First-episode psychosis and disengagement from treatment: a systematic review

Examining the role of insight, social support, and barriers in treatment engagement in individuals diagnosed with psychotic disorders

Treatment engagement for individuals with psychotic disorders is often low, and engagement is considered critical to improving outcomes and reducing chronicity of the illness. Lack of insight in psychosis has been associated with poor treatment engagement and is considered a core feature of psychotic disorders. One factor that may improve treatment engagement in psychosis, perhaps for individuals with low insight, is social support. Social support may improve treatment engagement by promoting insight or overriding the challenges of engagement related to insight, however, the relationships between insight, social support, and treatment engagement are not clear. The current study hypothesized that greater insight and social support would result in better treatment engagement, and that greater social support would enhance treatment engagement for individuals with low insight. Sixty-eight (N = 68) participants with a psychotic disorder completed clinical interview and self-report measures. A relationship between insight and treatment engagement was not found, thus, social support did not moderate a relationship between the two. Participants reported on multiple treatment barriers impacting treatment engagement. As such, the impact of barriers to treatment may require consideration before accurately measuring the above constructs.

How theories, models, and frameworks have been used to implement digital health interventions in services for people with severe mental health problems: a scoping review

BACKGROUND

Digital health interventions have the potential to improve the efficacy and accessibility of mental health services for people with severe mental health problems, but their integration into routine practice is a challenge. The real-world implementation of digital health interventions should be considered alongside digital intervention development. However, little is known about the quality of implementation research in this area, including the extent to which implementation science theories, models and frameworks are used. The aim of this review was to synthesise evidence regarding the application of theories, models and frameworks in research investigating the implementation of digital health interventions in services for people with severe mental health problems. Secondary aims were to consider the contexts within which studies had been undertaken and the degree of service user involvement in this research.

METHODS

A scoping review method was employed. Electronic databases were systematically searched for published papers in English and reference lists of included studies were hand searched. Included studies used an implementation science theory, model, or framework to understand, guide or evaluate the implementation of digital health interventions in services for people with severe mental health problems.

RESULTS

Twelve eligible studies were identified. Studies were primarily undertaken in community mental health services with staff participants and there was variation in the types of digital interventions that were investigated. Eight different implementation science theories, models, and frameworks were used and were mainly employed to guide qualitative analysis. Most studies were undertaken in the early exploratory stages of implementation projects and there was little evidence regarding factors affecting the longer-term sustainment of digital health interventions in practice. Only one study reported the inclusion of service users in the design of the implementation study.

CONCLUSIONS

The use of implementation theories, models, and frameworks in efforts to implement digital health interventions in routine care for people with severe mental health problems is limited. Researchers should consider integrating such approaches throughout the research process and ensure service users are involved in this work. Further research regarding implementation processes, and the reach and sustainment of digital health interventions in routine practice, is required.

The Early Youth Engagement (EYE-2) intervention in first-episode psychosis services: pragmatic cluster randomised controlled trial and cost-effectiveness evaluation

BACKGROUND

Early intervention in psychosis (EIP) services improve outcomes for young people, but approximately 30% disengage.

AIMS

To test whether a new motivational engagement intervention would prolong engagement and whether it was cost-effective.

METHOD

We conducted a multicentre, single-blind, parallel-group, cluster randomised controlled trial involving 20 EIP teams at five UK National Health Service (NHS) sites. Teams were randomised using permuted blocks stratified by NHS trust. Participants were all young people (aged 14-35 years) presenting with a first episode of psychosis between May 2019 and July 2020 (N = 1027). We compared the novel Early Youth Engagement (EYE-2) intervention plus standardised EIP (sEIP) with sEIP alone. The primary outcome was time to disengagement over 12-26 months. Economic outcomes were mental health costs, societal costs and socio-occupational outcomes over 12 months. Assessors were masked to treatment allocation for primary disengagement and cost-effectiveness outcomes. Analysis followed intention-to-treat principles. The trial was registered at ISRCTN51629746.

RESULTS

Disengagement was low at 15.9% overall in standardised stand-alone services. The adjusted hazard ratio for EYE-2 + sEIP (n = 652) versus sEIP alone (n = 375) was 1.07 (95% CI 0.76-1.49; P = 0.713). The health economic evaluation indicated lower mental healthcare costs linked to reductions in unplanned mental healthcare with no compromise of clinical outcomes, as well as some evidence for lower societal costs and more days in education, training, employment and stable accommodation in the EYE-2 group.

CONCLUSIONS

We found no evidence that EYE-2 increased time to disengagement, but there was some evidence for its cost-effectiveness. This is the largest study to date reporting positive engagement, health and cost outcomes in a total EIP population sample. Limitations included high loss to follow-up for secondary outcomes and low completion of societal and socio-occupational data. COVID-19 affected fidelity and implementation. Future engagement research should target engagement to those in greatest need, including in-patients and those with socio-occupational goals.

Homelessness and First-Episode Psychosis: An Integrative Review

BACKGROUND

About 115,000 young people in the United States experience a first episode of psychosis (FEP) annually. FEP is associated with functional decline and long-term executive functioning impairment. Schizophrenia is a risk factor for homelessness with up to 20% of individuals diagnosed experiencing homelessness. Homelessness conveys many burdens including higher rates of victimization, incarceration, and substance use. The intersection of homelessness and FEP represents a uniquely vulnerable population undergoing the compounding effects of two highly stigmatizing burdensome experiences that negatively impact health outcomes, treatment engagement, and life expectancy.

AIMS

This study reviews the literature to explore what is currently known about the impacts of homelessness on individuals with FEP, knowledge gaps, directions for research, and recommendations for action.

METHODS

An integrative review was conducted in April 2023 with APAPsychInfo, APAPsychArticle, Medline, and CINAHL.

RESULTS

This is the first known review to examine available literature on homelessness and FEP. Current literature examines aspects of FEP and homelessness, but not the likely compounding and interacting relationships between multiple variables. Although the associations among variables such as FEP, homelessness, substance use, legal involvement, family involvement, and treatment engagement have not been studied, the literature available may be suggestive of a compounding negative effect on FEP outcomes.

CONCLUSION

FEP programs should define homelessness, report rates of homelessness, and conduct research examining the compounding effects of homelessness and FEP as well as other factors like race and ethnicity. Research and policy should support housing interventions for homeless individuals to improve treatment engagement and health outcomes.

Barriers and facilitators to engagement in psychological therapy in first episode psychosis: A meta-ethnography and qualitative comparative analysis

OBJECTIVES

Disengagement from psychological therapies in first-episode psychosis (FEP) is a common occurrence, with personal costs associated with untreated problems. This study aimed to establish the barriers and facilitators of people experiencing FEP to engagement in psychological therapies by undertaking a meta-ethnography and Qualitative Comparative Analysis (QCA) of existing qualitative literature.

METHODS

A systematic search was conducted in multiple databases including Psychinfo, Ovid Medline, Web of Science, EthOs, OPENgrey and Procrest in July 2021 (updated in July 2024). The search identified 6966 titles and 71 full texts that were reviewed for eligibility. Twenty-three studies were found to meet eligibility and were critically appraised. Data was systematically extracted and synthesized in a meta-ethnography and QCA.

RESULTS

Seven themes were identified as barriers to engagement in psychological therapy (Ambivalence to therapy, Emotional distress, Fluctuating symptoms, Negative expectations, Physical capacity, Service limitations and Therapy preference unmet) and six themes were identified as facilitators (Destigmatizing, Accessibility of digital therapy, Positive expectations of therapy are met, Service factors, Therapists interpersonal approach and skills and Therapy preferences met). The QCA identified a model with the Therapists interpersonal approach and skills, as sufficient (i.e. whenever that condition is present, the outcome is also guaranteed to be present) for engagement in psychological therapy, while Emotional distress was a sufficient barrier to engagement.

CONCLUSIONS

Engagement is a multifaceted construct with many factors unique to an individual's experience, impacted by emotional, social, practical and service-level factors. Strengths, limitations and recommendations of the findings are discussed.

The Role of Shared Decision-Making in Promoting Family Participation in Treatment for Adolescents and Young Adults with First-Episode Psychosis

We aimed to examine the role of shared decision-making (SDM) in family participation in the treatment of adolescents and young adults with first-episode psychosis (FEP). Based on responses of 144 family members of OnTrackNY (OTNY) participants, we divided the sample into low participators and high participators. We calculated the total SDM score for each participant by summing the ratings across items inquiring about SDM and assessed the extent to which loved ones encouraged family participation in their care. Our results indicated that the level of loved ones' encouragement was significantly related to family participation. When controlling for loved ones' encouragement, we found that the total SDM score was significantly higher in the high participator group. These findings suggest that SDM may be influenced by loved ones' attitudes towards family involvement in treatment and SDM may play a role in promoting family participation in care for individuals with FEP.

