Symptomatic and functional outcome in youth at ultra-high risk for psychosis: a longitudinal study

Non-psychotic Outcomes in Young People at Ultra-High Risk of Developing a Psychotic Disorder: A Long-Term Follow-up Study

BACKGROUND

The majority of individuals at ultra-high risk (UHR) for psychosis do not transition to a full threshold psychotic disorder. It is therefore important to understand their longer-term clinical and functional outcomes, particularly given the high prevalence of comorbid mental disorders in this population at baseline.

AIMS

This study investigated the prevalence of non-psychotic disorders in the UHR population at entry and long-term follow-up and their association with functional outcomes. Persistence of UHR status was also investigated.

STUDY DESIGN

The sample comprised 102 UHR young people from the Personal Assessment and Crisis Evaluation (PACE) Clinic who had not transitioned to psychosis by long-term follow-up (mean = 8.8 years, range = 6.8-12.1 years since baseline).

RESULTS

Eighty-eight percent of participants at baseline were diagnosed with at least one mental disorder, the majority of which were mood disorders (78%), anxiety disorders (35%), and substance use disorders (SUDs) (18%). This pattern of disorder prevalence continued at follow-up, though prevalence was reduced, with 52% not meeting criteria for current non-psychotic mental disorder. However, 35% of participants developed a new non-psychotic mental disorder by follow-up. Presence of a continuous non-psychotic mental disorder was associated with poorer functional outcomes at follow-up. 28% of participants still met UHR criteria at follow-up.

CONCLUSIONS

The study adds to the evidence base that a substantial proportion of UHR individuals who do not transition to psychosis experience persistent attenuated psychotic symptoms and persistent and incident non-psychotic disorders over the long term. Long-term treatment and re-entry into services is indicated.

The heterogeneity of attenuated and brief limited psychotic symptoms: association of contents with age, sex, country, religion, comorbidities, and functioning

Introduction

The Attenuated Psychosis Symptoms (APS) syndrome mostly represents the ultra-high-risk state of psychosis but, as does the Brief Intermittent Psychotic Symptoms (BIPS) syndrome, shows a large variance in conversion rates. This may be due to the heterogeneity of APS/BIPS that may be related to the effects of culture, sex, age, and other psychiatric morbidities. Thus, we investigated the different thematic contents of APS and their association with sex, age, country, religion, comorbidity, and functioning to gain a better understanding of the psychosis-risk syndrome.

Method

A sample of 232 clinical high-risk subjects according to the ultra-high risk and basic symptom criteria was recruited as part of a European study conducted in Germany, Italy, Switzerland, and Finland. Case vignettes, originally used for supervision of inclusion criteria, were investigated for APS/BIPS contents, which were compared for sex, age, country, religion, functioning, and comorbidities using chi-squared tests and regression analyses.

Result

We extracted 109 different contents, mainly of APS (96.8%): 63 delusional, 29 hallucinatory, and 17 speech-disorganized contents. Only 20 contents (18.3%) were present in at least 5% of the sample, with paranoid and referential ideas being the most frequent. Thirty-one (28.5%) contents, in particular, bizarre ideas and perceptual abnormalities, demonstrated an association with age, country, comorbidity, or functioning, with regression models of country and obsessive-compulsive disorders explaining most of the variance: 55.8 and 38.3%, respectively. Contents did not differ between religious groups.

Conclusion

Psychosis-risk patients report a wide range of different contents of APS/BIPS, underlining the psychopathological heterogeneity of this group but also revealing a potential core set of contents. Compared to earlier reports on North-American samples, our maximum prevalence rates of contents were considerably lower; this likely being related to a stricter rating of APS/BIPS and cultural influences, in particular, higher schizotypy reported in North-America. The various associations of some APS/BIPS contents with country, age, comorbidities, and functioning might moderate their clinical severity and, consequently, the related risk for psychosis and/or persistent functional disability.

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.

Characteristics and clinical correlates of risk symptoms in individuals at clinical high-risk for psychosis: A systematic review and meta-analysis

Emerging evidence suggests that the duration of risk symptoms (DUR) may have an impact on clinical outcomes in clinical high-risk for psychosis (CHRP) participants. To explore this hypothesis, we performed a meta-analysis on studies that examined DUR in CHR-P individuals in relation to their clinical outcomes. This review was conducted in accordance with the PRISMA guidelines and the protocol was registered with PROSPERO on 16th April 2021 (ID no. CRD42021249443). Literature searches were conducted using PsycINFO and Web of Science in March and November 2021, for studies reporting on DUR in CHR-P populations, in relation to transition to psychosis or symptomatic, functional, or cognitive outcomes. The primary outcome was transition to psychosis, while the secondary outcomes were remission from CHR-P status and functioning at baseline. Thirteen independent studies relating to 2506 CHR-P individuals were included in the meta-analysis. The mean age was 19.88 years (SD = 1.61) and 1194 individuals (47.65 %) were females. The mean length of DUR was 23.61 months (SD = 13.18). There was no meta-analytic effect of DUR on transition to psychosis at 12-month follow-up (OR = 1.000, 95%CI = 0.999-1.000, k = 8, p = .98), while DUR was related to remission (Hedge's g = 0.236, 95%CI = 0.014-0.458, k = 4, p = .037). DUR was not related to baseline GAF scores (beta = -0.004, 95%CI = -0.025-0.017, k = 3, p = .71). The current findings suggest that DUR is not associated with transition to psychosis at 12 months, but may impact remission. However, the database was small and further research in this area is required.

Cognitive Patterns and Conversion in a Representative Sample of Individuals at Risk for Psychosis

ABSTRACT

Clinical high-risk (CHR) individuals belong to a heterogeneous group, of which only a few will cross the threshold for a clinical diagnosis. Cognitive disturbances are present in CHR subjects and may be indicative of transition. Our study aims to identify such deficits in a representative CHR for psychosis sample. Our sample comprised 92 CHR individuals and 54 controls from a representative cohort of the general population. They were followed up for a mean of 2.5 years, with 15 individuals converting to schizophrenia or other Diagnostic and Statistical Manual of Mental Disorders, 5th Edition diagnoses. Neurocognitive assessment was performed with the University of Pennsylvania Computerized Neuropsychological Testing, and CHR status was assessed with the Structured Interview for Prodromal Syndromes (SIPS). Baseline scores were entered in a latent profile analysis model. Our study brought forward a four-class model on cognitive performance. One class displayed better performance, whereas the other three performed worse, all compared with controls. The class with lower executive function also had the highest score on disorganized communication (SIPS P5 = 1.36, p < 0.05), although unrelated to conversion. Among the low performers, the class significantly related to conversion (p = 0.023) had the highest score in decreased expression of emotion (SIPS N3 = 0.85, p < 0.05). Our study brings new and relevant data on non-help-seeking CHR individuals and the relationship between cognitive patterns and conversion. We have highlighted a specific cognitive signature, associated with negative symptoms, which represents a stable trait with presumed lower conversion to a psychiatric illness.

Clinical outcomes in individuals at clinical high risk of psychosis who do not transition to psychosis: a meta-analysis

AIMS

The clinical outcomes of individuals at clinical high risk of psychosis (CHR-P) who do not transition to psychosis are heterogeneous and inconsistently reported. We aimed to comprehensively evaluate longitudinally a wide range of outcomes in CHR-P individuals not developing psychosis.

METHODS

"Preferred Reporting Items for Systematic reviews and Meta-Analyses" and "Meta-analysis Of Observational Studies in Epidemiology"-compliant meta-analysis (PROSPERO: CRD42021229212) searching original CHR-P longitudinal studies in PubMed and Web of Science databases up to 01/11/2021. As primary analysis, we evaluated the following outcomes within CHR-P non-transitioning individuals: (a) change in the severity of attenuated psychotic symptoms (Hedge's g); (b) change in the severity of negative psychotic symptoms (Hedge's g); (c) change in the severity of depressive symptoms (Hedge's g); (d) change in the level of functioning (Hedge's g); (e) frequency of remission (at follow-up). As a secondary analysis, we compared these outcomes in those CHR-P individuals who did not transition vs. those who did transition to psychosis at follow-up. We conducted random-effects model meta-analyses, sensitivity analyses, heterogeneity analyses, meta-regressions and publication bias assessment. The risk of bias was assessed using a modified version of the Newcastle-Ottawa Scale (NOS).

