Outreach and support in south London (OASIS), 2001-2011: ten years of early diagnosis and treatment for young individuals at high clinical risk for psychosis

Preventive Treatments for Psychosis: Umbrella Review (Just the Evidence)

Background: Indicated primary prevention in young people at Clinical High Risk for Psychosis (CHR-P) is a promising avenue for improving outcomes of one of the most severe mental disorders but their effectiveness has recently been questioned. Methods: Umbrella review. A multi-step independent literature search of Web of Science until January 11, 2019, identified interventional meta-analyses in CHR-P individuals. The individual randomised controlled trials that were analysed by the meta-analyses were extracted. A review of ongoing trials and a simulation of living meta-analysis complemented the analysis. Results: Seven meta-analyses investigating preventive treatments in CHR-P individuals were included. None of them produced pooled effect sizes across psychological, pharmacological, or other types of interventions. The outcomes analysed encompassed risk of psychosis onset, the acceptability of treatments, the severity of attenuated positive/negative psychotic symptoms, depression, symptom-related distress, social functioning, general functioning, and quality of life. These meta-analyses were based on 20 randomised controlled trials: the vast majority defined the prevention of psychosis onset as their primary outcome of interest and only powered to large effect sizes. There was no evidence to favour any preventive intervention over any other (or control condition) for improving any of these clinical outcomes. Caution is required when making clinical recommendations for the prevention of psychosis in individuals at risk. Discussion: Prevention of psychosis from a CHR-P state has been, and should remain, the primary outcome of interventional research, refined and complemented by other clinically meaningful outcomes. Stagnation of knowledge should promote innovative and collaborative research efforts, in line with the progressive and incremental nature of medical knowledge. Advancements will most likely be associated with the development of new experimental therapeutics that are ongoing along with the ability to deconstruct the high heterogeneity within CHR-P populations. This would require the estimation of treatment-specific effect sizes through living individual participant data meta-analyses, controlling risk enrichment during recruitment, statistical power, and embedding precision medicine within youth mental health services that can accommodate sequential prognosis and advanced trial designs. Conclusions: The evidence-based challenges and proposed solutions addressed by this umbrella review can inform the next generation of research into preventive treatments for psychosis.

Suicidal Thinking and Behavior in Adolescents at Ultra-High Risk of Psychosis: A Two-year Longitudinal Study

OBJECTIVE

Suicide risk in subjects at Ultra-High Risk of psychosis (UHR) has been rarely assessed in adolescence, but it is of obvious importance for prognostic and clinical care reasons. In this study, we aimed to prospectively assess suicide risk and behaviors in UHR adolescents.

METHOD

We examined 112 help-seeking adolescents (13-18 years, 50% males, 83.9% Caucasian) that were enrolled in the Reggio Emilia At-Risk Mental States (ReARMS) project and followed up for 2 years. Specific items derived from the Comprehensive Assessment of At-Risk Mental States (CAARMS) and the Beck Depression Inventory-II (BDI-II) were used to assess suicide risk. Suicide attempts and completed suicides were also recorded.

RESULTS

Baseline assessment detected 40 UHR adolescents, 32 FEP (first-episode psychosis), and 40 non-UHR/FEP. We found that 67.5% of UHR adolescents had suicidal ideation, and 18.5% to severe degree. Attempted suicide before enrollment was higher in the UHR group than in non-UHR/FEP peers (17.5% vs. 2.5%). BDI-II suicidal ideation severity was stable at 12-month follow-up and decreased at 24-month follow-up.

CONCLUSIONS

A high prevalence of suicidal ideation among UHR adolescents was found and supports the routine monitoring of risk of self-injurious thinking and behavior in this at-risk population.

Applying economic models to estimate local economic benefits of improved coverage of early intervention for psychosis

AIM

Early Intervention Psychosis Services (EIPS) for people experiencing First Episode Psychosis (FEP) offer important clinical and non-clinical benefits over standard care. Similarly, intervention for Clinical High Risk for Psychosis state (CHR-P) can prevent psychosis, ameliorate symptoms and have non-clinical benefits. This study aimed to estimate associated local economic benefits of FEP and CHR-P services compared with standard care.

METHODS

Across four south London boroughs, proportion of annual number of new cases of FEP and CHR-P seen by early intervention services was estimated. Economic modelling conducted for England's mental health strategy was applied to estimate local economic impacts of current and improved service provision.

RESULTS

Across four London boroughs during 2011/2012, proportion of 15-34 year olds with FEP seen by EIPS was 100.2% assuming 80/100 000 annual incidence whereas proportion with CHR-P seen by CHR-P services was 4.1% assuming 200/100 000 annual incidence. Application of economic modelling suggests that provision of EIPS to reach all new FEP cases each year would free up resources of £13.1m over 10 years including £2.0m to National Health Service (NHS) after the first year. Scaling up to reach all new CHR-P cases each year would free up resources of £19.7m over 10 years with an estimated 10-year cost of implementation gap for each 1 year cohort of £18.9m. An earlier related briefing resulted in increased funding for EIPS and new CHR-P services despite overall cuts to mental health services.

CONCLUSIONS

Estimation of local economic impacts of FEP and CHR-P services was associated with improved investment in such services.

Individualized prediction of psychosis in subjects with an at-risk mental state

Early intervention strategies in psychosis would significantly benefit from the identification of reliable prognostic biomarkers. Pattern classification methods have shown the feasibility of an early diagnosis of psychosis onset both in clinical and familial high-risk populations. Here we were interested in replicating our previous classification findings using an independent cohort at clinical high risk for psychosis, drawn from the prospective FePsy (Fruherkennung von Psychosen) study. The same neuroanatomical-based pattern classification pipeline, consisting of a linear Support Vector Machine (SVM) and a Recursive Feature Selection (RFE) achieved 74% accuracy in predicting later onset of psychosis. The discriminative neuroanatomical pattern underlying this finding consisted of many brain areas across all four lobes and the cerebellum. These results provide proof-of-concept that the early diagnosis of psychosis is feasible using neuroanatomical-based pattern recognition.

European college of neuropsychopharmacology network on the prevention of mental disorders and mental health promotion (ECNP PMD-MHP)

Prevention is the most promising way to reduce the high personal, familial, societal, clinical and economic costs of mental disorders in Europe and worldwide. A complementary approach is to go beyond the prevention of mental ill health, to promote good mental health. This manuscript highlights the first European consortium fostering cutting-edge multidisciplinary research in these two areas. The ECNP-funded Network on the Prevention of Mental Disorders and Mental Health Promotion (ECNP PMD-MHP) brings together European sites of excellence with different expertise for translational research collaboration, including partnerships with the industry. The ECNP PMD-MHP Network adopts a transdiagnostic, lifespan, clinical staging model which cuts across different mental disorders and different methodologies. The main aims of the ECNP PMD-MHP Network are to facilitate multidisciplinary collaboration, enhance knowledge and data sharing, standardise core assessment and outcome measures, promote clinical research, apply for grant funding, and generate research reports. By supporting collaborative research, the ECNP PMD-MHP Network will be vital for fostering European psychiatry in the field of prevention of mental disorders and promotion of good mental health.

Unmet needs for treatment in 102 individuals with brief and limited intermittent psychotic symptoms (BLIPS): implications for current clinical recommendations

AIMS

To investigate clinical outcomes and unmet needs in individuals at Clinical High Risk for Psychosis presenting with Brief and Limited Intermittent Psychotic Symptoms (BLIPS).

METHODS

Prospective naturalistic long-term (up to 9 years) cohort study in individuals meeting BLIPS criteria at the Outreach And Support In South-London (OASIS) up to April 2016. Baseline sociodemographic and clinical characteristics, specific BLIPS features, preventive treatments received and clinical outcomes (psychotic and non-psychotic) were measured. Analyses included Kaplan Meier survival estimates and Cox regression methods.

RESULTS

One hundred and two BLIPS individuals were followed up to 9 years. Across BLIPS cases, 35% had an abrupt onset; 32% were associated with acute stress, 45% with lifetime trauma and 20% with concurrent illicit substance use. The vast majority (80%) of BLIPS individuals, despite being systematically offered cognitive behavioural therapy for psychosis, did not fully engage with it and did not receive the minimum effective dose. Only 3% of BLIPS individuals received the appropriate dose of cognitive behavioural therapy. At 4-year follow-up, 52% of the BLIPS individuals developed a psychotic disorder, 34% were admitted to hospital and 16% received a compulsory admission. At 3-year follow-up, 52% of them received an antipsychotic treatment; at 4-year follow-up, 26% of them received an antidepressant treatment. The presence of seriously disorganising and dangerous features was a strong poor prognostic factor.

