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Schultze-Lutter F, Rahman J, Ruhrmann S, Michel C, Schimmelmann BG, Maier W, Klosterkötter J. Duration of unspecific prodromal and clinical high risk states, and early help-seeking in first-admission psychosis patients. Soc Psychiatry Psychiatr Epidemiol 2015; 50:1831-41. [PMID: 26155901 DOI: 10.1007/s00127-015-1093-3] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Accepted: 06/29/2015] [Indexed: 12/18/2022]
Abstract
PURPOSE Prevention of psychosis requires both presence of clinical high risk (CHR) criteria and early help-seeking. Previous retrospective studies of the duration of untreated illness (i.e. prodrome plus psychosis) did not distinguish between prodromal states with and without CHR symptoms. Therefore, we examined the occurrence of CHR symptoms and first help-seeking, thereby considering effects of age at illness-onset. METHODS Adult patients first admitted for psychosis (n = 126) were retrospectively assessed for early course of illness and characteristics of first help-seeking. RESULTS One-hundred and nine patients reported a prodrome, 58 with CHR symptoms. In patients with an early illness-onset before age 18 (n = 45), duration of both illness and psychosis were elongated, and CHR symptoms more frequent (68.9 vs. 33.3 %) compared to those with adult illness-onset. Only 29 patients reported help-seeking in the prodrome; this was mainly self-initiated, especially in patients with an early illness-onset. After the onset of first psychotic symptoms, help-seeking was mainly initiated by others. State- and age-independently, mental health professionals were the main first point-of-call (54.0 %). CONCLUSIONS Adult first-admission psychosis patients with an early, insidious onset of symptoms before age 18 were more likely to recall CHR symptoms as part of their prodrome. According to current psychosis-risk criteria, these CHR symptoms, in principle, would have allowed the early detection of psychosis. Furthermore, compared to patients with an adult illness-onset, patients with an early illness-onset were also more likely to seek help on their own account. Thus, future awareness strategies to improve CHR detection might be primarily related to young persons and self-perceived subtle symptoms.
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Affiliation(s)
- Frauke Schultze-Lutter
- University Hospital of Child and Adolescent Psychiatry, University of Bern, Bolligenstrasse 111, Haus A, 3000, Bern 60, Switzerland.
| | - Jonas Rahman
- University Hospital of Child and Adolescent Psychiatry, University of Bern, Bolligenstrasse 111, Haus A, 3000, Bern 60, Switzerland
| | - Stephan Ruhrmann
- Department of Psychiatry and Psychotherapy, University of Cologne, Cologne, Germany
| | - Chantal Michel
- University Hospital of Child and Adolescent Psychiatry, University of Bern, Bolligenstrasse 111, Haus A, 3000, Bern 60, Switzerland
| | - Benno G Schimmelmann
- University Hospital of Child and Adolescent Psychiatry, University of Bern, Bolligenstrasse 111, Haus A, 3000, Bern 60, Switzerland
| | - Wolfgang Maier
- Department of Psychiatry and Psychotherapy, University of Bonn, Bonn, Germany
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252
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Fusar-Poli P, Cappucciati M, Rutigliano G, Schultze-Lutter F, Bonoldi I, Borgwardt S, Riecher-Rössler A, Addington J, Perkins D, Woods SW, McGlashan TH, Lee J, Klosterkötter J, Yung AR, McGuire P. At risk or not at risk? A meta-analysis of the prognostic accuracy of psychometric interviews for psychosis prediction. World Psychiatry 2015; 14:322-32. [PMID: 26407788 PMCID: PMC4592655 DOI: 10.1002/wps.20250] [Citation(s) in RCA: 181] [Impact Index Per Article: 20.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
An accurate detection of individuals at clinical high risk (CHR) for psychosis is a prerequisite for effective preventive interventions. Several psychometric interviews are available, but their prognostic accuracy is unknown. We conducted a prognostic accuracy meta-analysis of psychometric interviews used to examine referrals to high risk services. The index test was an established CHR psychometric instrument used to identify subjects with and without CHR (CHR+ and CHR-). The reference index was psychosis onset over time in both CHR+ and CHR- subjects. Data were analyzed with MIDAS (STATA13). Area under the curve (AUC), summary receiver operating characteristic curves, quality assessment, likelihood ratios, Fagan's nomogram and probability modified plots were computed. Eleven independent studies were included, with a total of 2,519 help-seeking, predominately adult subjects (CHR+: N=1,359; CHR-: N=1,160) referred to high risk services. The mean follow-up duration was 38 months. The AUC was excellent (0.90; 95% CI: 0.87-0.93), and comparable to other tests in preventive medicine, suggesting clinical utility in subjects referred to high risk services. Meta-regression analyses revealed an effect for exposure to antipsychotics and no effects for type of instrument, age, gender, follow-up time, sample size, quality assessment, proportion of CHR+ subjects in the total sample. Fagan's nomogram indicated a low positive predictive value (5.74%) in the general non-help-seeking population. Albeit the clear need to further improve prediction of psychosis, these findings support the use of psychometric prognostic interviews for CHR as clinical tools for an indicated prevention in subjects seeking help at high risk services worldwide.
