Diagnostic and Prognostic Significance of Brief Limited Intermittent Psychotic Symptoms (BLIPS) in Individuals at Ultra High Risk

Adapting the early recognition inventory ERIraos to Estonian: A validation study

AIM

Validated assessment tools are needed to identify clinically high risk for psychosis. This study aimed to validate the early recognition inventory ERIraos, which consists of the ERIraos Checklist for risk screening and the ERIraos Symptom List for a more thorough risk assessment in the Estonian language to detect psychotic prodromal symptoms.

METHODS

A prospective cohort study provided an opportunity to evaluate the characteristics of the ERIraos instrument in predicting the increased risk of a psychotic disorder in the future. The 177 study participants, aged 13-42 years old, were divided into groups without an increased risk and three risk groups with different risk severity levels based on the ERIraos Symptom List assessment.

RESULTS

The results indicated excellent inter-rater reliability for the ERIraos Symptom List total score. The ability of the ERIraos checklist to screen persons with an elevated psychosis risk was very good (ROC-AUC = 0.86). The capability of the ERIraos Symptom List scores to predict the probability of transitioning to psychosis within 2 years was very good (ROC-AUC = 0.83). Brief limited intermittent psychotic symptoms and observable behavioural and affective symptoms were statistically significant predictors of transition to psychosis. There were strong and statistically significant correlations between the ERIraos Symptom List scores and other clinical measures assessing functioning and psychopathology.

CONCLUSIONS

The results of this study demonstrate the reliability and validity of the Estonian version of the ERIraos instrument and support the usability of ERIraos as a two-step tool for the early recognition of psychosis risk.

The Translational Future of Stress Neurobiology and Psychosis Vulnerability: A Review of the Evidence

Psychosocial stress is a well-established risk factor for psychosis, yet the neurobiological mechanisms underlying this relationship have yet to be fully elucidated. Much of the research in this field has investigated hypothalamic-pituitary-adrenal (HPA) axis function and immuno-inflammatory processes among individuals with established psychotic disorders. However, as such studies are limited in their ability to provide knowledge that can be used to develop preventative interventions, it is important to shift the focus to individuals with increased vulnerability for psychosis (i.e., high-risk groups). In the present article, we provide an overview of the current methods for identifying individuals at high-risk for psychosis and review the psychosocial stressors that have been most consistently associated with psychosis risk. We then describe a network of interacting physiological systems that are hypothesised to mediate the relationship between psychosocial stress and the manifestation of psychotic illness and critically review evidence that abnormalities within these systems characterise highrisk populations. We found that studies of high-risk groups have yielded highly variable findings, likely due to (i) the heterogeneity both within and across high-risk samples, (ii) the diversity of psychosocial stressors implicated in psychosis, and (iii) that most studies examine single markers of isolated neurobiological systems. We propose that to move the field forward, we require well-designed, largescale translational studies that integrate multi-domain, putative stress-related biomarkers to determine their prognostic value in high-risk samples. We advocate that such investigations are highly warranted, given that psychosocial stress is undoubtedly a relevant risk factor for psychotic disorders.

Identifying individuals at risk of developing psychosis: A systematic review of the literature in primary care services

AIM

Psychosis and related disorders are a major public health issue. Early identification and prevention for those at high risk (at-risk-mental-state, ARMS) is important. General practitioners (GPs) are often the first point of contact for health services. In this review we aim to identify (1) the most common methods for identifying individuals with an ARMS in primary care, (2) the methods for improving identification of individuals with an ARMS in primary care, and (3) the most common barriers that prevent GPs from screening for individuals with an ARMS.

METHODS

We conducted a systematic review (PROSPERO 42021245095) of quantitative and qualitative studies with no date restriction. Searches were performed in September 2021. Studies' quality was appraised using Mixed Methods Appraisal tool (MMAT).

RESULTS

We identified 16 eligible studies, and all but one provided quantitative data. Nearly two-thirds of studies were classified as 'medium' quality. Employing narrative synthesis, we identified three themes relating to (1) improving GP knowledge and confidence in identifying individuals with an ARMS, (2) balancing the over- and under-identification of individuals with an ARMS in primary care, and (3) supporting GPs as significant stakeholders in early diagnosis and treatment of individuals with an ARMS.

CONCLUSIONS

Improved identification of individuals with an ARMS is needed. We identified various strategies, including development and implementation of identification methods (e.g., screening measures), educational interventions for GPs (e.g., workshops), and systemic interventions (e.g., simplifying referrals to secondary care, developing integrated services). When implemented successfully, these interventions may help facilitate the access to appropriate care for individuals with an ARMS.

Parsing neurobiological heterogeneity of the clinical high-risk state for psychosis: A pseudo-continuous arterial spin labelling study

Introduction

The impact of the clinical high-risk for psychosis (CHR-P) construct is dependent on accurately predicting outcomes. Individuals with brief limited intermittent psychotic symptoms (BLIPS) have higher risk of developing a first episode of psychosis (FEP) compared to individuals with attenuated psychotic symptoms (APS). Supplementing subgroup stratification with information from candidate biomarkers based on neurobiological parameters, such as resting-state, regional cerebral blood flow (rCBF), may help refine risk estimates. Based on previous evidence, we hypothesized that individuals with BLIPS would exhibit increased rCBF compared to APS in key regions linked to dopaminergic pathways.

Methods

Data from four studies were combined using ComBat (to account for between-study differences) to analyse rCBF in 150 age- and sex-matched subjects (n = 30 healthy controls [HCs], n = 80 APS, n = 20 BLIPS and n = 20 FEP). Global gray matter (GM) rCBF was examined in addition to region-of-interest (ROI) analyses in bilateral/left/right frontal cortex, hippocampus and striatum. Group differences were assessed using general linear models: (i) alone; (ii) with global GM rCBF as a covariate; (iii) with global GM rCBF and smoking status as covariates. Significance was set at p < 0.05.

Results

Whole-brain voxel-wise analyses and Bayesian ROI analyses were also conducted. No significant group differences were found in global [F(3,143) = 1,41, p = 0.24], bilateral frontal cortex [F(3,143) = 1.01, p = 0.39], hippocampus [F(3,143) = 0.63, p = 0.60] or striatum [F(3,143) = 0.52, p = 0.57] rCBF. Similar null findings were observed in lateralized ROIs (p > 0.05). All results were robust to addition of covariates (p > 0.05). No significant clusters were identified in whole-brain voxel-wise analyses (p > 0.05FWE). Weak-to-moderate evidence was found for an absence of rCBF differences between APS and BLIPS in Bayesian ROI analyses.

Conclusion

On this evidence, APS and BLIPS are unlikely to be neurobiologically distinct. Due to this and the weak-to-moderate evidence for the null hypothesis, future research should investigate larger samples of APS and BLIPS through collaboration across large-scale international consortia.

Psychotic disorders as a framework for precision psychiatry

People with psychotic disorders can show marked interindividual variations in the onset of illness, responses to treatment and relapse, but they receive broadly similar clinical care. Precision psychiatry is an approach that aims to stratify people with a given disorder according to different clinical outcomes and tailor treatment to their individual needs. At present, interindividual differences in outcomes of psychotic disorders are difficult to predict on the basis of clinical assessment alone. Therefore, current research in psychosis seeks to build models that predict outcomes by integrating clinical information with a range of biological measures. Here, we review recent progress in the application of precision psychiatry to psychotic disorders and consider the challenges associated with implementing this approach in clinical practice.

Prevalence and incidence of psychotic disorders in 22q11.2 deletion syndrome: a meta-analysis

22q11.2 deletion syndrome (22q.11.2DS) might be one of the strongest genetic risk factors for psychosis, but robust estimates of prevalence and incidence of psychotic disorders in this condition are not available. To address this gap, we performed a multistep systematic PRISMA/MOOSE-compliant literature search of articles reporting prevalence (primary outcome) or incidence (secondary outcome) of psychotic disorders in 22q11.2DS samples (protocol: https://osf.io/w6hpg) using random-effects meta-analysis, subgroup analyses and meta-regressions. The pooled prevalence of psychotic disorders was 11.50% (95%CI:9.40-14.00%), largely schizophrenia (9.70%, 95%CI:6.50-14.20). Prevalence was significantly higher in samples with a mean age over 18 years, with both psychiatric and non-psychiatric comorbidities and recruited from healthcare services (compared to the community). Mean age was also significantly positively associated with prevalence in meta-regressions (p < 0.01). The pooled incidence of psychotic disorders was 10.60% (95%CI:6.60%-16.70%) at a mean follow-up time of 59.27 ± 40.55 months; meta-regressions were not significant. To our knowledge, this is the first comprehensive systematic review and meta-analysis of the prevalence and incidence of psychotic disorders in 22q11.2DS individuals. It demonstrates that around one in ten individuals with 22q11.2DS displays comorbid psychotic disorders, and around one in ten will develop psychosis in the following five years, indicating that preventive approaches should be implemented systematically in 22q11.2DS.

