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A theory-informed approach to understanding family correlates of treatment use among Latinxs with psychotic symptoms

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A theory-informed approach to understanding family correlates of treatment use among Latinxs with psychotic symptoms

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Content Running head: FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS A THEORY-INFORMED APPROACH TO UNDERSTANDING FAMILY CORRELATES OF TREATMENT USE AMONG LATINXS WITH PSYCHOTIC SYMPTOMS by Vanessa Calderon, M.A. A Dissertation Presented to the FACULTY OF THE USC GRADUATE SCHOOL UNIVERSITY OF SOUTHERN CALIFORNIA In Partial Fulfillment of the Requirements for the Degrees DOCTOR OF PHILOSOPHY and MASTER OF PUBLIC HEALTH (PSYCHOLOGY / PUBLIC HEALTH) August 2022 Copyright 2022 Vanessa Calderon FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS ii Acknowledgements I am grateful to the many people who made this dissertation project possible. Thank you to my advisor and committee chair, Dr. Steve Lopez, for all your support and guidance over the many years and pivotal moments leading up to this dissertation. I would also like to thank my dissertation committee members, Dr. Concepcion Barrio, Dr. Stanley Huey, and Dr. Richard John for their helpful feedback and input throughout the development of this project. I am grateful to the research assistants, Crystal, Kate, Maya, Sabrina, and Sophie, who committed themselves to their work on this project and all other members of the research teams that contributed to carrying out these studies. Thank you to the individuals and families that participated in the research and graciously shared their experiences with us. I also want to thank my family for their unconditional support (both emotional and instrumental) and encouragement. Gracias madre por siempre ser mi inspiración y ejemplo. Thank you to my friends and loved ones who were so generous with their words of encouragement, advice, and patience. I extend my sincere gratitude to all of you for helping me along this journey. FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS iii TABLE OF CONTENTS Acknowledgements..........................................................................................................................ii List of Tables…..............................................................................................................................iv List of Figures..................................................................................................................................v Abstract ..........................................................................................................................................vi Chapter 1: Introduction ...................................................................................................................1 Chapter 2: Study 1: Family Support and Service Use Among Latinxs with Psychotic Experiences ...………....................................................................................................................16 Methods ….............................................................................................................21 Results …...............................................................................................................24 Discussion .............................................................................................................28 Chapter 3: Study 2: Family Correlates of Medication Adherence in First-Episode Psychosis ...………........................................................................................................................34 Methods ….............................................................................................................39 Results …...............................................................................................................46 Discussion .............................................................................................................50 Chapter 4: General Discussion ......................................................................................................60 References .....................................................................................................................................65 Tables …........................................................................................................................................91 Figures .........................................................................................................................................105 Appendices ...………...................................................................................................................109 Appendix A: Burden Assessment Scale .............................................................109 Appendix B: Expanded Brief Dyadic Scale of Expressed Emotion (BDSEE)………………………………………………………………………..110 FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS iv List of Tables Table 1. Study 1 Key Characteristics by Psychiatric and Non-Psychiatric Groups …………….91 Table 2. Study 1 Correlation Matrix for Group with a Lifetime Psychiatric Diagnosis…………92 Table 3. Study 1 Correlation Matrix for Group Without a Lifetime Psychiatric Diagnosis…......93 Table 4. Study 1 Logistic Regressions Including Interaction Term in Psychiatric Diagnosis Group…………………………………………………………………………………………….94 Table 5. Study 1 Logistic Regressions Including Interaction Term in Non-Psychiatric Diagnosis Group…………………………………………………………………………………………….95 Table 6. Study 2 Instrumental Support Coding Examples……………………………………….96 Table 7. Study 2 Medication Adherence Examples……………………………………………...97 Table 8. Study 2 Demographics and Key Characteristics………………………………………..98 Table 9. Study 2 Correlation Matrix for Key Demographics and Variables of Interest in Original Sample……………………………………………………………………………………………99 Table 10. Study 2 Correlation Matrix for Key Demographics and Variables of Interest in Imputed Sample………………………………………………………………………………...100 Table 11. Study 2 Logistic Regressions Using Original and Imputed Data……………………101 Table 12. Study 2 Logistic Regressions with Covariates………………………………………102 Table 13. Study 2 Logistic Regressions Including Interaction Using Original Data…….……..103 Table 14. Study 2 Logistic Regressions Including Interaction Using Imputed Data…….……..104 FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS v List of Figures Figure 1. Conceptual Model of Family Factors Predicting Treatment Behavior………………105 Figure 2. Moderation Model of Psychotic Experiences and Family Support on Service Utilization………………………………………………………………………………………106 Figure 3. Study 1 Alternative Service Use Among Latinxs with A Lifetime Psychiatric Diagnosis.……………………………………………………………………………………….107 Figure 4. Conceptual Model of Family Factors Predicting Medication Adherence……………108 FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS vi Abstract Early treatment in psychosis is associated with improved outcomes. However, service utilization and adherence rates are generally low. Much of the prior treatment use literature has focused on the individual with psychosis. The present study integrates Family Systems Theory and the Alternative Resource Hypothesis to conceptualize family dynamics and the potential role of stigma towards professional services. We evaluated components of a conceptual model of treatment behavior among Latinxs with non-clinical and clinical psychotic symptoms. We conducted two studies. Our first study examined whether psychotic experiences moderates the relationship between family support and service use in a sample of Latinxs with and without psychiatric illness. We identified a significant interaction between psychotic experiences and family support for alternative service use among Latinxs with a psychiatric illness, such that at greater levels of family support Latinxs with psychotic experiences were more likely to use alternative services whereas Latinxs without psychotic experiences were less likely to use alternative services. Family support was not significantly related to any type of service use in those without a psychiatric diagnosis. The second study examined family correlates of medication adherence in first-episode psychosis. None of the family factors predicted medication adherence. In exploratory analyses, individual characteristics (i.e., sex, age) were found to be associated with medication adherence. Qualitative narratives present potential themes for further inquiry. Results of the present studies indicate that family factors may play nuanced and dynamic roles in treatment use. Due to the complexity of early phases of psychosis the family role may be less prominent than patient characteristics. This research contributes to our growing understanding of factors implicated in treatment behavior among Latinxs with psychotic symptoms, which can be used to tailor clinical interventions for this underserved population. FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS A Theoretical Approach to Understanding Family Correlates of Treatment Use Among Latinxs with Psychotic Symptoms Psychosis is characterized by a cluster of symptoms that represent disruptions to an individual’s cognition and sensory perceptions. Psychosis can be a feature of several different psychological and health conditions, most commonly schizophrenia. Schizophrenia is characterized by the presence of positive psychotic symptoms, such as delusions and hallucinations, negative symptoms, such as blunted affect and anhedonia, and cognitive symptoms, such as disorganized speech and thought content (American Psychiatric Association, 2013). Approximately 24 million people worldwide (0.32% of the population) have a diagnosis of schizophrenia (World Health Organization, 2022). Although schizophrenia is not as common as other mental disorders such as anxiety or depression, it has been ranked among the top fifteen leading causes of disability in the world (Mathers, 2008). Schizophrenia tends to develop during late adolescence and early adulthood (McGrath et al., 2008), which are critical periods of neural development and identity formation. The presence of psychotic symptoms, particularly during a critical period of development, can be highly disruptive for individuals and can impair their ability to engage in social and occupational pursuits. As such, schizophrenia is associated with significant impairment in multiple domains, including activities of daily living, educational attainment, employment, and social relationships (Harvey et al., 2012). Moreover, mortality rates among individuals with schizophrenia are 2-3 times higher than the general population (Laursen et al., 2014; McGrath et al., 2008). Psychosis Continuum The psychosis continuum posits a developmental trajectory of schizophrenia and other psychotic illnesses spanning pre-syndromal stages including premorbid and clinical high risk FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 8 phases, the syndromal stage including first-episode psychosis, and the progressive stage, or ongoing psychotic illness (Lieberman et al., 2019). In this dissertation, we are focusing on psychotic experiences (as a proxy for pre-syndromal psychosis) and first-episode psychosis or syndromal stage because these represent critical points for prevention and early intervention (Fusar-Poli et al., 2013). Pre-syndromal Stage The pre-syndromal stage of psychosis includes the prodromal or “clinical high risk” phase. It has been estimated that approximately 75% of individuals with a psychotic illness experienced a clinical high-risk period (Fusar-Poli et al., 2013). During this stage, individuals may experience cognitive or affective impairments that are considered precursors of a psychotic illness. Individuals in the clinical high-risk stage may endorse attenuated psychotic symptoms that do meet diagnostic criteria due to their subthreshold intensity or frequency (Fusar-Poli et al., 2017). It is estimated that approximately one-third of individuals with clinical high risk psychosis will go on to develop a psychotic illness (Cannon et al., 2008). Although not everyone deemed at clinical high risk will go on to develop a psychotic illness, they commonly exhibit co- occurring mental disorders, including anxiety and depression, or will go on to develop non- psychotic psychopathology (McGorry et al., 2008), further highlighting the clinical utility of intervening during the clinical high-risk phase. Treatment recommendations during the pre- syndromal phase focus on primary prevention, including psychoeducation, psychosocial therapy, vocational support, substance use reduction, and monitoring (Fusar-Poli et al., 2017). Syndromal Stage The syndromal stage of the psychosis continuum includes first-episode psychosis during which patients meet diagnostic criteria for a psychotic illness for the first time. The most FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 9 common diagnoses are schizophrenia and schizoaffective disorder. A first-episode of psychosis is typically characterized by the acute onset of psychotic symptoms that are typically accompanied by impairment in occupational or social functioning. This phase is often followed by a recovery or post-acute phase (Fusar-Poli et al., 2017). The five years following a first- episode are considered a “critical period” during which time treatment is particularly important for better outcomes (Crumlish et al., 2009). Treatment recommendations for first episode psychosis span early intervention and secondary prevention, including psychoeducation psychosocial therapy, antipsychotic medication, vocational rehabilitation, and substance use reduction, when applicable (Fusar-Poli et al., 2017). Treatment During the Early Stages of Psychosis Treatment during the early phases of psychosis has been associated with better outcomes. Appropriate treatment could potentially prevent an individual from progressing to a subsequent stage or, once in remission, regress to a previous stage (McGorry et al., 2008). Meta-analyses have reported that treatment during the clinical high-risk period reduces the risk of psychotic illness onset by 50-66% after one year (Fusar-Poli et al., 2013; van der Gaag et al., 2013). Additionally, early treatment during this stage has been proposed to promote engagement with mental health services and alleviate co-occurring disorders, decrease the duration of untreated psychosis by connecting individuals with care earlier in the illness trajectory, and enhance early detection of a first-episode, which could reduce its severity (Fusar-Poli et al., 2017). Mental health service use during the clinical high-risk phase is important not only to prevent or delay progression to a psychotic illness, but also to address co-occurring mental illness. Notably, existing research has reported that a majority of individuals sought help for co-occurring FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 10 concerns (i.e., depression, anxiety, and substance use) prior to the onset of a first-episode of psychosis (Rietdijk et al., 2011). Treatment is also critical during a first-episode of psychosis. Antipsychotic medications are considered a crucial component of effective treatment of schizophrenia (Lehman et al., 2004). Antipsychotic non-adherence is considered to be one of the most important challenges to effective treatment of schizophrenia, more so than the efficacy of the medications (Kreyenbuhl et al., 2011). Medication non-adherence in schizophrenia is associated with poorer functional, clinical, and social outcomes including psychiatric hospitalizations, arrests, substance use, and poorer life satisfaction (Ascher-Svanum et al., 2006b; Masand et al., 2009; Novick et al., 2010; Valenstein et al., 2002). Given the importance of the “critical period” following a first-episode of psychosis, nonadherence to medications can be particularly detrimental during this period. Medication nonadherence is one of the most significant predictors of relapse among first-episode patients (Caseiro et al., 2012; Pelayo-Teran et al., 2017). Despite the known benefits of medication and risks associated with nonadherence, medication nonadherence rates are estimated at over 50% for first-episode patients (Coldham et al., 2002; Rabinovitch et al., 2009). Latinxs and Disparities in Treatment Low mental health treatment use is of particular concern among Latinxs in the U.S. (Dixon et al., 2011). The 2019 National Survey on Drug Use and Health identified that only 34% of Latinx adults received mental health treatment compared to the U.S. average of 45% (SAMHSA, 2020). Additionally, Spanish-speaking and immigrant Latinxs are less likely to use mental health services than those who are English-speaking and are U.S.