Distress in relation to attenuated psychotic symptoms in the ultra-high-risk population is not associated with increased risk of psychotic disorder

Nutraceuticals in Psychiatric Disorders: A Systematic Review

Correct nutrition and diet are directly correlated with mental health, functions of the immune system, and gut microbiota composition. Diets with a high content of some nutrients, such as fibers, phytochemicals, and short-chain fatty acids (omega-3 fatty acids), seem to have an anti-inflammatory and protective action on the nervous system. Among nutraceuticals, supplementation of probiotics and omega-3 fatty acids plays a role in improving symptoms of several mental disorders. In this review, we collect data on the efficacy of nutraceuticals in patients with schizophrenia, autism spectrum disorders, major depression, bipolar disorder, and personality disorders. This narrative review aims to provide an overview of recent evidence obtained on this topic, pointing out the direction for future research.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

Aim

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

Methods

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

Results

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

Conclusion

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

Distress Related to Attenuated Psychotic Symptoms: Static and Dynamic Association With Transition to Psychosis, Nonremission, and Transdiagnostic Symptomatology in Clinical High-Risk Patients in an International Intervention Trial

This study examined whether distress in relation to attenuated psychotic symptoms (DAPS) is associated with clinical outcomes in an ultra-high risk (UHR) for psychosis sample. We also investigated whether DAPS is associated with cognitive style (attributional style and cognitive biases) and whether amount of psychosocial treatment provided is associated with reduction in DAPS. The study was a secondary analysis of the "Neurapro" clinical trial of omega-3 fatty acids. Three hundred and four UHR patients were recruited across 10 early intervention services. Data from baseline assessment, regular assessments over 12 months, and medium term follow-up (mean = 3.4 years) were used for analysis. Findings indicated: a positive association between DAPS assessed over time and transition to psychosis; a significant positive association between baseline and longitudinal DAPS and transdiagnostic clinical and functional outcomes; a significant positive association between baseline and longitudinal DAPS and nonremission of UHR status. There was no relationship between severity of DAPS and cognitive style. A greater amount of psychosocial treatment (cognitive-behavioral case management) was associated with an increase in DAPS scores. The study indicates that UHR patients who are more distressed by their attenuated psychotic symptoms are more likely to have a poorer clinical trajectory transdiagnostically. Assessment of DAPS may therefore function as a useful marker of risk for a range of poor outcomes. The findings underline the value of repeated assessment of variables and incorporation of dynamic change into predictive modeling. More research is required into mechanisms driving distress associated with symptoms and the possible bidirectional relationship between symptom severity and associated distress.

Identifying and changing cognitive vulnerability in the classroom: preliminary evaluation of CUES-Ed, a school-based universal cognitive behavioural early intervention service for 7-10 year olds

BACKGROUND

School-based early intervention may alleviate current emotional and behavioural problems, and, by targeting underlying vulnerability, safeguard children's future mental health. Improving on mixed outcomes to date is an international public health priority. CUES-Ed is a classroom-based, clinician-led, universal cognitive behavioural programme for primary school children, designed to promote emotional literacy and regulation. Additionally, CUES-Ed targets cognitive mechanisms implicated in the future development of mental disorder: stigmatising appraisals of emotional expression and of unusual perceptual experiences, and the tendency to jump-to-conclusions (JTC). We report here on fitness for purpose of our in-service assessment of cognitive vulnerability, and change in cognitive vulnerability following CUES-Ed and compared with a naturalistic waitlist.

METHODS

From 05/2017-11/2017, 960 children participated (900 CUES-Ed; 60 naturalistic waitlist). Assessments were completed in whole classes; 732 children provided pre-post data on all measures; 227 were missing data through absence or poor completion (n = 1 declined assessment).

RESULTS

Relationships between baseline cognitive vulnerability measures and their components were consistent with reliable and valid assessment. Cognitive vulnerability reduced from before to after CUES-Ed and compared with the naturalistic waitlist, for JTC (large effects) and stigmatising appraisals (small-medium effects), for all children (ESs pre-post: 0.2-1.0; between-group: 0.1-1.0) and vulnerable subgroups (ESs pre-post: 0.5-1.7; between-group: 0.2-2.0).

CONCLUSIONS

Targeted cognitive vulnerability mechanisms change following CUES-Ed. As stigmatising appraisals and JTC may increase vulnerability to future mental illness, findings suggest a promise in reducing future risk. A formally controlled research study, with longer-term follow-up, is required to test this. Limitations and implications for future evaluation are discussed.

