2021 Congress Recordings

The last decades of research have revolutionized the understanding of psychosis. We now have an increasingly clearer picture of the psychological mechanisms that drive the formation and maintenance of psychotic symptoms and are beginning to translate this knowledge into targeted interventions. Within this broader context, this talk will spotlight the link between emotion processing and delusions and its implications for psychological interventions. The first part of the talk will cover research on the link between negative affect and delusions. Using a variety of designs, including longitudinal surveys, experimental and experience-sampling methods this research clearly demonstrates that negative affect precedes, accompanies and follows delusions. It has also shown that interventions that are successful in reducing negative affect tend to attenuate delusions as well. Taken together, this research renders support to the notion of a causal role of negative affect for delusion formation and maintenance. The second part will introduce two lines of research that are exploring the exact mechanisms that link negative affect to delusions. One possibility is that delusions arise from a failure to downregulate negative affect. Indeed, patients with delusions report to use fewer ‘functional’ affect regulation strategies (e.g., reappraisal). They also show a lower heart rate variability, a physiological indicator of affect regulation difficulties. Another possibility is that delusions stem from difficulties in emotional learning. This view is indirectly supported by experimental studies showing heightened fear responses to neutral faces in patients with delusions, indicating a tendency to overgeneralize and by self-reported safety behaviour, pointing to a maintaining role of avoidance.

Although these lines of research are still in their early stages, they already promise novel opportunities for intervention. These will be discussed in the last part of the talk. They include training of specific affect regulation strategies or enabling corrective social experiences. Novel technology could be used to enhance the effectiveness of this approaches, for example by prompting 35 2021 Congress of the Schizophrenia International Research Society the use of emotion regulation strategies in daily life or by creating virtual social learning environments to promote emotional learning.

The literature has detailed differences in the rate of psychosis for racial and cultural groups in high income countries. For instance; in the UK, some racialized groups including people of African and Caribbean heritage and those with South Asian origins have been shown to be at higher risk of psychosis than the White British population.

There has been significant investigation of the possible causes for these increased incidence rates. This work has contributed to the renaissance in research into how social factors may influence psychosis risk. Complex and intriguing multi-level and life course perspectives on causation have led to integrative theories. These have included, but are not limited to concepts such as gene environment interaction, neurogenesis and inflammation as pathways through which social inequities, adverse childhood experiences, stress and perceived racism get under the skin. There has also been consideration of the role of possible psychosis risk indicators such as stress reactivity among other concepts.

There has, however, been less consideration about what can be done to decrease disparities in incidence of psychosis.

In both wave 1 and wave 2 of the covid-19 pandemic, high income countries have reported higher rates of infection, hospitalizations and death for racialized groups. Black populations and those of South Asian origin have again been among the groups reported at higher risk. Similar to the psychosis literature, there has been significant discussion and investigation of possible causes of the disparities. Again, the role of social factors has been considered. The literature suggests that increased covid-19 risks for certain racialised populations may be because of at least four reasons:

1) increased risk of exposure to covid-19 because they are more likely to be essential workers and are more likely to be mobile; 2) decreased ability to protect themselves from covid-19 because they are less able to follow public health guidelines; for instance people who are lower income and live in over crowded homes are 43 2021 Congress of the Schizophrenia International Research Society less able to physically distance; 3) increased risk of serious impacts of infection because of existing higher rates of chronic illnesses such as diabetes (which are in part linked to social factors) and poorer access to healthcare during a pandemic; and, 4) risks linked to the disproportionate impacts of the pandemic-related economic downturn. But one difference in the covid-19 pandemic has been the number of places where the evidence of disparities has been used to develop multi-level interventions to both decrease disparities in illness rates and improve outcomes.

This presentation will explore how the identification of racial disparities in covid-19 infection in Toronto, Ontario led to a complex policy and practice intervention to promote equity and will discuss what we can learn from this about how to address the cross cultural causes of psychosis.

The literature has detailed differences in the rate of psychosis for racial and cultural groups in high income countries. For instance; in the UK, some racialized groups including people of African and Caribbean heritage and those with South Asian origins have been shown to be at higher risk of psychosis than the White British population.

There has been significant investigation of the possible causes for these increased incidence rates. This work has contributed to the renaissance in research into how social factors may influence psychosis risk. Complex and intriguing multi-level and life course perspectives on causation have led to integrative theories. These have included, but are not limited to concepts such as gene environment interaction, neurogenesis and inflammation as pathways through which social inequities, adverse childhood experiences, stress and perceived racism get under the skin. There has also been consideration of the role of possible psychosis risk indicators such as stress reactivity among other concepts.

