Improving the Detection of Individuals at Clinical Risk for Psychosis in the Community, Primary and Secondary Care: An Integrated Evidence-Based Approach

Abstract

Background: The first rate-limiting step for improving outcomes of psychosis through preventive interventions in people at clinical high risk for psychosis (CHR-P) is the ability to accurately detect individuals who are at risk for the development of this disorder. Currently, this detection power is sub-optimal. Methods: This is a conceptual and nonsystematic review of the literature, focusing on the work conducted by leading research teams in the field. The results will be structured in the following sections: understanding the CHR-P assessment, validity of the CHR-P as a universal risk state for psychosis, and improving the detection of at-risk individuals in secondary mental health care, in primary care, and in the community. Results: CHR-P instruments can provide adequate prognostic accuracy for the prediction of psychosis provided that they are employed in samples who have undergone risk enrichment during recruitment. This substantially limits their detection power in real-world settings. Furthermore, there is initial evidence that not all cases of psychosis onset are preceded by a CHR-P stage. A transdiagnostic individualized risk calculator could be used to automatically screen secondary mental health care medical notes to detect those at risk of psychosis and refer them to standard CHR-P assessment. Similar risk estimation tools for use in primary care are under development and promise to boost the detection of patients at risk in this setting. To improve the detection of young people who may be at risk of psychosis in the community, it is necessary to adopt digital and/or sequential screening approaches. These solutions are based on recent scientific evidence and have potential for implementation internationally. Conclusions: The best strategy to improve the detection of patients at risk for psychosis is to implement a clinical research program that integrates different but complementary detection approaches across community, primary, and secondary care. These solutions are based on recent scientific advancements in the development of risk estimation tools and e-health approaches and have the potential to be applied across different clinical settings.

Annual Research Review: Prevention of psychosis in adolescents – systematic review and meta‐analysis of advances in detection, prognosis and intervention

“…Study quality was assessed in all the included studies. A modified version of the Newcastle-Ottawa scale for crosssectional and cohort studies, ranging from 0 to 8, was used to remain consistent with previous studies (Fusar-Poli, Tantardini, de Simone, Ramella-Cravaro, et al, 2017;Salazar de Pablo, Catalan, & Fusar-Poli, 2019) (Table S3).…”

Risk factors for eating disorders: an umbrella review of published meta-analyses

“…The results so far have shown that the pre-assessment of risk should be improved to find subjects actually at risk of developing mental disorders. [28][29][30][31][32] Since preventive interventions are not free from potential side effects, they must be performed only for individuals with an epidemiologically and clinically significant risk of any mental illness. 33 Putative risk factors, whose associations have been inflated by biased results, must be replaced with convincing ones, as is being done for several other mental disorders, including schizophrenia, 34,35 autism, 36,37 depression, 38 bipolar disorder, 39 post-traumatic stress disorder, 40 anxiety spectrum disorder and obsessive compulsive disorder.…”

Clinical presentation and need for treatment of a cohort of subjects accessing to a mental illness prevention service

“…A provocative editorial has stated that psychogeriatrics starts right after adolescence, suggesting that the current worldwide mental health services organization splitting adult (age ≥ 18) from childhood/adolescence psychiatry fails to prevent or to intervene early in subjects with mental illness. (Parellada, 2013 ) Hence, mental illness prevention services have been and are being set up in several contexts, (Fusar-Poli et al, 2018; Fusar-Poli, Davies et al, 2019 ; Fusar-Poli, Estradé et al, 2019 ; Fusar-Poli, Oliver et al, 2019 ; McGorry, Hartmann, Spooner, & Nelson, 2018 ) with age intake threshold often below age 18.…”