Interventions in the initial prodromal states of psychosis in Germany: concept and recruitment

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.

The effect of cognitive remediation in individuals at ultra-high risk for psychosis: a systematic review

Cognitive deficits are prominent features of the ultra-high risk state for psychosis that are known to impact functioning and course of illness. Cognitive remediation appears to be the most promising treatment approach to alleviate the cognitive deficits, which may translate into functional improvements. This study systematically reviewed the evidence on the effectiveness of cognitive remediation in the ultra-high risk population. The electronic databases MEDLINE, PsycINFO, and Embase were searched using keywords related to cognitive remediation and the UHR state. Studies were included if they were peer-reviewed, written in English, and included a population meeting standardized ultra-high risk criteria. Six original research articles were identified. All the studies provided computerized, bottom-up-based cognitive remediation, predominantly targeting neurocognitive function. Four out of five studies that reported a cognitive outcome found cognitive remediation to improve cognition in the domains of verbal memory, attention, and processing speed. Two out of four studies that reported on functional outcome found cognitive remediation to improve the functional outcome in the domains of social functioning and social adjustment. Zero out of the five studies that reported such an outcome found cognitive remediation to affect the magnitude of clinical symptoms. Research on the effect of cognitive remediation in the ultra-high risk state is still scarce. The current state of evidence indicates an effect of cognitive remediation on cognition and functioning in ultra-high risk individuals. More research on cognitive remediation in ultra-high risk is needed, notably in large-scale trials assessing the effect of neurocognitive and/or social cognitive remediation on multiple outcomes.

Coping and the stages of psychosis: an investigation into the coping styles in people at risk of psychosis, in people with first-episode and multiple-episode psychoses

AIM

The concept of coping is central to recent models of psychosis. The aim of the present paper is to explore whether specific coping styles relate to certain stages of the disorder.

METHODS

Thirty-nine clients at clinical high risk (CHR) of first-episode psychosis, 19 clients with first-episode psychosis and 52 clients with multiple-episode psychosis completed a Stress Coping Questionnaire. This questionnaire consists of 114 items defining one overall positive coping scale (with three subscales) and one negative coping scale. Analyses of variance with group as between-subject factor and coping behaviour as within-subject factor were used to identify different coping patterns.

RESULTS

On the level of subscales no group differences could be detected, but analysis of variance revealed slightly different patterns: CHR clients used significantly more negative than positive coping styles (P = 0.001), followed by patients with multiple-episode psychosis (P = 0.074). First-episode patients were most likely to use negative as well as positive coping (P = 0.960). Across all stages of illness, stress control was significantly preferred compared to the other positive coping styles distraction and devaluation. Again, this pattern was especially pronounced for at-risk clients and patients with multiple-episode psychosis, whereas patients with first-episode psychosis were most likely to use devaluation as well as distraction.

CONCLUSIONS

The overall coping styles were similar across the different stages of psychosis. However, at-risk persons presented especially pronounced negative coping and a small range of strategies, indicating a specific need for psychosocial support in this stage of the disorder.

[Concept and results of the German Research Network on Schizophrenia]

BACKGROUND

The German Research Network on Schizophrenia (GRNS) was funded by the Federal Ministry of Education and Research (BMBF) from 1999 to 2011. The aim was to obtain a better horizontal and vertical networking of German research and care facilities on schizophrenia, in order to investigate open research questions, to transfer the results into clinical practice and improve care and quality of life in patients with schizophrenia.

OBJECTIVES/METHODS

This paper describes the concept and operations of the GRNS as well as its results on the basis of selected research projects.

RESULTS

The GRNS comprised about 25 clinical trials of high practical relevance, which were closely interrelated regarding content, methodology and organization. The trials primarily served the development and evaluation of new and established diagnostic and therapeutic approaches, the assessment of the status quo of clinical care, as well as its improvements, together with the investigation of basic scientific questions. Many substantial results to highly relevant issues were obtained, which led or will lead to an improvement in mental health care.

CONCLUSIONS

Quantitative and qualitative evaluation parameters, such as scientific publications and obtaining additional grants, as well as promotion of young scientists, public relations activities, congress activities and the foundation of a European Schizophrenia Association, document the successful work of the network. Successful funding requests will allow us to continue cooperative schizophrenia research in Germany as initiated by the GRNS, without necessarily always binding these activities formally to the GRNS.

Coping as a predictor of treatment outcome in people at clinical high risk of psychosis

AIM

The concept of coping is relevant to recent models of psychosis, and people with established psychotic disorders have been found to predominately use maladaptive coping strategies. This study aimed to examine the general coping patterns of people at clinical high risk of psychosis (CHR) and to investigate whether pre-therapy coping behaviour plays a role in predicting responsiveness to early interventions.

