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

The key role of specific DSM-5 diagnostic criteria in the early development of alcohol use disorder: Findings from the RADAR prospective cohort study

BACKGROUND

Prevention and early intervention of alcohol use disorder (AUD) is a public health priority, yet there are gaps in our understanding of how AUD emerges, which symptoms of AUD come first, and whether there are modifiable risk factors that forecast the development of the disorder. This study investigated potential early-warning-sign symptoms for the development of AUD.

METHODS

Data were from the RADAR study, a prospective cohort study of contemporary emerging adults across Australia (n = 565, mean age = 18.9, range = 18-21 at baseline, 48% female). Participants were interviewed five times across a 2.5-year period. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) AUD criteria and diagnoses were assessed by clinical psychologists using the Structured Clinical Interview for DSM-IV (SCID-IV), modified to cover DSM-5 criteria. Hazard analyses modeled the time from first alcoholic drink to the emergence of any AUD criteria and determined which first-emergent AUD criteria were associated with a faster transition to disorder.

RESULTS

By the final time point, 54.8% of the sample had experienced at least one DSM-5 AUD criterion and 26.1% met criteria for DSM-5 AUD. The median time from first AUD criterion to a diagnosis of AUD was 4 years. Social problems from drinking (hazard ratio [HR] = 3.24, CI95 = 2.14, 4.92, p < 0.001), major role (HR = 2.53, CI95 = 1.58, 4.06, p < 0.001), and drinking larger amounts/for longer than intended (HR = 2.04, CI95 = 1.20, 3.46, p = 0.008) were first-onset criteria associated with a faster transition to AUD.

CONCLUSION

In the context of a prospective general population cohort study of the temporal development of AUD, alcohol-related social problems, major role problems, and using more or for longer than intended are key risk factors that may be targeted for early intervention.

Prodromal symptoms and the duration of untreated psychosis in first episode of psychosis patients: what differences are there between early vs. adult onset and between schizophrenia vs. bipolar disorder?

To assess the role of age (early onset psychosis-EOP < 18 years vs. adult onset psychosis-AOP) and diagnosis (schizophrenia spectrum disorders-SSD vs. bipolar disorders-BD) on the duration of untreated psychosis (DUP) and prodromal symptoms in a sample of patients with a first episode of psychosis. 331 patients with a first episode of psychosis (7-35 years old) were recruited and 174 (52.6%) diagnosed with SSD or BD at one-year follow-up through a multicenter longitudinal study. The Symptom Onset in Schizophrenia (SOS) inventory, the Positive and Negative Syndrome Scale and the structured clinical interviews for DSM-IV diagnoses were administered. Generalized linear models compared the main effects and group interaction. 273 AOP (25.2 ± 5.1 years; 66.5% male) and 58 EOP patients (15.5 ± 1.8 years; 70.7% male) were included. EOP patients had significantly more prodromal symptoms with a higher frequency of trouble with thinking, avolition and hallucinations than AOP patients, and significantly different median DUP (91 [33-177] vs. 58 [21-140] days; Z = - 2.006, p = 0.045). This was also significantly longer in SSD vs. BD patients (90 [31-155] vs. 30 [7-66] days; Z = - 2.916, p = 0.004) who, moreover had different profiles of prodromal symptoms. When assessing the interaction between age at onset (EOP/AOP) and type of diagnosis (SSD/BD), avolition was significantly higher (Wald statistic = 3.945; p = 0.047), in AOP patients with SSD compared to AOP BD patients (p = 0.004). Awareness of differences in length of DUP and prodromal symptoms in EOP vs. AOP and SSD vs. BD patients could help improve the early detection of psychosis among minors.

School-based Evaluation Advancing Response for Child Health (SEARCH): a mixed longitudinal cohort study from multifaceted perspectives in Jiangsu, China

BACKGROUND

Schools play a crucial role in providing mental health services to children and adolescents. However, the vastness of the student population and mental health workforce shortage in China severely limit the capacity for adequate care access and delivery.

OBJECTIVE

We propose a large, mixed longitudinal cohort study, 'School-based Evaluation Advancing Response for Child Health (SEARCH)', aimed at addressing the increasing demand from individuals seeking access to mental healthcare services.

METHODS

SEARCH uses a digital platform and school-based protocol for comprehensive assessment of the mental well-being of Chinese students in grades 4-12 incorporating individual, caregiver and teacher input, including capture of facial and acoustic features and response times, as well as mental well-being assessments.

FINDINGS

We completed first wave data collection from nearly 20 000 participants (students, caregivers and teachers) at 11 schools, grades 4-12, in 3 cities in Jiangsu province in Southeast China from September 2022 to February 2023. We intend to conduct follow-up assessments for grades 4 through 12 at the 11 school sites every 6 months for 5 years.

CONCLUSIONS

SEARCH will provide important insight into the developmental trajectory of mental well-being in Chinese children and adolescents. The study protocol does not simply focus on student self-report and incorporates caregiver and teacher viewpoints as well. It also collects objective indicators that may facilitate development of screening tools.

CLINICAL IMPLICATIONS

We believe future study findings will guide the development and implementation of school-based mental healthcare initiatives to improve the well-being of children and adolescents.

Anatomical variations in the insular cortex in individuals at a clinical high-risk state for psychosis and patients with schizophrenia

Introduction

Since the number of insular gyri is higher in schizophrenia patients, it has potential as a marker of early neurodevelopmental deviations. However, it currently remains unknown whether the features of the insular gross anatomy are similar between schizophrenia patients and individuals at risk of psychosis. Furthermore, the relationship between anatomical variations in the insular cortex and cognitive function has not yet been clarified.

Methods

The gross anatomical features (i.e., the number of gyri and development pattern of each gyrus) of the insular cortex were examined using magnetic resonance imaging, and their relationships with clinical characteristics were investigated in 57 subjects with an at-risk mental state (ARMS) and 63 schizophrenia patients in comparison with 61 healthy controls.

Results

The number of insular gyri bilaterally in the anterior subdivision was higher in the ARMS and schizophrenia groups than in the control group. The schizophrenia group was also characterized by a higher number of insular gyri in the left posterior subdivision. A well-developed right middle short insular gyrus was associated with symptom severity in first-episode schizophrenia patients, whereas chronic schizophrenia patients with a well-developed left accessory gyrus were characterized by less severe cognitive impairments in motor and executive functions. The features of the insular gross anatomy were not associated with clinical characteristics in the ARMS group.

Discussion

The features of the insular gross anatomy that were shared in the ARMS and schizophrenia groups may reflect a vulnerability to psychosis that may be attributed to anomalies in the early stages of neurodevelopment. However, the contribution of the insular gross anatomy to the clinical characteristics of schizophrenia may differ according to illness stages.

Neuronal dysfunction in individuals at early stage of schizophrenia, A resting-state fMRI study

Schizophrenia has been associated with abnormal intrinsic brain activity, involving various cognitive impairments. Qualitatively similar abnormalities are seen in individuals at ultra-high risk (UHR) for psychosis. In this study, resting-state fMRI (rs-fMRI) data were collected from 44 drug-naïve first-episode schizophrenia (Dn-FES) patients, 48 UHR individuals, and 40 healthy controls (HCs). The fractional amplitude of low-frequency fluctuations (fALFF), regional homogeneity (ReHo), and functional connectivity (FC), were performed to evaluate resting brain function. A support vector machine (SVM) was applied for classification analysis. Compared to HCs, both clinical groups showed increased fALFF in the central executive network (CEN), decreased ReHo in the ventral visual pathway (VVP) and decreased FC in temporal-sensorimotor regions. Excellent performance was achieved by using fALFF value in distinguishing both FES (sensitivity=83.21%, specificity=80.58%, accuracy=81.37%, p=0.009) and UHR (sensitivity=75.88%, specificity=85.72%, accuracy=80.72%, p<0.001) from HC group. Moreover, the study highlighted the importance of frontal and temporal alteration in the pathogenesis of schizophrenia. However, no fMRI features were observed that could well distinguish Dn-FES from UHR group. To conclude, fALFF in the CEN may provide potential power for identifying individuals at the early stage of schizophrenia and the alteration in the frontal and temporal lobe may be important to these individuals.

Reduced willingness to expend effort for rewards is associated with risk for conversion and negative symptom severity in youth at clinical high-risk for psychosis

BACKGROUND

Schizophrenia (SZ) is typically preceded by a prodromal (i.e. pre-illness) period characterized by attenuated positive symptoms and declining functional outcome. Negative symptoms are prominent among individuals at clinical high-risk (CHR) for psychosis (i.e. those with prodromal syndromes) and predictive of conversion to illness. Mechanisms underlying negative symptoms are unclear in the CHR population.

METHODS

The current study evaluated whether CHR participants demonstrated deficits in the willingness to expend effort for rewards and whether these impairments are associated with negative symptoms and greater risk for conversion. Participants included 44 CHR participants and 32 healthy controls (CN) who completed the Effort Expenditure for Reward Task (EEfRT).