Digital health for early psychosis in Ghana: patient and caregiver needs and preferences

In West Africa, the long-term consequences of poor early psychosis recovery include poverty, neglect, and community ostracization. To understand the potential for digital health approaches to support early psychosis care in Ghana, we conducted a survey study among early psychosis patients and their caregivers about mental health needs, technology use and access, and interest in digital mental health. Hospital staff at Accra Psychiatric Hospital reviewed hospital medical records from January 2023 - December 2023 identifying young adults (≥18 years old) who had experienced psychosis symptoms for the first time within the prior five years. Trained data assessors contacted these individuals via telephone and invited them and their caregivers to participate; those providing informed consent were interviewed via phone in Twi or English. Overall, 256 individuals participated in the survey, including 121 young adults experiencing early psychosis and 135 caregivers of early psychosis patients. The majority (80%) of early psychosis patients and their caregivers expressed interest in digital mental health for early psychosis and had access to a mobile phone (91%) and necessary mobile infrastructure. Early psychosis patients were most interested in information about managing stress and improving mood via a digital resource (72%). Caregivers desired a digital tool to provide information about psychosis symptoms (86%). Our study among those experiencing early psychosis and their caregivers in Ghana suggests readiness and acceptability of digital mental health for early psychosis care.

Case Study Analysis of a Decision Coaching Intervention for Young Adults with Early Psychosis

Young adults with early psychosis often disengage from essential early intervention services (i.e., Coordinated Specialty Care or CSC in the United States). While decision support interventions improve service engagement, their use in this population is underexplored. This study evaluated the feasibility, acceptability, fidelity, and potential impact of a decision coaching intervention for young adults with early psychosis in CSC services. Using a mixed-method, longitudinal, collective case study design, we assessed the intervention's impact on decision-making needs through the Decisional Conflict Scale and qualitative interviews. We also evaluated feasibility, fidelity, and acceptability through observations and feedback from interventionists and participants. Eight young adults from three CSC programs participated, showing variable engagement, with generally favorable fidelity and acceptability ratings. The Decisional Conflict Scale revealed mixed findings, while four themes from qualitative interviews emerged: Perspective and Information Seeking, Motivation and Prioritization, Empowerment and Confidence, and Critical Thinking and Evaluation. The findings suggest that training CSC providers-including peer specialists and clinicians-to deliver decision coaching with fidelity is feasible, well-received by young adults, and potentially impactful on decision-making. Replication in a larger controlled trial, addressing observed study limitations, is warranted. This trial was registered with ClinicalTrials.gov (Identifier: NCT04532034) on August 28, 2020, as Temple University Protocol Record 261047, Facilitating Engagement in Evidence-Based Treatment for Early Psychosis (https://clinicaltrials.gov/ct2/show/NCT04532034?term=NCT04532034&draw=2&rank=1).

Referral pathways to early intervention services for psychosis and their influence on perceptions of care: An interpretive phenomenological analysis

AIM

Most young adults experiencing psychosis enter early intervention services (EIS) via inpatient and emergency departments. These experiences are suggested to negatively impact their views of treatment and engagement in EIS. However, limited research has examined the impact of young adults' prior help-seeking experiences on these outcomes. The present study aimed to explore how young adults engaged in EIS have experienced initial help-seeking and make sense of these experiences in the context of their current treatment.

METHODS

Using an interpretative phenomenological analysis approach, semi-structured interviews were conducted with 12 young adults (mean age = 24.83) within their first 3-12 months of treatment in EIS. Interviews aimed to examine their experiences of help-seeking and referral to EIS as well as the impact of these experiences on their subsequent perception of, and engagement with EIS.

RESULTS

3 superordinate themes emerged: (1) Navigating the Maze of Healthcare (2) Dignity and (3) Impact of Help-Seeking and Referral Experiences. Participants with referral pathways involving urgent care services described more adversity during their referral pathway and tended to describe help-seeking experiences as contributing to negative views towards EIS and diminished engagement in treatment.

CONCLUSIONS

The impact of early negative experiences with healthcare on views towards EIS and engagement is evident in participants' accounts. Sense making was further contextualized by participants' illness insight, degree of recovery, and social support throughout experiences. Emergent themes highlight the need for psychiatric services to emphasize service users' dignity and for EIS to provide opportunities for patients to process past negative mental healthcare experiences to strengthen engagement.

The Development and Piloting of an Early Youth-Engagement (EYE) Model to Improve Engagement of Young People in First Episode Psychosis Services: A Mixed Methods Study

AIM

Psychosis is associated with significant health and societal costs. Early intervention in psychosis services (EIP) are highly effective in promoting recovery, yet substantial proportions of young people disengage. The current study aimed to develop and evaluate a novel engagement intervention in EIP services.

METHOD

A qualitative investigation of facilitators and barriers to engagement in 68 first episode psychosis patients, family members and young people, and a Delphi consultation with 27 regional and national youth and psychosis service leads informed the development of the intervention. A mixed-methods feasibility-pilot study then compared engagement outcomes in 298 EIP service users in two cohorts: standard EIP versus standard EIP plus the novel early youth-engagement (EYE) intervention. A qualitative study explored intervention experiences in 22 randomly selected service users, carers and clinicians. A process evaluation explored delivery.

RESULTS

Disengagement was 24% in the standard EIP cohort compared to 14.5% in the standard EIP plus EYE intervention cohort. A 95% Bayesian credibility interval revealed a 95% probability that the true reduction in disengagement lay somewhere between 0% and 18%. The number needed to treat was 11, 95% CI [5, 242]. Use of the EYE resources was associated with engagement. Qualitiative feedback supported effects on communication, social network engagement, service user goals, mental health and well-being outcomes.

CONCLUSION

The EYE intervention was designed from a service user, young person and carer perspective. Both qualitative and quantitative data support impacts on engagement. We now need to evaluate effectiveness, cost-effectiveness and implementation in a multi-site randomised controlled trial.

Clinical high risk for psychosis and service disengagement: Incidence and predictors across 2 years of follow-up

BACK: Service disengagement is common in subjects at CHR-P (clinical high risk for psychosis), potentially worsening daily functioning and increasing the duration of untreated psychosis. That is why to identify baseline predictors of service disengagement could help better tailoring follow-up on every CHR-P individual.

AIMS

Since there are few studies on this topic, the goals of this examination were: (1) to calculate service disengagement rates in a CHR-P sample along 2-years of follow-up; and (2) to examine the most relevant predictive factors of disengagement at baseline.

METHODS

All young CHR-P participants were enrolled within the 'Parma At-Risk Mental States' (PARMS) protocol. At entry, the Global Assessment of Functioning (GAF) scale and the positive and negative syndrome scale (PANSS) were completed. Cox regression analyses were used.

RESULTS

Hundred and eighty CHR-P subjects were recruited in this examination. During the follow-up, a 2-year service disengagement prevalence rate of 15% was observed. A statistically robust predictive factor of service disengagement was a lower prescription of antidepressant drug at entry. Other relevant baseline predictive factors were migrant status, higher GAF score, lower levels of anxious-depressive symptoms and a lower acceptance of psychosocial interventions.

DISCUSSION

Baseline presence of anxious-depressive features in CHR-P individuals could favour engagement to specialized EIP services. However, implementing strategies to improve patients' motivation and involvement in care are needed.

Putting measurement-based care into action: a multi-method study of the benefits of integrating routine client feedback in coordinated specialty care programs for early psychosis

BACKGROUND

Measurement-based care (MBC) is an effective tool in the delivery of evidence-based practices (EBPs). MBC utilizes feedback loops to share information and drive changes throughout a learning healthcare system. Few studies have demonstrated this practice in team-based care for young people with early psychosis. This paper describes the development of a personalized feedback report derived from routine assessments that is shared with clients and clinicians as part of a MBC process.

METHODS

We used a multi-method approach to evaluate the implementation of a personalized feedback report at 5 early psychosis coordinated specialty care programs (CSC). We compared clients enrolled in CSC who did and did not receive a feedback report over the first 6 months of treatment. The sample included 204 clients: 146 who did not receive the feedback report (treatment as usual, TAU) and were enrolled over 2 years, and 58 who received the feedback report. A subset of 67 clients completed measures at both intake and 6-month follow-up, including 42 who received the personalized feedback report and 25 who did not. We compared the two groups with regard to self-reported symptoms, likelihood of completing treatment, and perception of shared decision making. We conducted qualitative interviews with 5 clients and 5 clinicians to identify the benefits and challenges associated with the personalized feedback report.

RESULTS

The total sample showed significant improvements in shared decision-making and in their intent to complete the program. Post hoc analyses revealed significant increases in the personalized feedback group, and non-significant changes in the TAU group, although group-by-time interactions did not reach statistical significance. The feedback report group engaged in significantly more sessions of Supported Employment and Education (SEE), case management, and peer support, and fewer medication visits over the first 6 months of treatment. Both groups showed significant improvement in symptoms and functioning. Results from the qualitative analysis indicated that the experience of receiving the reports was valuable and validating for both patients and clinicians.

CONCLUSIONS

A personalized feedback report was integrated into standard of care for early psychosis programs. This process may improve shared decision-making, strengthen the likelihood to stay in treatment, and increase treatment attendance in psychosocial interventions. We posit that this process facilitates recovery-oriented care, strengths-focused treatment planning, enhances intrinsic motivation, and strengthens the therapeutic alliance.