CONCLUSIONS

BLIPS individuals display severe clinical outcomes beyond their very high risk of developing psychosis and show poor compliance with preventive cognitive behavioural therapy. BLIPS individuals have severe needs for treatment that are not met by current preventive strategies.

Clinical-learning versus machine-learning for transdiagnostic prediction of psychosis onset in individuals at-risk

Predicting the onset of psychosis in individuals at-risk is based on robust prognostic model building methods including a priori clinical knowledge (also termed clinical-learning) to preselect predictors or machine-learning methods to select predictors automatically. To date, there is no empirical research comparing the prognostic accuracy of these two methods for the prediction of psychosis onset. In a first experiment, no improved performance was observed when machine-learning methods (LASSO and RIDGE) were applied-using the same predictors-to an individualised, transdiagnostic, clinically based, risk calculator previously developed on the basis of clinical-learning (predictors: age, gender, age by gender, ethnicity, ICD-10 diagnostic spectrum), and externally validated twice. In a second experiment, two refined versions of the published model which expanded the granularity of the ICD-10 diagnosis were introduced: ICD-10 diagnostic categories and ICD-10 diagnostic subdivisions. Although these refined versions showed an increase in apparent performance, their external performance was similar to the original model. In a third experiment, the three refined models were analysed under machine-learning and clinical-learning with a variable event per variable ratio (EPV). The best performing model under low EPVs was obtained through machine-learning approaches. The development of prognostic models on the basis of a priori clinical knowledge, large samples and adequate events per variable is a robust clinical prediction method to forecast psychosis onset in patients at-risk, and is comparable to machine-learning methods, which are more difficult to interpret and implement. Machine-learning methods should be preferred for high dimensional data when no a priori knowledge is available.

E-Clinical High Risk for Psychosis: Viewpoint on Potential of Digital Innovations for Preventive Psychiatry

E-mental health is an emerging area of research that has the potential to overcome some of the current barriers to progress in working with people at clinical high risk for psychosis (CHR-P). This article provides an overview of how e-mental health could be used in the detection, prediction, and treatment in the CHR-P population. Specifically, we evaluate e-detection, e-prediction, and e-therapeutics for this clinical population. E-mental health holds great promise to improve current management of CHR-P individuals.

Integrated Mental Health Services for the Developmental Period (0 to 25 Years): A Critical Review of the Evidence

Background: The developmental period from 0 to 25 years is a vulnerable time during which children and young people experience many psychosocial and neurobiological changes and an increased incidence of mental illness. New clinical services for children and young people aged 0 to 25 years may represent a radical transformation of mental healthcare. Method: Critical, non-systematic review of the PubMed literature up to 3rd January 2019. Results: Rationale: the youngest age group has an increased risk of developing mental disorders and 75% of mental disorders begin by the age of 24 and prodromal features may start even earlier. Most of the risk factors for mental disorders exert their role before the age of 25, profound maturational brain changes occur from mid-childhood through puberty to the mid-20s, and mental disorders that persist in adulthood have poor long-term outcomes. The optimal window of opportunity to improve the outcomes of mental disorders is the prevention or early treatment in individuals aged 0 to 25 within a clinical staging model framework. Unmet needs: children and young people face barriers to primary and secondary care access, delays in receiving appropriate treatments, poor engagement, cracks between child and adult mental health services, poor involvement in the design of mental health services, and lack of evidence-based treatments. Evidence: the most established paradigm for reforming youth mental services focuses on people aged 12-25 who experienced early stages of psychosis. Future advancements may include early stages of depression and bipolar disorders. Broader youth mental health services have been implemented worldwide, but no single example constitutes best practice. These services seem to improve access, symptomatic and functional outcomes, and satisfaction of children and young people aged 12-25. However, there are no robust controlled trials demonstrating their impact. Very limited evidence is available for integrated mental health services that focus on people aged 0-12. Conclusions: Children and young people aged 12-25 need youth-friendly mental health services that are sensitive to their unique stage of clinical, neurobiological, and psychosocial development. Early intervention for psychosis services may represent the starting platform to refine the next generation of integrated youth mental health services.

Oxytocin modulates hippocampal perfusion in people at clinical high risk for psychosis

Preclinical and human studies suggest that hippocampal dysfunction is a key factor in the onset of psychosis. People at Clinical High Risk for psychosis (CHR-P) present with a clinical syndrome that can include social withdrawal and have a 20-35% risk of developing psychosis in the next 2 years. Recent research shows that resting hippocampal blood flow is altered in CHR-P individuals and predicts adverse clinical outcomes, such as non-remission/transition to frank psychosis. Previous work in healthy males indicates that a single dose of intranasal oxytocin has positive effects on social function and marked effects on resting hippocampal blood flow. The present study examined the effects of intranasal oxytocin on hippocampal blood flow in CHR-P individuals. In a double-blind, placebo-controlled, crossover design, 30 CHR-P males were studied using pseudo-continuous Arterial Spin Labelling on 2 occasions, once after 40IU intranasal oxytocin and once after placebo. The effects of oxytocin on left hippocampal blood flow were examined in a region-of-interest analysis of data acquired at 22-28 and at 30-36 minutes post-intranasal administration. Relative to placebo, administration of oxytocin was associated with increased hippocampal blood flow at both time points (p = .0056; p = .034), although the effect at the second did not survive adjustment for the effect of global blood flow. These data indicate that oxytocin can modulate hippocampal function in CHR-P individuals and therefore merits further investigation as a candidate novel treatment for this group.

Individualized Prediction of Transition to Psychosis in 1,676 Individuals at Clinical High Risk: Development and Validation of a Multivariable Prediction Model Based on Individual Patient Data Meta-Analysis

Background: The Clinical High Risk state for Psychosis (CHR-P) has become the cornerstone of modern preventive psychiatry. The next stage of clinical advancements rests on the ability to formulate a more accurate prognostic estimate at the individual subject level. Individual Participant Data Meta-Analyses (IPD-MA) are robust evidence synthesis methods that can also offer powerful approaches to the development and validation of personalized prognostic models. The aim of the study was to develop and validate an individualized, clinically based prognostic model for forecasting transition to psychosis from a CHR-P stage. Methods: A literature search was performed between January 30, 2016, and February 6, 2016, consulting PubMed, Psychinfo, Picarta, Embase, and ISI Web of Science, using search terms ("ultra high risk" OR "clinical high risk" OR "at risk mental state") AND [(conver* OR transition* OR onset OR emerg* OR develop*) AND psychosis] for both longitudinal and intervention CHR-P studies. Clinical knowledge was used to a priori select predictors: age, gender, CHR-P subgroup, the severity of attenuated positive psychotic symptoms, the severity of attenuated negative psychotic symptoms, and level of functioning at baseline. The model, thus, developed was validated with an extended form of internal validation. Results: Fifteen of the 43 studies identified agreed to share IPD, for a total sample size of 1,676. There was a high level of heterogeneity between the CHR-P studies with regard to inclusion criteria, type of assessment instruments, transition criteria, preventive treatment offered. The internally validated prognostic performance of the model was higher than chance but only moderate [Harrell's C-statistic 0.655, 95% confidence interval (CIs), 0.627-0.682]. Conclusion: This is the first IPD-MA conducted in the largest samples of CHR-P ever collected to date. An individualized prognostic model based on clinical predictors available in clinical routine was developed and internally validated, reaching only moderate prognostic performance. Although personalized risk prediction is of great value in the clinical practice, future developments are essential, including the refinement of the prognostic model and its external validation. However, because of the current high diagnostic, prognostic, and therapeutic heterogeneity of CHR-P studies, IPD-MAs in this population may have an limited intrinsic power to deliver robust prognostic models.

Neurochemical effects of oxytocin in people at clinical high risk for psychosis

Alterations in neurochemical metabolites are thought to play a role in the pathophysiology of psychosis onset. Oxytocin, a neuropeptide with prosocial and anxiolytic properties, modulates glutamate neurotransmission in preclinical models but its neurochemical effects in people at high risk for psychosis are unknown. We used proton magnetic resonance spectroscopy (¹H-MRS) to examine the effects of intranasal oxytocin on glutamate and other metabolites in people at Clinical High Risk for Psychosis (CHR-P) in a double-blind, placebo-controlled, crossover design. 30 CHR-P males were studied on two occasions, once after 40IU intranasal oxytocin and once after placebo. The effects of oxytocin on the concentration of glutamate, glutamate+glutamine and other metabolites (choline, N-acetylaspartate, myo-inositol) scaled to creatine were examined in the left thalamus, anterior cingulate cortex (ACC) and left hippocampus, starting approximately 75, 84 and 93 min post-dosing, respectively. Relative to placebo, administration of oxytocin was associated with an increase in choline levels in the ACC (p=.008, Cohen's d = 0.54). There were no other significant effects on metabolite concentrations (all p>.05). Our findings suggest that, at ∼75-99 min post-dosing, a single dose of intranasal oxytocin does not alter levels of neurochemical metabolites in the thalamus, ACC, or hippocampus in those at CHR-P, aside from potential effects on choline in the ACC.

