Over 30 years of STEP: The Pittsburgh experience with first-episode psychosis

AIMS

For over 30 years, combined research and treatment settings in the US have been critical to conceptualizing care for first-episode psychosis (FEP). Here we describe an early example of such a context, the Services for the Treatment of Early Psychosis (STEP) clinic, which is affiliated with the University of Pittsburgh.

METHODS

We describe STEP's historical roots and establishment in the early 1990s; STEP's research and treatment contributions, alongside its growth and ongoing leadership.

RESULTS

Research-based clinics, like STEP, preceded and helped pave the way for the Recovery After an Initial Schizophrenia Episode project in the US and the ensuing Coordinated Specialty Care (CSC) approach, now widely adopted in the US. Early clinic-based research at STEP helped establish protocols for psychopharmacology, the relevance of effective early treatment, including psychosocial approaches, and highlighted disparities in treatment outcomes across race/ethnicity. Multidisciplinary collaboration and dialogue with consumers contributed to early treatment, combining psychosocial and pharmacological approaches. STEP adopted CSC and is situated within a bi-state Learning Health System. STEP has retained a relatively unique 5-year treatment model and exists within continuum of care ideally suited to studying psychotic illness and treatment outcomes.

CONCLUSIONS

STEP remains the largest academic FEP clinic in Pennsylvania. Academic FEP clinics like STEP will have a critical role within Learning Health Systems nationally to model participatory approaches, sustain early intervention treatment quality and ongoing treatment developments.

Service User Representation in Qualitative Research on Cognitive Health and Related Interventions for Psychosis: A Scoping Review

BACKGROUND AND HYPOTHESIS

Cognitive health in schizophrenia spectrum psychosis has received substantial empirical attention in recent decades, coinciding with the development and implementation of interventions including cognitive remediation. Subjective experience in psychosis, including qualitative explorations of service user perspectives, has also proliferated; however, there is no available synthesis of service user representation in the psychosis cognitive health literature. This scoping review investigated prevalence and characteristics of qualitative research reporting service user perspectives across the extant research on cognitive health and related interventions in psychosis.

STUDY DESIGN

We conducted a literature search on qualitative methods in cognitive health and/or related interventions across PubMed, Web of Science, and PsycInfo databases. The review followed the PRISMA-ScR guidelines for scoping reviews and identified 23 papers. Data extraction included study design and sample characteristics, qualitative methodology, and reporting.

STUDY RESULTS

Of 23 articles, 18 reported on user experiences of interventions, most often in the context of feasibility/acceptability for otherwise quantitative trials. Five studies described service user experiences of cognitive health separately from interventions. Only 3 included any service user involvement or participatory methods. Twenty articles reported any demographic characteristics, and fewer than half (11) reported any racial or ethnic sample characteristics. There was substantial variability in qualitative methodology and reporting across studies.

CONCLUSIONS

Qualitative methodology is lacking in its representation and rigor across the cognitive health literature for schizophrenia spectrum psychosis. Additional inclusion of service user lived experience is critical for future research to better characterize cognitive health and inform interventions to promote recovery.

Using latent class analysis to investigate enduring effects of intersectional social disadvantage on long-term vocational and financial outcomes in the 20-year prospective Chicago Longitudinal Study

BACKGROUND

Class and social disadvantage have long been identified as significant factors in the etiology and epidemiology of psychosis. Few studies have explicitly examined the impact of intersecting social disadvantage on long-term employment and financial independence.

METHODS

We applied latent class analysis (LCA) to 20-year longitudinal data from participants with affective and non-affective psychosis (n = 256) within the Chicago Longitudinal Research. LCA groups were modeled using multiple indicators of pre-morbid disadvantage (parental social class, educational attainment, race, gender, and work and social functioning prior to psychosis onset). The comparative longitudinal work and financial functioning of LCA groups were then examined.

RESULTS

We identified three distinct latent classes: one comprised entirely of White participants, with the highest parental class and highest levels of educational attainment; a second predominantly working-class group, with equal numbers of Black and White participants; and a third with the lowest parental social class, lowest levels of education and a mix of Black and White participants. The latter, our highest social disadvantage group experienced significantly poorer employment and financial outcomes at all time-points, controlling for diagnosis, symptoms, and hospitalizations prior to baseline. Contrary to our hypotheses, on most measures, the two less disadvantaged groups did not significantly differ from each other.

CONCLUSIONS

Our analyses add to a growing literature on the impact of multiple forms of social disadvantage on long-term functional trajectories, underscoring the importance of proactive attention to sociostructural disadvantage early in treatment, and the development and evaluation of interventions designed to mitigate ongoing social stratification.

Trauma and Trauma-Informed Care in Early Intervention in Psychosis: State of Implementation and Provider Views on Challenges

OBJECTIVE

Although trauma is increasingly recognized as a major risk factor for psychosis and for its link to treatment outcomes, the landscape of trauma-related practices in specialized early psychosis services in the United States and other countries remains only poorly characterized. Research documenting the perspectives of frontline providers is also lacking. The primary goals of this study were to document the state of trauma-related policy implementation in early intervention in psychosis (EIP) programs and to gather provider perspectives.

METHODS

This was a mixed-methods project involving an international EIP provider survey, followed by in-depth provider interviews. The survey was disseminated in Australia, Canada, Chile, the United Kingdom, and the United States. In total, 164 providers, representing 110 unique sites, completed the survey. Frequencies were calculated for responses to survey items, and open-ended responses were analyzed with a systematic content analysis.

RESULTS

The survey findings suggested low implementation rates for a variety of assessment and support practices related to trauma and trauma-informed care. Coding of open-ended responses revealed numerous concerns and uncertainties among providers regarding the relationship between trauma and psychosis and the state of the EIP field.

