Prevention of Psychosis

Abstract

IMPORTANCE Detection, prognosis, and indicated interventions in individuals at clinical high risk for psychosis (CHR-P) are key components of preventive psychiatry. OBJECTIVE To provide a comprehensive, evidence-based systematic appraisal of the advancements and limitations of detection, prognosis, and interventions for CHR-P individuals and to formulate updated recommendations. EVIDENCE REVIEW Web of Science, Cochrane Central Register of Reviews, and Ovid/PsychINFO were searched for articles published from January 1, 2013, to June 30, 2019, to identify meta-analyses conducted in CHR-P individuals. MEDLINE was used to search the reference lists of retrieved articles. Data obtained from each article included first author, year of publication, topic investigated, type of publication, study design and number, sample size of CHR-P population and comparison group, type of comparison group, age and sex of CHR-P individuals, type of prognostic assessment, interventions, quality assessment (using AMSTAR [Assessing the Methodological Quality of Systematic Reviews]), and key findings with their effect sizes.FINDINGS In total, 42 meta-analyses published in the past 6 years and encompassing 81 outcomes were included. For the detection component, CHR-P individuals were young (mean [SD] age, 20.6 [3.2] years), were more frequently male (58%), and predominantly presented with attenuated psychotic symptoms lasting for more than 1 year before their presentation at specialized services. CHR-P individuals accumulated several sociodemographic risk factors compared with control participants. Substance use (33% tobacco use and 27% cannabis use), comorbid mental disorders (41% with depressive disorders and 15% with anxiety disorders), suicidal ideation (66%), and self-harm (49%) were also frequently seen in CHR-P individuals. CHR-P individuals showed impairments in work (Cohen d = 0.57) or educational functioning (Cohen d = 0.21), social functioning (Cohen d = 1.25), and quality of life (Cohen d = 1.75). Several neurobiological and neurocognitive alterations were confirmed in this study. For the prognosis component, the prognostic accuracy of CHR-P instruments was good, provided they were used in clinical samples. Overall, risk of psychosis was 22% at 3 years, and the risk was the highest in the brief and limited intermittent psychotic symptoms subgroup (38%). Baseline severity of attenuated psychotic (Cohen d = 0.35) and negative symptoms (Cohen d = 0.39) as well as low functioning (Cohen d = 0.29) were associated with an increased risk of psychosis. Controlling risk enrichment and implementing sequential risk assessments can optimize prognostic accuracy. For the intervention component, no robust evidence yet exists to favor any indicated intervention over another (including needs-based interventions and control conditions) for preventing psychosis or ameliorating any other outcome in CHR-P individuals. However, because the uncertainty of this evidence is high, needs-based and psychological interventions should still be offered. CONCL...

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

“…The achievements and challenges of the CHR-P paradigm have been recently appraised by an umbrella review (9). In brief, three CHR-P subgroups have been established: attenuated psychotic symptoms; brief limited and intermittent psychotic symptoms (BLIPS) and genetic risk and deterioration (GRD) syndrome (9,10). There are substantial diagnostic (11), prognostic (10,12), clinical (13), and therapeutic (14) differences across these three subgroups.…”

“…Although specific knowledge for APS is limited, CHR-P individuals show impairments in work, educational and social functioning as well as poor quality of life (9,36). Furthermore, psychopathology can adversely influence functioning (37).…”

“…Negative symptoms have been associated with functioning, both daily (38), work related (39) and real-world functioning (40). Among CHR-P individuals, the severity of attenuated positive and negative symptoms has been associated with some outcomes [e.g., transition to psychosis (9, 21)] but not with others [e.g., cannabis use (9)]. Our preliminary results showed that poorer functioning in adolescents with APS was associated with more severe attenuated positive, negative, and general symptoms (22).…”

Community Psychosis Risk Screening: An Instrument Development Investigation

“…It is now clear that a period characterized by functional decline and subthreshold psychotic symptoms exists prior to the onset of a full-blown psychotic disorders, such as schizophrenia [5]. This period is termed the prodrome of psychosis and can range in duration from brief to approximately 5 years, with the majority of cases developing a psychotic disorder within 1 year [6][7][8][9]. Prodromal signs include changes in perceptual and thought processes within the past year, such as hearing things that others do not hear without clear conviction that the experiences occurred [5].…”

“…Self-report approaches to identification of those at risk for psychosis have been investigated in a series of studies and demonstrate good validity and promising positive predictive values (PPVs) when compared with semistructured interviews [13,14]. Although there are findings from Europe of successful community psychosis risk screening [15,16], nearly all of the existing screening tool-to-interview validation studies have used treatment seeking and/or clinical high risk (CHR) for psychosis samples, carefully selected and recruited for genetic risk or suspected clinical risk, through referrals or preliminary phone screenings [6]. Thus, valid and effective early screening in non-clinical US samples is needed.…”