Mental Health in Childhood and Adolescence: The Role of Polyunsaturated Fatty Acids

There is increasing awareness of the importance of polyunsaturated fatty acids (PUFAs) for optimal brain development and function. In recent decades, researchers have confirmed the central role of PUFAs in a variety of patho-physiological processes. These agents modulate the mechanisms of brain cell signalling including the dopaminergic and serotonergic pathways. Therefore, nutritional insufficiencies of PUFAs may have adverse effects on brain development and developmental outcomes. The role of n-3 PUFAs has been studied in several psychiatric disorders in adulthood: schizophrenia, major depression, bipolar disorder, anxiety disorders, obsessive-compulsive disorder, post-traumatic stress disorder, attention deficit hyperactivity disorder (ADHD), autism spectrum disorders, eating disorders, substance use disorder, and borderline personality disorder. In contrast to the great number of studies conducted in adults, there are only limited data on the effects of n-3 PUFA supplementation in children and adolescents who suffer from mental disorders or show a high risk of developing psychiatric disorders. The aim of this review is to provide a complete and updated account of the available evidence of the impact of polyunsaturated fatty acids on developmental psychopathology in children and adolescents and the effect of fatty acid supplementation during developmental milestones, particularly in high-risk populations of children with minimal but detectable signs or symptoms of mental disorders.

Cognitive behavioural therapy for help-seeking adolescents and young adults with at-risk-mental state: Effects on subclinical positive symptoms

AIM

Cognitive behavioural therapy (CBT) is effective for at-risk-mental state (ARMS) in reducing/delaying transition to psychosis. However, previous systematic reviews pointed out the small number of trials as a limitation and suggested that additional outcomes should be evaluated, not only prevention of first psychosis episode. No study assessed the CBT effects on subclinical psychotic symptoms. The present study investigated the effects of CBT on the transition risk (primary outcome), and on overall remission from ARMS and severity of subclinical symptoms, that is, unusual content of thought, non-bizarre ideas, perceptual abnormalities, disorganized speech (secondary outcome).

METHODS

CBT consisted of 30 individual weekly sessions over 7 months. Fifty-eight participants with ARMS detected by the Comprehensive Assessment of At-Risk-Mental States were randomized to CBT or control condition.

RESULTS

Respectively in the CBT and control groups, 1 (3.40%) and 5 (26.31%) participants at post-treatment and 3 (10.30%) and 8 (42.10%) at follow-up made transition with a difference between the two groups, despite at borderline significance. At post-treatment and follow-up, respectively, the number of participants recovered from ARMS was significantly higher in CBT (76.92% and 61.53%) than in control (10.52% and 15.80%). Participants in the control group reported lower reductions on all the subclinical symptoms over time as compared with those in CBT.

CONCLUSIONS

This is the first study assessing CBT on subclinical positive symptoms in ARMS. CBT seems to be a tailored approach able to produce short- and long-term benefits on this outcome.

Community Psychosis Risk Screening: An Instrument Development Investigation

Schizophrenia and other psychotic disorders are serious psychiatric disorders that are associated with substantial societal, family, and individual costs/distress. Evidence suggests that early intervention can improve prognostic outcomes; therefore, it is essential to accurately identify those at risk for psychosis before full psychotic symptoms emerge. The purpose of our study is to develop a brief, valid screening questionnaire to identify individuals at risk for psychosis in non-clinical populations across 3 large, community catchment areas with diverse populations. This is a needed study, as the current screening tools for at-risk psychotic populations in the US have been validated only in clinical and/or treatment seeking samples, which are not likely to generalize beyond these specialized settings. The specific aims are as follows: (1) to determine norms and prevalence rates of attenuated positive psychotic symptoms across 3 diverse, community catchment areas and (2) to develop a screening questionnaire, inclusive of both symptom-based and risk factor-based questions. Our study will develop an essential screening tool that will identify which individuals have the greatest need of follow-up with structured interviews in both research and clinical settings. Our study has the potential for major contributions to the early detection and prevention of psychotic disorders.

