Service Engagement in First-Episode Psychosis: Current Issues and Future Directions

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.

Leveraging Personal Technologies in the Treatment of Schizophrenia Spectrum Disorders: Scoping Review

BACKGROUND

Digital mental health is a rapidly growing field with an increasing evidence base due to its potential scalability and impacts on access to mental health care. Further, within underfunded service systems, leveraging personal technologies to deliver or support specialized service delivery has garnered attention as a feasible and cost-effective means of improving access. Digital health relevance has also improved as technology ownership in individuals with schizophrenia has improved and is comparable to that of the general population. However, less digital health research has been conducted in groups with schizophrenia spectrum disorders compared to other mental health conditions, and overall feasibility, efficacy, and clinical integration remain largely unknown.

OBJECTIVE

This review aims to describe the available literature investigating the use of personal technologies (ie, phone, computer, tablet, and wearables) to deliver or support specialized care for schizophrenia and examine opportunities and barriers to integrating this technology into care.

METHODS

Given the size of this review, we used scoping review methods. We searched 3 major databases with search teams related to schizophrenia spectrum disorders, various personal technologies, and intervention outcomes related to recovery. We included studies from the full spectrum of methodologies, from development papers to implementation trials. Methods and reporting follow the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines.

RESULTS

This search resulted in 999 studies, which, through review by at least 2 reviewers, included 92 publications. Included studies were published from 2010 to 2023. Most studies examined multitechnology interventions (40/92, 43%) or smartphone apps (25/92, 27%), followed by SMS text messaging (16/92, 17%) and internet-based interventions (11/92, 12%). No studies used wearable technology on its own to deliver an intervention. Regarding the stage of research in the field, the largest number of publications were pilot studies (32/92, 35%), followed by randomized control trials (RCTs; 20/92, 22%), secondary analyses (16/92, 17%), RCT protocols (16/92, 17%), development papers (5/92, 5%), and nonrandomized or quasi-experimental trials (3/92, 3%). Most studies did not report on safety indices (55/92, 60%) or privacy precautions (64/92, 70%). Included studies tend to report consistent positive user feedback regarding the usability, acceptability, and satisfaction with technology; however, engagement metrics are highly variable and report mixed outcomes. Furthermore, efficacy at both the pilot and RCT levels report mixed findings on primary outcomes.

CONCLUSIONS

Overall, the findings of this review highlight the discrepancy between the high levels of acceptability and usability of these digital interventions, mixed efficacy results, and difficulties with sustained engagement. The discussion highlights common patterns that may underscore this observation in the field; however, as this was a scoping review, a more in-depth systematic review or meta-analysis may be required to better understand the trends outlined in this review.

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.

Comparing Email Versus Text Messaging as Delivery Platforms for Supporting Patients With Major Depressive Disorder: Noninferiority Randomized Controlled Trial

BACKGROUND

The prevalence of major depressive disorder (MDD) poses significant global health challenges, with available treatments often insufficient in achieving remission for many patients. Digital health technologies, such as SMS text messaging-based cognitive behavioral therapy, offer accessible alternatives but may not reach all individuals. Email communication presents a secure avenue for health communication, yet its effectiveness compared to SMS text messaging in providing mental health support for patients with MDD remains uncertain.

OBJECTIVE

This study aims to compare the efficacy of email versus SMS text messaging as delivery platforms for supporting patients with MDD, addressing a critical gap in understanding optimal digital interventions for mental health care.

METHODS

A randomized noninferiority pilot trial was conducted, comparing outcomes for patients receiving 6-week daily supportive messages via email with those receiving messages via SMS text message. This duration corresponds to a minimum of 180 days of message delivery. The supportive messages maintained consistent length and structure across both delivery methods. Participants (N=66) were recruited from the Access 24/7 clinic in Edmonton, Alberta, among those who were diagnosed with MDD. The outcomes were measured at baseline and 6 months after enrollment using the Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), and the World Health Organization Well-Being Index (WHO-5).

RESULTS

Most of the participants were females (n=43, 65%), aged between 26 and 40 years (n=34, 55%), had high school education (n=35, 58%), employed (n=33, 50%), and single (n=24, 36%). Again, most participants had had no history of any major physical illness (n=56, 85%) and (n=61, 92%) responded "No" to having a history of admission for treatment of mood disorders. There was no statistically significant difference in the mean changes in PHQ-9, GAD-7, and WHO-5 scores between the email and SMS text messaging groups (mean difference, 95% CI: -1.90, 95% CI -6.53 to 2.74; 5.78, 95% CI -1.94 to 13.50; and 11.85, 95% CI -3.81 to 27.51), respectively. Both supportive modalities showed potential in reducing depressive symptoms and improving quality of life.

CONCLUSIONS

The study's findings suggest that both email and SMS text messaging interventions have equivalent effectiveness in reducing depression symptoms among individuals with MDD. As digital technology continues to evolve, harnessing the power of multiple digital platforms for mental health interventions can significantly contribute to bridging the existing treatment gaps and improving the overall well-being of individuals with depressive conditions. Further research is needed with a larger sample size to confirm and expand upon these findings.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04638231; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8552095/.

Care coordinator delivered method of levels therapy to improve engagement and other outcomes in early psychosis (CAMEO): protocol for a feasibility cluster-randomised controlled trial

BACKGROUND

Rates of disengagement from early intervention in psychosis (EIP) services are high. Care coordinators make up the largest staff group in EIP services and have the most frequent and sustained contact with service users. The quality of relationships between service users and care coordinators plays a central role in determining the effectiveness of EIP services. Care coordinators, however, are not routinely offered training in psychosocial interventions that could enhance the therapeutic impact of their role. Method of levels (MOL) is a flexible, transdiagnostic cognitive therapy with potential advantages over previously evaluated approaches. Training care coordinators in MOL could make their routine contacts with service users more helpful and improve outcomes such as recovery rates and levels of engagement.

AIMS

This study aims to assess the feasibility of training care coordinators in EIP services to deliver MOL, to understand whether this approach might improve service user engagement and recovery from psychosis compared to treatment as usual, and to assess the feasibility of conducting a cluster-randomised controlled trial (C-RCT) with clustering at the level of teams. Specific feasibility outcomes relate to the recruitment and retention of participants, care coordinators' level of engagement with the MOL training and supervision programme, implementation of MOL in practice, and the acceptability of the intervention amongst participants.

METHODS

A feasibility parallel group cluster-randomised controlled trial (C-RCT) designs with two arms: (1) treatment as usual (TAU) or (2) TAU plus support from a care coordinator who has received training in MOL. Randomisation will take place at the level of EIP teams with an allocation ratio of 1:2 in favour of the intervention arm. Our recruitment target is 12 EIP teams, 24 care coordinators working in participating EIP teams, and up to 96 service users working with participating care coordinators. Outcomes will be collected at baseline, 3 months, and 6 months. Qualitative methods will be used to understand participants' experiences of the study, MOL training programme, and MOL intervention.