Transdiagnostic Risk Calculator for the Automatic Detection of Individuals at Risk and the Prediction of Psychosis: Second Replication in an Independent National Health Service Trust

BACKGROUND

The benefits of indicated primary prevention among individuals at Clinical High Risk for Psychosis (CHR-P) are limited by the difficulty in detecting these individuals. To overcome this problem, a transdiagnostic, clinically based, individualized risk calculator has recently been developed and subjected to a first external validation in 2 different catchment areas of the South London and Maudsley (SLaM) NHS Trust.

METHODS

Second external validation of real world, real-time electronic clinical register-based cohort study. All individuals who received a first ICD-10 index diagnosis of nonorganic and nonpsychotic mental disorder within the Camden and Islington (C&I) NHS Trust between 2009 and 2016 were included. The model previously validated included age, gender, ethnicity, age by gender, and ICD-10 index diagnosis to predict the development of any ICD-10 nonorganic psychosis. The model's performance was measured using Harrell's C-index.

RESULTS

This study included a total of 13702 patients with an average age of 40 (range 16-99), 52% were female, and most were of white ethnicity (64%). There were no CHR-P or child/adolescent services in the C&I Trust. The C&I and SLaM Trust samples also differed significantly in terms of age, gender, ethnicity, and distribution of index diagnosis. Despite these significant differences, the original model retained an acceptable predictive performance (Harrell's C of 0.73), which is comparable to that of CHR-P tools currently recommended for clinical use.

CONCLUSIONS

This risk calculator may pragmatically support an improved transdiagnostic detection of at-risk individuals and psychosis prediction even in NHS Trusts in the United Kingdom where CHR-P services are not provided.

Real World Implementation of a Transdiagnostic Risk Calculator for the Automatic Detection of Individuals at Risk of Psychosis in Clinical Routine: Study Protocol

Background: Primary indicated prevention in individuals at-risk for psychosis has the potential to improve the outcomes of this disorder. The ability to detect the majority of at-risk individuals is the main barrier toward extending benefits for the lives of many adolescents and young adults. Current detection strategies are highly inefficient. Only 5% (standalone specialized early detection services) to 12% (youth mental health services) of individuals who will develop a first psychotic disorder can be detected at the time of their at-risk stage. To overcome these challenges a pragmatic, clinically-based, individualized, transdiagnostic risk calculator has been developed to detect individuals at-risk of psychosis in secondary mental health care at scale. This calculator has been externally validated and has demonstrated good prognostic performance. However, it is not known whether it can be used in the real world clinical routine. For example, clinicians may not be willing to adhere to the recommendations made by the transdiagnostic risk calculator. Implementation studies are needed to address pragmatic challenges relating to the real world use of the transdiagnostic risk calculator. The aim of the current study is to provide in-vitro and in-vivo feasibility data to support the implementation of the transdiagnostic risk calculator in clinical routine. Method: This is a study which comprises of two subsequent phases: an in-vitro phase of 1 month and an in-vivo phase of 11 months. The in-vitro phase aims at developing and integrating the transdiagnostic risk calculator in the local electronic health register (primary outcome). The in-vivo phase aims at addressing the clinicians' adherence to the recommendations made by the transdiagnostic risk calculator (primary outcome) and other secondary feasibility parameters that are necessary to estimate the resources needed for its implementation. Discussion: This is the first implementation study for risk prediction models in individuals at-risk for psychosis. Ultimately, successful implementation is the true measure of a prediction model's utility. Therefore, the overall translational deliverable of the current study would be to extend the benefits of primary indicated prevention and improve outcomes of first episode psychosis. This may produce significant social benefits for many adolescents and young adults and their families.

'At risk mental state' clinics for psychosis - an idea whose time has come - and gone!

At Risk Mental State (ARMS) clinics are specialised mental health services for young, help-seeking people, thought to be at ultra-high risk of developing psychosis. Their stated purpose is to reduce transitions from the ARMS state to clinical psychotic disorder. Reports of ARMS clinics provide 'evidence-based recommendations' or 'guidance' for the treatment of such individuals, and claim that such clinics prevent the development of psychosis. However, we note that in an area with a very well-developed ARMS clinic (South London), only a very small proportion (4%) of patients with first episode psychosis had previously been seen at this clinic with symptoms of the ARMS. We conclude that the task of reaching sufficient people to make a major contribution to the prevention of psychosis is beyond the power of ARMS clinics. Following the preventative approaches used for many medical disorders (e.g. lung cancer, coronary artery disease), we consider that a more effective way of preventing psychosis will be to adopt a public health approach; this should attempt to decrease exposure to environmental factors such as cannabis use which are known to increase risk of the disorder.

Federated multi-site longitudinal study of at-risk mental state for psychosis in Japan

There has been recent accumulation of evidence and clinical guidance regarding the at-risk mental state (ARMS) for psychosis. However, most studies have been observational cohort and intervention studies of Western populations. To assess the validity of the ARMS concept and the transition rate to psychosis in a non-Western nation, we retrospectively combined and analyzed clinical data of individuals diagnosed with ARMS who were prospectively followed-up at three specialized clinical services for ARMS in Japan. In total, we included 309 individuals with ARMS, of whom 43 developed overt psychosis. We estimated cumulative transition rates to psychosis with the Kaplan-Meier method, obtaining rates of 12% at 12, 16% at 24, 19% at 36, and 20% at 48 months. Only two individuals reported past cannabis use. Despite several differences among the three sites, transition rates did not differ among them. Furthermore, the transition rate of children aged between 14 and 17 years did not differ from that of individuals aged 18 years or older. Regression analysis revealed that meeting the brief limited intermittent psychotic symptoms (BLIPS) criterion was associated with an increased risk of transition to psychosis, whereas genetic risk factors were not. Although antipsychotic prescription was relatively frequent in this cohort, there was no evidence supporting frequent use of antipsychotics for this population. In conclusion, our findings support the assertion that the current concept of ARMS is applicable in Japan. Development of local clinical guidelines and training for clinicians is necessary to disseminate this concept to more clinical settings.

Open-label study of cognitive behavioural therapy for individuals with at-risk mental state: Feasibility in the Japanese clinical setting

AIM

To date, most cognitive behavioural therapy (CBT) trials for individuals with at-risk metal state (ARMS) have been conducted in few Western countries and its feasibility in other regions, including Japan, has not been established.

METHODS

We designed an open-label pilot study. Fourteen ARMS participants received CBT over 6 months and were followed-up for 6 months.

RESULTS

Thirteen individuals completed the CBT intervention and assessments. The mean total score on the Positive and Negative Syndrome Scale improved from 60.2 to 46.0 after the intervention (Cohen's d = 1.1). The effects were maintained at the follow-up assessment. One participant transitioned to psychosis after the CBT intervention, and was the only patient who received antipsychotics.

CONCLUSIONS

We confirmed the feasibility of the provision of CBT for ARMS in Japan. Since overprescription of antipsychotics is a matter of great concern in Japan, CBT could be a valuable alternative treatment strategy.

The relationship between ethnicity and service access, treatment uptake and the incidence of psychosis among people at ultra high risk for psychosis

Black ethnicity is associated with increased risk for psychosis in South London. This study explored the distribution of ethnicity among services users at ultra high risk for psychosis (UHR) and examined the influence of ethnicity on service access, treatment uptake and incidence of psychosis. The ethnic distribution of 228 people at UHR for psychosis, seen in an early detection clinical service over 10 years, was compared with 146 people with first episode psychosis from the same geographic region and census figures for the local population. Black service users were significantly over-represented in the UHR group compared to the background population (34% vs 21%; p < 0.05); but less so than in the first episode sample (58% vs 19%; p < 0.05). Within the UHR sample, there was no strong evidence of differences between ethnic groups in the types of treatment provided, nor in the rate of transition to psychosis over 2 years. The absence of differences between ethnic groups in rates of transition to psychosis raises the possibility that access to mental health care at the high risk stage might have reduced the influence of ethnicity on the incidence of psychosis in this sample. This would need to be replicated in a larger sample.

Association of Hippocampal Glutamate Levels With Adverse Outcomes in Individuals at Clinical High Risk for Psychosis

Importance

Preclinical and human data suggest that hippocampal dysfunction plays a critical role in the onset of psychosis. Neural hyperactivity in the hippocampus is thought to drive an increase in subcortical dopamine function through glutamatergic projections to the striatum.

