Randomized controlled multicentre trial of cognitive behaviour therapy in the early initial prodromal state: effects on social adjustment post treatment

Social and occupational recovery in early psychosis: a systematic review and meta-analysis of psychosocial interventions

BACKGROUND

Psychosis, even in its early stages, ranks highly among the causes of disability worldwide, resulting in an increased focus on improved recovery of social and occupational functioning. This study aimed to provide an estimate of the effectiveness of psychosocial interventions for improving functioning in early psychosis. We also sought evidence of superiority between intervention approaches.

METHODS

An electronic search was conducted using PubMed and PsycINFO to identify original articles reporting on trials of psychosocial interventions in early-stage psychosis, published up to December 2020 and is reported following PRISMA guidelines. Data were extracted on validated measures of functioning from included studies and pooled standardised mean difference (SMD) was estimated.

RESULTS

In total, 31 studies involving 2811 participants were included, focusing on: cognitive behavioural therapy for psychosis (CBTp), family-based therapy, supported employment, cognitive remediation training (CRT) and multi-component psychosocial interventions. Across interventions, improved function was observed (SMD = 0.239; 95% confidence interval 0.115-0.364, p < 0.001). Effect sizes varied by intervention type, stage of illness, length and duration of treatment and outcome measure used. In particular, interventions based on CRT significantly outperformed symptom-focused CBT interventions, while multi-component interventions were associated with largest gains.

CONCLUSIONS

Psychosocial interventions, particularly when provided as part of a multi-component intervention model and delivered in community-based settings are associated with significant improvements in social and occupational function. This review underscores the value of sensitively tracking and targeting psychosocial function as part of the standard provided by early intervention services.

Cognitive-Behavioral Social Skills Training: Outcome of a Randomized Controlled Trial for Youth at Risk of Psychosis

Aim

Difficulties in social functioning have been observed in youth at clinical high-risk (CHR) of psychosis even in those who do not go on to develop a psychotic illness. Few treatment studies have attempted to improve social functioning in this population. The aim of this study was to conduct a randomized trial comparing the effects of Cognitive-Behavioral Social Skills Training (CBSST) with a supportive therapy (ST).

Methods

Both CBSST and ST were weekly group therapies, delivered over 18 weeks. This was a 2-arm trial with single-blinded ratings and intention-to-treat analyses. Assessments occurred at baseline, end-of-treatment, and 12 months after the baseline assessment. The primary outcome was social and role functioning and defeatist performance attitudes were the secondary outcome. Attenuated positive and negative symptoms, anxiety, depression, self-efficacy, and beliefs about self and others were examined as exploratory outcomes.

Results

There were no significant differences between the 2 groups at baseline or either of the 2 follow-ups. However, at follow-ups, in each group there were significant improvements in clinical symptoms. These could not be attributed to group treatment since there was no control or wait-list group.

Conclusions

Since poor social functioning is one of the most observed difficulties in CHR individuals, and a decline in social functioning may be a significant predictor of later transition to psychosis, future work will be needed to find effective treatments for this decline in functioning for CHR youth.

Has improved treatment contributed to the declining rate of transition to psychosis in ultra-high-risk cohorts?

BACKGROUND

The factors contributing to declining psychotic disorder transition rates in ultra-high-risk populations remain unclear. We examined the contribution of longitudinal changes in standard clinical treatment ('treatment as usual') to this decline.

METHOD

An audit was conducted on 105 clinical files of patients who received standard care at a specialised ultra-high-risk service. The session notes of these files were quantified, allowing examination of treatment quantity, targets, psychotherapy, and medication. Differences in these aspects across patients' year of clinic entry were assessed. Variables with significant differences across years were examined using cox regression to assess their contribution to psychosis transition rates.

RESULTS

Findings were that, as a function of patients' year of clinic entry, there were increases in: patients' number of sessions, cognitive behavioural therapy (CBT), problem and solving therapy. There was a relationship between baseline year cohort and psychosis transition rate, with lower rates observed in more recent cohorts. When changes in treatment between cohorts were adjusted for, the relationship between baseline year cohort and transition rate disappeared. The relationship between baseline year and transition rate was attenuated most by increases in CBT.

CONCLUSION

Changes in standard treatment, particularly increases in CBT, may have contributed to the decline in psychosis risk observed in recent ultra-high-risk cohorts, although these variables do not fully explain this trend. Implications for clinical practice, prediction and intervention research are discussed. Future ultra-high-risk research should investigate the impact of other treatment factors, such as therapeutic alliance.

Preventive interventions for individuals at ultra high risk for psychosis: An updated and extended meta-analysis

Intervention at the earliest illness stage, in ultra or clinical high-risk individuals, or indicated prevention, currently represents the most promising strategy to ameliorate, delay or prevent psychosis. We review the current state of evidence and conduct a broad-spectrum meta-analysis of various outcomes: transition to psychosis, attenuated positive and negative psychotic symptoms, mania, depression, anxiety, general psychopathology, symptom-related distress, functioning, quality of life, and treatment acceptability. 26 randomized controlled trials were included. Meta-analytically pooled interventions reduced transition rate (risk ratio [RR] = 0.57, 95%CI 0.41-0.81) and attenuated positive psychotic symptoms at 12-months (standardized mean difference = -0.15, 95%CI = -0.28--0.01). When stratified by intervention type (pharmacological, psychological), only the pooled effect of psychological interventions on transition rate was significant. Cognitive behavioral therapy (CBT) was associated with a reduction in incidence at 12-months (RR = 0.52, 95%CI = 0.33-0.82) and 18-48-months (RR = 0.60, 95%CI = 0.42-0.84), but not 6-months. Findings at 12-months and 18-48-months were robust in sensitivity and subgroup analyses. All other outcomes were non-significant. To date, effects of trialed treatments are specific to transition and, a lesser extent, attenuated positive symptoms, highlighting the future need to target other symptom domains and functional outcomes. Sound evidence supports CBT in reducing transition and the value of intervening at this illness stage. STUDY REGISTRATION: Research Registry ID: reviewregistry907.

