervention for psychosis and the social disengagement of youths not in education, employment, or training (NEET), this study sought to examine how being vocationally inactive (NEET) affects engagement in early intervention services. Both baseline vocational status and vocational trajectory in the first year of treatment were analyzed. METHODS: Data from 394 patients of a Canadian early intervention service were analyzed using time-to-event and Cox proportional hazards regression analyses. Two-year disengagement rates were compared between patients who were vocationally inactive and active at baseline and between those who remained vocationally inactive until month 12 and those who were vocationally inactive only at baseline. Pertinent sociodemographic (age, sex, visible minority status, social and material deprivation indices, and family involvement), and clinical (duration of untreated psychosis, substance use disorder, medication nonadherence, and baseline positive and negative symptoms) factors were considered. RESULTS: There was no statistically significant difference between the disengagement rates of those who were vocationally inactive (N=154) and those who were vocationally active (N=240) at baseline. Those who remained vocationally inactive at month 12 (N=77) were likelier to disengage in the second year than those who were vocationally inactive only at baseline (N=48) (χ2=5.44, df=1, p<0.05). This comparison remained significant in the regression analysis (hazard ratio [HR]=8.52, 95% confidence interval [95% CI]=1.54-47.1). The association of disengagement from services with lack of family contact with the treatment team (HR=3.91, 95% CI=0.98-15.6) and with greater material deprivation (HR=1.03, 95% CI=1.00-1.07) trended toward significance. CONCLUSIONS: The functional recovery of youths who are vocationally inactive when they enter services can affect their long-term service engagement and merits targeting by evidence-based interventions.

Disengagement in immigrant groups receiving services for a first episode of psychosis.

OBJECTIVE: Although early intervention (EI) programs for psychosis invest in clients remaining engaged in treatment, disengagement remains a concern. It is not entirely clear whether immigrants are likelier to disengage. The rates and predictors of disengagement for immigrant vis-à-vis non-immigrant clients in a Canadian EI setting were analyzed. METHOD: 297 clients were included in a time-to-event analysis with Cox Proportional Hazards regression models. Immigrant status (first- or second-generation immigrant or non-immigrant), age, gender, education, substance abuse, family contact, social and material deprivation and medication non-adherence were tested as predictors of service disengagement. RESULTS: 24.2% (n=72) of the clients disengaged from services before completing two years. Disengagement rates did not differ between first-generation immigrants (23.3%), second-generation immigrants (22.7%) and non-immigrants (25.3%). For all clients, only medication non-adherence predicted disengagement (HR=3.81, 95% CI 2.37-6.14). For first-generation immigrants, age (HR=1.17, 95% CI 1.02-1.34) and medication non-adherence (HR=2.92, 95% CI 1.09-7.85) were significant predictors. For second-generation immigrants, material deprivation (HR=1.03, 95% CI 1.00-1.05) and medication non-adherence (HR=11.07, 95% CI 3.20-38.22) were significant. CONCLUSION: Disengagement rates may be similar between immigrants and non-immigrants, but their reasons for disengagement may differ. Medication adherence was an important predictor for all, but the role of various sociodemographic factors differed by group. Sustaining all clients' engagement in EI programs may therefore require multi-pronged approaches.

Symptom profiles and explanatory models of first-episode psychosis in African-, Caribbean- and European-origin groups in Ontario.

AIM: To assess variability in symptom presentation and explanatory models of psychosis for people from different ethnic groups. METHODS: Clients with first-episode psychosis (n = 171) who identified as black African, black Caribbean or white European were recruited from early intervention programmes in Toronto and Hamilton. We compared results by ethnic group for symptom profiles and explanatory models of illness. RESULTS: Clients of black Caribbean origin had a lower odds of reporting that they were speaking incomprehensibly (OR = 0.36; 95% CI: 0.14-0.90) and black African clients had a greater odds of reporting persistent aches or pains (OR = 2.92; 95% CI: 1.32-6.50). Black African clients had a lower odds of attributing the cause of psychosis to hereditary factors (OR = 0.41; 95% CI: 0.19-0.89) or to substance abuse (OR = 0.29; 95% CI: 0.13-0.67) and had a lower odds of assigning responsibility for their illness to themselves (OR = 0.41; 95% CI: 0.19-0.89). CONCLUSIONS: Understanding the differences in illness models for ethnic minority groups may help improve the cultural competence of mental health services.

Stigmatizing attitudes toward mental illness among primary school children in Kenya.

BACKGROUND: Literature describing stigmatizing attitudes towards people with mental illness by children in the developing world is lacking. Children's mental health issues in the Kenyan context are especially pertinent due to the increased likelihood of exposure to risk factors and the high prevalence of mental disorders. The objective of the current study was to examine socio-demographic factors associated with the endorsement of stigmatizing attitudes towards people with mental illness among Kenyan school children. METHODS: We analyzed cross-sectional survey data from 4585 primary school-aged children in standards one through seven in the Eastern Province of Kenya. We examined relationships between the endorsement of stigmatizing attitudes and age, gender, district, religion, being in the standard appropriate for one's age, and parental employment status. RESULTS: Stigma scores decreased with increasing age (ß = -0.83; 95 % CI = -0.99 to -0.67). Boys had higher stigma scores compared to girls (ß = 1.55; 95 % CI = 0.86-2.24). Students from the rural district had higher average stigma scores as compared to those from the peri-urban district (ß = 1.14; 95 % CI = 0.44-1.84). Students who were not in the standard appropriate for their age had lower stigma scores than those who were in the standard typical for their age (ß = -1.60; 95 % CI = -2.43 to -0.77). CONCLUSIONS: Stigmatizing attitudes toward the mentally ill exist among primary school children in Kenya; thus, anti-stigma interventions are needed, and our findings highlight particular subgroups that could be targeted.

