Disability in people clinically at high risk of psychosis

Longitudinal validation of psychosis risk screening tools

The development of widely used interview tools has helped to standardize the criteria for a "clinical high risk" syndrome, thus enabling advances in efforts to develop interventions for this phase of illness. These assessments, however, are burdensome to administer and not likely to be adopted for widespread use. Scalable early intervention depends on the availability of brief, low-cost assessment tools that can serve to screen populations of interest or triage treatment-seekers toward specialized care. The current study examines the sensitivity, specificity, and predictive strength of three self-report measures (Prime Screen-Revised, Prodromal Questionnaire-Brief, and Youth Psychosis at Risk Questionnaire-Brief) with regard to psychosis onset and symptom persistence over six months of follow-up within an indicated sample of 54 adolescents and young adults ages 12-22. Within this sample, all three measures demonstrated excellent sensitivity to emerging psychosis and strong agreement with clinician evaluations of attenuated psychosis symptoms. Additionally, all screeners obtained negative predictive values of 1.00 with regard to psychosis onset, indicating that an individual scoring below the recommended threshold score would be extremely unlikely to develop psychosis over the following six months. The longitudinal validation of psychosis risk screening tools constitutes an important step toward establishing a standard of care for early identification and monitoring in this vulnerable population.

Changes in neurocognitive functioning during transition to manifest disease: comparison of individuals at risk for schizophrenic and bipolar affective psychoses

BACKGROUND

Neurocognitive deficits are important aspects of schizophrenic disorder because they have a strong impact on social and vocational outcomes. Previously it was assumed that cognitive abilities progressively deteriorate with illness onset. However, recent research results have contradicted this with observations of continuous or even improved performance in individuals at risk for psychosis or manifest schizophrenia. The objective of our longitudinal study was to examine neurocognitive functioning in help-seeking individuals meeting basic symptoms or ultra-high-risk criteria for schizophrenic psychosis (HRSchiz) or risk criteria for affective psychosis (HRBip). The progression of cognitive functioning in individuals converting to psychosis was compared with that of at-risk individuals who did not convert during the follow-up period.

METHOD

Data were available from 86 study participants who completed neurocognitive and clinical assessments at baseline and, on average, 12.8 (s.d. = 1.5) months later. Neurocognitive measures were grouped according to their load in factor analysis to five cognitive domains: speed, attention, fluency, learning and memory, and working memory.

RESULTS

Neurocognitive functioning in HRSchiz and HRBip individuals generally improved over time. Subjects converting to manifest psychosis displayed a stable neurocognitive profile from baseline to follow-up. Compared with non-converters, they had already demonstrated a significantly lower level of performance during their baseline examinations.

CONCLUSIONS

Our data provide no evidence for a progressive cognitive decline in individuals at risk of psychosis. In line with the neurodevelopmental model, our findings suggest that cognitive deficits are already present very early, before or during the prodromal stage of the illness.

Self-awareness of functional impairment in individuals at clinical high-risk for psychosis

AIMS

A major public health concern associated with schizophrenia is the long-term disability that involves an inability to function independently in the community. An individual's self-awareness of functional impairment may be a significant factor contributing to long-term disability. In fact, subjective interpretation of one's illness impacts treatment participation and adherence, and is linked to poor outcomes. However, it remains unclear how illness-related functional impairment is perceived by individuals prior to the onset of psychosis. This study aims to examine the relationship between clinician-based and self-report assessments of functioning, as well as the contribution of clinical symptoms to this relationship in individuals at clinical high-risk for psychosis.

METHODS

The Sheehan Disability Scale, a self-rated instrument, was used to measure disruption in daily functioning in social and role functioning due to symptoms in a sample of 73 treatment-seeking patients at clinical high-risk for psychosis and 50 healthy controls.

RESULTS

Relative to healthy controls, clinical high-risk patients self-reported significant disruptions in social and role functioning. In addition, a specific relationship emerged in that clinician-rated measures of functioning and depression were related to subjective functioning.

CONCLUSIONS

These findings suggest that clinical high-risk patients are significantly disturbed by their illness. Self-reported disruption of daily functioning was associated with clinician-rated functioning and depressive symptoms, further highlighting the impact of functional impairments on the level of distress experienced by patients in the early phases of the illness. Intervention strategies that repair functional impairment before the onset of psychosis may prevent long-term disability.

Are people at risk of psychosis also at risk of suicide and self-harm? A systematic review and meta-analysis

BACKGROUND

Suicide and self-harm are prevalent in individuals diagnosed with psychotic disorders. However, less is known about the level of self-injurious thinking and behaviour in those individuals deemed to be at ultra-high risk (UHR) of developing psychosis, despite growing clinical interest in this population. This review provides a synthesis of the extant literature concerning the prevalence of self-harm and suicidality in the UHR population, and the predictors and correlates associated with these events.

METHOD

A search of electronic databases was undertaken by two independent reviewers. A meta-analysis of prevalence was undertaken for self-harm, suicidal ideation and behaviour. A narrative review was also undertaken of analyses examining predictors and correlates of self-harm and suicidality.

RESULTS

Twenty-one eligible studies were identified. The meta-analyses suggested a high prevalence of recent suicidal ideation (66%), lifetime self-harm (49%) and lifetime suicide attempts (18%). Co-morbid psychiatric problems, mood variability and a family history of psychiatric problems were among the factors associated with self-harm and suicide risk.

CONCLUSIONS

Results suggest that self-harm and suicidality are highly prevalent in the UHR population, with rates similar to those observed in samples with diagnosed psychotic disorders. Appropriate monitoring and managing of suicide risk will be important for services working with the UHR population. Further research in this area is urgently needed considering the high rates identified.

Courses of helping alliance in the treatment of people with severe mental illness in Europe: a latent class analytic approach

PURPOSE

The helping alliance (HA) between patient and therapist has been studied in detail in psychotherapy research, but less is known about the HA in long-term community mental health care. The aim of this study was to identify typical courses of the HA and their predictors in a sample of people with severe mental illness across Europe over a measurement period of one year.

METHODS

Self-ratings of the HA by 588 people with severe mental illness who participated in a multicentre European study (CEDAR; ISRCTN75841675) were examined using latent class analysis.

RESULTS

Four main patterns of alliance were identified: (1) high and stable (HS, 45.6 %), (2) high and increasing (HI, 36.9 %), (3) high and decreasing (HD, 11.3 %) and (4) low and increasing (LI, 6.1 %). Predictors of class membership were duration of illness, ethnicity, and education, receipt of state benefits, recovery, and quality of life.

CONCLUSIONS

Results support findings from psychotherapy research about a predominantly stable course of the helping alliance in patients with severe mental illness over time. Implications for research and practice indicate to turn the attention to subgroups with noticeable courses.

Challenges in the early detection and intervention of the psychosis-risk syndrome

The concept of a clinical high-risk state for psychosis has been used to describe individuals who have prodromal symptoms of psychosis and, thus, are at high-risk of developing psychosis. This high-risk concept promotes a more detailed developmental understanding of the evolution of psychosis and provides a theoretical basis for providing necessary mental health services to people at clinically high-risk of developing psychosis. Early detection and intervention can potentially change the course of psychotic conditions and, thus, prevent or minimize the associated disability. This is a relatively new area of interest, so more studies are needed to fully understand this high-risk condition.