The predictive validity and outcome of ICD-10 and DSM-5 short-lived psychotic disorders: a review and meta-analysis

The ICD-10 Classification of Mental and Behavioural Disorders introduced the category of 'acute and transient psychotic disorders' (ATPDs) encompassing polymorphic, schizophrenic and predominantly delusional subtypes, and the forthcoming ICD-11 revision has restricted it to polymorphic psychotic disorder, while the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) listed 'brief psychotic disorder' (BPD). To assess the predictive validity and outcome of ATPDs and BPD, relevant papers in English, French and German were searched in PubMed and Web of Science. Where possible meta-analysis of prognostic validators (diagnostic stability, course, outcome and response to treatment) was conducted. Fifty studies published between January 1993 and July 2019 were found. The clinical and functional outcome of ATPDs proved better than in schizophrenia and related disorders, but mortality risk is high, particularly suicide, and treatment trials provide little evidence. Meta-analysis of 25 studies (13,507 cases) revealed that 55% (95% CI 49-62) do not change diagnosis, 25% (95% CI 20-31) converted into schizophrenia and related disorders, and 12% (95% CI 7-16) into affective disorders on average over 6.3 years. Subgroup meta-analysis estimated prospective consistency of polymorphic psychotic disorder (55%; 95% CI 52-58) significantly greater than that of the ATPD subtypes with schizophrenic (OR 1.7; 95% CI 1.4-2.0) and predominantly delusional (OR 1.3; 95% CI 1.1-1.5) symptoms. Moreover, the diagnostic stability of BPD (13 studies; 294 cases) was 45% (95% CI 32-50) over a mean 4.2 years. Although these findings indicate that short-lived psychotic disorders have little predictive validity, significant differences among the ATPD subtypes support the revised ICD-11 ATPD category.

Examining the variability of neurocognitive functioning in individuals at clinical high risk for psychosis: a meta-analysis

This study aims to meta-analytically characterize the presence and magnitude of within-group variability across neurocognitive functioning in young people at Clinical High-Risk for psychosis (CHR-P) and comparison groups. Multistep, PRISMA/MOOSE-compliant systematic review (PROSPERO-CRD42020192826) of the Web of Science database, Cochrane Central Register of Reviews and Ovid/PsycINFO and trial registries up to July 1, 2020. The risk of bias was assessed using a modified version of the NOS for cohort and cross-sectional studies. Original studies reporting neurocognitive functioning in individuals at CHR-P compared to healthy controls (HC) or first-episode psychosis (FEP) patients were included. The primary outcome was the random-effect meta-analytic variability ratios (VR). Secondary outcomes included the coefficient of variation ratios (CVR). Seventy-eight studies were included, relating to 5162 CHR-P individuals, 2865 HC and 486 FEP. The CHR-P group demonstrated higher variability compared to HC (in descending order of magnitude) in visual memory (VR: 1.41, 95% CI 1.02-1.94), executive functioning (VR: 1.31, 95% CI 1.18-1.45), verbal learning (VR: 1.29, 95% CI 1.15-1.45), premorbid IQ (VR: 1.27, 95% CI 1.09-1.49), processing speed (VR: 1.26, 95% CI 1.07-1.48), visual learning (VR: 1.20, 95% CI 1.07-1.34), and reasoning and problem solving (VR: 1.17, 95% CI 1.03-1.34). In the CVR analyses the variability in CHR-P population remains in the previous neurocognitive domains and emerged in attention/vigilance, working memory, social cognition, and visuospatial ability. The CHR-P group transitioning to psychosis showed greater VR in executive functioning compared to those not developing psychosis and compared to FEP groups. Clinical high risk for psychosis subjects shows increased variability in neurocognitive performance compared to HC. The main limitation of this study is the validity of the VR and CVR as an index of variability which has received debate. This finding should be explored by further individual-participant data research and support precision medicine approaches.

Schizophrenia

Schizophrenia, characterised by psychotic symptoms and in many cases social and occupational decline, remains an aetiological and therapeutic challenge. Contrary to popular belief, the disorder is modestly more common in men than in women. Nor is the outcome uniformly poor. A division of symptoms into positive, negative, and disorganisation syndromes is supported by factor analysis. Catatonic symptoms are not specific to schizophrenia and so-called first rank symptoms are no longer considered diagnostically important. Cognitive impairment is now recognised as a further clinical feature of the disorder. Lateral ventricular enlargement and brain volume reductions of around 2% are established findings. Brain functional changes occur in different subregions of the frontal cortex and might ultimately be understandable in terms of disturbed interaction among large-scale brain networks. Neurochemical disturbance, involving dopamine function and glutamatergic N-methyl-D-aspartate receptor function, is supported by indirect and direct evidence. The genetic contribution to schizophrenia is now recognised to be largely polygenic. Birth and early life factors also have an important aetiological role. The mainstay of treatment remains dopamine receptor-blocking drugs; a psychological intervention, cognitive behavioural therapy, has relatively small effects on symptoms. The idea that schizophrenia is better regarded as the extreme end of a continuum of psychotic symptoms is currently influential. Other areas of debate include cannabis and childhood adversity as causative factors, whether there is progressive brain change after onset, and the long-term success of early intervention initiatives.

Clinical outcomes in individuals at clinical high risk of psychosis who do not transition to psychosis: a meta-analysis

AIMS

The clinical outcomes of individuals at clinical high risk of psychosis (CHR-P) who do not transition to psychosis are heterogeneous and inconsistently reported. We aimed to comprehensively evaluate longitudinally a wide range of outcomes in CHR-P individuals not developing psychosis.

METHODS

"Preferred Reporting Items for Systematic reviews and Meta-Analyses" and "Meta-analysis Of Observational Studies in Epidemiology"-compliant meta-analysis (PROSPERO: CRD42021229212) searching original CHR-P longitudinal studies in PubMed and Web of Science databases up to 01/11/2021. As primary analysis, we evaluated the following outcomes within CHR-P non-transitioning individuals: (a) change in the severity of attenuated psychotic symptoms (Hedge's g); (b) change in the severity of negative psychotic symptoms (Hedge's g); (c) change in the severity of depressive symptoms (Hedge's g); (d) change in the level of functioning (Hedge's g); (e) frequency of remission (at follow-up). As a secondary analysis, we compared these outcomes in those CHR-P individuals who did not transition vs. those who did transition to psychosis at follow-up. We conducted random-effects model meta-analyses, sensitivity analyses, heterogeneity analyses, meta-regressions and publication bias assessment. The risk of bias was assessed using a modified version of the Newcastle-Ottawa Scale (NOS).

RESULTS

Twenty-eight studies were included (2756 CHR-P individuals, mean age = 20.4, 45.5% females). The mean duration of follow-up of the included studies was of 30.7 months. Primary analysis: attenuated psychotic symptoms [Hedges' g = 1.410, 95% confidence interval (CI) 1.002-1.818]; negative psychotic symptoms (Hedges' g = 0.683, 95% CI 0.371-0.995); depressive symptoms (Hedges' g = 0.844, 95% CI 0.371-1.317); and functioning (Hedges' g = 0.776, 95% CI 0.463-1.089) improved in CHR-P non-transitioning individuals; 48.7% remitted at follow-up (95% CI 39.3-58.2%). Secondary analysis: attenuated psychotic symptoms (Hedges' g = 0.706, 95% CI 0.091-1.322) and functioning (Hedges' g = 0.623, 95% CI 0.375-0.871) improved in CHR-P individuals not-transitioning compared to those transitioning to psychosis, but there were no differences in negative or depressive symptoms or frequency of remission (p > 0.05). Older age was associated with higher improvements of attenuated psychotic symptoms (β = 0.225, p = 0.012); publication years were associated with a higher improvement of functioning (β = -0.124, p = 0.0026); a lower proportion of Brief Limited Intermittent Psychotic Symptoms was associated with higher frequencies of remission (β = -0.054, p = 0.0085). There was no metaregression impact for study continent, the psychometric instrument used, the quality of the study or proportion of females. The NOS scores were 4.4 ± 0.9, ranging from 3 to 6, revealing the moderate quality of the included studies.