There has, however, been less consideration about what can be done to decrease disparities in incidence of psychosis.

In both wave 1 and wave 2 of the covid-19 pandemic, high income countries have reported higher rates of infection, hospitalizations and death for racialized groups. Black populations and those of South Asian origin have again been among the groups reported at higher risk. Similar to the psychosis literature, there has been significant discussion and investigation of possible causes of the disparities. Again, the role of social factors has been considered. The literature suggests that increased covid-19 risks for certain racialised populations may be because of at least four reasons:

1) increased risk of exposure to covid-19 because they are more likely to be essential workers and are more likely to be mobile; 2) decreased ability to protect themselves from covid-19 because they are less able to follow public health guidelines; for instance people who are lower income and live in over crowded homes are 43 2021 Congress of the Schizophrenia International Research Society less able to physically distance; 3) increased risk of serious impacts of infection because of existing higher rates of chronic illnesses such as diabetes (which are in part linked to social factors) and poorer access to healthcare during a pandemic; and, 4) risks linked to the disproportionate impacts of the pandemic-related economic downturn. But one difference in the covid-19 pandemic has been the number of places where the evidence of disparities has been used to develop multi-level interventions to both decrease disparities in illness rates and improve outcomes.

This presentation will explore how the identification of racial disparities in covid-19 infection in Toronto, Ontario led to a complex policy and practice intervention to promote equity and will discuss what we can learn from this about how to address the cross cultural causes of psychosis.

Functional MRI (fMRI) investigators have long sought to inform psychiatric research and practice. First, through developing a better scientific understanding of normative human brain development, the perturbations that lead to mental illness, and the impact of therapeutic interventions. Such knowledge can inform clinical nosology and decision making, as well as help identify critical periods for intervention and prevention. Secondly, by developing clinical applications of fMRI that can guide individual-specific decisions (e.g., diagnosis, prognosis, treatment selection) and interventions (e.g., imaging-guided brain stimulation). While these goals once seemed unattainable, the maturation of fMRI techniques has brought the measurement of individual-level differences - a critical prerequisite - within reach. This plenary will identify and discuss four critical gaps in efforts to achieve clinical utility, which if not corrected, can jeopardize the progress of psychiatric fMRI research.

The core symptoms of schizophrenia typically emerge during late adolescence and early adulthood and there is considerable evidence that the emerging symptoms are nested within neurodevelopment processes that take place earlier in development. However, many questions remain regarding at what stage during typical brain development do the deviations take place in those who begin showing prodromal or more severe symptoms of schizophrenia. Large population-based studies provide the opportunity to study trajectories of brain development, including premorbid and early prodromal measures of brain structure and function. The goal of this presentation is to provide an overview of the neuroimaging and behavioral component of the Generation R Study, which is a large epidemiological study of child development. The role of population-based neuroimaging studies in better understanding emerging psychopathology will be discussed. In addition, there will be a focus on typical development during fetal and early life and one potential pathway to the development of psychotic disorders that could potentially be translated into primary prevention. Put on your seat belt for this talk, it’ll be fun.

This session truly aligns with the theme of this year’s meeting “Bringing Precision Medicine to Mental Health Services”. Both presentation focus on how evidence based research findings can find their way to outside of the academic research clinics, to reach surrounding communities. Dr. Dixon will discuss successful strategies and pitfalls of how implementation science can help a statewide adoption of an evidence based early psychosis program in New York State. Dr. Heinssen will introduce the concept of learning healthcare and the Early Psychosis Intervention Network (EPINET). These initiatives show the power of working together – researchers, clinicians, service users and their families – and standardization to improve health care and stimulate research.

The Diversity Task Force (DTF) aims to prioritize diversity and inclusivity as essential core values of SIRS and to support multicultural perspectives. In this second DTF workshop, we highlight diverse and innovative approaches to achieving progress in global mental health research and addressing ethnic and gender disparities on multiple levels.