RESULTS

Compared to CN, CHR participants displayed reduced likelihood of exerting high effort for high probability and magnitude rewards. Among CHR participants, reduced effort expenditure was associated with greater negative symptom severity and greater probability of conversion to a psychotic disorder on a cross-sectional risk calculator.

CONCLUSIONS

Findings suggest that effort-cost computation is a marker of illness liability and a transphasic mechanism underlying negative symptoms in the SZ spectrum.

History of trauma is a critical treatment target for individuals at clinical high-risk for psychosis

People meeting criteria for a clinical high-risk (CHR) for psychosis syndrome frequently represent a heterogeneous, help-seeking, and dynamic population. Among the numerous symptoms and risk factors for psychosis, exposure to trauma stands out as both highly prevalent and poorly understood. Indeed, while up to 80% of individuals meeting criteria for a CHR syndrome report trauma histories, there is currently limited research dedicated to this specific area. This is particularly problematic as trauma is tied to risk for conversion, leads to a range of clinical issues, and contributes to disability and poor quality of life. Fortunately, recent research in the general population has led to a significant evolution in the way trauma is assessed and understood, and further, some studies have indicated that targeted trauma interventions in formal psychotic disorders are highly effective. However, direct adoption is challenging as the CHR syndrome holds a number of unique concerns (e.g., clinical heterogeneity, developmental trauma), and characteristically, involves a developing pediatric or young adult population that also comes with specific considerations (e.g., living with caregivers, transitionary period in roles). In this "perspective" we frame the issues around understanding trauma in CHR individuals, discuss viable treatments and unique considerations, and provide suggestions for future steps in developing and incorporating trauma-focused interventions in this population.

Brain structural abnormalities of the associative striatum in adolescents and young adults at genetic high-risk of schizophrenia: Implications for illness endophenotypes

OBJECTIVE

Dysfunction in cortico-striatal circuitry represents a core component of the pathophysiology in schizophrenia (SZ) but its potential as a candidate endophenotype of the illness is often confounded by neuroleptic medication.

METHODS

Accordingly, 26 adolescent and young adult participants at genetic high-risk for schizophrenia, but who were asymptomatic and neuroleptic naïve, and 28 age-matched controls underwent 1.5T structural magnetic resonance imaging of the striatum, manually parcellated into limbic (LST), associative (AST), and sensorimotor (SMST) functional subregions.

RESULTS

In relation to their age peers, participants at genetic high-risk for schizophrenia showed overall lower striatal gray matter volume with their most pronounced loss, bilaterally in the AST, but not the LST or SMST. Neuropsychological testing revealed reduced executive functioning for genetically at-risk participants, although the groups did not differ significantly in overall intelligence or oral reading. For controls but not for at-genetic high-risk participants, stronger executive functioning correlated with increased bilateral AST volume.

CONCLUSIONS

Reduced bilateral AST volume in genetic high-risk adolescents and young adults, accompanied by heritable loss of higher cognitive brain-behavior relationships, might serve as a useful endophenotype of SZ.

Mental health, risk and protective factors at micro- and macro-levels across early at-risk stages for psychosis: The Mirorr study

BACKGROUND

The clinical staging model states that psychosis develops through subsequent stages of illness severity. To better understand what drives illness progression, more extensive comparison across clinical stages is needed. The current paper presents an in-depth characterization of individuals with different levels of risk for psychosis (i.e., different early clinical stages), using a multimethod approach of cross-sectional assessments and daily diary reports.

METHODS

Data came from the Mirorr study that includes N = 96 individuals, divided across four subgroups (n₁  = 25, n₂  = 27, n₃  = 24, and n₄  = 20). These subgroups, each with an increasing risk for psychosis, represent clinical stages 0-1b. Cross-sectional data and 90-day daily diary data on psychopathology, well-being, psychosocial functioning, risk and protective factors were statistically compared across subgroups (stages) and descriptively compared across domains and assessment methods.

RESULTS

Psychopathology increased across subgroups, although not always linearly and nuanced differences were seen between assessment methods. Well-being and functioning differed mostly between subgroup 1 and the other subgroups, suggesting differences between non-clinical and clinical populations. Risk and protective factors differed mostly between the two highest and lowest subgroups, especially regarding need of social support and coping, suggesting differences between those with and without substantial psychotic experiences. Subgroup 4 (stage 1b) reported especially high levels of daily positive and negative psychotic experiences.

CONCLUSIONS

Risk for psychosis exists in larger contexts of mental health and factors of risk and protection that differ across stages and assessment methods. Taking a broad, multi-method approach is an important next step to understand the complex development of youth mental health problems.

App-enhanced transdiagnostic CBT for adolescents with mood or psychotic spectrum disorders

BACKGROUND

Although transdiagnostic forms of cognitive-behavioral therapy (CBT) have been evaluated in individuals with depressive and anxiety disorders, few studies have examined their suitability for more severe disorders, such as recurrent or persistent major depressive disorder, bipolar disorder, or psychotic spectrum disorders. This study examined the acceptability and initial efficacy of an app-enhanced Unified Protocol for Adolescents [UP-A] when including youth with more severe mood disorders or psychotic spectrum disorders.

METHODS

We first adapted a mobile application (app), based on user-centered feedback from adolescents and their parents, to assist participants in reviewing session content, practicing skills learned in previous treatment sessions, and monitoring symptomatic progress. A total of 24 adolescents (M age = 15.2 years, SD = 1.6) with mood or psychotic spectrum disorders and their parents then participated in an open trial of the app-enhanced group treatment given over 9 weekly sessions.

RESULTS

Adolescent participants and their parents rated the group treatment and mobile app as acceptable and useful. We observed significant improvements over the 9-week treatment in adolescents' depressive symptoms, attenuated psychotic symptoms, and global functioning. The frequency with which adolescents used the mobile app between sessions was positively related to symptomatic and functional gains.

CONCLUSIONS

Initial findings suggest the acceptability and feasibility of a mobile app that enabled adolescent participants and their parents to review session content and practice treatment skills. Findings also indicated improvements in psychiatric and functional outcomes among the adolescent participants over the course of the app-enhanced treatment. Randomized clinical trials are needed to evaluate the efficacy of app-enhanced CBT in improving symptoms and functioning in adolescents with mood or psychotic spectrum disorders.

Efficacy, Tolerability, and Acceptance of Long-Lasting Antipsychotics in Children and Adolescents: A Systematic Review

Objectives: While long-lasting antipsychotics (LLA) were specifically developed to address the problem of adherence in patients with chronic psychiatric disorders, their role in pediatric populations is not clear. Methods: To document the efficacy, tolerance, and acceptance of LLAs in children and adolescents, a literature search was conducted using several databases for published studies (PubMed, PsycINFO) from January 1965 to December 2020. Twenty-two studies were identified (16 case reports/series, 3 open label studies, 2 controlled studies, and 1 retrospective analysis of national database). Results: Demographic features were widely heterogeneous across studies (total N = 480, 58% male, mean age = 15.0 ± 1.8). Case reports/series presented positive therapeutic outcomes in noncompliant youths with severe mental illness. Three open-label one-arm studies supported the clinical efficacy of risperidone long-acting injection in patients previously stabilized with oral risperidone. One study showed lower clinical symptoms and higher functioning at 12 months in youths treated for an acute psychotic episode with paliperidone palmitate compared to oral risperidone. The types and rates of side effects of LLA were comparable to those observed for oral antipsychotics. Two studies suggested better metabolic and neurological tolerance of LLA compared to an oral form. Preliminary evidence supported a satisfactory level of treatment satisfaction in patients treated with LLA and their families, while concerns were raised regarding practical administration in outpatient services. However, the average quality of the evidence based on the RoB2 tool was low. Conclusions: The level of evidence was low for the efficacy of LLA in pediatric populations and very low for the tolerance and acceptance. It concerned mostly the effect of risperidone long-acting injection in adolescents with psychotic disorders. Randomized maintenance clinical trials using noninferiority analysis would be more appropriate for further research.

Is it possible to stage schizophrenia? A systematic review

INTRODUCTION

A staging model is a clinical tool used to define the development of a disease over time. In schizophrenia, authors have proposed different theoretical staging models of increasing complexity. Therefore, the aims of our study were to provide an updated and critical view of the proposed clinical staging models for schizophrenia and to review the empirical data that support them.

METHODS

Systematic literature review following PRISMA guidelines. From the PubMed database and backward reference search, a total of 141 records were retrieved, but only 20 were selected according to the inclusion criteria: (a) available in English; (b) participants with schizophrenia ≥ 18 years; and (c) theoretical and empirical research studies intended to develop, validate, and/or improve staging models of schizophrenia.

RESULTS

Different clinical staging models for schizophrenia were identified, information about the proposed stages was tabulated and presented in the Results section (Tables 1, 2). Most of which include neuroimaging, functioning, and psychopathology, but only two models add objective biomarkers and none include patient point of view. However, few models have been psychometrically tested or used small samples and thus have been validated only partially. In addition, five studies proposed therapeutic interventions according to the stage of the disorder from a theoretical point of view.

