Recruitment strategies for the detection of individuals at clinical high risk of developing psychosis

Recruitment, data collection, participation rate, and representativeness of the international cross-sectional PRICOV-19 study across 38 countries

BACKGROUND

Recruitment for surveys has been a great challenge, especially in general practice.

METHODS

Here, we reported recruitment strategies, data collection, participation rates (PR) and representativeness of the PRICOV-19 study, an international comparative, cross-sectional, online survey among general practices (GP practices) in 37 European countries and Israel.

RESULTS

Nine (24%) countries reported a published invitation; 19 (50%) had direct contact with all GPs/GP practices; 19 (50%) contacted a sample of GPs /GP practices; and 7 (18%) used another invitation strategy. The median participation rate was 22% (IQR = 10%, 28%). Multiple invitation strategies (P-value 0.93) and multiple strategies to increase PR (P-value 0.64) were not correlated with the PR. GP practices in (semi-) rural areas, GP practices serving more than 10,000 patients, and group practices were over-represented (P-value < 0.001). There was no significant correlation between the PR and strength of the primary care (PC) system [Spearman's r 0.13, 95% CI (-0.24, 0.46); P-value 0.49]; the COVID-19 morbidity [Spearman's r 0.19, 95% CI (-0.14, 0.49); P-value 0.24], or COVID-19 mortality [Spearman's r 0.19, 95% CI (-0.02, 0.58); P-value 0.06] during the three months before country-specific study commencement.

CONCLUSION

Our main contribution here was to describe the survey recruitment and representativeness of PRICOV-19, an important and novel study.

Changes in community providers' screening behaviours, referral practices, and clinical confidence following participation in an early psychosis educational campaign

AIM

Successful delivery of care to individuals with early psychosis depends on the ability of community providers to identify and refer appropriate candidates for services. Although specialty centres commonly rely upon education and outreach campaigns to building bridges with community providers, few studies have examined the effectiveness of these campaigns or the mechanisms by which they may achieve their intended effects.

METHODS

We surveyed community clinicians (N = 39) about their screening behaviours, referral practices, and confidence in managing early psychosis just before and 3-6 months after attending an educational event designed to promote recognition and quality treatment of early psychosis.

RESULTS

Three to six months following attendance, providers reported screening a greater proportion of clients for early psychosis, referring a greater number of clients to specialty services, and feeling more confident in their ability to respond to clients with early psychosis. Increases in confidence following attendance were associated with corresponding increases in screening behaviour.

CONCLUSIONS

The results suggest that outreach campaigns designed to enhance community providers' knowledge about early psychosis assessment and resources may be effective in promoting screening, referrals, and confidence in managing psychosis. Gains in provider confidence may contribute to increases in screening. Given the lack of control group and relatively short follow-up period, more research is needed to determine the effects of early psychosis educational events and the mechanisms by which they may promote successful treatment delivery for young people in need.

Using Digital Tools to Engage Patients With Psychosis and Their Families in Research: Survey Recruitment and Completion in an Early Psychosis Intervention Program

BACKGROUND

Barriers to recruiting and retaining people with psychosis and their families in research are well-established, potentially biasing clinical research samples. Digital research tools, such as online platforms, mobile apps, and text messaging, have the potential to address barriers to research by facilitating remote participation. However, there has been limited research on leveraging these technologies to engage people with psychosis and their families in research.

OBJECTIVE

The objective of this study was to assess the uptake of digital tools to engage patients with provisional psychosis and their families in research and their preferences for different research administration methods.

METHODS

This study used Research Electronic Data Capture (REDCap)-a secure web-based platform with built-in tools for data collection and storage-to send web-based consent forms and surveys on service engagement via text message or email to patients and families referred to early psychosis intervention services; potential participants were also approached or reminded about the study in person. We calculated completion rates and timing using remote and in-person methods and compensation preferences.

