Identification and prediction of clinical high risk of psychosis in Chinese outpatients using two-stage screening

Identification of youth at clinical high-risk for psychosis: A community-based study from India

AIM

A two-stage process, wherein self-report screening precedes the structured interview, is suggested for identifying individuals at clinical high-risk for psychosis (CHR-P) in community samples. Aim of this study was to screen a community youth sample from India for CHR-P using the two-stage method. Specific objectives were to assess concordant validity of the self-report measure and predictive validity of the two-stage method.

METHODS

Based on probability sampling, 2025 youth aged 15-24 years were recruited from one rural and one urban area of Telangana, a Telugu-speaking state in India. Telugu version of the PRIME Screen-Revised (PS-R) and structured interview for psychosis-risk syndromes (SIPS) were used. CHR-P positive and negative cohorts were followed-up for transition to psychosis at 3-monthly intervals.

RESULTS

One hundred ten individuals screened positive on PS-R. SIPS conducted on 67 out of 110 individuals confirmed 62 (92.54%) to be CHR-P positive. PS-R showed 98.41% sensitivity and 90.74% specificity. Among CHR-P positive, three participants transitioned to psychosis in 15 months. The hazard ratio for psychosis transition was 11.4.

CONCLUSIONS

Screening accuracy of PS-R in the community youth sample in Telangana is optimum. The hazard ratio for psychosis transition in the community identified CHR-P indicates good predictive validity for the two-stage method.

Screening for psychotic experiences and psychotic disorders in general psychiatric settings: a systematic review and meta-analysis

Background

The absence of systematic screening for psychosis within general psychiatric services contribute to substantial treatment delays and poor long-term outcomes. We conducted a meta-analysis to estimate rates of psychotic experiences, clinical high-risk for psychosis syndrome (CHR-P), and psychotic disorders identified by screening treatment-seeking individuals to inform implementation recommendations for routine psychosis screening in general psychiatric settings.

Methods

PubMed and Web of Science databases were searched to identify empirical studies that contained information on the point prevalence of psychotic experiences, CHR-P, or psychotic disorders identified by screening inpatient and outpatient samples aged 12-64 receiving general psychiatric care. Psychotic experiences were identified by meeting threshold scores on validated self-reported questionnaires, and psychotic disorders and CHR-P by gold-standard structured interview assessments. A meta-analysis of each outcome was conducted using the Restricted Maximum Likelihood Estimator method of estimating effect sizes in a random effects model.

Results

41 independent samples (k=36 outpatient) involving n=25,751 patients (58% female, mean age: 24.1 years) were included. Among a general psychiatric population, prevalence of psychotic experiences was 44.3% (95% CI: 35.8-52.8%; 28 samples, n=21,957); CHR-P was 26.4% (95% CI: 20.0-32.7%; 28 samples, n=14,395); and psychotic disorders was 6.6% (95% CI: 3.3-9.8%; 32 samples, n=20,371).

Conclusions

High rates of psychotic spectrum illness in general psychiatric settings underscore need for secondary prevention with psychosis screening. These base rates can be used to plan training and resources required to conduct assessments for early detection, as well as build capacity in interventions for CHR-P and early psychosis in non-specialty mental health settings.

Comprehensive review of multidimensional biomarkers in the ShangHai At Risk for Psychosis (SHARP) program for early psychosis identification

Psychosis is recognized as one of the largest contributors to nonfatal health loss, and early identification can largely improve routine clinical activity by predicting the psychotic course and guiding treatment. Clinicians have used the clinical high-risk for psychosis (CHR) paradigm to better understand the risk factors that contribute to the onset of psychotic disorders. Clinical factors have been widely applied to calculate the individualized risks for conversion to psychosis 1-2 years later. However, there is still a dearth of valid biomarkers to predict psychosis. Biomarkers, in the context of this paper, refer to measurable biological indicators that can provide valuable information about the early identification of individuals at risk for psychosis. The aim of this paper is to critically review studies assessing CHR and suggest possible biomarkers for application of prediction. We summarized the studies on biomarkers derived from the findings of the ShangHai at Risk for Psychosis (SHARP) program, including those that are considered to have the most potential. This comprehensive review was conducted based on expert opinions within the SHARP research team, and the selection of studies and results presented in this paper reflects the collective expertise of the team in the field of early psychosis identification. The three dimensions with potential candidates include neuroimaging dimension of brain structure and function, electrophysiological dimension of event-related potentials (ERPs), and immune dimension of inflammatory cytokines and complement proteins, which proved to be useful in supporting the prediction of psychosis from the CHR state. We suggest that these three dimensions could be useful as risk biomarkers for treatment optimization. In the future, when available for the integration of multiple dimensions, clinicians may be able to obtain a comprehensive report with detailed information of psychosis risk and specific indications about preferred prevention.