Intervention strategies for ultra-high risk for psychosis: Progress in delaying the onset and reducing the impact of first-episode psychosis

Over a quarter of a century ago, the formulation of the "at risk mental state" and operational criteria to prospectively identify individuals at "clinical" or "ultra-high risk" (UHR) for psychosis created a global wave of research momentum aimed at predicting and preventing first-episode psychosis. A substantial number of randomized controlled trials (RCTs) were conducted to determine if transition to psychosis could be delayed or even prevented. The efficacy of a range of interventions was examined, with standard meta-analyses clearly indicating that these could at least delay transition for 1-2 years and that outcomes improve. Recently, network meta-analyses have attempted to identify the most effective intervention. These highlighted the fact that no one form of intervention is superior to the rest, a finding interpreted in such a way as to create doubts concerning the value of intervening. These doubts have been reinforced by a subsequent Cochrane review which judged the quality of the evidence as low or very low. Here, we report a narrative review of findings from RCTs and meta-analyses on the efficacy of interventions in UHR. We also critique the network meta-analyses and the Cochrane review, and indicate that many of the trials were of the highest possible quality for such research, and were published in top ranked psychiatry journals, which demand such quality. Although outcomes vary, and the UHR group is clearly heterogeneous, we highlight the clinical benefits of psychosocial treatment. The next generation of clinical trials seek to elucidate the optimal type, duration and sequence of interventions.

Psychological interventions for people with psychotic experiences: A systematic review and meta-analysis of controlled and uncontrolled effectiveness and economic studies

OBJECTIVE

Many people with psychotic experiences do not develop psychotic disorders, yet those who seek help demonstrate high clinical complexity and poor outcomes. In this systematic review and meta-analysis, we evaluated the effectiveness and cost-effectiveness of psychological interventions for people with psychotic experiences.

METHOD

We searched 13 databases for studies of psychological interventions for adults with psychotic experiences, but not psychotic disorders. Our outcomes were the proportion of participants remitting from psychotic experiences (primary); changes in positive and negative psychotic symptoms, depression, anxiety, functioning, distress, and quality of life; and economic outcomes (secondary). We analysed results using multilevel random-effects meta-analysis and narrative synthesis.

RESULTS

A total of 27 reports met inclusion criteria. In general, there was no strong evidence for the superiority of any one intervention. Five studies reported on our primary outcome, though only two reports provided randomised controlled trial evidence that psychological intervention (specifically, cognitive behavioural therapy) promoted remission from psychotic experiences. For secondary outcomes, we could only meta-analyse trials of cognitive behavioural therapy. We found that cognitive behavioural therapy was more effective than treatment as usual for reducing distress (pooled standardised mean difference: -0.24; 95% confidence interval = [-0.37, -0.10]), but no more effective than the control treatment for improving any other outcome. Individual reports indicated that cognitive behavioural therapy, mindfulness-based cognitive therapy, sleep cognitive behavioural therapy, systemic therapy, cognitive remediation therapy, and supportive treatments improved at least one clinical or functional outcome. Four reports included economic evaluations, which suggested cognitive behavioural therapy may be cost-effective compared with treatment as usual.

CONCLUSION

Our meta-analytic findings were primarily null, with the exception that cognitive behavioural therapy may reduce the distress associated with psychotic experiences. Our analyses were limited by scarcity of studies, small samples and variable study quality. Several intervention frameworks showed preliminary evidence of positive outcomes; however, the paucity of consistent evidence for clinical and functional improvement highlights a need for further research into psychological treatments for psychotic experiences.

PROSPERO PROTOCOL REGISTRATION NUMBER

CRD42016033869.

EPA guidance on the early intervention in clinical high risk states of psychoses

This guidance paper from the European Psychiatric Association (EPA) aims to provide evidence-based recommendations on early intervention in clinical high risk (CHR) states of psychosis, assessed according to the EPA guidance on early detection. The recommendations were derived from a meta-analysis of current empirical evidence on the efficacy of psychological and pharmacological interventions in CHR samples. Eligible studies had to investigate conversion rate and/or functioning as a treatment outcome in CHR patients defined by the ultra-high risk and/or basic symptom criteria. Besides analyses on treatment effects on conversion rate and functional outcome, age and type of intervention were examined as potential moderators. Based on data from 15 studies (n = 1394), early intervention generally produced significantly reduced conversion rates at 6- to 48-month follow-up compared to control conditions. However, early intervention failed to achieve significantly greater functional improvements because both early intervention and control conditions produced similar positive effects. With regard to the type of intervention, both psychological and pharmacological interventions produced significant effects on conversion rates, but not on functional outcome relative to the control conditions. Early intervention in youth samples was generally less effective than in predominantly adult samples. Seven evidence-based recommendations for early intervention in CHR samples could have been formulated, although more studies are needed to investigate the specificity of treatment effects and potential age effects in order to tailor interventions to the individual treatment needs and risk status.

Interventions for prodromal stage of psychosis

BACKGROUND

Psychosis is a serious mental condition characterised by a loss of contact with reality. There may be a prodromal period or stage of psychosis, where early signs of symptoms indicating onset of first episode psychosis (FEP) occur. A number of services, incorporating multimodal treatment approaches (pharmacotherapy, psychotherapy and psychosocial interventions), developed worldwide, now focus on this prodromal period with the aim of preventing psychosis in people at risk of developing FEP.

OBJECTIVES

The primary objective is to assess the safety and efficacy of early interventions for people in the prodromal stage of psychosis. The secondary objective is, if possible, to compare the effectiveness of the various different interventions.

SEARCH METHODS

We searched Cochrane Schizophrenia's study-based Register of studies (including trials registers) on 8 June 2016 and 4 August 2017.

SELECTION CRITERIA

All randomised controlled trials (RCTs) evaluating interventions for participants older than 12 years, who had developed a prodromal stage of psychosis.

DATA COLLECTION AND ANALYSIS

Review authors independently inspected citations, selected studies, extracted data, and assessed study quality.