RESULTS

Twenty-eight studies were included (2756 CHR-P individuals, mean age = 20.4, 45.5% females). The mean duration of follow-up of the included studies was of 30.7 months. Primary analysis: attenuated psychotic symptoms [Hedges' g = 1.410, 95% confidence interval (CI) 1.002-1.818]; negative psychotic symptoms (Hedges' g = 0.683, 95% CI 0.371-0.995); depressive symptoms (Hedges' g = 0.844, 95% CI 0.371-1.317); and functioning (Hedges' g = 0.776, 95% CI 0.463-1.089) improved in CHR-P non-transitioning individuals; 48.7% remitted at follow-up (95% CI 39.3-58.2%). Secondary analysis: attenuated psychotic symptoms (Hedges' g = 0.706, 95% CI 0.091-1.322) and functioning (Hedges' g = 0.623, 95% CI 0.375-0.871) improved in CHR-P individuals not-transitioning compared to those transitioning to psychosis, but there were no differences in negative or depressive symptoms or frequency of remission (p > 0.05). Older age was associated with higher improvements of attenuated psychotic symptoms (β = 0.225, p = 0.012); publication years were associated with a higher improvement of functioning (β = -0.124, p = 0.0026); a lower proportion of Brief Limited Intermittent Psychotic Symptoms was associated with higher frequencies of remission (β = -0.054, p = 0.0085). There was no metaregression impact for study continent, the psychometric instrument used, the quality of the study or proportion of females. The NOS scores were 4.4 ± 0.9, ranging from 3 to 6, revealing the moderate quality of the included studies.

CONCLUSIONS

Clinical outcomes improve in CHR-P individuals not transitioning to psychosis but only less than half remit over time. Sustained clinical attention should be provided in the longer term to monitor these outcomes.

Changes in the cognitive function of Chinese college students with a clinical high risk of psychosis

The purpose of our study was to explore the value of measuring cognitive functions for predicting the conversion to psychosis in Chinese college students with a clinical high risk (CHR). A total of 115 CHR students and 99 healthy controls were enrolled. All included participants were recruited from colleges in Wuhan, China. The MATRICS Consensus Cognitive Battery was used to evaluate cognitive function. CHR individuals were followed for 2 years, and the cognitive function of CHR individuals who later converted to psychosis (CHR-C) was compared to CHR individuals who did not convert (CHR-NC). Of the 107 CHR individuals that completed the 2- year follow-up, 29 (27.1%) developed a psychotic disorder. CHR individuals demonstrated poorer performance on all cognitive function tests compared to controls. CHR-C participants exhibited poorer performance on all cognitive tests except the Trail Making Test A and Continuous Performance Test-Identical Pairs compared to CHR-NC participants. The most significant differences displayed between CHR-C and CHR-NC groups were in visual learning, working memory, and reasoning and problem solving. The degree of cognitive impairment in visual learning and working memory may be a predictive marker for individuals who are at risk of developing psychosis.

Conversion to psychosis in adolescents and adults: similar proportions, different predictors

BACKGROUND

Age effects may be important for improving models for the prediction of conversion to psychosis for individuals in the clinical high risk (CHR) state. This study aimed to explore whether adolescent CHR individuals (ages 9-17 years) differ significantly from adult CHR individuals (ages 18-45 years) in terms of conversion rates and predictors.

METHOD

Consecutive CHR individuals (N = 517) were assessed for demographic and clinical characteristics and followed up for 3 years. Individuals with CHR were classified as adolescent (n = 244) or adult (n = 273) groups. Age-specific prediction models of psychosis were generated separately using Cox regression.

RESULTS

Similar conversion rates were found between age groups; 52 out of 216 (24.1%) adolescent CHR individuals and 55 out of 219 (25.1%) CHR adults converted to psychosis. The conversion outcome was best predicted by negative symptoms compared to other clinical variables in CHR adolescents (χ² = 7.410, p = 0.006). In contrast, positive symptoms better predicted conversion in CHR adults (χ² = 6.585, p = 0.01).

CONCLUSIONS

Adolescent and adult CHR individuals may require a different approach to early identification and prediction. These results can inform the development of more precise prediction models based on age-specific approaches.

Efficacy of psychological interventions in young individuals at ultra-high risk for psychosis: A naturalistic study

AIM

Early detection and intervention in individuals at risk for developing psychosis have become a priority for many clinical services around the world. Limited naturalistic evidence is available on whether detection and intervention for ultra-high risk (UHR) is effective by means of reducing psychosis risk and improving functioning.

METHODS

We compared functioning scores over 5.9 (±7.7) months of time between UHR individuals (n = 61) and help-seeking adolescents without a specific UHR profile (general adolescent help-seeking population [HSP]; n = 82) aged 12 to 25 years receiving psychological interventions at a specialized UHR service in the Netherlands. Attenuated psychotic symptoms (APS) were evaluated over time within the UHR group. In addition, the impact of duration of treatment, <7 sessions, 8 to 21 sessions and >20 sessions, as well as treatment type, that is, cognitive behavioural therapy (CBT) and CBT + add on treatment, were evaluated.

RESULTS

Both UHR and HSP showed an increase in functioning over time (P < .001), with no difference between these groups. The UHR group showed a reduction of APS over time (P < .001). More than 20 treatment sessions was more effective than 1 to 6 treatment sessions (P < .01, partial eta squared = .08) and CBT was equally effective as CBT-add on in improving functioning.

CONCLUSIONS

The findings of this study suggest that psychological treatment is just as effective in improving functioning in UHR as in HSP. Moreover, it decreases APS in UHR. Improvement in functioning is not affected by treatment type, but positively affected by the duration of treatment.

Prediction of clinical outcomes beyond psychosis in the ultra-high risk for psychosis population

AIM

Several prediction models have been introduced to identify young people at greatest risk of transitioning to psychosis. To date, none has examined the possibility of developing a clinical prediction model of outcomes other than transition. The aims of this study were to examine the association between baseline clinical predictors and outcomes including, but not limited to, transition to psychosis in young people at risk for psychosis, and to develop a prediction model for these outcomes.

METHODS

Several evidence-based variables previously associated with transition to psychosis and some important clinical comorbidities experienced by ultra-high risk (UHR) individuals were identified in 202 UHR individuals. Secondary analysis of the Neurapro clinical trial were conducted to investigate the associations between these variables and favourable (remission and recovery) or unfavourable (transition to psychosis, no remission, any recurrence and relapse) clinical outcomes. Logistic regression, best subset selection, Akaike Information Criterion and receiver operating characteristic curves were used to seek the best prediction model for clinical outcomes from all combinations of possible predictors.

RESULTS

When considered individually, only higher general psychopathology levels (P = .023) was associated with the unfavourable outcomes. Prediction models suggest that general psychopathology and functioning are predictive of unfavourable outcomes.

CONCLUSION

The predictive performance of the resulting models was modest and further research is needed. Nonetheless, when designing early intervention centres aiming to support individuals in the early phases of a mental disorder, the proper assessment of general psychopathology and functioning should be considered in order to inform interventions and length of care provided.

Negative Prognostic Effect of Baseline Antipsychotic Exposure in Clinical High Risk for Psychosis (CHR-P): Is Pre-Test Risk Enrichment the Hidden Culprit?

INTRODUCTION

Sample enrichment is a key factor in contemporary early-detection strategies aimed at the identification of help-seekers at increased risk of imminent transition to psychosis. We undertook a meta-analytic investigation to ascertain the role of sample enrichment in the recently highlighted negative prognostic effect of baseline antipsychotic (AP) exposure in clinical high-risk (CHR-P) of psychosis individuals.

METHODS

Systematic review and meta-analysis of all published studies on CHR-P were identified according to a validated diagnostic procedure. The outcome was the proportion of transition to psychosis, which was calculated according to the Freeman-Tukey double arcsine transformation.