CONCLUSIONS

Clinical outcomes improve in CHR-P individuals not transitioning to psychosis but only less than half remit over time. Sustained clinical attention should be provided in the longer term to monitor these outcomes.

Mapping the implementation and challenges of clinical services for psychosis prevention in England

INTRODUCTION

Indicated primary prevention of psychosis is recommended by NICE clinical guidelines, but implementation research on Clinical High Risk for Psychosis (CHR-P) services is limited.

METHODS

Electronic audit of CHR-P services in England, conducted between June and September 2021, addressing core implementation domains: service configuration, detection of at-risk individuals, prognostic assessment, clinical care, clinical research, and implementation challenges, complemented by comparative analyses across service model. Descriptive statistics, Fisher's exact test and Mann-Whitney U-tests were employed.

RESULTS

Twenty-four CHR-P clinical services (19 cities) were included. Most (83.3%) services were integrated within other mental health services; only 16.7% were standalone. Across 21 services, total yearly caseload of CHR-P individuals was 693 (average: 33; range: 4-115). Most services (56.5%) accepted individuals aged 14-35; the majority (95.7%) utilized the Comprehensive Assessment of At Risk Mental States (CAARMS). About 65% of services reported some provision of NICE-compliant interventions encompassing monitoring of mental state, cognitive-behavioral therapy (CBT), and family interventions. However, only 66.5 and 4.9% of CHR-P individuals actually received CBT and family interventions, respectively. Core implementation challenges included: recruitment of specialized professionals, lack of dedicated budget, and unmet training needs. Standalone services reported fewer implementation challenges, had larger caseloads (p = 0.047) and were more likely to engage with clinical research (p = 0.037) than integrated services.

DISCUSSION

While implementation of CHR-P services is observed in several parts of England, only standalone teams appear successful at detection of at-risk individuals. Compliance with NICE-prescribed interventions is limited across CHR-P services and unmet needs emerge for national training and investments.

Clinical characterization of brief psychotic disorders triggered by the COVID-19 pandemic: a multicenter observational study

This study aimed to characterize the clinical profile of patients with brief psychotic disorders (BPD) triggered by the psychosocial distress derived from the COVID-19 crisis. A multicenter study was conducted from March 14 to May 14, 2020 (the peak weeks of the pandemic in Europe). All consecutive patients presenting non-affective psychotic episodes with a duration of untreated psychosis of less than 1 month and whose onset was related to the COVID-19 crisis were recruited, but only those patients meeting Diagnostic Statistical Manual 5th edition (DSM-5) criteria for "BPD with marked stressors" (DSM-5 code: 298.8) during follow-up were finally included. Patients' sociodemographic and clinical characteristics were collected at baseline and summarized with descriptive statistics. During the study period, 57 individuals with short-lived psychotic episodes related to the emotional stress of the COVID-19 pandemic were identified, of whom 33 met DSM-5 criteria for "BPD with marked stressors". The mean age was 42.33 ± 14.04 years, the gender distribution was almost the same, and the majority were rated as having good premorbid adjustment. About a quarter of the patients exhibited suicidal symptoms and almost half presented first-rank schizophrenia symptoms. None of them were COVID-19 positive, but in more than half of the cases, the topic of their psychotic features was COVID-19-related. The coronavirus pandemic is triggering a significant number of BPD cases. Their risk of suicidal behavior, their high relapse rate, and their low temporal stability make it necessary to closely monitor these patients over time.

Diagnosis, prognosis, and treatment of brief psychotic episodes: a review and research agenda

Brief psychotic episodes represent an intriguing paradox in clinical psychiatry because they elude the standard knowledge that applies to the persisting psychotic disorders such as schizophrenia. This Review describes key diagnostic considerations such as conceptual foundations, current psychiatric classification versus research-based operationalisations, epidemiology, and sociocultural variations; prognostic aspects including the risk of psychosis recurrence, types of psychotic recurrences, other clinical outcomes, prognostic factors; and therapeutic issues such as treatment guidelines and unmet need of care. The advances and challenges associated with the scientific evidence are used to set a research agenda in this area. We conclude that brief psychotic episodes can be reconceptualised within a clinical staging model to promote innovative translational research and improve our understanding and treatment of psychotic disorders.

Identifying Electroencephalography Biomarkers in Individuals at Clinical High Risk for Psychosis in an International Multi-Site Study

BACKGROUND

The clinical high-risk for psychosis (CHR-P) paradigm was introduced to detect individuals at risk of developing psychosis and to establish preventive strategies. While current prediction of outcomes in the CHR-P state is based mostly on the clinical assessment of presenting features, several emerging biomarkers have been investigated in an attempt to stratify CHR-P individuals according to their individual trajectories and refine the diagnostic process. However, heterogeneity across subgroups is a key challenge that has limited the impact of the CHR-P prediction strategies, as the clinical validity of the current research is limited by a lack of external validation across sites and modalities. Despite these challenges, electroencephalography (EEG) biomarkers have been studied in this field and evidence suggests that EEG used in combination with clinical assessments may be a key measure for improving diagnostic and prognostic accuracy in the CHR-P state. The PSYSCAN EEG study is an international, multi-site, multimodal longitudinal project that aims to advance knowledge in this field.

METHODS

Participants at 6 international sites take part in an EEG protocol including EEG recording, cognitive and clinical assessments. CHR-P participants will be followed up after 2 years and subcategorised depending on their illness progression regarding transition to psychosis. Differences will be sought between CHR-P individuals and healthy controls and between CHR-P individuals who transition and those who do not transition to psychosis using data driven computational analyses.

DISCUSSION

This protocol addresses the challenges faced by previous studies of this kind to enable valid identification of predictive EEG biomarkers which will be combined with other biomarkers across sites to develop a prognostic tool in CHR-P. The PSYSCAN EEG study aims to pave the way for incorporating EEG biomarkers in the assessment of CHR-P individuals, to refine the diagnostic process and help to stratify CHR-P subjects according to risk of transition. This may improve our understanding of the CHR-P state and therefore aid the development of more personalized treatment strategies.

Timing of antipsychotics and benzodiazepine initiation during a first episode of psychosis impacts clinical outcomes: Electronic health record cohort study

The impact of timing of antipsychotics and benzodiazepine treatment during a first episode of psychosis on clinical outcomes is unknown. We present a RECORD-compliant electronic health record cohort study including patients (n = 4,483, aged 14-35) with a primary diagnosis of any non-organic ICD-10 first episode of psychosis at SLAM-NHS between 2007 and 2017. The impact of antipsychotic timing (prescription > 1 week after a first episode of psychosis) was assessed on the primary outcome (risk of any psychiatric inpatient admission over 6 years), and secondary outcomes (cumulative duration of any psychiatric/medical/accident/emergency [A&E] admission over 6 years). The impact of prescribing benzodiazepine before antipsychotic at any point and of treatment patterns (antipsychotic alone, benzodiazepine alone, combination of antipsychotic with benzodiazepine) within the first week after a first episode of psychosis were also assessed. Survival analyses and zero-inflated negative binomial regressions, adjusted for core covariates, and complementary analyses were employed. Antipsychotic prescribed >1 week after a first episode of psychosis did not affect the risk of any psychiatric admission (HR = 1.04, 95% CI = 0.92-1.17, p = 0.557), but increased the duration of any psychiatric (22-28%), medical (78-35%) and A&E (30-34%) admission (months 12-72). Prescribing benzodiazepine before antipsychotic at any point did not affect the risk of any psychiatric admission (HR = 1.03, 95% CI = 0.94-1.13, p = 0.535), but reduced the duration of any psychiatric admission (17-24%, months 12-72), and increased the duration of medical (71-45%, months 12-72) and A&E (26-18%, months 12-36) admission. Prescribing antipsychotic combined with benzodiazepine within the first week after a first episode of psychosis showed better overall clinical outcomes than antipsychotic or benzodiazepine alone. Overall, delaying antipsychotic 1 week after a first episode of psychosis may worsen some clinical outcomes. Early benzodiazepine treatment can be considered with concomitant antipsychotic but not as standalone intervention.

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.

Predictors of diagnostic stability in brief psychotic disorders: Findings from a 3-year longitudinal study

INTRODUCTION

Brief psychotic disorder (BPD) is a relatively uncommon and underexplored psychotic condition. Even though BPD has been related to a more favorable outcome than other schizophrenia spectrum disorders (SSD), current knowledge of its predictive factors remains scant. This study aimed to examine its prevalence and find early predictors of BPD diagnostic stability.

