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Naughton S, Clarke M. Debate: CAMHS will be at the forefront of the next generation of psychosis risk models, but further integration with early intervention psychosis services is needed to realise this potential: Re Debate: Prevention of psychosis in adolescents - does CAMHS have a role? Child Adolesc Ment Health 2024; 29:316-318. [PMID: 38601982 DOI: 10.1111/camh.12713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/05/2024] [Indexed: 04/12/2024]
Abstract
The detection of psychosis and its prodrome have unique considerations in a child and adolescent population. Young people attending CAMHS are already a high-risk group, which confers significant limitations in applying the current clinical high-risk (CHR) model. This has catalysed calls for a transdiagnostic approach to psychosis risk prediction, but without a clear pathway forward. We contribute to the debate opened by Salazar de Pablo and Arango (2023, Child and Adolescent Mental Health) on the role of CAMHS in this initiative. CAMHS have a key role in developing comprehensive longitudinal datasets to inform risk models. Closer integration with early intervention in psychosis (EIP) services will be needed to realise this potential. This integration is also required to reliably detect prodromes and emerging psychosis in young people. Where there is robust evidence to support prevention initiatives, we should proceed with their implementation, even in the absence of enhanced risk models.
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Affiliation(s)
- Sean Naughton
- DETECT, Early Intervention in Psychosis Service, Co. Dublin, Ireland
- School of Medicine, University College Dublin, Dublin 4, Ireland
| | - Mary Clarke
- DETECT, Early Intervention in Psychosis Service, Co. Dublin, Ireland
- School of Medicine, University College Dublin, Dublin 4, Ireland
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Bolhuis K, Ghirardi L, Kuja-Halkola R, Lång U, Cederlöf M, Metsala J, Corcoran P, O’Connor K, Dodd P, Larsson H, Kelleher I. Risk of Psychosis Among Individuals Who Have Presented to Hospital With Self-harm: A Prospective Nationwide Register Study in Sweden. Schizophr Bull 2024; 50:881-890. [PMID: 38243843 PMCID: PMC11283185 DOI: 10.1093/schbul/sbae002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2024]
Abstract
BACKGROUND AND HYPOTHESIS Recent research showed that young people who presented to hospital with self-harm in Finland had a significantly elevated risk of later psychosis. We investigated the prospective relationship between hospital presentation for self-harm and risk of psychosis in an unprecedentedly large national Swedish cohort. STUDY DESIGN We used inpatient and outpatient healthcare registers to identify all individuals born between 1981 and 1993 who were alive and living in Sweden on their 12th birthday and who presented to hospital one or more times with self-harm. We compared them with a matched cohort, followed up for up to 20 years, and compared the cumulative incidence of psychotic disorders. Furthermore, we examined whether the strength of the relationship between hospital presentation for self-harm and later psychosis changed over time by examining for cohort effects. STUDY RESULTS In total, 28 908 (2.0%) individuals presented to hospital with self-harm without prior psychosis diagnosis during the follow-up. For individuals who presented to hospital with self-harm, the cumulative incidence of diagnosed psychosis was 20.7% at 20 years follow-up (hazard radio = 13.9, 95% CI 13.3-14.6, P-value <5 × 10-308). There was no evidence of a dilution of the effect over time: while the incidence of hospital self-harm presentation increased, this did not result in an attenuation over time of the strength of the relationship between hospital self-harm presentation and subsequent psychosis. CONCLUSIONS Individuals who present to hospital with self-harm in their teens and 20s represent an important risk group for psychosis prediction and prevention.
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Affiliation(s)
- Koen Bolhuis
- Department of Child and Adolescent Psychiatry/Psychology, Erasmus Medical Centre-Sophia Children’s Hospital, Rotterdam, The Netherlands
- Department of Psychiatry, Royal College of Surgeons in Ireland, Dublin, Ireland
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Laura Ghirardi
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- MediNeos Observational Research—IQVIA, Data Management & Statistics, Modena, Italy
| | - Ralf Kuja-Halkola
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Ulla Lång
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
- Finnish Institute for Health and Welfare, Helsinki, Finland
- University of Oulu, School of Medicine, Oulu, Finland
| | - Martin Cederlöf
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Johanna Metsala
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
- Finnish Institute for Health and Welfare, Helsinki, Finland
| | - Paul Corcoran
- National Suicide Research Foundation, University College Cork, Cork, Ireland
- School of Public Health, University College Cork, Cork, Ireland
| | - Karen O’Connor
- Rise, South Lee Mental Health Services, Cork & Department of Psychiatry, University College Cork, Cork, Ireland
- National Clinical Programme for Early Intervention in Psychosis, Health Service Executive Dublin, Dublin, Ireland
| | - Philip Dodd
- National Office for Suicide Prevention, Health Service Executive Dublin, Dublin, Ireland
| | - Henrik Larsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Ian Kelleher
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
- University of Oulu, School of Medicine, Oulu, Finland
- University College Dublin, School of Medicine, Dublin, Ireland
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Paquin V, Malla AK, Iyer SN, Lepage M, Joober R, Shah JL. Combinations and Temporal Associations Among Precursor Symptoms Before a First Episode of Psychosis. Schizophr Bull 2024; 50:860-870. [PMID: 37861419 PMCID: PMC11283192 DOI: 10.1093/schbul/sbad152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
BACKGROUND AND HYPOTHESIS Symptoms that precede a first episode of psychosis (FEP) can ideally be targeted by early intervention services with the aim of preventing or delaying psychosis onset. However, these precursor symptoms emerge in combinations and sequences that do not rest fully within traditional diagnostic categories. To advance our understanding of illness trajectories preceding FEP, we aimed to investigate combinations and temporal associations among precursor symptoms. STUDY DESIGN Participants were from PEPP-Montréal, a catchment-based early intervention program for FEP. Through semistructured interviews, collateral from relatives, and a review of health and social records, we retrospectively measured the presence or absence of 29 precursor symptoms, including 9 subthreshold psychotic and 20 nonpsychotic symptoms. Sequences of symptoms were derived from the timing of the first precursor symptom relative to the onset of FEP. STUDY RESULTS The sample included 390 participants (68% men; age range: 14-35 years). Combinations of precursor symptoms most frequently featured depression, anxiety, and substance use. Of 256 possible pairs of initial and subsequent precursor symptoms, many had asymmetrical associations: eg, when the first symptom was suspiciousness, the incidence rate ratio (IRR) of subsequent anxiety was 3.40 (95% confidence interval [CI]: 1.79, 6.46), but when the first symptom was anxiety, the IRR of subsequent suspiciousness was 1.15 (95% CI: 0.77, 1.73). CONCLUSIONS A detailed examination of precursor symptoms reveals diverse clinical profiles that cut across diagnostic categories and evolve longitudinally prior to FEP. Their identification may contribute to risk assessments and provide insights into the mechanisms of illness progression.
