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JHU Center Talk Revised

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Emily Kline

on 7 May 2015

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Transcript of JHU Center Talk Revised

Psychosis Risk Screening:
Measure Validation & Practitioner Perceptions

Duration of Untreated Psychosis (DUP)
Defining Clinical High-Risk
Study #1:
Convergent & Discriminant Validity
Schizophrenia and other psychoses continue to have devastating effects on individuals, families, and society
Stigma/beliefs about mental illness
'Prodromal period' characterized by appearance of attenuated or brief psychosis-like symptoms that impact functioning or engender distress
We administered 3 screeners as well as measures assessing related & unrelated domains of psychopathology to UMBC undergraduates (N = 328)
Emily Kline, M.A.
University of Maryland, Baltimore County

Duration of Untreated Psychosis
Clinical High-Risk Research
Relevance for Pediatric Primary Care
Assessment Tools
Screener Validation Studies
Pilot Project

Shortening DUP
Many factors contribute to treatment delays...
Clinical high-risk (CHR) approach has generated enthusiasm - reliably identifies a group with elevated risk.
Assessing Psychosis Risk
"SIPS" is the most widely used assessment for CHR status
~35% of those meeting CHR criteria expected to develop psychotic illness within 3 years
SIPS is useful, but difficult to 'export' beyond specialty settings --
Requires training for reliability
Takes ~45-60 minutes, depending on presenting case
Brief Assessments
Questionnaires that are easy, quick, and affordable to administer would be better for primary care
Self-report tools have many potential uses:
Screening to detect individuals who may benefit from clinical evaluation and referral
Monitoring symptoms over time (consistent with best-practice guidelines)
Identifying research samples of interest
Quantifying symptoms in order to understand epidemiology, covariates, & progression
Psychosis Risk Screeners
A few
measures targeting attenuated symptoms have emerged

How well do screening results align with the 'gold-standard' interview assessment (SIPS)?
Study # 5:
Practitioner Survey

(Preliminary) Results
Next Steps

Recruit via advertising at meetings and conferences

As of May 2013, 49 responses
Question 2: From client's perspective, how user-friendly is the questionnaire?
Question 3: How clinically useful is this information?
Some patients do better than others - why?
DUP is a
prognostic marker
Accessible/affordable care
MH provider knowledge
Could we shorten or eliminate DUP by honing in on a high-risk state?
Typically during adolescence; 1-5 years prior to first clear psychotic episode
Question 1: How good are these tools for assessing risk?
Shorter DUP associated with better treatment response, lower mortality, and more complete recovery over time
Prime Screen-Revised
12 items matched to SIPS probes
Response choices range from 0 (definitely disagree) to 6 (definitely agree)
Total calculated by counting items endorsed 5/6
Score range 0-12
Authors recommend screening threshold of 2 or more 5/6 responses
Prodromal Questionnaire-Brief
21 items
Items endorsed yes/no; for "yes" items, respondents indicate distress on Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree)
Score range 0-105
Authors recommend screening threshold of 6 or higher
Youth Psychosis At-Risk Questionnaire-Brief
28 items with response options yes (scored as 1); no/unsure (scored as 0)
Score range 0-28
Authors recommend threshold of 11 or more endorsements
Study #2:
Criterion Validity
Relevance for Pediatrics?
Relevance for Primary Care?
In Progress...
Study #4: Predictive Validity
Kline et al., 2012
Do screeners measure a consistent and distinctive construct?
We administered 3 screeners and SIPS to 49 participants ages 12-22 receiving MH services
SIPS Diagnoses
No SIPS Diagnosis: 29 (59%)
High-Risk: 16 (33%)
Psychotic Disorder: 4 (8%)
Screener-SIPS Correlations
How well do screening thresholds predict diagnosis?
Screeners do well as continuous measures
How well do screeners predict psychosis onset and symptom progression over time?
Psychotic disorder prevalence is high (~3%; van Os et al., 2009)
Pathways to Care for 100 FEP Hospital Admissions