Age-related changes in self-reported psychotic experiences in clinical help-seeking population: From 15 to 45 years

AIMS

Psychotic experiences differ with age. It is currently unknown whether there were specific patterns and associations between the presentation of psychotic experiences and age. This study aimed to explore age-related differences (15-45 years) in self-reported psychotic experiences in a large-scale clinical population.

METHODS

A total of 2542 consecutive new patients aged 15-45 years were recruited on their first visit to the Shanghai Mental Health Center and screened with the PRIME Screen-Revised (PS-R). According to the clinical diagnostic information of patients from their outpatient medical records compiled by their clinicians, four diagnostic categories were applied: 1) psychotic disorder; 2) mood disorder; 3) anxiety disorder and 4) others.

RESULTS

The PS-R scores of self-reported psychotic experiences declined with age, except for two age ranges: ≤18 years for overall sample (≤18 vs. 19-34 years: t = 5.531, df = 2202, p < .001) and 37-40 years for female sample (37-40 vs. >40 years: t = 1.985, df = 138, p = .049), which showed upward trends, contrary to those of others. There were no significant differences in self-reported psychotic experiences between age groups in patients with psychotic disorders, while significant age differences were found in all nonpsychotic patients.

CONCLUSION

These findings support the view that frequent PS-R screening demonstrated that psychotic experiences decline with age in the clinical population. Early detection of psychosis should focus on not only adolescents but also women aged >36 years.

Prognostic accuracy and clinical utility of psychometric instruments for individuals at clinical high-risk of psychosis: a systematic review and meta-analysis

Accurate prognostication of individuals at clinical high-risk for psychosis (CHR-P) is an essential initial step for effective primary indicated prevention. We aimed to summarise the prognostic accuracy and clinical utility of CHR-P assessments for primary indicated psychosis prevention. Web of Knowledge databases were searched until 1st January 2022 for longitudinal studies following-up individuals undergoing a psychometric or diagnostic CHR-P assessment, reporting transition to psychotic disorders in both those who meet CHR-P criteria (CHR-P + ) or not (CHR-P-). Prognostic accuracy meta-analysis was conducted following relevant guidelines. Primary outcome was prognostic accuracy, indexed by area-under-the-curve (AUC), sensitivity and specificity, estimated by the number of true positives, false positives, false negatives and true negatives at the longest available follow-up time. Clinical utility analyses included: likelihood ratios, Fagan's nomogram, and population-level preventive capacity (Population Attributable Fraction, PAF). A total of 22 studies (n = 4 966, 47.5% female, age range 12-40) were included. There were not enough meta-analysable studies on CHR-P diagnostic criteria (DSM-5 Attenuated Psychosis Syndrome) or non-clinical samples. Prognostic accuracy of CHR-P psychometric instruments in clinical samples (individuals referred to CHR-P services or diagnosed with 22q.11.2 deletion syndrome) was excellent: AUC = 0.85 (95% CI: 0.81-0.88) at a mean follow-up time of 34 months. This result was driven by outstanding sensitivity (0.93, 95% CI: 0.87-0.96) and poor specificity (0.58, 95% CI: 0.50-0.66). Being CHR-P + was associated with a small likelihood ratio LR + (2.17, 95% CI: 1.81-2.60) for developing psychosis. Being CHR-P- was associated with a large LR- (0.11, 95%CI: 0.06-0.21) for developing psychosis. Fagan's nomogram indicated a low positive (0.0017%) and negative (0.0001%) post-test risk in non-clinical general population samples. The PAF of the CHR-P state is 10.9% (95% CI: 4.1-25.5%). These findings consolidate the use of psychometric instruments for CHR-P in clinical samples for primary indicated prevention of psychosis. Future research should improve the ability to rule in psychosis risk.

Relationships between self-reflectiveness and clinical symptoms in individuals during pre-morbid and early clinical stages of psychosis

Background

Self-reflectiveness, one dimension of cognitive insight, plays a protective role in an individual's mental state. Both high and low levels of self-reflectiveness have been reported in patients with schizophrenia and individuals at clinical high risk for the illness.

