Prevalence and clinical significance of DSM-5-attenuated psychosis syndrome in adolescents and young adults in the general population: the Bern Epidemiological At-Risk (BEAR) study

Development of the PSYCHS: Positive SYmptoms and Diagnostic Criteria for the CAARMS Harmonized with the SIPS

AIM

To harmonize two ascertainment and severity rating instruments commonly used for the clinical high risk syndrome for psychosis (CHR-P): the Structured Interview for Psychosis-risk Syndromes (SIPS) and the Comprehensive Assessment of At-Risk Mental States (CAARMS).

METHODS

The initial workshop is described in the companion report from Addington et al. After the workshop, lead experts for each instrument continued harmonizing attenuated positive symptoms and criteria for psychosis and CHR-P through an intensive series of joint videoconferences.

RESULTS

Full harmonization was achieved for attenuated positive symptom ratings and psychosis criteria, and modest harmonization for CHR-P criteria. The semi-structured interview, named Positive SYmptoms and Diagnostic Criteria for the CAARMS Harmonized with the SIPS (PSYCHS), generates CHR-P criteria and severity scores for both CAARMS and SIPS.

CONCLUSIONS

Using the PSYCHS for CHR-P ascertainment, conversion determination, and attenuated positive symptom severity rating will help in comparing findings across studies and in meta-analyses.

Development of the PSYCHS: Positive SYmptoms and Diagnostic Criteria for the CAARMS Harmonized with the SIPS

Aim

To harmonize two ascertainment and severity rating instruments commonly used for the clinical high risk syndrome for psychosis (CHR-P): the Structured Interview for Psychosis-risk Syndromes (SIPS) and the Comprehensive Assessment of At-Risk Mental States (CAARMS).

Methods

The initial workshop is described in the companion report from Addington et al. After the workshop, lead experts for each instrument continued harmonizing attenuated positive symptoms and criteria for psychosis and CHR-P through an intensive series of joint videoconferences.

Results

Full harmonization was achieved for attenuated positive symptom ratings and psychosis criteria, and partial harmonization for CHR-P criteria. The semi-structured interview, named P ositive SY mptoms and Diagnostic Criteria for the C AARMS H armonized with the S IPS (PSYCHS), generates CHR-P criteria and severity scores for both CAARMS and SIPS.

Conclusion

Using the PSYCHS for CHR-P ascertainment, conversion determination, and attenuated positive symptom severity rating will help in comparing findings across studies and in meta-analyses.

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSION

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

The exploration of a screen model for detecting undergraduates at higher risk for developing psychosis: A cross-sectional study in a medical university

PURPOSE

To examine a screen model for detecting undergraduates with higher risk for developing psychosis (HRDP).

DESIGN AND METHODS

A cross-sectional design with convenience sampling was used. The screen model included exploration stage by self-report scales and confirmation stage by face-to-face interviews.

FINDINGS

A total of 273 students were detected from 4744 surveys during 4 years. Of them, 120 students with HRDP were identified and 7 had been diagnosed as schizophrenia or bipolar disorders at 12-month follow-up.

PRACTICE IMPLICATIONS

This screen model can be used in early detection for undergraduates with HRDP from large general samples.

Influence of mental health literacy on help-seeking behaviour for mental health problems in the Swiss young adult community: a cohort and longitudinal case-control study

Poor knowledge about mental health disorders and their treatment likely contributes to the large treatment gap reported for mental health problems. Therefore, we studied the association between mental health literacy (MHL) and active help-seeking in a community sample. Participants were recruited from an add-on questionnaire study to the 'Bern Epidemiological At-Risk' (BEAR) study on 16-40-year-old community subjects of the Swiss canton Bern. At baseline, data of N = 1504, and at 3-year follow-up, data of N = 535 were available. Based on an unlabelled case vignette (on depression or schizophrenia), MHL was assessed by the questionnaire of Angermeyer and colleagues. Cross-sectional and longitudinal baseline predictors of help-seeking were analysed using path analyses. Additionally, sensitivity analyses of the prospective model were computed for sex, vignette, and baseline mental health problems/disorders. Cross-sectionally, help-seeking was associated with non-endorsement of biogenetic causal explanations, presence of mental health problems/disorders, help-seeking before baseline, poorer functioning, and lower health satisfaction. The prospective model was similar; yet, help-seeking at follow-up was associated with endorsements of the causal explanation 'biogenetics' and, additionally, 'childhood trauma' but not the presence of baseline mental health problems/disorders. Sensitivity analyses revealed a significant impact on sex, vignette, and mental health problems/disorders. For example, actual functional problems were predictive in males, while health satisfaction was predictive in females. Our findings indicate that future studies on drivers of help-seeking should assess very large community samples with case vignettes on different mental disorders to examine appropriate subgroups and their likely interaction to address group-specific factors in awareness campaigns.

The Important Role of Stereotypes in the relation between Mental Health Literacy and Stigmatization of Depression and Psychosis in the Community

Increased mental health literacy (MHL) has not reduced stigmatization of people with mental disorder. Thus, we examined the role of stereotypes in the interplay of MHL (correct labelling, causal explanations) and the wish for social distance (WSD) from people with depressive and psychotic symptoms in a community sample of 1526 German-speaking participants in the Swiss 'Bern Epidemiological At-Risk' study (age 16-40 years; response rate: 60.1%). Following the presentation of an unlabelled case vignette of depression or psychosis, MHL, stereotypes and WSD were assessed in a questionnaire survey. Their interrelations were studied using structural equation modelling. MHL was not directly linked to WSD, only the psychosocial causal model was directly negatively associated with WSD. Perceived dangerousness particularly increased WSD, this was increased by a biogenetic causal model and decreased by a psychosocial causal model. Awareness-campaigns that, next to biological causes, emphasize psychosocial causes of mental disorders might better reduce stigmatization.

The Bern Early Recognition and Intervention Centre for mental crisis (FETZ Bern)-An 8-year evaluation

AIM

Early detection of, and intervention for, psychosis during its prodromal phase has the potential to alter the course of the disease and has therefore become a major objective of modern clinical psychiatry. An increasing number of early detection and intervention services have been established in Europe and worldwide. This study aims to describe and evaluate an early detection and intervention service for children, adolescents and adults (FETZ Bern) aged from eight to 40 years with a population catchment area of 1.035 million in Bern, Switzerland.

METHODS

Routine demographic, diagnostic and service usage data were collected upon admission to the service. Using a retrospective, descriptive and naturalistic study design, data was analysed for different age groups (children, adolescents and adults) and where available, outcome data after 12 and 24 months was evaluated.

RESULTS

The FETZ Bern has received 827 referrals with full diagnostic data available for 353 patients. The majority of the assessed patients were young males. While 40% met criteria for a clinical high-risk state of psychosis, 20% were diagnosed with fully manifest psychosis at time of admission, and another 40% had one or more non-psychotic axis-I diagnoses.

CONCLUSIONS

The FETZ Bern is the first early detection centre worldwide assessing children aged younger than 12 years, as well as adolescents and young adults in one service. Given that developmental peculiarities are important in understanding and ultimately treating psychosis, the FETZ Bern, with its emphasis on developmental peculiarities, should be considered as a model for other similar services.

Perceived Family Functioning Profile in Adolescents at Clinical High Risk for Psychosis: Rigidity as a Possible Preventive Target

The presence of a positive family relationship has been suggested as a protective factor from parental stress and from the development of full-blown psychosis. However, to date, there is limited research on family functioning in adolescents with psychosis and at clinical high risk for psychosis (CHR-P). This study is aimed at comparing family functioning and perceived stress in parents of adolescents with either CHR-P, early onset psychosis (EOP), or other psychiatric disorders (no CHR-P). As a secondary aim, it will correlate family functioning with parental perceived stress in order to find critical targets of intervention. We conducted a Reporting of Studies Conducted Using Observational Routinely-Collected Health Data (RECORD)-compliant, real-world, cross-sectional study. One-hundred and eleven adolescents aged 12-17 who access the institute of hospitalization and care with scientific character (IRCCS) Mondino Foundation Neuropsychiatric services (Pavia, Italy) between 2017 and 2020 and their parents (n = 222) were included. Sociodemographic characteristics of adolescents and their parents were collected. Family functioning was evaluated through the Family Adaptability and Cohesion Evaluation Scale-IV (FACES-IV) and the level of stress through the Perceived Stress Scale (PSS). Twenty adolescents had EOP, 38 had CHR-P, and 59 had no CHR-P. In total, 2.6% of CHR-P adolescents were adopted, 76.3% had separated-divorced parents, and 34.2% of parents had a depressive disorder. Among the FACES-IV sub-scale, maternal rigidity was progressively increased from no-CHR-P to CHR-P to EOP group, with statistical differences between EOP and the other two groups (p = 0.01). CHR-P mothers and fathers showed a high level of PSS values, without group difference. Lastly, PSS values correlated positively with the Rigidity, Disengagement, and Chaos scale of FACES-IV and negatively with the Communication scale (p < 0.05). Our results suggest that family functioning has a central role and could represent a worthwhile target of intervention for adolescents at CHR-P, leading the way to new preventive approaches.

