Psychosocial outcome in patients at clinical high risk of psychosis: a prospective follow-up

Review of factors resulting in systemic biases in the screening, assessment, and treatment of individuals at clinical high-risk for psychosis in the United States

Background

Since its inception, research in the clinical high-risk (CHR) phase of psychosis has included identifying and exploring the impact of relevant socio-demographic factors. Employing a narrative review approach and highlighting work from the United States, sociocultural and contextual factors potentially affecting the screening, assessment, and service utilization of youth at CHR were reviewed from the current literature.

Results

Existing literature suggests that contextual factors impact the predictive performance of widely used psychosis-risk screening tools and may introduce systemic bias and challenges to differential diagnosis in clinical assessment. Factors reviewed include racialized identity, discrimination, neighborhood context, trauma, immigration status, gender identity, sexual orientation, and age. Furthermore, racialized identity and traumatic experiences appear related to symptom severity and service utilization among this population.

Conclusions

Collectively, a growing body of research from the United States and beyond suggests that considering context in psychosis-risk assessment can provide a more accurate appraisal of the nature of risk for psychosis, render more accurate results improving the field's prediction of conversion to psychosis, and enhance our understanding of psychosis-risk trajectories. More work is needed in the U.S. and across the globe to uncover how structural racism and systemic biases impact screening, assessment, treatment, and clinical and functional outcomes for those at CHR.

The associations between attenuated psychosis symptoms and functioning in Black and White youth at clinical high-risk for psychosis

Extensive research has demonstrated racial disparities, particularly among Black individuals, in both presentation and course of psychosis spectrum disorders. Few studies, however, have examined racial differences in the clinical high-risk (CHR) phase of illness. It is unclear if functional deficits seen in association with CHR symptoms generalize to marginalized racial groups, or whether race may play a role in the link between symptoms and functioning. In a sample of youth at CHR (N = 46), the present study examined the effect of race (Black and White represented in this sample) on the relation between CHR symptoms and social/role functioning. Race had a moderating effect on the relation between CHR symptoms and social functioning for total positive symptom score (p < .04, f² = 0.10). Although positive symptoms were associated with worse social functioning for White participants, no association was found for Black participants. Follow up analyses indicated suspiciousness was a statistically significant predictor of social functioning for White participants but was unrelated to functioning for Black participants. Results may be indicative of phenomenon experienced by individuals within racial minority groups (e.g., "healthy suspiciousness") or potential measurement validity concerns. Findings further the understanding of racial differences in the CHR phase of illness among White and Black youth and highlight limitations of the existing CHR literature and assessment tools for diverse youth.

Machine learning based prediction and the influence of complement - Coagulation pathway proteins on clinical outcome: Results from the NEURAPRO trial

BACKGROUND

Functional outcomes are important measures in the overall clinical course of psychosis and individuals at clinical high-risk (CHR), however, prediction of functional outcome remains difficult based on clinical information alone. In the first part of this study, we evaluated whether a combination of biological and clinical variables could predict future functional outcome in CHR individuals. The complement and coagulation pathways have previously been identified as being of relevance to the pathophysiology of psychosis and have been found to contribute to the prediction of clinical outcome in CHR participants. Hence, in the second part we extended the analysis to evaluate specifically the relationship of complement and coagulation proteins with psychotic symptoms and functional outcome in CHR.

MATERIALS AND METHODS

We carried out plasma proteomics and measured plasma cytokine levels, and erythrocyte membrane fatty acid levels in a sub-sample (n = 158) from the NEURAPRO clinical trial at baseline and 6 months follow up. Functional outcome was measured using Social and Occupational Functional assessment Score (SOFAS) scale. Firstly, we used support vector machine learning techniques to develop predictive models for functional outcome at 12 months. Secondly, we developed linear regression models to understand the association between 6-month follow-up levels of complement and coagulation proteins with 6-month follow-up measures of positive symptoms summary (PSS) scores and functional outcome.

