Racial differences in attenuated psychotic symptoms during the COVID‐19 pandemic

Rates of attenuated psychotic symptoms (APS) have increased during the COVID‐19 pandemic; however, it is unclear whether this is most evident among individuals from marginalized racial groups.


| INTRODUCTION
The coronavirus has led to millions of infections and deaths worldwide (World Health Organization, 2022), produced widespread economic disruption (Maital & Barzani, 2020), and had a detrimental impact on mental health (e.g., mood and anxiety disorders) (Cullen et al., 2020;Winkler et al., 2020).The negative physical and mental health effects of the coronavirus and its associated pandemic may be greater among individuals from marginalized ethnic and racial groups, potentially due to exacerbation of pre-existing health disparities and discrimination (Maleku et al., 2022;Salerno et al., 2020).
Considering that marginalized communities are systemically impacted by the COVID-19 pandemic in terms of other mental health (Smith et al., 2020), it is possible that individuals from these communities are also experiencing greater increases in APS.The current study examined whether the proportion of individuals with levels of APS in the at-risk range differed during the pandemic compared to prepandemic in a clinical help-seeking sample.It was hypothesized that the proportion of individuals exceeding the threshold for APS would be: (1) greater during the pandemic compared to pre-pandemic; (2) systemically higher for individuals from marginalized groups (Asian, Black) during the pandemic compared to pre-pandemic.Participants were recruited for studies examining mechanisms of psychosis risk and negative symptoms (Bartolomeo et al., 2021;Chang et al., 2021;Gold et al., 2020;Strauss et al., 2021Strauss et al., , 2023;;Strauss & Chapman, 2018).Pre-and during pandemic cases did not differ in age or sex; however, there were slightly fewer Asian and more White participants during the pandemic (Table 1).

| Procedures
All participants provided informed consent for screening procedures approved by the University of Georgia Institutional Review Board.
Participants completed a demographic screening questionnaire and the PRIME Screen-Revised (PS-R; Miller, 2004).The PRIME screen is a 12-item self-report questionnaire assessing APS with items scored on a 0 (definitely disagree) to a 6 (definitely agree) scale.In this study, a positive result on the PRIME screen was indicated by three or more responses of a 6 (definitely agree) or a 5 (somewhat agree), indicating heightened risk for APS and further assessment is warranted.This scoring method has demonstrated good sensitivity and specificity (Kline et al., 2012).

| RESULTS
In the full sample, the chi-square test was significant, such that APS (three or more responses of a 6 [definitely agree] or 5 [somewhat agree] on the PRIME) were higher during the pandemic (41%) compared to pre-pandemic (23%), χ 2 = 14.53, p < .001.In the reduced sample (n = 371), the rate of participants exceeding the APS cut-off differed among the three racial groups from pre-pandemic to duringpandemic timepoints, M 2 (1) = 11.27,p = .001.Within each race, post hoc tests indicated that Black participants had significantly higher rates of APS during the pandemic than pre-pandemic; however, although rates also increased substantially for Asian and White participants during the pandemic, the difference between pre-and duringpandemic did not significantly differ for these groups (Table 2).i