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

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

Anomalous self-experiences (ASE) in relation to clinical high risk for psychosis (CHRP), childhood trauma and general psychopathology among adolescent and young adult help seekers

BACKGROUND

Anomalous self-experiences (ASE) are suggested as a phenotypic core feature of schizophrenia spectrum disorders and present in at risk samples as well. In our study, we investigated the relation between ASE and clinical high risk state for psychosis (CHRP) against the background of further influencing factors like childhood trauma and general psychopathology.

METHODS

126 help-seeking adolescents were included. CHR-P patients were identified using the Structured Interview for Psychosis-Risk Syndromes (SIPS). ASE were assessed with the Inventory of Psychotic-like Anomalous Self-Experiences (IPASE). Childhood trauma, depression and anxiety were assessed with well-established questionnaires (CTQ; PHQ-9; GAD-7).

RESULTS

CHR-P subgroup (n = 50, 39.7%) show significantly higher scores in IPASE total (t (81.07) = -5.150, p = .000) and CTQ total (t (85.95) = -2.75, p = .007) in comparison with the non CHR-P subgroup. Logistic regression analysis confirmed that IPASE total could predict CHR-P status (OR 1.03, 95% CI 1.01-1.04, p = .000). Furthermore, CTQ total and IPASE total show moderate to strong positive correlation (r = 0.44, p < .001) as well as CTQ total with both IPASE subdomains Cognition (r = 0.404, p < .001) and Self- Awareness (r = 0.443, p < .001).

CONCLUSION

The CHR-P subgroup shows significantly more ASE than the non CHR-P subgroup. Further, ASE predicted CHR-P status. Our results indicated that ASE could play a considerable role in the identification of high risk for developing schizophrenia spectrum disorder and could complement CHR-P testing. Importantly, it seems that ASE may be related to exposure to childhood trauma.

Risk and protective factors for mental disorders beyond genetics: an evidence-based atlas

Decades of research have revealed numerous risk factors for mental disorders beyond genetics, but their consistency and magnitude remain uncer-tain. We conducted a "meta-umbrella" systematic synthesis of umbrella reviews, which are systematic reviews of meta-analyses of individual studies, by searching international databases from inception to January 1, 2021. We included umbrella reviews on non-purely genetic risk or protective factors for any ICD/DSM mental disorders, applying an established classification of the credibility of the evidence: class I (convincing), class II (highly suggestive), class III (suggestive), class IV (weak). Sensitivity analyses were conducted on prospective studies to test for temporality (reverse causation), TRANSD criteria were applied to test transdiagnosticity of factors, and A Measurement Tool to Assess Systematic Reviews (AMSTAR) was employed to address the quality of meta-analyses. Fourteen eligible umbrella reviews were retrieved, summarizing 390 meta-analyses and 1,180 associations between putative risk or protective factors and mental disorders. We included 176 class I to III evidence associations, relating to 142 risk/protective factors. The most robust risk factors (class I or II, from prospective designs) were 21. For dementia, they included type 2 diabetes mellitus (risk ratio, RR from 1.54 to 2.28), depression (RR from 1.65 to 1.99) and low frequency of social contacts (RR=1.57). For opioid use disorders, the most robust risk factor was tobacco smoking (odds ratio, OR=3.07). For non-organic psychotic disorders, the most robust risk factors were clinical high risk state for psychosis (OR=9.32), cannabis use (OR=3.90), and childhood adversities (OR=2.80). For depressive disorders, they were widowhood (RR=5.59), sexual dysfunction (OR=2.71), three (OR=1.99) or four-five (OR=2.06) metabolic factors, childhood physical (OR=1.98) and sexual (OR=2.42) abuse, job strain (OR=1.77), obesity (OR=1.35), and sleep disturbances (RR=1.92). For autism spectrum disorder, the most robust risk factor was maternal overweight pre/during pregnancy (RR=1.28). For attention-deficit/hyperactivity disorder (ADHD), they were maternal pre-pregnancy obesity (OR=1.63), maternal smoking during pregnancy (OR=1.60), and maternal overweight pre/during pregnancy (OR=1.28). Only one robust protective factor was detected: high physical activity (hazard ratio, HR=0.62) for Alzheimer's disease. In all, 32.9% of the associations were of high quality, 48.9% of medium quality, and 18.2% of low quality. Transdiagnostic class I-III risk/protective factors were mostly involved in the early neurodevelopmental period. The evidence-based atlas of key risk and protective factors identified in this study represents a benchmark for advancing clinical characterization and research, and for expanding early intervention and preventive strategies for mental disorders.

Predictors of help-seeking behaviour in people with mental health problems: a 3-year prospective community study

BACKGROUND

The majority of people with mental illness do not seek help at all or only with significant delay. To reduce help-seeking barriers for people with mental illness, it is therefore important to understand factors predicting help-seeking. Thus, we prospectively examined potential predictors of help-seeking behaviour among people with mental health problems (N = 307) over 3 years.

METHODS

Of the participants of a 3-year follow-up of a larger community study (response rate: 66.4%), data of 307 (56.6%) persons with any mental health problems (age-at-baseline: 16-40 years) entered a structural equation model of the influence of help-seeking, stigma, help-seeking attitudes, functional impairments, age and sex at baseline on subsequent help-seeking for mental health problems.

RESULTS

Functional impairment at baseline was the strongest predictor of follow-up help-seeking in the model. Help-seeking at baseline was the second-strongest predictor of subsequent help-seeking, which was less likely when help-seeking for mental health problems was assumed to be embarrassing. Personal and perceived stigma, and help-seeking intentions had no direct effect on help-seeking.

CONCLUSIONS

With only 22.5% of persons with mental health problems seeking any help for these, there was a clear treatment gap. Functional deficits were the strongest mediator of help-seeking, indicating that help is only sought when mental health problems have become more severe. Earlier help-seeking seemed to be mostly impeded by anticipated stigma towards help-seeking for mental health problems. Thus, factors or beliefs conveying such anticipated stigma should be studied longitudinally in more detail to be able to establish low-threshold services in future.

Preventive psychiatry: a blueprint for improving the mental health of young people

Preventive approaches have latterly gained traction for improving mental health in young people. In this paper, we first appraise the conceptual foundations of preventive psychiatry, encompassing the public health, Gordon's, US Institute of Medicine, World Health Organization, and good mental health frameworks, and neurodevelopmentally-sensitive clinical staging models. We then review the evidence supporting primary prevention of psychotic, bipolar and common mental disorders and promotion of good mental health as potential transformative strategies to reduce the incidence of these disorders in young people. Within indicated approaches, the clinical high-risk for psychosis paradigm has received the most empirical validation, while clinical high-risk states for bipolar and common mental disorders are increasingly becoming a focus of attention. Selective approaches have mostly targeted familial vulnerability and non-genetic risk exposures. Selective screening and psychological/psychoeducational interventions in vulnerable subgroups may improve anxiety/depressive symptoms, but their efficacy in reducing the incidence of psychotic/bipolar/common mental disorders is unproven. Selective physical exercise may reduce the incidence of anxiety disorders. Universal psychological/psychoeducational interventions may improve anxiety symptoms but not prevent depressive/anxiety disorders, while universal physical exercise may reduce the incidence of anxiety disorders. Universal public health approaches targeting school climate or social determinants (demographic, economic, neighbourhood, environmental, social/cultural) of mental disorders hold the greatest potential for reducing the risk profile of the population as a whole. The approach to promotion of good mental health is currently fragmented. We leverage the knowledge gained from the review to develop a blueprint for future research and practice of preventive psychiatry in young people: integrating universal and targeted frameworks; advancing multivariable, transdiagnostic, multi-endpoint epidemiological knowledge; synergically preventing common and infrequent mental disorders; preventing physical and mental health burden together; implementing stratified/personalized prognosis; establishing evidence-based preventive interventions; developing an ethical framework, improving prevention through education/training; consolidating the cost-effectiveness of preventive psychiatry; and decreasing inequalities. These goals can only be achieved through an urgent individual, societal, and global level response, which promotes a vigorous collaboration across scientific, health care, societal and governmental sectors for implementing preventive psychiatry, as much is at stake for young people with or at risk for emerging mental disorders.