Rates and predictors of service disengagement in first episode psychosis: Results from a 2-year follow-up study in an Italian real-world care setting

AIM

Service disengagement is a major problem for "Early Intervention in Psychosis" (EIP). Understanding predictors of engagement is also crucial to increase effectiveness of mental health treatments, especially in young people with First Episode Psychosis (FEP). No Italian investigation on this topic has been reported in the literature to date. The goal of this research was to assess service disengagement rate and predictors in an Italian sample of FEP subjects treated within an EIP program across a 2-year follow-up period.

METHODS

All patients were young FEP help-seekers, aged 12-35 years, recruited within the "Parma Early Psychosis" (Pr-EP) program. At baseline, they completed the Positive And Negative Syndrome Scale (PANSS) and the Global Assessment of Functioning (GAF) scale. Univariate and multivariate Cox regression analyses were carried out.

RESULTS

489 FEP subjects were enrolled in this study. Across the follow-up, a 26 % prevalence rate of service disengagement was found. Particularly strong predictors of disengagement were living with parents, poor treatment adherence at entry and a low baseline PANSS "Disorganization" factor score.

CONCLUSION

More than a quarter of our FEP individuals disengaged the Pr-EP program during the first 2 years of intervention. A possible solution to reduce disengagement and to facilitate re-engagement of these young patients might be to offer the option of low-intensity monitoring and support, also via remote technology and tele-mental health care.

Psychosis and help-seeking behaviour-A systematic review of the literature

PURPOSE

Many people with psychosis do not seek help which delays access to recommended treatments. Duration of untreated psychosis is associated with poor healthcare outcomes and increased risk of relapse. The reasons why people delay accessing treatment remain unclear. This is the first systematic review to synthesise the literature examining professional and non-professional help-seeking in psychosis across clinical and subclinical populations.

METHODS

We searched four databases (APA PsycINFO, APA PsycArticles, Medline and British Library EThOS) to generate a comprehensive account of the quantitative literature. Heterogeneity of measures precluded a meta-analysis.

RESULTS

We identified 19 articles (including 9686 participants) that met criteria for the review. Help-seeking in psychosis is associated with being female, having a higher level of education, and experiencing more than one symptom. People with psychosis report stigma, poor mental health literacy and lack of family support as key barriers. Clinicians report childhood physical abuse, insecure attachment and severity of psychosis as additional barriers. We also found differences in preferred sources of help across cultures. There is currently no consensus on reliable help-seeking measures.

CONCLUSIONS

This is the first systematic review to examine help-seeking behaviour in psychosis. Assertive and culturally sensitive engagement efforts should be targeted towards people with a history of early adversity, poor mental health literacy, limited social support and more severe psychosis.

Engagement and Acceptability of Acceptance and Commitment Therapy in Daily Life in Early Psychosis: Secondary Findings From a Multicenter Randomized Controlled Trial

BACKGROUND

Acceptance and commitment therapy (ACT) is promising in the treatment of early psychosis. Augmenting face-to-face ACT with mobile health ecological momentary interventions may increase its treatment effects and empower clients to take treatment into their own hands.

OBJECTIVE

This study aimed to investigate and predict treatment engagement with and acceptability of acceptance and commitment therapy in daily life (ACT-DL), a novel ecological momentary intervention for people with an ultrahigh risk state and a first episode of psychosis.

METHODS

In the multicenter randomized controlled trial, 148 individuals with ultrahigh risk or first-episode psychosis aged 15-65 years were randomized to treatment as usual only (control) or to ACT-DL combined with treatment as usual (experimental), consisting of 8 face-to-face sessions augmented with an ACT-based smartphone app, delivering ACT skills and techniques in daily life. For individuals in the intervention arm, we collected data on treatment engagement with and acceptability of ACT-DL during and after the intervention. Predictors of treatment engagement and acceptability included baseline demographic, clinical, and functional outcomes.

RESULTS

Participants who received ACT-DL in addition to treatment as usual (n=71) completed a mean of 6 (SD 3) sessions, with 59% (n=42) of participants completing all sessions. App engagement data (n=58) shows that, on a weekly basis, participants used the app 13 times and were compliant with 6 of 24 (25%) notifications. Distribution plots of debriefing scores (n=46) show that 85%-96% of participants reported usefulness on all acceptability items to at least some extent (scores ≥2; 1=no usefulness) and that 91% (n=42) of participants reported perceived burden by number and length of notifications (scores ≥2; 1=no burden). Multiple linear regression models were fitted to predict treatment engagement and acceptability. Ethnic minority backgrounds predicted lower notification response compliance (B=-4.37; P=.01), yet higher app usefulness (B=1.25; P=.049). Negative (B=-0.26; P=.01) and affective (B=0.14; P=.04) symptom severity predicted lower and higher ACT training usefulness, respectively. Being female (B=-1.03; P=.005) predicted lower usefulness of the ACT metaphor images on the app.

CONCLUSIONS

Our results corroborate good treatment engagement with and acceptability of ACT-DL in early psychosis. We provide recommendations for future intervention optimization.

TRIAL REGISTRATION

OMON NL46439.068.13; https://onderzoekmetmensen.nl/en/trial/24803.

Reasons for disengagement in first-episode psychosis - perspectives from service users and their caregivers

BACKGROUND

The efforts of early psychosis intervention programmes can be impeded by difficulties in maintaining the engagement of service users. As disengagement is often an autonomous decision made by service users, the main aim of this study was to gain insight into the reasons for service user disengagement through qualitative interviews with the service users themselves, and caregivers as proxies or secondary informants.

METHODS

Participants recruited for the study were enrolled in the Early Psychosis Intervention Programme in Singapore for at least a year, aged 21 and above, able to communicate in English, and had disengaged for at least three months. The recruitment and interview processes were conducted independently for service user and caregiver participants. Potential participants were invited to a face-to-face semi-structured interview over video call or in-person. Each interview spanned one to two hours, and comprised five phases - icebreaker, exploration of the participant's experience with EPIP before deciding to disengage, discussion of reasons for disengagement, exploration of the post-disengagement experience, and feedback and suggestions for EPIP. Recruitment aimed to conclude after 10-15 participants were interviewed for both service user and caregiver groups, with the expectation that data sufficiency would be reached with no new themes being generated.

RESULTS

Ultimately, 12 service user and 12 caregiver participants were recruited. There were six pairs of service user and caregiver dyads, where the caregivers interviewed were caring for service users also enrolled in the study. Valuable qualitative insights were gathered, including the type of disengagement, medication compliance during disengagement, the decision-making process behind disengaging, and circumstances surrounding re-engagement. A total of five categories each with subthemes were identified from the reasons for service user disengagement - individual factors, stigma, progression, treatment factors, and external factors.

CONCLUSIONS

There is a need to narrow down urgent areas of attention, aligning the study themes with established risk factors so that feasible solutions can be developed and appropriate care models can be adopted, to minimise adverse outcomes related to disengagement. It is important to keep an open mind to understand what personal recovery means to the individual service user, so that treatment goals can be better harmonised.

Impact of family engagement on client participation in coordinated specialty care for first episodes of psychosis

BACKGROUND

Coordinated specialty care (CSC) programs for first episodes of psychosis are increasingly offered in the United States. A component of CSC programs is active family engagement in treatment, though research on the impact of this engagement is limited. This study examined the characteristics of families engaged compared to families not engaged in treatment, and the impact of family engagement on client participation and medication adherence over the first 6 months of treatment.

METHODS

Using data from the Early Psychosis Intervention Network (EPINET) research hub in Minnesota (EPI-MINN), we compared two groups of individuals: clients who had a family member(s) engaged in their treatment vs. clients who did not. Family engagement was defined as any treatment services provided to a family member(s) by CSC clinical staff. The groups were compared on intake demographic variables, duration of untreated psychosis (DUP), hospitalizations, symptom severity, and functioning. A comparison of the total number of treatment visits during the first 6 months of treatment was tested using both nonparametric (Mann Whitney U) and parametric (ANCOVA) tests. Group comparisons on self ratings of "intent to attend visits," "intent to complete the program," and medication adherence were tested with ANCOVA and Chi-Square.

RESULTS

Family-engaged clients were younger, with less years of education, and more often White; clients without family engagement were more often Black. Family engagement was positively associated with increased total number of visits for all interventions with the exceptions of client peer support and case management visits. Family engagement increased clients' self-reported intent to attend visits, though not intention to complete the program, which was moderately to markedly high in both groups. No differences were noted with medication adherence, with high rates of adherence across the entire study sample.

CONCLUSIONS

Overall, results of the study support the benefits of family engagement in CSC on client participation, though future research is needed to understand why Black families are less engaged and what treatment adaptations are needed to reduce these racial differences. The results also support the value of CSC programs for medication adherence, a critical factor in symptom reduction and mental health recovery.

Developing a spectrum model of engagement in services for first episode psychosis: beyond attendance

Background

Early intervention services (EIS) for psychosis have proven highly effective in treating first episode psychosis. Yet, retention or "engagement" in EIS remains highly variable. Dis/engagement as a contested concept and fluid process involving relationships between service providers and service users remains poorly understood. This study aimed to critically evaluate and explain the dynamic interplay of service provider-user relationships in effecting dis/engagement from an early intervention program for psychosis.