1. Drs. Jun Miyata and Nicolas Crossley will describe their efforts to implement large international research networks and offer insight gained from multinational collaborations.
2. Drs. Eric Tan and Sara Ann Lee will depict the state of the psychosis research in Asia and draw attention to the challenges facing Asian scientists and clinicians.
3. Dr. Lebogang Phahladira will provide an overview of the current state of psychosis research in the sub-Saharan Africa, with a specific focus on South Africa.
4. Dr. Lynn DeLisi will highlight the prevalence of gender bias in science and barriers that prevent women from breaking the glass ceiling.
5. Drs. Kia Crittenden and Margaret Niznikiewicz will discuss the importance of engaging women and minorities in clinical trials and evaluate potential strategies to improve inclusivity.

After these presentations, we will invite the audience for discussions moderated by Drs Mary Cannon and Kim Do. We have much to learn and benefit from the work conducted around the world by all stakeholders including researchers, clinicians, educators, as well as persons with lived experiences. Enhanced diversity of ideas, expertise and resources through open dialogues, exchanges and collaborations at SIRS will facilitate progress in the field.

 One of the challenges for the global mental health in the past
decade is to identify effective biomarkers for early identification and intervention of psychosis. Despite this growing focus, much remains unknown regarding the mechanisms underlying the
development of psychosis and the sensitivity and specificity of these potential biomarkers. This symposium will focus on the clinical utility of some promising biomarkers and their applications to facilitate the precision approach of schizophrenia to clinical settings. Four speakers will present work on this issue.

Prof. James Waltz (Maryland Psychiatric Research Centre) will adopt a computational psychiatry approach to support measures pertaining to the representation and use of uncertainty in learning
and decision-making are predictive of severity of positive symptoms in schizophrenia. Prof. Raymond Chan (Institute of Psychology, Chinese Academy of Sciences) will provide up-to-date
findings to re-orientate the important roles of neurological soft signs in precision psychiatry for psychosis. Prof. Vijay Mittal (Northwestern University) will evaluate three novel types of biomarkers assessment (language features, automated facial emotion analysis and instrumental motor function) for clinical high-risk youth. His findings show that use of automated analyses and
standardized assessments have potential clinical application. Prof. Kathryn Eve Lewandowski (McLean Hospital, Harvard Medical School) will adopt a hierarchical cluster analysis to identify
subgroups of psychotic disorders with similar motivational profiles. Her findings highlight 4 subgroups of patients with distinct patterns of motivational impairments.

Finally, Prof. William Carpenter (Maryland Psychiatric Research Centre) will integrate the above findings into a precision psychiatry framework and facilitate a discussion of them. Overall, this
symposium will provide attendees with an up-to-date perspective on precision approach to psychosis.

Negative symptoms are the strongest predictor of psychosocial
functioning and subjective quality of life in patients with psychosis. Accordingly, they are referred to as an important treatment target by both patients and mental health professionals. At the same
time, negative symptoms have been found to barely respond to treatment. One reason for the unsatisfying effects of existing approaches could be the limited understanding of the mechanisms
driving negative symptoms in daily life and a lack of interventions directly targeting these mechanisms. The aim of this symposium is to merge findings of recent studies on negative symptoms in light of their relevance for the development of future interventions.

Inez Myin-Germeys will reflect on how negative symptoms are expressed in daily life. Based on the findings of an experience sampling study, she will review the phenomenology of negative
symptoms and discuss potential mechanisms. She will further evaluate whether a lack of opportunity to participate in certain daily life activities could also explain the characteristic
inactivity of patients with negative symptoms.

Stefan Kaiser will discuss the therapeutic potential of pro- and anti-dopaminergic agents in the treatment of patients with negative symptoms. He will review data from neuroimaging studies
investigating dysfunctions in the neural reward system of patients with negative symptoms to deduce a rationale for the use of pro- and anti-dopaminergic agents. He will then present and
evaluate the findings of two meta-analyses on the efficacy and the dose-response effect of these drugs on negative symptoms.

Andre Aleman will focus on the functional neuroanatomy of goal-directed behavior and apathy in patients with negative symptoms. Based on the findings of a recent randomized-controlled trial, he
will evaluate the therapeutic potentials of transcranial magnetic brain stimulation to alleviate negative symptoms and especially apathy. He will also discuss methodological aspects of the trial
design and the implications for neuroanatomical hypotheses about goal-directed behavior and negative symptoms.

Gregory Strauss will evaluate the potential benefit of digital phenotyping methods in the assessment of negative symptoms. He will review a series of studies that examined the psychometric properties of digital phenotyping, such as phone accelerometry and ambient sound as parameters of negative symptoms. Based on the findings of a machine learning algorithm, he will discuss the potential benefits of their use as outcome measures in clinical trials and psychopathology research.