METHODS

One hundred twenty-eight help-seeking CHR outpatients were randomized into two treatment groups: either receiving integrated psychological intervention (IPI), including cognitive behaviour therapy, or supportive counselling (SC) for 12 months. Of those, 91 persons completed a Stress Coping Questionnaire (SCQ) at intake: 45 in the IPI group and 46 in the SC group. General coping behaviour in this sample was analysed and several regressions were conducted separately for each treatment group to examine coping as a predictor of outcome after 12 months of different forms of treatment.

RESULTS

Participants relied significantly more on negative than on positive coping strategies, t(90) = -7.185, P < 0.001, and within the positive strategies, stress control was the most preferred one, t(90) = 10.979, P < 0.001. Several pre-therapy coping strategies significantly predicted improvement in symptomatic outcome in both treatment groups, explaining between 16% and 25% of variance. The predictive value of coping was higher in the SC group.

CONCLUSIONS

Maladaptive coping behaviours were found to emerge in the early stages of psychosis and coping behaviour contributed significantly to the prediction of post-treatment symptom improvement. These findings indicate a need for psychosocial support and coping strategy enhancement in people at risk of psychosis.

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.

Psychosis risk screening: a systematic review

Despite the wealth of evidence linking duration of untreated psychosis to critical illness outcomes, most clinicians do not utilize any formal evaluation tools to identify attenuated or emerging psychotic symptoms. Given the costs associated with training and administration, interview-based assessments such as the Structured Interview for Psychosis Risk Syndromes (SIPS) are not likely to be widely adopted for clinical use. The ability to identify high-risk individuals through low-cost, brief methods is essential to the success of scalable prevention efforts. The aim of this article is to present a comprehensive review of the use of self-report forms as psychosis risk "screeners." A literature search revealed 34 investigations in which authors used a self-report questionnaire as a first-step screener in a clinical high-risk assessment protocol. Information about each screener, including reported psychometric data, is presented within the review. Psychosis risk screeners have been used in diverse samples with the goals of validating assessments, screening populations for clinical referral, recruiting samples of interest for research participation, and estimating symptom prevalence and severity. Screeners focusing on attenuated psychotic experiences appear to measure a reliable construct with variable prevalence in help-seeking and general population samples. Administration of screeners to help-seeking populations can identify enriched samples with substantially elevated likelihood of meeting CHR criteria and transitioning to psychosis over time. More research is needed, however, to establish reliable norms and screening thresholds, as score elevations indicating a likely high-risk respondent appear to be unreliable across populations and settings.

The predictive validity of bipolar at-risk (prodromal) criteria in help-seeking adolescents and young adults: a prospective study

OBJECTIVES

There are no established tools to identify individuals at risk for developing bipolar disorder. We developed a set of ultra-high-risk criteria for bipolar disorder [bipolar at-risk (BAR)]. The primary aim of the present study was to determine the predictive validity of the BAR criteria.

METHODS

This was a 12-month prospective study that was conducted at Orygen Youth Health Clinical Program, a public mental health program for young people aged 15-24 years in metropolitan Melbourne, Australia. At intake, BAR screen-positive individuals and a matched group of individuals who did not meet BAR criteria were observed over a period of 12 months. The BAR criteria include general criteria such as being in the peak age range for the onset of the disorder, as well as sub-threshold mania, depression plus cyclothymic features, and depression plus genetic risk. Conversion to first-episode mania/hypomania was defined by the presence of DSM-IV manic symptoms for more than four days, in line with the DSM-IV definition of hypomania/mania.

RESULTS

A total of 559 help-seeking patients were screened. Of the eligible participants, 59 (10.6%) met BAR criteria. Thirty-five participants were included in the BAR group and 35 matched participants were selected to be in the control group. During the follow-up, five BAR patients out of 35 (14.3%) converted to first-episode hypomania/mania as opposed to none in the non-BAR group [χ(2) (1) = 5.38, p = 0.020]. Four out of these five converters had a DSM-IV diagnosis of bipolar I or bipolar II disorder.

CONCLUSIONS

These findings support the possibility of identification of persons prior to the onset of mania/hypomania. The proposed criteria need further evaluation in larger, prospective studies with longer follow-up periods.

The impact of social stress on self-esteem and paranoid ideation

BACKGROUND

Vulnerability-stress models propose that social stress triggers psychotic episodes in high risk individuals. Previous studies found not only stress but also a decrease in self-esteem to precede the formation of delusions. As evidence for causal conclusions has not been provided yet, the present study assessed the direct impact of social stress on paranoid beliefs using an experimental design and considered a decrease in self-esteem as a mediator and the proneness to psychosis and paranoia as moderators of the effect.

METHODS

A nonclinical population sample (n = 76) was randomly assigned to an experimental (EG) or a control group condition (CG). In the EG, participants were excluded during a virtual ball game (Cyberball) by the other two players and received a negative feedback after performing a test. The CG was included in the game and received a neutral feedback. Before and after the experimental conditions, emotions, self-esteem and paranoid beliefs were assessed using state-adapted questionnaires.

RESULTS

After the social stress induction, the EG reported a higher increase in subclinical paranoid beliefs compared to the CG. The impact of social stress on paranoid ideation was mediated by a decrease in self-esteem and moderated by proneness to paranoia. Individuals who felt distressed by paranoid thoughts at baseline were more likely to react with an increase in paranoid ideation under social stress.