RESULTS

Thirty-three eligible studies were identified, including 16 samples with details on AP exposure at baseline and 17 samples with baseline AP exposure as exclusion criterion for enrollment. Those with baseline exposure to AP (n = 395) had higher transition rates (29.9%; 95% CI: 25.1%-34.8%) than those without baseline exposure to AP in the same study (n = 1289; 17.2%; 15.1%-19.4%) and those coming from samples that did not include people who were exposed to AP at baseline (n = 2073; 16.2%; 14.6%-17.8%; P < .05 in both the fixed-effects and the random-effects models). Heterogeneity within studies was substantial, with values above 75% in all comparisons.

CONCLUSIONS

Sample enrichment is not a plausible explanation for the higher risk of transition to psychosis of CHR-P individuals who were already exposed to AP at the enrollment in specialized early-detection programs. Baseline exposure to AP at CHR-P assessment is a major index of enhanced, imminent risk of psychosis.

Towards clinical application of prediction models for transition to psychosis: A systematic review and external validation study in the PRONIA sample

A multitude of prediction models for a first psychotic episode in individuals at clinical high-risk (CHR) for psychosis have been proposed, but only rarely validated. We identified transition models based on clinical and neuropsychological data through a registered systematic literature search and evaluated their external validity in 173 CHRs from the Personalised Prognostic Tools for Early Psychosis Management (PRONIA) study. Discrimination performance was assessed with the area under the receiver operating characteristic curve (AUC), and compared to the prediction of clinical raters. External discrimination performance varied considerably across the 22 identified models (AUC 0.40-0.76), with two models showing good discrimination performance. None of the tested models significantly outperformed clinical raters (AUC = 0.75). Combining predictions of clinical raters and the best model descriptively improved discrimination performance (AUC = 0.84). Results show that personalized prediction of transition in CHR is potentially feasible on a global scale. For implementation in clinical practice, further rounds of external validation, impact studies, and development of an ethical framework is necessary.

Expanding the search for emerging mental ill health to safeguard student potential and vocational success in high school: A narrative review

AIM

Young people experiencing mental ill health are more likely than their healthy aged peers to drop out of high school. This can result in social exclusion and vocational derailment. Identifying young people at risk and taking action before an illness is established or school dropout occurs is an important goal. This study aimed to examine evidence for the risk markers and at risk mental states of the clinical staging model (stage 0-1b) and whether these risk states and early symptoms impact school participation and academic attainment.

METHOD

This narrative review assembles research from both the psychiatry and education literature. It examines stage 0 to stage 1b of the clinical staging model and links the risk states and early symptoms to evidence about the academic success of young people in high school.

RESULTS

In accordance with the clinical staging model and evidence from education literature, childhood trauma and parental mental illness can impact school engagement and academic progress. Sleep disturbance can result in academic failure. Undifferentiated depression and anxiety can increase the risk for school dropout. Subthreshold psychosis and hypomanic states are associated with functional impairment and high rates of Not in Employment, Education, or Training (NEET) but are not recognized in the education literature.

CONCLUSION

Risk markers for emerging mental ill health can be identified in education research and demonstrate an impact on a student's success in high school. Clear referral protocols need to be embedded into school life to reduce risk of progression to later stages of illness and support school participation and success.

Sex differences in symptomatology of psychosis-risk patients and in prediction of psychosis

Sex differences may be important for understanding underlying pathophysiological mechanisms and developing effective preventions and treatments of mental disorders. Despite sex differences in the onset of psychosis, patients at clinical high risk for psychosis (CHR) are underinvestigated for sex effects, especially with respect to models for prediction of conversion to psychosis. We studied psychopathological sex differences in referrals to a German early detection service and in its subgroup of converters and examined sex-specific psychopathological prediction models. In 152 male and 90 female referrals (88% at CHR; 35% converters), symptoms assessed with the Structured Interview for Psychosis-Risk Syndromes were investigated for sex differences using effect sizes. Sex-specific prediction models of psychosis were separately generated using Cox regressions with a LASSO operator. We found different small sex effects (0.10 < Rosenthal's r < 0.30) in the referral and in the converter sample. In the referral sample, exclusively, males showed more pronounced symptoms (all negative symptoms incl. reduced stress tolerance, grandiosity, and disorganized communication); in converters, females experienced more pronounced perceptual abnormalities, bizarre thinking, and odd behaviors, while males expressed and experienced emotions to a lower degree. Furthermore, sexes differed in psychosis-predictive symptoms: "suspiciousness" and "disorganized communication" were prominent in prediction of psychosis in males, whereas "trouble with focus and attention" was so in females. While most sex differences in patients attending an early detection service seem to reflect general differences that are not specifically related to psychosis, others might be psychosis-specific. These results can inform the development of more individualized and effective interventions for CHR patients based on more precise sex-specific prediction models.

Effects of age and sex on clinical high-risk for psychosis in the community

BACKGROUND

Recent reports of both heightened prevalence rates and limited clinical relevance of clinical high-risk (CHR) criteria and their relevant symptoms in children and adolescents indicate an important role of neurodevelopment in the early detection of psychoses. Furthermore, sex effects in CHR symptoms have been reported, though studies were inconclusive. As sex also impacts on neurodevelopment, we expected that sex might have an additional contribution to age in the prevalence and clinical relevance of CHR symptoms and criteria.

AIM

To investigate age and sex effects on CHR criteria and symptoms and their association with psychosocial impairment and mental disorder.

METHODS

In this cross-sectional cohort study, n = 2916 8- to 40-year-olds, randomly drawn from the population register of the Swiss canton Bern, were assessed in semi-structured interviews by phone or face-to-face for CHR symptoms and criteria using the Structured Interview for Psychosis-Risk Syndromes and the Schizophrenia Proneness Instrument in its child and youth, and adult version, respectively. Furthermore, social and occupational functioning and DSM-IV axis I disorders were assessed. Simple and interaction effects of age and sex on CHR symptoms and criteria, and interaction effects of age, sex, and CHR symptoms and criteria on presentation of functional impairment and of non-psychotic disorder were investigated using logistic regression analyses.

RESULTS

Altogether, 542 (18.6%) participants reported any CHR symptom; of these, 261 (9.0%) participants reported any one of the 11 criteria relevant cognitive and perceptual basic symptoms, and 381 (13.1%) any one of the five attenuated or transient psychotic symptoms (attenuated psychotic symptoms/brief intermittent psychotic symptoms). Fewer participants met any one of the CHR criteria (n = 82, 2.8%) or any one of the three recently recommended CHR criteria (n = 38, 1.3%). Both age and sex were significantly (P < 0.05) associated with CHR symptoms and criteria, mostly by younger age and female sex. Though slightly differing between symptom groups, age thresholds were detected around the turn from adolescence to adulthood; they were highest for cognitive basic symptoms and CHR criteria. With the exception of the infrequent speech disorganization attenuated psychotic symptom, the interaction of age with CHR symptoms and criteria predicted functional impairment; whereas, independent of each other, sex and CHR symptoms mostly predicted mental disorders.

CONCLUSION

Age and sex differentially impact on CHR symptoms and criteria; these differences may support better understanding of causal pathways. Thus, future CHR studies should consider effects of sex and age.

Clinical Validity of DSM-5 Attenuated Psychosis Syndrome: Advances in Diagnosis, Prognosis, and Treatment

IMPORTANCE

Since the release of the DSM-5 diagnosis of attenuated psychosis syndrome (DSM-5-APS) in 2013, several research studies have investigated its clinical validity. Although critical and narrative reviews have reviewed these progresses, no systematic review has comprehensively summarized the available evidence regarding the clinical validity of DSM-5-APS.

OBJECTIVE

To provide current evidence on the clinical validity of DSM-5-APS, focusing on recent advances in diagnosis, prognosis, and treatment.

EVIDENCE REVIEW

A multistep literature search using the Web of Science database, Cochrane Central Register of Reviews, Ovid/PsychINFO, conference proceedings, and trial registries from database inception to June 16, 2019, was conducted following PRISMA and MOOSE guidelines and PROSPERO protocol. Studies with original data investigating individuals diagnosed using DSM-5-APS or meeting comparable criteria were included. The results of the systematic review were summarized in tables and narratively synthesized against established evidence-based antecedent, concurrent, and prognostic validators. A quantitative meta-analysis was conducted to explore the cumulative risk of psychosis onset at 6, 12, 24, and 36 months in individuals diagnosed using DSM-5-APS criteria.