DISCUSSION

This is the first study that aims to evaluate the feasibility of training EIP care coordinators to deliver MOL in their routine practice. Training care coordinators in MOL could enhance the quality of relationships between care coordinators and service users and improve outcomes for people experiencing early psychosis. Results will be used to determine the appropriateness of progressing to a larger evaluation trial.

TRIAL REGISTRATION

This study was prospectively registered with the ISRCTN Registry (14082421).

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.

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.

Trust of patients and families in mental healthcare providers and institutions: a cross-cultural study in Chennai, India, and Montreal, Canada

PURPOSE

Cross-cultural psychosis research has typically focused on a limited number of outcomes (generally symptom-related). It is unknown if the purported superior outcomes for psychosis in some low- and middle-income countries extend to fundamental treatment processes like trust. Addressing this gap, we studied two similar first-episode psychosis programs in Montreal, Canada, and Chennai, India. We hypothesized higher trust in healthcare institutions and providers among patients and families in Chennai at baseline and over follow-up.

METHODS

Upon treatment entry and at months 3, 12 and 24, trust in healthcare providers was measured using the Wake Forest Trust scale and trust in the healthcare and mental healthcare systems using two single items. Nonparametric tests were performed to compare trust levels across sites and mixed-effects linear regression models to investigate predictors of trust in healthcare providers.

RESULTS

The study included 333 patients (Montreal = 165, Chennai = 168) and 324 family members (Montreal = 128, Chennai = 168). Across all timepoints, Chennai patients and families had higher trust in healthcare providers and the healthcare and mental healthcare systems. The effect of site on trust in healthcare providers was significant after controlling for sociodemographic characteristics known to impact trust. Patients' trust in doctors increased over follow-up.

CONCLUSION

This study uniquely focuses on trust as an outcome in psychosis, via a comparative longitudinal analysis of different trust dimensions and predictors, across two geographical settings. The consistent differences in trust levels between sites may be attributable to local cultural values and institutional structures and processes and underpin cross-cultural variations in treatment engagement and outcomes.

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).

The Frequency of Design Studies Targeting People With Psychotic Symptoms and Features in Mental Health Care Innovation: Secondary Analysis of a Systematic Review

This study examined and reflected on the frequency of people with psychotic symptoms and features as the target population in design studies for mental health care innovation.

The relationship between therapeutic alliance, frequency of consultation and uptake of telemedicine among patients seeking treatment for early psychosis: A moderated mediation model

Background

Telehealth services ensure the delivery of healthcare services to a wider range of consumers through online platforms. Nonetheless, the acceptance and uptake of telehealth remain elusive. This study aims to understand the (a) uptake and (b) acceptability of telemedicine, (c) if therapeutic alliance mediates the relationship between the frequency of consultations with clinicians and the uptake of telemedicine in patients with early psychosis, and (d) role of education in moderating the relationship between therapeutic alliance and the uptake of telemedicine for their mental healthcare.

Methods

A convenience sample of outpatients (n = 109) seeking treatment for early psychosis and their care providers (n = 106) were recruited from a tertiary psychiatric care centre. Sociodemographic and clinical characteristics, therapeutic alliance (Working Alliance Inventory), and telemedicine use were captured through self-administered surveys. The moderated mediation analysis was performed using PROCESS macro 3.4.1 with therapeutic alliance and level of education as the mediating and moderating factors, respectively.

Results

The acceptance of telemedicine was high (possibly will use: 47.7%; definitely will use: 26.6%) whilst the uptake was low (11%). Therapeutic alliance mediated the relationship between the frequency of consultation and the uptake of telemedicine (β: 0.326; CI: 0.042, 0.637). This effect was moderated by the level of education (β: -0.058; p < 0.05).

Conclusion

Therapeutic alliance mediates the relationship between the frequency of consultations and the uptake of telemedicine services with the level of education moderating this mediation. Focusing on the patients with lower education to improve their telemedicine knowledge and therapeutic alliance might increase the uptake.

Clinician perspectives on providing telepsychiatry services to young adults with first-episode psychosis during COVID-19

BACKGROUND

Telepsychiatry has the potential to facilitate access to mental health services for young people with first-episode of psychosis (FEP); however, limited attention has been given regarding the perceptions of mental health providers in this regard.

OBJECTIVE

To assess service providers' perceptions on the use of telepsychiatry and changes over time.

METHODS

Longitudinal survey (conducted at two time points) of 26 service providers, including physicians, nurses, social workers, occupational therapists, and peer support workers, recruited from a specialized program for FEP providing telepsychiatry services through REACTS (videoconferencing platform).

RESULTS

Responses during the initial and the follow-up survey were similar. Most participants used REACTS nine times or more, with more than half reporting that sessions lasted more than 30 min. Over time, there was a trend towards higher frequency of use and lower duration of sessions. The majority perceived REACTS as safe and easy to use and indicated they would recommend REACTS to colleagues. Although participants reported some issues related to set-up and initial use, internet accessibility, and sound and image, most of these concerns decreased during follow-up. Participants appreciated the usability and utility of REACTS, and reported several benefits of telepsychiatry, including facilitating client engagement, assessment and continuity.

CONCLUSIONS

Service providers expressed positive perceptions regarding the use of telepsychiatry. Despite analysis being limited to a small sample, this study raises awareness of telepsychiatry's value and feasibility for offering services to young populations with FEP and the importance of conducting research on clinician perspectives in this regard.

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.

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.

Experiences of a Digital Mental Health Intervention from the Perspectives of Young People Recovering from First-Episode Psychosis: A Focus Group Study

Horyzons is a digital health intervention designed to support recovery in young people receiving specialized early intervention services for first-episode psychosis (FEP). Horyzons was developed in Australia and adapted for implementation in Canada based on input from clinicians and patients (Horyzons-Canada Phase 1) and subsequently pilot-tested with 20 young people with FEP (Horyzons-Canada Phase 2).

OBJECTIVE

To understand the experiences of young adults with FEP who participated in the pilot study based on focus group data.

METHODS

Among the twenty individuals that accessed the intervention, nine participated across four focus groups. Three team members were involved in data management and analysis, informed by a thematic analysis approach. A coding framework was created by adapting the Phase 1 framework to current study objectives, then revised iteratively by applying it to the current data. Once the coding framework was finalized, it was systematically applied to the entire dataset.