LIMITATIONS

The results need to be confirmed in a patient sample to draw conclusions about the processes involved in the formation of delusions in clinically relevant stages.

CONCLUSIONS

The impact of social stress on symptom formation and self-esteem is discussed in terms of recent models of symptom formation and interventions in psychosis.

Neurophysiological correlates of impaired facial affect recognition in individuals at risk for schizophrenia

BACKGROUND

Impairments in facial affect recognition are well documented in individuals suffering from schizophrenia. The aim of the present study was to characterize potential impairments in affect recognition and their electrophysiological correlates in at-risk individuals. Such characterization should add to the question whether the neural processes underlying facial affect recognition deficits might be part of a basic neural dysfunction reflecting a vulnerability factor of schizophrenia.

METHODS

To test facial affect recognition, a digitized series of pictures of facial affect, previously used in related studies, was presented to 37 at-risk individuals and 32 healthy controls. Simultaneously, event-related potentials (ERPs) were recorded to investigate electrophysiological activity during the task.

RESULTS

At-risk individuals showed significant impairments in facial affect recognition and reduced amplitudes in the ERP components P100, N170, and N250. Furthermore, prodromal signs in these individuals were associated with a poorer task performance and a diminished N250 amplitude.

CONCLUSIONS

The findings suggest that impairments in facial affect recognition precede the onset of the initial psychotic episode. The impairments are associated with neurophysiological abnormalities similar to those observed in manifest schizophrenia and therefore may serve as indicators of vulnerability for developing schizophrenia.

A promoter variant of SHANK1 affects auditory working memory in schizophrenia patients and in subjects clinically at risk for psychosis

Mutations in postsynaptic scaffolding genes contribute to autism, thus suggesting a role in pathological processes in neurodevelopment. Recently, two de novo mutations in SHANK3 were described in schizophrenia patients. In most cases, abnormal SHANK3 genotype was also accompanied by cognitive disruptions. The present study queries whether common SHANK variants may also contribute to neuropsychological dysfunctions in schizophrenia. We genotyped five common coding or promoter variants located in SHANK1, SHANK2 and SHANK3. A comprehensive test battery was used to assess neuropsychological functions in 199 schizophrenia patients and 206 healthy control subjects. In addition, an independent sample of 77 subjects at risk for psychosis was analyzed for replication of significant findings. We found the T allele of the SHANK1 promoter variant rs3810280 to lead to significantly impaired auditory working memory as assessed with digit span (12.5 ± 3.6 vs. 14.8 ± 4.1, P < .001) in schizophrenia cases, applying strict Bonferroni correction for multiple testing. This finding was replicated for forward digit span in the at-risk sample (7.1 ± 2.0 vs. 8.3 ± 2.0, P = .044). Previously, altered memory functions and reduced dendritic spines and postsynaptic density of excitatory synapses were reported in SHANK1 knock-out mice. Moreover, the atypical neuroleptic clozapine was found to increase SHANK1 density in rats. Our findings suggest a role of SHANK1 in working memory deficits in schizophrenia, which may arise from neurodevelopmental changes to prefrontal cortical areas.

Preventing progression to first-episode psychosis in early initial prodromal states

BACKGROUND

Young people with self-experienced cognitive thought and perception deficits (basic symptoms) may present with an early initial prodromal state (EIPS) of psychosis in which most of the disability and neurobiological deficits of schizophrenia have not yet occurred.

AIMS

To investigate the effects of an integrated psychological intervention (IPI), combining individual cognitive-behavioural therapy, group skills training, cognitive remediation and multifamily psychoeducation, on the prevention of psychosis in the EIPS.

METHOD

A randomised controlled, multicentre, parallel group trial of 12 months of IPI v. supportive counselling (trial registration number: NCT00204087). Primary outcome was progression to psychosis at 12- and 24-month follow-up.

RESULTS

A total of 128 help-seeking out-patients in an EIPS were randomised. Integrated psychological intervention was superior to supportive counselling in preventing progression to psychosis at 12-month follow-up (3.2% v. 16.9%; P = 0.008) and at 24-month follow-up (6.3% v. 20.0%; P = 0.019).

CONCLUSIONS

Integrated psychological intervention appears effective in delaying the onset of psychosis over a 24-month time period in people in an EIPS.

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.

Antipsychotic medication for early episode schizophrenia

BACKGROUND

Long-term treatment with antipsychotic medications in early episode schizophrenia spectrum disorders is common, but both short and long-term effects on the illness are unclear. There have been numerous suggestions that people with early episodes of schizophrenia appear to respond differently than those with multiple prior episodes. The number of episodes may moderate response to drug treatment.

OBJECTIVES

To assess the effects of antipsychotic medication treatment on people with early episode schizophrenia spectrum disorders.