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Affiliation(s)
- Vincent Paquin
- Prevention and Early Intervention Program for Psychosis (PEPP-Montreal), Douglas Mental Health University Institute, Montreal, QC, Canada
- Department of Psychiatry, McGill University, Montreal, QC, Canada
| | - Ashok K Malla
- Prevention and Early Intervention Program for Psychosis (PEPP-Montreal), Douglas Mental Health University Institute, Montreal, QC, Canada
- Department of Psychiatry, McGill University, Montreal, QC, Canada
| | - Srividya N Iyer
- Prevention and Early Intervention Program for Psychosis (PEPP-Montreal), Douglas Mental Health University Institute, Montreal, QC, Canada
- Department of Psychiatry, McGill University, Montreal, QC, Canada
| | - Martin Lepage
- Prevention and Early Intervention Program for Psychosis (PEPP-Montreal), Douglas Mental Health University Institute, Montreal, QC, Canada
- Department of Psychiatry, McGill University, Montreal, QC, Canada
- Integrated Program in Neuroscience, McGill University, Montreal, QC, Canada
| | - Ridha Joober
- Prevention and Early Intervention Program for Psychosis (PEPP-Montreal), Douglas Mental Health University Institute, Montreal, QC, Canada
- Department of Psychiatry, McGill University, Montreal, QC, Canada
| | - Jai L Shah
- Prevention and Early Intervention Program for Psychosis (PEPP-Montreal), Douglas Mental Health University Institute, Montreal, QC, Canada
- Department of Psychiatry, McGill University, Montreal, QC, Canada
- Integrated Program in Neuroscience, McGill University, Montreal, QC, Canada
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Benson NM, Yang Z, Fung V, Normand SL, Keshavan MS, Öngür D, Hsu J. Medical and Psychiatric Care Preceding the First Psychotic Disorder Diagnosis. Schizophr Bull 2024; 50:437-446. [PMID: 37606279 PMCID: PMC10919781 DOI: 10.1093/schbul/sbad125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/23/2023]
Abstract
BACKGROUND Individuals with psychotic symptoms experience substantial morbidity and have shortened life expectancies; early treatment may mitigate the worst effects. Understanding care preceding a first psychotic disorder diagnosis is critical to inform early detection and intervention. STUDY DESIGN In this observational cohort study using comprehensive information from the Massachusetts All-Payer Claims Database, we identified the first psychotic disorder diagnosis in 2016, excluding those with historical psychotic disorder diagnoses in the prior 48 months among those continuous enrollment data. We reviewed visits, medications, and hospitalizations 2012-2016. We used logistic regression to examine characteristics associated with pre-diagnosis antipsychotic use. STUDY RESULTS There were 2505 individuals aged 15-35 years (146 per 100 000 similarly aged individuals in the database) with a new psychotic disorder diagnosis in 2016. Most (97%) had at least one outpatient visit in the preceding 48 months; 89% had a prior mental health diagnosis unrelated to psychosis (eg, anxiety [60%], depression [60%]). Many received psychotropic medications (77%), including antipsychotic medications (46%), and 68% had a visit for injury or trauma during the preceding 48 months. Characteristics associated with filling an antipsychotic medication before the psychotic disorder diagnosis included male sex and Medicaid insurance at psychosis diagnosis. CONCLUSIONS In this insured population of Massachusetts residents with a new psychotic disorder diagnosis, nearly all had some healthcare utilization, visits for injury or trauma were common, and nearly half filled an antipsychotic medication in the preceding 48 months. These patterns of care could represent either pre-disease signals, delays, or both in receiving a formal diagnosis.
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Affiliation(s)
- Nicole M Benson
- Psychotic Disorders Division, McLean Hospital, Belmont, MA, USA
- Mongan Institute, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Zhiyou Yang
- Mongan Institute, Massachusetts General Hospital, Boston, MA, USA
| | - Vicki Fung
- Mongan Institute, Massachusetts General Hospital, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Sharon-Lise Normand
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
- Department of Biostatistics, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Matcheri S Keshavan
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
- Department of Psychiatry, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Dost Öngür
- Psychotic Disorders Division, McLean Hospital, Belmont, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - John Hsu
- Mongan Institute, Massachusetts General Hospital, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
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Strelchuk D, Wiles N, Derrick C, Zammit S, Turner K. The identification and management of people with an at-risk mental state (ARMS) for psychosis in primary and secondary care services: A qualitative interview study. Early Interv Psychiatry 2023; 17:1116-1124. [PMID: 37041715 DOI: 10.1111/eip.13412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 02/07/2023] [Accepted: 03/28/2023] [Indexed: 04/13/2023]
Abstract
AIMS Early intervention in people with an at-risk mental state (ARMS) for psychosis can prevent the onset of psychosis. Clinical guidelines recommend that ARMS are referred to triage services, and then to Early Intervention (EI) teams in secondary care for assessment and treatment. However, little is known about how ARMS patients are identified and managed in UK primary and secondary care. This study explored patients' and clinicians' views of ARMS patients' care pathways. METHODS Eleven patients, 20 GPs, 11 clinicians from the triaging Primary Care Liaison Services (PCLS) and 10 EI clinicians were interviewed. Data were analysed thematically. RESULTS Most patients said their symptoms started in adolescence with depression and anxiety. Before being referred to EI teams, most patients were referred by their GP to well-being services for talking therapies, which they had not found helpful. Some GPs said secondary care's high acceptance thresholds and scarce treatment availability made them reluctant to refer to EI teams. Triage in PCLS was influenced by patients' risk of self-harm, and formulation of psychotic symptoms; only those without clear evidence of other pathology and not at high risk of self-harm were referred to EI teams, the others being referred to Recovery/Crisis services. Although patients referred to EI teams were offered an assessment, only some EI teams were commissioned to treat ARMS. CONCLUSIONS Individuals meeting ARMS criteria might not receive early intervention due to high treatment thresholds and limited treatment availability in secondary care, suggesting clinical guidelines are not being met for this patient group.
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Affiliation(s)
- Daniela Strelchuk
- Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Nicola Wiles
- Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Catherine Derrick
- Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Stan Zammit
- Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
- MRC Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neuroscience, Cardiff University, Cardiff, UK
| | - Katrina Turner
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
- Centre for Academic Primary Care, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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Whitfield E, White B, Denaxas S, Lyratzopoulos G. Diagnostic windows in non-neoplastic diseases: a systematic review. Br J Gen Pract 2023; 73:e702-e709. [PMID: 37308303 PMCID: PMC10285689 DOI: 10.3399/bjgp.2023.0044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 02/28/2023] [Accepted: 04/04/2023] [Indexed: 06/14/2023] Open
Abstract
BACKGROUND Investigating changes in prediagnostic healthcare utilisation can help identify how much earlier conditions could be diagnosed. Such 'diagnostic windows' are established for cancer but remain relatively unexplored for non-neoplastic conditions. AIM To extract evidence on the presence and length of diagnostic windows for non-neoplastic conditions. DESIGN AND SETTING A systematic review of studies of prediagnostic healthcare utilisation was carried out. METHOD A search strategy was developed to identify relevant studies from PubMed and Connected Papers. Data were extracted on prediagnostic healthcare use, and evidence of diagnostic window presence and length was assessed. RESULTS Of 4340 studies screened, 27 were included, covering 17 non-neoplastic conditions, including both chronic (for example, Parkinson's disease) and acute conditions (for example, stroke). Prediagnostic healthcare events included primary care encounters and presentations with relevant symptoms. For 10 conditions, sufficient evidence to determine diagnostic window presence and length was available, ranging from 28 days (herpes simplex encephalitis) to 9 years (ulcerative colitis). For the remaining conditions, diagnostic windows were likely to be present, but insufficient study duration was often a barrier to robustly determining their length, meaning that diagnostic window length may exceed 10 years for coeliac disease, for example. CONCLUSION Evidence of changing healthcare use before diagnosis exists for many non-neoplastic conditions, establishing that early diagnosis is possible, in principle. In particular, some conditions may be detectable many years earlier than they are currently diagnosed. Further research is required to accurately estimate diagnostic windows and to determine how much earlier diagnosis may be possible, and how this might be achieved.