-born (Alegria et al., 2007; Vega et al., 1999). Similar disparities have been observed with psychotropic medication FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 11 adherence, such that Latinxs, specifically monolingual Spanish speakers (Diaz et al., 2005), are less adherent than White individuals (Lanouette et al., 2009). With regards to psychosis, Latinxs are not only more likely than European-Americans to experience psychotic-like symptoms and receive psychotic illness diagnoses (Lewis-Fernandez et al., 2009; Schwartz & Blankenship, 2014), existing data indicates similar disparities in access to treatment in psychosis. Commercially insured Latinxs recently diagnosed with a psychotic illness are less likely to receive outpatient mental health care than White adults (van der Ven et al., 2020). Additionally, Latinxs receive fewer case management services for schizophrenia than do European-Americans (Barrio et al., 2003). Latinxs are also less adherent to antipsychotic medications than White individuals with schizophrenia (Gilmer et al., 2004; Opolka et al., 2003). Both Gilmer et al. (2004) and Opolka et al. (2003) drew from pharmacy records of commercially insured adults. Gilmer et al. (2004) also identified that those living with family were more likely to be adherent than those living independently. Overall, available data indicates that Latinxs represent a particularly vulnerable group that faces disparities with regards to diagnosis of psychosis and treatment utilization, however a lot remains to be learned regarding correlates of treatment use in this population across early phases of psychosis. Barriers to Care Several barriers to treatment use have been identified across the psychosis continuum. Stigma and interpersonal conflict were identified as barriers to initiating treatment during the clinical high-risk phase (Boydell et al., 2013; Byrne & Morrison, 2010; Welsh & Tiffin, 2012). Similarly, stigma along with misattribution of symptoms, and self-reliance have been found to be treatment barriers in psychotic illness (Cabassa et al., 2018; Gronholm et al., 2017; Judge et al., 2005). Additional barriers that have been reported in psychosis include a lack of supportive FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 12 caregivers or friends (Cole et al., 1995), and the cognitive and affective impairment that can be symptomatic features the illness (Haddad et al., 2014). Ethnic differences have been observed with regards to the impact of shame as a barrier to help seeking in early psychosis (Wong et al., 2009). Qualitative reports of Latinx families with serious and persistent mental illness indicated that cultural beliefs, insurance coverage, and use of alternative services were barriers to treatment usage (Marquez & Ramirez Garcia, 2013). Additional barriers that have been posited to be particularly relevant amongst Latinx communities include concerns regarding documentation status and deportation and lack of access to culturally and linguistically appropriate services (Alderman & Domingues, 2019; Alegria et al., 2007). Factors Associated with Treatment Use and Adherence On the other hand, various facilitators of treatment utilization and adherence across the stages of psychosis have also been reported in the literature. Individual level factors such as patient insight (Kamali et al., 2006; Lepage et al., 2009) and substance use (Perkins et al., 2008; Tucker, 2009) have been found to predict medication adherence among first episode psychosis patients. A review of antipsychotic nonadherence among patients with schizophrenia, identified individual levels factors (i.e., poor insight, negative attitudes towards medication, prior nonadherence), illness related correlates (i.e., substance use, shorter duration of illness), and treatment determinants (i.e., inadequate discharge planning, poor therapeutic alliance) as the most consistent predictors (Lacro et al., 2002). The same review concluded that other factors, including age, gender, ethnicity, education, marital status, family involvement, symptom severity, and side effects, were not consistently related to adherence across studies. A more recent meta-analysis concluded that patient insight and positive attitude towards medication were the most consistent predictors of adherence for people with schizophrenia whereas all other FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 13 patient, medication, and environment related factors, including the family, had mixed results (Sendt et al., 2015). Discrepancies in Family Support Findings Despite the recommendations to include family in psychosis treatment (Dixon et al., 2010), research on family correlates of treatment use have been mixed. For example, two studies included in the Sendt et al.’s (2015) review that did not find significant results utilized patient self-report questionnaires of social contact among Germans with psychotic illness (Klingberg et al., 2008) and social support among Taiwanese people with schizophrenia (Huang et al., 2009), whereas one study that did find a significant positive relationship utilized clinician impression ratings of social support in Canadians with first episode psychosis (Rabinovitch et al., 2009). Additional studies not included in the aforementioned reviews found an inverse relationship between changes in social support and adherence over time (Rabinovitch et al., 2013), and greater odds of adherence among Mexican-Americans with schizophrenia and strong family instrumental support measured via a qualitative interview (Ramirez Garcia et al., 2006). Notable differences between studies could account for the discrepant findings related to the role of family support, including construct measurement (i.e., measures used, type of support), sample demographics (i.e., ethnicity, country), and phase of the illness (i.e., first episode psychosis versus progressive states). Limitations of Literature on Determinants of Psychosis Treatment Behavior Family-related factors have been given minimal attention in the literature relative to other contributors. For example, Lacro et al.’s (2002) review of antipsychotic nonadherence identified only four studies that examined family involvement in medication adherence in schizophrenia out of a total of thirty-nine articles reviewed. The authors concluded that family involvement FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 14 during hospitalization and at follow-up was not a consistent predictor of nonadherence due to mixed results. Lacro et al. (2002) also indicated that there were insufficient studies examining other family factors (i.e., knowledge of schizophrenia) to determine whether they are consistent predictors of adherence. A more recent review also concluded that environmental factors were understudied, reporting that family related determinants were assessed in only about half of the studies whereas patient-level factors were evaluated in all but one of the 13 included studies (Sendt et al., 2015). Additionally, most studies have specifically examined the role of family support or involvement versus other aspects of the family. Furthermore, few studies have examined family factors related to treatment behavior among Latinxs with psychosis. This is particularly relevant given that families may play a uniquely important role in psychotropic medication adherence among Latinxs (Lanouette et al., 2009). Additionally, qualitative studies have identified that the family plays a key role in pathways to care for first episode psychosis (Cabassa et al., 2018) and medication adherence in schizophrenia (Saba et al., 2019). Latinxs with schizophrenia are also twice as likely to live with family members than other ethnic groups (Barrio et al., 2003), suggesting that this population may be particularly impacted by familial dynamics. Similarly, existing studies have reported disparate findings of the association between expressed emotion, typically operationalized as caregiver emotional overinvolvement and criticism, and antipsychotic medication adherence in European (Morken et al., 2007; Sellwood et al., 2003) and U.S. Latinx samples (Ramirez Garcia et al., 2006). In a study conducted in England, patients with high EE family members were more likely to be nonadherent versus low EE families (Sellwood et al., 2003). On the other hand, a different study did not find an association between EE and adherence in a sample of Mexican- Americans (Ramirez Garcia et al., 2006). These disparate findings point to potential ethnic or FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 15 cultural differences in the way family dynamics interact with treatment behavior, however more research is needed in this area. Another notable limitation of the health behavior literature is that many have traditionally tended to focus on individual-oriented theories, such as the Health Belief Model that examines patients’ perceptions of the need for and benefits of treatment (Crosby & Noar, 2010). A meta- analysis of theory use in medication adherence intervention research concluded that none of the 124 reviewed studies drew on theories related to social context (Conn et al., 2016), which as the authors note is a considerable limitation given that health behavior occurs in an environment extending past the individual (Crosby & Noar, 2010). Outside of intervention research, more recent studies have utilized social context informed theories to examine treatment behavior in psychosis. For example, recent studies have drawn on the Network-Episode Model, which emphasizes the role of social networks and social process in mental health service use (Ben- David et al., 2019b), or the Unified Theory of Behavior to account for service use among clinical high risk populations (Ben-David et al., 2019a). Drawing on well-supported theories can strengthen our conceptualization of service use and treatment adherence among individuals with psychotic symptoms, which will promote identification of intervention targets to increase treatment effectiveness. Family Systems Theory Bowen’s Family Systems Theory (FST) expands upon the prevailing individual level focus and helps further our understanding of family processes implicated in treatment behavior in psychosis (Edelman, 2010). FST conceptualizes the family as an emotional unit and emphasizes that the experiences, behaviors, and emotions of one member of the family influences all others in the family (Bowen, 1978). FST focuses on the role of anxiety, or stress, FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 16 within a family. The theory posits that while families are generally able to adapt to some anxiety, chronic or severe anxiety, which can be introduced by illness, will result in familial dysfunction. According to FST, as the family adapts to the illness, caregivers may become more attuned to the ill relative who will in turn be increasingly dependent on and reactive to the caregiver. For example, when a child becomes ill a parent may become overinvolved in caring for them and the child will grow accustomed to the parent’s involvement. The child may become hypersensitive to changes in the parent’s responsiveness or caretaking, which could lead to distress and tension. There are eight key interlocking concepts of FST (Bowen, 1978). We will be highlighting two FST concepts that may be particularly relevant with regards to treatment use in psychosis. Differentiation of self refers to an individual’s ability to distinguish emotional and cognitive systems, such that they are able to make autonomous choices while remaining emotionally connected to others (Haefner, 2014). Bowen conceptualized that there is a spectrum of differentiation, and all individuals fall somewhere along the spectrum (Edelman, 2010). Individuals who are low on the differentiation spectrum are more dependent and emotionally fused in relationships, meaning that they struggle to think rationally and instead react emotionally. They are also less able to adapt to stressors. A second key concept in FST is emotional cutoff, which is described as the individual’s attempt to cope with the emotional issues in the family by detaching themselves either physically or emotionally (Haefner, 2014). It has been posited that people with psychosis may struggle with differentiation of self by the sheer nature of the illness and its impact on affective and cognitive functioning (Edelman, 2010). As Edelman (2010) proposed, individuals with psychosis may demonstrate low differentiation and could be more dependent or “emotionally fused” with their caregivers. Thus, the person with psychosis will be more reactive to changes in the familial emotional climate and FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 17 may “cut themselves off” by either physically removing themselves from the home or distancing themselves from the family through retaliatory behaviors, such as treatment nonadherence. In other words, the presence of psychosis in a family could lead to increased tension and hyperreactivity between the ill relative and caregiver. The caregiver may respond to the illness related stressors by increasing or decreasing the support and affect that they express towards their ill relative. Given the nature of psychosis, the low differentiated ill relative will respond to the familial environment by either increasing relatedness to the family unit or detaching themselves from the family and consequently treatment. FST and Treatment Behavior in Psychosis Different FST related constructs have been examined in the context of psychosis. For example, a FST framework to the study of treatment behavior in psychosis suggests that the presence of an ill family member poses unique stressors that influence the family unit and their interactions (Mitrani et al., 2005). The stress introduced by clinical features of schizophrenia (i.e., symptom severity, functional impairment, relapse frequency) have been found to predict caregiver burden among a Latinx sample (Grandon et al., 2008). Caregiver burden, which often includes poorer mental and physical well-being, has been identified in families of people with psychosis (Dillinger & Kersun, 2020). Furthermore, the way in which families engage with their ill relative amidst the stress, could impact the behavior of the person with psychosis. For example, within the existing literature, expressed emotion has been suggested to result in a feeling of loss of autonomy in people with psychosis that consequently influences behaviors such as treatment adherence (Breitborde et al., 2009; Moore et al., 2000). Overall, FST suggests that the burden experienced by a family of a person with psychosis and the way in which they respond may influence the ill relative’s treatment behavior. If a family member experiences less FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 18 burden or is better able to cope with the experienced burden, and consequently maintains a positive and supportive home environment, their ill relative may be more likely to unite with the family and engage in health promoting behaviors. Alternatively, if a caregiver is heavily burdened, they may respond by being overly reactive to the ill relative, which in turn may prompt the person with psychosis to disengage from the family unit and treatment in retaliation. Alternative Resource Hypothesis The conceptualization of FST and treatment behaviors in psychosis presented above supposes that families are in support of professional treatment (i.e., mental health services and medication). However, the underutilization of mental health services by Latinx communities warrants exploration of the possibility that caregivers are not in support of treatment due to issues such as stigma and the availability of alternative sources of support for psychosis. A systematic review of early psychosis identified stigma as an important barrier to help-seeking behaviors (Gronholm et al., 2017). Furthermore, ethnic minorities have been found to report greater stigma related to psychosis than non-ethnic minorities (Wong et al., 2009). The Alternative Resource Hypothesis (ARH) posits that the family can be considered “alternative resources” to formal mental health care among Latinxs (Rogler, 1985, 1989). For example, when an individual notices the signs of emotional or mental disturbances, they may be inclined to rely on the support of the family or other culturally accepted practices, such as religion, instead of formal treatment. The willingness of Latinxs to seek help from family and religious-affiliated practices has been supported in the literature (Alvidrez, 1999; Kane & Williams, 2000) and has been suggested to partially account for their underutilization of formal mental health services (Villatoro et al., 2014). Although not explicitly addressed by ARH, the severity of the symptoms could also play a role in the use of professional versus alternative FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 19 services. Research has indicated that the use of psychiatric medications is perceived to be a marker of more severe mental illness among Latinxs (Interian et al., 2007), thus it may be that mental health treatment is reserved for more serious conditions. At levels deemed to be less severe, families may rely on internal or culturally normative sources of support. Our Conceptual Model Integrating FST and ARH We have integrated ARH and FST as a framework with which to develop a conceptual model depicting the ways in which Latinx families influence treatment behavior in psychosis (see Figure 1). The presence of psychotic symptoms introduces novel stressors in the family unit, which we are operationalizing as caregiver burden. In a family where the caregiver experiences minimal burden or can cope with the burden and maintain a supportive and positive environment (paths a1 and a2 of the conceptual model; see Figure 1), the ill relative may be more likely to unite with the caregiver. The way in which the ill relative connects with the caregiver may depend on the caregiver’s expectations (paths b1 and b2 of the conceptual model; see Figure 1). For example, when symptoms are more severe and/or family members perceive need for professional treatment, operationalized as knowledge, their support and emotional environment will prompt the ill relative to utilize professional treatment in a show of cooperation. However, when symptoms are less severe and/or family members do not perceive a need for professional care, the ill relative may instead rely on the caregiver’s support as a primary resource and be less inclined to seek professional treatment. Existing Research Supporting FST and ARH Conceptual Model Existing data supports segments of the proposed conceptual model (see Figure 1). Firstly, research indicates that the families of persons with schizophrenia experience burden, which varies over time relative to their use of coping strategies, support networks, and the patient’s FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 20 social functioning (Magliano et al., 2000). Comparable rates of burden have also been observed in pre-syndromal populations (Wong et al., 2008). This finding supports the crux of FST, which stipulates that psychosis symptoms result in increased stress in the family unit. Beginning with path c’ between family burden and treatment behavior, prior research has identified that greater caregiver burden, along with other markers of mental health, is associated with greater likelihood of patient non-adherence (Kretchy et al., 2018). The authors posited that burdened caregivers were less able to supervise their ill relatives’ medication administration (i.e., instrumental support). Additionally, review articles have concluded that family interventions of people with psychiatric illness decrease caregiver burden, reduce stress from negative family dynamics, and improve relationships, family functioning and coping (Cuijpers, 1999; MacDonald et al., 2018), suggesting the role of similar mechanisms. The mechanisms underlying why burden predicts poorer treatment behavior in psychosis is not fully understood. Per FST, we propose two potential mediating pathways, the first of which is through expressed emotion. Several studies have reported that caregivers of people with psychosis who experience greater burden have higher levels of expressed emotion (Alvarez- Jimenez et al., 2010; Carra et al., 2012; Moller-Leimkuhler & Wiesheu, 2012; Scazufca & Kuipers, 1996; Smith et al., 1993), supporting path a1 of our conceptual model (see Figure 1). A handful of studies have examined the relationship between high expressed emotion and non- adherence of antipsychotics in schizophrenia with mixed results (e.g., Ramirez et al., 2008; Sellwood et al., 2002). Despite the inconsistent findings, conceptually high expressed emotion is thought to represent a “threat to patient’s freedom of choice” resulting in patient non-adherence in retaliation (Moore et al., 2000), which is consistent with the FST notion that familial stress can FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 21 impact differentiation of self and impact patient treatment behavior. Thus, we propose that expressed emotion may represent a mediating pathway in our model (see Figure 1, path b1). The second mediator in our model is family support (see Figure 1). To our knowledge no studies have evaluated family support as a mediator of the relationship between burden and adherence, studies have examined the individual pathways. For example, a study of Nigerian people with schizophrenia and other major affective disorders and their caregivers reported that when patients expected greater support caregiver burden was lower (Ohaeri, 2001). Due to the cross-sectional nature of the study the direction of the relationship cannot be determined thus lending probable evidence for path b1 of our conceptual model (see Figure 1). Prior research has also identified that instrumental or “task-oriented” support in particular tends to be associated with greater medication adherence (Baloush-Kleinman et al., 2011; Coldham et al., 2002; Ramirez Garcia et al., 2006). This finding supports the conceptualization of FST that family support may promote treatment behaviors, such as going to doctor’s appointments and refilling prescriptions, and is depicted in path b2 of Figure 1. Finally, we integrate ARH to account for variability in families’ willingness to utilize professional treatment. We conceptualize that families that perceive need for professional care by either the severity of the symptoms or by greater awareness of the symptoms