Disorder, not just state of risk: Meta-analysis of functioning and quality of life in people at high risk of psychosis

Fusar‐Poli, Paolo; Rocchetti, Matteo; Sardella, Alberto; Avila, Alessia; Brandizzi, Martina; Caverzasi, Edgardo; Politi, Pierluigi; Ruhrmann, Stephan; McGuire, Philip

doi:10.1192/bjp.bp.114.157115

Cited by 236 publications

(206 citation statements)

References 84 publications

(101 reference statements)

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“…Firstly, this state is the closest antecedent of psychosis by definition, with onset of the disorder occurring from within a few months of ultra-high-risk diagnosis 110 . Indeed, some ultra-highrisk individuals already present with severe symptoms, including short-lived psychotic episodes 111,112 , affective symptoms 113 and impaired functioning 114 . Secondly, the ultra-high-risk state is intrinsically heterogeneous 10,115 , including different subgroups 115 and varying diagnostic operationalizations 116 .…”

Section: Discussionmentioning

confidence: 99%

What causes psychosis? An umbrella review of risk and protective factors

et al. 2018

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Psychosis is a heterogeneous psychiatric condition for which a multitude of risk and protective factors have been suggested. This umbrella review aimed to classify the strength of evidence for the associations between each factor and psychotic disorders whilst controlling for several biases. The Web of Knowledge database was searched to identify systematic reviews and meta-analyses of observational studies which examined associations between socio-demographic, parental, perinatal, later factors or antecedents and psychotic disorders, and which included a comparison group of healthy controls, published from 1965 to January 31, 2017. The literature search and data extraction followed PRISMA and MOOSE guidelines. The association between each factor and ICD or DSM diagnoses of non-organic psychotic disorders was graded into convincing, highly suggestive, suggestive, weak, or non-significant according to a standardized classification based on: number of psychotic cases, random-effects p value, largest study 95% confidence interval, heterogeneity between studies, 95% prediction interval, small study effect, and excess significance bias. In order to assess evidence for temporality of association, we also conducted sensitivity analyses restricted to data from prospective studies. Fifty-five meta-analyses or systematic reviews were included in the umbrella review, corresponding to 683 individual studies and 170 putative risk or protective factors for psychotic disorders. Only the ultra-high-risk state for psychosis (odds ratio, OR59.32, 95% CI: 4.91-17.72) and Black-Caribbean ethnicity in England (OR54.87, 95% CI: 3.96-6.00) showed convincing evidence of association. Six factors were highly suggestive (ethnic minority in low ethnic density area, second generation immigrants, trait anhedonia, premorbid IQ, minor physical anomalies, and olfactory identification ability), and nine were suggestive (urbanicity, ethnic minority in high ethnic density area, first generation immigrants, North-African immigrants in Europe, winter/spring season of birth in Northern hemisphere, childhood social withdrawal, childhood trauma, Toxoplasma gondii IgG, and non-right handedness). When only prospective studies were considered, the evidence was convincing for ultra-high-risk state and suggestive for urbanicity only. In summary, this umbrella review found several factors to be associated with psychotic disorders with different levels of evidence. These risk or protective factors represent a starting point for further etiopathological research and for the improvement of the prediction of psychosis.

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Section: Discussionmentioning

confidence: 99%

What causes psychosis? An umbrella review of risk and protective factors

et al. 2018

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“…This assertion was based on population-based studies which seemed to reveal that the psychosis phenotype was more widely distributed in the general population 4 5. Conversely, all samples of UHR patients with even subthreshold psychotic symptoms were functionally impaired,6 distressed and seeking help. They clearly were in need of care even prior to reaching full diagnostic threshold.…”

Section: Challenges and Confusions: Uhr And Need For Carementioning

confidence: 95%

Ultra-high-risk paradigm: lessons learnt and new directions

McGorry

Mei

2018

Evid Based Mental Health

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Within the embryonic early psychosis field in the early 1990s, the conceptualisation and definition of an at-risk or ultra-high-risk (UHR) mental state for psychosis was a breakthrough which transformed the clinical and research landscape in psychiatry. Twenty-five years later, we have a new evidence base that has illuminated the neurobiology of the onset phase of psychotic disorder, delivered Cochrane level 1 evidence showing that the onset of full-threshold sustained psychotic disorder can be at least delayed, and is paving the way to a new generation of transdiagnostic research. Here, we document the contribution of the UHR approach to understanding the underlying mechanisms of psychosis onset as well as the long-term outcomes. Particularly, we highlight that psychosis onset can be delayed in those meeting UHR criteria and that these criteria have a higher valence for subsequent psychotic disorders and some valence for persistent non-psychotic syndromes. Critiques have helped to identify some of the limitations of this paradigm, which are acknowledged. These include evidence that psychotic disorders can emerge more acutely and from other, as yet undefined, precursor states. Rather than defending, or alternatively questioning the value of, the UHR approach, we propose a broader, transdiagnostic staging model that is consistent with the pluripotent and variably comorbid trajectories for mental disorders. This approach moves beyond psychosis to capture a wider range of subthreshold symptoms and full-threshold disorders, thus enhancing prediction for the emergence and progression of a range of mental disorders, as well as providing new avenues for early intervention and prevention.

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“…Beyond these limitations, the key finding of 2.09% psychosis risk (at 2.5 years) in people meeting UHR from the general population is of crucial clinical relevance. It is strikingly lower than the annualized 2-year 20% (95% CI: 17%-25%) 5 transition risk in help-seeking UHR samples, that are characterized by frequent comorbid affective disorders and functional impairments 6 .…”

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confidence: 95%

“…Since prevention programs address risk and protective factors that are common to a range of behavioral problems, they produce positive outcomes not just in drug taking but also in reducing aggression, early pregnancies, and drugged driving, and improve mental health and educational outcomes. Highest priority should be given to interventions targeting children and youth, since the earlier the use of drugs the greater the risk for substance use disorders and the higher their severity 6 . Implement evidence-based treatments for substance use disorders.…”

Section: Paolo Fusar-polimentioning

confidence: 99%

Disorder, not just state of risk: Meta-analysis of functioning and quality of life in people at high risk of psychosis

Abstract: Our results indicate that the high-risk state is characterised by consistent and large impairments of functioning and reduction in QoL similar to those in other coded psychiatric disorders.

Cited by 236 publications

References 84 publications

What causes psychosis? An umbrella review of risk and protective factors

What causes psychosis? An umbrella review of risk and protective factors

Ultra-high-risk paradigm: lessons learnt and new directions

Why ultra high risk criteria for psychosis prediction do not work well outside clinical samples and what to do about it

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