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Affiliation(s)
- Emma Whitfield
- ECHO (Epidemiology of Cancer Healthcare & Outcomes), Department of Behavioural Science and Health, Institute of Epidemiology and Health Care, University College London (UCL), London, and Institute of Health Informatics, UCL, London
| | - Becky White
- ECHO (Epidemiology of Cancer Healthcare & Outcomes), Department of Behavioural Science and Health, Institute of Epidemiology and Health Care, University College London (UCL), London
| | - Spiros Denaxas
- Institute of Health Informatics, UCL, London; associate director, British Heart Foundation Data Science Centre, London; Health Data Research UK, London, and UCL Hospitals Biomedical Research Centre, London
| | - Georgios Lyratzopoulos
- ECHO (Epidemiology of Cancer Healthcare & Outcomes), Department of Behavioural Science and Health, Institute of Epidemiology and Health Care, University College London (UCL), London
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7
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Carter B, Rodrigues R, Reid J, Archie S, Terry AL, Palaniyappan L, MacDougall AG, Voineskos A, Jan SH, Jaakkimainen L, Chen B, Sawh N, Anderson KK. Sex differences in the clinical presentation of early psychosis in a primary care setting. Arch Womens Ment Health 2023:10.1007/s00737-023-01329-w. [PMID: 37266694 DOI: 10.1007/s00737-023-01329-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 05/15/2023] [Indexed: 06/03/2023]
Abstract
Primary care is an important part of the help-seeking pathway for young people experiencing early psychosis, but sex differences in clinical presentation in these settings are unexplored. We aimed to identify sex differences in clinical presentation to primary care services in the 1-year period prior to a first diagnosis of psychotic disorder. We identified first-onset cases of non-affective psychotic disorder over a 10-year period (2005-2015) using health administrative data linked with electronic medical records (EMRs) from primary care (n = 465). Detailed information on encounters in the year prior to first diagnosis was abstracted, including psychiatric symptoms, other relevant behaviours, and diagnoses recorded by the family physician (FP). We used modified Poisson regression models to examine sex differences in the signs, symptoms, and diagnoses recorded by the FP, adjusting for various clinical and sociodemographic factors. Positive symptoms (PR = 0.76, 95%CI: 0.58, 0.98) and substance use (PR = 0.54, 95%CI: 0.40, 0.72) were less prevalent in the medical records of women. Visits by women were more likely to be assigned a diagnosis of depression or anxiety (PR = 1.18, 95%CI: 1.00, 1.38), personality disorder (PR = 5.49, 95%CI: 1.22, 24.62), psychological distress (PR = 11.29, 95%CI: 1.23, 103.91), and other mental or behavioral disorders (PR = 3.49, 95%CI: 1.14, 10.66) and less likely to be assigned a diagnosis of addiction (PR = 0.33, 95%CI: 0.13, 0.87). We identified evidence of sex differences in the clinical presentation of early psychosis and recorded diagnoses in the primary care EMR. Further research is needed to better understand sex differences in clinical presentation in the primary care context, which can facilitate better understanding, detection, and intervention for first-episode psychotic disorders.
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Affiliation(s)
- Brooke Carter
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, 1465 Richmond Street, PHFM 3135, London, ON, N6G 2M1, Canada
| | - Rebecca Rodrigues
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, 1465 Richmond Street, PHFM 3135, London, ON, N6G 2M1, Canada
| | | | - Suzanne Archie
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada
| | - Amanda L Terry
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, 1465 Richmond Street, PHFM 3135, London, ON, N6G 2M1, Canada
- Department of Family Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Lena Palaniyappan
- Department of Psychiatry, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Department of Psychiatry, Douglas Mental Health University Institute, McGill University, Montreal, QC, Canada
| | - Arlene G MacDougall
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, 1465 Richmond Street, PHFM 3135, London, ON, N6G 2M1, Canada
- Department of Psychiatry, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Aristotle Voineskos
- Department of Psychiatry, Campbell Family Mental Health Research Institute, CAMH, Toronto, ON, Canada
| | - Saadia Hameed Jan
- Department of Family Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Liisa Jaakkimainen
- ICES, Toronto, ON, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | | | | | - Kelly K Anderson
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, 1465 Richmond Street, PHFM 3135, London, ON, N6G 2M1, Canada.
- ICES, Toronto, ON, Canada.
- Department of Psychiatry, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada.
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8
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Radez J, Waite F, Izon E, Johns L. Identifying individuals at risk of developing psychosis: A systematic review of the literature in primary care services. Early Interv Psychiatry 2023; 17:429-446. [PMID: 36632681 PMCID: PMC10946574 DOI: 10.1111/eip.13365] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 10/12/2022] [Accepted: 01/02/2023] [Indexed: 01/13/2023]
Abstract
AIM Psychosis and related disorders are a major public health issue. Early identification and prevention for those at high risk (at-risk-mental-state, ARMS) is important. General practitioners (GPs) are often the first point of contact for health services. In this review we aim to identify (1) the most common methods for identifying individuals with an ARMS in primary care, (2) the methods for improving identification of individuals with an ARMS in primary care, and (3) the most common barriers that prevent GPs from screening for individuals with an ARMS. METHODS We conducted a systematic review (PROSPERO 42021245095) of quantitative and qualitative studies with no date restriction. Searches were performed in September 2021. Studies' quality was appraised using Mixed Methods Appraisal tool (MMAT). RESULTS We identified 16 eligible studies, and all but one provided quantitative data. Nearly two-thirds of studies were classified as 'medium' quality. Employing narrative synthesis, we identified three themes relating to (1) improving GP knowledge and confidence in identifying individuals with an ARMS, (2) balancing the over- and under-identification of individuals with an ARMS in primary care, and (3) supporting GPs as significant stakeholders in early diagnosis and treatment of individuals with an ARMS. CONCLUSIONS Improved identification of individuals with an ARMS is needed. We identified various strategies, including development and implementation of identification methods (e.g., screening measures), educational interventions for GPs (e.g., workshops), and systemic interventions (e.g., simplifying referrals to secondary care, developing integrated services). When implemented successfully, these interventions may help facilitate the access to appropriate care for individuals with an ARMS.
