Introduction: Fidelity assessments can support healthcare services to deliver care consistent with best practices. However, early psychosis (EP) fidelity assessment tools typically require a volume of service data that is often unavailable to small or new programs. In this study, we pilot a formative fidelity assessment approach to address these challenges. Methods: A formative assessment approach to using the First Episode Psychosis Services – Fidelity Scale (FEPS-FS) was developed to enable the assessment of small and new EP programs. Over 48 months, EPI-CAL EP learning health care network programs completed standard FEPS-FS fidelity assessments, formative assessments for new programs, or formative assessments for small programs, depending upon program eligibility. Results: Of 27 remote fidelity assessments completed with EP programs across California, nine (33.3%) had insufficient service data to complete a standard FEPS-FS assessment. Utilizing the proposed formative assessment approach, one program met the criteria for a new program assessment, and seven a small program assessment. In the new program assessment approach, 34 of 36 items could be assessed. In the small program assessments, a median of 19 items was scored, with a mean FEPS-FS score range from 3.45 to 4.12. Conclusion: These findings suggest that a formative approach to fidelity assessment can generate a meaningful amount of data, capture known variability between programs, and potentially identify areas for service improvement to enhance quality for small and new programs. However, critical data regarding the delivery of pharmacological and psychosocial care were not captured, highlighting the limitations of the approach.

Introduction A global movement focused on early intervention in bipolar disorder is long overdue. Given a dearth of work towards establishing coordinated efforts in this field, we aimed to explore what can be learned from successful global mental health movements. Methods We interviewed nine experts involved in the development of global mental health movements. Reflexive thematic analysis was used. Results Seven themes were generated: (1) “What do You Want to Be and for Whom?”, (2) There are Pros and Cons with Consensus in Ideas and Approaches, (3) The Catalytic Role of Early Action, (4) People are the Heart of a Movement, (5) Make it Matter, (6) Size and Structure Can Impact Effectiveness, and (7) Challenges of Scaling Up and Maintaining a Movement. Conclusions These learnings provide a framework for building a Global Alliance for early intervention in bipolar disorder, centring early action, nurturing passionate leadership, and inclusive collaboration.

Post-secondary students are confronted by multiple factors that may impact their mental health, including heightened academic demands, financial burdens, new living circumstances, social isolation, and an increased need to be self-reliant. While student mental health is a priority for post-secondary institutions, there is a marked gap in evidence regarding what supports and interventions are most effective, for whom, and in what contexts. Digital technologies can improve the accessibility of mental health care and facilitate comprehensive data collection; however, we argue that there is an urgent need for these tools to be co-designed with students to ensure they are relevant, useable, and responsive to their real-world experiences, implemented with human support to optimise outcomes, and championed by organisational leadership to promote adoption. Further, it is essential that clinical and service usage data is tracked alongside academic performance to prioritise both student mental health and academic success in alignment within institutional priorities.

Background: Early intervention in Psychosis (EIP) services are vital in reducing long-term impact of first-episode psychosis (FEP). However, women with FEP encounter unique biological, social and systemic challenges that may delay diagnosis, hinder access to cares and affect treatment engagement. Aims: This study explores clinicians’ perspectives on the sex-specific needs of women with FEP, focusing on hormonal influences, caregiving responsibilities stigma and systemic barriers to care within EIP services. Method: A qualitative design was employed, utilising semi-structured interviews with 20 clinicians from EIP and adult mental health services in Dublin, Ireland. Reflective Thematic Analysis was used to identify key themes, with an inductive constructivist approach underpinning the analysis. Results: Five key themes emerged: (1) Sex differences in presentation, with women showing later onset, higher emotional distress, and lower rates of substance-induced psychosis; (2) Hormonal interactions, highlighting the impact of menstruation, pregnancy, and menopause on symptomatology and treatment response; (3) Shame and adjustment, with internalised stigma, delayed help-seeking, and disruption of social roles (4) Barriers to care, including caregiving responsibilities and inflexible service models. Clinicians emphasised the need for integrated, sex-sensitive, and trauma-informed care, as well as improved collaboration between psychiatry, gynaecology, and endocrinology and; (5) Recommendations for improving care. Conclusions: Women with FEP face multifaceted barriers to accessing and engaging with EIP services. Implementing clinician recommendations namely, flexible and integrated care, trauma-informed and sex-sensitive approaches, and robust cross-disciplinary collaboration is vital for improving outcomes. Future research should incorporate service user perspectives to further refine inclusive and effective EIP pathways for women.

