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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. [ABSTRACT FROM AUTHOR]

Purpose: To study the impact of supervised antipsychotic medication discontinuation on clinical and functional outcomes in first-episode psychosis (FEP) in two different cultural environments. Method: FEP patients(N = 253), treated in two early intervention services (Montreal, Canada and Chennai, India) for 2 years, were assessed for medication use, positive and negative symptom remission and social–occupational functioning at regular intervals. Results: Between months 4 and 24 of treatment, 107 patients discontinued medication ('Off'group) as compared to 146 who stayed on medication ('On'group). Medication discontinuation was higher in Chennai as compared to Montreal (n = 80, 49.07% vs n = 27, 16.87%; χ2 37.80, p < 0.001), with no difference in time to discontinuation [Means(SDs) = 10.64(6.82) and 10.04(5.43), respectively, p = 0.71). At month 24 (N = 235), there were no differences in the rate of positive symptom remission between the on and Off groups (81.5 vs 88.0%, respectively) at both sites. The rate of negative symptom remission was lower among patients in the On compared to the Off group (63.2 vs 87.9%, respectively, χ2 = 17.91, p < 0.001), but only in Montreal (55.4% vs 80.0%, respectively, χ2 = 4.12, p < 0.05). Social and Occupational Functioning Assessment Scale scores were equally high in both Off and On medication groups in Chennai [Means (SDs) = 79.43(12.95) and 73.59(17.63), respectively] but higher in the Off compared to the On group in Montreal Means (SDs) = 77.47(14.97) and 64.94(19.02), respectively; Time × site interaction F = 3.96(1,217), p < 0.05]. Medication status (On–Off) had no impact on the outcomes, independent of other variables known to influence outcomes. Conclusion: Certain cultural environments and patient characteristics may facilitate supervised discontinuation of antipsychotic medication following treatment of an FEP without negative consequences. [ABSTRACT FROM AUTHOR]

Introduction: Although extensively studied in high-income countries (HICs) and less so in low- and middle-income countries (LMICs), pathways to care and treatment delays in early psychosis have not been compared across contexts. We compared pathways to early intervention for psychosis in an HIC (Montreal, Canada) and an LMIC (Chennai, India). We hypothesised that the duration of untreated psychosis (DUP) would be longer in Chennai. Methods: The number of contacts preceding early intervention, referral sources, first contacts, and DUP and its referral and help-seeking components of first-episode psychosis patients at both sites were similarly measured and compared using chi-square analyses and t tests/one-way ANOVAs. Results: Overall and help-seeking DUPs of Chennai (N = 168) and Montreal (N = 165) participants were not significantly different. However, Chennai patients had shorter referral DUPs [mean = 12.0 ± 34.1 weeks vs. Montreal mean = 13.2 ± 28.7 weeks; t(302.57) = 4.40; p < 0.001] as the early intervention service was the first contact for 44% of them (vs. 5% in Montreal). Faith healers comprised 25% of first contacts in Chennai. Those seeing faith healers had significantly shorter help-seeking but longer referral DUPs. As predicted, most (93%) Montreal referrals came from medical sources. Those seeing psychologists/counsellors/social workers as their first contact had longer DUPs. Conclusion: Differences in cultural views about mental illnesses and organizational structures shape pathways to care and their associations with treatment delays across contexts. Both formal and informal sources need to be targeted to reduce delays. Early intervention services being the first portal where help is sought can reduce DUP especially if accessed early on in the illness course. [ABSTRACT FROM AUTHOR]

Purpose: While the prevalence of delusional themes appears to be consistent across geographic contexts, little is known about the relative prevalence of such themes within a given setting over periods of time. We therefore investigated delusional themes across 12 years of presentation to a catchment-based early intervention service for first episode psychosis (FEP). Methods: Systematically collected data from 500 patients at an early intervention service for FEP were analyzed. Four cohorts of 3 years each, from 2006 to 2017, were used to compare the frequency of delusion themes across cohorts. We also integrated into the analysis baseline sociodemographic factors such as gender, age, and highest level of education and clinical factors such as anxiety, depression, suicidality, hallucinations, and primary diagnosis (affective or non-affective psychosis). Results: Sex and education level were stable across cohorts, while patient age varied (p = 0.047). Clinical anxiety, depression, and suicidality at entry were also stable. Across cohorts, the proportion of patients with affective versus non-affective diagnosis differed (p = 0.050), with no differences in global rating of delusion severity or theme prevalence except for delusions of guilt or sin (p = 0.001). This single theme difference was not correlated with age or diagnosis. Conclusion: Our study suggests relatively stable prevalence of delusion themes across cohorts of individuals experiencing FEP. This demonstrates the potential utility of studying thematic content both for understanding delusions in clinical populations and in research. Future explorations of the relationships between delusion themes and across individual patient episodes should be conducted. [ABSTRACT FROM AUTHOR]