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Affiliation(s)
- Jerica Radez
- Oxford Institute of Clinical Psychology Training and Research, Medical Sciences Division, University of OxfordOxfordUK
- Oxford Health NHS Foundation TrustOxfordUK
| | - Felicity Waite
- Oxford Health NHS Foundation TrustOxfordUK
- Department of PsychiatryUniversity of OxfordOxfordUK
| | - Emma Izon
- Oxford Institute of Clinical Psychology Training and Research, Medical Sciences Division, University of OxfordOxfordUK
- Oxford Health NHS Foundation TrustOxfordUK
| | - Louise Johns
- Oxford Institute of Clinical Psychology Training and Research, Medical Sciences Division, University of OxfordOxfordUK
- Oxford Health NHS Foundation TrustOxfordUK
- Department of PsychiatryUniversity of OxfordOxfordUK
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9
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Wiener JC, Rodrigues R, Reid JNS, Archie S, Booth RG, Cheng C, Jan SH, Kurdyak P, MacDougall AG, Palaniyappan L, Ryan BL, Anderson KK. Patient and Physician Factors Associated with First Diagnosis of Non-affective Psychotic Disorder in Primary Care. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2023; 50:212-224. [PMID: 36403173 DOI: 10.1007/s10488-022-01233-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/20/2022] [Indexed: 11/21/2022]
Abstract
Primary care physicians play a central role in pathways to care for first-episode psychosis, and their increased involvement in early detection could improve service-related outcomes. The aim of this study was to estimate the proportion of psychosis first diagnosed in primary care, and identify associated patient and physician factors. We used linked health administrative data to construct a retrospective cohort of people aged 14-35 years with a first diagnosis of non-affective psychosis in Ontario, Canada between 2005-2015. We restricted the sample to patients with help-seeking contacts for mental health reasons in primary care in the six months prior to first diagnosis of psychotic disorder. We used modified Poisson regression models to examine patient and physician factors associated with a first diagnosis of psychosis in primary care. Among people with early psychosis (n = 39,449), 63% had help-seeking contacts in primary care within six months prior to first diagnosis. Of those patients, 47% were diagnosed in primary care and 53% in secondary/tertiary care. Patients factors associated with lower likelihood of diagnosis in primary care included male sex, younger age, immigrant status, and comorbid psychosocial conditions. Physician factors associated with lower likelihood of diagnosis in primary care included solo practice model, urban practice setting, international medical education, and longer time since graduation. Our findings indicate that primary care is an important contact for help-seeking and diagnosis for a large proportion of people with early psychosis. For physicians less likely to diagnose psychosis in primary care, targeted resources and interventions could be provided to support them in caring for patients with early psychosis.
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Affiliation(s)
- Joshua C Wiener
- Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada. .,Western Centre for Public Health and Family Medicine, 1465 Richmond Street, London, ON, N6G 2M1, Canada.
| | - Rebecca Rodrigues
- Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | | | - Suzanne Archie
- Department of Psychiatry & Behavioural Neurosciences, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Richard G Booth
- Arthur Labatt Family School of Nursing, Faculty of Health Sciences, Western University, London, ON, Canada
| | - Chiachen Cheng
- Northern Ontario School of Medicine, Thunder Bay, ON, Canada
| | - Saadia Hameed Jan
- Department of Family Medicine, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Paul Kurdyak
- ICES, Toronto, ON, Canada.,Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Arlene G MacDougall
- Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada.,Department of Psychiatry, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada.,Lawson Health Research Institute, London, ON, Canada
| | - Lena Palaniyappan
- Department of Psychiatry, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada.,Lawson Health Research Institute, London, ON, Canada.,Robarts Research Institute, Western University, London, ON, Canada
| | - Bridget L Ryan
- Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada.,Department of Family Medicine, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Kelly K Anderson
- Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada.,ICES, Toronto, ON, Canada.,Department of Psychiatry, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
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Oliver D, Arribas M, Radua J, Salazar de Pablo G, De Micheli A, Spada G, Mensi MM, Kotlicka-Antczak M, Borgatti R, Solmi M, Shin JI, Woods SW, Addington J, McGuire P, Fusar-Poli P. Prognostic accuracy and clinical utility of psychometric instruments for individuals at clinical high-risk of psychosis: a systematic review and meta-analysis. Mol Psychiatry 2022; 27:3670-3678. [PMID: 35665763 PMCID: PMC9708585 DOI: 10.1038/s41380-022-01611-w] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 04/21/2022] [Accepted: 04/28/2022] [Indexed: 02/08/2023]
Abstract
Accurate prognostication of individuals at clinical high-risk for psychosis (CHR-P) is an essential initial step for effective primary indicated prevention. We aimed to summarise the prognostic accuracy and clinical utility of CHR-P assessments for primary indicated psychosis prevention. Web of Knowledge databases were searched until 1st January 2022 for longitudinal studies following-up individuals undergoing a psychometric or diagnostic CHR-P assessment, reporting transition to psychotic disorders in both those who meet CHR-P criteria (CHR-P + ) or not (CHR-P-). Prognostic accuracy meta-analysis was conducted following relevant guidelines. Primary outcome was prognostic accuracy, indexed by area-under-the-curve (AUC), sensitivity and specificity, estimated by the number of true positives, false positives, false negatives and true negatives at the longest available follow-up time. Clinical utility analyses included: likelihood ratios, Fagan's nomogram, and population-level preventive capacity (Population Attributable Fraction, PAF). A total of 22 studies (n = 4 966, 47.5% female, age range 12-40) were included. There were not enough meta-analysable studies on CHR-P diagnostic criteria (DSM-5 Attenuated Psychosis Syndrome) or non-clinical samples. Prognostic accuracy of CHR-P psychometric instruments in clinical samples (individuals referred to CHR-P services or diagnosed with 22q.11.2 deletion syndrome) was excellent: AUC = 0.85 (95% CI: 0.81-0.88) at a mean follow-up time of 34 months. This result was driven by outstanding sensitivity (0.93, 95% CI: 0.87-0.96) and poor specificity (0.58, 95% CI: 0.50-0.66). Being CHR-P + was associated with a small likelihood ratio LR + (2.17, 95% CI: 1.81-2.60) for developing psychosis. Being CHR-P- was associated with a large LR- (0.11, 95%CI: 0.06-0.21) for developing psychosis. Fagan's nomogram indicated a low positive (0.0017%) and negative (0.0001%) post-test risk in non-clinical general population samples. The PAF of the CHR-P state is 10.9% (95% CI: 4.1-25.5%). These findings consolidate the use of psychometric instruments for CHR-P in clinical samples for primary indicated prevention of psychosis. Future research should improve the ability to rule in psychosis risk.
