Is the Clinical High-Risk State a Valid Concept? Retrospective Examination in a First-Episode Psychosis Sample

Shah, Jai; Crawford, Anne; Mustafa, Sally; Iyer, Srividya N.; Joober, Ridha; Malla, Ashok

doi:10.1176/appi.ps.201600304

Cited by 65 publications

(72 citation statements)

References 26 publications

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“…As well as early intervention for FEP, a new approach has emerged over the past two decades, based on the ability to identify help-seeking individuals displaying clinical features of an "At Risk Mental State," also described as "Ultra High-Risk" and "Clinical High-Risk for Psychosis (CHR-P)" (Fusar-Poli et al, 2012;Fusar-Poli, 2017;Yung et al, 1996;Yung, Phillips, Yuen, & McGorry, 2004). Of relevance for this study, recent evidence confirmed that most FEP cases are preceded by CHR-P features (Shah et al, 2017). Help-seeking behaviour (Falkenberg et al, 2015) and functional deterioration are usual.…”

mentioning

confidence: 78%

“…Since most cases of psychosis are preceded by CHR-P (Shah et al, 2017) and 36% of people with CHR-P develop FEP after 3 years (Fusar-Poli et al, 2012), number of new CHR-P cases were estimated as at least three times higher than number of FEPs. For this paper, we therefore estimated annual CHR-P incidence as 200/100 000 of the 15-34 population although also applied a more conservative annual incidence of 150/100 000.…”

Section: -34 Year Oldsmentioning

confidence: 99%

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Applying economic models to estimate local economic benefits of improved coverage of early intervention for psychosis

Campion

Taylor

McDaid

et al. 2019

Early Intervention Psych

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Aim Early Intervention Psychosis Services (EIPS) for people experiencing First Episode Psychosis (FEP) offer important clinical and non‐clinical benefits over standard care. Similarly, intervention for Clinical High Risk for Psychosis state (CHR‐P) can prevent psychosis, ameliorate symptoms and have non‐clinical benefits. This study aimed to estimate associated local economic benefits of FEP and CHR‐P services compared with standard care. Methods Across four south London boroughs, proportion of annual number of new cases of FEP and CHR‐P seen by early intervention services was estimated. Economic modelling conducted for England's mental health strategy was applied to estimate local economic impacts of current and improved service provision. Results Across four London boroughs during 2011/2012, proportion of 15‐34 year olds with FEP seen by EIPS was 100.2% assuming 80/100 000 annual incidence whereas proportion with CHR‐P seen by CHR‐P services was 4.1% assuming 200/100 000 annual incidence. Application of economic modelling suggests that provision of EIPS to reach all new FEP cases each year would free up resources of £13.1m over 10 years including £2.0m to National Health Service (NHS) after the first year. Scaling up to reach all new CHR‐P cases each year would free up resources of £19.7m over 10 years with an estimated 10‐year cost of implementation gap for each 1 year cohort of £18.9m. An earlier related briefing resulted in increased funding for EIPS and new CHR‐P services despite overall cuts to mental health services. Conclusions Estimation of local economic impacts of FEP and CHR‐P services was associated with improved investment in such services.

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mentioning

confidence: 78%

Section: -34 Year Oldsmentioning

confidence: 99%

Applying economic models to estimate local economic benefits of improved coverage of early intervention for psychosis

Campion

Taylor

McDaid

et al. 2019

Early Intervention Psych

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“…Within the first 3 months of entry into PEPP, patients were evaluated with the Topography of Psychotic Episode (TOPE) , a retrospective assessment of 27 potential early signs and symptoms of psychosis. The TOPE is part of the Circumstances of Onset and Relapse Schedule (CORS), which determines pathways to care through detailed interviews with the patient and, when available, his or her relative(s), and review of all health and educational records.…”

