Systematic Review and Meta-analysis: Psychosis Risk in Children and Adolescents With an At-Risk Mental State

Internal Validation of the Latvian Version of 16-Item Prodromal Questionnaire in A Help-Seeking Adolescent Population: Psychometric Analysis and Associated Factors

OBJECTIVES

The prodromal phase of a psychotic disorder is a period of altered functioning before the onset of the acute state; several interviews have been developed to determine whether individuals present with prodromal symptoms. The 16-item Prodromal Questionnaire (PQ-16) is a screening tool for evaluating those at risk of developing a psychotic disorder. The study aimed to evaluate the psychometric properties of the Latvian version of the PQ-16 in a sample of help-seeking adolescents referred for diagnostic assessment and look for possible associated socio-demographic and health-related factors.

METHODS

A cross-sectional study included patients admitted for evaluation between November 2022 and February 2023 in Riga's Children's Clinical University Hospital Child Psychiatry clinic. The data were collected during outpatient consultations by mental health professionals. We used the Latvian translation of PQ-16 and the socio-demographic and health-related factors questionnaire. Data were analysed with IBM SPSS 28; the scale's diagnostic accuracy and internal validity were examined.

RESULTS

The study involved 107 adolescents aged 12% to 17%, 80.5% female, with a mean age of 14.98 (CI 14.70-15.26). Socio-demographic data and health-related variables did not significantly differ between the sexes (p > 0.05). The Latvian PQ-16 demonstrated excellent internal reliability with a Cronbach's alpha of 0.890. All 16 items were found to be valid with p < 0.001. A significant number of participants (73.8%) scored above the current cut-off of ≥ 6 with a mean of 9.17 (95% CI 8.41-9.93). Certain socio-demographic factors, such as female gender (p < 0.001), fair school performance (p = 0.048) and recent changes in school performance (p < 0.001), demonstrated a significant association with higher scores. Additionally, there were found significant associations between positive screening and health-related factors such as obstetric complications (p = 0.044), smoking (p = 0.002), alcohol consumption (p = 0.021), history of bullying in school (p < 0.001) and emotional abuse at home (p = 0.011).

CONCLUSIONS

Latvian translation of PQ-16 showed high internal reliability and validity levels. Positive PQ-16 screening was associated with female gender, worsened school performance, obstetric complications, substance abuse and experienced emotional violence. The average score of 9.17 positive answers and 73.8% of participants screening positive for attenuated psychotic symptoms is significantly higher than in recent studies under similar conditions.

The impact of affective and negative symptoms on the development of psychosis in a six-year follow-up of a community-based population

PURPOSE

The Clinical High Risk (CHR) concept has a limited transition risk to psychotic disorders (PD). This study investigates the association between affective and negative symptoms, currently not included in the CHR concept, and the risk of transition to PD in a community-based population of 2185 participants in Turkey.

METHODS

Participants were assessed twice over six years using a multistage sampling technique. Two separate linear regression analyses were conducted on data from both assessments, investigating the relationship between affective and negative symptoms, subclinical and clinical psychotic experiences (PE) and progression to PD.

RESULTS

The overall transition rate to PD was 1.3%. The analysis showed no increased risk of developing PD for the 'subclinical PE only' group at follow-up, compared to the 'no PE' group. However, being classified as having 'clinical PE only' (OR: 6.23; p = 0.010) and 'clinical PE + affective/negative symptoms' (OR: 8.48; p = 0.001) at baseline was associated with an increased risk of developing PD at follow-up. The presence of 'affective/negative symptoms' at baseline was associated with an increased risk of incident subclinical PE (RR: 1.98; p = 0.001), incident clinical PE (RR: 3.14; p = 0.001), and incident PD (RR: 4.21; p = 0.030) at follow-up.

CONCLUSION

The results confirm the significance of the baseline severity of positive symptoms in predicting the transition to PD and suggest that both positive and affective/negative symptoms impact the transition risk to PD and incident psychotic symptoms. This highlights the potential utility of defining CHR groups based on a combination of positive, affective, and negative symptoms.

Effectiveness of Omega-3 Fatty Acids Versus Placebo in Subjects at Ultra-High Risk for Psychosis: The PURPOSE Randomized Clinical Trial

BACKGROUND AND HYPOTHESES

In the past 2 decades, substantial effort has been put into research on therapeutic options for people at ultra-high risk (UHR) for developing a first episode of psychosis (FEP), focusing on omega-3 polyunsaturated fatty acids (PUFAs) in preventing transition to psychosis. Despite an initial positive finding, subsequent studies failed to find a beneficial effect. The current study aimed to further investigate the effect of omega-3 PUFAs in UHR, to determine whether this line of research is worth pursuing.

STUDY DESIGN

A double-blind, randomized, placebo-controlled study testing the efficacy of 6-month treatment with omega-3 PUFAs in 135 subjects at UHR for FEP, aged 13 to 20 years on the prevention of a transition to psychosis, followed up for 18 months post-treatment. The trial was conducted at 16 general hospitals and psychiatric specialty centers located in 8 European countries and Israel.