of psychosis are more likely to recommend treatment versus those with less severe symptoms and families that are less knowledgeable. One study found that although knowledge of psychosis is higher among Latinx caregivers than their relatives with first-episode psychosis, it is still relatively low (Lopez et al., 2018). Furthermore, Lopez et al. (2018) found evidence suggesting that knowledge of psychotic symptoms and attributing symptoms to the illness are associated with greater likelihood of recommending professional treatment. As such, we would expect that knowledge FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 22 will indicate whether caregivers see the need for professional support or rely on alternative resources for their ill relative, thus impacting the strength of the relationships between support/expressed emotion and treatment behavior (paths a2 and b2; see Figure 1). Present Studies This dissertation incorporates FST and ARH to test family processes and treatment use in Latinxs with psychotic symptoms. It consists of two studies that each focus on distinct presentations of psychotic symptoms in a non-clinical and clinical population. Study 1 examines the interaction of family support and psychotic experiences on different types of service use among Latinxs (path b2 of our conceptual model; see Figure 1). We focus on service use specifically because psychosocial treatment is recommended over psychotropic medications for subclinical or pre-syndromal psychotic symptoms (Addington & van der Gaag, 2015). Study 2 assesses multiple family correlates of medication adherence among Latinxs with first-episode psychosis (see Figure 4). In this study, we highlight medication adherence given that antipsychotics are considered first line treatment for schizophrenia (Kreyenbuhl et al., 2010). Together these studies expand on the current broadly patient-focused literature on treatment behavior in psychosis and contributes to our understanding of the role of the family. Study 1: Family Support and Service Use Among Latinxs with Psychotic Experiences Psychotic experiences reflect brief, attenuated manifestations of symptoms observed in psychosis spectrum disorders. These experiences do not meet clinical criteria for a psychotic illness and can be common in the general population (Scott et al., 2006; van Os et al., 2001) with an estimated prevalence of 7.2% worldwide (Nuevo et al., 2012). Although the presence of subthreshold psychotic symptoms alone does not necessarily indicate greater risk for a psychotic disorder (van Os et al., 2009), they hold important clinical utility. Psychotic experiences have FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 23 been associated with distress and poor functioning (Yung et al., 2009), suicidality (Kelleher, Lynch, et al., 2012), non-psychotic mental illness (DeVylder et al., 2014; Wigman et al., 2012), and physical health conditions (Oh & DeVylder, 2015). Negative functional and clinical outcomes associated with psychotic experiences (i.e., suicidal ideation, work loss, marital issues, and impairment) have been observed across racial/ethnic groups (DeVylder et al., 2014), including Latinx populations (Olfson et al., 2002). Psychotic Experiences and Mental Health Service Use Available data indicates that people with psychotic experiences need and utilize mental health services. For example, one study identified that 29% of people with psychotic experiences, specifically those who experienced hallucinations, demonstrated a need for care (Bak et al., 2005). Furthermore, a meta-analysis found that individuals who reported psychotic experiences were approximately twice as likely to endorse mental health service utilization than those who did not report any psychotic experiences (Bhavsar et al., 2018). Among U.S. Latinxs, psychotic experiences are associated with a greater likelihood of mental health service utilization (Lewis-Fernandez et al., 2009). However, not all individuals with psychotic experiences utilize professional services. Extant research indicates that help-seeking need and behavior is at least partially attributable to associated distress (Bak et al., 2005; van Os et al., 2009). As such, it seems that factors of the psychotic experiences, including the symptom type and level of distress, may be important determinants of service utilization. Psychotic Experiences and Co-occurring Disorders Psychotic experiences are associated with an increased likelihood of other non-psychotic psychiatric symptoms (Varghese et al., 2011) and co-occurring psychopathology (Kelleher, Keeley, et al., 2012). Those with psychotic experiences and psychiatric diagnoses represent a FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 24 particularly vulnerable group at risk of worse outcomes. For example, the copresence of psychotic experiences and affective symptoms is associated with greater risk of being at clinical high risk for psychosis (Svirskis et al., 2005) and developing a psychotic illness (Krabbendam et al., 2005) versus having psychotic experiences alone. Additionally, the presence of psychotic experiences is linked with poorer illness course among those with co-occurring mood or anxiety disorders (Wigman et al., 2012) and worse outcomes among those with concurrent major depression (Perlis et al., 2011) compared to those without psychotic experiences. Thus, the combined impact of subthreshold psychotic symptoms and psychiatric illness appears to contribute to poorer outcomes and well-being. People with psychotic experiences and co-occurring psychiatric illness are also more likely to use professional services than those with psychotic experiences alone (Wigman et al., 2012). One possible explanation for this finding is that the presence of a psychiatric illness may increase the burden experienced by individuals with psychotic experiences, which in turn promotes treatment seeking (Falkenberg et al., 2015). Alternatively, individuals may be more likely to seek services for affective symptoms as opposed to psychotic symptoms due to the stigma associated with psychosis (Falkenberg et al., 2015). Regardless of the reason or intervention target, treatment leads to improvements in psychotic symptoms as well as the co- occurring psychiatric illness (Yung et al., 2007). As such, the presence of psychotic experiences indicates a need for clinical services whether treatment focuses on the psychotic experiences or co-occurring symptoms. Determinants of Service Use for People with Psychotic Experiences Several determinants of service use among individuals with psychotic experiences in addition to co-occurring psychopathology have been reported. Barragan et al. (2016) identified FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 25 differential correlates for various types of service use in an epidemiological study of the general population with a focus on inclusion of underrepresented ethnic groups. The authors reported that people who were not married or cohabitating and those who attended religious services were more likely to use informal and mental health services, whereas older age, race (i.e., being African-American), and attending religious services predicted informal and medical provider visits. Although Barragan et al. (2016) did not identify family support as a significant predictor of service use, a recent review article concluded that the family plays a critical role in seeking treatment among people with prodromal psychotic symptoms (Allan et al., 2021). To our knowledge, no studies have reported determinants of mental health service use for Latinxs with psychotic experiences, however family correlates have been identified in mental health service use among Latinxs more broadly, including, greater family conflict and lower cohesion (Chang et al., 2013) and mixed results regarding social support (Chang & Biegel, 2018; Miville & Constantine, 2006). The ways in which the family may promote service use among this population particularly within the context of co-occurring psychopathology is not yet fully understood. A Theory Based Framework for Service Use Family Systems Theory (FST) and the Alternative Resource Hypothesis (ARH) provide a framework with which to understand how family dynamics can influence service use. Drawing on FST, we conceptualize that the presence of mental health symptoms introduces stress into the family unit, which is greater among those also reporting psychotic experiences. The familial environment will influence whether the individual with the psychotic experiences will seek services, such that in a supportive family environment the individual may be more inclined to “unite” with their family. Given that individuals are more likely to seek professional services for FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 26 non-psychotic conditions as opposed to psychosis symptoms due to stigma (Falkenberg et al., 2015), per the ARH, it is reasonable to expect that they may be more inclined to reach out to less stigmatizing supports, such as family or religious services, for psychosis symptoms, as opposed to professional services. Furthermore, prior research has reported that when Latinx family members can provide adequate support for their relatives their of use mental health services is low (Kouyoumdjian et al., 2003; Vega et al., 2001), suggesting that the severity of their condition, operationalized by the presence of psychotic experiences and nonpsychotic mental illness, may differentially influence the type of services sought, whether the symptoms are severe enough to warrant professional services or perceived to be manageable within the family and alternative supports. The Present Study The present study evaluates path b 2 of our conceptual model (see Figure 1) in two subgroups: those with lifetime psychiatric illness and those without lifetime psychiatric illness. Consistent with FST, mental illness symptoms introduce stress in the family unit, which will impact family behaviors (in this case family support) and consequently influence the ill relative’s service use behavior. We are proposing that stress levels are greater for those with psychiatric illness than for those without, representing more impaired versus less impaired groups respectively. In the present study, psychotic experiences is a proxy of perceived need for professional services operating on the ARH conceptualization that greater severity of symptoms, in this case the presence of psychotic experiences, will promote professional service use. Our first study aim is to evaluate whether psychotic experiences moderates the relationship between family support and service use among Latinxs with and without a history of psychiatric diagnosis FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 27 (see Figure 2). We conceptualize the non-psychiatric group as a less severe population, which in turn introduces less stress or burden into the family unit than the more severe psychiatric group. Drawing on FST and ARH we hypothesize the following: (1) greater family support in the non-psychiatric (or less severely impaired) group will associated with greater likelihood of alternative (or less stigmatizing) service use and lower likelihood of professional (i.e., medical and mental health) service use, whereas (2) greater family support in the psychiatric (or more severely impaired) group will be associated with greater likelihood of all types of service use (professional and alternative). With regards to psychotic experiences, we hypothesize that: (3) psychotic experiences will be associated with greater likelihood of all types of service use across groups. Lastly, we hypothesize a moderating effect of psychotic experiences, which will be considered to be a proxy of perceived need for treatment, such that: (4) the effects will be stronger for those with psychotic experiences. Methods Participants Study participants were drawn from the National Latino Asian American Study (NLAAS), which is a nationally representative survey that assessed the prevalence and service use of mental health disorders among Latinx and Asian American adults living in the U.S. Data was collected between May 2002-December 2003. Additional details on the methodology are described in an earlier article (Pennell et al., 2004). Of note, there were a total of 2,554 Latinx participants with an overall response rate of 75.5% (Heeringa et al., 2004). The present study assessed a subset of the total Latinx sample, specifically the 25% of respondents that were randomly selected to respond to items regarding service utilization (N = 645) in the original study. FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 28 Measures Demographic Variables Respondents’ sex (male/female), age, education level, language preferences, and citizenship status were included as demographic variables. DSM-IV Diagnosis Lifetime psychiatric illness was determined based on the World Mental Health Survey Initiative version of the World Health Organization Composite International Diagnostic Interview (WMH-CIDI), which is a structured diagnostic instrument utilizing DSM-IV criteria (Kessler & Üstün, 2004). The WMH-CIDI was administered by trained lay interviewers. Diagnoses were determined for the following conditions: depressive disorders, anxiety disorders (i.e., agoraphobia without panic disorder, panic disorder, generalized anxiety disorder, social phobia), and substance use disorder. Psychotic Experiences Data on psychotic experiences was assessed through the WHO-CIDI 3.0 psychosis screen questions administered in the NLAAS. Respondents were asked to indicate whether they had experienced six different types of psychotic experiences across their lifetime, including 1) visual hallucinations, 2) auditory hallucinations, 3) thought insertion, 4) thought control, 5) telepathy, and (6) delusions of persecution. Respondents were also prompted to specify whether these experiences occurred while they were not under the influence of substances, falling asleep, or dreaming. Previous studies have validated the use of the WHO-CIDI psychosis screen with hospital admissions and future psychotic disorder diagnosis in a dose-response manner (Kaymaz et al., 2012). Due to the skewed distribution of the psychotic experiences data, the variable was dichotomized into present or not present. FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 29 Family Support We drew on previous studies that have examined family support in the NLAAS by looking at three items (Darghouth et al., 2015; Villatoro et al., 2014): (1) the frequency of communication and interactions with family or relatives on a 5-point scale (i.e., less than once a month, once a month, a few times a month, a few times a week, most every day), (2) the dependability on family or relatives for help with serious problems on a 4-point scale (i.e., not at all, a little, some, a lot), and (3) the ability to open up to family or relatives about worries on a 4- point scale (i.e., not at all, a little, some, a lot). Cronbach’s alpha for these three items in the present study sample is .71. Service Utilization Past year service utilization was assessed via responses to a single item inquiring whether respondents made at least one visit to a service provider for “problems with emotions, mental health, or use of alcohol or drugs” within the 12 months preceding the interview. Respondents were asked to specify the type of service provider from a list of 10 options. Responses were grouped into four provider categories based on criteria utilized in a previous study (Villatoro et al., 2014). Specialty mental health services included visits with a psychiatrist, therapist, social worker or counselor in a mental health setting, other mental health professional, or using a mental health-related hotline. General medical services included visiting a physician, nurse practitioner, or other health professional. Informal/religious services included visiting a religious leader, healer, self-help group, or online support groups. A fourth composite variable (i.e., any mental health service) was derived by collapsing the three aforementioned categories to assess seeking any type of care within the past year. Analytical Strategy FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 30 Descriptive statistics were calculated for the subset of participants included in the present study (i.e., Latinxs with data on service use). It is worth noting that psychiatric diagnosis is a strong predictor of service use, and would account for a great deal of variance, which could obscure potential effects of psychotic experiences and family support. As such, we decided to analyze the two subgroups separately. Specifically, two subgroups were created to identify psychiatric (more impaired) and non-psychiatric (less impaired) groups: (1) Latinxs with a lifetime DSM-IV psychiatric diagnosis, and (2) Latinxs without any lifetime DSM-IV psychiatric diagnosis. Bivariate analyses were performed to determine correlations between the binary dependent variables (i.e., service use type), independent variables of interest (i.e., psychotic experiences, family support), and relevant demographics that may need to be statistically controlled for in each of the two subgroups. Separate logistic regression models were conducted to examine hypothesis 1 - the main effects of psychotic experiences and family support on service use for each of the four categories (i.e., specialty mental health services, general medical services, informal or religious services, and any mental health service). A second set of regression analyses included the interaction term (psychotic experiences * family support) to examine hypothesis 2 - whether psychotic experiences moderates the relationship between family support and service use. A third set of analyses included covariates and the interaction term. Results Descriptive Results Demographics Latinxs with a lifetime psychiatric diagnosis were primarily female (55%), U.S. citizens (75%), and spoke mostly English at home (52%). Whereas the non-psychiatric diagnosis group FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 31 was 53% female, 60% U.S. citizens, and were more evenly distributed in terms of language spoken (i.e., 39% spoke mostly Spanish at home and 34% spoke mostly English at home). There were no differences in terms of age (psychiatric diagnosis subgroup and non-psychiatric diagnosis subgroup means were 40.9. Most Latinxs completed up to 12 years of education (psychiatric subgroup = 66%, non-psychiatric subgroup = 63%). These results along with demographic data for the full sample are summarized in Table 1. Service Utilization Among Latinxs with a lifetime psychiatric diagnosis approximately 70% utilized any type of service over the past year. Of these, 48% utilized mental health services, 42% utilized general medical services, and 44% utilized alternative services. Although not explicitly hypothesized it is unsurprising that Latinxs without a lifetime psychiatric diagnosis utilized past year services at lower rates. More specifically, approximately 20% utilized any type of service, 12% sought mental health services, 8% received general medical services, and 11% utilized alternative services. Chi-Square Tests of Independence were performed to assess differences in service use between the psychiatric and non-psychiatric illness groups. There were statistically significant differences between the two groups in each of the service use categories. Results are reported in Table 1. Psychotic Experiences Overall, 12% of the full sample endorsed a lifetime psychotic experience. Latinxs with a psychiatric diagnosis were significantly more likely to report lifetime psychotic experiences (22%) than those without a diagnosis (8%). A Chi-Square Test of Independence identified a FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 32 statistically significant difference in psychotic experiences between the psychiatric and non- psychiatric illness groups. Results are reported in Table 1. Family Support There were no statistically significant differences between groups on family support, with the psychiatric subgroup reporting a mean of 9.5 and the non- psychiatric subgroup reporting 9.8 on average (range: 3-13). Results are reported in Table 1. Correlations Results of correlations for the lifetime psychiatric diagnosis subgroup are reported in Table 2. With regards to demographics, age was positively associated with medical service use. Females were more likely to utilize medical services, mental health services, and “any” services. Additionally, US citizens were more likely to utilize “any” services and alternative services. Lifetime psychotic experiences was correlated with any service use as well as general medical service use. Family support was not associated with service use. Results of correlations for the non-psychiatric diagnosis subgroup are reported in Table 3. As with the psychiatric subgroup, all service utilization types were significantly associated with each other. Sex was significantly related to each of the types of service utilization, such that females were more likely to use services. Education also predicted any service use, mental health, and alternative service use but not medical service utilization. Additionally, U.S. citizens were more likely to utilize mental health services only. Lifetime psychotic experiences were correlated with any service use, general medical services, as well as mental health service use. Family support and age were not correlated with any type of service use. Regression Results Main Effects FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 33 We assessed the main effects of psychotic experiences and family support with each service utilization outcome variable for each of the two subgroups. Within the psychiatric diagnosis subgroup, psychotic experiences were significantly related to any service use (B = 0.82, p = .05) and general medical service use (B = 0.74, p < .05), such that those with psychotic experiences were 2.3 times more likely to utilize any type of services and 2.1 times more likely to utilize general medical services than those without psychotic experiences. Family support was not related to or any service use (B = 0.04, p = .505), mental health service use (B = -0.07, p = .151), general medical service use (B = -0.01, p = .908), or alternative service use (B = -0.01, p = .946). Among Latinxs without a lifetime psychiatric diagnosis, the presence of psychotic experiences was significantly associated with any service use (B = 1.03, p < .01), mental health services (B = 0.97, p < .05), and alternative service use (B = 1.29, p < .01). More specifically, those with psychotic experiences were 2.8 times more likely to utilize any services, 2.6 times more likely to utilize mental health services, and 3.7 times more likely to utilize alternative services than those without psychotic experiences. Family support did not significantly predict any service use (B = 0.03, p = .594), mental health service use (B = 0.02, p = .707), general medical service use (B = 0.13, p = .099), or alternative service use (B = 0.04, p = .578). Interaction Effects An additional set of logistic regression analyses evaluated the interaction between family support and psychotic experiences for each of the service use category models in the separate subgroups. When including the interaction term in the logistic regression models of the psychiatric diagnosis group, the main effects of psychotic experience on any service use (B = 0.82, p = .05) and general medical service use (B = 0.75, p < .05) remained significant. We FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 34 identified a significant interaction between psychotic experiences and family support for alternative service use (B = -0.28, p < .05), indicating that the level of family support differentially predicted alternative service use depending on whether Latinxs with a psychiatric diagnosis endorsed psychotic experiences. Results are reported in Table 4. The interaction effect appeared to be largely driven by a steep decline in alternative service use at greater levels of family support for those without psychotic experiences and slightly increasing odds of alternative service use with greater support for those with psychotic experiences (Figure 3). The interaction remained significant when including covariates (i.e., citizenship status) in the model (B = -0.29, p < .05). With regards to the non-psychiatric subgroup, the main effect of psychotic experiences remained statistically significant for any service use (B = 0.96, p < .05), mental health service use (B = 0.95, p < .05), and alternative service use (B = 1.05, p < .05) when including family support as a moderator in the models. The interaction term was not significant in any of the service use models with or without covariates. Results are reported in Table 5. Discussion The present study expands upon prior research assessing service use among individuals with psychotic experiences, by focusing on an underserved population (i.e., Latinxs) and evaluating the role of a culturally salient factor (i.e., family support). Most prior research has emphasized the role of individual level factors in mental health treatment engagement, however families play an important role in initiating treatment (MacDonald et al., 2018) and are routinely included in optimal treatment recommendations for psychosis (Dixon et al., 2010). Additionally, the family may also play a unique and critical role among Latinx with psychosis given that FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 35 families are often involved in the early treatment for Latinxs with first-episode psychosis (Hernandez et al., 2019). Psychotic Experiences and Service Use We identified differential patterns of psychotic experiences predicting service use. Among a more severe group, Latinxs with a lifetime psychiatric diagnosis, having psychotic experiences was associated with a greater likelihood of utilizing general medical services, whereas among those without a psychiatric diagnosis history, psychotic experiences were associated with greater odds of utilizing specialty mental health services and alternative services. Given that Latinxs with a psychiatric diagnosis were found to be more likely to have utilized all types of services in the past year, it appears that the added presence of psychotic experiences had little impact on specialty mental health service use. The presence of psychotic experiences may not have contributed sufficient added distress to warrant use of mental health services, however, may have been sufficiently noteworthy to report to a general practitioner. Alternatively, prior research has conceptualized psychotic experiences as a general marker of distress that may encompass mental and physical health conditions (Oh et al., 2020). As such, it is possible that those with psychotic experiences were experiencing physical health symptoms that account for the greater odds of medical services use. Latinxs without a psychiatric diagnosis on the other hand may be prompted to seek specialty mental health services that they are not otherwise connected to. The greater odds of both specialty mental health and alternative services could indicate the variability in impairment or distress associated with the psychotic experiences that has been found to better predict service use (Bak et al., 2005; van Os et al., 2009) yet was not captured in the present study. For example, individuals who experience more distress or impairment or are more aware of the clinical FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 36 significance of psychotic experiences may be more likely to seek mental health services whereas those with less intense symptoms may be seeking alternative types of support. However, it is important to note that due to the cross-sectional nature of the data, we can only speculate but cannot specify the direction of the relationship between psychotic experiences, psychiatric illness, and service use. As such, it is possible that the service use preceded the onset of psychotic experiences and/or psychiatric illness and may be associated with other areas of impairment not otherwise captured in our data. Family Support and Service Use Contrary to our hypothesis, family support did not predict service use in any of the service type categories for both the psychiatric and non-psychiatric groups. There are several potential reasons for the lack of significant findings. For one, we did not have adequate data to account for the frequency and impairment of the psychotic experiences, which may have influenced the salience of the experiences to others. It could be that the psychotic experiences occurred outside of the awareness of the family members and did not introduce sufficient stress, per Family Systems Theory, so as to impact their support and family dynamics. Additionally, our measure of family support included different facets of support (e.g., quality time, emotional support). Prior studies have identified that instrumental support in particular may be more predictive of treatment adherence than emotional support among Latinxs with psychosis (Ramirez Garcia et al., 2006). Thus, it is possible that our measure did not adequately capture the aspect of family support that is most important with regards to service use among this population. Similarly, it is also conceivable that other family factors beyond support may serve a greater role in service use among Latinxs with psychotic experiences and/or psychiatric illness. Lack of familial knowledge about psychosis symptoms as well as issues of psychosis stigma, FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 37 which have been identified as barriers to service use in this population (Ben-David et al., 2019a), may be stronger predictors of treatment utilization than family support. Future research should further examine these factors. Family Support and Psychotic Experiences Interaction Effects One key finding related to family support was identified among Latinxs with a history of psychiatric illness. Among Latinxs with mental illness and no psychotic experiences, greater family support contributes to a decreased likelihood of seeking alternative services, whereas those with psychotic experiences demonstrated higher odds of alternative service use with greater family support. In other words, Latinxs with a psychiatric illness and no psychotic experiences who perceive a lot of support from their family are less likely to use alternative services than those with less family support, and Latinxs with psychotic experiences plus greater family support are more likely to utilize alternative services. This finding is consistent with our hypothesis that greater family support would predict greater likelihood of alternative service use among Latinxs with a psychiatric diagnosis and psychotic experiences. However, we did not anticipate a cross-over effect, such that for those without psychotic experiences greater family support predicted a lower likelihood of utilizing alternative services. These findings suggest that family support and alternative services (e.g., hotlines, faith groups) may serve a similar role for Latinxs with a psychiatric condition. Consistent with Family Systems Theory, the presence of a relative with a mental illness without psychotic experiences may introduce a degree of stress in the family unit that caregivers are able to meet with greater internal support and may not require additional resources outside of the family unit. On the other hand, the addition of psychotic experiences to the psychiatric diagnosis may introduce sufficient stress and subsequent burden FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 38 within the family unit as to encourage seeking outside support that is still within culturally acceptable means. We did not observe any interaction effects in other professional service domains. Within the context of the Alternative Resource Hypothesis, it seems that even when presented with psychiatric illness and psychotic experiences, families who would be expected to be in need of additional support due to added stress, per Family Systems Theory, may still chose to pursue resources that are considered less stigmatizing, more specifically alternative services. As such, it may be that the presence of psychotic experiences does not add sufficient burden in the family unit, whether it be due to the transient nature of the symptoms or lack of awareness by family members, to promote professional service use and override stigmatizing beliefs regarding mental health treatment. Alternatively, it is possible that individuals may already be connected with professional services due to the mental illness diagnosis and the psychotic experience is sufficiently addressed in the existing treatment. However, due to the cross-sectional nature of the study this suggestion cannot be determined using the present data. Psychotic Experience Rates The percentage of Latinxs who reported lifetime psychotic experiences in our sample (12%) was comparable to prior studies (10-14%; Cohen & Marino, 2013; Lewis-Fernandez et al., 2009) although lower than a primarily Latinx sample of low-income primary care patients (21%; Olfson et al., 2002). It is worth noting that the higher rates observed by Olfson et al. (2002) could be at least partially attributed to the fact that their sample was treatment-seeking and had high rates of non-psychotic psychopathology. Olfson et al.’s (2002) rates of psychotic experiences were more consistent with the percentage we observed among Latinxs with a psychiatric illness FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 39 in the present study (22%). Furthermore, our findings were consistent with prior literature identifying higher rates of psychotic experiences among individuals with other psychopathology. Mental Health Service Use Rates The rates of mental health service use among Latinxs with a psychiatric diagnosis were slightly higher in our study (44%) than more recent national surveys (34%) and are closer to the U.S. average across race-ethnicity groups (45%; SAMHSA, 2020). It is possible that our study used a broader definition of mental health services including hotlines. A stricter definition of mental health service use along with data on continuity of care would provide important information regarding patterns of mental health service use among Latinxs. Limitations We must consider several limitations of the present study when interpreting the results. Due to the retrospective nature of the data collection, participants’ responses were subject to recall bias and potential underreporting of symptoms. Additionally, given that the data are cross- sectional, we cannot make any definitive conclusions regarding temporal relationships. It is unclear whether the psychiatric illness diagnosis and psychotic experiences occurred simultaneously, so as to indicate co-occurring symptoms indicating greater distress. Similarly, it is uncertain if past-year service use followed the onset of the psychotic experiences and/or psychiatric illness (assessed over the lifetime). Follow up research with large sample sizes would benefit from examining the presence of co-occurring psychotic experiences and psychiatric illness prospectively. Finally, the frequency and distress associated with the psychotic experiences were not available for analysis. Prior research has indicated that psychotic experience intensity and frequency are more sensitive risk markers than the presence of the experiences themselves and FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 40 are have been associated with worse outcomes (i.e., greater odds of a future psychotic illness diagnosis) as well as determining a clinical high risk state (Miller et al., 2003). Future studies would benefit from evaluating these aspects of the psychotic experiences to determine whether individuals warrant clinical care (Bak et al., 2005) in the absence of a co-occurring psychiatric illness. Conclusion The present study contributes to the literature on service use among Latinxs with psychotic experiences and other mental illnesses. We found that the presence of psychotic experiences is associated with a greater likelihood of different types of service use among Latinxs with and without psychiatric diagnoses. We drew on Family Systems Theory and the Alternative Resource Hypothesis to begin developing a conceptual model of the ways in which family dynamics contribute to treatment utilization among Latinxs with psychosis. In our sample, family support did not predict service use among Latinxs with and without psychiatric illness and/or psychotic experiences. However, family support was found to contribute to decreased odds of alternative service use for Latinxs with a psychiatric illness and psychotic experiences suggesting that these services may serve a similar purpose. Clinicians would benefit from inquiring about alternative service use in addition to family dynamics when working with Latinxs with psychotic experiences. Study 2: Family Correlates of Medication Adherence in First-Episode Psychosis Psychotropic medication, specifically second-generation antipsychotics, are considered to be the first-line of treatment for schizophrenia (Lehman et al., 2004). Medication adherence, or the extent to which people are taking their medication as indicated by their provider (Osterberg & Blaschke, 2005), has been posited to be one of the main barriers to effective treatment for FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 41 individuals with schizophrenia (Kreyenbuhl et al., 2011) and is associated with worse outcomes. Non-adherent patients with schizophrenia are 3.7 times more likely to relapse than adherent patients (Fenton et al., 1997). The risk of relapse may be particularly pronounced in early psychosis during which time medication adherence was found to be the strongest predictor of relapse (Caseiro et al., 2012). Furthermore, even brief pauses in medication-taking behavior have been associated with a greater risk of relapse (Masand et al., 2009). In addition to increased likelihood of relapse, medication non-adherence has also been associated with worse functional outcomes, such as greater risk of hospitalization and increased use of emergency services, poorer mental health including greater substance use and positive psychotic symptoms, and poorer quality of life (Ascher-Svanum et al., 2006a; Coldham et al., 2002). Medication Adherence in Psychosis Despite the evidence demonstrating the benefits of antipsychotic medication, a significant proportion of individuals with serious mental illness are non-adherent. A recent meta-analysis found that 56% of individuals with schizophrenia were not adherent to their medications (Semahegn et al., 2020). This is consistent with an earlier review which identified a median nonadherence rate of 55% during the first 2 years following a psychotic episode (Fenton et al., 1997). Medication adherence during the early symptomatic phases of psychosis is particularly important given that past medication nonadherence is also associated with increased likelihood of nonadherence in the future (Haddad et al., 2014). Determinants of Medication Non-adherence Various factors have been identified to contribute to antipsychotic medication nonadherence. A meta-analysis of