RESULTS

Four themes were identified: (1) Perceiving Horyzons-Canada as helpful for recovery; (2) Appreciating core intervention components (i.e., peer networking; therapeutic content; moderation) and ease of use; (3) Being unaware of its features; and (4) Expressing concerns, suggestions, and future directions.

CONCLUSIONS

Horyzons-Canada was well received, with participants wanting it to grow in scale, accessibility, and functionality.

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.

Trust of patients and families in mental healthcare providers and institutions: A cross-cultural study in Chennai, India and Montreal, Canada

Purpose

Cross-cultural psychosis research has typically focused on a limited number of outcomes (generally symptom-related). It is unknown if the purported superior outcomes for psychosis in some low- and middle-income countries extend to fundamental treatment processes like trust. Addressing this gap, we studied two similar first-episode psychosis programs in Montreal, Canada and Chennai, India. We hypothesized higher trust in healthcare institutions and providers among patients and families in Chennai at baseline and over follow-up.

Methods

Upon treatment entry and at months 3, 12 and 24, trust in healthcare providers was measured using the Wake Forest Trust scale and trust in the healthcare and mental healthcare systems using two single items. Non-parametric tests were performed to compare trust levels across sites and mixed-effects linear regression models to investigate predictors of trust in healthcare providers.

Results

The study included 333 patients (Montreal=165, Chennai=168) and 324 family members (Montreal=128, Chennai=168). Across all timepoints, Chennai patients and families had higher trust in healthcare providers and the healthcare and mental healthcare systems. The effect of site on trust in healthcare providers was significant after controlling for sociodemographic characteristics known to impact trust. Patients' trust in doctors increased over follow-up.

Conclusion

This study uniquely focuses on trust as an outcome in psychosis, via a comparative longitudinal analysis of different trust dimensions and predictors, across two geographical settings. The consistent differences in trust levels between sites may be attributable to local cultural values and institutional structures and processes and underpin cross-cultural variations in treatment engagement and outcomes.

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.

Mixed-effects models reveal prediction of long-term outcome by duration of untreated psychosis (DUP) and illness (DUI) varies with quantile gradation but is invariant with time across 7 years in the Cavan-Monaghan First Episode Psychosis Study (CAMFEPS)

While associations between duration of untreated psychosis (DUP) and outcome have been widely reported, how long these relationships endure following initiation of treatment and how such associations are distributed across the range of DUP values encountered remain unclear. This study investigates prospectively (i) whether prediction of outcome by DUP and by duration of untreated illness (DUI) diminishes, remains stable or increases in the long term after initiating treatment, and (ii) whether these relationships for differing indices of outcome vary across gradations of DUP-DUI values. Sixty-two subjects were evaluated prospectively for DUP, DUI, premorbid features, psychopathology and quality of life at both first episode psychosis (FEP) and at 7-year follow-up; functionality and service engagement were assessed at follow-up. Data were analysed using mixed-effects models for DUP and DUI quantiles. Prediction by longer DUP and DUI of greater psychopathology, particularly negative symptoms, and lower quality of life remained stable between FEP and follow-up; longer DUP and DUI also predicted lower functionality and service engagement at follow-up. While most associations were confined to the longest DUP-DUI quartile, those between DUP-DUI and negative symptoms and quality of life were distributed in a graded manner across DUP-DUI quartiles. Material confounding with premorbid features, including lead-time bias, was not supported. These findings suggest that benefits of reducing DUP-DUI may endure for at least a decade beyond FEP and that even modest reductions in DUP-DUI may confer particular advantage in the more debilitating and intransigent domain of impairment.

The Impact of Policy Changes, Dedicated Funding and Implementation Support on Early Intervention Programs for Psychosis

INTRODUCTION

Early intervention services for psychosis (EIS) are associated with improved clinical and economic outcomes. In Quebec, clinicians led the development of EIS from the late 1980s until 2017 when the provincial government announced EIS-specific funding, implementation support and provincial standards. This provides an interesting context to understand the impacts of policy commitments on EIS. Our primary objective was to describe the implementation of EIS three years after this increased political involvement.

METHODS

This cross-sectional descriptive study was conducted in 2020 through a 161-question online survey, modeled after our team's earlier surveys, on the following themes: program characteristics, accessibility, program operations, clinical services, training/supervision, and quality assurance. Descriptive statistics were performed. When relevant, we compared data on programs founded before and after 2017.

RESULTS

Twenty-eight of 33 existing EIS completed the survey. Between 2016 and 2020, the proportion of Quebec's population having access to EIS rose from 46% to 88%; >1,300 yearly admissions were reported by surveyed EIS, surpassing governments' epidemiological estimates. Most programs set accessibility targets; adopted inclusive intake criteria and an open referral policy; engaged in education of referral sources. A wide range of biopsychosocial interventions and assertive outreach were offered by interdisciplinary teams. Administrative/organisational components were less widely implemented, such as clinical/administrative data collection, respecting recommended patient-to-case manager ratios and quality assurance.

CONCLUSION

Increased governmental implementation support including dedicated funding led to widespread implementation of good-quality, accessible EIS. Though some differences were found between programs founded before and after 2017, there was no overall discernible impact of year of implementation. Persisting challenges to collecting data may impede monitoring, data-informed decision-making, and quality improvement. Maintaining fidelity and meeting provincial standards may prove challenging as programs mature and adapt to their catchment area's specificities and as caseloads increase. Governmental incidence estimates may need recalculation considering recent epidemiological data.

Telepsychiatry services during COVID-19: A cross-sectional survey on the experiences and perspectives of young adults with first-episode psychosis

INTRODUCTION

Limited evidence exists on the implementation of telepsychiatry within the context of early intervention services for psychosis, the need for which has become even more relevant during the COVID-19 pandemic. To address this gap, we investigated the experiences and perspectives of young adults recovering from a first-episode psychosis (FEP) following their use of telepsychiatry services (i.e. use of video conferencing technology to deliver mental health services to patients in real time).

METHODS

A cross-sectional online survey study was implemented between November 19^th , 2020 and March 9^th , 2021 with young adults recruited from a specialized program for FEP located in an urban Canadian setting. Data were analysed using descriptive statistics, exploratory (Fisher's exact test), and content analysis.

RESULTS

Among 51 participants (mean age = 26.0, SD = 4.7; 56.9% female), the majority were satisfied with the service (91%, 46/51), perceived that the platform was easy to use (90%, 46/51) and felt secure in terms of confidentiality (82%, 42/51). Satisfaction was related to perceptions regarding ease of use, image quality, and employment/studying status. Several partially or totally agreed that the presence of a third party was essential to login during the first few sessions (35%, 18/51), and some needed technical support (24%, 12/51) throughout the sessions.