Screening of the college students at clinical high risk for psychosis in China: a multicenter epidemiological study

BACKGROUND

To investigate a 3-stage screening procedure and explore the clinical features of subjects at Clinical High Risk (CHR) for psychosis in a representative sample of Chinese college students.

METHODS

An epidemiological survey of the prevalence of the CHR syndrome in Chinese college students that was selected by stratified random sampling from Shanghai, Nanjing and Nanchang cities was done following a 3-stage procedure. Participants were initially screened with the Prodromal Questionnaire-brief version (PQ-B), and whose distress score of PQ-B exceeded 24 would be invited to a telephone assessment using the subscale for positive symptoms of the Scale of Prodromal Symptoms (SOPS)/Structured Interview for Prodromal Syndromes (SIPS). Lastly, participants who scored 3 or higher in any item of the subscale would be administered with the SIPS interview conducted by trained researchers to confirm the diagnosis of CHR syndrome.

RESULTS

Twenty-three thousand sixty-three college students completed the survey during September 2017 to October 2018. Seventy-two students were diagnosed as CHR subjects, and the detection rate in the total sample was 0.3%. The peak age range for the first diagnosis of CHR was 17 to 20 years. Thirteen and forty-six were set as the cutoff points of PQ-B total score and distress score to balance the greatest sensitivity and specificity. Binary logistic regression revealed that 8 items in PQ-B showed significant distinction for detecting CHR subjects.

CONCLUSIONS

The 3-stage screening method can be utilized in the detection of CHR subjects for psychosis in the general population, during which delusional ideas, perceptual abnormalities and suspiciousness deserve great attention.

Prognostic Accuracy of DSM-5 Attenuated Psychosis Syndrome in Adolescents: Prospective Real-World 5-Year Cohort Study

There is limited research in adolescents at risk for psychosis. The new Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition attenuated psychosis syndrome (DSM-5 APS) criteria have not been validated in this group. We conducted a RECORD-compliant, real-world, prospective, 5-year cohort study addressing clinical profile, transition to psychosis, and prognostic accuracy of DSM-5 APS in help-seeking inpatient/outpatient adolescents accessing Children and Adolescent Neuropsychiatric services at IRCCS Mondino Foundation (Pavia, Lombardy, Italy) between 2012 and 2019. About 243 adolescents (31 early-onset psychosis [EOP]; 110 meeting DSM-5 APS criteria, DSM-5 APS; 102 not meeting psychotic or DSM-5 APS criteria, non-APS) were included. At baseline, DSM-5 APS adolescents (aged 15.4 ± 1.6) had on average 2.3 comorbid disorders (higher than EOP/non-APS, P < .001). DSM-5 APS adolescents had an intermediate psychopathological profile between non-APS/EOP (P < .001) and worsen Clinical Global Impression-Severity than non-APS (P < .001). DSM-5 APS functioning was intermediate between non-APS and EOP. 39.1% of DSM-5 APS were treated with psychotropic drugs (average = 64 days); 53.6% received psychotherapy. Follow-up of DSM-5 APS and non-APS groups lasted 33 and 26 months, respectively (median). The cumulative risk of transition at 1-5 years was 13%, 17%, 24.2%, 26.8%, and 26.8% in the DSM-5 APS group, 0%, 0%, 3.2%, 3.2%, and 3.2% in the non-APS group. The 5-year prognostic accuracy of the DSM-5 APS in adolescent was adequate (area under the curve = 0.77; Harrell's C = 0.736, 95%CI 0.697-0.775), with high sensitivity (91.3%) and suboptimal specificity (63.2%). The DSM-5 APS diagnosis can be used to detect help-seeking adolescents at risk of psychosis and predict their long-term outcomes. Future research should consolidate these findings.

Establishing a clinical service to prevent psychosis: What, how and when? Systematic review

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.

Recency and intensification of positive symptoms enhance prediction of conversion to syndromal psychosis in clinical high-risk patients

BACKGROUND

Early detection and intervention strategies in patients at clinical high-risk (CHR) for syndromal psychosis have the potential to contain the morbidity of schizophrenia and similar conditions. However, research criteria that have relied on severity and number of positive symptoms are limited in their specificity and risk high false-positive rates. Our objective was to examine the degree to which measures of recency of onset or intensification of positive symptoms [a.k.a., new or worsening (NOW) symptoms] contribute to predictive capacity.

METHODS

We recruited 109 help-seeking individuals whose symptoms met criteria for the Progression Subtype of the Attenuated Positive Symptom Psychosis-Risk Syndrome defined by the Structured Interview for Psychosis-Risk Syndromes and followed every three months for two years or onset of syndromal psychosis.

RESULTS

Forty-one (40.6%) of 101 participants meeting CHR criteria developed a syndromal psychotic disorder [mostly (80.5%) schizophrenia] with half converting within 142 days (interquartile range: 69-410 days). Patients with more NOW symptoms were more likely to convert (converters: 3.63 ± 0.89; non-converters: 2.90 ± 1.27; p = 0.001). Patients with stable attenuated positive symptoms were less likely to convert than those with NOW symptoms. New, but not worsening, symptoms, in isolation, also predicted conversion.

CONCLUSIONS

Results suggest that the severity and number of attenuated positive symptoms are less predictive of conversion to syndromal psychosis than the timing of their emergence and intensification. These findings also suggest that the earliest phase of psychotic illness involves a rapid, dynamic process, beginning before the syndromal first episode, with potentially substantial implications for CHR research and understanding the neurobiology of psychosis.

Markers of Psychosis Risk in the General Population

The categorical approach to defining schizophrenia spectrum disorders requires meeting established criteria. To advance early identification and intervention in young people, the field has progressed to studying help-seeking individuals who are at clinical high risk based on subthreshold psychosis spectrum symptoms, and criteria have been articulated for qualifying individuals as at risk. A broader dimensional examination of psychosis has been applied to population-based studies on non-help seekers. This review highlights the ascertainment and assessment approaches to such population-based studies. Most studies are cross-sectional and rely on questionnaires with limited overlap of tools. However, several consistent findings emerge on symptoms, neurocognitive deficits, and neuroimaging parameters and other biomarkers associated with emergence and persistence of psychotic features. The findings are consistent with the literature on abnormalities associated with schizophrenia, including the presence of neurocognitive deficits; abnormalities in brain structure, function, and connectivity that are related to distress; impairment; and functional outcome. These findings support the validity of studying psychosis experiences during development in a way that can chart the emergence of psychosis in the context of general psychopathology. Such studies are necessary for establishing developmental trajectories that characterize this emergence and for identifying risk and resilience biomarkers moderating or modulating the full range of schizophrenia-related manifestations. More community-based studies are needed, with better standardization and harmonization of measures and incorporating longitudinal follow-up, to establish mechanistic links between cellular-molecular aberrations and specific manifestations of psychosis as envisioned by the precision medicine agenda.

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

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Terminology and assessment tools of psychosis: A systematic narrative review

AIM

Phenomena within the psychosis continuum that varies in frequency/duration/intensity have been increasingly identified. Different terms describe these phenomena, however there is no standardization within the terminology. This review evaluated the definitions and assessment tools of seven terms - (i) 'psychotic experiences'; (ii) 'psychotic-like experiences'; (iii) 'psychotic-like symptoms'; (iv) 'attenuated psychotic symptoms'; (v) 'prodromal psychotic symptoms'; (vi) 'psychotic symptomatology'; and (vii) 'psychotic symptoms'.

METHODS

EMBASE, MEDLINE, and CINAHL were searched during February-March 2019. Inclusion criteria included 1989-2019, full text, human, and English. Papers with no explicit definition or assessment tool, duplicates, conference abstracts, systematic reviews, meta-analyses, or no access were excluded.

RESULTS

A total of 2238 papers were identified and of these, 627 were included. Definitions and assessment tools varied, but some trends were found. Psychotic experiences and psychotic-like experiences were transient and mild, found in the general population and those at-risk. Psychotic-like symptoms were subthreshold and among at-risk populations and non-psychotic mental disorders. Attenuated psychotic symptoms were subthreshold but associated with distress, risk, and help-seeking. Prodromal psychotic symptoms referred to the prodrome of psychotic disorders. Psychotic symptomatology included delusions and hallucinations within psychotic disorders. Psychotic symptoms was the broadest term, encompassing a range of populations but most commonly involving hallucinations, delusions, thought disorder, and disorganization.