STUDY RESULTS

There was no beneficial effect of treatment with omega-3 PUFAs compared to placebo; the rate of transition over 2 years did not differ between treatment arms nor was there a difference in change in symptom severity after 6-month treatment. Dropout rates and serious adverse events were similar across the groups.

CONCLUSIONS

This is the third study that fails to replicate the original finding on the protective effect of omega-3 PUFAs in UHR subjects for transition to psychosis. The accumulating evidence therefore suggests that omega-3 PUFAs do not reduce transition rates to psychosis in those at increased risk at 2 years follow-up.

CLINICAL TRIALS

This trial is registered with ClinicalTrials.gov (NCT02597439; Study Details | Placebo-controlled Trial in Subjects at Ultra-high Risk for Psychosis With Omega-3 Fatty Acids in Europe | ClinicalTrials.gov).

Clinical and functional outcomes at 7-year follow-up of children presenting putative antecedents of schizophrenia at age 9-12 years

Identification of youth presenting early risk factors for psychosis may facilitate preventive intervention. Through school-based screening, we recruited 112 children aged 9-12 years who presented multiple putative antecedents of schizophrenia (ASz), a family history of schizophrenia (FHx), or neither of these risk factors (typically-developing; TD). Clinical and functional outcomes were assessed at age 17-21 years (N = 93). Compared to the TD group, the ASz group had higher total Prodromal Questionnaire (PQ) scores (β = 10.59, 95% CI = 3.76, 17.42) and total psychopathology scores (β = 6.13, 95% CI: 1.03, 11.23), were more likely to score above-threshold on the PQ positive symptoms scale (OR = 4.00, 95% CI = 1.08, 14.83), and had lower scores on the Social and Occupational Functioning Scale (β = -9.43, 95% CI = -15.08, -3.77) at follow-up. The FHx and TD groups did not differ on any outcome. Findings suggest that population screening for putative antecedents of schizophrenia may identify children who would benefit from preventative intervention.

Schizophrenia spectrum disorders in children and adolescents: Clinical, phenomenological, diagnostic, and prognostic features across subtypes

Schizophrenia spectrum disorders (SSD) typically have a diagnostically recognizable onset in young adulthood, yet it is not unusual that help-seeking due to initial SSD-related clinical manifestations emerge in earlier developmental phases, such as childhood and adolescence. Varieties of SSD manifestations in children and adolescents can be distinguished according to variations in clinical expressivity, severity and timing (i.e. developmental stage). Some individuals may reach the full clinical threshold for a diagnosis of schizophrenia according to the same descriptive diagnostic criteria used for adults, and in this case, it's possible to distinguish a pre-pubertal onset in childhood (aka Very Early Onset Schizophrenia, VEOS) and a post-pubertal onset in adolescence (aka Early Onset Schizophrenia, EOS). Other individuals may not reach such clinically overt diagnostic threshold but nonetheless present Childhood Schizotypal Disorder (CSD) or a Clinical High-Risk for Psychosis (CHRP). While EOS is clinically more similar to the canonical adult-onset presentation, the other 3 subgroups (i.e. VEOS, CSD, CHRP) present more nuances and specific clinical characteristics, which require ad-hoc developmental and phenomenological considerations for appropriate differential diagnosis and prognosis. Therefore, current scoping review intends to saturate such knowledge gap with respect to early SSD-phenotypes.

Psychotic-like experiences in a nationally representative study of general population adolescents

BACKGROUND

Subclinical psychotic-like experiences (PLEs) are common among general population adolescents but have been found to correlate with various problems in well-being. Due to limited sample sizes these effects have not been well differentiated by sex and age.

METHODS

Using a nationally representative survey of almost 160,000 adolescents, we studied endorsement and correlates of PLEs by sex among middle adolescence pupils (ages 14-16) and late adolescence students (ages 16-20). PLEs were investigated with three questionnaire items: auditory and visual hallucinatory experiences and suspicious thought content, using a frequency response scale.

RESULTS

Weekly PLEs were reported by 14 % of the adolescents, more often in females (17 %) than males (11 %) and in the younger age group (17 %) compared to the older adolescents (10 %). A latent PLE factor represented the three assessed PLEs with good fit. Factor scores were highest for the younger females and lowest for the older males. The PLE factor correlated with two latent factors of other well-being, namely living environment ("adversity", loading most heavily on parental mental abuse; r = 0.63), and concurrent mental health ("distress", loading most heavily on depressive symptoms; r = 0.50). Adversity was associated especially strongly with PLEs in 14-16-year-old males.

CONCLUSIONS

This cross-sectional study reaching the whole 14-20 age group in schools in Finland offers data on the meaning and relevance of PLEs as general markers of vulnerability. Many adolescents experience PLEs recurrently and these experiences are associated with a wide variety of burden in the adolescent's everyday life.