CONCLUSIONS

An expansion of research and service development aimed at better meeting the trauma-related needs of young people with psychosis is essential, with implications for EIP outcomes and service user and staff experiences.

Cycles of reform in the history of psychosis treatment in the United States

The history of psychosis treatment follows a series of four cycles of reform which provide a framework for understanding mental health services in the United States. The first three cycles of reform promoted the view that early treatment of mental disorders would reduce chronic impairment and disability. The Moral Treatment era (early 1800's to 1890) featured freestanding asylums, the Mental Hygiene movement (1890 to World War II) introduced psychiatric hospitals and clinics, and the Community Mental Health Reform period (World War II to late 1970's) produced community mental health centers. None of these approaches succeeded in achieving the disability-prevention goals of early treatment of psychosis. The fourth cycle, the Community Support Reform era (late 1970's to the present) shifted the focus to caring for those already disabled by a mental disorder within their communities and using natural support systems. This shift embraced a broader social welfare framework and included additional services and supports, such as housing, case management, and education. Psychosis became more central during the current Community Support Reform era partly because individuals with psychosis continued to have disabling life experiences despite efforts at reform. Some degree of recovery from psychosis is possible, and individuals with serious impairment may move towards social integration and community participation. Early intervention for young people with psychosis focuses on reducing the negative sequelae of psychosis and promotes recovery-oriented changes in service delivery. The role of social control, the involvement of service users and their families, and the balance between psychosocial and biomedical treatments play an important role in this history. This paper describes the reform cycles, their political and policy contexts, and what influenced its successes and shortcomings.

Use of Assistive Technology for Persons with Psychosocial Disability: Systematic Review

BACKGROUND

Assistive technology (AT) refers to assistive products (AP) and associated systems and services that are relevant for function, independence, well-being, and quality of life for individuals with disabilities. There is a high unmet need for AT for persons with disabilities and this is worse for persons with cognitive and mental or psychosocial disabilities (PDs). Further, information and knowledge on AT for PDs is limited.

OBJECTIVE

The aim of this review was to explore the pattern of AT use among persons with PDs and its associated socioeconomic and health benefits.

METHODS

The review was reported according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses), and we conducted systematic searches in the 4 databases: PubMed, Embase.com, APA PsycInfo (Ebsco), and Web of Science (Core Collection) with the following index terms: "Assistive Technology," "Self-Help Devices," "Quality of Life," "Activities of Daily Living," "Mental Disorders." We included only AT individuals with PDs can independently use without reliance on a provider. Identified papers were exported to EndNote (Clarivate) and we undertook a narrative synthesis of the included studies.

RESULTS

In total, 5 studies were included in the review which reported use of different AT for schizophrenia, bipolar disorder, depression and anxiety disorders. The APs described in the included studies are Palm tungsten T3 handheld computer, MOBUS, personal digital assistant, automated pill cap, weighted chain blankets, and smartphone function. All the AT products identified in the studies were found to be easily usable by individuals with PDs. The APs reported in the included studies have broad impact and influence on social function, productivity, and treatment or management. The studies were heterogeneous and were all conducted in high-income countries.

CONCLUSIONS

Our study contributes to and strengthens existing evidence on the relevance of AT for PDs and its potential to support socioeconomic participation and health. Although AT has the potential to improve function and participation for individuals with PDs; this review highlights that research on the subject is limited. Further research and health policy changes are needed to improve research and AT service provision for individuals with PDs especially in low-income settings.

TRIAL REGISTRATION

PROSPERO CRD42022343735; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=343735.

Recovering the Vocational Self?: Service User Accounts of Barriers to Work and School and the Role of Early Psychosis Services in Supporting Career Development

Vocational recovery is frequently identified as a primary goal of specialized early intervention in psychosis services (EIS). However, few studies have investigated the multi-level impacts of psychosis and its social sequelae on emerging vocational identities and mechanisms by which EIS may contribute to longer-term career development. The goal of this study was to deepen our understanding of the experiences of young adults with early psychosis during and following discharge from EIS as they relate to vocational derailment, identity and career development. We conducted in-depth interviews with 25 former EIS recipients and five family members (N = 30). Interviews were analyzed using modified grounded theory, with an orientation to generating a rich, theory informed understanding young people's experiences. Approximately half of the participants in our sample were not in employment, education, or training (NEET) and had applied for or were receiving disability benefits (SSI/SSDI). Among those participants who were working, the majority reported short-term, low-wage work. Thematic findings elucidate factors underlying the erosion of vocational identity, as well as ways in which both participant-reported vocational service characteristics and socioeconomic background shape different pathways to college, work and/or disability benefits both during and following discharge from EIS. Findings underscore the need for additional research on vocational identity among youth and young adults with early psychosis and the development and evaluation of interventions designed to support career development, address social and structural barriers to education and training, and foster long-term socioeconomic mobility.

Programmatic Support for Peer Specialists that Serve Transition Age Youth Living with Serious Mental Illness: Perspectives of Program Managers from Two Southern California Counties

Peer Specialists (PS) often work in outpatient mental health programs serving transition age youth (TAY). This study examines program managers' perspectives on efforts to strengthen PS' professional development. In 2019, we interviewed program managers (n = 11) from two Southern California Counties employed by public outpatient mental health programs (n = 8) serving TAY and conducted thematic analyses. We present themes and illustrative quotes. PS' roles are highly flexible; thus, PM support PS to strengthen skills to address organization-facing and client-facing responsibilities. PM addressed time management, documentation, PS integration into the organization, and workplace relationships. Trainings to better support clients included addressing cultural competency to serve LGBTQ TAY and racial/ethnic subgroups. Diverse supervision modalities address PS' diverse needs. Supporting PS' technical and administrative skills (e.g., planning, interpersonal communication skills) may aid their implementation of a complex role. Longitudinal research can examine the impact of organizational supports on PS' job satisfaction, career trajectories, and TAY clients' engagement with services.

