Identifying patients at risk of psychosis: a qualitative study of GP views in South West England

BackgroundEarly intervention in people with an at-risk mental state for psychosis can decrease the rates of transition to psychosis. GPs play a key role in the identification of this patient group but very few studies have explored GPs’ awareness of patients who are at risk of psychosis.AimTo explore GPs’ views and experiences of identifying patients with an at-risk mental state for psychosis, and the barriers and facilitators to identification.Design and settingIn-depth semi-structured interviews were held with GPs working in South West England primary care. The interviews were conducted between March and July 2019.MethodA topic guide was used to ensure consistency across interviews. This guide was revised to incorporate a definition of the at-risk mental state for psychosis, as after conducting a few interviews it became clear that some GPs were not familiar with this construct. Interviews were audiorecorded and analysed thematically.ResultsA total of 20 GPs were interviewed. Some GPs were not familiar with the concept of being at risk of developing psychosis, and perceived that they may not have the right skills to identify this patient group. Other barriers related to patients not presenting or disclosing psychotic symptoms, and limitations imposed by scarce resources on the structure and provision of NHS services, such as lack of continuity of care and high thresholds for accessing specialised services.ConclusionIdentifying people at risk of psychosis in primary care is difficult. Provision of GP training, development of policies that support continuity of care, and improved access to specialised services could help improve the identification of this patient group.

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Policies and strategies to retain and support the return of experienced GPs in direct patient care: the ReGROUP mixed-methods study

Health Services and Delivery Research ◽

10.3310/hsdr07140 ◽

2019 ◽

Vol 7 (14) ◽

pp. 1-288 ◽

Cited By ~ 1

Author(s):

John L Campbell ◽

Emily Fletcher ◽

Gary Abel ◽

Rob Anderson ◽

Rupatharshini Chilvers ◽

...

Keyword(s):

Primary Care ◽

At Risk ◽

General Practice ◽

Mixed Methods ◽

Patient Care ◽

Mixed Methods Study ◽

Direct Patient Care ◽

South West ◽

Career Break ◽

South West England

BackgroundUK general practice faces a workforce crisis, with general practitioner (GP) shortages, organisational change, substantial pressures across the whole health-care system and an ageing population with increasingly complex health needs. GPs require lengthy training, so retaining the existing workforce is urgent and important.Objectives(1) To identify the key policies and strategies that might (i) facilitate the retention of experienced GPs in direct patient care or (ii) support the return of GPs following a career break. (2) To consider the feasibility of potentially implementing those policies and strategies.DesignThis was a comprehensive, mixed-methods study.SettingThis study took place in primary care in England.ParticipantsGeneral practitioners registered in south-west England were surveyed. Interviews were with purposively selected GPs and primary care stakeholders. A RAND/UCLA Appropriateness Method (RAM) panel comprised GP partners and GPs working in national stakeholder organisations. Stakeholder consultations included representatives from regional and national groups.Main outcome measuresSystematic review – factors affecting GPs’ decisions to quit and to take career breaks. Survey – proportion of GPs likely to quit, to take career breaks or to reduce hours spent in patient care within 5 years of being surveyed. Interviews – themes relating to GPs’ decision-making. RAM – a set of policies and strategies to support retention, assessed as ‘appropriate’ and ‘feasible’. Predictive risk modelling – predictive model to identify practices in south-west England at risk of workforce undersupply within 5 years. Stakeholder consultation – comments and key actions regarding implementing emergent policies and strategies from the research.ResultsPast research identified four job-related ‘push’ factors associated with leaving general practice: (1) workload, (2) job dissatisfaction, (3) work-related stress and (4) work–life balance. The survey, returned by 2248 out of 3370 GPs (67%) in the south-west of England, identified a high likelihood of quitting (37%), taking a career break (36%) or reducing hours (57%) within 5 years. Interviews highlighted three drivers of leaving general practice: (1) professional identity and value of the GP role, (2) fear and risk associated with service delivery and (3) career choices. The RAM panel deemed 24 out of 54 retention policies and strategies to be ‘appropriate’, with most also considered ‘feasible’, including identification of and targeted support for practices ‘at risk’ of workforce undersupply and the provision of formal career options for GPs wishing to undertake portfolio roles. Practices at highest risk of workforce undersupply within 5 years are those that have larger patient list sizes, employ more nurses, serve more deprived and younger populations, or have poor patient experience ratings. Actions for national organisations with an interest in workforce planning were identified. These included collection of data on the current scope of GPs’ portfolio roles, and the need for formal career pathways for key primary care professionals, such as practice managers.LimitationsThe survey, qualitative research and modelling were conducted in one UK region. The research took place within a rapidly changing policy environment, providing a challenge in informing emergent policy and practice.ConclusionsThis research identifies the basis for current concerns regarding UK GP workforce capacity, drawing on experiences in south-west England. Policies and strategies identified by expert stakeholders after considering these findings are likely to be of relevance in addressing GP retention in the UK. Collaborative, multidisciplinary research partnerships should investigate the effects of rolling out some of the policies and strategies described in this report.Study registrationThis study is registered as PROSPERO CRD42016033876 and UKCRN ID number 20700.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

