Family-level predictors and correlates of the duration of untreated psychosis in African American first-episode patients

Systematic review of pathways to care in the U.S. for Black individuals with early psychosis

The pathway to receiving specialty care for first episode psychosis (FEP) among Black youth in the US has received little attention despite documented challenges that negatively impact engagement in care and clinical outcomes. We conducted a systematic review of US-based research, reporting findings related to the pathway experiences of Black individuals with FEP and their family members. A systematic search of PubMed, PsycInfo, and Embase/Medline was performed with no date restrictions up to April 2021. Included studies had samples with at least 75% Black individuals and/or their family members or explicitly examined racial differences. Of the 80 abstracts screened, 28 peer-reviewed articles met the inclusion criteria. Studies were categorized into three categories: premordid and prodromal phase, help-seeking experiences, and the duration of untreated psychosis (DUP). Compounding factors such as trauma, substance use, and structural barriers that occur during the premorbid and prodromal contribute to delays in treatment initiation and highlight the limited use of services for traumatic childhood experiences (e.g., sexual abuse). Studies focused on help-seeking experiences demonstrated the limited use of mental health services and the potentially traumatic entry to services (e.g., law enforcement), which is associated with a longer DUP. Although the majority of studies focused on help-seeking experiences and predictors of DUP, findings suggests that for Black populations, there is a link between trauma and substance use in the pathway to care that impacts the severity of symptoms, initiation of treatment, and DUP. The present review also identifies the need for more representative studies of Black individuals with FEP.

Systematic Review of Cultural Aspects of Stigma and Mental Illness among Racial and Ethnic Minority Groups in the United States: Implications for Interventions

Stigma is integral to understanding mental health disparities among racial and ethnic minority groups in the United States. We conducted a systematic review to identify empirical studies on cultural aspects of mental illness stigma (public, structural, affiliative, self) among three racial and ethnic minority groups (Asian Americans, Black Americans, Latinx Americans) from 1990 to 2019, yielding 97 articles. In comparison studies (N = 25), racial and ethnic minority groups often expressed greater public and/or self-stigma than White American groups. In within-group studies (N = 65; Asian American, n = 21; Black American, n = 18; Latinx American; n = 26), which were primarily qualitative (73%), four major cultural themes emerged: 1) service barriers including access and quality (structural stigma); 2) family experiences including concealment for family's sake, fear of being a burden, and stigma extending to family (affiliative stigma); 3) lack of knowledge about mental illness and specific cultural beliefs (public stigma); and 4) negative emotional responses and coping (self-stigma). These findings confirmed stigma has both similar and unique cultural aspects across groups. Despite this, few studies tested stigma reduction interventions (N = 7). These cultural insights can inform contextual change at the health systems and community levels to reduce stigma, and empowerment at the interpersonal and individual levels to resist stigma.

Similarities and Differences in Associations Between Duration of Untreated Psychosis (DUP) and Demographic, Premorbid, and Symptom Severity Measures in Two Samples of First-Episode Psychosis Patients from Mexico and the United States

Early-psychosis researchers have documented that duration of untreated psychosis (DUP) is an important predictor of outcomes in first-episode psychosis. Very few cross-national studies have been conducted, and none have been carried out involving patients from both Mexico and the U.S. We collaborated to answer three questions: (1) Are DUP estimates similar in two very different settings and samples? (2) Are demographic variables, premorbid adjustment, and symptom severity similarly related to DUP in the two different settings? (3) Does the same set of variables account for a similar proportion of variance in DUP in the two settings? Data on sociodemographic characteristics, premorbid adjustment, symptom severity, and DUP were available for 145 Mexican and 247 U.S. first-episode psychosis patients. DUP was compared, and bivariate analyses and multiple linear regressions were carried out in each sample. DUP estimates were similar (medians of 35 weeks in Mexico and 38 weeks in the U.S.). In the Mexican sample, DUP was associated with gender, employment status, premorbid social adjustment, and positive symptom severity (explaining 18% of variance). In the U.S. sample, DUP was associated with age, employment status, premorbid social adjustment, and positive symptom severity (but in the opposite direction of that observed in the Mexican sample), accounting for 25% of variance. Additional cross-national collaborations examining key facets of early-course psychotic disorders, including DUP, will clarify the extent of generalizability of findings, strengthen partnerships for more internationally relevant studies, and support the global movement to help young people struggling with first-episode psychosis and their families.

Family Experiences Prior to the Initiation of Care for First-Episode Psychosis: A Meta-Synthesis of Qualitative Studies

OBJECTIVES

This study systematically reviewed existing qualitative evidence of family members' experiences prior to the initiation of mental health services for a loved one experiencing their first episode of psychosis (FEP).

METHODS

A meta-synthesis review of published peer-reviewed qualitative studies conducted between 2010 and 2019 were included. Keyword searches were performed in four electronic databases and the reference lists of primary manuscripts. Two independent reviewers used the Critical Appraisal Skills Programme (CASP) qualitative checklist to assess methodological quality of each study.

RESULTS

A total of 365 articles were initially identified and 9 were articles identified in a secondary review and literature search. A total of 21 met inclusion criteria. Of those included in this review 169, mothers were the primary family to recall experiences. The meta-synthesis identified four major themes related to family member experiences prior to the initiation of mental health services for FEP: the misinterpretation of signs, the emotional impact of FEP on family members, the effect of stigma on family members, and engaging with resources prior to mental health services for FEP.

