Working with Asian American youth at clinical high risk for psychosis: a case illustration

Understanding the factors related to how East and Southeast Asian immigrant youth and families access mental health and substance use services: A scoping review

The objective of the review is to identify factors related to how East and Southeast Asian immigrant youth aged 12-24 and their families access mental health and substance use (MHSU) services. To address how East and Southeast Asian youth and their families access mental health and substance use services, a scoping review was conducted to identify studies in these databases: PubMed, MEDLINE (Ovid), EMBASE (Ovid), PsychINFO, CINAHL, and Sociology Collection. Qualitative content analysis was used to deductively identify themes and was guided by Bronfenbrenner's Ecological Systems Theory, the process-person-context-time (PPCT) model, and the five dimensions of care accessibility (approachability, acceptability, availability and accommodation, appropriateness, affordability). Seventy-three studies met the inclusion criteria. The dimensions of healthcare accessibility shaped the following themes: 1) Acceptability; 2) Appropriateness; 3) Approachability; 4) Availability and Accommodation. Bronfenbrenner's Ecological Systems Theory and the PPCT model informed the development of the following themes: 1) Immediate Environment/Proximal Processes (Familial Factors, Relationships with Peers; 2) Context (School-Based Services/Community Resources, Discrimination, Prevention, Virtual Care); 3) Person (Engagement in Services/Treatment/Research, Self-management); 4) Time (Immigration Status). The study suggests that there is a growing body of research (21 studies) focused on identifying acceptability factors, including Asian cultural values and the model minority stereotype impacting how East and Southeast Asian immigrant youth access MHSU services. This review also highlighted familial factors (16 studies), including family conflict, lack of MHSU literacy, reliance on family as support, and family-based interventions, as factors affecting how East and Southeast Asian immigrant youth access MHSU care. However, the study also highlighted a dearth of research examining how East and Southeast Asian youth with diverse identities access MHSU services. This review emphasizes the factors related to the access to MHSU services by East and Southeast Asian immigrant youth and families while providing insights that will improve cultural safety.

Gender-affirming care in the assessment and treatment of psychosis risk: Considering minority stress in current practice and future research

INTRODUCTION

Although research has documented the marked disparities in rates of psychosis-spectrum diagnoses in various socially marginalized populations, there is limited research addressing the needs of gender expansive individuals in the context of psychosis-spectrum illnesses using a minority stress lens. As clinical high-risk for psychosis (CHR-p) assessment and treatment becomes accessible to increasingly diverse populations, there is a need for clinicians to demonstrate greater clinical competency working with individuals across diverse social backgrounds and identities.

METHODS

We examined rates of gender expansive (GE) patients seeking evaluation at an urban-based CHR-p clinic and compared the diagnostic profile of GE individuals to cisgender patients. Post-hoc analyses were conducted on clinical variables with significant differences between the cisgender and GE groups.

RESULTS

The proportion of GE patients seeking evaluation increased from 2017 (9.3%) to 2021 (16.7%). Compared to cisgender youth, GE patients had significantly higher depressive, social anxiety, borderline personality disorder symptoms, higher levels of suicidality and non-suicidal self-injurious behaviour, and lower role functioning. Gender identity was predictive of suicidality controlling for social anxiety, borderline symptoms, and role functioning.

CONCLUSIONS

We review implications for CHR-p treatment and discuss ways to integrate minority stress theory and gender-affirming practices into coordinated specialty care for CHR-p patients.

A systematic review of persons of color participation in first episode psychosis coordinated specialty care randomized controlled trials in North America

The population of persons of color (POC) are increasing in the United States. Unfortunately, POC are significantly impacted by serious mental illness; psychosis represents a mental health disparity among POC. Fortunately, first episode coordinated specialty care (CSC) is an effective treatment for individuals who are in the early phases of a psychotic disorder. This systematic review of the literature examined POC inclusion rates in randomized controlled trials (RCT) examining First Episode Psychosis (FEP) programs. Our review yielded seven articles that met inclusion criteria. Our findings were mixed-researchers conducting RCTs on FEP programs did an excellent job including African American participants suggesting that findings from RCTs on FEP programs may generalize to African American participants. Regarding Latines, they were broadly underrepresented in RCTs on FEP CSC. Based on the data, we cannot definitively conclude to what extent findings from RCTs on FEP CSC generalize to Latines although results from studies that included a reasonable number of Latines offer promising results. Asians were overrepresented in three of the seven studies included in this review; thus it seems that the findings from RCTs on FEP CSC generalize to the Asian population in the United States.

Psychosis risk stigma and help-seeking: Attitudes of Chinese and Taiwanese residing in the United States

AIM

Intervention during the clinical high-risk phase for psychosis (CHR) can reduce duration of untreated psychosis and associated negative outcomes. Early treatment access and sustained engagement are important to understand for effective intervention. Understanding stigma and help-seeking processes is particularly important for groups that experience mental healthcare disparities such as those of Chinese heritage living in the United States.

