Establishing a clinical service to prevent psychosis: What, how and when? Systematic review

Abstract

The first rate-limiting step to successfully translate prevention of psychosis in to clinical practice is to establish specialised Clinical High Risk for Psychosis (CHR-P) services. This study systematises the knowledge regarding CHR-P services and provides guidelines for translational implementation. We conducted a PRISMA/MOOSE-compliant (PROSPERO-CRD42020163640) systematic review of Web of Science to identify studies until 4/05/2020 reporting on CHR-P service configuration, outreach strategy and referrals, service user characteristics, interventions, and outcomes. Fifty-six studies (1998–2020) were included, encompassing 51 distinct CHR-P services across 15 countries and a catchment area of 17,252,666 people. Most services (80.4%) consisted of integrated multidisciplinary teams taking care of CHR-P and other patients. Outreach encompassed active (up to 97.6%) or passive (up to 63.4%) approaches: referrals came mostly (90%) from healthcare agencies. CHR-P individuals were more frequently males (57.2%). Most (70.6%) services accepted individuals aged 12–35 years, typically assessed with the CAARMS/SIPS (83.7%). Baseline comorbid mental conditions were reported in two-third (69.5%) of cases, and unemployment in one third (36.6%). Most services provided up to 2-years (72.4%), of clinical monitoring (100%), psychoeducation (81.1%), psychosocial support (73%), family interventions (73%), individual (67.6%) and group (18.9%) psychotherapy, physical health interventions (37.8%), antipsychotics (87.1%), antidepressants (74.2%), anxiolytics (51.6%), and mood stabilisers (38.7%). Outcomes were more frequently ascertained clinically (93.0%) and included: persistence of symptoms/comorbidities (67.4%), transition to psychosis (53.5%), and functional status (48.8%). We provide ten practical recommendations for implementation of CHR-P services. Health service knowledge summarised by the current study will facilitate translational efforts for implementation of CHR-P services worldwide.

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

“…This meta-analysis is based on a large dataset encompassing 75 studies and 5,288 CHR-P individuals. The mean age of 20 years and minimally higher frequency of males (55.5%) in the CHR-P individuals of the meta-analysed cohorts is consistent with the typical sociodemographic profile of this group [11] . The large number of studies identified indicates that, as well as transition to psychosis, other outcomes are increasingly being evaluated in prospective studies of CHR-P subjects.…”

“…However, two recent meta-analyses of randomised controlled trials conducted in CHR-P individuals found that antipsychotics were not superior to other interventions for improving APS [ 24 , 60 ]. It is also likely that antipsychotics are initially prescribed to those CHR-P individuals who have higher levels of APS [ 11 , 61 ] and are perceived as being at higher risk of developing psychosis, and therefore have more chances to display relative improvements over follow-up time. Although in the past antipsychotics have been compared to placebo in CHR-P individuals [47] , they are currently not recommended by clinical guidelines for CHR-P individuals due to the lack of preventive evidence and low benefit to risk ratio [4] .…”

“…CHR-P individuals are adolescents and young adults, and typically accumulate risk factors for psychotic disorders [ [5] , [6] , [7] ], present with subtle clinical symptoms [8] and suffer from functional impairment [9] . Because of these problems (as well as comorbid psychiatric conditions), they often seek help at mental health clinics [ 10 , 11 ], where specialised psychometric instruments are used to formulate a group-level prognosis [12] .…”

Age at onset of mental disorders worldwide: large-scale meta-analysis of 192 epidemiological studies

“…Although many mental health services have tried to address this discontinuity of care [63,64], significant gaps remain. Future mental health reforms could leverage and refine clinical high-risk services for young people at risk of psychosis, which typically accepts referrals aged 14-35 years and therefore provide essential transitional care to this vulnerable young population [15,17,58].…”

“…For example, young people with attenuated symptoms for psychosis [10][11][12][13] and functional impairments accumulate several risk factors and have a 25% probability of developing the disorder over 3 years [14]. Clinical care for these individuals is typically implemented in specialised clinical services [15][16][17][18] and has the potential to delay or impede the transition to psychosis, although the efficacy of preventive interventions awaits more robust evidence [19][20][21]. Targeted preventive approaches involve screening programmes in asymptomatic individuals who have significant risk factors for certain psychiatric disorders [7,22,23] (primary selective prevention [7,8]) or public health campaigns in the general population (primary universal prevention) [7,8,24].…”