Objective

To examine the association between hippocampal glutamate levels in individuals at clinical high risk for psychosis and their subsequent clinical outcomes.

Design, Setting, and Participants

This cross-sectional study of 86 individuals at clinical high risk for psychosis and 30 healthy control individuals, with a mean follow-up of 18.5 months, was conducted between November 1, 2011, and November 1, 2017, at early detection services in London and Cambridge, United Kingdom.

Main Outcomes and Measures

Concentrations of glutamate and other metabolites were measured in the left hippocampus using 3-T proton magnetic resonance spectroscopy at the first clinical presentation. At follow-up, clinical outcomes were assessed in terms of transition or nontransition to psychosis using the Comprehensive Assessment of the At-Risk Mental State criteria and the level of overall functioning using the Global Assessment of Function scale.

Results

Of 116 total participants, 86 were at clinical high risk for psychosis (50 [58%] male; mean [SD] age, 22.4 [3.5] years) and 30 were healthy controls (14 [47%] male; mean [SD] age, 24.7 [3.8] years). At follow-up, 12 clinical high-risk individuals developed a first episode of psychosis whereas 74 clinical high-risk individuals did not; 19 clinical high-risk individuals showed good overall functioning (Global Assessment of Function ≥65), whereas 38 clinical high-risk individuals had a poor functional outcome (Global Assessment of Function <65). Compared with clinical high-risk individuals who did not become psychotic, clinical high-risk individuals who developed psychosis showed higher hippocampal glutamate levels (mean [SD], 8.33 [1.48] vs 9.16 [1.28] glutamate levels; P = .048). The clinical high-risk individuals who developed psychosis also had higher myo-inositol levels (mean [SD], 7.60 [1.23] vs 6.24 [1.36] myo-inositol levels; P = .002) and higher creatine levels (mean [SD], 8.18 [0.74] vs 7.32 [1.09] creatine levels; P = .01) compared with clinical high-risk individuals who did not become psychotic, and higher myo-inositol levels compared with healthy controls (mean [SD], 7.60 [1.23] vs 6.19 [1.51] myo-inositol levels; P = .005). Higher hippocampal glutamate levels in clinical high-risk individuals were also associated with a poor functional outcome (mean [SD], 8.83 [1.43] vs 7.76 [1.40] glutamate levels; P = .02). In the logistic regression analyses, hippocampal glutamate levels were significantly associated with clinical outcome in terms of transition and nontransition to psychosis (β = 0.48; odds ratio = 1.61; 95% CI, 1.00-2.59; P = .05) and overall functioning (β = 0.53; odds ratio = 1.71; 95% CI, 1.10-2.66; P = .02).

Conclusions and Relevance

The findings indicate that adverse clinical outcomes in individuals at clinical high risk for psychosis may be associated with an increase in baseline hippocampal glutamate levels, as well as an increase in myo-inositol and creatine levels. This conclusion suggests that these measures could contribute to the stratification of clinical high-risk individuals according to future clinical outcomes.

Unmet needs in patients with brief psychotic disorders: Too ill for clinical high risk services and not ill enough for first episode services

BACKGROUND

Patients with acute and transient psychotic disorders (ATPDs) are by definition remitting, but have a high risk of developing persistent psychoses, resembling a subgroup of individuals at Clinical High Risk for Psychosis (CHR-P). Their pathways to care, treatment offered and long-term clinical outcomes beyond risk to psychosis are unexplored. We conducted an electronic health record-based retrospective cohort study including patients with ATPDs within the SLaM NHS Trust and followed-up to 8 years.

METHODS

A total of 2561 ATPDs were included in the study. A minority were detected (8%) and treated (18%) by Early Intervention services (EIS) and none by CHR-P services. Patients were offered a clinical follow-up of 350.40 ± 589.90 days. The cumulative incidence of discharges was 40% at 3 months, 60% at 1 year, 69% at 2 years, 77% at 4 years, and 82% at 8 years. Treatment was heterogeneous: the majority of patients received antipsychotics (up to 52%), only a tiny minority psychotherapy (up to 8%).

RESULTS

Over follow-up, 32.88% and 28.54% of ATPDS received at least one mental health hospitalization or one compulsory hospital admission under the Mental Health Act, respectively. The mean number of days spent in psychiatric hospital was 66.39 ± 239.44 days.

CONCLUSIONS

The majority of ATPDs are not detected/treated by EIS or CHR-P services, receive heterogeneous treatments and short-term clinical follow-up. ATPDs have a high risk of developing severe clinical outcomes beyond persistent psychotic disorders and unmet clinical needs that are not targeted by current mental health services.

The Provision of Education and Employment Support At the Outreach and Support in South London (OASIS) Service for People at Clinical High Risk for Psychosis

Clinical services for the early detection of individuals at clinical high risk of psychosis, such as Outreach and Support in South-London (OASIS), have been successful in providing psychological intervention and psychosocial support to young people experiencing emerging signs of serious mental disorders. Despite this, several studies have repeatedly shown that vocational and functional recovery in the clinical high risk for psychosis population is still low. This study aimed at evaluating the presence and nature of educational and employment focused interventions within the OASIS service, in order to inform research and clinical interventions aimed at supporting young people with early signs of psychosis on their path to vocational recovery. The specific objectives were to compare current practice i) to standards defined by the National Institute of Care Excellence guidelines; and ii) to principles defined by Individual Placement and Support (IPS). Nine standards of practice were derived. The OASIS caseload electronic records entered between January 2015 and January 2017 were manually screened. Data collected include sociodemographic, assessment of employment and educational status and support needs, interventions received, contacts with schools, employers and external vocational providers, employment, and educational status. Standards were considered as "met" if they were met for at least 90% of clients. Results suggest that, two out of nine standards were met while the remaining standards were only partially met. In particular, support provided was always focused on competitive employment and mainstream education and support was always based on people's interest. Implications for clinical and research practice are discussed.

Transdiagnostic Individualized Clinically Based Risk Calculator for the Detection of Individuals at Risk and the Prediction of Psychosis: Model Refinement Including Nonlinear Effects of Age

Background: The first rate-limiting step for primary indicated prevention of psychosis is the detection of young people who may be at risk. The ability of specialized clinics to detect individuals at risk for psychosis is limited. A clinically based, individualized, transdiagnostic risk calculator has been developed and externally validated to improve the detection of individuals at risk in secondary mental health care. This calculator employs core sociodemographic and clinical predictors, including age, which is defined in linear terms. Recent evidence has suggested a nonlinear impact of age on the probability of psychosis onset. Aim: To define at a meta-analytical level the function linking age and probability of psychosis onset. To incorporate this function in a refined version of the transdiagnostic risk calculator and to test its prognostic performance, compared to the original specification. Design: Secondary analyses on a previously published meta-analysis and clinical register-based cohort study based on 2008-2015 routine secondary mental health care in South London and Maudsley (SLaM) National Health Service (NHS) Foundation Trust. Participants: All patients receiving a first index diagnosis of non-organic/non-psychotic mental disorder within SLaM NHS Trust in the period 2008-2015. Main outcome measure: Prognostic accuracy (Harrell's C). Results: A total of 91,199 patients receiving a first index diagnosis of non-organic and non-psychotic mental disorder within SLaM NHS Trust were included in the derivation (33,820) or external validation (54,716) datasets. The mean follow-up was 1,588 days. The meta-analytical estimates showed that a second-degree fractional polynomial model with power (-2, -1: age1 = age^-2 and age2 = age^-1) was the best-fitting model (P < 0.001). The refined model that included this function showed an excellent prognostic accuracy in the external validation (Harrell's C = 0.805, 95% CI from 0.790 to 0.819), which was statistically higher than the original model, although of modest magnitude (Harrell's C change = 0.0136, 95% CIs from 0.006 to 0.021, P < 0.001). Conclusions: The use of a refined version of the clinically based, individualized, transdiagnostic risk calculator, which allows for nonlinearity in the association between age and risk of psychosis onset, may offer a modestly improved prognostic performance. This calculator may be particularly useful in young individuals at risk of developing psychosis who access secondary mental health care.