DISCUSSION

In conclusion, it is possible to stage schizophrenia, but the models developed have several limitations. Empirical validation and inclusion of more specific biomarkers and measures of other life areas affected by schizophrenia could help in the development of more valid models.

Early intervention service systems for youth mental health: integrating pluripotentiality, clinical staging, and transdiagnostic lessons from early psychosis

Challenges associated with operationalising services for the at-risk mental state for psychosis solely in that same diagnostic silo are increasingly well recognised-namely, the differential risk for psychosis being a function of sampling enrichment strategies, declining transition rates to psychosis, questions regarding the validity of transition as an outcome, and the frequent development of non-psychotic disorders. However, recent epidemiological and clinical research suggests that not all threshold-level psychoses are likely to occur homotypically; early-stage non-psychotic syndromes might exhibit heterotypic shifts to a first episode of psychosis, without an identifiable at-risk mental state. These findings, along with the relevance of outcomes beyond traditional diagnoses or syndromes, have substantive implications for developing next-generation early intervention infrastructures. Along with the idea of general at-risk clinics for early-stage pluripotential syndromes, we examine how this reality might affect service design, such as the need for close linkage with centres of expertise for threshold-level disorders when transitions to later stages occur, the balance between generic and specific interventions amid the need for person-centred care, and the challenges this reorientation might pose for broader mental health systems.

Clinical high-risk criteria of psychosis in 8–17-year-old community subjects and inpatients not suspected of developing psychosis

BACKGROUND

In children and adolescents compared to adults, clinical high-risk of psychosis (CHR) criteria and symptoms are more prevalent but less psychosis-predictive and less clinically relevant. Based on high rates of non-converters to psychosis, especially in children and adolescents, it was suggested that CHR criteria were: (1) Pluripotential; (2) A transdiagnostic risk factor; and (3) Simply a severity marker of mental disorders rather than specifically psychosis-predictive. If any of these three alternative explanatory models were true, their prevalence should differ between persons with and without mental disorders, and their severity should be associated with functional impairment as a measure of severity.

AIM

To compare the prevalence and severity of CHR criteria/symptoms in children and adolescents of the community and inpatients.

METHODS

In the mainly cross-sectional examinations, 8–17-year-old community subjects (n = 233) randomly chosen from the population register of the Swiss Canton Bern, and inpatients (n = 306) with primary diagnosis of attention-deficit/hyperactivity disorder (n = 86), eating disorder (n = 97), anxiety including obsessive–compulsive disorder (n = 94), or autism spectrum disorder (n = 29), not clinically suspected to develop psychosis, were examined for CHR symptoms/criteria. Positive items of the Structured Interview for Psychosis-Risk Syndromes (SIPS) were used to assess the symptomatic ultra-high-risk criteria, and the Schizophrenia Proneness Instrument, Child and Youth version (SPI-CY) was used to assess the 14 basic symptoms relevant to basic symptom criteria. We examined group differences in frequency and severity of CHR symptoms/criteria using χ² tests and nonparametric tests with Cramer’s V and Rosenthal’s r as effect sizes, and their association with functioning using correlation analyses.

RESULTS

The 7.3% prevalence rate of CHR criteria in community subjects did not differ significantly from the 9.5% rate in inpatients. Frequency and severity of CHR criteria never differed between the community and the four inpatient groups, while the frequency and severity of CHR symptoms differed only minimally. Group differences were found in only four CHR symptoms: suspiciousness/persecutory ideas of the SIPS [χ² (4) = 9.425; P = 0.051, Cramer’s V = 0.132; and Z = -4.281, P < 0.001; Rosenthal’s r = 0.184], and thought pressure [χ² (4) = 11.019; P = 0.026, Cramer’s V = 0.143; and Z = -2.639, P = 0.008; Rosenthal’s r = 0.114], derealization [χ² (4) = 32.380; P < 0.001, Cramer’s V = 0.245; and Z = -3.924, P < 0.001; Rosenthal’s r = 0.169] and visual perception disturbances [χ² (4) = 10.652; P = 0.031, Cramer’s V = 0.141; and Z = -2.822, P = 0.005; Rosenthal’s r = 0.122] of the SPI-CY. These were consistent with a transdiagnostic risk factor or dimension, i.e., displayed higher frequency and severity in inpatients, in particular in those with eating, anxiety/obsessive–compulsive and autism spectrum disorders. Low functioning, however, was at most weakly related to the severity of CHR criteria/symptoms, with the highest correlation yielded for suspiciousness/persecutory ideas (Kendall’s tau = -0.172, P < 0.001).

CONCLUSION

The lack of systematic differences between inpatients and community subjects does not support suggestions that CHR criteria/symptoms are pluripotential or transdiagnostic syndromes, or merely markers of symptom severity.

Psychosis in Women: Time for Personalized Treatment

Early detection and prompt treatment of psychosis is of the utmost importance. The great variability in clinical onset, illness course, and response to pharmacological and psychosocial treatment is in great part gender-related. Our aim has been to review narratively the literature focusing on gender related differences in the psychoses, i.e., schizophrenia spectrum disorders. We searched the PubMed/Medline, Scopus, Embase, and ScienceDirect databases on 31 July 2021, focusing on recent research regarding sex differences in early psychosis. Although women, compared to men, tend to have better overall functioning at psychotic symptom onset, they often present with more mood symptoms, may undergo misdiagnosis and delay in treatment and are at a higher risk for antipsychotic drug-induced metabolic and endocrine-induced side effects. Furthermore, women with schizophrenia spectrum disorders have more than double the odds of having physical comorbidities than men. Tailored treatment plans delivered by healthcare services should consider gender differences in patients with a diagnosis of psychosis, with a particular attention to early phases of disease in the context of the staging model of psychosis onset.

Follow-up of subjects labelled with putative pre-psychotic states: Viewed from a transdiagnostic clinical high-at-risk mental state (CHARMS) paradigm

BACKGROUND

Follow-up of subjects with putative pre-psychotic states is essential to clarify the transition process to psychosis, while "non-converters" also deserve clinical attention as many may evolve into other psychiatric disorders with diverse outcomes. This study aimed to examine help-seeking individuals who have been labelled at clinical high-risk state but not converting to full-blown psychosis during first two years of follow-up.

METHODS

A retrospective observational cohort study of help-seeking subjects was conducted by reviewing medical records of participants in a previous early psychosis study at the study hospital between 2006 and 2020. We portrayed those who developed first episode psychosis after first 2-year follow-up in detail, and provided sketches of clinical macrophenotypes other than psychosis emerging from subjects among different risk groups.

RESULTS

Among 132 eligible subjects, data of 98 (74.2%) were available for detailed evaluation. Of these, 15 transitioned to first-episode psychosis (11.4%) with time to psychosis from 2 to 11 years, 11 had anxiety spectrum (8.3%), 11 had depressive spectrum (8.3%), 10 had obsessive compulsive (7.6%), 5 had bipolar spectrum disorders (3.8%), 13 had predominantly schizotypal (9.8%) and 4 had other personality traits (3%), and 13 had problems attributable to adjustment or developmental issues (9.8%).

CONCLUSIONS

Various diagnoses, either full- or sub-threshold, appropriately describe the diverse clinical phenomenology of a cohort presenting with non-specific and/or subthreshold psychotic symptoms. The clinical high-at-risk mental state (CHARMS) paradigm provides a reasonable transdiagnostic approach for orienting clinicians' attention toward young subjects seeking mental health help at an early stage of illness to potentially pluripotent trajectories.

Precursors and correlates of transient and persistent longitudinal profiles of psychotic experiences from late childhood through early adulthood

BACKGROUND

Psychotic experiences are reported by 5-10% of young people, although only a minority persist and develop into psychotic disorders. It is unclear what characteristics differentiate those with transient psychotic experiences from those with persistent psychotic experiences that are more likely to be of clinical relevance.

AIMS

To investigate how longitudinal profiles of psychotic experiences, created from assessments at three different time points, are influenced by early life and co-occurring factors.

METHOD

Using data from 8045 individuals from a birth cohort study, longitudinal profiles of psychotic experiences based on semi-structured interviews conducted at 12, 18 and 24 years were defined. Environmental, cognitive, psychopathological and genetic determinants of these profiles were investigated, along with concurrent changes in psychopathology and cognition.

RESULTS

Following multiple imputations, the distribution of longitudinal profiles of psychotic experiences was none (65.7%), transient (24.1%), low-frequency persistent (8.4%) and high-frequency persistent (1.7%). Individuals with high-frequency persistent psychotic experiences were more likely to report traumatic experiences, other psychopathology, a more externalised locus of control, reduced emotional stability and conscientious personality traits in childhood, compared with those with transient psychotic experiences. These characteristics also differed between those who had any psychotic experiences and those who did not.