DISCUSSION

A model for conceptualizing the required terms is proposed and future directions needed to advance this field of research are discussed.

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

IMPORTANCE

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

OBJECTIVE

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

EVIDENCE REVIEW

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

FINDINGS

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

CONCLUSIONS AND RELEVANCE

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

Hippocampal Pathology in Clinical High-Risk Patients and the Onset of Schizophrenia

BACKGROUND

We examined neuroimaging-derived hippocampal biomarkers in subjects at clinical high risk (CHR) for psychosis to further characterize the pathophysiology of early psychosis. We hypothesized that glutamate hyperactivity, reflected by increased metabolic activity derived from functional magnetic resonance imaging in the CA1 hippocampal subregion and from proton magnetic resonance spectroscopy-derived hippocampal levels of glutamate/glutamine, represents early hippocampal dysfunction in CHR subjects and is predictive of conversion to syndromal psychosis.

METHODS

We enrolled 75 CHR individuals with attenuated positive symptom psychosis-risk syndrome as defined by the Structured Interview for Psychosis-risk Syndromes. We used optimized magnetic resonance imaging techniques to measure 3 validated in vivo pathologies of hippocampal dysfunction-focal cerebral blood volume, focal atrophy, and evidence of elevated glutamate concentrations. All patients were imaged at baseline and were followed for up to 2 years to assess for conversion to psychosis.

RESULTS

At baseline, compared with control subjects, CHR individuals had high glutamate/glutamine and elevated focal cerebral blood volume on functional magnetic resonance imaging, but only baseline focal hippocampal atrophy predicted progression to syndromal psychosis.

CONCLUSIONS

These findings provide evidence that CHR patients with attenuated psychotic symptoms have glutamatergic abnormalities, although only CHR patients who develop syndromal psychosis exhibit focal hippocampal atrophy. Furthermore, these results support the growing evidence that hippocampal dysfunction is an early feature of schizophrenia and related psychotic disorders.

Basic Symptoms Are Associated With Age in Patients With a Clinical High-Risk State for Psychosis: Results From the PRONIA Study

In community studies, both attenuated psychotic symptoms (APS) and basic symptoms (BS) were more frequent but less clinically relevant in children and adolescents compared to adults. In doing so, they displayed differential age thresholds that were around age 16 for APS, around age 18 for perceptive BS, and within the early twenties for cognitive BS. Only the age effect has previously been studied and replicated in clinical samples for APS. Thus, we examined the reported age effect on and age thresholds of 14 criteria-relevant BS in a patient sample at clinical-high risk of psychosis (N = 261, age 15-40 yrs.), recruited within the European multicenter PRONIA-study. BS and the BS criteria, "Cognitive Disturbances" (COGDIS) and "Cognitive-perceptive BS" (COPER), were assessed with the "Schizophrenia Proneness Instrument, Adult version" (SPI-A). Using logistic regressions, prevalence rates of perceptive and cognitive BS, and of COGDIS and COPER, as well as the impact of social and role functioning on the association between age and BS were studied in three age groups (15-18 years, 19-23 years, 24-40 years). Most patients (91.2%) reported any BS, 55.9% any perceptive and 87.4% any cognitive BS. Furthermore, 56.3% met COGDIS and 80.5% COPER. Not exhibiting the reported differential age thresholds, both perceptive and cognitive BS, and, at trend level only, COPER were less prevalent in the oldest age group (24-40 years); COGDIS was most frequent in the youngest group (15-18 years). Functional deficits did not better explain the association with age, particularly in perceptive BS and cognitive BS meeting the frequency requirement of BS criteria. Our findings broadly confirmed an age threshold in BS and, thus, the earlier assumed link between presence of BS and brain maturation processes. Yet, age thresholds of perceptive and cognitive BS did not differ. This lack of differential age thresholds might be due to more pronounced the brain abnormalities in this clinical sample compared to earlier community samples. These might have also shown in more frequently occurring and persistent BS that, however, also resulted from a sampling toward these, i.e., toward COGDIS. Future studies should address the neurobiological basis of CHR criteria in relation to age.

Age effects on basic symptoms in the community: A route to gain new insight into the neurodevelopment of psychosis?

Reports of limited clinical significance of attenuated psychotic symptoms before age 15/16 indicate an important role of neurodevelopment in the early detection of psychoses. Therefore, we examined if age also exerts an influence on the prevalence and clinical significance of the 14 cognitive and perceptive basic symptoms (BS) used in psychosis-risk criteria and conceptualized as the most direct self-experienced expression of neurobiological aberrations. A random representative general population sample of the Swiss canton Bern (N = 689, age 8-40 years, 06/2011-05/2014) was interviewed for BS, psychosocial functioning, and current mental disorder. BS were reported by 18% of participants, mainly cognitive BS (15%). In regression analyses, age affected perceptive and cognitive BS differently, indicating an age threshold for perceptive BS in late adolescence (around age 18) and for cognitive BS in young adulthood (early twenties)-with higher prevalence, but a lesser association with functional deficits and the presence of mental disorder in the below-threshold groups. Thereby, interaction effects between age and BS on functioning and mental disorder were commonly stronger than individual effects of age and BS. Indicating support of the proposed "substrate-closeness" of BS, differential age effects of perceptual and cognitive BS seem to follow normal brain maturation processes, in which they might occur as infrequent and temporary non-pathological disturbances. Their persistence or occurrence after conclusion of main brain maturation processes, however, might signify aberrant maturation or neurodegenerative processes. Thus, BS might provide important insight into the pathogenesis of psychosis and into differential neuroprotective or anti-inflammatory targets.

Does hallucination perceptual modality impact psychosis risk?

OBJECTIVE

Subthreshold perceptual abnormalities are commonly used to identify individuals at clinical high risk (CHR) for developing a psychotic disorder. Predictive validity for modality-specific perceptual abnormality severity on psychosis risk is unknown.

METHODS

We examined prospectively collected data from 164 individuals age 12-35 meeting criteria for CHR followed for 6-24 months or until conversion to psychosis. Using intake interview notes, baseline perceptual abnormality scores were split into auditory, visual, somatic/tactile, and olfactory/gustatory components, and auditory scores were further split into those for verbal vs non-verbal content. Relationships between perceptual abnormality characteristics and conversion were assessed with Cox proportional hazards regression and logistic regression.

RESULTS

Unusual thought content and paranoia were predictive of conversion, but no modality-specific perceptual abnormality score predicted conversion status or days to conversion. However, when auditory perceptual abnormalities were further categorized as verbal vs non-verbal, the severity of verbal experiences was predictive of conversion to psychosis (P = 0.007).

CONCLUSIONS

Perceptual abnormality scores failed to meaningfully predict conversion to psychosis in either direction in this CHR sample. However, verbal auditory experiences may identify a group of CHR individuals at elevated risk of conversion. Further exploration of the relationship between phenomenological aspects of perceptual abnormalities and conversion risk is warranted.

Screening nursing students to identify those at high risk of poor mental health: a cross-sectional survey

OBJECTIVES

This study aimed to identify those at high risk of poor mental health among nursing students and to examine the relationships and consistency among five mental health assessments.

DESIGN

A cross-sectional design with purposive sampling was used. Four mental health screening tools plus previous mental health history/information were conducted during June 2015 to October 2016.

SETTING

A nursing major university in Taiwan.

PARTICIPANTS

A total of 2779 participants aged between 19 and 45 years were recruited.

MAIN OUTCOME MEASURES

Five mental health risks were identified: increased risk for ultra-high risk, putative prepsychosis states, high trait anxiety, high state anxiety with genetic risk and depression.

RESULTS

Out of the 3395 collected questionnaire, 2779 (82%) were found valid and included in the study. 612 (22%) of the participants were identified to be at mental health risk. 12 of them appeared positive in four, 79 in three, 148 in two and 373 in one of the adopted mental health screening tools. 69 participants had the experience of seeking medical help due to mental health issues, and 58% of them were identified to be at risk of mental health during the screening. Trait and state anxiety scored the highest in correlation analysis (r(2620)=0.76, p<0.001). Correlations were observed in the scores on the subscales of Chinese Version of Schizotypal Personality Questionnaire-Brief (CSPQ-B) and those of Brief self-report Questionnaire for Screening Putative Prepsychotic States (BQSPS), and the highest correlation coefficients was (r(2740)=0.70, p<0.001). Although both of the screening tools are used to assess mental illness risk at its prodromal phase, but CSPQ-B in general appeared to have more rigorous screening criteria than BQSPS.

