Ethnicity and variability of psychotic symptoms

Service User Representation in Qualitative Research on Cognitive Health and Related Interventions for Psychosis: A Scoping Review

BACKGROUND AND HYPOTHESIS

Cognitive health in schizophrenia spectrum psychosis has received substantial empirical attention in recent decades, coinciding with the development and implementation of interventions including cognitive remediation. Subjective experience in psychosis, including qualitative explorations of service user perspectives, has also proliferated; however, there is no available synthesis of service user representation in the psychosis cognitive health literature. This scoping review investigated prevalence and characteristics of qualitative research reporting service user perspectives across the extant research on cognitive health and related interventions in psychosis.

STUDY DESIGN

We conducted a literature search on qualitative methods in cognitive health and/or related interventions across PubMed, Web of Science, and PsycInfo databases. The review followed the PRISMA-ScR guidelines for scoping reviews and identified 23 papers. Data extraction included study design and sample characteristics, qualitative methodology, and reporting.

STUDY RESULTS

Of 23 articles, 18 reported on user experiences of interventions, most often in the context of feasibility/acceptability for otherwise quantitative trials. Five studies described service user experiences of cognitive health separately from interventions. Only 3 included any service user involvement or participatory methods. Twenty articles reported any demographic characteristics, and fewer than half (11) reported any racial or ethnic sample characteristics. There was substantial variability in qualitative methodology and reporting across studies.

CONCLUSIONS

Qualitative methodology is lacking in its representation and rigor across the cognitive health literature for schizophrenia spectrum psychosis. Additional inclusion of service user lived experience is critical for future research to better characterize cognitive health and inform interventions to promote recovery.

Prevalence and risk factors of self-reported psychotic experiences among high school and college students: A systematic review, meta-analysis, and meta-regression

BACKGROUND

Adolescents are at high risk of incident psychopathology. Fleeting psychotic experiences (PEs) that emerge in young people in response to stress may be warning signs that are missed by research that fails to study stressed populations, such as late high school and college/university students. Our aim in this systematic review was to conduct a meta-analysis that estimates prevalence rates of PEs in students, and to assess whether these rates differ by gender, age, culture, and COVID-19 exposure.

METHOD

We searched nine electronic databases, from their inception until January 31, 2022 for relevant studies. We pooled the estimates using the DerSimonian-Laird technique and random-effects meta-analysis. Our main outcome was the prevalence of self-reported PEs in high school and college/university students. We subsequently analyzed our data by age, gender, population, country, culture, evaluation tool, and COVID-19 exposure.

RESULTS

Out of 486 studies retrieved, a total of 59 independent studies met inclusion criteria reporting 210' 024 students from 21 different countries. Nearly one in four students (23.31%; 95% CI 18.41%-29.05%), reported having experienced PEs (heterogeneity [Q = 22,698.23 (62), p = 0.001] τ²  = 1.4418 [1.0415-2.1391], τ = 1.2007 [1.0205-1.4626], I²  = 99.7%, H = 19.13 [18.59-19.69]). The 95% prediction intervals were 04.01%-68.85%. Subgroup analyses showed that the pooled prevalence differed significantly by population, culture, and COVID-19 exposure.

CONCLUSION

This meta-analysis revealed high prevalence rates of self-reported PEs among teen and young adult students, which may have significance for mental health screening in school settings. An important realization is that PEs may have very different mental health meaning in different cultures.

Factor structure and item response of psychosis symptoms among Kenyan adults

BACKGROUND

The aim of this study was to evaluate the construct validity of the psychosis module of the Mini International Neuropsychiatric Interview version 7.0.2 (MINI-7).

METHOD

We utilized data collected from 2738 participants with a primary psychotic or bipolar disorder. Participants were drawn from two Kenyan sites of a large multi-center neuropsychiatric genetic study. The factor structure of the MINI-7 psychosis items were explored using confirmatory factor analyses (CFA) and Item Response Theory approach, for the full sample and by gender.