Neurocognitive profiles in help-seeking individuals: comparison of risk for psychosis and bipolar disorder criteria

BACKGROUND

Neurocognitive deficits are important aspects of the schizophrenic disorders because they have a strong impact on social and vocational outcomes. We expanded on previous research by focusing on the neurocognitive profiles of persons at high risk (HR) or ultra-high risk (UHR) for schizophrenic and affective psychoses. Our main aim was to determine whether neurocognitive measures are sufficiently sensitive to predict a group affiliation based on deficits in functional domains.

METHOD

This study included 207 help-seeking individuals identified as HR (n = 75), UHR (n = 102) or at high risk for bipolar disorder (HRBip; n = 30), who were compared with persons comprising a matched, healthy control group (CG; n = 50). Neuropsychological variables were sorted according to their load in a factor analysis and were compared among groups. In addition, the likelihood of group membership was estimated using logistic regression analyses.

RESULTS

The performance of HR and HRBip participants was comparable, and intermediate between the controls and UHR. The domain of processing speed was most sensitive in discriminating HR and UHR [odds ratio (OR) 0.48, 95% confidence interval (CI) 0.28-0.78, p = 0.004] whereas learning and memory deficits predicted a conversion to schizophrenic psychosis (OR 0.47, 95% CI 0.25-0.87, p = 0.01).

CONCLUSIONS

Performances on neurocognitive tests differed among our three at-risk groups and may therefore be useful in predicting psychosis. Overall, cognition had a profound effect on the extent of general functioning and satisfaction with life for subjects at risk of psychosis. Thus, this factor should become a treatment target in itself.

What drives poor functioning in the at-risk mental state? A systematic review

BACKGROUND

Transition to psychotic disorder has been the traditional outcome of interest for research in the at-risk mental state (ARMS). However, there is growing recognition that individuals with ARMS may function poorly regardless of whether they develop psychosis. We aimed to review the literature to determine whether there are specific factors associated with, or predictive of, functional impairment in the ARMS population.

METHOD

An electronic database search of MEDLINE, PsycINFO and Embase from inception until May 2014 was conducted using keyword search terms synonymous with the at-risk mental state and functioning. Eligible studies were original peer-reviewed English language research articles with populations that met validated at-risk diagnostic criteria and examined the cross-sectional or longitudinal association between any variable and a measure of functioning.

RESULTS

Seventy-two eligible studies were identified. Negative symptoms and neurocognitive impairment were associated with poor functioning in cross-sectional studies. Negative and disorganised symptoms, neurocognitive deficits and poor functioning at baseline were predictive of poor functional outcome in longitudinal studies. Positive symptoms were unrelated to functioning in both cross-sectional and longitudinal studies. Functional disability was persistent and resistant to current treatments.

CONCLUSIONS

Negative and disorganised symptoms and cognitive deficits pre-date frank psychotic symptoms and are risk factors for poor functioning. This is consistent with a subgroup of ARMS individuals potentially having neurodevelopmental schizophrenia. Treatments aimed at improving functioning must be considered a priority on par with preventing transition to psychosis in the development of future interventions in the ARMS group.

Evidence-based psychotherapy for the prevention and treatment of first-episode psychosis

The aim of psychotherapy among individuals at clinical high risk (CHR) for psychosis is to prevent transition to full-blown psychosis. Psychotherapy in individuals with a first-episode psychosis (FEP) aims to reduce relapse rates. Remission of (pre-) psychotic symptoms, psychosocial functioning, quality of life, comorbid disorders and self-esteem are also important outcomes in individuals at CHR and with FEP. Antipsychotics, Qmega-3-Fatty acids and psychotherapy have been found to be effective in CHR for most of these aims. Thereby psychotherapy presents a better benefit/risk ratio than antipsychotic medication. The most evidence-based intervention is cognitive-behavioral therapy (CBT). Psychotherapy is mostly offered to FEP patients within specialized early intervention services (including assertiveness community treatment and antipsychotic medication). Thereby, CBT is effective for positive symptoms and family intervention is particularly effective for the prevention of relapses. We introduce the principles of CBT for psychosis and suggest adaptions for individuals at CHR and FEP. We conclude that the needs of young people at CHR and with FEP are best met by specially designed, low threshold outpatient clinical services, which include intensive psychotherapy treatment. A number of countries have implemented early detection and intervention services based on this model, while the implementation within in Germany is still marginal.

Prediction and prevention of psychosis: current progress and future tasks

Prevention of psychoses has been intensively investigated within the past two decades, and particularly, prediction has been much advanced. Depending on the applied risk indicators, current criteria are associated with average, yet significantly heterogeneous transition rates of ≥30 % within 3 years, further increasing with longer follow-up periods. Risk stratification offers a promising approach to advance current prediction as it can help to reduce heterogeneity of transition rates and to identify subgroups with specific needs and response patterns, enabling a targeted intervention. It may also be suitable to improve risk enrichment. Current results suggest the future implementation of multi-step risk algorithms combining sensitive risk detection by cognitive basic symptoms (COGDIS) and ultra-high-risk (UHR) criteria with additional individual risk estimation by a prognostic index that relies on further predictors such as additional clinical indicators, functional impairment, neurocognitive deficits, and EEG and structural MRI abnormalities, but also considers resilience factors. Simply combining COGDIS and UHR criteria in a second step of risk stratification produced already a 4-year hazard rate of 0.66. With regard to prevention, two recent meta-analyses demonstrated that preventive measures enable a reduction in 12-month transition rates by 54-56 % with most favorable numbers needed to treat of 9-10. Unfortunately, psychosocial functioning, another important target of preventive efforts, did not improve. However, these results are based on a relatively small number of trials; and more methodologically sound studies and a stronger consideration of individual profiles of clinical needs by modular intervention programs are required.

The WERCAP Screen and the WERC Stress Screen: psychometrics of self-rated instruments for assessing bipolar and psychotic disorder risk and perceived stress burden

BACKGROUND

Identification of individuals in the prodromal phase of bipolar disorder and schizophrenia facilitates early intervention and promises an improved prognosis. There are no current assessment tools for clinical risk symptoms of bipolar disorder, and psychosis-risk assessment generally involves semi-structured interviews, which are time consuming and rater dependent. We present psychometric data on two novel quantitative questionnaires: the Washington Early Recognition Center Affectivity and Psychosis (WERCAP) Screen for assessing bipolar and psychotic disorder risk traits, and the accompanying WERC Stress Screen for assessing individual and total psychosocial stressor severities.

METHODS

Prevalence rates of the WERCAP Screen were evaluated among 171 community youth (aged 13-24 years); internal consistency was assessed and k-means cluster analysis was used to identify symptom groups. In 33 participants, test-retest reliability coefficients were assessed, and ROC curve analysis was used to determine the validity of the psychosis section of the WERCAP Screen (pWERCAP) against the Structured Interview of Psychosis-Risk Symptoms (SIPS). Correlations of the pWERCAP, the affectivity section of the WERCAP Screen (aWERCAP) and the WERC Stress Screen were examined to determine the relatedness of scores with cognition and clinical measures.