Pan-London Network for Psychosis-Prevention (PNP)

Background: The empirical success of the Clinical High Risk for Psychosis (CHR-P) paradigm is determined by the concurrent integration of efficient detection of cases at-risk, accurate prognosis, and effective preventive treatment within specialized clinical services. The characteristics of the CHR-P services are relatively under-investigated. Method: A Pan-London Network for psychosis prevention (PNP) was created across urban CHR-P services. These services were surveyed to collect the following: description of the service and catchment area, outreach, service users, interventions, and outcomes. The results were analyzed with descriptive statistics and Kaplan Meier failure function. Results: The PNP included five CHR-P services across two NHS Trusts: Outreach and Support In South-London (OASIS) in Lambeth and Southwark, OASIS in Croydon and Lewisham, Tower Hamlets Early Detection Service (THEDS), City & Hackney At-Risk Mental State Service (HEADS UP) and Newham Early Intervention Service (NEIS). The PNP serves a total population of 2,318,515 Londoners (830,889; age, 16-35 years), with a yearly recruitment capacity of 220 CHR-P individuals (age, 22.55 years). Standalone teams (OASIS and THEDS) are more established and successful than teams that share their resources with other mental health services (HEADS UP, NEIS). Characteristics of the catchment areas, outreach and service users, differ across PNP services; all of them offer psychotherapy to prevent psychosis. The PNP is supporting several CHR-P translational research projects. Conclusions: The PNP is the largest CHR-P clinical network in the UK; it represents a reference benchmark for implementing detection, prognosis, and care in the real-world clinical routine, as well as for translating research innovations into practice.

Basic Self-Disturbances Related to Reduced Anterior Cingulate Volume in Subjects at Ultra-High Risk for Psychosis

Introduction: Alterations of the "pre-reflective" sense of first-person perspective (e.g., of the "basic self") are characteristic features of schizophrenic spectrum disorders and are significantly present in the prodromal phase of psychosis and in subjects at ultra-high risk for psychosis (UHR). Studies in healthy controls suggest that neurobiological substrate of the basic self involves cortical midline structures, such as the anterior and posterior cingulate cortices. Neuroimaging studies have identified neuroanatomical cortical midline structure abnormalities in schizophrenic spectrum disorders. Objectives: i) To compare basic self-disturbances levels in UHR subjects and controls and ii) to assess the relationship between basic self-disturbances and alterations in cortical midline structures volume in UHR subjects. Methods: Thirty-one UHR subjects (27 antipsychotic-naïve) and 16 healthy controls were assessed using the 57-item semistructured Examination of Anomalous Self-Experiences (EASE) interview. All subjects were scanned using magnetic resonance imaging (MRI) at 3 T, and gray matter volume was measured in a priori defined regions of interest (ROIs) in the cortical midline structures. Results: EASE scores were much higher in UHR subjects than controls (p < 0.001). The UHR group had smaller anterior cingulate volume than controls (p = 0.037). There were no structural brain imaging alterations between UHR individuals with or without self-disturbances. Within the UHR sample, the subgroup with higher EASE scores had smaller anterior cingulate volumes than UHR subjects with lower EASE scores and controls (p = 0.018). In the total sample, anterior cingulate volume was inversely correlated with the EASE score (R = 0.52, p < 0.016). Conclusions: Basic self-disturbances in UHR subjects appear to be related to reductions in anterior cingulate volume.

Improving the Detection of Individuals at Clinical Risk for Psychosis in the Community, Primary and Secondary Care: An Integrated Evidence-Based Approach

Background: The first rate-limiting step for improving outcomes of psychosis through preventive interventions in people at clinical high risk for psychosis (CHR-P) is the ability to accurately detect individuals who are at risk for the development of this disorder. Currently, this detection power is sub-optimal. Methods: This is a conceptual and nonsystematic review of the literature, focusing on the work conducted by leading research teams in the field. The results will be structured in the following sections: understanding the CHR-P assessment, validity of the CHR-P as a universal risk state for psychosis, and improving the detection of at-risk individuals in secondary mental health care, in primary care, and in the community. Results: CHR-P instruments can provide adequate prognostic accuracy for the prediction of psychosis provided that they are employed in samples who have undergone risk enrichment during recruitment. This substantially limits their detection power in real-world settings. Furthermore, there is initial evidence that not all cases of psychosis onset are preceded by a CHR-P stage. A transdiagnostic individualized risk calculator could be used to automatically screen secondary mental health care medical notes to detect those at risk of psychosis and refer them to standard CHR-P assessment. Similar risk estimation tools for use in primary care are under development and promise to boost the detection of patients at risk in this setting. To improve the detection of young people who may be at risk of psychosis in the community, it is necessary to adopt digital and/or sequential screening approaches. These solutions are based on recent scientific evidence and have potential for implementation internationally. Conclusions: The best strategy to improve the detection of patients at risk for psychosis is to implement a clinical research program that integrates different but complementary detection approaches across community, primary, and secondary care. These solutions are based on recent scientific advancements in the development of risk estimation tools and e-health approaches and have the potential to be applied across different clinical settings.

Prevalence of non-psychotic disorders in ultra-high risk individuals and transition to psychosis: A systematic review

Despite the growing interest in the prodromes of psychosis, the proper identification of those Ultra High Risk (UHR) subjects who will convert to psychosis remains an unresolved issue. It remains to be fully understood whether the risk of transition to psychosis is incremented by the concomitant presence of non-psychotic symptoms. We performed a systematic review in order to estimate: prevalence rates of non-psychotic disorders in UHR individuals and whether any comorbid disorder impacts on the risk of transition to frank psychosis. The review was conducted using the PRISMA guidelines by searching PubMed until August 2017. The inclusion criteria were: studies with appropriate definition of UHR/ ARMS (At Risk Mental States for psychosis); cross-sectional design (for prevalence rates) or longitudinal design (for transition rates to psychosis); adolescents and/or adults; specified instrument/interview for the diagnosis of mental disorder/symptoms. We included 46 English-language articles. We found that non-psychotic symptoms are a prevalent concern in UHR individuals, and this is true for all comorbid disorders examined. None of the mental disorder examined appear to be a marker for transition to psychosis. Our systematic review found that the great majority of UHR individuals actually has a highly prevalent clearly defined, above-the-threshold mental disorder that should constitute the primary focus of intervention.

Prefrontal GABA levels, hippocampal resting perfusion and the risk of psychosis

Preclinical models propose that the onset of psychosis is associated with hippocampal hyperactivity, thought to be driven by cortical GABAergic interneuron dysfunction and disinhibition of pyramidal neurons. Recent neuroimaging studies suggest that resting hippocampal perfusion is increased in subjects at ultra-high risk (UHR) for psychosis, but how this may be related to GABA concentrations is unknown. The present study used a multimodal neuroimaging approach to address this issue in UHR subjects. Proton magnetic resonance spectroscopy and pulsed-continuous arterial spin labeling imaging were acquired to investigate the relationship between medial prefrontal (MPFC) GABA+ levels (including some contribution from macromolecules) and hippocampal regional cerebral blood flow (rCBF) in 36 individuals at UHR of psychosis, based on preclinical evidence that MPFC dysfunction is involved in hippocampal hyperactivity. The subjects were then clinically monitored for 2 years: during this period, 7 developed a psychotic disorder and 29 did not. At baseline, MPFC GABA+ levels were positively correlated with rCBF in the left hippocampus (region of interest analysis, p = 0.044 family-wise error corrected, FWE). This correlation in the left hippocampus was significantly different in UHR subjects who went on to develop psychosis relative to those who did not (p = 0.022 FWE), suggesting the absence of a correlation in the latter subgroup. These findings provide the first human evidence that MPFC GABA+ concentrations are related to resting hippocampal perfusion in the UHR state, and offer some support for a link between GABA levels and hippocampal function in the development of psychosis.

Increased Resting Hippocampal and Basal Ganglia Perfusion in People at Ultra High Risk for Psychosis: Replication in a Second Cohort

We recently reported that resting hippocampal, basal ganglia and midbrain perfusion is elevated in people at ultra high risk (UHR) for psychosis. The present study sought to replicate our previous finding in an independent UHR cohort, and examined the relationship between resting perfusion in these regions, psychosis and depression symptoms, and traumatic experiences in childhood. Pseudo-Continuous Arterial Spin Labelling (p-CASL) imaging was used to measure resting cerebral blood flow (rCBF) in 77 UHR for psychosis individuals and 25 healthy volunteers in a case-control design. UHR participants were recruited from clinical early detection services at 3 sites in the South of England. Symptoms levels were assessed using the Comprehensive Assessment of At Risk Mental States (CAARMS), the Hamilton Depression Scale (HAM-D), and childhood trauma was assessed retrospectively using the Childhood Trauma Questionnaire (CTQ). Right hippocampal and basal ganglia rCBF were significantly increased in UHR subjects compared to controls, partially replicating our previous finding in an independent cohort. In UHR participants, positive symptoms were positively correlated with rCBF in the right pallidum. CTQ scores were positively correlated with rCBF values in the bilateral hippocampus and negatively associated with rCBF in the left prefrontal cortex. Elevated resting hippocampal and basal ganglia activity appears to be a consistent finding in individuals at high risk for psychosis, consistent with data from preclinical models of the disorder. The association with childhood trauma suggests that its influence on the risk of psychosis may be mediated through an effect on hippocampal function.