CONCLUSIONS

These findings indicate that the same risk factors are associated with incidence as with persistence of psychotic experiences. Thus, it might be that the severity of exposure, rather than the presence of specific disease-modifying factors, is most likely to determine whether psychotic experiences are transient or persist, and potentially develop into a clinical disorder over time.

Defeatist performance beliefs in individuals at clinical high-risk for psychosis and outpatients with chronic schizophrenia

AIM

Prior studies indicate that defeatist performance beliefs (DPBs) are elevated in those in the chronic phase of schizophrenia (SZ) and associated with negative symptoms, functional outcome and neurocognitive impairment. However, it is unclear whether these same patterns of results hold in participants at clinical high-risk (CHR) for psychosis.

METHODS

Two studies were conducted to determine whether prior results in SZ could be replicated and extended to CHR. Participants included 184 healthy controls (CN) and 186 outpatients with chronic SZ for Study 1, and 30 CN and 35 CHR in Study 2. In both studies, participants completed the DPB scale and measures of negative symptoms, psychosocial functioning and neurocognition.

RESULTS

Both chronic SZ and CHR participants had elevated DPBs compared to CN (p's < .01). In SZ, higher DPBs were associated with greater negative symptoms (r's = .31-.37, p's < .01), poorer social functioning and impaired social cognition (r = -.40, P < .001). In CHR, greater DPBs were associated with poorer social functioning (r = -.52, P < .05) and impairments in the neurocognitive domains of reasoning (r = -.48, P < .05) and processing speed (r = -.41, P < .05). Models testing whether DPBs mediated links between negative symptoms and functioning, negative symptoms and cognition and cognition and functioning were nonsignificant in SZ and CHR samples.

CONCLUSIONS

Findings generally provide support for the cognitive model of negative symptoms and functioning and suggest that DPBs are an important clinical target across phases of psychotic illness.

Large-scale evaluation of the Positive and Negative Syndrome Scale (PANSS) symptom architecture in schizophrenia

Although the Positive and Negative Syndrome Scale (PANSS) is widely utilized in schizophrenia research, variability in specific item loading exist, hindering reproducibility and generalizability of findings across schizophrenia samples. We aim to establish a common PANSS factor structure from a large multi-ethnic sample and validate it against a meta-analysis of existing PANSS models. Schizophrenia participants (N = 3511) included in the current study were part of the Singapore Translational and Clinical Research Program (STCRP) and the Clinical Antipsychotic Trials for Intervention Effectiveness (CATIE). Exploratory Factor Analysis (EFA) was conducted to identify the factor structure of PANSS and validated with a meta-analysis (N = 16,171) of existing PANSS models. Temporal stability of the PANSS model and generalizability to individuals at ultra-high risk (UHR) of psychosis were evaluated. A five-factor solution best fit the PANSS data. These were the i) Positive, ii) Negative, iii) Cognitive/disorganization, iv) Depression/anxiety and v) Hostility factors. Convergence of PANSS symptom architecture between EFA model and meta-analysis was observed. Modest longitudinal reliability was observed. The schizophrenia derived PANSS factor model fit the UHR population, but not vice versa. We found that two other domains, Social Amotivation (SA) and Diminished Expression (DE), were nested within the negative symptoms factor. Here, we report one of the largest transethnic factorial structures of PANSS symptom domains (N = 19,682). Evidence reported here serves as crucial consolidation of a common PANSS structure that could aid in furthering our understanding of schizophrenia.

Computerized Assessment of Psychosis Risk

Early detection and intervention with young people at clinical high risk (CHR) for psychosis is critical for prevention efforts focused on altering the trajectory of psychosis. Early CHR research largely focused on validating clinical interviews for detecting at-risk individuals; however, this approach has limitations related to: (1) specificity (i.e., only 20% of CHR individuals convert to psychosis) and (2) the expertise and training needed to administer these interviews is limited. The purpose of our study is to develop the computerized assessment of psychosis risk (CAPR) battery, consisting of behavioral tasks that require minimal training to administer, can be administered online, and are tied to the neurobiological systems and computational mechanisms implicated in psychosis. The aims of our study are as follows: (1A) to develop a psychosis-risk calculator through the application of machine learning (ML) methods to the measures from the CAPR battery, (1B) evaluate group differences on the risk calculator score and test the hypothesis that the risk calculator score of the CHR group will differ from help-seeking and healthy controls, (1C) evaluate how baseline CAPR battery performance relates to symptomatic outcome two years later (i.e., conversion and symptomatic worsening). These aims will be explored in 500 CHR participants, 500 help-seeking individuals, and 500 healthy controls across the study sites. This project will provide a next-generation CHR battery, tied to illness mechanisms and powered by cutting-edge computational methods that can be used to facilitate the earliest possible detection of psychosis risk.

Genetic liability in individuals at ultra-high risk of psychosis: A comparison study of 9 psychiatric traits

Individuals at ultra-high risk (UHR) of psychosis are characterised by the emergence of attenuated psychotic symptoms and deterioration in functioning. In view of the high non-psychotic comorbidity and low rates of transition to psychosis, the specificity of the UHR status has been called into question. This study aims to (i) investigate if the UHR construct is associated with the genetic liability of schizophrenia or other psychiatric conditions; (ii) examine the ability of polygenic risk scores (PRS) to discriminate healthy controls from UHR, remission and conversion status. PRS was calculated for 210 youths (nUHR = 102, nControl = 108) recruited as part of the Longitudinal Youth at Risk Study (LYRIKS) using nine psychiatric traits derived from twelve large-scale psychiatric genome-wide association studies as discovery datasets. PRS was also examined to discriminate UHR-Healthy control status, and healthy controls from UHR remission and conversion status. Result indicated that schizophrenia PRS appears to best index the genetic liability of UHR, while trend level associations were observed for depression and cross-disorder PRS. Schizophrenia PRS discriminated healthy controls from UHR (R2 = 7.9%, p = 2.59 x 10-3, OR = 1.82), healthy controls from non-remitters (R2 = 8.1%, p = 4.90 x 10-4, OR = 1.90), and converters (R2 = 7.6%, p = 1.61 x 10-3, OR = 1.82), with modest predictive ability. A trend gradient increase in schizophrenia PRS was observed across categories. The association between schizophrenia PRS and UHR status supports the hypothesis that the schizophrenia polygenic liability indexes the risk for developing psychosis.

An Analysis of the Pattern of Adaptive Emotion Regulation Associated with Low Paranoid Ideation in Healthy and Clinical Samples

Background

Research on emotion regulation and paranoid ideation has mostly focused on isolated regulation strategies and has remained largely inconclusive. According to the emotion regulation model by Berking and Whitley (in: Affect Regulation Training, Springer, New York 2014) successful modification or acceptance/tolerance of emotions requires an adequate comprehension (awareness, clarity, understanding) of emotions and adequate self-support.

Method

Building on this model, we investigated whether comprehension and self-support strengthen the negative association between modification and acceptance/tolerance and paranoid ideation. In study 1, we examined the hypotheses cross-sectionally based on questionnaire data from a combined sample (N = 125) consisting of people with a psychotic disorder, people at risk of developing psychosis, and healthy controls. In study 2, we examined the same hypotheses longitudinally by employing the experience sampling method in people with clinically relevant psychopathology below diagnostic threshold (N = 138).

Results

In study 1, the association between modification and paranoid ideation was not moderated by comprehension or self-support. However, comprehension and self-support moderated the association between acceptance/tolerance and paranoid ideation. In study 2, the interaction effect between comprehension and acceptance/tolerance on paranoid ideation was confirmed.

Conclusion

The results indicate that comprehending and accepting/tolerating emotions could be protective against paranoid ideation.

Treating sleep problems in young people at ultra-high-risk of psychosis: study protocol for a single-blind parallel group randomised controlled feasibility trial (SleepWell)

BACKGROUND

Effective interventions, targeting key contributory causal factors, are needed to prevent the emergence of severe mental health problems in young people. Insomnia is a common clinical issue that is problematic in its own right but that also leads to the development and persistence of psychotic experiences. The implication is that treating sleep problems may prevent the onset of psychosis. We collected initial case series data with 12 young people at ultra-high-risk of psychosis. Post-intervention, there were improvements in sleep, depression and psychotic experiences. Now we test the feasibility of a randomised controlled trial, with a clinical aim to treat sleep problems and hence reduce depression, psychotic experiences, and prevent transition to psychosis.

METHODS AND ANALYSIS

A randomised controlled feasibility trial will be conducted. Forty patients aged 14 to 25 years who are at ultra-high-risk of psychosis and have sleep disturbance will be recruited from National Health Service (NHS) mental health services. Participants will be randomised to receive either a novel, targeted, youth-focussed sleep intervention in addition to usual care or usual care alone. Assessor-blinded assessments will be conducted at baseline, 3 months (post-intervention) and 9 months (follow-up). The eight-session psychological intervention will target the key mechanisms which disrupt sleep: circadian rhythm irregularities, low sleep pressure, and hyperarousal. To gain an in-depth understanding of participants' views on the acceptability of the intervention and study procedures, 16 participants (n=10 intervention, n=6 control) will take part in qualitative interviews. Analyses will focus on feasibility outcomes (recruitment, retention, and treatment uptake rates) and provide initial CI estimates of intervention effects. Thematic analysis of the qualitative interviews will assess the acceptability of the intervention and trial procedures.