RESULTS

Cluster analysis identified three groups of participants: a normative (47%), a psychosis-affectivity (18%) and an affectivity only (35%) group. Internal consistency of the aWERCAP and pWERCAP resulted in alphas of 0.87 and 0.92, and test-retest reliabilities resulted in intraclass correlation coefficients of 0.76 and 0.86 respectively. ROC curve analysis showed the optimal cut-point on the pWERCAP as a score of >30 (sensitivity: 0.89; specificity: 1.0). There was a significant negative correlation between aWERCAP scores and total cognition (R=-0.42), and between pWERCAP scores and sensorimotor processing speed. Total stress scores correlated significantly with scores on the aWERCAP (R=0.88), pWERCAP (R=0.62) and total cognition (R=-0.44).

CONCLUSIONS

Our results show that the WERCAP Screen and the WERC Stress Screen are easy to administer and derived scores are related to cognitive and clinical traits. This suggests that their use could have particular benefits for epidemiologic studies and in busy clinical settings. Longitudinal studies would be required to evaluate clinical outcomes with high questionnaire scores.

Evidence for an agitated-aggressive syndrome predating the onset of psychosis

BACKGROUND

Aggression and suicidality prior to the initiation of treatment are frequent phenomena in psychosis patients. Increased scores in the Brief Psychiatric Rating Scale Excited Component (BPRS-EC) have been shown to predict involuntary treatment, aggression, and suicide in first-episode psychosis (FEP) patients. However, it is unclear if an agitated-aggressive syndrome as measured with the BPRS-EC is already present in at-risk mental state (ARMS).

METHODS

BPRS-EC scores from 43 ARMS patients, 50 FEP patients, and 25 healthy controls (HC) were analyzed. Multivariate analyses were performed to review if group differences were mediated by potential confounders. In addition, the association of BPRS-EC scores with clinical variables was examined.

RESULTS

BPRS-EC scores were significantly different across diagnostic groups (H(2)=22.1; p<.001), and post-hoc analyses showed significantly higher BPRS-EC scores for ARMS (p=.001) and for FEP patients (p<.001) compared to HC. Differences remained significant after controlling for gender, years of education, and intelligence. No significant differences emerged between ARMS and FEP patients. BPRS-EC was significantly correlated with lower intelligence (r=-.27; p=.008), reduced level of functioning (r=-.44; p<.001), and with smoking behavior (r=.22; p=.019).

CONCLUSIONS

ARMS and FEP patients in our sample had significantly higher BPRS-EC scores compared to HC. This may constitute a correlate of an agitated-aggressive syndrome and an increased risk for aggression and suicidality.

Symptomatic and functional remission of subjects at clinical high risk for psychosis: a 2-year naturalistic observational study

BACKGROUND

The aim of this study was to assess the frequency and predictors of symptomatic and functional remission in individuals at clinical high risk (CHR) for psychosis at 1-2 years of follow-up.

METHODS

Help-seeking CHR individuals with symptomatic (Scale of Prodromal Symptoms (SOPS) positive scores <3) and functional (Global Assessment of Functioning (GAF) score >60) (CHR-R) remission at 12-24 months were compared to non-remitted individuals (CHR-NR) regarding baseline and treatment characteristics, symptom changes and predictors. Time to full remission was compared with that of symptomatic remission only.

RESULTS

Of 73 individuals, 29 (39.7%) achieved full remission; 44 (60.3%) did not. Compared to CHR-NR individuals, CHR-R individuals had lower baseline SOPS positive symptoms (p=0.017), antipsychotic use (p=0.004), antipsychotic chlorpromazine dose equivalents (p=0.001) and anxiolytic use (p=0.004). In survival analyses, the estimated full remission rate was 48.3% (95% confidence interval (CI)=36.2-61.9) and symptomatic remission rate was 67.5% (CI95=55.4-79.2). Time to full remission was longer than time to symptomatic remission (p=0.017). Linear mixed-effect models revealed significantly greater improvements from 6 months onward in CHR-R subjects compared to CHR-NR subjects regarding SOPS positive symptoms (p=0.003), highest SOPS positive symptom (p<0.001) and GAF scores (p=0.004). Examining baseline predictors, time to full remission was significantly longer in patients with higher SOPS positive scores (p=0.017).

CONCLUSIONS

More stringent remission criteria that include functional status in addition to attenuated positive symptom severity should be applied to CHR subjects. Furthermore, more attention should be given to CHR individuals with highly positive prodromal symptoms at baseline.

Adolescents at ultra-high risk for psychosis: long-term outcome of individuals who recover from their at-risk state

Studies of individuals at ultra-high risk (UHR) for psychosis have mostly reported on long-term outcome of those individuals who develop psychosis compared to those who do not. However, these studies show that a large number of UHR individuals no longer meet criteria for UHR at follow-up. Therefore, this study aimed to investigate functioning at 6-year follow-up in remitted individuals, and to explore the course of their clinical symptoms. Forty-four UHR adolescents completed extensive clinical assessments at baseline and participated in long-term follow-up approximately six years later. UHR adolescents who had either converted to psychosis or who still met UHR criteria (n=26) at follow-up were compared to individuals who had remitted from their UHR status (n=18) on clinical and psychosocial variables. Results show that more than 40% of UHR individuals had fully remitted from their UHR status. At six-year follow-up, remitted individuals had improved clinically on most symptoms. The course of their symptoms showed that the most substantial reduction in positive symptoms occurred within the first two years, while improvements in general, mood and anxiety symptoms occurred at a later stage. Baseline socio-demographic characteristics and clinical symptoms did not distinguish between remitters and non-remitters. Although remitters no longer met criteria for UHR, they did meet diagnostic criteria for a wide range of psychiatric disorders. Our findings suggest that, when related to long-term outcome, UHR criteria capture non-specific psychotic symptoms rather than risk for psychosis per se and relate more to general psychopathology.

Anomalous self-experiences contribute independently to social dysfunction in the early phases of schizophrenia and psychotic bipolar disorder

BACKGROUND

Psychotic disorders are associated with significant social dysfunction. Anomalous self-experiences (ASE) present in psychotic disorders could contribute to social dysfunction.

AIM

To investigate if ASE contribute to social dysfunction in the early phases of psychotic disorders after controlling for factors related to social functioning including diagnoses.

METHODS

ASE were assessed by means of the EASE (Examination of Anomalous Self-Experience) in 76 patients referred to their first adequate treatment for schizophrenia or psychotic bipolar disorder. Diagnoses, symptom severity, and functioning were assessed using the Structured Clinical Interview for the Positive and Negative Syndrome Scale, Calgary Depression Scale for Schizophrenia, Premorbid Adjustment Scale, Global Assessment of Functioning--Split Version, and Social Functioning Scale. Neurocognitive assessments included measures of psychomotor speed, working memory, executive and memory functions. Duration of untreated psychosis was also assessed.

RESULTS

High levels of ASE were significantly associated with poorer social functioning in the early phases of schizophrenia and psychotic bipolar disorder also after correcting for diagnosis.

CONCLUSION

This study demonstrates the significance of ASE for social dysfunction in patients with psychotic disorders, and contributes to the understanding of the complexity of illness-related factors that affect social functioning.

