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Estradé A, Salazar de Pablo G, Zanotti A, Wood S, Fisher HL, Fusar-Poli P. Public health primary prevention implemented by clinical high-risk services for psychosis. Transl Psychiatry 2022; 12:43. [PMID: 35091529 PMCID: PMC8799684 DOI: 10.1038/s41398-022-01805-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 01/08/2022] [Accepted: 01/14/2022] [Indexed: 02/06/2023] Open
Abstract
Clinical High Risk for Psychosis (CHR-P) services have been primarily developed to support young people with attenuated symptoms (indicated prevention). No evidence-based appraisal has systematically investigated to what extent these clinics may implement other preventive approaches. PRISMA 2020-compliant systematic review of Web of Science, Cochrane Central Register of Reviews, and Ovid/PsychINFO, from inception until 14th June 2021, identifying original studies describing public health strategies: (a) service characteristics (configuration of mental health service, outreach, pathways to care); (b) universal interventions (general population); (c) selective interventions targeting CHR-P service-users or family/carers. Public health preventive initiatives were systematically stratified according to core social determinants of mental disorders associated with the 2030 Sustainable Development Goals promoted by the United Nations Member States (UN 2030 SDG) and good mental health outcomes. A total of 66 publications were included, providing data on 13 standalone, 40 integrated, three networks, and six regional or international surveys of CHR-P services across Europe, Asia, Oceania, Africa, North and South America, providing care to >28 M people. CHR-P services implement numerous public health initiatives targeting social and cultural (16 initiatives), economic (seven initiatives), demographic (six initiatives), environmental events (four initiatives) and neighbourhood (three initiatives) UN 2030 SGD determinants of mental disorders. There is additional evidence for CHR-P services promoting good mental health. The main barriers were the lack of resources for expanding public health prevention at a large scale. CHR-P services implement numerous public health prevention initiatives and promotion of good mental health beyond indicated prevention of psychosis.
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Affiliation(s)
- Andrés Estradé
- grid.13097.3c0000 0001 2322 6764Early Psychosis: Interventions and Clinical-detection (EPIC) Lab, Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - Gonzalo Salazar de Pablo
- grid.13097.3c0000 0001 2322 6764Early Psychosis: Interventions and Clinical-detection (EPIC) Lab, Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK ,grid.410526.40000 0001 0277 7938Institute of Psychiatry and Mental Health, Department of Child and Adolescent Psychiatry, Hospital General Universitario Gregorio Marañón School of Medicine, Universidad Complutense, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), CIBERSAM, Madrid, Spain ,grid.37640.360000 0000 9439 0839Child and Adolescent Mental Health Services, South London and Maudsley NHS Foundation Trust, London, UK
| | - Alice Zanotti
- grid.8982.b0000 0004 1762 5736Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Scott Wood
- grid.47100.320000000419368710Yale School of Medicine, Yale University, New Heaven, CT USA
| | - Helen L. Fisher
- grid.13097.3c0000 0001 2322 6764King’s College London, Social, Genetic & Developmental Psychiatry Centre, Institute of Psychiatry, Psychology & Neuroscience, London, UK ,grid.13097.3c0000 0001 2322 6764Economic & Social Research Council (ESRC) Centre for Society and Mental Health, King’s College London, London, UK
| | - Paolo Fusar-Poli
- Early Psychosis: Interventions and Clinical-detection (EPIC) Lab, Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK. .,Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy. .,National Institute for Health Research, Maudsley Biomedical Research Centre, South London and Maudsley NHS Foundation Trust, London, UK. .,OASIS Service, South London and Maudsley NHS Foundation Trust, London, UK.
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Bielawski T, Albrechet-Souza L, Frydecka D. Endocannabinoid system in trauma and psychosis: distant guardian of mental stability. Rev Neurosci 2021; 32:707-722. [PMID: 33656307 DOI: 10.1515/revneuro-2020-0102] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Accepted: 01/08/2021] [Indexed: 11/15/2022]
Abstract
Central endocannabinoid system (eCBS) is a neuromodulatory system that inhibits potentially harmful, excessive synaptic activation. Endocannabinoid receptors are abundant among brain structures pivotal in different mental disorders development (for example, hippocampus, amygdala, medial-prefrontal cortex, hypothalamus). Here, we review eCBS function in etiology of psychosis, emphasizing its role in dealing with environmental pressures such as traumatic life events. Moreover, we explore eCBS as a guard against hypothalamic-pituitary-adrenal axis over-activation, and discuss its possible role in etiology of different psychopathologies. Additionally, we review eCBS function in creating adaptive behavioral patterns, as we explore its involvement in the memory formation process, extinction learning and emotional response. We discuss eCBS in the context of possible biomarkers of trauma, and in preclinical psychiatric conditions, such as at-risk mental states and clinical high risk states for psychosis. Finally, we describe the role of eCBS in the cannabinoid self-medication-theory and extinction learning.