barriers to medication adherence in schizophrenia, identified factors at varying levels, including those related to the illness (i.e., insight, cognitive FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 42 impairment), medication (i.e., side effects, effectiveness), physician/health services (i.e., therapeutic alliance, accessibility), caregivers (i.e., attitudes, stigma), and individual level factors (i.e., attitudes, stigma) (Haddad et al., 2014). Many interventions aiming to improve medication adherence have focused on individual level factors. These include psychoeducation, behavioral interventions, motivational interviewing, and cognitive approaches, with psychoeducation alone interventions being the least effective (Haddad et al., 2014). However public health literature informs us that factors at varying ecological levels impact individual behavior. Consistent with this model, interventions that have focused on a combination of targets in addition to the patient (i.e., family, clinicians) were found to be the most effective at improving adherence (Barkhof et al., 2012; Kane et al., 2013). The Role of the Family The family may be a particularly important intervention target with regards to medication adherence in schizophrenia. For one, the age of onset of psychosis is typically during adolescence and emerging adulthood (Hafner et al., 1994), during which times individuals may be more dependent on family. Furthermore, only 25-40% of individuals with schizophrenia live independently (Leung et al., 2008). A study of people with schizophrenia in the United States, found that approximately 46% live with family, including parents, partners, and other relatives (Tsai et al., 2011). Notably, Latinxs with schizophrenia are twice as likely to live with family members than other ethnic groups (Barrio et al., 2003). Conceptual Framework We are drawing on existing theories to further our understanding of the role of the family on medication adherence in early psychosis. Family Systems Theory and the Alternative FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 43 Resource Hypothesis account for the dynamic nature of family relationships as well as the influence of stigma that could account for the discrepant findings regarding family support and adherence reported in the literature. Although we are focusing on these two frameworks to guide our conceptual model, we recognize that medication adherence, like treatment behavior more broadly, is influenced by multiple systems and factors. As such, in addition to our primary focus on family, we will also explore patient characteristics and clinical correlates as potential covariates. Family Systems Theory According to Family Systems Theory (FST; Bowen, 1960; Bowen, 1978), the presence of an illness, such as schizophrenia, heightens the normative “anxiety” or stressors within the family. How the caregiver responds to the illness-related stressors (i.e., demonstrating positive affect and support or becoming overly critical and unsupportive), will influence the ill relative’s willingness to “unite” with the family, and engage in health promoting behaviors (i.e., taking antipsychotic medication). Two processes underlying this relationship are proposed. Caregivers who experience minimal burden or are able to cope with the stress introduced by the psychotic illness may (1) have greater bandwidth to provide their ill relative with more instrumental support including medication management, or alternatively, caregivers may (2) provide patients with a positive environment that encourages them to act in alignment with their caregiver’s wishes (i.e., take their medication). Alternative Resource Hypothesis This conceptualization of FST in the context of psychosis assumes that caregivers are encouraging their ill relatives to take antipsychotic medication. However, issues such as stigma, shame, and lack of knowledge could make families less likely to recognize the need for and FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 44 encourage professional treatment. According to the ARH, given the importance of the family in Latinx culture coupled with stigma about disclosing mental health issues individuals endorsing mental health problems may be more inclined to seek support from their family or other culturally acceptable means, such as prayer, versus seeking professional services (Alvidrez, 1999). We would expect that within families that are able to maintain a positive and supportive environment, people with psychosis might actually be less likely to take their antipsychotic medication if their family believes that family support and culturally acceptable resources (i.e., prayer) are sufficient to cope with the illness and accompanied stress. As such, we are interested in evaluating the effect of perceived need of antipsychotic medication (i.e., knowledge). The Present Study The present study draws on Family Systems Theory and the Alternative Resource Hypothesis to begin testing components of a proposed conceptual model of family processes within the context of medication adherence in Latinxs with first episode psychosis (see Figure 4). We conceptualize that less illness-related stress (i.e., burden) will be associated with a more supportive and lower expressed emotion family environment (paths a1 and b1), which will in turn be predictive of the ill relative’s medication adherence behavior (paths a2 and b2). Additionally, the caregiver’s knowledge of psychotic symptoms, will be used as a proxy of whether a caregiver perceives a need for professional treatment, and hypothesized to moderate the relationships between support/expressed emotion and adherence (see Figure 4). The present study evaluated the different pathways within the proposed conceptual model. We hypothesize the following direct relationships: (1) caregiver burden will be negatively associated with adherence, such that greater burden will predict less likelihood of regular adherence (path c’ of Figure 4), (2) caregiver burden will be positively correlated with FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 45 expressed emotion (path a1 of Figure 4) and negatively correlated with instrumental support (path a2 of Figure 4), (3) expressed emotion will be inversely related to medication adherence, such that greater expressed emotion will be associated with lower likelihood of adherence (path b1 of Figure 4), and (4) greater instrumental support will be associated with greater likelihood of medication adherence (path b2 of Figure 4). We will also evaluate moderated pathways b1 and b2 and hypothesize the following: (1) caregiver knowledge will moderate the relationship between expressed emotion and adherence such that at greater levels of knowledge, less expressed emotion will predict greater likelihood of adherence whereas at lower levels of knowledge, less expressed emotion will predict lower likelihood of adherence, and (2) caregiver knowledge will moderate the relationship between instrumental support and adherence such that at higher levels of knowledge those with greater support will be more likely to be adherent whereas at lower levels of knowledge those with greater support will be less likely to be adherent. Finally, although we are primarily interested in family correlates of medication adherence, we will also include patient and clinical characteristics (i.e., age, sex, symptom severity) as potential covariates. Method Participants Participants were drawn from a larger study assessing a communication campaign aimed at reducing the duration of untreated psychosis among Latinxs with first-episode psychosis (Lopez et al., 2022). Data collection for the study took place between May 2014-December 2018. Participants were recruited from a public outpatient clinic and a psychiatric hospital in Southern California. To be included in the study, participants had to have a psychotic disorder diagnosis (i.e., schizophrenia, schizoaffective disorder, schizophreniform disorder, psychotic depression, FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 46 bipolar disorder with psychosis, brief psychotic disorder, or psychotic disorder NOS), less than one year of continuous antipsychotic medication, and be between 15-64 years of age. Psychiatric diagnosis was confirmed by the clinician-administered SCID-IV (Structured Clinical Interview for DSM-IV). The present study evaluated a subset of the full sample, including only individuals who identified as Latinx (n = 131), which comprised a majority of the overall sample (N = 137). Measures Patients and their primary caregiver were asked to complete a baseline assessment for the parent study shortly after the patients entered mental health services at the recruiting sites. Study instruments included: (1) a qualitative interview inquiring about family dynamics and pathways to care, (2) clinician-administered interviews evaluating diagnoses and symptomatology, (3) a fictional vignette followed by closed and open-ended questions assessing psychosis literacy, and (4) self-report questionnaires. Patients and their primary caregivers were interviewed separately whenever possible. Interviews and instruments were completed in either English or Spanish depending on the participant’s preference. The dependent variable (i.e., medication adherence) was captured from the patients’ medical records over the 12 months following their baseline assessment. Different sets of raters were assigned to code the qualitative interview, medical records, and open-ended responses to minimize bias. Caregiver Burden The objective subscale of the Burden Assessment Scale (BAS; Reinhard et al., 1994) was used to measure caregiver burden associated with the patient’s illness. The objective subscale includes 9-items that measure the behavioral effects of caring for a relative with serious mental illness, including disruptions in finances, personal activities, the household, and their social life (see Appendix A). Caregivers were asked to indicate how much they had been affected by caring FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 47 for their ill relative in the aforementioned domains using a rating scale from not at all (1) to a lot (4). We utilized mean scores in the present study resulting in a range of 1-4. The BAS has been found to be a valid and reliable measure of caregiver burden (Reinhard et al., 1994). Cronbach’s alpha in the present study is calculated at .88. Family Support Family support was assessed using qualitative interviews conducted with patients. The main author developed an initial working operationalization of family support based on existing literature on the topic (Gottlieb & Bergen, 2010; Streeter & Franklin, 1992). After the development of an initial manual, a team of four undergraduate research assistants and the first author met to discuss and refine the definitions using sample patient interviews that were not part of the final study sample. Additional categories and definitions were added to the manual. After several revisions, the coders began rating the same sample interview transcripts independently, arriving at consensus ratings and discussing discrepancies as a team. Once an acceptable level of reliability was achieved (ICC ≥ .75), coders rated transcripts independently. Raters periodically coded the same set of transcripts and met as a team to discuss ratings and identify any rater drift. This pattern was repeated until all available transcripts were coded. We measured various indices of support, including instrumental support, emotional support, quality time, support amount, and support quality. The present study focused on instrumental support, which is defined as ‘‘task-oriented’’ help (e.g., financial assistance, medication management). We utilized a count of the number of supportive statements mentioned by the participant during the interview. See Table 6 for examples. ICC estimates for instrumental support between the four raters and consensus ratings were calculated based on a single-rating, consistency, 2-way mixed-effects model. ICCs ranged from .77 to .89. FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 48 Expressed Emotion Expressed emotion was based on the Brief Dyadic Scale of Expressed Emotion (BDSEE) self-report measure (see Appendix B). The BDSEE measures three dimensions of expressed emotion including emotional overinvolvement, criticism, and warmth from the patient’s perspective. The scale includes 14-items rated on a 10-point scale. We utilized the mean scores in the present study for a range of 1-10. The BDSEE has been found to have good reliability and construct validity (Medina-Pradas et al., 2011). Criticism, warmth, and emotional overinvolvement demonstrated good internal consistency (a = .88, .76, and .74, respectively. Due to the moderate correlation between criticism and emotional overinvolvement (r(108) = .52, p < .001), we collapsed the two subscales to create an overall measure of expressed emotion, a = .81. The present study did not evaluate warmth. Caregiver Knowledge Knowledge of psychosis was assessed with a single open-ended question (i.e., “What are the symptoms or signs of a serious mental illness?”). Three independent raters coded verbatim responses for correct identification of the 3 main symptoms of psychosis: delusions, hallucinations, and disorganized speech. Raters were trained to identify verbatim and descriptive mentions of psychotic symptoms using a detailed codebook that has been utilized in previous studies (Calderon et al., 2022; Calderon et al., 2015; Casas et al., 2014; Lopez et al., 2018; Lopez et al., 2009). Responses were assigned a rating of 0-3 based on the number of psychotic symptoms that were correctly identified. Raters achieved good to excellent interrater reliability (κ = .74-1.0). Patient Medication Adherence FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 49 Adherence was assessed using the patients’ electronic medical records. A post- baccalaureate research assistant and the first author rated adherence on a 3-point scale: not adherent (0), somewhat adherent (1), fully adherent (2). The use of three similar categories has been implemented in previous studies measuring adherence via patient charts (Coldham et al., 2002; Kopelowicz et al., 2012). Raters were instructed to follow percentage cutoffs of: fully adherent is taking medication 75% or more of the time, somewhat adherent is taking medication 50-74% and non-adherent is taking medication below 50% of the time. Coders assigned a 0-2 rating for each individual note documenting a patient encounter from when they enrolled in the study to 12 months later. After assigning ratings for each encounter within a patient’s chart over the course of 12 months, coders subsequently used the individual encounter ratings to assign a monthly adherence rating using the same 0-2 scores. Monthly ratings were derived based on the individual note ratings and assessment of missed appointments and gaps in the patient’s record. Coders were trained to assign a rating based on multiple criteria. One approach was to take notice of any indications regarding the number of missed medication days as well as missed appointments within the medical notes. For example, if a patient had monthly appointments and the clinician documented that the patient missed anything less than a week of oral medication in one of their monthly visit notes, they would be rated as fully adherent for that month because they would have taken their medication for three out of four weeks, equaling 75% adherence. For patients receiving depot injections, raters were instructed to take note of follow up appointments and whether there was a note for the patient on the date of their follow up. Raters were also instructed to recognize patterns in the patient’s appointments (e.g., they were receiving a shot every month). In these cases, any gaps in notes or notes documenting missed injection FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 50 appointments were used as evidence for a “non-adherent” rating because the patient would not have received any medication without attending the injection appointment. Another way to determine an adherence code was based on observing whether clinician notes commented on patient’s adherence directly (e.g., “adherence is good”) or indirectly (e.g., “patient is reporting side effects from medication”). With regards to direct mentions of adherence, comments reporting that adherence was “good” were assigned a rating of “fully adherent,” mentions of “acceptable” adherence were assigned as “somewhat adherent”, and statements of “poor” adherence were considered “non-adherent.” Indirect mentions of medication adherence include comments regarding reported side effects. If there was indication of side effects, the patient was rated as “fully adherent” unless additional information provided sufficient reason to assign a different code. In cases where there was insufficient information to determine adherence for a particular note, coders assigned a “3” indicating insufficient information to arrive at a rating. Table 7 reports coding examples for the different medication adherence categories. Based on the bimodal distribution of the data and small percentage of patient’s falling within the “somewhat adherent” rating across the 12 months, we collapsed the original non- adherent and somewhat adherent ratings to create a stricter dichotomous variable indicating regular adherence (≥ 75%) or irregular adherence (< 75%), consistent with cut-off adherence percentage used in prior literature (Rabinovitch et al., 2009; Ramirez Garcia et al., 2006). Two independent coders (including the first author) were trained to code for medication adherence. After reviewing the codebook, they independently reviewed and rated the same 10 sample cases. Coders continued this procedure until achieving an acceptable level of reliability between coders regarding whether there was sufficient information to assign a medication FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 51 adherence rating (κ = .86), the medication adherence rating assigned for each encounter (ICC = .87, 95% CI [0.8, 0.9]), and monthly adherence ratings (ICC = .89, 95% CI [0.8, 0.9]). Coders then proceeded to review cases independently. Once reliability was achieved coders raters the same set of patient records after coding five to ten charts independently to assess for any drift. Symptom Severity The Positive and Negative Symptom Scale, or PANSS, (Kay et al., 1987) was administered to evaluate patients’ psychotic symptomatology. The PANSS is largely considered to be the “gold standard” for evaluating antipsychotic treatment efficacy (Opler et al., 2017). Trained clinicians conducted interviews with the participants and arrived at ratings for each of the items using multiple sources including patient report, caregiver report, and interviewer observations, as outlined in the manual. The PANSS consists of 30 items that are rated on a 7- point scale and correspond with three subscales: positive scale, negative scale, and general scale. The positive scale consists of seven items assessing for positive psychotic symptoms, including: delusions, conceptual disorganization, hallucinations, excitement, grandiosity, suspiciousness, and hostility. The negative scale consists of seven items measuring blunted affect, emotional withdrawal, poor rapport, social withdrawal, difficulty in abstract thinking, lack of spontaneity, and stereotyped thinking. The general scale includes 16 items assessing other symptoms observed in psychotic patients, for example: somatic concern, anxiety, depression, uncooperativeness, lack of judgment and insight, and poor impulse control. The PANSS has been found