RESULTS

The CFA revealed that a 1-factor model provided adequate fit for the MINI-7 psychosis items for the full sample (x2 = 397.92, df = 35, p < .0001; RMSEA = 0.06; CFI = 0.92; TLI = 0.90) as well as for the female (x2 = 185.16.92, df = 35, p < .0001; RMSEA = 0.06; CFI = 0.93; TLI = 0.91) and male groups (x2 = 242.09, df = 35, p < .0001; RMSEA = 0.06; CFI = 0.92; TLI = 0.89). Item thresholds for the full sample, and female and male groups were highest for 'odd beliefs' (-1.42, -1.33, and -1.51 respectively) and lowest for 'visual hallucinations' (-0.03, -0.04, and -0.01 respectively).

LIMITATIONS

Our study used a hospital-based population, which may have excluded patients with milder psychotic symptoms. Findings may therefore not be generalizable to the community setting.

CONCLUSIONS

Our findings indicate good construct validity of the MINI-7 psychosis module, and provides support for use of the tool in diagnosing psychotic disorders in clinical settings in Kenya.

Young migrants to Australia identified as being at ultra-high risk for psychosis: Pathways to care and clinical characteristics

INTRODUCTION

Despite the established finding that migrants are at higher risk of developing a first-episode psychosis, they are under-represented in cohorts of young people identified as being at ultra-high risk for psychosis (UHR). Therefore, in order to determine the reasons for these conflicting findings, this study examined the pathways to care and clinical presentation of migrants attending an At-Risk Mental State clinic.

METHODOLOGY

This study included consecutive UHR cases identified over five years attending the PACE clinic in Melbourne, Australia. The CAARMS was used to assess the severity of attenuated psychotic symptoms. Depressive symptoms and functioning were measured using the PHQ9 and GAF, respectively.

RESULTS

Over the five-year study period, 461 UHR young people attended the PACE clinic and 13.7% were first-generation migrants. A higher proportion of migrants were referred by community health services, such as general practitioners, than other referral sources. Australian born UHR patients were more likely to be referred via another mental health service. There was no difference in the type or severity of attenuated psychotic symptoms based on migrant status, except that there was a trend for young African migrants to have more severe unusual thought content. Depressive symptoms and poor functioning were highly prevalent across the total cohort and did not differ according to migrant status.

CONCLUSIONS

It is not yet understood why migrants are under-represented in UHR cohorts. Qualitative interviews of migrants, who are not typically identified in the UHR stage, could provide insights into the barriers to accessing care.

Psychotic-like experiences among 9,564 Kenyan adolescents and young adults

OBJECTIVE

To investigate the prevalence and characteristics of psychotic-like experiences (PLE) in a large cohort of Kenyan adolescents and young adults.

METHOD

The Washington Early Recognition Center Affectivity and Psychosis (WERCAP) Screen was used to the study the 12-month prevalence of PLE's among 9,564 Kenyan youths (aged 15-25 yrs), and the rates of psychosis high-risk (HR) and medium-risk (MR) cases, based on cut-off scores. Relationships with clinical, demographic and economic profiles were investigated.

RESULTS

Across all participants, 72% reported having had at least one PLE over the last year. 4.6% and 30.6% were HR and MR based on symptom scores. There were similar PLE rates in females and males. PLE severity correlated with mood (r=0.67), stress (r=0.46), and autistic traits (r=0.18). PLE severity was also related to poverty, lower education attainment, and underemployment. Compared to controls, HR and MR youths were more likely to report lifetime substance use and to have more significant use.

CONCLUSION

Psychosis screening can provide valuable information about individuals and may help identify those who may require clinical assessment and intervention to improve outcomes. This is particularly relevant in many parts of Africa where the resources are limited for treating more advanced illness.

Association Between Race/Ethnicity and Disparities in Health Care Use Before First-Episode Psychosis Among Privately Insured Young Patients

IMPORTANCE

Racial/ethnic disparities in health care use and clinical outcomes for behavioral health disorders, including psychosis, are well documented, but less is known about these disparities during the period leading up to first-episode psychosis (FEP).

OBJECTIVE

To describe the racial/ethnic disparities in behavioral health care use and prescription drug use of children and young adults before the diagnosis of FEP.