RESULTS AND CONCLUSION

A prediction model based on clinical and biological data including the plasma proteome, erythrocyte fatty acids and cytokines, poorly predicted functional outcome at 12 months follow-up in CHR participants. In linear regression models, four complement and coagulation proteins (coagulation protein X, Complement C1r subcomponent like protein, Complement C4A & Complement C5) indicated a significant association with functional outcome; and two proteins (coagulation factor IX and complement C5) positively associated with the PSS score. Our study does not provide support for the utility of cytokines, proteomic or fatty acid data for prediction of functional outcomes in individuals at high-risk for psychosis. However, the association of complement protein levels with clinical outcome suggests a role for the complement system and the activity of its related pathway in the functional impairment and positive symptom severity of CHR patients.

Short-term functional outcome in psychotic patients: results of the Turku early psychosis study (TEPS)

BACKGROUND

Functional recovery of patients with clinical and subclinical psychosis is associated with clinical, neuropsychological and developmental factors. Less is known about how these factors predict functional outcomes in the same models. We investigated functional outcomes and their predictors in patients with first-episode psychosis (FEP) or a confirmed or nonconfirmed clinical high risk of psychosis (CHR-P vs. CHR-N).

METHODS

Altogether, 130 patients with FEP, 60 patients with CHR-P and 47 patients with CHR-N were recruited and extensively examined at baseline (T0) and 9 (T1) and 18 (T2) months later. Global Assessment of Functioning (GAF) at T0, T1 and T2 and psychotic, depression, and anxiety symptoms at T1 and T2 were assessed. Functional outcomes were predicted using multivariate repeated ANOVA.

RESULTS

During follow-up, the GAF score improved significantly in patients with FEP and CHR-P but not in patients with CHR-N. A single marital status, low basic education level, poor work situation, disorganization symptoms, perceptual deficits, and poor premorbid adjustment in patients with FEP, disorganization symptoms and poor premorbid adjustment in patients with CHR-P, and a low basic education level, poor work situation and general symptoms in patients with CHR-N predicted poor functional outcomes. Psychotic symptoms at T1 in patients with FEP and psychotic and depression symptoms at T1 and anxiety symptoms at T2 in patients with CHR-P were associated with poor functioning.

CONCLUSIONS

In patients with FEP and CHR-P, poor premorbid adjustment and disorganization symptomatology are common predictors of the functional outcome, while a low education level and poor work situation predict worse functional outcomes in patients with FEP and CHR-N. Interventions aimed at improving the ability to work and study are most important in improving the functioning of patients with clinical or subclinical psychosis.

EPA guidance on the early intervention in clinical high risk states of psychoses

This guidance paper from the European Psychiatric Association (EPA) aims to provide evidence-based recommendations on early intervention in clinical high risk (CHR) states of psychosis, assessed according to the EPA guidance on early detection. The recommendations were derived from a meta-analysis of current empirical evidence on the efficacy of psychological and pharmacological interventions in CHR samples. Eligible studies had to investigate conversion rate and/or functioning as a treatment outcome in CHR patients defined by the ultra-high risk and/or basic symptom criteria. Besides analyses on treatment effects on conversion rate and functional outcome, age and type of intervention were examined as potential moderators. Based on data from 15 studies (n = 1394), early intervention generally produced significantly reduced conversion rates at 6- to 48-month follow-up compared to control conditions. However, early intervention failed to achieve significantly greater functional improvements because both early intervention and control conditions produced similar positive effects. With regard to the type of intervention, both psychological and pharmacological interventions produced significant effects on conversion rates, but not on functional outcome relative to the control conditions. Early intervention in youth samples was generally less effective than in predominantly adult samples. Seven evidence-based recommendations for early intervention in CHR samples could have been formulated, although more studies are needed to investigate the specificity of treatment effects and potential age effects in order to tailor interventions to the individual treatment needs and risk status.