to have good reliability and criterion-related and construct validity (Kay et al., 1988). Internal consistency in the present sample was fair to good for general and negative scales (a = .75 and .81 respectively) but poor for the positive scale (a = .48). The proposed 5-factor model of the PANSS (van der Gaag et al., 2006) was applied but did not significantly improve internal FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 52 consistency of the positive scale (a = .50), thus the 3-factor model was used in subsequent analysis. Analytical Strategy Descriptive statistics were calculated. Bivariate analyses were performed to determine correlations between the binary dependent variables (i.e., medication adherence), independent variables of interest (i.e., support, expressed emotion, knowledge), and relevant demographics that may need to be statistically controlled for. Logistic regression analyses were conducted to evaluate the relationship between the family variables and medication adherence. Results Missing Data The percentage of missing values ranged from less than 1% for patient demographics (i.e., sex and age) to 49% for medication adherence. Only 63% of the full Latinx sample (n = 131) signed the HIPAA documentation granting researchers access to their medical record information (n = 83). Of those who granted access, data was available for 81% (n = 67). The missing medication adherence data was due to missing medical record numbers, inactive records in the medical system, not having any entries in their medical records for the duration of the study period or having insufficient information to rate medication adherence over the course of the study period. Missing data from other measures were primarily missing due to patients not having a caregiver to participate in the study and survey/interview nonresponse. Little’s MCAR test indicated that data was missing completely at random, X 2 (640) = 620.15, p = .71. Using a traditional listwise deletion method, only 54% of the sample for which we had medication adherence data would have been available for analysis (n = 36). We utilized multiple imputation (MI) to address the problem of missing data under the assumption that missing values FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 53 were missing at random (Schafer & Graham, 2002). All variables included in the study model (i.e., caregiver burden, family support, expressed emotion, and caregiver knowledge) as well as potential covariates (i.e., demographics, PANNS scales) were included in the imputation process. The decision to include both the dependent and independent variables in the imputation model follows guidance indicating that not including the dependent variable could contribute to biased estimates (Graham, 2009). Interaction terms (i.e., support*knowledge and expressed emotion*knowledge) were also created and included in the imputation model consistent with recommendations by Graham (2009). Total scale scores versus individual scale items were included in the imputation model when appropriate following guidelines reported by Graham (2009). Additional auxiliary variables (i.e., number of family members, emotional support, warmth) were also included to improve imputation quality (Collins et al., 2001). We utilized SPSS 27 ‘multiple imputation’ command using Fully Conditional Specification imputation method suitable for data missing at random and Predictive Mean Matching. Forty imputed datasets were generated in accordance with recommendations for detecting a small effect size with 50% missing data (Graham et al., 2007). Analyses for the 40 imputed datasets were pooled in accordance with Rubin’s rules (Rubin, 2004). Imputed values compare reasonably well to observed values and results are similar to those using listwise deletion. Analyses with the original and imputed data are presented. MI reporting follow guidelines outlined by Manly and Wells (2015). Descriptives Demographics Descriptive statistics can be found in Table 8. A majority of the patients identified as men (71%), 25.2 years old on average (SD = 9.1) and completed an average of 11.1 (SD = 2.9) years FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 54 of education. With regards to symptom severity, patients’ mean total PANSS symptoms scores were 28.3 (SD = 6.4) on the positive symptom subscale, 19.3 (SD = 7.7) on the negative symptom subscale, and 38.7 (SD = 10.2) on the general symptom subscale. Demographic data was only available for up to 79 caregivers. Caregivers are mostly women (82%) with a mean age of 42.9 (SD = 10.1) and an average of 10.7 years of education (SD = 3.9). The imputed sample demographics were fairly consistent with the original sample (see Table 8). Symptom Severity With regards to the PANSS, the positive scale mean was 28.3 (SD = 6.4) in the original sample and 28.3 in the imputed sample. The negative scale mean was 19.3 (SD = 7.7) in the original sample and 19.3 in the imputed sample. In the original sample, the PANSS general scale mean was 38.7 (SD = 10.2) and 38.5 in the imputed sample. Family Factors The mean caregiver burden score was 2.8 (SD = 0.8) for the original Latinx sample and for the imputed sample. The instrumental support mean was 4.1 (SD = 2.4) for the original sample and 4.0 in the imputed sample. Expressed emotion was 5.5 (SD = 1.9) on average in the original sample and 5.5 in the imputed sample. The mean caregiver knowledge score was 1.3 (SD = 0.8) for the original sample and 1.3 in the imputed sample. Medication Adherence In the original sample, 29 participants (43.3%) were medication adherent. The imputed sample resulted in 60.40 (46%) participants designated as adherent. Correlations Bivariate analyses were conducted to assess relationships between demographics and variables of interest. Correlation statistics for the original Latinx sample can be found in Table 9. FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 55 Correlation statistics for the imputed sample can be found in Table 10. Sex differences in the family variables were identified. Caregiver sex was negatively associated with instrumental support r(74) = -.37, p < .001, such that female caregivers were more supportive (M = 4.5, SD = 2.2) than male caregivers (M = 2.6, SD = 1.4). The correlation was not statistically significant in the imputed sample, r(129) = -.14, p = .36). Caregiver sex was negatively associated with expressed emotion in the original data r(74) = -.26, p < .05, such that female caregivers demonstrated greater expressed emotion (M = 5.8, SD = 1.8) than male caregivers (M = 4.6, SD = 2.3). However results were not statistically significant using the imputed data r(129) = -.16, p = .21). Sex differences also emerged with regards to medication adherence in the original data, such that women patients were more likely to be adherent (65%) than men patients (36%), X 2 (1, N = 67) = 4.26, p < .05. These findings were not statistically significant in the imputed sample r(129) = -.11, p = .45). Medication adherence also varied according to the patients’ age in the original data, such that adherent patients were older (M = 27.9, SD = 1.0) than non-adherent patients (M = 22.9, SD = 5.9), t(65) = 11.80, p < .05. These findings were not statistically significant in the imputed sample r(129) = .17, p = .20). No other demographic, family, or symptom severity variables were significantly related to adherence. With regards to the family factors, caregiver burden was positively related to expressed emotion in the original sample r(91) = .29, p < .05) and imputed data r(129) = .24, p < .05), supporting path a 1 of our conceptual model. No other proposed associations between family variables were observed. Regression Results A logistic regression was conducted including the family variables (i.e., support, expressed emotion) and medication adherence. The logistic regression model using the original FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 56 data was not statistically significant, X 2 (2, N = 44) = 1.81, p = .41. The model explained 5.4% of the variance in adherence. Neither expressed emotion (OR = 0.81, 95% CI [0.58, 1.13]) or instrumental support (OR = 0.94, 95% CI [0.72, 1.23]) significantly predicted adherence. The overall logistic regression model statistic was not available for the pooled imputed data. None of the individual family predictors were associated with adherence using the imputed data: expressed emotion (OR = 1.0, 95% CI [0.76, 1.28]) and instrumental support (OR = 0.97, 95% CI [0.75, 1.25]). Results are presented in Table 11. A second set of logistic regression analyses included the significant demographic covariates identified in the correlations (i.e., patient age and sex). The logistic regression model using the original data was not statistically significant, X 2 (4, N = 36) = 5.17, p = .27. The model explained 14.8% of the variance in adherence. None of the predictors or covariates were significantly associated with adherence. The overall logistic regression model statistic was not available for the pooled imputed data. None of the predictors or covariates were associated with adherence in the imputed sample. Results are presented in Table 12. Moderated Regression Results An additional set of logistic regression analyses were conducted to evaluate paths b 1 and b 2 of the conceptual model including caregiver knowledge as a moderator. The first model evaluating path b 1 (the relationship between expressed emotion and medication adherence; see Figure 4) including knowledge as a moderator was not statistically significant, X 2 (3, N = 48) = 0.89, p = .83. The model explained 2.5% of the variance in adherence. None of the independent variables including the interaction term were statistically significant. The second model evaluating path b 2 (the relationship between instrumental support and medication adherence; see Figure 4) including knowledge as a moderator was not statistically significant, X 2 (3, N = 38) = FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 57 5.85, p = .12. The model explained 19.1% of the variance in adherence. None of the independent variables including the interaction term were statistically significant. See Table 13 for complete results. Moderated regression analyses using imputed data were not statistically significant. The overall logistic regression model statistic was not available for the pooled imputed data (see Table 14). Discussion Family Correlates of Adherence Accordant with our hypotheses, we observed significant associations between caregiver burden and expressed emotion, such that greater burden was associated with greater expressed emotion. This finding is consistent with Family Systems Theory which posits that the stress introduced to the family by an illness such as psychosis can contribute to increased tension in the family dynamics. Our finding is in agreement with prior studies reporting such a relationship (e.g., Nuralita et al., 2019) and supports path a 1 in our conceptual model. Gender Differences in Family Factors Although we did not hypothesize to find sex differences in family factors, we identified these patterns in our original data, which are consistent with prior research. More specifically, we found that female caregivers were more supportive and demonstrated greater expressed emotion than male caregivers. It is worth noting that most caregivers in our sample identified as female whereas most patients identified as male. Gender differences in caregiver burden have been identified in families of people with dementia (Xiong et al., 2020) and schizophrenia (Yu et al., 2019). Yu et al. (2019) suggested two possible explanations for the observed differences, including gender role theory which posits that gender differences in the emotional connectedness to the ill relative along with a decreased likelihood of seeking external support may account for FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 58 the differences between male and female caregivers. Alternatively, the authors also suggested that the gender differences may be due to varying types of coping skills used between men and women. Furthermore, parent-child dyads of different genders may represent unique dynamics. A systematic review of caregivers of ill relatives with serious mental illness in non-western countries concluded that being a female caregiver and caring for a male relative was generally associated with greater burden (Alqhtani, 2021). It is important to note that these differences were not observed in our imputed data. Additionally, the present study assessed (male/female) sex and did not inquire about gender identity. Dynamics in different gender pairings of caregivers and ill relatives should be further examined within the context of Family Systems Theory. Family and Adherence Inconsistent with our hypotheses, none of the family factors were correlated with medication adherence. This was particularly surprising given prior studies that have identified instrumental support as a predictor of medication adherence among Mexican-Americans with schizophrenia (Hosch et al., 1995; Ramirez Garcia et al., 2006). It is worth noting that Ramirez Garcia et al. (2006) identified a larger range of instrumental support in their sample (1-20) compared to the present study (1-10). Although the authors coded qualitative interviews for the presence of instrumental or “task oriented” support like the present study, the specifics of the coding manual and procedures are unclear. Additionally, Ramirez Garcia et al. (2006) included families of people with schizophrenia whereas our study included first-episode psychosis, specifically. Extant studies focusing on first-episode psychosis have found mixed results regarding the role of family support and involvement on medication adherence (Coldham et al., 2002; Rabinovitch et al., 2009). One such prior study of first-episode psychosis patients found FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 59 that although family support predicted concurrent medication adherence it did not predict future adherence (Rabinovitch et al., 2013). This study suggests that changes in support could play a more significant role in predicting adherence over time versus baseline scores. Furthermore, this conceptualization is consistent with the dynamic nature of FST and bidirectional nature of behavior in family units. Inconsistent with our hypothesis, expressed emotion was not significantly associated with medication adherence in our study. Prior literature has demonstrated mixed findings with regards to the relationship between expressed emotion and adherence. Whereas some have identified that people with caregivers with high expressed emotion are more likely to be medication non- adherent (Sellwood et al., 2003), other studies have not found a relationship between expressed emotion and adherence (Ramirez Garcia et al., 2006). These studies have utilized varying measures of expressed emotion with distinct populations. For example, Ramirez Garcia et al. (2006) utilized a 60-90 minute semi-structured interview designed to evaluate expressed emotion (i.e., CFI) in a sample of Mexican-American caregivers of patients with schizophrenia. Sellwood et al. (2002) on the other hand, used a five-minute speech sample (FMSS) conducted with British people with schizophrenia and their caregivers. Our study used a validated questionnaire of expressed emotion (i.e., BDSEE) from the patient’s perspective. It is possible that perceived versus received expressed emotion could differentially predict outcomes, as has been observed in the social support literature (e.g., Kaul & Lakey, 2003). Furthermore, consistent with Family Systems Theory, both patient and caregivers’ perspectives and how these interact could play an important role in the patient’s behavior. Future research should examine these questions with larger samples. FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 60 Finally, we did not find evidence that knowledge of psychosis moderates the relationships between expressed emotion/family support and adherence. We conceptualized knowledge as a proxy of “perceived need.” In other words, if caregivers are more familiar with the symptoms of the illness, they are more likely to recommend professional treatment, in this case antipsychotic medication adherence. However, it is worth noting that we operationalized knowledge as a general awareness of the main positive symptoms of psychosis (i.e., delusions, hallucination, disorganized speech). This definition of knowledge does not capture whether caregivers are able to recognize the symptoms in their ill relative. Furthermore, related concepts such as family attitudes towards medication, which have been identified as a predictor of antipsychotic adherence (Baloush-Kleinman et al., 2011), may be a better operationalization of familial support of medication than perceived need. Patient-level Correlates Consistent with the literature on patient-level determinants of medication adherence during first-episode psychosis, we found that female sex and older age were significantly correlated with regular adherence. Although it was not explicitly predicted, this finding regarding patient characteristics is not surprising based on prior literature and emphasizes the important role of individual level factors. In continuing to examine the contributors to medication adherence in psychosis, we cannot ignore patient characteristics. However, characteristics that are not malleable, such as age, present minimal opportunity for direct intervention beyond demographic targets. As such, we should continue to explore other factors at varying levels of the socioecological environment that may influence adherence and thus present opportunities for intervention. Medication Adherence Rates FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 61 Medication adherence rates in our sample (46%) were consistent with Semahegn et al. (2020), whose review of antipsychotic adherence studies reported 44% adherence, however lower than an earlier review which restricted adherence to > 75% (50%; Lacro et al., 2002). The adherence rate in our study was also accordant with another study of Latinxs with schizophrenia using a 75% operationalization of adherence (43%; Ramirez Garcia et al., 2006). The congruity of our rates of antipsychotic adherence lends credibility to our measure of adherence. Moreover, it adds to the limited body of literature reporting antipsychotic adherence among Latinxs in their first year following a first episode of psychosis. Family Support Narratives Although we did not conduct a formal analysis of the qualitative interviews, we have selected key excerpts that elucidate important points regarding the role of the family. We selected four interviews that highlighted themes related to family dynamics and the ways in which families promoted treatment use. In several instances, participants discussed receiving various types of support from their relatives ranging from financial, assistance with tasks of daily living, and emotional and instrumental support. Participants described receiving various types of instrumental support from their families including behaviors that encouraged treatment behaviors such as medication adherence and attending clinic visits. Participants also described receiving emotional support from family members that promoted positive mental health. Participant 1 (21-year-old male): “Uh these days, well [my family has] been helping me like get through the medication, which is taking me to this hospital or this medical clinic. And then like they, also my sister hel--been helping a lot too since I've been to the hospital.” Participant 2 (19-year-old female): “[My