DESIGN, SETTING, AND PARTICIPANTS

An observational cohort study was conducted using medical and prescription drug claims from January 1, 2007, to September 30, 2015, obtained from Optum's deidentified Clinformatics Data Mart Database, a commercial claims database augmented with race/ethnicity and socioeconomic variables. Data analysis was performed from February 6, 2018, to October 10, 2020. First-episode psychosis was determined by the presence of psychosis diagnoses on claims for at least 1 hospitalization or 2 outpatient events, with a continuous enrollment requirement of at least 2 years before the first diagnosis. Participants included 3017 Black, Hispanic, or White patients who were continually enrolled in commercial insurance plans and received an FEP diagnosis between the ages of 10 and 21 years.

MAIN OUTCOMES AND MEASURES

Race/ethnicity was determined from a commercial claims database. Rates of inpatient admission, emergency department presentation, and outpatient visits (including psychotherapy), behavioral health disorder diagnoses, and antipsychotic/antidepressant prescription fills were determined for the year before FEP. Race/ethnicity was also obtained from Optum's claims database. With use of multivariable logistic regression, results were adjusted for covariates including estimated household income, age, sex, and geographic division in the US.

RESULTS

Of the 3017 patients with FEP, 643 Black or Hispanic patients (343 [53.3%] Black, 300 [46.7%] Hispanic, 324 [50.4%] male, mean [SD] age, 17.2 [2.76] years) were less likely than 2374 White patients (1210 [51.0%] male, mean age, 17.0 [2.72] years) to receive comorbid behavioral health disorder diagnoses in the year before the diagnosis of FEP (410 [63.8%] vs 1806 [76.1%], χ2 = 39.3; P < .001). Except for emergency care, behavioral health care use rates were lower in Black and Hispanic patients vs White patients (424 [65.9%] vs 1868 [78.7%]; χ2 = 45.0; P < .001), particularly for outpatient visits with behavioral health care professionals (232 [36.1%] vs 1236 [52.1%]; χ2 = 51.7; P < .001). After adjustment for socioeconomic covariates, behavioral health care use rates (68.9% vs 79.2%; P < .001), outpatient visits with behavioral health professionals (37.7% vs 51.2%; P < .001), and other outcomes remained significantly lower for Black and Hispanic patients vs White patients.

CONCLUSIONS AND RELEVANCE

The results of this study extend existing research findings of well-known racial/ethnic disparities in the population of patients who are diagnosed with FEP. These differences were apparent in young patients with continuous commercial health insurance and after controlling for household income. Providing equal access to preventive outpatient behavioral health care may increase opportunities for timely detection of psychotic symptoms and early intervention and improve differential outcomes after FEP.

Prevalence and Correlates of Psychotic Like Experiences in a Large Community Sample of Young Adults in Tunisia

Despite the increased focus on non-clinical psychosis populations, no community surveys have properly investigated the phenotypal expression of Psychotic like experiences (PLEs) in the Arab-Muslim world. We aimed to examine the prevalence and correlates of PLEs in a large sample of Tunisian college students. A total of 1489 students (64.3% female, aged 18-40) participated in a cross-sectional survey. The Positive Subscale of Community Assessment of Psychotic Experiences was used to measure PLEs. The rates of PLEs found in our work were relatively high compared with those found in previous international studies, with 51.4% of the participants reporting at least one positive PLE 'nearly-always'. After controling for confounding variables, other drug use in the past year represented the only substance use variable among the significant predictors in the final model. Our findings should raise awareness of the need for implementing an early intervention programs in our region.

Cultural differences in positive psychotic experiences assessed with the Community Assessment of Psychic Experiences-42 (CAPE-42): a comparison of student populations in the Netherlands, Nigeria and Norway

BACKGROUND

Previous studies have suggested that culture impacts the experience of psychosis. The current study set out to extend these findings by examining cultural variation in subclinical positive psychotic experiences in students from The Netherlands, Nigeria, and Norway. Positive psychotic experiences were hypothesized to (i) be more frequently endorsed by, and (ii) cause less distress in Nigerian vs. Dutch and Norwegian students.

