Early detection and intervention evaluation for people at risk of psychosis: multisite randomised controlled trial

Research in young people at ultra-high risk for psychosis: a review of the current evidence

Background

The past 15 years have seen a growing interest in early intervention and detection of psychosis before the onset of the first episode. Recent proposals to include a psychosis risk syndrome (PRS) in DSM 5 have focused attention on the evidence base achieved to date in this field.

Aims

This article aims to (1) review the underlying principles of early identification and intervention during the pre-psychotic phase, (2) summarise the naturalistic follow-up studies conducted to date in this ‘at-risk’ population, (3) discuss the identified clinical risk factors for transition to psychosis, (4) summarise the interventional studies both psychological and pharmacological completed to date and (5) briefly discuss the controversy around the proposed inclusion of the PRS in DSM 5.

Methods

Electronic databases EmBase, MedLine and PsychInfo were searched using the keywords ultra-high risk/at-risk mental state/risk syndrome/pre-psychotic/prodrome/prodromal and psychosis/schizophrenia.

Results

The evidence suggests that it is possible to identify individuals who may be at risk of developing psychosis. Results from intervention studies, mostly involving second-generation antipsychotics and cognitive behavioural therapy, are currently insufficient to make treatment recommendations for this group. The emerging research with regard to possible neuroprotective factors such as omega fatty acids is promising, but will require replication in larger cohorts before it can be recommended.

Conceptual issues in the classification of psychosis

PURPOSE OF REVIEW

To provide an update on the conceptual status of attenuated psychosis syndrome (APS) as a psychiatric disorder.

RECENT FINDINGS

In May 2012, the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) Task Force announced that the planned introduction of APS as a new diagnosis in DSM-5 was cancelled and that APS was being moved to 'Section III' of the manual as a diagnostic construct requiring more work. Recent studies of APS have reflected this uncertainty and debate over its validity.

SUMMARY

Before and after the decision in May 2012 to remove APS as a new diagnosis in DSM-5, scientific work has proceeded in a robust manner to shore up the validity of APS as a diagnostic construct. Recent work on APS has revolved around a series of unresolved questions: the actual incidence of conversion of APS to full-blown psychosis, the identification of the subgroup that will convert, the appropriate treatment for APS, the ability of treatment to prevent conversion to psychosis, the wide range of long-term outcomes of APS and finally the decision whether to include APS as a formal psychiatric diagnosis. Although the debate continues, a substantial number of the major researchers have argued that APS does not yet enjoy a degree of validity that warrants inclusion as a formal diagnosis.

Bridging paradigms: hybrid mechanistic-discriminative predictive models

Many disease processes are extremely complex and characterized by multiple stochastic processes interacting simultaneously. Current analytical approaches have included mechanistic models and machine learning (ML), which are often treated as orthogonal viewpoints. However, to facilitate truly personalized medicine, new perspectives may be required. This paper reviews the use of both mechanistic models and ML in healthcare as well as emerging hybrid methods, which are an exciting and promising approach for biologically based, yet data-driven advanced intelligent systems.

Early interventions to prevent psychosis: systematic review and meta-analysis

OBJECTIVE

To determine whether any psychological, pharmacological, or nutritional interventions can prevent or delay transition to psychotic disorders for people at high risk.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Embase, Medline, PreMedline, PsycINFO, and CENTRAL were searched to November 2011 without restriction to publication status.

REVIEW METHODS

Randomised trials comparing any psychological, pharmacological, nutritional, or combined intervention with usual services or another treatment. Studies of participants with a formal diagnosis of schizophrenia or bipolar disorder were excluded. Studies were assessed for bias, and relevant limitations were considered in summarising the results.