Pathways to care in subjects at high risk for psychotic disorders - a European perspective

Evidence-based decisions on indicated prevention in early psychosis require large-scale studies on the pathways to care in high-risk subjects. EPOS (The European Prediction of Psychosis Study), a prospective multi-center, naturalistic field study in four European countries (Finland, Germany, The Netherlands and England), was designed to acquire accurate knowledge about pathways to care and delay in obtaining specialized high risk care. Our high risk sample (n=233) reported on average 2.9 help-seeking contacts, with an average delay between onset of relevant problems to initial help-seeking contact of 72.6 weeks, and between initial help-seeking contact and reaching specialized high risk care of 110.9 weeks. This resulted in a total estimated duration of an unrecognized risk for psychosis of 3 ½ years. Across EPOS EU regions, about 90% of care pathway contacts were within professional health care sectors. Between EPOS regions, differences in the pathways parameters including early detection and health-care systems were often very pronounced. High-risk participants who later made transition to a full psychotic disorder had significantly longer delays between initial help-seeking and receiving appropriate interventions. Our study underlines the need for regionally adapted implementation of early detection and intervention programs within respective mental health and health care networks, including enhancing public awareness of early psychosis.

Obstetrical complications and Apgar score in subjects at risk of psychosis

The objective of the study was to identify associations between a history of obstetrical complications (OCs) and the future development of symptoms indicating risk of psychosis (At Risk Mental State - ARMS). The frequency of OCs was assessed in 66 ARMS subjects, 50 subjects with the first episode of schizophrenia (FES) and 50 healthy controls. Obstetrical data was obtained from medical documentation and evaluated with the Lewis and Murray Scale. Definite OCs, according to the Lewis and Murray Scale, occurred significantly more frequently in the ARMS group compared to the controls (χ(2) = 7.79, p = 0.005; OR = 4.20, 95% CI = 1.46-12.11), as well as in the FES subjects compared to the controls (χ(2) = 8.39, p = 0.004; OR = 4.64, 95% CI = 1.56-13.20). Apgar scores in the first (Apgar 1) and the fifth minute after birth (Apgar 5) were significantly lower in the FES subjects compared to the controls (for Apgar 1 score Z = 4.439, p < 0.0001; for Apgar 5 score Z = 5.250, p < 0.0001). The ARMS subjects demonstrated significantly lower Apgar 5 scores compared to the healthy controls (Z = 3.458, p = 0.0016). The results indicate that OCs and low Apgar 5 score should be considered important factors in identifying subjects at risk of developing psychosis.

Comorbid depressive and anxiety disorders in 509 individuals with an at-risk mental state: impact on psychopathology and transition to psychosis

BACKGROUND

The current diagnostic system for subjects at enhanced clinical risk of psychosis allows concurrent comorbid diagnoses of anxiety and depressive disorders. Their impact on the presenting high-risk psychopathology, functioning, and transition outcomes has not been widely researched.

METHODS

In a large sample of subjects with an At-Risk Mental State (ARMS, n = 509), we estimated the prevalence of DSM/SCID anxiety or depressive disorders and their impact on psychopathology, functioning, and psychosis transition. A meta-analytical review of the literature complemented the analysis.

RESULTS

About 73% of ARMS subjects had a comorbid axis I diagnosis in addition to the "at-risk" signs and symptoms. About 40% of ARMS subjects had a comorbid diagnosis of depressive disorder while anxiety disorders were less frequent (8%). The meta-analysis conducted in 1683 high-risk subjects confirmed that baseline prevalence of comorbid depressive and anxiety disorders is respectively 41% and 15%. At a psychopathological level, comorbid diagnoses of anxiety or depression were associated with higher suicidality or self-harm behaviors, disorganized/odd/stigmatizing behavior, and avolition/apathy. Comorbid anxiety and depressive diagnoses were also associated with impaired global functioning but had no effect on risk of transition to frank psychosis. Meta-regression analyses confirmed no effect of baseline anxiety and/or depressive comorbid diagnoses on transition to psychosis.

CONCLUSIONS

The ARMS patients are characterized by high prevalence of anxiety and depressive disorders in addition to their attenuated psychotic symptoms. These symptoms may reflect core emotional dysregulation processes and delusional mood in prodromal psychosis. Anxiety and depressive symptoms are likely to impact the ongoing psychopathology, the global functioning, and the overall longitudinal outcome of these patients.

Negative psychotic symptoms and impaired role functioning predict transition outcomes in the at-risk mental state: a latent class cluster analysis study

BACKGROUND

Many research groups have attempted to predict which individuals with an at-risk mental state (ARMS) for psychosis will later develop a psychotic disorder. However, it is difficult to predict the course and outcome based on individual symptoms scores.

METHOD

Data from 318 ARMS individuals from two specialized services for ARMS subjects were analysed using latent class cluster analysis (LCCA). The score on the Comprehensive Assessment of At-Risk Mental States (CAARMS) was used to explore the number, size and symptom profiles of latent classes.

RESULTS

LCCA produced four high-risk classes, censored after 2 years of follow-up: class 1 (mild) had the lowest transition risk (4.9%). Subjects in this group had the lowest scores on all the CAARMS items, they were younger, more likely to be students and had the highest Global Assessment of Functioning (GAF) score. Subjects in class 2 (moderate) had a transition risk of 10.9%, scored moderately on all CAARMS items and were more likely to be in employment. Those in class 3 (moderate-severe) had a transition risk of 11.4% and scored moderately severe on the CAARMS. Subjects in class 4 (severe) had the highest transition risk (41.2%), they scored highest on the CAARMS, had the lowest GAF score and were more likely to be unemployed. Overall, class 4 was best distinguished from the other classes on the alogia, avolition/apathy, anhedonia, social isolation and impaired role functioning.

CONCLUSIONS

The different classes of symptoms were associated with significant differences in the risk of transition at 2 years of follow-up. Symptomatic clustering predicts prognosis better than individual symptoms.

Prediction of functional outcome in individuals at clinical high risk for psychosis

IMPORTANCE

A major public health concern associated with schizophrenia and psychotic disorders is the long-term disability that involves impaired cognition, lack of social support, and an inability to function independently in the community. A critical goal of early detection and intervention studies in psychosis is therefore to understand the factors leading to this often profound impairment.

OBJECTIVE

To develop a predictive model of functional (social and role) outcome in a clinical high-risk sample for psychosis.

DESIGN

Prospective, naturalistic, longitudinal 3- to 5-year follow-up study.

SETTING

The Recognition and Prevention Program in New York, a research clinic located in the Zucker Hillside Hospital in New York.

PARTICIPANTS

One hundred one treatment-seeking patients at clinical high risk for psychosis. Ninety-two (91%) were followed up prospectively for a mean (SD) of 3 (1.6) years.

INTERVENTION

Neurocognitive and clinical assessment.

MAIN OUTCOMES AND MEASURES

The primary outcome variables were social and role functioning at the last follow-up visit.

