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

The association of bullying and self-esteem with psychotic-like experiences and clinical high risk for psychosis symptoms

BACKGROUND

Bullying has become a significant global health problem due to its high prevalence worldwide and long-term consequences on mental health, including the onset of psychotic symptoms. This study focuses on exploring the prevalence of bullying across three groups of Mexican individuals with different levels of psychosis risk symptoms: non-psychosis risk (non-PR), psychotic-like experiences (PLEs), and at clinically high-risk for psychosis (CHR-P). In addition, we compare sociodemographic features, self-esteem, and self-reported bullying between the groups and then examine whether these variables are associated with the probability of belonging to the PLEs or CHR-P groups compared to the non-PR.

METHODS

A general population sample completed the Prodromal Questionnaire-Brief (PQ-B) to determine the presence of PLEs. Those meeting the PQ-B cut-off threshold were assigned to the PLEs group (n = 490), while those who scored below the cut-off comprised the non-PR group (n = 1,125). The CHR-P group (n = 45) was an independent clinical sample meeting the criteria established by the Comprehensive Assessment of At-Risk Mental States. All participants completed self-reports of sociodemographic characteristics, bullying, and self-esteem.

RESULTS

The CHR-P group had a higher percentage of men, single participants, and lower levels of education than the PLEs and the non-PR groups. PLEs and CHR-P participants reported a lower socioeconomic status, lower self-esteem, and higher prevalence of bullying than the non-PR group. The multinomial logistic regression indicated that the factors associated with belonging to the CHR-P group were lower education, being a man, and being single. Furthermore, being younger, having lower self-esteem, and having experienced bullying were associated with belonging to the PLEs and CHR-P groups. Among all these variables, bullying emerged as a robust risk factor associated with psychosis risk symptoms since it increased the odds of being CHR-P by threefold compared to the non-PR group, and it also increased the risk of PLEs compared to the non-PR group.

CONCLUSIONS

Findings highlight the relevance of prioritizing anti-bullying school-based programs to provide a safer school environment, as well as strengthening self-esteem (potential protective factor) in vulnerable individuals to reduce the risk of developing psychosis and minimize the long-term impact of bullying victimization on further mental health conditions.

PSYSCAN multi-centre study: baseline characteristics and clinical outcomes of the clinical high risk for psychosis sample

Predicting outcomes in individuals at clinical high risk (CHR) of developing psychosis remains challenging using clinical metrics alone. The PSYSCAN project aimed to enhance predictive value by integrating data across clinical, environmental, neuroimaging, cognitive, and peripheral blood biomarkers. PSYSCAN employed a naturalistic, prospective design across 12 sites (Europe, Australia, Asia, Americas). Assessments were conducted at baseline, 3, 6, and 12 months, with follow-ups at 18 and 24 months to evaluate clinical and functional outcomes. The study included 238 CHR individuals and 134 healthy controls (HC). At baseline, CHR and HC groups differed significantly in age, education, IQ, and vocational and relationship status. Cannabis and tobacco use did not significantly differ between groups, however CHR individuals had higher proportion of moderate to high risk of tobacco abuse. A substantial portion of the CHR sample met DSM criteria for anxiety (53.4%) and/or mood disorders (52.9%), with some prescribed antidepressants (38.7%), antipsychotics (13.9%), or benzodiazepines (16.4%). Over the follow-up period, 25 CHR individuals (10.5%) transitioned to psychosis. However, the CHR group as a whole showed improvements in functioning and attenuated psychotic symptoms. Similar to other recent multi-centre studies, the CHR cohort exhibits high comorbidity rates and relatively low psychosis transition rates. These findings highlight the clinical heterogeneity within CHR populations and suggest that outcomes extend beyond psychosis onset, reinforcing the need for broader prognostic models that consider functional and transdiagnostic outcomes.

Commentary: Response - Building on existing knowledge and redefining rather than abandoning the well-established 'clinical high risk for psychosis' prevention paradigm: Commentary on Tiffin and Kelleher "Time to abandon the 'clinical high risk state for psychosis" (CHR-P) concept in adolescence?"

We appreciate the commentary by Tiffin and Kelleher on our systematic review and meta-analysis. The CHR-P paradigm remains one of the most established preventive approaches in mental health. While concerns have been raised regarding the clinical utility of the CHR-P paradigm, its implementation in specialized services worldwide supports its relevance. These services provide evidence-based interventions, reducing unnecessary antipsychotic use and guiding treatment strategies. Tiffin and Kelleher's critique largely focuses on transition rates and age cutoffs. While we argue that transition rates in adolescents at CHR-P are significant, other outcomes need to be considered. Among others, negative symptoms are clinically significant in adolescents at CHR-P, impairing functioning and long-term outcomes. We think we should refine and improve the CHR-P paradigm rather than simply abandoning it. With advancements in precision medicine, we can improve risk stratification and tailor interventions to better serve individuals at risk. We can also expand the paradigm, so it supports other help-seeking adolescents at risk requiring transdiagnostic, developmentally sensitive interventions to prevent psychosis.

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.

Navigating the Maze: Caregiver Perspectives on Pathways to Mental Health Care for U.S. Youth at Clinical High Risk for Psychosis

AIM

Treatment for youth who are at clinical high risk for psychosis (CHR-P) presents an opportunity for early intervention with the capacity to decrease the burden associated with a potential psychotic disorder later in life. However, significant barriers prevent youth at CHR-P from accessing speciality mental health services. Few studies have examined the pathways to care for youth at CHR-P within the U.S. health system.

METHODS

The present study reports the results of a codebook thematic analysis of qualitative interviews conducted with caregivers (primarily parents) of 15 youth (ages 12-25 years) who entered a CHR-P speciality program. Using a semi-structured interview, we inquired about their experiences navigating the health system to eventually arrive at the speciality program, including help-seeking events and referrals, caregivers' attributions for youths' CHR-P symptoms, and barriers and facilitators to care.

RESULTS

Caregivers reported confusion and uncertainty regarding the causes of symptoms. They also disclosed the significant challenges to obtaining mental health care, including low mental health literacy, illness stigma, provider unavailability or appropriateness and adequacy of referrals. Most of the youth had encounters with emergency services during their help-seeking journey.

CONCLUSION

Our results help define targets for future policy, research and clinical efforts to improve access to speciality care for youth at CHR-P in the U.S.

Preventing psychosis in people at clinical high risk: an updated meta-analysis by the World Psychiatric Association Preventive Psychiatry section

Recently published large-scale randomised controlled trials (RCTs) have questioned the efficacy of preventive interventions in individuals at clinical high risk for psychosis (CHR-P). We conducted a systematic review and meta-analysis to include this new evidence and provide future directions for the field. We followed the PRISMA guidelines and a pre-registered protocol, with a literature search conducted from inception to November 2023. We included RCTs that collected data on psychosis transition (the primary outcome) in CHR-P. Secondary outcomes were symptoms severity and functioning. Investigated time points were 6,12,24,36, and +36 months. We used odd ratios (ORs) and standardised mean differences (SMD) as summary outcomes. Heterogeneity was estimated with the Higgins I2. Twenty-four RCTs, involving 3236 CHR-P individuals, were included. Active interventions were Cognitive Behavioural Therapy (CBT), family-focused therapy, Integrated Psychological Therapy, antipsychotics, omega-3 fatty acids, CBT plus risperidone, minocycline, and other non-pharmacological approaches (cognitive remediation, sleep-targeted therapy, brain stimulation). Results showed no evidence that any of the investigated active interventions had a sustained and robust effect on any of the investigated outcomes in CHR-P, when compared to control interventions, including CBT on transition to psychosis at 12 months (9 RCTs; OR: 0.64; 95% CI: 0.39-1.06; I2: 21%; P = 0.08). These results highlight the need for novel treatment approaches in CHR-P. Future studies should consider the heterogeneity of this clinical population and prioritise stratification strategies and bespoke treatments.