MAIN RESULTS

We included 20 studies with 2151 participants. The studies analysed 13 different comparisons. Group A comparisons explored the absolute effects of the experimental intervention. Group B were comparisons within which we could not be clear whether differential interactive effects were also ongoing. Group C comparisons explored differential effects between clearly distinct treatments. A key outcome for this review was 'transition to psychosis'. For details of other main outcomes please see 'Summary of findings' tables. In Group A (comparisons of absolute effects) we found no clear difference between amino acids and placebo (risk ratio (RR) 0.48 95% confidence interval (CI) 0.08 to 2.98; 2 RCTs, 52 participants; very low-quality evidence). When omega-3 fatty acids were compared to placebo, fewer participants given the omega-3 (10%) transitioned to psychosis compared to the placebo group (33%) during long-term follow-up of seven years (RR 0.24 95% CI 0.09 to 0.67; 1 RCT, 81 participants; low-quality evidence). In Group B (comparisons where complex interactions are probable) and in the subgroup focusing on antipsychotic drugs added to specific care packages, the amisulpiride + needs-focused intervention (NFI) compared to NFI comparison (no reporting of transition to psychosis; 1 RCT, 102 participants; very low-quality evidence) and the olanzapine + supportive intervention compared to supportive intervention alone comparison (RR 0.58 95% CI 0.28 to 1.18; 1 RCT, 60 participants; very low-quality evidence) showed no clear differences between groups. In the second Group B subgroup (cognitive behavioural therapies (CBT)), when CBT + supportive therapy was compared with supportive therapy alone around 8% of participants allocated to the combination of CBT and supportive therapy group transitioned to psychosis during follow-up by 18 months, compared with double that percentage in the supportive therapy alone group (RR 0.45 95% CI 0.23 to 0.89; 2 RCTs, 252 participants; very low-quality evidence). The CBT + risperidone versus CBT + placebo comparison identified no clear difference between treatments (RR 1.02 95% CI 0.39 to 2.67; 1 RCT, 87 participants; very low-quality evidence) and this also applies to the CBT + needs-based intervention (NBI) + risperidone versus NBI comparison (RR 0.75 95% CI 0.39 to 1.46; 1 RCT, 59 participants; very low-quality evidence). Group C (differential effects) also involved six comparisons. The first compared CBT with supportive therapy. No clear difference was found for the 'transition to psychosis' outcome (RR 0.74 95% CI 0.28 to 1.98; 1 RCT, 72 participants; very low-quality evidence). The second subgroup compared CBT + supportive intervention was compared with a NBI + supportive intervention, again, data were equivocal, few and of very low quality (RR 6.32 95% CI 0.34 to 117.09; 1 RCT, 57 participants). In the CBT + risperidone versus supportive therapy comparison, again there was no clear difference between groups (RR 0.76 95% CI 0.28 to 2.03; 1 RCT, 71 participants; very low-quality evidence). The three other comparisons in Group C demonstrated no clear differences between treatment groups. When cognitive training was compared to active control (tablet games) (no reporting of transition to psychosis; 1 RCT, 62 participants; very low quality data), family treatment compared with enhanced care comparison (RR 0.54 95% CI 0.18 to 1.59; 2 RCTs, 229 participants; very low-quality evidence) and integrated treatment compared to standard treatment comparison (RR 0.57 95% CI 0.28 to 1.15; 1 RCT, 79 participants; very low-quality evidence) no effects of any of these approaches was evident.

AUTHORS' CONCLUSIONS

There has been considerable research effort in this area and several interventions have been trialled. The evidence available suggests that omega-3 fatty acids may prevent transition to psychosis but this evidence is low quality and more research is needed to confirm this finding. Other comparisons did not show any clear differences in effect for preventing transition to psychosis but again, the quality of this evidence is very low or low and not strong enough to make firm conclusions.

Interventions and social functioning in youth at risk of psychosis: A systematic review and meta-analysis

AIM

Youth at clinical high risk (CHR) for psychosis often exhibit difficulties in social functioning and poorer social functioning may be predictive of transition to a psychotic disorder. Therefore, the primary objective of this systematic review was to summarize the impact of all interventions on social functioning in CHR samples.

METHOD

Electronic databases PsycINFO, CINAHL, Embase, EBM, and MEDLINE were searched from 1951 to June 2017. Studies were selected if they included any intervention that reported changes in social functioning in youth at CHR. Data were evaluated using random effects pairwise meta-analyses, stratified by time, and reported as the standardized mean difference (SMD).

RESULTS

Nineteen studies met our inclusion criteria, including a total of 1513 CHR participants. The mean age was 20.5 years and 47% were male. Cognitive behavioural therapy (4 studies) did not significantly improve social functioning at 6 months (SMD = 0.06; 95% confidence interval [CI] = -0.35, 0.46), 12 months (SMD = -0.15; 95% CI = -0.38, 0.08) and 18 months (SMD = 0.20; 95% CI = -0.10, 0.50). Omega-3 (2 studies) did not significantly improve social functioning at 6 months (SMD = 0.01; 95% CI = -0.21, 0.24) and 12 months (SMD = -0.08; 95% CI = -0.33, 0.17). Lastly, cognitive remediation (3 studies) did not significantly improve social functioning at 2- to 3-month follow-up (SMD = 0.13, 95% CI = -0.18, 0.43).

CONCLUSIONS

This systematic review and meta-analysis demonstrated that no treatment significantly improved social functioning in youth at CHR. Future randomized control trials are required that are designed to target and improve social functioning in youth at CHR for psychosis.

Early Intervention in Mental Health for Adolescents and Young Adults: A Systematic Review

OBJECTIVE. The purpose of this systematic review was to describe the evidence for the effectiveness of early intervention to improve and maintain performance in occupations for youths with or at risk for serious mental illness (SMI).

METHOD. Titles and abstracts of 670 articles were reviewed, 234 were retrieved for full review, and 30 met inclusion criteria.

RESULTS. Moderate to strong evidence supports cognitive remediation (CR) and mixed evidence supports cognitive–behavioral therapy (CBT) as an adjunct modality to improve general functioning. Moderate to strong evidence supports use of supported employment and supported education (SE/E) to improve social and occupational outcomes in employment and academics. Strong evidence supports family psychoeducation (FPE) to prevent relapse and rehospitalization and improve problem-solving skills and general functioning.

CONCLUSION. Occupational therapy practitioners should integrate CR, SE/E, and FPE into early intervention with youth with or at risk for SMI. In addition, CBT is an effective modality for use with this population.

Supported employment and education in comprehensive, integrated care for first episode psychosis: Effects on work, school, and disability income

BACKGROUND

Participation in work and school are central objectives for first episode psychosis (FEP) programs, but evidence effectiveness has been mixed in studies not focused exclusively on supported employment and education (SEE). Requirements for current motivation to work or go to school limit the generalizability of such studies.

METHODS

FEP participants (N=404) at thirty-four community treatment clinics participated in a cluster randomized trial that compared usual Community Care (CC) to NAVIGATE, a comprehensive, team-based treatment program that included ≥5h of SEE services per week, , grounded in many of the principles of the Individual Placement and Support model of supported employment combined with supported education services. All study participants were offered SEE regardless of their initial interest in work or school. Monthly assessments over 24months recorded days of employment and attendance at school, days of participation in SEE, and both employment and public support income (including disability income). General Estimation Equation models were used to compare CC and NAVIGATE on work and school participation, employment and public support income, and the mediating effect of receiving ≥3 SEE visits on these outcomes.

RESULTS

NAVIGATE treatment was associated with a greater increase in participation in work or school (p=0.0486) and this difference appeared to be mediated by SEE. No group differences were observed in earnings or public support payments.