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Negative psychotic symptoms and impaired role functioning predict transition outcomes in the at-risk mental state: a latent class cluster analysis study

Psychological Medicine ◽

10.1017/s0033291713000251 ◽

2013 ◽

Vol 43 (11) ◽

pp. 2311-2325 ◽

Cited By ~ 71

Author(s):

L. R. Valmaggia ◽

D. Stahl ◽

A. R. Yung ◽

B. Nelson ◽

P. Fusar-Poli ◽

...

Keyword(s):

At Risk ◽

Cluster Analysis ◽

Mental State ◽

Latent Class ◽

Mental States ◽

Psychotic Symptoms ◽

Role Functioning ◽

Latent Class Cluster Analysis ◽

At Risk Mental State

BackgroundMany research groups have attempted to predict which individuals with an at-risk mental state (ARMS) for psychosis will later develop a psychotic disorder. However, it is difficult to predict the course and outcome based on individual symptoms scores.MethodData from 318 ARMS individuals from two specialized services for ARMS subjects were analysed using latent class cluster analysis (LCCA). The score on the Comprehensive Assessment of At-Risk Mental States (CAARMS) was used to explore the number, size and symptom profiles of latent classes.ResultsLCCA produced four high-risk classes, censored after 2 years of follow-up: class 1 (mild) had the lowest transition risk (4.9%). Subjects in this group had the lowest scores on all the CAARMS items, they were younger, more likely to be students and had the highest Global Assessment of Functioning (GAF) score. Subjects in class 2 (moderate) had a transition risk of 10.9%, scored moderately on all CAARMS items and were more likely to be in employment. Those in class 3 (moderate–severe) had a transition risk of 11.4% and scored moderately severe on the CAARMS. Subjects in class 4 (severe) had the highest transition risk (41.2%), they scored highest on the CAARMS, had the lowest GAF score and were more likely to be unemployed. Overall, class 4 was best distinguished from the other classes on the alogia, avolition/apathy, anhedonia, social isolation and impaired role functioning.ConclusionsThe different classes of symptoms were associated with significant differences in the risk of transition at 2 years of follow-up. Symptomatic clustering predicts prognosis better than individual symptoms.

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

Psychological Medicine ◽

10.1017/s003329171900299x ◽

2019 ◽

pp. 1-7 ◽

Cited By ~ 6

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.

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Transition to Psychosis: 6-Month follow-up of a Chinese High-Risk Group in Hong Kong

Australian & New Zealand Journal of Psychiatry ◽

10.1080/j.1440-1614.2006.01817.x ◽

2006 ◽

Vol 40 (5) ◽

pp. 414-420 ◽

Cited By ~ 25

Author(s):

May M.L. Lam ◽

Se-Fong Hung ◽

Eric Y.H. Chen

Keyword(s):

At Risk ◽

High Risk ◽

Mental State ◽

Functional Decline ◽

High Risk Group ◽

Psychotic Symptoms ◽

Syndrome Scale ◽

History Of ◽

At Risk Mental State

Objectives: The identification of individuals at high risk of becoming psychotic within the near future creates opportunities for early intervention before the onset of psychosis. This study sets out to identify a group of symptomatic young people in a Chinese population with the high likelihood of transition to psychosis within a follow-up period of 6 months, and to determine the rate of transition to psychosis in this group. Method: Symptomatic individuals with a family history of psychotic disorder, subthreshold psychotic symptoms or brief transient psychotic symptoms were identified using the operationalized criteria of an ‘At Risk Mental State’. The individuals were prospectively assessed monthly on a measure of psychopathology for 6 months. Results: Eighteen out of 62 individuals (29%) made the transition to frank psychosis within a 6 month follow-up period, with the majority occurring within 3 months. In addition, significant differences were found in the intake Positive and Negative Syndrome Scale, Comprehensive Assessment of ‘At Risk Mental State’ and Global Assessment of Functioning scores between the group that ultimately became psychotic and the group that did not. Conclusion: The period of the highest risk of transition to psychosis was within the 3 months after the study began. Thus, distressed youths in our outpatient clinic, who meet the high-risk criteria should be monitored most closely in the initial 3 months, particularly those individuals with high levels of psychopathology and functional decline.