Aim This study assessed feasibility of a stepped-care model for those at clinical high-risk for psychosis (CHRp) within a coordinated specialty care clinic in the United States. Methods Youth aged 12-30 completed a 12-month, three-step intervention where persistent or worsening symptoms received increasingly intensive treatment including Supportive Problem Solving, Cognitive Behavioral Case Management and a Selective Serotonin Reuptake Inhibitor. Results Of 32 CHR youth admitted to the clinic over 18 months, 12 were eligible for the study, ten consented, eight participated, and five completed. Major reasons for ineligibility were loss to follow-up during engagement, pressing comorbid concerns that required other specialty care, and medication preferences. Those who completed treatment showed clinically significant improvements in multiple domains and no worsening. Three discontinued due to medication needs (more intensive care, perceived side effects) with the remainder of the sample showing small-to-moderate and moderate-to-large effect sizes in social functioning, depression, and attenuated psychosis symptoms by 12-month follow-up. Conclusions This preliminary study supports larger scale trials of stepped-care interventions for CHRp in the US, but also illuminates key features of the US healthcare system that must shape implementation. The stepped-care intervention appeared tolerable and feasible in those who engaged, but comorbid treatment needs in this heterogenous population, including medication needs/preferences, and disengagement during referral to psychosis specialty care precluded participation for many. Future studies will need to evaluate larger samples, account for needs and preferences for medication, and should place screening and early steps in general outpatient mental health services to evaluate real-world effectiveness.

Introduction: Since 2019, a rapid learning health system for Quebec’s Early Intervention Services for psychosis named SARPEP (Système Apprenant Rapide pour les programmes de Premiers Épisodes Psychotiques) operates to bridge the evidence-practice gap across the province. Despite strong stakeholder support and government recommendations, peer support services remained poorly available. To address this gap, since 2023, the PAIRPEP project was co-developed to support and evaluate the implementation of peer support and family peer support. This paper describes the co-designed study protocol, embedded within this learning health system. Methods: This participatory, mixed-methods study aims to examine the PAIRPEP intervention implementation longitudinally over 3 years across 12 Early Intervention Services and its impact on multiple stakeholders. Informed by the Medical Research Council framework for complex interventions, the project includes a co-designed (with multiple stakeholders) multimodal capacity-building program with specific components developed to overcome barriers to peer support and family peer support integration. Quantitative questionnaires are collected every four months from clinicians and continuously from youth and families (questionnaires, satisfaction surveys) using the learning health system electronic platform. Focus groups are conducted annually over three years with eight stakeholder groups. The analysis integrates findings using thematic synthesis and joint displays to assess convergence and divergence across methods and perspectives. Results and conclusion: This protocol paper outlines the study’s co-design, procedures, and anticipated contributions. Embedding large-scale innovative intervention implementation (such as peer support) within an RLHS can foster real-time feedback, iterative refinement, and inform clinical practice and policies.

Abstract Introduction: Severe mental illnesses in young people (0–25 years) are often preceded by subtle changes in communication and thinking, detectable in speech and language. Speech and language markers are promising for early detection; however, no systematic review has evaluated their prospective utility in predicting mental health disorders in youth. We systematically reviewed longitudinal studies assessing speech and language markers as predictors of major mental health disorder onset or symptom progression in youth. Methods: We searched for longitudinal studies using recorded speech samples to predict diagnostic changes or symptom severity in major depressive disorder (MDD), psychosis, ADHD, substance use disorder, bipolar disorder, OCD, and eating disorders. Risk of bias was assessed using the Newcastle Ottawa Scale. Our protocol was pre-registered [CRD42024579798]. Results: Of 2,259 articles, 10 studies met inclusion criteria, covering MDD (n=2), psychosis (n=5), and ADHD (n=3). No eligible studies were found for OCD, substance use, bipolar, or eating disorders. Both manual and computational speech analyses were used, with speech samples from parents and youth. Predictive speech markers included parental expressed emotion (MDD, ADHD), formal thought disorder (psychosis), and acoustic/linguistic features (psychosis, ADHD). Study quality was moderate to good (mean score: 5.5/8). Conclusions: Externally validated longitudinal studies on the predictive value of speech and language markers of youth-onset mental disorders are scarce and restricted to a few target disorders. Nonetheless, existing studies highlight the potential of applying Natural Language Processing methods to speech samples from both youth and parents for early identification. Keywords: prediction; speech; youth mental health