Beyond the Descriptive: A Comprehensive, Multidomain Validation of Symptom Trajectories for Individuals at Clinical High Risk for Psychosis

BACKGROUND

Although the clinical high risk for psychosis (CHR-P) criteria are widely used to ascertain individuals at heightened risk for imminent onset of psychosis, it remains controversial whether CHR-P status defines a diagnostic construct in its own right. In a previous study, CHR-P nonconverters were observed to follow 3 distinct trajectories in symptoms and functioning: remission, partial remission, and maintenance of symptoms and functional impairments at subthreshold levels of intensity.

METHODS

Here, we utilized the NAPLS3 (North American Prodrome Longitudinal Study phase 3) sample (N = 806) to determine whether 1) the same trajectory groups can be detected when assessing symptoms at 2-month intervals over an 8-month period and 2) the resulting trajectory groups differ from each other and from healthy control participants and converting CHR-P cases in terms of risk factors, comorbidities, and functional outcomes.

RESULTS

Three distinctive subgroups within the CHR nonconverters were identified, largely paralleling those observed previously. Importantly, these extracted groups, together with non-CHR control participants and CHR converters, differed from each other significantly on putative etiological risk factors (e.g., predicted risk scores, physiological and self-report measures of stress), affective comorbidities, and functional outcomes, thus providing converging evidence supporting the validity of the identified trajectory groups.

CONCLUSIONS

This pattern, together with the fact that even the subgroup of CHR-P nonconverters who showed a remission trajectory deviated from healthy control participants, supports treating the CHR-P syndrome not only as a status that denotes risk for onset of full psychosis but also as a marker of ongoing distress for a population that is in need of interventions.

Internal Validation of the Latvian Version of 16-Item Prodromal Questionnaire in A Help-Seeking Adolescent Population: Psychometric Analysis and Associated Factors

OBJECTIVES

The prodromal phase of a psychotic disorder is a period of altered functioning before the onset of the acute state; several interviews have been developed to determine whether individuals present with prodromal symptoms. The 16-item Prodromal Questionnaire (PQ-16) is a screening tool for evaluating those at risk of developing a psychotic disorder. The study aimed to evaluate the psychometric properties of the Latvian version of the PQ-16 in a sample of help-seeking adolescents referred for diagnostic assessment and look for possible associated socio-demographic and health-related factors.

METHODS

A cross-sectional study included patients admitted for evaluation between November 2022 and February 2023 in Riga's Children's Clinical University Hospital Child Psychiatry clinic. The data were collected during outpatient consultations by mental health professionals. We used the Latvian translation of PQ-16 and the socio-demographic and health-related factors questionnaire. Data were analysed with IBM SPSS 28; the scale's diagnostic accuracy and internal validity were examined.

RESULTS

The study involved 107 adolescents aged 12% to 17%, 80.5% female, with a mean age of 14.98 (CI 14.70-15.26). Socio-demographic data and health-related variables did not significantly differ between the sexes (p > 0.05). The Latvian PQ-16 demonstrated excellent internal reliability with a Cronbach's alpha of 0.890. All 16 items were found to be valid with p < 0.001. A significant number of participants (73.8%) scored above the current cut-off of ≥ 6 with a mean of 9.17 (95% CI 8.41-9.93). Certain socio-demographic factors, such as female gender (p < 0.001), fair school performance (p = 0.048) and recent changes in school performance (p < 0.001), demonstrated a significant association with higher scores. Additionally, there were found significant associations between positive screening and health-related factors such as obstetric complications (p = 0.044), smoking (p = 0.002), alcohol consumption (p = 0.021), history of bullying in school (p < 0.001) and emotional abuse at home (p = 0.011).

CONCLUSIONS

Latvian translation of PQ-16 showed high internal reliability and validity levels. Positive PQ-16 screening was associated with female gender, worsened school performance, obstetric complications, substance abuse and experienced emotional violence. The average score of 9.17 positive answers and 73.8% of participants screening positive for attenuated psychotic symptoms is significantly higher than in recent studies under similar conditions.

Clinical high risk for psychosis and service disengagement: Incidence and predictors across 2 years of follow-up

BACK: Service disengagement is common in subjects at CHR-P (clinical high risk for psychosis), potentially worsening daily functioning and increasing the duration of untreated psychosis. That is why to identify baseline predictors of service disengagement could help better tailoring follow-up on every CHR-P individual.

AIMS

Since there are few studies on this topic, the goals of this examination were: (1) to calculate service disengagement rates in a CHR-P sample along 2-years of follow-up; and (2) to examine the most relevant predictive factors of disengagement at baseline.

METHODS

All young CHR-P participants were enrolled within the 'Parma At-Risk Mental States' (PARMS) protocol. At entry, the Global Assessment of Functioning (GAF) scale and the positive and negative syndrome scale (PANSS) were completed. Cox regression analyses were used.

RESULTS

Hundred and eighty CHR-P subjects were recruited in this examination. During the follow-up, a 2-year service disengagement prevalence rate of 15% was observed. A statistically robust predictive factor of service disengagement was a lower prescription of antidepressant drug at entry. Other relevant baseline predictive factors were migrant status, higher GAF score, lower levels of anxious-depressive symptoms and a lower acceptance of psychosocial interventions.

DISCUSSION

Baseline presence of anxious-depressive features in CHR-P individuals could favour engagement to specialized EIP services. However, implementing strategies to improve patients' motivation and involvement in care are needed.

Heterogeneity in assessing the risk of developing a psychotic disorder given a previous subclinical psychotic-like experience in children and adolescents: A systematic review and meta-analysis

Psychotic-like experiences (PLEs) are common in the general population. Child and adolescent PLEs are the most prevalent and linked with future psychotic disorders. Significant heterogeneity in PLE assessment has obscured its clinical utility to identify psychosis-prone trajectories and improve clinical outcomes. This meta-analysis aimed to assess i) PLE prevalence in children and adolescents and ii) their relationship with subsequent psychotic disorder while exploring sources of heterogeneity. PubMed, Embase, PsycINFO, and CINAHL databases were searched in August 2023 for population-based longitudinal studies that assessed child or adolescent PLEs and early adulthood psychotic outcomes. Six studies were included (n = 16,560), showing a pooled PLE prevalence of 17.3 %. Child and adolescent PLEs were associated with an increased risk of psychotic disorder in early adulthood (unadjusted OR = 3.80, 95 % CI: 2.31-6.26), with a population attributable fraction of 32.6 %. Significant heterogeneity in the strength of this relationship (I2 = 70 %, p = .01) was related to assessment type (self-report vs. interview). This review contends that interview-based PLE assessments could more accurately identify children or adolescents on a path towards psychosis and are better suited for psychotic risk identification. Further research is needed to elucidate interactions between PLEs and other psychotic risk factors.