Barriers to Meaningful Participatory Mental Health Services Research and Priority Next Steps: Findings From a National Survey

OBJECTIVE

A growing consensus has emerged regarding the importance of stakeholder involvement in mental health services research. To identify barriers to and the extent of stakeholder involvement in participatory research, the authors undertook a mixed-methods study of researchers and community members who reported participation in such research.

METHODS

Eight consultative focus groups were conducted with diverse groups of stakeholders in mental health services research (N=51 unique participants, mostly service users), followed by a survey of service users, family members, community providers, and researchers (N=98) with participatory research experience. Focus groups helped identify facilitators and barriers to meaningful research collaboration, which were operationalized in the national survey. Participants were also asked about high-priority next steps.

RESULTS

The barrier most strongly endorsed as a large or very large problem in the field was lack of funding for stakeholder-led mental health services research (76%), followed by lack of researcher training in participatory methods (74%) and insufficiently diverse backgrounds among stakeholders (69%). The two most frequently identified high-priority next steps were ensuring training and continuing education for researchers and stakeholders (33%) and authentically centering lived experience and reducing tokenism in research (26%).

CONCLUSIONS

These findings suggest a need for increased attention to and investment in the development, implementation, and sustainment of participatory methods that prioritize collaboration with direct stakeholders, particularly service users, in U.S. mental health services research. The findings also underscore the presence and potentially important role of researchers who dually identify as service users and actively contribute a broader orientation from the service user-survivor movement.

Changes in knowledge, behavioural expectations, self-efficacy, and stigma after an educational campaign about early psychosis for jail correction officers

AIM

Given a lack of interventions to identify and engage individuals with early psychosis in jail and connect them to specialty care in the community upon release, we designed a Targeted Educational Campaign (TEC) for correction officers working in jails. We report on impacts of the TEC on officers' cognitive and attitudinal outcomes.

METHODS

Three different cohorts of officers-totaling n = 451-took part in a survey: 200 at baseline before the TEC began, 123 at 6-months into the TEC, and 128 at 12-months into the TEC. Among each cohort of officers, four constructs were measured: (1) knowledge about early psychosis; (2) self-efficacy around detecting early psychosis and referring to mental health services within the jail; (3) expectations about the benefits of detection and referral to specialty care; and (4) social distance stigma toward detainees with early psychosis.

RESULTS

While exposure to TEC elements was as-planned in the first 6-months, exposure diminished substantially at 12-months, coinciding with increasing fatigue among correction officers due to the COVID-19 pandemic as well as serious staffing shortages. Knowledge, behavioural expectations, and self-efficacy scores improved from baseline to 6-months, with greater exposure to roll-call messages driving scores. Knowledge and behavioural expectations at 12-months were associated with having received an information post card. Social distance stigma worsened across timepoints.

CONCLUSIONS

An educational campaign for jail staff can enhance knowledge, self-efficacy, and behavioural expectations regarding early psychosis, though only while the campaign elements are active. Further research should investigate whether or not social distance stigma or other types of stigma increase alongside improvements.

PERSPECTIVE: Forecasting the Future: Lived Experience and the Transformation of Mental Health Services Research in the United States

Over the past two decades, consensus has emerged in WHO and other international organizations regarding the foundational role and importance of integrated service users - individuals with lived experience of mental health services and systems - into mental health clinical and services research. At present, support and infrastructure in the United States (US) lags behind many other high-income, Anglophone and Western European countries. This Perspective, originally part of the 2022 NIMH Mental Health Services Research Conference's "Forecasting the Future" plenary panel, makes the case for systematic and coordinated investment in the policy, funding, infrastructure and organizational change that would be necessary to substantively strengthen participatory and co-produced mental health services research in the US.

Cracks that Let the Light in: Collective Reflections on Integrating Lived Experience of Psychosis in Research and Policy in the Context of a Global Commission

Within psychiatric research fields, there has been a marked uptick of interest in service user involvement in recent years. Nevertheless, it is often unclear how robust or impactful common forms of inclusion are, and the extent to which they have included individuals with psychosis. Using collective auto-ethnography, this paper describes the experiences of 8 academic and non-academic members of the 'lived experience' and participatory research workgroup of a global psychosis Commission and our navigation of power and power hierarchies, differences in background and training, and multiple vectors of identity, diversity, and privilege. We conclude that the realities of "involvement" are much messier, more fraught, and less intrinsically empowering than often signaled in calls for involvement and co-production. We nevertheless stress the power of collective dialogue and support-between and among a pluralistic group-and of honesty and transparency about challenges, barriers, and the colonial underpinnings and geopolitics of global mental health.

A262 NEONATAL ACUTE LIVER FAILURE DUE TO PRESUMED GESTATIONAL ALLOIMMUNE LIVER DISEASE - A CASE REPORT

Background

Neonatal acute liver failure (NALF) is a rare disease that is distinct from acute liver failure seen in older children and adults. Gestational alloimmune liver disease (GALD) is the most frequent cause, is initiated in utero by sensitization of the maternal immune system to a fetal hepatocyte antigen and subsequent production of maternal immunoglobulin G antibodies that cross the placenta. Maternal IgG binds to a fetal hepatocyte antigen and initiates an innate immune response involving the terminal complement cascade and membrane attach complex. The understanding of the alloimmune origin has led to the use of intravenous immunoglobulin (IVIG) treatment and exchange transfusion, significantly increasing survival. However, approximately 25% of patients may not respond and require salvage liver transplantation. In spite of an increased rate of comorbidities, concern for technical difficulties and limited graft availability, young infants eligible for transplant have been shown to have similar overall patient and graft survival rates compared to older children with other indications for liver transplant.