Antipointing: perception-based visual information renders an offline mode of control.

Recent work by our group reported that mirror-symmetrical reaching movements (i.e., antipointing) are supported by perception-based visual information (Heath et al. 2009a). The present study was designed to determine if the perception-based visual information supporting antipointing results in a primarily offline mode of control; that is, a mode of control wherein the response unfolds with few-if any-online limb corrections. Participants reached directly to (propointing) or mirror-symmetrical (antipointing) to targets presented in the left and right visual fields. To examine the extent reaches were controlled online versus offline, we computed the proportion of variance (R (2)) explained by the position of the limb at 75% of movement time relative to the response's ultimate movement endpoint. The endpoints for propointing in left and right visual fields demonstrated robust endpoint accuracy and stability and were tied to low R (2) values. In contrast, antipointing elicited a marked degree of endpoint variability and were characterized by a visual-field specific pattern of endpoint bias. Moreover, the R (2) values for antipointing were more robust than propointing counterparts. Therefore, we propose that the metrical visual information supporting stimulus-driven propointing results in a primarily online mode of control whereas the relative nature of the perception-based visual information supporting antipointing results in an offline mode of control. More directly, we propose that the offline control of antipointing is attributed to the "slow" cognitive processing of visuoperceptual networks.

The antipointing task: vector inversion is supported by a perceptual estimate of visual space.

The authors examined whether the visual field-specific endpoint bias of mirror-symmetrical reaching movements (i.e., antipointing) is related to top-down decoupling of the normal spatial relations between target and response (i.e., visuomotor inhibition) or the inversion of target coordinates to a mirror-symmetrical location (i.e., vector inversion). Participants completed pro- and antipointing movements in left and right visual space under conditions in which movement type was performed in separate blocks (i.e., blocked condition) and when randomly interleaved on a trial-by-trial basis (i.e., random condition). Most important, the random condition entailed equivalent premovement inhibition across pro- and antipointing. Propointing produced comparable endpoint accuracy in left and right visual space whereas antipointing under- and overshot target position: a finding characterizing blocked and random conditions. The authors attribute the visual field-specific bias of antipointing to the obligatory nature of the task and the integration of visuoperceptual networks to support vector inversion.

Anti-pointing is mediated by a perceptual bias of target location in left and right visual space.

We sought to determine whether mirror-symmetrical limb movements (so-called anti-pointing) elicit a pattern of endpoint bias commensurate with perceptual judgments. In particular, we examined whether asymmetries related to the perceptual over- and under-estimation of target extent in respective left and right visual space impacts the trajectories of anti-pointing. In Experiment 1, participants completed direct (i.e. pro-pointing) and mirror-symmetrical (i.e. anti-pointing) responses to targets in left and right visual space with their right hand. In line with the anti-saccade literature, anti-pointing yielded longer reaction times than pro-pointing: a result suggesting increased top-down processing for the sensorimotor transformations underlying a mirror-symmetrical response. Most interestingly, pro-pointing yielded comparable endpoint accuracy in left and right visual space; however, anti-pointing produced an under- and overshooting bias in respective left and right visual space. In Experiment 2, we replicated the findings from Experiment 1 and further demonstrate that the endpoint bias of anti-pointing is independent of the reaching limb (i.e. left vs. right hand) and between-task differences in saccadic drive. We thus propose that the visual field-specific endpoint bias observed here is related to the cognitive (i.e. top-down) nature of anti-pointing and the corollary use of visuo-perceptual networks to support the sensorimotor transformations underlying such actions.

Action without awareness: reaching to an object you do not remember seeing.

BACKGROUND: Previous work by our group has shown that the scaling of reach trajectories to target size is independent of obligatory awareness of that target property and that "action without awareness" can persist for up to 2000 ms of visual delay. In the present investigation we sought to determine if the ability to scale reaching trajectories to target size following a delay is related to the pre-computing of movement parameters during initial stimulus presentation or the maintenance of a sensory (i.e., visual) representation for on-demand response parameterization. METHODOLOGY/PRINCIPAL FINDINGS: Participants completed immediate or delayed (i.e., 2000 ms) perceptual reports and reaching responses to different sized targets under non-masked and masked target conditions. For the reaching task, the limb associated with a trial (i.e., left or right) was not specified until the time of response cuing: a manipulation that prevented participants from pre-computing the effector-related parameters of their response. In terms of the immediate and delayed perceptual tasks, target size was accurately reported during non-masked trials; however, for masked trials only a chance level of accuracy was observed. For the immediate and delayed reaching tasks, movement time as well as other temporal kinematic measures (e.g., times to peak acceleration, velocity and deceleration) increased in relation to decreasing target size across non-masked and masked trials. CONCLUSIONS/SIGNIFICANCE: Our results demonstrate that speed-accuracy relations were observed regardless of whether participants were aware (i.e., non-masked trials) or unaware (i.e., masked trials) of target size. Moreover, the equivalent scaling of immediate and delayed reaches during masked trials indicates that a persistent sensory-based representation supports the unconscious and metrical scaling of memory-guided reaching.