Treatment approaches in the psychosis prodrome

Interest in intervening prior to the onset of psychosis, in the prodromal or clinical high-risk (CHR) phase of illness, gained momentum in the 1990s. Initial treatment trials were conducted with the goal of preventing psychosis, but results to date have been equivocal. Only a few trials have found partial benefit of specific treatments over control conditions on transition rates, and even fewer show long-term gains. Challenges include high attrition and feasibility issues, especially for antipsychotic medication and cognitive remediation trials. While better tolerated, psychosocial therapy trials have mixed results, though when combined, meta-analyses show advantages compared to other treatments. Integrated treatment approaches lack specificity and the promising initial Omega-3 trial has not been replicated. Aside from conversion, early intervention appears to improve clinical outcomes including positive symptoms, depression, and anxiety. Importantly, treatment trials have not had a notable impact on functional outcomes, making this a crucial area for future research.

Psychosis prediction in Secondary Mental Health Services. a Broad, Comprehensive Approach to the “at Risk Mental State” Syndrome

BackgroundAccuracy of risk algorithms for psychosis prediction in “at risk mental state” (ARMS) samples may differ according to the recruitment setting. Standardized criteria used to detect ARMS individuals may lack specificity if the recruitment setting is a secondary mental health service. The authors tested a modified strategy to predict psychosis conversion in this setting by using a systematic selection of trait-markers of the psychosis prodrome in a sample with a heterogeneous ARMS status.Methods138 non-psychotic outpatients (aged 17–31) were consecutively recruited in secondary mental health services and followed-up for up to 3 years (mean follow-up time, 2.2 years; SD = 0.9). Baseline ARMS status, clinical, demographic, cognitive, and neurological soft signs measures were collected. Cox regression was used to derive a risk index.Results48% individuals met ARMS criteria (ARMS-Positive, ARMS+). Conversion rate to psychosis was 21% for the overall sample, 34% for ARMS+, and 9% for ARMS-Negative (ARMS−). The final predictor model with a positive predictive validity of 80% consisted of four variables: Disorder of Thought Content, visuospatial/constructional deficits, sensory-integration, and theory-of-mind abnormalities. Removing Disorder of Thought Content from the model only slightly modified the predictive accuracy (−6.2%), but increased the sensitivity (+9.5%).ConclusionsThese results suggest that in a secondary mental health setting the use of trait-markers of the psychosis prodrome may predict psychosis conversion with great accuracy despite the heterogeneity of the ARMS status. The use of the proposed predictive algorithm may enable a selective recruitment, potentially reducing duration of untreated psychosis and improving prognostic outcomes.