Purpose: Interventions aimed at influencing specific pathways to care may reduce the duration of untreated psychosis (DUP). The purpose of this study was to reduce delay in referral to an early intervention service following first contact for help seeking for psychosis in a defined urban catchment area. Methods: Using a historical control design, we conducted a targeted intervention comprised of intensive training and education regarding first onset of psychosis and benefits of early intervention with all potential points of contact in pathways to care in a defined catchment area of a specialized early intervention (EI) service. Data collected on different components of DUP [help seeking (H-DUP) and referral (R-DUP)] and demographic and clinical characteristics on patients seeking treatment of first episode of a psychotic (FEP) disorder accepted in the EI service for 3 years before and 3 years after the intervention were contrasted. No other systemic changes occurred in this catchment area during this period. Results: There was a significant increase in the number of cases of FEP referred to the EI service post-intervention from hospitals other than the parent institute, in the proportion with a diagnosis of affective psychosis and proportion of patients from a lower socioeconomic status (SES). Although largest proportion of patients continued to make their first contact with community services, the latter failed to refer cases of psychosis to the EI service despite making a large number of mostly non-cases (for psychosis). The intervention had no direct effect on total DUP, R-DUP or H-DUP. After controlling for diagnosis and SES, post-intervention, R-DUP remained significantly lower for patients making first contact with the emergency service of the parent institute. Conclusions: The intervention failed to reduce R-DUP for patients making contact with or referred from community services and most patients still used hospital resources to enter treatment at the EI service. [ABSTRACT FROM AUTHOR]

Purpose: The early phases of psychosis, including the prodrome, often feature educational/occupational difficulties and various symptoms and signs, that can render or keep youths "Not in Employment, Education or Training" (NEET). Conversely, NEET status itself may increase risk for illness progression and impaired functioning, and impede access to appropriate services for psychosis. As these issues have not been investigated, we aimed to examine differences in the illness and care pathways and characteristics of youths with psychosis who are NEET and non-NEET.Methods: Youths entering a catchment-based Canadian early intervention service for psychosis (N = 416) were assessed as being NEET or non-NEET and compared on symptomatology, premorbid adjustment, prodrome and duration of untreated psychosis (DUP).Results: Thirty-nine percent of the sample was NEET. Compared to non-NEET youths, NEET youths had 34% higher negative symptoms scores, longer prodromes (median of 52 weeks vs. 24 weeks), and were more often continuously ill after their first psychiatric change until the onset of psychosis (62% vs. 45%). Both groups had similar premorbid adjustment scores until late adolescence when scores were significantly worse for NEET youths. Accounting for other predictors, NEET youths had 23% longer DUPs on average, despite having made more help-seeking attempts.Conclusions: Despite being more narrowly defined, NEET status was thrice as prevalent in our sample as in the Canadian population. The NEET group followed a distinct trajectory of persistent symptoms and functional decline before presenting with a psychotic disorder. The systemic delays that NEET youths encountered indicate a need for better-targeted early identification efforts. [ABSTRACT FROM AUTHOR]

Purpose: To explore the unintended impact of a targeted case identification (TCI) campaign for first episode psychosis (FEP) on people not experiencing FEP ("non-cases") with respect to referral patterns and reasons for being a non-case.Methods: Sources of referral, reasons for being a non-case, and subsequent referral destinations of non-cases were examined before and after a TCI.Results: Following the TCI, a greater proportion of non-cases lived outside the study catchment area. A smaller proportion was referred by the parent hospital's emergency room or had a substance-induced psychosis.Conclusions: TCIs for FEP may have unintended effects, with implications for early case identification and early intervention services. [ABSTRACT FROM AUTHOR]

Purpose: The objective of this review is to report on recent developments in youth mental health incorporating all levels of severity of mental disorders encouraged by progress in the field of early intervention in psychotic disorders, research in deficiencies in the current system and social advocacy.Methods: The authors have briefly reviewed the relevant current state of knowledge, challenges and the service and research response across four countries (Australia, Ireland, the UK and Canada) currently active in the youth mental health field.Results: Here we present information on response to principal challenges associated with improving youth mental services in each country. Australia has developed a model comprised of a distinct front-line youth mental health service (Headspace) to be implemented across the country and initially stimulated by success in early intervention in psychosis; in Ireland, Headstrong has been driven primarily through advocacy and philanthropy resulting in front-line services (Jigsaw) which are being implemented across different jurisdictions; in the UK, a limited regional response has addressed mostly problems with transition from child-adolescent to adult mental health services; and in Canada, a national multi-site research initiative involving transformation of youth mental health services has been launched with public and philanthropic funding, with the expectation that results of this study will inform implementation of a transformed model of service across the country including indigenous peoples.Conclusions: There is evidence that several countries are now engaged in transformation of youth mental health services and in evaluation of these initiatives. [ABSTRACT FROM AUTHOR]