FINDINGS

The systematic review included 56 articles, which reported on 124 validators, including 15 antecedent, 55 concurrent, and 54 prognostic validators. The epidemiological prevalence of the general non-help-seeking young population meeting DSM-5-APS criteria was 0.3%; the prevalence of individuals meeting DSM-5-APS criteria was variable in clinical samples. The interrater reliability for DSM-5-APS criteria was comparable with that of other DSM-5 mental disorders and can be optimized by the use of specific psychometric instruments. DSM-5-APS criteria were associated with frequent depressive comorbid disorders, distress, suicidality, and functional impairment. The meta-analysis included 23 prospective cohort studies, including 2376 individuals. The meta-analytical risk of psychosis onset was 11% at 6 months, 15% at 12 months, 20% at 24 months, and 23% at 36 months. Research into predisposing and precipitating epidemiological factors, neurobiological correlates, and effective treatments for DSM-5-APS criteria has been limited.

CONCLUSIONS AND RELEVANCE

Over recent years, DSM-5-APS criteria have received substantial concurrent and prognostic validation, mostly driven by research into the clinical high-risk state for psychosis. Precipitating and predisposing factors, neurobiological correlates, and effective treatments are undetermined to date.

Clinical and functional long-term outcome of patients at clinical high risk (CHR) for psychosis without transition to psychosis: A systematic review

BACKGROUND

Research on patients at clinical high risk (CHR) for psychosis has so far mainly focused on those with transition to frank psychosis (CHR-T patients). However, the majority of CHR patients do not transition (CHR-NT patients) and relatively little information is available on their clinical and functional outcome.

METHODS

We conducted a systematic review on clinical and functional long-term outcome of CHR-NT patients. Studies were included if they had an average follow-up period of at least 24 months and reported on long-term outcome of CHR-NT patients in one or more of the following domains: (non-)remission from CHR, prevalence of clinical symptoms and/or clinical diagnoses (axis I and II), and psychosocial functioning.

RESULTS

Ten publications from seven different single or multicenter studies with average follow-up durations of 2-7.5 years could be included. At the last follow-up assessment 28-71% of CHR-NT patients were not remitted from their CHR and 22-82% still had at least one clinical diagnosis. Approximately half of CHR-NT patients presented with poor psychosocial outcome at 2-year and 6-year follow-up.

CONCLUSIONS

The results suggest that, in the long-term, the majority of CHR-NT patients are not in full clinical remission and seem to suffer from one or more clinical disorders and psychosocial impairments. Since relatively few studies could be identified, further research is required to better understand the trajectories and clinical needs of CHR-NT patients.

Gender differences in first self-perceived signs and symptoms in patients with an at-risk mental state and first-episode psychosis

AIM

Gender differences in the current symptomatology of patients with psychotic disorders have previously been described in the literature. However, it has not yet been investigated whether gender differences exist in the very first self-perceived signs or symptoms of illness onset. The aim of this study was to investigate this aspect in at-risk mental state (ARMS) and first-episode psychosis (FEP) patients.

METHODS

ARMS and FEP were recruited via the early detection of psychosis (FePsy) clinic Basel, Switzerland. The Basel Interview for Psychosis (BIP) was used to retrospectively assess the first 3 self-perceived signs and symptoms at illness onset. Differences between gender and patient groups on single item and symptom cluster levels were analysed using logistic regression models.

RESULTS

One-hundred-thirty six ARMS (91 men, 45 women) and 89 FEP patients (63 men, 26 women) could be recruited for this study. On a single item level, women more frequently reported "unusual anxiety, fears" and men (at a trend level) "social withdrawal" as being among their 3 first self-perceived symptoms, independent of diagnostic group. On the symptom cluster level, women more frequently reported "increased worrying/anxiety" and (sub-threshold) "hallucinations", independent of diagnostic group. Problems with "thinking, concentration" were reported more frequently by men in the ARMS group only.

CONCLUSION

Our results suggest that only few and relatively small gender differences exist in the first self-perceived signs and symptoms. While men initially mainly notice negative/cognitive symptoms, women first notice (sub-threshold) positive and affective symptoms.

At-risk studies and clinical antecedents of psychosis, bipolar disorder and depression: a scoping review in the context of clinical staging

Identifying young people at risk of developing serious mental illness and identifying predictors of onset of illness has been a focus of psychiatric prediction research, particularly in the field of psychosis. Work in this area has facilitated the adoption of the clinical staging model of early clinical phenotypes, ranging from at-risk mental states to chronic and severe mental illness. It has been a topic of debate if these staging models should be conceptualised as disorder-specific or transdiagnostic. In order to inform this debate and facilitate cross-diagnostic discourse, the present scoping review provides a broad overview of the body of literature of (a) longitudinal at-risk approaches and (b) identified antecedents of (homotypic) illness progression across three major mental disorders [psychosis, bipolar disorder (BD) and depression], and places these in the context of clinical staging. Stage 0 at-risk conceptualisations (i.e. familial high-risk approaches) were identified in all three disorders. However, formalised stage 1b conceptualisations (i.e. ultra-high-risk approaches) were only present in psychosis and marginally in BD. The presence of non-specific and overlapping antecedents in the three disorders may support a general staging model, at least in the early stages of severe psychotic or mood disorders.

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.

Impact of rurality and substance use on young people at ultra high risk for psychosis

BACKGROUND

Longitudinal research into early intervention for youth at ultra high risk (UHR) for psychosis demonstrates beneficial outcomes including increased treatment compliance and greater participation in education and the workforce. Despite known barriers for rural youth accessing mental health services, research comparing urban and rural UHR youth is lacking. The study included an examination of the impact of substance use on functioning of UHR youth.

METHODS

Youth aged 12 to 25 years were recruited from the urban area of Newcastle or the rural area of Orange, New South Wales, Australia, and identified as UHR by the Comprehensive Assessment of At Risk Mental States. Rural and urban youth were compared on clinical profiles, social and occupational functioning and substance use.

RESULTS

The rural youth showed different help-seeking behaviours and had greater functional impairment than urban youth. Substance use was common across the sample of 57 youth (mean age 16.5 years, 56% female) and a history of hazardous substance use was associated with higher levels of depression. Rural youth (n = 32) were more likely than urban youth to be taking antidepressants at baseline (44% compared with 16%).

CONCLUSION

Different patterns of help seeking by rural UHR youth suggest a need for greater access to psychosis informed primary care early intervention services. Interventions should target functional decline to prevent adverse outcomes such as reduced community participation and unemployment. In addition, interventions for substance use should be a priority for UHR youth, who should also be screened and monitored for depressive symptoms and treated for depression if indicated.

Cognitive Deficits in Psychotic Disorders: A Lifespan Perspective

Individuals with disorders that include psychotic symptoms (i.e. psychotic disorders) experience broad cognitive impairments in the chronic state, indicating a dimension of abnormality associated with the experience of psychosis. These impairments negatively impact functional outcome, contributing to the disabling nature of schizophrenia, bipolar disorder, and psychotic depression. The robust and reliable nature of cognitive deficits has led researchers to explore the timing and profile of impairments, as this may elucidate different neurodevelopmental patterns in individuals who experience psychosis. Here, we review the literature on cognitive deficits across the life span of individuals with psychotic disorder and psychotic-like experiences, highlighting the dimensional nature of both psychosis and cognitive ability. We identify premorbid generalized cognitive impairment in schizophrenia that worsens throughout development, and stabilizes by the first-episode of psychosis, suggesting a neurodevelopmental course. Research in affective psychosis is less clear, with mixed evidence regarding premorbid deficits, but a fairly reliable generalized deficit at first-episode, which appears to worsen into the chronic state. In general, cognitive impairments are most severe in schizophrenia, intermediate in bipolar disorder, and the least severe in psychotic depression. In all groups, cognitive deficits are associated with poorer functional outcome. Finally, while the generalized deficit is the clearest and most reliable signal, data suggests specific deficits in verbal memory across all groups, specific processing speed impairments in schizophrenia and executive functioning impairments in bipolar disorder. Cognitive deficits are a core feature of psychotic disorders that provide a window into understanding developmental course and risk for psychosis.