Background: Early intervention and prevention in youth mental health are essential, with up to 75% of mental illnesses emerging before the age of 25. Over the past two decades, enhanced primary care models, such as Jigsaw in Ireland, have been developed to provide accessible, evidence-based mental health support for young people aged 12–25 years. Understanding trends in service utilisation and factors influencing engagement is critical for optimising service delivery and ensuring equitable access to care. Objectives: This study examines (1) trends in service utilisation within Jigsaw between 2017 and 2022 and (2) factors associated with session attendance, considering demographic, services related and contextual influences. Methods: A secondary analysis of routine clinical data was conducted, including 23,227 young people aged 12–25 who accessed Jigsaw services from 2017-2022. Time series analyses assessed trends in service demand, presenting issues, and wait times. Negative binomial regression models evaluated predictors of session attendance. Results: A steady increase in referrals was found over time. Anxiety was the most consistent predictor of increased attendance across both age groups (12-16 and 17-25), while psychological distress predicted lower attendance in the older cohort. Wait times had a greater impact on the older group, and seasonal patterns were evident across both groups. Gender and referral source effects decreased with age. Conclusions: Findings underscore increasing demand for Jigsaw’s primary care youth mental health services and highlight key factors influencing attendance. Service planners should consider gender-sensitive engagement strategies, the role of referral pathways, and seasonal variations in demand when allocating resources. Addressing long waiting times and enhancing support for highly distressed young people may improve engagement and retention.

Background: The implementation strategies used to facilitate the delivery of youth mental health interventions are rarely reported. Specifying and reporting implementation strategies for impactful innovations that have demonstrated good clinical outcomes has the potential to support replication in other contexts and accelerate adoption of effective youth mental health interventions. Methods: Key project personnel conducted a retrospective review of implementation strategies used in a national programme of enhanced primary care youth mental health services. These strategies were classified and reported using the pragmatic implementation-reporting tool. We used univariate statistics to describe the implementation strategy types, temporality, dosage, and actors. We conducted linear regression techniques to predict time investment. Results: We identified 30 implementation strategies used across the course of one year. Twenty percent of strategies identified were in the domains of evaluative and iterative strategies and developing stakeholder engagement. This was followed by training and educating stakeholders, providing interactive assistance and supporting clinicians. In terms of dosage, interactive assistance accounted for over half of all time invested. Regression analysis showed that interactive assistance was the only category to predict increased person hours. Conclusions: By specifying and reporting the implementation strategies used in a youth mental health primary care programme, the pragmatic implementation-reporting tool can help demonstrate resourcing and skills required to reach programme sustainment.

Introduction: People with psychotic disorders face a significant disparity in life expectancy, primarily due to preventable health conditions. Mental health clinicians play a vital role in addressing these issues, yet barriers such as lack of training, low confidence, and unclear role responsibility impede effective interventions. This study explores the motivation, perceived competence, and communication styles of clinicians addressing physical health for young people with first-episode psychosis, using Self-Determination Theory as a framework. Methods: A mixed-methods design was employed, involving semi-structured interviews with six case managers and five psychiatrists at a specialized early intervention service. Thematic analysis identified key themes, and quantitative ratings assessed attitudes, perceived competence, and communication styles. Results were synthesized into Self-Determination Theory constructs. Results: Quantitative ratings highlighted gaps in training, resources, and prioritization of physical health. Seven themes emerged from clinician interviews: 1) role responsibility, 2) constrained autonomy, 3) autonomous motivation, 4) clinician competence, 5) perceived young person’s competence, 6) domain-dependent communication, and 7) the centrality of relatedness for treatment. Clinicians reported a more directive approach for weight-related issues compared to substance use. Conclusion: Clinicians face significant systemic and individual barriers to addressing physical health in first-episode psychosis. Enhancing autonomy-supportive environments, clarifying role responsibilities, and providing targeted training could improve engagement and outcomes. Integrating physical health within mental health care must be prioritized to reduce disparities.