CONCLUSIONS

Additional research is needed to develop healthy communication strategies that effectively deliver educational information about psychosis. This meta-synthesis also identified the need to understand help-seeking behaviors among families of those with FEP in effort to reduce the duration of untreated psychosis and improve pathways to care often initiated by a family member.

Developing and implementing a culturally informed mily otivational ngagement trategy (FAMES) to increase family engagement in first episode psychosis programs: mixed methods pilot study protocol

INTRODUCTION

Despite the proven effectiveness of coordinated specialty care (CSC) programmes for first episode psychosis in the USA, CSC programmes often have low levels of engagement in family psychoeducation, and engagement of racial and ethnic minority family members is even lower than that for non-Latino white family members. The goal of this study is to develop and evaluate a culturally informed FAmily Motivational Engagement Strategy (FAMES) and implementation toolkit for CSC providers.

METHODS AND ANALYSIS

This protocol describes a mixed methods, multi-phase study that blends intervention mapping and the Promoting Action on Research in Health Services framework to develop, modify and pilot-test FAMES and an accompanying implementation toolkit. Phase 1 will convene a Stakeholder Advisory Committee to inform modifications based on findings from phases 1 and 2. During phase 1, we will also recruit approximately 200 family members to complete an online survey to assess barriers and motivation to engage in treatment. Phase 2 we will recruit five family members into a 3-month trial of the modified FAMES and implementation toolkit. Results will guide the advisory committee in refining the intervention and implementation toolkit. Phase 3 will involve a 16-month non-randomised, stepped-wedge trial with 50 family members from five CSC programmes in community-based mental health clinics to examine the acceptability, feasibility and initial impact of FAMES and the implementation toolkit.

ETHICS AND DISSEMINATION

This study received Institutional Review Board approval from Washington State University, protocol #17 812-001. Results will be disseminated via peer review publications, presentations at national and international conferences, and to local community mental health agencies and committees.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT04188366).

Understanding Individual and Family Experiences Associated with DUP: Lessons from the Early Assessment and Support Alliance (EASA) Program in Oregon, USA

Research shows that a longer duration of untreated psychosis (DUP) is associated with worse psychiatric outcomes, with average length of DUP of 73 weeks in the U.S. The aim was to examine the DUP period for first episode psychosis in Oregon, with a focus on the processes between the first positive symptoms and first treatment. To investigate DUP, researchers used methods consistent with grounded theory to collect data from 9 participants and their families about the process between onset of psychotic symptoms and entrance into treatment. Results suggest that recognition of symptoms was the primary driver of help-seeking in this study, and this was influenced by type of symptom as well as the presence or absence of supportive others, which in most cases was regular family contact. Implications indicate a need for in-depth research on individual and family recognition of symptoms, as well as underscoring the need for community education.

Neighborhood-level predictors of age at onset and duration of untreated psychosis in first-episode psychotic disorders

OBJECTIVE

Recent years have witnessed growing interest in the role of the social environment in the development and outcomes of schizophrenia. We investigated whether neighborhood characteristics are associated with two important prognostic factors in early-course psychosis, age at onset of psychosis (AOP) and duration of untreated psychosis (DUP).

METHODS

Data were collected from patients admitted to the hospital for first-episode schizophrenia-spectrum disorder. We collected data on perceived neighborhood disorder during childhood/adolescence and extracted data on 13 neighborhood characteristics from the American Community Survey based upon individual addresses. Four neighborhood-level factors were derived from factor analysis. Multiple logistic regression analyses assessed the association between specific neighborhood characteristics and the two prognostic factors (earlier AOP and longer DUP) in early-course psychosis.

RESULTS

143 participants had valid addresses geo-coded. Neighborhood-level residential instability was associated with an earlier AOP (OR = 1.760; p = 0.022) even after controlling for known risk factors (OR = 2.026; p = 0.020) and also after controlling for individual-level residential instability (OR = 1.917; p = 0.037). The general socioeconomic status neighborhood factor (OR = 1.119; p = 0.019) and perceived neighborhood disorder (OR = 1.075; p = 0.005) were associated with a longer DUP. But only perceived neighborhood disorder (OR = 1.146; p = 0.011) remained significant, and general socioeconomic status was close to significant (OR = 1.215; p = 0.062), after controlling for individual-level predictors and socioeconomic status.

CONCLUSIONS

This study found evidence that neighborhood-level characteristics (in this case, residential instability) may be associated with earlier AOP, and perceptions of neighborhood disorder are associated with a longer treatment delay. Socioenvironmental factors should be more consistently considered going forward in research on early psychotic disorders.

Effects of socio-demographic characteristics, premorbid functioning, and insight on duration of untreated psychosis in first-episode schizophrenia or schizophreniform disorder in Northern Malawi

AIM

Long duration of untreated psychosis (DUP) is prevalent and has been shown to be associated with poorer prognosis. Thus, knowledge of its determinants may help to target early interventions to reduce DUP on the needed population. Previous studies seeking to understand determinants of DUP have been inconclusive. Therefore, this study aimed to investigate the effects of socio-demographic characteristics, premorbid functioning, and insight on DUP in patients with first-episode schizophrenia or schizophreniform disorder.

METHODS

This cross-sectional study recruited 110 subjects (aged 18-65) during a pilot early intervention service for psychosis in Northern Malawi, between June 2009 and September 2012. Short DUP was defined as ≤6 months, whereas long DUP was defined as >6 months. Unadjusted and adjusted analyses were performed to identify determinants of DUP.

RESULTS

Of the 110 subjects, 99 (90%) had schizophrenia. Median DUP was 27.5 months, while mean (SD) DUP was 71.24 (92.32) months. In addition, at least 75% had long DUP, which was associated with lower level of education, poor insight, younger age at onset, and at least one parent deceased.