ETHICS AND DISSEMINATION

The trial has received ethical approval from the NHS Health Research Authority. Findings will be disseminated through peer-reviewed publications, conference presentations, and lay networks.

TRIAL REGISTRATION NUMBER

ISRCTN85601537.

Suicide and Schizophrenia: an Interplay of Factors

PURPOSE OF REVIEW

The main purpose of this review is to elucidate the interplay of various factors in the relationship between suicide and schizophrenia. Suicide and schizophrenia have been interlinked as a symptom, factor in recovery and prognosis, outcome measure and response to psychotic symptoms in patients with schizophrenia. Many biomarkers have been identified in relation to the two phenomena.

RECENT FINDINGS

The analysis of the papers of the last 5 years (2015-2019) and till date has revealed studies looking at outcomes in relation to suicide, biological markers to determine the protection from and occurrence of suicide in schizophrenia and demographic factors that play a role in the occurrence of suicide in patients with schizophrenia. Suicide is a common occurrence in patients with schizophrenia and must be studied further in diverse populations of the disorder to help determine exact relationships between these two variables that will aid in clinical recovery, better outcome and improve prognosis.

EEG microstates as biomarker for psychosis in ultra-high-risk patients

Resting-state EEG microstates are brief (50-100 ms) periods, in which the spatial configuration of scalp global field power remains quasi-stable before rapidly shifting to another configuration. Changes in microstate parameters have been described in patients with psychotic disorders. These changes have also been observed in individuals with a clinical or genetic high risk, suggesting potential usefulness of EEG microstates as a biomarker for psychotic disorders. The present study aimed to investigate the potential of EEG microstates as biomarkers for psychotic disorders and future transition to psychosis in patients at ultra-high-risk (UHR). We used 19-channel clinical EEG recordings and orthogonal contrasts to compare temporal parameters of four normative microstate classes (A-D) between patients with first-episode psychosis (FEP; n = 29), UHR patients with (UHR-T; n = 20) and without (UHR-NT; n = 34) later transition to psychosis, and healthy controls (HC; n = 25). Microstate A was increased in patients (FEP & UHR-T & UHR-NT) compared to HC, suggesting an unspecific state biomarker of general psychopathology. Microstate B displayed a decrease in FEP compared to both UHR patient groups, and thus may represent a state biomarker specific to psychotic illness progression. Microstate D was significantly decreased in UHR-T compared to UHR-NT, suggesting its potential as a selective biomarker of future transition in UHR patients.

Enhancing Psychosis Risk Prediction Through Computational Cognitive Neuroscience

Research suggests that early identification and intervention with individuals at clinical high risk (CHR) for psychosis may be able to improve the course of illness. The first generation of studies suggested that the identification of CHR through the use of specialized interviews evaluating attenuated psychosis symptoms is a promising strategy for exploring mechanisms associated with illness progression, etiology, and identifying new treatment targets. The next generation of research on psychosis risk must address two major limitations: (1) interview methods have limited specificity, as recent estimates indicate that only 15%-30% of individuals identified as CHR convert to psychosis and (2) the expertise needed to make CHR diagnosis is only accessible in a handful of academic centers. Here, we introduce a new approach to CHR assessment that has the potential to increase accessibility and positive predictive value. Recent advances in clinical and computational cognitive neuroscience have generated new behavioral measures that assay the cognitive mechanisms and neural systems that underlie the positive, negative, and disorganization symptoms that are characteristic of psychotic disorders. We hypothesize that measures tied to symptom generation will lead to enhanced sensitivity and specificity relative to interview methods and the cognitive intermediate phenotype measures that have been studied to date that are typically indicators of trait vulnerability and, therefore, have a high false positive rate for conversion to psychosis. These new behavioral measures have the potential to be implemented on the internet and at minimal expense, thereby increasing accessibility of assessments.

Measuring psychopathology as it unfolds in daily life: addressing key assumptions of intensive longitudinal methods in the TRAILS TRANS-ID study

BACKGROUND

Intensive longitudinal (IL) designs provide the potential to study symptoms as they evolve in real-time within individuals. This has promising clinical implications, potentially allowing conclusions at the level of specific individuals. The current study aimed to establish the feasibility of IL designs, as indicated by self-rated burden and attrition, in the context of psychiatry. Additionally, we evaluated three core assumptions about the instruments (diary items) used in IL designs. These assumptions are: diary items (1) reflect experiences that change over time within individuals (indicated by item variability), (2) are interpreted consistently over time, and (3) correspond to retrospective assessments of psychopathology.

METHODS

TRAILS TRANS-ID is an add-on IL study in the clinical cohort of the TRAILS study. Daily diaries on psychopathological symptoms for six consecutive months were completed by 134 at risk young adults (age 22.6 ± 0.6 years). At baseline, immediately after the diary period, and one year after the diary period, participants completed a diagnostic interview.

RESULTS

Excellent compliance (88.5% of the diaries completed), low participant burden (M = 3.21; SD = 1.42; range 1-10), and low attrition (8.2%) supported the feasibility of six-month IL designs. Diary items differed in their variability over time. Evaluation of the consistency of diary item interpretations showed that within-individual variability in scores could not be attributed to changing interpretations over time. Further, daily symptom reports reasonably correlated with retrospective assessments (over a six month period) of psychopathology obtained with the diagnostic interview, suggesting that both measures might complement each other.

CONCLUSION

The current study is the first to show that IL designs over extensive periods (i.e., multiple months) in psychiatry are feasible, and meet three core assumptions to study change in psychopathology. This might allow for addressing novel and promising hypotheses in our field, and might substantially alter how we treat and study mental ill-health.

Physical Illnesses Before Diagnosed as Schizophrenia: A Nationwide Case-Control Study

Some physical illnesses are potentially associated with the development of schizophrenia. However, few studies have investigated these associations. Here, we examined physical illnesses and medical utilization patterns existing before patients received a diagnosis of schizophrenia. We enrolled a large representative cohort of the general population in Taiwan (N = 1 000 000) and identified 1969 young patients with a new diagnosis of schizophrenia from January 1, 2000 to December 31, 2013. We conducted a nested case-control study based on risk-set sampling. Each case was age-matched and sex-matched with 4 controls selected from the general population. The case and control groups were compared on the basis of various clinical characteristics. Conditional logistic regression was used to estimate the magnitude of risk associated with newly diagnosed schizophrenia. Within the 1 year before the schizophrenia diagnosis, the cases were most likely to visit the psychiatry department, followed by internal medicine and family medicine departments. According to multivariate analysis, compared with the controls, the cases had substantially higher risk of physical conditions in the prodromal phase, including hypertension (adjusted risk ratio [aRR] = 1.93, P = .001), other forms of heart disease (aRR = 2.07, P < .001), cerebrovascular diseases (aRR = 2.96, P = .001), chronic obstructive pulmonary disease (aRR = 1.50, P = .005), asthma (aRR = 1.76, P = .003), and irritable bowel syndrome (aRR = 2.00, P < .001). A wide range of psychiatric diseases and concomitant use of medications were significantly associated with schizophrenia development. In conclusion, several physical illnesses were identified to be associated with schizophrenia development, indicating that people with these illnesses could be vulnerable to schizophrenia.

The Prevalence of Negative Symptoms Across the Stages of the Psychosis Continuum

BACKGROUND

Patients in every stage of the psychosis continuum can present with negative symptoms. While no treatment is currently available to address these symptoms, a more refined characterization of their course over the lifetime could help in elaborating interventions. Previous reports have separately investigated the prevalence of negative symptoms within each stage of the psychosis continuum. Our aim in this review is to compare those prevalences across stages, thereby disclosing the course of negative symptoms.

METHODS

We searched several databases for studies reporting prevalences of negative symptoms in each one of our predetermined stages of the psychosis continuum: clinical or ultra-high risk (UHR), first-episode of psychosis (FEP), and younger and older patients who have experienced multiple episodes of psychosis (MEP). We combined results using the definitions of negative symptoms detailed in the Brief Negative Symptom Scale, a recently developed tool. For each negative symptom, we averaged and weighted by the combined sample size the prevalences of each negative symptom at each stage.

RESULTS

We selected 47 studies totaling 1872 UHR, 2947 FEP, 5039 younger MEP, and 669 older MEP patients. For each negative symptom, the prevalences showed a comparable course. Each negative symptom decreased from the UHR to FEP stages and then increased from the FEP to MEP stages.

CONCLUSIONS

Certain psychological, environmental, and treatment-related factors may influence the cumulative impact of negative symptoms, presenting the possibility for early intervention to improve the long-term course.

