scholarly journals M21. THE STEP TRIAL: A SEQUENTIAL MULTIPLE ASSIGNMENT RANDOMISED TRIAL (SMART) OF INTERVENTIONS FOR PATIENTS AT ULTRA-HIGH RISK OF PSYCHOSIS - STUDY RATIONALE, DESIGN AND BASELINE DATA

2020 ◽  
Vol 46 (Supplement_1) ◽  
pp. S141-S141
Author(s):  
Barnaby Nelson ◽  
G Paul Amminger ◽  
Hok Pan Yuen ◽  
Melissa Kerr ◽  
Jessica Spark ◽  
...  
Keyword(s):  
High Risk ◽  
Case Management ◽  
Psychotic Disorder ◽  
Psychosocial Functioning ◽  
Randomised Trial ◽  
Antidepressant Medication ◽  
Clinical Population ◽  
Psychotic Symptoms ◽  
Retention Data ◽  
Cognitive Behavioural

Abstract Background Although approximately twenty randomised controlled trials have now been conducted with young people identified as being at high clinical risk of psychotic disorder, it remains unclear what the optimal type and sequence of treatments are for this clinical population. There has also been increased focus on clinical outcomes other than transition to psychotic disorder, such as psychosocial functioning, persistent attenuated psychotic symptoms and non-psychotic disorders. At Orygen, we are currently conducting a trial of a sequence of interventions consisting of two psychosocial therapies (support and problem solving [SPS] and cognitive-behavioural case management [CBCM]) and antidepressant medication. The primary outcome of the study is functional outcome after 6 months. This presentation will outline the background, rationale, design, recruitment and retention data and preliminary baseline results. Methods STEP is a sequential multiple assignment randomised trial (SMART) of treatments for young people (12–25 year olds) who meet ultra high risk for psychosis (UHR) criteria. Participants were recruited from primary (headspace) and secondary/tertiary (Orygen Youth Health) mental health services in Melbourne, Australia. The trial consists of three steps: Step 1: SPS (1.5 months); Step 2: SPS vs Cognitive Behavioural Case Management (4.5 months); Step 3: Cognitive Behavioural Case Management + Antidepressant Medication vs Cognitive Behavioural Case Management + Placebo (6 months). Patients who do not respond by the end of each step graduate to the next step in treatment. Responders are randomised to SPS or monitoring. Treatment response is based a combination of reduced attenuated psychotic symptoms, rated using the Comprehensive Assessment of At-Risk Mental States (CAARMS), and functional improvement (Social and Occupational Functioning Assessment Scale [SOFAS]) at the end of the treatment step. A ‘fast fail’ option is built into Step 3, whereby patients who deteriorate or have not responded 3 months into Step 3 are offered a choice of continuing existing treatment or commencing omega-3 fatty acids or low-dose antipsychotic medication. The intervention is for 12 months, with follow up at 18 and 24 months. A pilot study using the same design is currently being conducted at The University of California Davis. Results Recruitment has recently completed, with 342 patients recruited over a 2.4 year period, representing the largest UHR treatment study conducted to date. Preliminary results indicate an 8% response rate to Step 1 and a 23% response rate to Step 2. Discontinuation rates are 15% (step 1), 43% (step 2), 32% (step 3), primarily due to participants being lost to follow up or not wanting to start medication. The current transition to psychosis rate is 10.2%. Baseline clinical data are currently being analysed and will be presented at the conference. Discussion Preliminary results indicate high non-response rates following SPS and moderate non-response rates following extended SPS or CBCM, possibly partly due to the stringent definition of response, which required substantial and persistent improvement in both attenuated psychotic symptoms and functioning. Discontinuation rates are low to moderate, reflecting the complexity and severity of this clinical population. The recruitment and retention data show that it is possible to conduct large-scale and complex stepped care trials with this high risk population in a primary mental health care setting (headspace services). Outcomes will inform the most effective type and sequence of treatments for improving psychosocial functioning, symptoms and reducing risk of developing psychotic disorder in this group, as well as identify predictors of treatment response.

scholarly journals What makes the psychosis ‘clinical high risk’ state risky: psychosis itself or the co-presence of a non-psychotic disorder?