SEARCH STRATEGY

We searched the Cochrane Schizophrenia Group register (July 2007) as well as references of included studies. We contacted authors of studies for further data.

SELECTION CRITERIA

Studies with a majority of first and second episode schizophrenia spectrum disorders comparing initial antipsychotic medication treatment with placebo, milieu, or psychosocial treatment.

DATA COLLECTION AND ANALYSIS

Working independently, we critically appraised records from 681studies, of which five studies met inclusion criteria. John Rathbone from the Schizophrenia Group supported us with the data extraction. We calculated risk ratios (RR) and their 95% confidence intervals (CI) where possible. For continuous data, we calculated mean difference (MD). We calculated numbers needed to treat/harm (NNT/NNH) where appropriate.

MAIN RESULTS

Five studies with a combined N = 998 met inclusion criteria. Four studies (N = 724) provided leaving the study early data and results suggested that individuals treated with a typical antipsychotic medication are less likely to leave the study early than those treated with placebo (Chlorpromazine: 3 RCTs N = 353, RR 0.4 CI 0.3 to 0.5, NNT 3.2, Fluphenaxine: 1 RCT N = 240, RR 0.5 CI 0.3 to 0.8, NNT 5; Thioridazine: 1 RCT N = 236, RR 0.44 CI 0.3 to 0.7, NNT 4.3, Trifulperazine: 1 RCT N = 94, RR 0.96 CI 0.3 to 3.6). Two studies (Cole 1964; May 1976) contributed data to assessment of side effects and present a general pattern of more frequent side effects among individuals treated with typical antipsychotic medications compared to placebo. Rappaport 1978 suggested a higher rehospitalisation rate for those receiving chlorpromazine compared to placebo (N = 80, RR 2.29 CI 1.3 to 4.0, NNH 2.9). However, a higher attrition in the placebo group is likely to have introduced a survivor bias into this comparison, as this difference becomes non-significant in a sensitivity analysis on intent-to-treat participants (N = 127, RR 1.69 CI 0.9 to 3.0). One study (May 1976) contributes data to a comparison of trifluoperazine to psychotherapy on long-term health in favour of the trifluoperazine group (N = 92, MD 5.8 CI 1.6 to 0.0); however, data from this study are also likely to contain biases due to selection and attrition. One study (Mosher 1995) contributes data to a comparison of typical antipsychotic medication to psychosocial treatment on six-week outcome measures of global psychopathology (N = 89, MD 0.01 CI -0.6 to 0.6) and global improvement (N = 89, MD -0.03 CI -0.5 to 0.4), indicating no between-group differences. On the whole, there is very little useable data in the few studies meeting inclusion criteria.

AUTHORS' CONCLUSIONS

With only a few studies meeting inclusion criteria, and with limited useable data in these studies, it is not possible to arrive at definitive conclusions. The preliminary pattern of evidence suggests that people with early episode schizophrenia treated with typical antipsychotic medications are less likely to leave the study early, but more likely to experience medication-related side effects. Data are too sparse to assess the effects of antipsychotic medication on outcomes in early episode schizophrenia.

Early and broadly defined psychosis risk mental states

Current definitions of the prodromal (or at-risk mental state) phase of schizophrenia include attenuated and/or transient psychotic symptoms as well as a combination of different risk indicators and a recent significant deterioration in global functioning. Data accumulated to date suggest rates of conversion to frank psychosis within two years in 25 to 40% of cases supporting the validity of these criteria. However, at this late phase of illness, functional deterioration is often already pronounced, highlighting the need for earlier identification. Moreover, negative symptoms and social impairments, cognitive deficits, other non-psychotic psychopathology and/or functional decline and non-specific biological indicators, often can be detected well before the at-risk mental state as currently defined; indicating that a broad characterization of an earlier stage may be possible. Identifying specific criteria to define this group of individuals, starting from the framework of familial high-risk, can help define a broader group of people, including earlier at-risk mental states, for future research. The hope is that this research will help facilitate intervention at earlier stages that may in turn minimize functional deterioration, and delay, attenuate or even prevent transition to psychosis. The disadvantages as well as the potential benefits of this approach are discussed.

Ultra high risk (UHR) for psychosis criteria: are there different levels of risk for transition to psychosis?

INTRODUCTION

The ultra high risk (UHR) for psychosis criteria have been validated in a number of studies. However, it is not known whether particular UHR criteria (Attenuated Psychotic Symptoms (APS), Brief Limited Intermittent Psychotic Symptoms (BLIPS) or Trait vulnerability criteria), or combination of criteria, is associated with a higher risk of transition to psychosis. The current study investigated this issue over a 6-month follow-up period. We hypothesised that the risk of transition would increase in the following order: Trait alone<APS alone < APS+Trait<BLIPS.

METHOD

Data on UHR intake criteria and transition to psychosis status at 6 months were analysed for UHR patients seen at the PACE clinic, Orygen Youth Health between January 2000 and November 2008.