Early intervention for everyone? A review of cross-cultural issues and their treatment in ultra-high-risk (UHR) cohorts

AIM

Over the past 20 years, early management of psychosis has become both a research and policy priority. In Western countries, psychotic disorders appear more prevalent in migrant and minority ethnic groups than in native or dominant groups. Moreover, disparities exist in health conditions and access to care among immigrants and minority ethnic groups, compared with native-born and majority groups. Appropriate early detection tools are necessary for the different groups.

METHODS

This systematic review provides a synthesis of the assessment and discussion of transcultural issues in ultra-high-risk (UHR) cohorts. The Medline database was searched via PubMed for peer-reviewed articles published in English from 1995 to 2017. All 79 studies included are prospective UHR cohort studies that used the Comprehensive Assessment of At-Risk Mental States (CAARMS).

RESULTS

In UHR cohort studies that used the CAARMS, transcultural data (native language, ethnicity, place of birth, migration) are rarely collected, and inadequate ability to speak the dominant language is a common exclusion criterion. When they are included, the CAARMS scores differ between some minorities and the native-born majority group.

CONCLUSIONS

This systematic review demonstrates barriers to the access to participation in early intervention research for migrants and ethnic minorities. This selection bias may result in lower validity for the CAARMS among these populations and thus in inadequate intervention programmes. Along with targeted studies, minorities' access to participation in UHR cohorts should be improved through 3 tools: interpreters at recruitment and for administration of CAARMS, a guide to cultural formulation and transcultural data collection.

Implementing the access and waiting time standard for early intervention in psychosis in the United Kingdom: An evaluation of referrals and post-assessment outcomes over the first year of operation

AIM

Improving timely access to evidence-based treatment for people aged 14-65 years experiencing a first episode psychosis (FEP) or an at-risk mental state (ARMS) for psychosis is a national priority within the United Kingdom. An early intervention in psychosis (EIP) access and waiting time standard has been set which has extended the age range and acceptance criteria for services.

METHODS

This descriptive evaluation reports upon the referrals and access to treatment times within an EIP service over the first year of operating in line with the access and waiting time standard. Patient pathways and post-assessment status are also described.

RESULTS

The service received 406 referrals, of which 88% (n = 357) were assessed. The mean length of time to treatment was 1.5 weeks, with 88% being seen within 2 weeks. Of those who engaged in an assessment, 34% (n = 138) were identified as ARMS cases and 30% (n = 123) were identified as FEP. Over 35 year olds accounted for 22% (n = 80) of the total accepted cases.

CONCLUSIONS

The findings indicate clinical and operational issues, which will need careful consideration in the future planning of services. The high number of ARMS cases highlights the importance of clear treatment pathways and targeted interventions and may suggest a need to commission distinct ARMS services. The number of people who met the extended age and service acceptance criteria may suggest a need to adapt or redesign clinical services to meet the age-specific needs of over 35 year olds and those with an ARMS. It is unclear how changes to the remit of EIP services will impact upon future clinical outcomes.

Clinical and demographic predictors of continuing remission or relapse following discontinuation of antipsychotic medication after a first episode of psychosis. A systematic review

BACKGROUND

Clinical guidelines recommend maintenance treatment with antipsychotic medication for one to two years following remission of symptoms after a first episode of psychosis. However, recent research has suggested that this may not be indicated. Consistent predictors of outcome would be beneficial to guide clinicians as to which individuals are likely to have a successful discontinuation.

OBJECTIVES

This study reviews the literature with the aim of identifying demographic and clinical predictors of either relapse or continued remission in those with a first episode of psychosis following discontinuation of antipsychotic medication.

METHODOLOGY

Data Sources: A systematic search of PubMed, CINAHL, and PsychInfo databases was performed. Eligibility Criteria: Cohort, case-control and clinical trials that were published in English, included participants with a first episode of psychosis, and examined clinical and demographic predictors of relapse or continued remission after antipsychotic discontinuation.

RESULTS

Eleven studies fulfilled inclusion criteria. No positive findings were replicated across cohorts. Predictors of relapse: male sex, unemployment, prior psychiatric admission, premorbid adjustment, childhood isolation, premorbid functioning, schizoid-schizotypal traits, schizophrenia diagnosis, concomitant medication, and more severe negative symptoms. Some positive findings must be interpreted in the context of conflicting and replicated negative findings: sex, employment status, level of education, premorbid functioning, symptom severity, and schizophrenia diagnosis. Other replicated non-predictive findings: age, ethnicity, marital status, family history, disorganized thoughts, affective symptoms, cannabis abuse, clinical global impression, social integration, duration and dose of antipsychotic treatment, and compliance.

CONCLUSION

No positive findings have been replicated across study cohorts. Non-predictive findings have been replicated.

Semistructured Interview for Bipolar At Risk States (SIBARS)

The external prognostic accuracy of Bipolar At Risk (BAR) criteria is undetermined and no psychometric tools are available to measure them. We present here three studies that overcome these limitations. Study 1 and 2 investigated the prognostic accuracy (Harrell's C) of the original BAR and revised Bipolar At Risk States (BARS) criteria respectively for the prediction of bipolar disorders, using a retrospective cohort of individuals at Clinical High Risk for Psychosis (CHR-P). Study 3 validated externally the prognostic accuracy of a newly developed Semistructured Interview of At Risk Bipolar States (SIBARS) in an independent prospective CHR-P cohort. In study 1 (n = 205), those meeting BAR criteria had an increased risk of developing bipolar disorders (HR = 5.30) relative to those not meeting them, but the prognostic accuracy was poor (Harrell's C = 0.659). In study 2 (n = 205), those meeting the refined BARS criteria had a higher risk of developing bipolar disorders than those not meeting them (HR = 12.364), with an adequate prognostic accuracy (Harrell's C = 0.777). Study 3 (n = 71) confirmed that SIBARS criteria had an adequate prognostic accuracy (Harrell's C = 0.742) and clinical utility. Overall, these findings suggest that the SIBARS could be used for the detection of individuals at risk of developing bipolar disorders in CHR-P services.

Substance use and at-risk mental state for psychosis in 2102 prisoners: the case for early detection and early intervention in prison

AIM

Prisoners exhibit high rates of substance use and mental health problems. In the present study, we sought to gain a detailed understanding of substance use amongst young prisoners to inform early detection and early intervention strategies in a prison setting.

METHODS

This is a cross-sectional study of 2102 prisoners who were screened by the London Early Detection and Prevention in Prison Team (LEAP). Data on the use of substances were collected including age of first use, recent use, duration of use and poly-drug use. The Prodromal Questionnaire - Brief Version was used to screen for the at-risk mental state.

RESULTS

We found high rates of lifetime and recent use and low age of first use of a number of substances. We also found strong associations between substance use and screening positive for an at-risk mental state. Logistic regression analysis confirmed that use of any drug in the last year, poly-drug and early use, as well as heavy alcohol use, were related to an increased risk of screening positive.

CONCLUSIONS

Substance use in the prison population is not only widespread and heavy but is also strongly linked with a higher risk of developing mental health problems. The need for early detection and early intervention in prison is discussed.

Polish individuals with an at-risk mental state: demographic and clinical characteristics

AIM

The aim of this study is to present sociodemographic and clinical characteristics of Polish individuals with an at-risk mental state (ARMS).

METHODS

A group of 99 individuals meeting the ARMS criteria were assessed in terms of sociodemographic data, psychopathological symptoms, psychosocial functioning and comorbidity.

RESULTS

The sample (mean age 19 years) was 54.55% women. At baseline, nearly 73% of the sample was educated, and 20.20% were employed. Approximately 87.88% of the participants lived with their families. Nearly 77% of the sample presented attenuated psychotic symptoms (APS), 17.17% demonstrated APS with accompanying vulnerability traits and 19.19% showed vulnerability features only. The mean Social and Occupational Functioning Assessment Scale score was 49.55 (±7.70). No effect of age, gender or level of functioning on psychopathological symptoms was observed. The most common comorbid diagnoses were depressive (44.44%) and anxiety disorders (19.19%), which coexisted in 5.05% of the individuals. Approximately 28.28% of the diagnoses met the criteria for personality disorders. The dropout rate from the study was 19.09%, with stigma as the most common reason.

CONCLUSIONS

Polish ARMS individuals are help-seeking young people most commonly presenting APS or vulnerability features. Despite a high level of psychosocial dysfunction, these individuals remain educationally active. Most individuals showed comorbid diagnoses (commonly depressive or anxiety disorders). Despite some differences resulting from the socioeconomic situation of the country or the specificity of the mental health services, the characteristics of the sample remain consistent with descriptions of ARMS populations worldwide. This study reaffirms the need for organizing early intervention services in non-stigmatizing settings.

