Psychosis screening in schools: Considerations and implementation strategies

Psychotic-like experiences in a nationally representative study of general population adolescents

BACKGROUND

Subclinical psychotic-like experiences (PLEs) are common among general population adolescents but have been found to correlate with various problems in well-being. Due to limited sample sizes these effects have not been well differentiated by sex and age.

METHODS

Using a nationally representative survey of almost 160,000 adolescents, we studied endorsement and correlates of PLEs by sex among middle adolescence pupils (ages 14-16) and late adolescence students (ages 16-20). PLEs were investigated with three questionnaire items: auditory and visual hallucinatory experiences and suspicious thought content, using a frequency response scale.

RESULTS

Weekly PLEs were reported by 14 % of the adolescents, more often in females (17 %) than males (11 %) and in the younger age group (17 %) compared to the older adolescents (10 %). A latent PLE factor represented the three assessed PLEs with good fit. Factor scores were highest for the younger females and lowest for the older males. The PLE factor correlated with two latent factors of other well-being, namely living environment ("adversity", loading most heavily on parental mental abuse; r = 0.63), and concurrent mental health ("distress", loading most heavily on depressive symptoms; r = 0.50). Adversity was associated especially strongly with PLEs in 14-16-year-old males.

CONCLUSIONS

This cross-sectional study reaching the whole 14-20 age group in schools in Finland offers data on the meaning and relevance of PLEs as general markers of vulnerability. Many adolescents experience PLEs recurrently and these experiences are associated with a wide variety of burden in the adolescent's everyday life.

Screening for psychotic experiences and psychotic disorders in general psychiatric settings: a systematic review and meta-analysis

Background

The absence of systematic screening for psychosis within general psychiatric services contribute to substantial treatment delays and poor long-term outcomes. We conducted a meta-analysis to estimate rates of psychotic experiences, clinical high-risk for psychosis syndrome (CHR-P), and psychotic disorders identified by screening treatment-seeking individuals to inform implementation recommendations for routine psychosis screening in general psychiatric settings.

Methods

PubMed and Web of Science databases were searched to identify empirical studies that contained information on the point prevalence of psychotic experiences, CHR-P, or psychotic disorders identified by screening inpatient and outpatient samples aged 12-64 receiving general psychiatric care. Psychotic experiences were identified by meeting threshold scores on validated self-reported questionnaires, and psychotic disorders and CHR-P by gold-standard structured interview assessments. A meta-analysis of each outcome was conducted using the Restricted Maximum Likelihood Estimator method of estimating effect sizes in a random effects model.

Results

41 independent samples (k=36 outpatient) involving n=25,751 patients (58% female, mean age: 24.1 years) were included. Among a general psychiatric population, prevalence of psychotic experiences was 44.3% (95% CI: 35.8-52.8%; 28 samples, n=21,957); CHR-P was 26.4% (95% CI: 20.0-32.7%; 28 samples, n=14,395); and psychotic disorders was 6.6% (95% CI: 3.3-9.8%; 32 samples, n=20,371).

Conclusions

High rates of psychotic spectrum illness in general psychiatric settings underscore need for secondary prevention with psychosis screening. These base rates can be used to plan training and resources required to conduct assessments for early detection, as well as build capacity in interventions for CHR-P and early psychosis in non-specialty mental health settings.

Reorienting the focus from an individual to a community-level lens to improve the pathways through care for early psychosis in the United States

The implementation of coordinated specialty care in the U.S. over the past decade has led to the improvements of clinical and functional outcomes among individuals in the early stages of psychosis. While there have been advancements in the delivery of early intervention services for psychosis, it has almost exclusively focused on short-term change at the individual level. In light of these advancements, research has identified gaps in access to care and delivery of services that are driven by different levels of determinants and have the biggest impact on historically excluded groups (e.g., ethnoracial minoritized communities). Interventions or efforts that place an emphasis on community level (structural or sociocultural) factors and how they may influence pathways to care and through care, specifically for those who have been historically excluded, have largely been missing from the design, dissemination and implementation of early psychosis services. The present paper uses a structural violence framework to review current evidence related to pathways to care for early psychosis and the physical/built environment and conditions (e.g., urbanicity, residential instability) and formal and informal community resources. Suggestions on future directions are also provided, that focus on enriching communities and creating sustainable change that spans from pathways leading to care to 'recovery.' In all, this lays the groundwork for a proposed paradigm shift in research and practice that encompasses the need for an emphasis on structural competency and community-driven approaches.

Youth Mental Health Screening and Linkage to Care

One Mind, in partnership with Meadows Mental Health Policy Institute, convened several virtual meetings of mental health researchers, clinicians, and other stakeholders in 2020 to identify first steps toward creating an initiative for early screening and linkage to care for youths (individuals in early adolescence through early adulthood, ages 10-24 years) with mental health difficulties, including serious mental illness, in the United States. This article synthesizes and builds on discussions from those meetings by outlining and recommending potential steps and considerations for the development and integration of a novel measurement-based screening process in youth-facing school and medical settings to increase early identification of mental health needs and linkage to evidence-based care. Meeting attendees agreed on an initiative incorporating a staged assessment process that includes a first-stage brief screener for several domains of psychopathology. Individuals who meet threshold criteria on the first-stage screener would then complete an interview, a second-stage in-depth screening, or both. Screening must be followed by recommendations and linkage to an appropriate level of evidence-based care based on acuity of symptoms endorsed during the staged assessment. Meeting attendees proposed steps and discussed additional considerations for creating the first nationwide initiative for screening and linkage to care, an initiative that could transform access of youths to mental health screening and care.