Terminology and assessment tools of psychosis: A systematic narrative review

AIM

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

METHODS

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

RESULTS

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

DISCUSSION

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

Young Patients With Persistent and Complex Care Needs Require an Integrated Care Approach: Baseline Findings From the Multicenter Youth Flexible ACT Study

Background: The Multicenter Youth Flexible ACT Study is an ongoing observational prospective cohort study that examines the effects of Youth Flexible ACT (Assertive Community Treatment) on young people with complex care needs who are difficult to engage in traditional (office-based) mental health services. However, a clear and detailed description of this patient group is lacking. In the current paper, we present baseline characteristics and psychosocial outcomes of the Youth Flexible ACT target group and explore the existence of underlying specific patient subgroups. Methods: Sixteen Youth Flexible ACT teams from seven mental healthcare institutes in the Netherlands participated in the study. Research participants were monitored for 18 months and administered questionnaires measuring psychiatric- and social functioning every 6 months, yielding four measurements. Baseline data were obtained from 199 adolescents, their mental health workers, and parents/carers. Latent Class Analysis based on HoNOSCA scores (measuring psychosocial and daily functioning) was conducted to identify underlying subgroups. Results: The target group of Youth Flexible ACT mainly consisted of patients older than 15 years of age with a history of (specialized) mental healthcare. They face many complex problems, including trauma; developmental, mood, and anxiety disorders; and problems with school attendance, family life, and peer relationships. Other frequently reported difficulties were substance misuse, the involvement of the legal system or police, problems with intellectual functioning, and personal finance. Patients were classified into four distinct classes: the "internalizing," "externalizing," "non-specific," and the "overly impulsive" subgroup. Each subgroup had its unique pattern of difficulties and focus, respectively, high levels of depression and anxiety, disruptive behavior, unspecific difficulties, and substance misuse. Conclusions: As expected, patients in Youth Flexible ACT experienced many severe problems, rendering them vulnerable to fragmented and, thus, ineffective care. Our findings underscore the need for an integrated care approach with a multidisciplinary team of skilled professionals that can bridge these wide-ranging psychosocial problems, as each class of participants experienced a different set of difficulties. Youth Flexible ACT teams need to adjust their care services accordingly.

Impact of distress related to attenuated psychotic symptoms in individuals at ultra high risk of psychosis: Findings from the Longitudinal Youth at Risk Study

AIM

Recent studies have highlighted that attenuated psychotic symptoms (APS) are an important source of distress in ultra high risk (UHR) individuals and that this distress is related to transition to psychosis (TTP). This study examined distress associated with APS in UHR individuals and investigated its association with TTP.

METHODS

The Comprehensive Assessment of At-Risk Mental State (CAARMS) was used to identify 173 UHR individuals, who were included as participants in the study. Distress related to APS was self-reported. Functioning was assessed on the Social and Occupational Functioning Assessment Scale. Associations between each of the 4 APS subscales in the CAARMS-non-bizarre ideas (NBI), perceptual abnormalities (PA), unusual thought content (UTC) and disorganized speech (DS)-with its distress level were examined.

RESULTS

Of the 173 UHR participants, 154 (89%) reported distress related to one or more APS. NBI was rated to be the most distressing out of the 4 APS by the highest number of participants (32.9%) compared to UTC (12.1%), PA (24.9%) and DS (2.9%). Mean distress scores were significantly associated with CAARMS composite scores (P < .001). However, there was no significant relationship between distress scores and functioning. Both mean distress scores (OR = 1.034, P = .029) and functioning (OR = 0.892, P = .022) were significant predictors of transition to psychosis at 1 year of follow-up.

CONCLUSIONS

This study provides additional evidence to link subjective distress experienced by UHR individuals to APS and to their subsequent clinical outcomes and has significant clinical implications.

Early intervention for everyone? A review of cross-cultural issues and their treatment in ultra-high-risk (UHR) cohorts

AIM

Over the past 20 years, early management of psychosis has become both a research and policy priority. In Western countries, psychotic disorders appear more prevalent in migrant and minority ethnic groups than in native or dominant groups. Moreover, disparities exist in health conditions and access to care among immigrants and minority ethnic groups, compared with native-born and majority groups. Appropriate early detection tools are necessary for the different groups.

METHODS

This systematic review provides a synthesis of the assessment and discussion of transcultural issues in ultra-high-risk (UHR) cohorts. The Medline database was searched via PubMed for peer-reviewed articles published in English from 1995 to 2017. All 79 studies included are prospective UHR cohort studies that used the Comprehensive Assessment of At-Risk Mental States (CAARMS).

RESULTS

In UHR cohort studies that used the CAARMS, transcultural data (native language, ethnicity, place of birth, migration) are rarely collected, and inadequate ability to speak the dominant language is a common exclusion criterion. When they are included, the CAARMS scores differ between some minorities and the native-born majority group.

CONCLUSIONS

This systematic review demonstrates barriers to the access to participation in early intervention research for migrants and ethnic minorities. This selection bias may result in lower validity for the CAARMS among these populations and thus in inadequate intervention programmes. Along with targeted studies, minorities' access to participation in UHR cohorts should be improved through 3 tools: interpreters at recruitment and for administration of CAARMS, a guide to cultural formulation and transcultural data collection.