Methods

Forty study participants, 16 service providers and 24 service users (19 current and 5 disengaged) from a Canadian EIS program, were administered semi-structured interviews. Qualitative analysis was conducted using grounded theory methods, with findings captured and reconceptualized in a novel explanatory model.

Findings

A model of engagement with eight major domains of engagement in EIS positioned along a control-autonomy spectrum was developed from the findings, with Clinical engagement (attendance) and Life engagement (life activities) at opposite ends of the spectrum, interspersed by six intermediate domains: Medication/treatment, Symptoms/illness, Mental health, Physical health/wellness, Communication, and Relationships, each domain bearing uniquely on engagement.

Conclusions

An examination of service user and service provider perspectives on the various domains identified in the spectrum model, and their dynamic interplay, reveals the complexity of choices faced by service users in engaging and not engaging with services.

The Impact of Structural Integration on Clinical Outcomes among Individuals with Serious Mental Illness and Chronic Illness

Though considered a best practice, there is substantial variation in how integrated behavioral health (IBH) services are structured. This study examined the impact of IBH structure on health outcomes among individuals with serious mental illness (SMI) and chronic disease receiving care in community health centers (CHCs). Data from the ADVANCE network identified 8,548 individuals with co-occurring SMI diabetes and 16,600 with an SMI and hypertension. Logistic regression tested whether IBH type impacted disease specific health outcomes among these populations. Among those with diabetes or hypertension, colocated care was associated with better health outcomes related to HbA1c, blood pressure control, and BMI compared to less coordinated and unintegrated care, though there was significant variation in this relationship across SMI diagnoses. Results reflect that colocation of primary care and behavioral health may improve outcomes for individuals with bipolar disorder or major depression and chronic disease, but that CHC-based integrated care may not be optimized for individuals with schizophrenia.

Secure attachment imagery facilitates help-seeking and help-acceptance in psychosis

OBJECTIVES

People with psychosis delay accessing recommended treatments, resulting in poor healthcare outcomes and increased risk of relapse. Means of improving help-seeking and help-acceptance could reduce duration of untreated psychosis (DUP). This study examined the role of attachment style in help-seeking and help-acceptance in psychosis.

DESIGN

We used an experimental design to test the effect of attachment imagery priming on help-seeking and help-acceptance intentions, in a sample with self-reported psychosis. The independent variables were attachment imagery condition (secure vs. avoidant) and time (pre- vs. post-prime). The dependent variables were state paranoia, help-seeking intentions and help-acceptance intentions.

METHODS

We used an online research platform to recruit people with psychosis (n = 61). Participants were randomly allocated to the secure or avoidant attachment priming condition. All completed measures of state paranoia, help-seeking, and help-acceptance, before and after priming.

RESULTS

In comparison with the avoidant condition, secure attachment imagery resulted in reduced paranoia and increased help-seeking and acceptance intentions, all with large effect sizes.

CONCLUSIONS

This is the first study to use an experimental design to assess the role of attachment style in help-seeking and help-acceptance in a clinical sample. Attachment style is causally linked to behavioural intentions that contribute to DUP. Clinicians should assess attachment and help-seeking and acceptance, highlight these in formulation, and prioritise in treatment planning. Interventions that enhance help-seeking and acceptance could improve access to recommended treatments and reduce DUP.

Adapting the Parent Connector program for caregivers of adults with SMI: the Family Connector experience

Caregivers play an essential role in the recovery of their adult loved ones with serious mental illness (SMI). Promoting caregiver empowerment and well-being is critical but has often been overlooked. Family peer interventions are well-suited to fill this need; however, research is limited supporting their use with caregivers of adults with SMI. Our team is currently engaged in a study evaluating an adapted version of the evidenced-based Parent Connectors program1,2, renamed Family Connectors (FC), for caregivers of young adults recently discharged from the First Episode Psychosis program in New York (OnTrackNY). This paper, written collaboratively with family peer professionals, describes the adaptation process we followed to systematically document the family peer professional experience one year into delivering the FC program to this novel population. Modifications made to improve intervention fit included tailoring the content of the intervention, incorporating an outside approach into the program, lengthening the service in some cases, and adding a weekly peer supervision meeting. We hope that these insights are used to inform future efforts to advance support for families of loved ones with SMI, and more broadly, that our approach serves as a model for effective collaboration to improve the application of peer support services for unique groups.

Short-term disengagement from early intervention service for first-episode psychosis: findings from the "Parma Early Psychosis" program

PURPOSE

Service disengagement is a major concern for "Early Intervention in Psychosis" (EIP). Indeed, identifying predictors of engagement is crucial to maximize mental healthcare interventions in first-episode psychosis (FEP). No Italian study on this topic has been reported to date. Thus, the aims of this investigation were: (1) to examine short-term disengagement rate in an Italian population of FEP patients treated within an EIP service across a 1-year follow-up period, and (b) to assess the most relevant predictors of disengagement in the first year of treatment.

METHODS

All participants were young FEP help-seeking patients, aged 12-35 years, enrolled within the "Parma Early Psychosis" (Pr-EP) protocol. At baseline, they completed the Positive And Negative Syndrome Scale (PANSS), the Health of the Nation Outcome Scale (HoNOS) and the Global Assessment of Functioning (GAF) scale. Univariate and multivariate Cox regression analyses were used.

RESULTS

496 FEP individuals were enrolled in this research. Across the follow-up, a 16.5% prevalence of short-term disengagement was found. Particularly robust predictors of service disengagement were poor baseline treatment non-adherence, living with parents and the presence of brief psychotic disorder or schizophreniform disorder at entry.

CONCLUSION

About 16% of FEP patients disengaged the Pr-EP program within the first year of treatment. A solution to reduce disengagement and/or to favor re-engagement of these subjects might be to remain on EIP program caseloads allowing the option for low-intensity support and monitoring, also via remote technology.

Rates and predictors of service disengagement in adolescents with first episode psychosis: results from the 2-year follow-up of the Pr-EP program

Service disengagement is a major concern for "Early Intervention in Psychosis" (EIP). Indeed, understanding predictors of engagement is important for the effectiveness of mental health interventions, to improve outcome and quality of life, also in adolescents with first episode psychosis (FEP). No specific European investigation on this topic in adolescence has been reported in the literature to date. The aim of this study was to investigate service disengagement rate and predictors in an Italian sample of FEP adolescents treated within an EIP program during a 2-year follow-up period. All participants were adolescents help-seekers (aged 12-18 years) enrolled in the "Parma Early Psychosis" (Pr-EP) program. At baseline, they completed the Positive and Negative Syndrome Scale (PANSS) and the Global Assessment of Functioning (GAF) scale. Univariate and multivariate Cox regression analyses were performed. 71 FEP adolescents were recruited in this research. During the 2 years of our follow-up, a 25.4% prevalence rate of service disengagement was found. Particularly robust predictors of disengagement were lower baseline acceptance of psychosocial interventions, substance abuse at entry, and lower baseline PANSS "Disorganization" factor score. Approximately, 1/4 of our FEP adolescents disengaged from the Pr-EP program during the first 2 years of treatment. A possible solution to decrease disengagement and to favor re-engagement of these young individuals might be to provide the option of low-intensity monitoring and support, also via remote technology.

Difficult-to-Engage Patients with Severe Mental Illness in Rural Community Settings: Results of the Greek Hybrid Assertive Community Treatment Model of Mental Healthcare

Background: Modified Assertive Community Treatment (ACT) in rural settings may be effective in the care of patients with severe mental illness (SMI) that are difficult to engage in community care. The objective of the present study was to explore the impact of the care by a hybrid ACT team on SMI patients' hospitalizations, length of hospital stay, symptomatology and functioning in a rural community treatment setting in Greece. Methods: The hybrid ACT team is an expansion of the services of the well-established generic Mobile Mental Health Unit in a rural area of Northwest Greece, and delivers home-based care for patients with SMI. This was a 3-year prospective, mirror image, pre-post observational study. Patients' symptomatology, functioning and general outcome were measured with the use of the Brief Psychiatric Rating Scale (BPRS), the Global Assessment of Functioning Scale (GAF), and the Health of the Nation Outcome Scale (HοNOS). Results: The mean age of the 23 enrolled patients was 52.4 years and the mean age of disease onset was 23.5 years, with a mean number of hospitalizations 10.74. Over the 16-month follow-up patients' hospitalizations, both voluntary and involuntary, had been significantly reduced by almost 80%. Length of hospital stay had been significantly reduced by 87%, whereas patients' functioning and symptomatology had been significantly improved, by 17% and 14.5%, respectively. Conclusions: The model of hybrid ACT in rural areas in Greece may be effective in the treatment of difficult-to-engage patients with SMI and may improve patients' outcomes.