METHODS

SSD diagnosis following Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria was explored in a large epidemiological cohort (n = 569) of non-affective first-episode psychosis (FEP) patients enrolled in a three-year longitudinal intervention program (PAFIP). Premorbid, sociodemographic, and clinical information was collected to characterize BPD patients and determine factors predictive of diagnostic stability. Multivariate analysis included predictors selected from clinical knowledge and also those that had achieved marginal significance (p ≤ 0.1) in univariate analysis.

RESULTS

A total of 59 patients enrolled in the PAFIP program (10.4% of the whole cohort) met DSM-IV criteria for BPD, of whom 40 completed the three-year follow-up. The temporal stability of BPD in our sample was as high as 40% (n = 16). Transition from BPD to schizophrenia occurred in 37% (n = 15) of patients. Fewer hallucinations at baseline and better insight independently significantly predicted BPD diagnostic stability over time.

CONCLUSION

Our findings confirm that BPD is a clinical condition with moderate-to-low temporal stability and demonstrate that approximately two-thirds of FEP individuals experiencing BPD will develop a long-lasting psychotic disorder during follow-up, mainly schizophrenia.

Clinical outcomes in brief psychotic episodes: a systematic review and meta-analysis

AIMS

Patients with brief psychotic episodes (BPE) have variable and fluctuating clinical outcomes which challenge psychiatric care. Our meta-analysis aims at providing a comprehensive summary of several clinical outcomes in this patient group.

METHODS

A multistep systematic PRISMA/MOOSE-compliant literature search was performed for articles published from inception until 1st March 2021. Web of Science database was searched, complemented by manual search of original articles reporting relevant outcomes (psychotic recurrence, prospective diagnostic change or stability, remission, quality of life, functional status, mortality and their predictors) for patients diagnosed with acute and transient psychotic disorders (ATPD), brief psychotic disorders (BPD), brief intermittent psychotic symptoms (BIPS) and brief limited intermittent psychotic symptoms (BLIPS). Random-effects methods and Q-statistics were employed, quality assessment with Newcastle-Ottawa Scale, assessment of heterogeneity with I2 index, sensitivity analyses (acute polymorphic psychotic disorders, APPD) and multiple meta-regressions, assessment of publication bias with funnel plot, Egger's test and meta-regression (psychotic recurrence and sample size).

RESULTS

A total of 91 independent articles (n = 94 samples) encompassed 37 ATPD, 24 BPD, 19 BLIPS and 14 BIPS samples, totalling 15 729 individuals (mean age: 30.89 ± 7.33 years, mean female ratio: 60%, 59% conducted in Europe). Meta-analytical risk of psychotic recurrence for all BPE increased from 15% (95% confidence interval (CI) 12-18) at 6 months, 25% (95% CI 22-30) at 12 months, 30% (95% CI 27-33) at 24 months and 33% (95% CI 30-37) at ⩾36 months follow-up, with no differences between ATPD, BPD, BLIPS and BIPS after 2 years of follow-up. Across all BPE, meta-analytical proportion of prospective diagnostic stability (average follow-up 47 months) was 49% (95% CI 42-56); meta-analytical proportion of diagnostic change (average follow-up 47 months) to schizophrenia spectrum psychoses was 19% (95% CI 16-23), affective spectrum psychoses 5% (95% CI 3-7), other psychotic disorders 7% (95% CI 5-9) and other (non-psychotic) mental disorders 14% (95% CI 11-17). Prospective diagnostic change within APPD without symptoms of schizophrenia was 34% (95% CI 24-46) at a mean follow-up of 51 months: 18% (95% CI 11-30) for schizophrenia spectrum psychoses and 17% (95% CI 10-26) for other (non-psychotic) mental disorders. Meta-analytical proportion of baseline employment was 48% (95% CI 38-58), whereas there were not enough data to explore the other outcomes. Heterogeneity was high; female ratio and study quality were negatively and positively associated with risk of psychotic recurrence, respectively. There were no consistent factor predicting clinical outcomes.

CONCLUSIONS

Short-lived psychotic episodes are associated with a high risk of psychotic recurrences, in particular schizophrenia spectrum disorders. Other clinical outcomes remain relatively underinvestigated. There are no consistent prognostic/predictive factors.

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.

Developing and Validating an Individualized Clinical Prediction Model to Forecast Psychotic Recurrence in Acute and Transient Psychotic Disorders: Electronic Health Record Cohort Study

Acute and transient psychotic disorders (ATPDs) include short-lived psychotic episodes with a high probability of developing psychotic recurrences. Clinical care for ATPD is currently limited by the inability to predict outcomes. Real-world electronic health record (EHR)-based retrospective cohort study STROBE/RECORD compliant included all individuals accessing the South London and Maudsley NHS Trust between 2006 and 2017 and receiving a first diagnosis of ATPD (F23, ICD-10). After imputing missing data, stepwise and LASSO Cox regression methods employing a priori predictors (n = 23) were compared to develop and internally validate an individualized risk prediction model to forecast the risk of psychotic recurrences following TRIPOD guidelines. The primary outcome was prognostic accuracy (area under the curve [AUC]). 3018 ATPD individuals were included (average age = 33.75 years, 52.7% females). Over follow-up (average 1042 ± 1011 days, up to 8 years) there were 1160 psychotic recurrences (events). Stepwise (n = 12 predictors) and LASSO (n = 17 predictors) regression methods yielded comparable prognostic accuracy, with an events per variable ratio >100 for both models. Both models showed an internally validated adequate prognostic accuracy from 4 years follow-up (AUC 0.70 for both models) and good calibration. A refined model was adapted in view of the new ICD-11 criteria on 307 subjects with polymorphic ATPD, showing fair prognostic accuracy at 4 years (AUC: stepwise 0.68; LASSO 0.70). This study presents the first clinically based prediction model internally validated to adequately predict long-term psychotic recurrence in individuals with ATPD. The model can be automatable in EHRs, supporting further external validations and refinements to improve its prognostic accuracy.

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.

Probability of Transition to Psychosis in Individuals at Clinical High Risk: An Updated Meta-analysis

IMPORTANCE

Estimating the current likelihood of transitioning from a clinical high risk for psychosis (CHR-P) to psychosis holds paramount importance for preventive care and applied research.

OBJECTIVE

To quantitatively examine the consistency and magnitude of transition risk to psychosis in individuals at CHR-P.

DATA SOURCES

PubMed and Web of Science databases until November 1, 2020. Manual search of references from previous articles.

STUDY SELECTION

Longitudinal studies reporting transition risks in individuals at CHR-P.

DATA EXTRACTION AND SYNTHESIS

Meta-analysis compliant with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) and Meta-analysis of Observational Studies in Epidemiology (MOOSE) reporting guidelines; independent data extraction, manually and through digitalization of Kaplan-Meier curves.

MAIN OUTCOME AND MEASURES

Primary effect size was cumulative risk of transition to psychosis at 0.5, 1, 1.5, 2, 2.5, 3, 4, and more than 4 years' follow-up, estimated using the numbers of individuals at CHR-P transitioning to psychosis at each time point. These analyses were complemented by meta-analytical Kaplan-Meier curves and speed of transition to psychosis (hazard rate). Random-effects meta-analysis, between-study heterogeneity analysis, study quality assessment, and meta-regressions were conducted.