Identification and treatment of individuals with childhood-onset and early-onset schizophrenia

Approximately 8 % of patients with schizophrenia are diagnosed before age 18, and 18 % experience their first symptoms before age 18. This narrative review explores the management of patients with early-onset schizophrenia (EOS) and childhood-onset schizophrenia (COS) from diagnosis to their transition to adult care settings. Early diagnosis of schizophrenia in children and adolescents is essential for improving outcomes, but delays are common due to overlapping of symptoms with developmental phenomena and other psychiatric conditions, including substance use, and lack of clinicians' awareness. Once diagnosed, antipsychotic treatment is key, with specific second-generation agents generally being preferred due to better tolerability and their broader efficacy evidence-base in youth. Dosing should be carefully individualized, considering age-related differences in drug metabolism and side effect liability. Clinicians must be vigilant in detecting early non-response and consider switching or dose escalation when appropriate. Since early age of illness onset is a consistent risk factor for treatment-resistant schizophrenia (TRS), clinicians need to be competent in diagnosing TRS and using clozapine. Since COS and EOS are associated with cognitive deficits and impaired functioning, psychosocial interventions should be considered to improve overall functioning and quality of life. Good long-term outcomes depend on continuous treatment engagement, and successful transitioning from pediatric to adult care requires careful planning, early preparation, and collaboration between pediatric and adult clinicians. Targeting functional outcomes and quality of life in addition to symptom remission can improve overall patient well-being. Comprehensive evaluations, age-specific assessments, and targeted interventions are needed to address the unique challenges of EOS and COS.

Examining psychotic experiences in two generations - findings from a rural household-based cohort study; the Lolland-Falster Health Study

BACKGROUND

Psychotic disorders are highly heritable, yet the evidence is less clear for subclinical psychosis expression, such as psychotic experiences (PEs). We examined if PEs in parents were associated with PEs in offspring.

METHODS

As part of the Danish general population Lolland-Falster Health Study, families with youths aged 11-17 years were included. Both children and parents reported PEs according to the Psychotic Like Experiences Questionnaire, counting only 'definite' PEs. Parents additionally reported depressive symptoms, anxiety, and mental wellbeing. The associations between parental and child PEs were estimated using generalized estimating equations with an exchangeable correlation structure to account for the clustering of observations within families, adjusting for sociodemographic characteristics.

RESULTS

Altogether, 984 youths (mean age 14.3 years [s.d. 2.0]), 700 mothers, and 496 fathers from 766 households completed PEs-questionnaires. Offspring of parents with PEs were at an increased risk of reporting PEs themselves (mothers: adjusted risk ratio (aRR) 2.42, 95% CI 1.73-3.38; fathers: aRR 2.25, 95% CI 1.42-3.59). Other maternal problems (depression, anxiety, and poor mental well-being), but not paternal problems, were also associated with offspring PEs. In multivariate models adjusting for parental problems, PEs, but not other parental problems, were robustly associated with offspring PEs (mothers: aRR 2.25, 95% CI 1.60-3.19; fathers: aRR 2.44, 95% CI 1.50-3.96).

CONCLUSIONS

The current findings add novel evidence suggesting that specific psychosis vulnerability in families is expressed at the lower end of the psychosis continuum, underlining the importance of assessing youths' needs based on psychosis vulnerability broadly within the family systems.

Clinical and neurodevelopmental predictors of psychotic disorders in children and adolescents at clinical high risk for psychosis: the CAPRIS study

BACKGROUND

The neurodevelopmental hypothesis of schizophrenia represents the disorder as an expression of an alteration during the brain development process early in life. Neurodevelopmental variables could become a trait marker, and the study of these variables in children and adolescents at clinical high risk for psychosis (CHR) could identify a specific cluster of patients who later developed psychosis. The aim of this study is to describe clinical and neurodevelopment predictors of transition to psychosis in child and adolescent participants at CHR. Naturalistic longitudinal two-center study of 101 CHR and 110 healthy controls (HC) aged 10-17. CHR participants were children and adolescents aged 10-17, meeting one or more of the CHR criteria assessed at baseline and at 18 months' follow-up. Neurodevelopmental variables assessed were obstetric complications, delay in principal development milestones, and presence of a neurodevelopment diagnosis. Pairwise comparisons, linear regressions, and binary logistic regression were performed.A transition rate of 23.3% at 1.5 years was observed. Participants who developed psychosis (CHR-P) showed higher rates of grandiosity and higher proportions of antipsychotic medication intake at baseline compared to participants who did not develop a psychotic disorder (CHR-NP). In terms of neurodevelopment alterations, CHR-P group showed a higher proportion of participants reporting delay in language development than the CHR-NP and HC groups. The odds of psychosis increased by 6.238 CI 95% [1.276-30.492] for a one-unit increase in having a positive score in grandiosity; they increased by 4.257 95% CI [1.293-14.023] for a one-unit increase in taking antipsychotic medication, and by 4.522 95% [1.185-64.180] for showing language development delay. However, the p-values did not reach significance after adjusting for multiple comparisons.A combination of clinical and neurodevelopmental alterations could help predict the transition to psychotic disorder in a CHR child and adolescent sample. Our results suggest the potential utility of collecting information about neurodevelopment and using these variable multifactorial models to predict psychosis disorders.