METHODS

Psychology students, aged 18 to 30 years, from universities in the Netherlands (n = 245), Nigeria (n = 478), and Norway (n = 162) were assessed cross-sectionally with regard to the frequency of subclinical positive psychotic experiences and related distress, using the Community Assessment of Psychic Experiences (CAPE-42). Multi-group confirmatory factor analysis and multivariate analysis of covariance were performed to assess measurement invariance of the positive symptom dimension (CAPE-Pos) and compare mean frequency and associated distress of positive psychotic experiences across study samples.

RESULTS

Only CAPE-Pos items pertaining to the dimensions 'strange experiences' and 'paranoia' met assumptions for (partial) measurement invariance. Frequencies of these experiences were higher in the Nigerian sample, compared to both the Dutch and Norwegian samples, which were similar. In addition, levels of experience-related distress were similar or higher in the Nigerian sample compared to respectively the Dutch and Norwegian samples.

CONCLUSION

Although positive psychotic experiences may be more commonly endorsed in non-Western societies, our findings do not support the notion that they represent a more benign, and hence less distressing aspect of human experience. Rather, the experience of psychotic phenomena may be just as, if not more, distressing in African than in European culture. However, observed differences in CAPE-Pos frequency and distress between samples from different cultural settings may partly reflect differences in the measure rather than in the latent trait. Future studies may therefore consider further cross-cultural adaptation of CAPE-42, in addition to explicitly examining cultural acceptance of psychotic phenomena, and environmental and other known risk factors for psychosis, when comparing and interpreting subclinical psychotic phenomena across cultural groups.

Transdiagnostic dimensions of psychopathology at first episode psychosis: findings from the multinational EU-GEI study

BACKGROUND

The value of the nosological distinction between non-affective and affective psychosis has frequently been challenged. We aimed to investigate the transdiagnostic dimensional structure and associated characteristics of psychopathology at First Episode Psychosis (FEP). Regardless of diagnostic categories, we expected that positive symptoms occurred more frequently in ethnic minority groups and in more densely populated environments, and that negative symptoms were associated with indices of neurodevelopmental impairment.

METHOD

This study included 2182 FEP individuals recruited across six countries, as part of the EUropean network of national schizophrenia networks studying Gene-Environment Interactions (EU-GEI) study. Symptom ratings were analysed using multidimensional item response modelling in Mplus to estimate five theory-based models of psychosis. We used multiple regression models to examine demographic and context factors associated with symptom dimensions.

RESULTS

A bifactor model, composed of one general factor and five specific dimensions of positive, negative, disorganization, manic and depressive symptoms, best-represented associations among ratings of psychotic symptoms. Positive symptoms were more common in ethnic minority groups. Urbanicity was associated with a higher score on the general factor. Men presented with more negative and less depressive symptoms than women. Early age-at-first-contact with psychiatric services was associated with higher scores on negative, disorganized, and manic symptom dimensions.

CONCLUSIONS

Our results suggest that the bifactor model of psychopathology holds across diagnostic categories of non-affective and affective psychosis at FEP, and demographic and context determinants map onto general and specific symptom dimensions. These findings have implications for tailoring symptom-specific treatments and inform research into the mood-psychosis spectrum.

Cultural considerations in the diagnosis and treatment of schizophrenia: A case example from India

Culture plays an important role in the presentation, help seeking, treatment and outcomes of psychiatric illnesses like schizophrenia. We report a case of paranoid schizophrenia in a 35-year-old lady, from South India, whose clinical presentation was influenced by various sociocultural factors. These cultural constructs were taken into consideration to formulate an acceptable and effective management plan. A detailed case description using a cultural formulation to highlight the etic and emic perspectives and challenges in treatment and management are discussed.

Modelling difficulties in abstract thinking in psychosis: the importance of socio-developmental background

INTRODUCTION

Abstract thinking is important in modern understanding of neurocognitive abilities, and a symptom of thought disorder in psychosis. In patients with psychosis, we assessed if socio-developmental background influences abstract thinking, and the association with executive functioning and clinical psychosis symptoms.

