Preventive Treatments for Psychosis: Umbrella Review (Just the Evidence)

Abstract

Background: Indicated primary prevention in young people at Clinical High Risk for Psychosis (CHR-P) is a promising avenue for improving outcomes of one of the most severe mental disorders but their effectiveness has recently been questioned. Methods: Umbrella review. A multi-step independent literature search of Web of Science until January 11, 2019, identified interventional meta-analyses in CHR-P individuals. The individual randomised controlled trials that were analysed by the meta-analyses were extracted. A review of ongoing trials and a simulation of living meta-analysis complemented the analysis. Results: Seven meta-analyses investigating preventive treatments in CHR-P individuals were included. None of them produced pooled effect sizes across psychological, pharmacological, or other types of interventions. The outcomes analysed encompassed risk of psychosis onset, the acceptability of treatments, the severity of attenuated positive/negative psychotic symptoms, depression, symptom-related distress, social functioning, general functioning, and quality of life. These meta-analyses were based on 20 randomised controlled trials: the vast majority defined the prevention of psychosis onset as their primary outcome of interest and only powered to large effect sizes. There was no evidence to favour any preventive intervention over any other (or control condition) for improving any of these clinical outcomes. Caution is required when making clinical recommendations for the prevention of psychosis in individuals at risk. Discussion: Prevention of psychosis from a CHR-P state has been, and should remain, the primary outcome of interventional research, refined and complemented by other clinically meaningful outcomes. Stagnation of knowledge should promote innovative and collaborative research efforts, in line with the progressive and incremental nature of medical knowledge. Advancements will most likely be associated with the development of new experimental therapeutics that are ongoing along with the ability to deconstruct the high heterogeneity within CHR-P populations. This would require the estimation of treatment-specific effect sizes through living individual participant data meta-analyses,

Prenatal and perinatal risk and protective factors for psychosis: a systematic review and meta-analysis

“…A third implication is that our results can advance preventive strategies. To date, prevention of psychosis has predominantly focused on delivering psychosocial interventions 45,75 to people with subthreshold symptoms 76 of the disorder (i.e. indicated prevention 77 ).…”

Identifying extended psychosis phenotypes at school: Associations with socio-emotional adjustment, academic, and neurocognitive outcomes

“…Hence, schools have a key role in the early identification and prevention of individuals at risk for mental disorders (e.g., psychosis) as well as in promoting the optimal child and adolescent development. However, to achieve this goal adequate measurement tools [14,15] and empirically validated treatments are needed [16,17].…”

Prescribing for the early symptoms of psychosis

“…Currently there is not enough evidence for advocating treatments that may prevent a transition from ARMS to psychosis (primary prevention) 11 . If assessing GPs are uncertain, they are encouraged not to simply dismiss clinical presentations as normal adolescence or substance misuse.…”