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Affiliation(s)
- Paolo Fusar-Poli
- King's College London, Institute of Psychiatry, London, UK
- OASIS Service, South London and Maudsley NHS Foundation Trust, London, UK
| | | | | | - Frauke Schultze-Lutter
- University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
| | - Ilaria Bonoldi
- King's College London, Institute of Psychiatry, London, UK
| | | | | | - Jean Addington
- Hotchkiss Brain Institute, Department of Psychiatry, University of Calgary, Calgary, Alberta, Canada
| | - Diana Perkins
- Department of Psychiatry, University of North Carolina, Chapel Hill, NC, USA
| | - Scott W Woods
- Department of Psychiatry, Yale University, New Haven, CT, USA
| | | | - Jimmy Lee
- Department of General Psychiatry, Institute of Mental Health, Singapore, Singapore
| | | | - Alison R Yung
- Institute of Brain, Behaviour and Mental Health, University of Manchester, Manchester, UK
| | - Philip McGuire
- King's College London, Institute of Psychiatry, London, UK
- OASIS Service, South London and Maudsley NHS Foundation Trust, London, UK
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253
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Schimmelmann BG, Michel C, Martz-Irngartinger A, Linder C, Schultze-Lutter F. Age matters in the prevalence and clinical significance of ultra-high-risk for psychosis symptoms and criteria in the general population: Findings from the BEAR and BEARS-kid studies. World Psychiatry 2015; 14:189-97. [PMID: 26043337 PMCID: PMC4471976 DOI: 10.1002/wps.20216] [Citation(s) in RCA: 101] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Early detection of psychosis is an important topic in psychiatry. Yet, there is limited information on the prevalence and clinical significance of high-risk symptoms in children and adolescents as compared to adults. We examined ultra-high-risk (UHR) symptoms and criteria in a sample of individuals aged 8-40 years from the general population of Canton Bern, Switzerland, enrolled from June 2011 to May 2014. The current presence of attenuated psychotic symptoms (APS) and brief intermittent psychotic symptoms (BLIPS) and the fulfillment of onset/worsening and frequency requirements for these symptoms in UHR criteria were assessed using the Structured Interview for Psychosis Risk Syndromes. Additionally, perceptive and non-perceptive APS were differentiated. Psychosocial functioning and current non-psychotic DSM-IV axis I disorders were also surveyed. Well-trained psychologists performed assessments. Altogether, 9.9% of subjects reported APS and none BLIPS, and 1.3% met all the UHR requirements for APS. APS were related to more current axis I disorders and impaired psychosocial functioning, indicating some clinical significance. A strong age effect was detected around age 16: compared to older individuals, 8-15-year olds reported more perceptive APS, that is, unusual perceptual experiences and attenuated hallucinations. Perceptive APS were generally less related to functional impairment, regardless of age. Conversely, non-perceptive APS were related to low functioning, although this relationship was weaker in those below age 16. Future studies should address the differential effects of perceptive and non-perceptive APS, and their interaction with age, also in terms of conversion to psychosis.
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Affiliation(s)
- Benno G Schimmelmann
- University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University of BernBolligenstrasse 111, 3000 Bern 60, Switzerland
| | - Chantal Michel
- University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University of BernBolligenstrasse 111, 3000 Bern 60, Switzerland
| | - Alexandra Martz-Irngartinger
- University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University of BernBolligenstrasse 111, 3000 Bern 60, Switzerland
| | - Caroline Linder
- University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University of BernBolligenstrasse 111, 3000 Bern 60, Switzerland
| | - Frauke Schultze-Lutter
- University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University of BernBolligenstrasse 111, 3000 Bern 60, Switzerland
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254
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Ruhrmann S, Schultze-Lutter F, Schmidt SJ, Kaiser N, Klosterkötter J. Prediction and prevention of psychosis: current progress and future tasks. Eur Arch Psychiatry Clin Neurosci 2014; 264 Suppl 1:S9-16. [PMID: 25256263 DOI: 10.1007/s00406-014-0541-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2014] [Accepted: 09/06/2014] [Indexed: 12/28/2022]
Abstract
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.
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Affiliation(s)
- Stephan Ruhrmann
- Department of Psychiatry and Psychotherapy, University of Cologne, Kerpener Strasse 62, 50924, Cologne, Germany,
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