2021 ◽  
Vol 30 ◽  
Author(s):  
Laila Hasmi ◽  
Lotta-Katrin Pries ◽  
Margreet ten Have ◽  
Ron de Graaf ◽  
Saskia van Dorsselaer ◽  
...  
Keyword(s):  
High Risk ◽  
Drug Use ◽  
Psychotic Disorder ◽  
Positive Family History ◽  
Mental Health Service Use ◽  
Psychotic Symptoms ◽  
Polygenic Risk Score ◽  
Clinical High Risk ◽  
Drug Use Disorders ◽  
Per Se

Abstract Aims Although attenuated psychotic symptoms in the psychosis clinical high-risk state (CHR-P) almost always occur in the context of a non-psychotic disorder (NPD), NPD is considered an undesired ‘comorbidity’ epiphenomenon rather than an integral part of CHR-P itself. Prospective work, however, indicates that much more of the clinical psychosis incidence is attributable to prior mood and drug use disorders than to psychosis clinical high-risk states per se. In order to examine this conundrum, we analysed to what degree the ‘risk’ in CHR-P is indexed by co-present NPD rather than attenuated psychosis per se. Methods We examined the incidence of early psychotic experiences (PE) with and without NPD (mood disorders, anxiety disorders, alcohol/drug use disorders), in a prospective general population cohort (n = 6123 at risk of incident PE at baseline). Four interview waves were conducted between 2007 and 2018 (NEMESIS-2). The incidence of PE, alone (PE-only) or with NPD (PE + NPD) was calculated, as were differential associations with schizophrenia polygenic risk score (PRS-Sz), environmental, demographical, clinical and cognitive factors. Results The incidence of PE + NPD (0.37%) was lower than the incidence of PE-only (1.04%), representing around a third of the total yearly incidence of PE. Incident PE + NPD was, in comparison with PE-only, differentially characterised by poor functioning, environmental risks, PRS-Sz, positive family history, prescription of antipsychotic medication and (mental) health service use. Conclusions The risk in ‘clinical high risk’ states is mediated not by attenuated psychosis per se but specifically the combination of attenuated psychosis and NPD. CHR-P/APS research should be reconceptualised from a focus on attenuated psychotic symptoms with exclusion of non-psychotic DSM-disorders, as the ‘pure' representation of a supposedly homotypic psychosis risk state, towards a focus on poor-outcome NPDs, characterised by a degree of psychosis admixture, on the pathway to psychotic disorder outcomes.

scholarly journals Two-year follow-up of a Chinese sample at clinical high risk for psychosis: timeline of symptoms, help-seeking and conversion

2016 ◽  
Vol 26 (3) ◽  
pp. 287-298 ◽  
Author(s):  
T. H. Zhang ◽  
H. J. Li ◽  
K. A. Woodberry ◽  
L. H. Xu ◽  
Y. Y. Tang ◽  
...  
Keyword(s):  
High Risk ◽  
Symptom Onset ◽  
Help Seeking ◽  
Cox Regression ◽  
Clinical Population ◽  
Psychotic Symptoms ◽  
Clinical High Risk ◽  
Chinese Sample ◽  
Over Time

Background.Chinese psychiatrists have gradually started to focus on those who are deemed to be at ‘clinical high-risk (CHR)’ for psychosis; however, it is still unknown how often those individuals identified as CHR from a different country background than previously studied would transition to psychosis. The objectives of this study are to examine baseline characteristics and the timing of symptom onset, help-seeking, or transition to psychosis over a 2-year period in China.Method.The presence of CHR was determined with the Structured Interview for Prodromal Syndromes (SIPS) at the participants' first visit to the mental health services. A total of 86 (of 117) CHR participants completed the clinical follow-up of at least 2 years (73.5%). Conversion was determined using the criteria of presence of psychotic symptoms (in SIPS). Analyses examined baseline demographic and clinical predictors of psychosis and trajectory of symptoms over time. Survival analysis (Kaplan–Meier) methods along with Log-rank tests were performed to illustrate the relationship of baseline data to either conversion or non-conversion over time. Cox regression was performed to identify baseline predictors of conversion by the 2-year follow-up.Results.In total 25 (29.1%) of 86 completers transitioned to a psychotic disorder over the course of follow-up. Among the CHR sample, the mean time between attenuated symptom onset and professional help-seeking was about 4 months on average, and converters developed fully psychotic symptoms about 12 months after symptom onset. Compared with those CHR participants whose risk syndromes remitted over the course of the study, converters had significantly longer delays (p = 0.029) for their first visit to a professional in search of help. At baseline assessment, the conversion subgroup was younger, had poorer functioning, higher total SIPS positive symptom scores, longer duration of untreated prodromal symptoms, and were more often given psychosis-related diagnoses and subsequently prescribed antipsychotics in the clinic.Conclusions.Chinese CHR identified primarily by a novel clinical screening approach had a 2-year transition rate comparable with those of specialised help-seeking samples world-wide. Early clinical intervention with this functionally deteriorating clinical population who are suffering from attenuated psychotic symptoms, is a next step in applying the CHR construct in China.