RESULTS

A total of 130 studies and 9222 individuals at CHR-P were included. The mean (SD) age was 20.3 (4.4) years, and 5100 individuals (55.3%) were male. The cumulative transition risk was 0.09 (95% CI, 0.07-0.10; k = 37; n = 6485) at 0.5 years, 0.15 (95% CI, 0.13-0.16; k = 53; n = 7907) at 1 year, 0.20 (95% CI, 0.17-0.22; k = 30; n = 5488) at 1.5 years, 0.19 (95% CI, 0.17-0.22; k = 44; n = 7351) at 2 years, 0.25 (95% CI, 0.21-0.29; k = 19; n = 3114) at 2.5 years, 0.25 (95% CI, 0.22-0.29; k = 29; n = 4029) at 3 years, 0.27 (95% CI, 0.23-0.30; k = 16; n = 2926) at 4 years, and 0.28 (95% CI, 0.20-0.37; k = 14; n = 2301) at more than 4 years. The cumulative Kaplan-Meier transition risk was 0.08 (95% CI, 0.08-0.09; n = 4860) at 0.5 years, 0.14 (95% CI, 0.13-0.15; n = 3408) at 1 year, 0.17 (95% CI, 0.16-0.19; n = 2892) at 1.5 years, 0.20 (95% CI, 0.19-0.21; n = 2357) at 2 years, 0.25 (95% CI, 0.23-0.26; n = 1444) at 2.5 years, 0.27 (95% CI, 0.25-0.28; n = 1029) at 3 years, 0.28 (95% CI, 0.26-0.29; n = 808) at 3.5 years, 0.29 (95% CI, 0.27-0.30; n = 737) at 4 years, and 0.35 (95% CI, 0.32-0.38; n = 114) at 10 years. The hazard rate only plateaued at 4 years' follow-up. Meta-regressions showed that a lower proportion of female individuals (β = -0.02; 95% CI, -0.04 to -0.01) and a higher proportion of brief limited intermittent psychotic symptoms (β = 0.02; 95% CI, 0.01-0.03) were associated with an increase in transition risk. Heterogeneity across the studies was high (I2 range, 77.91% to 95.73%).

CONCLUSIONS AND RELEVANCE

In this meta-analysis, 25% of individuals at CHR-P developed psychosis within 3 years. Transition risk continued increasing in the long term. Extended clinical monitoring and preventive care may be beneficial in this patient population.

Transition to psychosis in randomized clinical trials of individuals at clinical high risk of psychosis compared to observational cohorts: a systematic review and meta-analysis

BACKGROUND

Individuals at clinical high risk of psychosis (CHR-P) recruited in randomized clinical trials (RCTs) and observational cohorts may display a different enrichment and hence risk of transition to psychosis. No meta-analysis has ever addressed this issue.

METHODS

"Preferred Reporting Items for Systematic reviews and Meta-Analyses" (PRISMA) and "Meta-analysis Of Observational Studies in Epidemiology" (MOOSE)-compliant meta-analysis. PubMed and Web of Science were searched until November 2020 (PROSPERO:CRD42021229223). We included nonoverlapping longitudinal studies (RCTs-control condition and observational cohorts) reporting the transition to psychosis in CHR-P individuals. The primary effect size measure was the cumulative risk of transition at 0.5, 1, and 2 years follow-up in RCTs compared to observational cohorts. Random effects meta-analyses, heterogeneity assessment, quality assessment, and meta-regressions were conducted.

RESULTS

Ninety-four independent studies (24 RCTs, 70 observational cohorts) and 9,243 individuals (mean age = 20.1 ± 3.0 years; 43.7% females) were included. The meta-analytical risk of transitioning to psychosis from a CHR-P stage was 0.091 (95% confidence intervals [CI] = 0.068-0.121) at 0.5 years, 0.140 (95% CI = 0.101-0.191) at 1 year and 0.165 (95% CI = 0.097-0.267) at 2 years follow-up in RCTs, and 0.081 (95% CI = 0.067-0.099) at 0.5 years, 0.138 (95% CI = 0.114-0.167) at 1 year, and 0.174 (95% CI = 0.156-0.193) at 2 years follow-up in observational cohorts. There were no between-group differences in transition risks (p > 0.05). The proportion of CHR-P individuals with substance use disorders (excluding alcohol and cannabis) was higher in observational cohorts (16.8, 95% CI = 13.3-21.0%) than in RCTs (3.4, 95% CI = 0.8-12.7%; p = 0.018).

CONCLUSIONS

There is no meta-analytic evidence supporting sampling biases in RCTs of CHR-P individuals. Further RCTs are needed to detect effective interventions to prevent psychosis in this at-risk group.

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.

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.

Prognostic significance of psychotic relapse in patients with first-episode acute and transient psychosis: New empirical support for ICD-11

This study examined the impact of psychotic relapse on the diagnostic stability of acute and transient psychotic disorders (ATPD), and how this potential risk factor could differentiate 'acute polymorphic psychotic disorder without symptoms of schizophrenia' (APPD; ICD-10 code F23.0) from the remaining non-APPD subtypes (F23.1-9). A two-year cohort study was performed on 68 patients with first-episode ATPD. At the end of follow-up, the diagnostic stability of ATPD was 55.9% and the overall rate of psychotic relapse was 61.8%. Statistical analysis showed that recurrence was an independent risk factor for diagnostic shift in ATPDs (relative risk [RR] = 1.67, 95% confidence interval [CI] = 1.17-2.39; p = 0.005) and that this risk differed among their subtypes insofar as its appearance significantly increased the likelihood of diagnostic change in patients with non-APPD subtypes (RR = 2.52, 95% CI = 1.56-4.07; p < 0.001), but not in those with APPD (RR = 0.95, 95% CI = 0.57-1.57; p = 0.844). Our findings confirm the negative implications of recurrence in patients with ATPD, encourage long-term intervention targeting relapse prevention in this population, and provide new empirical evidence in support of narrowing the ATPD category to APPD in the upcoming ICD-11.

Annual Research Review: Prevention of psychosis in adolescents - systematic review and meta-analysis of advances in detection, prognosis and intervention

BACKGROUND

The clinical high-risk state for psychosis (CHR-P) paradigm has facilitated the implementation of psychosis prevention into clinical practice; however, advancements in adolescent CHR-P populations are less established.

METHODS

We performed a PRISMA/MOOSE-compliant systematic review of the Web of Science database, from inception until 7 October 2019, to identify original studies conducted in CHR-P children and adolescents (mean age <18 years). Findings were systematically appraised around core themes: detection, prognosis and intervention. We performed meta-analyses (employing Q statistics and I ² test) regarding the proportion of CHR-P subgroups, the prevalence of baseline comorbid mental disorders, the risk of psychosis onset and the type of interventions received at baseline. Quality assessment and publication bias were also analysed.

RESULTS

Eighty-seven articles were included (n = 4,667 CHR-P individuals). Quality of studies ranged from 3.5 to 8 (median 5.5) on a modified Newcastle-Ottawa scale. Detection: Individuals were aged 15.6 ± 1.2 years (51.5% males), mostly (83%) presenting with attenuated positive psychotic symptoms. CHR-P psychometric accuracy improved when caregivers served as additional informants. Comorbid mood (46.4%) and anxiety (31.4%) disorders were highly prevalent. Functioning and cognition were impaired. Neurobiological studies were inconclusive.

PROGNOSIS

Risk for psychosis was 10.4% (95%CI: 5.8%-18.1%) at 6 months, 20% (95%CI: 15%-26%) at 12 months, 23% (95%CI: 18%-29%) at 24 months and 23.3% (95%CI: 17.3%-30.7%) at ≥36 months.

INTERVENTIONS

There was not enough evidence to recommend one specific treatment (including cognitive behavioural therapy) over the others (including control conditions) to prevent the transition to psychosis in this population. Randomised controlled trials suggested that family interventions, cognitive remediation and fish oil supplementation may improve cognition, symptoms and functioning. At baseline, 30% of CHR-P adolescents were prescribed antipsychotics and 60% received psychotherapy.

CONCLUSIONS

It is possible to detect and formulate a group-level prognosis in adolescents at risk for psychosis. Future interventional research is required.

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

Third external replication of an individualised transdiagnostic prediction model for the automatic detection of individuals at risk of psychosis using electronic health records

BACKGROUND

Primary indicated prevention is a key target for reducing the incidence and burden of schizophrenia and related psychotic disorders. An individualised, clinically-based transdiagnostic model for the detection of individuals at risk of psychosis has been developed and validated in two large, urban healthcare providers. We tested its external validity in a geographically and demographically different non-urban population.

METHOD

Retrospective EHR cohort study. All individuals accessing secondary healthcare provided by Oxford Health NHS Foundation Trust between 1st January 2011 and 30th November 2019 and receiving a primary index diagnosis of a non-psychotic or non-organic mental disorder were considered eligible. The previously developed model was applied to this database and its external prognostic accuracy was measured with Harrell's C.

FINDINGS

The study included n = 33,710 eligible individuals, with an average age of 27.7 years (SD = 19.8), mostly white (92.0%) and female (57.3%). The mean follow-up was 1863.9 days (SD = 948.9), with 868 transitions to psychosis and a cumulative incidence of psychosis at 6 years of 2.9% (95%CI: 2.7-3.1). Compared to the urban development database, Oxford Health was characterised by a relevant case mix, lower incidence of psychosis, different distribution of baseline predictors, higher proportion of white females, and a lack of specialised clinical services for at risk individuals. Despite these differences the model retained an adequate prognostic performance (Harrell's C = 0.79, 95%CI: 0.78-0.81), with no major miscalibration.