METHODS

Participants (n = 174) had a diagnosis of psychotic or bipolar disorder, were 17-65 years, intelligence quotient (IQ) > 70, fluent in a Scandinavian language, and their full primary education in Norway. Immigrants (N = 58) were matched (1:2) with participants without a history of migration (N = 116). All participants completed a neurocognitive and clinical assessment. Socio-developmental background was operationalised as human developmental index (HDI) of country of birth, at year of birth. Structural equation modelling was used to assess the model with best fit.

RESULTS

The model with best fit, χ² = 96.591, df = 33, p < .001, confirmed a significant indirect effect of HDI scores on abstract thinking through executive functioning, but not through clinical psychosis symptoms.

CONCLUSIONS

This study found that socio-developmental background influences abstract thinking in psychosis by indirect effect through executive functioning. We should take into account socio-developmental background in the interpretation of neurocognitive performance in patients with psychosis, and prioritise cognitive remediation in treatment of immigrant patients.

Prevalence and clinical significance of DSM-5-attenuated psychosis syndrome in adolescents and young adults in the general population: the Bern Epidemiological At-Risk (BEAR) study

OBJECTIVE

Section III of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) lists attenuated psychosis syndrome as a condition for further study. One important question is its prevalence and clinical significance in the general population.

METHOD

Analyses involved 1229 participants (age 16-40 years) from the general population of Canton Bern, Switzerland, enrolled from June 2011 to July 2012. "Symptom," "onset/worsening," "frequency," and "distress/disability" criteria of attenuated psychosis syndrome were assessed using the structured interview for psychosis-risk syndromes. Furthermore, help-seeking, psychosocial functioning, and current nonpsychotic axis I disorders were surveyed. Well-trained psychologists performed assessments using the computer-assisted telephone interviewing technique.

RESULTS

The symptom criterion was met by 12.9% of participants, onset/worsening by 1.1%, frequency by 3.8%, and distress/disability by 7.0%. Symptom, frequency, and distress/disability were met by 3.2%. Excluding trait-like attenuated psychotic symptoms (APS) decreased the prevalence to 2.6%, while adding onset/worsening reduced it to 0.3%. APS were associated with functional impairments, current mental disorders, and help-seeking although they were not a reason for help-seeking. These associations were weaker for attenuated psychosis syndrome.

CONCLUSIONS

At the population level, only 0.3% met current attenuated psychosis syndrome criteria. Particularly, the onset/worsening criterion, originally included to increase the likelihood of progression to psychosis, lowered its prevalence. Because progression is not required for a self-contained syndrome, a revision of the restrictive onset criterion is proposed to avoid the exclusion of 2.3% of persons who experience and are distressed by APS from mental health care. Secondary analyses suggest that a revised syndrome would also possess higher clinical significance than the current syndrome.

Symptom Profile and Severity in a Sample of Nigerians with Psychotic versus Nonpsychotic Major Depression

The therapeutic strategies in managing patients with psychotic major depression (PMD) differ from those with non-psychotic major depression (NMD), because of differences in clinical profile and outcome. However, there is underrecognition of psychotic symptoms in depressed patients. Previous studies in Western population suggest that certain symptom patterns, apart from psychosis which may be concealed, can facilitate the discrimination of PMD from NMD. These studies may have limited applicability to sub-Saharan Africa due to cross-cultural differences in the phenomenology of depression. This study compared the rates and severity of depressive symptoms in outpatients with PMD (n = 129) and NMD (n = 117) using the Structured Clinical Interview for Depression (SCID) and Hamilton Depression Rating Scale (HAM-D). Patients with PMD had statistically significantly higher rates of suicidal ideation, suicidal attempt, psychomotor agitation, insomnia, and reduced appetite. Patients with NMD were more likely to manifest psychomotor retardation and somatic symptoms. PMD was associated with greater symptom severity. On logistic regression analysis, suicidal ideation, psychomotor disturbances, insomnia, and somatic symptoms were predictive of diagnostic status. The presence of these symptoms clusters may increase the suspicion of occult psychosis in patients with depression, thereby informing appropriate intervention strategies.

Comparing the clinical presentation of first-episode psychosis across different migrant and ethnic minority groups in Montreal, Quebec

OBJECTIVE

To explore differences in severity and nature of symptoms of first-episode psychosis (FEP) according to ethnic group and migrant status.