Purpose

The primary aim of our study is to report a case of NALF with successful liver transplant.

Method

We present the case of a preterm girl with NALF due to GALD refractory to medical management, requiring liver transplantation.

Result(s)

This is a 35-week preterm girl, with scant pre-natal care, birth weight of 1.825 kg and Apgar 9/9. She is the seventh child of non-consanguineous parents, with healthy siblings. On day-of-life (DOL) 1 she presented with acute kidney injury, progressive worsening metabolic acidosis and hyperammonemia and was found to be profoundly coagulopathic (INR 6), with normal liver enzymes and liver failure was diagnosed. Initial investigation ruled out congenital infections, sepsis, neonatal hemophagocytic lymphohistiocytosis and metabolic diseases. Magnetic resonance imaging of the body demonstrated findings in keeping with iron deposition in the thyroid, liver and pancreas, suggestive of GALD. Completed double volume exchange transfusion and IVIG on DOL 9 and repeat IVIG on DOL 13 and 15, with partial improvement in INR. Due to persistent ascites, conjugated hyperbilirubinemia and hyperammonemia she was transferred for urgent liver transplant assessment. Persistent liver dysfunction in the form of hyperammonemia, hypoglycemia and progressive coagulopathy led to transplant listing on DOL 30. ABO incompatible deceased donor liver transplant was completed on DOL 62 (4.075 kg, estimated dry weight 3.5 kg). The procedure was uncomplicated, liver enzymes normalized, coagulopathy and hypoglycemia resolved. She was transferred to the ward on post-operative day (POD) 6. and weaned off sedatives and transitioned to oral feeds within 2 weeks of transplant, with complex abdominal wound closure on POD 29.

Conclusion(s)

Successful liver transplantation is possible in neonates with acute liver failure due to GALD refractory to medical management and weighing 4kg or less.

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Disclosure of Interest

None Declared

MICROBIOME & MICROBIAL THERAPY

Strengthening Review and Publication of Participatory Mental Health Research to Promote Empowerment and Prevent Co-optation

As reviewers, editors, and researchers with lived experience of mental health challenges, addiction, and/or psychosocial distress/disability, the authors have struggled to find an adequate way to address inappropriate or misleading use of the term "participatory methods" to describe research that involves people with lived experience in only a superficial or tokenistic manner. The authors of this article have found that, in their experience, editors or other reviewers often appear to give authors extensive leeway on claims of participatory methods that more accurately reflect tokenism or superficial involvement. The problem of co-optation is described, examples from the authors' experiences are given, the potential harms arising from co-optation are articulated, and a series of concrete actions that journal editors, reviewers, and authors can take to preserve the core intent of participatory approaches are offered. The authors conclude with a call to action: the mental health field must ensure that power imbalances that sustain epistemic injustice against people with lived experience are not worsened by poorly conducted or reported studies or by tokenistic participatory methods.

Beyond Binary Narratives of Mental Health Advocacy: Latent Profiles of Mental Health Activists and Advocates With Lived Experience

OBJECTIVE

In this article, the authors used data from a national survey of mental health activists and advocates (MHAAs) with lived experience of psychiatric disabilities to investigate attitudes toward psychiatric care.

METHODS

The authors distributed a survey, developed by a team led by researchers who were also service users, to both mainstream and more critical advocacy groups and networks (N=547 participants), and they analyzed the data by using latent class analysis (LCA). Four survey variables regarding beliefs about involuntary hospitalization, assisted outpatient treatment, medication, and diagnosis were used to generate latent subgroups. The authors explored associations between key survey variables and latent classes with chi-square tests and analysis of variance.

RESULTS

LCA indicated an optimal six-class solution. The classes existed on a spectrum of positions, ranging from highly favorable views of traditional psychiatric practices to highly critical views, with classes in the middle representing distinct profiles of attitudes toward treatment and diagnosis. Significant between-group differences were found for participants' psychiatric treatment histories, motivations to engage in activism and advocacy, and views about mental health care and advocacy priorities.

CONCLUSIONS

Findings reveal considerable heterogeneity among MHAAs and challenge binary narratives of mental health advocacy.

1103 AN EVALUATION OF A GERIATRICIAN-LED ACUTE MEDICAL ADMISSION UNIT AT MORRISTON HOSPITAL, SWANSEA

Introduction

The medical intake at Morriston Hospital is accepted on two units; Rapid Assessment Unit (RAU) and Acute Medical Assessment Unit. Both were acute physician-led until July 2021

Method

(Phase 1). From July 2021, RAU became geriatrician-led (Phase 2). This evaluation concerns the performance of RAU.

Phase 1 (Acute Physician-Led Unit) Between 01/08/2020-30/06/2021, there were 3102 admissions with a median length of stay (LOS) of 2 days on RAU. 37.2% of patients were discharged directly from the unit. (SBUHB data). A detailed analysis of 496 patients consecutively assessed between November 2020–January 2021 showed a median LOS on RAU of 1, 28.8% were discharged directly from RAU. Overall health board (HB) median LOS for the cohort was 7. In over 70 years, median LOS on RAU was 1, overall HB LOS 9.

Phase 2 (Geriatrician-Led Unit) 1237 patients were assessed July-December 2021, with a median LOS of 2 days. 42.8% of patients were discharged from RAU. (SBUHB data). A detailed analysis of 566 patients consecutively assessed between September-November 2021 showed a median LOS on RAU of 2, 41.7% discharged directly from RAU. Overall HB median LOS for the entire cohort was 5. For the > 70 years, median LOS on RAU was 2, overall HB LOS was 7. Patient flow through assessment areas is dependent on the function of downstream medical wards. Mean LOS within medicine at Morriston increased 1.5 days between Phase 1 and Phase 2.