METHODS

Chinese and Taiwanese participants (N = 215) residing in the United States were randomly assigned to one of three CHR vignette conditions based on the "what matters most" stigma framework for Chinese groups, which identifies capacities that define "personhood" and thereby shapes stigma for members of a particular cultural group. Participants completed measures of help-seeking attitudes, family stigma and individual stigma.

RESULTS

More stigma towards the CHR vignette character's family was associated with positive CHR help-seeking attitudes. Participants who read the vignette describing CHR affecting family obligations, "what matters most" and participants who read the vignette describing CHR symptomology only had more positive CHR help-seeking attitudes compared to participants who read the vignette describing CHR affecting individual aspirations.

CONCLUSIONS

Chinese and Taiwanese residing in the United States may perceive professional mental healthcare to be especially relevant for persons with CHR when symptoms are particularly stigmatizing for the person's family and when symptoms threaten the person's ability to fulfil family obligations (ie, "what matters most"). Clinical implications of findings include the importance of emphasizing positive treatment outcomes that increase an individual's ability to engage in valued life domains.

Parent perceptions of mental illness in Chinese American youth

BACKGROUND

Although parents are often the first to facilitate help-seeking in their children, parental perceptions regarding mental health serve as a significant barrier to the access of mental health services. This study examined mental health perceptions held by Chinese immigrant parents of youth.

METHODS

Eighteen parents (13 female, 5 male), who identified as having children between the ages of 13 and 21 years, participated in audio-recorded interviews using five vignettes depicting depression with and without a somatic emphasis, schizophrenia with paranoid features, attenuated psychosis syndrome, and social anxiety in youth. Questions about potential causes, likely diagnosis, and health-seeking behaviors in relation to these vignettes were asked. Interviews were analyzed for themes using a deductive-inductive hybrid approach, informed by the explanatory models that have shed light on Asian perceptions of mental illness and approaches to help-seeking.

RESULTS

While Asian groups are often considered as lacking in mental health knowledge, we found that Chinese immigrant parents were comfortable with psychological terminology as it pertained to identifying causes and describing supportive strategies and the seeking of Western-based providers. However, the majority of Chinese immigrant parent respondents did not easily note suicidality. Furthermore, respondents did not consider social anxiety as a major mental health issue among Chinese immigrant parents and attributed social anxiety to personality or cultural differences.

DISCUSSION

These findings provide an understanding of how Chinese immigrant parents conceptualize mental illness and help-seeking, which may be helpful for providers when working with Chinese immigrant parents of children that have a mental health concern.

Baseline demographics, clinical features and predictors of conversion among 200 individuals in a longitudinal prospective psychosis-risk cohort

BACKGROUND

DSM-5 proposes an Attenuated Psychosis Syndrome (APS) for further investigation, based upon the Attenuated Positive Symptom Syndrome (APSS) in the Structured Interview for Psychosis-Risk Syndromes (SIPS). SIPS Unusual Thought Content, Disorganized Communication and Total Disorganization scores predicted progression to psychosis in a 2015 NAPLS-2 Consortium report. We sought to independently replicate this in a large single-site high-risk cohort, and identify baseline demographic and clinical predictors beyond current APS/APSS criteria.

METHOD

We prospectively studied 200 participants meeting criteria for both the SIPS APSS and DSM-5 APS. SIPS scores, demographics, family history of psychosis, DSM Axis-I diagnoses, schizotypy, and social and role functioning were assessed at baseline, with follow-up every 3 months for 2 years.

RESULTS

The conversion rate was 30% (n = 60), or 37.7% excluding participants who were followed under 2 years. This rate was stable across time. Conversion time averaged 7.97 months for 60% who developed schizophrenia and 15.68 for other psychoses. Mean conversion age was 20.3 for males and 23.5 for females. Attenuated odd ideas and thought disorder appear to be the positive symptoms which best predict psychosis in a logistic regression. Total negative symptom score, Asian/Pacific Islander and Black/African-American race were also predictive. As no Axis-I diagnosis or schizotypy predicted conversion, the APS is supported as a distinct syndrome. In addition, cannabis use disorder did not increase risk of conversion to psychosis.

CONCLUSIONS

NAPLS SIPS findings were replicated while controlling for clinical and demographic factors, strongly supporting the validity of the SIPS APSS and DSM-5 APS diagnosis.

Informed consent in the psychosis prodrome: ethical, procedural and cultural considerations

Research focused on the prodromal period prior to the onset of psychosis is essential for the further development of strategies for early detection, early intervention, and disease pre-emption. Such efforts necessarily require the enrollment of individuals who are at risk of psychosis but have not yet developed a psychotic illness into research and treatment protocols. This work is becoming increasingly internationalized, which warrants special consideration of cultural differences in conceptualization of mental illness and international differences in health care practices and rights regarding research participation. The process of identifying and requesting informed consent from individuals at elevated risk for psychosis requires thoughtful communication about illness risk and often involves the participation of family members. Empirical studies of risk reasoning and decisional capacity in young people and individuals with psychosis suggest that most individuals who are at-risk for psychosis can adequately provide informed consent; however ongoing improvements to tools and procedures are important to ensure that this work proceeds with maximal consideration of relevant ethical issues. This review provides a discussion of these issues in the context of international research efforts.