The effectiveness of public health interventions, initiatives, and campaigns designed to improve pathways to care for individuals with psychotic disorders: A systematic review

PURPOSE

Lengthy duration of untreated psychosis (DUP) and duration of untreated illness (DUI) in people at clinical high-risk for psychosis (CHR-P) and first episode psychosis (FEP) is associated with poorer outcomes. However, individuals with FEP often experience negative pathways to care involving contacts with police, crisis services and requiring compulsory admissions, and evidence suggests individuals with both FEP and CHR-P often experience lengthy delays to treatment. Early detection interventions, such as public health interventions, may be one way to reduce delays. This systematic review aimed to synthesise the available evidence on such interventions.

METHODS

The EMBASE, PsychINFO, CINAHL, and MEDLINE databases were searched. Studies were included if they compared an intervention designed to improve timely access to treatment for individuals with FEP or CHR-P to standard treatment provision. Interventions may be targeted at potential patients, their families, the general public, or non-healthcare professionals. Outcomes of interest were DUP or DUI, and/or characteristics of pathways to care.

RESULTS

Nineteen studies met the inclusion criteria. All consisted of FEP populations, none of CHR-P populations. Employing narrative synthesis, we found mixed results about the effectiveness of interventions at reducing DUP and interventions appeared to differentially impact groups. Pathways to care information was limited and mixed.

CONCLUSION

Findings on the effectiveness of interventions designed to improve timely access to treatment were inconclusive. More research is warranted to better understand where delays occur and factors which may influence this for both FEP and CHR-P populations which may help to develop targeted interventions to address delays.

Heterogeneity of clinical symptomatology in pediatric patients at clinical high risk for psychosis

OBJECTIVE

Widespread use of diagnostic tools like the Structured Interview for Prodromal Symptoms (SIPS) has highlighted that youth at Clinical High Risk for Psychosis (CHR-P) present with heterogeneous symptomatology. This pilot study aims to highlight the range of clinical characteristics of CHR-P youth, investigate the role of the non-positive (negative, disorganization, and general) symptoms in risk assessment, and determine if specific profiles are associated with severe symptomatology.

METHODS

38 participants aged 7-18 were administered the SIPS and designated as CHR-P. Descriptive statistics and mean difference t-tests were used to describe the range in prevalence and severity of SIPS symptoms and to identify symptoms associated with greater overall symptomatology.

RESULTS

Participants who had a greater number of positive symptoms also had significantly more negative, disorganization, and general symptoms. A number of SIPS symptoms were associated with greater number of positive symptoms.

CONCLUSION

CHR-P youth represent a heterogeneous group, presenting with a wide range in clinical presentation as reflected in both the number of SIPS symptoms and their severity. Though the severity and duration of positive SIPS symptoms determines the CHR-P classification, high ratings on several of the other SIPS negative, disorganization, and general items may be useful indicators of elevated symptomatology.

Psychotic symptoms with and without a primary psychotic disorder in children requiring inpatient mental health admission

Psychotic symptoms are relatively common in children and adolescents attending mental health services. On most occasions, their presence is not associated with a primary psychotic disorder, and their clinical significance remains understudied. No studies to date have evaluated the prevalence and clinical correlates of psychotic symptoms in children requiring inpatient mental health treatment. All children aged 6 to 12 years admitted to an inpatient children's unit over a 9-year period were included in this naturalistic study. Diagnosis at discharge, length of admission, functional impairment, and medication use were recorded. Children with psychotic symptoms without a childhood-onset schizophrenia spectrum disorder (COSS) were compared with children with COSS and children without psychotic symptoms using Chi-square and linear regressions. A total of 211 children were admitted during this period with 62.4% experiencing psychotic symptoms. The most common diagnosis in the sample was autism spectrum disorder (53.1%). Psychotic symptoms were not more prevalent in any diagnosis except for COSS (100%) and intellectual disability (81.8%). Psychotic symptoms were associated with longer admissions and antipsychotic medication use. The mean length of admission of children with psychotic symptoms without COSS seems to lie in between that of children without psychotic symptoms and that of children with COSS. We concluded that psychotic symptoms in children admitted to the hospital may be a marker of severity. Screening for such symptoms may have implications for treatment and could potentially contribute to identifying more effective targeted interventions and reducing overall morbidity.

An exploratory study of psychosis risk factors in individuals who are referred but do not meet criteria for an early intervention in psychosis service

BACKGROUND

The 'at-risk mental state' (ARMS) for psychosis has been critiqued for its limited prognostic ability and identification of a limited proportion of those who will develop a first episode of psychosis (FEP). Broadening the search for high-risk groups is key to improving population-level ascertainment of psychosis risk.