mom] she's been really supportive and understanding throughout this whole process and um she's never once doubted me and um is always checking up on me and just makes sure that I'm doing okay… it just sorta FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 62 validates what I'm going through, um you know that I'm not just crazy or that I'm not making it up that someone actually supports me and believes me.” Participant 3 (22-year-old male): “[My mom] just got me a car… she gives me allowance, 'cause I don't have a job right now, trying to get my life together. Uh she helps me with anything I need, you know, she cooks good food, she gives me a ride to places when I need it, you know, that's about it. Just psychological, you know, and... you know, she keeps me afloat.” Participants also described the importance of their parents being knowledgeable about mental health and providing them with support to aid them in their recovery. On the other hand, another participant commented on the consequences of lack of knowledge about psychosis and treatment, which involved law enforcement and involuntary hospitalizations. Participant 2: “I think just the supportive part, uh I know, a lot of- well I wouldn't say a lot, 'cuz I don't have a lot, but my friend um, she argues with her mother a lot, as well, and um her mom doesn't really listen to her, or support her. Because my friend um has depression, but her mother doesn't think that that's real, she doesn't think that mental illnesses are real, and so I can't imagine that at all. So I think that something that I really appreciate about my family is that they support me and they understand and think that, you know what is happening to me is real… It makes me feel um noticed as a person, not as some head case or something, um it makes me feel valid, and just equal to my family members, not—not something less.” Participant 3: “Uh, before I like, before I went to the mental heal--mental institution. That's when I was like—[my family was] like scared and, you know, they called uh ambulance, and I didn't wanna comply with ambulance, so they called the cops, and they handcuffed me, and they took me to uh psychiatric hospital, and then from there they transferred me to the mental institution. I was there for a week.” Participants also discussed the ways in which the familial environment encouraged their treatment use. In some cases, parents provided reminders whereas in other families the person with psychosis engaged in treatment in order to make their families happy. These quotes begin to address the posited reasons underlying the ways in which patient treatment behavior may be shaped by family dynamics proposed by FST. More specifically, whether treatment use is an effort to unite with family and comply with their wishes or is a function of explicitly being FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 63 reminded to take medication by their relatives (i.e., instrumental support). These quotes indicate that both explanations may be at play for different individuals. Participant 1: “[My parents] let me do like pretty much whatever h-whatever I wanna do, so like if I wanna go out, they let me go out. If... they're not, they're not that strict on me so… As long as I'm doing something they like so. As long as I'm doing good, they'll let me go out and stuff.” Participant 3: “I just wanna make my mom happy. 'Cause she wants to do this, so you know, I'll do it do it for her. If it wasn't for her, I'd just be doing my own thing right now… I wouldn't be here right now. You know, I'd be cruising or something or doing- read, or drawing or something, yeah… I think [seeking services is] really good because it's gonna improve my relationship with my mom. She's gonna know what she can fix and then I'm gonna know what I can fix in order to live happily ever after.” Participant 2: “Unfortunately I always forget to take my pills… So she's always there to remind me… Um just little things like that and uh so, remind me to uh eat sometimes or take a shower, brush my teeth… my sister was really um, there for me as well, and um she would hear me out, and you know she would say, 'If you're hallucinating, please tell me, don't keep it bottled inside, don't feel like you're alone, wake me up at the night if you see something or feel something.' Um so she and my mom I would say are the two people that really really helped me, and um she wanted me to get help as well.” It is important to acknowledge that not all participants reported receiving high levels of support from their families and many described interpersonal conflicts. Participant 3 described how stressors introduced into the family unit led to conflict which ultimately resulted in them disconnecting from the family. The following quote in particular highlights the ways in which conflictual family dynamics can cause individuals to disengage from the family unit, which is consistent with FST. Moreover, the quoted person with psychosis is speaking to a desire for autonomy which is not supported in a hostile home environment. “We uh, fought, I fought with my mom, I fought with my brother, and I was in bad terms with them, and then, um, yes, all the stress and financial problems, kind of like, led me to, like "I wanna be independent." So I tried to be independent, but I couldn't with the job that I had, so yeah… my mom didn't want me to leave, but we were fighting a lot, and I was just like, "forget this, I'd rather just go." FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 64 Additionally, some individuals reported predominantly negative family dynamics and receiving minimal support. Participant 4 (39-year-old female) reported a significant amount of family conflict and tension, which she identified as a contributor to her mental health symptoms. She responded that “nobody” helps her in her family upon interviewer prompting. She also went on to express, “all my problems go back to [my mom] … and her...her husband. And to my father. They're the cause of my problems, right there. Lack of self esteem…” Furthermore, when asked if there was anything she would want to change about her family she responded, “I would want to change the family.” Family Narratives Conclusion These qualitative excerpts highlight the nuanced ways that families play a role in medication adherence among Latinxs with first-episode psychosis. There was variability in terms of how much support participants were perceiving from their families. We also identified examples of families directly influencing participants to take their antipsychotic medication through explicit reminders (e.g., instrumental support) as well as indirectly by providing a positive home environment that encouraged participants to want to please their relatives and act in accordance with their wishes. Additionally, the importance of family knowledge of psychosis symptoms and where to seek treatment was also reported by the participants in our study. Future research exploring such qualitative narratives can be used to further develop our conceptual model of FST and ARH influences on medication adherence in this population. We also identified some examples of negative family dynamics that warrant further exploration. The present study recruited patients and their caregivers. Although not all participants had caregivers involved in the study, a majority did. It is possible that our study resulted in a self-selected group of individuals with psychosis with more positive relationships FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 65 with their families. However, it is important to note that we did observe variability in the distribution of our family support measure (range = 1 to 10), thus this does not seem to fully account for our null findings. Future studies should assess both positive and negative family dynamics among Latinxs with early psychosis in order to best capture Family Systems Theory processes including the role of stress and bidirectional behaviors. Limitations and Future Directions The results of the present study must be interpreted while considering several limitations. Notably, we had significant missing data that without statistical imputation methods, was insufficient to detect dynamic relationships within the proposed conceptual model. Family Systems Theory emphasizes the dynamic nature between the ways family members interact with their ill relative, and vice versa. Future studies should examine the proposed model using a larger sample in order to evaluate mediating and moderating effects. Additionally, we intentionally focused on the patients’ perspectives of family support due to prior research indicating that perceived support is more predictive of health outcomes than enacted or received support (Barrera, 1986). However, consistent with Family Systems Theory we might expect that both caregiver and patient perspectives as well as the potential discrepancies between the two may differentially impact adherence. As such, future studies should examine these dynamics. It is also worth noting that the internal consistency of the positive subscale of the PANSS in our study was low. This was surprising given that the PANSS is a validated and highly researched measure of psychotic symptoms severity that is considered to be the “gold standard” with regards to antipsychotic treatment outcomes (Opler et al., 2017). Future studies should conduct a factor analysis to determine the best fitting factor model in this population. Additionally, our use of medical records to rate medication adherence resulted in a notable FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 66 proportion of missing and non-ratable data. Future studies should systematically collect data on medication adherence over time. Finally, we were unable to assess longitudinal data on family factors and their relationship with adherence over time. Additional research would benefit from analyzing changes in support and expressed emotion over time and how these predict concurrent and future adherence. Conclusion The present study evaluated relationships between family variables that can inform future research and clinical practice for Latinx families of people with first-episode psychosis. Caregivers of people with psychosis, particularly women, will benefit from services to decrease burden. Although we did not identify any significant family predictors, qualitative excerpts suggest that families may play a more nuanced role in treatment behavior than initially conceptualized. Furthermore, utilizing theories that emphasize environmental factors can enhance the development of conceptual models for medication adherence that incorporate multifactorial contributors beyond the individual patient as well as dynamic interpersonal relationships over time. General Discussion This dissertation drew on existing theories to propose and begin to evaluate a conceptual model of treatment use among Latinxs with psychosis symptoms that emphasizes the role of the family. We assessed different aspects of the proposed model that will aid in its further refinement. By narrowing in on psychotic experiences and first-episode psychosis we were able to focus on correlates of early treatment and secondary prevention in the early phases of psychosis symptoms. Families are often cited as playing an important role in the initiation of mental health services and pathways to care (Cabassa et al., 2018). However existing research has found mixed results regarding family factors implicated in the treatment use process for this FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 67 population. We expanded on this literature by incorporating two frameworks that emphasize contextual factors beyond the individual patient. Family Systems Theory and the Alternative Resource Hypothesis can shape our conceptualization of the familial response to the introduction of stress by the presence of psychotic symptoms and the factors that inform whether individuals utilize professional or alternative treatments. The results of study 1 suggest that family support is a correlate of alternative service use in Latinxs with psychopathology and psychotic experiences. In a more severe population of Latinxs with psychiatric illness having greater family support without psychotic experiences predicted decreased likelihood of alternative service use whereas having greater family support for those with psychotic experiences predicted a greater likelihood of alternative service use. In a clinical sample however, family support did not play a significant role in medication adherence. We did not evaluate any alternative treatment use in study 2, thus we are unable to conclude whether a similar pattern would emerge in a first-episode psychosis population. Future studies should examine this question empirically. We did not identify any evidence for the proposed family pathways outlined in our conceptual model in Study 2. In exploratory analyses to identify potential covariates, we found that demographic patient characteristics, specifically age and sex, predicted medication adherence over the course of 12 months (in our original data). We did not find clinical correlates to significantly predict antipsychotic adherence. Although not what we initially hypothesized, these findings shed light on variables that can be used to target adherence interventions to populations that may be most at-risk of poor adherence. Although family variables did not predict professional service use or antipsychotic adherence in our two studies, excerpts from the qualitative interviews from Study 2 shed light on FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 68 the potential nuanced role of the family. Selected patient interviews revealed themes of family instrumental and emotional support, cohesion, and knowledge. It is important to acknowledge that these quotes were specifically chosen by the first author to illustrate family dynamics and were not randomly selected, thus no conclusive results can be drawn at this stage. However, the emerging themes in these interviews are consistent with prior qualitative research that has identified the family to play an important role in the treatment process for individuals with psychosis (e.g., Hernandez et al., 2019). Qualitative methods are often employed to answer “how” questions, or the processes underlying behaviors (Buston et al., 1998). Further exploration of qualitative interviews may elucidate the nuanced ways in which Latinx people with first- episode psychosis and caregivers perceive and experience family factors, beyond the presence of perceived instrumental support, and how these may or may not relate to treatment use. This data could be used to help refine the constructs and pathways of a conceptual model of treatment behavior in psychosis. Furthermore, the quantitative results of our studies should be interpreted with methodological limitations in mind. Although Study 1 had the strengths of being a large, nationally representative sample, measures were cross sectional, thus the timing and directionality of symptoms and service use were not clearly defined. Additionally, we lacked data on the frequency and distress associated with the psychotic experiences that may be stronger indicators of treatment use than the mere presence of any lifetime psychotic experience. Future studies should evaluate family correlates in a true pre-syndromal psychosis sample longitudinally and include measures of the severity of the symptoms. Study 2 had the strength of measuring adherence longitudinally with a clinical population, however, measures of family variables were taken at baseline and not reassessed over time. Family Systems Theory emphasizes the recursive FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 69 and bidirectional effects of family factors (Miklowitz, 2004). Using a nuanced and dynamic approach to family correlates of treatment is particularly important so as to not place blame on caregivers and relatives of persons with schizophrenia or highlight only negative aspects of family environments (Miklowitz, 2004). Thus, future research will benefit from evaluating changes in family factors over time as well patient and caregiver perspectives, in order to comprehensively attend to the dynamic nature of family systems. The present studies also shed light on treatment utilization rates among Latinxs with psychosis. Results highlight the need for greater mental health treatment utilization rates among this underserved population. Our findings were consistent with prior research reporting medication adherence among Latinxs with psychosis (43%) and demonstrated slightly higher rates of mental health service use among Latinxs with non-psychotic psychiatric illness (48%). Overall, these results indicate that more than half of Latinxs with mental illness are not utilizing professional treatment. The need for addressing disparities in access to treatment among Latinxs has been consistently cited in the literature (Lopez et al., 2012). Multi-family groups, particularly those that incorporate cultural adaptations, have been shown to effectively increase adherence rates among Latinxs with psychotic illness (Kopelowicz et al., 2012, 2015). One identified mechanism underlying the effectiveness of multi-family groups is subjective norms, or the patients’ beliefs regarding loved ones’ thoughts about their behavior (Kopelowicz et al., 2015). This construct stems from the Theory of Planned Behavior, which incorporates the social context and how this may inform individual beliefs and consequently behaviors. It is consistent with Family Systems Theory, by addressing the interplay between patient and relative beliefs, as well as the Alternative Resource Theory, by allowing for varying beliefs regarding utilization of FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 70 professional services. Furthermore, the successful trials by Kopelowicz et al. (2012, 2015) emphasize that families do play a role in treatment use behaviors among Latinxs with psychosis and are integral components of effective interventions. Future research should continue to refine the underlying mechanisms so as to further elucidate relevant family processes in treatment use among this population. Overall, we did not identify the patterns that we expected to find with regards to family correlates of treatment use. Although some significant relationships were identified in study 1, we conclude that the individual contributions of the family may be more nuanced than initially conceptualized given the complexity of early psychosis and its presentation. We propose that at early stages of psychosis, families and individuals with psychosis may still be grappling with their experience and symptoms. More research is needed to understand the patient and family experience and beliefs regarding service utilization in this population. Drawing on qualitative and theory-informed approaches can help to further refine the family factors that are most relevant. Additionally, we should also continue to consider the multi-factorial nature of treatment use. Researchers have posited that a multi-faceted conceptualization of treatment initiation in psychosis which includes correlates at various levels is optimal (Compton & Broussard, 2011). As such, despite our focus on understanding the nuanced ways in which family variables contribute to treatment use in this population, we cannot ignore the role of other factors. Future models should incorporate theories that represent individual and environmental dynamics in order to better represent pathways to treatment use. FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 71 References Addington, J., & van der Gaag, M. (2015). Psychosocial treatments for clinical high risk individuals. Schizophr Bull, 41(1), 22. https://doi.org/10.1093/schbul/sbu140 Alderman, T., & Domingues, I. (2019). 