CONCLUSION

For expediting early identification high risk of poor mental health, easy-to-use screening questionnaires can be adopted to assess the mental health state of nursing students whose mental well-being and overall health are of vital importance to the entire healthcare industry.

The Validation of the Free Fantasy Questionnaire for Children and Adolescents: From Imaginary Playmate to "Dreamtime"

Fantasy in children is a precocious and important skill. In normal subjects some imaginative events, very close to hallucinations (perception-like experiences), have been found. Therefore, a better knowledge on both fantasy and the difference between imagination and the external world is needed. The aims of this study are: (a) to validate a new questionnaire for fantasy in children and adolescents; (b) to test its clinical application in ADHD children. 1.707 participants aged 8-18 years were enrolled: 1557 were recruited from a survey in six schools, whereas 150 participants were recruited in an ADHD Center. They filled out a new questionnaire, the Free Fantasy Questionnaire for Children and Adolescents, FFQ. Statistical analyses were performed to validate the FFQ and to study five parameters of fantasy. Analyses showed good properties of the FFQ as regards factor structure and reliability. Descriptive analysis showed that: 10% of the adolescents frequently have fantasy with paracosmos and 9.5% sometimes have a fantasy with imaginary relatives. Moreover, in the 64.3% of participants of primary school, in the 34.5% of lower-secondary, and in the 27.4% of upper-secondary school Perception-like experiences, involving invisible but real personages, were found. Quality of fantasy and Lack of control on imagination are correlated with a high score in the Reality/Unreality Dimension and Perception-like experiences. As regards ADHD participants, the 40% of the group showed Perception-like experiences: the 21.66% of them reported a very high score in the dimension Reality/Unreality, have some dissociative symptoms, and the 3.33% presented a clear dissociative identity disorder. All were free from psychosis or neurologic disorders. A new questionnaire to study fantasy in children and adolescents was validated. Many children and adolescents of the general population declared Perception-like experiences. These events seem to be specific, and probably normal, features of the mind; they could be better named as "Dreamtime," whereas only in extreme conditions they could represent a risk for dissociation.

Attenuated psychosis and basic self-disturbance as risk factors for depression and suicidal ideation/behaviour in community-dwelling adolescents

BACKGROUND AND AIMS

Adolescents at clinical high risk (CHR) for psychosis, as defined by the presence of attenuated psychosis symptoms (APS), exhibit increased levels of suicidal ideation and behaviour. However, no research thus far has examined the link between basic self-disturbances (SDs), an established marker for CHR, and suicidality/self-harm in this population. The goal of this pilot study was to assess the association between SD, depression and suicidal ideation and behaviour among non-help-seeking adolescents from the community.

METHOD

A total of 100 community-dwelling adolescents (age range: 13-16) were assessed using the Examination of Anomalous Self-experience, Prodromal Questionnaire, Structured Interview for Prodromal Syndromes, Mood and Anxiety Symptom Questionnaire and the Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS). The K-SADS was used to derive a binary diagnosis of unipolar depression, as well as to measure suicidal ideation and behaviour and self-harm.

RESULTS

In a multiple regression analysis, SD accounted for variance in depressive symptoms and suicidality/self-harm over and above that accounted for by APS. Moreover, SD accounted for variance in suicidality/self-harm over and above that accounted for by depression symptoms.

CONCLUSIONS

These pilot results suggest that SD might be a unique dimension of vulnerability to depression and suicidality/self-harm in adolescence. Also, they encourage assessment of SD as part of a suicide risk assessment, particularly in the context of risk for subsequent psychosis.

'Something wasn't quite right': a novel phenomenological analysis of internet discussion posts detailing initial awareness of psychosis

INTRODUCTION

A significant number of psychosis studies have focussed on and have attempted to model and frame the earliest psychosis experiences. Using a wide array of methodologies and targeting a variety of 'at risk' groups, researchers have offered much to inform our treatment responses, and understanding of psychosis onset and development.

OBJECTIVES

Due to the nature of scientific investigation however and investigator led exploration, those who experience psychosis are rarely afforded ultimate free rein to dictate and direct the exchange of information or to impose their unique narrative on that which is being explored. In an attempt to address this, the current study opportunistically harvested rich self-report data from replies to the question, "People that have been diagnosed with schizophrenia, what was the first time you noticed something wasn't quite right?" on the internet discussion forum Reddit.com.

METHODS

User data was analysed using Interpretive Phenomenological Analysis to identify key themes in participants' first experiences and initial awareness of psychosis.

RESULTS

While respondents varied widely in their recounted experiences and chose to describe these experiences in a variety of ways, analysis showed that (i) respondent distress was associated with psychosis onset timeframe, negative-voice auditory hallucinations, visual hallucinations, paranoid delusions, and insight (ii) early childhood psychosis experience resulted in novel explanatory schemas and psychosis/distress progression with contributory factors in adolescence and (iii) 41.3% of the sample reported self-realisation in gaining insight and greater insight was associated with help-seeking behaviour.

CONCLUSIONS

This novel use of publicly shared experiential data might enrich our existing qualitative literature concerning early psychosis.

A Mentalization-Informed Staging Approach to Clinical High Risk for Psychosis

The practice of diagnosis is fundamentally designed to orient treatment. In the case of early diagnosis for schizophrenia spectrum disorders (SSP) risk, the empirical base for such a practice is still young, and many clinical questions arise in the everyday clinical application of risk algorithms and ensuing therapeutic options. One of the key questions that we will focus on is the following: in cases of SSP where symptoms are successfully treated, why does residual social functioning impairment remain the most serious obstacle to remission and reinsertion in society? We will present the evidence suggesting that the roots of residual social functioning impairment may, in many cases, come from thwarted or arrested development in the specialization of social cognition during adolescence and early adulthood. We will review the evidence suggesting that both during the premorbid phase and clinical high-risk phase, attenuated psychotic symptoms may impede the maturation of key social cognitive processes, particularly the suite of reflective thinking processes coming under the term of mentalization. From this evidence base, we will adapt the staging model of SSP progression in function of our mentalization-informed model, tailored to provide a coherent framework of care addressing the key clinical needs at every stage of psychosis progression.

Negative Life Events and Problematic Internet Use as Factors Associated With Psychotic-Like Experiences in Adolescents

Objectives: Psychotic-like experiences (PLEs) and problematic internet use (PIU) are common in adolescents. However, little is known about the association between PLEs and PIU among adolescents. The present study examined the associations between PLEs and PIU and negative life events among adolescents. Methods: In total, 1,678 adolescents attending high school were recruited for a cross-sectional survey. They completed self-reported assessments of PLEs using the Prodromal Questionnaire-16 (PQ-16) and measures of depression, anxiety, self-esteem, internet use, and negative life events using the Center for Epidemiological Studies Depression Scale (CES-D), the State-Trait Anxiety Inventory (STAI), the Rosenberg Self-Esteem Scale (RSES), the Korean Scale for Internet Addiction (K-scale), and the Lifetime Incidence of Traumatic Events for Children (LITE-C), including cybersexual harassment and school violence. Results: A total of 1,239 subjects (73.8%) scored at least 1 on the PQ-16. The mean total and distress PQ-16 scores were significantly higher in students who used mental health services. The total and distress prodromal questionnaire-16 (PQ-16) scores were positively correlated with the CES-D, STAI-S, STAI-T, LITE-C, and K-scale scores but negatively correlated with the RSES score. Hierarchical linear regression analysis revealed that PLEs were significantly associated with a high K-scale score and the incidence of negative life events, such as LITE-C, cybersexual harassment, and bully-victims. Conclusion: Our results demonstrate that PIU and negative life experiences were significantly associated with PLEs in adolescents. Assessment and therapeutic intervention with regard to internet use as a coping strategy for stress are needed to prevent the development of clinical psychotic symptoms.

The mediating role of borderline personality features in the relationship between childhood trauma and psychotic-like experiences in a sample of help-seeking non-psychotic adolescents and young adults

Objective:

Psychotic-like experiences (PLEs) often occur across different non-psychotic disorders in adolescent and young adult population and are related to early trauma. However, the mechanisms of how exposure to early trauma shapes the risk of PLEs are unclear. In our study, we investigated whether borderline personality features and further non-psychotic symptoms, i.e. factors related to both PLEs and childhood trauma, may mediate the relationship between childhood trauma and PLEs.