RESULTS

11 trials including 1246 participants and eight comparisons were included. Median sample size of included trials was 81 (range 51-288). Meta-analyses were performed for transition to psychosis, symptoms of psychosis, depression, and mania; quality of life; weight; and discontinuation of treatment. Evidence of moderate quality showed an effect for cognitive behavioural therapy on reducing transition to psychosis at 12 months (risk ratio 0.54 (95% confidence interval 0.34 to 0.86); risk difference -0.07 (-0.14 to -0.01). Very low quality evidence for omega-3 fatty acids and low to very low quality evidence for integrated psychotherapy also indicated that these interventions were associated with reductions in transition to psychosis at 12 months.

CONCLUSIONS

Although evidence of benefits for any specific intervention is not conclusive, these findings suggest that it might be possible to delay or prevent transition to psychosis. Further research should be undertaken to establish conclusively the potential for benefit of psychological interventions in the treatment of people at high risk of psychosis.

Cognitive interventions targeting brain plasticity in the prodromal and early phases of schizophrenia

Several important paradigm shifts have occurred in the field of schizophrenia treatment, including an increased focus on early detection, the development of preemptive interventions, and the view of schizophrenia as a neurodevelopmental disease characterized by decreased efficiency and abnormal connectivity in cortical and subcortical neural networks. In this review, we briefly describe some of the neural impairments that contribute to the development of schizophrenia, with an emphasis on the impact of stress and trauma on cognitively vulnerable neural systems. We then present current data on two behavioral interventions that target these critical risk factors and that aim to preempt the onset of schizophrenia in vulnerable individuals or improve the clinical course in recent-onset schizophrenia: cognitive therapy and computerized cognitive training.

Identification of young people in the early stages of psychosis: validation of a checklist for use in primary care

The study aims to establish the concordant validity of the Early Detection Primary Care Checklist (PCCL); a 20 item tool designed to help primary care practitioners identify young people in the early stages of psychosis. The checklist was completed by the referring practitioners of 176 young people referred to early detection teams across the UK. The concordant validity of the checklist was established by comparing screen results with a standardised psychiatric assessment for identifying young people who may be at a risk of developing psychosis (CAARMS). Preliminary analysis found that the simple checklist as originally conceived had excellent sensitivity (96%) but poor specificity (10%). Subsequent exploratory analysis led to the development of two better performing models for the combination of item responses to predict CAARMS outcomes. The first retained the use of all 20 checklist items and achieved sensitivity of 89% and specificity of 60%. The second retained six checklist items with p-values of 0.2 or above and achieved sensitivity of 88% and specificity of 47%. Although the initial checklist did not perform well as a screening tool the two models perform well in comparison to other, much longer, screening tools for this population. These tools are not intended as a diagnostic instrument; rather it has been designed as a bridge between primary care and specialist services and to build on the skills and knowledge already held by primary care practitioners. Following a consideration of the limitations of this study, the continued evaluation of the tools performance in practice is recommended.

Cognitive behavioral therapy for subjects at ultrahigh risk for developing psychosis: a randomized controlled clinical trial

BACKGROUND

Evidence for the effectiveness of treatments for subjects at ultrahigh risk (UHR) for developing psychosis remains inconclusive.

OBJECTIVE

A new cognitive behavioral intervention specifically targeted at cognitive biases (ie, Cognitive Behavioral Therapy [CBT] for UHR patients plus treatment as usual [TAU] called CBTuhr) is compared with TAU in a group of young help-seeking UHR subjects.

METHODS

A total of 201 patients were recruited at 4 sites and randomized. In most cases, CBTuhr was an add-on therapy because most people were seeking help for a comorbid disorder. The CBT was provided for 6 months, and the follow-up period was 18 months.

RESULTS

In the CBTuhr condition, 10 patients transitioned to psychosis compared with 22 in the TAU condition (χ(2) (1) = 5.575, P = .03). The number needed to treat (NNT) was 9 (95% confidence interval [CI]: 4.7-89.9). At 18-month follow-up the CBTuhr group was significantly more often remitted from an at-risk mental state, with a NNT of 7 (95% CI: 3.7-71.2). Intention-to-treat analysis, including 5 violations against exclusion criteria, showed a statistical tendency (χ(2) (1) = 3.338, P = .06).