AIMS

To explore risk enrichment in diagnostic, demographic and socio-functional domains among individuals referred to an early intervention in psychosis (EIP) service not meeting ARMS or FEP criteria.

METHOD

A retrospective file review of 16 years of referrals to a tertiary EIP service in Ireland was undertaken. Diagnostic outcomes from standardised assessments (Structured Clinical Interview for DSM), demographic (age, gender, family history, nationality) and socio-occupational (relationship status, living status, working status) variables were compiled for those not meeting criteria. These were compared with individuals diagnosed with an FEP in the same period.

RESULTS

From 2005 to 2021 inclusive, of 2025 index assessments, 27.6% (n = 558) did not meet either FEP or ARMS criteria, which is notably higher than the 5.4% (n = 110) meeting ARMS criteria. This group had high psychiatric morbidity, with 65.4% meeting criteria for at least one DSM Axis I disorder. Depressive, anxiety and substance use disorders predominated. Their functional markers were poor, and comparable to the FEP cohort.

CONCLUSIONS

This group is enriched for psychosis risk factors. They are a larger group than those meeting ARMS criteria, a finding that may reflect EIP service configuration. They may be an important focus for further study in the search for at-risk populations beyond the current ARMS model.

Debate: Child and adolescent mental health services: time to take the lead in prevention of psychosis in youth

Children and adolescents are at risk of developing mental disorders that have lifelong consequences. This debate piece argues that youth meeting the criteria for clinical high risk for psychosis cannot be assessed and treated with the same tools as adults, given that they often present with different patterns and timecourse of symptoms, age-specific comorbidities and follow different pathways to care. It looks at the key role that Child and Adolescent Mental Health Services and other professionals can play by using an age-specific approach to detecting and preventing psychosis.

Recent Updates on Predicting Conversion in Youth at Clinical High Risk for Psychosis

PURPOSE OF REVIEW

This review highlights recent advances in the prediction and treatment of psychotic conversion. Over the past 25 years, research into the prodromal phase of psychotic illness has expanded with the promise of early identification of individuals at clinical high risk (CHR) for psychosis who are likely to convert to psychosis.

RECENT FINDINGS

Meta-analyses highlight conversion rates between 20 and 30% within 2-3 years using existing clinical criteria while research into more specific risk factors, biomarkers, and refinement of psychosis risk calculators has exploded, improving our ability to predict psychotic conversion with greater accuracy. Recent studies highlight risk factors and biomarkers likely to contribute to earlier identification and provide insight into neurodevelopmental abnormalities, CHR subtypes, and interventions that can target specific risk profiles linked to neural mechanisms. Ongoing initiatives that assess longer-term (> 5-10 years) outcome of CHR participants can provide valuable information about predictors of later conversion and diagnostic outcomes while large-scale international biomarker studies provide hope for precision intervention that will alter the course of early psychosis globally.

Prognostic models predicting transition to psychotic disorder using blood-based biomarkers: a systematic review and critical appraisal

Accumulating evidence suggests individuals with psychotic disorder show abnormalities in metabolic and inflammatory processes. Recently, several studies have employed blood-based predictors in models predicting transition to psychotic disorder in risk-enriched populations. A systematic review of the performance and methodology of prognostic models using blood-based biomarkers in the prediction of psychotic disorder from risk-enriched populations is warranted. Databases (PubMed, EMBASE and PsycINFO) were searched for eligible texts from 1998 to 15/05/2023, which detailed model development or validation studies. The checklist for Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies (CHARMS) was used to guide data extraction from eligible texts and the Prediction Model Risk of Bias Assessment Tool (PROBAST) was used to assess the risk of bias and applicability of the studies. A narrative synthesis of the included studies was performed. Seventeen eligible studies were identified: 16 eligible model development studies and one eligible model validation study. A wide range of biomarkers were assessed, including nucleic acids, proteins, metabolites, and lipids. The range of C-index (area under the curve) estimates reported for the models was 0.67-1.00. No studies assessed model calibration. According to PROBAST criteria, all studies were at high risk of bias in the analysis domain. While a wide range of potentially predictive biomarkers were identified in the included studies, most studies did not account for overfitting in model performance estimates, no studies assessed calibration, and all models were at high risk of bias according to PROBAST criteria. External validation of the models is needed to provide more accurate estimates of their performance. Future studies which follow the latest available methodological and reporting guidelines and adopt strategies to accommodate required sample sizes for model development or validation will clarify the value of including blood-based biomarkers in models predicting psychosis.

Reduced magnetic mismatch negativity: a shared deficit in psychosis and related risk

BACKGROUND

Abnormal auditory processing of deviant stimuli, as reflected by mismatch negativity (MMN), is often reported in schizophrenia (SCZ). At present, it is still under debate whether this dysfunctional response is specific to the full-blown SCZ diagnosis or rather a marker of psychosis in general. The present study tested MMN in patients with SCZ, bipolar disorder (BD), first episode of psychosis (FEP), and in people at clinical high risk for psychosis (CHR).

