Real-world long-term outcomes in individuals at clinical risk for psychosis: The case for extending duration of care

Abstract

Background Most services for individuals at Clinical High Risk for Psychosis (CHR-P) provide short-term clinical care. This study determines the real-world and long-term clinical outcomes beyond transition to psychosis in a large cohort of CHR-P individuals. Method Retrospective RECORD-compliant real-world Electronic Health Records (EHR) cohort study in secondary mental health care (the South London and the Maudsley -SLaM- NHS Foundation Trust). All CHR-P patients accessing the CHR-P service at SLaM in the period 2001–2018 were included. Main outcomes were long-term cumulative risk of first: (i) developing an ICD-10 psychotic disorder (primary outcome), receiving a treatment with (iia) antipsychotic medication, (iib) benzodiazepines, (iic) other psychotropic medications, (iid) psychotherapy, receiving an (iiia) informal or (iiib) compulsory admission into a mental health hospital, and the time to these events; (iiic) number of days spent in hospital and (iv) cumulative risk of death for any reason and age/gender Standardised Mortality Ratio (SMR). Data were extracted from the EHR and analysed with Kaplan Meier failure functions, Cox and zero-inflated negative binomial regressions. Findings 600 CHR-P patients (80.43% Attenuated Psychotic Symptoms, APS; 18.06%, Brief and Limited Intermittent Psychotic Symptoms, BLIPS, 1.51% Genetic Risk and Deterioration Syndrome) were included (mean age 22.63 years, range 13–36; 55.33% males; 46.44% white, mean duration of untreated attenuated psychotic symptoms 676.32 days, 1105.40 SD). The cumulative risk to first psychosis was 0.365 (95%CI 0.302–0.437) at 11 years; first antipsychotic 0.777 (95%CI 0.702–0.844) at 9 years; first benzodiazepine 0.259 (95%CI 0.183–0.359) at 12 years; first other types of medications 0.630 (95%CI 0.538–0.772) at 9 years; first psychotherapy 0.814 (95%CI 0.764–0.859) at 9 years; first informal admission 0.378 (95%CI 0.249–0.546) at 12 years; first compulsory admission 0.251 (95%CI 0.175–0.352) at 12 years; those admitted spent on average 94.84 (SD=169.94) days in hospital; the cumulative risk of death for any reason was 0.036 (95%CI 0.012–0.103) at 9 years, with an SMR of 3.9 (95%CI 1.20–6.6). Compared to APS, BLIPS had a higher risk of developing psychosis, being admitted compulsorily into hospital, receiving antipsychotics and benzodiazepines and lower probability of receiving psychotherapy. Other prognostic factors of long-term outcomes included age, symptoms severity, duration of untreated attenuated psychotic symptoms, ethnicity and employment status. Interpretation Duration of care provided by CHR-P services should be expanded to address long-term real-world outcomes. Funding This study was supported by the King's College London Confidence in Concept award from the Medical Research Council (MRC) (MC_PC_16048) to PF-P. GSP is supported by the Alicia Koplowitz Foundation. HB is supported by a National Institute for...

Longitudinal outcome of attenuated positive symptoms, negative symptoms, functioning and remission in people at clinical high risk for psychosis: a meta-analysis

“…It is thus possible that some of the initial improvements are diminished following discharge from clinical CHR-P services. A similar effect has previously been observed for transition to psychosis, the risk of which persists after the cessation of clinical care from CHR-P services [50] . Notably, the baseline severity of attenuated positive, negative/depressive symptoms and functioning are the strongest meta-analytic predictors of outcome in CHR-P samples (attenuated positive symptoms SMD=0.35, global functioning SMD=-0.29, negative symptoms SMD=0.39) [7] .…”

“…The main clinical implication of this study is to provide evidence for extending clinical CHR-P care in the long-term, beyond 2 years. This conclusion is supported by evidence that other negative outcomes keep increasing in the long-term (after 2 years), including the risk of psychosis onset, informal and compulsory hospital admissions and cumulative exposure to psychotropic medications [50]. Extending the duration of care might be able to address many of these risks and poor outcomes.…”

“…A third hypothesis may be that these symptomatic and functional improvements could also be related to the care that is often provided by CHR-P clinical services, which can include clinical monitoring, crisis management, support, case management, psychosocial assistance, psychoeducation and medications [ [47] , [48] , [49] ]. However, as antipsychotic medications typically used in CHR-P clinics do not reach the minimum effective dosage for treating psychotic symptoms [50] , their impact on outcomes is questionable.…”

Clinical characterization of brief psychotic disorders triggered by the COVID-19 pandemic: a multicenter observational study

“…× 1) but avoiding any aetiological implication, and in the forthcoming ICD-11 that specifier will no longer be available in the new ATPD category [ 11 , 15 , 16 ]. Furthermore, it is noteworthy that there is a diagnostic and prognostic overlap between BPD/ATPD and other operationalizations of short-lived psychotic episodes used in the Clinical High Risk for Psychosis (CHR-P) paradigm such as “Brief Limited Intermittent Psychotic Symptoms” (BLIPS) and “Brief Intermittent Psychotic Symptoms” (BIPS) [ 17 – 19 ]. According to the diathesis-stress model [ 20 ], individuals with brief reactive psychosis have a latent psychological vulnerability (such as heightened emotional reactivity) that makes them more vulnerable to psychotic symptoms when faced with stressful environmental factors [ 13 ].…”

Negative Prognostic Effect of Baseline Antipsychotic Exposure in Clinical High Risk for Psychosis (CHR-P): Is Pre-Test Risk Enrichment the Hidden Culprit?

“…However, another explanatory hypothesis is also possible, that is, that the higher conversion rates in AP-exposed CHR-P might be an epiphenomenon of the enrichment strategies adopted in the different study settings (aka pretest risk enrichment). Concretely, it is possible that the different recruitment and sampling strategies in the studies could lead to different pretest prevalence of more severe cases across the CHR-P centers ( Fusar-Poli et al, 2016 , 2017 ).…”