The symposium will advance our knowledge on how negative symptoms manifest in daily life from a patients’ perspective, how they could be treated and how negative symptom outcomes in clinical trials could be best assessed. This knowledge will inform future clinical research and the development of evidence-based treatment options for patients with negative symptoms.

Subtle language impairment is a feature of schizophrenia and its risk states. It is characterized by reductions in coherence (tangentiality, derailment) and complexity (concreteness, poverty of content). Recently, artificial intelligence has been used to characterize this subtle language impairment, such that linguistic biomarkers of psychosis and its risk states have been identified and even replicated. They are now being evaluated at the population level for variance with demographics, and studied in respect to neural correlates, such that these biomarkers may be informative in respect to theories of pathophysiology.

This symposium includes four presenters who together have done much of the pioneering work in the use of artificial intelligence, specifically natural language processing (NLP) and machine
learning (ML), to understand language impairments in psychosis and its risk states. The field is now at a crossroads. The speakers will not only present data, but along with the discussant, Dr. Barnaby Nelson, also consider potential pitfalls, provide a roadmap to move these biomarkers along to clinical practice, and also review how artificial intelligence and human intelligence may be applied
to the same data in parallel, potentially increasing synergy.

The first presentation will be by Dr. Brita Elvevåg, who first applied the NLP approach of latent semantic analysis (LSA) to speech and language in schizophrenia more than a decade ago. Dr.
Elvevåg used LSA to operationalize decreases in coherence, finding correlates in clinical ratings, neural activity, genetics and function. She has used NLP to develop applications for cognitive
assessment that are brief, acceptable and easy to use. In this presentation, Dr. Elvevåg will review potential pitfalls in NLP analyses in psychosis, including concerns re generalizability and specificity, and risk for bias. She argues for models that are explainable and transparent, rely on longitudinal
data, and incorporate other modes of communication.

The second presentation is by Natália Mota, who has applied graph theory to the study of language in psychosis, finding expected differences between mania and nonaffective psychosis, identifying
correlates with negative symptoms, cognitive deficits and brain activity and predictors of psychosis and schizophrenia diagnosis. Dr. Mota is dedicated to translating her work on language and
psychosis risk to real-life screening and clinical practice in Brazil, and other low-income countries. Dr. Mota will describe work she has done in developing an app for language analysis that is
inexpensive, friendly and easy to use, which has been piloted in children, and also in rural and urban areas of Brazil.

In the third presentation, Dr. Rezaii will describe her work on the use of NLP to predict psychosis among individuals at clinical high risk for psychosis, finding accuracy rates that exceed symptom
ratings. She will present on the use of additional methods, beyond LSA and speech graph analysis, to examine the poverty of content in speech, specifically by measuring semantic density (the
number of components of meaning in a sentence). She also introduces the idea of using the specific content or meaning of what is said to expand predictive power.

In the last presentation, Dr. Guillermo Cecchi will discuss novel applications of NLP in schizophrenia and to better understand through language proposed core deficits, such as in ipseity, or the
concept of disturbance of perception of self. His approach is a model for combining human intelligence (clinical ratings, qualitative research) with artificial intelligence to better understand
schizophrenia and other disturbances in thought, language and self-concept.

Current research delving on the perinatal origins of schizophrenia
can line up with the developmental origins of health and disease model, with interesting findings in metabolism, neuroimaging, cognition, clinical symptomatology and functional outcome. While an indirect marker of the intrauterine environment, such as birth weight has been able to correlate with different metabolic parameters, cognitive function or cortical morphology, further traslational research is required to fully evaluate the impact of the intrauterine development and its difficulties-obstetric complications- on the outcome of psychosis.

The initial prenatal origins of disease model coined by David Barker has later been widened to include also the perinatal events and its first two years in order to fully understand how mammals
are programmed due to the environment for a better chance of survival. Interestingly the epigenetic programming mechanisms work under the expected perinatal circumstances however if
the environment modifies the mechanism become maladaptive, diseases arouse and mortality increases. So, previous mechanism might underlie the excess of medical morbidity and early
mortality found in schizophrenia and other abnormalities at onset.

We aim to work out later research in the realm of obstetric complications and its outcome in different areas of schizophrenia. Metabolic findings which might underlie the excess of morbidity and early mortality. Neuroimaging aspects which might help decipher its presence at onset. Cognitive outcomes which might be present at onset due to early life stressful events. Clinical and epidemiological issues which might help understand the co-occurrence of psychosis and other findings.