CONCLUSIONS

Long DUP is prevalent in Northern Malawi. Thus, early interventions to reduce DUP are warranted in this population. Although having at least one parent deceased predicted long DUP in this study, this remains speculative because factors, such as timing of parents' death and grief reactions of the patients were not assessed. Therefore, further investigations incorporating these factors are needed to ascertain this result.

Family processes and duration of untreated psychosis among US Latinos

AIM

Little is known about family processes and treatment seeking among Latinos with first-episode psychosis (FEP) living in the United States. This study examined family processes prior to treatment and their relation to duration of untreated psychosis (DUP) among Latinos with FEP and their family caregivers.

METHODS

Thirty-three Latinos with FEP and their low-acculturated family caregivers (n = 33) participated in qualitative semi-structured interviews focused on treatment-seeking experience and family relationships. Transcripts were analysed using thematic analysis and themes were grouped based on short (n = 18) or long (n = 15) DUP.

RESULTS

Findings revealed differences based on DUP length. Patients with short DUP had stronger family relationships characterized by open communication and disclosure of symptoms that facilitated awareness and direct action by family caregivers. However, patients with long DUP had more troubled family relationships that often challenged early treatment seeking.

CONCLUSIONS

Findings highlight the relevance of family context in the provision of early treatment for Latinos with FEP. Family-based services are needed that increase awareness of symptoms and provide families with support that can facilitate ongoing patient treatment during this critical period.

Family experiences in the identification of the first-episode psychosis in young patients

The study aimed to understand the family experience in the identification of the first-episode psychosis in young family members. Qualitative research using symbolic interactionism and narrative. Data were collected through depth interview with 13 relatives of 11 young patients treated for the first-episode psychosis. The families showed behavior consistent with the meanings they gave to the disease process of the young relatives, represented by categories: "waiting move: trying to justify the behavior of the adolescent", "not understanding the psychosis", and "seeking help". This research fostered the understanding of how families decided to seek help in the healthcare system. The nursing interventions with these families could contribute to early detection and beginning of treatment.

Is early management of psychosis designed for migrants? Improving transcultural variable collection when measuring duration of untreated psychosis

AIM

A background of migration is an established risk factor for psychosis. At the same time, over the last 25 years, many countries have developed specialized services for the assessment and care of people with early psychosis. Evaluation of these services often focuses on the duration of untreated psychosis (DUP).

METHODS

We conducted a systematic review with an electronic search of key words in 3 databases to determine the extent to which studies measuring DUP consider transcultural variables, including migration status, national origin, ethnicity and language.

RESULTS

We identified 18 studies that included transcultural variables and measured DUP. They differed in their design, aims and methodology, and could not be directly compared. Common themes nonetheless appeared.

CONCLUSIONS

Most of the studies exploring DUP took little account of transcultural variables. Definitions of transcultural indicators were heterogeneous and often vague. Lack of language proficiency was often an exclusion criterion, and none of the studies used interpreters. We propose some basic transcultural variable and recommendations to include in future studies and recommendations to improve their internal and external validity.

Racial-Ethnic Disparities in First-Episode Psychosis Treatment Outcomes From the RAISE-ETP Study

OBJECTIVE

This study examined racial and ethnic differences in treatment outcomes among participants in a randomized controlled trial of an intervention for first-episode psychosis called NAVIGATE.

METHODS

Secondary data analyses were conducted for participants randomly assigned to usual community care (N=181) and NAVIGATE (N=223). Generalized estimating equations assessed whether race and ethnicity were associated with psychiatric symptoms and service use (medication management, family psychoeducation, and individual therapy) over a 24-month treatment period, accounting for baseline symptoms, duration of untreated psychosis, and insurance status.

RESULTS

Among persons in usual community care, non-Hispanic blacks scored significantly higher throughout treatment on measures of positive symptoms (β=2.15, p=.010), disorganized thoughts (β=1.15, p=.033), and uncontrolled hostility (β=.74, p=.027), compared with non-Hispanic whites, and non-Hispanic blacks were less likely than non-Hispanic whites to receive individual therapy (OR=.45, p=.001). Families of Hispanic participants in usual community care were less likely than non-Hispanic white families to receive family psychoeducation (OR=.20, p=.01). For NAVIGATE participants, race and ethnicity were not associated with differences in psychiatric symptoms over time; families of non-Hispanic black participants were less likely than those of non-Hispanic white participants to receive family psychoeducation (OR=.53, p=.009). Hispanic participants in NAVIGATE were more likely than non-Hispanic white participants to receive medication management (OR=2.93, p=.001).

CONCLUSIONS

In usual community care, non-Hispanic blacks scored higher on measures of psychiatric symptoms and were less likely to receive important services, compared with non-Hispanic whites. In NAVIGATE, racial and ethnic differences in psychiatric symptoms were not evident, although non-Hispanic blacks were less likely than non-Hispanic whites to receive family psychoeducation.

Mental health-related stigma and pathways to care for people at risk of psychotic disorders or experiencing first-episode psychosis: a systematic review

BACKGROUND

Stigma associated with mental illness can delay or prevent help-seeking and service contact. Stigma-related influences on pathways to care in the early stages of psychotic disorders have not been systematically examined.