Interpersonal emotion regulation and symptom dimensions of psychosis proneness in young adults

This study investigated the relative associations of psychosis proneness symptom domains with habitual interpersonal emotion regulation (IER) use in a sample of young adults (n = 420, age 18-29). Multiple regression models showed that attenuated negative symptoms were related to using less, while attenuated positive symptoms and depression were related to using more IER. These findings suggest symptom-specific IER patterns across different symptom dimensions of psychosis proneness.

Pathways to care in youth and young adults at clinical high risk for psychosis in Switzerland: Current situation and clinical implementation of the PsyYoung project

AIM

We aim to give an insight into the current situation in Switzerland concerning the pathways to care of young people with clinical high risk of psychosis. In a second step we propose a procedure of optimizing pathways to care developed within the project PsyYoung.

METHODS

A qualitative survey derived and adapted from Kotlicka-Antczak et al. (2020) was conducted in large early detection services of three Swiss cantons (Geneva, Basel-Stadt, Vaud) focusing on pathways to care. More specifically, using questionnaires delivered to the heads of participating services, information was collected on referral sources, on activities to implement outreach campaigns and on the use of a pre-screening tool.

RESULTS

Main results on referral source indicated that sources were variable but seemed to come primarily from the medical sector and more so from the psychiatric sector. Very few referrals came from non-medical sectors. Outreach activities included the contact to other clinics as well as through brochures and posters. All services but one used the Prodromal Questionnaire - 16 as pre-screening tool.

CONCLUSIONS

All in all, the results indicate a referral and care pathway system implemented mostly within the medical and particularly mental health sector. Accordingly, the PsyYoung project proposes a procedure for pathways to care which could help overcome the obstacle of referrals being restrained to a narrow field of mental health and to harmonize the referral process within services dedicated to the same aim of helping young people at high risk of developing a psychosis.

Clinical and functional outcomes at 7-year follow-up of children presenting putative antecedents of schizophrenia at age 9-12 years

Identification of youth presenting early risk factors for psychosis may facilitate preventive intervention. Through school-based screening, we recruited 112 children aged 9-12 years who presented multiple putative antecedents of schizophrenia (ASz), a family history of schizophrenia (FHx), or neither of these risk factors (typically-developing; TD). Clinical and functional outcomes were assessed at age 17-21 years (N = 93). Compared to the TD group, the ASz group had higher total Prodromal Questionnaire (PQ) scores (β = 10.59, 95% CI = 3.76, 17.42) and total psychopathology scores (β = 6.13, 95% CI: 1.03, 11.23), were more likely to score above-threshold on the PQ positive symptoms scale (OR = 4.00, 95% CI = 1.08, 14.83), and had lower scores on the Social and Occupational Functioning Scale (β = -9.43, 95% CI = -15.08, -3.77) at follow-up. The FHx and TD groups did not differ on any outcome. Findings suggest that population screening for putative antecedents of schizophrenia may identify children who would benefit from preventative intervention.

The Relationship between Clinical and Psychophysical Assessments of Visual Perceptual Disturbances in Individuals at Clinical High Risk for Psychosis: A Preliminary Study

This study investigated relations between a measure of early-stage visual function and self-reported visual anomalies in individuals at clinical high risk for psychosis (CHR-P). Eleven individuals at CHR identified via the Structured Interview for Psychosis-Risk Syndromes (SIPS) were recruited from a CHR-P research program in NYC. The sample was ~36% female, ranging from 16 to 33 years old (M = 23.90, SD = 6.14). Participants completed a contrast sensitivity task on an iPad with five spatial frequencies (0.41-13 cycles/degree) and completed the self-report Audio-Visual Abnormalities Questionnaire. Higher contrast sensitivity (better performance) to low spatial frequencies was associated with higher perceptual (r = 0.616, p = 0.044) and visual disturbances (r = 0.667, p = 0.025); lower contrast sensitivity to a middle spatial frequency was also associated with higher perceptual (r = -0.604, p = 0.049) and visual disturbances (r = -0.606, p = 0.048). This relation between the questionnaire and contrast sensitivity to low spatial frequency may be indicative of a reduction in lateral inhibition and "flooding" of environmental stimuli. The association with middle spatial frequencies, which play a critical role in face processing, may result in a range of perceptual abnormalities. These findings demonstrate that self-reported perceptual anomalies occur in these individuals and are linked to performance on a measure of early visual processing.

Using brain structural neuroimaging measures to predict psychosis onset for individuals at clinical high-risk

Machine learning approaches using structural magnetic resonance imaging (sMRI) can be informative for disease classification, although their ability to predict psychosis is largely unknown. We created a model with individuals at CHR who developed psychosis later (CHR-PS+) from healthy controls (HCs) that can differentiate each other. We also evaluated whether we could distinguish CHR-PS+ individuals from those who did not develop psychosis later (CHR-PS-) and those with uncertain follow-up status (CHR-UNK). T1-weighted structural brain MRI scans from 1165 individuals at CHR (CHR-PS+, n = 144; CHR-PS-, n = 793; and CHR-UNK, n = 228), and 1029 HCs, were obtained from 21 sites. We used ComBat to harmonize measures of subcortical volume, cortical thickness and surface area data and corrected for non-linear effects of age and sex using a general additive model. CHR-PS+ (n = 120) and HC (n = 799) data from 20 sites served as a training dataset, which we used to build a classifier. The remaining samples were used external validation datasets to evaluate classifier performance (test, independent confirmatory, and independent group [CHR-PS- and CHR-UNK] datasets). The accuracy of the classifier on the training and independent confirmatory datasets was 85% and 73% respectively. Regional cortical surface area measures-including those from the right superior frontal, right superior temporal, and bilateral insular cortices strongly contributed to classifying CHR-PS+ from HC. CHR-PS- and CHR-UNK individuals were more likely to be classified as HC compared to CHR-PS+ (classification rate to HC: CHR-PS+, 30%; CHR-PS-, 73%; CHR-UNK, 80%). We used multisite sMRI to train a classifier to predict psychosis onset in CHR individuals, and it showed promise predicting CHR-PS+ in an independent sample. The results suggest that when considering adolescent brain development, baseline MRI scans for CHR individuals may be helpful to identify their prognosis. Future prospective studies are required about whether the classifier could be actually helpful in the clinical settings.