RESULTS

A total of 928 new referrals were accepted into the PACE clinic over this period of whom 817 (88%) had baseline information available for analysis. The percentage of subjects who presented with APS, Trait and BLIPS were 83%, 27% and 4%, respectively. When the two intermediate groups (APS alone and APS+Trait) were combined, there was evidence that the risk of transition increased in the order of Trait alone<APS<BLIPS (p=0.024, adjusted analysis).

CONCLUSIONS

Our data suggest that UHR intake criteria predict transition over 6 months in the order of Trait alone<APS<BLIPS. The fact that BLIPS patients are at the highest risk of transition over the short term is consistent with the "early" versus "late" prodrome model. It also indicates that particular clinical attention may need to be paid to BLIPS patients, especially early in the course of treatment.

Intervention in at-risk states for developing psychosis

Indicated prevention is currently one of the most promising approaches to fight the individual and societal burden associated with psychosis and particularly schizophrenia. The number of studies is still limited, yet encouraging results have been reported from pharmacological and psychotherapeutic trials. Furthermore, it has become clear that persons characterized by the at-risk criteria are already ill and do not only need preventive intervention but also treatment. As is indicated by a recent study successfully using omega-3 fatty acids for both purposes, it may be promising to develop and investigate interventions especially for the at-risk state, independent of their effectiveness in manifest disease states. An overview on the current findings and ongoing research in this area is provided.

Sensitivity and specificity of the Chinese version of the Schizotypal Personality Questionnaire-Brief for identifying undergraduate students susceptible to psychosis

BACKGROUND

Early interventions can improve treatment outcomes for individuals with major psychiatric disorders and with nonspecific symptoms but increasingly impaired cognitive perception, emotions, and behaviour. One way used to identify people susceptible to psychosis is through the schizotypal personality trait. Persons with schizotypal characteristics have been identified with the widely used Schizotypal Personality Questionnaire-Brief. However, no suitable instruments are available to screen individuals in the Taiwanese population for evidence of early psychotic symptoms.

OBJECTIVES

The purpose of this study was to test the sensitivity and specificity of the Chinese version of the Schizotypal Personality Questionnaire-Brief for identifying undergraduate students' susceptibility to psychosis.

DESIGN

Two-stage, cross-sectional survey design.

SETTING AND PARTICIPANTS

The self-administered scale was tested in a convenience sample of 618 undergraduate students at a medical university in Taiwan. Among these students, 54 completed the scale 2 weeks apart for test-retest reliability, and 80 were tested to identify their susceptibility to psychosis.

DATA COLLECTION AND ANALYSIS

In Stage I, participants with scores in the top 6.5% were classified as the high-score group (n=40). The control group (n=40) was randomly selected from the remaining participants with scores <15 and matched by gender. These 80 students were asked to participate in psychiatric interviews in Stage II. The instrument was tested for reliability using intraclass correlation coefficients and the Kuder-Richardson formula 20. The instrument was analysed for optimal sensitivity and specificity using odds-ratio analysis and receiver operating characteristic curves.

RESULTS

The 22-item Chinese version of the Schizotypal Personality Questionnaire-Brief had a 2-week test-retest reliability of 0.82 and internal consistency of 0.76. The optimal cut-off score was 17, with odds ratios of 24.4 and an area under the receiver operating characteristic curves of 0.83. The instrument had a sensitivity of 80.0% and specificity of 85.9% in identifying undergraduate students' susceptibility to psychosis.

CONCLUSIONS

The Chinese version Schizotypal Personality Questionnaire-Brief is a reliable instrument, but should not be used as a screening tool until its psychometric properties have been evaluated in more detail. Other screening tools need to be used in future studies with the CSPQ-B to improve the accuracy of identifying susceptibility to psychosis among young adults.

DAOA/G72 predicts the progression of prodromal syndromes to first episode psychosis

The genetic factors determining the progression of prodromal syndromes to first episode schizophrenia have remained enigmatic to date. In a unique prospective multicentre trial, we assessed whether variants at the D-amino acid oxidase activator (DAOA)/G72 locus influence progression to psychosis. Young subjects with a prodromal syndrome were observed prospectively for up to 2 years to assess the incidence of progression to schizophrenia or first episode psychosis. Of the 82 probands with a prodromal syndrome, 21 probands experienced progression to psychosis within the observation period. Assessment of nine common variants in the DAOA/G72 locus yielded two variants with the predictive value for symptom progression: all four probands with the rs1341402 CC genotype developed psychosis compared with 17 out of 78 probands with the TT or CT genotypes (chi(2) = 12.348; df = 2; p = 0.002). The relative risk for progression to psychosis was significantly increased in the CC genotype: RR = 4.588 (95% CI = 2.175-4.588). Similarly, for rs778294, 50% of probands with the AA genotype, but only 22% of probands with a GG or GA genotype progressed to psychosis (chi(2) = 7.027; df = 2; p = 0.030). Moreover, haplotype analysis revealed a susceptibility haplotype for progression to psychosis. This is one of the first studies to identify a specific genetic factor for the progression of prodromal syndromes to schizophrenia, and further underscores the importance of the DAOA/G72 gene for schizophrenia.

