March 16, 2020
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Researchers report substantial advances in detection, prognosis of individuals at clinical high risk for psychosis

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Paolo Fusar-Poli

Researchers have made substantial advances in the detection and prognosis of individuals at clinical high risk for psychosis, according to results of a systematic review published in JAMA Psychiatry.

However, effective indicated interventions have yet to be identified. Furthermore, the evidence suggested a need for specialized services to detect these at-risk individuals in primary and secondary care settings, to offer psychological and needs-based interventions, and to formulate a prognosis with validated psychometric instruments, researchers wrote.

“Preventing severe mental disorders is possible and should become the cornerstone of clinical psychiatry,” Paolo Fusar-Poli, MD, PhD, of the department of psychosis studies at King’s College London, told Healio Psychiatry. “Prevention is the most effective avenue for improving the lives of many young people who may be affected with severe mental disorders. Evidence from this study can inform the development of clinical services for these young patients and their care, as well as clinical guidelines.”

The clinical high risk for psychosis (CHR-P) paradigm has gained significant traction over the past 2 decades, having stimulated hundreds of research publications. Thus, CHR-P represents the most established preventive approach in clinical psychiatry, and a periodic review of its progress and limitations is vital, the researchers noted.

To appraise the advances and limitations of detection, prognosis and interventions for individuals with CHR-P, Fusar-Poli and colleagues identified meta-analyses conducted in this patient population. They obtained data including sample size of the CHR-P population and comparison group, age and sex of these individuals, type of prognostic assessment, interventions, quality assessment and key findings with their effect sizes.

The researchers evaluated 42 meta-analyses published in the past 6 years and encompassing 81 outcomes. Regarding the detection component, individuals with CHR-P were more frequently male (58%), young (mean age, 20.6 years) and predominantly presented with attenuated psychotic symptoms that lasted for more than 1 year before their presentation at specialized services.

Compared with control participants, those with CHR-P had several sociodemographic risk factors, as well as considerable rates of suicidal ideation (66%), self-harm (49%), comorbid mental disorders (41% with depressive disorders and 15% with anxiety disorders) and substance use (33% tobacco use and 27% cannabis use). This patient population also exhibited 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). Further, the researchers confirmed several neurocognitive and neurobiological alterations.

Regarding the prognostic component, they reported good prognostic accuracy of CHR-P instruments, as long as they were used in clinical samples. The risk for psychosis was highest in the brief and limited intermittent psychotic symptoms subgroup (38%), and overall risk for psychosis was 22% at 3 years. Baseline severity of attenuated psychotic (Cohen d = 0.35) and negative symptoms (Cohen d = 0.39), in addition to low functioning (Cohen d = 0.29), were associated with an increased risk for psychosis. The researchers noted that implementing sequential risk assessments and controlling risk enrichment can optimize prognostic accuracy.

Regarding the intervention component, Fusar-Poli and colleagues found no existing robust evidence to recommend any indicated intervention over another — including control conditions and needs-based interventions — for preventing psychosis or ameliorating any other outcome among individuals with CHR-P. However, needs-based and psychological interventions should still be offered, because the uncertainty of this evidence is high, they noted.

“I was pleased to find substantial evidence that it is now possible to detect young people with emerging mental disorders, to assess them and predict their outcomes, and potentially to treat them preventively,” Fusar-Poli told Healio Psychiatry. “Further, this study highlights that more effective preventive treatments for these individuals should be identified.”

In a related editorial, Patrick D. McGorry, MD, PhD, and Barnaby Nelson, PhD, both of the Centre for Youth Mental Health at the University of Melbourne in Australia, highlighted some potential weaknesses of this research.

“The conventional tools of evidence-based medicine have a major role in guiding the field of psychiatry,” they wrote. “However, they have limitations and are still subject to error and interpretation bias. We believe these orthodox technologies need modernization and better regulation because how they are deployed and interpreted can yield misleading results, which are accorded automatic respect, owing to the brand under which they appear.” – by Joe Gramigna

Disclosures: Fusar-Poli reports grants and personal fees from Lundbeck and personal fees from Menarini. Please see the study for all other authors’ relevant financial disclosures. The editorial authors report no relevant financial disclosures.