Accelerating Medicines Partnership® Schizophrenia (AMP® SCZ): Rationale and Study Design of the Largest Global Prospective Cohort Study of Clinical High Risk for Psychosis

This article describes the rationale, aims, and methodology of the Accelerating Medicines Partnership® Schizophrenia (AMP® SCZ). This is the largest international collaboration to date that will develop algorithms to predict trajectories and outcomes of individuals at clinical high risk (CHR) for psychosis and to advance the development and use of novel pharmacological interventions for CHR individuals. We present a description of the participating research networks and the data processing analysis and coordination center, their processes for data harmonization across 43 sites from 13 participating countries (recruitment across North America, Australia, Europe, Asia, and South America), data flow and quality assessment processes, data analyses, and the transfer of data to the National Institute of Mental Health (NIMH) Data Archive (NDA) for use by the research community. In an expected sample of approximately 2000 CHR individuals and 640 matched healthy controls, AMP SCZ will collect clinical, environmental, and cognitive data along with multimodal biomarkers, including neuroimaging, electrophysiology, fluid biospecimens, speech and facial expression samples, novel measures derived from digital health technologies including smartphone-based daily surveys, and passive sensing as well as actigraphy. The study will investigate a range of clinical outcomes over a 2-year period, including transition to psychosis, remission or persistence of CHR status, attenuated positive symptoms, persistent negative symptoms, mood and anxiety symptoms, and psychosocial functioning. The global reach of AMP SCZ and its harmonized innovative methods promise to catalyze the development of new treatments to address critical unmet clinical and public health needs in CHR individuals.

A Recovery-Oriented Approach: Application of Metacognitive Reflection and Insight Therapy (MERIT) for Youth with Clinical High Risk (CHR) for Psychosis

Clinical High Risk for psychosis (CHR) refers to a phase of heightened risk for developing overt psychosis. CHR often emerges during adolescence or early adulthood. CHR has been identified as a group to target for intervention, with the hope that early intervention can both stave off prolonged suffering and intervene before mental health challenges become part of an individual's identity. However, there are few treatment modalities that can address some of the specific needs of CHR. Metacognitive Reflection and Insight Therapy (MERIT) is an integrative psychotherapy that can be applied to the CHR population. MERIT offers unique advantages to working with the CHR population as it aims to improve self-direction and recovery through stimulation of metacognitive capacity, a phenomenon that has been associated with recovery. This paper explores unique aspects of the CHR population and how MERIT can address barriers to recovery for individuals experiencing psychosis-like symptoms. Several case examples and a clinical vignette using MERIT to support patients with CHR are offered to exemplify this approach. MERIT offers a way to assist persons with CHR to address barriers to their personal recovery and to develop nuanced understandings of ways to master challenges.

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.

Development of the PSYCHS: Positive SYmptoms and Diagnostic Criteria for the CAARMS Harmonized with the SIPS

AIM

To harmonize two ascertainment and severity rating instruments commonly used for the clinical high risk syndrome for psychosis (CHR-P): the Structured Interview for Psychosis-risk Syndromes (SIPS) and the Comprehensive Assessment of At-Risk Mental States (CAARMS).

METHODS

The initial workshop is described in the companion report from Addington et al. After the workshop, lead experts for each instrument continued harmonizing attenuated positive symptoms and criteria for psychosis and CHR-P through an intensive series of joint videoconferences.

RESULTS

Full harmonization was achieved for attenuated positive symptom ratings and psychosis criteria, and modest harmonization for CHR-P criteria. The semi-structured interview, named Positive SYmptoms and Diagnostic Criteria for the CAARMS Harmonized with the SIPS (PSYCHS), generates CHR-P criteria and severity scores for both CAARMS and SIPS.

CONCLUSIONS

Using the PSYCHS for CHR-P ascertainment, conversion determination, and attenuated positive symptom severity rating will help in comparing findings across studies and in meta-analyses.

Psychotic symptoms with and without a primary psychotic disorder in children requiring inpatient mental health admission

Psychotic symptoms are relatively common in children and adolescents attending mental health services. On most occasions, their presence is not associated with a primary psychotic disorder, and their clinical significance remains understudied. No studies to date have evaluated the prevalence and clinical correlates of psychotic symptoms in children requiring inpatient mental health treatment. All children aged 6 to 12 years admitted to an inpatient children's unit over a 9-year period were included in this naturalistic study. Diagnosis at discharge, length of admission, functional impairment, and medication use were recorded. Children with psychotic symptoms without a childhood-onset schizophrenia spectrum disorder (COSS) were compared with children with COSS and children without psychotic symptoms using Chi-square and linear regressions. A total of 211 children were admitted during this period with 62.4% experiencing psychotic symptoms. The most common diagnosis in the sample was autism spectrum disorder (53.1%). Psychotic symptoms were not more prevalent in any diagnosis except for COSS (100%) and intellectual disability (81.8%). Psychotic symptoms were associated with longer admissions and antipsychotic medication use. The mean length of admission of children with psychotic symptoms without COSS seems to lie in between that of children without psychotic symptoms and that of children with COSS. We concluded that psychotic symptoms in children admitted to the hospital may be a marker of severity. Screening for such symptoms may have implications for treatment and could potentially contribute to identifying more effective targeted interventions and reducing overall morbidity.

The Cascade of Care for Early Psychosis Detection in a College Counseling Center

OBJECTIVE

Programs for early detection of psychosis help identify individuals experiencing emerging psychosis and link them with appropriate services, thereby reducing the duration of untreated psychosis (DUP). The authors used the cascade-of-care framework to identify various care stages between screening and enrollment in coordinated specialty care (CSC) and to determine attrition at each stage, with the goal of identifying points in the referral process that may affect DUP.

METHODS

Project partners included a college counseling center and CSC program. All college students seeking mental health services at a counseling center between 2020 and 2022 (N=1,945) completed the Prodromal Questionnaire-Brief (PQ-B) at intake. Students who met the distress cutoff score were referred for a phone screening. Those who met criteria on the basis of this screening were referred for assessment and possible enrollment into CSC.

RESULTS

Six stages in the cascade of care for early detection were identified. Of the students who completed the PQ-B as part of intake (stage 1), 547 (28%) met the PQ-B cutoff score (stage 2). Counselors referred 428 (78%) students who met the PQ-B cutoff score (stage 3), and 212 (50%) of these students completed the phone screening (stage 4). Seventy-two (34%) students completed a CSC eligibility assessment (stage 5), 21 (29%) of whom were enrolled in CSC (stage 6).

CONCLUSIONS

The cascade-of-care framework helped conceptualize the flow within a program for early psychosis detection in order to identify stages that may contribute to lengthier DUP. Future research is warranted to better understand the factors that contribute to DUP at these stages.

Clinical and Functional Outcomes of Community-Recruited Individuals at Clinical High-Risk for Psychosis: Results From the Youth Mental Health Risk and Resilience Study (YouR-Study)

Clinical high-risk for psychosis (CHR-P) individuals are typically recruited from clinical services but the clinical and functional outcomes of community-recruited CHR-P individuals remain largely unclear. The Youth Mental Health Risk and Resilience Study (YouR-Study) obtained a community sample of CHR-P individuals through an online-screening approach and followed-up these individuals for a period of up to 3 years to determine transition rates, persistence of attenuated psychotic symptoms (APS) and functional outcomes. Baseline data were obtained from n = 144 CHR-P participants, n = 51 participants who met online cutoff criteria but not CHR-P criteria (CHR-Ns), and n = 58 healthy controls. Baseline assessments included clinical measures for assessing CHR-P status, including the Comprehensive Assessment of At-Risk Mental States (CAARMS) and the Schizophrenia Proneness Instrument, Adult version (SPI-A), as well as functioning and cognitive measures. CHR-P and CHR-N groups were followed-up. Results show that 12.1% of CHR-P individuals transitioned to psychosis over 3 years, with no transitions in the CHR-N group. Nearly 60% of CHR-P individuals experienced poor functional outcome (PFO) and over 40% experienced persistent APS. A combination of CAARMS/SPI-A criteria was associated with a higher likelihood of PFO, but not with transition to psychosis nor APS persistence. However, transition risk was generally higher among those meeting both CAARMS/SPI-A criteria (64.3%) vs CAARMS (28.6%) or SPI-A (7.1%) alone. In summary, community-recruited CHR-P individuals are characterized by similar clinical characteristics and longitudinal outcomes to those recruited from clinical services, emphasizing the need to widen the scope of early detection and intervention strategies.