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Affiliation(s)
- Dominic Oliver
- Early Psychosis: Interventions and Clinical-detection (EPIC) Lab, Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK.
| | - Maite Arribas
- Early Psychosis: Interventions and Clinical-detection (EPIC) Lab, Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Joaquim Radua
- Early Psychosis: Interventions and Clinical-detection (EPIC) Lab, Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- Imaging of Mood- and Anxiety-Related Disorders (IMARD) Group, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), CIBERSAM, Barcelona, Spain
- Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institute, Stockholm, Sweden
| | - Gonzalo Salazar de Pablo
- Early Psychosis: Interventions and Clinical-detection (EPIC) Lab, Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- Child and Adolescent Mental Health Services, South London & Maudsley NHS Trust, London, UK
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Andrea De Micheli
- Early Psychosis: Interventions and Clinical-detection (EPIC) Lab, Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- OASIS Service, South London and Maudsley National Health Service (NHS) Foundation Trust, London, UK
| | - Giulia Spada
- Early Psychosis: Interventions and Clinical-detection (EPIC) Lab, Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Martina Maria Mensi
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
- IRCCS Mondino Foundation, Childhood and Adolescent Neuropsychiatry Unit, Pavia, Italy
| | - Magdalena Kotlicka-Antczak
- Early Psychosis Diagnosis and Treatment Lab, Department of Affective and Psychotic Disorders, Medical University of Lodz, Lodz, Poland
| | - Renato Borgatti
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
- IRCCS Mondino Foundation, Childhood and Adolescent Neuropsychiatry Unit, Pavia, Italy
| | - Marco Solmi
- Early Psychosis: Interventions and Clinical-detection (EPIC) Lab, Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- Department of Psychiatry, University of Ottawa, Ottawa, ON, Canada
- Department of Mental Health, The Ottawa Hospital, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute (OHRI), University of Ottawa, Ottawa, ON, Canada
| | - Jae Il Shin
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, South Korea
| | - Scott W Woods
- Department of Psychiatry, Yale University, New Haven, CT, USA
| | - Jean Addington
- Department of Psychiatry, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Philip McGuire
- OASIS Service, South London and Maudsley National Health Service (NHS) Foundation Trust, London, UK
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- National Institute for Health Research, Maudsley Biomedical Research Centre, South London and Maudsley National Health Service (NHS) Foundation Trust, London, UK
| | - Paolo Fusar-Poli
- Early Psychosis: Interventions and Clinical-detection (EPIC) Lab, Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- OASIS Service, South London and Maudsley National Health Service (NHS) Foundation Trust, London, UK
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
- National Institute for Health Research, Maudsley Biomedical Research Centre, South London and Maudsley National Health Service (NHS) Foundation Trust, London, UK
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11
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Sullivan SA, Kounali D, Morris R, Kessler D, Hamilton W, Lewis G, Lilford P, Nazareth I. Developing and internally validating a prognostic model (P Risk) to improve the prediction of psychosis in a primary care population using electronic health records: The MAPPED study. Schizophr Res 2022; 246:241-249. [PMID: 35843156 DOI: 10.1016/j.schres.2022.06.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 05/17/2022] [Accepted: 06/25/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND An accurate risk prediction algorithm could improve psychosis outcomes by reducing duration of untreated psychosis. OBJECTIVE To develop and validate a risk prediction model for psychosis, for use by family doctors, using linked electronic health records. METHODS A prospective prediction study. Records from family practices were used between 1/1/2010 to 31/12/2017 of 300,000 patients who had consulted their family doctor for any nonpsychotic mental health problem. Records were selected from Clinical Practice Research Datalink Gold, a routine database of UK family doctor records linked to Hospital Episode Statistics, a routine database of UK secondary care records. Each patient had 5-8 years of follow up data. Study predictors were consultations, diagnoses and/or prescribed medications, during the study period or historically, for 13 nonpsychotic mental health problems and behaviours, age, gender, number of mental health consultations, social deprivation, geographical location, and ethnicity. The outcome was time to an ICD10 psychosis diagnosis. FINDINGS 830 diagnoses of psychosis were made. Patients were from 216 family practices; mean age was 45.3 years and 43.5 % were male. Median follow-up was 6.5 years (IQR 5.6, 7.8). Overall 8-year psychosis incidence was 45.8 (95 % CI 42.8, 49.0)/100,000 person years at risk. A risk prediction model including age, sex, ethnicity, social deprivation, consultations for suicidal behaviour, depression/anxiety, substance abuse, history of consultations for suicidal behaviour, smoking history and prescribed medications for depression/anxiety/PTSD/OCD and total number of consultations had good discrimination (Harrell's C = 0.774). Identifying patients aged 17-100 years with predicted risk exceeding 1.0 % over 6 years had sensitivity of 71 % and specificity of 84 %. FUNDING NIHR, School for Primary Care Research, Biomedical Research Centre.
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Affiliation(s)
- Sarah A Sullivan
- Centre for Academic Mental Health, Bristol Medical School, Population Health Sciences, University of Bristol, Bristol, UK; National Institute for Health Research, Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust, University of Bristol, Bristol, UK.
| | - Daphne Kounali
- Centre for Academic Mental Health, Bristol Medical School, Population Health Sciences, University of Bristol, Bristol, UK; National Institute for Health Research, Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust, University of Bristol, Bristol, UK.
| | - Richard Morris
- National Institute for Health Research, Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust, University of Bristol, Bristol, UK; Centre for Academic Primary Care, Bristol Medical School, Population Health Sciences, University of Bristol, Bristol, UK.
| | - David Kessler
- Centre for Academic Mental Health, Bristol Medical School, Population Health Sciences, University of Bristol, Bristol, UK.
| | | | - Glyn Lewis
- UCL Division of Psychiatry, Maple House, Tottenham Court Rd, London W1T 7NF, UK.
| | - Philippa Lilford
- Centre for Academic Mental Health, Bristol Medical School, Population Health Sciences, University of Bristol, Bristol, UK.
| | - Irwin Nazareth
- UCL Division of Psychiatry, Maple House, Tottenham Court Rd, London W1T 7NF, UK.