Applying a Transdiagnostic Cognitive-Behavioral Treatment to Adolescents at High Risk for Serious Mental Illness: Rationale and Preliminary Findings

Given the chronic and deleterious course of serious mental illness (SMI; schizophrenia and bipolar disorder), significant efforts have been undertaken to improve prediction of SMI and provide treatment for adolescents in the early, putatively prodromal stage of these illnesses. While risk assessments and disorder-specific treatments for adolescents at risk for SMI have shown some efficacy, significant issues remain around disorder-specific treatments for these youth. There is substantial heterogeneity of psychopathology within adolescents at high risk for SMI that leads to many false-positives and varying diagnostic outcomes. As a result, initial treatment focusing on broad symptoms and skills has been proposed in place of disorder-specific treatments. We discuss the rationale for providing an already-developed and empirically supported transdiagnostic treatment for emotional disorders (termed the Unified Protocol) as a first-line staging of treatment for adolescents experiencing early SMI symptoms. Additionally, we outline the open trial we are piloting using this transdiagnostic treatment in adolescents between the ages of 13 - 17 who have begun experiencing distressing yet subsyndromal psychosis or bipolar mood symptoms. Preliminary findings suggest feasibility and acceptability as well as initial efficacy in improving psychiatric symptoms, quality of life, and difficulties regulating emotions. We also present case studies from our open trial. A unified, cognitive-behavioral treatment for early presentations of SMI has important clinical and public health benefits, including streamlining treatment and providing broad skills that are applicable to a wide range of psychopathology.

Mental Health Service Use and Psychopharmacological Treatment Following Psychotic Experiences in Preadolescence

OBJECTIVE

Psychotic experiences affect more than 10% of children and often co-occur with nonpsychotic mental disorders. However, longitudinal studies of the outcome of psychotic experiences based on unbiased information on mental health service use and psychotropic medications are scarce. The authors investigated whether psychotic experiences at ages 11-12 predicted a psychiatric diagnosis or treatment with psychotropic medications by ages 16-17.

METHODS

In a longitudinal register-based follow-up study of the Copenhagen Child Cohort 2000, a total of 1,632 children ages 11-12 were assessed for psychotic experiences in face-to-face interviews. The children were also assessed for mental disorders and IQ. National registries provided information on perinatal and sociodemographic characteristics, on psychiatric disorders diagnosed at child and adolescent mental health services, and on prescribed psychotropic medications through ages 16-17.

RESULTS

Among children who had not been previously diagnosed, and after adjustment for sociodemographic and perinatal adversities and IQ, psychotic experiences at ages 11-12 predicted receiving a psychiatric diagnosis in child and adolescent mental health services before ages 16-17 (adjusted hazard ratio=3.13, 95% CI=1.93, 5.07). The risk was increased if the child met criteria for a co-occurring mental disorder (not diagnosed in mental health settings) at baseline compared with no psychotic experiences or diagnosis at baseline (adjusted hazard ratio=7.85, 95% CI=3.94, 15.63), but having psychotic experiences alone still marked a significantly increased risk of later psychiatric diagnoses (adjusted hazard ratio=2.76, 95% CI=1.48, 5.13). Similar patterns were found for treatment with psychotropic medications.

CONCLUSIONS

Psychotic experiences in childhood predict mental health service use and use of psychotropic medications during adolescence. The study findings provide strong evidence that psychotic experiences in preadolescence index a transdiagnostic vulnerability for diagnosed psychopathology in adolescence.

Checking the predictive accuracy of basic symptoms against ultra high-risk criteria and testing of a multivariable prediction model: Evidence from a prospective three-year observational study of persons at clinical high-risk for psychosis

Background:

The aim of this study was to critically examine the prognostic validity of various clinical high-risk (CHR) criteria alone and in combination with additional clinical characteristics.

Methods:

A total of 188 CHR positive persons from the region of Zurich, Switzerland (mean age 20.5 years; 60.2% male), meeting ultra high-risk (UHR) and/or basic symptoms (BS) criteria, were followed over three years. The test battery included the Structured Interview for Prodromal Syndromes (SIPS), verbal IQ and many other screening tools. Conversion to psychosis was defined according to ICD-10 criteria for schizophrenia (F20) or brief psychotic disorder (F23).

Results:

Altogether n = 24 persons developed manifest psychosis within three years and according to Kaplan–Meier survival analysis, the projected conversion rate was 17.5%. The predictive accuracy of UHR was statistically significant but poor (area under the curve [AUC] = 0.65, P < .05), whereas BS did not predict psychosis beyond mere chance (AUC = 0.52, P = .730). Sensitivity and specificity were 0.83 and 0.47 for UHR, and 0.96 and 0.09 for BS. UHR plus BS achieved an AUC = 0.66, with sensitivity and specificity of 0.75 and 0.56. In comparison, baseline antipsychotic medication yielded a predictive accuracy of AUC = 0.62 (sensitivity = 0.42; specificity = 0.82). A multivariable prediction model comprising continuous measures of positive symptoms and verbal IQ achieved a substantially improved prognostic accuracy (AUC = 0.85; sensitivity = 0.86; specificity = 0.85; positive predictive value = 0.54; negative predictive value = 0.97).

Conclusions:

We showed that BS have no predictive accuracy beyond chance, while UHR criteria poorly predict conversion to psychosis. Combining BS with UHR criteria did not improve the predictive accuracy of UHR alone. In contrast, dimensional measures of both positive symptoms and verbal IQ showed excellent prognostic validity. A critical re-thinking of binary at-risk criteria is necessary in order to improve the prognosis of psychotic disorders.

Predictive validity of conversion from the clinical high risk syndrome to frank psychosis

Although the clinical high risk for psychosis (CHR) paradigm has become well-established over the past two decades, one key component has received surprisingly little investigative attention: the predictive validity of the criteria for conversion or transition to frank psychosis. The current study evaluates the predictive validity of the transition to psychosis as measured by the Structured Interview for Psychosis-Risk Syndromes (SIPS) in CHR individuals. Participants included 33 SIPS converters and 399 CHR non-converters both from the North American Prodromal Longitudinal Study (NAPLS-2), as well as a sample of 67 separately ascertained first-episode psychosis (FEP) patients from the STEP program. Comparisons were made at baseline and one-year follow-up on demographic, diagnostic stability (SCID), and available measurement domains relating to severity of illness (psychotropic medication, psychosocial treatment, and resource utilization). Principal findings are: 1) a large majority of cases in both SIPS converters (n = 27/33, 81.8%) and FEP (n = 57/67, 85.1%) samples met criteria for continued psychosis at one-year follow-up; 2) follow-up prescription rates for current antipsychotic medication were higher in SIPS converters (n = 17/32, 53.1%) compared to SIPS non-converters (n = 81/397, 20.4%), and similar as compared to FEP cases (n = 39/65, 60%); and 3) at follow-up, SIPS converters had higher rates of resource utilization (psychiatric hospitalizations, day hospital admissions, and ER visits) than SIPS non-converters and were similar to FEP in most categories. The results suggest that the SIPS definition of psychosis onset carries substantial predictive validity. Limitations and future directions are discussed.

What Causes the Onset of Psychosis in Individuals at Clinical High Risk? A Meta-analysis of Risk and Protective Factors

Twenty percent of individuals at clinical high risk for psychosis (CHR-P) develop the disorder within 2 years. Extensive research has explored the factors that differentiate those who develop psychosis and those who do not, but the results are conflicting. The current systematic review and meta-analysis comprehensively addresses the consistency and magnitude of evidence for non-purely genetic risk and protective factors associated with the risk of developing psychosis in CHR-P individuals. Random effects meta-analyses, standardized mean difference (SMD) and odds ratio (OR) were used, in combination with an established stratification of evidence that assesses the association of each factor and the onset of psychotic disorders (from class I, convincing evidence to class IV weak evidence), while controlling for several types of biases. A total of 128 original controlled studies relating to 26 factors were retrieved. No factors showed class I-convincing evidence. Two further factors were associated with class II-highly suggestive evidence: attenuated positive psychotic symptoms (SMD = 0.348, 95% CI: 0.280, 0.415) and global functioning (SMD = -0.291, 95% CI: -0.370, -0.211). There was class III-suggestive evidence for negative psychotic symptoms (SMD = 0.393, 95% CI: 0.317, 0.469). There was either class IV-weak or no evidence for all other factors. Our findings suggest that despite the large number of putative risk factors investigated in the literature, only attenuated positive psychotic symptoms, global functioning, and negative psychotic symptoms show suggestive evidence or greater for association with transition to psychosis. The current findings may inform the refinement of clinical prediction models and precision medicine in this field.