METHOD

This review systematically assessed findings from qualitative, quantitative and mixed-methods research studies on the relationship between stigma and pathways to care (i.e. processes associated with help-seeking and health service contact) among people experiencing first-episode psychosis or at clinically defined increased risk of developing psychotic disorder. Forty studies were identified through searches of electronic databases (CINAHL, EMBASE, Medline, PsycINFO, Sociological Abstracts) from 1996 to 2016, supplemented by reference searches and expert consultations. Data synthesis involved thematic analysis of qualitative findings, narrative synthesis of quantitative findings, and a meta-synthesis combining these results.

RESULTS

The meta-synthesis identified six themes in relation to stigma on pathways to care among the target population: 'sense of difference', 'characterizing difference negatively', 'negative reactions (anticipated and experienced)', 'strategies', 'lack of knowledge and understanding', and 'service-related factors'. This synthesis constitutes a comprehensive overview of the current evidence regarding stigma and pathways to care at early stages of psychotic disorders, and illustrates the complex manner in which stigma-related processes can influence help-seeking and service contact among first-episode psychosis and at-risk groups.

CONCLUSIONS

Our findings can serve as a foundation for future research in the area, and inform early intervention efforts and approaches to mitigate stigma-related concerns that currently influence recognition of early difficulties and contribute to delayed help-seeking and access to care.

Duration of untreated psychosis in an Egyptian sample: Sociodemographic and clinical variables

BACKGROUND

Duration of untreated psychosis (DUP) has been considered as a poor prognostic factor for psychotic disorder. Several studies have been investigating different predictors of DUP in Western countries, while in Egypt only a few studies have examined various predictors of DUP.

AIMS

To study DUP in Egyptian patients with psychotic disorders and to investigate how certain illnesses, patient, socio-cultural risk factors and help-seeking behaviour are correlated with prolonged DUP.

METHOD

The sample included 100 patients with Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR) diagnosis of psychotic disorder were selected and interviewed to assess DUP. They were interviewed using the Structured Clinical Interview for DSM-IV axis I disorders (SCID-I), Positive and Negative Syndrome Scale (PANSS) and Global Assessment of Functioning (GAF) scale.

RESULTS

Mean (±standard deviation ( SD)) of DUP was found to be 36.93(±45.27) months. DUP was correlated with various sociodemographic and clinical variables. Following log transformation of DUP, correlation with PANSS scores was done and revealed highly significant statistical relation of DUP to PANSS negative and PANSS positive scores. In linear regression analysis, it was found that age of patients, the age of onset, residence, being illiterate, the insidious mode of onset, negative family history of psychiatric disorder and the severity of illness as indicated by PANSS are among DUP predictors.

CONCLUSION

Longer DUP results from multiple patient- and illness-related factors. This has many implications in targeting early intervention with specific consideration to cultural factors.

Marijuana use in the immediate 5-year premorbid period is associated with increased risk of onset of schizophrenia and related psychotic disorders

OBJECTIVES

Several studies suggest that adolescent marijuana use predicts earlier age at onset of schizophrenia, which is a crucial prognostic indicator. Yet, many investigations have not adequately established a clear temporal relationship between the use and onset.

METHODS

We enrolled 247 first-episode psychosis patients from six psychiatric units and collected data on lifetime marijuana/alcohol/tobacco use, and ages at onset of prodrome and psychosis in 210 of these patients. Cox regression (survival analysis) was employed to quantify hazard ratios (HRs) for effects of diverse premorbid use variables on psychosis onset.

RESULTS

Escalation of premorbid use in the 5years prior to onset was highly predictive of an increased risk for onset (e.g., increasing from no use to daily use, HR=3.6, p<0.0005). Through the analysis of time-specific measures, we determined that daily use approximately doubled the rate of onset (HR=2.2, p<0.0005), even after controlling for simultaneous alcohol/tobacco use. Building on previous studies, we were able to determine that cumulative marijuana exposure was associated with an increased rate of onset of psychosis (p=0.007), independent of gender and family history, and this is possibly the reason for age at initiation of marijuana use also being associated with rate of onset in this cohort.

CONCLUSIONS

These data provide evidence of a clear temporal relationship between escalations in use in the five years pre-onset and an increased rate of onset, demonstrate that the strength of the association is similar pre- and post-onset of prodromal symptoms, and determine that early adult use may be just as important as adolescent use in these associations.

The Help-Seeking Experiences of Parents of Children with a First-Episode of Psychosis

The objective was to understand the experiences of parents as they sought psychological and specialized medical services for a loved one having a first episode of psychosis. The research method was qualitative and the data gathering was done through semi-structured interviews. Eleven parents of eight adolescent or young adult children consented to be interviewed. Data from these interviews were coded and sorted. Parents reported that many of their encounters resulted in delays in accessing treatment. These encounters were characterized by misattributions of the child's behavior, poor advice, misdiagnosis, disbelief in the seriousness of the child's condition, and an unwillingness to share information. But parents also reported that encounters with other individuals were characterized by helpful advice, emotional support, and suggestions as to how to access early intervention services. Encounters with many professionals were generally not helpful to parents. These encounters served as roadblocks to accessing proper treatment for their child. More publicity, outreach, and education are recommended in the professional community.