The Translational Future of Stress Neurobiology and Psychosis Vulnerability: A Review of the Evidence

Psychosocial stress is a well-established risk factor for psychosis, yet the neurobiological mechanisms underlying this relationship have yet to be fully elucidated. Much of the research in this field has investigated hypothalamic-pituitary-adrenal (HPA) axis function and immuno-inflammatory processes among individuals with established psychotic disorders. However, as such studies are limited in their ability to provide knowledge that can be used to develop preventative interventions, it is important to shift the focus to individuals with increased vulnerability for psychosis (i.e., high-risk groups). In the present article, we provide an overview of the current methods for identifying individuals at high-risk for psychosis and review the psychosocial stressors that have been most consistently associated with psychosis risk. We then describe a network of interacting physiological systems that are hypothesised to mediate the relationship between psychosocial stress and the manifestation of psychotic illness and critically review evidence that abnormalities within these systems characterise highrisk populations. We found that studies of high-risk groups have yielded highly variable findings, likely due to (i) the heterogeneity both within and across high-risk samples, (ii) the diversity of psychosocial stressors implicated in psychosis, and (iii) that most studies examine single markers of isolated neurobiological systems. We propose that to move the field forward, we require well-designed, largescale translational studies that integrate multi-domain, putative stress-related biomarkers to determine their prognostic value in high-risk samples. We advocate that such investigations are highly warranted, given that psychosocial stress is undoubtedly a relevant risk factor for psychotic disorders.

Psychiatric burden in a cohort of adults with Niemann Pick type C disease: from psychotic symptoms to frontal lobe behavioral disorders

OBJECTIVES

To describe Niemann-Pick type C (NP-C) behavioral symptoms (focusing on psychotic symptoms) and its relation to frontal lobe functioning.

METHODS

We retrospectively reviewed medical charts of NP-C-patients followed in the Lysosomal Diseases reference center in Paris Pitié-Salpêtrière. We collected demographic data, psychiatric clinical manifestations, psychometric scales, and extended neuropsychological data including executive and behavioral frontal lobe functions evaluations.

RESULTS

Nineteen patients were included in the study with ten of them having experienced at least one acute psychotic episode, being inaugural for six of them. Most of the patients suffered from behavioral (15/17) and cognitive disorders (18/19) (including executive dysfunction (11/12), apathy (13/17), impaired social cognition (11/13) and stereotyped behaviors (5/10). For five patients, quality of life was significantly impaired by these abnormal behaviors. Concerning frontal neuropsychological evaluation, Facial emotion recognition was by far the most performed neuropsychological test (n = 8) and the score was always abnormal. It is noteworthy that psychotic symptoms were often drug resistant (8/9) and that Miglustat was associated with a better control of psychotic symptoms.

CONCLUSIONS

We report a high frequency of psychiatric symptoms in NP-C encompassing acute psychotic manifestations, often presenting early in the course of the disease with atypical features. We also report disabling behavioral manifestations related to frontal dysfunction.

Perspective on clinical high-risk for psychosis in Africa

Clinical High Risk for Psychosis has evolved in recent years as a conceptual and clinical entity, representing a shift in focus from the syndromal psychosis state to a recognition of the pre-psychotic state as a period of potential preventive intervention. Much existing evidence has been generated from well-resourced countries, with a more limited body of literature available from Africa and other Majority World countries. Against a backdrop of prevailing systemic challenges, it is necessary to appraise the state of knowledge on Clinical High Risk for Psychosis in Africa. In this perspective article, we cover epidemiology, risk factors, predictors of psychosis conversion, as well as an overview of sociocultural factors, notably stigma, and the barriers to mental health services in African settings. We discuss existing and promising assessment approaches and reflect on preventive and early intervention strategies. We conclude with recommendations including the need for more clinical, longitudinal, and collaborative research anchored in an integrative transdisciplinary approach. We highlight the need for more culturally valid assessment tools and strategies to improve access to and utilization of services while also reducing stigma.

Meta-analytic prevalence of comorbid mental disorders in individuals at clinical high risk of psychosis: the case for transdiagnostic assessment

Comorbid mental disorders in subjects at clinical high risk for psychosis (CHR-P) may impact preventive care. We conducted a PRISMA/MOOSE-compliant systematic meta-analysis, searching PubMed/PsycInfo up to June 21st, 2021 for observational studies/randomized controlled trials reporting on comorbid DSM/ICD-mental disorders in CHR-P subjects ( protocol ). The primary and secondary outcomes were baseline and follow-up prevalence of comorbid mental disorders. We also explored the association of comorbid mental disorders compared with CHR-P versus psychotic/non-psychotic control groups, their impact on baseline functioning and transition to psychosis. We conducted random-effects meta-analyses, meta-regression, and assessed heterogeneity/publication bias/quality (Newcastle Ottawa Scale, NOS). We included 312 studies (largest meta-analyzed sample = 7834, any anxiety disorder, mean age = 19.98 (3.40), females = 43.88%, overall NOS > 6 in 77.6% of studies). The prevalence was 0.78 (95% CI = 0.73-0.82, k = 29) for any comorbid non-psychotic mental disorder, 0.60 (95% CI = 0.36-0.84, k = 3) for anxiety/mood disorders, 0.44 (95% CI = 0.39-0.49, k = 48) for any mood disorders, 0.38 (95% CI = 0.33-0.42, k = 50) for any depressive disorder/episode, 0.34 (95% CI = 0.30-0.38, k = 69) for any anxiety disorder, 0.30 (95% CI 0.25-0.35, k = 35) for major depressive disorders, 0.29 (95% CI, 0.08-0.51, k = 3) for any trauma-related disorder, 0.23 (95% CI = 0.17-0.28, k = 24) for any personality disorder, and <0.23 in other mental disorders (I2 > 50% in 71.01% estimates). The prevalence of any comorbid mental disorder decreased over time (0.51, 95% CI = 0.25-0.77 over 96 months), except any substance use which increased (0.19, 95% CI = 0.00-0.39, k = 2, >96 months). Compared with controls, the CHR-P status was associated with a higher prevalence of anxiety, schizotypal personality, panic, and alcohol use disorders (OR from 2.90 to 1.54 versus without psychosis), a higher prevalence of anxiety/mood disorders (OR = 9.30 to 2.02) and lower prevalence of any substance use disorder (OR = 0.41, versus psychosis). Higher baseline prevalence of alcohol use disorder/schizotypal personality disorder was negatively associated with baseline functioning (beta from -0.40 to -0.15), while dysthymic disorder/generalized anxiety disorder with higher functioning (beta 0.59 to 1.49). Higher baseline prevalence of any mood disorder/generalized anxiety disorder/agoraphobia (beta from -2.39 to -0.27) was negatively associated with transition to psychosis. In conclusion, over three-quarters of CHR-P subjects have comorbid mental disorders, which modulate baseline functionig and transition to psychosis. Transdiagnostic mental health assessment should be warranted in subjects at CHR-P.