scholarly journals The reality of at risk mental state services: a response to recent criticisms

2019 ◽  
pp. 1-7 ◽  
Author(s):  
Alison R. Yung ◽  
Stephen J. Wood ◽  
Ashok Malla ◽  
Barnaby Nelson ◽  
Patrick McGorry ◽  
...  
Keyword(s):  
At Risk ◽  
High Risk ◽  
Psychotic Disorder ◽  
Mental State ◽  
Help Seeking ◽  
Psychotic Symptoms ◽  
Ultra High Risk ◽  
Psychological Medicine ◽  
Poor Outcomes ◽  
At Risk Mental State

AbstractBackgroundIn the 1990s criteria were developed to detect individuals at high and imminent risk of developing a psychotic disorder. These are known as the at risk mental state, ultra high risk or clinical high risk criteria. Individuals meeting these criteria are symptomatic and help-seeking. Services for such individuals are now found worldwide. Recently Psychological Medicine published two articles that criticise these services and suggest that they should be dismantled or restructured. One paper also provides recommendations on how ARMS services should be operate.MethodsIn this paper we draw on the existing literature in the field and present the perspective of some ARMS clinicians and researchers.ResultsMany of the critics' arguments are refuted. Most of the recommendations included in the Moritz et al. paper are already occurring.ConclusionsARMS services provide management of current problems, treatment to reduce risk of onset of psychotic disorder and monitoring of mental state, including attenuated psychotic symptoms. These symptoms are associated with a range of poor outcomes. It is important to assess them and track their trajectory over time. A new approach to detection of ARMS individuals can be considered that harnesses broad youth mental health services, such as headspace in Australia, Jigsaw in Ireland and ACCESS Open Minds in Canada. Attention should also be paid to the physical health of ARMS individuals. Far from needing to be dismantled we feel that the ARMS approach has much to offer to improve the health of young people.

scholarly journals Resurrection of the Follow-Back Method to Study the Transdiagnostic Origins of Psychosis

2021 ◽  
Author(s):  
Jim van Os ◽  
Annette Schaub ◽  
William T Carpenter
Keyword(s):  
High Risk ◽  
General Population ◽  
Psychotic Disorder ◽  
Help Seeking ◽  
Psychotic Disorders ◽  
Common Mental Disorders ◽  
Psychotic Symptoms ◽  
Clinical High Risk ◽  
Representative Cohort ◽  
Representative Samples

Abstract There has been a major drive in research trying to understand the onset of psychosis. Clinical-high risk (CHR) studies focus on opportunistic help-seeking samples with non-psychotic disorders and a degree of psychosis admixture of variable outcome, but it is unlikely that these represent the population incidence of psychotic disorders. Longitudinal cohort studies of representative samples in the general population have focused on development and outcome of attenuated psychotic symptoms, but typically have low power to detect transition to clinical psychotic disorder. In this issue of Schizophrenia Bulletin, Cupo and colleagues resurrect a time-honored method to examine psychosis onset: the epidemiological follow-back study, modernizing it to fit the research framework of the early intervention era. The authors set out to investigate the hypothesis that psychotic disorder represents the poorest outcome fraction of initially non-psychotic, common mental disorders and present compelling findings, unifying previous opportunistic CHR and representative cohort-based work.

scholarly journals A Randomized Controlled Trial of the Effectiveness of Computer-Assisted Cognitive Remediation (CACR) in Adolescents with Psychosis or at High Risk of Psychosis

2013 ◽  
Vol 42 (4) ◽  
pp. 421-434 ◽  
Author(s):  
Laurent Holzer ◽  
Sebastien Urben ◽  
Christina Moses Passini ◽  
Laure Jaugey ◽  
Michael H. Herzog ◽  
...  
Keyword(s):  
Randomized Controlled Trial ◽  
High Risk ◽  
Computer Games ◽  
Cognitive Abilities ◽  
Psychosocial Functioning ◽  
Controlled Trial ◽  
Cognitive Remediation ◽  
Psychotic Symptoms ◽  
Computer Assisted ◽  
Randomized Controlled