| DISCUSSION
Consistent with past studies on the general population (Gizdic et al., 2022;Loch et al., 2022;Mengin et al., 2022;Tso & Park, 2020), rates of APS were higher during the pandemic than pre-pandemic.
The extension of this finding to clinical help-seeking samples is important because risk for conversion is $3.5Â higher among help-seeking samples which necessitate extensive clinical services (Kaymaz et al., 2012;Staines et al., 2022).Given the complexities of providing mental health services during the pandemic, knowing which clinical populations are of greatest need can allow available resources to be utilized most efficiently.
Second, Black individuals experienced increased rates of exceeding the APS cut-off during the pandemic compared to pre-pandemic compared to Asian and White individuals (Byrne et al., 2021).There are several plausible explanations for why Black individuals experienced greater increases in APS during the pandemic, including greater exposure to discrimination, structural racism, and reduced access to mental health services (Abedi et al., 2021;Laurencin & Walker, 2020;Lee & Waters, 2021;Tan et al., 2022;Wu et al., 2021).However, the differential effect of the pandemic on APS for Black compared to Asian participants was surprising given both are marginalized racial groups that experienced increased race-related stressors during the pandemic (Liu et al., 2020;Ruiz et al., 2020).One possible explanation is that Black individuals experienced a greater increase in stressors than other races.For example, sociopolitical events during the early stages of the pandemic resulted in high rates of racial trauma for members of the Black community (Eichstaedt et al., 2021).When coupled with pre-existing chronic stressors, which worsened during the pandemic (e.g., structural racism, health disparities reducing access to healthcare), Black individuals may have experienced a compounding of acute and chronic race-related-stressors that were less prevalent among other marginalized racial groups (Thomeer et al., 2022).
Certain limitations should be considered.First, within-subject comparisons were not possible because we did not have longitudinal data across the 6-year period.Use of between-subject comparisons may be impacted by cohort effects, although this seems unlikely given the short timeframe.Second, the PRIME screen, has been central to clinical high risk for psychosis (CHR) screening and is an invaluable clinical and research tool; however, it does not afford the same sensitivity and specificity as clinical interview-based measures.Use of a self-report screener may be more likely to lead to a higher number of false positive CHR cases than structured interviews.Third, the PRIME Screen was the only APS screening measure used, and a prior study found that it significantly predicts risk status for White but not Black participants (Millman et al., 2019).However, this does not explain the greater increases in screened APS rates during the pandemic in Black participants.Fourth, online recruitment methods were utilized more during the pandemic, and may have resulted in a qualitatively different group of participants during the pandemic.However, participant demographics are generally similar in the pre-and during-pandemic samples.Lastly, post-pandemic period spanned 2.5 years, which encompasses a variety of COVID-related events (i.e., lockdown, reopening, etc.).It is unclear which of these events might drive effects.
Despite these limitations, findings have important implications.Our data provide additional evidence for how Black individuals are systemically affected by the COVID-19 pandemic; these effects have been demonstrated in physical health outcomes and now in APS (Novacek et al., 2020;Travers et al., 2021).Following other health campaigns that proved successful, such as the HIV/AIDS campaign in the United States, attempts to reduce health disparities and increase equity could be enhanced by targeting those who are most likely to be experiencing poor psychiatric outcomes during the pandemic (Novacek et al., 2020).T A B L E 2 Differences in attenuated psychotic symptoms (APS) rates per pandemic time period and race.
Participants included 435 clinical help-seeking individuals who were referred by a clinician or advertisement to the Georgia Psychiatric Risk Evaluation Program from October 2017 to July 2022.Recruitment occurred in the state of Georgia in the United States of America and spanned approximately 2.5 years pre-pandemic (n = 169) and 2.5 years during the pandemic (n = 266).During the pandemic, recruitment was conducted completely online as opposed to prepandemic times when both online and in-person methods were used.

A
binary variable was created to indicate pandemic time: screens completed before March 15, 2020 were classified as "pre-pandemic," whereas screens completed on and after March 15, 2020 were classified as "during pandemic."This timeframe was based on when the state of Georgia issued lockdown orders.Pre-and during-pandemic samples were compared on demographic variables using one-way ANOVAs and chi-square tests.A chi-square test was used to compare positive screening results between pre-and during-pandemic time periods.Cochran-mantel-haenszel tests were conducted to determine whether the rate of APS differed across the three most highly powered racial groups (Asian, Black, White) from pre-pandemic to during-pandemic timepoints; other racial groups were not included in these analyses due to insufficient sample size.
Systematic screening may be an important first step for engaging individuals in clinical services, followed by longitudinal symptom monitoring and culturally tailored interventions.Given limitations of the pandemic, telehealth and mobile applications may provide a promising means of reaching individuals at risk for developing psychosis.ACKNOWLEDGEMENTS This study was supported by the NARSAD Young Investigator Grant to G.P.S. from the Brain and Behavior Research Foundation and R01-MH116039, R01-MH120092, and R21-MH119438 to G.P.S. from the National Institute of Mental Health.The authors would like to acknowledge and thank members of the study team who collected and coded data, specifically Alysia Berglund, Ashley Zollicoffer, Gifty Ayawvi, Luyu Zhang, and Delaney Collins, and participants who generously devoted their time and effort to completing the study.
Note: All values represent means with standard deviations in parentheses unless otherwise stated.