RESULTS

Poor social outcome was predicted by reduced processing speed (odds ratio [OR], 1.38; 95% CI, 1.050-1.823; P = .02), impaired social functioning at baseline (OR, 1.85; 95% CI, 1.258-2.732; P = .002), and total disorganized symptoms (OR, 5.06; 95% CI, 1.548-16.527; P = .007). Reduced performance on tests for verbal memory (OR, 1.74; 95% CI, 1.169-2.594; P = .006), role functioning at baseline (OR, 1.34; 95% CI, 1.053-1.711; P = .02), and motor disturbances (OR, 1.77; 95% CI, 1.060-2.969; P = .03) predicted role outcome. The areas under the curve for the social and role prediction models were 0.824 (95% CI, 0.736-0.913; P < .001) and 0.77 (95% CI, 0.68-0.87; P < .001), respectively, demonstrating a high discriminative ability. In addition, poor functional outcomes were not entirely dependent on the development of psychosis, because 40.3% and 45.5% of nonconverters at clinical high risk had poor social and role outcomes, respectively.

CONCLUSIONS AND RELEVANCE

Results from this study support the increasing emphasis on functional decline as a critically important outcome that parallels conversion to psychosis and suggest that both psychosis and long-term functional disability are equally important targets for prevention. Reduced neurocognitive performance, functional impairments, and nonpositive attenuated symptoms at baseline were associated with an increased risk of poor functional outcomes in our sample. Poor functional outcomes were not entirely dependent on positive symptoms and the development of psychosis, further highlighting the need for intervention at this early stage of development for those who do and do not convert to a full-blown psychotic disorder.

Development of liability syndromes for schizophrenia: where did they come from and where are they going?

Three decades after Paul Meehl proposed the term "schizotaxia" to describe a conceptual framework for understanding the liability to schizophrenia, Ming Tsuang et al. at Harvard University reformulated the concept as a clinical syndrome with provisional research criteria. The reformulated view relied heavily on more recent data showing that many non-psychotic, un-medicated biological relatives of individuals with schizophrenia showed difficulties in cognitive and other clinical functions that resembled those seen in their ill relatives. The reformulation raised questions about both whether and when liability could be assessed validly in the absence of psychosis, and about the extent to which symptoms of liability are reversible. Both questions bear on the larger issue of early intervention in schizophrenia. This article reviews the efforts of Tsuang et al. to conceptualize and validate schizotaxia as one such syndrome of liability. Towards this end, liability is considered first more generally as an outcome of interactive genetic and environmental factors. Liability is then considered in the context of endophenotypes as a concept that is both broader and is potentially more specific (and predictive) than many DSM or ICD diagnostic symptoms. Liability syndromes are then considered in the context of their proximity to illness, first by reviewing prodromal syndromes (which are more proximal), and then by considering schizotaxia, which, as it is currently formulated, is pre-prodromal and, therefore, less proximal. Finally, challenges to validation and future directions for research are considered.

Psychiatric morbidity, functioning and quality of life in young people at clinical high risk for psychosis

OBJECTIVE

Recent studies suggest that psychotic-like experiences may also act as markers for non-psychotic psychiatric disorders, which may indicate that the focus of research in individuals at high risk (HR) for psychosis needs updating. In this study we thoroughly examined the clinical and functional characteristics of a consecutive cohort of young people at HR for psychosis and compared them to a matched sample of healthy volunteers.

METHOD

Between February 2010 and September 2012 60 help-seeking HR individuals, aged 16-35, were recruited from CAMEO Early Intervention in Psychosis Service, Cambridgeshire, UK. Forty-five age- and gender-matched healthy volunteers were randomly recruited from the same geographical area. Sociodemographic, psychiatric morbidity, functioning and quality of life measures were compared between both groups.

RESULTS

HR individuals suffered a wide range of DSM-IV psychiatric disorders, mainly within the affective and anxiety diagnostic spectra. In comparison to healthy volunteers, young people at HR reported more suicidal ideation/intention, depressive and anxiety symptoms and presented with remarkably poor functioning and quality of life.

CONCLUSION

The presence of co-morbid moderate or severe depressive and anxiety symptoms was common in our sample of young people at enhanced risk for psychosis. A HR mental state may be associated not only with an increased risk for psychosis, but also other psychiatric disorders. Our findings may have implications for the future implementation of therapeutic interventions that this population could benefit from.

Symptom dimensions and functional impairment in early psychosis: more to the story than just negative symptoms

Functional impairment is a defining feature of psychotic disorders and usually appears well before their onset. Negative symptoms play a prominent role in the impaired functioning of individuals with schizophrenia and those at clinical-high-risk (CHR) for psychosis. Despite high rates of depression and anxiety in early psychosis, few studies have examined the contribution of these symptoms to functioning in the putative 'prodrome.' In the current study, we tested the hypotheses that 1) worse negative and disorganized, but not positive, symptoms would be significantly related to impaired social and role functioning in two cohorts of CHR individuals (combined N=98) and a separate sample of individuals with recent-onset (RO) psychotic disorders (N=88); and 2) worse anxiety and depression would be significantly related to impaired functioning in both samples, above and beyond the contributions of negative and disorganized symptoms. Findings largely supported our hypotheses that more severe negative and disorganized symptoms were related to poorer social and role functioning in both samples. Anxiety and depression severity were significantly related to poorer functioning in both samples. In addition, depression, but not anxiety, predicted poorer global and social functioning above and beyond that explained by negative symptoms in the CHR sample. These results suggest the need for phase-specific treatment in early psychosis, with a focus on symptom dimensions to improve functional outcomes for CHR individuals.

Association between psychopathology and problems of psychosocial functioning in the long-term outcome of patients diagnosed with schizophrenic, schizoaffective and affective disorders

Mental health problems do significantly impact on a person's functioning. In the past, problems with psychosocial functioning were mainly associated with the diagnoses of schizophrenia. However, nowadays it is clear that impaired psychosocial functioning is also a common phenomenon in people suffering from affective disorders. Only few studies have investigated psychosocial functioning in patients with affective, schizoaffective and schizophrenic disorders in the long-term and in a comparative approach. In the present study, we analysed the association between psychopathology and psychosocial functioning. This question is relevant as symptom remission and sufficient levels of functioning are considered as important indicators of patients' recovery from their mental health problems. The here reported findings refer to the data of a sample of 177 patients with life-time diagnoses belonging to the schizophrenic, schizoaffective or affective spectrum according to the ICD-10 criteria. Psychopathological, socio-demographic and other illness-related variables were assessed at the index hospitalisation and at the 15-year follow-up evaluation. In the present study, psychopathology is focused on data assessed with the PANSS (Positive and Negative Syndrome Scale). Information about patients' psychosocial functioning was assessed by using a modified and extended version of the WHO disability assessment scale (WHO-DAS-M). The association between psychosocial functioning and psychopathology was analysed by correlation analyses with the total sample and diagnostic subsamples. The consistency of correlations across the diagnostic groups and domains of psychosocial functioning was calculated. Findings revealed for all diagnostic groups that higher levels of psychopathology were associated with higher levels of problems in psychosocial functioning in various domains. Though there seem to be some differences between psychopathological dimensions and their effects on different aspects of psychosocial functioning, findings across the three diagnostic categories were fairly consistent. The present findings do highlight the importance of symptom remission in achieving social recovery and preventing impairment in psychosocial functioning in all major psychiatric disorders.