Development of the PSYCHS: Positive SYmptoms and Diagnostic Criteria for the CAARMS Harmonized with the SIPS

Aim

To harmonize two ascertainment and severity rating instruments commonly used for the clinical high risk syndrome for psychosis (CHR-P): the Structured Interview for Psychosis-risk Syndromes (SIPS) and the Comprehensive Assessment of At-Risk Mental States (CAARMS).

Methods

The initial workshop is described in the companion report from Addington et al. After the workshop, lead experts for each instrument continued harmonizing attenuated positive symptoms and criteria for psychosis and CHR-P through an intensive series of joint videoconferences.

Results

Full harmonization was achieved for attenuated positive symptom ratings and psychosis criteria, and partial harmonization for CHR-P criteria. The semi-structured interview, named P ositive SY mptoms and Diagnostic Criteria for the C AARMS H armonized with the S IPS (PSYCHS), generates CHR-P criteria and severity scores for both CAARMS and SIPS.

Conclusion

Using the PSYCHS for CHR-P ascertainment, conversion determination, and attenuated positive symptom severity rating will help in comparing findings across studies and in meta-analyses.

Sampling from different populations: Sociodemographic, clinical, and functional differences between samples of first episode psychosis individuals and clinical high-risk individuals who progressed to psychosis

Over the past two decades, research and clinical resources on clinical high risk (CHR) for psychosis have both expanded, with goals to better understanding risk and protective factors on the course of illness and inform early intervention efforts. However, some studies have highlighted potential sampling bias among CHR research studies, raising questions about generalizability of findings and inequitable access to early detection and intervention. The current study sought to explore these questions by comparing 94 participants in a CHR longitudinal monitoring study across North America (NAPLS-2) who converted to syndromal psychosis over the course of the study (CHR-CV) to 171 participants who presented for treatment at a localized first-episode psychosis service (FES) after converting. CHR-CV participants were significantly more likely to be White and have a college-educated parent, while FES participants were more likely to be Black and first- or second-generation immigrants. On average, CHR-CV participants were younger at onset of attenuated positive symptoms, had a longer period of attenuated symptoms prior to conversion, and were more likely to be treated with antipsychotics prior to conversion compared to those in FES programs. After controlling for time since conversion, CHR-CV participants had higher global functioning and were less likely to have experienced recent psychiatric hospitalization. Findings suggest that CHR research and FES clinics may be sampling from different populations, although conclusions are limited by inconsistent sampling frames and methods. Integrated early detection that targets defined geographic catchments may deliver more epidemiologically representative samples to both CHR research and FES.

Skills program for awareness, connectedness, and empowerment: A conceptual framework of a skills group for individuals with a psychosis-risk syndrome

Intervention strategies for those diagnosed with psychotic disorders such as schizophrenia can be effective in reducing symptoms and improving quality of life. While strides have been made in developing prevention and intervention strategies earlier on in the disease progression, among those at clinical high-risk (CHR) for psychosis, challenges with heterogeneity can limit symptom and diagnosis specific treatment. Here, we discuss a newly developed therapy skills group called the Skills Program for Awareness, Connectedness, and Empowerment (SPACE) that integrates different types of behavioral skills - standard and radically open dialectical behavioral therapy as well as cognitive behavioral therapy - for CHR youth between the ages of 13-18 years. With the diathesis-stress framework serving as a foundation, the intervention is divided into three stages. These stages target specific signs and symptoms contributing to the progression of CHR symptoms. Stage 1 targets stress (with the goal of developing awareness and reducing distress), stage 2 targets self-disturbances (with a goal of increasing self-connectedness), and stage 3 targets social connectedness (with a goal of improving social domains of functioning). The focus of this article is to introduce the theoretical framework underlying the pilot skills group and discuss ongoing progress.

Clinical Trial Registration

NCT05398120; https://clinicaltrials.gov/ct2/show/NCT05398120.

Psychosocial factors associated with the risk of developing psychosis in a Mexican general population sample

Epidemiological evidence has linked an array of sociodemographic and psychosocial factors with an increased risk of developing psychosis. However, research in samples from low- and middle-income countries is still scarce. This study used a Mexican sample to explore (i) sociodemographic and psychosocial differences between individuals with and without a positive screen for Clinical High-Risk for psychosis (CHR), and (ii) sociodemographic and psychosocial factors associated with screening positive for CHR. The sample consisted of 822 individuals from the general population who completed an online survey. Of the participants, 17.3% (n = 142) met the CHR screening criteria. Comparisons between those who screened positive (CHR-positive group) and those who did not (Non-CHR group) showed that participants in the CHR-positive group were younger, had a lower educational level, and reported more mental health problems than the Non-CHR group. Furthermore, relative to the Non-CHR group, the CHR-positive group had a greater prevalence of medium/high risk associated with cannabis use, a higher prevalence of adverse experiences (bullying, intimate partner violence, and experiencing a violent or unexpected death of a relative or friend), as well as higher levels of childhood maltreatment, poorer family functioning, and more distress associated with the COVID-19 pandemic. Groups did not differ in sex, marital/relationship status, occupation, and socio-economic status. Finally, when examined in multivariate analyses, the variables associated with screening positive for CHR were: having an unhealthy family functioning (OR = 2.75, 95%CI 1.69-4.46), a higher risk associated with cannabis use (OR = 2.75, 95%CI 1.63-4.64), a lower level of education (OR = 1.55, 95%CI 1.003-2.54), having experienced a major natural disaster (OR = 1.94, 95%CI 1.18-3.16), having experienced a violent or unexpected death of a relative or friend (OR = 1.85, 95%CI 1.22-2.81), higher levels of childhood emotional abuse (OR = 1.88, 95%CI 1.09-3.25), physical neglect (OR = 1.68, 95%CI 1.08-2.61), and physical abuse (OR = 1.66, 95%CI 1.05-2.61), and higher COVID-related distress (OR = 1.10, 95%CI 1.01-1.20). An older age was a protective factor for screening positive for CHR (OR = 0.96, 95%CI 0.92-0.99). Overall, the findings highlight the importance of examining potential psychosocial contributors to psychosis vulnerability across different sociocultural contexts to delineate risk and protective processes relevant to specific populations and better target preventive intervention efforts.

Detection of clinical high risk for psychosis in child and adolescent mental health services: Validation of the first step with the French versions of the Prodromal Questionnaire (fPQ-16) and scale of Perceptual and Cognitive Aberrations (fPCA)

AIM

To validate the French versions of the 16-items Prodromal Questionnaire (PQ-16) and the 9-items scale of Perceptual and Cognitive Aberrations (PCA) to facilitate screening of psychosis risk in native French-speaking young individuals referred to Child and Adolescent Mental Health Services.