RESULTS

A total of 447 patients with provisional psychosis and 187 of their family members agreed to receive the web-based consent form, and approximately half of the patients (216/447, 48.3%) and family members (109/187, 58.3%) consented to participate in the survey. Most patients (182/229, 79.5%) and family members (75/116, 64.7%) who completed the consent form did so remotely, with more family members (41/116, 35.3%) than patients (47/229, 20.5%) completing it in person. Of those who consented, 77.3% (167/216) of patients and 72.5% (79/109) of family members completed the survey, and most did the survey remotely. Almost all patients (418/462, 90.5%) and family members (174/190, 91.6%) requested to receive the consent form and survey by email, and only 4.1% (19/462) and 3.2% (6/190), respectively, preferred text message. Just over half of the patients (91/167, 54.5%) and family members (42/79, 53.2%) preferred to receive electronic gift cards from a coffee shop as study compensation. Most surveys were completed on weekdays between 12 PM and 6 PM.

CONCLUSIONS

When offered the choice, most participants with psychosis and their families chose remote administration methods, suggesting that digital tools may enhance research recruitment and participation in this population, particularly in the context of the COVID-19 global pandemic.

Does an integrated outreach intervention targeting multiple stages of early psychosis improve the identification of individuals at clinical high risk?

AIMS

To explore the impact of a targeted case identification intervention, with training and education regarding first-episode psychosis and clinical high-risk syndromes, on the referral and identification of those at high risk.

METHODS

Using a historical control design, referral information from pre-intervention and post-intervention periods was collected via administrative data and clinician notes from a catchment-based early psychosis service.

RESULTS

A significant increase in the number of referrals sent to the service's clinical high-risk unit was observed following the intervention (P = 0.01). The proportion of referrals eligible was significantly higher post-intervention (P = 0.03), with the majority (26/44, 59.1%) referred via the first-episode psychosis service unit.

CONCLUSIONS

An integrated outreach intervention for both first-episode psychosis and the clinical high-risk state was effective in increasing referrals of eligible cases to the service's at-risk unit. Rather than being stage-specific, targeted case identification strategies and service integration should span across the early stages of psychosis.

Resilience in individuals at clinical high risk for psychosis

AIMS

It has been suggested that resilience may be a protective factor with respect to mental illness. This may be an important factor for those who are vulnerable to psychiatric illness. Thus, the aims of this paper were to compare levels of resilience between individuals at clinical high risk (CHR) for psychosis and healthy controls, and to examine associations between resilience and clinical measures, functioning and trauma of CHR participants.

METHODS

Eighty participants, 40 CHR and 40 University of Calgary undergraduate students, completed two resilience questionnaires: the Connor-Davidson Resilience Scale and the Child and Youth Resilience Measure.

RESULTS

A t-test revealed a significant difference between the groups on levels of resilience (t = 4.34, P < 0.01), demonstrating that CHR participants have lower levels of resilience than healthy controls. In terms of the associations between resilience and measures of mental health of CHR participants, it was found that higher levels of resilience were related to lower negative symptoms, depression and anxiety. Furthermore, resilient CHR participants showed higher levels of role functioning and generally reported higher positive schemas of self and others, as well as lower stress to reported life events. No associations were found between resilience and attenuated psychotic symptoms, social functioning, IQ and trauma.

CONCLUSIONS

The results of the current study suggest that resilience may be beneficial to other mental issues present in CHR individuals but this may not be the case for attenuated psychotic symptoms.

The Dark Side of the Moon: Meta-analytical Impact of Recruitment Strategies on Risk Enrichment in the Clinical High Risk State for Psychosis

BACKGROUND

The individual risk of developing psychosis after being tested for clinical high-risk (CHR) criteria (posttest risk of psychosis) depends on the underlying risk of the disease of the population from which the person is selected (pretest risk of psychosis), and thus on recruitment strategies. Yet, the impact of recruitment strategies on pretest risk of psychosis is unknown.