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Affiliation(s)
- Tomasz Bielawski
- Department of Psychiatry, Wroclaw Medical University, 10 Pasteur Street, 50-367Wroclaw, Poland.,Department of Physiology, School of Medicine, Louisiana State University Health Sciences Center, New Orleans, LA70112, USA
| | - Lucas Albrechet-Souza
- Department of Physiology, School of Medicine, Louisiana State University Health Sciences Center, New Orleans, LA70112, USA.,Alcohol & Drug Center of Excellence, School of Medicine, Louisiana State University Health Sciences Center, New Orleans, LA70112, USA
| | - Dorota Frydecka
- Department of Psychiatry, Wroclaw Medical University, 10 Pasteur Street, 50-367Wroclaw, Poland
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Salazar de Pablo G, Estradé A, Cutroni M, Andlauer O, Fusar-Poli P. Establishing a clinical service to prevent psychosis: What, how and when? Systematic review. Transl Psychiatry 2021; 11:43. [PMID: 33441556 PMCID: PMC7807021 DOI: 10.1038/s41398-020-01165-x] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 11/27/2020] [Accepted: 12/03/2020] [Indexed: 01/29/2023] Open
Abstract
The first rate-limiting step to successfully translate prevention of psychosis in to clinical practice is to establish specialised Clinical High Risk for Psychosis (CHR-P) services. This study systematises the knowledge regarding CHR-P services and provides guidelines for translational implementation. We conducted a PRISMA/MOOSE-compliant (PROSPERO-CRD42020163640) systematic review of Web of Science to identify studies until 4/05/2020 reporting on CHR-P service configuration, outreach strategy and referrals, service user characteristics, interventions, and outcomes. Fifty-six studies (1998-2020) were included, encompassing 51 distinct CHR-P services across 15 countries and a catchment area of 17,252,666 people. Most services (80.4%) consisted of integrated multidisciplinary teams taking care of CHR-P and other patients. Outreach encompassed active (up to 97.6%) or passive (up to 63.4%) approaches: referrals came mostly (90%) from healthcare agencies. CHR-P individuals were more frequently males (57.2%). Most (70.6%) services accepted individuals aged 12-35 years, typically assessed with the CAARMS/SIPS (83.7%). Baseline comorbid mental conditions were reported in two-third (69.5%) of cases, and unemployment in one third (36.6%). Most services provided up to 2-years (72.4%), of clinical monitoring (100%), psychoeducation (81.1%), psychosocial support (73%), family interventions (73%), individual (67.6%) and group (18.9%) psychotherapy, physical health interventions (37.8%), antipsychotics (87.1%), antidepressants (74.2%), anxiolytics (51.6%), and mood stabilisers (38.7%). Outcomes were more frequently ascertained clinically (93.0%) and included: persistence of symptoms/comorbidities (67.4%), transition to psychosis (53.5%), and functional status (48.8%). We provide ten practical recommendations for implementation of CHR-P services. Health service knowledge summarised by the current study will facilitate translational efforts for implementation of CHR-P services worldwide.
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Affiliation(s)
- Gonzalo Salazar de Pablo
- Early Psychosis: Interventions and Clinical-detection (EPIC) Lab, Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- Institute of Psychiatry and Mental Health, Department of Child and Adolescent Psychiatry, Hospital General Universitario Gregorio Marañón School of Medicine, Universidad Complutense, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), CIBERSAM, Madrid, Spain
| | - Andrés Estradé
- Early Psychosis: Interventions and Clinical-detection (EPIC) Lab, Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- Department of Clinical and Health Psychology, Catholic University, Montevideo, Uruguay
| | - Marcello Cutroni
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Olivier Andlauer
- Heads UP Service, East London NHS Foundation Trust, London, UK
- Centre for Psychiatry, Wolfson Institute of Preventive Medicine, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Paolo Fusar-Poli
- Early Psychosis: Interventions and Clinical-detection (EPIC) Lab, Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK.
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy.
- National Institute for Health Research, Maudsley Biomedical Research Centre, South London and Maudsley NHS Foundation Trust, London, UK.
- OASIS Service, South London and Maudsley NHS Foundation Trust, London, UK.
