Towards a framework for good outcome in people at clinical high risk for psychosis: A Delphi consensus study

Personal Recovery Among People at Risk for Developing Serious Mental Health Problems: A Qualitative Systematic Review

OBJECTIVE

Personal recovery refers to a person's pursuit of a full, meaningful life despite the potentially debilitating impact of a mental illness. An evidence base describing personal recovery among people at risk for developing a mental illness is lacking, limiting the potential for mental health services to support personal recovery. To address this gap, the authors synthesized the extant research describing personal recovery among people at risk for developing a mental illness.

METHODS

A systematic search of several literature databases (MEDLINE, Embase, APA PsycInfo, Web of Science Core Collection, and Cochrane Library) was conducted to retrieve qualitative and case studies and first-person accounts. The Joanna Briggs Institute guidelines for systematic reviews were followed. Included studies reported on participants at variable risk for developing a schizophrenia spectrum, bipolar, major depressive, or borderline personality disorder. Articles were retrieved through a librarian-assisted search and through use of additional strategies (e.g., expert consultation). Abstracts were screened by the research team, and themes were developed by using thematic synthesis.

RESULTS

The 36 included articles were synthesized, and six themes were generated: difficulties and challenges; establishing an understanding of, and finding ways to cope with, one's mental health challenges; reestablishing a sense of agency and personhood; receiving support from people and services, as well as restoring relationships; reestablishing hope, meaning, and purpose; and overcoming stigma and destigmatizing mental illness in others.

CONCLUSIONS

These findings provide a conceptual foundation that can guide future research on personal recovery and clinical interventions that foster it among people at risk for mental illness.

Examining service-user perspectives for the development of a good outcome checklist for individuals at clinical high risk for psychosis

AIMS

Around 15% of patients at clinical high risk for psychosis (CHR-P) experience symptomatic remission and functional recovery at follow-up, yet the definition of a good outcome (GO) in this population requires further development. Outcomes are typically designed and rated by clinicians rather than patients, to measure adverse as opposed to GOs. Here we investigate how CHR-P subjects define a GO, with the aim of developing a checklist that could be used to measure GO in this clinical group.

METHODS

A set of GO-focused questions were designed in collaboration with a service-user. CHR-P patients (n = 48) were asked to rate the importance of items that could indicate short-term (1 year) and long-term (5 years) GO. These items were then ranked using the relative importance index (RII).

RESULTS

Patients rated improvement in subjective wellbeing (RII = 0.829) and non-specific presenting symptoms (RII = 0.817) amongst the factors most important for indicating GO in the short-term, and improved resilience (RII = 0.879) and negative symptoms (RII = 0.858) as key items for indicating long-term GO. Patients regarded building resilience (RII = 0.842) and having support from mental health services (RII = 0.833) as being protective for their mental health. These measures were included in a preliminary 12-item GO checklist (GO-12) for assessing GO in CHR-P subjects.

CONCLUSIONS

Patient-defined measures of GO included items that are not incorporated into conventional measures of outcomes in CHR-P subjects, such as subjective wellbeing and resilience. Integrating patient-defined metrics of GO may improve the assessment of outcomes in the CHR-P population.

Longitudinal outcome of attenuated positive symptoms, negative symptoms, functioning and remission in people at clinical high risk for psychosis: a meta-analysis

BACKGROUND

Little is known about clinical outcomes other than transition to psychosis in people at Clinical High-Risk for psychosis (CHR-P). Our aim was to comprehensively meta-analytically evaluate for the first time a wide range of clinical and functional outcomes beyond transition to psychosis in CHR-P individuals.

METHODS

PubMed and Web of Science were searched until November 2020 in this PRISMA compliant meta-analysis (PROSPERO:CRD42020206271). Individual longitudinal studies conducted in individuals at CHR-P providing data on at least one of our outcomes of interest were included. We carried out random-effects pairwise meta-analyses, meta-regressions, and assessed publication bias and study quality. Analyses were two-tailed with α=0.05.

FINDINGS

75 prospective studies were included (n=5,288, age=20.0 years, females=44.5%). Attenuated positive symptoms improved at 12 (Hedges' g=0.753, 95%CI=0.495-1.012) and 24 (Hedges' g=0.836, 95%CI=0.463-1.209), but not ≥36 months (Hedges' g=0.315. 95%CI=-0.176-0.806). Negative symptoms improved at 12 (Hedges' g=0.496, 95%CI=0.315-0.678), but not 24 (Hedges' g=0.499, 95%CI=-0.137-1.134) or ≥36 months (Hedges' g=0.033, 95%CI=-0.439-0.505). Depressive symptoms improved at 12 (Hedges' g=0.611, 95%CI=0.441-0.782) and 24 (Hedges' g=0.583, 95%CI=0.364-0.803), but not ≥36 months (Hedges' g=0.512 95%CI=-0.337-1.361). Functioning improved at 12 (Hedges' g=0.711, 95%CI=0.488-0.934), 24 (Hedges' g=0.930, 95%CI=0.553-1.306) and ≥36 months (Hedges' g=0.392, 95%CI=0.117-0.667). Remission from CHR-P status occurred in 33.4% (95%CI=22.6-44.1%) at 12 months, 41.4% (95%CI=32.3-50.5%) at 24 months and 42.4% (95%CI=23.4-61.3%) at ≥36 months. Heterogeneity across the included studies was significant and ranged from I2=53.6% to I2=96.9%. The quality of the included studies (mean±SD) was 4.6±1.1 (range=2-8).