Section: Methodsmentioning

confidence: 99%

“…Although the results of these studies have been inconsistent, previous efforts comparing patients entering FEP services de novo (vs. those who entered after receiving interventions during the CHR phase) presume that the former group would have invariably experienced STPS. Yet recent reports indicate that only 46–68% of FEP patients report STPS before their psychosis and that these symptom trajectories predict differential clinical and functional outcomes over time .…”

Section: Introductionmentioning

confidence: 99%

Medication adherence in first episode psychosis: the role of pre‐onset subthreshold symptoms

Daneault

Maraj

Lepage

et al. 2019

Acta Psychiatr Scand

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JL. Medication adherence in first episode psychosis: the role of pre-onset subthreshold symptomsObjective: The experience of pre-onset subthreshold psychotic symptoms (STPS, signifying a clinical high-risk state) in first episode psychosis (FEP) predicts poorer outcomes during treatment, possibly through differential adherence to medication. We explored whether adherence differs between FEP patients with and without pre-onset STPS. Methods: Antipsychotic medication adherence was compared in 263 STPS+ and 158 STPSÀ subjects in a specialized early intervention program for FEP. Data were gathered from a larger observational study conducted between 2003 and 2016. STPS status, sociodemographic, and baseline clinical variables were tested as predictors of non-adherence using univariate and multivariate logistic regressions. Time to onset of non-adherence was analyzed using Kaplan-Meier curves. The same predictors were tested as predictors of time to onset of non-adherence using Cox regression models. Results: Medication non-adherence was higher in STPS+ participants (78.9% vs. 68.9%). STPS status (OR 1.709), substance use disorder (OR 1.767), and milder positive symptoms (OR 0.972) were significant baseline predictors of non-adherence. Substance use disorder (HR 1.410), milder positive symptoms (HR 0.990), and lack of contact between the clinical team and relatives (HR 1.356) were significant baseline predictors of time to nonadherence. Conclusion: FEP patients who experience pre-onset STPS are more likely to be non-adherent to antipsychotic medication over 2 years of intervention. FEP programs should routinely evaluate pre-onset symptomatology to deliver more personalized treatments, with emphasis on engaging both patients and family members from the beginning of care. Significant outcomes• The experience of pre-onset subthreshold psychotic symptoms (STPS) was associated with higher rates of antipsychotic medication non-adherence over the first 2 years of treatment in a specialized early intervention program for first episode psychosis (FEP).• There was no difference in insight at baseline between FEP patients who had experienced pre-onset STPS and those who had not.• Substance use disorder at baseline, milder positive symptoms at baseline, and lack of contact between the clinical team and relatives at baseline were also associated with non-adherence. Limitations• Some (n = 182) patients provided consent for research but did not complete assessments required for assignment of STPS status and thus could not be included in the analyses. These may represent a subset of patients who are less engaged in services and less adherent to medication.• As with all retrospective instruments, the CORS and TOPE (used to determine STPS status) are potentially susceptible to recall bias.• The PANSS-G12, used to measure insight, may conflate several concepts in a one-dimensional measure.

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“…This means that specialised UHR services that focus exclusively on early psychotic symptoms may not capture all cases who transition to psychosis as alternative pathways leading to a psychotic disorder have emerged. For instance, they have been shown to emerge following a period of non-psychotic at-risk states,18 with approximately one-third of patients with FEP not experiencing subthreshold psychotic symptoms 19. This suggests that the wider enhanced primary care youth mental health model of headspace is likely to capture a fuller range of pathways and be more inclusive 20.…”

Section: Transition and Its Limitationsmentioning

confidence: 99%

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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Is the Clinical High-Risk State a Valid Concept? Retrospective Examination in a First-Episode Psychosis Sample

Cited by 65 publications

References 26 publications

Applying economic models to estimate local economic benefits of improved coverage of early intervention for psychosis

Applying economic models to estimate local economic benefits of improved coverage of early intervention for psychosis

Medication adherence in first episode psychosis: the role of pre‐onset subthreshold symptoms

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

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