Duration of untreated prodromal symptoms and 12-month functional outcome of individuals at risk of psychosis

Individuals seeking help from prodromal services may have been experiencing attenuated psychotic features and psychosocial impairments for a long period prior to referral. The effect of an extended duration of these untreated ;at risk' symptoms on patients' long-term functional outcome was assessed in a 12-month longitudinal observational study (n=49). A longer duration of untreated ;at risk' symptoms was correlated with a reduced improvement in Global Assessment of Functioning scores after 12 months (beta=-0.375, P=0.008). This effect was independent of age and gender and may have implications for the improvement of treatment strategies in pre-psychotic phases.

Update on the management of symptoms in schizophrenia: focus on amisulpride

Amisulpride is an atypical antipsychotic drug with a unique receptor pharmacology which is dose dependent. It is a standard treatment in dysthymia as well as in psychosis. Amisulpride is efficacious, effective and well tolerated in positive symptoms of schizophrenia: there is extensive evidence that it treats negative symptoms when given in low doses, although relative lack of EPS and an antidepressant effect may contribute. In first-episode patients amisulpride is an option, although there is little comparative work available. Amisulpride has the best evidence as an effective adjunct to clozapine treatment. Regarding intellectual function, amisulpride appears cognitive sparing but the clinical relevance of this remains obscure. There is evidence that amisulpride can improve social function but again there is little comparative work to demonstrate any particular advantages. Regarding the current conventional versus atypical antipsychotic controversy, amisulpride did better in switching studies and meta-analyses than in the single large pragmatic randomized trial reported to date. It is a versatile drug, and may offer advantages over other atypical antipsychotic drugs in the treatment of negative and depressive symptoms, and tolerability advantages such as the avoidance of weight gain. Essentially it rests with the treating clinician to employ a rational psychopharmacological approach towards the individual patient: there will be few circumstances in which amisulpride will not be a likely contender as a treatment choice.

Use of Palm computer as an adjunct to cognitive-behavioural therapy with an ultra-high-risk patient: a case report

AIM

Recently, attempts have been made to develop cognitive-behaviour therapy (CBT) treatment models to target negative symptoms in individuals with schizophrenia, as well as individuals at ultra-high risk (UHR) for psychosis. Successful CBT treatment is founded on active patient participation including completion of homework assignments such as daily logs of activities and experiences. However, these very negative symptoms may themselves hinder the rate of homework assignment completion. We describe a case report of using experience sampling method with a Palm computer as an adjunct to CBT with a female patient at UHR status with predominantly negative symptoms. Our aim was to assess the feasibility and effectiveness of this methodology to improve homework completion and overcome treatment barriers associated with negative symptoms.

METHODS

Over the course of treatment, the patient was provided with a Palm computer to carry with her throughout her daily activities. The Palm computer was pre-programmed to beep randomly 10 times per day (10 a.m.-12 a.m.) over each three-day assessment period to elicit information on daily functioning.

RESULTS

The use of the Palm computer was acceptable to the patient and resulted in a substantial increase in homework completion. This methodology resulted in rich information about the patients' daily functioning and patterns of improvement during treatment. The experience sampling method data were also successfully used in the application of treatment interventions.

CONCLUSION

The findings support the feasibility and effectiveness of using Palm computers as adjunct to CBT with UHR individuals with predominantly negative symptoms. The implications for treatment and future research directions are discussed.

Indicated prevention of schizophrenia

INTRODUCTION

Despite recent advances in their treatment, schizophrenic disorders are still among the diseases that most severely impair patients' quality of life. For this reason, centers for the early recognition of schizophrenic disorders have come into existence worldwide. In these centers, much effort is devoted to the development and testing of suitable preventive strategies.

METHODS

In this article, we selectively review the literature on the currently available means of assessing the individual risk of becoming ill with schizophrenia and of preventing the imminent onset of the disease.

RESULTS

The currently recognized neurobiological and psychosocial risk factors are not predictive enough to enable the development and application of selective prevention measures for asymptomatic persons at risk. The imminent onset of schizophrenia can be predicted with high accuracy, however, in cases where an initially non-psychotic patient develops early cognitive symptoms that imply a risk of schizophrenia and then, later on in the prodrome of the disease (which typically lasts about five years), goes on to develop high-risk symptoms with mild psychosis. At this point, a differential strategy of indicated prevention can be put into action, including cognitive behavioral therapy, atypical antipsychotics in low doses, and neuroprotective agents.

DISCUSSION

The current state of knowledge in this innovative field of research leads us to expect that it will soon be possible to offer individually tailored preventive measures to persons seeking medical help and advice because of the early warning signs of schizophrenia.

