Individualized Diagnostic and Prognostic Models for Psychosis Risk Syndromes: Do Not Underestimate Antipsychotic Exposure

Lack of transparency on baseline pharmacological treatments in Clinical High-Risk for psychosis (CHR-P) may degrade precision: A systematic review and meta-analysis

The field of Clinical High-Risk for Psychosis (CHR-P) is a dynamic area within contemporary psychiatry and serves as a crucial testing ground for precision prognostic models. Nonetheless, some foundational aspects remain inadequately conceptualized and consequently not transparently reported, such as baseline pharmacotherapy. A systematic review and meta-analysis were conducted by searching the MEDLINE and Cochrane Library databases for studies published up to August 31, 2024. Eligible studies included CHR-P samples, reported numeric data on outcomes at follow-up, and examined the transition to psychosis as an outcome. Data extraction adhered to PRISMA guidelines, focusing on baseline pharmacological exposure to antipsychotics, antidepressants, benzodiazepines, and mood stabilizers. A total of 95 studies were analyzed. The majority of studies (96.8 %) explicitly stated whether baseline exposure to antipsychotics was allowed as part of the inclusion criteria. However, actual baseline exposure to antipsychotics was quantified in only 60 % of these studies. Exposure to non-antipsychotic psychoactive therapies was reported in only a fraction of the studies (36.8 % for antidepressants, 16.8 % for benzodiazepines, and 14.7 % for mood stabilizers). In CHR-P longitudinal studies, the meta-analytic proportions of self-disclosed baseline pharmacological exposure ranged from 23.5 % to 24.5 % for antipsychotics, 28.5 % to 30.6 % for antidepressants, 11.2 % to 14.6 % for benzodiazepines, and 5.6 % to 5.9 % for mood stabilizers. Overall, a non negligible fraction of CHR-P participants is already under psychoactive pharmacological treatment at enrollment. The lack of consistent transparency in this respect may limit the effectiveness of prognostic models. Improved reporting practices are necessary to enhance precision in preventive psychiatry.

Baseline Exposure to Antipsychotic Medication in Young People at Clinical High Risk for Psychosis: A 2-Year Italian Follow-Up Study

OBJECTIVE

Despite various models examining baseline factors, predicting outcomes in individuals at clinical high risk for psychosis (CHR-P) remains challenging. Specifically, neglecting factors like ongoing antipsychotic (AP) medications introduce bias and reduce method precision. The main aim of this research was to determine if the presence of AP prescription at baseline identifies a CHR-P subgroup with worse prognostic outcomes over a 2-year period.

METHODS

A group of 180 FEP individuals (92 CHR-P/AP+, 88 CHR-P/AP-) were evaluated at baseline and after 24 months using the PANSS and GAF scales. Individuals with baseline AP prescription were included in the CHR-P/AP+ subgroup; those not taking APs were grouped as CHR-P/AP-. Univariate Cox regression analysis and mixed-design ANOVA were performed.

RESULTS

After 2 years, CHR-P/AP+ had a higher rate of new hospitalization but lower rate of service disengagement. No significant inter-group difference in psychosis transition rate was found. A "time-×-group" interaction effect on longitudinal improvement in PANSS total score was observed in CHR-P/AP+ subjects.

CONCLUSIONS

It is advisable to conduct a more extensive outcome evaluation beyond the psychometric criteria for CHR-P and the mere consideration of psychosis transition. Such an approach would facilitate the identification of specific CHR-P subgroups with divergent prognoses and different AP response.

Clinical High-Risk for Psychosis (CHR-P) circa 2024: Synoptic analysis and synthesis of contemporary treatment guidelines

The construct of Clinical-High Risk for Psychosis (CHR-P) identifies young help-seeking subjects in putative prodromal stages of psychosis and is a central component of the Early Intervention (EI) paradigm in Mental Health, aimed at facilitating rapid entry into appropriate care pathways to prevent the onset of psychosis or mitigate is biopsychosocial consequences. This approach, which promotes an innovative culture of care for early, at risk situations, is inspired by a clinical staging concept as a guide to optimal treatment. The objective of this article is to map the existing guidelines in the field of CHR-P treatment recommendations, examine overlaps and differences, and critically evaluate blind spots to be addressed in future guideline updated. The search identified 9 guidelines focused on CHR-P or schizophrenia and other psychotic conditions but containing a specific section on CHR-P or prodromal psychosis. All guidelines acknowledge that psychosis is preceded by more or less pronounced prodromal stages, and most detail CHR-P criteria. Among guidelines, 8 out of 9 indicate cognitive-behavioural therapy as the best psychotherapeutic option and 7 out of 9 suggest that antipsychotics can be prescribed as second option in case psychosocial and/or other pharmacological interventions prove insufficient or inadequate in reducing clinical severity and subjective suffering. Antidepressants, mood stabilizers, and benzodiazepines were considered for the treatment of comorbid disorders. Only the European Psychiatric Association Guidance paper distinguished treatment recommendations for adults and minors. Agreements in treatment guidelines were discussed in light of recent meta-analytical evidences on pharmacological and non-pharmacological treatments for CHR-P, suggesting the need to provide an updated, age-sensitive consensus on how to manage CHR-P individuals.

Baseline antipsychotic prescription and short-term outcome indicators in individuals at clinical high-risk for psychosis: Findings from the Parma At-Risk Mental States (PARMS) program

AIM

The prognostic prediction of outcomes in individuals at clinical high-risk for psychosis (CHR-P) is still a significant clinical challenge. Among multiple baseline variables of risk calculator models, the role of ongoing pharmacological medications has been partially neglected, despite meta-analytical evidence of higher risk of psychosis transition associated with baseline prescription exposure to antipsychotics (AP) in CHR-P individuals. The main aim of the current study was to test the hypothesis that ongoing AP need at baseline indexes a subgroup of CHR-P individuals with more severe psychopathology and worse prognostic trajectories along a 1-year follow-up period.