Methods:

Two hundred inpatients aged 16–21 years who were treated due to non-psychotic disorders were included. PLEs were assessed with the Prodromal Questionnaire (PQ-16). Childhood Trauma was assessed with the Adverse Childhood Experience Questionnaire (ACE). Borderline personality features were assessed by using the Borderline-Symptom Checklist (BSL-23). Presence and frequency of depressive symptoms and anxiety were assessed by Patient Health Questionnaire (PHQ-9) and Generalized Anxiety Disorder Questionnaire (GAD-7).

Table 1

Results:

A significant relationship between childhood trauma (ACE total score) and PLEs was found (ß = 0.30, 95% CI 0.247--0.659). In particular, emotional neglect (r = 0.298, p < 0.001) and sexual abuse (r = 0.264, p < 0.001) were significantly associated with PLEs. Borderline personality features fully mediated the relationship of childhood trauma and PLEs (ß = 0.12, 95% CI: -0.019--0.370). Anxiety and Depression showed a significant, but partial mediation of the relationship.

Conclusion:

Borderline personality features seem to be an important mediator of the relationship between childhood trauma and PLEs in adolescent patients with different non-psychotic psychiatric disorders. Theoretical and clinical implications are discussed.

Brain regional homogeneity and function connectivity in attenuated psychosis syndrome -based on a resting state fMRI study

BACKGROUND

By combining regional homogeneity (ReHo) and functional connectivity (FC) analyses, this study aimed to explore brain functional alterations in Attenuated Psychosis Syndrome (APS), which could provide complementary information for the neurophysiological indicators for schizophrenia (SZ) associated brain dysfunction.

METHODS

Twenty-one APS subjects and twenty healthy controls were enrolled in the data acquisition of demographics and clinical characteristics as well as structural and resting-state functional magnetic resonance imaging (rs-fMRI). ReHo analysis was conducted to determine the peak coordinate of the abnormal regional brain activity. Then, identified brain regions were considered as seed regions and were used to calculate FC between reginal brain voxels and whole brain voxels. Finally, potential correlations between imaging indices and clinical data were also explored.

RESULTS

Four APS and two HC subjects were excluded because the largest dynamic translation or rotation had exceeded 2 mm / 2°. Compared with healthy controls (HCs), APS subjects exhibited higher ReHo values in the right middle temporal gyrus (MTG) and lower ReHo values in the left middle frontal gyrus (MFG), left superior frontal gyrus (SFG), left postcentral gyrus (PoCG), and left superior frontal gyrus, medial (SFGmed). Considered these areas as seed regions, the APS subjects showed abnormal enhancement in functional brain connections, predominantly in the frontal and temporal lobes.

CONCLUSIONS

We concluded that the APS subjects had spatially regional dysfunction and remoted synchronous dysfunction in the frontal and temporal lobes of the brain, and changes in ReHo and FC patterns may reveal the mechanism of brain dysfunctions and may serve as an imaging biomarker for the diagnosis and evaluation of SZ.

Screening for psychosis risk among adolescents in Child and Adolescent Mental Health Services: a description of the first step with the 16-item version of the Prodromal Questionnaire (PQ-16)

AIM

Although the 16-item version of the Prodromal Questionnaire (PQ-16) is used as a screener in the early detection of psychosis risk, little is known about PQ-16 scores among adolescents referred to the Child and Adolescent Mental Health Services. We assessed such scores in adolescents referred to these services in the Netherlands, and also their associations with age, gender, diagnosis and level of functioning.

METHODS

The PQ-16 was added to regular intake procedures.

RESULTS

The PQ-16 was completed by 176 adolescents (mean age 14.58 years; standard deviation = 1.50; 55.1% females), 34.7% of whom scored above the current cut-off score of ≥6 items. Positive item scores with the highest odds ratio for scoring above the cut-off were related to tasting or smelling things, seeing things and hearing thoughts out aloud. There were no age-, gender- or disorder-related differences in total scores on the PQ-16. Lower Global Assessment of Functioning scores were associated with higher total scores on the PQ-16.

CONCLUSIONS

The PQ-16 is easy to implement in routine assessment and can be useful to bring up potential psychotic symptoms for further exploration in an early stage, especially in adolescents with low Global Assessment of Functioning scores. The PQ-16 total scores were not confounded by differences in age, gender or disorder. Future research should investigate the true nature of PQ-16 items and whether the item scores and cut-off scores of the PQ-16 in adolescence have any predictive value regarding the development of an ultra high-risk status, a psychotic disorder or other mental disorders.

Functioning mediates help-seeking for mental problems in the general population

Aims:

Absent or delayed help-seeking is considered to aggravate the immense personal and societal burden caused by mental disorders. Therefore, we cross-sectionally examined rates and clinical and sociodemographic moderators of early help-seeking for current clinician-assessed non-psychotic mental problems/disorders in the community.

Methods:

Altogether, 2683 individuals of the Swiss Canton Bern (16–40 years old, response rate 63.4%) were interviewed by telephone for current axis-I problems/disorders using the Mini-International Neuropsychiatric Interview, for psychosocial functioning using the Social and Occupational Functioning Assessment Scale, and for help-seeking for mental problems.

Results:

In total, 1122 (41.8%) reported mental problems. Of these, 769 (68.5%) affirmed any one screening question and 353 (31.5%) fulfilled criteria for any current axis-I disorder, and 396 (35.3%) reported any lifetime help-seeking (28.3% sought help in the past and 7.0% were in current treatment). In path analyses, current help-seeking was associated mainly by type and number of mental problems/disorders mediated by functional impairment, in addition to older age, no current partner, and past treatment.

Conclusion:

Our cross-sectional data indicate a gap in help-seeking for mental problems/disorders. The relationship between number of mental problems/disorders and help-seeking mediated by functional impairment confirm that individuals commonly do not seek help until problems are severe enough to cause problems in occupational and psychosocial functioning, driving the already immense costs of mental disorders. Thus, campaigns promoting early help-seeking, including early diagnostic clarification of and support for subthreshold mental problems in terms of an indicated prevention, should focus on psychosocial functioning, aside from signs of mental illness.

Prevalence and clinical relevance of interview-assessed psychosis-risk symptoms in the young adult community

BACKGROUND

An efficient indicated prevention of psychotic disorders requires valid risk criteria that work in both clinical and community samples. Yet, ultra-high risk and basic symptom criteria were recently recommended for use in clinical samples only. Their use in the community was discouraged for lack of knowledge about their prevalence, clinical relevance and risk factors in non-clinical, community settings when validly assessed with the same instruments used in the clinic.

METHODS

Using semi-structured telephone interviews with established psychosis-risk instruments, we studied the prevalence of psychosis-risk symptoms and criteria, their clinical relevance (using presence of a non-psychotic mental disorder or of functional deficits as proxy measures) and their risk factors in a random, representative young adult community sample (N=2683; age 16-40 years; response rate: 63.4%).

RESULTS

The point-prevalence of psychosis-risk symptoms was 13.8%. As these mostly occurred too infrequent to meet frequency requirements of psychosis-risk criteria, only 2.4% of participants met psychosis-risk criteria. A stepwise relationship underlay the association of ultra-high risk and basic symptoms with proxy measures of clinical relevance, this being most significant when both occurred together. In line with models of their formation, basic symptoms were selectively associated with age, ultra-high risk symptoms with traumatic events and lifetime substance misuse.

CONCLUSIONS

Psychosis-risk criteria were uncommon, indicating little risk of falsely labelling individuals from the community at-risk for psychosis. Besides, both psychosis-risk symptoms and criteria seem to possess sufficient clinical relevance to warrant their broader attention in clinical practice, especially if ultra-high risk and basic symptoms occur together.

The interplay of etiological knowledge and mental illness stigma on healthcare utilisation in the community: A structural equation model

BACKGROUND

The stigma of mental illness, especially personal attitudes towards psychiatric patients and mental health help-seeking, is an important barrier in healthcare utilisation. These attitudes are not independent of each other and are also influenced by other factors, such as mental health literacy, especially the public's causal explanations for mental problems. We aimed to disentangle the interrelations between the different aspects of stigma and causal explanations with respect to their association with healthcare utilisation.