The C'JAAD: a French team for early intervention in psychosis in Paris

AIM

The aim is to describe a centre operating in Paris that pioneers the early intervention for young people at the onset and at high risk of psychosis in France.

METHODS

Comprehensive descriptive analysis of different clinical and service measures is used in describing the implementation of the C'JAAD (Evaluation Centre for Young Adults and Adolescents) using data from an ongoing prospective non-interventional research programme.

RESULTS

Over a 2-year period, 151 patients were referred to the C'JAAD and included in the ICAAR research programme. After evaluation by the Comprehensive Assessment of the At-Risk Mental States Scale, 53.7% were identified at risk of developing a psychosis, 20.6% presented a full-blown psychosis and 25.7% were considered not at risk of developing a psychosis. A total of 84% of the at-risk subjects suffered from a psychiatric co-morbidity, of which anxiodepressive symptoms being the most frequent (39%). The global functioning of these at-risk subjects was seriously impaired (average Social and Occupational Functioning Assessment Scale score = 48.9). More than one third of the patients was self-referred (33.8%), 22.5% were addressed by a psychiatrist whereas 10.6% were referred by a general practitioner.

CONCLUSIONS

In this paper, we report for the first time the activities of the C'JAAD, the pioneer unit in France for early detection and treatment of young adults with early psychosis. These observations indicate that such early intervention centre is a feasible and sustainable extension of traditional care for people with mental disorders in this country and offers promising perspective for the development of further centres.

Neighbourhood deprivation is positively associated with detection of the ultra-high risk (UHR) state for psychosis in South East London

BACKGROUND

Individuals are defined as being at ultra-high risk (UHR) for psychosis based on a combination of attenuated psychotic symptoms, help-seeking behaviour, genetic risk, and social/occupational deterioration. Limited evidence is available on whether UHR detection differs by neighbourhood, and potential explanations.

AIMS

To examine neighbourhood distribution of detected UHR using cases from the OASIS service in South East London, investigating neighbourhood deprivation as an explanatory variable.

METHODS

Geographic data were collected on patients who met UHR criteria over a fourteen-year period, at the neighbourhood (lower super output area, LSOA) level. Rates were calculated based on cases and age-specific population estimates. Poisson regression assessed associations between UHR rate and neighbourhood deprivation, and with particular deprivation domains, adjusting for referrals for UHR assessment, population density, and proportions of non-White people, and young single people.

RESULTS

Rate of UHR detection was statistically related to neighbourhood deprivation, but referral rate was not: compared to the least deprived neighbourhoods, the most deprived neighbourhoods had a greater than two-fold increase in incidence rate of detected UHR (adjusted incidence rate ratio (IRR): 2.11, 95% confidence interval (CI): 1.21,3.67). In contrast, a small, imprecise association was observed for referral for assessment for UHR (adjusted IRR: 1.26 (95%CI: 0.84,1.89)). Evidence was also found for associations of UHR detection rate with domains of deprivation pertaining to health and barriers to services.

CONCLUSIONS

The distribution of UHR detection rates by neighbourhood is not random and may be explained in part by differences in the social environment between neighbourhoods.

Why transition risk to psychosis is not declining at the OASIS ultra high risk service: The hidden role of stable pretest risk enrichment

BACKGROUND

The reason for declining risk to psychosis across individuals assessed and meeting Ultra High Risk (UHR) criteria is still unclear. No studies have investigated the potential substantial role of the underlying risk enrichment across all the individuals undergoing an UHR assessment.

METHODS

Cohort study including all non-psychotic subjects who were assessed on suspicion of psychosis risk by the OASIS UHR service in the period 2001 to 2015. Posttest (after UHR assessment) and pretest risk (before UHR assessment) of psychosis were stratified and compared across three time periods (2001-2005, 2006-2010, 2011-2015) with Cox analysis and modulating factors were investigated.

RESULTS

The posttest risk of psychosis at the OASIS service has increased from the initial pilot years of the service (2001-2005) and then stabilised and not declined over the following decade (2006-2010 and 2011-2015). This was paralleled by a similar course of pretest risk for psychosis. Stability of pretest risk for psychosis over the past decade was associated with a lack of change in ethnicity and to counterweighting changes in the type of referral sources over different time periods.

CONCLUSIONS

The time course of transition risk to psychosis in UHR services is strictly associated with the time course of pretest risk enrichment. If the latter remains stable over time, as for the OASIS service, no declining transition risk is observed over the most recent years. Pretest risk enrichment is determined by recruitment and sampling strategies. This study confirms the need to control these factors in the UHR field.

Interpersonal sensitivity in those at clinical high risk for psychosis mediates the association between childhood bullying victimisation and paranoid ideation: A virtual reality study

BACKGROUND

Experience of bullying victimisation in childhood and heightened interpersonal sensitivity have been independently linked to the clinical high risk for psychosis.

AIM

To examine the potential mediating effect of interpersonal sensitivity in explaining the link between childhood bullying victimisation and real-time paranoid ideation in adult participants at clinical high risk for psychosis.

METHOD

In a cross-sectional study data were collected for 64 individuals at clinical high risk for psychosis. Measures included history of bullying victimisation, interpersonal sensitivity and state paranoid ideation following exposure to a social virtual reality environment. The virtual reality scenario was a London Underground journey.

RESULTS

Path analysis indicated that interpersonal sensitivity fully explained the significant association between severe bullying victimisation in childhood and paranoid ideation in the clinical-high risk group. Based on AIC criteria the best model selected was the full mediation model: severe bullying→interpersonal sensitivity→state paranoid ideation. The results suggest that severity of bullying is more important than frequency of bullying in explaining state paranoid ideation.

CONCLUSIONS

The significant role played by interpersonal sensitivity in the association between being bullied in childhood and paranoid ideation in the clinical high risk group suggests that this could become a target for intervention.

Diagnostic and Prognostic Significance of DSM-5 Attenuated Psychosis Syndrome in Services for Individuals at Ultra High Risk for Psychosis

BACKGROUND

The diagnostic and prognostic significance of the DSM-5-defined Attenuated Psychosis Syndrome (DSM-5-APS) in individuals undergoing an ultra high risk (UHR) clinical assessment for suspicion of psychosis risk is unknown.

METHODS

Prospective cohort study including all consecutive help-seeking individuals undergoing both a DSM-5-APS and a Comprehensive Assessment of At Risk Mental States (CAARMS 12/2006) assessment for psychosis risk at the Outreach and Support in South London (OASIS) UHR service (March 2013-April 2014). The diagnostic significance of DSM-5-APS was assessed with percent overall agreement, prevalence bias adjusted kappa, Bowker's test, Stuart-Maxwell test, residual analysis; the prognostic significance with Cox regression, Kaplan-Meier failure function, time-dependent area under the curve (AUC) and net benefits analysis. The impact of specific revisions of the DSM-5-APS was further tested.

RESULT

In 203 help-seeking individuals undergoing UHR assessment, the agreement between the DSM-5-APS and the CAARMS 12/2006 was only moderate (kappa 0.59). Among 142 nonpsychotic cases, those meeting DSM-5-APS criteria had a 5-fold probability (HR = 5.379) of developing psychosis compared to those not meeting DSM-5-APS criteria, with a 21-month cumulative risk of psychosis of 28.17% vs 6.49%, respectively. The DSM-5-APS prognostic accuracy was acceptable (AUC 0.76 at 24 months) and similar to the CAARMS 12/2006. The DSM-5-APS designation may be clinically useful to guide the provision of indicated interventions within a 7%-35% (2-year) range of psychosis risk. The removal of the criterion E or C of the DSM-5-APS may improve its prognostic performance and transdiagnostic value.

CONCLUSIONS

The DSM-5-APS designation may be clinically useful in individuals accessing clinical services for psychosis prevention.

Imaging and Genetic Biomarkers Predicting Transition to Psychosis

The search for diagnostic and prognostic biomarkers in schizophrenia care and treatment is the focus of many within the research community. Longitudinal cohorts of patients presenting at elevated genetic and clinical risk have provided a wealth of data that has informed our understanding of the development of schizophrenia and related psychotic disorders.Imaging follow-up of high-risk cohorts has demonstrated changes in cerebral grey matter of those that eventually transition to schizophrenia that predate the onset of symptoms and evolve over the course of illness. Longitudinal follow-up studies demonstrate that observed grey matter changes can be employed to differentiate those who will transition to schizophrenia from those who will not prior to the onset of the disorder.In recent years our understanding of the genetic makeup of schizophrenia has advanced significantly. The development of modern analysis techniques offers researchers the ability to objectively quantify genetic risk; these have been successfully applied within a high-risk paradigm to assist in differentiating between high-risk individuals who will subsequently become unwell and those who will not.This chapter will discuss the application of imaging and genetic biomarkers within high-risk groups to predict future transition to schizophrenia and related psychotic disorders. We aim to provide an overview of current approaches focussing on grey matter changes that are predictive of future transition to illness, the developing field of genetic risk scores and other methods being developed to aid clinicians in diagnosis and prognosis.