Symptomatic and Functional Remission in Young Adults with a Psychotic Disorder in a Rehabilitation Focused Team

The aim of this study is to assess symptomatic remission (SR) and functional remission (FR) in a rehabilitation focused program for young adults with a psychotic disorder in the Netherlands, and to investigate which individual and mental health care factors are associated with SR and/or FR, by using Routine Outcome Monitoring data and data on met needs and unmet needs for care. Data of 287 young adults were collected. Almost 40% achieved or maintained SR, 34% FR, and 26% achieved or maintained both. In addition to sociodemographic factors, living independently, paid employment, higher levels of compliance with treatment, and better fulfillment of unmet needs for care in relation to psychological distress, company and daytime activities were associated with better outcomes on SR and/or FR. Our findings underscore that to successfully improve and sustain remission in young adults with a psychotic disorder, it is needed to conduct specific research into the relationship between SR and FR.

Individuals at high risk for psychosis experience more childhood trauma, life events and social support deficit in comparison to healthy controls

Evidence for psychological risk factors on prodromal state of psychosis remained limited and inconsistent. This study aimed to investigate childhood trauma, life events and social support in subjects with high risk for psychosis (HR), first episode psychosis with schizophrenia (FEP) and healthy control (HC). In the study, 56 FEP, 83 HR and 61 HC underwent face-to-face clinical interview and psychological assessment, including Childhood Trauma Questionnaire (CTQ), Life Events Scale (LES) and Perceived Social Support Scale (PSSS). The results showed that in univariate analysis, HR individuals had more childhood trauma, more recent life events and less social support than HC group, and these findings were also supported by ANCOVA analysis except for the results related to social support after taking age, education, marital and employment status as covariates. Logistic regression analysis revealed that HR group was significantly associated with more childhood trauma, poorer overall function and unmarried state than HC group after controlling the interfering factors. HR group was similar with FEP group in these assessments. In conclusion, HR individuals experienced more childhood trauma, life events and social support deficit than HC group, which may be risk factors of conversion to psychosis. Further explorations are warranted to develop optimal psychosocial interventions.

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

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

Physical effort exertion and pain: Links with trait-based risk for psychopathology

People with serious mental illness (SMI) are at an increased risk for physical health complications, such as cardiovascular disease and obesity. Low levels of physical activity is a major contributor to these health complications. One factor associated with limited physical activity in the broader sedentary population is pain. While preliminary findings suggest an association between lack of physical activity and pain in SMI, conclusions are still unclear. Thus, the goal of this correlational study was to examine associations between trait-based risk for psychopathology (hypomanic personality, schizotypy, and anhedonic depression) and the experience of pain following a physical endurance/effort task. Healthy participants (N = 43; 18 females) completed self-report measures of trait-based risk for psychopathology. They also reported on the experience of pain before and after the Time To Exhaustion (TTE) test. Findings revealed that risk for psychosis and anhedonic depression were associated with increases in pain following the TTE test, accounting for other key variables, such as age and self-reported physical exercise. Risk for mania was unrelated to changes in pain. These results suggest that the experience of pain in relation to physical endurance/effort may contribute to diminished physical activity among people at risk for SMI.

Psychopathology and social functioning of 42 subjects from a Danish ultra high-risk cohort

AIM

To make a thorough characterization of the co-morbidity, psychopathology and demographics in the first Danish ultra high-risk (UHR) sample.

METHOD

Forty-two UHR subjects went through comprehensive interviews assessing their psychopathology, psychiatric disorders, substance use and family history of psychiatric disorders.

RESULTS

All UHR subjects met the criteria of at least 1 axis I diagnosis in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) and met on average four diagnoses (both axis I and II), mostly within the areas of depression, anxiety and substance abuse. A total of 48% had schizotypal personality disorder and 19% had borderline personality disorder. Level of functioning was low with a mean score on the Social and Occupational Functioning Assessment Scale corresponding to "major impairment in several areas," and mean scores in the Global Functioning: Social and Role scales between "moderate impairment in social functioning" and "very serious impairment independently." Forty-seven percent were unemployed and 29% on sick leave. Fifty-five percent relied financially on public support.