Blended care in psychosis - A systematic review

Blended-care, a psychosocial intervention combining traditional, face-to-face therapy with digital mental health tools, has shown potential for improving therapeutic processes, fostering patient engagement, and augmenting clinical outcomes. This systematic review aimed to evaluate the development and effectiveness of blended-care interventions tailored for adults diagnosed with schizophrenia-spectrum disorders or other conditions with psychotic features. Our search strategy spanned three electronic databases (PsycINFO, Web of Science, and PubMed) in accordance with the reporting guidelines outlined by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. We identified 11 papers, each examining the use of one of eight distinct blended-care interventions. Significantly, the majority of these papers (10/11, 91 %) examined these interventions exclusively within controlled research environments, demonstrating both acceptability and favourable impacts on symptomatology and recovery (e.g., 0.22 ≤ Cohen's ds ≤ 1.00). Only one intervention was examined in research settings and real-world conditions, and the shift resulted in low real-world uptake (e.g., only 50 % of practitioners were able to engage at least one of their clients with the intervention) and an inability to reproduce positive changes in clinical outcomes. Additional research is needed to determine the viability of successfully developing and implementing blended-care interventions for psychosis in real-world conditions. An exploration of the developmental processes that could facilitate the transition from research settings to routine clinical practice is vital.

Cognitive behavioural therapy for psychosis: The end of the line or time for a new approach?

PURPOSE

Following its introduction in the early 1990s, cognitive behavioural therapy for psychosis (CBTp) has been evaluated in a large number of clinical trials and is now established as a recommended treatment in the UK National Health Service and elsewhere in the world. Meta-analyses, however, indicate modest effects compared to treatment as usual or comparison therapies such as supportive counselling. Here, we seek to identify factors impacting the effectiveness of CBTp, and avenues for future psychotherapy research that may improve outcomes.

METHOD

We outline two recent umbrella reviews and discuss factors likely to impact the effectiveness of CBTp.

RESULTS

Modest effect sizes from meta-analyses mask heterogeneous outcomes, with some people benefiting and others possibly being harmed by therapy. Common factors such as the therapeutic alliance play an important role in determining outcomes but have been largely neglected by CBTp researchers. There is also the promise of improving outcomes by identifying and targeting the psychological mechanisms that either maintain psychotic symptoms (e.g. worry) or are causally implicated (e.g. trauma).

CONCLUSIONS

It is unlikely that everyone with psychosis will be equally responsive to the same therapeutic protocols. We need a new, personalised psychotherapy approach to CBTp research and practice, and can learn from research for anxiety and depression examining predictors of therapeutic response to inform treatment decisions. Precision psychological therapies informed by a combination of individual characteristics, common factors and a focus on specific mechanisms will require new research strategies and are likely to lead to improved outcomes for people with psychosis.

Putting measurement-based care into action: A mixed methods study of the benefits of integrating routine client feedback in coordinated specialty care programs for early psychosis

Background

Measurement-based care (MBC) is an effective tool in the delivery of evidence-based practices (EBPs). MBC utilizes feedback loops to share information and drive changes throughout a learning healthcare system. Few studies have demonstrated this practice in team-based care for people with early psychosis. This paper describes the development of a personalized feedback report derived from routine assessments that is shared with clients and clinicians as part of a MBC process.

Methods

We used a quasi pre-post comparison design with mixed methods to evaluate the implementation of a personalized feedback report at 5 early psychosis coordinated specialty care programs (CSC). We compared clients enrolled in CSC who did and did not receive a feedback report over the first 6 months of treatment. The sample included 204 clients: 146 who did not receive the feedback report and were enrolled over 2 years, and 58 who received the feedback report. A subset of 67 clients completed measures at both intake and 6-month follow-up, including 42 who received the report and 25 who did not. We compared the two groups with regard to self-reported symptoms, likelihood of completing treatment, and perception of shared decision making. We conducted qualitative interviews with 5 clients and 5 clinicians to identify the benefits and challenges associated with the personalized feedback report.

Results

People who received a personalized feedback report reported significant improvements in shared decision-making and had greater improvements over time in their intent to attend future treatment sessions. They engaged in more sessions for Supported Employment and Education (SEE), case management, and peer support, and fewer medication visits over the first 6 months of treatment. Both groups showed significant improvement in symptoms and functioning. Results from the qualitative analysis indicated that the experience of receiving the reports was valuable and validating for both patients and clinicians.

Conclusions

A personalized feedback report was integrated into standard of care for early psychosis programs. This process may improve shared decision-making, strengthen the likelihood to stay in treatment, and increase engagement in psychosocial interventions. We posit that this process facilitates strengths-focused discussions, enhances intrinsic motivation, and strengthens the therapeutic alliance.

An SMS text messaging intervention to improve clinical engagement in early psychosis: A pilot randomized-controlled trial

Disengagement of youth with psychosis from Early Psychosis Intervention (EPI) services continues to be a significant barrier to recovery, with approximately one-third prematurely discontinuing treatment despite the ongoing need. The current pilot trial sought to evaluate the preliminary efficacy and feasibility of a weekly short message service (SMS) intervention to improve engagement in EPI services. This was a longitudinal single-blinded randomized control trial in which participants were assigned to receive either an active or sham SMS intervention over nine months. Sixty-one participants with early psychosis between the ages of 16 and 29 were enrolled, randomized, and received at least part of the intervention. Primary outcomes consisted of participant clinic attendance rates over the course of the intervention and clinician-rated engagement. Secondary measures included patient-rated therapeutic rapport, attitude toward medication, psychopathology, cognition, functioning, and intervention feedback from participants. Compared to the sham group, participants receiving the active intervention did not show improved appointment attendance rates; however, did exhibit some improvements in aspects of engagement, including improved clinician-rated availability, attitude toward medication, positive symptoms, avolition-apathy and social functioning. Thus, contrary to our hypotheses, digitally augmented care did not result in enhanced engagement in EPI services, as measured by clinic attendance, although with some indication that it may contribute to improved attitude toward medication and, potentially, medication adherence. Weekly SMS text messaging appeared to result in a pattern of engagement whereby individuals who were improving clinically attended appointments less often, possibly due to inadvertent use of the intervention to check in with clinicians. TRIAL REGISTRATION: ClinicalTrials.gov (NCT04379349).

Remission with or without comorbid substance use disorders in early psychosis: long-term outcome in integrated care (ACCESS III study)

Introduction

Schizophrenia-Spectrum-Disorders are associated with poor long-term outcome as well as disability and often severely affect the lives of patients and their families often from symptom onset. Up to 70% of first episode psychosis (FEP) patients suffer from comorbid substance use disorders (SUD). We aimed at studying the course of illness in FEP patients within evidence-based care, with and without comorbid SUD, to examine how decreased, remitted or persistent substance use impacted rates of a combined symptomatic and functional long-term recovery compared with patients without SUD.

Methods

ACCESS III is an integrated care model for FEP or patients in the early phase of non-affective and affective psychotic disorders. Treatment trajectories of patients, who had been in ACCESS care for 1 year, with and without SUD were compared with regard to the course of illness and quality of life using Mixed Model Repeated Measures (MMRM) and recovery rates were compared using binary logistic regression. Change in substance use was coded as either persistent, decreased/remitted or no use.

Results

ACCESS III was a prospective 1-year study (N = 120) in patients aged 12-29 years. Of these, 74 (61.6%) had a comorbid SUD at admission. There were no group differences regarding the course of illness between patients with or without comorbid SUD or between patients with a substance abuse or substance dependence. The only outcome parameter that was affected by SUD was quality of life, with larger improvement found in the group without substance use (p = 0.05) compared to persistent and remitted users. Using LOCF, 44 patients (48.9%) fulfilled recovery criteria at the endpoint; recovery did not differ based on substance use status.

Discussion

SUD and especially substance dependence are common in psychotic disorders even in FEP patients. Evidence-based integrated care led to long-term improvement in patients with comorbid SUD and rate of recovery did not differ for patients with substance use.

Demographic predictors of lack of current mental health treatment among university students with a schizophrenia spectrum disorder

AIM

To identify the demographic predictors of lack of current mental health (MH) treatment among university students with a schizophrenia spectrum disorder (SSD).

METHODS

Adult university students with a self-identified diagnosis of an SSD (schizophreniform, schizophrenia, schizoaffective disorder) were identified from the 2019-2020 Healthy Minds Study survey. In this study, pertinent demographic factors included age, race/ethnicity, sex assigned at birth, gender identity, sexual orientation, parental education, financial stress, and employment. Multivariable modelling was used to investigate the demographic predictors of lack of current psychotherapy treatment, no current antipsychotic use, and lack of any MH treatment (defined as concurrent lack of psychotherapy and antipsychotic treatment).

RESULTS

Of the 135 included students with a SSD, the median age was 23 years old and 79 (58.5%) were assigned female at birth. Fifty-five participants (40.7%) lacked any current MH treatment. In fully adjusted models, lack of current MH treatment was associated with working more than 20 h per week (OR 2.9 [1.2-7.1], p = 0.02). No current antipsychotic use was associated with Hispanic/Latino race/ethnicity (OR 4.2 (1.2-14.5), p = 0.04). Lack of current psychotherapy treatment was associated with cisgender male identity (OR 5.5 [2.0-15.2], p < 0.01), working greater than 20 hours per week (OR 6.5 [2.2-19.2], p < 0.01), and having one or more structural or attitudinal barriers to care (OR = 4.6 [1.5-13.9], p < 0.01).