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A randomised controlled trial of cognitive behaviour therapy versus non-directive reflective listening for young people at ultra high risk of developing psychosis: The detection and evaluation of psychological therapy (DEPTh) trial. Schizophr Res 2016; 176:212-219. [PMID: 27554197 DOI: 10.1016/j.schres.2016.08.008] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 08/07/2016] [Accepted: 08/08/2016] [Indexed: 11/21/2022]
Abstract
BACKGROUND Intervention trials for young people at ultra high risk (UHR) for psychosis have shown cognitive behaviour therapy (CBT) to have promising effects on treating psychotic symptoms but have not focused on functional outcomes. We hypothesized that compared to an active control, CBT would: (i) reduce the likelihood of, and/or delay, transition to psychosis; (ii) reduce symptom severity while improving social functioning and quality of life, whether or not transition occurred. METHOD This was a single-blind randomised controlled trial for young people at UHR for psychosis comparing CBT to an active control condition, Non Directive Reflective Listening (NDRL), both in addition to standard care, with a 6month treatment phase and 12months of follow-up. Statistical analysis is based on intention-to-treat and used random effect models to estimate treatment effects common to all time-points. RESULTS Fifty-seven young people (mean age=16.5years) were randomised to CBT (n=30) or NDRL (n=27). Rate of transition to psychosis was 5%; the 3 transitions occurred in the CBT condition (baseline, 2months, 5months respectively). The NDRL condition resulted in a significantly greater reduction in distress associated with psychotic symptoms compared to CBT (treatment effect=36.71, standard error=16.84, p=0.029). There were no significant treatment effects on frequency and intensity of psychotic symptoms, global, social or role functioning. CONCLUSION Our sample was higher functioning, younger and experiencing lower levels of psychotic like experiences than other trials. The significantly better treatment effect of NDRL on distress associated with psychotic symptoms supports the recommendations for a stepped-care model of service delivery. This treatment approach would accommodate the younger UHR population and facilitate timely intervention. TRIAL REGISTRATION ANZCTR 12606000101583.
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Conrad AM, Lewin TJ, Sly KA, Schall U, Halpin SA, Hunter M, Carr VJ. Ten-year audit of clients presenting to a specialised service for young people experiencing or at increased risk for psychosis. BMC Psychiatry 2014; 14:318. [PMID: 25403891 PMCID: PMC4239381 DOI: 10.1186/s12888-014-0318-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Accepted: 10/24/2014] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Despite strong research interest in psychosis risk identification and the potential for early intervention, few papers have sought to document the implementation and evaluation of specialised psychosis related services. Assessment of Ultra High Risk (UHR) has been given priority, but it is equally as important to identify appropriate comparison groups and other baseline differences. This largely descriptive service evaluation paper focuses on the 'baseline characteristics' of referred clients (i.e., previously assessed characteristics or those identified within the first two months following service presentation). METHODS Data are reported from a 10-year layered service audit of all presentations to a 'Psychological Assistance Service' for young people (PAS, Newcastle, Australia). Baseline socio-demographic and clinical characteristics (N =1,997) are described (including clients' psychosis and UHR status, previous service contacts, hospitalisation rates, and diagnostic and comorbidity profiles). Key groups are identified and comparisons made between clients who received ongoing treatment and those who were primarily assessed and referred elsewhere. RESULTS Clients averaged 19.2 (SD =4.5) years of age and 59% were male. One-tenth of clients (9.6%) were categorised as UHR, among whom there were relatively high rates of attenuated psychotic symptoms (69.1%), comorbid depression (62.3%), anxiety (42.9%), and attentional and related problems (67.5%). Overall, one-fifth (19.8%) experienced a recent psychotic episode, while a further 14.5% were categorised as having an existing psychosis (46.7% with a schizophrenia diagnosis), amongst whom there were relatively high rates of comorbid substance misuse (52.9%), psychosocial (70.2%) and physical health (37.7%) problems. The largest group presenting to PAS were those with non-psychotic disorders (43.7%), who provide a valuable comparison group against which to contrast the health trajectories of those with UHR and recent psychosis. Ongoing treatment by PAS was preferentially given to those experiencing or at risk for psychosis and those reporting greater current distress or dysfunction. CONCLUSIONS Whether or not UHR clients transition to psychosis, they displayed high rates of comorbid depression and anxiety at service presentation, with half receiving ongoing treatment from PAS. Although international comparisons with similar services are difficult, the socio-demographic and comorbidity patterns observed here were viewed as largely consistent with those reported elsewhere.
