The Cascade of Care for Early Psychosis Detection in a College Counseling Center

OBJECTIVE

Programs for early detection of psychosis help identify individuals experiencing emerging psychosis and link them with appropriate services, thereby reducing the duration of untreated psychosis (DUP). The authors used the cascade-of-care framework to identify various care stages between screening and enrollment in coordinated specialty care (CSC) and to determine attrition at each stage, with the goal of identifying points in the referral process that may affect DUP.

METHODS

Project partners included a college counseling center and CSC program. All college students seeking mental health services at a counseling center between 2020 and 2022 (N=1,945) completed the Prodromal Questionnaire-Brief (PQ-B) at intake. Students who met the distress cutoff score were referred for a phone screening. Those who met criteria on the basis of this screening were referred for assessment and possible enrollment into CSC.

RESULTS

Six stages in the cascade of care for early detection were identified. Of the students who completed the PQ-B as part of intake (stage 1), 547 (28%) met the PQ-B cutoff score (stage 2). Counselors referred 428 (78%) students who met the PQ-B cutoff score (stage 3), and 212 (50%) of these students completed the phone screening (stage 4). Seventy-two (34%) students completed a CSC eligibility assessment (stage 5), 21 (29%) of whom were enrolled in CSC (stage 6).

CONCLUSIONS

The cascade-of-care framework helped conceptualize the flow within a program for early psychosis detection in order to identify stages that may contribute to lengthier DUP. Future research is warranted to better understand the factors that contribute to DUP at these stages.

Addiction

Alcohol and psycho-active substance misuse has far-reaching social, psychological and physical consequences. Advances in neuroimaging technology have allowed neurobiological theories of addiction to become better characterized. We describe the neurobiology of dependence, withdrawal, abstinence and craving states in alcohol, stimulant and opiate misuse. Structural neuroimaging techniques such as CT and MRI with new analytical approaches such as voxel-based morphometry have shown wide-spread changes in stimulant and opiate abuse and atrophy, particularly in the frontal lobes, in alcoholism. Functional neuroimaging techniques such as PET, SPECT and fMRI reveal altered regional cerebral activity by all drugs of abuse. The neurochemistry of addiction, particularly involving dopamine, serotonin, opiate and GABA, has been studied with PET and SPECT and similarities between all drugs of abuse have been found such as reduced dopaminergic markers. The evidence derived from these advances in neuroimaging is likely to herald the emergence of new biological treatments in this important field.

Public perceptions. The generation claim

There is a growing perception that support for the NHS is falling off among the young. The evidence for this is not conclusive. Dissatisfaction with the NHS is more likely to be linked to increased expectations rather than lack of social solidarity.

Treatment decisions. Whys and wherefores

A review of challenges to five health authorities' refusals to fund treatment found none of the health authorities had an explicit process for decision making which would stand up to public scrutiny. None had an appeals procedure for contested decisions. This will become an issue for primary care groups and trusts as they will face the same challenges as HAs which refuse treatment. There is the added complication that the doctors will be acting both as agents for their patients and stewards of the resources for the community of patients they serve. Where there are restrictions on treatment, conflict might be avoided by the use of widely available guidelines. Dilemmas over refusing individual patients treatment will not be entirely resolved by evidence-based decisions.

Public consultation. Consulting room

The government's consultation exercise over the NHS was rare in attempting to capture the views of a large number of citizens other than through a survey. The exercise raised questions about whether or not the government had a plan for the NHS. In the long term, the government may have to consult the public in the context of rationing.

Expert patients. So you think you know it all?

The government's proposal to set up an expert patients programme to enable those with chronic illnesses and disabilities to manage their condition is a welcome step towards greater user involvement. The programme should avoid a medical model and take account of patients' social circumstances. The programme must include evaluation. Health professionals in the UK have yet to embrace patient self-management. To date they have been reluctant to refer service users to self-help groups.

Patient surveys. There for the asking

The government's proposal to survey 100,000 patients a year in order to improve services faces considerable organisational problems. We estimate it will cost 200,000 pounds a year. The simple opinion poll approach should be avoided in favour of a detailed questionnaire. A rolling programme of surveys in specific service areas might be more meaningful than a comprehensive annual survey. The aims of capturing patients' views and comparing performance across the country could prove incompatible.

Information for public choice

The kind of information the public will need in order to take part in the rationing debate is examined. The public are interested in the debate both as taxpayers and as patients and they can have an input in a number of different ways. Their involvement at the level of general discussions about values and service priorities is problematic, because some of the methods used do not allow participants to ask questions or work through the implications of the information they have access to. The mechanisms for ensuring their involvement in planning service strategies are better known and the information requirements are clear. When patients are given more say in decisions about their treatment and care, they may choose different options to those favoured by health professionals, but more work still needs to be done on developing and presenting complex medical information and helping patients to make decisions.

Comparative studies on the sense organs on the antennae and maxillary palps of selected male culicine mosquitoes

The sense organs on the antennae and maxillary palps of male Aedes atropalpus (Coquillett), Aedes aegypti (L.), Culex territans Walker, and Culex pipiens L. are similar to those observed on female culicines including water, olfactory, and carbon dioxide receptors. Although males have the same variety, they have fewer of each type of sense organ. The difference in number of any one type of sense organ is more variable in the female than the male except for the sensilla basiconica.

Studies on the sense organs on the palps of selected culicine mosquitoes

Four structures are found on the maxillary palps of female culicine mosquitoes: microtrichia, scales, sensilla chaetica, and thin-walled, bulb-shaped organs. The bulb organs are localized on the distal half of the ventral part of palpal segment 4, have perforated walls, are carbon dioxide receptors (Kellogg, in press), and vary in number among the species from 29/palp on Aedes aegypti to 89/palp on Culex restuans. An explanation for observed behavioral responses to carbon dioxide is given.