CONCLUSIONS

Compared with TAU, this new CBT (focusing on normalization and awareness of cognitive biases) showed a favorable effect on the transition to psychosis and reduction of subclinical psychotic symptoms in subjects at UHR to develop psychosis.

Chances and risks of predicting psychosis

Prevention is currently regarded a promising strategy for fighting the unfavorable consequences of psychosis. Yet, for the error probability inherent in any predictive approach, benefits and costs must be carefully weighed against each other. False attribution of risk may unnecessarily provoke stress and anxiety, and lead to unwarranted intervention exposure. However, clinical risk samples already exhibit psychopathological symptoms, cognitive and functional impairments, and help-seeking for mental problems. Thus, the risk of futile interventions is low as long as preventive measures also provide treatment for current complaints. Differentiation between still normal and clinically relevant mental states is another challenge as psychotic-like phenomena occur frequently in the general population, especially in younger adolescents. Reported prevalence rates vary with age, and if severe in terms of frequency and persistence, these phenomena considerably increase risk of psychosis in clinical as well as general population samples. Stigmatization is another concern, though insufficiently studied. Yet, at least more severe states of risk, which are accompanied by changes in thinking, feeling, and behavior, might lead to unfavorable, (self-) stigmatizing effects already by themselves, independent of any diagnostic "label," and to stress and confusion for the lack of understanding of what is going on. To further improve validity of risk criteria, advanced risk algorithms combining multi-step detection and risk stratification procedures should be developed. However, all prediction models possess a certain error probability. Thus, whether a risk model justifies preventive measures can only be decided by weighing the costs of unnecessary intervention and the benefits of avoiding a potentially devastating outcome.

Psychotic symptoms in young people without psychotic illness: mechanisms and meaning

Psychotic symptoms are common in the general population. There is evidence for common mechanisms underlying such symptoms in health and illness (such as the functional role of mesocorticostriatal circuitry in error-dependent learning) and differentiating factors (relating to non-psychotic features of psychotic illness and to social and emotional aspects of psychotic symptoms). Clinicians should be aware that psychotic symptoms in young people are more often associated with common mental disorders such as depression and anxiety than with severe psychotic illness.

Attenuated psychosis and the schizophrenia prodrome: current status of risk identification and psychosis prevention

Recent efforts in the prevention of schizophrenia have focused on defining psychosis-risk syndromes and evaluating treatments that can prevent transition to psychosis in these ultra-high risk groups. In this review, different kinds of prevention approaches are enumerated and necessary conditions for a disease-prevention strategy are summarized. The broad overlap as well as the significant difference between a schizophrenia prodrome and a 'psychosis-risk syndrome' is discussed and the present status of approaches to identify individuals at increased risk for developing psychosis and schizophrenia are critically examined along with evaluations on therapeutic interventions to reduce these risks. Finally, to conclude, recommendations for current best clinical practice and key questions for the future are suggested.

Need-Adapted and Open-Dialogue Treatments: Empirically Supported Psychosocial Interventions for Schizophrenia and Other Psychotic Disorders

Purpose: People experiencing acute or severe psychosis in the United States do not typically have access to alternatives to standard practice. To provide people with psychotic symptoms meaningful choices in treatment, alternative approaches should be evaluated for potential integration into the mental health service system. The need-adapted and open-dialogue approaches are psychotherapeutically focused interventions for psychosis that were developed in Finland. If these treatments are found to be effective, they could potentially be used in the United States. Method: This narrative review uses systematic and transparent methods to locate and synthesize findings from treatment, quasi-treatment, and pretreatment outcome studies of the need-adapted and open-dialogue approaches. Results: One hundred twelve potentially relevant studies were identified for this review using electronic searches and reference harvesting. Of those, 7 met the review’s inclusion criteria. These studies revealed that the open-dialogue and need-adapted treatments had outcomes that were equivalent or superior to those of standard care. Discussion: More research is needed on these promising modalities before they are routinely incorporated into U.S. practice.