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The Relationship Between Negative Symptoms and Cognitive Functioning in Patients with an at Risk Mental State for Psychosis

European Psychiatry ◽

10.1016/j.eurpsy.2017.02.097 ◽

2017 ◽

Vol 41 (S1) ◽

pp. S270-S271

Author(s):

L. Leanza ◽

L. Egloff ◽

E. Studerus ◽

C. Andreou ◽

U. Heitz ◽

...

Keyword(s):

At Risk ◽

Cognitive Functioning ◽

Mental State ◽

Verbal Fluency ◽

Negative Symptoms ◽

Psychotic Symptoms ◽

First Episode ◽

Clinical Impression ◽

The Relationship ◽

At Risk Mental State

IntroductionNegative symptoms and cognitive impairments are both present in patients with an at risk mental state (ARMS) for psychosis and negatively affect functioning and outcome. According to previous studies in patients with first-episode psychosis, negative symptoms are negatively associated with cognitive functioning while positive symptoms do not seem to be associated. Yet, little is known about the specific relationship of negative symptoms and cognitive functioning in ARMS patients.ObjectiveTo evaluate, the relationship between negative symptoms and cognitive functioning in ARMS patients.MethodsData of 154 ARMS patients were collected within the prospective Basel early detection of psychosis (FePsy) study. Negative symptoms were assessed with the SANS, positive psychotic symptoms with the BPRS, cognitive functioning with an extensive neuropsychological test battery. Multiple regressions were applied and results were controlled for age and gender.ResultsRegression analyses showed a significant, negative association between negative but not positive psychotic symptoms and cognitive functioning, showing the strongest association with verbal fluency (see Fig. 1). However, results mainly did not withstand correction for multiple testing.ConclusionsThe association found between verbal fluency and negative symptoms may be indicative of an overlap between those constructs. Finally, verbal fluency might have a strong influence on the clinical impression of negative symptoms, especially on alogia.Disclosure of interestThe authors have not supplied their declaration of competing interest.

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Access and Waiting Time Standard for Early Intervention in Psychosis: At Risk Mental State Identification and Interventions Accepted within a Routine Service

10.53902/jpssr.2021.01.000501 ◽

2021 ◽

Vol 1 (1) ◽

Author(s):

Vidyah Adamson

Keyword(s):

At Risk ◽

Early Intervention ◽

Waiting Time ◽

Mental State ◽

Psychotic Symptoms ◽

Service Users ◽

Routine Service ◽

Time Standard ◽

Early Intervention In Psychosis ◽

At Risk Mental State

Aim: Following the introduction of an access and waiting time standard for Early Intervention in Psychosis (EIP) services, the identification and treatment of people experiencing an At-Risk Mental State (ARMS) for psychosis has become a national priority. However, there is a dearth of literature concerning what is offered to and accepted by ARMS service users within routine services. Methods: This descriptive evaluation reports upon the assessment and treatment of people with an at-risk mental state identified during the first year of a routine service operating in line with the EIP standard. The paper details referral sources, referral to treatment times, socio-demographic characteristics, ARMS subgroups and the interventions accepted by these service users. Results: A total of 138 ARMS cases were identified over the evaluation period, with 73% (n=101) aged between 18-34 years and 86% (n=118) meeting attenuated psychotic symptoms criteria. The majority (64%) of service users engaged in multiple interventions; 54% (n=75) accepted psychoeducation and coping skills enhancement work, 42% (n=58) participated in a sleep programme, 33% (n=45) undertook coping with voices and visions work and 28% (n=39) engaged in individual psychological therapy. Conclusion: The findings indicate that the majority of ARMS service users presenting to the EIP service were aged 18-34 and experienced attenuated psychotic symptoms. A range of NICE and CBT informed interventions as well as individual psychological therapies appear to be acceptable to ARMS service users and many engaged in multiple interventions offered.

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Interpersonal sensitivity in the at-risk mental state for psychosis

Psychological Medicine ◽

10.1017/s0033291711002996 ◽

2012 ◽

Vol 42 (9) ◽

pp. 1835-1845 ◽

Cited By ~ 40

Author(s):

A. Masillo ◽

F. Day ◽

J. Laing ◽

O. Howes ◽

P. Fusar-Poli ◽

...