METHOD

We administered rating scales to assess positive and negative symptoms, as well as general psychopathology, to 301 consecutive patients presenting with an FEP within a defined catchment area in Montreal, Quebec, classified according to ethnicity and migrant status. Symptom scores of Euro-Canadian patients without a recent history of migration, that is, the reference group (n = 145), were compared with those of African and Afro-Caribbean (n = 39), Asian (n = 27), Central and South American (n = 15), Middle Eastern and North African (n = 24), and European and North American (n = 39) patients.

RESULTS

Except for referral source, there were no significant differences between ethnic groups on any demographic variables. The African and Afro-Caribbean group had a higher level of negative symptoms (especially alogia) and general psychopathology scores on the Positive and Negative Syndrome Scale (especially, uncooperativeness, preoccupation, and poor attention), compared with the reference group. Ethnic groups did not differ on the Scale for the Assessment of Positive Symptoms scores.

CONCLUSIONS

A comparison of FEP patients from different ethnic groups and native-born Euro-Canadians revealed no significant differences in the nature of positive symptoms at first presentation or in age at onset, suggesting that there was no evidence for the hypothesis that ethnic minorities are misdiagnosed as psychotic. Increased severity of negative symptoms and general psychopathology, specifically among the black ethnic minority group, may have implications for the role of ethnicity for the treatment and outcome of the initial episode of psychotic disorders.

Longitudinal treatment outcome of African American and Caucasian patients with first episode psychosis

The purpose of our analyses to examine the outcome differences between African American and Caucasian first-episode psychotic patients over the course of one year, to explore the interactive effects of gender, diagnosis, and race on treatment outcome. A consecutive series of patients (N=199) were recruited into our study from the inpatient and outpatient services at a psychiatric clinic. Global functioning, positive, negative, affective, and depression symptoms and treatment adherence were assessed at baseline prior to treatment and during follow-up up to one year. African American patients (N=62) were found to experience significantly less improvement in symptoms, bizarre behavior, avolition, anhedonia, and functional performance, and affective symptoms than their Caucasian counterparts (N=137). In addition, African American female patients experienced less improvement in affective flattening. While both groups of patients have experienced significant improvement during the one-year treatment, that of the African American patients was less optimal.

Migration from Mexico to the United States and subsequent risk for depressive and anxiety disorders: a cross-national study

CONTEXT

Migration is suspected to increase risk for depressive and anxiety disorders.

OBJECTIVE

To test the hypothesized increase in risk for depressive and anxiety disorders after arrival in the United States among Mexican migrants.

DESIGN

We combined data from surveys conducted separately in Mexico and the United States that used the same diagnostic interview. Discrete time survival models were specified to estimate the relative odds of first onset of depressive disorders (major depressive episode and dysthymia) and anxiety disorders (generalized anxiety disorder, social phobia, panic disorder, and posttraumatic stress disorder) among migrants after their arrival in the United States compared with nonmigrant Mexicans who have a migrant in their immediate family.

SETTING

Population surveys in the United States and Mexico.

PARTICIPANTS

Two thousand five hundred nineteen nonmigrant family members of migrants in Mexico and 554 Mexican migrants in the United States.

MAIN OUTCOME MEASURES

First onset of any depressive or anxiety disorder.

RESULTS

After arrival in the United States, migrants had a significantly higher risk for first onset of any depressive or anxiety disorder than did nonmigrant family members of migrants in Mexico (odds ratio, 1.42; 95% confidence interval, 1.04-1.94). Associations between migration and disorder varied across birth cohorts. Elevated risk among migrants relative to nonmigrants was restricted to the 2 younger cohorts (those aged 18-25 or 26-35 years at interview). In the most recent birth cohort, the association between migration and first onset of any depressive or anxiety disorder was particularly strong (odds ratio, 3.89; 95% confidence interval, 2.74-5.53).

CONCLUSIONS

This is, to our knowledge, the first study to compare risk for first onset of psychiatric disorder between representative samples of migrants in the United States and nonmigrants in Mexico. The findings are consistent with the hypothesized adverse effect of migration from Mexico to the United States on the mental health of migrants, but only among migrants in recent birth cohorts.