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Affiliation(s)
- Agatha M Conrad
- CTNMH (MH-READ), Hunter New England Mental Health and the University of Newcastle, McAuley Centre, The Mater, PO Box 833, Newcastle, NSW 2300 Australia
| | - Terry J Lewin
- CTNMH (MH-READ), Hunter New England Mental Health and the University of Newcastle, McAuley Centre, The Mater, PO Box 833, Newcastle, NSW 2300 Australia ,Schizophrenia Research Institute, Darlinghurst, Sydney NSW 2010 Australia
| | - Ketrina A Sly
- CTNMH (MH-READ), Hunter New England Mental Health and the University of Newcastle, McAuley Centre, The Mater, PO Box 833, Newcastle, NSW 2300 Australia
| | - Ulrich Schall
- CTNMH (MH-READ), Hunter New England Mental Health and the University of Newcastle, McAuley Centre, The Mater, PO Box 833, Newcastle, NSW 2300 Australia ,Schizophrenia Research Institute, Darlinghurst, Sydney NSW 2010 Australia ,Psychological Assistance Service, Hunter New England Mental Health, Newcastle, NSW 2300 Australia
| | - Sean A Halpin
- CTNMH (MH-READ), Hunter New England Mental Health and the University of Newcastle, McAuley Centre, The Mater, PO Box 833, Newcastle, NSW 2300 Australia ,Psychological Assistance Service, Hunter New England Mental Health, Newcastle, NSW 2300 Australia ,School of Psychology, University of Newcastle, Callaghan, NSW 2308 Australia
| | - Mick Hunter
- School of Psychology, University of Newcastle, Callaghan, NSW 2308 Australia
| | - Vaughan J Carr
- Schizophrenia Research Institute, Darlinghurst, Sydney NSW 2010 Australia ,School of Psychiatry, University of New South Wales, Kensington, NSW 2033 Australia
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Premorbid functional development and conversion to psychosis in clinical high-risk youths. Dev Psychopathol 2014; 25:1171-86. [PMID: 24229556 DOI: 10.1017/s0954579413000448] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Deterioration in premorbid functioning is a common feature of schizophrenia, but sensitivity to psychosis conversion among clinical high-risk samples has not been examined. This study evaluates premorbid functioning as a predictor of psychosis conversion among a clinical high-risk sample, controlling for effects of prior developmental periods. Participants were 270 clinical high-risk individuals in the North American Prodrome Longitudinal Study-I, 78 of whom converted to psychosis over the next 2.5 years. Social, academic, and total maladjustment in childhood, early adolescence, and late adolescence were rated using the Cannon-Spoor Premorbid Adjustment Scale. Early adolescent social dysfunction significantly predicted conversion to psychosis (hazard ratio = 1.30, p = .014), independently of childhood social maladjustment and independently of severity of most baseline positive and negative prodromal symptoms. Baseline prodromal symptoms of disorganized communication, social anhedonia, suspiciousness, and diminished ideational richness mediated this association. Early adolescent social maladjustment and baseline suspiciousness together demonstrated moderate positive predictive power (59%) and high specificity (92.1%) in predicting conversion. Deterioration of academic and total functioning, although observed, did not predict conversion to psychosis. Results indicate early adolescent social dysfunction to be an important early predictor of conversion. As such, it may be a good candidate for inclusion in prediction algorithms and could represent an advantageous target for early intervention.
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Tarbox SI, Addington J, Cadenhead KS, Cannon TD, Cornblatt BA, Perkins DO, Seidman LJ, Tsuang MT, Walker EF, Heinssen R, McGlashan TH, Woods SW. Functional development in clinical high risk youth: prediction of schizophrenia versus other psychotic disorders. Psychiatry Res 2014; 215:52-60. [PMID: 24200216 PMCID: PMC3946851 DOI: 10.1016/j.psychres.2013.10.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2012] [Revised: 10/07/2013] [Accepted: 10/11/2013] [Indexed: 11/18/2022]
Abstract
This study evaluates premorbid social and academic functioning in clinical high-risk individuals as predictors of transition to schizophrenia versus another psychotic disorder. Participants were 54 individuals enrolled in phase one of the North American Prodrome Longitudinal Study who over two and a half years of follow-up met criteria for schizophrenia/schizophreniform disorder (n=28) or another psychotic disorder (n=26). Social and academic functioning in childhood, early adolescence, and late adolescence was assessed at baseline using the Cannon-Spoor Premorbid Adjustment Scale. Social maladjustment in late adolescence predicted significantly higher odds of transition to schizophrenia versus another psychotic disorder independent of childhood and early adolescent adjustment (OR=4.02) and conveyed unique risk over academic maladjustment (OR=5.64). Premorbid academic maladjustment was not associated with psychotic disorder diagnosis. Results support diagnostic specificity of premorbid social dysfunction to schizophrenia in clinical high-risk youth and underscore an important role for social maladjustment in the developmental pathology of schizophrenia and its prediction.
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Affiliation(s)
- Sarah I Tarbox
- Yale University School of Medicine, Department of Psychiatry, 34 Park Street, 38D, New Haven, CT 06519, USA.