INTERPRETATION

The transdiagnostic, individualised, clinically-based risk calculator is transportable outside urban healthcare providers. Further research should test transportability of this risk prediction model in an international setting.

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.

Real-world digital implementation of the Psychosis Polyrisk Score (PPS): A pilot feasibility study

BACKGROUND

The Psychosis Polyrisk Score (PPS) is a potential biomarker integrating non-purely genetic risk/protective factors for psychosis that may improve identification of individuals at risk and prediction of their outcomes at the individual subject level. Biomarkers that are easy to administer are direly needed in early psychosis to facilitate clinical implementation. This study digitally implements the PPS and pilots its feasibility of use in the real world.

METHODS

The PPS was implemented digitally and prospectively piloted across individuals referred for a CHR-P assessment (n = 16) and healthy controls (n = 66). Distribution of PPS scores was further simulated in the general population.

RESULTS

98.8% of individuals referred for a CHR-P assessment and healthy controls completed the PPS assessment with only one drop-out. 96.3% of participants completed the assessment in under 15 min. Individuals referred for a CHR-P assessment had high PPS scores (mean = 6.2, SD = 7.23) than healthy controls (mean = -1.79, SD = 6.78, p < 0.001). In simulated general population data, scores were normally distributed ranging from -15 (lowest risk, RR = 0.03) to 39.5 (highest risk, RR = 8912.51).

DISCUSSION

The PPS is a promising biomarker which has been implemented digitally. The PPS can be easily administered to both healthy controls and individuals at potential risk for psychosis on a range of devices. It is feasible to use the PPS in real world settings to assess individuals with emerging mental disorders. The next phase of research should be to include the PPS in large-scale international cohort studies to evaluate its ability to refine the prognostication of outcomes.

Worldwide implementation of clinical services for the prevention of psychosis: The IEPA early intervention in mental health survey

BACKGROUND

Clinical research into the Clinical High Risk state for Psychosis (CHR-P) has allowed primary indicated prevention in psychiatry to improve outcomes of psychotic disorders. The strategic component of this approach is the implementation of clinical services to detect and take care of CHR-P individuals, which are recommended by several guidelines. The actual level of implementation of CHR-P services worldwide is not completely clear.

AIM

To assess the global geographical distribution, core characteristics relating to the level of implementation of CHR-P services; to overview of the main barriers that limit their implementation at scale.

METHODS

CHR-P services worldwide were invited to complete an online survey. The survey addressed the geographical distribution, general implementation characteristics and implementation barriers.

RESULTS

The survey was completed by 47 CHR-P services offering care to 22 248 CHR-P individuals: Western Europe (51.1%), North America (17.0%), East Asia (17.0%), Australia (6.4%), South America (6.4%) and Africa (2.1%). Their implementation characteristics included heterogeneous clinical settings, assessment instruments and length of care offered. Most CHR-P patients were recruited through mental or physical health services. Preventive interventions included clinical monitoring and crisis management (80.1%), supportive therapy (70.2%) or structured psychotherapy (61.7%), in combination with pharmacological treatment (in 74.5%). Core implementation barriers were staffing and financial constraints, and the recruitment of CHR-P individuals. The dynamic map of CHR-P services has been implemented on the IEPA website: https://iepa.org.au/list-a-service/.

CONCLUSIONS

Worldwide primary indicated prevention of psychosis in CHR-P individuals is possible, but the implementation of CHR-P services is heterogeneous and constrained by pragmatic challenges.

Outreach and support in South-London (OASIS) 2001-2020: Twenty years of early detection, prognosis and preventive care for young people at risk of psychosis

This study aims to describe twenty years of early detection, prognosis and preventive care in the Outreach and Support In South-London (OASIS) mental health service for individuals at Clinical High risk of psychosis (CHR-P). The study presents a comprehensive analysis of the 2001- 2020 activity of the OASIS team encompassing core domains: (i) service characteristics, (ii) detection, (iii) prognosis, (iv) treatment and (v) clinical research. The analyses employed descriptive statistics, population-level data, the epidemiological incidence of psychosis, Kaplan Meier failure functions and Greenwood 95% CIs and Electronic Health Records. OASIS is part of the South London and Maudsley (SLaM) NHS trust, the largest European mental health provider, serving a total urban population of 1,358,646 individuals (population aged 16-35: 454,525). Incidence of psychosis in OASIS's catchment area ranges from 58.3 to 71.9 cases per 100,000 person-years, and it is higher than the national average of 41.5 cases per 100,000 person-year. OASIS is a standalone, NHS-funded, multidisciplinary (team leader, consultant and junior psychiatrists, clinical psychologists, mental health professionals), transitional (for those aged 14-35 years) community mental health service with a yearly caseload of 140 CHR-P individuals. OASIS regularly delivers a comprehensive service promotion outreach to several local community organisations. Referrals to OASIS (2366) are made by numerous agencies; about one-third of the referrals eventually met CHR-P criteria. Overall, 600 CHR-P individuals (55.33% males, mean age 22.63 years, white ethnicity 46.44%) have been under the care of the OASIS service: 80.43% met attenuated psychotic symptoms, 18.06% brief and limited intermittent psychotic symptoms and 1.51% genetic risk and deterioration CHR-P criteria. All CHR-P individuals were offered cognitive behavioural therapy and psychosocial support; medications were used depending on individual needs. The cumulative risk of psychosis at ten years was 0.365 (95%CI 0.302-0.437). At six years follow-up, across two-third of individuals non-transitioning to psychosis, 79.24% still displayed some mental health problem, and only 20.75% achieved a complete clinical remission. Research conducted at OASIS encompassed clinical, prognostic, neurobiological and interventional studies and leveraged local, national and international infrastructures; over the past ten years, OASIS-related research attracted about £ 50 million of grant income, with 5,922 citations in the international databases. Future developments may include broadening OASIS to prevent other serious mental disorders beyond psychosis and fostering translational risk prediction and interventional research. With a twenty-years activity, OASIS' cutting-edge quality of preventive care, combined with translational research innovations, consolidated the service as a leading reference model for evidence-based prevention of psychosis worldwide.

Impact of coronavirus syndromes on physical and mental health of health care workers: Systematic review and meta-analysis

BACKGROUND

Health care workers (HCW) are at high risk of developing physical/mental health outcomes related to coronavirus syndromes. Nature and frequency of these outcomes are undetermined.

METHODS

PRISMA/MOOSE-compliant (PROSPERO-CRD42020180205) systematic review of Web of Science/grey literature until 15th April 2020, to identify studies reporting physical/mental health outcomes in HCW infected/exposed to Severe Acute Respiratory Syndrome -SARS-, Middle East Respiratory Syndrome -MERS-, Novel coronavirus -COVID-19-. Proportion random effect meta-analyses, I² statistic, quality assessment and sensitivity analysis.

RESULTS

115 articles were included (n=60,458 HCW, age 36.1±7.1, 77.1% female). Physical health outcomes: 75.9% HCW infected by SARS/MERS/COVID-19 reported fever (95%CI=65.9-83.7%, k=12, n=949), 47.9% cough (95%CI=39.2-56.8%, k=14, n=970), 43.6% myalgias (95%CI=31.9-56.0%, k=13, n=898), 42.3% chills (95%CI=20.2-67.9%, k=7, n=716), 41.2% fatigue (95%CI=18.2-68.8%, k=6, n=386), 34.6% headaches (95%CI=23.1-48.2%, k=11, n=893), 31.2% dyspnoea (95%CI=23.2-40.5%, k=12, n=1003), 25.3% sore throat (95%CI=18.8-33.2%, k=8, n=747), 22.2% nausea/vomiting (95%CI=14.9-31.8%, k=6, n=662), 18.8% diarrhoea (95%CI=11.9-28.4%, k=9, n=824). Mental health outcomes: 62.5% HCW exposed to SARS/MERS/COVID-19 reported general health concerns (95%CI=57.0-67,8%, k=2, n=2254), 43.7% fear (95%CI=33.9-54.0%, k=4, n=584), 37.9% insomnia (95%CI=30.9-45.5%, k=6, n=5067), 37.8% psychological distress (95%CI=28.4-48.2%, k=15, n=24,346), 34.4% burnout (95%CI=19.3-53.5%, k=3, n=1337), 29.0% anxiety features (95%CI=14.2-50.3%, k=6, n=9191), 26.3% depressive symptoms (95%CI=12.5-47.1%, k=8, n=9893), 20.7% post-traumatic stress disorder features (95%CI=13.2-31%, k=11, n=3826), 16.1% somatisation (95%CI=0.2-96.0%, k=2, n=2184), 14.0% stigmatisation feelings (95%CI=6.4-28.1%, k=2, n=411).