Measuring psychosocial outcome is good

PURPOSE OF REVIEW

Poor psychosocial functioning in schizophrenia can be conceptualized as an early indicator of chronic neurodevelopmental illness. Alternatively, impaired psychosocial functioning could be the result of social and environmental factors associated with the onset of psychotic illness. We review recent evidence on psychosocial outcome in the early phases of psychotic illness, when young people are less removed from their developmental trajectory, any brain changes may be mutable and there may be greater opportunity for intervention.

RECENT FINDINGS

In samples with first-episode psychosis, poor premorbid functioning, stable negative symptoms and impaired social cognition and neurocognition may indicate individuals likely to experience poor psychosocial outcome. There is also some evidence of social/environmental predictors of poor outcome. Recent findings from at-risk samples suggest similar patterns, although more research is needed.

SUMMARY

It is likely that for some patients poor psychosocial outcome is the result of longstanding neurological changes, whereas for others it is related to the secondary consequences of having psychosis. We suggest that measuring psychosocial outcome in the early stages of psychosis is important for our understanding of the cause of schizophrenia, but argue for the importance of the patient's subjective view on their psychosocial recovery.

Prediction of psychosis in clinical high-risk patients by the Schizotypal Personality Questionnaire. Results of the EPOS project

OBJECTIVE

Schizotypal features indicate proneness to psychosis in the general population. It is also possible that they increase transition to psychosis (TTP) among clinical high-risk patients (CHR). Our aim was to investigate whether schizotypal features predict TTP in CHR patients.

METHODS

In the EPOS (European Prediction of Psychosis Study) project, 245 young help-seeking CHR patients were prospectively followed for 18 months and their TTP was identified. At baseline, subjects were assessed with the Schizotypal Personality Questionnaire (SPQ). Associations between SPQ items and its subscales with the TTP were analysed in Cox regression analysis.

RESULTS

The SPQ subscales and items describing ideas of reference and lack of close interpersonal relationships were found to correlate significantly with TTP. The co-occurrence of these features doubled the risk of TTP.

CONCLUSIONS

Presence of ideas of reference and lack of close interpersonal relations increase the risk of full-blown psychosis among CHR patients. This co-occurrence makes the risk of psychosis very high.

Dynamic association between interpersonal functioning and positive symptom dimensions of psychosis over time: a longitudinal study of healthy adolescents

BACKGROUND

Cross-sectional studies have indicated that alterations in social functioning, particularly interpersonal functioning, are associated with the occurrence of psychotic symptoms and experiences at different levels of the extended psychosis phenotype (ranging from population psychometric expression of liability to overt psychotic disorder). However, more research is needed on the development of this association over time.

METHODS

Cross-lagged path modeling was used to analyze bidirectional, longitudinal associations between 4 dimensions of subclinical psychotic experiences (persecutory ideation, bizarre experiences, perceptual abnormalities, and magical thinking) and interpersonal functioning in an adolescent general population sample (N = 881 at T1, N = 652 at T2, and N = 512 at T3) assessed 3 times in 3 years.

RESULTS

All symptom dimensions showed some association with interpersonal functioning over time, but only bizarre experiences and persecutory ideation were consistently and longitudinally associated with interpersonal functioning. Poorer interpersonal functioning predicted higher levels of bizarre experiences and persecutory ideation at later measurement points (both T1 to T2 and T2 to T3).

CONCLUSIONS

Poor interpersonal functioning in adolescence may reflect the earliest expression of neurodevelopmental alterations preceding expression of psychotic experiences in a symptom-specific fashion.

The Strauss and Carpenter Prognostic Scale in subjects clinically at high risk of psychosis

OBJECTIVE

To investigate the predictive value of the Strauss and Carpenter Prognostic Scale (SCPS) for transition to a first psychotic episode in subjects clinically at high risk (CHR) of psychosis.

METHOD

Two hundred and forty-four CHR subjects participating in the European Prediction of Psychosis Study were assessed with the SCPS, an instrument that has been shown to predict outcome in patients with schizophrenia reliably.

RESULTS

At 18-month follow-up, 37 participants had made the transition to psychosis. The SCPS total score was predictive of a first psychotic episode (P < 0.0001). SCPS items that remained as independent predictors in the Cox proportional hazard model were as follows: most usual quality of useful work in the past year (P = 0.006), quality of social relations (P = 0.006), presence of thought disorder, delusions or hallucinations in the past year (P = 0.001) and reported severity of subjective distress in past month (P = 0.003).

CONCLUSION

The SCPS could make a valuable contribution to a more accurate prediction of psychosis in CHR subjects as a second-step tool. SCPS items assessing quality of useful work and social relations, positive symptoms and subjective distress have predictive value for transition. Further research should focus on investigating whether targeted early interventions directed at the predictive domains may improve outcomes.

The psychosis high-risk state: a comprehensive state-of-the-art review

CONTEXT

During the past 2 decades, a major transition in the clinical characterization of psychotic disorders has occurred. The construct of a clinical high-risk (HR) state for psychosis has evolved to capture the prepsychotic phase, describing people presenting with potentially prodromal symptoms. The importance of this HR state has been increasingly recognized to such an extent that a new syndrome is being considered as a diagnostic category in the DSM-5.

OBJECTIVE

To reframe the HR state in a comprehensive state-of-the-art review on the progress that has been made while also recognizing the challenges that remain.

DATA SOURCES

Available HR research of the past 20 years from PubMed, books, meetings, abstracts, and international conferences.

STUDY SELECTION AND DATA EXTRACTION

Critical review of HR studies addressing historical development, inclusion criteria, epidemiologic research, transition criteria, outcomes, clinical and functional characteristics, neurocognition, neuroimaging, predictors of psychosis development, treatment trials, socioeconomic aspects, nosography, and future challenges in the field.

DATA SYNTHESIS

Relevant articles retrieved in the literature search were discussed by a large group of leading worldwide experts in the field. The core results are presented after consensus and are summarized in illustrative tables and figures.

CONCLUSIONS

The relatively new field of HR research in psychosis is exciting. It has the potential to shed light on the development of major psychotic disorders and to alter their course. It also provides a rationale for service provision to those in need of help who could not previously access it and the possibility of changing trajectories for those with vulnerability to psychotic illnesses.

The ultra-high risk concept-a review

Attempts to identify people at imminent risk of psychotic disorder have been made during the past 20 years. High-risk criteria have been developed, and despite findings of a recent decline in the rate of onset of psychosis associated with these criteria, people identified still have a significantly greater risk, compared with the general population. Intervention studies in this group indicate that psychological treatments and fish oil appear to be just as effective as antipsychotics. Future research should refine risk factors for psychosis and examine outcomes other than psychosis. Research is also needed into what harms and benefits are associated with making the high-risk criteria into a formal diagnosis.

Transition to first episode psychosis in ultra high risk populations: does baseline functioning hold the key?

BACKGROUND

Baseline functioning has been found to be a strong predictor of transition to psychosis in ultra high risk populations. However, the time course of functioning may enhance prediction. We investigated whether there were different patterns of functioning over time and whether particular temporal patterns were related to baseline characteristics and psychosis outcome.

METHOD

Functional data was assessed at baseline and after 3 to 6year follow-up in an ultra high risk sample (n=158; 92 female, mean age=19.28 (SD=3.33), range=14-29). Using the median score of the GAF and the QLS scale, a 'High' and 'Low' group (comprising of subjects functioning above or below median at both baseline and follow-up) and a 'Deterioration' group and 'Improving' group were created.