| | - Jean Addington
- University of Calgary, Department of Psychiatry, Calgary, Alberta, Canada
| | - Kristin S Cadenhead
- University of California, San Diego, Department of Psychiatry, La Jolla, CA 92093, USA
| | - Tyrone D Cannon
- University of California, Los Angeles, Department of Psychology, Los Angeles, CA 90095, USA
| | - Barbara A Cornblatt
- The Zucker Hillside Hospital, Psychiatry Research, North Shore - Long Island Jewish Health System, Glen Oaks, NY 11004, USA; Albert Einstein College of Medicine, Department of Psychiatry, Bronx, NY 10461, USA; The Feinstein Institute for Medical Research, North Shore - Long Island Jewish Health System, Manhasset, NY 11030, USA
| | - Diana O Perkins
- University of North Carolina at Chapel Hill, Department of Psychiatry, Chapel Hill, NC 27599, USA
| | - Larry J Seidman
- Harvard Medical School, Departments of Psychiatry at Massachusetts Mental Health Center Public Psychiatry Division, Beth Israel Deaconess Medical Center, and Massachusetts General Hospital, Boston, MA 02115, USA
| | - Ming T Tsuang
- University of California, San Diego, Center for Behavioral Genomics, Department of Psychiatry, La Jolla, CA 92037, USA; Harvard Institute of Psychiatric Epidemiology and Genetics, Boston, MA 02115, USA
| | - Elaine F Walker
- Emory University, Department of Psychology, Atlanta, GA 30322, USA
| | - Robert Heinssen
- National Institute of Mental Health, Division of Adult Translational Research and Treatment Development, Bethesda, MD 20892, USA
| | - Thomas H McGlashan
- Yale University School of Medicine, Department of Psychiatry, 34 Park Street, 38D, New Haven, CT 06519, USA
| | - Scott W Woods
- Yale University School of Medicine, Department of Psychiatry, 34 Park Street, 38D, New Haven, CT 06519, USA
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Fusar-Poli P, Borgwardt S, Bechdolf A, Addington J, Riecher-Rössler A, Schultze-Lutter F, Keshavan M, Wood S, Ruhrmann S, Seidman LJ, Valmaggia L, Cannon T, Velthorst E, De Haan L, Cornblatt B, Bonoldi I, Birchwood M, McGlashan T, Carpenter W, McGorry P, Klosterkötter J, McGuire P, Yung A. The psychosis high-risk state: a comprehensive state-of-the-art review. JAMA Psychiatry 2013; 70:107-20. [PMID: 23165428 PMCID: PMC4356506 DOI: 10.1001/jamapsychiatry.2013.269] [Citation(s) in RCA: 975] [Impact Index Per Article: 88.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
CONTEXT During the past 2 decades, a major transition in the clinical characterization of psychotic disorders has occurred. The construct of a clinical high-risk (HR) state for psychosis has evolved to capture the prepsychotic phase, describing people presenting with potentially prodromal symptoms. The importance of this HR state has been increasingly recognized to such an extent that a new syndrome is being considered as a diagnostic category in the DSM-5. OBJECTIVE To reframe the HR state in a comprehensive state-of-the-art review on the progress that has been made while also recognizing the challenges that remain. DATA SOURCES Available HR research of the past 20 years from PubMed, books, meetings, abstracts, and international conferences. STUDY SELECTION AND DATA EXTRACTION Critical review of HR studies addressing historical development, inclusion criteria, epidemiologic research, transition criteria, outcomes, clinical and functional characteristics, neurocognition, neuroimaging, predictors of psychosis development, treatment trials, socioeconomic aspects, nosography, and future challenges in the field. DATA SYNTHESIS Relevant articles retrieved in the literature search were discussed by a large group of leading worldwide experts in the field. The core results are presented after consensus and are summarized in illustrative tables and figures. CONCLUSIONS The relatively new field of HR research in psychosis is exciting. It has the potential to shed light on the development of major psychotic disorders and to alter their course. It also provides a rationale for service provision to those in need of help who could not previously access it and the possibility of changing trajectories for those with vulnerability to psychotic illnesses.
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Affiliation(s)
- Paolo Fusar-Poli
- Department of Psychosis Studies, King's College London, London, UK.
| | - Stefan Borgwardt
- Department of Psychiatry, University of Basel, Basel, Switzerland
| | - Andreas Bechdolf
- Department of Psychiatry and Psychotherapy, University of Cologne, Cologne, Germany
| | - Jean Addington
- Department of Psychiatry, University of Calgary, Calgary, Alberta, Canada
| | | | - Frauke Schultze-Lutter
- University Hospital of Child and Adolescent Psychiatry, University of Bern, Bern, Switzerland
| | - Matcheri Keshavan
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Stephen Wood
- Melbourne Neuropsychiatry Centre, Department of Psychiatry, The University of Melbourne and Melbourne Health, Melbourne, Australia; School of Psychology, University of Birmingham, Birmingham, United Kingdom
| | - Stephan Ruhrmann
- Department of Psychiatry and Psychotherapy, University of Cologne, Cologne, Germany
| | - Larry J. Seidman
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts; Department of Psychiatry, Harvard Medical School, Massachusetts General Hospital, Boston
| | - Lucia Valmaggia
- Departments of Psychosis Studies and Psychology, King's College London, London, United Kingdom; OASIS team for prodromal psychosis, NHSSLAM Foundation Trust, London
| | - Tyrone Cannon
- Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles
| | - Eva Velthorst
- Department of Early Psychosis, Academic Medical Center, Amsterdam, the Netherlands
| | - Lieuwe De Haan
- Department of Early Psychosis, Academic Medical Center, Amsterdam, the Netherlands
| | - Barbara Cornblatt
- Department of Psychiatry Research, The Zucker Hillside Hospital, New York, New York
| | - Ilaria Bonoldi
- OASIS team for prodromal psychosis, NHSSLAM Foundation Trust, London; Department of Psychosis Studies King's College London, London, United Kingdom