headspace is Australia's National Youth Mental Health Foundation. There are over 165 youth-friendly multidisciplinary services located in every state and territory across Australia. Considerable Government funds are allocated to headspace centres with the aim of targeting mild-to-moderate mental health disorders for young people aged 12 to 25 years. Young people present for help for a wide range of concerns including mood disorders, anxiety disorders, peer difficulties, and substance use issues. Recent research has demonstrated that a high percentage of young people accessing care at headspace centres are experiencing significant body image concerns and are engaging in disordered eating behaviours. These include dietary restriction, binge eating and purging behaviours such as self-induced vomiting. The headspace centre model includes both general practitioners and mental health clinicians as part of the clinical team. This multi-disciplinary model enables centres the basic staffing needed to provide effective interventions for mild-to-moderate eating disorder presentations. While offering early intervention for eating disorders is within the scope of headspace centres, full integration of eating disorders care into the core business of headspace centres is still ongoing. Many headspace clinicians are not confident in assessing for or treating eating disorders leading to non-specific treatments for eating behaviours that are not evidence based or referrals to external specialized services which are associated with high costs and long waiting times, preventing access to timely and affordable early intervention. headspace centres are well placed with existing resources to provide effective and accessible early intervention for eating disorders to young Australians at risk.

Background: Fidelity assessments are crucial for ensuring evidence-based delivery of first episode psychosis (FEP) services. The First Episode Psychosis Services Fidelity Scale (FEPS-FS) is a validated tool for evaluating FEP programs, but its application in Asian contexts remains unexplored. This study applies and adapts the FEPS-FS to evaluate Singapore’s Early Psychosis Intervention Programme (EPIP) in 2024, examining its contextual applicability within Singapore’s healthcare framework. Methods: Fidelity was assessed at EPIP through program data analysis, health record reviews, and interviews with staff, patients, and families. Three evaluators scored 37 items on a 5-point scale, with ratings determined by consensus. Two items were selectively added from an earlier FEPS-FS version to address local contexts. Items rated ≤3 indicated areas needing attention. The FRAME methodology documented adaptations for local challenges, particularly in weight management and substance use interventions. Results: EPIP demonstrated high fidelity to evidence-based FEP practices, particularly in program structure and clinical processes. Twenty items achieved maximum ratings, including team integration, family engagement, and clozapine adherence. Lower ratings (≤3) identified gaps in participant ratios, psychiatrist caseload, and medication practices. Five items, primarily related to psychological and occupational therapies and substance use interventions, were unscored due to documentation differences, highlighting the need for tailored adaptations. Conclusion: This study demonstrates EPIP’s strong adherence to evidence-based practices while highlighting areas for improvement, particularly in resource allocation and documentation. The findings underscore the need for culturally sensitive adaptations of fidelity measures and innovative solutions to address challenges in early psychosis services within Asian healthcare systems. Future research should focus on developing structured documentation systems that balance standardization with personalized care, and explore strategies to enhance metabolic health interventions and substance use management in the local context.

