Identification and treatment of early symptoms of severe mental illness in youth

Several studies have shown that 75% of the serious and chronic psychiatric
disorders develop before the age of 25. Early symptoms of these disorders are
often seen in adolescence. The development of this early symptoms into severe
disorders may be prevented by offering early treatment in the adolescence.
Preventing severe psychiatric disorder is especially important for non-western
ethnic minorities that are insufficiently reached by the mental health care
institutions in the Netherlands, while non-western migrant youth have more
psychological problems compared to their Dutch peers. The hypothesis is that
problems of migrant youth accumulate, resulting in an overrepresentation of
migrant youth in forensic mental health care.
To date there is no existing appropriate treatment for dynamic early symptoms,
common psychiatric treatment in the (youth) mental health care is based on
disease categories. To reduce early symptoms, treatment should be more
development-oriented with a strong focus on risk and protective factors. In
addition to the general factors, factors which mainly migrant youth have to
deal with (e.g. social exclusion) should be taking in account. By offering an
accessible cultural adapted psychosocial treatment the development of
psychiatric disorders may be prevented in both Dutch and migrant youth.

The aims of this study are to reduce early symptoms of severe psychiatric
disorders.

1.Developing a intervention which focuses on the reduction of early symptoms of
psychiatric disorders by combining elements of existing methods, namely an
empowerment program for the prevention of marginalization of (migrant) youth
(POWER) and a psychological intervention for treatment of cognitive biases
(Cognitive Bias Modification).

2. Using a culture-sensitive protocol to recruit participants, causing at least
60% of adolescents with persistent symptoms of mental disorders agreeing to
participated in the study.

3. Investigate the effectiveness (see a.) and the degree of cultural
sensitivity (see b.) of the intervention:
a. adolescents in the intervention show a reduction of symptoms of
psychiatric disorders and show better social functioning immediately after the
intervention and six months after the intervention compared to the measurement
before the intervention took place.
b. the effect of the intervention is present and equally large in all ethnic
groups.

At several schools, adolescents are screened for psychological problems and
contextual risk factors. Participants will be selected based on the results of
questionnaires that were previously filled out by them. Adolescents fill out
digital questionnaires about psychological problems and functional impairment
at two moments in time (with an interference of at least 12 months).
Adolescents will be selected for the intervention if they have at least mild
symptoms and/or impairment in social functioning at both measurements.

The intervention is composed of two existing and effective metnodes, namely:

1. POWER is an empowerment program developed by the Trimbos Institute which
focuses on reduces factors like marginalization, identity problems, social
exclusion, powerlessness and a negative self-esteem, migrant youth have to deal
with. These factors have previously been associated with depression, anxiety
and psychosis. The POWER program includes psycho-education, experiential
learning and behavioral change, and uses role models. The following topics are
covered in POWER: (cultural) identity, relationships and sexuality, dealing
with frustration, crime, health and substance use, environment, spending
leisure, education and work, and future prospects.
Not only the content of the program is adapted to the target group, the method
of recruitment is also culture sensitive. Migrant youth are hardly reached,
this has to do with lack of confidence health care and research institutions.
These institutions often associated with previous negative experiences, fear of
negative consequences of providing personal information and fear that
confidentiality is not guaranteed. For recruitment of youth POWER has
successfully used informal social networks and local immigrant key figures.
These people were able to recruite potential participants. POWER has been used
by more than sixty trainers in several places in the Netherlands, the
experiences of young people, community and trainers are positive.

2. Cognitive Bias Modification (CBM) is a psychological intervention that
directly affects distorted dysfunctional thought patterns by using computer
tasks. CBM is based on the theory that a cognitive scheme helps to reduce,
categorize and interpret incoming information in a certain way. This affects
which information comes to attention and how this information is interpreted.
For example, several studies have shown that people with an anxiety disorder
mainly pay attention to signals of threat (e.g. noticing disapproving faces
instead of neutral faces). The tendency to systematically noticing negative
information is known as attention bias. Such biases make relatively innocent
situations threatening and thereby increase the risk of dysfunctional emotional
and behavioral consequences. Cognitive biases play a major role in the
emergence and persistence of psychiatric symptoms. CBM reduces dysfunctional
thought patterns by neutralizing thought patterns. CBM is an intervention which
has proven to be effective in various psychiatric disorders.

Priop to the treatment program, a psychological interview will be conducted.
Participants follow an eight week treatment program. This program takes place
at the school of the participants. Each meeting has a duration of one and a
half hour. Participants will also complete a number of questionnaires.

Burden:
- Psychological interview prior to the treatment program.
- Questionnaires: before, after (directly and after 6 months) of the
intervention.
- Computer Tasks: in all eight meetings, the participants will perform an
computer task (finding positive stimuli among negative stimuli)
- Group Assignments: role plays and group discussions.

Risks:
- Emotional burden of completing the questionnaires and attending the group
assignments.