METHODS

This research was settled within the 'Parma At-Risk Mental States' program. Baseline and 1-year follow-up assessment included the Positive And Negative Syndrome Scale (PANSS) and the Global Assessment of Functioning (GAF). CHR-P individuals who were taking AP medications at entry were included in the CHR-P-AP+ subgroup. The remaining participants were grouped as CHR-P-AP-.

RESULTS

Hundred and seventy-eight CHR-P individuals (aged 12-25 years) were enrolled (91 CHR-P-AP+, 87 CHR-P-AP-). Compared to CHR-P AP-, CHR-P AP+ individuals had older age, greater baseline PANSS 'Positive Symptoms' and 'Negative Symptoms' factor subscores and a lower GAF score. At the end of our follow-up, CHR-P-AP+ subjects showed higher rates of psychosis transition, new hospitalizations and urgent/non-planned visits compared to CHRP- AP- individuals.

CONCLUSIONS

In agreement with increasing empirical evidence, also the results of the current study suggest that AP need is a significant prognostic variable in cohorts of CHR-P individuals and should be included in risk calculators.

Baseline benzodiazepine exposure is associated with greater risk of transition in clinical high-risk for psychosis (CHR-P): a meta-analysis

BACKGROUND

Emerging meta-analytical evidence indicates that baseline exposure to antipsychotics and to antidepressants in individuals at clinical high-risk for psychosis (CHR-P) have opposite prognostic effects as regards imminent transition to psychosis, with antipsychotics associated with higher risk and antidepressants associated with a lower risk in comparison to not-exposed individuals. Despite their common use, baseline exposure to benzodiazepines (BDZ) in CHR-P has surprisingly received poor attention as a potential risk modulator for transition to psychosis. The current systematic review and meta-analysis were performed to fix such a knowledge gap.

METHODS

Systematic scrutiny of Medline and Cochrane library, performed up to 31 December 2022, searching for English-language studies on CHR-P reporting numeric data about the sample, the transition outcome at a predefined follow-up time and raw data on BDZ baseline exposure in relation to such outcome.

RESULTS

Of 1893 identified records, five studies were included in the systematic review and meta-analysis. The proportion of participants with exposure to BDZ at baseline ranged from 5.5% (one study) to 46.2%, with an average of 16.8%. At the end of the period of observation, i.e., the follow-up as reported in the study, 28.4% [95% confidence interval (CI) 19.7-39.1%] participants developed psychosis among the BDZ-exposed against 9.3% (7.3 to 11.9%) among the controls. CHR-P participants who were already under BDZ treatment at baseline had more than double chance of transition to psychosis than CHR-P participants who were BDZ-naïve. The risk ratio (RR) was 2.42 (95% CI 1.38-4.23) in the common effects model (z = 3.09; p = 0.002), and 2.40 (1.53 to 3.77) in the random-effects model (z = 5.40; p = 0.006; tau-squared = 0.0). There was no relevant heterogeneity: Cochran's Q = 1.49; df = 4; p = 0.828; I2 = 0.0% (95% CI 0.0-79%). Quality was good in four studies.

CONCLUSIONS

Ongoing BDZ exposure at inception in CHR-P is associated with a higher risk of transition to psychosis at follow up. This meta-analytic association, which echoes a similar effect of baseline antipsychotic exposure, plausibly indicates that the clinicians' prescription of pharmacological intervention captures some form of prognostically-relevant information (e.g. an anxiety permeated mental state requiring BDZ prescription) that are not adequately encompassed by current CHR-P categorical criteria.

Do antidepressants prevent transition to psychosis in individuals at clinical high-risk (CHR-P)? Systematic review and meta-analysis

BACKGROUND

Emerging meta-analytical evidence indicates that baseline exposure to antipsychotics in individuals at clinical high-risk for psychosis (CHR-P) is associated with a higher risk of an imminent transition to psychosis. Despite their tolerability profile and potential beneficial effects, baseline exposure to antidepressants (AD) in CHR-P has surprisingly received far less attention as a potential risk modulator for transition to psychosis. The current systematic review and meta-analysis were performed to fix such a knowledge gap.

METHODS

Systematic scrutiny of Medline and Cochrane library, performed up to 1 August 2021, searching for English-language studies on CHR-P reporting numeric data about the sample, the transition outcome at a predefined follow-up time and raw data on AD baseline exposure in relation to such outcome.

RESULTS

Of 1942 identified records, 16 studies were included in the systematic review and meta-analysis. 26% of the participants were already exposed to AD at baseline; at the end of the follow-up 13.5% (95% CI 10.2-17.1%) of them (n = 448) transitioned to psychosis against 21.0% (18.9 to 23.3%) of non-AD exposed CHR-P (n = 1371). CHR-P participants who were already under AD treatment at baseline had a lower risk of transition than non-AD exposed CHR-P. The RR was 0.71 (95% CI 0.56-0.90) in the fixed-effects model (z = -2.79; p = 0.005), and 0.78 (0.58-1.05) in the random-effects model (z = -1.77; p = 0.096; tau-squared = 0.059). There was no relevant heterogeneity (Cochran's Q = 18.45; df = 15; p = 0.239; I2 = 18.7%).

CONCLUSIONS

Ongoing AD exposure at inception in CHR-P is associated to a reduced risk of transition to psychosis at follow up.