Keyword(s):

At Risk ◽

Mental State ◽

Interpersonal Sensitivity ◽

Self Report ◽

Avoidant Coping ◽

Psychotic Symptoms ◽

Emotional States ◽

Paranoid Ideation ◽

Prodromal Phase ◽

At Risk Mental State

BackgroundInterpersonal sensitivity is a personality trait described as excessive awareness of both the behaviour and feelings of others. Although interpersonal sensitivity has been found to be one of the vulnerability factors to depression, there has been little interest in its relationship with the prodromal phase of psychosis. The aims of this study were to examine the level of interpersonal sensitivity in a sample of individuals with an at-risk mental state (ARMS) for psychosis and its relationship with other psychopathological features.MethodMethod.Sixty-two individuals with an ARMS for psychosis and 39 control participants completed a series of self-report questionnaires, including the Interpersonal Sensitivity Measure (IPSM), the Prodromal Questionnaire (PQ), the Ways of Coping Questionnaire (WCQ) and the Depression and Anxiety Stress Scale (DASS).ResultsIndividuals with an ARMS reported higher interpersonal sensitivity compared to controls. Associations between interpersonal sensitivity, positive psychotic symptoms (i.e. paranoid ideation), avoidant coping and symptoms of depression, anxiety and stress were also found.ConclusionsThis study suggests that being ‘hypersensitive’ to interpersonal interactions is a psychological feature of the putatively prodromal phase of psychosis. The relationship between interpersonal sensitivity, attenuated positive psychotic symptoms, avoidant coping and negative emotional states may contribute to long-term deficits in social functioning. We illustrate the importance, when assessing a young client with a possible ARMS, of examining more subtle and subjective symptoms in addition to attenuated positive symptoms.

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Long-term rates of remission and late psychotic transition of individuals at risk for psychosis

European Psychiatry ◽

10.1016/j.eurpsy.2017.01.2105 ◽

2017 ◽

Vol 41 (S1) ◽

pp. S186-S186 ◽

Cited By ~ 2

Author(s):

K. Beck ◽

C. Andreou ◽

E. Studerus ◽

L. Egloff ◽

U. Heitz ◽

...

Keyword(s):

At Risk ◽

Mental State ◽

Research Field ◽

Initial Assessment ◽

Psychotic Symptoms ◽

Term Outcome ◽

Long Term Outcome ◽

At Risk Mental State

IntroductionIn the growing research field of early psychosis detection in patients with an at risk mental state (ARMS), most studies focus on the transition to frank psychosis. However, the majority of ARMS patients do not go on to develop frank psychosis and reported transition rates are declining. Little is known about the long-term outcome of these non-transitioned patients (ARMS-NT).ObjectivesTo investigate in preliminary analyses the long-term outcome of ARMS-NT patients with respect to persistence of ARMS signs and symptoms and the rates of late psychotic transition.MethodsThe ongoing study “FePsy-BHS-NT” follows up ARMS-NT without transition during at least the first two years for up to 15 years after their initial assessment. ARMS status is ascertained with the Basel Screening Instrument for Psychosis (BSIP). ARMS remission is defined as the absence of attenuated psychotic symptoms or brief limited intermittent psychotic symptoms for at least 12 consecutive months.ResultsIn this preliminary sample of 51 ARMS-NT, the majority of patients (70.6%) have remitted from their at risk mental state, 13.7% remain at risk and 15.7% have made a late psychotic transition during the course of long-term follow up (median = 5.75, range 4–11 years after initial assessment).ConclusionsThe considerable rates of ARMS persistence and late psychotic transition indicate that longer follow-up durations than commonly recommended should be contemplated in ARMS patients. Potential predictors of favorable long-term clinical outcome, as well as psychosocial, neurocognitive and other outcomes of ARMS-NT patients will be further evaluated in the present study.Disclosure of interestThe authors have not supplied their declaration of competing interest.