Aims

This study aimed to explore the relationship patterns between self-reflectiveness and clinical symptoms in individuals during the pre-morbid and early clinical stages of psychosis.

Methods

A total of 181 subjects, including individuals with attenuated positive symptoms (APS, n=122) and patients with first-episode psychosis (FEP, n=59), completed the Beck Cognitive Insight Scale and were evaluated using the Schedule of Assessment of Insight and Positive and Negative Syndrome Scale. All subjects were classified into three groups according to their level of self-reflectiveness: low level (LSR, n=59), medium level (MSR, n=67) and high level (HSR, n=55). Both linear and non-linear relationships between self-reflectiveness and clinical symptoms were explored.

Results

More individuals with APS were classified into the MSR group, while more patients with FEP were classified into the LSR group. The LSR group demonstrated less awareness of illness than the MSR and HSR groups, more stereotyped thinking and poorer impulse control but less anxiety than the MSR group, and lower levels of blunted affect and guilt feelings than the HSR group. The MSR group demonstrated lower stereotyped thinking than the HSR group. Compared to the LSR group, the MSR group had increased self-reflectiveness, improved awareness of illness, decreased stereotyped thinking, and better impulse control, but increased feelings of guilt. The HSR group showed increased stereotyped thinking when compared to the MSR group, but the other variables did not change significantly between these two groups. Overall, self-reflectiveness demonstrated an approximately inverse S-shaped relationship with the awareness of illness, a U-shaped relationship with stereotyped thinking and poor impulse control, and an almost linear relationship with anxiety and guilt feelings.

Conclusions

Self-reflectiveness demonstrates complex relationships with clinical symptoms and fails to exert significant positive effects when reaching a certain high level.

Gender differences in screening self-reported psychotic symptoms in a first help-seeking population

Gender differences in the frequency and severity of psychotic symptoms have been widely reported. However, in the screening process for the detection of early psychosis, gender differences were largely overlooked in China. This study investigated gender differences in self-reported psychotic symptoms in a clinical population who initially visited a mental health service. In total, 1931 consecutive new patients were included in the current analysis, with a mean age of 25.3 years, including 852 (44.1%) men and 1079 (55.9%) women, of whom 388 (20.1%) had psychotic disorders and 1543 (79.9%) had non-psychotic disorders. Psychotic symptoms were assessed using the PRIME Screen-Revised (PS-R) questionnaire. The cohort was grouped according to gender, age (adolescents ≤ 21 years, adults > 21 years), and clinical diagnosis. Within the full sample, gender differences in psychotic symptoms were not significant, except that females appeared to have more severe symptoms of disorganized communication than males. However, gender differences began to appear at subgroup levels, after stratification by age and diagnosis. Female adolescents reported more severe psychotic symptoms than male adolescents, especially in the symptom of perceptual abnormalities, which refer to hallucinations. Different patterns and predictors were found to significantly discriminate between psychotic and non-psychotic disorders among age and gender groups. Our study highlights gender differences in the severity, frequency, and pattern of self-reported psychotic symptoms when screening in a first help-seeking population. Therefore, gender differences should be considered during psychotic symptoms screening.

Prevalence of Individuals at Clinical High-Risk of Psychosis in the General Population and Clinical Samples: Systematic Review and Meta-Analysis

(1) The consistency and magnitude of the prevalence of Clinical High-Risk for Psychosis (CHR-P) individuals are undetermined, limiting efficient detection of cases. We aimed to evaluate the prevalence of CHR-P individuals systematically assessed in the general population or clinical samples. (2) PRISMA/MOOSE-compliant (PROSPERO: CRD42020168672) meta-analysis of multiple databases until 21/01/21: a random-effects model meta-analysis, heterogeneity analysis, publication bias and quality assessment, sensitivity analysis—according to the gold-standard CHR-P and pre-screening instruments—leave-one-study-out analyses, and meta-regressions were conducted. (3) 35 studies were included, with 37,135 individuals tested and 1554 CHR-P individuals identified (median age = 19.3 years, Interquartile range (IQR) = 15.8–22.1; 52.2% females, IQR = 38.7–64.4). In the general population (k = 13, n = 26,835 individuals evaluated), the prevalence of the CHR-P state was 1.7% (95% Confidence Interval (CI) = 1.0–2.9%). In clinical samples (k = 22, n = 10,300 individuals evaluated), the prevalence of the CHR-P state was 19.2% (95% CI = 12.9–27.7%). Using a pre-screening instrument was associated with false negatives (5.6%, 95% CI = 2.2–13.3%) and a lower CHR-P prevalence (11.5%, 95% CI = 6.2–20.5%) compared to using CHR-P instruments only (28.5%, 95% CI = 23.0–34.7%, p = 0.003). (4) The prevalence of the CHR-P state is low in the general population and ten times higher in clinical samples. The prevalence of CHR-P may increase with a higher proportion of females in the general population and with a younger population in clinical samples. The CHR-P state may be unrecognized in routine clinical practice. These findings can refine detection and preventive strategies.