The relationship between family resiliency factors and caregiver-perceived duration of untreated psychosis in persons with first-episode psychosis

Although the family has an important role in the early detection and intervention of first-episode psychosis (FEP), there are few findings reporting associations between family strengths and early treatment-seeking experiences. This study aimed to investigate, within the framework of the resiliency model of family stress, adjustment, and adaptation, the association between family coping strategies, resource management factors and duration of untreated psychosis (DUP) in Iranian families with one adult child with FEP. Hundred and seven individuals referred to three medical centers in Tehran and diagnosed with FEP participated in this study. Caregiver-perceived DUP was measured via semi-structured interviews administered to primary caregivers. They also completed two questionnaires regarding family resources of stress management and family coping strategies. Data analysis indicated that the Family Inventory of Resources of Management (FIRM) total scale score did not significantly explain the variance of caregiver-perceived DUP, but one of the FIRM subscales, the Extended Family Social Support, and the Family Crisis-Oriented Personal Evaluation scale (F-COPES) total score and one its subscales, the Acquiring Social Support, explained a significant amount of the variance of caregiver-perceived DUP. The results suggest that higher family resiliency, especially social support, facilitates the family's appropriate adaptive reaction (i.e., treatment-seeking), with the consequent decrease of DUP.

Measuring insight through patient self-report: an in-depth analysis of the factor structure of the Birchwood Insight Scale

Little research has focused on item analysis and factor structure of the most commonly used measures of insight. We examined the factorial structure of the Birchwood Insight Scale (BIS), a brief, easy-to-administer, self-report measure. We studied the BIS in 327 first-episode psychosis patients, including a test sample (n=163) and a validation sample (n=164). We then used data from 100 patients with chronic serious mental illnesses as a second, external validation sample. Exploratory factor analysis was conducted with the test subsample, and confirmatory factor analyses with the two validation samples. Confirmatory factor analyses (in both the first-episode psychosis validation sample and the chronic serious mental illness sample) indicated that a single-factor solution, with seven items loading on a single factor-with item 1 ("Some of your symptoms are made by your mind") eliminated-was the best-fitting model. Seven of the eight original BIS items loading on a single factor fit the data well in these samples. Researchers using this efficient measure of patient-reported insight should assess the item distributions and factor structure of the BIS in their samples, and potentially consider eliminating item 1.

Subtyping first-episode non-affective psychosis using four early-course features: potentially useful prognostic information at initial presentation

AIM

Heterogeneity of symptoms, course and outcomes in primary psychotic disorders complicates prognosis, treatment and diverse aspects of research. This study aimed to identify interpretable subtypes of first-episode non-affective psychosis based on four early-course features (premorbid academic functioning, premorbid social functioning, duration of the prodrome and age at onset of psychosis).

METHODS

Data from 200 well-characterized patients hospitalized in public-sector inpatient units for first-episode non-affective psychosis were used in latent profile analyses. Derived subtypes were then compared along a number of clinical dimensions using analyses of variance.

RESULTS

Using four early-course features, three classes were derived. A good premorbid/short prodrome subtype was characterized by a lower severity of positive symptoms, better social/occupational/global functioning, and a shorter duration of untreated psychosis; a poor premorbid/early onset subtype demonstrated greater negative and preoccupation symptoms, as well as greater psychosocial problems; and a long prodrome/late onset subtype was characterized by greater dysphoric symptoms.

CONCLUSIONS

Findings indicate a need for further research with first-episode samples on the utility of subtyping based on early-course (premorbid, prodromal and onset-related) characteristics. Such efforts could enhance the parsing of heterogeneity, thereby advancing clinical practice and research.

Demographic, socio-environmental, and substance-related predictors of duration of untreated psychosis (DUP)

OBJECTIVE

Longer duration of untreated psychosis (DUP) is associated with poorer early-course and long-term outcomes, and is a target of early detection and intervention efforts. Given the paucity of research on childhood and adolescent stressors (e.g., maltreatment and neighborhood disorder) as potential predictors of DUP, limited research on premorbid substance use as a determinant of DUP, and inconclusive findings on the association between DUP and neurocognition, we conducted three sets of analyses to address these issues. Mode of onset of psychosis was also considered, given its established role as an illness-level correlate of DUP.

METHODS

We rigorously assessed DUP and other pertinent variables in 180 predominantly African American, low-income, and socially disadvantaged first-episode psychosis patients hospitalized in five psychiatric units.

RESULTS

Mode of onset of psychosis, prior incarceration, and the level of childhood/adolescent maltreatment were all significant independent predictors of DUP. Regarding premorbid substance use, having ever used cannabis and the amount of premorbid alcohol use were significantly associated with DUP. None of the seven neurocognitive domains assessed were even modestly, or clinically meaningfully, associated with DUP.

CONCLUSIONS

These and other findings on DUP may be informative for early detection and intervention services. For example, such services might benefit from special outreach to criminal justice settings and disadvantaged neighborhoods, and to young people likely to have a history of childhood/adolescent maltreatment and gradually developing psychotic symptoms.

Subscale structure for the Positive and Negative Syndrome Scale (PANSS): a proposed solution focused on clinical validity

Although the items of the Positive and Negative Syndrome Scale (PANSS) are ordinal, continuous data methods are consistently used to analyze them. The current study addresses this issue by applying a categorical method and critically examining the ideas of item inclusion and goodness of fit. Data from 1527 subjects were used to test a proposed solution to the factor structure of the PANSS using a categorical factor analytic method. The model was made more generalizable by setting a minimum level of association between the item and the factor, and the results were then compared to existing solutions. The model was also tested for consistency in a first-episode sample. Use of categorical methods indicated similar results to previous analyses; however, it is demonstrated that the strength of the estimates can be unstable when items are shared across factors. The current study demonstrates that solutions can change substantially when a model is over-fitted, and therefore use of measures of fit as the criterion for an acceptable model can mask important relationships and decrease clinical validity.

