At risk or not at risk? A meta‐analysis of the prognostic accuracy of psychometric interviews for psychosis prediction

Abstract

An accurate detection of individuals at clinical high risk (CHR) for psychosis is a prerequisite for effective preventive interventions. Several psychometric interviews are available, but their prognostic accuracy is unknown. We conducted a prognostic accuracy meta-analysis of psychometric interviews used to examine referrals to high risk services. The index test was an established CHR psychometric instrument used to identify subjects with and without CHR (CHR1 and CHR2). The reference index was psychosis onset over time in both CHR1 and CHR2 subjects. Data were analyzed with MIDAS (STATA13). Area under the curve (AUC), summary receiver operating characteristic curves, quality assessment, likelihood ratios, Fagan's nomogram and probability modified plots were computed. Eleven independent studies were included, with a total of 2,519 help-seeking, predominately adult subjects (CHR1: N51,359; CHR2: N51,160) referred to high risk services. The mean follow-up duration was 38 months. The AUC was excellent (0.90; 95% CI: 0.87-0.93), and comparable to other tests in preventive medicine, suggesting clinical utility in subjects referred to high risk services. Meta-regression analyses revealed an effect for exposure to antipsychotics and no effects for type of instrument, age, gender, follow-up time, sample size, quality assessment, proportion of CHR1 subjects in the total sample. Fagan's nomogram indicated a low positive predictive value (5.74%) in the general non-help-seeking population. Albeit the clear need to further improve prediction of psychosis, these findings support the use of psychometric prognostic interviews for CHR as clinical tools for an indicated prevention in subjects seeking help at high risk services worldwide.

The Clinical High-Risk State for Psychosis (CHR-P), Version II

“…The use of CHR-P criteria is associated with high prognostic accuracy (AUC at 38 mo = 0.9) that is comparable to other paradigms of preventative medicine, 5 leading to correct 38-month disease prediction in approximately onefourth of the cases (26%), 5 a risk that peaks in the initial 2 years and then plateaus. 6 However, the CHR-P criteria yield successful predictive results only if they are applied to selected samples of individuals.…”

“…6 However, the CHR-P criteria yield successful predictive results only if they are applied to selected samples of individuals. 5 Indeed, recent evidence suggests that significant psychosis risk enrichment occurs before the CHR-P assessment (15% pretest risk at 38 mo, 7 for details see Fusar-Poli and Schultze-Lutter ). For example, applying CHR-P criteria to samples with a lower pretest risk of psychosis 9 may substantially dilute the prognostic accuracy of the paradigm and eventually lead to negative findings in the research studies (eg, Klauser et al 10 ; see also table 2 in the study 5 for more examples).…”

“…5 Indeed, recent evidence suggests that significant psychosis risk enrichment occurs before the CHR-P assessment (15% pretest risk at 38 mo, 7 for details see Fusar-Poli and Schultze-Lutter ). For example, applying CHR-P criteria to samples with a lower pretest risk of psychosis 9 may substantially dilute the prognostic accuracy of the paradigm and eventually lead to negative findings in the research studies (eg, Klauser et al 10 ; see also table 2 in the study 5 for more examples). Within help-seeking individuals undergoing CHR-P assessment, the pretest risk of psychosis is substantial (15 of 26 [58%]) 11 and heterogeneous (95% CI 9%-24%).…”

Intensive community outreach for those at ultra high risk of psychosis: dilution, not solution

“…Indeed, it is not only CAARMS criteria that determine the actual risk of psychosis-transition but also the underlying prevalence of psychosis-risk in the population referred. In a recent meta-analysis, psychosis risk in populations seeking help at high risk services was on average 0.15 (at 38 months) 2 . This is significantly higher than the 0.001 risk of psychosis within 38 months (incidence of psychosis 0.0317 per 100 person-years 95%CI: 0.025-0.041) 3 in the general population.…”

Self-disorders: A promising Candidate for Early Detection

“…In brief, the prognostic value of the CHR approach seems to depend on the examined sample. For example, its utility for a non-helpseeking sample was low, but it was excellent for a sample of help-seeking individuals who had been referred to specialized services (i.e., an enriched sample) (8). In our view, part of the problem is that both BLIPS and APS include near-psychotic or brief psychotic features, so the samples tend to center on individuals in the late prodromal pre-psychotic phase.…”