CONCLUSION

A comprehensive, team-based FEP treatment approach was associated with greater improvement in work or school participation, and this effect appears to be mediated, in part, by participation in SEE.

Early Intervention in Schizophrenia: A Literature Review

Schizophrenia is a debilitating psychiatric disorder seen across the world. Recently, investigators have witnessed an upsurge in research on the potential benefits of early intervention during the prodromal stage: the sooner people start the treatment at their first psychotic episode, the better outcome on symptom relief and better functioning. This paper aims to critically review and synthesize empirical evidence published between 2005 and 2015 regarding the effectiveness of preemptive interventions on transition rate, symptom severity, depression, anxiety, and function level. Randomized controlled trials were identified in seven different electronic databases and twelve studies were included in this review. Findings indicated that intervention was designed not only for help-seeking individuals, but also for their family members. Also, the applications for psychiatric nursing are discussed.

The Common Elements of treatment engagement for clinically high-risk youth and youth with first-episode psychosis

AIM

Without treatment, clinically high-risk (CHR) youth or youth with first-episode psychosis (FEP) have increased risk for significant complications from their illness; yet, treatment engagement among these youth is critically low. The purpose of this study was to examine engagement efforts with CHR/FEP youth to stimulate new ideas that might facilitate participation in services for this population.

METHODS

A literature review using distillation methods identified engagement practices reported in two bodies of literature. The first body of literature (i.e. 'CHR/FEP engagement') included 13 studies employing qualitative designs to explore consumer perspectives about treatment engagement practices in samples of CHR/FEP youth and their families. The second body of research (i.e. 'CHR/FEP RCTs') included 18 randomized controlled trials (RCTs) testing treatments for CHR/FEP youth and their families. Engagement practice frequencies were compared with the frequency of these practices within effective engagement interventions, as tested in 40 RCTs within the broader child and adolescent mental health literature (i.e. 'CAMH engagement').

RESULTS

Treatment attrition and attendance were the most frequent engagement outcomes measured in the CHR/FEP RCTs. There were notable efforts described in the CHR/FEP RCTs towards engaging youth and families, yet CHR/FEP RCTs reportedly included only a small proportion of engagement practices described in either the CHR/FEP or CAMH engagement literatures.

CONCLUSION

Results suggest there might be practices available to complement current efforts at engaging CHR/FEP youth in treatment, and that increased attention to the measurement of engagement outcomes could provide important information regarding engagement in a population with low treatment engagement rates.

Recommendations for the optimal care of patients with recent-onset psychosis in the Asia-Pacific region

Providing optimal care to patients with recent-onset psychosis can improve outcomes and reduce relapse. However, there is a lack of consistency of the implementation of guidelines for such patients across the Asia-Pacific region. We determined a pragmatic set of recommendations for use on a day-to-day basis to help provide optimal care at this crucial stage of illness. The recommendations were developed over a series of meetings by an international faculty of 15 experts from the Asia-Pacific region, Europe, and South Africa. A structured search of the PubMed database was conducted. This was further developed based on the faculty's clinical experience and knowledge of the literature into 10 key aspects of optimal care for patients during the first five years of a diagnosis of a psychotic disorder, with particular relevance to the Asia-Pacific region. Several common principles emerged: adherence to antipsychotic medications is crucial; substance abuse, psychiatric and medical comorbidities should be addressed; psychosocial interventions play a pivotal role; and family members can play a vital role in overall patient care. By following these recommendations, clinicians may improve outcomes for patients with recent-onset psychosis.

Employment and educational outcomes in early intervention programmes for early psychosis: a systematic review

AIMS

Young adults with early psychosis want to pursue normal roles - education and employment. This paper summarises the empirical literature on the effectiveness of early intervention programmes for employment and education outcomes.

METHODS

We conducted a systematic review of employment/education outcomes for early intervention programmes, distinguishing three programme types: (1) those providing supported employment, (2) those providing unspecified vocational services and (3) those without vocational services. We summarised findings for 28 studies.

RESULTS

Eleven studies evaluated early intervention programmes providing supported employment. In eight studies that reported employment outcomes separately from education outcomes, the employment rate during follow-up for supported employment patients was 49%, compared with 29% for patients receiving usual services. The two groups did not differ on enrolment in education. In four controlled studies, meta-analysis showed that the employment rate for supported employment participants was significantly higher than for control participants, odds ratio = 3.66 [1.93-6.93], p < 0.0001. Five studies (four descriptive and one quasi-experimental) of early intervention programmes evaluating unspecified vocational services were inconclusive. Twelve studies of early intervention programmes without vocational services were methodologically heterogeneous, using diverse methods for evaluating vocational/educational outcomes and precluding a satisfactory meta-analytic synthesis. Among studies with comparison groups, 7 of 11 (64%) reported significant vocational/education outcomes favouring early intervention over usual services.

CONCLUSIONS

In early intervention programmes, supported employment moderately increases employment rates but not rates of enrolment in education. These improvements are in addition to the modest effects early programmes alone have on vocational/educational outcomes compared with usual services.

Psychotherapy for adolescents and young adults at high risk for psychosis: a systematic review

AIM

Unlike medication treatment, which may confer an unfavourable risk-benefit ratio, psychosocial intervention has been an emerging target of recent randomized controlled trials (RCTs) assessing its efficacy in delaying or preventing the onset of psychosis in individuals identified at 'clinical high risk'. Literature comparing qualitative differences in these psychotherapeutic interventions is scarce. The aim of the current study was to conduct a PRISMA systematic review evaluating the efficacy of psychotherapeutic interventions in reducing the rates of conversion to psychosis in clinical high-risk individuals.

METHODS

RCTs were identified in PubMed, Medline and PsycINFO databases up to 30 November 2013. Six studies (comprising 800 participants) met review inclusion criteria. Three investigators performed data extraction independently by using a pre-structured selection form, and conducted risk of bias assessment employing the Cochrane approach.

RESULTS

All six studies employed cognitive behaviour therapy as a core element. Three trials achieved a significant effect. The two trials that employed cognitive behaviour therapy enhanced for the specialized needs of clinical high-risk patients maintained significant effects at post-treatment follow up.

CONCLUSION

Evidence from recent trials suggest that cognitive behaviour therapy may be beneficial in delaying or preventing onset of psychosis in clinical high-risk individuals, although effect sizes to date appear small. Further research is needed in larger samples to establish whether cognitive behaviour therapy is efficacious, and if additional intervention components can enhance established psychotherapies.