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12
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González-Valderrama A, Jongsma HE, Mena C, Castañeda CP, Nachar R, Undurraga J, Crossley N, Aceituno D, Iruretagoyena B, Gallardo C, Mondaca P, Monje M, Irarrazaval M, Zavala C, Valmaggia L, Kirkbride JB. The incidence of non-affective psychotic disorders in Chile between 2005 and 2018: results from a national register of over 30 000 cases. Psychol Med 2022; 52:914-923. [PMID: 32758314 PMCID: PMC9005445 DOI: 10.1017/s0033291720002664] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 06/22/2020] [Accepted: 07/07/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Evidence suggests the incidence of non-affective psychotic disorders (NAPDs) varies across persons and places, but data from the Global South is scarce. We aimed to estimate the treated incidence of NAPD in Chile, and variance by person, place and time. METHODS We used national register data from Chile including all people, 10-65 years, with the first episode of NAPD (International Classification of Diseases, Tenth Revision: F20-F29) between 1 January 2005 and 29 August 2018. Denominators were estimated from Chilean National Census data. Our main outcome was treated incidence of NAPD and age group, sex, calendar year and regional-level population density, multidimensional poverty and latitude were exposures of interest. RESULTS We identified 32 358 NAPD cases [12 136 (39.5%) women; median age-at-first-contact: 24 years (interquartile range 18-39 years)] during 171.1 million person-years [crude incidence: 18.9 per 100 000 person-years; 95% confidence interval (CI) 18.7-19.1]. Multilevel Poisson regression identified a strong age-sex interaction in incidence, with rates peaking in men (57.6 per 100 000 person-years; 95% CI 56.0-59.2) and women (29.5 per 100 000 person-years; 95% CI 28.4-30.7) between 15 and 19 years old. Rates also decreased (non-linearly) over time for women, but not men. We observed a non-linear association with multidimensional poverty and latitude, with the highest rates in the poorest regions and those immediately south of Santiago; no association with regional population density was observed. CONCLUSION Our findings inform the aetiology of NAPDs, replicating typical associations with age, sex and multidimensional poverty in a Global South context. The absence of association with population density suggests this risk may be context-dependent.
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Affiliation(s)
- Alfonso González-Valderrama
- Early Intervention Program, Instituto Psiquiátrico Dr J Horwitz Barak, Santiago, Chile
- School of Medicine, Universidad Finis Terrae, Santiago, Chile
| | - Hannah E. Jongsma
- Psylife Group, Division of Psychiatry, University College London, London, UK
| | - Cristián Mena
- Early Intervention Program, Instituto Psiquiátrico Dr J Horwitz Barak, Santiago, Chile
| | - Carmen Paz Castañeda
- Early Intervention Program, Instituto Psiquiátrico Dr J Horwitz Barak, Santiago, Chile
| | - Rubén Nachar
- Early Intervention Program, Instituto Psiquiátrico Dr J Horwitz Barak, Santiago, Chile
- School of Medicine, Universidad Finis Terrae, Santiago, Chile
| | - Juan Undurraga
- Early Intervention Program, Instituto Psiquiátrico Dr J Horwitz Barak, Santiago, Chile
- Department of Neurology and Psychiatry, Faculty of Medicine, Clínica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Nicolás Crossley
- Department of Psychiatry, School of Medicine, Pontificia Universidad Católica de Chile, Santiago Metropolitan Region, Chile
- Biomedical Imaging Center, Pontificia Universidad Católica de Chile, Santiago Metropolitan Region, Chile
- Department of Psychosis Studies, King's College London, Institute of Psychology, Psychiatry, and Neuroscience, London, UK
| | - David Aceituno
- Department of Psychiatry, School of Medicine, Pontificia Universidad Católica de Chile, Santiago Metropolitan Region, Chile
- Department of Health Service and Population Research, King's College London, Institute of Psychology, Psychiatry, and Neuroscience, London, UK
| | - Barbara Iruretagoyena
- Early Intervention Program, Instituto Psiquiátrico Dr J Horwitz Barak, Santiago, Chile
- Department of Psychiatry, School of Medicine, Pontificia Universidad Católica de Chile, Santiago Metropolitan Region, Chile
| | - Carlos Gallardo
- Early Intervention Program, Instituto Psiquiátrico Dr J Horwitz Barak, Santiago, Chile
| | - Pilar Mondaca
- Early Intervention Program, Instituto Psiquiátrico Dr J Horwitz Barak, Santiago, Chile
| | - Matías Monje
- Early Intervention Program, Instituto Psiquiátrico Dr J Horwitz Barak, Santiago, Chile
| | - Matías Irarrazaval
- Department of Mental Health, Ministry of Health, Santiago, Chile
- Millennium Institute for Research in Depression and Personality, Santiago, Chile
- Faculty of Medicine, Clínica Psiquiátrica Universitaria, University of Chile, Santiago, Chile
| | - Cynthia Zavala
- Department of Mental Health, Ministry of Health, Santiago, Chile
| | - Lucia Valmaggia
- Department of Psychology, King's College London, Institute of Psychology, Psychiatry, and Neuroscience, London, UK
| | - James B. Kirkbride
- Psylife Group, Division of Psychiatry, University College London, London, UK
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13
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Bolhuis K, Lång U, Gyllenberg D, Kääriälä A, Veijola J, Gissler M, Kelleher I. Hospital Presentation for Self-Harm in Youth as a Risk Marker for Later Psychotic and Bipolar Disorders: A Cohort Study of 59 476 Finns. Schizophr Bull 2021; 47:1685-1694. [PMID: 33991091 PMCID: PMC8530384 DOI: 10.1093/schbul/sbab061] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Expanding clinical strategies to identify high risk groups for psychotic and bipolar disorders is a research priority. Considering that individuals diagnosed with psychotic and bipolar disorder are at high risk of self-harm, we hypothesised the reverse order relationship would also be true (ie, self-harm would predict psychotic/bipolar disorder). Specifically, we hypothesised that hospital presentation for self-harm would be a marker of high risk for subsequent development of psychotic/bipolar disorder and sought to test this hypothesis in a large population sample. This prospective register-based study included everyone born in Finland in 1987, followed until age 28 years (N = 59 476). We identified all hospital records of self-harm presentations, as well as all ICD-10 healthcare registrations of first diagnoses of psychotic and bipolar disorders. Cox proportional hazards models were used to assess the relationship between self-harm and psychotic/bipolar disorders. Of all individuals who presented to hospital with self-harm (n = 481), 12.8% went on to receive a diagnosis of psychosis (hazard ratio [HR] = 6.03, 95% confidence interval [CI] 4.56-7.98) and 9.4% a diagnosis of bipolar disorder (HR = 7.85, 95% CI 5.73-10.76) by age 28 years. Younger age of first self-harm presentation was associated with higher risk-for individuals who presented before age 18 years, 29.1% developed a psychotic or bipolar disorder by age 28 years. Young people who present to hospital with self-harm are at high risk of future psychotic and bipolar disorders. They represent an important cohort for the prevention of serious mental illness.