Altered activation and connectivity in a hippocampal-basal ganglia-midbrain circuit during salience processing in subjects at ultra high risk for psychosis

Animal models of psychosis propose that abnormal hippocampal activity drives increased subcortical dopamine function, which is thought to contribute to aberrant salience processing and psychotic symptoms. These effects appear to be mediated through connections between the hippocampus, ventral striatum/pallidum and the midbrain. The aim of the present study was to examine the activity and connectivity in this pathway in people at ultra high risk (UHR) for psychosis. Functional magnetic resonance imaging was used to compare neural responses in a hippocampal-basal ganglia-midbrain network during reward, novelty and aversion processing between 29 UHR subjects and 32 healthy controls. We then investigated whether effective connectivity within this network is perturbed in UHR subjects, using dynamic causal modelling (DCM). Finally, we examined the relationship between alterations in activation and connectivity in the UHR subjects and the severity of their psychotic symptoms. During reward anticipation, UHR subjects showed greater activation than controls in the ventral pallidum bilaterally. There were no differences in activation during novelty or aversion processing. DCM revealed that reward-induced modulation of connectivity from the ventral striatum/pallidum to the midbrain was greater in UHR subjects than controls, and that in UHR subjects, the strength of connectivity in this pathway was correlated with the severity of their abnormal beliefs. In conclusion, ventral striatal/pallidal function is altered in people at UHR for psychosis and this is related to the level of their psychotic symptoms.

Improving outcomes of first-episode psychosis: an overview

Outcomes of psychotic disorders are associated with high personal, familiar, societal and clinical burden. There is thus an urgent clinical and societal need for improving those outcomes. Recent advances in research knowledge have opened new opportunities for ameliorating outcomes of psychosis during its early clinical stages. This paper critically reviews these opportunities, summarizing the state-of-the-art knowledge and focusing on recent discoveries and future avenues for first episode research and clinical interventions. Candidate targets for primary universal prevention of psychosis at the population level are discussed. Potentials offered by primary selective prevention in asymptomatic subgroups (stage 0) are presented. Achievements of primary selected prevention in individuals at clinical high risk for psychosis (stage 1) are summarized, along with challenges and limitations of its implementation in clinical practice. Early intervention and secondary prevention strategies at the time of a first episode of psychosis (stage 2) are critically discussed, with a particular focus on minimizing the duration of untreated psychosis, improving treatment response, increasing patients' satisfaction with treatment, reducing illicit substance abuse and preventing relapses. Early intervention and tertiary prevention strategies at the time of an incomplete recovery (stage 3) are further discussed, in particular with respect to addressing treatment resistance, improving well-being and social skills with reduction of burden on the family, treatment of comorbid substance use, and prevention of multiple relapses and disease progression. In conclusion, to improve outcomes of a complex, heterogeneous syndrome such as psychosis, it is necessary to globally adopt complex models integrating a clinical staging framework and coordinated specialty care programmes that offer pre-emptive interventions to high-risk groups identified across the early stages of the disorder. Only a systematic implementation of these models of care in the national health care systems will render these strategies accessible to the 23 million people worldwide suffering from the most severe psychiatric disorders.

Do fewer males present to clinical high-risk services for psychosis relative to first-episode services?

AIM

A decline in the rate of transition to psychosis in patients presenting with clinical high-risk has been reported in the literature. Several hypotheses have been put forward to explain this decline. In this brief report, we aimed to explore whether the demographic group presenting to clinical high-risk services differs from the 'end-point' population who present with first-episode psychosis (FEP), by focusing on gender.

METHOD

Gender distribution was compared between clinical high-risk (CHR) and FEP using data extracted from published study samples and clinical data from corresponding cohorts within the same catchment area in South London.

RESULTS

The proportion of males was significantly higher in FEP compared to CHR services in the literature describing Europe, Australia and North America and in the clinical cohort from South London.

CONCLUSION

Males are under-represented in existing CHR services in Europe, Australia and North America. This could reflect less willingness in males to seek help if experiencing low-level psychological distress and may be related to the declining transition.

Only a small proportion of patients with first episode psychosis come via prodromal services: a retrospective survey of a large UK mental health programme

BACKGROUND

Little is known about patients with a first episode of psychosis (FEP) who had first presented to prodromal services with an "at risk mental state" (ARMS) before making the transition to psychosis. We set out to identify the proportion of patients with a FEP who had first presented to prodromal services in the ARMS state, and to compare these FEP patients with FEP patients who did not have prior contact with prodromal services.

METHODS

In this study information on 338 patients aged ≤37 years who presented to mental health services between 2010 and 2012 with a FEP was examined. The data on pathways to care, clinical and socio-demographic characteristics were extracted from the Biomedical Research Council Case Register for the South London and Maudsley NHS Trust.

RESULTS

Over 2 years, 14 (4.1% of n = 338) young adults presented with FEP and had been seen previously by the prodromal services. These ARMS patients were more likely to enter their pathway to psychiatric care via referral from General Practice, be born in the UK and to have had an insidious mode of illness onset than FEP patients without prior contact with the prodromal services.

CONCLUSIONS

In the current pathways to care configuration, prodromal services are likely to prevent only a few at-risk individuals from transitioning to psychosis even if effective preventative treatments become available.

The associations between quality of life and clinical symptoms in individuals with an at-risk mental state and first-episode psychosis

Quality of life (QOL) is strongly associated with severity of clinical symptoms and is often compromised in patients with chronic or first-episode psychosis (FEP). However, it remains unclear whether baseline QOL in individuals with an at-risk mental state (ARMS) for psychosis is higher or lower than that in patients with FEP, or what specific clinical symptoms relate to a decreased QOL in individuals with ARMS and FEP. The World Health Organization's WHOQOL-BREF, an instrument assessing QOL, was administered to 104 individuals with ARMS and 53 with FEP. Clinical symptoms were assessed by the Positive and Negative Syndrome Scale and the Beck Depression Inventory-II. We compared the four domain scores of the WHOQOL-BREF between the two groups, and calculated Pearson correlations between each WHOQOL-BREF domain score and the clinical symptoms and compared these correlations between the groups. We observed significant correlations between poor QOL and severity of depressive symptoms in both the FEP and ARMS group. No between-group differences were found in any correlation coefficients between WHOQOL-BREF domains and clinical symptoms. Thus, depressive symptoms should be investigated as a key factor relating to poor QOL in both individuals with ARMS and those with FEP.

Formal thought disorder in people at ultra-high risk of psychosis

BACKGROUND

Formal thought disorder is a cardinal feature of psychosis. However, the extent to which formal thought disorder is evident in ultra-high-risk individuals and whether it is linked to the progression to psychosis remains unclear.

AIMS

Examine the severity of formal thought disorder in ultra-high-risk participants and its association with future psychosis.

METHOD

The Thought and Language Index (TLI) was used to assess 24 ultra-high-risk participants, 16 people with first-episode psychosis and 13 healthy controls. Ultra-high-risk individuals were followed up for a mean duration of 7 years (s.d.=1.5) to determine the relationship between formal thought disorder at baseline and transition to psychosis.

RESULTS

TLI scores were significantly greater in the ultra-high-risk group compared with the healthy control group (effect size (ES)=1.2), but lower than in people with first-episode psychosis (ES=0.8). Total and negative TLI scores were higher in ultra-high-risk individuals who developed psychosis, but this was not significant. Combining negative TLI scores with attenuated psychotic symptoms and basic symptoms predicted transition to psychosis (P=0.04; ES=1.04).

CONCLUSIONS

TLI is beneficial in evaluating formal thought disorder in ultra-high-risk participants, and complements existing instruments for the evaluation of psychopathology in this group.

DECLARATION OF INTERESTS

None.

COPYRIGHT AND USAGE

© The Royal College of Psychiatrists 2017. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license.

What Is an Attenuated Psychotic Symptom? On the Importance of the Context

Attenuated psychotic symptoms (APS) are the key criteria to identify the individuals at enhanced risk of developing psychotic disorders. Competing clinicians-rated or self-rated psychometric instruments can also be used to detect APS, which makes it difficult to interpret their actual clinical significance. This article summarizes the empirical differences between the clinicians-rated and self-rated interviews and explores the impact of the context (referral pathways, settings, and assessment procedures) on the clinical significance of the APS.