Prediction and prevention of the first psychotic episode: new directions and opportunities

In the last few decades, substantial research has focused on the possibility of early detection and prevention of the first psychotic episode in young individuals at risk of developing this mental disturbance; however, unresolved clinical and ethical issues still call for further investigations. New perspectives and opportunities may come from the identification of selective psychopathological and instrumental markers linking the appearance of subtle psychotic symptoms with the clinical outcome of specific mental pathologies. Furthermore, empirically derived algorithms and risk staging models should facilitate the identification of targeted prevention therapies, possibly improving the efficacy of well-tolerated therapeutic approaches, such as psychological interventions and natural compound supplementations. To date, the collected evidence on the efficacy and tolerability of pharmacological prevention therapies raises more doubts than hopes. A very early detection of risk and appropriate symptomatic pattern classifications may provide a chance to better match prevention strategies with the development of psychosis.

Cognitive behavioural therapy for psychosis prevention: a systematic review and meta-analysis

BACKGROUND

Clinical equipoise regarding preventative treatments for psychosis has encouraged the development and evaluation of psychosocial treatments, such as cognitive behavioural therapy (CBT).

METHOD

A systematic review and meta-analysis was conducted, examining the evidence for the effectiveness of CBT-informed treatment for preventing psychosis in people who are not taking antipsychotic medication, when compared to usual or non-specific control treatment. Included studies had to meet basic quality criteria, such as concealed and random allocation to treatment groups.

RESULTS

Our search produced 1940 titles, out of which we found seven completed trials (six published). The relative risk (RR) of developing psychosis was reduced by more than 50% for those receiving CBT at every time point [RR at 6 months 0.47, 95% confidence interval (CI) 0.27-0.82, p = 0.008 (fixed-effects only: six randomized controlled trials (RCTs), n = 800); RR at 12 months 0.45, 95% CI 0.28-0.73, p = 0.001 (six RCTs, n = 800); RR at 18-24 months 0.41, 95% CI 0.23-0.72, p = 0.002 (four RCTs, n = 452)]. Heterogeneity was low in every analysis and the results were largely robust to the risk of an unpublished 12-month study having unfavourable results. CBT was also associated with reduced subthreshold symptoms at 12 months, but not at 6 or 18-24 months. No effects on functioning, symptom-related distress or quality of life were observed. CBT was not associated with increased rates of clinical depression or social anxiety (two studies).

CONCLUSIONS

CBT-informed treatment is associated with a reduced risk of transition to psychosis at 6, 12 and 18-24 months, and reduced symptoms at 12 months. Methodological limitations and recommendations for trial reporting are discussed.

Symptom dimensions and functional impairment in early psychosis: more to the story than just negative symptoms

Functional impairment is a defining feature of psychotic disorders and usually appears well before their onset. Negative symptoms play a prominent role in the impaired functioning of individuals with schizophrenia and those at clinical-high-risk (CHR) for psychosis. Despite high rates of depression and anxiety in early psychosis, few studies have examined the contribution of these symptoms to functioning in the putative 'prodrome.' In the current study, we tested the hypotheses that 1) worse negative and disorganized, but not positive, symptoms would be significantly related to impaired social and role functioning in two cohorts of CHR individuals (combined N=98) and a separate sample of individuals with recent-onset (RO) psychotic disorders (N=88); and 2) worse anxiety and depression would be significantly related to impaired functioning in both samples, above and beyond the contributions of negative and disorganized symptoms. Findings largely supported our hypotheses that more severe negative and disorganized symptoms were related to poorer social and role functioning in both samples. Anxiety and depression severity were significantly related to poorer functioning in both samples. In addition, depression, but not anxiety, predicted poorer global and social functioning above and beyond that explained by negative symptoms in the CHR sample. These results suggest the need for phase-specific treatment in early psychosis, with a focus on symptom dimensions to improve functional outcomes for CHR individuals.

Treatment possibilities for individuals at clinical high risk of psychosis

AIM

The purpose of this study was to undertake a first step in trying to understand the types of treatments young people at clinical high risk of psychosis are interested in pursuing.

METHODS

The sample consisted of 30 young people who were current participants in the ongoing North American Prodrome Longitudinal Study (NAPLS 2) and who met criteria for being at clinical high risk for psychosis. Participants were administered a questionnaire that asked them to identify the types of mental health problems they were currently getting help with or would like to get help with and the types of treatments they thought would be helpful and may be interested in receiving.

RESULTS

Results showed that when individuals first began participation in NAPLS, almost half had no expectations for treatment. They wanted help but they did not really know what kind of help to be asking for. Participants had a wide range of concerns for which they wanted help. Although a majority endorsed attenuated positive symptoms as a concern, many other issues such a family and social problems were often identified. For those who were already receiving help, the general opinion was that it was beneficial.

CONCLUSIONS

The findings suggest that this population sees many different interventions as being potentially helpful. Furthermore, they are open to participating in a variety of treatments, including psychotherapeutic and psychiatric interventions as well as more general treatments addressing a range of possible deficits or difficulties.

How should we intervene in psychosis risk syndromes?

Summary

Research diagnostic instruments such as the Structured Interview for Prodromal Syndromes (SIPS) are now able to reliably identify individuals with different types of psychosis risk syndromes (PRS). About one-third of individuals with PRS convert to a diagnosable psychotic disorder within three years of the initial assessment. Currently available randomized controlled trials of interventions aimed at reducing the rate of psychotic conversion of PRS are promising, but they are too small and too short in duration to provide definitive conclusions about effectiveness. Given the high level of false positives (i.e., most individuals with PRS do not progress to frank psychosis) and the lack of definitive evidence about effectiveness, we recommend a staged approach to intervention in PRS that only uses antipsychotic medication after other, more benign approaches have been tried. At present the best approach appears to be to develop high-quality case-management systems for individuals with PRS that provide close follow-up, psychoeducation and psychosocial support to patients and family members, and, possibly, psychotherapeutic and pharmacological treatments (with antipsychotic medications or neuroprotective agents). The effectiveness of these proposed interventions needs to be tested in large randomized controlled trials that follow up subjects for at least three years.

Early interventions to prevent psychosis: systematic review and meta-analysis

OBJECTIVE

To determine whether any psychological, pharmacological, or nutritional interventions can prevent or delay transition to psychotic disorders for people at high risk.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Embase, Medline, PreMedline, PsycINFO, and CENTRAL were searched to November 2011 without restriction to publication status.

REVIEW METHODS

Randomised trials comparing any psychological, pharmacological, nutritional, or combined intervention with usual services or another treatment. Studies of participants with a formal diagnosis of schizophrenia or bipolar disorder were excluded. Studies were assessed for bias, and relevant limitations were considered in summarising the results.