METHODS

Source-based MEG activity evoked during a passive auditory oddball task was recorded from 135 patients grouped according to diagnosis (SCZ, BD, FEP, and CHR) and 135 healthy controls also divided into four subgroups, age- and gender-matched with diagnostic subgroups. The magnetic MMN (mMMN) was analyzed as event-related field (ERF), Theta power, and Theta inter-trial phase coherence (ITPC).

RESULTS

The clinical group as a whole showed reduced mMMN ERF amplitude, Theta power, and Theta ITPC, without any statistically significant interaction between diagnosis and mMMN reductions. The mMMN subgroup contrasts showed lower ERF amplitude in all the diagnostic subgroups. In the analysis of Theta frequency, SCZ showed significant power and ITPC reductions, while only indications of diminished ITPC were observed in CHR, but no significant decreases characterized BD and FEP.

CONCLUSIONS

Significant mMMN alterations in people experiencing psychosis, also for diagnoses other than SCZ, suggest that this neurophysiological response may be a feature shared across psychotic disorders. Additionally, reduced Theta ITPC may be associated with risk for psychosis.

Lost in Translation: Challenges in the Diagnosis and Treatment of Early-Onset Schizophrenia

Early-onset schizophrenia (EOS) is a heterogeneous condition that has a serious, insidious clinical course and poor long-term mental health outcomes. The clinical presentations are highly complex due to the overlapping symptomatology with other illnesses, which contributes to a delay in the diagnosis. The objective of the review is to study if an earlier age of onset (AAO) of EOS has poor clinical outcomes, the diagnostic challenges of EOS, and effective treatment strategies. The review provides a comprehensive literature search of 5966 articles and summarizes 126 selected for empirical evidence to methodically consider challenges in diagnosing and treating EOS for practicing clinicians. The risk factors of EOS are unique but have been shared with many other neuropsychiatric illnesses. Most of the risk factors, including genetics and obstetric complications, are nonmodifiable. The role of early diagnosis in reducing the duration of untreated psychosis (DUP) remains critical to reducing overall morbidity. Many specific issues contribute to the risk and clinical outcomes. Therefore, issues around diagnostic ambiguity, treatment resistance, nonadherence, and rehospitalizations further extend the DUP. There is hesitancy to initiate clozapine early, even though the empirical evidence strongly supports its use. There is a growing body of research that suggests the use of long-acting injectables to address nonadherence, and these measures are largely underutilized in acute settings. The clinical presentations of EOS are complex. In addition to the presence of specific risk factors, patients with an early onset of illness are also at a higher risk for treatment resistance. While there is a need to develop tools for early diagnosis, established evidence-based measures to address nonadherence, psychoeducation, and resistance must be incorporated into the treatment planning.

Investigating the effectiveness of three school based interventions for preventing psychotic experiences over a year period - a secondary data analysis study of a randomized control trial

INTRODUCTION

Psychotic experiences (PEs) are associated with increased risk of later mental disorders and so could be valuable in prevention studies. However, to date few intervention studies have examined PEs. Given this lack of evidence, in the current study a secondary data analysis was conducted on a clustered-randomized control trial (RCT) of 3 school based interventions to reduce suicidal behaviour, to investigate if these may reduce rates of PEs, and prevent PE, at 3-month and 1-year follow-up.

METHODS

The Irish site of the Saving and Empowering Young Lives in Europe study, trial registration (DRKS00000214), a cluster-RCT designed to examine the effect of school-based interventions on suicidal thoughts and behaviour. Seventeen schools (n = 1096) were randomly assigned to one of three intervention arms or a control arm. The interventions included a teacher training (gate-keeper) intervention, an interactive educational (universal-education) intervention, and a screening and integrated referral (selective-indicative) intervention. The primary outcome of this secondary data-analysis was reduction in point-prevalence of PEs at 12 months. A second analysis excluding those with PEs at baseline was conducted to examine prevention of PEs. Additional analysis was conducted of change in depression and anxiety scores (comparing those with/without PEs) in each arm of the intervention. Statistical analyses were conducted using mixed-effects modelling.

RESULTS

At 12-months, the screening and referral intervention was associated with a significant reduction in PEs (OR:0.12,95%CI[0.02-0.62]) compared to the control arm. The teacher training and education intervention did not show this effect. Prevention was also observed only in the screening and referral arm (OR:0.30,95%CI[0.09-0.97]). Participants with PEs showed higher levels of depression and anxiety symptoms, compared to those without, and different responses to the screening and referral intervention & universal-education intervention.

CONCLUSIONS

This study provides the first evidence for a school based intervention that reduce & prevent PEs in adolescence. This intervention is a combination of a school-based screening for psychopathology and subsequent referral intervention significantly reduced PEs in adolescents. Although further research is needed, our findings point to the effectiveness of school-based programmes for prevention of future mental health problems.