METHOD

Participants (N = 87, age range 10-18 years) were diagnosed with a non-psychotic disorder according to the Diagnostic and Statistical Manual of Mental Disorders. The French versions of the PQ-16 and PCA were developed using a forward-backward translation procedure. Psychometric properties were tested including (i) internal validity with Pearson correlations and Cronbach's coefficients, and (ii) external validity by correlations with each other's.

RESULTS

(i) Correlations between fPQ-16 and fPCA total scores and individual items were mostly >.4. Cronbach's coefficients were .80 for the fPQ-16 and .61 for the fPCA. (ii) The fPQ-16 and fPCA total scores were significantly correlated with a large effect size (r_s  = 0.66).

CONCLUSION

The fPQ-16 and the fPCA are psychometrically acceptable instruments for the screening of potential psychotic symptoms in French-speaking children and young adolescents under 18 years old referred to Child and Adolescent Mental Health Services.

Reverse Engineering of Digital Measures: Inviting Patients to the Conversation

Background

Digital measures offer an unparalleled opportunity to create a more holistic picture of how people who are patients behave in their real-world environments, thereby establishing a better connection between patients, caregivers, and the clinical evidence used to drive drug development and disease management. Reaching this vision will require achieving a new level of co-creation between the stakeholders who design, develop, use, and make decisions using evidence from digital measures.

Summary

In September 2022, the second in a series of meetings hosted by the Swiss Federal Institute of Technology in Zürich, the Foundation for the National Institutes of Health Biomarkers Consortium, and sponsored by Wellcome Trust, entitled "Reverse Engineering of Digital Measures," was held in Zurich, Switzerland, with a broad range of stakeholders sharing their experience across four case studies to examine how patient centricity is essential in shaping development and validation of digital evidence generation tools.

Key Messages

In this paper, we discuss progress and the remaining barriers to widespread use of digital measures for evidence generation in clinical development and care delivery. We also present key discussion points and takeaways in order to continue discourse and provide a basis for dissemination and outreach to the wider community and other stakeholders. The work presented here shows us a blueprint for how and why the patient voice can be thoughtfully integrated into digital measure development and that continued multistakeholder engagement is critical for further progress.

The First Year of the Psychiatric Diseases Section

Since its inception in May 2021, the Psychiatric Diseases Section of Brain Sciences has grown to include a staff of 28 academic editors with expertise related to clinical psychiatry, in addition to its supporting staff of managing and English-language editors [...].

The Mini-SIPS: development of a brief clinical structured interview guide to diagnosing DSM-5 Attenuated Psychosis Syndrome and training outcomes

OBJECTIVE

The Mini-SIPS, a condensed version of the Structured Interview for Psychosis-Risk Syndromes (SIPS), is intended to efficiently identify for clinicians the minimum information needed to support a DSM-5 Attenuated Psychosis Syndrome (APS) diagnosis.

METHODS

The instrument and the DSM-5 criteria are accessible through the online training program.

RESULTS

Most individuals (67.5%) in the first 212 to complete the training program indicated an intended use of the Mini-SIPS exclusively for clinical purposes. Performance on the post-training quiz was excellent for those with and without prior training in structured diagnostic interviewing.

CONCLUSION

The Mini-SIPS, and accompanying training program, are offered as public-domain clinical resources to the mental health community.

Prognostic accuracy and clinical utility of psychometric instruments for individuals at clinical high-risk of psychosis: a systematic review and meta-analysis

Accurate prognostication of individuals at clinical high-risk for psychosis (CHR-P) is an essential initial step for effective primary indicated prevention. We aimed to summarise the prognostic accuracy and clinical utility of CHR-P assessments for primary indicated psychosis prevention. Web of Knowledge databases were searched until 1st January 2022 for longitudinal studies following-up individuals undergoing a psychometric or diagnostic CHR-P assessment, reporting transition to psychotic disorders in both those who meet CHR-P criteria (CHR-P + ) or not (CHR-P-). Prognostic accuracy meta-analysis was conducted following relevant guidelines. Primary outcome was prognostic accuracy, indexed by area-under-the-curve (AUC), sensitivity and specificity, estimated by the number of true positives, false positives, false negatives and true negatives at the longest available follow-up time. Clinical utility analyses included: likelihood ratios, Fagan's nomogram, and population-level preventive capacity (Population Attributable Fraction, PAF). A total of 22 studies (n = 4 966, 47.5% female, age range 12-40) were included. There were not enough meta-analysable studies on CHR-P diagnostic criteria (DSM-5 Attenuated Psychosis Syndrome) or non-clinical samples. Prognostic accuracy of CHR-P psychometric instruments in clinical samples (individuals referred to CHR-P services or diagnosed with 22q.11.2 deletion syndrome) was excellent: AUC = 0.85 (95% CI: 0.81-0.88) at a mean follow-up time of 34 months. This result was driven by outstanding sensitivity (0.93, 95% CI: 0.87-0.96) and poor specificity (0.58, 95% CI: 0.50-0.66). Being CHR-P + was associated with a small likelihood ratio LR + (2.17, 95% CI: 1.81-2.60) for developing psychosis. Being CHR-P- was associated with a large LR- (0.11, 95%CI: 0.06-0.21) for developing psychosis. Fagan's nomogram indicated a low positive (0.0017%) and negative (0.0001%) post-test risk in non-clinical general population samples. The PAF of the CHR-P state is 10.9% (95% CI: 4.1-25.5%). These findings consolidate the use of psychometric instruments for CHR-P in clinical samples for primary indicated prevention of psychosis. Future research should improve the ability to rule in psychosis risk.

Mitochondrial Impairment: A Common Motif in Neuropsychiatric Presentation? The Link to the Tryptophan-Kynurenine Metabolic System

Nearly half a century has passed since the discovery of cytoplasmic inheritance of human chloramphenicol resistance. The inheritance was then revealed to take place maternally by mitochondrial DNA (mtDNA). Later, a number of mutations in mtDNA were identified as a cause of severe inheritable metabolic diseases with neurological manifestation, and the impairment of mitochondrial functions has been probed in the pathogenesis of a wide range of illnesses including neurodegenerative diseases. Recently, a growing number of preclinical studies have revealed that animal behaviors are influenced by the impairment of mitochondrial functions and possibly by the loss of mitochondrial stress resilience. Indeed, as high as 54% of patients with one of the most common primary mitochondrial diseases, mitochondrial encephalomyopathy with lactic acidosis and stroke-like episodes (MELAS) syndrome, present psychiatric symptoms including cognitive impairment, mood disorder, anxiety, and psychosis. Mitochondria are multifunctional organelles which produce cellular energy and play a major role in other cellular functions including homeostasis, cellular signaling, and gene expression, among others. Mitochondrial functions are observed to be compromised and to become less resilient under continuous stress. Meanwhile, stress and inflammation have been linked to the activation of the tryptophan (Trp)-kynurenine (KYN) metabolic system, which observably contributes to the development of pathological conditions including neurological and psychiatric disorders. This review discusses the functions of mitochondria and the Trp-KYN system, the interaction of the Trp-KYN system with mitochondria, and the current understanding of the involvement of mitochondria and the Trp-KYN system in preclinical and clinical studies of major neurological and psychiatric diseases.