Which came first, delusions or hallucinations? An exploration of clinical differences among patients with first-episode psychosis based on patterns of emergence of positive symptoms

Remarkably little is known about patterns of emergence of specific symptoms in the early course of nonaffective psychotic disorders. Some 159 well-characterized first-episode psychosis patients were categorized into those with: (1) delusions only (n=29, 18.2%); (2) delusions that emerged at least 1 month before hallucinations (n=31, 19.5%); (3) hallucinations that began at least 1 month before delusions (n=26, 16.4%); and (4) delusions and hallucinations that emerged concomitantly, within the same month (n=73, 45.9%). These four groups were compared across a number of clinical features, including duration of untreated psychosis, symptom severity, insight, and functioning, while controlling for potential confounders. Patients with delusions and hallucinations emerging within the same month had a shorter duration of untreated psychosis than those in whom one psychotic symptom emerged greater than one month before the other. The delusions-only group had significantly less severe positive, negative, and general psychopathology symptom scores, as well as better social and occupational functioning. Replication and further elucidation of specific patterns of symptom emergence would deepen the field's understanding of early-course phenomenology, and may inform efforts to improve upon nosology, prognostication, and treatment selection.

[Tunisian mothers' beliefs about their child's first psychotic episode]

INTRODUCTION

Initiating psychiatric treatment depends on several factors including clinical, personal, familial and economic factors. In the case of a first psychotic episode in an adolescent, parents, especially mothers, have a critical role in initiating psychiatric treatment for their child.

OBJECTIVE

In this study, we investigated mothers' beliefs about their child's first psychotic episode.

METHODS

Participants were adolescents consulting the department of Child and Adolescent Psychiatry of the Razi hospital in Tunisia. They were aged from 12 to 19 years at the onset of their medical follow-up. Their diagnoses were schizophrenia, schizoaffective disorder and schizophreniform disorder according to DSM-IV. A questionnaire was submitted to patients' mothers after their approval. It was divided into two parts. The first part was used to collect information on socio-demographic and clinical characteristics of the mothers and their children. The second part was composed of the following four questions in Tunisian dialect: (1) what did you think was the matter when you first noticed psychotic symptoms in your child? (2) what was the main reason for which you thought psychiatric treatment was necessary? (3) what obstacles did you perceive in initiating psychiatric treatment? (4) do you have any advice or suggestions for caregivers on how they could facilitate an early start of treatment?

RESULTS

Twenty-two mothers were included. The mean age of the mothers at onset of the follow-up of their child was 42 years (SD: 4.81). Ten mothers had never been schooled, five had primary school level, four had secondary school level, three had bachelor's degree and two had a diploma of doctorate; 63.6% of the mothers were housewives. The mean age of patients was 13.77 years at the start of their medical follow-up (SD= ± 2.14). Most of the patients were male (14 males for eight girls). Most patients were diagnosed as having schizophrenia (91%); 4.5% were diagnosed with schizoaffective disorder and 4.5% with schizophreniform disorder. The duration of untreated psychosis (DUP) was 11.5 months. Longer duration of untreated psychosis was associated with male gender (P=0.008). A significant relationship was also found between long DUP and stigmatization of mental hospital and psychiatry (respectively P=0.04 and P=0.05). Most of the mothers did not think that their child initially suffered from a psychotic disorder. In 63.3%, the cause of the child's symptomatology was attributed to spirit possession. The others reasons for seeking psychiatric treatment were: behavioral disorder in 77.3%, inefficacity of traditional practices in 54.5%, and patient refusal (40.9%). Stigmatization of the Razi hospital, the unique psychiatric hospital in the country, and of psychiatry in general were evoked by mothers as the main obstacles in initiating psychiatric treatment in more than half of the cases (70%). Others obstacles were: fear of side effects of psychiatric treatment (50%), patient refusal (40.9%), inaccessibility to psychiatric services (31.8%) and fear of an addiction to psychotropic agents (31.8%). Thirty-six percent of mothers underlined the need to consult in the occurrence of school difficulties or any change in the child's behavior; 27% proposed educational and anti-stigmatizing campaigns about the signs of early psychosis through radio, newspapers, cinema, and TV media advertisements. Making teachers and educators sensitive to psychosis was proposed by 13.6% of mothers; 9.1% thought that diagnostic skills should be improved in general practitioners.

CONCLUSION

Knowledge of attitudes of mothers towards the illness of their child prior to psychiatric treatment and towards the start of treatment is essential for the development of interventions for reducing duration of untreated psychosis.

Family history of psychosis negatively impacts age at onset, negative symptoms, and duration of untreated illness and psychosis in first-episode psychosis patients

Family history (FH) of psychosis has been a focus of investigations attempting to explain the heterogeneity in schizophrenia. Previous studies have demonstrated that FH is associated with earlier age at onset, severity of positive and negative symptoms, and the duration of untreated illness (DUI). The current study examined the impact of FH on the clinical presentation and help-seeking behaviors of a well-characterized, first-episode sample. The present study utilized the Symptom Onset in Schizophrenia (SOS) Inventory, the Positive and Negative Syndrome Scale (PANSS), and structured interviews on FH to examine these relationships in a large (n=152) sample of predominantly African American patients. Results showed that patients with a first-degree FH of psychosis had a younger age at onset of both the prodrome and psychosis, but did not differ in duration of prodromal period. Furthermore, FH and sex interacted to influence severity of negative, but not positive symptoms. Finally, FH interacted with sex to influence both the DUI and DUP in that only males with FH had longer DUI and DUP. The findings have implications for understanding the impact of specific family-related mechanisms on both clinical and help-seeking factors, as well as for informing future family-based intervention efforts.