Background: Stepped care is being adopted in many countries as a framework for organizing mental health care in diverse contexts. However, there is a lack of consistency in how it has been defined and operationalized, limiting its effective application in practice. We describe the development of standards for implementing stepped care in Canadian child and youth mental health contexts using a consensus-based approach. These standards are intended to support systems planners in creating more cohesive child and youth mental health systems across Canadian settings. Methods: This study employed learning alliance and Delphi methodologies. A pan-Canadian multi-round Delphi process conducted in English and French was used to derive consensus on the inclusion and wording of individual clauses in the implementation standard. Consensus with a threshold of 70% was set to determine inclusion of individual clauses in the final standard. Results: 68 individuals participated in the Delphi study (with a 76.48% retention rate) representing lived experience, service delivery, policy, and research expertise. Participant feedback indicated a desire for greater specificity, disagreements regarding the concept of shared decision-making, and pragmatic questions about leading systems-wide activities. Over 3 rounds, 29 clause items were revised and reduced to a final list of 24 clause items comprising implementation standards. Discussion: The results of this study represent the first multi-stakeholder, consensus-driven set of standards for implementing stepped care in child and youth mental health settings across Canada. With these standards, we aspire to provide a blueprint for advocacy and reform toward stronger, more coordinated mental health systems.

Background and Aims Recent studies have shown that communicating and psycho-educating young individuals and their families about high-risk psychosis can offer benefits, like validation and access to specialized care. However, it can also negatively impact self-perception, distress, and help-seeking behavior. In a recent study [(Sol-Nottes et al., 2024)](#ref-0030), we demonstrated that clinicians view positive reframing as a way to mitigate these concerns. This study aimed to extend those findings to community dwelling adolescents with high versus low levels of distressing ‘prodromal’ experiences. An additional goal was to explore the moderating role of sex and culture. Methods The study replicated the design from Sol-Nottes et al. (2024). 108 adolescents were randomly assigned to view either negatively or positively framed simulated feedback sessions, followed by questions about the session’s impact. Prior to viewing the simulated session, all participants completed the brief version of the Prodromal Questionnaire [(Loewy et al., 2011)](#ref-0019). Results As hypothesized, positive framing significantly reduced fear and stigma. However, contrary to our secondary hypothesis, these effects were not moderated by the level of prodromal symptoms. Finally, exploratory analyses revealed a moderating effect of sex and culture, with a stronger effect of positive reframing on stigma, mobilization to seek help, and hopefulness, among male and Arab adolescents. Conclusions These findings provide further support for the potential beneficial effect of positive reframing in the context of at-risk mental states and highlight the importance of cultural factors. Together, these results lay the groundwork for clinical trials on positive framing in real-world settings.

Aims: Both substance use and mental illness commonly onset during adolescence or young adulthood, and rates of substance use in young people with mental illness are disproportionately high. This baseline data paper from a clinical trial testing an integrated early intervention for substance use and mental health problems aims to 1) describe the characteristics of participants enrolled; and 2) compare young people with a current and without a lifetime diagnosis of Substance Use Disorder (SUD) in terms of psychiatric symptoms, functioning, and substance use. Methods: Seventy-nine participants aged 12-25 years with high prevalence mental illness (e.g., depression, anxiety) and substance use seeking mental healthcare were recruited from headspace primary mental health centres in North-Western Melbourne. At baseline, they completed self-report and interview measures of psychiatric diagnoses and symptoms, functioning, and substance use. We compared those with a current (n=51) and without a lifetime (n=21) SUD on these measures. Results: Youth with an SUD endorsed more severe depressive and anxiety symptoms, and lower quality of life and role functioning than those who used substances without a lifetime SUD. They also had more alcohol-related problems and higher frequency cannabis use, and higher risk scores for alcohol, tobacco, cannabis, cocaine, amphetamine-type stimulants, and hallucinogen use. There were no group differences in social and occupational functioning or subjectively-rated sleep quality. Conclusions: Findings highlight the need for early identification and integrated care models within youth mental health services to address the high prevalence and impact of problematic substance use, potentially reducing adverse effects of co-occurring SUD and mental illness on youth development and functioning.