Cannabis Use in Autism: Reasons for Concern about Risk for Psychosis

Being particularly vulnerable to the pro-psychotic effects of cannabinoid exposure, autism spectrum individuals present with an increased risk of psychosis, which may be passed on to their own children. More specifically, cannabis exposure among autism spectrum individuals seems to exert disruptive epigenetic effects that can be intergenerationally inherited in brain areas which play a critical role in schizophrenia pathophysiology. Additionally, because of such cannabinoid-induced epigenetic effects, autism candidate genes present with bivalent chromatin markings which make them more vulnerable to subsequent disruption, possibly leading to psychosis onset later in life. Thus, findings support a developmental trajectory between autism and psychosis, as per endocannabinoid system modulation. However, such evidence has not received the attention it deserves.

Three prominent self-report risk measures show unique and overlapping utility in characterizing those at clinical high-risk for psychosis

Self-report questionnaires have been developed to efficiently assess psychosis risk and vulnerability. Despite this, the validity of these questionnaires for assessing specific positive symptoms in those at clinical high risk for psychosis (CHR) is unclear. Positive symptoms have largely been treated as a uniform construct in this critical population and there have been no reports on the construct validity of questionnaires for assessing specific symptoms. The present study examined the convergent, discriminant, and criterion validity of the Launay Slade Hallucination Scale-Revised (LSHS-R), Prodromal Questionnaire-Brief (PQB), and Community Assessment of Psychic Experiences positive scale (CAPE-P) using a multimethod approach. CHR individuals (N = 71) and healthy controls (HC; N = 71) completed structured clinical interviews, self-report questionnaires, and neuropsychological tests. Questionnaire intercorrelations indicated strong convergent validity (i.e., all rs > .50); however, evidence for discriminant validity was more variable. In examining relations to interviewer-assessed psychosis symptoms, all questionnaires demonstrated evidence of criterion validity, though the PQB showed the strongest convergent correlations (e.g., r = .48 with total symptoms). In terms of discriminant validity for specific positive symptoms, results were again more variable. PQB subscales demonstrated limited specificity with positive symptoms, whereas CAPE-P subscales showed some specificity and the LSHS-R showed high specificity. In addition, when correlations with internalizing and externalizing symptoms were examined, only the PQB showed consistent significant correlations. These results are interpreted in terms of the strengths and limitations of each measure, their value for screening, and their potential utility for clarifying differences between specific positive symptoms.

The Interplay between Vitamin D, Exposure of Anticholinergic Antipsychotics and Cognition in Schizophrenia

Vitamin D deficiency is a frequent finding in schizophrenia and may contribute to neurocognitive dysfunction, a core element of the disease. However, there is limited knowledge about the neuropsychological profile of vitamin D deficiency-related cognitive deficits and their underlying molecular mechanisms. As an inductor of cytochrome P450 3A4, a lack of vitamin D might aggravate cognitive deficits by increased exposure to anticholinergic antipsychotics. This cross-sectional study aims to assess the relationship between 25-OH-vitamin D-serum concentrations, anticholinergic drug exposure and neurocognitive functioning (Brief Assessment of Cognition in Schizophrenia, BACS, and Trail Making Test, TMT) in 141 patients with schizophrenia. The anticholinergic drug exposure was estimated by adjusting the concentration of each drug for its individual muscarinic receptor affinity. Using regression analysis, we observed a positive relationship between vitamin D levels and processing speed (TMT-A and BACS Symbol Coding) as well as executive functioning (TMT-B and BACS Tower of London). Moreover, a negative impact of vitamin D on anticholinergic drug exposure emerged, but the latter did not significantly affect cognition. When other cognitive items were included as regressors, the impact of vitamin D remained only significant for the TMT-A. Among the different cognitive impairments in schizophrenia, vitamin D deficiency may most directly affect processing speed, which in turn may aggravate deficits in executive functioning. This finding is not explained by a cytochrome P450-mediated increased exposure to anticholinergic antipsychotics.

Early Markers in Resistant Schizophrenia: Effect of the First Antipsychotic Drug

Background: Schizophrenia is a mental illness with a multifactorial etiology and clinical presentation. Treatment is mainly with antipsychotic drugs. Despite the increasing number of antipsychotic drugs, there has been no significant change in the percentage of resistant cases. These data gave us reason to look for a link between the effect of the first individually selected antipsychotic drug and the established resistance to therapy. Method: An assessment has been made of 105 patients with chronic schizophrenia with consecutive psychotic episodes. The choice of antipsychotic has been made on the basis of clinical features, history of efficacy of previously used neuroleptics, anthropometric features, as well as somatic comorbidities. Accidental use of benzodiazepines in anxiety conditions as well as correctors in indications for extrapyramidal problems have been reported. Assessment was made based on clinical observation as well as on changes in PANSS score. Results: Of the 105 observed patients, the effectiveness of the first antipsychotic effect was found in 46.7% of patients. Follow-up of patients for a period of 12 weeks revealed that 45 (42.8%) of them had resistant schizophrenia, while the remaining 60 (57.2%) achieved clinical remission and initial functional recovery. The effect of the first antipsychotic drug was established in 9 (20%) of the patients with resistant schizophrenia and in 40 (66.57%) of the patients in clinical remission. Conclusion: The evaluation of the first antipsychotic medication is significant for the prognosis of patients with schizophrenia. Its lack of effectiveness indicates a high probability of resistance and can be a good indicator of earlier change and a possible search for more “aggressive” measures to prevent future resistance and possible disability.

Dissociative Model in Patients With Resistant Schizophrenia

BACKGROUND

Schizophrenia is a severe mental illness in which, despite the growing number of antipsychotics from 30 to 50% of patients remain resistant to treatment. Many resistance factors have been identified. Dissociation as a clinical phenomenon is associated with a loss of integrity between memories and perceptions of reality. Dissociative symptoms have also been found in patients with schizophrenia of varying severity. The established dispersion of the degree of dissociation in patients with schizophrenia gave us reason to look for the connection between the degree of dissociation and resistance to therapy.

METHODS

The type of study is correlation analysis. 106 patients with schizophrenia were evaluated. Of these, 45 with resistant schizophrenia and 60 with clinical remission. The Positive and Negative Syndrome Scale (PANSS) and Brief Psychiatric Rating Scale (BPRS) scales were used to assess clinical symptoms. The assessment of dissociative symptoms was made with the scale for dissociative experiences (DES). Statistical methods were used to analyze the differences in results between the two groups of patients.

RESULTS

Patients with resistant schizophrenia have a higher level of dissociation than patients in remission. This difference is significant and demonstrative with more than twice the level of dissociation in patients with resistant schizophrenia.The level of dissociation measured in patients with resistant schizophrenia is as high as the points on the DES in dissociative personality disorder.

CONCLUSION

Patients with resistant schizophrenia have a much higher level of dissociation than patients in clinical remission. The established difference between the two groups support to assume that resistance to the administered antipsychotics is associated with the presence of high dissociation in the group of resistant patients. These results give us explanation to think about therapeutic options outside the field of antipsychotic drugs as well as to consider different strategies earlier in the diagnostic process.