Unemployment among patients with newly diagnosed first-episode psychosis: prevalence and clinical correlates in a U.S. sample

PURPOSE

Although it is well established that people with schizophrenia have markedly high rates of unemployment, less is known about the prevalence and clinical correlates of unemployment in patients newly diagnosed with first-episode psychosis. This analysis documented the prevalence of unemployment and examined previously reported clinical correlates of unemployment in patients with first-episode psychosis hospitalized in an urban, public-sector setting in the southeastern US.

METHODS

Participants (n = 181) were assessed as part of an overarching study of first-episode psychosis using a variety of standardized research instruments. The rate of unemployment was compared to that documented in the general population according to US census data. Bivariate tests of associations between employment status and a number of variables of interest were followed by a multiple logistic regression model based on a previous study from Dublin, Ireland.

RESULTS

Some 65.0% of first-episode patients were unemployed in the month prior to hospital admission, which is substantially higher than the rate of unemployment during the same period in the two counties in which recruitment took place. In bivariate tests, unemployment was associated with younger age, fewer years of educational attainment, lower global functioning scores, and more severe negative symptoms. In the logistic regression model, only age and global functioning were independently significant correlates.

CONCLUSIONS

The remarkably high rate of unemployment in this young, first-episode sample, and the evidence of associations between unemployment, greater symptomatology, and poorer functioning, argue for further research and development on supported employment programs for such patients.

Clinical correlates of maltreatment and traumatic experiences in childhood and adolescence among predominantly African American, socially disadvantaged, hospitalized, first-episode psychosis patients

Associations among maltreatment and traumatic experiences in childhood and adolescence, later substance use, and subsequent mental health outcomes for individuals with schizophrenia-spectrum disorders have been initially explored in previous studies; however, research on these factors in socially disadvantaged patients with first-episode psychosis is unavailable. This exploratory, correlational analysis examined associations between maltreatment and trauma-related variables (e.g., traumatic experiences, parental harsh discipline, violence exposure) and: social variables (years of education attained and extent of Axis IV psychosocial problems at initial hospitalization), substance abuse (age at initiation of alcohol and cannabis use, as well as estimates of lifetime intake of both), and positive and negative symptom severity. Rates of childhood abuse and traumatic events were remarkably high in the sample. Years of educational attainment and number of Axis IV psychosocial problems were substantially correlated with several domains of childhood abuse/traumatic events. Age at initiation of alcohol and cannabis use, and lifetime alcohol and cannabis intake, were correlated with a number of trauma domains. Whereas positive symptom severity was correlated with four of the trauma variables, negative symptom severity was correlated only with prior emotional neglect. These results provide insights into the relations among childhood traumatic events, substance use, and clinical features of first-episode psychosis, creating hypotheses for future research.

Predictors of initiation and engagement in substance abuse treatment among individuals with co-occurring serious mental illness and substance use disorders

Research has documented the significant challenges of engaging individuals with comorbid serious mental illness (SMI) and substance use disorders (SUDs) in substance abuse treatment. To date it is unclear which factors predict treatment initiation and engagement in this group of individuals with SUDs. In this study we conducted two analyses using data from a randomized trial of substance abuse treatment in outpatients with SMI: the first examining predictors (collected during screening) of completing an initial intake assessment and the second examining predictors (collected during the intake assessment) of becoming engaged in treatment. Results indicated that males and those with schizophrenia spectrum diagnoses were less likely to complete the intake assessment. Participants who reported more positive feelings about their family were more likely to engage in substance abuse treatment. Participants who were recently arrested were less likely to engage in treatment. Those who met criteria for current drug dependence were less likely to engage in treatment. Overall, these findings are a useful step in determining factors that predict substance abuse treatment initiation and engagement in individuals with SMI and SUDs.

Impaired insight in patients with newly diagnosed nonaffective psychotic disorders with and without deficit features

Patients with schizophrenia who have primary, enduring negative symptoms, or the deficit syndrome, have poorer psychosocial functioning but lesser clinical distress compared with nondeficit patients. Poor awareness of impairment in patients with deficit schizophrenia may contribute to this seeming contradiction. We hypothesized that poor insight would be present early in the course of illness in deficit patients, and that those with deficit features would have greater impairment in insight than those without deficit features. One-hundred one first-episode patients with nonaffective psychotic disorders were categorized into deficit (n=31) and nondeficit (n=70) groups. The deficit patients had significantly poorer insight than nondeficit patients when rated using a self-report questionnaire, and nearly significantly poorer insight rated by clinical researchers. Further, this effect remained for self-rated insight and reached statistical significance for researcher-rated insight after controlling for positive, negative, and general psychopathology symptoms. These results suggest that the treatment of deficit patients may be particularly complicated by poor insight.

Pre-illness cannabis use and the early course of nonaffective psychotic disorders: associations with premorbid functioning, the prodrome, and mode of onset of psychosis

INTRODUCTION

Limited research indicates that pre-illness cannabis use may result in an earlier age at onset of psychosis, though little is known about the influence of prior cannabis use on the premorbid and prodromal phases. This study examined the effects of prior or concurrent cannabis (as well as nicotine and alcohol) use on: (1) early adolescent (12-15 years) premorbid functioning, (2) late adolescent (16-18 years) premorbid functioning, (3) two features of the prodrome, and (4) mode of onset of psychosis.

METHODS

Participants included 109 well-characterized first-episode patients hospitalized in public-sector settings. Assessments included ages at initiation of first, weekly, and daily use of substances, the Premorbid Adjustment Scale, the Symptom Onset in Schizophrenia inventory, and a consensus-based best estimate of mode of onset.