CONCLUSIONS

The demographic predictors of lack of current MH treatment varied between psychotherapy and antipsychotic use, suggesting university health centres should consider interventions targeting several at-risk populations to increase treatment use among students with a SSD.

The use of implementation science to close the research-to-treatment gap for cognitive impairment in psychosis

For people living with psychosis, cognitive impairment is common and can have significant impacts for functional recovery, impacting engagement with treatment and quality of life more broadly. There is now strong evidence for the effectiveness of cognition-focused treatments, such as cognitive remediation to improve clinical and functional outcomes for people with psychosis. However, engagement with treatment has been a long-standing issue in mental health care, including for people with psychosis, who often experience difficulties with motivation. While research on clinical effectiveness of cognition-focused treatment is growing, to date there has been little research focused on the implementation of such treatments and it is not clear how best to support uptake and engagement across diverse mental health settings. Implementation science is the study of methods and strategies to promote the adoption, application, and maintenance of evidence-based practices in routine care. To integrate cognition-focused treatments into routine practice, and improve engagement with treatment and the quality and effectiveness of care for people with psychosis, researchers need to embrace implementation science and research. This paper provides a succinct overview of the field of implementation science, current evidence for implementation of cognition-focused treatments for psychosis and practical guidance for using implementation science in clinical research. The future of psychosis research includes multidisciplinary teams of clinical researchers and implementation scientists, working together with providers and consumers to build the evidence that can improve the implementation of cognition-focused treatments.

Predictors of treatment attrition of cognitive health interventions in first episode psychosis

AIM

Dropping out of psychological interventions is estimated to occur in up to a third of individuals with psychosis. Given the high degree of attrition in this population, identifying predictors of attrition is important to develop strategies to retain individuals in treatment. We observed a particularly high degree of attrition (48%) in a recent randomized controlled study assessing cognitive health interventions for first-episode psychosis participants with comorbid social anxiety. Due to the importance of developing interventions for social anxiety in first episode psychosis, the aim of the present study was to identify putative predictors of attrition through a secondary analysis of data.

METHODS

Participants (n = 96) with first episode psychosis and comorbid social anxiety were randomized to receive cognitive behavioural therapy for social anxiety or cognitive remediation. Differences between completers and non-completers (<50% intervention completed) were compared using t-tests or chi-square analyses; statistically significant variables were entered into a multivariate logistic regression model.

RESULTS

Non-completers tended to be younger, had fewer years of education and had lower levels of social anxiety compared to completers. Lower baseline social anxiety and younger age were statistically significant predictors of non-completion in the logistic regression model.

CONCLUSIONS

Age and social anxiety were predictors of attrition in cognitive health interventions in first episode psychosis populations with comorbid social anxiety. In the ongoing development of social anxiety interventions for this population, future studies should investigate specific engagement strategies, intervention formats and outcome monitoring to improve participant retention in treatment.

Care Pathways and Initial Engagement in Early Psychosis Intervention Services Among Youths and Young Adults

Importance

Broad efforts to improve access to early psychosis intervention (EPI) services may not address health disparities in pathways to care and initial engagement in treatment.

Objective

To understand factors associated with referral from acute hospital-based settings and initial engagement in EPI services.

Design, Setting, and Participants

This retrospective cohort study used electronic medical record data from all patients aged 16 to 29 years who were referred to a large EPI program between January 2018 and December 2019. Statistical analysis was performed from March 2022 to February 2023.

Exposures

Patients self-reported demographic information in a structured questionnaire. The main outcome for the first research question (referral source) was an exposure for the second research question (initial attendance).

Main Outcomes and Measures

Rate of EPI referral from acute pathways compared with other referral sources, and rate of attendance at the consultation appointment.

Results

The final study population included 999 unique patient referrals. At referral, patients were a mean (SD) age of 22.5 (3.5) years; 654 (65.5%) identified as male, 323 (32.3%) female, and 22 (2.2%) transgender, 2-spirit, nonbinary, do not know, or prefer not to answer; 199 (19.9%) identified as Asian, 176 (17.6%) Black, 384 (38.4%) White, and 167 (16.7%) other racial or ethnic groups, do not know, or prefer not to answer. Participants more likely to be referred to EPI services from inpatient units included those who were older (relative risk ratio [RRR], 1.10; 95% CI, 1.05-1.15) and those who identified as Black (RRR, 2.11; 95% CI, 1.38-3.22) or belonging to other minoritized racial or ethnic groups (RRR, 1.79; 95% CI, 1.14-2.79) compared with White participants. Older patients (RRR, 1.16; 95% CI, 1.11-1.22) and those who identified as Black (RRR, 1.67; 95% CI, 1.04-2.70) or belonging to other minoritized racial or ethnic groups (RRR, 2.11; 95% CI, 1.33-3.36) were more likely to be referred from the emergency department (ED) compared with White participants, whereas participants who identified as female (RRR, 0.51 95% CI, 0.34-.74) had a lower risk of ED referral compared with male participants. Being older (odds ratio [OR], 0.95; 95% CI, 0.90-1.00) and referred from the ED (OR, 0.40; 95% CI, 0.27-0.58) were associated with decreased odds of attendance at the consultation appointment.

Conclusions and relevance

In this cohort study of patients referred to EPI services, disparities existed in referral pathways and initial engagement in services. Improving entry into EPI services may help facilitate a key step on the path to recovery among youths and young adults with psychosis.

Pathways Through Early Psychosis Care for U.S. Youths From Ethnically and Racially Minoritized Groups: A Systematic Review

OBJECTIVE

The authors of this systematic review examined service utilization and outcomes among youths from ethnoracially minoritized groups after the youths initiated treatment for a psychotic disorder-that is, the youths' "pathway through care." Also examined were potential moderating variables in pathways through care for these youths at the clinic, family, and cultural levels. The goal was to describe methodologies, summarize relevant findings, highlight knowledge gaps, and propose future research on pathways through care for young persons from ethnoracially minoritized groups who experience early psychosis.

METHODS

The PubMed, PsycInfo, and Web of Science literature databases were systematically searched for studies published between January 1, 2010, and June 1, 2021. Included articles were from the United States and focused on young people after they initiated treatment for early psychosis. Eighteen studies met inclusion criteria.

RESULTS

Sixteen of the 18 studies were published in the past 5 years, and 11 had an explicit focus on race and ethnicity as defined by the studies' authors. Studies varied in terminology, outcomes measures, methodologies, and depth of analysis. Being an individual from an ethnoracially minoritized group appeared to affect care utilization and outcomes. Insufficient research was found about potential moderating variables at the clinic, family, and cultural levels.

CONCLUSIONS

Studies of pathways through care for persons from minoritized groups warrant further funding and attention.

Predictors of treatment discontinuation during an 18-month multi-site randomized trial of Cognitive Enhancement Therapy for early course schizophrenia

Treatment discontinuation during clinical trials in schizophrenia is a critical challenge, especially for longer-term interventions in the early course. This research explored predictors of treatment discontinuation in an outpatient early course schizophrenia sample (N = 102) during an 18-month multi-site trial of Cognitive Enhancement Therapy (n = 58) and Enriched Supportive Therapy (n = 44). Fifty-three (52%) participants discontinued, with no significant difference between the treatment groups in discontinuation rate. Univariate and multivariate binary logistic regression models explored differences in key demographic and cognitive and behavioral outcomes between participants who completed and discontinued treatment. Significant multivariate predictors of discontinuation included IQ (linear) and problem solving (curvilinear). The concave shape of the problem solving prediction demonstrated that initially as scores were increasing the probability of non-completion was increasing. However, after a score of 41 (below average problem solving), the probability of being a non-completer decreased as performance increased. Non-completers had significantly lower IQ scores compared to completers. Post-hoc analyses indicated that participants who discontinued prior to mid-treatment exhibited the greatest intellectual challenges, with comparisons moderate-to-large in strength. IQ and problem solving are likely important factors to assess at pre-treatment in early course schizophrenia trials to identify those most vulnerable to discontinuation.

Effectiveness of the early intervention service for first-episode psychosis in Navarra (PEPsNa): Broadening the scope of outcome measures

BACKGROUND

This study compares the effectiveness of a new early intervention service for firstepisode psychosis (FEP) in patients under conventional treatment. Six primary and 10 secondary outcome measures are used to better characterize the comparative effectiveness between two FEP groups.

METHODS

This study plans to enroll 250 patients aged 15-55 years with FEP from all inpatient and outpatient mental health services and primary health care from January 2020 until December 2022. The control group will be composed of 130 FEP patients treated in mental health centers in the 2 years prior to the start of PEPsNa (Programa de Primeros Episodios de Psicosis de Navarra). The primary outcome measures are symptomatic remission, functional recovery, personal recovery, cognitive performance, functional capacity in real-world settings, and costs. The secondary outcome measures are duration of untreated psychosis, substance abuse rate, antipsychotic monotherapy, minimal effective dose of antipsychotic drugs, therapeutic alliance, drop-out rate, number of relapses, global mortality and suicidality, resource use, and general satisfaction in the program.