Corpus callosum shape and morphology in youth across the psychosis Spectrum

The corpus callosum is the largest white matter tract in the human brain connecting and coordinating homologous regions of the right and left hemispheres and has been strongly implicated in the pathogenesis of psychosis. We investigated corpus callosum morphology in a large community cohort of 917 individuals (aged 8-21), including 267 endorsing subsyndromal or threshold psychotic symptoms (207 on the psychosis spectrum and 60 with limited psychosis based on previously published criteria) and 650 non-psychotic volunteers. We used a highly reliable and previously published algorithm to automatically identify the midsagittal plane and to align the corpus callosum along the anterior and posterior commissures for segmentation, thereby eliminating these sources of error variance in dependent measures, which included perimeter, length, mean thickness and shape (circularity). The parcellation scheme divided the corpus callosum into 7 subregions that consisted of the rostrum, genu, rostral body, anterior midbody, posterior midbody, isthmus, and splenium. Both individuals endorsing psychotic symptoms and those with limited psychosis had significantly (p<.05) smaller area and lower thickness measures compared to healthy volunteers, but did not differ significantly from each other. Findings were relatively widespread indicating a relatively global effect not circumscribed to any particular corpus callosum subregion. These data are consistent with the hypothesis that corpus callosum abnormalities may be evident early in the course of illness and predate the onset of frank psychosis. Given that these measures can be easily obtained and are highly reliable they may assist in the identification of individuals at future risk for psychosis.

A comparison of conversion rates, clinical profiles and predictors of outcomes in two independent samples of individuals at clinical high risk for psychosis in China

OBJECTIVE

In a previous epidemiological study, we reported on the ascertainment and outcomes of "clinical high risk" (CHR) individuals at the Shanghai Mental Health Center (SMHC, "2011 cohort"). The current study compares demographic and clinical characteristics, including conversion rates, of this sample with a subsequently recruited, independent CHR sample and with published data from western samples.

METHOD

A new sample of 100 CHR subjects ("2013 cohort") was selected based on screening and semi-structured interviews. Both studies used the Structured Interview for Prodromal Syndromes (SIPS) for CHR assessment and conducted a naturalistic two-year follow-up. The two cohorts were compared on conversion rates, demographic and clinical characteristics, psychosis risk symptoms, and risk factors for psychotic conversion.

RESULTS

Ninety one (91%) of the 2013 cohort subjects completed the clinical two-year follow-up and 25 (27.5% of the 91) converted to a psychotic disorder over the follow-up period. A comparison of conversions to full psychosis between the 2013 and the 2011 cohorts showed no significant difference in time to conversion (Pairwise comparison: χ²=0.3, p=0.562). Both cohort studies showed that CHR subjects with more severe clinical symptoms at baseline and decline in functioning were more likely to convert to psychosis.

CONCLUSIONS

Conversion rates in this new, independent Chinese sample are similar to those reported in non-Chinese samples and to the 2011 cohort. Future research is needed to examine whether the implementation of early intervention for CHR/prodromal symptoms reduces the risk of psychosis and decreases the conversion rate.

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.

Course of clinical high-risk states for psychosis beyond conversion

BACKGROUND

The main focus of research on clinical high-risk states for psychosis (CHR) has been the development of algorithms to predict psychosis. Consequently, other outcomes have been neglected, and little is known about the long-term diagnostic and functional outcome among those not converting to psychosis.

METHODS

In a naturalistic study, incidence, persistence, and remission rates of CHR states according to symptomatic ultra-high risk or cognitive disturbances criteria were investigated in 160 of 246 outpatients of an early detection of psychoses service (21.1% CHR negative and 78.9% CHR positive at baseline) who had not converted to psychosis within follow-up (median 53.7 months, range 13.9-123.7 months).

RESULTS

Remission rate of CHR status was 43.3% of all 194 CHR-positive cases, including converters, or 72.4% if only the 116 non-converters were considered, persistence rate was 27.6%, and new occurrence rate in initially CHR-negative patients was 9.1%. At follow-up, 54.5% of the non-converters met criteria of at least one Axis-I diagnosis, mainly affective and anxiety disorders, and had functional problems. The severity of risk at baseline was not associated with a higher presence of Axis-I diagnosis at follow-up.

CONCLUSIONS

During follow-up, CHR symptoms remitted in one-third of initially CHR-positive patients, while almost 10% met CHR criteria newly in CHR-negative adults presenting at early detection services. The presence of CHR criteria seems to maintain the risk for lower functioning and mental disorders, particularly for affective disorders. Thus, therapeutic efforts targeting CHR patients should also focus on the current mental disorders as well as social and role functions to improve the long-term outcome.

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.

Baseline demographics, clinical features and predictors of conversion among 200 individuals in a longitudinal prospective psychosis-risk cohort

BACKGROUND

DSM-5 proposes an Attenuated Psychosis Syndrome (APS) for further investigation, based upon the Attenuated Positive Symptom Syndrome (APSS) in the Structured Interview for Psychosis-Risk Syndromes (SIPS). SIPS Unusual Thought Content, Disorganized Communication and Total Disorganization scores predicted progression to psychosis in a 2015 NAPLS-2 Consortium report. We sought to independently replicate this in a large single-site high-risk cohort, and identify baseline demographic and clinical predictors beyond current APS/APSS criteria.

METHOD

We prospectively studied 200 participants meeting criteria for both the SIPS APSS and DSM-5 APS. SIPS scores, demographics, family history of psychosis, DSM Axis-I diagnoses, schizotypy, and social and role functioning were assessed at baseline, with follow-up every 3 months for 2 years.

RESULTS

The conversion rate was 30% (n = 60), or 37.7% excluding participants who were followed under 2 years. This rate was stable across time. Conversion time averaged 7.97 months for 60% who developed schizophrenia and 15.68 for other psychoses. Mean conversion age was 20.3 for males and 23.5 for females. Attenuated odd ideas and thought disorder appear to be the positive symptoms which best predict psychosis in a logistic regression. Total negative symptom score, Asian/Pacific Islander and Black/African-American race were also predictive. As no Axis-I diagnosis or schizotypy predicted conversion, the APS is supported as a distinct syndrome. In addition, cannabis use disorder did not increase risk of conversion to psychosis.

CONCLUSIONS

NAPLS SIPS findings were replicated while controlling for clinical and demographic factors, strongly supporting the validity of the SIPS APSS and DSM-5 APS diagnosis.

Two-year follow-up of a Chinese sample at clinical high risk for psychosis: timeline of symptoms, help-seeking and conversion

BACKGROUND

Chinese psychiatrists have gradually started to focus on those who are deemed to be at 'clinical high-risk (CHR)' for psychosis; however, it is still unknown how often those individuals identified as CHR from a different country background than previously studied would transition to psychosis. The objectives of this study are to examine baseline characteristics and the timing of symptom onset, help-seeking, or transition to psychosis over a 2-year period in China.

METHOD

The presence of CHR was determined with the Structured Interview for Prodromal Syndromes (SIPS) at the participants' first visit to the mental health services. A total of 86 (of 117) CHR participants completed the clinical follow-up of at least 2 years (73.5%). Conversion was determined using the criteria of presence of psychotic symptoms (in SIPS). Analyses examined baseline demographic and clinical predictors of psychosis and trajectory of symptoms over time. Survival analysis (Kaplan-Meier) methods along with Log-rank tests were performed to illustrate the relationship of baseline data to either conversion or non-conversion over time. Cox regression was performed to identify baseline predictors of conversion by the 2-year follow-up.

RESULTS

In total 25 (29.1%) of 86 completers transitioned to a psychotic disorder over the course of follow-up. Among the CHR sample, the mean time between attenuated symptom onset and professional help-seeking was about 4 months on average, and converters developed fully psychotic symptoms about 12 months after symptom onset. Compared with those CHR participants whose risk syndromes remitted over the course of the study, converters had significantly longer delays (p = 0.029) for their first visit to a professional in search of help. At baseline assessment, the conversion subgroup was younger, had poorer functioning, higher total SIPS positive symptom scores, longer duration of untreated prodromal symptoms, and were more often given psychosis-related diagnoses and subsequently prescribed antipsychotics in the clinic.

CONCLUSIONS

Chinese CHR identified primarily by a novel clinical screening approach had a 2-year transition rate comparable with those of specialised help-seeking samples world-wide. Early clinical intervention with this functionally deteriorating clinical population who are suffering from attenuated psychotic symptoms, is a next step in applying the CHR construct in China.