RESULTS

11 trials including 1246 participants and eight comparisons were included. Median sample size of included trials was 81 (range 51-288). Meta-analyses were performed for transition to psychosis, symptoms of psychosis, depression, and mania; quality of life; weight; and discontinuation of treatment. Evidence of moderate quality showed an effect for cognitive behavioural therapy on reducing transition to psychosis at 12 months (risk ratio 0.54 (95% confidence interval 0.34 to 0.86); risk difference -0.07 (-0.14 to -0.01). Very low quality evidence for omega-3 fatty acids and low to very low quality evidence for integrated psychotherapy also indicated that these interventions were associated with reductions in transition to psychosis at 12 months.

CONCLUSIONS

Although evidence of benefits for any specific intervention is not conclusive, these findings suggest that it might be possible to delay or prevent transition to psychosis. Further research should be undertaken to establish conclusively the potential for benefit of psychological interventions in the treatment of people at high risk of psychosis.

The ultra-high risk concept-a review

Attempts to identify people at imminent risk of psychotic disorder have been made during the past 20 years. High-risk criteria have been developed, and despite findings of a recent decline in the rate of onset of psychosis associated with these criteria, people identified still have a significantly greater risk, compared with the general population. Intervention studies in this group indicate that psychological treatments and fish oil appear to be just as effective as antipsychotics. Future research should refine risk factors for psychosis and examine outcomes other than psychosis. Research is also needed into what harms and benefits are associated with making the high-risk criteria into a formal diagnosis.

Is clinical intervention in the ultra high risk phase effective?

Recent research suggests that early intervention in psychosis might improve the chances of recovery and may even be able to prevent the onset of psychotic disorders. Clinical intervention in subjects at ultra high risk (UHR) of psychosis can have three different objectives. The first aim is to improve the 'prodromal' symptoms and problems that subjects usually present with. The second is to reduce the risk of the subsequent onset of frank psychosis. The third objective is to minimize the delay before the initiation of antipsychotic treatment in the subgroup of UHR subjects that go on to develop a first episode of psychosis. Both pharmacological and psychological interventions appear to be effective in reducing the severity of presenting symptoms in UHR subjects. Clinical trials of the impact of these interventions on the risk of subsequent transition to psychosis have been positive, but have involved small samples, and thus the issue of whether the effects persist in the long term remains to be determined. The monitoring of UHR subjects for the first signs of frank psychosis is an effective means of reducing the delay between the onset of the first episode and the start of antipsychotic treatment. Follow-up studies are required to test whether the reduction in this delay leads to an improved long term outcome. To date, the majority of the interventions that have been used in UHR subjects, such as case management, antipsychotic medication, and cognitive behavior therapy have previously been employed in patients with established psychosis. However, it is possible that treatments that are not normally used in patients with psychotic disorders may prove effective when applied at this stage.

Young people at ultra high risk for psychosis: research from the PACE clinic

Over the last fifteen years, attempts have been made to prospectively identify individuals in the prodromal phase of schizophrenia and other psychotic disorders. The ultra high risk approach, based on a combination of known trait and state risk factors, has been the main strategy used. The validation of the ultra high risk criteria allowed for predictive research in this population in an attempt to identify clinical, neurocognitive and neurobiological risk factors for psychosis onset. It also led to a series of intervention studies in this population, which have included the use of low dose antipsychotic medication, cognitive therapy, and omega-3 fatty acids. Although there is moderate evidence for the effectiveness of specific intervention strategies in this population, the most effective type and duration of intervention is yet to be determined. A current controversy in the field is whether to include an adaption of the ultra high risk criteria (the attenuated psychosis syndrome) in the next version of the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition).

Evaluation and treatment of children and adolescents with psychotic symptoms

In recent years, there have been increasing efforts to develop early detection and prevention strategies for patients at risk of the development of psychotic disorders. These efforts have led to improved recognition and characterization of psychotic symptoms in youth. This review focuses on the evaluation of children and adolescents with psychotic symptoms who are experiencing functional impairment but who do not meet current criteria for schizophrenia. For this article, emphasis is placed on the evaluation of symptoms, differential diagnosis, and consideration of potential interventions.

Cognitive behaviour therapy for schizophrenia

Schizophrenia is one of the major and potentially severe mental illnesses. Even with best practices, there are limitations to the effectiveness of treatments that include medications for this disorder. Relapse rates are high and often those with the illness remain symptomatic and functionally impaired. All the evidence suggests that individuals with schizophrenia do best with a combination of pharmacological and psychosocial intervention. One psychosocial treatment that has received much attention is cognitive behaviour therapy (CBT). This brief review will address what we know about the use and effectiveness of CBT at all phases of schizophrenia and its strengths, weaknesses and its future.

Managing the prodrome of schizophrenia

It is a well-known fact that managing schizophrenia patients as early as possible has a positive impact on the psychopathological and psychosocial outcomes of the disorder. Identifying people at risk for this serious disorder before its outbreak has become a major research aim in the past decade. Consequently, the intuitive notion that intervening at this early stage, before a diagnosis of schizophrenia is established, could be a preventive measure has been scientifically studied. In this context, a number of interventions, both pharmacological and psychosocial, have been evaluated in prospective controlled clinical trials. Amisulpride, olanzapine, risperidone, omega-3 fatty acids, and antidepressants have been compared to placebo or other control interventions and have been found somewhat helpful. With the exception of omega-3 fatty acids, however, the original positive findings were not maintained in follow-up studies. In addition, the rates of conversion to psychosis, although generally lower in the experimental treatment groups, were also reasonably low in the control groups. Similar findings have been established in psychotherapy trials.All evidence taken together makes it difficult to justify specific interventions at the prodromal stage of schizophrenia from the perspective of preventing or delaying the onset of the disorder. On the other hand, as many of the affected individuals suffer considerably, symptomatic treatment certainly is called for even though the evidence whether it should be pharmacological or psychosocial is not yet available.

Cognitive behavioral therapy in prodromal psychosis

There is a strong impetus in the psychosis research field to develop interventions that aim to prevent the onset of psychotic disorders. Over the past 15 years there has been a tremendous development in the work aimed at understanding the pre-psychotic period. More recently there has been a focus on developing and testing treatments both pharmacological and psychological that could potentially prevent or delay the onset of psychosis. One of the psychological treatments that has received the most attention is cognitive behavioral therapy (CBT). Relatively few trials have been completed and this paper reviews the existing trials. Implications of these trials for the treatment of this early phase as well as for designing future studies are discussed.