Specific adolescent prodromal symptoms associated with onset of psychosis in the Northern Finland Birth Cohort 1986

BACKGROUND

Several psychological symptoms in adolescence associate with later development of psychosis. However, it is unclear which symptoms specifically predict psychotic disorders rather than psychiatric disorders in general. We conducted a prospective study comparing how specific adolescent psychotic-like symptoms, predicted psychotic and non-psychotic hospital-treated psychiatric disorders in the population-based Northern Finland Birth Cohort 1986 (NFBC1986).

METHODS

At age 15-16 years, 6632 members of the NFBC1986 completed the PROD-screen questionnaire. New hospital-treated mental disorders of the NFBC1986 participants were detected between age 17 and 30 years from the Finnish Care Register for Health Care. Multiple covariates were used in the analysis.

RESULTS

During the follow-up, 1.1% of the participants developed a psychotic and 3.2% a non-psychotic psychiatric disorder. Three symptoms were specifically associated with onset of psychosis compared to non-psychotic psychiatric disorders: 'Difficulty in controlling one's speech, behaviour or facial expression while communicating' (adjusted OR 4.00; 95% CI 1.66-9.92), 'Difficulties in understanding written text or heard speech' (OR 2.25; 1.12-4.51), and 'Difficulty or uncertainty in making contact with other people' (OR 2.20; 1.03-4.67). Of these, the first one remained statistically significant after Bonferroni correction for multiple comparisons.

CONCLUSION

To our knowledge, this is the first general-population-based prospective study exploring psychiatric symptoms predicting the onset of hospital-treated first-episode psychosis in comparison to non-psychotic disorders. We found three symptoms related with difficulties in social interaction which predicted onset of psychosis. This is a novel finding and should be replicated.

Potential for prediction of psychosis and bipolar disorder in Child and Adolescent Mental Health Services: a longitudinal register study of all people born in Finland in 1987

Current strategies to predict psychosis identify only a small proportion of individuals at risk. Additional strategies are needed to increase capacity for pre-diction and prevention of serious mental illness, ideally during childhood and adolescence. One possible approach would be to investigate systems in which psychosis risk factors are concentrated during childhood. One notable such system is represented by Child and Adolescent Mental Health Services (CAMHS). Although psychotic disorders are uncommon in CAMHS, many risk factors for psychosis are highly prevalent in young people who enter this system. We hypothesized, therefore, that youth attending CAMHS would be a high-risk group for psychosis if followed into adulthood and, furthermore, that CAMHS systems would capture a substantial proportion of future psychosis cases. We constructed a total population cohort study of all Finns born in 1987 (N=55,875), linking together extensive register data on health care contacts from birth through age 28 years. We identified all individuals diagnosed with a psychotic or bipolar disorder by age 28 (N=1,785). The risk of psychosis/bipolar disorder by age 28 years was 1.8% for individuals who had not attended CAMHS during childhood or adolescence, whereas it was 12.8% for those with a history of any outpatient CAMHS contact (odds ratio, OR=7.9, 95% CI: 7.2-8.7). Furthermore, the risk of psychosis/bipolar disorder by age 28 years was 2.3% for individuals without a history of inpatient CAMHS admission, whereas it was 24.0% for those with a history of inpatient CAMHS admission (OR=13.3, 95% CI: 11.9-14.9), and 36.5% for those with a history of inpatient CAMHS admission in adolescence (age 13-17 years) (OR=24.2, 95% CI: 21.2-27.6). Individuals who attended CAMHS but received no mental disorder diagnosis had an equally high risk of subsequently developing a psychosis/bipolar disorder as individuals who did receive a diagnosis (OR=0.9, 99.5% CI: 0.7-1.1). Compared to other CAMHS attendees, individuals who developed psychosis or bipolar disorder were more likely to have had an initial CAMHS diagnosis of depressive or other mood disorder (OR=2.3, 99.5% CI: 1.6-3.0) and disruptive behaviour disorder (OR=1.7, 99.5% CI: 1.2-2.5). Of all psychosis/bipolar diagnoses by age 28 years, 50.2% occurred in individuals who had, at some point in childhood or adolescence, attended CAMHS, indicating that CAMHS represent not only a high-risk but also a high-capacity system for prediction of psychosis/bipolar disorder. These findings suggest an enormous, untapped potential for large-scale psychosis/bipolar disorder prediction and prevention research within existing specialist CAMHS.

No Meta-analytic Effect of Age on Probability of Developing Psychosis in Individuals at Clinical High Risk

OBJECTIVE

The clinical high risk for psychosis (CHR-P) holds the potential to improve outcomes through primary indicated prevention. Its impact is determined by efficient detection, prognostication and prophylactic interventions. Specifically, ascertaining the likelihood of psychosis onset from a CHR-P state is of paramount relevance to inform clinical care. The objective of this paper is to provide a critical analysis of the impact of age on the likelihood of developing psychosis in CHR-P individuals.

METHOD

Critical analysis of recent publications in the light of evidence-based meta-analyses.

