Screening for the at-risk mental state in educational settings: A systematic review

Screening for Psychotic Experiences and Psychotic Disorders in General Mental Health Treatment Settings: A Systematic Review and Meta-Analysis

BACKGROUND

The absence of systematic psychosis screening within general mental health services contributes to substantial treatment delays and poor long-term outcomes for individuals with psychotic symptoms. We conducted a meta-analysis to estimate rates of subclinical psychotic symptoms for psychotic experiences (PE), clinical high-risk for psychosis syndrome (CHR-P), and psychotic disorders that were identified via studies screening treatment-seeking individuals. These rates can inform implementation recommendations for routine psychosis screening in general mental health settings.

METHODS

PubMed and Web of Science databases were searched to identify empirical studies with information on PE, CHR-P, or psychotic disorder prevalence identified by screening inpatients and outpatients (age < 65 years) receiving general mental health care. PE was identified using threshold scores on validated self-reported questionnaires, and CHR-P and psychotic disorder were identified using gold-standard structured interview assessments. A meta-analysis of each outcome was conducted using the restricted maximum likelihood estimator method to assess effect sizes in a random effects model.

RESULTS

The analyses included 41 independent samples (k = 32 outpatient, k = 2 inpatient, k = 7 combined settings) with a total of 25,751 patients (58% female, mean age: 24.1 years). PE prevalence was 44.3% (95% CI: 35.8-52.8%; 28 samples, n = 21,957); CHR-P prevalence was 26.4% (95% CI: 20.0-32.7%; 28 samples, n = 14,395); and psychotic disorder prevalence was 6.6% (95% CI: 3.3-9.8%; 32 samples, n = 20,371). Rates did not differ by sex, age, or setting type.

CONCLUSIONS

The high prevalence of psychotic symptoms in general mental health treatment settings underscores the need for early-detection psychosis screening. These base rates can be used to plan training and allocation of resources required to conduct psychosis assessments and build capacity for delivering interventions for CHR-P and early psychosis in non-specialty mental health treatment settings.

Psychological and social difficulties in young non-help-seeking adolescents at risk for psychosis: insights from a large cohort study

Background

This study used data from the Norwegian Mother, Father, and Child Cohort Study (MoBa), and explored the psychological and social challenges of 14-year-olds who report psychotic symptoms. Research on help-seeking youths indicates comorbid symptoms of depression, anxiety, and social deterioration, but less is known about non-help-seeking individuals who may not use healthcare services, possibly skewing comorbidity profiles. Also, findings suggest that adolescents manifesting psychotic symptoms refrain from pursuing help. This gap underscores the necessity of studying non-help-seeking adolescents to better understand their needs and the risks they face without intervention.

Methods

We analyzed responses from adolescents who completed the 14-year questionnaire in MoBa (N = 127), identifying those as at risk by their high scores on psychosis-risk items, within the top 0.4% (N = 58). Comparative analyses were conducted against matched controls to assess differences in psychological and social functioning (N = 69).

Results

Results indicated that the at-risk adolescents experience significantly more depression and anxiety and have lower self-esteem and poorer social functioning than controls. Social functioning parameters, including leisure activities, social competence, quality of parental relationship, and sense of school belonging, were significantly worse than those observed in controls. The results indicate a pronounced vulnerability among non-help-seeking adolescents at-risk, similar to issues seen in help-seeking youths.

Conclusion

These findings highlight the importance of early identification and intervention strategies that reach beyond traditional clinical settings, suggesting the efficacy of population or community-based screenings to prevent long-term adverse outcomes. The study proposes a broader understanding of psychosis risk, stressing the importance of inclusive approaches to support at-risk adolescents effectively.

Psychotic-like experiences in a nationally representative study of general population adolescents

BACKGROUND

Subclinical psychotic-like experiences (PLEs) are common among general population adolescents but have been found to correlate with various problems in well-being. Due to limited sample sizes these effects have not been well differentiated by sex and age.

METHODS

Using a nationally representative survey of almost 160,000 adolescents, we studied endorsement and correlates of PLEs by sex among middle adolescence pupils (ages 14-16) and late adolescence students (ages 16-20). PLEs were investigated with three questionnaire items: auditory and visual hallucinatory experiences and suspicious thought content, using a frequency response scale.