CONCLUSION

As seen in previous UHR populations, Danish UHR subjects had low function socio-economically and met criteria of several psychiatric diagnoses, suggesting that they require pharmacological and non-pharmacological psychiatric treatment as well as vocational and educational guidance and support.

Prediction Models of Functional Outcomes for Individuals in the Clinical High-Risk State for Psychosis or With Recent-Onset Depression: A Multimodal, Multisite Machine Learning Analysis

IMPORTANCE

Social and occupational impairments contribute to the burden of psychosis and depression. There is a need for risk stratification tools to inform personalized functional-disability preventive strategies for individuals in at-risk and early phases of these illnesses.

OBJECTIVE

To determine whether predictors associated with social and role functioning can be identified in patients in clinical high-risk (CHR) states for psychosis or with recent-onset depression (ROD) using clinical, imaging-based, and combined machine learning; assess the geographic, transdiagnostic, and prognostic generalizability of machine learning and compare it with human prognostication; and explore sequential prognosis encompassing clinical and combined machine learning.

DESIGN, SETTING, AND PARTICIPANTS

This multisite naturalistic study followed up patients in CHR states, with ROD, and with recent-onset psychosis, and healthy control participants for 18 months in 7 academic early-recognition services in 5 European countries. Participants were recruited between February 2014 and May 2016, and data were analyzed from April 2017 to January 2018.

AIN OUTCOMES AND MEASURES

Performance and generalizability of prognostic models.

RESULTS

A total of 116 individuals in CHR states (mean [SD] age, 24.0 [5.1] years; 58 [50.0%] female) and 120 patients with ROD (mean [SD] age, 26.1 [6.1] years; 65 [54.2%] female) were followed up for a mean (SD) of 329 (142) days. Machine learning predicted the 1-year social-functioning outcomes with a balanced accuracy of 76.9% of patients in CHR states and 66.2% of patients with ROD using clinical baseline data. Balanced accuracy in models using structural neuroimaging was 76.2% in patients in CHR states and 65.0% in patients with ROD, and in combined models, it was 82.7% for CHR states and 70.3% for ROD. Lower functioning before study entry was a transdiagnostic predictor. Medial prefrontal and temporo-parieto-occipital gray matter volume (GMV) reductions and cerebellar and dorsolateral prefrontal GMV increments had predictive value in the CHR group; reduced mediotemporal and increased prefrontal-perisylvian GMV had predictive value in patients with ROD. Poor prognoses were associated with increased risk of psychotic, depressive, and anxiety disorders at follow-up in patients in the CHR state but not ones with ROD. Machine learning outperformed expert prognostication. Adding neuroimaging machine learning to clinical machine learning provided a 1.9-fold increase of prognostic certainty in uncertain cases of patients in CHR states, and a 10.5-fold increase of prognostic certainty for patients with ROD.

CONCLUSIONS AND RELEVANCE

Precision medicine tools could augment effective therapeutic strategies aiming at the prevention of social functioning impairments in patients with CHR states or with ROD.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

AIM

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

METHOD

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

RESULTS

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

CONCLUSION

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

Long-term employment among people at ultra-high risk for psychosis

BACKGROUND

Psychotic disorders are associated with high rates of sustained unemployment, however, little is known about the long-term employment outcome of people at ultra-high risk (UHR) of developing psychosis. We sought to investigate the long-term unemployment rate and baseline predictors of employment status at follow-up in a large UHR cohort.

METHOD

268 UHR patients recruited from the Personal Assessment and Crisis Evaluation clinic in Melbourne, Australia were followed-up over 2-14years after initial presentation to the service. Individuals in no form of employment or education were classed as unemployed. Logistic regression analyses were used to examine predictors of employment outcome.