Our approach would like to highlight the already proved effect of early life stressful events (obstetric complications) in the outcome of schizophrenia (metabolism) while suggesting its effect
on other areas such as neuroimaging, cognition, clinical and describing specific pathways. Our approach suggest that some disturbances found in patients even at onset might be epiphenomena from previous perinatal conditions.

There is a major drive to personalise diagnosis and treatment of
psychotic disorders. However, there is considerable variability between patients in terms of clinically important outcomes such as who develops psychosis, whether it is an affective or schizophreniform psychotic disorder, whether their illness will respond to first-line antipsychotics or not and require clozapine treatment, and if they will develop metabolic syndrome as well. This
variability is a major clinical problem as it leads to inappropriate and delayed treatment, which leads to health burden, side-effects and costs.

This symposium brings together complementary approaches to address this challenge. Dr Cannon will present the latest, unpublished data on clinical and neuroimaging predictors of psychosis from one of the largest and longest longitudinal studies of people at risk for psychosis in the world. He will focus on a frequent phenotyping approach that integrates imaging and clinical measures, showing that the trajectory of brain imaging changes distinguishes people who will go on to develop psychosis from those who remit. Dr Tamminga will present novel EEG, neuroimaging and cognitive data from a large transdiagnostic multi-centre study of people with psychotic disorders that
predicts response to treatment. Dr Howes will present new data on the potential of dopaminergic and glutamatergic imaging to predict treatment resistance and pharmacoeconomic analysis on the
cost-saving of fast-tracking treatment resistant patients to clozapine. Dr Perry will present the development of a tool to predict the development of metabolic syndrome in patients with
first-episode psychosis, and its evaluation in two different clinical cohorts and a birth cohort, and the potential of this to guide treatment choices. Finally, Dr Suvisaari will discuss the new
understanding and lessons that can be drawn from the different approaches covered in the symposium. She is both a practising psychiatrist as well as a researcher with expertise in precision
medicine, so will be able to provide both translational and research perspectives.

The symposium shows geographical, gender and career diversity, including contributors from six different institutions and three different countries, as well as leading female researchers and
clinicians and early career researchers (Perry, Suvisaari, Tamminga). Moreover, the symposium covers a range of clinical and experimental techniques, including structural and functional imaging, EEG, and metabolomics. In addition, a number of different linear and non-linear analytic and prediction models are considered. By drawing these different approaches together in one
symposium, the session will enable comparisons to be made across techniques and approaches to consider the potential to develop personalised diagnosis and treatment for people with psychotic disorders.

Loneliness is currently considered one of the biggest risk factors for mortality and morbidity. Individuals with a severe mental illness such as a psychotic disorder are at high risk of becoming socially isolated – in part because of the stigma linked with their condition, as well as their difficulties in engaging and maintaining romantic relationships. A healthy romantic relationship is considered a protective factor against the negative effects of stress on one’s mental health and can help support the person’ recovery, but unhealthy or tumultuous romantic relationships can also become stressors and risk factors for relapse. Love, sexuality, and the
development of intimate bonds are basic human needs and are also considered an important part of one’s personal recovery. Yet, a long history of taboo surrounding the existence of a sexual and
romantic life of people with mental disorders have contributed to the paucity of information currently available in this domain.

The current symposium presents novel results stemming from three teams working on this topic (Montreal, Canada, Maastricht, Netherlands, and Manchester, England). First, a systematic review on romantic relationships and sexuality will be presented by Briana
Cloutier (team of T. Lecomte), covering 43 studies on sexuality. The review highlights the international interest for this topic, as well as the gaps in the literature. The second presentation, by José de Jager (team of J. van Os), will describe subjective perceptions
of problems participants encountered in establishing intimacy and maintaining intimate relationships. This qualitative study of 28 participants with psuychotic disorders revealed five important themes related to various obstacles they encountered. This will be followed by Rebecca White (team of F. Varese) discussing the results of an online survey pertaining to romantic relationship satisfaction in link with other well-being and psychological variables in young individuals with a psychotic disorder.

Finally, Tania Lecomte will present results from a multiple single-case experimental design study assessing the impact of a novel group intervention to help young men with early psychosis develop
healthy romantic relationships.