Results

Acute geriatricians have delivered the 72hr LOS standard that SBUHB has set for assessment areas. The unit has achieved a reduction in overall LOS for the cohort of patients evaluated (p<.01), especially for the > 70 years (p=.007).

Conclusion

This data supported a change in practice; RAU has taken a frailty specific intake since January 2022.

Psychosis Outside the Box: A User-Led Project to Amplify the Diversity and Richness of Experiences Described as Psychosis

Despite some progress toward greater inclusion, individuals with personal experience of psychosis are rarely integrated into the training of clinicians or knowledge generation. Their exclusion increases the risk that dominant ways of conceptualizing psychosis primarily reflect second- and third-person observations rather than first-person experiences. Observed only from the outside, the richness, complexity, and depth of experiences falling under the psychosis umbrella are easily lost. The authors describe a project-Psychosis Outside the Box-to solicit, compile, and amplify direct accounts of experiences that have been neglected in mainstream research and pedagogy, including the subjective experiences of visuals, felt presences, alterations of time and space, and "negative symptoms."

Identifying indicators of community participation-promoting efforts within coordinated specialty care: A modified e-Delphi study of stakeholder perspectives

AIM

Community participation in occupational, social, recreational, and other domains is critically important during young adulthood. Coordinated Specialty Care (CSC) programs provide developmentally tailored care to young adults experiencing early psychosis within the United States, but little is known about the breadth of efforts to promote community participation. This study aimed to develop and evaluate indicators of these efforts based on the perspectives of a national multi-stakeholder group.

METHODS

Seventeen stakeholders (i.e., young adults with early psychosis, family members, experts by profession) participated in a modified e-Delphi study, conducted in two rounds. The purpose of round one was to generate a comprehensive list of community participation-promoting indicators. During round two, stakeholders rated the importance and feasibility of the implementation of each indicator. Descriptive statistics and percentage of agreement regarding round two ratings were assessed.

RESULTS

During round one, 186 indicators of activities and/or practices designed to promote community participation were identified; this list was reduced to 44 by eliminating redundancies or indicators not related to community participation. In round two, we found broad agreement regarding the importance, but significant variation in perceived feasibility of indicators. The highest-rated indicators in both categories pertained to staff knowledge (regarding barriers and supports to participation and the importance of participation to health) and strategies for addressing participation barriers.

CONCLUSIONS

This study is expected to facilitate the identification and development of promising CSC activities and practices designed to promote community participation among young adults while potentially also enhancing engagement in services and improving clinical outcomes.

Body mass index and survival in people with heart failure

Background

People with obesity are twice as likely to develop heart failure (HF) compared to people with a healthy body mass index (BMI) [1]. However, among people with HF a higher BMI has been linked to a reduced risk of all-cause mortality, a concept known as the “obesity paradox” [2].

Purpose

To examine the association between BMI and survival in patients with chronic HF among a large primary care cohort.

Methods

We extracted data from the Clinical Practice Research Datalink of primary care records from 1st January 2000 to 31st December 2017 and included 47,531 patients with an incident diagnosis of HF, who were aged 45 years and over and who had a recorded BMI. Patients were stratified into categories of baseline BMI as underweight (BMI <18.5 kg/m2), healthy weight (BMI 18.5 to 24.9 kg/m2), overweight (BMI 25.0 to 29.9 kg/m2) or obese, with obesity split into class I (30.0–34.9 kg/m2), class II (35.0–39.9 kg/m2) and class III (40 kg/m2 and over). The primary outcome was all-cause mortality. We used Kaplan-Meier curves and log rank tests to compare survival in people with HF, based on baseline BMI. We also report a Cox regression model for risk of all-cause mortality among people with HF comparing BMI categories.

Results

There were 25,013 deaths during the study follow-up. The average age of participants was 77.1 years (SD 10.6) and mean BMI was 27.9 (SD 6.1). In an age- and sex-adjusted analysis, people who were underweight were at increased risk of all-cause mortality compared to people with healthy weight (HR 1.52, 95% CI 1.41 to 1.64). People with overweight (HR 0.81, 95% CI 0.79 to 0.84), obesity class I (HR 0.79, 95% CI 0.76 to 0.82) and obesity class II (HR 0.78, 95% CI 0.74 to 0.82) were at decreased risk of all-cause mortality. People with obesity class III had no difference in risk of death compared to people with healthy weight (HR 0.95, 95% CI 0.88 to 1.02). In a Kaplan-Meier analysis, there was an inverse relationship between body weight and risk of death, even within the first year of follow-up.

Conclusion

In our large community cohort of people with HF, we found an inverse relationship between BMI and survival. Underweight people with HF have the poorest prognosis and should be identified as high-risk. Conversely, people with HF who are overweight or obese (class I and II) are at lower risk of death confirming the obesity paradox in a real-world primary care population. These findings suggest a more cautious approach to weight management in overweight and obese patients may be needed for people with HF in primary care.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The SurviveHF study was funded by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Oxford at Oxford Health NHS Foundation Trust and the Wellcome Institutional Strategic Fund. The funders did not have any role in the design of the study, analysis and interpretation of the data, or writing of the results for publication.

Survival among people with heart failure and atrial fibrillation; a population cohort study

Background

People with chronic heart failure (HF) have a poor prognosis, with survival rates at five year follow-up close to 50%.1 More than half of patients with HF will develop atrial fibrillation (AF). The presence of AF in people with HF has been associated with a poor prognosis, irrespective of left ventricular ejection fraction. 2,3 However, the majority of studies to date have analysed prognosis among secondary care cohorts or randomised trial participants, who may not be representative of patients with chronic HF in the community.2

Purpose

To examine the association between survival in patients with HF and AF compared to either condition alone, among a large primary care cohort.