RESULTS

A high rate of unemployment was present at follow-up in this UHR sample (23%). At baseline, those who were unemployed at follow-up had a longer duration of untreated illness, more severe negative symptoms, lower IQ, poorer social and occupational functioning and reported more childhood trauma than the employed group. At follow-up, unemployed individuals exhibited significantly more severe symptoms on all measures and were more likely to have been diagnosed with a mood, anxiety, psychotic or substance use disorder. Childhood trauma and the duration of untreated illness at baseline were significant independent predictors of employment status at follow-up in the multivariate analyses.

CONCLUSIONS

Nearly a quarter of this UHR sample was unemployed at long-term follow-up. The duration of untreated illness and the effects of childhood trauma are potentially modifiable risk factors for long-term employment outcome in this group. Vocational support may be beneficial for many UHR patients presenting to services.

Neuroanatomical Predictors of Functional Outcome in Individuals at Ultra-High Risk for Psychosis

Most individuals at ultra-high risk (UHR) for psychosis do not transition to frank illness. Nevertheless, many have poor clinical outcomes and impaired psychosocial functioning. This study used voxel-based morphometry to investigate if baseline grey and white matter brain densities at identification as UHR were associated with functional outcome at medium- to long-term follow-up. Participants were help-seeking UHR individuals (n = 109, 54M:55F) who underwent magnetic resonance imaging at baseline; functional outcome was assessed an average of 9.2 years later. Primary analysis showed that lower baseline grey matter density, but not white matter density, in bilateral frontal and limbic areas, and left cerebellar declive were associated with poorer functional outcome (Social and Occupational Functioning Assessment Scale [SOFAS]). These findings were independent of transition to psychosis or persistence of the at-risk mental state. Similar regions were significantly associated with lower self-reported levels of social functioning and increased negative symptoms at follow-up. Exploratory analyses showed that lower baseline grey matter densities in middle and inferior frontal gyri were significantly associated with decline in Global Assessment of Functioning (GAF) score over follow-up. There was no association between baseline grey matter density and IQ or positive symptoms at follow-up. The current findings provide novel evidence that those with the poorest functional outcomes have the lowest grey matter densities at identification as UHR, regardless of transition status or persistence of the at-risk mental state. Replication and validation of these findings may allow for early identification of poor functional outcome and targeted interventions.

Examining the association between social cognition and functioning in individuals at ultra-high risk for psychosis

OBJECTIVE

Social and role functioning are compromised for the majority of individuals at ultra-high risk of psychosis, and it is important to identify factors that contribute to this functional decline. This study aimed to investigate social cognitive abilities, which have previously been linked to functioning in schizophrenia, as potential factors that impact social, role and global functioning in ultra-high risk patients.

METHOD

A total of 30 ultra-high risk patients were recruited from an established at-risk clinical service in Melbourne, Australia, and completed a battery of social cognitive, neurocognitive, clinical and functioning measures. We examined the relationships between all four core domains of social cognition (emotion recognition, theory of mind, social perception and attributional style), neurocognitive, clinical and demographic variables with three measures of functioning (the Global Functioning Social and Role scales and the Social and Occupational Functioning Assessment Scale) using correlational and multiple regression analyses.

RESULTS

Performance on a visual theory of mind task (visual jokes task) was significantly correlated with both concurrent role ( r = 0.425, p = 0.019) and global functioning ( r = 0.540, p = 0.002). In multivariate analyses, it also accounted for unique variance in global, but not role functioning after adjusting for negative symptoms and stress. Social functioning was not associated with performance on any of the social cognition tasks.

CONCLUSION

Among specific social cognitive abilities, only a test of theory of mind was associated with functioning in our ultra-high risk sample. Further longitudinal research is needed to examine the impact of social cognitive deficits on long-term functional outcome in the ultra-high risk group. Identifying social cognitive abilities that significantly impact functioning is important to inform the development of targeted intervention programmes for ultra-high risk individuals.

Deconstructing Vulnerability for Psychosis: Meta-Analysis of Environmental Risk Factors for Psychosis in Subjects at Ultra High-Risk

Background

Subjects at ultra high-risk (UHR) for psychosis have an enhanced vulnerability to develop the disorder but the risk factors accounting for this accrued risk are undetermined.