METHODS

Stigma and causal explanations were assessed cross-sectional using established German questionnaires with two unlabelled vignettes (schizophrenia and depression) in a random-selection representative community sample (N = 1375, aged 16-40 years). They were interviewed through a prior telephone survey for current mental disorder (n = 192) and healthcare utilisation (n = 377). Structural equation modelling was conducted with healthcare utilisation as outcome and stigma and causal explanations as latent variables. The final model was additionally analysed based on the vignettes.

RESULTS

We identified two pathways. One positive associated with healthcare utilisation, with high psychosocial stress and low constitution/personality related causal explanations, via positive perception of help-seeking and more help-seeking intentions. One negative associated with healthcare utilisation, with high biogenetic and constitution/personality, and low psychosocial stress related explanations, via negative perception of psychiatric patients and a strong wish for social distance. Sensitivity analysis generally supported both pathways with some differences in the role of biogenetic causal explanation.

CONCLUSION

Our results indicate that campaigns promoting early healthcare utilisation should focus on different strategies to promote facilitation and reduce barriers to mental healthcare.

Demographic and clinical characteristics of diagnosed and non-diagnosed psychotic disorders in the community

AIM

Retrospective studies of first-episode psychosis patients have reported that psychosis often remains untreated for some time. Yet, from clinical samples, the characteristics and number of non-diagnosed untreated psychosis patients in a community can only be estimated. Thus, this short report compares socio-demographic and clinical features of diagnosed and non-diagnosed psychotic individuals assessed in the community.

METHODS

Using telephone interviews, we clinically assessed 2682 community participants (aged 16-40 years) in the Canton of Bern, Switzerland, to examine the characteristics of non-diagnosed psychosis.

RESULTS

Of the 41 detected psychosis patients (1.5% of the sample), 21 (54%) had already been diagnosed and treated. Non-diagnosed individuals experienced a delusional disorder (DD) (n = 10) more frequently than diagnosed individuals (n = 1), but did not differ in other socio-demographic characteristics.

CONCLUSION

Further study of DD should be emphasized, along with increased awareness of the condition in primary healthcare services, as individuals with DD might present themselves for other complaints.

Course of clinical high-risk states for psychosis beyond conversion

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Diagnostic and Prognostic Significance of DSM-5 Attenuated Psychosis Syndrome in Services for Individuals at Ultra High Risk for Psychosis

BACKGROUND

The diagnostic and prognostic significance of the DSM-5-defined Attenuated Psychosis Syndrome (DSM-5-APS) in individuals undergoing an ultra high risk (UHR) clinical assessment for suspicion of psychosis risk is unknown.

METHODS

Prospective cohort study including all consecutive help-seeking individuals undergoing both a DSM-5-APS and a Comprehensive Assessment of At Risk Mental States (CAARMS 12/2006) assessment for psychosis risk at the Outreach and Support in South London (OASIS) UHR service (March 2013-April 2014). The diagnostic significance of DSM-5-APS was assessed with percent overall agreement, prevalence bias adjusted kappa, Bowker's test, Stuart-Maxwell test, residual analysis; the prognostic significance with Cox regression, Kaplan-Meier failure function, time-dependent area under the curve (AUC) and net benefits analysis. The impact of specific revisions of the DSM-5-APS was further tested.

RESULT

In 203 help-seeking individuals undergoing UHR assessment, the agreement between the DSM-5-APS and the CAARMS 12/2006 was only moderate (kappa 0.59). Among 142 nonpsychotic cases, those meeting DSM-5-APS criteria had a 5-fold probability (HR = 5.379) of developing psychosis compared to those not meeting DSM-5-APS criteria, with a 21-month cumulative risk of psychosis of 28.17% vs 6.49%, respectively. The DSM-5-APS prognostic accuracy was acceptable (AUC 0.76 at 24 months) and similar to the CAARMS 12/2006. The DSM-5-APS designation may be clinically useful to guide the provision of indicated interventions within a 7%-35% (2-year) range of psychosis risk. The removal of the criterion E or C of the DSM-5-APS may improve its prognostic performance and transdiagnostic value.

CONCLUSIONS

The DSM-5-APS designation may be clinically useful in individuals accessing clinical services for psychosis prevention.

Psychosis risk screening: Validation of the youth psychosis at-risk questionnaire - brief in a community-derived sample of adolescents

There have been several attempts to identify individuals potentially at high risk for psychotic-spectrum disorders using brief screening measures. However, relatively few studies have tested the psychometric properties of the psychosis screening measures in representative samples of adolescents. The main purpose of the present study was to analyse the prevalence, factorial structure, measurement invariance across gender, and reliability of the Youth Psychosis At-Risk Questionnaire - Brief (YPARQ-B) in a community-derived sample of adolescents. Additionally, the relationship between YPARQ-B, depressive symptoms, psychopathology, stress manifestations, and prosocial skills was analysed. One thousand and twenty students from high schools participated in a cross-sectional survey. The YPARQ-B, the Reynolds Adolescent Depression Scale, the Strengths and Difficulties Questionnaire, and the Student Stress Inventory - Stress Manifestations were used. A total of 85.1% of the total sample self-reported at least one subclinical psychotic experience. We observed a total of 10.9% of adolescents with a cutoff score of ≥11 or 6.8% with a cutoff score of ≥13. The analysis of internal structure of the YPARQ-B yielded an essentially unidimensional structure. The YPARQ-B scores showed measurement invariance across gender. The internal consistency of the YPARQ-B total score was 0.94. Furthermore, self-reported subclinical psychotic experiences were associated with depressive symptoms, emotional and behavioural problems, poor prosocial skills, and stress manifestations. These results would appear to indicate that YPARQ-B is a brief and easy tool to assess self-reported subclinical psychotic experiences in adolescents from the general population. The assessment of these experiences in community settings, and its associations with psychopathology, may help us to enhance the possibility of an early identification of adolescents potentially at risk for psychosis and mental health problems.

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Chinese label for people at risk for psychosis

AIM

With the movement of early detection and intervention for people at risk for psychosis, there is a growing need for a uniform terminology to describe the condition. A diagnostic label that can adapt into local culture and value may have positive effect in minimizing stigma. This study explored the preference of Chinese label for people at risk of psychosis and its associated stigma in Hong Kong.

METHODS

A total of 149 individuals from the general public and 51 health-care professionals were recruited between March 2013 and May 2014. The condition of at risk for psychosis was described in a vignette. Participants' preference of label and perceived stigma of the condition and their basic demographics were collected by self-administered questionnaires.

RESULTS

The most preferred Chinese label was 'yun-niang-qi' (developing period, 45%), followed by 'qian-qu-qi' (precursor period, 19%), 'feng-xian-qi' (risky period, 18%), 'zao-xian-qi' (early sign period, 16%) and 'gao-wei-qi' (high risk period, 4%). Gender, age, occupation and previous contact with mental health were not associated with preference of any Chinese label.

CONCLUSIONS

The process in searching for this potential and locally accepted label for people at risk for psychosis has raised the awareness among the professionals. A proper label may help promote future clinical research and mental health services in Hong Kong.

Clinical presentation of Attenuated Psychosis Syndrome in children and adolescents: Is there an age effect?

There is limited research on clinical features related to age of presentation of the Attenuated Psychosis Syndrome in children and adolescents (CAD). Based on findings in CAD with psychosis, we hypothesized that an older age at presentation of Attenuated Psychosis Syndrome would be associated with less severe symptoms and better psychosocial functioning than presentation in childhood or younger adolescence. Ninety-four CAD (age 9-18) meeting Attenuated Psychosis Syndrome criteria participated in the study. The sample was divided and compared according to the age of presentation of Attenuated Psychosis Syndrome (9-14 vs 15-18 years). The predictive value of age of Attenuated Psychosis Syndrome presentation was investigated using receiver operating characteristic (ROC)-curve calculations. The two Attenuated Psychosis Syndrome groups were homogeneous in terms of gender distribution, IQ scores and comorbid diagnoses. Older Attenuated Psychosis Syndrome patients showed better functioning and lower depressive scores. ROC curves revealed that severity of functional impairment was best predicted using an age of presentation cut-off of 14.9 years for social functioning and 15.9 years for role functioning. This study partially confirmed our hypothesis; older age at presentation of Attenuated Psychosis Syndrome was associated with less functional impairment, but age was not associated with psychotic symptoms.