This symposium presents research findings from three
geographically distinct, low and middle-income countries (LMIC) with samples ascertained primarily from rural locales. Many individuals with chronic psychotic disorders in under-resourced LMIC settings have a prolonged duration of untreated psychosis (DUP) prior to their first contact with treatment services, providing a unique opportunity to study how prolonged DUP is associated with clinical outcomes. The identification and treatment of these individuals is a high priority goal of several low- and middle-income countries. This provides a unique opportunity to characterize the
untreated course of psychosis using modern diagnostic tools by comparing the characteristics of recent-onset cases to those of individuals with 10 to 50 years of untreated psychosis at the time of their initial contact with treatment services. Additionally, increasing efforts to identify and initiate treatment for individuals with psychosis (IWP) in rural regions of LMIC has led to new programs to treat these IWP at first contact. In this symposium, we present ongoing research from the some of the most prominent community-based and first contact studies of IWP from China, India, and Ethiopia. Symposium presenters will address how symptomatology, cognitive functioning, and functional outcomes manifest in untreated IWP, and how these may vary among IWP with short and long DUP. Assessing IWP from LMICs with much longer DUP (10-50 years) will enable delineation of the natural trajectory of long-term functional declines in IWP, providing crucial insights into the neurobiological course of chronic psychosis. Further, a new treatment program for first contact IWP will be described in India, as well as the challenges in establishing a first-contact treatment center within a low-resource setting. Lastly, we present new data concerning modifications to established
cognitive functioning measures that are required to assess IWP from rural areas who often have very low education and are unfamiliar with Western testing procedures. Presenters will also
compare the findings from these three countries with findings from first-contact studies in high income countries to illuminate the course of untreated psychosis as well as treatment targets for
LMIC across different global settings.

Since the inception of the early intervention for psychosis services
(EIS) model in the early 1990s, it has evolved and spread worldwide. Initially emerging from research projects and the efforts of highly engaged clinicians, interest among policymakers in
several countries and jurisdictions for widespread implementation of EIS has grown in the last two decades. Pioneers of the model and nations which have made efforts to implement this model of
care are joining in this symposium: Australia, Denmark, the United Kingdom (England), and the Canadian province of Quebec. This symposium (chaired by Abdel-Baki and Bertulies-Esposito) will
offer the perspectives of clinicians and researchers involved in widespread implementation of EIS in each of these jurisdictions, covering the pathway to implementation, with its challenges and
successes. Particular attention will be paid to program fidelity to the EIS model and its integration in the implementation process.

First, Killackey (Australia) will present the path towards successfully developing a national network of EIS, which has not been without challenges and setbacks. Although the world-renowned Early
Psychosis Prevention and Intervention Centre was implemented in 1992, it is only in the last decade, that the country has shaped a national strategy for EIS implementation, which was adopted
in 2013. The development of a fidelity scale, barriers and facilitators in the process, future challenges and program outcomes will also be discussed.

Nordentoft (Denmark) will then present how the OPUS trial demonstrated the superiority of EIS compared to treatment as usual for several key outcome measures and how this led to
implementation of the model throughout the country. To enhance implementation outcomes, a variety of tools were put in place, such as manuals, training opportunities, and a fidelity scale.
Furthermore, dedicated funding for EIS implementation was made available to facilitate the process. Today, this model continues to add innovative care components.

England’s approach, based on standards of care and yearly program auditing since 2016, will be presented by French. The auditing method relies on patient data and a questionnaire regarding services. In the 2019/2020 audit, 155 programs participated, which shows an improvement in several outcome measures, such as recording patient outcomes, cognitive behavioural therapy for psychosis, and supported employment and education programmes. However, slight decreases in
other components of care were noted: family interventions, timely access and clozapine use. Globally, EIS in England provide high-quality evidence-based services, which seem to be appreciated by service users.

Bertulies-Esposito (Canada) will present Quebec’s situation where program development and implementation between 1987 and 2017 relied on highly motivated clinicians who lacked
institutional support. However, in 2017, the provincial government announced additional and protected funding to expand current EIS and implement programs in all regions. Surveys regarding
essential components of care were conducted before (2016) and after (2020) increased government involvement. Factors influencing program implementation quality were also surveyed in the latter.

Finally, Iyer (Canada) will synthesize the four presentations’ content and lead a discussion on EIS implementation, including clinical, research and policy implications. This symposium will highlight
the critical role of government involvement in widespread implementation of EIS and highlight common and unique mechanisms for such involvement, including frameworks, standards, audits, dedicated funding and implementation support.