RESULTS

Chi-square analyses showed that the Low and Deteriorating functioning groups were the most likely to develop first-episode psychosis (FEP). Importantly, UHR individuals with deteriorating functioning were at higher risk of transition than those whose functioning was low at baseline but improved over time (GAF: X(2)=5.10, df=1, p=.02; QLS: X(2)=9.13, df=1, p=.003). Binary logistic regression analyses showed that a decline in functioning was more strongly associated with FEP (GAF: p=<.0001; QLS: p<.0001) than the level of baseline functioning (GAF: p=.005; QLS: p=.09). The deteriorating group could not be distinguished from the High group in terms of baseline symptomatology.

DISCUSSION

With the addition of the 'low functioning' criterion to the UHR criteria, we may miss out on some true positive cases. Limiting our attention to baseline poor functioning may therefore distort the picture in terms of risk for psychosis.

'At-risk' for psychosis research: where are we heading?

The 'at-risk' criteria are a useful paradigm for investigating the psychological, neurocognitive, neurobiological and genetic risk factors for psychosis, specifically schizophrenia. To date, the primary outcome of interest in at-risk research has been the development of psychotic disorder, whereby patients are categorized as either having 'transitioned' or 'not transitioned'. Despite the acceptance of this dichotomy, it is important to consider that the threshold at which psychotic symptoms progress from attenuated to frank 'psychotic disorder' is arbitrary and may be incorrect or meaningless in terms of neurobiological and functional changes associated with psychosis. This has implications for clinical care and the search for markers of schizophrenia. We present recent research suggesting that the term 'outcome' needs to be broadened to incorporate non-psychotic diagnoses, functioning and negative symptoms. Shifting the traditional notion of outcome is the future challenge for at-risk research, but the inclusion of outcomes other than psychosis is likely to result in better aetiological models of psychotic illness.

Tai-chi for residential patients with schizophrenia on movement coordination, negative symptoms, and functioning: a pilot randomized controlled trial

Objective. Patients with schizophrenia residing at institutions often suffer from negative symptoms, motor, and functional impairments more severe than their noninstitutionalized counterparts. Tai-chi emphasizes body relaxation, alertness, and movement coordination with benefits to balance, focus, and stress relief. This pilot study explored the efficacy of Tai-chi on movement coordination, negative symptoms, and functioning disabilities towards schizophrenia. Methods. A randomized waitlist control design was adopted, where participants were randomized to receive either the 6-week Tai-chi program and standard residential care or only the latter. 30 Chinese patients with schizophrenia were recruited from a rehabilitation residency. All were assessed on movement coordination, negative symptoms, and functional disabilities at baseline, following intervention and 6 weeks after intervention. Results. Tai-chi buffered from deteriorations in movement coordination and interpersonal functioning, the latter with sustained effectiveness 6 weeks after the class was ended. Controls showed marked deteriorations in those areas. The Tai-chi group also experienced fewer disruptions to life activities at the 6-week maintenance. There was no significant improvement in negative symptoms after Tai-chi. Conclusions. This study demonstrated encouraging benefits of Tai-chi in preventing deteriorations in movement coordination and interpersonal functioning for residential patients with schizophrenia. The ease of implementation facilitates promotion at institutional psychiatric services.

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

INTRODUCTION

Prevention of psychosis has become a major objective of modern clinical psychiatry. An increasing number of new services have been established in Europe and in the world. The OASIS team has become an established model where clinical practice and research are fully integrated in the field of preventative interventions in psychosis.

METHOD

Comprehensive analysis of different clinical and service measures describing the 2001-2011 implementation of the OASIS team.

RESULTS

Over the last decade, the OASIS team has received a total of 1102 referrals, mostly young males from ethnic minorities. After the assessment, 35% were diagnosed with an At Risk Mental State (ARMS) while 32% were already psychotic. Within the ARMS, 70% met the inclusion criteria for the attenuated psychotic symptoms subgroup, 1% met the inclusion criteria for the genetic deterioration syndrome, 9% met inclusion criteria for a brief and self-limited intermittent psychotic episode and the others met inclusion criteria for more than one subgroup. Most of them had at least one comorbid diagnosis, mainly relating to anxiety and depressive domains. The majority of the OASIS clients received cognitive behavioural therapy alone or in combination with antidepressants/antipsychotics. Over the 2-year follow-up time, 44 subjects (15.2%) developed a frank psychotic episode.

CONCLUSIONS

The OASIS service represents one of the largest and most established prodromal services in the world. The burden of research evidence and the translational impact produced on the clinical practice support the OASIS as a model for the development of similar services.

Risk factors for psychosis: impaired social and role functioning

OBJECTIVES

Risk for psychosis is currently defined primarily on the basis of attenuated positive symptoms (APS), with no inclusion of the functional deficits characteristic of schizophrenia. Impaired social and role functioning have been of interest for reflecting poor outcome but far less is known about the developmental impact of these deficits as vulnerability or risk factors.

METHODS

Age-appropriate social and role functioning were prospectively assessed in 100 individuals at clinical high risk (CHR) for psychosis included in the 8-site North American Prodromal Longitudinal Study database. A nested case-control design was used to compare changes in social and role functioning in 26 individuals converting to psychosis shortly after baseline assessment and 24 converting over a year later. Individuals in each converter subgroup were directly matched to a non-converter at the same site, controlling for time to conversion, age, gender, and severity of baseline symptoms.

RESULTS

At baseline, CHR subjects who later became psychotic were significantly more likely to be impaired socially than matched non-converters. Onset of psychosis did not further disrupt social difficulties. Role functioning showed some of the same trends, but the overall pattern was not as consistent as for the social domain. Controlling for neurocognition did not change the pattern of group differences.

CONCLUSIONS

Early impaired social functioning appears to be a risk factor for psychosis and, added to APS, could potentially contribute to accurate identification of CHR individuals and provide a new direction for early intervention to reduce long-term disability.

Development of the Global Disability Scale (Glo.Di.S): preliminary results

BACKGROUND

The assessment of functioning and disability is an important part of the clinical evaluation, since it measures disease burden and reflects the effectiveness of therapeutic planning and interventions. The aim of the current study was to develop such a self-report instrument on the basis of a review of the literature, and compatible with the WHO approach.

MATERIAL AND METHODS

The review of the literature led to the development of the Global Disability Scale (Glo.Di.S) with 25 items assessing different aspects of disability. The study sample included 728 persons from vulnerable populations (homeless, jobless, very low income, single parent families etc.; (29.12% males and 70.88% females; aged 55.96 ± 15.22 years). The protocol included also the STAI and the CES-D. The statistical analysis included factor analysis item analysis and ANCOVA.

RESULTS

The factor analysis revealed the presence of 4 factors explaining 71% of total variance (Everyday functioning, Social and interpersonal functioning, Severity and Mental disability). Chronbach's alpha for the whole scale was 0.95 and for subscales were 0.74-0.94.

DISCUSSION

The results of the current study suggest that the Glo.Di.S. has the potential to serve as a reliable and valid tool for assessing functioning and disability. Further research is needed to prove that it could be useful across countries, populations and diseases, and whether it provides data that are culturally meaningful and comparable. It can be used in surveys and in clinical research settings and it can generate information of use in evaluating health needs and the effectiveness of interventions to reduce disability and improve health.