Persistence or recurrence of non-psychotic comorbid mental disorders associated with 6-year poor functional outcomes in patients at ultra high risk for psychosis

BACKGROUND

Patients at ultra-high risk for psychosis (UHR) are a highly heterogeneous group in terms of clinical and functional outcomes. Several non-psychotic mental disorders co-occur together with the UHR state. Little is known about the impact of non-psychotic comorbid mental disorders on clinical and functional outcomes of UHR patients.

METHODS

The sample included 154 UHR help-seeking patients (identified with the CAARMS, comprehensive assessment of the at-risk mental state), evaluated at baseline on the Ham-D, Ham-A (Hamilton depression/anxiety rating scale), and PANSS (positive and negative syndrome scale). 74 patients completed the 6-year follow-up assessment (mean=6.19, SD=1.87). Comorbid disorders at follow-up were assessed with the SCID I and II. Global functioning was rated on the global assessment of functioning (GAF) scale.

RESULTS

In the present sample, 6-year risk of psychosis transition was 28.4%. Among non-transitioned UHR patients, 28.3% reported attenuated psychotic symptoms (APS) and 45.3% remained functionally impaired at follow-up (GAF<60). 56.8% patients were affected by at least one comorbid disorder at follow-up. Among UHR patients who presented with some comorbid disorder at baseline, 61.5% had persistent or recurrent course. Incident comorbid disorders emerged in 45.4% of baseline UHR patients. The persistence or recurrence of non-psychotic comorbid mental disorders was associated with poorer global functional outcomes at follow-up.

LIMITATIONS

A substantial proportion of the initial sample was not available for follow-up interviews and some groups in the analyses had small sample size. Predictors of longitudinal outcomes were not explored.

CONCLUSIONS

Among UHR patients, persistence or recurrence of non-psychotic comorbid mental disorders, mostly affective disorders, is associated with 6-year poor functional outcomes.

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.

Baseline putamen volume as a predictor of positive symptom reduction in patients at clinical high risk for psychosis: A preliminary study

OBJECTIVES

Illness course in individuals at clinical high risk (CHR) status for psychosis is heterogeneous, which limits effective treatment for all CHR subgroups. Baseline predictors of positive symptom trajectory in the CHR group will reduce such limitations. We singled out the putamen, thought to be involved in the generation of the key schizophrenia symptoms early in the course of disease, as a potential predictor of positive symptom trajectory in CHR patients.

METHOD

We recruited 45 CHR patients and 29 age- and gender-matched healthy controls (HC). The CHR group was divided into patients with positive symptom reduction (CHR-R) and patients without positive symptom reduction (CHR-NR) at 6 months. Comparisons were made between the baseline putamen volumes of CHR-R, CHR-NR and HC groups. The relationship between baseline putamen volumes and clinical measures was investigated.

RESULTS

Left putamen volumes of CHR-R patients were significantly smaller than those of HCs (p=0.002) and of CHR-NR patients (p=0.024). CHR-R patients had significantly reduced leftward laterality compared to HCs (p=0.007). In the CHR-R group, bilateral putamen volumes were correlated with positive symptom severity at baseline (r=-0.552, p=0.001) and at 6 months (r=-0.360, p=0.043), and predicted positive symptom score change in 6 months at a trend level (p=0.092).

CONCLUSION

Smaller left putamen volumes in CHR-R patients, and the correlation between positive symptom severity and putamen volumes suggest that putamen volume is a possible risk-stratifier and predictor of clinical course in the CHR population.

Twelve-month psychosis-predictive value of the ultra-high risk criteria in children and adolescents

OBJECTIVE

The validity of current ultra-high risk (UHR) criteria is under-examined in help-seeking minors, particularly, in children below the age of 12 years. Thus, the present study investigated predictors of one-year outcome in children and adolescents (CAD) with UHR status.

METHOD

Thirty-five children and adolescents (age 9-17 years) meeting UHR criteria according to the Structured Interview for Psychosis-Risk Syndromes were followed-up for 12 months. Regression analyses were employed to detect baseline predictors of conversion to psychosis and of outcome of non-converters (remission and persistence of UHR versus conversion).

RESULTS

At one-year follow-up, 20% of patients had developed schizophrenia, 25.7% had remitted from their UHR status that, consequently, had persisted in 54.3%. No patient had fully remitted from mental disorders, even if UHR status was not maintained. Conversion was best predicted by any transient psychotic symptom and a disorganized communication score. No prediction model for outcome beyond conversion was identified.

CONCLUSIONS

Our findings provide the first evidence for the predictive utility of UHR criteria in CAD in terms of brief intermittent psychotic symptoms (BIPS) when accompanied by signs of cognitive impairment, i.e. disorganized communication. However, because attenuated psychotic symptoms (APS) related to thought content and perception were indicative of non-conversion at 1-year follow-up, their use in early detection of psychosis in CAD needs further study. Overall, the need for more in-depth studies into developmental peculiarities in the early detection and treatment of psychoses with an onset of illness in childhood and early adolescence was further highlighted.

Emotion recognition deficits as predictors of transition in individuals at clinical high risk for schizophrenia: a neurodevelopmental perspective

BACKGROUND

Schizophrenia is characterized by profound and disabling deficits in the ability to recognize emotion in facial expression and tone of voice. Although these deficits are well documented in established schizophrenia using recently validated tasks, their predictive utility in at-risk populations has not been formally evaluated.

METHOD

The Penn Emotion Recognition and Discrimination tasks, and recently developed measures of auditory emotion recognition, were administered to 49 clinical high-risk subjects prospectively followed for 2 years for schizophrenia outcome, and 31 healthy controls, and a developmental cohort of 43 individuals aged 7-26 years. Deficit in emotion recognition in at-risk subjects was compared with deficit in established schizophrenia, and with normal neurocognitive growth curves from childhood to early adulthood.

RESULTS

Deficits in emotion recognition significantly distinguished at-risk patients who transitioned to schizophrenia. By contrast, more general neurocognitive measures, such as attention vigilance or processing speed, were non-predictive. The best classification model for schizophrenia onset included both face emotion processing and negative symptoms, with accuracy of 96%, and area under the receiver-operating characteristic curve of 0.99. In a parallel developmental study, emotion recognition abilities were found to reach maturity prior to traditional age of risk for schizophrenia, suggesting they may serve as objective markers of early developmental insult.

CONCLUSIONS

Profound deficits in emotion recognition exist in at-risk patients prior to schizophrenia onset. They may serve as an index of early developmental insult, and represent an effective target for early identification and remediation. Future studies investigating emotion recognition deficits at both mechanistic and predictive levels are strongly encouraged.

Disorder, not just state of risk: meta-analysis of functioning and quality of life in people at high risk of psychosis

BACKGROUND

The nosology of the psychosis high-risk state is controversial. Traditionally conceived as an 'at risk' state for the development of psychotic disorders, it is also conceptualised as a clinical syndrome associated with functional impairment.

AIMS

To investigate meta-analytically the functional status of patients at high clinical risk for psychosis and its association with longitudinal outcomes.

METHOD

Three meta-analyses compared level of functioning (n = 3012) and quality of life (QoL) (n = 945) between a high-risk group, a healthy control group and group with psychosis, and baseline functioning in people in the high-risk group who did or did not have a transition to psychosis at follow-up (n = 654).

RESULTS

People at high risk had a large impairment in functioning (P<0.001) and worse QoL (P = 0.001) than the healthy control group, but only small to moderately better functioning (P = 0.012) and similar QoL (P = 0.958) compared with the psychosis group. Among the high-risk group, those who did not develop psychosis reported better functioning (P = 0.001) than those who did.

CONCLUSIONS

Our results indicate that the high-risk state is characterised by consistent and large impairments of functioning and reduction in QoL similar to those in other coded psychiatric disorders.