Early intervention for psychosis

BACKGROUND

Proponents of early intervention have argued that outcomes might be improved if more therapeutic efforts were focused on the early stages of schizophrenia or on people with prodromal symptoms. Early intervention in schizophrenia has two elements that are distinct from standard care: early detection, and phase-specific treatment (phase-specific treatment is a psychological, social or physical treatment developed, or modified, specifically for use with people at an early stage of the illness).Early detection and phase-specific treatment may both be offered as supplements to standard care, or may be provided through a specialised early intervention team. Early intervention is now well established as a therapeutic approach in America, Europe and Australasia.

OBJECTIVES

To evaluate the effects of: (a) early detection; (b) phase-specific treatments; and (c) specialised early intervention teams in the treatment of people with prodromal symptoms or first-episode psychosis.

SEARCH STRATEGY

We searched the Cochrane Schizophrenia Group Trials Register (March 2009), inspected reference lists of all identified trials and reviews and contacted experts in the field.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) designed to prevent progression to psychosis in people showing prodromal symptoms, or to improve outcome for people with first-episode psychosis. Eligible interventions, alone and in combination, included: early detection, phase-specific treatments, and care from specialised early intervention teams. We accepted cluster-randomised trials but excluded non-randomised trials.

DATA COLLECTION AND ANALYSIS

We reliably selected studies, quality rated them and extracted data. For dichotomous data, we estimated relative risks (RR), with the 95% confidence intervals (CI). Where possible, we calculated the number needed to treat/harm statistic (NNT/H) and used intention-to-treat analysis (ITT).

MAIN RESULTS

Studies were diverse, mostly small, undertaken by pioneering researchers and with many methodological limitations (18 RCTs, total n=1808). Mostly, meta-analyses were inappropriate. For the six studies addressing prevention of psychosis for people with prodromal symptoms, olanzapine seemed of little benefit (n=60, 1 RCT, RR conversion to psychosis 0.58 CI 0.3 to 1.2), and cognitive behavioural therapy (CBT) equally so (n=60, 1 RCT, RR conversion to psychosis 0.50 CI 0.2 to 1.7). A risperidone plus CBT plus specialised team did have benefit over specialist team alone at six months (n=59, 1 RCT, RR conversion to psychosis 0.27 CI 0.1 to 0.9, NNT 4 CI 2 to 20), but this was not seen by 12 months (n=59, 1 RCT, RR 0.54 CI 0.2 to 1.3). Omega 3 fatty acids (EPA) had advantage over placebo (n=76, 1 RCT, RR transition to psychosis 0.13 CI 0.02 to 1.0, NNT 6 CI 5 to 96). We know of no replications of this finding.The remaining trials aimed to improve outcome in first-episode psychosis. Phase-specific CBT for suicidality seemed to have little effect, but the single study was small (n=56, 1 RCT, RR suicide 0.81 CI 0.05 to 12.26). Family therapy plus a specialised team in the Netherlands did not clearly affect relapse (n=76, RR 1.05 CI 0.4 to 3.0), but without the specialised team in China it may (n=83, 1 RCT, RR admitted to hospital 0.28 CI 0.1 to 0.6, NNT 3 CI 2 to 6). The largest and highest quality study compared specialised team with standard care. Leaving the study early was reduced (n=547, 1 RCT, RR 0.59 CI 0.4 to 0.8, NNT 9 CI 6 to 18) and compliance with treatment improved (n=507, RR stopped treatment 0.20 CI 0.1 to 0.4, NNT 9 CI 8 to 12). The mean number of days spent in hospital at one year were not significantly different (n=507, WMD, -1.39 CI -2.8 to 0.1), neither were data for 'Not hospitalised' by five years (n=547, RR 1.05 CI 0.90 to 1.2). There were no significant differences in numbers 'not living independently' by one year (n=507, RR 0.55 CI 0.3 to 1.2). At five years significantly fewer participants in the treatment group were 'not living independently' (n=547, RR 0.42 CI 0.21 to 0.8, NNT 19 CI 14 to 62). When phase-specific treatment (CBT) was compared with befriending no significant differences emerged in the number of participants being hospitalised over the 12 months (n=62, 1 RCT, RR 1.08 CI 0.59 to 1.99).Phase-specific treatment E-EPA oils suggested no benefit (n=80, 1 RCT, RR no response 0.90 CI 0.6 to 1.4) as did phase-specific treatment brief intervention (n=106, 1 RCT, RR admission 0.86 CI 0.4 to 1.7). Phase-specific ACE found no benefit but participants given vocational intervention were more likely to be employed (n=41, 1 RCT, RR 0.39 CI 0.21 to 0.7, NNT 2 CI 2 to 4). Phase-specific cannabis and psychosis therapy did not show benefit (n=47, RR cannabis use 1.30 CI 0.8 to 2.2) and crisis assessment did not reduce hospitalisation (n=98, RR 0.85 CI 0.6 to 1.3). Weight was unaffected by early behavioural intervention.

AUTHORS' CONCLUSIONS

There is emerging, but as yet inconclusive evidence, to suggest that people in the prodrome of psychosis can be helped by some interventions. There is some support for specialised early intervention services, but further trials would be desirable, and there is a question of whether gains are maintained. There is some support for phase-specific treatment focused on employment and family therapy, but again, this needs replicating with larger and longer trials.

Prevention of the first episode of psychosis

Long a desired goal but increasingly a focus of research on clinical practice, prevention of psychosis has emerged as one of the most promising and effective areas of investigational interest and effort in psychiatry. Spurred by long-term studies that have associated outcome with duration of untreated psychosis, current research is focused on improving the accuracy of prediction based on clinical and neurocognitive measures and on refining treatments of the earliest symptoms of the psychoses. Both efforts are bearing success, although there remains ambiguity as to the most effective preventive interventions. This article reviews the leading studies of, and remaining issues for, this important enterprise.

Early signs, diagnosis and therapeutics of the prodromal phase of schizophrenia and related psychotic disorders

During recent decades, interest in the prevention of mental illnesses has increased. Improved diagnostic tools, the advent of atypical antipsychotic medications and the development of phase-specific psychosocial treatments have made intervention research in people at ultra-high risk for developing schizophrenia or a related psychotic disorder possible. Preliminary data suggest that low doses of atypical antipsychotic medications augmented by psychosocial treatments may delay the onset of psychosis in some individuals. Findings support further research for the establishment of best-practice standards.