Aim: In 2016, the Access and Waiting Time Standard (AWTS) was introduced in England, UK, outlining that people with first-episode psychosis should receive treatment from an early intervention for psychosis (EIP) service within two weeks. We examined sociodemographic, pathways to care (PtC), and clinical factors associated with EIP service wait time. Method: We collected de-identified data from a large mental health provider in South London, UK. We included patients referred and accepted to EIP services as inpatient or community contacts between 1st May 2016 and 30th April 2019, providing 3 years of data from the introduction of AWTS. Descriptive statistics and multivariable linear regression were performed. Results: A total of 1806 patients were identified with a mean age of 30 (SD:10.7) years, of whom 86.3% (n=1559) accessed community EIP and 13.7% (n=247) accessed inpatient EIP; of these, 26.7% were not seen within 2 weeks. Community EIP patients waited longer adj.β =2.21 days (95% CI: 2.05 – 2.37) compared with inpatient EIP patients, and being older was associated with longer wait time. Conversely, a shorter wait time was associated with A&E [adj.β = -0.22 days (95% CI: -0.36, -0.10)] and ‘other’ [adj.β = -0.21 days (95% CI: -0.36, -0.03)] PtC. White non-British and South Asian patients had shorter wait times compared with White British patients; however, this difference diminished after adjusting for PtC and clinical factors. Conclusions: Our findings indicate that individual factors, PtC, and mode of contact influence wait time for EIP services. More than a quarter of patients were not seen within 2 weeks, indicating that targeted support in community EIP services is needed to meet clinical guidelines.

Background: Trauma exposure is pervasive in people with an At Risk Mental State (ARMS) and is associated with adverse clinical and functional outcomes. While promising developments have been made in treating trauma in psychosis, evidence regarding the efficacy of trauma therapies in ARMS individuals is limited. This trial aims to evaluate the feasibility of conducting a future randomised controlled trial (RCT) to determine the efficacy of Eye Movement Desensitisation and Reprocessing (EMDR) and Trauma Focused Cognitive Behavioural Therapy (TF-CBT) in people with ARMS. Method: 75 ARMS individuals with a history of trauma will be randomised to receive 24 sessions of EMDR plus treatment as usual (TAU), 24 sessions of TF-CBT+TAU, or TAU alone. Feasibility will be determined against pre-specified thresholds for recruitment, retention, treatment engagement, and fidelity. To examine the promise of efficacy of EMDR and TF-CBT, participants will complete a battery of clinical and mechanistic measures at baseline and 9-month post-randomisation, including assessments of attenuated psychotic symptoms and post-traumatic symptoms. Clinical notes will be reviewed to identify transitions to first episode psychosis up to 12-months post-randomisation. Qualitative interviews with trial participants, therapists, and professional stakeholders will explore the acceptability of EMDR and TF-CBT and factors to facilitate future implementation of trauma therapies in routine practice.  Conclusions: If a large-scale RCT is deemed feasible, it will be possible to establish whether EMDR and/or TF-CBT represent beneficial treatments to augment existing evidence-based care for individuals at ultra-high risk for future psychosis, potentially reducing transition rates and improving clinical outcomes for ARMS individuals.

Aim To investigate treatment retention rates, dropout predictors and dropout chronology across patients with substance use disorders at a Women-Specific Outpatient Service in Brazil, across different age strata: Emerging Adults (18-25), Middle Aged Adults (26-59), and Older Adults ( 60+). Methods An observational cohort study, across 27 years. Sociodemographic and other exposures information were collected at enrollment. Survival curves with dropout as event were estimated for each age stratum and log rank tests were performed. Survival probabilities and Cox proportional hazards models were used to gauge dropout risk and determine dropout risk factors. Hazard functions of dropout were estimated to understand chronology of dropout across age strata. Results 714 women were included. Emerging adults exhibited significantly lower treatment retention with 10.2% survival at 104 weeks p<0.0001), and increased rate of early dropout, compared to the other age stratas. Higher education was a protective factor, associated with lower dropout risk (HR= 0.73, p=0.02). Cocaine/crack as the main substance of abuse was a risk factor (HR=1.36 , p=0.003). Hazard function curves showed a first peak of dropout in emerging adults at 12 weeks of treatment. Conclusions Emerging adulthood is a critical period for health interventions. The gender gap is narrowing and even inverting among Emerging Adults, and women are still underrepresented in studies. We found very high and early dropout rates among Emerging Adults in our sample. These findings underscore the necessity for early-stage risk stratification and intervention protocols for this subpopulation.