DISCUSSION

This study arises from the growing need to broaden the scope of outcome measures in FEP patients and to account for unmet needs of recovery for FEPs. It aims to contribute in the dissemination of the NAVIGATE model in Europe and to provide new evidence of the effectiveness of early intervention services for stakeholders of the National Health Service.

Role of Clinical Insight at First Month in Predicting Relapse at the Year in First Episode of Psychosis (FEP) Patients

INTRODUCTION

Clinical insight constitutes a useful marker of the progress and outcome of the First Episode of Psychosis (FEP), and lack of insight has been associated with more severe psychopathology, treatment non-adherence, and rehospitalization/relapse. In this study, we aimed to further investigate the possible role of insight as a predictor of relapse, its relation to diagnosis, and other parameters of positive psychotic symptomatology (delusions, hallucinations, and suspiciousness).

METHODS

The Athens FEP study employed a prospective, longitudinal cohort design in which consecutive newly diagnosed patients with psychosis were interviewed and asked to voluntarily participate after completing informed consent. A total of 88/225 patients were examined at three different time points (baseline, month, and year). Their scores in the relevant items of the Positive and Negative Syndrome Scale (PANSS) were compared (G12 for insight, P1 for delusions, P3 for hallucinations, and P6 for suspiciousness), and they were further associated to diagnosis and the outcome at the end of the year (remission/relapse).

RESULTS

In total, 22/88 patients with relapse at the year had greater scores in G12 for both the month and the year, and this finding was corroborated after adjusting the statistical analysis for demographics, diagnosis, social environment, and depression via multiple logistic regression analysis. Moreover, delusions and suspiciousness were significantly higher in patients diagnosed with non-affective psychosis compared to those diagnosed with affective psychosis (p < 0.001) at the first month.

CONCLUSIONS

Lack of insight at the first month may serve as a predictor of relapse at the year.

Mobile health in the specific management of first-episode psychosis: a systematic literature review

Purpose

The purpose of this systematic literature review is to assess the therapeutic efficacy of mobile health methods in the management of patients with first-episode psychosis (FEP).

Method

The participants are patients with FEP. The interventions are smartphone applications. The studies assess the preliminary efficacy of various types of application.

Results

One study found that monitoring symptoms minimized relapses, visits to A&E and hospital admissions, while one study showed a decrease in positive psychotic symptoms. One study found an improvement in anxiety symptoms and two studies noted an improvement in psychotic symptoms. One study demonstrated its efficacy in helping participants return to studying and employment and one study reported improved motivation.

Conclusion

The studies suggest that mobile applications have potential value in the management of young patients with FEP through the use of various assessment and intervention tools. This systematic review has several limitations due to the lack of randomized controlled studies available in the literature.

Taking a Look at How Family Member Engagement Influences Service User Engagement in New Journeys: a Coordinated Specialty Care Program

Family members are integral to the care and support of individuals experiencing early psychosis, and while studies have brought to light the impact of family engagement, there is a dearth in the literature on the ways family engagement in services affects service user engagement. The present study examined the relationship between initial family engagement and service user engagement among 349 service users enrolled in New Journeys, a network of coordinated specialty care (CSC) programs. Service users whose family members were initially engaged in treatment in the first month were more likely to remain engaged and attend appointments during the first 7 months relative to service users whose family members were not initially engaged (χ-2=88.4; p < 0.001). Overall, for a one unit increase in total number of appointments attended by family members in the first 24 months, the odds of service users' engagement increased by 14% (OR: 1.14, CI: 1.12-1.16). Findings demonstrate the association between family engagement and the engagement of service users in CSC.

Cannabis use among patients presenting to the emergency department for psychosis: Associations with restraint use, medication administration, psychiatric hospitalization, and repeat visits

Cannabis use is associated with increased severity of psychotic symptoms and the risk of acute agitation and aggressive behavior in inpatient (IP) and outpatient settings. Whether or not cannabis use is associated with increased acuity of psychosis-related ED presentations and risk of repeat ED visits for psychosis is unclear. In this retrospective study of 2,134 ED visits for acute psychosis, we investigated the risk of physical restraint, parenteral medication administration, psychiatric hospitalization, and recurrent ED visits. We examined ED visits between March 1, 2019 and February 28, 2021 based on urinary Tetrahydrocannabinol (THC) screen status (positive vs negative vs no screen). The risk of physical restraint, parenteral antipsychotic, and benzodiazepine administration was significantly greater in ED visits with a positive THC screen compared to those with a negative or no THC screen. We did not find an association between a positive urinary THC screen and IP hospitalization or the risk of recurrent ED presentation for psychosis within 90 days. These findings suggest that positive urinary THC may predict acute agitation or acuity of symptoms in ED settings and underscores the importance of screening for THC during ED presentations for psychosis.

Neglecting the care of people with schizophrenia: here we go again

Specialist early intervention teams consider clinician-patient engagement and continuity of care to be a driving philosophy behind the treatment they provide to people who have developed schizophrenia or a related psychotic illness. In almost all countries where this service model has been implemented there is a dearth of available data about what is happening to patients following time-limited treatment. Information on discharge pathways in England indicates that some early intervention specialists are discharging most of their patients from all psychiatric services after only 2 or 3 years of input. Some ex-patients will be living in a state of torment and neglect due to an untreated psychosis. In the UK, general practitioners should refuse to accept these discharge pathways for patients with insight-impairing mental illnesses.

Clinical insights: Preventing psychosis treatment disengagement

Many patients with schizophrenia spectrum disorders disengage from treatment, with negative impacts on prognosis and recovery. This commentary provides an overview of common reasons underlying treatment dropout and strategies for overcoming obstacles and enhancing patient engagement. Basic clinical skills such as open-ended questions and reflective listening can be powerful tools in unmasking structural and attitudinal barriers to psychosis care.

Recent substance use among clients with early psychosis and the potential to graduate from New Journeys

AIM

This study examined the relationship between recent substance use prior to intake and program graduation among young adults with early psychosis enrolled in coordinated specialty care.

METHODS

Participants (N = 248) were from New Journeys, a network of coordinated specialty care programs in Washington State. Recent (i.e., past 30 days) alcohol, cannabis, and other substance use was collected at intake and process data (e.g., contact) was collected by clinicians across a 2-year period.

RESULTS

At intake, 32% of participants reported alcohol use only, 26% cannabis use only, and 15% both alcohol and cannabis use. Participants who reported alcohol use only (p = .02), cannabis use only (p = .03), and any substance use (p = .02) had significantly lower chances of graduating from coordinated specialty care than individuals who do not use substances.

CONCLUSIONS

Unlike prior work, recent substance use influences clients' potential to graduate from New Journeys. Additional focus on the implementation of substance use treatment, with an emphasis on alcohol use, in coordinated specialty care programs is needed improve program completion rates.

Treatment engagement in first-episode schizophrenia: Associations between intrinsic motivation and attendance during cognitive training and an aerobic exercise program

Systematic cognitive training and aerobic exercise programs have emerged as promising interventions to improve cognitive deficits in first-episode schizophrenia, with successful outcomes closely linked with greater treatment engagement (e.g., higher attendance and homework completion rates). Unfortunately, treatment disengagement from these services remains a persistent issue. Intrinsic motivation, or the willingness to exert effort because a task is inherently interesting or meaningful, has emerged as a promising malleable personal factor to enhance treatment engagement. This study investigated whether early task-specific intrinsic motivation and its domains (e.g., interest, perceived competence, and value) predicted treatment engagement within the context of intensive cognitive training and aerobic exercise interventions over a 6-month period. Thirty-nine participants with first-episode schizophrenia were administered baseline measures of task-specific intrinsic motivation inventories, one for cognitive training and one for exercise, and completed a 6-month randomized clinical trial comparing a neuroplasticity-based cognitive training plus aerobic exercise program against the same cognitive training alone. Results indicated that higher baseline scores of intrinsic motivation for cognitive training, specifically early perceptions of task interest and value, were predictive of greater cognitive training and exercise group attendance. Scores for exercise-specific intrinsic motivation were generally unrelated to indices of exercise participation, with the exception that the gain over time in perceived choice for exercise was linked with greater exercise homework completion and a similar directional tendency for greater in-clinic exercise attendance. This study provides support for monitoring and enhancing motivation early during service delivery to maximize engagement and the likelihood of successful treatment outcomes.

Impact of a brief intervention to improve engagement in a recovery program for young adults with serious mental illness

OBJECTIVE

Serious mental illnesses (SMI) commonly emerge during young adulthood. Effective treatments for this population exist; however, engagement in treatment is a persistent challenge. This study examines the impact of Just Do You (JDY), an innovative intake-focused intervention designed to improve engagement in treatment and enhance personal recovery.

METHODS

The study used a parallel group randomized trial to examine if and how JDY improved recovery among 121 young adults with SMI from low-resourced communities referred to personalized recovery-oriented services (PROS). Measures of engagement (buy-in and attendance) and personal recovery in this pilot study were assessed at baseline and 3-month follow-up.