Methods

We extracted data from the Clinical Practice Research Datalink of primary care records from 1st January 2000 to 31st December 2018 and included all patients aged 45 years and over who were registered at an up-to-standard practice for a minimum of 12 months. Records were linked to Hospital Episode Statistics for secondary care data. The primary outcome was all-cause mortality. Exposure groups were defined as HF+AF, HF or AF, with exposure status treated as a time-varying covariate across follow-up. We used Cumulative Hazard plots to compare survival in people with HF and AF, compared to people with either condition alone or neither. We also report a Cox regression model for risk of all-cause mortality among people with HF and AF, adjusting for age, sex, ethnicity, smoking status and comorbid cardiovascular disease.

Results

There were 314,042 deaths during the study follow-up. The average age of participants was 58.0 years (SD 10.6) and 51.4% were women. At some point across follow-up, 94,990 people had HF alone, 147,815 had AF alone and 74,470 had both HF and AF. In an unadjusted Cox regression analysis, people with HF and AF were at the greatest risk of death (HR 17.94, 95% CI 17.75 to 18.13), followed by people with HF alone (HR 12.00, 95% CI 11.87 to 12.13), and AF alone (HR 6.14, 95% CI 6.08 to 6.21) compared to people with neither HF nor AF. In the fully adjusted analysis, the risk of death remained highest among people with HF and AF (HR 3.78, 95% CI 3.73 to 3.83), followed by people with HF alone (HR 3.06, 95% CI 3.02 to 3.10), then people with AF alone (HR 1.85, 95%, CI 1.82 to 1.87). In a cumulative hazard plot, the risk of death across follow-up was similar among people with HF and AF, compared to those with HF alone.

Conclusion

In our large community cohort, we found HF and AF was associated with a worse prognosis than either condition alone. Both HF and AF were also associated with a poor prognosis. These results support the findings of previous secondary care and trial studies regarding the importance of AF as a prognostic indicator among people with HF. Further research could aim to identify preventive strategies that might improve prognosis among this high-risk group of patients.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The study was undertaken as part of NRJ's Doctoral Research Fellowship, supported by the Wellcome Trust (grant number 203921/Z/16/Z), with additional funding for this project from the National Institute for Health Research (NIHR) Collaboration for Applied Health Research (CLAHRC) Oxford at Oxford Health NHS Foundation Trust (P2-001).

Meaningful Participatory Research in a Multistakeholder Collaboration on Youth Pathways to Care: Implementation and Reflections

The authors of this column describe and reflect on challenges and successes encountered during implementation of a participatory research collaborative focused on the pathways to mental health care for youths and young adults. The collaborative centered development of stakeholder partner-led, small-scale research projects, supported by the academic research team. The column calls for greater investment in research projects that are selected and designed by community stakeholders.

Embedding lived experience into mental health academic research organizations: Critical reflections

Background

As part of a growing emphasis on engaging people with lived experience of mental health conditions in mental health research, there are increasing calls to consider and embed lived experience throughout academic research institutes. This extends beyond the engagement of lay patients and also considers the potential roles of academic researchers with lived experience. When the lived experience of academic researchers is applied to academic work, there is the potential to improve the relevance of the research, while destigmatizing mental illness within academia. However, there are different and often contrasting perspectives on the way a lived experience academic researcher initiative should be implemented.

Objectives

This article describes some of the key issues to be considered when planning an initiative that leverages and values the lived experience of academic researchers, including the advantages and disadvantages of each potential approach.

Discussion & Recommendations

Institutions are encouraged to reflect on the ways that they might support and value lived experience among academic researchers. In developing any such initiative, institutions are encouraged to be transparent about their objectives and values, undertake a careful planning process, involve researchers with lived experience from the outset and consistently challenge the stigma experienced by academic researchers with lived experience.

Patient or Public Contribution

Multiple authors are academic researchers with lived experience of mental health conditions.

Youths' and Young Adults' Experiences of Police Involvement During Initiation of Involuntary Psychiatric Holds and Transport

Over the past decade, police involvement in behavioral health crisis response has generated concern and controversy. Despite the salience and timeliness of this topic, the literature on service user experiences of interactions with officers is small and studies of youths and young adults are nonexistent. The authors aimed to investigate youths' and young adults' experiences of police involvement in involuntary psychiatric hold initiation and transport. In-depth interviews were conducted with 40 participants (ages 16-27) who had experienced an involuntary hold; the 28 participants who reported police involvement are the focus of this analysis. Data were inductively coded, and codes were grouped into larger themes. A majority of participants reported negative experiences; major themes characterizing negative encounters were the framing of distress as criminal or of intervention as disciplinary rather than therapeutic, perceived aggression and callousness from police officers, and poor communication. The authors also characterized the positive experiences of officer involvement reported by a minority of participants and youths' perspectives on the degree of control officers could exert over initiation and transport decisions. Findings help center the voices of youths and young adults with mental health challenges and raise important questions about contemporary policies regarding police involvement in crisis response and, more broadly, about coercive responses to distress or emotional crisis.

An Intersectional Approach to Ethnoracial Disparities in Pathways to Care Among Individuals With Psychosis in Coordinated Specialty Care

Importance

Intersecting factors of social position including ethnoracial background may provide meaningful ways to understand disparities in pathways to care for people with a first episode of psychosis.

Objective

To examine differences in pathways to care by ethnoracial groups and by empirically derived clusters combining multiple factors of social and clinical context in an ethnoracially diverse multisite early-intervention service program for first-episode psychosis.

Design, Setting, and Participants

This cohort study used data collected on individuals with recent-onset psychosis (<2 years) by clinicians with standardized forms from October 2013 to January 2020 from a network of 21 coordinated specialty care (CSC) programs in New York State providing recovery-oriented, evidence-based psychosocial interventions and medications to young people experiencing early psychosis.