Method

Systematic review of associations between genetic or environmental risk factors for psychosis that are widely established in the literature and UHR state, based on comparisons to controls.

Results

Forty-four studies encompassing 170 independent datasets and 54 risk factors were included. There were no studies on association between genetic or epigenetic risk factors and the UHR state that met the inclusion criteria. UHR subjects were more likely to show obstetric complications, tobacco use, physical inactivity, childhood trauma/emotional abuse/physical neglect, high perceived stress, childhood and adolescent low functioning, affective comorbidities, male gender, single status, unemployment and low educational level as compared to controls.

Conclusions

The increased vulnerability of UHR subjects can be related to environmental risk factors like childhood trauma, adverse life events and affective dysfunction. The role of genetic and epigenetic risk factors awaits clarification.

Baseline grey matter volume of non-transitioned "ultra high risk" for psychosis individuals with and without attenuated psychotic symptoms at long-term follow-up

INTRODUCTION

Two thirds of individuals identified as ultra-high risk (UHR) for psychosis do not transition to psychosis over the medium to long-term (non-transition; UHR-NT). Nevertheless, many of these individuals have persistent attenuated psychotic symptoms (APS). The current study examined whether there were differences in baseline grey matter volume (i.e. at initial identification as UHR) in UHR-NT individuals whom had APS compared to those without APS (No-APS) at medium to long-term follow-up.

METHODS

Participants were help-seeking individuals who were identified as being at UHR for psychosis between 2 and 12years previously (mean=7.5). The sample consisted of 109 participants who underwent a Magnetic Resonance Imaging scan at baseline and who had not been observed to develop a psychotic disorder over the follow-up period (UHR-NT). Using voxel-based morphometry, baseline grey matter volume (GMV) was compared between participants with (N=30) and without (N=79) APS at follow-up.

RESULTS

At baseline, the APS and No-APS groups were clinically indistinguishable. At follow-up, the APS group had significantly worse symptoms and impaired functioning. Individuals with APS had reduced baseline GMV in frontal, temporal, posterior and cingulate regions compared to those without APS at follow-up. Reduced GMV was associated with more severe positive, negative and depressive symptoms and lower global functioning in the combined UHR-NT cohort. These associations were independent of later APS outcome.

DISCUSSION

This study found that differences in regional GMV are discernible at an early stage of UHR and may be specific to individuals who have APS and psychopathology at follow-up. Our findings suggest that lower GMV at baseline may confer neurobiological risk for later APS and/or increased psychopathology while the absence of these structural abnormalities might be protective.

Progress and Future Directions in Research on the Psychosis Prodrome: A Review for Clinicians

LEARNING OBJECTIVES

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ABSTRACT

The psychosis prodrome, or period of clinical and functional decline leading up to acute psychosis, offers a unique opportunity for identifying mechanisms of psychosis onset and for testing early-intervention strategies. We summarize major findings and emerging directions in prodromal research and provide recommendations for clinicians working with individuals suspected to be at high risk for psychosis. The past two decades of research have led to three major advances. First, tools and criteria have been developed that can reliably identify imminent risk for a psychotic disorder. Second, longitudinal clinical and psychobiological data from large multisite studies are strengthening individual risk assessment and offering insights into potential mechanisms of illness onset. Third, psychosocial and pharmacological interventions are demonstrating promise for delaying or preventing the onset of psychosis in help-seeking, high-risk individuals. The dynamic psychobiological processes implicated in both risk and onset of psychosis, including altered gene expression, cognitive dysfunction, inflammation, gray and white matter brain changes, and vulnerability-stress interactions suggest a wide range of potential treatment targets and strategies. The expansion of resources devoted to early intervention and prodromal research worldwide raises hope for investigating them. Future directions include identifying psychosis-specific risk and resilience factors in children, adolescents, and non-help-seeking community samples, improving study designs to test hypothesized mechanisms of change, and intervening with strategies that, in order to improve functional outcomes, better engage youth, address their environmental contexts, and focus on evidence-based neurodevelopmental targets. Prospective research on putatively prodromal samples has the potential to substantially reshape our understanding of mental illness and our efforts to combat it.