RESULTS

Weekly PLEs were reported by 14 % of the adolescents, more often in females (17 %) than males (11 %) and in the younger age group (17 %) compared to the older adolescents (10 %). A latent PLE factor represented the three assessed PLEs with good fit. Factor scores were highest for the younger females and lowest for the older males. The PLE factor correlated with two latent factors of other well-being, namely living environment ("adversity", loading most heavily on parental mental abuse; r = 0.63), and concurrent mental health ("distress", loading most heavily on depressive symptoms; r = 0.50). Adversity was associated especially strongly with PLEs in 14-16-year-old males.

CONCLUSIONS

This cross-sectional study reaching the whole 14-20 age group in schools in Finland offers data on the meaning and relevance of PLEs as general markers of vulnerability. Many adolescents experience PLEs recurrently and these experiences are associated with a wide variety of burden in the adolescent's everyday life.

Screening for psychotic experiences and psychotic disorders in general psychiatric settings: a systematic review and meta-analysis

Background

The absence of systematic screening for psychosis within general psychiatric services contribute to substantial treatment delays and poor long-term outcomes. We conducted a meta-analysis to estimate rates of psychotic experiences, clinical high-risk for psychosis syndrome (CHR-P), and psychotic disorders identified by screening treatment-seeking individuals to inform implementation recommendations for routine psychosis screening in general psychiatric settings.

Methods

PubMed and Web of Science databases were searched to identify empirical studies that contained information on the point prevalence of psychotic experiences, CHR-P, or psychotic disorders identified by screening inpatient and outpatient samples aged 12-64 receiving general psychiatric care. Psychotic experiences were identified by meeting threshold scores on validated self-reported questionnaires, and psychotic disorders and CHR-P by gold-standard structured interview assessments. A meta-analysis of each outcome was conducted using the Restricted Maximum Likelihood Estimator method of estimating effect sizes in a random effects model.

Results

41 independent samples (k=36 outpatient) involving n=25,751 patients (58% female, mean age: 24.1 years) were included. Among a general psychiatric population, prevalence of psychotic experiences was 44.3% (95% CI: 35.8-52.8%; 28 samples, n=21,957); CHR-P was 26.4% (95% CI: 20.0-32.7%; 28 samples, n=14,395); and psychotic disorders was 6.6% (95% CI: 3.3-9.8%; 32 samples, n=20,371).

Conclusions

High rates of psychotic spectrum illness in general psychiatric settings underscore need for secondary prevention with psychosis screening. These base rates can be used to plan training and resources required to conduct assessments for early detection, as well as build capacity in interventions for CHR-P and early psychosis in non-specialty mental health settings.

The diagnostic accuracy of screening for psychosis spectrum disorders in behavioral health clinics integrated into primary care

Screening for psychosis spectrum disorders in primary care could improve early identification and reduce the duration of untreated psychosis. However, the accuracy of psychosis screening in this setting is unknown. To address this, we conducted a diagnostic accuracy study of screening for psychosis spectrum disorders in eight behavioral health services integrated into primary care clinics. Patients attending an integrated behavioral health appointment at their primary care clinic completed the Prodromal Questionnaire - Brief (PQ-B) immediately prior to their intake assessment. This was compared to a diagnostic phone interview based on the Structured Interview for Psychosis Risk Syndromes (SIPS). In total, 145 participants completed all study procedures, of which 100 screened positive and 45 negative at a provisional PQ-B threshold of ≥20. The PQ-B was moderately accurate at differentiating psychosis spectrum from no psychosis spectrum disorders; a PQ-B distress score of ≥27 had a sensitivity and specificity of 71.2 % and 57.0 % respectively. In total, 66 individuals (45.5 %) met criteria for a psychosis spectrum disorder and 24 (16.7 %) were diagnosed with full psychosis, indicating a high prevalence of psychosis in the sample. Overall, screening for psychosis spectrum disorders in an IBH primary care setting identified a relatively high number of individuals and may identify people that would otherwise be missed. The PQ-B performed slightly less well than in population-based screening in community mental health settings. However, the findings suggest this may represent an effective way to streamline the pathway between specialty early psychosis programs and primary care clinics for those in need.