Exposures

Ethnoracial group and other factors of social position (eg, insurance status, living situation, English fluency, geographic region) intersecting with first-contact experiences (ie, type of first service, referral source, and symptoms at referral).

Main Outcomes and Measures

Outcome measures were time from onset to first contact, first contact to CSC, and onset to CSC.

Results

The total study sample consists of 1726 individuals aged 16 to 30 years and included 452 women (26%), 1263 men (73%), and 11 (<1%) with another gender enrolled in the network of CSC programs. The total sample consisted of 153 Asian (9%), 599 Black (35%), 454 Latinx (26%), and 417 White individuals (24%). White individuals had a significantly shorter time from onset to first contact (median [IQR], 17 [0-80] days) than Asian (median [IQR], 34 [7-94] days) and Black (median [IQR], 30 [1-108] days) individuals but had the longest period from first contact to CSC (median [IQR], 102.5 [45-258] days). Five distinct clusters of individuals emerged that cut across ethnoracial groups. The more disadvantaged clusters in terms of both social position and first-contact experiences had the longest time from onset to first contact, which were longer than for any single ethnoracial group.

Conclusions and Relevance

In this cohort study of individuals with recent-onset psychosis, time-to-treatment outcomes differed by ethnoracial group and by empirically derived clusters combining multiple factors of social and clinical context. The examination of disparities in durations to treatment through an intersectional, ethnoracial lens may improve understanding of the inequities resulting from the various intersecting factors that may compound delays in treatment initiation.

User attitudes towards virtual home assessment technologies

Telehealth has long been highlighted as a way to solve issues of efficiency and effectiveness in healthcare and to improve patients' care and has become fundamental to address patients' needs during the COVID-19 pandemic; however previous studies have shown mixed results in the user acceptance of such technologies. Whilst many previous studies have focussed on clinical application of telehealth, we focus on the adoption of telehealth for virtual assessments visits aimed to evaluate the suitability of a property where a patient is discharged, and eventual adaptations needed. We present a study of stakeholders' attitudes towards such virtual assessment visits. The study has been carried out with healthcare professionals and patients and allowed us to identify user attitudes, barriers and facilitators for the success of virtual assessment visits from the point of view of healthcare professionals and patients. Finally, we discuss implications for designers of telehealth services and guidelines that can be derived from our study.

Addressing sexuality and intimate relations in community mental health services for people with serious mental illness: A qualitative study of mental health practitioners' experiences

OBJECTIVE

The literature on the experience of mental health providers (MHPs) working with people with serious mental illness (SMI) in community-based mental health programs related to sex, sexuality, and intimacy is scarce. The purpose of the present study was to explore the situations, thoughts, feelings, dilemmas, and challenges experienced by MHPs around these issues.

METHOD

Semistructured interviews were conducted with 13 MHPs working with people with SMI in six different community mental health programs in Israel.

RESULTS

Four main themes emerged: (a) lack of professional training and skill sets to discuss clients' sexuality and intimacy issues, (b) ambivalence regarding the status and appropriateness of sexual relationships and intimacy as recovery-related goals, (c) discomfort discussing sexuality as a barrier to shared decision making and person-centered care, and (d) distinct programmatic and structural barriers to discussing and addressing needs and preferences related to sexuality and intimacy.

DISCUSSION

The study highlights challenges experienced by MHPs working with people with SMI when confronted with sexual activities, relationships, and intimacy issues raised by service users. The development and implementation of trainings and resources designed to bolster MHPs' skill sets addressing sexuality and intimacy should be a priority for the field of psychiatric rehabilitation.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

MHPs who work with people with SMI in community-based settings often experience complex thoughts, feelings, dilemmas, and challenges related to clients' desire for or involvement in intimate and sexual relationships. Our study indicates a need to develop and implement stronger training and supervision to support MHPs to respond effectively to these complex situations and associated challenges. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Early intervention service systems for youth mental health: integrating pluripotentiality, clinical staging, and transdiagnostic lessons from early psychosis

Challenges associated with operationalising services for the at-risk mental state for psychosis solely in that same diagnostic silo are increasingly well recognised-namely, the differential risk for psychosis being a function of sampling enrichment strategies, declining transition rates to psychosis, questions regarding the validity of transition as an outcome, and the frequent development of non-psychotic disorders. However, recent epidemiological and clinical research suggests that not all threshold-level psychoses are likely to occur homotypically; early-stage non-psychotic syndromes might exhibit heterotypic shifts to a first episode of psychosis, without an identifiable at-risk mental state. These findings, along with the relevance of outcomes beyond traditional diagnoses or syndromes, have substantive implications for developing next-generation early intervention infrastructures. Along with the idea of general at-risk clinics for early-stage pluripotential syndromes, we examine how this reality might affect service design, such as the need for close linkage with centres of expertise for threshold-level disorders when transitions to later stages occur, the balance between generic and specific interventions amid the need for person-centred care, and the challenges this reorientation might pose for broader mental health systems.

Conceptualization and Study of Antipsychotic Medication Use: From Adherence to Patterns of Use

Despite treatment guidelines recommending antipsychotic medication (APM) as the frontline treatment for schizophrenia, its use remains a controversial topic, and nonadherence rates range between 40% and 60%. At the heart of the debate lies a divergence of views about the tradeoffs between side effects and efficacy, particularly over the long term. This Open Forum describes a series of challenges pertaining to the conceptualization and operationalization of APM use. The authors suggest pragmatic recommendations oriented toward shifting the dialogue from often-polarized positions about APM to a transformed research culture prioritizing service users' choices about diverse utilization patterns.