Attitudes and beliefs of Tunisian High-School teachers about schizophrenia: The impact of vignette gender

BACKGROUND

Teachers have a crucial active role in provision of mental health services to students and fighting against mental health stigma in schools, hence their attitudes and beliefs toward mental illness should be assessed.

METHOD

We carried-out a cross-sectional study with a non-probabilistic sample of 304 higher secondary school teachers. We used a structured questionnaire in which a vignette describing an individual with schizophrenia was presented, and was followed by a series of stigma-related questions.

RESULTS

A substantial proportion of teachers endorsed stressful life events (79.6%) as a cause of schizophrenia, elicited feelings of discomfort (41.4%) and incomprehension (41.1%) with the person displaying symptoms of schizophrenia, and agreed that the person's condition will deteriorate even more (45.4%). Teachers perceived that the person described in the vignette is dependent on others, lacks will, is different from others and is unpredictable in 65.1%, 59.2%, 55.6%, and 49.7% of cases, respectively. In addition, 38.5% and 34.2% of teachers recommended turning to traditional healers and to a Sheikh or an imam of a mosque, respectively. Regarding gender effects, females with schizophrenia were regarded as more likely to be unable to make her own decisions and to be dependent on others than males, and were less likely to be recommended for seeking help from a family physician or to consult a psychiatric hospital than males.

CONCLUSION

In the light of our findings, raising awareness of teachers of the impact of mental health issues on students should be prioritized in high schools in Tunisia.

Equity in Mental Health Services for Youth at Clinical High Risk for Psychosis: Considering Marginalized Identities and Stressors

Prevention and early intervention programs have been initiated worldwide to serve youth at Clinical High Risk for Psychosis (CHR-P), who are adolescents and young adults experiencing subclinical psychosis and functional impairment. The primary goals of these efforts are to prevent or mitigate the onset of clinical psychosis, while also treating comorbid issues. It is important to consider issues of diversity, equity, and inclusion in CHR-P work, especially as these programs continue to proliferate around the world. Further, there is a long history in psychiatry of misdiagnosing and mistreating psychosis in individuals from racial and ethnic minority groups. Although there have been significant developments in early intervention psychosis work, there is evidence that marginalized groups are underserved by current CHR-P screening and intervention efforts. These issues are compounded by the contexts of continued social marginalization and significant mental health disparities in general child/adolescent services. Within this narrative review and call to action, we use an intersectional and minority stress lens to review and discuss current issues related to equity in CHR-P services, offer evidence-based recommendations, and propose next steps. In particular, our intersectional and minority stress lenses incorporate perspectives for a range of marginalized and underserved identities related to race, ethnicity, and culture; faith; immigration status; geography/residence; gender identity; sexual orientation; socioeconomic status/class; and ability status.

A cluster randomised controlled trial of a web-based youth mental health service in Australian schools

BACKGROUND

Secondary schools have attempted to address gaps in help-seeking for mental health problems with little success. This trial evaluated the effectiveness of a universal web-based service (Smooth Sailing) for improving help-seeking intentions for mental health problems and other related outcomes among students.

METHODS

A cluster randomised controlled trial was conducted to evaluate the 12-week outcomes of the Smooth Sailing service among 1841 students from 22 secondary schools in New South Wales, Australia. Assignment was conducted at the school level. The control condition received school-as-usual. The primary outcome was help-seeking intentions for general mental health problems at 12-weeks post-baseline. Secondary outcomes included help-seeking behaviour, anxiety and depressive symptoms, psychological distress, psychological barriers to help-seeking, and mental health literacy. Data were analysed using mixed linear models. This trial was registered with the Australian and New Zealand Clinical Trials Registry (ACTRN12618001539224).

FINDINGS

At 12-weeks post-baseline, there was a marginal statistical difference in the relative means of help-seeking intentions (effect size=0•10, 95%CI: -0•02-0•21) that favoured the intervention condition. Help-seeking from adults declined in both conditions. There was a greater reduction in the number of students who "needed support for their mental health but were not seeking help" in the intervention condition (OR: 2•08, 95%CI: 1•72-2.27, P<•0001). No other universal effects were found. Participants found the service easy to use and understand; However, low motivation, time, forgetfulness, and lack of perceived need were barriers to use.

INTERPRETATION

Smooth Sailing led to small improvements in help-seeking intentions. Refinements are needed to improve its effectiveness on other mental health outcomes and to increase student uptake and engagement.

FUNDING

HSBC and Graf Foundation.

Preliminary support for using the Atypicality Scale from the Behavior Assessment System for Children, Second Edition, to screen for psychosis-spectrum disorders within a college counselling centre

AIM

Evidence supports the use of brief psychosis-spectrum screeners for identifying individuals at risk for psychosis. Screening has not been well-studied in help-seeking college samples. This study investigated the use of the Behavior Assessment System for Children, Second Edition (BASC-2) Atypicality Scale as a psychosis-spectrum screening tool within a university counselling centre.

METHODS

Atypicality scores from the BASC-2 were compared to interview-based assessment, the Structured Interview for Psychosis-risk Syndromes (SIPS), to explore associations across the measures and evaluate the scale's ability to identify individuals who meet criteria for a psychosis-spectrum diagnosis.

RESULTS

Forty-three participants completed the BASC-2 and SIPS, and 23 were SIPS-positive. Compared to the SIPS-negative group, the SIPS-positive group had significantly higher Atypicality scores. Exploratory results indicated that Atypicality scores identified SIPS-positive individuals with an overall accuracy of 72% (78% sensitivity, 65% specificity).

CONCLUSION

The Atypicality Scale may be an appropriate first-line psychosis-spectrum screening tool in college counselling centres.