LIMITATIONS

Limited amount of evidence for some outcomes and suboptimal design in several studies included.

CONCLUSIONS

SARS/MERS/COVID-19 have a substantial impact on the physical and mental health of HCW, which should become a priority for public health strategies.

Real-World Clinical Outcomes Two Years After Transition to Psychosis in Individuals at Clinical High Risk: Electronic Health Record Cohort Study

The objective of this study is to describe the 2-year real-world clinical outcomes after transition to psychosis in patients at clinical high-risk. The study used the clinical electronic health record cohort study including all patients receiving a first index primary diagnosis of nonorganic International Classification of Diseases (ICD)-10 psychotic disorder within the early psychosis pathway in the South London and Maudsley (SLaM) National Health Service (NHS) Trust from 2001 to 2017. Outcomes encompassed: cumulative probability (at 3, 6, 12, and 24 months) of receiving a first (1) treatment with antipsychotic, (2) informal admission, (3) compulsory admission, and (4) treatment with clozapine and (5) numbers of days spent in hospital (at 12 and 24 months) in patients transitioning to psychosis from clinical high-risk services (Outreach and Support in south London; OASIS) compared to other first-episode groups. Analyses included logistic and 0-inflated negative binomial regressions. In the study, 1561 patients were included; those who had initially been managed by OASIS and had subsequently transitioned to a first episode of psychosis (n = 130) were more likely to receive antipsychotic medication (at 3, 6, and 24 months; all P < .023), to be admitted informally (at all timepoints, all P < .004) and on a compulsory basis (at all timepoints, all P < .013), and to have spent more time in hospital (all timepoints, all P < .007) than first-episode patients who were already psychotic when seen by the OASIS service (n = 310), or presented to early intervention services (n = 1121). The likelihood of receiving clozapine was similar across all groups (at 12/24 months, all P < .101). Transition to psychosis from a clinical high-risk state is associated with severe real-world clinical outcomes. Prevention of transition to psychosis should remain a core target of future research. The study protocol was registered on www.researchregistry.com; researchregistry5039).

Individualized Diagnostic and Prognostic Models for Patients With Psychosis Risk Syndromes: A Meta-analytic View on the State of the Art

BACKGROUND

The clinical high risk (CHR) paradigm has facilitated research into the underpinnings of help-seeking individuals at risk for developing psychosis, aiming at predicting and possibly preventing transition to the overt disorder. Statistical methods such as machine learning and Cox regression have provided the methodological basis for this research by enabling the construction of diagnostic models (i.e., distinguishing CHR individuals from healthy individuals) and prognostic models (i.e., predicting a future outcome) based on different data modalities, including clinical, neurocognitive, and neurobiological data. However, their translation to clinical practice is still hindered by the high heterogeneity of both CHR populations and methodologies applied.

METHODS

We systematically reviewed the literature on diagnostic and prognostic models built on Cox regression and machine learning. Furthermore, we conducted a meta-analysis on prediction performances investigating heterogeneity of methodological approaches and data modality.

RESULTS

A total of 44 articles were included, covering 3707 individuals for prognostic studies and 1052 individuals for diagnostic studies (572 CHR patients and 480 healthy control subjects). CHR patients could be classified against healthy control subjects with 78% sensitivity and 77% specificity. Across prognostic models, sensitivity reached 67% and specificity reached 78%. Machine learning models outperformed those applying Cox regression by 10% sensitivity. There was a publication bias for prognostic studies yet no other moderator effects.

CONCLUSIONS

Our results may be driven by substantial clinical and methodological heterogeneity currently affecting several aspects of the CHR field and limiting the clinical implementability of the proposed models. We discuss conceptual and methodological harmonization strategies to facilitate more reliable and generalizable models for future clinical practice.

Intranasal oxytocin increases heart-rate variability in men at clinical high risk for psychosis: a proof-of-concept study

Autonomic nervous system (ANS) dysfunction (i.e., increased sympathetic and/or decreased parasympathetic activity) has been proposed to contribute to psychosis vulnerability. Yet, we still lack directed therapeutic strategies that improve ANS regulation in psychosis or at-risk states. The oxytocin system constitutes a potential therapeutic target, given its role in ANS regulation. However, whether intranasal oxytocin ameliorates autonomic regulation during emerging psychosis is currently unknown. We pooled together two datasets, one of 30 men at clinical high risk for psychosis (CHR-P), and another of 17 healthy men, who had participated in two double-blinded, placebo-controlled, randomised, crossover MRI studies with similar protocols. All participants self-administered 40 IU of intranasal oxytocin or placebo using a nasal spray. We recorded pulse plethysmography during a period of 8 min at about 1 h post dosing and estimated heart rate (HR) and high-frequency HR variability (HF-HRV), an index of cardio-parasympathetic activity. CHR-P and healthy men did not differ at resting HR or HF-HRV under placebo. We found a significant condition × treatment effect for HF-HRV, showing that intranasal oxytocin, compared with placebo, increased HF-HRV in CHR-P but not in healthy men. The main effects of treatment and condition were not significant. In this proof-of-concept study, we show that intranasal oxytocin increases cardio-parasympathetic activity in CHR-P men, highlighting its therapeutic potential to improve autonomic regulation in this clinical group. Our findings support the need for further research on the preventive and therapeutic potential of intranasal oxytocin during emerging psychosis, where we lack effective treatments.

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

IMPORTANCE

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

OBJECTIVE

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

EVIDENCE REVIEW

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

FINDINGS

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

CONCLUSIONS AND RELEVANCE

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

Acute oxytocin effects in inferring others' beliefs and social emotions in people at clinical high risk for psychosis

Social deficits are key hallmarks of the Clinical High Risk for Psychosis (CHR-P) state and of established psychotic disorders, and contribute to impaired social functioning, indicating a potential target for interventions. However, current treatments do not significantly ameliorate social impairments in CHR-P individuals. Given its critical role in social behaviour and cognition, the oxytocinergic (OT) system is a promising target for novel interventions in CHR-P subjects. In a double-blind, placebo-controlled, crossover design, 30 CHR-P males were studied using functional magnetic resonance imaging (fMRI) on two occasions, once after 40IU self-administered intranasal OT and once after placebo. A modified version of the Sally-Anne task was used to assess brain activation during inferring others' beliefs and social emotions. The Reading the Mind in the Eyes Test was acquired prior to the first scan to test whether OT effects were moderated by baseline social-emotional abilities. OT did not modulate behavioural performances but reduced activation in the bilateral inferior frontal gyrus compared with placebo while inferring others' social emotions. Furthermore, the relationship between brain activation and task performance after OT administration was moderated by baseline social-emotional abilities. While task accuracy during inferring others' social emotion increased with decreasing activation in the left inferior frontal gyrus in CHR-P individuals with low social-emotional abilities, there was no such relationship in CHR-P individuals with high social-emotional abilities. Our findings may suggest that acute OT administration enhances neural efficiency in the inferior frontal gyrus during inferring others' social emotions in those CHR-P subjects with low baseline social-emotional abilities.

The "Parma-Early Psychosis" program: General description and process analysis after 5 years of clinical activity

AIM

From January 2013, the Parma Department of Mental Health developed a specific protocol of care (the "Parma-Early Psychosis" [Pr-EP] program) as a diffused service for early intervention in psychosis. The aims of the present research are (a) to describe the Pr-EP macroscopic organization and (b) to analyse specific process indicators across the first 5 years from its establishment.

METHODS

All participants were adolescent and adult help-seekers, aged 12-54 years, with a First Episode Psychosis (FEP) or at Ultra-High Risk for developing psychosis, according to well-defined diagnostic criteria.

RESULTS

At baseline, 358 individuals were offered a dedicated protocol of care and only 40 (11.8%) dropped out during the first year of intervention. In particular, an increase of referrals over time was notably found (especially in adolescence). Furthermore, Duration of Untreated Psychosis decreased over time. The baseline prevalence of FEP diagnosis was 61.4%, with schizophrenia as markedly prevalent Diagnostic and Statistical Manual of mental disorders, IV edition, Text Revised (DSM-IV-TR) diagnosis (41%). The vast majority of UHR individuals met criteria for "Attenuated Psychotic Symptoms" (>90%), and major depressive disorder was the most frequent diagnosis (>55%). Finally, we found considerable percentages of current history of substance abuse (>58%) and of comorbidity with DSM-IV-TR personality disorders (60%).