CONCLUSIONS

This study shows that telepsychiatry is feasible and acceptable to implement for patients in the early phase of psychosis recovery. It also highlights the importance of making technical support available, especially in the first few times of using the service, and addressing patient concerns regarding confidentiality, even when using secured health technologies.

Context and contact: a comparison of patient and family engagement with early intervention services for psychosis in India and Canada

BACKGROUND

It is unknown whether patient disengagement from early intervention services for psychosis is as prevalent in low- and middle-income countries (LMICs) like India, as it is in high-income countries (HICs). Addressing this gap, we studied two first-episode psychosis programs in Montreal, Canada and Chennai, India. We hypothesized lower service disengagement among patients and higher engagement among families in Chennai, and that family engagement would mediate cross-site differences in patient disengagement.

METHODS

Sites were compared on their 2-year patient disengagement and family engagement rates conducting time-to-event analyses and independent samples t tests on monthly contact data. Along with site and family involvement, Cox proportional hazards regression included known predictors of patient disengagement (e.g. gender).

RESULTS

The study included data about 333 patients (165 in Montreal, 168 in Chennai) and their family members (156 in Montreal, 168 in Chennai). More Montreal patients (19%) disengaged before 24 months than Chennai patients (1%), χ²(1, N = 333) = 28.87, p < 0.001. Chennai families had more contact with clinicians throughout treatment (Cohen's d = -1.28). Family contact significantly predicted patient disengagement in Montreal (HR = 0.87, 95% CI 0.81-0.93). Unlike in Chennai, family contact declined over time in Montreal, with clinicians perceiving such contact as not necessary (Cohen's d = 1.73).

CONCLUSIONS

This is the first investigation of early psychosis service engagement across a HIC and an LMIC. Patient and family engagement was strikingly higher in Chennai. Maintaining family contact may benefit patient engagement, irrespective of context. Findings also suggest that differential service utilization may underpin cross-cultural variations in psychosis outcomes.

A Serious Game for Young People With First Episode Psychosis (OnTrack>The Game): Qualitative Findings of a Randomized Controlled Trial

BACKGROUND

Several studies have shown the benefits of coordinated specialty care (CSC) for individuals with first episode psychosis; however, pathways to care are marred by lack of knowledge, stigma, and difficulties with treatment engagement. Serious games or video interventions may provide a way to address these factors.

OBJECTIVE

This study focuses on qualitative results of a randomized controlled trial comparing OnTrack>The Game (OTG) with recovery videos (RVs) on engagement, stigma, empowerment, hope, recovery, and understanding of psychosis in clients receiving CSC. Clinicians are also interviewed regarding their perceptions of the interventions and suggestions for improvement.

METHODS

A total of 16 clients aged 16-30 years, with first episode psychosis attending a CSC program in New York State, and 9 clinicians participated in the qualitative interviews. Interviews were analyzed using the rapid identification of themes from audio recordings method.

RESULTS

For clients, themes included relatability of game content, an increased sense of hope and the possibility of recovery, decreased self-stigma and public stigma, increased understanding of the importance of social support, and increased empowerment in the OTG group. Clinicians had a preference for RV and provided suggestions for dissemination and implementation.

CONCLUSIONS

Themes that may help inform future research in this area, particularly regarding dissemination and implementation of OTG and RV, emerged.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03390491; https://clinicaltrials.gov/ct2/show/NCT03390491.

A Digital Health Innovation to Prevent Relapse and Support Recovery in Youth Receiving Specialized Services for First-Episode Psychosis: Protocol for a Pilot Pre-Post, Mixed Methods Study of Horyzons-Canada (Phase 2)

BACKGROUND

Psychotic disorders are among the most disabling of all mental disorders. The first-episode psychosis (FEP) often occurs during adolescence or young adulthood. Young people experiencing FEP often face multiple barriers in accessing a comprehensive range of psychosocial services, which have predominantly been delivered in person. New models of service delivery that are accessible, sustainable, and engaging are needed to support recovery in youth diagnosed with FEP.

OBJECTIVE

In this paper, we describe a protocol to implement and evaluate the acceptability, safety, and potential efficacy of an online psychosocial therapeutic intervention designed to sustain recovery and prevent relapses in young adults diagnosed with FEP. This intervention was originally developed and tested in Australia and has been adapted for implementation and evaluation in Canada and is called Horyzons-Canada (HoryzonsCa).

METHODS

This cohort study is implemented in a single-center and applies a pre-post mixed methods (qualitative-quantitative convergent) design. The study involves recruiting 20 participants from a specialized early intervention program for psychosis located in Montreal, Canada and providing them with access to the HoryzonsCa intervention for 8 weeks. Data collection includes interview-based psychometric measures, self-reports, focus groups, and interviews.

RESULTS

This study received funding from the Brain and Behavior Research Foundation (United States), the Quebec Health Research Funding Agency (Canada), and the Canada Research Chairs Program. The study was approved by the Research Ethics Board of the Centre intégré universitaire de santé et de services sociaux de l'Ouest-de-l'Île-de-Montréal on April 11, 2018 (#IUSMD 17-54). Data were collected from August 16, 2018, to April 29, 2019, and a final sample of 20 individuals participated in the baseline and follow-up interviews, among which 9 participated in the focus groups. Data analysis and reporting are in process. The results of the study will be submitted for publication in 2021.

CONCLUSIONS

This study will provide preliminary evidence on the acceptability, safety, and potential efficacy of using a digital health innovation adapted for the Canadian context to deliver specialized mental health services to youth diagnosed with FEP.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN43182105; https://www.isrctn.com/ISRCTN43182105.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR1-10.2196/28141.

Comparison of antipsychotic naïve first-episode psychosis patients and healthy controls in Uganda

INTRODUCTION

The risk factors for a first episode of psychosis in low and middle-income countries (LMICs) are not well described. The study compared the association of different risk factors in patients with first-episode psychosis patients and healthy controls from an LMIC context.

METHODS

A comparative, descriptive, cross-sectional study was performed in antipsychotic naïve first-episode psychosis patients and healthy controls at the National referral hospital in Uganda. Standardized tools were used to assess sociodemographic (e.g., age, sex, socioeconomic status) and clinical (e.g., childhood trauma, quality of life) variables. First episode psychosis participants were compared to healthy controls in terms of sociodemographic and clinical variables, and logistic regression was used to determine predictors of FEP.

RESULTS

Our final sample included 198 antipsychotic naïve first-episode psychosis participants and 82 controls. Most participants were female (68.5%) with a mean age of 29.4 years. After adjusting for age and sex, FEP patients when compared to controls were less likely to be female [AOR 0.18 (95%CI 0.03-0.85; p = .031)], more likely to have experienced emotional abuse [AOR 1.30 (95%CI 1.02-1.65; p = .032)] and more likely to have a poor quality of life [AOR 0.93 (95%CI 0.89-0.97; p = .002)].