A Weighted Gene Co-expression Network Analysis Reveals lncRNA Abnormalities in the Peripheral Blood Associated With Ultra-High-Risk for Psychosis

Objective: The primary study aim was to identify long non-coding RNA (lncRNA) abnormalities associated with ultra-high-risk (UHR) for psychosis based on a weighted gene co-expression network analysis. Methods: UHR patients were screened by the structured interview for prodromal syndromes (SIPS). We performed a WGCNA analysis on lncRNA and mRNA microarray profiles generated from the peripheral blood samples in 14 treatment-seeking patients with UHR who never received psychiatric medication and 18 demographically matched typically developing controls. Gene Ontology (GO) analysis and canonical correlation analysis were then applied to reveal functions and correlation between lncRNAs and mRNAs. Results: The lncRNAs were organized into co-expressed modules by WGCNA, two modules of which were strongly associated with UHR. The mRNA networks were constructed and two disease-associated mRNA modules were identified. A functional enrichment analysis showed that mRNAs were highly enriched for immune regulation and inflammation. Moreover, a significant correlation between lncRNAs and mRNAs were verified by a canonical correlation analysis. Conclusion: We identified novel lncRNA modules related to UHR. These results contribute to our understanding of the molecular basis of UHR from the perspective of systems biology and provide a theoretical basis for early intervention in the assumed development of schizophrenia.

Distress related to psychotic symptoms in individuals at high risk of psychosis

This study assessed the relationship between distress, severity and frequency of attenuated psychotic symptoms in individuals meeting Ultra High Risk (UHR) criteria, both at baseline and over time. It also assessed distress in relation to attenuated symptoms and whether cognitive behavioural therapy (CBT) reduced distress over time by symptom type. At baseline a combined total of 592 UHR participants (mean age 19.9; males, 53.9%) from two studies were assessed using a confirmatory factor analysis (CFA). Change over time from this baseline point was assessed using latent growth curve (LGC) models, based on participants from one of the studies. Distress associated with psychotic symptom was shown to be a separate psychological construct from severity and frequency. Distress was also significantly associated with severity but not frequency. Longitudinal LGC models with 244 participants showed that distress, severity and frequency all reduced over six months, although the rate of distress reduction varied across symptom type. Non-bizarre ideas (NBI) were more distressing and had the fastest rate of distress reduction over time. The baseline distress for some symptoms also strongly predicted the symptom severity change over time, suggesting that distress may cause change in the UHR criteria for unusual thought content (UTC) and NBI symptoms. CBT was not shown to be significantly different from treatment as usual (TAU) in its effect on distress. However, distress reduces over time, particularly in the first 3 months after presentation. We recommend that distress should be used as an outcome in future research and as a clinical indicator. (250 words).

Advances in clinical staging, early intervention, and the prevention of psychosis

The development of effective intervention and prevention strategies among individuals with psychosis risk syndromes may help to reduce symptomatology and conversion to a psychotic disorder. Although strides have been made in this area, more work is needed, particularly given the setbacks that remain (such as heterogeneity among this group). There has been a shift with the introduction of clinical staging models toward expanding current intervention and prevention efforts to a more developmental and transdiagnostic approach. With this, this article seeks to review treatments both recently and currently discussed in the staging literature, introduce advances in psychosis risk syndrome treatments that may be beneficial to consider in clinical staging heuristics, and pinpoint other promising options.

Spanish validation of the self-evaluation of negative symptoms scale SNS in an adolescent population

BACKGROUND

Negative symptoms (NS) may be observed in the general population in an attenuated form and in high-risk mental states. However, they have been less studied in the general population than positive symptoms, in spite of their importance at the insidious onset of schizophrenia and their appearance before positive symptoms. This study aimed to analyze the empirical structure of the Spanish version of the Self-Evaluation of Negative Symptoms (SNS) Scale and find its psychometric properties and invariance of measurement across sex and age in a sample of adolescents.

METHODS

The sample consisted of 4521 adolescents (53.6% female) from 11 to 18 years of age.

RESULTS

Confirmatory Factor Analysis of the SNS confirmed an internal structure of five first-order factors by the characteristic dimensions of NS: avolition, social withdrawal, diminished emotional range, anhedonia, alogia, and one second-order factor which includes the total NS score. Multi-group confirmatory factor analysis showed that the scale was invariant across sex and age. Total scale reliability was adequate. A strong relationship was found between the SNS with depressive symptomatology, moderate with ideas of reference and low with aberrant salience.

CONCLUSION

The results back use of the Spanish version of the SNS scale for detection of NS in the general population of adolescents.

Basic self-disturbances independently predict recovery in psychotic disorders: A seven year follow-up study

BACKGROUND

Recovery is the ultimate goal of psychosis treatment. Basic self-disturbances (BSDs) are non-psychotic phenomena associated with clinical outcome, present in prodromal, psychotic and residual phases of psychotic disorders.

AIM

To investigate the relationship between BSDs and recovery seven years after first treatment in patients with psychotic disorders.

METHOD

Prospective longitudinal study of 56 patients recruited during first adequate treatment for schizophrenia (n = 35) and other psychotic disorders (n = 21) (psychotic bipolar disorder, delusional disorder, psychotic disorder NOS). At baseline and follow-up BSDs were assessed using the Examination of Anomalous Self-Experience (EASE) manual, while standard clinical instruments were used to ascertained diagnosis, clinical symptom severity, and functioning. Recovery was defined as absence of psychotic symptoms and regaining of functioning that persisted the last two years before follow-up.

RESULTS

At follow up, 34% achieved recovery (5 (14%) with schizophrenia and 14 (67%) with other psychoses at baseline). Recovery was predicted by an absence of a schizophrenia diagnosis, low baseline level of BSDs and further reductions in BSDs from baseline to follow-up. Change in BSDs was the strongest predictor, also after adjusting for premorbid adjustment and duration of untreated psychosis, and was not confounded by diagnosis.

CONCLUSION

Low baseline levels of basic self-disturbances and further reductions over time independently predict recovery seven years later in first treated psychosis patients.

Evaluation of the Combined Treatment Approach "Robin" (Standardized Manual and Smartphone App) for Adolescents at Clinical High Risk for Psychosis

Introduction: The prevention of schizophrenia and other psychotic disorders has led researchers to focus on early identification of individuals at clinical high risk (CHR) for psychosis and to treat the at-risk symptoms in the pre-psychotic period. Although at-risk symptoms such as attenuated hallucinations or delusions are common in adolescents and associated with a marked reduction in global functioning, the evidence base of effective interventions for adolescents at CHR state and even first-episode psychosis is limited. Thus, the present protocol describes a study design that combines therapy modules for CHR adolescents with a smartphone application supporting the young individuals between the therapy sessions. The treatment approach "Robin" is based on existing therapy strategies for adolescents with first episode of psychosis and the available recommendations for adults with at-risk symptoms. Methods: The evaluation aims firstly to compare the efficacy of Robin in 30 CHR adolescents aged 14-18 to an active control group (treatment as usual) from a previous study. Primary outcome measures will be at-risk symptomatology, comorbid diagnosis, functioning, self-efficacy, and quality of life. For the prospective intervention condition (16 weekly individual sessions + a minimum 4 family sessions), help-seeking adolescents with CHR for psychosis, aged 14-18, will be recruited over 3 years. At-risk and comorbid symptoms, functioning, self-efficacy, and quality of life are monitored at six time points (baseline, during the treatment period; immediately after intervention; and 6, 12, and 24 months later) and compared with the respective measures of the active control group. Discussion: To the best of our knowledge, this is the first controlled trial to test the efficacy of a specific early psychosis treatment in combination with a smartphone application for adolescents at CHR for developing psychosis. The results of the study are expected to add information that may substantially decrease the burden of CHR adolescents and increase their resilience. It may offer age-adapted and targeted strategies to guide clinicians in the treatment of these vulnerable individuals. Furthermore, research in the field of early intervention will be enriched by our findings. Clinical Trial Registration: www.ClinicalTrials.gov, identifier NCT03829527.

Psychosis Polyrisk Score (PPS) for the Detection of Individuals At-Risk and the Prediction of Their Outcomes

Primary prevention in individuals at Clinical High Risk for psychosis (CHR-P) can ameliorate the course of psychotic disorders. Further advancements of knowledge have been slowed by the standstill of the field, which is mostly attributed to its epidemiological weakness. The latter, in turn, underlies the limited identification power of at-risk individuals and the relatively modest ability of CHR-P interviews to rule-in a state of risk for psychosis. In the first part, this perspective review discusses these limitations and traces a new approach to overcome them. Theoretical concepts to support a Psychosis Polyrisk Score (PPS) integrating genetic and non-genetic risk and protective factors for psychosis are presented. The PPS hinges on recent findings indicating that risk enrichment in CHR-P samples is accounted for by the accumulation of non-genetic factors such as: parental and sociodemographic risk factors, perinatal risk factors, later risk factors, and antecedents. In the second part of this perspective review we present a prototype of a PPS encompassing core predictors beyond genetics. The PPS prototype may be piloted in the next generation of CHR-P research and combined with genetic information to refine the detection of individuals at-risk of psychosis and the prediction of their outcomes, and ultimately advance clinical research in this field.