METHODS

Meta-analysis of the pretest risk of psychosis in help-seeking patients selected to undergo CHR assessment: total transitions to psychosis over the pool of patients assessed for potential risk and deemed at risk (CHR+) or not at risk (CHR-). Recruitment strategies (number of outreach activities per study, main target of outreach campaign, and proportion of self-referrals) were the moderators examined in meta-regressions.

RESULTS

11 independent studies met the inclusion criteria, for a total of 2519 (CHR+: n = 1359; CHR-: n = 1160) help-seeking patients undergoing CHR assessment (mean follow-up: 38 months). The overall meta-analytical pretest risk for psychosis in help-seeking patients was 15%, with high heterogeneity (95% CI: 9%-24%, I (2) = 96, P < .001). Recruitment strategies were heterogeneous and opportunistic. Heterogeneity was largely explained by intensive (n = 11, β = -.166, Q = 9.441, P = .002) outreach campaigns primarily targeting the general public (n = 11, β = -1.15, Q = 21.35, P < .001) along with higher proportions of self-referrals (n = 10, β = -.029, Q = 4.262, P = .039), which diluted pretest risk for psychosis in patients undergoing CHR assessment.

CONCLUSIONS

There is meta-analytical evidence for overall risk enrichment (pretest risk for psychosis at 38 monhts = 15%) in help-seeking samples selected for CHR assessment as compared to the general population (pretest risk of psychosis at 38 monhts=0.1%). Intensive outreach campaigns predominantly targeting the general population and a higher proportion of self-referrals diluted the pretest risk for psychosis.

Meta-cognition is associated with cortical thickness in youth at clinical high risk of psychosis

Meta-cognition is compromised in people with schizophrenia and people at clinical high risk (CHR) of psychosis. In the current work in a CHR sample, we hypothesized that meta-cognitive functions would correlate with cortical thickness in five brain regions implicated in the pathogenesis of psychosis: inferior and middle frontal cortices, anterior cingulate cortex, superior temporal cortex and insula. Secondly, we hypothesized that similar neural systems would underlie different meta-cognitive functions. Narratives were gathered for 29 youth at CHR of psychosis using a semi-structured interview. Four meta-cognitive functions within the narratives were measured with the Meta-cognition Assessment Scale and regressed on cortical thickness from our a priori regions of interest using FreeSurfer. Mapping statistics from our a priori regions of interest revealed that meta-cognition functions were associated with cortical thickness in inferior and middle frontal gyri, superior temporal cortex and insula. The distribution of cortical thickness was partially similar across the four MAS items. Results confirm our hypothesis that cortical thickness is significantly associated with meta-cognition in brain regions that consistently show gray matter reductions across the schizophrenia spectrum. Evidence for thickness covariation in a variety of regions suggests partial dependence in the neural architecture underlying various meta-cognitive functions in CHR.

Reliability and validity of the Calgary Depression Scale for Schizophrenia (CDSS) in youth at clinical high risk for psychosis

Assessment of depression in individuals who are considered to be at clinical high risk (CHR) for psychosis is important as high rates of depression have been reported in CHR individuals. The Calgary Depression Scale (CDSS) is the most widely used scale for assessing depression in schizophrenia. It has excellent psychometric properties, internal consistency, inter-rater reliability, sensitivity, specificity, and discriminant and convergent validity. The aim of this study was to test the reliability and validity of the CDSS in a sample of youth at CHR for psychosis. Participants were assessed for depression, presence of axis 1 mood disorders, and prodromal symptoms using the CDSS, the Structured Clinical Interview for DSM-IV Disorders (SCID-1), and the Scale of Prodromal Symptoms (SOPS). The CDSS total score as well as all individual items, except "guilty ideas of reference," were significantly associated with the presence of a major depressive disorder. Significant correlations were observed between CDSS total score and the dysphoric mood item on the SOPS. There was some evidence of overlap between the CDSS and both attenuated positive symptoms and negative symptoms as assessed by the SOPS. It is concluded that CDSS is a reliable scale suitable for assessing depression in individuals considered to be at CHR for psychosis.