DISCUSSION

The risk factors for a first episode of psychosis in this low and middle-income population were like those described in high-income countries. Further studies on interventions to prevent the transition to psychotic disorders in this sub-groups of patients are recommended. Also, the use of specialized early intervention services in improving the quality of life needs to be evaluated.

Measuring therapeutic engagement in acute mental health inpatient environments: the perspectives of service users and mental health nurses

BACKGROUND

A key component of caring for service users (SUs) in acute mental health inpatient environments is Therapeutic Engagement (TE). To that end, the Therapeutic Engagement Questionnaire (TEQ) was developed and validated. The TEQ measures TE between SUs and registered mental health nurses (RMHNs) from the perspective of both parties and can quantify and recognise how nurses engage with SUs and monitor this activity as well as its enhancement of SU care and recovery. The aim of this study was to explore the views of SUs and RMHNs in relation to the TEQ and how it could be adopted into clinical practice within an acute inpatient environment.

METHODS

As part of the validation stage of the development of the TEQ, the views of 628 SUs and 543 RMHNs were collected using a qualitative approach by way of free text at the end of the questionnaire. Two questions required free text response: - 'what do you think of the TEQ?', and 'how can it be utilised?'

RESULTS

Following thematic analysis, it was found that both sets of participants stated that such a tool could be utilised to improve the service, could help nurses with reflective practice, be utilised as part of clinical supervision and to aid nurses' professional development. The nurse participants also stated that such a tool would help track SU participation and enablement in their care. Furthermore, the nurses noted that the tool would help to reinforce the core 'caring' value of nursing and the overall goal of recovery. The SUs added that the TEQ would recognise the work of mental health nurses and provide them with a clear opportunity to express their views in relation to nursing staff.

CONCLUSIONS

Therapeutic engagement (TE) has been identified as part of the repertoire of mental health nursing and both groups of participants identified how a tool to assess this construct may be utilised in day-to-day clinical practice to the benefit of each group.

Investigating the impact of involuntary psychiatric hospitalization on youth and young adult trust and help-seeking in pathways to care

PURPOSE

Few studies have focused on the experience of involuntary psychiatric hospitalization among youth, especially the impact of these experiences on engagement with mental health services post-discharge. In this study, we contribute to a deeper understanding of youth experiences of involuntary hospitalization (IH) and its subsequent impacts on trust, help-seeking, and engagement with clinicians.

METHODS

The study utilized a grounded theory approach, conducting in-depth interviews with 40 youth and young adults (ages 16-27) who had experienced at least one prior involuntary hospitalization.

RESULTS

Three quarters of the youth reported negative impacts of IH on trust, including unwillingness to disclose suicidal feelings or intentions. Selective non-disclosure of suicidal feelings was reported even in instances in which the participant continued to meet with providers following discharge. Factors identified as contributing to distrust included perceptions of inpatient treatment as more punitive than therapeutic, staff as more judgmental than empathetic, and hospitalization overall failing to meet therapeutic needs. Conversely, participants reporting more mixed experiences of hospitalization and simultaneously strong indirect benefits, including greater family support, diminished family judgement members and greater access to care.

CONCLUSION

Findings draw attention to the ways in which coercive experiences may impact youth pathways to and through care. Additional research is needed to understand the impact of these experiences across larger samples, and their influence on downstream outcomes including engagement and long-term wellbeing. Finally, these data may inform the development and testing of inpatient and post-discharge interventions designed to mitigate potential harm.

Text Messaging Versus Email Messaging to Support Patients With Major Depressive Disorder: Protocol for a Randomized Hybrid Type II Effectiveness-Implementation Trial

BACKGROUND

Major depressive disorder (MDD) accounts for 40.5% of disability-adjusted life years caused by mental and substance use disorders. Barriers such as stigma and financial and physical access to care have been reported, highlighting the need for innovative, accessible, and cost-effective psychological interventions. The effectiveness of supportive SMS text messaging in alleviating depression symptoms has been proven in clinical trials, but this approach can only help those with mobile phones.

OBJECTIVE

This paper presents the protocol for a study that will aim to evaluate the feasibility, comparative effectiveness, and user satisfaction of daily supportive email messaging as an effective strategy compared to daily supportive text messaging as part of the treatment of patients with MDD.

METHODS

This trial will be carried out using a hybrid type II implementation-effectiveness design. This design evaluates the effectiveness of an implementation strategy or intervention, while also evaluating the implementation context associated with the intervention. Patients with MDD receiving usual care will be randomized to receive either daily supportive email messaging or daily supportive text messaging of the same content for 6 months. The Patient Health Questionnaire-9, the Generalized Anxiety Disorder-7, and the 5-item World Health Organization Well-Being Index will be used to evaluate the effectiveness of both strategies. The implementation evaluation will be guided by the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework, as well as the Consolidated Framework for Implementation Research. All outcome measures will be analyzed using descriptive and inferential statistics. Qualitative data will be analyzed using thematic analysis.

RESULTS

Data collection for this trial began in April 2021. We expect the study results to be available within 18 months of study commencement. The results will shed light on the feasibility, acceptability, and effectiveness of using automated emails as a strategy for delivering supportive messages to patients with MDD in comparison to text messaging.

CONCLUSIONS

The outcome of this trial will have translational impact on routine patient care and access to mental health, as well as potentially support mental health policy decision-making for health care resource allocation.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04638231; https://clinicaltrials.gov/ct2/show/NCT04638231.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/29495.

mHealth for Young Adults with Early Psychosis: User Preferences and Their Relationship to Attitudes About Treatment-Seeking

A long duration of untreated psychosis reduces benefits of early intervention for early psychosis. Digital technologies have potential to encourage help-seeking and reduce barriers to care. Because of high rates of smartphone ownership, mobile health (mHealth) interventions may be particularly well-suited to increase access. There is a lack of available information on the specific features that may be most appealing to young adults with early psychosis. The present study remotely recruited 77 young adults with psychosis and surveyed their interest in mHealth features, delivery modalities, and attitudes toward treatment. Overall, respondents reported high utilization of digital health and high interest in psychosis-specific mHealth. They expressed the highest interest (ordered by mean score by item) in information about medications and side effects (n = 69, 89.6% reporting being “interested” or “very interested”), managing stress and improving mood (n = 67, 89.3%) and symptoms of psychosis (n = 66, 88%), as well as in tracking changes in symptoms (n = 70, 90.9%), and goals (n = 66, 86.9%). They also reported high interest in content being delivered as text (n = 69, 89.6%) and also in communicating directly with providers. Respondents were less interested in social features, and those with most negative attitudes toward help-seeking had particularly low interest in features related to disclosing symptoms to others. These results suggest mHealth may have potential to engage individuals with early psychosis, and that the most effective strategies may be those that are most straightforward, including direct psychoeducational information.