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Feasibility study of eye movement desensitisation and reprocessing (EMDR) in people with an at-risk mental state (ARMS) for psychosis: study protocol

BMJ Open ◽

10.1136/bmjopen-2020-038620 ◽

2020 ◽

Vol 10 (10) ◽

pp. e038620

Author(s):

Daniela Strelchuk ◽

Nicola Wiles ◽

Katrina M Turner ◽

Catherine Derrick ◽

Stan Zammit

Keyword(s):

At Risk ◽

Eye Movement ◽

Mental Health Professionals ◽

Mental State ◽

Large Scale ◽

Traumatic Event ◽

Controlled Trial ◽

Secondary Outcome ◽

Psychotic Symptoms ◽

At Risk Mental State

IntroductionTrauma can play an important role in the development of psychosis, yet no studies have investigated whether a trauma-focused psychological therapy could prevent the onset of psychosis in people at high risk of developing this condition. This study aims to establish whether it would be feasible to conduct a multicentre randomised controlled trial (RCT) to investigate the clinical and cost-effectiveness of eye movement desensitisation and reprocessing (EMDR) therapy to prevent the onset of psychosis in people with an at-risk mental state (ARMS).Methods/analysisThis is a single-arm trial with a nested qualitative study where all participants (target n=20) will be offered EMDR. Eligible participants are those who meet criteria for ARMS; have experienced a traumatic event before the onset of ARMS symptomatology; and have at least one symptom of post-traumatic stress disorder (PTSD). Participants will be followed up at 4, 8 and 12 months after the baseline assessment. The primary outcome measure is transition to psychosis, and secondary outcome measures include severity of psychotic symptoms, PTSD, depression, anxiety, impaired functioning, health status and resource use. The analysis will aim to establish the rates of recruitment and retention for a large-scale RCT. Interviews with therapists and patients will explore their views of the study and their experiences of delivering or receiving EMDR.Ethics and disseminationThis protocol has been approved by the South West-Cornwall and Plymouth Research Ethics Committee (Reference 18/SW/0037). Findings will be disseminated through journal publications, conference presentations and meetings with service users, their families, mental health professionals and commissioners.Trial registration numberISRCTN31976295.

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S88. THE EFFECT OF SLEEP QUALITY ON ATTENUATED PSYCHOTIC SYMPTOMS IN A NON-CLINICAL SAMPLE OF YOUNG ADULTS

Schizophrenia Bulletin ◽

10.1093/schbul/sbaa031.154 ◽

2020 ◽

Vol 46 (Supplement_1) ◽

pp. S67-S68

Author(s):

Donncha Hanna ◽

Ciaran James Shannon ◽

Stephen Clarke ◽

Sarah Davidson ◽

Ciaran Mulholland

Keyword(s):

At Risk ◽

General Population ◽

Sleep Quality ◽

Sleep Disturbance ◽

Mental State ◽

Psychotic Symptoms ◽

Poor Sleep ◽

Unique Contribution ◽

Poor Sleep Quality ◽

At Risk Mental State

Abstract Background Background: One factor known to be associated with attenuated psychotic symptoms is poor sleep but it is not known if poor sleep increases the likelihood of experiencing multiple attenuated psychotic symptoms, which research suggests may be suggestive of an At-Risk Mental State (ARMS). The study aimed to determine if poor sleep quality makes a unique contribution to predicting the number of attenuated psychotic symptoms endorsed in a prodromal questionnaire and the level of distress associated with the symptoms, when accounting for demographics, depression and drug/alcohol use variables. Methods Method: An online survey was conducted using Amazon’s online crowdsourcing service Mechanical Turk (MTurk). The sample was 1,013 adults (18 to 36 years) from the general population in the USA. The survey consisted of the Prodromal Questionnaire 16 (PQ-16), the Pittsburgh Sleep Quality Index, the Patient Health Questionnaire 9 (PHQ-9), the DAST-10 and the AUDIT. Regression analyses were performed with the PQ-16 as the dependent variable, and sleep quality as the predictor variable, while controlling for sociodemographic variables, depression, and alcohol/drug abuse. Results Results: 37% of the sample endorsed six or more PQ-16 items, which may be suggestive of an at-risk mental state, with sleep disturbance significantly increasing the likelihood (Odds ratio 2.09 <.001) of endorsing six or more PQ-16 items. After controlling for socio-demographic variables, depression and drug/alcohol abuse, poor sleep quality made a unique contribution of 5.8% of the variance accounted for in level of distress experienced by attenuated psychotic symptoms. Discussion Conclusion: A significant proportion of young adults in the general population may have an at-risk mental state. The results add to the evidence that sleep disturbance is a contributory factor in attenuated psychotic symptoms. Further research is required to investigate the possible mechanisms (e.g. impaired cognitive processes) through which poor sleep influences attenuated psychotic symptoms and if effective treatment of sleep disturbance can influence the likelihood of developing an at-risk mental state.

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