| | - Max Birchwood
- School of Psychology, University of Birmingham, Birmingham, United Kingdom
| | | | - William Carpenter
- Maryland Psychiatric Research Center, University of Maryland School of Medicine, Baltimore
| | - Patrick McGorry
- Orygen Youth Health Research Centre, University of Melbourne, Melbourne
| | | | - Philip McGuire
- Department of Psychosis Studies King's College London, London, United Kingdom; OASIS team for prodromal psychosis, NHSSLAM Foundation Trust, London
| | - Alison Yung
- Orygen Youth Health Research Centre, University of Melbourne, Melbourne
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Pukrop R, Klosterkötter J. Neurocognitive indicators of clinical high-risk states for psychosis: a critical review of the evidence. Neurotox Res 2010; 18:272-86. [PMID: 20405352 DOI: 10.1007/s12640-010-9191-1] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2009] [Revised: 02/01/2010] [Accepted: 04/01/2010] [Indexed: 11/30/2022]
Abstract
The present review investigates the empirical evidence from cross-sectional and long-term follow-up studies on neurocognitive indicators of an increased risk for developing schizophrenia spectrum psychoses in clinically defined high-risk samples. First, the investigations at the Cologne center for early recognition and intervention are briefly summarized and then integrated within the available literature. Thirty-two studies with original data could be identified by extensive literature search. Cross-sectional investigations of neurocognitive baseline assessments in high-risk samples with unknown conversion status have produced rather inconsistent results. Nevertheless, most convincing evidence could be collected for abnormal functioning in processing speed measures (digit symbol coding, Trailmaking Test-B, Stroop Color Naming), the Continuous Performance Test, verbal working memory measures, verbal memory and learning, and verbal fluency, though negative findings have also been reported in every instance. Moreover, high-risk subjects were found to perform both at the schizophrenia performance level and at a close to normal level. Longitudinal follow-up assessments provided predictive evidence with regard to psychosis conversion for measures of processing speed and of verbal memory and learning. However, a substantial number of negative findings does not allow for straight-forward conclusions. Finally, some reasons for inconsistent findings are discussed critically speculating on demographic differences, reliability and sample sizes, and conceptual imprecision in communicating results.
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Affiliation(s)
- Ralf Pukrop
- Department of Psychiatry and Psychotherapy, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany.
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10
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Correll CU, Hauser M, Auther AM, Cornblatt BA. Research in people with psychosis risk syndrome: a review of the current evidence and future directions. J Child Psychol Psychiatry 2010; 51:390-431. [PMID: 20214698 PMCID: PMC3085111 DOI: 10.1111/j.1469-7610.2010.02235.x] [Citation(s) in RCA: 150] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
After decades of research, schizophrenia and related psychotic disorders are still among the most debilitating disorders in medicine. The chronic illness course in most individuals, greater treatment responsiveness during the first episode, progressive gray matter decline during early disease stages, and retrospective accounts of 'prodromal' or early illness signs and symptoms formed the basis for research on the psychosis risk syndrome (PRS), known variably as 'clinical high risk' (CHR), or 'ultra-high risk' (UHR), or 'prodromal'. The pioneering era of research on PRS focused on the development and validation of specific assessment tools and the delineation of high risk criteria. This was followed by the examination of conversion rates in psychosis risk cohorts followed naturalistically, identification of predictors of conversion to psychosis, and investigation of interventions able to abort or delay the development of full psychosis. Despite initially encouraging results concerning the predictive validity of PRS criteria, recent findings of declining conversion rates demonstrate the need for further investigations. Results from intervention studies, mostly involving second-generation antipsychotics and cognitive behavioral therapy, are encouraging, but are currently still insufficient to make treatment recommendations for this early, relatively non-specific illness phase. The next phase of research on PRS, just now beginning, has moved to larger, 'multisite' projects to increase generalizability and to ensure that sufficiently large samples at true risk for psychosis are included. Emphasis in these emerging studies is on: 1) identification of biomarkers for conversion to psychosis; 2) examination of non-antipsychotic, neuroprotective and low-risk pharmacologic and non-pharmacologic interventions; 3) testing of potentially phase-specific interventions; 4) examination of the relationship between treatment response during PRS and prognosis for the course of illness; 5) follow-up of patients who developed schizophrenia despite early interventions and comparison of illness trajectories with patients who did not receive early interventions; 6) characterization of individuals with outcomes other than schizophrenia-spectrum disorders, such as bipolar disorder and remission from PRS, including false positive cases; and 7) assessment of meaningful social and role functioning outcomes. While the research conducted to date has already yielded crucial information, the translation of the concept of a clinically identifiable PRS into clinical practice does not seem justified at this point.
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Affiliation(s)
- Christoph U Correll
- The Zucker Hillside Hospital, North Shore - Long Island Jewish Health System, Glen Oaks, New York 11004, USA.