Adapted from
Burnett et al., 1999
Are we ready for psychosis risk screening?
Generalizability of prior results
Provider burden
What do providers think about screening
Clinical utility?
Open to MH & PC providers
Providers review information about screeners, look at the measures as completed by one high-risk adolescent, and complete a brief questionnaire
Paper and online formats
Expand recruitment to primary care
Further program of validation research
Do screeners work as well in a general population sample?
How well do screeners predict future diagnoses?
Learn from family & consumer perspectives
Explore screener impact on DUP - can screening streamline pathways to specialty care?
Study #3:
Multi-Informant Screening
Does including caregiver responses enhance screener accuracy?
We created a modified Prime Screen for caregivers
52 caregiver-teen dyads completed screeners
Teens completed SIPS
SIPS Diagnoses
No SIPS Diagnosis: 25 (48%)
High-Risk: 21 (40%)
Psychotic Disorder: 6 (12%)
Screener-SIPS Correlations
Can caregiver screening predict diagnosis?
Parents and teens do not agree! (r < 0.1)
Relative to same-age teens receiving MH services for other concerns, CHR youth have worse functioning and more polypharmacy
Thank you to my mentors,
Drs. Jason Schiffman & Gloria Reeves
And thank you to my wonderful coworkers in the Youth FIRST & CHAMPS lab teams!
Marshall et al., 2005 Perkins et al., 2004
Franz et al., 2010
Compton et al., 2010
Large et al., 2008
Cannon et al., 2008
Miller et al., 2003
Miller et al., 2004
Ord et al., 2004
Loewy et al., 2011
For which age groups would this measure be appropriate?
Which would you choose?
No Idea: "I would have to seek advice from a colleague."
Safety Concerns: "Assess for suicide risk or need for hospitalization."
Triage tool: "We would most likely make this questionnaire a part of our intake process. High scorers would see our psychiatrist for med evaluation. Other services (therapy, support group, targeted case management) would depend on client's needs."
How would you respond to a high-scoring patient?
Cue for Referral: "I would refer for additional or more specialized care."
Therapeutic Tool: "I would ask them about which one concerns them the most or how frequently they experience it. I would find out if it is interferring with their life in any way. I would ask if there is anything they have noticed that triggers it."
Feel like someone is watching me...
Wonder if I am predicting the future...
Hear strange noises when no one's around...
Clear pattern of CONVERGENT & DISCRIMINANT correlations
Psychosis has peak incidence during late teens/early 20s (Amminger et al., 2006)

Pre-psychotic symptoms associated with distress, impairment, & behavior problems
Symptoms disrupt critical developmental tasks & milestones of adolescence
Primary care is site of screening for both medical (diabetes, HPV) and behavioral (ADHD, bullying) issues (Brown & Wissow, 2010)
PCPs are a common point of contact
Patients referred via primary care are LESS LIKELY to experience involuntary hospital admissions
Earliest stages of illness associated with highest risk of substance use, victimization, and violence toward self or others; 20% will attempt suicide (Large & Nielssen et al., 2011; Robinson et al., 2010)
Analogous to screening for other neurodevelopmental disorders (e.g., autism), but among teens rather than young children
What do we know about screeners?
Do screeners "work"?
Who should we screen?
Which is best?
What do providers think?
Screeners also demonstrated high TEST-RETEST reliability (r = .8)
Kline et al., 2012
Best threshold might vary depending on sample and/or goals of screening
Prime performs well with half as many items
PQ-B provides valuable info about distress
Teens over-report, parents under-report
Combining teen & parent screens increases prediction of diagnosis
Kline et al., 2013
Early intervention is key!
Little use outside validation samples
Validated against different standards, in different samples, settings, languages, & cultures
Difficult to decide which (if any) to use

How can we expand recruitment to primary care?

What are potential advantages and/or barriers to psychosis risk screening?

Other questions?
We want to determine...
Early intervention matters
PCPs can make a difference
Screeners are good for identifying symptoms
JHU Center for Mental Health in Pediatric Primary Care
Maryland Department of Health and Mental Hygiene
Mental Hygiene Administration through the 1915(c) Home and Community-Based Waiver Program Management
Workforce Development and Evaluation (OPASS# 13-10954G/M00B3400369)
Baltimore Mental Health Systems
Research Seed Funding Initiative (RSFI) grant from UMBC
The Passano Foundation
# practitioners endorsing
Age Groups
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