EPA guidance on the early detection of clinical high risk states of psychoses

The aim of this guidance paper of the European Psychiatric Association is to provide evidence-based recommendations on the early detection of a clinical high risk (CHR) for psychosis in patients with mental problems. To this aim, we conducted a meta-analysis of studies reporting on conversion rates to psychosis in non-overlapping samples meeting any at least any one of the main CHR criteria: ultra-high risk (UHR) and/or basic symptoms criteria. Further, effects of potential moderators (different UHR criteria definitions, single UHR criteria and age) on conversion rates were examined. Conversion rates in the identified 42 samples with altogether more than 4000 CHR patients who had mainly been identified by UHR criteria and/or the basic symptom criterion 'cognitive disturbances' (COGDIS) showed considerable heterogeneity. While UHR criteria and COGDIS were related to similar conversion rates until 2-year follow-up, conversion rates of COGDIS were significantly higher thereafter. Differences in onset and frequency requirements of symptomatic UHR criteria or in their different consideration of functional decline, substance use and co-morbidity did not seem to impact on conversion rates. The 'genetic risk and functional decline' UHR criterion was rarely met and only showed an insignificant pooled sample effect. However, age significantly affected UHR conversion rates with lower rates in children and adolescents. Although more research into potential sources of heterogeneity in conversion rates is needed to facilitate improvement of CHR criteria, six evidence-based recommendations for an early detection of psychosis were developed as a basis for the EPA guidance on early intervention in CHR states.

Measuring stages of recovery from psychosis

BACKGROUND

Mental health consumers invite us to abandon the pathology model, which is tied to pessimism, and instead to embrace a model of personal recovery that goes beyond being free from symptoms, and involves self-management of the illness. The Stages of Recovery Instrument (STORI) is a measure developed from the perspective of consumers according to a conceptual five-stage model of recovery.

AIMS

The main aim of this work was to study the psychometric properties of the STORI, but we also set out to compare the stages of recovery in our sample with the five-stage model in the sample with which the scale was developed.

METHODS

Our sample consisted of 95 people diagnosed with schizophrenia-spectrum psychoses, with a mean age of 34.74 (SD=9.25).

RESULTS

The STORI scores showed adequate psychometric properties in this sample. Cluster analysis indicated that the three-cluster model fitted the data better than the five-cluster model. Internal consistency of the STORI scores ranged between .83 and .87. STORI stages were associated with Recovery Styles Questionnaire scores.

DISCUSSION

The results provide empirical validation of the STORI in other countries. Empirical evidence revealed that the stages of recovery found in our own and other clinical samples differ from those found in the samples with which the scale was developed.

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.

Symptom trajectories and psychosis onset in a clinical high-risk cohort: the relevance of subthreshold thought disorder

BACKGROUND

Prior studies have implicated baseline positive and negative symptoms as predictors of psychosis onset among individuals at clinical high risk (CHR), but none have evaluated latent trajectories of symptoms over time. This study evaluated the dynamic evolution of symptoms leading to psychosis onset in a CHR cohort.

METHOD

100 CHR participants were assessed quarterly for up to 2.5 years. Latent trajectory analysis was used to identify patterns of symptom change. Logistic and proportional hazards models were employed to evaluate the predictive value for psychosis onset of baseline symptoms and symptom trajectories.

RESULTS

Transition rate to psychosis was 26%. Disorganized communication (i.e., subthreshold thought disorder) presented an increased hazard for psychosis onset, both at baseline (Hazard Ratio (95% CI)=1.4 (1.1-1.9)) and as a trajectory of high persistent disorganized communication (Hazard Ratio (95% CI)=2.2 (1.0-4.9)). Interval clinical data did not improve the predictive value of baseline symptoms for psychosis onset.

CONCLUSIONS

High baseline disorganized communication evident at ascertainment tended to persist and lead to psychosis onset, consistent with prior behavioral and speech analysis studies in similar cohorts. Remediation of language dysfunction therefore may be a candidate strategy for preventive intervention.

What drives poor functioning in the at-risk mental state? A systematic review

BACKGROUND

Transition to psychotic disorder has been the traditional outcome of interest for research in the at-risk mental state (ARMS). However, there is growing recognition that individuals with ARMS may function poorly regardless of whether they develop psychosis. We aimed to review the literature to determine whether there are specific factors associated with, or predictive of, functional impairment in the ARMS population.

METHOD

An electronic database search of MEDLINE, PsycINFO and Embase from inception until May 2014 was conducted using keyword search terms synonymous with the at-risk mental state and functioning. Eligible studies were original peer-reviewed English language research articles with populations that met validated at-risk diagnostic criteria and examined the cross-sectional or longitudinal association between any variable and a measure of functioning.

RESULTS

Seventy-two eligible studies were identified. Negative symptoms and neurocognitive impairment were associated with poor functioning in cross-sectional studies. Negative and disorganised symptoms, neurocognitive deficits and poor functioning at baseline were predictive of poor functional outcome in longitudinal studies. Positive symptoms were unrelated to functioning in both cross-sectional and longitudinal studies. Functional disability was persistent and resistant to current treatments.

CONCLUSIONS

Negative and disorganised symptoms and cognitive deficits pre-date frank psychotic symptoms and are risk factors for poor functioning. This is consistent with a subgroup of ARMS individuals potentially having neurodevelopmental schizophrenia. Treatments aimed at improving functioning must be considered a priority on par with preventing transition to psychosis in the development of future interventions in the ARMS group.

Symptomatic and functional remission of subjects at clinical high risk for psychosis: a 2-year naturalistic observational study

BACKGROUND

The aim of this study was to assess the frequency and predictors of symptomatic and functional remission in individuals at clinical high risk (CHR) for psychosis at 1-2 years of follow-up.

METHODS

Help-seeking CHR individuals with symptomatic (Scale of Prodromal Symptoms (SOPS) positive scores <3) and functional (Global Assessment of Functioning (GAF) score >60) (CHR-R) remission at 12-24 months were compared to non-remitted individuals (CHR-NR) regarding baseline and treatment characteristics, symptom changes and predictors. Time to full remission was compared with that of symptomatic remission only.

RESULTS

Of 73 individuals, 29 (39.7%) achieved full remission; 44 (60.3%) did not. Compared to CHR-NR individuals, CHR-R individuals had lower baseline SOPS positive symptoms (p=0.017), antipsychotic use (p=0.004), antipsychotic chlorpromazine dose equivalents (p=0.001) and anxiolytic use (p=0.004). In survival analyses, the estimated full remission rate was 48.3% (95% confidence interval (CI)=36.2-61.9) and symptomatic remission rate was 67.5% (CI95=55.4-79.2). Time to full remission was longer than time to symptomatic remission (p=0.017). Linear mixed-effect models revealed significantly greater improvements from 6 months onward in CHR-R subjects compared to CHR-NR subjects regarding SOPS positive symptoms (p=0.003), highest SOPS positive symptom (p<0.001) and GAF scores (p=0.004). Examining baseline predictors, time to full remission was significantly longer in patients with higher SOPS positive scores (p=0.017).

CONCLUSIONS

More stringent remission criteria that include functional status in addition to attenuated positive symptom severity should be applied to CHR subjects. Furthermore, more attention should be given to CHR individuals with highly positive prodromal symptoms at baseline.

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.

Sex differences in first-episode psychosis and in people at ultra-high risk

Sex-related differences in the clinical expression and outcome of schizophrenia have long been recognized; this study set out to evaluate whether they extend to those subjects who are at high risk of developing psychosis. In a sample enrolled in two early intervention programs in northern Italy, patients with first-episode psychosis (FEP; n=152) were compared to patients at ultra-high risk of psychosis (UHR; n=106) on a series of sex-related clinical characteristics of schizophrenia. In both the FEP and the UHR samples, males outnumbered females. In FEP patients, women had been referred at an older age than men and had a shorter duration of untreated illness (DUI) and of untreated psychosis. In UHR patients no sex differences were found in age of onset or DUI. There was no diagnosis by sex interaction on symptoms severity or level of functioning at presentation. The limited number of women in both samples, and the exclusion of people who were older than 30 and of those with substance dependence may have reduced the extent of sex-related differences in this study. Sex differences of precipitating factors for psychosis might be worthy of further investigation.

Lessons learned from the psychosis high-risk state: towards a general staging model of prodromal intervention

BACKGROUND

The past two decades have seen exponential clinical and research interest in help-seeking individuals presenting with potentially prodromal symptoms for psychosis. However, the epidemiological validity of this paradigm has been neglected, limiting future advancements in the field.