CONCLUSIONS

An "Early Intervention in psychosis" service in Italian child/adolescent and adult mental health services is feasible, also in adolescents, who have a high risk of falling through the child-adult service gap.

Implementation of a Real-Time Psychosis Risk Detection and Alerting System Based on Electronic Health Records using CogStack

Recent studies have shown that an automated, lifespan-inclusive, transdiagnostic, and clinically based, individualized risk calculator provides a powerful system for supporting the early detection of individuals at-risk of psychosis at a large scale, by leveraging electronic health records (EHRs). This risk calculator has been externally validated twice and is undergoing feasibility testing for clinical implementation. Integration of this risk calculator in clinical routine should be facilitated by prospective feasibility studies, which are required to address pragmatic challenges, such as missing data, and the usability of this risk calculator in a real-world and routine clinical setting. Here, we present an approach for a prospective implementation of a real-time psychosis risk detection and alerting service in a real-world EHR system. This method leverages the CogStack platform, which is an open-source, lightweight, and distributed information retrieval and text extraction system. The CogStack platform incorporates a set of services that allow for full-text search of clinical data, lifespan-inclusive, real-time calculation of psychosis risk, early risk-alerting to clinicians, and the visual monitoring of patients over time. Our method includes: 1) ingestion and synchronization of data from multiple sources into the CogStack platform, 2) implementation of a risk calculator, whose algorithm was previously developed and validated, for timely computation of a patient's risk of psychosis, 3) creation of interactive visualizations and dashboards to monitor patients' health status over time, and 4) building automated alerting systems to ensure that clinicians are notified of patients at-risk, so that appropriate actions can be pursued. This is the first ever study that has developed and implemented a similar detection and alerting system in clinical routine for early detection of psychosis.

Predictors of diagnostic stability in acute and transient psychotic disorders: validation of previous findings and implications for ICD-11

Acute and transient psychotic disorders (ATPD) have moderate prospective diagnostic stability. Female gender, older age at onset, good premorbid adjustment, abrupt onset, shifting polymorphic symptomatology and absence of schizophrenic features have been found to be predictive factors of diagnostic stability in ATPDs. Nevertheless, most of these findings need to be replicated. The purpose of this study was to evaluate the diagnostic stability of patients with ATPD, and to determine whether previously accepted predictors of diagnostic stability for ATPD could be externally validated in our cohort. To that end, a prospective 2-year observational study was conducted on patients with first-episode ATPD. Multivariate analysis was performed to determine factors associated with ATPD diagnostic stability at the end of the follow-up period. The following prior knowledge variables were analyzed: female gender, older age at onset, good premorbid adjustment, abrupt onset, shifting polymorphic symptomatology and absence of schizophrenic features. Sixty-eight patients with first-episode ATPD completed the follow-up, of whom 55.9% (n = 38) retained their diagnosis of ATPD at the end of the study. Multivariate analysis revealed that diagnostic stability was independently significantly associated with the presence of shifting polymorphic symptomatology (OR = 7.42, 95% CI 1.65-33.30; p = 0.009) and the absence of schizophrenic features (OR = 6.37, 95% CI 1.47-27.54; p = 0.013) at the onset of the psychotic disorder. Our findings provide empirical support for the ICD-11 proposal restricting the new ATPD category to the acute polymorphic disorder without schizophrenia symptoms.

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.

Duration of the psychosis prodrome

The recognition of a prodromal period preceding the onset of frank psychosis dates back to its first descriptions. Despite insights gained from a prospective approach to the study of the Clinical High Risk syndrome for psychosis (CHR-P), a prospectively-based understanding of the duration of the psychosis prodrome and the factors that may influence is not well-established. Here we analyze data from the second North American Prodrome Longitudinal Study (NAPLS-2) to characterize prodrome duration in those who converted to psychosis. Of the 764 participants identified as being at CHR-P, 94 converted to psychosis and 92 of these had recorded estimates of prodrome onset. Estimates of prodrome duration were derived from CHR-P syndrome onset and conversion dates from the Structured Interview for Psychosis-risk Syndromes. Results identified a mean prodrome duration of 21.6 months. Neither CHR-P sub-syndrome nor medication exposure was found to significantly influence prodrome duration in this sample. These results provide the most precise estimate of prodrome duration to date, although results are limited to prodromes identified by ascertainment as being at CHR-P. Our findings also suggest a rule of thirds with regard to prodrome duration in those followed for two years: one third of CHR-P patients who convert will do so by 1 year after CHR-P syndrome onset, another third 1-2 years after onset, and the final third more than 2 years after onset.

Regional brain volumes in brief psychotic disorder

Brief psychotic disorder (BPD) is a relatively rare representative of psychotic disorders. Structural brain abnormalities in BPD are not known. We compared 30 patients with BPD and 30 matched healthy controls using high-resolution structural T1-weighted magnetic resonance imaging (MRI). We performed cortical/subcortical reconstruction and volumetric segmentation using FreeSurfer v6.0. Results revealed that the caudal/rostral middle frontal cortex, superior frontal cortex, and the frontal pole were significantly smaller in patients with BPD compared to controls. The number of lifetime psychotic episodes negatively correlated with caudal middle frontal and frontal pole volumes. These results indicate structural abnormalities of the frontal cortex in BPD, which are associated with the number of psychotic relapses.

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

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

DSM-5 Attenuated Psychosis Syndrome in Adolescents Hospitalized With Non-psychotic Psychiatric Disorders

Introduction: Although attenuated psychotic symptoms often occur for the first time during adolescence, studies focusing on adolescents are scarce. Attenuated psychotic symptoms form the criteria to identify individuals at increased clinical risk of developing psychosis. The study of individuals with these symptoms has led to the release of the DSM-5 diagnosis of Attenuated Psychosis Syndrome (APS) as a condition for further research. We aimed to characterize and compare hospitalized adolescents with DSM-5-APS diagnosis vs. hospitalized adolescents without a DSM-5-APS diagnosis. Methods: Interviewing help-seeking, hospitalized adolescents (aged 12-18 years) and their caregivers independently with established research instruments, we (1) evaluated the presence of APS among non-psychotic adolescents, (2) characterized and compared APS and non-APS individuals regarding sociodemographic, illness and intervention characteristics, (3) correlated psychopathology with levels of functioning and severity of illness and (4) investigated the influence of individual clinical, functional and comorbidity variables on the likelihood of participants to be diagnosed with APS. Results: Among 248 consecutively recruited adolescents (age=15.4 ± 1.5 years, females = 69.6%) with non-psychotic psychiatric disorders, 65 (26.2%) fulfilled APS criteria and 183 (73.8%) did not fulfill them. Adolescents with APS had higher number of psychiatric disorders than non-APS adolescents (3.5 vs. 2.4, p < 0.001; Cohen's d = 0.77), particularly, disruptive behavior disorders (Cramer's V = 0.16), personality disorder traits (Cramer's V = 0.26), anxiety disorders (Cramer's V = 0.15), and eating disorders (Cramer's V = 0.16). Adolescents with APS scored higher on positive (Cohen's d = 1.5), negative (Cohen's d = 0.55), disorganized (Cohen's d = 0.51), and general symptoms (Cohen's d = 0.84), and were more severely ill (Cohen's d = 1.0) and functionally impaired (Cohen's d = 0.31). Negative symptoms were associated with lower functional levels (Pearson ρ = -0.17 to -0.20; p = 0.014 to 0.031). Global illness severity was associated with higher positive, negative, and general symptoms (Pearson ρ = 0.22 to 0.46; p = 0.04 to p < 0.001). APS status was independently associated with perceptual abnormalities (OR = 2.0; 95% CI = 1.6-2.5, p < 0.001), number of psychiatric diagnoses (OR = 1.5; 95% CI = 1.2-2.0, p = 0.002), and impaired stress tolerance (OR = 1.4; 95% CI = 1.1-1.7, p = 0.002) (r ² = 0.315, p < 0.001). Conclusions: A considerable number of adolescents hospitalized with non-psychotic psychiatric disorders meet DSM-5-APS criteria. These help-seeking adolescents have more comorbid disorders and more severe symptoms, functional impairment, and severity of illness than non-APS adolescents. Thus, they warrant high intensity clinical care.