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

AIM

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

METHODS

The PQ-16 was added to regular intake procedures.

RESULTS

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

CONCLUSIONS

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

Beyond the "at risk mental state" concept: transitioning to transdiagnostic psychiatry

The "at risk mental state" for psychosis approach has been a catalytic, highly productive research paradigm over the last 25 years. In this paper we review that paradigm and summarize its key lessons, which include the valence of this phenotype for future psychosis outcomes, but also for comorbid, persistent or incident non-psychotic disorders; and the evidence that onset of psychotic disorder can at least be delayed in ultra high risk (UHR) patients, and that some full-threshold psychotic disorder may emerge from risk states not captured by UHR criteria. The paradigm has also illuminated risk factors and mechanisms involved in psychosis onset. However, findings from this and related paradigms indicate the need to develop new identification and diagnostic strategies. These findings include the high prevalence and impact of mental disorders in young people, the limitations of current diagnostic systems and risk identification approaches, the diffuse and unstable symptom patterns in early stages, and their pluripotent, transdiagnostic trajectories. The approach we have recently adopted has been guided by the clinical staging model and adapts the original "at risk mental state" approach to encompass a broader range of inputs and output target syndromes. This approach is supported by a number of novel modelling and prediction strategies that acknowledge and reflect the dynamic nature of psychopathology, such as dynamical systems theory, network theory, and joint modelling. Importantly, a broader transdiagnostic approach and enhancing specific prediction (profiling or increasing precision) can be achieved concurrently. A holistic strategy can be developed that applies these new prediction approaches, as well as machine learning and iterative probabilistic multimodal models, to a blend of subjective psychological data, physical disturbances (e.g., EEG measures) and biomarkers (e.g., neuroinflammation, neural network abnormalities) acquired through fine-grained sequential or longitudinal assessments. This strategy could ultimately enhance our understanding and ability to predict the onset, early course and evolution of mental ill health, further opening pathways for preventive interventions.

Childhood unusual experiences in community Child and Adolescent Mental Health Services in South East London: Prevalence and impact

BACKGROUND

Distressing 'psychotic-like' or unusual experiences (UEDs) signify increased mental health risk in the general population, including greater likelihood and severity of co-occurring non-psychotic mental health problems, and, from fourteen years of age, increased risk of a future psychotic illness. Healthcare guidelines for under eighteens recommend psychological intervention for UEDs, to reduce current distress and adverse functional impact, and, potentially, future mental health risk. Children tend not to report UEDs unless directly asked, indicating a need for routine screening. We report on the feasibility of a routine screening methodology, and screening outcomes, in Child and Adolescent Mental Health Services (CAMHS) in South East London, United Kingdom.

METHOD

Four general community CAMHS teams were invited to screen, by adding a nine-item self-report UED measure to their routine assessment battery. Screening data were collected over 18months from 02/2015 to 07/2016.

RESULTS

All but one team agreed to screen. Each team saw around 300 accepted referrals during the audit period (total: 900); 768 of these (85%) were successfully screened; of those screened, 68% (n=524) self-reported UEs, 60% (n=461) with associated distress/adverse functional impact. Screening was acceptable to clinicians, children and families.

CONCLUSIONS

Assessing UEDs routinely in CAMHS is feasible, and suggests that around two thirds of assessed referrals could potentially benefit from interventions targeting UEDs. Additional training may be required for the CAMHS workforce to address this need.

Influence of depressive symptoms on distress related to positive psychotic-like experiences in women

The Community Assessment of Psychic Experiences (CAPE) is an effective instrument for detection of the presence of psychotic symptoms and associated distress in the general population. However, little research has studied distress associated with positive psychotic-like experiences (PLEs). Our aim is to study PLE-related distress using the CAPE. In this study we analysed factors associated with differences in PLE-related distress in a sample of 200 non-clinical participants recruited by snowball sampling. Presence of PLEs and related psychological distress was measured using the CAPE questionnaire. The influence of age, gender, educational level and drug use was studied. In univariate analysis we found that gender and CAPE positive, depressive and negative scores, were associated with CAPE positive distress. Using multiple linear regression, we found that only the effect of gender, and the interaction between frequency of depression and gender, remained statistically significant. In our sample interaction between gender and depressive symptoms is a determining factor in distress associated with positive PLEs. The results of this study may be useful for the implementation of prevention programs.