Kraepelin and psychotic prodromal conditions

When Emil Kraepelin combined the formerly distinct entities of dementia paranoides, catatonia and hebephrenia to form the concept of 'dementia praecox' in 1896, he was well aware that this new disease entity--first coined 'schizophrenia' by Eugen Bleuler in 1908--does not generally only start off with the first psychotic manifestation. Even in his original observations, the characteristic psychotic phenomena developed via transition sequences from rather uncharacteristic prodromal disturbances. Meanwhile an initial prodromal condition was shown for about 75% of first-episode psychosis patients, lasting 5 years on average, possessing pathological significance and leading to psychosocial disruptions. Whereas most symptoms of the initial prodromal condition appear to be rather unspecific and hard to distinguish from other psychiatric conditions especially depressive ones, some syndromes seem to enable an early detection and thus an indicated prevention. These are constituted by attenuated and/or transient psychotic symptoms on the one hand and certain cognitive-perceptive basic symptoms on the other. Whereas the former are thought to delineate an advanced prodromal state, the latter can occur early in course and even at the beginning of the transition sequence to first-rank symptoms. This review will outline the current state of the art of a phase specific early detection and intervention based on these syndromes.

Reduced subjective quality of life in persons at risk for psychosis

OBJECTIVE

Subjective quality of life (sQoL) and potentially contributing factors were investigated in individuals putatively in an early (EIPS) or late initial prodromal state (LIPS) and healthy controls (HC).

METHOD

Participants comprised 58 EIPS individuals, 157 LIPS individuals and 87 HC individuals. sQoL was assessed together with locus of control (LoC), coping, demography and psychopathology.

RESULTS

Putatively prodromal groups exhibited markedly lower sQoL than HC (all domains P < 0.00001). EIPS and LIPS individuals did not differ significantly. Depression was the most consistent explaining variable of sQoL in EIPS and LIPS individuals. In EIPS individuals, LoC emerged as an additional predictor.

CONCLUSION

Individuals at risk for psychosis experienced a marked impairment of sQoL across all domains. This was evident even in the early state, showed no significant further deterioration during the late state and was predominantly explained by non-specific symptoms.

The prevention of schizophrenia

Preventive strategies can be divided into universal, selective and indicated prevention and early intervention. Universal interventions are directed to the general population. Selective approaches are targeted at people who have risk factors for an illness, but who do not show any current signs. Indicated approaches target high risk individuals with minimal signs or symptoms foreshadowing mental disorder, but who do not meet diagnostic levels at the current time. Early intervention involves treating those with already diagnosable disorder in a timely and optimal manner aiming to decrease the severity of the illness, and reduce secondary morbidity. Although universal and selective interventions are not yet viable strategies, indicated prevention and early intervention are now realistic possibilities in schizophrenia. Development of methods to identify those at risk of psychosis continues to evolve. Promising results in the prevention and delay of transition to psychotic disorder from high risk state have been found. Early intervention in schizophrenia, including promotion of early help-seeking, has been shown to reduce the duration of untreated psychosis, which is known to be associated with poor outcome in schizophrenia. Early intervention programmes which optimise the care of the first episode have been shown to produce better outcomes than routine management.

Recruitment and treatment practices for help-seeking "prodromal" patients

The prodrome of psychosis has become a target for early identification and for treatments that address both symptoms and risk for future psychosis. Interest and activity in this realm is now worldwide. Clinical trials with rigorous methodology have only just begun, making treatment guidelines premature. Despite the sparse evidence base, treatments are currently applied to patients in the new prodromal clinics, usually treatments developed for established psychosis and modified for the prodromal phase. This communication will describe representative samplings of how treatment-seeking prodromal patients are currently recruited and treated in prodromal clinics worldwide. Recruitment includes how prodromal patients are sought, initially evaluated, apprised of their high-risk status, and informed of the risks and benefits of prodromal treatments and how their mental state is monitored over time. The treatment modalities offered (and described) include engagement, supportive therapy, case management, stress management, cognitive behavioral treatment, family-based treatment, antipsychotic pharmacotherapy, and non-antipsychotic pharmacotherapy. References for details are noted.

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

AIM

Improvement of social adjustment is a major aim of indicated prevention in young people at risk of developing psychosis. The present study explores the effect of specific cognitive behaviour therapy (CBT) as compared with supportive counselling (SC) on social adjustment in people in a potential early initial prodromal state of psychosis (EIPS) primarily defined by self-experienced cognitive thought and perception deficits (basic symptoms).

METHODS

A total of 128 help-seeking outpatients in the EIPS were randomized to receive either specific CBT or SC for 12 months. Social adjustment was assessed with the Social Adjustment Scale II (SAS II) at baseline, time of transition or post treatment

RESULTS

From 113 patients, who completed the SAS II at intake, 67 (59.3%) completed the SAS assessments at time of transition or post treatment. Both specific CBT and SC resulted in improvements in scales of SAS II, with no significant between-group differences post treatment.

CONCLUSIONS

  Although treatment in specially designed early detection and intervention centres improves functioning of people in the EIPS, specific CBT was not superior to SC. One could hypothesize that additional vocational rehabilitation, case management and involvement of multidisciplinary teams are needed to further improve short-term outcome of specific interventions on this dimension.