RESULTS

Participants in JDY reported more positive engagement outcomes; that is, relative to the control group they reported higher past two week attendance (b = 0.72, p < 0.05, Cohen's d = 0.56) and higher levels of buy-in to treatment (b = 2.42, p < 0.05, Cohen's d = 0.50). JDY also impacted young adults' personal recovery (b = 0.99, p < 0.05, Cohen's d = 1.15) and did so largely by increasing their level of buy-in to the treatment program.

CONCLUSION

This study suggests that an engagement intervention for young adults that orients, prepares, and empowers them to be active and involved in the larger treatment program makes a difference by improving engagement and enhancing recovery. Data also support conceptualizing and examining engagement beyond treatment attendance; in this study what mattered most for recovery was the level of buy-in to treatment among young adults.

Disengagement from early psychosis intervention services: an observational study informed by a survey of patient and family perspectives

Approximately one-third of patients with early psychosis disengage from services before the end of treatment. We sought to understand patient and family perspectives on early psychosis intervention (EPI) service engagement and use these findings to elucidate factors associated with early disengagement, defined as dropout from EPI in the first 9 months. Patients aged 16-29 referred to a large EPI program between July 2018-February 2020 and their family members were invited to complete a survey exploring facilitators and barriers to service engagement. A prospective chart review was conducted for 225 patients consecutively enrolled in the same EPI program, receiving the NAVIGATE model of coordinated specialty care, between July 2018-May 2019. We conducted a survival analysis, generating Kaplan-Meier curves depicting time to disengagement and Cox proportional hazards models to determine rate of disengagement controlling for demographic, clinical, and program factors. The survey was completed by 167 patients and 79 family members. The top endorsed engagement facilitator was related to the therapeutic relationship in both patients (36.5%) and families (43.0%). The top endorsed barrier to engagement was medication side effects in both patients (28.7%) and families (39.2%). In Cox proportional hazards models, medication nonadherence (HR = 2.37, 95% CI = 1.17-4.80) and use of individual psychotherapy (HR = .460, 95% CI = 0.220-0.962) were associated with early disengagement, but some of the health equity factors expected to affect engagement were not. Findings suggest that delivery of standardized treatment may buffer the effects of health disparities on service disengagement in early psychosis.

Pilot development and feasibility of telehealth Community Reinforcement and Family Training (CRAFT) for early psychosis and substance use

Substance use is associated with poor outcomes for individuals with early psychosis. Community Reinforcement and Family Training (CRAFT) is an evidence-based approach that helps families to reduce substance use, engage in treatment, and improve family wellbeing, but it has not yet been studied for psychosis and substance use. The present study aimed to develop and evaluate a telehealth intervention utilizing CRAFT for families experiencing early psychosis and substance use. Twenty family members completed six to eight telehealth sessions of CRAFT adapted for early psychosis (CRAFT-EP). Participants completed an assessment battery at baseline, mid- and post-intervention, a three-month follow-up, surveys after each session, and a focus group to measure mean percentage of sessions completed, mean program satisfaction ratings, telehealth preference, and qualitative feedback. Participants had 100% session completion, and program satisfaction was at or near excellent for 99% of sessions. Half of participants preferred a primarily virtual hybrid program, whereas 45% preferred exclusively virtual visits. Communication was the most helpful topic, and participants requested additional written examples and resources. CRAFT-EP is feasible and acceptable to serve as the active intervention in a pilot randomized controlled trial comparing treatment as usual plus CRAFT-EP to treatment as usual.

Three-year outcomes and predictors for full recovery in patients with early-stage psychosis

In the present study, various outcomes over 3-year period in patients with early stage psychosis including remission, recovery, relapse and medication adherence were investigated. Predictor for full recovery at year 3 was also examined. Three-year follow-up data in 534 patients with schizophrenia spectrum disorders (SSD) and psychotic disorder not otherwise specified (PNOS) were examined for overall outcome trajectories. The data of completers at year 3 (n = 157) were used to identify predictors for recovery using logistic regression. The rates of symptomatic remission and full recovery at 6-, 12-, 24-, and 36-month follow-up were 76.10, 69.20, 79.50, and 79.10%, and 22.80, 26.40, 28.60, and 39.60%, respectively. The rates of drop-out and relapse at 6-, 12-, 24-, and 36-month follow-up were 25.4, 29.5, 38.6, and 51.1%, and 3.7, 8.9, 19.0, and 38.9%, respectively. The rates of good adherence and prescription of Long-Acting Injectable Antipsychotics (LAIA) at 6-, 12-, 24- and 36-month follow-up were 87.8, 88.0, 91.9, and 93.9%, and 18.3, 21.7, 22.0, and 25.5%, respectively. Significant predictors for full recovery were duration of untreated psychosis (DUP), family intimacy and physical activity. We observed similar or better results on remission, recovery, and relapse rates compared to other previous studies. Effective psychosocial intervention should be provided to shorten the gap between remission and recovery rates and to address DUP, family issues, and exercise to enhance recovery.

Theoretical approaches to the engagement with patients in case-management programmes and assertive outreach teams: A systematic review of the literature

WHAT IS KNOWN ON THE SUBJECT?: It is generally accepted that all interventions carried out by mental health nurses involve engagement with the patient; this engagement is a process that is gradually constructed and is not immediate. In Spain during last decade, nurses working in assertive outreach teams have gradually replaced the traditional institutional setting in favour of environments that are more familiar to the patient. In contrast, when patients and nurses interact outside institutional settings, a new approach and skillset is required in order to adapt to the new environment. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: We have systematically identified and assessed the available evidence on how nurses work in assertive outreach team programmes. The therapeutic link is not just assistance; it is actually a construct, which is established between nurse and patient, with the aim of favouring, fostering and strengthening the therapeutic relationship. Only a few studies have discussed the nurse-patient therapeutic link in assertive outreach services. However, it seems important that nurses use a standardized language, that is, a language promoted as a model of correct use and used for functions of greater prestige, especially in public administration and teaching, to integrate it into the theoretical framework. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: With the synthesis that we present, we hope that it promote a more consistent use of the engagement concept in research on this topic. In turn, this will enhance staff support and training and will foster evidence-based practice. The conceptualization of nursing language and its use by professionals helps to improve practice and the lack of a theoretical framework with a nurse perspective. It is necessary to establish a consensus between mental health nurses around the engagement' meaning in the programmes of assertive outreach teams. ABSTRACT: Introduction During last decade in Spain, nurses working in assertive outreach programmes have replaced the traditional institutional setting in favour of the patient's own environment. Engagement with patients requires a different skillset when the axis of the nurse-patient interaction is the patient's own environment. The engagement alone could be associated with the innate concept of patient's care and the helping relationship. However, in the individualized care models, the engagement seems to be an instrument with its own characteristics for the purpose of providing mental health care. Aim/Question To systematically identify and assess the empirical evidence on the relationships and engagement between patients with mental illness (schizophrenia, psychotic disorders, schizoaffective disorders, mood disorders and disorders of adult personality) and nursing mental health nurses. Method Systematic literature review based on PRISMA guidance. Results We identified and reviewed seven primary research studies. Following the analytic processes, three themes emerged: existence of different engagement levels, training needs and skills in the creation and consolidation of the engagement, and engagement as process. Discussion The engagement of nurse and patient is understood as a process that incorporates different stages. Whilst it is established, the engagement is subject to positive and negative influences. For the creation of the engagement and its maintenance specialized skills, knowledge and personal attributes (resilience, psychosocial skills, compressive knowledge of mental health illnesses, capacity to build effective relationships, adaptability and problem-solving) are necessary, but the main focus is on context where it develops, selected by the patient himself, for example, his home. Implications for Practice Administrators may have questions about appropriate hiring practices for assertive outreach teams since certain skills are necessary to obtain un engagement process, and staff training should be considered a key issue to provide specific skills for enhancing engagement and the therapeutic relationship. Conclusion The engagement must be understood as a long-term process. For the creation of the engagement and its maintenance, specialized skills, knowledge and personal attributes are necessary.

Psychosis, Telehealth, and COVID-19: Successes and Lessons Learned From the First Wave of the Pandemic

OBJECTIVE

This brief report analyzes a first-episode psychosis (FEP) clinic's shift from in-person treatment to the provision of services through telemental health during the 2019 coronavirus disease (COVID-19) pandemic. The feasibility of using this technology was examined by assessing client engagement.

METHODS

The authors created and implemented procedures for the clinic's transition to telemental health. Once clients' consents were obtained, the Health Insurance Portability and Accountability Act (HIPAA) compliant platform was used to continue service provision.

RESULTS

Client engagement during this period improved compared to that of the same quarter in the previous year. Telemental health was also practical for providing groups and other supportive services to meet clients' needs.

CONCLUSION

Telemental health is an effective approach to providing care at an FEP clinic during a pandemic. Successes and lessons learned from the first wave of the pandemic can be used to prevent an uptick in symptoms and sustain engagement for this vulnerable population during the anticipated second wave.