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Abstract
Early intervention in schizophrenia is an emerging goal of research investigating the earliest phases of the illness, which occur predominantly in adolescence and young adulthood. In order to develop strategies for early intervention, individuals at highest risk for the development of psychosis must be accurately identified. Here we briefly review the historical approaches to the assessment of risk for schizophrenia and highlight the more recently developed interview-based methods for the assessment of incipient psychosis, with particular attention paid to their applicability in adolescence. We present a prototypical assessment battery that includes an integration of historical assessment approaches to form a comprehensive assessment of threshold and subthreshold psychopathology, and other assessment procedures targeted specifically at adolescents. This battery may assist in unraveling the complex presentation of prodromal symptoms during the adolescent developmental period.
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Affiliation(s)
- Karin Borgmann-Winter
- Schizophrenia Research Center and Brain Behavior Laboratory, University of Pennsylvania School of Medicine, 10 Gates Building, 3400 Spruce Street, Philadelphia, PA 19104, USA.
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Brewer WJ, Wood SJ, Phillips LJ, Francey SM, Pantelis C, Yung AR, Cornblatt B, McGorry PD. Generalized and specific cognitive performance in clinical high-risk cohorts: a review highlighting potential vulnerability markers for psychosis. Schizophr Bull 2006; 32:538-55. [PMID: 16782759 PMCID: PMC2632242 DOI: 10.1093/schbul/sbj077] [Citation(s) in RCA: 205] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Cognitive deficits are a core feature of established psychotic illnesses. However, the association between cognition and emerging psychosis is less understood. While there is some evidence that cognitive deficits are present prior to the onset of psychosis, findings are not consistent. In this article we provide an overview of the more general cognitive findings available from genetic high-risk studies, retrospective studies, and birth cohort studies. We then focus the review on neuropsychological performance in clinically "at-risk" groups. Overall, general cognitive ability as assessed by established batteries appears to remain relatively intact in these ultra-high risk cohorts and is a poor predictor close to illness onset relative to other vulnerability factors. Further decline may occur with illness progression, more consistent with state relative to trait factors. In addition, most established cognitive tasks involve several relatively discrete cognitive subprocesses, where findings from general batteries of subtests may mask specific deficits. In this context, our review suggests that relatively specific olfactory identification and spatial working memory deficits exist prior to illness onset and may be more potent trait markers for psychosis than cognitively dense tasks such as verbal memory. Suggestions for further research address the importance of standardization of inclusion criteria and the maintenance of basic neuropsychological assessment to allow better comparison of findings across centers. Further, in order to better understand the aetiopathology of cognitive dysfunction in psychosis, more experimental, hypothesis-driven measures of discrete cognitive processes are required. Delineation of the relationship between specific cognitive ability and symptoms from data-driven approaches may improve our understanding of the role of cognition during psychosis onset.
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Affiliation(s)
- Warrick J Brewer
- ORYGEN Research Centre and Early Psychosis Prevention and Intervention Centre, EPPIC, Department of Psychiatry, University of Melbourne, Australia.
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13
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Abstract
Neurological soft signs have been observed in patients with schizophrenia and their relatives. However, it has not been considered whether the increased rates of neurological soft signs are related to measures of psychosis proneness in the general population. We tested this hypothesis in a group of normal volunteers (n = 28) who scored highly for positive schizotypy when assessed online and a control group (n = 33) who scored below the mean. Compared with the controls, high psychosis-prone individuals showed significantly higher Total and Other Soft Signs subscale scores on the Neurological Evaluation Scale. It appears that soft signs are also associated with psychosis proneness when measured in the general population, which suggests that soft signs are distributed along a continuum of risk for schizophrenia.
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Affiliation(s)
- Emma Barkus
- Neuroscience and Psychiatry Department, University of Manchester, Stopford Building, Oxford Road, Manchester M13 9PT, UK.
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Van Os J, Delespaul P. Toward a world consensus on prevention of schizophrenia. DIALOGUES IN CLINICAL NEUROSCIENCE 2006. [PMID: 16060596 PMCID: PMC3181724 DOI: 10.31887/dcns.2005.7.1/jvanos] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Screening for preschizophrenia in the general population with the aim of preventing transition to full-blown illness is an epidemiological impossibility because a rare disease cannot be predicted. The lack of specificity resulting in abundance of false-positives can be remedied in part by using much more restrictive screening criteria that combine several indicators of risk for transition to schizophrenia. Raising the specificity (reducing the false-positives), however, can only be done at the expense of sensitivity (increasing the false-negatives). The most commonly used strategy to raise specificity is the sample enrichment strategy. This involves the creation of samples enriched with schizophrenia risk by selectively filtering at-risk people out over a range of consecutive referral processes starting in the general population, through to general practioners, mental health services, and the early detection clinic. However, improvements in specificity obtained by the sample enrichment strategy should not be attributed to the use of some predictive instrument that supposedly identifies high-risk individuals. The epidemiologically and ethically most viable way for screening and early detection is to selectively increase the permeability of the filters on the pathway to mental health care. This will occasion samples of help-seekers enriched with schizophrenia risk at the level of mental health services (thus reducing false-positives), while at the same time making an attempt to "attract" as many detectable schizophrenia prodromes as possible through the filters along the pathway to mental health care (thus reducing false-negatives). Early psychosis research has yielded some useful suggestions in that it is becoming increasingly clear that it is not just psychosis itself, but rather the clinical context of the psychotic experience that determines risk for transition to schizophrenia. Thus, risk for transition to full-blown psychotic disorder is to a large degree determined by size of psychosis "load," comorbid distress and depression, cannabis use, cognitive ability, and subjective reports of impairment and coping. Making a diagnosis of psychotic disorder is not an exact science: it involves an arbitrary cutoff imposed on dimensional variation of psychopathology and need for care over time. Gaining insight into the cognitive and biological factors that drive the dimensional variation, including therapeutic interventions, is arguably more useful than sterile dichotomous prediction models.