INTERPRETATION

CHR-P individuals improve on symptomatic and functional outcomes over time, but these improvements are not maintained in the longer term, and less than half fully remit. Prolonged duration of care may be needed for this patient population to optimize outcomes.

FUNDING

None.

Mental Health Services Research Targeting the Clinical High-Risk State for Psychosis: Lessons, Future Directions and Integration with Patient Perspectives

PURPOSE OF REVIEW

We summarize the history of the clinical high-risk stage of psychosis (CHR), current research on this stage and recent critiques of the field, and evaluate current CHR guidelines and frameworks.

RECENT FINDINGS

Following its identification and characterization, CHR services have successfully been developed in North America, Europe, Australia and elsewhere. As reflected in guidelines, these services and their orientation largely emerged as an outgrowth of the framework pioneered by early intervention services for first-episode psychosis. We critically discuss what is known so far about the subjective experience of the CHR syndrome, the meaning of this "unofficial" diagnosis as well as what is known and unknown about the service-related needs. While a range of outstanding questions remain in the field, there is a particular need for patient-oriented work and to investigate the service-related needs of young people at CHR.

Beyond the cognitive insight paradox: Self-reflectivity moderates the relationship between depressive symptoms and general psychological distress in psychosis

BACKGROUND

People with psychosis experience significant emotional burden and distress associated with the symptomatic consequences of their mental disorder, thus difficulting their recovery. Several studies have found self-reflectivity, a dimension of cognitive insight, to be associated with effects which taken together may seem paradoxical, by predicting less psychotic symptom severity but more depression. To elucidate this issue, we examined the influence of psychotic symptoms, depressive symptoms, and self-reflectivity, on psychological distress. Further, we tested whether self-reflectivity moderated the relationship between depressive symptoms and psychological distress.

METHODS

Seventy-six outpatients with psychotic-spectrum disorders were assessed using measures of psychotic symptoms, depressive symptoms, cognitive insight (i.e., self-reflectivity, self-certainty) and psychological distress.

RESULTS

A regression model revealed that depressive, positive symptoms and the interaction between depressive symptoms and self-reflectivity had a significant effect on psychological distress. The moderation analysis showed that higher levels of self-reflectivity were related to less psychological distress associated with depressive mood.

CONCLUSIONS

The role of self-reflectivity on depression and distress may be more complex than a direct effect. Interventions targeted to improve metacognition by enhancing self-reflectivity might be important for lowering the psychological distress associated with depressive symptoms in people with psychosis.

Prevention of Psychosis: Advances in Detection, Prognosis, and Intervention

IMPORTANCE

Detection, prognosis, and indicated interventions in individuals at clinical high risk for psychosis (CHR-P) are key components of preventive psychiatry.

OBJECTIVE

To provide a comprehensive, evidence-based systematic appraisal of the advancements and limitations of detection, prognosis, and interventions for CHR-P individuals and to formulate updated recommendations.

EVIDENCE REVIEW

Web of Science, Cochrane Central Register of Reviews, and Ovid/PsychINFO were searched for articles published from January 1, 2013, to June 30, 2019, to identify meta-analyses conducted in CHR-P individuals. MEDLINE was used to search the reference lists of retrieved articles. Data obtained from each article included first author, year of publication, topic investigated, type of publication, study design and number, sample size of CHR-P population and comparison group, type of comparison group, age and sex of CHR-P individuals, type of prognostic assessment, interventions, quality assessment (using AMSTAR [Assessing the Methodological Quality of Systematic Reviews]), and key findings with their effect sizes.

FINDINGS

In total, 42 meta-analyses published in the past 6 years and encompassing 81 outcomes were included. For the detection component, CHR-P individuals were young (mean [SD] age, 20.6 [3.2] years), were more frequently male (58%), and predominantly presented with attenuated psychotic symptoms lasting for more than 1 year before their presentation at specialized services. CHR-P individuals accumulated several sociodemographic risk factors compared with control participants. Substance use (33% tobacco use and 27% cannabis use), comorbid mental disorders (41% with depressive disorders and 15% with anxiety disorders), suicidal ideation (66%), and self-harm (49%) were also frequently seen in CHR-P individuals. CHR-P individuals showed impairments in work (Cohen d = 0.57) or educational functioning (Cohen d = 0.21), social functioning (Cohen d = 1.25), and quality of life (Cohen d = 1.75). Several neurobiological and neurocognitive alterations were confirmed in this study. For the prognosis component, the prognostic accuracy of CHR-P instruments was good, provided they were used in clinical samples. Overall, risk of psychosis was 22% at 3 years, and the risk was the highest in the brief and limited intermittent psychotic symptoms subgroup (38%). Baseline severity of attenuated psychotic (Cohen d = 0.35) and negative symptoms (Cohen d = 0.39) as well as low functioning (Cohen d = 0.29) were associated with an increased risk of psychosis. Controlling risk enrichment and implementing sequential risk assessments can optimize prognostic accuracy. For the intervention component, no robust evidence yet exists to favor any indicated intervention over another (including needs-based interventions and control conditions) for preventing psychosis or ameliorating any other outcome in CHR-P individuals. However, because the uncertainty of this evidence is high, needs-based and psychological interventions should still be offered.

CONCLUSIONS AND RELEVANCE

This review confirmed recent substantial advancements in the detection and prognosis of CHR-P individuals while suggesting that effective indicated interventions need to be identified. This evidence suggests a need for specialized services to detect CHR-P individuals in primary and secondary care settings, to formulate a prognosis with validated psychometric instruments, and to offer needs-based and psychological interventions.