Prediction and prevention of psychosis in youth at clinical high risk

Most individuals with schizophrenia retrospectively report a prodromal period characterized by increasing problems in thinking, feeling, and behaving. However, it is less clear how many individuals who display prodromal symptoms will subsequently develop a psychotic illness. Thus, a precondition for early intervention in psychosis is the accurate detection of those who may be at true risk of developing a psychotic illness. The aim of this article is to review current work addressing prediction and prevention in the prodrome to psychosis. First, we describe research efforts to develop and test operational criteria for prospectively assessing psychosis liability over time. Second, the clinical, functional, and biological features of the prodrome are presented, along with a discussion of the variables most frequently associated with psychosis onset. Next, treatment studies are reviewed. The review concludes with a framework for future early identification and treatment studies.

Pathways to psychosis: help-seeking behavior in the prodromal phase

BACKGROUND

Knowledge of pathways to care by help-seeking patients prior to the onset of psychosis may help to improve the identification of at-risk patients. This study explored the history of help-seeking behavior in secondary mental health care services prior to the onset of the first episode of psychosis.

METHOD

The psychiatric case register in The Hague was used to identify a cohort of 1753 people in the age range of 18-35 at first contact who developed a psychotic disorder in the period from 1 January 2005 to 31 December 2009. We retrospectively examined the diagnoses made at first contact with psychiatric services.

RESULTS

985 patients (56.2%) had been treated in secondary mental health services prior to the onset of psychosis. The most common disorders were mood and anxiety disorders (N=385 (39.1%)) and substance use disorders (N=211 (21.4%)). Affective psychoses were more often preceded by mood/anxiety disorders, while psychotic disorder NOS was more often preceded by personality disorder or substance abuse. The interval between first contact and first diagnosis of psychosis was approximately 69 months in cases presenting with mood and anxiety disorders and 127 months in cases presenting with personality disorders.

DISCUSSION

This study confirms the hypothesis that the majority of patients with psychotic disorders had been help-seeking for other mental disorders in the secondary mental health care prior to the onset of psychosis.

Neurocognitive predictors of functional outcome two to 13 years after identification as ultra-high risk for psychosis

BACKGROUND AND AIM

Little is known about the relationship between neurocognitive performance and functional outcome before the onset of frank psychosis. This longitudinal study aimed to investigate neurocognitive predictors of poor functional outcome in a group identified as ultra-high risk (UHR) for psychosis between two and 13 years prior.

METHOD

Individuals (N=230) identified as UHR for psychosis at the PACE Clinic in Melbourne completed assessment of psychopathology, functioning and neurocognition at baseline and follow-up. The mean length of follow-up was 7.26 years (SD 3.05).

RESULTS

Forty-one individuals with the poorest functional outcome were identified. Only 48.8% of this group had transitioned to psychosis. Poor functional outcome was associated with reduced performance at baseline in the specific neurocognitive domains of verbal learning and memory, processing speed and attention, and verbal fluency, but not global cognitive impairment. Reduced performance on a verbal story recall task, in combination with higher negative symptoms at baseline, was the best predictor of later poor outcome. Baseline positive psychotic symptoms and GAF scores were not associated with later poor outcome.

DISCUSSION

To date, this is the longest follow-up study of an UHR sample. Poor functional outcome was associated with specific neurocognitive decrements, regardless of transition to psychosis. The detection of individuals with poor functioning at follow-up, against a background of previously identified risk factors for psychotic disorder, may yield a valid group in which to study biomarkers and treatment of schizophrenia.

Physical illnesses, developmental risk factors and psychiatric diagnoses among subjects at risk of psychosis

Background

Subjects with psychoses have significantly increased rates of physical illnesses, but the nature of the relationship remains largely unknown.

Material and methods

The present study is part of the European Prediction of Psychosis Study (EPOS). Data were collected from 245 help-seeking individuals from six European centers (age 16–35) who met criteria for ultra-high risk of psychosis criteria. This paper seeks to investigate self-reported physical ill health and its associations with psychiatric symptoms and disorders, risk factors, and onset of psychosis during 48 months of follow-up.

Results

In multivariate analysis, lifetime panic disorder (OR = 2.43, 95%CI: 1.03–5.73), known complications during pregnancy and delivery (OR = 2.81, 95%CI: 1.10–7.15), female gender (OR = 2.88, 95%CI: 1.16–7.17), family history of psychosis (OR = 3.08, 95%CI: 1.18–8.07), and having a relationship (OR = 3.44, 95%CI: 1.33–8.94) were significantly associated with self-reported physician-diagnosed illness. In the Cox proportional hazard model we found no significant differences between those who had undergone a transition to psychosis and those who had not.

Conclusions

The physical health of patients defined to be at ultra-high risk of psychosis seems to be commonly impaired and associated with female gender, marital status, complications during pregnancy and birth, lifetime panic disorder, and genetic risk of psychosis.

Social disability at admission for a first psychosis does not predict clinical outcome at 5-year follow-up

Although it has often been reported that premorbid social deficits are associated with clinical outcome in schizophrenia, the association between clinical outcome and social disabilities during admission for a first psychosis is still unclear. We examined whether a detailed assessment of social disability (assessed using the Groninger Social Disabilities Schedule-II) in the month before admission for a first psychotic episode contributed to the prediction of disease outcome in terms of psychopathology in 82 patients with schizophrenia. After controlling for the Positive and Negative Syndrome Scale sum score at baseline, none of the social disability domains significantly predicted the number of relapses or the severity of clinical symptoms at a 5-year follow-up. Our results suggest that poor social functioning at admission does not necessarily predict poor disease outcome. Following Di Michele and Bolino (Psychopathology 37:98-104, 2004), we hypothesize that, to reliably predict the course of schizophrenia, it may be necessary to assess social functioning during clinical stabilization.

Measuring psychosocial outcomes in schizophrenia patients

PURPOSE OF REVIEW

Improvement in psychosocial functioning is nowadays considered an important and achievable goal of schizophrenia treatment. Therefore, treatment interventions are expected to have a positive influence both on symptoms and on social integration.In this nonsystematic literature review, we describe some of the available measures to assess social outcomes in schizophrenia treatment and their inherent limitations, and discuss future directions for research and clinical practice.

RECENT FINDINGS

The lack of consensus on the appropriate terminology and standards applied to index patients' level of functioning remains an obstacle in assessing psychosocial outcomes in schizophrenia. Although some scales appear advantageous in terms of ease of administration and reliability, they lack enough solid evidence that they are related to real-world outcomes or sensitive to change. Performance-based measures are being more widely used to assess functional capacity because they appear effective in predicting independent living and work, as compared with both self-report and clinical measures.

SUMMARY

We argue that assessment of psychosocial functioning should be an integral part of schizophrenia patients' assessment, in both the research and clinical setting. Ultimately, there exists no gold standard measure, but, of those available, the Personal and Social Performance (PSP) Scale and the UCSD Performance-based Skills Assessment (UPSA) have literature supporting their usefulness for assessing psychosocial outcomes in schizophrenia patients.