Clinical psychopathology in youth at familial high risk for psychosis

AIM

While the course of psychopathology has been explored from an index mental health diagnosis onwards, there are few detailed, prospective studies of the occurrence of clinical psychopathology in youth with familial risk for severe mental illnesses such as psychosis. We sought to describe the appearance of Axis I psychopathology in a unique sample of adolescents with a family history of schizophrenia (FHR).

METHODS

One hundred and sixty two first- and second-degree relatives (mean age 15.7 ± 3.6; range 8-25) of probands with schizophrenia or schizoaffective disorder were assessed at baseline and annual intervals for up to 3 years, focusing on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) Axis I psychopathology.

RESULTS

Fourteen individuals (8.6%) developed a psychotic disorder. One hundred and five subjects (65%) met criteria for an Axis I disorder over the course of the study, the most common of which was a depressive episode (40 subjects; 25%). Of the 148 individuals who did not develop psychosis, 91 (61%) had one or more Axis I disorders compared with 10/14 converters who had a comorbid Axis I disorder (71%). Ordered by increasing age of onset, diagnoses included cognitive and externalizing disorders, anxiety disorders, affective disorders, substance use disorders and psychotic disorders.

CONCLUSIONS

In addition to an elevated risk of psychosis, young FHR relatives manifest a broad range of non-psychotic Axis I psychopathology in childhood and adolescence. This breadth of diagnoses has implications for the structure and function of mental health services for young people.

Childhood theory of mind does not predict psychotic experiences and social functioning in a general population sample of adolescents

Aims

Theory of Mind (ToM) is often impaired in early and chronic phases of psychosis and it is often suggested that poor ToM is a trait vulnerability for psychosis. The aim of this study was to examine in an adolescent sample whether childhood ToM abilities can predict psychotic experiences over a period of six years and whether this is mediated by social functioning. To examine whether ToM is a specific predictor for psychosis, symptoms of depression and anxiety were also examined.

Materials and methods

A baseline case-control sample (T0: age 7–8 years) with and without auditory vocal hallucinations (AVH) in the general population was assessed after five years (T1: age 12–13 years) on ToM ability (ToM Storybook Frank), and after eleven years (T2: age 18–19 years) on psychotic experiences (Community Assessment of Psychic Experiences; CAPE), depressive and anxiety symptoms (Depression Anxiety and Stress Scale; DASS-21), and social functioning (Groningen Questionnaire on Social Behaviour; GSVG-45). Analyses were conducted on a subsample of 157 adolescents aged 18–19 years (T2) who had data available on ToM ability at T1.

Results

ToM at T1 was not predictive of psychotic experiences after six years (from age 12–13 to age 18–19) and social functioning was also not a mediator. ToM was not associated with psychopathology in general (depressive and anxiety symptoms) over six years (from age 12–13 to age 18–19).

Conclusions

The current study found no evidence for a longitudinal association between ToM ability and psychotic experiences, social functioning, and symptoms of depression and anxiety, in adolescence.

Can we predict the direction of sudden shifts in symptoms? Transdiagnostic implications from a complex systems perspective on psychopathology

Recently, there has been renewed interest in the application of assumptions from complex systems theory in the field of psychopathology. One assumption, with high clinical relevance, is that sudden transitions in symptoms may be anticipated by rising instability in the system, which can be detected with early warning signals (EWS). Empirical studies support the idea that this principle also applies to the field of psychopathology. The current manuscript discusses whether assumptions from complex systems theory can additionally be informative with respect to the specific symptom dimension in which such a transition will occur (e.g. whether a transition towards anxious, depressive or manic symptoms is most likely). From a complex systems perspective, both EWS measured in single symptom dynamics and network symptom dynamics at large are hypothesized to provide clues regarding the direction of the transition. Challenging research designs are needed to provide empirical validation of these hypotheses. These designs should be able to follow sudden transitions 'live' using frequent observations of symptoms within individuals and apply a transdiagnostic approach to psychopathology. If the assumptions proposed are supported by empirical studies then this will signify a large improvement in the possibility for personalized estimations of the course of psychiatric symptoms. Such information can be extremely useful for early intervention strategies aimed at preventing specific psychiatric problems.

The Dynamic Relations Among Peritraumatic Posttraumatic Stress Symptoms: An Experience Sampling Study During Wartime

The associations among peritraumatic posttraumatic stress symptoms (P-PTSS) in the immediate aftermath of trauma exposure, including those in the posttraumatic stress disorder clusters of intrusions, avoidance, negative cognitions and mood (NCM), and arousal, might indicate mechanisms through which enduring PTSD develops. During a period of war, exposed participants (N = 181) were sent twice-daily questionnaires for 30 days via smartphone. We repeatedly assessed the predictive associations between the P-PTSS clusters over time. We performed a multilevel pathway analysis built of multiple triple sequence responses (6,221 cases) on each of the four P-PTSS clusters at a mean time lag of 12 hr (Model A) and 24 hr (Model B) for 181 participants, 85 of whom had been diagnosed with a serious mental illness. Arousal predicted intrusion in Models A and B, b_A = 0.08, 95% CI [0.03, 0.12], p < .001 and b_B = 0.03, 95% CI [0.00, 0.07], p = .051, respectively; and NCM in Models A and B, b_A = 0.09, 95% CI [0.05, 0.12], p < .001 and b_B = 0.06, 95% CI [0.03, 0.09], p < .001, respectively. Intrusion predicted arousal in Model B, b_B = 0.05, 95% CI [0.01, 0.08], p = .010. NCM predicted arousal, b_A = 0.10, 95% CI [0.05, 0.14], p < .001, and avoidance b_A = 0.05, 95% CI [0.00, 0.11], p = .052, in Model A. Avoidance did not predict any other cluster. Arousal seemed to be acting as a hub, strengthening feedback loops to and from NCM and intrusion.

Improving the Detection of Individuals at Clinical Risk for Psychosis in the Community, Primary and Secondary Care: An Integrated Evidence-Based Approach

Background: The first rate-limiting step for improving outcomes of psychosis through preventive interventions in people at clinical high risk for psychosis (CHR-P) is the ability to accurately detect individuals who are at risk for the development of this disorder. Currently, this detection power is sub-optimal. Methods: This is a conceptual and nonsystematic review of the literature, focusing on the work conducted by leading research teams in the field. The results will be structured in the following sections: understanding the CHR-P assessment, validity of the CHR-P as a universal risk state for psychosis, and improving the detection of at-risk individuals in secondary mental health care, in primary care, and in the community. Results: CHR-P instruments can provide adequate prognostic accuracy for the prediction of psychosis provided that they are employed in samples who have undergone risk enrichment during recruitment. This substantially limits their detection power in real-world settings. Furthermore, there is initial evidence that not all cases of psychosis onset are preceded by a CHR-P stage. A transdiagnostic individualized risk calculator could be used to automatically screen secondary mental health care medical notes to detect those at risk of psychosis and refer them to standard CHR-P assessment. Similar risk estimation tools for use in primary care are under development and promise to boost the detection of patients at risk in this setting. To improve the detection of young people who may be at risk of psychosis in the community, it is necessary to adopt digital and/or sequential screening approaches. These solutions are based on recent scientific evidence and have potential for implementation internationally. Conclusions: The best strategy to improve the detection of patients at risk for psychosis is to implement a clinical research program that integrates different but complementary detection approaches across community, primary, and secondary care. These solutions are based on recent scientific advancements in the development of risk estimation tools and e-health approaches and have the potential to be applied across different clinical settings.

Should we intervene at stage 0? A qualitative study of attitudes of asymptomatic youth at increased risk of developing bipolar disorders and parents with established disease

BACKGROUND

Studies of potential interventions for asymptomatic individuals at risk of severe mental disorders (ie, clinical stage 0) have focused on genetic counselling or the views of adults with established disease. No study has interviewed youth at risk of bipolar disorders (BD).

METHODS

Qualitative analysis of interviews with asymptomatic adolescent offspring of adults with BD (OSBD = 7) and unrelated parents with bipolar disorders (PBD = 6) to examine manifest and latent themes in the dialogue.

RESULTS

Core themes in both groups were ignorance regarding the magnitude of risk of BD onset in offspring and greater concerns for the health of other family members than for oneself. Parents expressed anxieties in coping with the uncertainty about whether their children would inherit BD and their desire to reduce this risk was partly driven by guilt and their sense of responsibility; PBD favoured the introduction of specialized clinical OSBD services. In contrast, the priority for OSBD was advice on coping with a parent with BD; OSBD favoured access to generic non-clinical peer group support, which they perceived as less stigmatizing than specialist services.

CONCLUSION

The study highlights that youth at risk of BD should be allowed to express their ideas on what interventions they believe are likely to be most beneficial for them, as their views may differ from other advocates who are routinely consulted, such as PBD. A noteworthy finding was that OSBD thought that being included in the clinical dialogue about their parents' BD would decrease rather than increase their stress levels.