Childhood maltreatment and transition to psychotic disorder independently predict long-term functioning in young people at ultra-high risk for psychosis

BACKGROUND

Individuals identified as at ultra-high risk (UHR) for psychosis are at risk of poor functional outcome regardless of development of psychotic disorder. Studies examining longitudinal predictors of poor functioning have tended to be small and report only medium-term follow-up data. We sought to examine clinical predictors of functional outcome in a long-term longitudinal study.

METHOD

Participants were 268 (152 females, 116 males) individuals identified as UHR 2-14 years previously. A range of clinical and sociodemographic variables were assessed at baseline. Functioning at follow-up was assessed using the Social and Occupational Functioning Assessment Scale (SOFAS).

RESULTS

Baseline negative symptoms, impaired emotional functioning, disorders of thought content, low functioning, past substance use disorder and history of childhood maltreatment predicted poor functioning at follow-up in univariate analyses. Only childhood maltreatment remained significant in the multivariate analysis (p < 0.001). Transition to psychosis was also significantly associated with poor functioning at long-term follow-up [mean SOFAS score 59.12 (s.d. = 18.54) in the transitioned group compared to 70.89 (s.d. = 14.00) in the non-transitioned group, p < 0.001]. Childhood maltreatment was a significant predictor of poor functioning in both the transitioned and non-transitioned groups.

CONCLUSIONS

Childhood maltreatment and transition to psychotic disorder independently predicted poor long-term functioning. This suggests that it is important to assess history of childhood maltreatment in clinical management of UHR individuals. The finding that transition to psychosis predicts poor long-term functioning strengthens the evidence that the UHR criteria detect a subgroup at risk for schizophrenia.

Gender differences in individuals at high-risk of psychosis: a comprehensive literature review

Introduction. To date, few studies have focused on the characterization of clinical phenomenology regarding gender in population at high-risk of psychosis. This paper is an attempt to summarize the findings found in the scientific literature regarding gender differences in high-risk populations, taking into account parameters studied in populations with schizophrenia and other psychotic disorders, such as incidence, clinical expression, duration of untreated illness (DUI), social functioning, and cognitive impairment prior to full-blown psychosis development. Method. Studies were systematically searched in PubMed. Studies using gender variable as a control variable were excluded. 12 studies met inclusion criteria. Results. Most of the studies found a differential pattern between women and men as regards clinical, social, and cognitive variables in the prodromal phase, with worse performance in men except in cognitive functioning (more severe negative symptoms, worse social functioning, and longer DUI in men). Similar conversion rates over time were found between men and women. Conclusions. Many of the studies analyzed suggest that differences between men and women in the expression of psychosis extend across a continuum, from the subclinical forms of illness to the debut of psychosis. However, the small number of studies and their significant methodological and clinical limitations do not allow for firm conclusions.

The relationship of neurocognition and negative symptoms to social and role functioning over time in individuals at clinical high risk in the first phase of the North American Prodrome Longitudinal Study

OBJECTIVES

Impaired social, role, and neurocognitive functioning are preillness characteristics of people who later develop psychosis. In people with schizophrenia, neurocognition and negative symptoms are associated with functional impairment. We examined the relative contributions of neurocognition and symptoms to social and role functioning over time in clinically high-risk (CHR) individuals and determined if negative symptoms mediated the influence of cognition on functioning.

METHODS

Social, role, and neurocognitive functioning and positive, negative, and disorganized symptoms were assessed in 167 individuals at CHR for psychosis in the North American Prodrome Longitudinal Study Phase 1 (NAPLS-1), of whom 96 were reassessed at 12 months.