PLAN-e-PSY, a mobile application to improve case management and patient's functioning in first episode psychosis: protocol for an open-label, multicentre, superiority, randomised controlled trial

INTRODUCTION

The prognosis of first episode psychosis (FEP), which is a severe disorder, can be notably impaired by patients' disengagement from healthcare providers. Coordinated specialty care with case management is now considered as the gold standard in this population, but there are still challenges for engagement with subsequent functional impairments. Youth-friendly and patient-centred clinical approaches are sought to improve engagement in patients with FEP. Mobile applications are widely used by young people, including patients with FEP, and can increase the youth friendliness of clinical tools. We hypothesise that a co-designed mobile application used during case management can improve functioning in patients with FEP as compared with usual case management practices.

METHODS AND ANALYSIS

A mobile case management application for planning and monitoring individualised care objectives will be co-designed with patients, caregivers and health professionals in a recovery-oriented approach. The application will be compared with usual case management practices in a multicentre, two-arm and parallel groups clinical trial. Patients will be recruited by specialised FEP teams. Impact on functioning will be assessed using the Personal and Social Performance Scale; the variation between baseline and 12 months in each group (control and active) will be the primary outcome.

ETHICS AND DISSEMINATION

This study has been approved by the Inserm Institutional Review Board IRB00003888 (Comité d'évaluation éthique de l'INSERM, reference number 20-647). The results of the study will be published in a peer-reviewed journal and presented at national and international conferences. We will also communicate the results to patients and family representatives' associations. An optimised version of the application will be then disseminated through the French FEP network (Transition Network).

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov: NCT04657380.

Psychosocial interventions for people with a first episode psychosis: between tradition and innovation

PURPOSE OF REVIEW

Assessing recent evidence on psychosocial interventions for people with first episode psychosis (FEP).

RECENT FINDINGS

Family interventions (FI) reduce relapse rates, whilst cognitive behavioural therapy (CBT) shows a moderate effect in improving positive psychotic symptoms. Vocational interventions (VI) appear to be worthy of implementation within early intervention for psychosis (EIP) teams, but it is still unclear what is the most cost-effective strategy for their delivery. Promising interventions, which need more careful evaluation, focus on substance misuse, physical health comorbidities, improvement of social participation, peer support and the potential of new technologies.

SUMMARY

The first five years after the onset of psychotic symptoms are a 'critical period' in which psychosocial interventions can be particularly influential in determining prognosis. Traditional EIP interventions have different effectiveness profiles, i.e., FI reduce relapse rates, CBT has a moderate effectiveness on overall and positive symptoms and VI can improve educational and employment-related functioning. Newer interventions show promise on important targets for FEP treatment but require higher-quality evaluations. Decisions on which interventions to implement within EIP teams should be informed by high-quality evidence, but difficult choices will have to be made based on costs, professionals and technologies available, and local priorities.

Roles of peer specialists and use of mental health services among youth with serious mental illness

AIM

To examine whether roles of peer specialists affect service use among Black, Latinx and White youth ages 16-24 with serious mental illness (SMI) in Los Angeles and San Diego Counties.

METHODS

Administrative data from 2015 to 2018 was used to summarize service use among 6329 transition age youth age 16-24 with SMI who received services from 76 outpatient public mental health programs with peer specialists on staff. Roles of peer specialists were assessed via a program survey. Generalized linear models were used to assess the relationship between peer specialist characteristics and service use outcomes (ie, outpatient and inpatient).

RESULTS

Having a transition age youth peer specialist on staff (vs older peer specialists) and having peer specialists that provide four or more services (vs fewer services) was associated with an increase in annual outpatient visits in both counties (P = <.001 each). In Los Angeles County, having three or more peer specialist trainings (vs fewer trainings) was associated with lower use of inpatient services (P < .001). In San Diego County, having a transition age youth peer specialist and peer specialists that provide four or more services was associated with lower use of inpatient services (P < .001 each).

CONCLUSIONS

Types of peer support and number of types of peer services were associated with mental health service utilization. Detailed examination of the roles of peer specialists is merited to identify the specific pathways that improve outcomes.

Dynamic Interplay Between Insight and Persistent Negative Symptoms in First Episode of Psychosis: A Longitudinal Study

Persistent negative symptoms (PNS) are an important factor of first episode of psychosis (FEP) that present early on in the course of illness and have a major impact on long-term functional outcome. Lack of clinical insight is consistently associated with negative symptoms during the course of schizophrenia, yet only a few studies have explored its evolution in FEP. We sought to explore clinical insight change over a 24-month time period in relation to PNS in a large sample of FEP patients. Clinical insight was assessed in 515 FEP patients using the Scale to assess Unawareness of Mental Disorder. Data on awareness of illness, belief in response to medication, and belief in need for medication were analyzed. Patients were divided into 3 groups based on the presence of negative symptoms: idiopathic (PNS; n = 135), secondary (sPNS; n = 98), or absence (non-PNS; n = 282). Secondary PNS were those with PNS but also had clinically relevant levels of positive, depressive, or extrapyramidal symptoms. Our results revealed that insight improved during the first 2 months for all groups. Patients with PNS and sPNS displayed poorer insight across the 24-month period compared to the non-PNS group, but these 2 groups did not significantly differ. This large longitudinal study supported the strong relationship known to exist between poor insight and negative symptoms early in the course of the disorder and probes into potential factors that transcend the distinction between idiopathic and secondary negative symptoms.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The Availability of Peer Support and Disparities in Outpatient Mental Health Service Use Among Minority Youth with Serious Mental Illness

We examine whether the availability of peer support reduces disparities in service use among minority youth ages 16-24 with serious mental illness in Los Angeles and San Diego Counties. Administrative data from 2015-2018 was used to summarize service use among 13,363 transition age youth age 16-24 with serious mental illness who received services from 183 outpatient public mental health programs; 17.2% were Black, 67.4% were Latinx, and 15.4% were non-Latinx white. The availability of peer support was assessed via a program survey. Generalized linear models were used to assess the relationship between availability of peer support, defined as having a peer specialist on staff, and the annual number of outpatient mental health visits. We also examined the relationship between racial/ethnic concordance of youth and peer specialists and use of outpatient services. Forty-six percent of youth received services from programs that employed peer specialists. Among youth in both counties, the availability of peer support was associated with an increase in annual outpatient visits (P ≤ .05 each). Peer support was associated with reductions in service use disparities among Black and Latinx youth in Los Angeles County (P < .001 each). Peer concordance was associated with an increase in outpatient service use among Latinx youth in both counties (P < .05 each). Peer support was associated with increases in use of outpatient mental health services. Detailed examination of the context for youth peer support implementation is merited to identify the specific pathways that improve outcomes.