Assessment of adolescents at risk for psychosis

Early intervention in schizophrenia is an emerging goal of research investigating the earliest phases of the illness, which occur predominantly in adolescence and young adulthood. In order to develop strategies for early intervention, individuals at highest risk for the development of psychosis must be accurately identified. Here we briefly review the historical approaches to the assessment of risk for schizophrenia and highlight the more recently developed interview-based methods for the assessment of incipient psychosis, with particular attention paid to their applicability in adolescence. We present a prototypical assessment battery that includes an integration of historical assessment approaches to form a comprehensive assessment of threshold and subthreshold psychopathology, and other assessment procedures targeted specifically at adolescents. This battery may assist in unraveling the complex presentation of prodromal symptoms during the adolescent developmental period.

The German Research Network on Schizophrenia--impact on the management of schizophrenia

The German Research Network On Schizophrenia (GRNS) is a nationwide network currently comprising 16 psychiatric university departments and 14 state and district hospitals, as well as six local networks of psychiatric practices and general practitioners collaborating on about 25 interrelated, multicenter projects on schizophrenia research. The GRNS aims to intensify collaboration and knowledge exchange betvi/een leading research institutions and qualified routine care facilities, both within (horizontal network) and between (vertical network) the two levels of research and care, in order to create the scientific preconditions for optimization of the management of schizophrenia. The concept and the first results of studies aiming at the investigation of(i) strategies for early detection and early intervention in the prodromal stage of psychosis; (ii) treatment in first-episode schizophrenia; (iii) quality management; and (iv) destigmatization, are described as examples of this effort.

Prospective investigations of the prodromal state of schizophrenia: review of studies

OBJECTIVE

The paper presents a comprehensive overview of prospective studies monitoring or intervening in the pre-onset phase of first episode psychosis.

METHOD

A systematic literature search was conducted and supplemented by a manual search. All relevant studies were ordered and intensively reviewed according to specified criteria. Methodological and conceptual issues are discussed.

RESULTS

Reports of 23 prospective studies were found, some describing subsamples of larger samples. Major methodological and conceptual divergences exist.

CONCLUSION

Applied criteria detect individuals with a significantly increased risk of psychosis within the schizophrenia spectrum, but these criteria are only validated on clinical populations. The significance of differences in sample-characteristics is unclear. Most study samples are small. Results are preliminary and in need of further research before they constitute a realistic knowledge base. Methodological and conceptual issues should not be underestimated.

Recent approaches to psychological interventions for people at risk of psychosis

With the emerging global focus on early psychosis, indicated prevention in schizophrenia has increasingly become a focus of psychiatric research interests. It has been argued that CBT may have some advantages compared with antipsychotics regarding this issue. According to MEDLINE, EMBASE and Psycinfo two completed randomised controlled trials (RCTs; PACE, Melbourne, Australia; EDIE, Manchester, United Kingdom) and one ongoing RCT with only preliminary results published so far (FETZ, Cologne/Bonn, Germany) on indicated prevention in schizophrenia including manualised and standardised psychological treatment can be identified. The aims of the present paper are to present and discuss the three approaches with regard to (I) inclusion, exclusion and exit criteria, (II) characteristics of interventions and (III) evaluations. All interventions use intake, exclusion and exit criteria, which have been evaluated in prospective follow-along studies. The approaches are based on the general structure and principles of cognitive behavioural therapy which have been developed, applied and evaluated in a wide range of mental health problems. Despite several methodological limitations, the first evaluations indicate some effects with regard to three possible aims of early intervention: (1) improvement of present possible pre-psychotic symptoms, (2) prevention of social decline/stagnation and (3) prevention or delay of progression to psychosis. Even though the first results are promising, we conclude that several ethical issues have to be taken into consideration and further predictive and therapeutic research is needed to judge whether psychological intervention is a realistic option for the treatment of people at risk of psychosis.

Subjective quality of life in subjects at risk for a first episode of psychosis: a comparison with first episode schizophrenia patients and healthy controls

The concept of quality of life (QoL) is of growing relevance in schizophrenia research. However, there is to date no information on subjective QoL in subjects at risk for a first episode of psychosis in comparison to first episode schizophrenia patients (FE) or healthy controls (HC). Therefore 45 subjects in a putatively early initial prodromal state (EIPS), 40 FE and 45 HC were assessed on demographics, symptoms and subjective QoL as measured by the Modular System for Quality of Life. Results indicated that in most areas HC experienced the highest QoL scores followed in hierarchical order by EIPS and FE. EIPS and FE experienced significantly lower QoL than HC in 5 and 6 of 7 QoL domains. EIPS experienced the lowest ratings in affective QoL. Thus the data demonstrates that subjective QoL in subjects at risk for a first episode of psychosis is substantially reduced when compared with HC and suggests that subjective QoL is already compromised prior to the onset of first positive schizophrenia symptoms. These findings support the notion that subjects at risk for a first episode of psychosis constitute a clinical population for which further service and intervention research is indicated.