METHOD

We undertook a critical review of core epidemiological issues underlying the clinical high-risk (HR) state for psychosis and which model of prodromal intervention is best suited for mental health.

RESULTS

The HR state for psychosis model needs refining, to bring together population-based findings of high levels of psychotic experiences (PEs) and clinical expression of risk. Traditionally, outcome has been attributed to 'HR criteria' alone rather than taking into account sampling strategies. Furthermore, the exclusive focus on variably defined 'transition' obscures true variation in the slow and non-linear progression across stages of psychopathology. Finally, the outcome from HR states is variable, indicating that the underlying paradigm of 'schizophrenia light progressing to schizophrenia' is inadequate.

CONCLUSIONS

In the general population, mixed and non-specific expression of psychosis, depression, anxiety and subthreshold mania is common and mostly transitory. When combined with distress, it may be considered as the first, diagnostically neutral stage of potentially more severe psychopathology, which only later may acquire a degree of diagnostic specificity and possible relative resistance to treatment. Therefore, rather than creating silos of per-disorder ultra-HR syndromes, an early intervention focus on the broad syndrome of early mental distress, requiring phase-specific interventions, may be more profitable.

Practitioner review: schizophrenia spectrum disorders and the at-risk mental state for psychosis in children and adolescents--evidence-based management approaches

BACKGROUND

Schizophrenia spectrum disorders are severe mental illnesses which often result in significant distress and disability. Attempts have been made to prospectively identify and treat young people viewed as at high risk of impending nonaffective psychosis. Once a schizophrenia spectrum disorder has developed, prompt identification and management is required.

METHODS

This article reviews the literature relating to the assessment and management of 'at-risk mental states' (ARMS) and the treatment of schizophrenia spectrum disorders in children and adolescents. A systematic search of the literature was undertaken using EMBASE, MEDLINE, PsycINFO databases for the period January 1970-December 2012.

RESULTS

Evidence suggests that young people fulfilling the ARMS criteria are at high risk of adverse mental health outcomes but that the majority do not develop nonaffective psychosis over the medium term. Although clinical trial findings have been inconsistent, psychosocial approaches, such as cognitive behaviour therapy, may reduce the risk of transition to psychosis and improve some symptoms, at least over the short term. The effectiveness of psychotropic medication for the ARMS is uncertain although there is accumulating evidence for potential adverse effects of antipsychotic medication, even at low dose, in this population. For the schizophrenias, clinical trial findings suggest that, as in adults, antipsychotics should be selected on the basis of side-effect profile although clozapine may be helpful in treatment refractory illness. There are almost no studies of psychosocial treatments for schizophrenia in young people under 18, and some caution must be exercised when extrapolating the findings of adult studies to younger individuals.

CONCLUSIONS

A stepped care approach to the ARMS in young people represents a plausible potential management approach for those at high risk of serious mental health problems. However, predictive models currently lack precision and should focus on accurately identifying those at high risk for a variety of poor outcomes who may benefit most from intervention. There is also an urgent need for age-specific research in the area of psychosocial treatments for children and adolescents with schizophrenia.

Moving beyond transition outcomes: meta-analysis of remission rates in individuals at high clinical risk for psychosis

Recent evidence suggests that transition risks from initial clinical high risk (CHR) status to psychosis are decreasing. The role played by remission in this context is mostly unknown. The present study addresses this issue by means of a meta-analysis including eight relevant studies published up to January 2012 that reported remission rates from an initial CHR status. The primary effect size measure was the longitudinal proportion of remissions compared to non-remission in subjects with a baseline CHR state. Random effect models were employed to address the high heterogeneity across studies included. To assess the robustness of the results, we performed sensitivity analyses by sequentially removing each study and rerunning the analysis. Of 773 subjects who met initial CHR criteria, 73% did not convert to psychosis along a 2-year follow. Of these, about 46% fully remitted from the baseline attenuated psychotic symptoms, as evaluated on the psychometric measures usually employed by prodromal services. The corresponding clinical remission was estimated as high as 35% of the baseline CHR sample. The CHR state is associated with a significant proportion of remitting subjects that can be accounted by the effective treatments received, a lead time bias, a dilution effect, a comorbid effect of other psychiatric diagnoses.

At risk for schizophrenic or affective psychoses? A meta-analysis of DSM/ICD diagnostic outcomes in individuals at high clinical risk

BACKGROUND

The clinical high-risk state for psychosis (HRP) is associated with an enhanced probability of developing a psychotic episode over a relatively short period of time. However, the extent to which different diagnostic types of illness develop remains unclear.

METHODS

A systematic review was performed to identify studies of HRP participants reporting International Classfication of Diseases/Diagnostic and Statistical Manual of Mental Disorders diagnostic outcomes at follow-up. Demographic, clinical, and methodological variables were extracted from each publication or obtained directly from its authors. A meta-analysis was performed of transition to schizophrenic (SP) or affective psychoses (AP) and to specific diagnostic categories. Statistical heterogeneity and small study bias were assessed, and meta-regressions were performed.

RESULTS

Twenty-three studies were retrieved, including a total of 2182 HRP participants, 560 (26%) of them developed a frank psychotic disorder over the follow-up time (mean = 2.35 y). Among HRP participants who developed psychosis, 73% were diagnosed with SP and only 11% with AP (Risk Ratio, RR = 5.43, 95% CI from 3.35 to 8.83). The specific transition risk to ICD/DSM schizophrenia was of 15.7% (over 2.35y). Heterogeneity was statistically significant and moderate in magnitude. Use of basic symptoms criteria in the baseline clinical assessment was associated with a further increase in the proportion progressing to SP vs AP (RR = 17.1). There was no evidence of publication bias and the sensitivity analysis confirmed robustness of the above results.

CONCLUSIONS

The HRP state is heterogeneous in term of longitudinal diagnoses; however, the current HRP diagnostic criteria appear strongly biased toward an identification of early phases of SP rather than AP.

Sexual dimorphisms and prediction of conversion in the NAPLS psychosis prodrome

Sex differences in age at onset, symptomatology, clinical course (see Walker et al., 2002) and functional impairment (Thorup et al., 2007) are well documented in psychosis. The general pattern of findings is that males manifest an earlier onset, more severe symptoms and poorer prognosis than females. Limited studies examining individuals at clinical high-risk (CHR) suggest a similar pattern of sexual dimorphism (Holtzman et al., in review; Corcoran et al., 2011). As part of the North American Prodrome Longitudinal Study (NAPLS), the current study prospectively examined sexual dimorphisms in relationships among CHR symptoms, childhood (premorbid) academic and social functioning, baseline social and role functioning, and conversion to psychosis. Subjects included 276 (113F/163M) CHR NAPLS participants (ages 12-36.8years). All measures/criteria were assessed at baseline except conversion status, assessed at 6-month intervals up to 30months. Results show sex differences in baseline social and role functioning (though not in early childhood adjustment) that predate psychosis onset, with sexually dimorphic patterns in relation to prodromal symptoms. Among male (but not female) CHRs, baseline social functioning and positive prodromal symptoms predicted conversion. These findings help elucidate early course of vulnerability for, and maximally sensitive and specific etiological and prediction models of, psychosis conversion. Findings highlight the importance of considering sexually differentiated predictors of longitudinal course and outcome, in the context of emerging risk profiles. This may optimize efforts at early identification and individually tailored preventive interventions targeting different neurobiological markers/systems and/or cognitive-behavioral approaches. We speculate a contemporary, multidimensional model of psychosis risk that posits a role of sexually dimorphic, genetically linked influences that converge with a modulating role of gonadal hormones (see Walder et al., 2012) across a temporally sensitive neurodevelopmental trajectory towards conferring risk.

The ultra-high risk concept-a review

Attempts to identify people at imminent risk of psychotic disorder have been made during the past 20 years. High-risk criteria have been developed, and despite findings of a recent decline in the rate of onset of psychosis associated with these criteria, people identified still have a significantly greater risk, compared with the general population. Intervention studies in this group indicate that psychological treatments and fish oil appear to be just as effective as antipsychotics. Future research should refine risk factors for psychosis and examine outcomes other than psychosis. Research is also needed into what harms and benefits are associated with making the high-risk criteria into a formal diagnosis.