RESULTS

Participants having used cannabis at ≤15 years had better early adolescence social functioning than those who had not used cannabis (p=0.02). Conversely, those who had used cannabis at ≤18 years had poorer late adolescence academic functioning (p<0.001). Participants having used cannabis before onset of psychotic symptoms did not differ from those who had not in terms of having had an identifiable prodrome or the number of prodromal symptoms experienced. Whereas 42% of those having used cannabis daily had an acute mode of onset of psychosis, only 20% of those without prior daily cannabis use had an acute onset (p=0.04).

CONCLUSIONS

Findings suggest that cannabis use is associated with premorbid social and academic functioning and mode of onset. Further research is warranted to elucidate the complex associations between cannabis use and diverse early-course features.

Predictors of the discharge dosage of an atypical antipsychotic agent among hospitalized, treatment-naive, first-episode psychosis patients in naturalistic, public-sector settings

OBJECTIVE

Little is known about determinants of second-generation antipsychotic dosages during initial hospitalization of first-episode psychosis. This study examined potential predictors of dosage of an atypical antipsychotic agent, risperidone, at hospital discharge after initial evaluation and treatment of first-episode nonaffective psychosis in 3 naturalistic, public-sector treatment settings.

METHODS

The number of psychotropic agents prescribed and discharge antipsychotic dosage were abstracted from the medical record. Demographic and extensive clinical characteristics were assessed through a clinical research study conducted at the 3 sites. One-way analyses of variance, trend tests using specific linear combinations of estimates, and χ² tests assessed for associations between atypical antipsychotic dosage and 5 hypothesized predictors, as well as 12 exploratory variables.

RESULTS

Among 155 hospitalized first-episode patients, 121 (78.1%) were discharged on risperidone, and subsequent analyses focused on that subset. The mean risperidone dosage among those 121 patients was 4.26 mg; 31 received 1 to 2 mg, 45 received 3 to 4 mg, 37 received 5 to 6 mg, and 8 received more than 6 mg. Analyses suggested that older age at hospitalization, the number of psychotropic agents prescribed, excited symptoms, and premorbid social functioning may be predictors of the discharge dosage.

CONCLUSIONS

Although several factors emerged, in general, predictors of discharge dosages of second-generation agents, here exemplified by risperidone, in real-world practice settings remain to be clarified. Given the importance of antipsychotic initiation during first hospitalization, future research should test an even broader array of potential predictors.

Overview and initial validation of two detailed, multidimensional, retrospective measures of substance use: the Lifetime Substance Use Recall (LSUR) and Longitudinal Substance Use Recall for 12 Weeks (LSUR-12) Instruments

Research on comorbidities between substance use disorders and serious mental illnesses would be facilitated by new methods for collecting comprehensive data on substance use, including data on onset, progression, frequency, amounts, and consequential behaviors. Given substantial limitations of available instruments, and a nearly complete absence of methodologies that allow derivation of continuous measures that estimate dose or cumulative exposure, this report describes the development and initial validation of two interviewer-administered, multidimensional measures of substance use, the Lifetime Substance Use Recall (LSUR) and Longitudinal Substance Use Recall for 12 Weeks (LSUR-12) Instruments. Participants (n=60) in an ongoing study of first-episode psychosis were evaluated with the LSUR, LSUR-12, and a number of other concurrent measures pertaining to substance use, substance use disorder diagnoses, select demographic features, and two personality traits. Specific a priori hypothesis tests were selected to demonstrate validity, relying on effect sizes to estimate strengths of association, considering small-to-medium correlations (e.g., ρ) as |.20-.50| and medium-to-large effect sizes as >|.50|. Numerous associations were observed between key nicotine-, alcohol-, and cannabis-related variables from the LSUR and LSUR-12 and scores from other concurrently administered measures. These findings provide a thorough initial validation of scores obtained with the new multidimensional instruments. Although validity of the two new measures of lifetime and past 12-week substance use was demonstrated, empirical data on inter-rater and test-retest reliability are needed. Careful development, and demonstration of psychometric properties, of these and related instruments may advance the fields of addiction and comorbidity research.

Social functioning in urban, predominantly African American, socially disadvantaged patients with first-episode nonaffective psychosis

BACKGROUND

Social functioning impairments develop and accumulate even prior to initial treatment-seeking for first-episode psychosis. This study, the first to examine social functioning in low-income, urban, predominantly African American first-episode patients: (1) assesses the internal consistency of Social Functioning Scale (SFS) subscales in this relatively unique sample; (2) identifies demographic and clinical variables that may be predictive of poor social functioning in this particular population; and (3) assesses changes in SFS scores in a subsample re-assessed six months after initial hospitalization.

METHODS

109 participants (age, 23.1+/-4.7years; 76.1% male; 89.9% African American) hospitalized for a first episode of nonaffective psychosis in an urban, public-sector setting were administered the SFS along with other clinical research instruments. 34 (31.2%) returned for a follow-up clinical research assessment six months after baseline assessment. Associations between the variables of interest were analyzed utilizing independent samples Student's t-tests and Pearson correlations.

RESULTS

Associations were observed between social functioning domains and negative symptoms (r=-.21--.32, p<.05), depressive symptoms (r=-.20--.23, p<.05), and general psychopathology symptoms (r=-.23--.24, p<.05). No significant differences were found in SFS subscale scores between baseline and six-month follow-up.

CONCLUSIONS

Deficits in social functioning are meaningfully related to several domains of symptoms, and such deficits may be relatively stable in the early course of psychotic disorders. Such findings may inform development of psychosocial interventions targeting social functioning in first-episode patients.