Background: Computer assisted cognitive remediation (CACR) was demonstrated to be efficient in improving cognitive deficits in adults with psychosis. However, scarce studies explored the outcome of CACR in adolescents with psychosis or at high risk. Aims: To investigate the effectiveness of a computer-assisted cognitive remediation (CACR) program in adolescents with psychosis or at high risk. Method: Intention to treat analyses included 32 adolescents who participated in a blinded 8-week randomized controlled trial of CACR treatment compared to computer games (CG). Cognitive abilities, symptoms and psychosocial functioning were assessed at baseline and posttreatment. Results: Improvement in visuospatial abilities was significantly greater in the CACR group than in CG. Other cognitive functions, psychotic symptoms and psychosocial functioning improved significantly, but at similar rates, in the two groups. Conclusion: CACR can be successfully administered in this population; it proved to be effective over and above CG for the most intensively trained cognitive ability.

Cannabis Use is Not Associated With the Development of Psychosis in an ‘Ultra’ High-Risk Group

2002 ◽  
Vol 36 (6) ◽  
pp. 800-806 ◽  
Author(s):  
Lisa J Phillips ◽  
Christina Curry ◽  
Alison R Yung ◽  
Hok Pan Yuen ◽  
Steven Adlard ◽  
...  
Keyword(s):  
Risk Factor ◽  
High Risk ◽  
Psychotic Disorder ◽  
Risk Group ◽  
High Risk Group ◽  
Cannabis Use ◽  
Psychotic Symptoms ◽  
First Episode ◽  
Psychotic Episode ◽  
Ultra High Risk

Background: The association between cannabis use and the development of a first psychotic episode was studied in a group of 100 young people identified as being at very high risk for the onset of psychosis. Method: The ‘ultra’ high risk cohort was identified by the presence of subthreshold psychotic symptoms, or a combination of first-degree relative with a psychotic disorder and recent functional decline. Thirty-two per cent of the cohort developed an acute psychotic episode over the 12-month period after recruitment. As a component of a larger research study, the level of cannabis use by participants in the year prior to enrolment in the study was assessed at intake. Results: Cannabis use or dependence in the year prior to recruitment to this study was not associated with a heightened risk of developing psychosis over the following 12-month period and therefore did not appear to contribute to the onset of a psychotic disorder. Conclusion: The results of this study suggest that cannabis use may not play an integral role in the development of psychosis in a high-risk group. While this study does not support a role for cannabis in the development of first-episode psychosis, we cannot conclude that cannabis use should be completely ignored as a candidate risk factor for onset of psychosis. A number of weaknesses of the study (the low level of cannabis use in the current sample, the lack of monitoring of cannabis use after intake) suggest that it may be premature to dismiss cannabis use as a risk factor for the development of psychosis and further research is urged in this area.

scholarly journals CHANGING STAFF ATTITUDES AND EMPATHY FOR WORKING WITH PEOPLE WITH PSYCHOSIS

2002 ◽  
Vol 30 (4) ◽  
pp. 459-470 ◽  
Author(s):  
Hamish J. McLeod ◽  
Frank P. Deane ◽  
Bruce Hogbin
Keyword(s):  
Mental Health Professionals ◽  
Subjective Experience ◽  
Psychological Treatment ◽  
Important Variable ◽  
Clinical Population ◽  
Psychotic Symptoms ◽  
Treatment Delivery ◽  
Beneficial Effects ◽  
Cognitive Behavioural ◽  
Before And After

Seventy-seven mental health professionals completed a 3-day cognitive behavioural training course for managing hallucinations and delusions in schizophrenia. A questionnaire measuring attitudes and empathy towards working with people who have these symptoms was administered before and after the course. Significant increases in feelings of adequacy, legitimacy, employment related self-esteem, and expectations of work satisfaction were observed after the course and participants displayed high levels of motivation for working with this clinical population at both time points. In addition, the participants showed significant increases in perceived empathy for the experience of hallucinations and delusions. This was a predicted outcome as the course included exercises designed to enhance therapists' understanding of the subjective experience of psychotic symptoms. Empathy is recognized in the wider psychotherapy outcome literature as a therapeutically important variable that influences the formation of a therapeutic alliance but it is a relatively unexamined construct in CBT for psychosis. Further investigations in this area will potentially enhance psychological treatment delivery and subsequent outcomes for people who experience hallucinations and delusions. Furthermore, explication of such “non-specific” therapeutic factors may help to explain some of the transient but beneficial effects of unstructured “control” therapies observed in recent CBT for psychosis outcome trials.