Ultra high risk status and transition to psychosis in 22q11.2 deletion syndrome

The 22q11.2 deletion syndrome (22q11DS) is characterized by high rates of psychotic symptoms and schizophrenia, making this condition a promising human model for studying risk factors for psychosis. We explored the predictive value of ultra high risk (UHR) criteria in a sample of patients with 22q11DS. We also examined the additional contribution of socio-demographic, clinical and cognitive variables to predict transition to psychosis within a mean interval of 32.5 ± 17.6 months after initial assessment. Eighty-nine participants with 22q11DS (age range: 8-30 years; mean 16.1 ± 4.7) were assessed using the Structured Interview for Psychosis-Risk Syndromes. Information on Axis I diagnoses, internalizing and externalizing symptoms, level of functioning and IQ was also collected. At baseline, 22 (24.7%) participants met UHR criteria. Compared to those without a UHR condition, they had a significantly lower functioning, more frequent anxiety disorders, and more severe psychopathology. Transition rate to psychosis was 27.3% in UHR and 4.5% in non-UHR participants. Cox regression analyses revealed that UHR status significantly predicted conversion to psychosis. Baseline level of functioning was the only other additional predictor. This is the first study investigating the predictive value of UHR criteria in 22q11DS. It indicates that the clinical path leading to psychosis is broadly comparable to that observed in other clinical high-risk samples. Nevertheless, the relatively high transition rate in non-UHR individuals suggests that other risk markers should be explored in this population. The role of low functioning as a predictor of transition to psychosis should also be investigated more in depth.

Disturbances of the Basic Self and Prodromal Symptoms Among Young Adolescents From the Community: A Pilot Population-Based Study

BACKGROUND AND GOAL

Recent findings have provided preliminary support for the notion that basic self-disturbances (SD) are related to prodromal symptoms among nonpsychotic help-seeking adolescents. As a sizable proportion of adolescents who are at risk do not seek help, this study attempts to assess the extent to which these findings can be generalized to the entire population of adolescents who are at risk for psychosis.

METHOD

The concurrent relationship between SD and prodromal symptoms was explored in a sample of 100 non-help-seeking adolescents (age 13-15) from the community. SD were assessed with the Examination of Anomalous Self-Experience (EASE); prodromal symptoms and syndromes were assessed with the Structured Interview for Prodromal Syndromes (SIPS); psychosocial functioning was assessed with the "Social and Role Global Functioning Scales"; and level of distress with the Mood and Anxiety States Questionnaire (MASQ).

RESULTS

SD significantly correlated with sub-clinical psychotic symptoms (r = .70, P < .0001). This correlation was significantly stronger than those of SD with mood symptoms and social functioning. Finally, SD was the single best concurrent predictor of prodromal symptoms and syndromes.

CONCLUSIONS

These results provide preliminary support for the generalizability of the association between SD and prodromal symptoms for the entire population of adolescents who are clinically at high risk for psychosis. In addition, they further support the notion that this association is both specific and unique.

The Dark Side of the Moon: Meta-analytical Impact of Recruitment Strategies on Risk Enrichment in the Clinical High Risk State for Psychosis

BACKGROUND

The individual risk of developing psychosis after being tested for clinical high-risk (CHR) criteria (posttest risk of psychosis) depends on the underlying risk of the disease of the population from which the person is selected (pretest risk of psychosis), and thus on recruitment strategies. Yet, the impact of recruitment strategies on pretest risk of psychosis is unknown.

METHODS

Meta-analysis of the pretest risk of psychosis in help-seeking patients selected to undergo CHR assessment: total transitions to psychosis over the pool of patients assessed for potential risk and deemed at risk (CHR+) or not at risk (CHR-). Recruitment strategies (number of outreach activities per study, main target of outreach campaign, and proportion of self-referrals) were the moderators examined in meta-regressions.

RESULTS

11 independent studies met the inclusion criteria, for a total of 2519 (CHR+: n = 1359; CHR-: n = 1160) help-seeking patients undergoing CHR assessment (mean follow-up: 38 months). The overall meta-analytical pretest risk for psychosis in help-seeking patients was 15%, with high heterogeneity (95% CI: 9%-24%, I (2) = 96, P < .001). Recruitment strategies were heterogeneous and opportunistic. Heterogeneity was largely explained by intensive (n = 11, β = -.166, Q = 9.441, P = .002) outreach campaigns primarily targeting the general public (n = 11, β = -1.15, Q = 21.35, P < .001) along with higher proportions of self-referrals (n = 10, β = -.029, Q = 4.262, P = .039), which diluted pretest risk for psychosis in patients undergoing CHR assessment.

CONCLUSIONS

There is meta-analytical evidence for overall risk enrichment (pretest risk for psychosis at 38 monhts = 15%) in help-seeking samples selected for CHR assessment as compared to the general population (pretest risk of psychosis at 38 monhts=0.1%). Intensive outreach campaigns predominantly targeting the general population and a higher proportion of self-referrals diluted the pretest risk for psychosis.

Adolescents and adults at clinical high-risk for psychosis: age-related differences in attenuated positive symptoms syndrome prevalence and entanglement with basic symptoms

BACKGROUND

The attenuated positive symptoms syndrome (APSS) is considered an at-risk indicator for psychosis. However, the characteristics and developmental aspects of the combined or enriched risk criteria of APSS and basic symptom (BS) criteria, including self-experienced cognitive disturbances (COGDIS) remain under-researched.

METHOD

Based on the Structured Interview of Prodromal Syndromes (SIPS), the prevalence of APSS in 13- to 35-year-old individuals seeking help in an early recognition program for schizophrenia and bipolar-spectrum disorders was examined. BS criteria and COGDIS were rated using the Schizophrenia Proneness Instrument for Adults/Children and Youth. Participants meeting APSS criteria were compared with participants meeting only BS criteria across multiple characteristics. Co-occurrence (APSS+/BS+, APSS+/COGDIS+) was compared across 13-17, 18-22 and 23-35 years age groups.

RESULTS

Of 175 individuals (age = 20.6 ± 5.8, female = 38.3%), 94 (53.7%) met APSS criteria. Compared to BS, APSS status was associated with suicidality, higher illness severity, lower functioning, higher SIPS positive, negative, disorganized and general symptoms scores, depression scores and younger age (18.3 ± 5.0 v. 23.2 ± 5.6 years, p < 0.0001) with age-related differences in the prevalence of APSS (ranging from 80.3% in 13- to 17-year-olds to 33.3% in 23- to 35-year-olds (odds ratio 0.21, 95% confidence interval 0.11-0.37). Within APSS+ individuals, fewer adolescents fulfilled combined risk criteria of APSS+/BS+ or APSS+/COGDIS+ compared to the older age groups.

CONCLUSIONS

APSS status was associated with greater suicidality and illness/psychophathology severity in this help-seeking cohort, emphasizing the need for clinical care. The age-related differences in the prevalence of APSS and the increasing proportion of APSS+/COGDIS+ may point to a higher proportion of non-specific/transient, rather than risk-specific attenuated positive symptoms in adolescents.

Depression predicts persistence of paranoia in clinical high-risk patients to psychosis: results of the EPOS project

BACKGROUND

The link between depression and paranoia has long been discussed in psychiatric literature. Because the causality of this association is difficult to study in patients with full-blown psychosis, we aimed to investigate how clinical depression relates to the presence and occurrence of paranoid symptoms in clinical high-risk (CHR) patients.

METHODS

In all, 245 young help-seeking CHR patients were assessed for suspiciousness and paranoid symptoms with the structured interview for prodromal syndromes at baseline, 9- and 18-month follow-up. At baseline, clinical diagnoses were assessed by the Structured Clinical Interview for DSM-IV, childhood adversities by the Trauma and Distress Scale, trait-like suspiciousness by the Schizotypal Personality Questionnaire, and anxiety and depressiveness by the Positive and Negative Syndrome Scale.

RESULTS

At baseline, 54.3% of CHR patients reported at least moderate paranoid symptoms. At 9- and 18-month follow-ups, the corresponding figures were 28.3 and 24.4%. Depressive, obsessive-compulsive and somatoform disorders, emotional and sexual abuse, and anxiety and suspiciousness associated with paranoid symptoms. In multivariate modelling, depressive and obsessive-compulsive disorders, sexual abuse, and anxiety predicted persistence of paranoid symptoms.

CONCLUSION

Depressive disorder was one of the major clinical factors predicting persistence of paranoid symptoms in CHR patients. In addition, obsessive-compulsive disorder, childhood sexual abuse, and anxiety associated with paranoia. Effective pharmacological and psychotherapeutic treatment of these disorders and anxiety may reduce paranoid symptoms in CHR patients.