RESULTS

Regression analyses indicated that negative symptoms accounted for unique variance in social and role functioning at baseline and follow-up. Composite neurocognition accounted for unique, but modest, variance in social and role functioning at baseline and in role functioning at follow-up. Negative symptoms mediated the relationship between composite neurocognition and social and role functioning across time points. In exploratory analyses, individual tests (IQ estimate, Digit Symbol/Coding, verbal memory) selectively accounted for social and role functioning at baseline and follow-up after accounting for symptoms. When negative symptom items with content overlapping with social and role functioning measures were removed, the relationship between neurocognition and social and role functioning was strengthened.

CONCLUSION

The modest overlap among neurocognition, negative symptoms, and social and role functioning indicates that these domains make substantially separate contributions to CHR individuals.

Prediction and prevention of psychosis: current progress and future tasks

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

Psychotic symptoms, cognition and affect as predictors of psychosocial problems and functional change in first-episode psychosis

OBJECTIVE

To enable further understanding of how cognitive deficits and psychopathology impact psychosocial functioning in first-episode psychosis patients, we investigated how psychopathology and cognitive deficits are associated with psychosocial problems at baseline, and how these predict psychosocial functioning at 12 months follow-up. Also, we tested whether the effect of baseline psychopathology on psychosocial functioning decreases between baseline and 12 months and the effect of baseline cognition increases.

METHODS

Eight neurocognitive and four social cognitive subdomains and psychopathology (positive and negative symptoms, depression and anxiety) were assessed at baseline in 153 non-affective first-episode psychosis (FEP) patients. Psychosocial functioning (work/study, relationships, self-care, disturbing behavior and general psychosocial functioning) was assessed at baseline and 12 months. Spearman correlations were examined and backward regression models were computed to test our hypotheses.

RESULTS

At baseline, psychosocial functioning was associated strongest with positive and negative symptoms of all assessed clinical domains, followed by neurocognition and social cognition. In contrast, psychosocial functioning at 12 months was not predicted by psychotic symptoms, but rather by neurocognition, social cognition and depression. Change in social functioning in the first 12 months after baseline was predicted by positive and negative symptoms, but to a similar degree by neurocognition and social cognition.

CONCLUSIONS

Whereas psychotic symptoms show marked impact on psychosocial functioning at illness onset, cognitive deficits appear to be more accurate longitudinal predictors of psychosocial problems and functional recovery in the early course of psychosis.

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

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

Short-term functional outcome and premorbid adjustment in clinical high-risk patients. Results of the EPOS project

PURPOSE

In patients with schizophrenia, premorbid psychosocial adjustment is an important predictor of functional outcome. We studied functional outcome in young clinical high-risk (CHR) patients and how this was predicted by their childhood to adolescence premorbid adjustment.

METHODS

In all, 245 young help-seeking CHR patients were assessed with the Premorbid Adjustment Scale, the Structured Interview for Prodromal Syndromes (SIPS) and the Schizophrenia Proneness Instrument (SPI-A). The SIPS assesses positive, negative, disorganised, general symptoms, and the Global Assessment of Functioning (GAF), the SPI-A self-experienced basic symptoms; they were carried out at baseline, at 9-month and 18-month follow-up. Transitions to psychosis were identified. In the hierarchical linear model, associations between premorbid adjustment, background data, symptoms, transitions to psychosis and GAF scores were analysed.

RESULTS

During the 18-month follow-up, GAF scores improved significantly, and the proportion of patients with poor functioning decreased from 74% to 37%. Poor premorbid adjustment, single marital status, poor work status, and symptoms were associated with low baseline GAF scores. Low GAF scores were predicted by poor premorbid adjustment, negative, positive and basic symptoms, and poor baseline work status. The association between premorbid adjustment and follow-up GAF scores remained significant, even when baseline GAF and transition to psychosis were included in the model.

CONCLUSION

A great majority of help-seeking CHR patients suffer from deficits in their functioning. In CHR patients, premorbid psychosocial adjustment, baseline positive, negative, basic symptoms and poor working/schooling situation predict poor short-term functional outcome. These aspects should be taken into account when acute intervention and long-term rehabilitation for improving outcome in CHR patients are carried out.