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Schizophr Bull, 38(2), 215-218. https://doi.org/10.1093/schbul/sbr139 Wigman, J. T., van Nierop, M., Vollebergh, W. A., Lieb, R., Beesdo-Baum, K., Wittchen, H. U., & van Os, J. (2012). Evidence that psychotic symptoms are prevalent in disorders of anxiety and depression, impacting on illness onset, risk, and severity--implications for diagnosis and ultra-high risk research. Schizophr Bull, 38(2), 247-257. https://doi.org/10.1093/schbul/sbr196 Wong, C., Davidson, L., Anglin, D., Link, B., Gerson, R., Malaspina, D., McGlashan, T., & Corcoran, C. (2009). Stigma in families of individuals in early stages of psychotic illness: family stigma and early psychosis. Early Interv Psychiatry, 3(2), 108-115. https://doi.org/10.1111/j.1751-7893.2009.00116.x Wong, C., Davidson, L., McGlashan, T., Gerson, R., Malaspina, D., & Corcoran, C. (2008). Comparable family burden in families of clinical high-risk and recent-onset psychosis patients. Early Interv Psychiatry, 2(4), 256-261. https://doi.org/10.1111/j.1751- 7893.2008.00086.x FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 96 Xiong, C., Biscardi, M., Astell, A., Nalder, E., Cameron, J. I., Mihailidis, A., & Colantonio, A. (2020). Sex and gender differences in caregiving burden experienced by family caregivers of persons with dementia: A systematic review. PLoS One, 15(4), e0231848. https://doi.org/10.1371/journal.pone.0231848 Yu, Y., Zhou, W., Liu, Z.-w., Hu, M., Tan, Z.-h., & Xiao, S.-y. (2019). Gender differences in caregiving among a schizophrenia population. Psychology Research and Behavior Management, 12, 7. Yung, A. R., Buckby, J. A., Cosgrave, E. M., Killackey, E. J., Baker, K., Cotton, S. M., & McGorry, P. D. (2007). Association between psychotic experiences and depression in a clinical sample over 6 months. Schizophr Res, 91(1-3), 246-253. https://doi.org/10.1016/j.schres.2006.11.026 Yung, A. R., Nelson, B., Baker, K., Buckby, J. A., Baksheev, G., & Cosgrave, E. M. (2009). Psychotic-like experiences in a community sample of adolescents: implications for the continuum model of psychosis and prediction of schizophrenia. Aust N Z J Psychiatry, 43(2), 118-128. https://doi.org/10.1080/00048670802607188 FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 97 Table 1 Study 1 Key Characteristics by Psychiatric and Non-Psychiatric Groups Note. a Total n = 402, psychiatric group n = 135, non-psychiatric group n = 267. *p < .05. **p < .001. Characteristic Total Sample (N = 645) Psychiatric Group (n = 205) Non- Psychiatric Group (n = 440) Chi-square t-test Age in years (SD) 40.91 (15.20) 40.87 (14.16) 40.92 (15.68) 0.04 Sex Female (%) 346 (54%) 113 (55%) 233 (53%) 0.26 Male (%) 299 (46%) 92 (45%) 207 (47%) Education: ≤ 12 years (%) 413 (64%) 136 (66%) 277 (63%) 0.70 Language a Spanish only 19 (3%) 6 (4%) 13 (5%) 12.86* Mostly Spanish 136 (21%) 33 (24%) 103 (39%) Spanish & English 80 (12%) 24 (18%) 56 (21%) Mostly English 161 (25%) 70 (52%) 91 (34%) English only 6 (1%) 2 (2%) 4 (2%) Citizenship Status Citizen (%) 414 (64%) 153 (75%) 261 (60%) 14.43** Non-Citizen (%) 228 (35%) 51 (25%) 177 (40%) Psychotic experiences (%) 79 (12%) 45 (22%) 34 (8%) 26.21** Family support range: 3-13 (SD) 9.73 (2.69) 9.51 (2.78) 9.84 (2.64) 1.42 Service Use Any Type 36% 70% 20% 154.97** Mental Health 23% 48% 12% 105.55** General Medical 19% 42% 8% 101.64** Alternative 21% 44% 11% 96.27** FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 98 Table 2 Study 1 Correlation Matrix for Group with a Lifetime Psychiatric Diagnosis Note. n = 205. a 0 = male, 1 = female. * p < .05. ** p < .01. 1 2 3 4 5 6 7 8 9 10 1. Any Service Use — 2. Mental Health Service Use .629** — 3. Alternative Service Use .582** .355** — 4. Medical Service Use .548** .435** .205** — 5. Psychotic Experiences .139* .053 .024 .152* — 6. Family Support .050 -.099 -.004 -.004 .026 — 7. Age -.091 -.121 -.077 .162* .064 .087 — 8. Sex a .185** .165* .017 .162* .005 .098 .012 — 9. Education .073 .105 .087 .024 .083 .040 - .191** -.051 — 10. Citizenship Status .142* .108 .148* .075 -.075 .134 -.013 -.017 .162* — FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 99 Table 3 Study 1 Correlation Matrix for Group Without a Lifetime Psychiatric Diagnosis Note. n = 440. a 0 = male, 1 = female. * p < .05. ** p < .01. 1 2 3 4 5 6 7 8 9 10 1. Any Service Use — 2. Mental Health Service Use .729** — 3. Alternative Service Use .688** .387** — 4. Medical Service Use .601** .462** .277** — 5. Psychotic Experiences .136** .111* .155** .072 — 6. Family Support .031 .022 .032 .082 .041 — 7. Age -.002 .002 -.006 .059 .127** .109* — 8. Sex a .136** .142** .114* .099* .035 .043 .046 — 9. Education .099* .149** .101** -.052 .008 .013 -.051 .024 — 10. Citizenship Status .079 .096* .049 .037 .031 .134** .191** -.017 .264** — FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 100 Table 4 Study 1 Logistic Regressions Including Interaction Term in Psychiatric Diagnosis Group Note. n = 205. CI = confidence interval; PE = psychotic experiences. Variable B SE B Wald X 2 p OR 95% CI OR Any service use Psychotic experiences 0.82 0.43 3.76 .053 2.28 [1.0, 5.2] Family support 0.04 0.06 0.43 .512 1.04 [0.9, 1.2] PE*Support -0.02 0.15 0.01 .911 0.98 [0.7, 1.3] Mental health service use Psychotic experiences 0.37 0.37 1.00 .316 1.45 [0.7, 3.0] Family support -0.02 0.06 0.17 .683 0.98 [0.9, 1.1] PE*Support -0.29 0.16 3.30 .069 0.75 [0.6, 1.0] General medical service use Psychotic experiences 0.75 0.34 4.73 .030 2.17 [1.1, 4.2] Family support 0.02 0.06 0.08 .774 1.02 [0.9, 1.1] PE*Support -0.10 0.13 0.66 .418 0.90 [0.7, 1.2] Alternative service use Psychotic experiences 0.16 0.35 0.20 .659 1.17 [0.6, 2.3] Family support 0.05 0.06 0.90 .354 1.06 [0.9, 1.2] PE*Support -0.28 0.14 4.08 .043 0.76 [0.6, 1.0] FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 101 Table 5 Study 1 Logistic Regressions Including Interaction Term in Non-Psychiatric Diagnosis Group Note. n = 439. CI = confidence interval; PE = psychotic experiences. Variable B SE B Wald X 2 p OR 95% CI OR Any service use Psychotic experiences 0.96 0.39 5.91 .015 2.61 [1.2, 5.6] Family support 0.01 0.05 0.43 .836 1.01 [0.9, 1.1] PE*Support 0.15 0.16 0.81 .369 1.16 [0.8, 1.6] Mental health service use Psychotic experiences 0.95 0.45 4.49 .034 2.58 [1.1, 6.2] Family support 0.02 0.06 0.07 .796 1.02 [0.9, 1.1] PE*Support 0.05 0.18 0.07 .792 1.05 [0.7, 1.5] General medical service use Psychotic experiences 1.05 0.51 4.30 .038 2.86 [1.1, 7.7] Family support -0.04 0.07 0.01 .949 1.00 [0.9, 1.1] PE*Support 0.32 0.22 2.10 .147 1.37 [0.9, 2.1] Alternative service use Psychotic experiences 0.40 0.71 0.32 .571 1.50 [0.4, 6.0] Family support 0.10 0.08 1.62 .203 1.11 [0.9, 1.3] PE*Support 0.27 0.30 0.80 .372 1.31 [0.7, 2.4] FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 102 Table 6 Study 2 Instrumental Support Coding Examples Support Subcategory Operationalization Quotes Daily living support Participant reports receiving support with daily tasks and responsibilities from family members. Examples include family assisting patient in applying for jobs, running errands, and driving places. Interviewer: “Can you give me an idea of the things that [your mom] does for you?” Patient 1: “Sometimes with money if I need it and she has it.” Patient 2: “Kind of like with clothing, prepare my food, that kind of stuff for example.” Illness Management Participant indicates family member’s instrumental support with their mental illness (including substance use) and treatment related activities. Examples include family taking patient to medical appointments, assistance refilling medications, reminding patient to take medication, reinforcing that the patient should take their medication, and family interacting with medical providers. Patient 3: “Pasaron como una semana antes que me, paso una semana ya de ahi este- mi mama me llevó al [hospital], no se como se llame.” Translation: It was like one week before they, one week passed and from there my mom took me to the hospital, I’m not sure what it’s called. FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 103 Table 7 Study 2 Medication Adherence Examples Adherence Rating Examples Fully Adherent "client reported he is currently doing better now that he is taking medications. client stated he has been taking his medications" "Since last visit, patient been compliant with meds." "client has been getting monthly Invega Sustenna 156 mgs injections" Somewhat Adherent "pt was not taking meds but resumed them about 8 days ago" [note dated at end of the month, suggesting adherence for 8 out of 31 days = 26% of month] "states he has not been taking meds consistently since he doesn't hear the voices much" “Adherence to Medication: average." Not Adherent "States she was on medication for two years and recently stopped before hospitalization in November." [note from early December] "pt has been off all meds” “Adherence to Medication: poor." FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 104 Table 8 Study 2 Demographics and Key Characteristics Note. a SD not available for imputed data. Original Latinx Sample Imputed Data (n = 131) Characteristic n n (%) M (SD) n (%) M a Patient age in years 128 25.23 (9.09) 25.29 Caregiver age in years 78 42.92 (10.05) 43.11 Patient sex 130 Female 37 (28.5) 37.40 (28.5) Male 93 (71.0) 93.60 (71.5) Caregiver sex 79 Female 65 (82.3) 91.90 (70.2) Male 14 (17.7) 39.20 (29.8) Patient education in years 104 11.13 (2.90) 11.29 Caregiver education in years 77 10.65 (3.92) 10.70 PANSS Ratings Positive Symptoms 121 28.31 (6.36) 28.27 Negative Symptoms 118 19.28 (7.67) 19.32 General Symptoms 119 38.73 (10.21) 38.49 Caregiver Burden 107 2.77 (0.80) 2.78 Instrumental Support 82 4.06 (2.37) 4.00 Expressed Emotion 103 5.46 (1.91) 5.41 Caregiver Knowledge 93 1.31 (0.78) 1.27 Medication Adherence (% adherent) 67 29 (43.3) 60.40 (46) FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 105 Table 9 Study 2 Correlation Matrix for Key Demographics and Variables of Interest in Original Sample a 1 = female, 2 = male. * p < .05. ** p < .001. Variable 1 2 3 4 5 6 7 8 9 10 11 12 13 1. Caregiver Burden — 2. Family Support .01 — 3. Expressed Emotion .30** -.02 — 4. PANSS Negative Scale -.06 .06 -.07 — 5. PANSS General Scale .08 .04 -.08 .48** — 6. PANSS Positive Scale -.09 .14 .13 -.04 .29** — 7. Patient Sex a -.01 .08 .14 .03 -.03 .02 — 8. Patient Age -.06 -.19* -.13 -.14 -.01 -.11 - .27** — 9. Patient Education -.02 .02 .13 -.00 .06 .22* -.03 -.19* — 10. Caregiver Sex a -.15 -.12 - .28** .20* .30** -.05 -.15 .09 .14 — 11. Caregiver Age .28** -.02 .10 -.06 -.21* -.17 - .28** .08 .07 -.07 — 12. Caregiver Education .16 .07 .08 -.00 .09 -.08 .02 -.07 .10 .26** - .25** — 13. Medication Adherence -.13 -.06 -.03 .24 -.01 -.12 -.25* .30* -.05 .19 .15 -.18 — FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 106 Table 10 Study 2 Correlation Matrix for Key Demographics and Variables of Interest in Imputed Sample a 1 = female, 2 = male. * p < .05. ** p < .001. 1 2 3 4 5 6 7 8 9 10 11 12 13 1. Caregiver Burden — 2. Family Support .14 — 3. Expressed Emotion .24* .01 — 4. PANSS Negative Scale .00 .05 -.07 — 5. PANSS General Scale .16 -.04 -.10 .46* * — 6. PANSS Positive Scale -.01 .03 .06 -.03 .37* * — 7. Patient Sex a .05 .05 .12 .02 -.06 .03 — 8. Patient Age -.12 -.16 -.08 -.12 -.00 -.12 - .29* * — 9. Patient Education .04 .08 .10 -.02 .05 .21* -.07 -.21* — 10. Caregiver Sex a -.12 -.14 -.16 .11 .14 .02 -.20 .05 .09 — 11. Caregiver Age .06 .10 .05 .00 -.11 -.05 -.03 .04 .08 .00 — 12. Caregiver Education .09 -.06 .04 -.05 .04 -.02 .02 -.04 -.01 .13 -.20 — 13. Medication Adherence -.07 -.04 -.01 .19 -.02 -.02 -.11 .17 .01 .03 .09 -.08 — FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 107 Table 11 Study 2 Logistic Regressions Using Original and Imputed Data Note. a n = 44. b n = 131. CI = confidence interval. Variable B SE B Wald X 2 p OR 95% CI OR Original data a Instrumental support -0.06 0.14 0.19 .662 0.94 [0.7, 1.2] Expressed emotion -0.21 0.17 1.60 .206 0.81 [0.6, 1.1] Imputed data b Instrumental support -0.03 0.13 - .805 0.97 [0.8, 1.2] Expressed emotion -0.01 0.13 - .930 1.0 [0.8, 1.3] FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 108 Table 12 Study 2 Logistic Regressions with Covariates Note. a n = 44. b n = 131. CI = confidence interval. Variable B SE B Wald X 2 p OR 95% CI OR Original data a Instrumental support 0.03 0.15 0.03 .855 1.03 [0.8, 1.4] Expressed emotion -0.16 0.18 0.84 .358 0.85 [0.6, 1.2] Sex 0.59 0.80 0.55 .457 1.81 [0.4, 8.6] Age 0.06 0.05 1.65 .199 1.07 [1.0, 1.2] Imputed data b Instrumental support -0.01 0.14 - .964 0.99 [0.8, 1.3] Expressed emotion 0.01 0.15 - .925 1.01 [0.8, 1.4] Sex 0.34 0.77 - .659 1.41 [0.3, 6.5] Age 0.04 0.04 - .303 1.04 [1.0, 1.1] FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 109 Table 13 Study 2 Logistic Regressions Including Interaction Using Original Data Note. a n = 48. b n = 38. CI = confidence interval; EE = expressed emotion. Variable B SE B Wald X 2 p OR 95% CI OR Path b1 of conceptual model a Expressed emotion -0.04 0.30 0.02 .893 0.96 [0.5, 1.7] Caregiver knowledge 0.26 0.98 0.07 .793 1.29 [0.2, 8.9] EE*knowledge -0.71 0.20 0.12 .728 0.93 [0.6, 1.4] Path b2 of conceptual model b Instrumental support 0.05 0.34 0.02 .885 1.05 [0.5, 2.1] Caregiver knowledge 0.08 0.92 0.01 .935 1.08 [0.2, 6.5] Support*knowledge -0.25 0.22 1.34 .247 0.78 [0.5, 1.2] FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 110 Table 14 Study 2 Logistic Regressions Including Interaction Using Imputed Data Note. n = 131. CI = confidence interval; EE = expressed emotion. Variable B SE B Wald X 2 p OR 95% CI OR Path b1 of conceptual model Expressed emotion -0.01 0.24 - .980 0.99 [0.6, 1.6] Caregiver knowledge -0.13 0.81 - .873 0.88 [0.2, 4.3] EE*knowledge -0.01 0.16 - .933 0.93 [0.7, 1.4] Path b2 of conceptual model Instrumental support 0.15 0.24 - .540 1.16 [0.7, 1.9] Caregiver knowledge 0.40 0.65 - .535 1.50 [0.4, 5.4] Support*knowledge -0.17 0.14 - .244 0.85 [0.6, 1.1] FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 111 Figure 1 Conceptual Model of Family Factors Predicting Treatment Behavior Caregiver Burden Treatment Behavior Family Support Expressed Emotion Family Perceived Need for Treatment Path a1 Path b1 Path a2 Path b2 Path c’ Family Perceived Need for Treatment FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 112 Figure 2 Moderation Model of Psychotic Experiences and Family Support on Service Utilization Psychotic Experiences Family Support Service Use FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 113 Figure 3 Study 1 Alternative Service Use Among Latinxs with A Lifetime Psychiatric Diagnosis 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 -8 -6 -4 -2 0 2 4 6 Family Support no PE yes PE FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 114 Figure 4 Conceptual Model of Family Factors Predicting Medication Adherence Caregiver Burden Medication Adherence Family Support Expressed Emotion Caregiver Knowledge Path a1 Path b1 Path a2 Path b2 Path c’ Caregiver Knowledge FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 115 Appendix A Burden Assessment Scale I am going to read a list of things, which other people have found to happen to them because of their relative’s illness. Would you tell me to what extent you have had any of the following experiences in the past six months. 1 2 3 4 9 Not at all A little Some A lot NA Because of (the patient’s) illness, to what extent have you: _______ 1. Had financial problems _______ 2. Missed days at work (or school) _______ 3. Found it difficult to concentrate on your own activities _______ 4. Had to change your personal plans like taking a new job, or going on vacation _______ 5. Cut down on leisure time _______ 6. Found the household routine was upset (e.g., disrupted) _______ 7. Had less time to spend with friends _______ 8. Neglected other family members’ needs _______ 9. Experienced frictions with neighbors, friends, or relatives outside the home FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 116 Appendix B Expanded Brief Dyadic Scale of Expressed Emotion (BDSEE): English Instructions: These questions are about your views of your (please check one) ____son, ____daughter, ____spouse, ____sibling, ____parent, or ______________ other (specify). Thinking about the last three months, please circle the number between 1 and 10 that best corresponds to your view of your ill family member. 1. How critical are you of your ill family member? Not at all critical 1 2 3 4 5 6 7 8 9 10 Very critical indeed 2. How warm are you towards your ill family member? Not at all warm 1 2 3 4 5 6 7 8 9 10 Very warm indeed 3. How disapproving are you of what your ill family member does? Not at all disapproving 1 2 3 4 5 6 7 8 9 10 Very disapproving indeed 4. How caring are you of your ill family member? Not at all caring 1 2 3 4 5 6 7 8 9 10 Very caring indeed 5. How much do the things that _________ do annoy you? Not at all 1 2 3 4 5 6 7 8 9 10 Very much indeed 6. How much do you like to spend time and do things with __________? Does not like it at all 1 2 3 4 5 6 7 8 9 10 Like it very much indeed 7. Do the things that you do or say make _______ feel criticized by you? FAMILY AND PSYCHOSIS TREATMENT USE AMONG LATINXS 117 Does not feel criticized at all 1 2 3 4 5 6 7 8 9 10 Feels very criticized indeed 8. Do the things that you do or say make ________ feel loved by you? Does not feel loved at all 1 2 3 4 5 6 7 8 9 10 Feels very loved indeed 9. I let _________ do things on his/her own. (Reverse code) Never 1 2 3 4 5 Sometimes 6 7 8 9 10 Always 10. I meddle in or interfere with ________’s activities (his/her life and affairs). Never 1 2 3 4 5 Sometimes 6 7 8 9 10 Always 11. I make _________ feel that he/she is not capable of taking care of him/herself. Never 1 2 3 4 5 Sometimes 6 7 8 9 10 Always 12. The things I do or say make _________ feel controlled by me. Never 1 2 3 4 5 Sometimes 6 7 8 9 10 Always 13. I stress out easily because of ________’s problems. Never 1 2 3 4 5 Sometimes 6 7 8 9 10 Always 14. I cry easily when we talk about _______’s things. Never 1 2 3 4 5 Sometimes 6 7 8 9 10 Always

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University of Southern California Dissertations and Theses

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Asset Metadata

Creator Calderon, Vanessa (author)

Core Title A theory-informed approach to understanding family correlates of treatment use among Latinxs with psychotic symptoms

School College of Letters, Arts and Sciences

Degree Doctor of Philosophy / Master of Public Health

Degree Program Psychology / Public Health

Degree Conferral Date 2022-08

Publication Date 06/30/2022

Defense Date 05/05/2022

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag family systems,Latinx,OAI-PMH Harvest,psychosis

Format application/pdf (imt)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Lopez, Steven Regeser (committee chair), Barrio, Concepcion (committee member), Huey, Stanley (committee member), John, Richard (committee member)

Creator Email calderov@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-oUC111352069

Unique identifier UC111352069

Legacy Identifier etd-CalderonVa-10801

Document Type Dissertation

Format application/pdf (imt)

Rights Calderon, Vanessa

Type texts

Source 20220706-usctheses-batch-950 (batch), University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

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Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA

Repository Email cisadmin@lib.usc.edu