Disengagement From Early Intervention Services for Psychosis: A Systematic Review

OBJECTIVE

Therapeutic benefits associated with early services for psychosis are influenced by the degree to which participants engage in treatment. The main objective of this review was to analyze rates of disengagement in early psychosis services and identify predictors of disengagement in these settings.

METHODS

A systematic search for studies published in the 1966-2019 period was conducted in PubMed, Google Scholar, EBSCO, Ovid, and Embase. The Observational Cohort and Cross-Sectional Studies scale was used to assess the methodological quality of reports identified in this search. A revised version of the behavioral model of health service use was employed to evaluate and understand predictors of disengagement (categorized as predisposing, enabling, and need factors) identified in the studies with the highest quality.

RESULTS

Twenty studies met the inclusion criteria. Disengagement rates (12% to 53%) and definitions of disengagement varied widely across these studies. Most did not find a compelling association between predisposing factors (e.g., age) and disengagement. Enabling factors, such as lack of family support and living alone, were consistently found to be related to increased disengagement across studies. Finally, need factors, such as lower medication adherence and higher drug misuse, were associated with higher risk for disengagement.

CONCLUSIONS

Enabling and need factors seemed to be the most predictive of disengagement from early psychosis services. Substantial between-study variation in identified predictors of disengagement may be addressed by developing and applying a consensus definition of disengagement in future research.

Mental health practitioner experiences of engaging with service users in community mental health settings: A systematic review and thematic synthesis of qualitative evidence

WHAT IS KNOWN ON THE SUBJECT?: Engagement is regarded as important and beneficial for service users and mental health services A universal definition of engagement is not yet fully agreed upon. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Based upon their experience, mental health staff use varied engagement approaches to fit with the changeable and unique needs of people who use services (service users). Mental health staff demonstrate qualities such as persistence and adaptability to successfully engage with service users. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Irrespective of professional background, the role of community mental health staff is not restricted to any single approach. Practical help and social support are as seen as important as clinical treatment to establish successful engagement. Little is known about the engagement experiences of mental health staff working in early intervention settings as most studies in this review focused on the perspectives of staff based in assertive outreach or community mental health teams. There is a need to further understand staff experiences of engagement with service users in early intervention settings. Role descriptions and expectations of community mental health workers should account for the wide-ranging flexible approach required in order to deliver appropriate interventions. This may involve a focus on engagement in training programmes. ABSTRACT: Introduction Effective mental health care is dependent on engaging service users, but some individuals do not actively attend appointments, and may stop engaging with mental health services. Quantitative studies reveal some salient factors that seem to predict engagement, but these studies miss the nuances of good clinical practice in this area. A number of qualitative studies of health professionals' experiences and understanding of effective engagement have been published. Aim This review aimed to systematically identify, evaluate and synthesize results from these studies with a view to informing effective practice in this area. Methods Electronic databases MEDLINE, EMBASE, CINAHL, PsychINFO and AMED were searched (PROSPERO systematic review protocol registry (www.crd.york.ac.uk/prospero/; ID CRD42017083976). Of 799 records, ten papers met the inclusion criteria. All papers were subjected to quality appraisal based on the CASP checklist and data systematically extracted. A thematic synthesis of included studies examining mental health practitioners' experiences of engagement in community mental health settings was conducted. Results Mental health practitioners see engaging service users as depending upon complex, multi-dimensional phenomena which should include individualized person-centred approaches as well as practical, social and clinical support. Mental health practitioners demonstrate qualities such as determination and adaptability to establish and maintain engagement with service users. Implications for practice As a core aspect of nurse education, registered mental health nurses and other professionals would benefit from systematic guidance regarding engagement strategies. Most studies in this review focused on assertive outreach or community mental health teams, more clarification is needed of practitioner's engagement experiences in early intervention settings.

Predictors of Early Discharge From Early Intervention Services for Psychosis in New York State

OBJECTIVE

Although specialized early intervention services (EISs) for psychosis promote engagement in care, a substantial number of individuals who receive these services are discharged from care earlier than expected. The main goal of this study was to examine predictors of early discharge in a large sample of individuals enrolled in an EIS program in the United States.

METHODS

This cohort study (N=1,349) used programmatic data from OnTrackNY, an EIS program that delivers evidence-based interventions to youths across New York State experiencing a first episode of nonaffective psychosis. The main outcome was "early discharge," which was operationalized as discharge prior to completing 12 months of treatment. Cox proportional hazard regression models were used to assess the association between sociodemographic, clinical, and support system predictors and early discharge.

RESULTS

The estimated probability of discharge before 1 year was 32%. Participants who at baseline had poor medication adherence, had no health insurance, were living alone or with nonparental family, or were using cannabis were at higher risk of leaving services within the first 12 months after enrollment. Individuals with higher social functioning were at lower risk of being discharged early from OnTrackNY, but those with higher occupational functioning were at a higher risk.

CONCLUSIONS

Predictors of early discharge from EISs largely overlapped with previously identified predictors of poor prognosis in early psychosis. However, the association between early discharge and high occupational functioning indicates that trajectories leading up to discharge are heterogeneous.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Coordinated Specialty Care Discharge, Transition, and Step-Down Policies, Practices, and Concerns: Staff and Client Perspectives

OBJECTIVE

In recent years, optimizing the process of transition and discharge from coordinated specialty care (CSC), a program that provides early intervention in psychosis, has emerged as an important focus area for program administrators, clinicians, and policy makers. To explore existing CSC policies and practices and to understand frontline provider and client views on discharge, the authors conducted a comprehensive analysis of staff and client interview data from the Mental Health Block Grant 10% Set-Aside Study.

METHODS

Data from 66 interviews with groups of CSC providers and administrators representing 36 sites and 22 states were analyzed, as well as data from interviews with 82 CSC clients at 34 sites. Transcripts were coded by using systematic content analyses.

RESULTS

Analyses of data from providers and administrators showed the heterogeneity of CSC program practices and strategies regarding discharge and highlighted a range of concerns related to postdischarge service accessibility and quality. Analysis of data from client interviews reflected the heterogeneity of transition challenges that clients confront. A significant number of participants reported concerns about their readiness for discharge.

CONCLUSIONS

CSC discharge policies and practices vary across CSC programs and states. Frequent clinician and client concerns about optimal program length, transition, and postdischarge services highlight the importance of sustained policy and research efforts to develop evidence-informed practice guidelines and possible modifications to the time-limited CSC model that currently dominates the field.