Relationship Between Cognitive and Clinical Insight at Different Durations of Untreated Attenuated Psychotic Symptoms in High-Risk Individuals

Background: This study examines whether cognitive insight is impaired in high-risk individuals with attenuated psychotic symptoms (APS) and explores the relationship between cognitive and clinical insight at different durations of untreated attenuated psychotic symptoms (DUAPS). Methods: The Structured Interview for Psychosis high-risk Syndrome (SIPS) was used to identify APS individuals. APS (n = 121) and healthy control (HC, n = 87) subjects were asked to complete the Beck Cognitive Insight Scale (BCIS). Clinical insight of APS individuals was evaluated using the Schedule for Assessment of Insight (SAI). APS individuals were classified into four subgroups based on DUAPS, including 0-3, 4-6, 7-12, and >12 months. Power analysis for significant correlation was conducted using the WebPower package in R. Results: Compared with HC subjects, APS individuals showed poorer cognitive insight, with lower scores on BCIS self-reflectiveness and composite index (BCIS self-reflectiveness minus BCIS self-certainty). Only when DUAPS was longer than 12 months did the significant positive correlation between cognitive and clinical insight obtain the power about 0.8, including the associations between self-reflectiveness and awareness of illness, self-reflectiveness and the total clinical insight, and composite index and awareness of illness. The positive associations of composite index with awareness of illness within 0-3 months DUAPS and with the total score of SAI when DUAPS > 12 months were significant but failed to obtain satisfactory power. Conclusions: APS individuals may have impaired cognitive insight, demonstrating lower self-reflectiveness. The correlation between cognitive and clinical insight is associated with the duration of untreated attenuated psychotic symptoms.

Frequency of Self-reported Psychotic Symptoms among 2542 Outpatients at Their First Visit for Mental Health Services

Objective: Psychotic symptoms are prevalent in both clinical settings and the general population. The distribution of psychotic symptoms across patients with different types of psychotic and non-psychotic mental disorders is helpful for understanding symptom specificity. This study aimed to explore the distribution differences of psychotic symptoms in an outpatient population in terms of frequency, age, gender, and psychotic and non-psychotic disorders.Methods: Outpatients were recruited consecutively at their first visit to the Shanghai Mental Health Center. Psychotic symptoms over the preceding year were self-reported through the PRIME Screen-Revised (PS-R) questionnaire. Seven categories of psychotic symptoms were grouped: perplexity and delusional mood (Item-1,5); first rank symptoms (Item-3,6,11); overvalued beliefs (Item-2,4); suspiciousness/persecutory ideas (Item-7), grandiose ideas (Item 8), perceptual abnormalities (Item-9,10), and disorganized communication (Item-12). Comparisons were made with respect to age group, sex, and diagnostic category.Results: Of 2542 outpatients, 1448(57.0%) were screened as positive, which was defined as having two or more symptoms with at least "somewhat agree" scores, ranging from 0 to 6. The threshold of one or more "yes" items was an endorsement to categorize the participant as positive for psychotic symptoms. The frequency of psychotic symptoms declined with age. Younger patients tended to report more psychotic symptoms than older patients(p < .001). Suspiciousness(p = .038) and disorganized communication (p = .004) were more common in females than males. Age, first rank symptoms, suspiciousness/persecutory ideas, grandiose ideas, and perceptual abnormalities were found to significantly differ between psychotic and non-psychotic disorders.Conclusions: Psychotic symptoms appear to be common in the clinical population and represent nonspecific indicators of psychopathology. The difference between psychotic and non-psychotic psychopathologies is more a function of the presence, frequency, and severity of psychotic symptoms.