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Affiliation(s)
- Jim Van Os
- Department of Psychiatry and Neuropsychology, South Limburg Mental Health Research and Teaching Network, European Graduate School of Neuroscience, Maastricht University, The Netherlands.
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Haroun N, Dunn L, Haroun A, Cadenhead KS. Risk and protection in prodromal schizophrenia: ethical implications for clinical practice and future research. Schizophr Bull 2006; 32:166-78. [PMID: 16207892 PMCID: PMC2632176 DOI: 10.1093/schbul/sbj007] [Citation(s) in RCA: 173] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Over the last decade schizophrenia researchers have turned their attention to earlier identification in the prodromal period of illness. A greater understanding of both risk and protective factors can lead to improved prevention and treatment strategies in this vulnerable population. This research, however, has far-reaching ethical implications. One year follow-up data from 50 individuals who met established criteria for a prodromal state is used to illustrate ethical issues that directly affect clinicians and future research strategies. At 1-year follow-up, the psychotic transition rate was 13%, but it increased in subsequent years with smaller sample sizes. One-half developed an affective psychosis. The converted sample was older (p > 0.05) than the nonconverted sample and more likely to have a premorbid history of substance abuse, as well as higher clinical ratings on "subsyndromal" psychotic items (delusional thinking, suspiciousness, and thought disorder). Despite a lack of conversion, the nonconverted sample remained symptomatic and had a high rate of affective and anxiety disorders with evidence of functional disability. This conversion rate is relatively low compared to similar studies at 1 year. Specific risk factors were identified, but these findings need to be replicated in a larger cohort. By examining the rate of conversion and nonconversion in this sample as an example, we hope to contribute to the discussion of implications for clinical practice and the direction of future research in the schizophrenia prodrome. Finally, our data strengthen the evidence base available to inform the discussion of ethical issues relevant to this important research area.
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Affiliation(s)
| | | | | | - Kristin S Cadenhead
- To whom correspondence should be addressed; Department of Psychiatry, 0810, University of California, San Diego, 9500 Gilman Drive, La Jolla CA 92093-0810; tel: 619-725-3537, fax: 619-260-8437, e-mail:
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Bak M, Drukker M, van Os J, Delespaul P. Hospital comorbidity bias and the concept of schizophrenia. Soc Psychiatry Psychiatr Epidemiol 2005; 40:817-21. [PMID: 16172812 DOI: 10.1007/s00127-005-0971-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/22/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND The comorbidity bias predicts that if disease definition is based on observations of patients in the hospital, spurious comorbidity of psychopathological dimensions that increase the probability of hospital admission will be included in the disease concept, whereas comorbid dimensions that are not associated with admission will be excluded. The direction of any dimensional comorbidity bias in psychotic illness was assessed in a longitudinal analysis of the psychopathology of patients assessed both inside and outside the hospital. METHOD Four hundred and eighty patients with broadly defined psychotic disorders were assessed between one and nine times (median two times) over a 5-year period with, amongst others, the Brief Psychiatric Rating Scale. Dimensional comorbidities between positive symptoms, negative symptoms, depression/anxiety, and manic excitement were compared, in addition to their associations with current and future admission status. RESULTS Higher levels of psychopathology in all symptom domains were associated with both current and future hospital admissions. Associations between the positive, negative, and manic symptom domains were higher for patients in the hospital than for patients outside the hospital, in particular, between positive symptoms and manic excitement (beta=0.28, p<0.001). However, associations between depression and other symptom domains were higher in out-patients as compared to in-patients (positive symptoms and depression, beta=-0.26; p<0.002). CONCLUSION The current analyses suggest that, to the extent that disease concepts of psychosis do not take into account effects of dimensional comorbidity biases occasioned by differential psychopathology according to treatment setting, "florid" psychotic psychopathology may be overrepresented, whereas depressive symptoms may be spuriously excluded.
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Affiliation(s)
- Maarten Bak
- Dept. of Psychiatry and Neuropsychology, South Limburg Mental Health Research and Teaching Network, EURON, Maastricht University, Maastricht, The Netherlands.
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