Obstetric Complications and Transition to Psychosis in an ‘Ultra’ High Risk Sample

2005 ◽  
Vol 39 (6) ◽  
pp. 460-466 ◽  
Author(s):  
Yang Yun ◽  
Lisa J. Phillips ◽  
Sue Cotton ◽  
Alison R. Yung ◽  
Shona M. Francey ◽  
...  
Keyword(s):  
Risk Factor ◽  
High Risk ◽  
Psychotic Disorder ◽  
Psychotic Disorders ◽  
Functional Decline ◽  
Obstetric Complications ◽  
Psychotic Symptoms ◽  
Psychotic Episode ◽  
Degree Relative ◽  
Ultra High Risk

Objective: An association between birth and pregnancy complications and the later development of schizophrenia has been described for decades and obstetric complications (OCs) have been proposed as a vulnerability marker for psychosis in line with the neurodevelopmental hypothesis of psychotic disorders. Previous studies of OCs have focused on established schizophrenia. In this study, the association between OCs and the development of psychotic disorder was studied in a group of 74 young people identified as being at very high risk for the first onset of psychosis. Method: The ‘ultra’ high risk (UHR) cohort was identified by the presence of subthreshold psychotic symptoms, or a combination of first-degree relative with a psychotic disorder and recent functional decline. Thirty-eight per cent of the cohort developed an acute psychotic episode over the 12-month period after recruitment. As a component of a larger research study, the level of OCs experienced by the UHR cohort was assessed at intake. Results: Obstetric complicationswere not associated with the later development of psychosis in the UHR group included in this study. Conclusions: This study does not suppor t a role for OCs as a risk factorfor the later development of psychosis; however, we cannot conclude that they should be completely ignored as a candidate risk factor for onset of psychosis. A number of weaknesses of the study suggest that it may be premature to dismiss OCs as a risk factor for the development of psychosis and further research is urged in this area.

Do maternal psychotic symptoms predict offspring's psychotic disorder? Findings from the Helsinki High-Risk Study

2004 ◽  
Vol 125 (2) ◽  
pp. 105-115 ◽  
Author(s):  
Laura T. Niemi ◽  
Jaana M. Suvisaari ◽  
Jari K. Haukka ◽  
Jouko K. Lönnqvist
Keyword(s):  
High Risk ◽  
Psychotic Disorder ◽  
Psychotic Symptoms

Cannabis-induced attenuated psychotic symptoms: implications for prognosis in young people at ultra-high risk for psychosis

2016 ◽  
Vol 47 (4) ◽  
pp. 616-626 ◽  
Author(s):  
M. J. McHugh ◽  
P. D. McGorry ◽  
A. R. Yung ◽  
A. Lin ◽  
S. J. Wood ◽  
...  
Keyword(s):  
High Risk ◽  
Psychotic Disorder ◽  
Cannabis Use ◽  
Psychotic Symptoms ◽  
Cannabis Abuse ◽  
Dependent Relationship ◽  
Abuse Severity ◽  
Ultra High Risk ◽  
Prognostic Utility ◽  
History Of

BackgroundCannabis use shows a robust dose-dependent relationship with psychosis risk among the general population. Despite this, it has been difficult to link cannabis use with risk for transitioning to a psychotic disorder among individuals at ultra-high risk (UHR) for psychosis. The present study examined UHR transition risk as a function of cannabis use characteristics which vary substantially between individuals including age of first use, cannabis abuse severity and a history of cannabis-induced attenuated psychotic symptoms (APS).MethodParticipants were 190 UHR individuals (76 males) recruited at entry to treatment between 2000 and 2006. They completed a comprehensive baseline assessment including a survey of cannabis use characteristics during the period of heaviest use. Outcome was transition to a psychotic disorder, with mean time to follow-up of 5.0 years (range 2.4–8.7 years).ResultsA history of cannabis abuse was reported in 58% of the sample. Of these, 26% reported a history of cannabis-induced APS. These individuals were 4.90 (95% confidence interval 1.93–12.44) times more likely to transition to a psychotic disorder (p = 0.001). Greater severity of cannabis abuse also predicted transition to psychosis (p = 0.036). However, this effect was mediated by higher abuse severity among individuals with a history of cannabis-induced APS.ConclusionsFindings suggest that cannabis use poses risk in a subpopulation of UHR individuals who manifest cannabis-induced APS. Whether this reflects underlying genetic vulnerability requires further study. Nevertheless, findings reveal an important early marker of risk with potentially significant prognostic utility for UHR individuals.

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