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Affiliation(s)
- Koen Bolhuis
- Department of Psychiatry, Royal College of Surgeons in Ireland, Dublin, Ireland,Department of Child and Adolescent Psychiatry, Erasmus Medical Centre-Sophia Children’s Hospital, Rotterdam, The Netherlands
| | - Ulla Lång
- Department of Psychiatry, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - David Gyllenberg
- Department of Child Psychiatry and INVEST Research Flagship Center, University of Turku and Turku University Hospital, Turku, Finland,Department of Adolescent Psychiatry, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland,Finnish Institute for Health and Welfare, Helsinki, Finland
| | - Antti Kääriälä
- Finnish Institute for Health and Welfare, Helsinki, Finland
| | - Juha Veijola
- Research Unit of Clinical Neuroscience, Department of Psychiatry, University of Oulu; Department of Psychiatry, Oulu University Hospital, Oulu, Finland,Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Mika Gissler
- Department of Child Psychiatry and INVEST Research Flagship Center, University of Turku and Turku University Hospital, Turku, Finland,Finnish Institute for Health and Welfare, Helsinki, Finland,Karolinska Institute, Department of Neurobiology, Care Sciences and Society, Division of Family Medicine and Primary Care, Stockholm, Sweden
| | - Ian Kelleher
- Department of Psychiatry, Royal College of Surgeons in Ireland, Dublin, Ireland,Lucena Clinic Child and Adolescent Mental Health Service, Rathgar, Dublin, Ireland,School of Medicine, University College Dublin, Dublin, Ireland,To whom correspondence should be addressed; School of Medicine, University College Dublin, Dublin, Ireland; e-mail:
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14
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Schoer N, Rodrigues R, Reid J, Ryan BL, Lizotte DJ, Booth R, MacDougall AG, Kurdyak P, Anderson KK. Patterns of Primary Care Use Prior to a First Diagnosis of Nonaffective Psychotic Disorder in Ontario, Canada: Modèles d'utilisation des soins de première ligne avant un premier diagnostic de trouble psychotique non affectif en Ontario, Canada. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2021; 66:406-417. [PMID: 33016113 PMCID: PMC8172343 DOI: 10.1177/0706743720961732] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Many people experience early signs and symptoms before the onset of psychotic disorder, suggesting that there may be help-seeking prior to first diagnosis. The family physician has been found to play a key role in pathways to care. This study examined patterns of primary care use preceding a first diagnosis of psychotic disorder. METHODS We used health administrative data from Ontario (Canada) to construct a population-based retrospective cohort. We investigated patterns of primary care use, including frequency and timing of contacts, in the 6 years prior to a first diagnosis of psychosis, relative to a general population comparison group matched on age, sex, geographic area, and index date. We used latent class growth modeling to identify distinct trajectories of primary care service use, and associated factors, preceding the first diagnosis. RESULTS People with early psychosis contacted primary care over twice as frequently in the 6 years preceding first diagnosis (RR = 2.22; 95% CI, = 2.19 to 2.25), relative to the general population, with a sharp increase in contacts 10 months prior to diagnosis. They had higher contact frequency across nearly all diagnostic codes, including mental health, physical health, and preventative health. We identified 3 distinct service use trajectories: low-, medium-, and high-increasing usage. DISCUSSION We found elevated patterns of primary care service use prior to first diagnosis of psychotic disorder, suggesting that initiatives to support family physicians in their role on the pathway to care are warranted. Earlier intervention has implications for improved social, educational, and professional development in young people with first-episode psychosis.
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Affiliation(s)
- Nicole Schoer
- Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada
| | - Rebecca Rodrigues
- Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada
| | | | - Bridget L Ryan
- Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada.,Department of Family Medicine, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada
| | - Daniel J Lizotte
- Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada.,Department of Computer Science, The University of Western Ontario, London, Ontario, Canada
| | - Richard Booth
- Arthur Labatt Family School of Nursing, The University of Western Ontario, London, Ontario, Canada
| | - Arlene G MacDougall
- Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada.,Department of Family Medicine, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada
| | - Paul Kurdyak
- 50010ICES, Toronto, Ontario, Canada.,Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Ontario, Canada.,Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Kelly K Anderson
- Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada.,50010ICES, Toronto, Ontario, Canada.,Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada.,Department of Psychiatry, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada
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15
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Identifying patients at risk of psychosis: a qualitative study of GP views in South West England. Br J Gen Pract 2020; 71:e113-e120. [PMID: 33257466 PMCID: PMC7716867 DOI: 10.3399/bjgp20x713969] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 07/13/2020] [Indexed: 12/02/2022] Open
Abstract
Background Early intervention in people with an at-risk mental state for psychosis can decrease the rates of transition to psychosis. GPs play a key role in the identification of this patient group but very few studies have explored GPs’ awareness of patients who are at risk of psychosis. Aim To explore GPs’ views and experiences of identifying patients with an at-risk mental state for psychosis, and the barriers and facilitators to identification. Design and setting In-depth semi-structured interviews were held with GPs working in South West England primary care. The interviews were conducted between March and July 2019. Method A topic guide was used to ensure consistency across interviews. This guide was revised to incorporate a definition of the at-risk mental state for psychosis, as after conducting a few interviews it became clear that some GPs were not familiar with this construct. Interviews were audiorecorded and analysed thematically. Results A total of 20 GPs were interviewed. Some GPs were not familiar with the concept of being at risk of developing psychosis, and perceived that they may not have the right skills to identify this patient group. Other barriers related to patients not presenting or disclosing psychotic symptoms, and limitations imposed by scarce resources on the structure and provision of NHS services, such as lack of continuity of care and high thresholds for accessing specialised services. Conclusion Identifying people at risk of psychosis in primary care is difficult. Provision of GP training, development of policies that support continuity of care, and improved access to specialised services could help improve the identification of this patient group.
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16
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Chen Y, Farooq S, Edwards J, Chew-Graham CA, Shiers D, Frisher M, Hayward R, Sumathipala A, Jordan KP. Patterns of symptoms before a diagnosis of first episode psychosis: a latent class analysis of UK primary care electronic health records. BMC Med 2019; 17:227. [PMID: 31801530 PMCID: PMC6894287 DOI: 10.1186/s12916-019-1462-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 11/05/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The nature of symptoms in the prodromal period of first episode psychosis (FEP) remains unclear. The objective was to determine the patterns of symptoms recorded in primary care in the 5 years before FEP diagnosis. METHODS The study was set within 568 practices contributing to a UK primary care health record database (Clinical Practice Research Datalink). Patients aged 16-45 years with a first coded record of FEP, and no antipsychotic prescription more than 1 year prior to FEP diagnosis (n = 3045) was age, gender, and practice matched to controls without FEP (n = 12,180). Fifty-five symptoms recorded in primary care in the previous 5 years, categorised into 8 groups (mood-related, 'neurotic', behavioural change, volition change, cognitive change, perceptual problem, substance misuse, physical symptoms), were compared between cases and controls. Common patterns of symptoms prior to FEP diagnosis were identified using latent class analysis. RESULTS Median age at diagnosis was 30 years, 63% were male. Non-affective psychosis (67%) was the most common diagnosis. Mood-related, 'neurotic', and physical symptoms were frequently recorded (> 30% of patients) before diagnosis, and behavioural change, volition change, and substance misuse were also common (> 10%). Prevalence of all symptom groups was higher in FEP patients than in controls (adjusted odds ratios 1.33-112). Median time from the first recorded symptom to FEP diagnosis was 2-2.5 years except for perceptual problem (70 days). The optimal latent class model applied to FEP patients determined three distinct patient clusters: 'no or minimal symptom cluster' (49%) had no or few symptoms recorded; 'affective symptom cluster' (40%) mainly had mood-related and 'neurotic' symptoms; and 'multiple symptom cluster' (11%) consulted for three or more symptom groups before diagnosis. The multiple symptom cluster was more likely to have drug-induced psychosis, female, obese, and have a higher morbidity burden. Affective and multiple symptom clusters showed a good discriminative ability (C-statistic 0.766; sensitivity 51.2% and specificity 86.7%) for FEP, and many patients in these clusters had consulted for their symptoms several years before FEP diagnosis. CONCLUSIONS Distinctive patterns of prodromal symptoms may help alert general practitioners to those developing psychosis, facilitating earlier identification and referral to specialist care, thereby avoiding potentially detrimental treatment delay.