The structure of the Prodromal Questionnaire-16 (PQ-16) in a non-help-seeking youth population: Exploratory and confirmatory factor analyses study

AIMS

The present study aimed to examine the structure of the Prodromal Questionnaire-16 (PQ-16) in a non-help-seeking youth population through exploratory and confirmatory factor analysis. Previous studies have not examined the structure of this self-report measure in this age group outside a clinical setting.

METHODS

Participants (n = 1165) aged 11-19 years were recruited to an epidemiological study of young people in Northern Ireland, and completed the PQ-16 alongside other measures. The dataset was split randomly in two for separate factor analyses. A polychoric correlation matrix was created and exploratory factor analysis was used to identify the optimal number of factors. In addition, based on previous studies, six models were tested through confirmatory factor analysis to determine best fit. A one-factor, 3 two-factor, a three-factor and a four-factor model were all tested.

RESULTS

The exploratory factor analysis indicated a two-factor structure of the PQ-16 in this population, which we have labelled 'general unusual experiences' and 'hallucinations'. Confirmatory analysis indicated that the two-factor model identified through the exploratory analysis was the best fit for the data.

DISCUSSION

The present study suggests that the structure of the PQ-16 may vary across age groups in non-clinical settings, and adds further support to the validity of the PQ-16 is a cost-effective, easy to administer self-report measure that is suitable for use in non-help-seeking populations as a screening tool for prodromal symptoms.

Identifying individuals at risk of developing psychosis: A systematic review of the literature in primary care services

AIM

Psychosis and related disorders are a major public health issue. Early identification and prevention for those at high risk (at-risk-mental-state, ARMS) is important. General practitioners (GPs) are often the first point of contact for health services. In this review we aim to identify (1) the most common methods for identifying individuals with an ARMS in primary care, (2) the methods for improving identification of individuals with an ARMS in primary care, and (3) the most common barriers that prevent GPs from screening for individuals with an ARMS.

METHODS

We conducted a systematic review (PROSPERO 42021245095) of quantitative and qualitative studies with no date restriction. Searches were performed in September 2021. Studies' quality was appraised using Mixed Methods Appraisal tool (MMAT).

RESULTS

We identified 16 eligible studies, and all but one provided quantitative data. Nearly two-thirds of studies were classified as 'medium' quality. Employing narrative synthesis, we identified three themes relating to (1) improving GP knowledge and confidence in identifying individuals with an ARMS, (2) balancing the over- and under-identification of individuals with an ARMS in primary care, and (3) supporting GPs as significant stakeholders in early diagnosis and treatment of individuals with an ARMS.

CONCLUSIONS

Improved identification of individuals with an ARMS is needed. We identified various strategies, including development and implementation of identification methods (e.g., screening measures), educational interventions for GPs (e.g., workshops), and systemic interventions (e.g., simplifying referrals to secondary care, developing integrated services). When implemented successfully, these interventions may help facilitate the access to appropriate care for individuals with an ARMS.

The exploration of a screen model for detecting undergraduates at higher risk for developing psychosis: A cross-sectional study in a medical university

PURPOSE

To examine a screen model for detecting undergraduates with higher risk for developing psychosis (HRDP).

DESIGN AND METHODS

A cross-sectional design with convenience sampling was used. The screen model included exploration stage by self-report scales and confirmation stage by face-to-face interviews.

FINDINGS

A total of 273 students were detected from 4744 surveys during 4 years. Of them, 120 students with HRDP were identified and 7 had been diagnosed as schizophrenia or bipolar disorders at 12-month follow-up.

PRACTICE IMPLICATIONS

This screen model can be used in early detection for undergraduates with HRDP from large general samples.

The Structure of the Prodromal Questionnaire-16 (PQ-16): Exploratory and confirmatory factor analyses in a general non-help-seeking population sample

AIMS

To examine the structure of the Prodromal Questionnaire (PQ-16) in a non-help-seeking population through exploratory factor analysis and confirmatory factor analysis. Previous studies have not looked at the structure of this self-report measure outside clinical settings.

METHODS

Participants (n = 1045) were recruited through Amazon's Mechanical Turk (MTurk), and then completed the PQ-16. The data set was split randomly in two, one being used for exploratory factor analysis (EFA) and the other for confirmatory factor analysis (CFA). A polychoric correlation matrix was created and EFA was used to explore the factor structure of the PQ-16. Four models were tested through CFA to determine best fit: one, two, three and four-factor models were all analysed.