A preliminary evaluation of the validity of at-risk criteria for bipolar disorders in help-seeking adolescents and young adults

INTRODUCTION

We have developed ultra-high risk criteria for bipolar affective disorder (bipolar at-risk - BAR) which include general criteria such as being in the peak age range of the onset of the disorder and a combination of specific criteria including sub-threshold mania, depressive symptoms, cyclothymic features and genetic risk. In the current study, the predictive validity of these criteria were tested in help-seeking adolescents and young adults.

METHOD

This medical file-audit study was conducted at ORYGEN Youth Health (OYH), a public mental health program for young people aged between 15 and 24years and living in metropolitan Melbourne, Australia. BAR criteria were applied to the intake assessments of all non-psychotic patients who were being treated in OYH on 31 January, 2008. All entries were then checked for conversion criteria. Hypomania/mania related additions or alterations to existing treatments or initiation of new treatment by the treating psychiatrist served as conversion criteria to mania.

RESULTS

The BAR criteria were applied to 173 intake assessments. Of these, 22 patients (12.7%) met BAR criteria. The follow-up period of the sample was 265.5days on average (SD 214.7). There were significantly more cases in the BAR group (22.7%, n=5) than in the non-BAR group (0.7%, n=1) who met conversion criteria (p<.001).

CONCLUSIONS

These findings support the notion that people who develop a first episode of mania can be identified during the prodromal phase. The proposed criteria need further evaluation in prospective clinical trials.

Randomized-controlled trials in people at ultra high risk of psychosis: a review of treatment effectiveness

As an extension of the early intervention in psychosis paradigm, different focused treatments are now offered to individuals at ultra high risk of psychosis (UHR) to prevent transition to schizophrenia, however the effectiveness of these treatments is unclear. A systematic literature search in PubMed/Medline and PsycINFO was performed to derive information on randomized control trials (RCTs) in UHR samples. Seven reports were identified detailing results from five independent RCT studies. Two studies used antipsychotic drugs (one in combination with cognitive behavior therapy); one study employed cognitive therapy; one study used a two-year program of intensive community care with family psychoeducation; one study assessed the effectiveness of 3-months omega-3 polyunsaturated fatty acids (Omega-3 PUFAs) supplementation. Intensive community care and the Omega-3 PUFAs supplementation were effective in reducing the transition to psychosis at 12 months. Overall, rates of transition to psychosis at 1 year were 11% for focused treatment groups (n=180) and 31.6% for control UHR groups (n=157). Receiving any of the focused treatment was associated with a lower risk of developing psychosis if compared with no treatment or treatment as usual (Relative Risk=0.36; 95%CI: 0.22-0.59). The available evidence at 2/3 years follow-up indicates that the effects of focused treatments are not stable after intervention cessation and when treatment is delivered over a restricted time (e.g. 6 months or less), it may achieve only a delay in psychosis onset. Due to the heterogeneity in the interventions considered, the current results do not allow recommendation for any specific treatment.

An evidence map of interventions across premorbid, ultra-high risk and first episode phases of psychosis

The onset of psychotic disorders peaks in adolescence and young adulthood. Early interventions during the ultra-high risk and first episode stages of illness are increasingly emphasised given the greater opportunities for clinical and functional recovery during these early phases. As a large volume of such research now exists, there is a need to summarise the extent and distribution of research to ascertain what is, and is not yet known about the evidence-base for preventing and treating early psychotic disorders.

METHODS

An 'evidence mapping' methodology was used to systematically search for intervention studies published post-1980 in English (participant mean age: 6-30 years). Studies were restricted to systematic reviews, meta-analyses and controlled trials. The Cochrane Central Register of Controlled Trials, PSYCHINFO, MEDLINE and EMBASE were searched. Studies were screened according to these criteria and mapped on pre-defined study characteristics, including intervention types, stage of illness and type of study.

RESULTS

Fifty-eight controlled trials and 8 systematic reviews were identified. The majority pertained to the first episode stage of illness (n=37), indicated prevention (n=9) and relapse prevention (n=9). Most studies involved biological (n=32) or psychological (n=17) interventions. Antipsychotic medication (n=27) and cognitive behavioural therapy (CBT; n=10) were the most common intervention modalities.

CONCLUSIONS

The extant research is dominated by trials examining intervention for first episode psychosis with antipsychotic medication. Biological interventions other than antipsychotics are sparse for patients with established psychotic disorders. For at-risk populations, there is a need for high-quality prevention studies of pharmaceutical treatments (e.g. neuroprotective agents) and a broad range of psychosocial interventions, including, but not limited to, CBT.

Experience of trauma and conversion to psychosis in an ultra-high-risk (prodromal) group

OBJECTIVE

We aimed to replicate a recent finding of high prevalence of trauma history in patients at 'ultra-high risk' (UHR) of psychotic disorder and to investigate whether trauma predicts conversion to psychosis in this population.

METHOD

A consecutive sample of UHR patients was assessed. History of trauma was accessed with the General Trauma Questionnaire. Cox regression models were used to explore relationship between conversion to psychosis and trauma.

RESULTS

Of 92 UHR patients nearly 70% had experienced a traumatic event and 21.7% developed psychosis during follow-up (mean 615 days). Patients who had experienced a sexual trauma (36%) were significantly more likely to convert to first-episode psychosis (OR 2.96) after controlling for meeting multiple UHR intake groups.

CONCLUSION

UHR patients have a high prevalence of history of trauma. Previous sexual trauma may be a predictor of onset of psychotic disorder in this population.

Staging in neuropsychiatry: a heuristic model for understanding, prevention and treatment

The main mental disorders which develop and persist through adult life typically emerge during the critical developmental phase of adolescence and early adulthood, and are frequently associated with considerable associated distress and functional decline. Our current diagnostic system lacks validity and therapeutic utility, particularly for the early stages of these mental disorders, when symptoms are still evolving and may have not yet stabilised sufficiently to fit familiar or traditional syndromal criteria. Furthermore, there is often difficulty in distinguishing transient developmental or normative changes from the early symptoms of persistent and disabling mental illness. These factors point to the need for reform of our current diagnostic systems. The clinical staging model seeks to define the extent of progression of a disorder at a particular point in time and aims to differentiate early, milder clinical phenomena from those that accompany illness progression and chronicity. The staging framework allows clinicians to select treatments relevant to earlier stages of an illness, and to evaluate their effectiveness in preventing progression and producing remission or return to milder or earlier stages of disorder. For staging to be a valid approach, interventions in the early stages need to shown to be not only more effective but also safer than treatments delivered later in the course of illness. Staging may also allow a more efficient integration of our rapidly expanding knowledge of the biological, social and psychological vulnerability factors involved in development of mental illness into what may ultimately resemble a clinicopathological staging model.