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Affiliation(s)
- Ying Chen
- School of Primary, Community and Social Care, Keele University, Keele, ST5 5BG UK
| | - Saeed Farooq
- School of Primary, Community and Social Care, Keele University, Keele, ST5 5BG UK
| | - John Edwards
- School of Primary, Community and Social Care, Keele University, Keele, ST5 5BG UK
| | | | - David Shiers
- School of Primary, Community and Social Care, Keele University, Keele, ST5 5BG UK
- University of Manchester, Manchester, M13 9PL UK
- Psychosis Research Unit, Greater Manchester Mental Health NHS Trust, Manchester, M25 3BL UK
| | | | - Richard Hayward
- School of Primary, Community and Social Care, Keele University, Keele, ST5 5BG UK
| | - Athula Sumathipala
- School of Primary, Community and Social Care, Keele University, Keele, ST5 5BG UK
| | - Kelvin P. Jordan
- School of Primary, Community and Social Care, Keele University, Keele, ST5 5BG UK
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17
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Kennedy L, Johnson KA, Cheng J, Woodberry KA. A Public Health Perspective on Screening for Psychosis Within General Practice Clinics. Front Psychiatry 2019; 10:1025. [PMID: 32082199 PMCID: PMC7006053 DOI: 10.3389/fpsyt.2019.01025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 12/24/2019] [Indexed: 12/24/2022] Open
Abstract
Screening for major mental illness in adolescents and young adults has lagged behind screening for physical illness for a myriad of reasons. Existing pediatric behavioral health screening tools screen primarily for disorders of attention, disruptive behaviors, depression, and anxiety. A few also screen for substance use and suicide risk. Although it is now possible to reliably identify young people at imminent risk for a psychotic disorder, arguably the most severe of mental illnesses, general practitioners (GP) rarely screen for psychotic symptoms or recognize when to refer patients for a specialized risk assessment. Research suggests that barriers such as inadequate knowledge or insufficient access to mental health resources can be overcome with intensive GP education and the integration of physical and mental health services. Under the lens of two public health models outlining the conditions under which disease screening is warranted, we examine additional evidence for and against population-based screening for psychosis in adolescents and young adults. We argue that systematic screening within general health settings awaits a developmentally well-normed screening tool that includes probes for psychosis, is written at a sufficiently low reading level, and has acceptable sensitivity and, in particular, specificity for detecting psychosis and psychosis risk in both adolescents and young adults. As integrated healthcare models expand around the globe and psychosis-risk assessments and treatments improve, a stratified screening and careful risk management protocol for GP settings could facilitate timely early intervention that effectively balances the benefit/risk ratio of employing such a screening tool at the population level.
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Affiliation(s)
- Leda Kennedy
- Department of Psychiatry, Beth Israel Deaconess Medical Center, Boston, MA, United States.,Columbia Irving Medical Center, New York State Psychiatric Institute, New York, NY, United States
| | - Kelsey A Johnson
- Department of Psychiatry, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Joyce Cheng
- Department of Psychiatry, Beth Israel Deaconess Medical Center, Boston, MA, United States.,Wellesley College, Wellesley, MA, United States
| | - Kristen A Woodberry
- Department of Psychiatry, Beth Israel Deaconess Medical Center, Boston, MA, United States.,Center for Psychiatric Research, Maine Medical Center, Portland, ME, United States
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18
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Fusar-Poli P, Sullivan SA, Shah JL, Uhlhaas PJ. Improving the Detection of Individuals at Clinical Risk for Psychosis in the Community, Primary and Secondary Care: An Integrated Evidence-Based Approach. Front Psychiatry 2019; 10:774. [PMID: 31708822 PMCID: PMC6822017 DOI: 10.3389/fpsyt.2019.00774] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Accepted: 09/26/2019] [Indexed: 01/03/2023] Open
Abstract
Background: The first rate-limiting step for improving outcomes of psychosis through preventive interventions in people at clinical high risk for psychosis (CHR-P) is the ability to accurately detect individuals who are at risk for the development of this disorder. Currently, this detection power is sub-optimal. Methods: This is a conceptual and nonsystematic review of the literature, focusing on the work conducted by leading research teams in the field. The results will be structured in the following sections: understanding the CHR-P assessment, validity of the CHR-P as a universal risk state for psychosis, and improving the detection of at-risk individuals in secondary mental health care, in primary care, and in the community. Results: CHR-P instruments can provide adequate prognostic accuracy for the prediction of psychosis provided that they are employed in samples who have undergone risk enrichment during recruitment. This substantially limits their detection power in real-world settings. Furthermore, there is initial evidence that not all cases of psychosis onset are preceded by a CHR-P stage. A transdiagnostic individualized risk calculator could be used to automatically screen secondary mental health care medical notes to detect those at risk of psychosis and refer them to standard CHR-P assessment. Similar risk estimation tools for use in primary care are under development and promise to boost the detection of patients at risk in this setting. To improve the detection of young people who may be at risk of psychosis in the community, it is necessary to adopt digital and/or sequential screening approaches. These solutions are based on recent scientific evidence and have potential for implementation internationally. Conclusions: The best strategy to improve the detection of patients at risk for psychosis is to implement a clinical research program that integrates different but complementary detection approaches across community, primary, and secondary care. These solutions are based on recent scientific advancements in the development of risk estimation tools and e-health approaches and have the potential to be applied across different clinical settings.
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Affiliation(s)
- Paolo Fusar-Poli
- Early Psychosis: Interventions and Clinical-detection (EPIC) Lab, Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, United Kingdom.,OASIS service, South London and Maudsley NHS Foundation Trust, London, United Kingdom.,Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy.,National Institute for Health Research Maudsley Biomedical Research Centre, South London and Maudsley NHS Foundation Trust, London, United Kingdom
| | - Sarah A Sullivan
- Centre for Academic Mental Health, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Jai L Shah
- Prevention and Early Intervention Program for Psychosis (PEPP-Montréal), Douglas Mental Health University Institute, Montréal, QC, Canada.,ACCESS Open Minds (Pan-Canadian Youth Mental Health Services Research Network), Douglas Mental Health University Institute, Montreal, QC, Canada.,Department of Psychiatry, McGill University, Montreal, QC, Canada
| | - Peter J Uhlhaas
- Institute of Neuroscience and Psychology, University of Glasgow, Glasgow, United Kingdom.,Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin, Berlin, Germany
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19
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Brown HE. Identifying Risk of Psychosis in a Primary Care Setting. JAMA Netw Open 2018; 1:e185165. [PMID: 30646386 DOI: 10.1001/jamanetworkopen.2018.5165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Hannah E Brown
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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