RESULTS

EFA indicated a two-factor structure in the PQ-16 in a non-help-seeking population (with a mean age = 29.7 years). Factor 1 represented perceptual abnormalities/hallucinations and factor 2 general symptoms associated with psychosis-risk. CFA indicated that all the proposed models were suitable fits for the dataset. Fit indices for the three-factor model (factor 1 representing perceptual abnormalities/hallucinations, factor 2 unusual thought content, and factor 3 negative symptom) indicated that it appeared to be a better fit for the data than the one, two, and four factor models.

CONCLUSIONS

This study suggests that a three-factor model of the PQ-16 is a better fit than other proposed models in a non-help-seeking population. Future research of the structure of the PQ-16 in this population may benefit from recruiting subjects with a lower mean age than the current study.

Prevalence of Individuals at Clinical High-Risk of Psychosis in the General Population and Clinical Samples: Systematic Review and Meta-Analysis

(1) The consistency and magnitude of the prevalence of Clinical High-Risk for Psychosis (CHR-P) individuals are undetermined, limiting efficient detection of cases. We aimed to evaluate the prevalence of CHR-P individuals systematically assessed in the general population or clinical samples. (2) PRISMA/MOOSE-compliant (PROSPERO: CRD42020168672) meta-analysis of multiple databases until 21/01/21: a random-effects model meta-analysis, heterogeneity analysis, publication bias and quality assessment, sensitivity analysis—according to the gold-standard CHR-P and pre-screening instruments—leave-one-study-out analyses, and meta-regressions were conducted. (3) 35 studies were included, with 37,135 individuals tested and 1554 CHR-P individuals identified (median age = 19.3 years, Interquartile range (IQR) = 15.8–22.1; 52.2% females, IQR = 38.7–64.4). In the general population (k = 13, n = 26,835 individuals evaluated), the prevalence of the CHR-P state was 1.7% (95% Confidence Interval (CI) = 1.0–2.9%). In clinical samples (k = 22, n = 10,300 individuals evaluated), the prevalence of the CHR-P state was 19.2% (95% CI = 12.9–27.7%). Using a pre-screening instrument was associated with false negatives (5.6%, 95% CI = 2.2–13.3%) and a lower CHR-P prevalence (11.5%, 95% CI = 6.2–20.5%) compared to using CHR-P instruments only (28.5%, 95% CI = 23.0–34.7%, p = 0.003). (4) The prevalence of the CHR-P state is low in the general population and ten times higher in clinical samples. The prevalence of CHR-P may increase with a higher proportion of females in the general population and with a younger population in clinical samples. The CHR-P state may be unrecognized in routine clinical practice. These findings can refine detection and preventive strategies.

The Community Assessment of Psychic Experiences-Positive scale (CAPE-P15) accurately classifies and differentiates psychotic experience levels in adolescents from the general population

Background

There is increasing interest in studying psychotic symptoms in non-clinical populations, with the Community Assessment of Psychic Experiences-Positive scale (CAPE-P15) being one of the self-screening questionnaires used most commonly for this purpose. Further research is needed to evaluate the ability of the scale to accurately identify and classify positive psychotic experiences (PE) in the general population.

Aim

To provide psychometric evidence about the accuracy of the CAPE-P15 for detecting PE in a sample of Chilean adolescents from the general population and classifying them according to their PE severity levels.

Method

We administered the CAPE-P15 to a general sample of 1594 students aged 12 to 19. Based on Item Response Theory (IRT), we tested the accuracy of the instrument using two main parameters: difficulty and discrimination power of the 15 items.

Results

We found that the scale provides very accurate information about PE, particularly for high PE levels. The items with the highest capability to determine the presence of the latent trait were those assessing perceptual anomalies (auditory and visual hallucinations), bizarre experiences (a double has taken the place of others; being controlled by external forces), and persecutory ideation (conspiracy against me).

Conclusions

The CAPE-P15 is an accurate and suitable tool to screen PE and to accurately classify and differentiate PE levels in adolescents from the general population. Further research is needed to better understand how maladaptive psychological mechanisms influence relationships between PE and suicidal ideation (SI) in the general population.