RESULTS

Recent meta-analyses showed that the probability of developing psychosis from a CHR-P, which cumulates to 19% (95% CI 17% to 22%) at 2 years, increasing to 28% (95% CI 20% to 37%) at >4 years. Some studies suggest that lower age of CHR-P individuals is associated with a reduced transition to psychosis, but these studies are biased by the use of an arbitrary cut-off at the age of 18 years, which conflicts with the neurodevelopmental biology and the transitional (ie, including both adolescents and young adults) nature of the CHR-P paradigm. When age is tested as a continuous predictor in meta-regression analyses, there is no evidence that it is associated with the probability of developing psychosis (β = 0.0165, 95% CI -0.0362 to 0.0692).

CONCLUSIONS

There is no evidence that age impacts the probability of developing psychosis in individuals at CHR-P. Adolescents at CHR-P remain a vulnerable patient group that needs ongoing collaborative research and preventive efforts.

Editorial: Can At-Risk Mental State (ARMS) Diagnosis in Children and Adolescents Predict Transition to a Psychotic Disorder? We Are Not There Yet

Psychosis is one of the most extreme and feared forms of psychopathology. Because early intervention leads to better outcomes for psychotic disorders, our field is highly motivated to identify this problem in its earliest stages. Ideally, early intervention during childhood and adolescence would be optimal to help restore healthy brain development and prevent the onset of a psychotic disorder. Structural clinical interviews have been developed to identify youth who are at high risk for psychosis, based largely on the presence of attenuated and/or transient psychotic symptoms. However, these evaluations are challenging because of vast developmental differences among children, adolescents, and adults in how these experiences are understood and expressed. In the wake of a growing body of literature examining the utility of assessments for At Risk Mental States (ARMS) for predicting later transition to a psychotic disorder, the time is ripe for a systematic review to assess the state of this emerging field.

A Latent Profile Analysis of Psychotic Experiences, Non-psychotic Symptoms, Suicidal Ideation and Underlying Mechanisms in a Sample of Adolescents From the General Population

Psychotic experiences (PEs) are prevalent in the general population, particularly in adolescents. PEs are associated with various negative outcomes such as psychotic, depressive, anxiety and post-traumatic stress disorders and suicidal behavior. Recent studies in the general population have suggested that what makes PEs relevant is not so much the experiences per se, but their association with non-psychotic comorbidity and other transdiagnostic domains. Thus, there is a need for a better understanding of how PEs exist in a larger psychopathological context in adolescents. In the present study we aimed to explore this, using latent profile analysis (LPA) to identify different patterns in which PEs, psychiatric symptoms and psychological processes co-occur. LPA was conducted using data from an adolescent general population subsample (n = 335) with PEs. We conducted LPA, using measures of PEs, psychiatric symptoms and behaviors (depression, anxiety post-traumatic stress disorder and suicidal behavior) and cognitive and affective processes of entrapment/defeat and emotional regulation as manifest variables. We found that the best fit was obtained with a four-class solution that distinguished primarily between different levels of overall severity: "low symptomatology" (19.1%), "mild-moderate symptomatology" (39.4%), "moderate symptomatology" (33.7%); "high symptomatology" (7.8%). Levels of depression, post-traumatic stress symptoms and defeat/entrapment were most differentiated between classes. The high symptomatology group showed the highest scores in all psychiatric symptoms suicidal ideation, and emotional/cognitive domains, except in cognitive reappraisal. This group also showed the highest usage of emotional suppression. Our results suggest that the assessment of mental health risk in adolescents should be aware that PEs exist in a broad context of other domains of psychopathology and transdiagnostic cognitive and affective processes.

Screening for Early Emerging Mental Experiences (SEE ME): A Model to Improve Early Detection of Psychosis in Integrated Primary Care

Early intervention in serious mental health conditions relies on the accurate identification of adolescents and young adults at high risk or with very recent onset of psychosis. Current early detection strategies have had limited success, identifying only a fraction of these individuals within the recommended 3- to 6-month window. Broader public health strategies such as population screening are hampered by low base rates and poor self-report screen specificity. Screening for Early Emerging Mental Experiences (SEE ME) is a three-stage "SCREEN-TRIAGE-ENGAGE" model for the early detection of psychosis in integrated primary care adolescent and young adult patients during the period of peak onset. It builds on the KNOW THE SIGNS-FIND THE WORDS-MAKE THE CONNECTION framework outlined on psychosisscreening.org and developed with input from community collaborators. Systematic screening aims to expand the reach of early detection and reduce reliance on provider knowledge. Triage and engagement by trained mental health clinicians aims to improve the specificity of screen responses, enhance engagement in appropriate care, and reduce provider burden. Leveraging the low stigma of primary care, its reach to non-help-seeking adolescents and young adults, and the mental health training of clinicians within integrated care practices, SEE ME has potential to improve the benefit/risk ratio of early detection of psychosis by improving both the sensitivity and specificity of screening and clinical response. We review the rationale and design of this promising model.