Access, Detection and Psychological Treatments

Research Stream 1: Treatment and Cost Effectiveness The primary aim of Stream 1 is to evaluate the effectiveness of a model-driven psychological intervention, CBT in preventing or delaying the onset of a psychotic illness and to evaluate the effectiveness of CBT in reducing presenting concerns in a sample of help-seeking individuals who have been operationally defined to be at ultra high risk of developing a psychotic illness. CBT will be compared to supportive therapy (ST). We will also examine the cost-effectiveness of a preventive approach. Using a cost-consequence approach, we will examine the cost-effectiveness of CBT versus supportive therapy in addressing psychosis in the "ultra high risk" phase from the perspective of the payer (i.e., the Ministry of Health and Long-Term Care). The hypotheses are: (i) The time of conversion will be significantly longer for those in the CBT group compared to those in the ST condition. (ii) The mean level of attenuated psychotic symptoms (SOPS ratings ) will be significantly lower in the CBT group compared to the ST group at the completion of the intervention and at each follow up point. (iii) Levels of risk factors (measured by CMRS \& GHQ2) will be significantly lower in the CBT group compared to the ST group at the completion of the intervention and at each follow up point. (iv) Levels of depression and anxiety (measured by CDSS, BAS, SPAI2) will be significantly lower in the CBT group compared to the ST group at the completion of the intervention and at each follow up point. (v) Level of social functioning (measured by SFS2) will be significantly higher in the CBT group compared to the ST group at the termination of the trial and at each follow up point. (vi) CBT will be more cost-effective than ST. Research Stream 2: Pathways to Care The aim of stream 2 is to obtain the in-depth stories of the ways in which those at ultra high risk of developing a psychotic illness come to seek help from mental health services. By mental health services, we include the formal system (specialty mental health \& general medical care), lay system (friends, family, self-help), folk system (alternative healers) and human social service system (clergy, teachers, police). These will be sought from both the perspective of youth and from the perspective of their significant others. Multiple case studies using qualitative approaches will focus on the following four elements: 1) social content; 2) social support system, 3) the illness career; and, 4) the treatment system (See Appendix A for detailed components within these elements of the model). These case studies will be employed to further empirically develop theory relating to pathways to mental health care. Theoretical Propositions: The following four theoretical propositions related to pathways to mental health care were formulated based on the Network Episode Model described above. The focus of this stream will be upon the evaluation, refinement and elaboration of these four theoretical propositions. Multiple case study methodology will be employed to further empirically develop theory relating to pathways to mental health care. (i) Family content (e.g., beliefs about and experiences with the medical system), structure (e.g., size, amount of support) and function (e.g., advice, support or coercion) have a critical influence on the pathways to mental health care for youth at ultra high risk for psychosis.(ii) The community and school content, structure and function have a critical influence on the pathways to mental health care for youth at ultra high risk for psychosis.(iii) Problem recognition and the illness experience as perceived by the individual and significant others have a critical influence on the pathways to mental health care for youth at ultra high risk for psychosis.(iv) The content, structure and function (e.g. organizational constraints) of the treatment system have a critical influence on the pathways to mental health care for youth at ultra high risk for psychosis. Research Stream 3: Costs of Caring in Psychosis The aim of this third research stream is to explore the burden to the healthcare system and informal caregivers associated with this ultra high risk population. We seek to address three primary questions: (i) What are the key components affecting the costs of caring for the ultra high risk population? These costs will be considered with respect to both the formal and informal care providers (i.e., service system and family caregivers, respectively). (ii) What are other psychological costs of caring that informal caregivers face? (i.e. modification in parental work schedules to accommodate their child's needs, impact on other siblings) (iii) Over time, how do the costs of caring change in terms of the economic and psychological costs?