Predictors of study drop-out and service disengagement in patients at clinical high risk for psychosis

PURPOSE

Study drop-out during follow-up and service disengagement frequently occur in patients at clinical high risk for psychosis (CHR-P). However, little is known about their predictors. Therefore, we aimed to analyze the rate and reasons for drop-out and service disengagement in CHR-P patients and investigate their sociodemographic and clinical predictors.

METHODS

Data from 200 patients of the prospective Früherkennung von Psychosen (FePsy) study were analyzed with competing risks survival models, considering drop-out and transition to psychosis as competing events. To investigate whether symptoms changed immediately before drop-out, t tests were applied.

RESULTS

Thirty-six percent of patients dropped out within 5 years. Almost all drop-outs also disengaged from our service. Hence, study drop-out was used as a proxy for service disengagement. Patients with more severe baseline disorganized symptoms and a late inclusion into the study were significantly more likely to disengage. Immediately before disengagement, there was significant improvement in negative symptoms only.

CONCLUSION

A considerable proportion of CHR-P patients disengaged from our clinical study and service. Patients who were included during a later study period with more assessments disengaged more often, which might have been due to more frequent invitations to follow-up assessments and thereby increasing participation burden. Hence, our study provides a cautionary note on high-frequency follow-up assessments. Larger-scale studies evaluating predictors on multiple domains would help to further elucidate drop-out and disengagement.

Engagement in specialized early intervention services for psychosis as an interplay between personal agency and critical structures: A qualitative study

BACKGROUND

Specialized early intervention programs for individuals experiencing a first episode of psychosis prioritize service engagement, generally operationalized as attendance, treatment completion, therapeutic alliance, and treatment adherence. However, there are critical theoretical and methodological gaps in understanding how service users experience and define their engagement with the service.

OBJECTIVES

This study aimed to explore how current and former service users define their engagement with a specialized early intervention program.

DESIGN

A qualitative descriptive approach was used to explore service users' decisions to use, remain involved with, and/or leave early intervention services.

SETTING

This study took place in an early intervention service for psychosis in Montreal, Canada.

PARTICIPANTS

Twenty-four participants who had experienced a first episode of psychosis and had been engaged in the service to varying degrees (fully engaged, partially engaged, disengaged) took part in in-depth interviews.

METHODS

In-depth interviews were employed to collect rich insights into participants' experiences and perceptions. The interviews were transcribed and analysed using thematic analysis, beginning with an inductive approach and completing the analysis using a theoretical approach. During the analysis, our original notions of engagement and disengagement were challenged by theorizing engagement in terms of agency and structure. Researchers engaged in reflexive practices to maintain and promote research rigor and trustworthiness.

RESULTS

Participants' narratives were thematically analyzed and organized into three themes: fluidity and temporality of engagement and disengagement; engagement as an ongoing negotiation; and critical structures and agency. Participants described engagement in a variety of ways, some of which were broader than service use and focused on self-care and commitment to recovery. These conceptions were subject to change as the individuals' perceptions of their needs changed. As needs changed, individuals also negotiated and renegotiated their care needs with themselves and with their treatment team. These exercises of agency were constrained by key structures: the treatment team, family and friends, and societal conceptions of mental health.

CONCLUSIONS

Our study findings argue for an expanded definition of engagement which prioritizes individuals' experience and acknowledges the steps towards recovery that they may make outside of the purview of the service. It also underlines the importance of a treatment structure which aligns with individuals' needs for both support and autonomy.

The Use of Text Messaging to Improve Clinical Engagement for Individuals With Psychosis: Systematic Review

BACKGROUND

Individuals experiencing psychosis are at a disproportionate risk for premature disengagement from clinical treatment. Barriers to clinical engagement typically result from funding constraints causing limited access to and flexibility in services. Digital strategies, such as SMS text messaging, offer a low-cost alternative to potentially improve engagement. However, little is known about the efficacy of SMS text messaging in psychosis.

OBJECTIVE

This review aimed to address this gap, providing insights into the relationship between SMS text messaging and clinical engagement in the treatment of psychosis.

METHODS

Studies examining SMS text messaging as an engagement strategy in the treatment of psychosis were reviewed. Included studies were published from the year 2000 onward in the English language, with no methodological restrictions, and were identified using 3 core databases and gray literature sources.

RESULTS

Of the 233 studies extracted, 15 were eligible for inclusion. Most studies demonstrated the positive effects of SMS text messaging on dimensions of engagement such as medication adherence, clinic attendance, and therapeutic alliance. Studies examining the feasibility of SMS text messaging interventions found that they are safe, easy to use, and positively received.

CONCLUSIONS

Overall, SMS text messaging is a low-cost, practical method of improving engagement in the treatment of psychosis, although efficacy may vary by symptomology and personal characteristics. Cost-effectiveness and safety considerations were not adequately examined in the studies included. Future studies should consider personalizing SMS text messaging interventions and include cost and safety analyses to appraise readiness for implementation.

Youth Experiences With Referrals to Mental Health Services in Canada: Protocol for a Web-Based Cross-Sectional Survey Study

Background

Youth mental health is an important public health concern affecting low-, middle-, and high-income countries, and many young people in need of mental health services do not receive the care they need when they need it. An early step in accessing mental health care is the referral process, yet most of the research done on pathways to care has focused on clinical populations (eg, first-episode psychosis) recruited from mental health care settings. There has been limited research attention on the experiences of referral to mental health services from the perspectives of youth recruited from the general population who may or may not have received the services they need.

Objective

This study aims to investigate the experiences that youth between the ages of 17 and 30 years have with referrals to mental health services and to better understand their perspectives on the use of technology to facilitate referrals.

Methods

This study will use a cross-sectional, Web-based survey design. A convenience sample of 400 participants from 3 Canadian provinces (Quebec, Ontario, and British Columbia), between the ages of 17 and 30 years, will be recruited via Facebook and will be invited to complete a Web-based survey anonymously. A questionnaire including a series of quantitative and qualitative questions will ask participants about their sociodemographic characteristics, past experiences with referral and access to mental health services, and opinions about using technology to facilitate the referral process.

Results

Participant recruitment is planned to be initiated by early January 2020 and is estimated to be completed by May 2020. Data will be analyzed using descriptive statistics and logistic regression or chi-square tests for quantitative data, and descriptive content analysis will be used for the qualitative data.

Conclusions

The results of this study can help inform the improvement of referral policies and procedures in youth mental health service delivery. A better understanding of young people’s perspectives on referral processes and their opinions on how these processes can be improved are essential to providing appropriate and timely access to mental health care.

International Registered Report Identifier (IRRID)

PRR1-10.2196/16945