Rates of Inpatient and Emergency Room Use Before and After Discharge Among Medicaid Enrollees in OnTrackNY

OBJECTIVE

This study examined hospital and emergency room (ER) use among Medicaid enrollees before and after discharge from OnTrackNY, a coordinated specialty care program for recent-onset psychosis.

METHODS

Medicaid claims data were linked to program data. Inpatient hospitalization, inpatient days, and ER visits were assessed in the 6 months prior to OnTrackNY enrollment and 6 months prior to and after discharge. The sample consisted of 138 participants with continuous Medicaid enrollment during the study.

RESULTS

Inpatient visits significantly declined from the pre-OnTrackNY enrollment period to the predischarge period (β=-1.23, standard error [SE]=0.22, p<0.001), did not significantly change in the first 6 months after discharge (β=0.19, SE=0.26, p=0.48), and remained significantly lower than before OnTrackNY enrollment (β=-1.05, SE=0.20, p<0.001). Similar patterns were observed for inpatient days and ER use.

CONCLUSIONS

ER and hospital use declined during OnTrackNY participation and did not significantly change in the first 6 months after discharge.

Natriuretic peptide referral thresholds and heart failure diagnosis: population-based cohort study

Background

Natriuretic peptide (NP) testing is recommended by both the European Society of Cardiology (ESC) and the National Institute for Health and Care Excellence (NICE) for people presenting with symptoms of heart failure (HF) in primary care. However, ESC and NICE guidelines suggest different NP referral thresholds: ESC recommend referral at a lower NP level (BNP≥35pg/ml / NT-proBNP≥125pg/ml) compared to NICE (BNP≥100pg/ml/NT-proBNP≥400pg/ml).

Purpose

We aimed to evaluate NP test performance for HF diagnosis for ESC and NICE guideline-defined thresholds.

Methods

Population-based cohort study using linked primary and secondary care data from the Clinical Practice Research Datalink in England between 1st January 2000 and 31st December 2018. Participants were adults aged 45 years and above with a NP result: 74,233 had a BNP and 155,347 had a NT-proBNP measurement. The main outcome measures were diagnostic performance of NP test (sensitivity, specificity, positive predictive value, negative predictive value) by threshold.

Results

A total of 229,580 patients had a NP test and 21,102 (9.2%) were diagnosed with HF. The ESC NT-proBNP threshold of 125pg/ml had a sensitivity of 94.6% (94.2 to 95.0) and specificity of 50.0% (49.7 to 50.3) compared to sensitivity of 81.7% (81.0 to 82.3) and specificity of 80.3% (80.0 to 80.5) for the NICE NT-proBNP 400pg/ml threshold. For both guidelines, nearly all patients with a NP level below the threshold did not have HF (negative predictive value ESC 98.9% (98.8 to 99.0) and NICE 97.7% (97.6 to 97.8). Similar performance was found for BNP.

Conclusions

The performance of NP testing is dependent on the guideline-specified threshold for referral. In 100 people with HF, using the NICE threshold would falsely reassure 18 patients, whereas the lower ESC threshold would miss just 5 people but twice as many patients would be referred for diagnostic assessment. The optimal NP threshold for referral for HF diagnosis will depend on the healthcare setting. The trade-off between missing HF cases and overwhelming diagnostic services needs to be determined at a national level.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Institute for Health Research

Assessment of immune biomarkers and establishing a triple negative phenotype in gynecologic cancers

OBJECTIVE

Immuno-oncology (IO) has rapidly evolved, with many IO therapies either approved or under investigation for multiple malignancies. Biomarkers exist that can predict response to IO therapies including PD-L1 expression, microsatellite instability (MSI), and total mutation burden (TMB). This paper serves to analyze the presence of these biomarkers across gynecologic cancers.

METHODS

A total of 16,300 gynecologic cancer specimens submitted for molecular profiling to Caris Life Sciences were reviewed. Immunohistochemistry was performed using the SP142 anti-PD-L1 clone and assessed for intensity. Next-generation sequencing, immunohistochemistry, and fragment analysis were used to determine MSI status. TMB was measured by counting all non-synonymous missense mutations found per tumor not previously described as germline alterations. Chi-Square, Fisher Exact, and the Kruskal-Wallis test were used to compare cohorts.

RESULTS

Of 16,300 specimens, 54.1% were ovarian, 37.2% uterine, 7.2% cervical, 0.3% vulvar, 1.2% vaginal, with 0.1% unspecified. MSI-H was most frequent in uterine cancer (17.7%) and only 1% of ovarian cancers. PD-L1 expression was present in 38.3% of cervical and 62.5% of vulvar cancers, but less than 8% of ovarian and uterine cancers. TMB-H was present in 21.1% cervical, 19.7% uterine, and 5% ovarian cancers. Few specimens exhibited a "triple positive" phenotype - 0.3% ovarian, 1.5% uterine, and 1.5% cervical. Associations were seen between MSI, TMB, and PD-L1 across all cancer types.

CONCLUSIONS

The frequency of individual biomarkers pertinent to IO therapy varies by cancer type. HPV-driven genital tract cancers have higher frequencies of PD-L1 expression, MSI-H, and TMBH. Endometrial cancers are characterized by MSI-H and TMB, whereas ovarian cancers have a low frequency of MSI-H and modest PD-L1 or TMBH. The incidence of 'triple positive" cases was less than 2%.

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.

Service User Participation Within the Mental Health System: Deepening Engagement

Over the past decade, there has been a marked uptick in interest in increasing service user participation in the U.S. mental health care system, including clinical practice, research, and policy. Too often, however, these efforts remain superficial and unlikely to bring about the deeper transformation of systems long called for by grassroots activists. This Open Forum-addressed to mental health administrators, researchers, and clinicians-highlights the importance of considering diverse, critical perspectives and engaging in ways that move beyond purely intellectual rapprochement.