Treatments for high-risk groups

What are high-risk groups?

The primary aims of early intervention are to prevent or delay future transition to psychosis in high-risk individuals with early symptoms, and to reduce symptom severity in individuals following a first episode of psychosis. A key target of early intervention is “indicated prevention”, for individuals at high risk of psychosis who have been identified with detectable signs of possible disorder, but do not meet any diagnostic criteria for disorder. There are two key approaches for identifying patients with early signs that may suggest an ultra-high risk (UHR) of developing psychosis. The first approach is based on Huber’s Basic Symptoms (BS), which focuses on a detailed way of describing phenomenological (subjective) disturbances in the domains of perception, cognition, language, motor function, will, initiative and level of energy, and stress tolerance. Because the basic symptoms refer only to subtle subjectively experienced abnormalities, they may reflect an earlier phase in the disease process than the second approach, which identifies at-risk mental states as a combination of: a Family History (FH) of psychosis plus non-specific symptoms and recent decline in functioning; recent onset Attenuated Psychotic Symptoms (APS) with decline in functioning; and Brief Limited Intermittent Psychotic Symptoms (BLIPS). Whichever approach is utilised to identify those at UHR, a benefit of early intervention – should a transition to psychosis occur – is that the patient is already established in a treatment regime thus reducing the duration of untreated psychosis, which has been associated with increased illness severity.

What is the evidence for treatments for high-risk groups?

Moderate to high quality evidence shows a medium-sized effect of reduced risk of psychosis for up to one year with any focused treatment for ultra-high risk groups, and a small effect for up to four years. Moderate quality evidence suggests a medium-sized effect of cognitive behavioural therapies, either alone or combined with antipsychotic medication, for delaying transition to psychosis for up to two years. Moderate to low quality evidence suggests some benefit of Needs Focused Intervention plus amisulpride over Needs Focused Intervention alone for improving functioning and reducing symptom severity in the short term, although there may be more weight gain with amisulpride.

Also see the Signs and Symptoms, early detection topic, and the Course and Outcomes topic for first-episode and high risk groups.

April 2016

Cognition in high-risk groups

Who are people at high-risk of psychosis?

There are two key approaches for identifying people with early signs that may suggest a high risk of developing psychosis or schizophrenia. The first approach is based on Huber’s Basic Symptoms, which focuses on a detailed way of describing phenomenological (subjective) disturbances. Because the basic symptoms refer only to subtle subjectively experienced abnormalities, they may reflect an earlier phase in the disease process than the second approach, which identifies at-risk mental states as a combination of; a family history of psychosis (familial risk) plus non-specific symptoms and recent decline in functioning; recent onset Attenuated Psychotic Symptoms with decline in functioning; and Brief Limited Intermittent Psychotic Symptoms.

What is the evidence for cognitive functioning in high-risk groups?

High quality evidence shows a small to medium-sized effect of lower general intelligence, poor executive functioning, attention, visual memory, and social cognition in people at high risk of psychosis compared to people who are not at high risk of psychosis. Moderate to high quality evidence also suggests lower visual-spatial ability, olfactory functioning, verbal fluency, verbal memory, working memory, and learning. High quality evidence suggests people at clinical high risk of psychosis and familial high risk of psychosis are similarly impaired on processing speed, verbal and visual memory, attention and language fluency when compared with controls. People at familial high risk were more impaired on premorbid and current IQ than people at clinical high risk, and people at clinical high risk were more impaired on visuospatial working memory than people at familial high risk. Moderate quality evidence showed that people at high risk who converted to psychosis showed a medium-sized effect of lower olfactory functioning, general cognitive ability, language functioning, visual-spatial ability, memory, attention and executive functioning prior to conversion than people not at high risk of psychosis. Compared to people at high risk who did not convert to psychosis, moderate quality evidence showed that people at high risk who did converted to psychosis showed small to medium-sized effects of poor visual learning and working memory. Moderate to low quality evidence also suggests a medium-sized effect of lower general intelligence, verbal fluency, verbal memory, and visual memory.

 

April 2016

Treatments for high-risk groups

What are high-risk groups?

The primary aims of early intervention are to prevent or delay future transition to psychosis in high-risk individuals with early symptoms, and to reduce symptom severity in individuals following a first episode of psychosis. A key target of early intervention is “indicated prevention”, for individuals at high risk of psychosis who have been identified with detectable signs of possible disorder, but do not meet any diagnostic criteria for disorder.

There are two key approaches for identifying patients with early signs that may suggest an ultra-high risk (UHR) of developing psychosis. The first approach is based on Huber’s Basic Symptoms (BS), which focuses on a detailed way of describing phenomenological (subjective) disturbances in the domains of perception, cognition, language, motor function, will, initiative and level of energy, and stress tolerance. Because the basic symptoms refer only to subtle subjectively experienced abnormalities, they may reflect an earlier phase in the disease process than the second approach, which identifies at-risk mental states as a combination of: a Family History (FH) of psychosis plus non-specific symptoms and recent decline in functioning; recent onset Attenuated Psychotic Symptoms (APS) with decline in functioning; and Brief Limited Intermittent Psychotic Symptoms (BLIPS). Whichever approach is utilised to identify those at UHR, a benefit of early intervention – should a transition to psychosis occur – is that the patient is already established in a treatment regime thus reducing the duration of untreated psychosis, which has been associated with increased illness severity.

What is the evidence on treatments for high-risk groups?

Moderate to high quality evidence shows a medium-sized effect of reduced risk of psychosis for up to one year with any focused treatment for ultra-high risk groups, and a small effect for up to four years. Moderate quality evidence suggests a medium-sized effect of cognitive behavioural therapies, either alone or combined with antipsychotic medication, for delaying transition to psychosis for up to two years. Moderate to low quality evidence suggests some benefit of Needs Focused Intervention plus amisulpride over Needs Focused Intervention alone for improving functioning and reducing symptom severity in the short term, although there may be more weight gain with amisulpride.

Also see the Signs and Symptoms, early detection topic, the Course and Outcomes topic on first-episode psychosis and high-risk groups and duration of untreated psychosis, and the psychosocial treatment for high-risk groups topic.

April 2016

Early detection

What is early detection of psychosis?

Early detection refers to the correct identification of individuals who are at high risk of developing schizophrenia, with an emphasis on the development of frank psychosis. Several assessment tools have been constructed to effectively identify such individuals. Sensitivity of an assessment tool refers to the proportion of people who develop psychosis that were previously identified by the assessment tool as being at high risk. Specificity is the proportion of people who do not develop psychosis that were previously identified as not being at high risk. Assessment tools therefore aim to have both high sensitivity and high specificity.

Generally, there are two approaches that dictate the characteristics used as markers for detection.

The ultra-high risk approach focuses on a triad of at-risk mental states defined as:

1. Having a family history of psychosis plus non-specific symptoms and a recent decline in functioning

2. Showing recent onset of attenuated psychotic symptoms with a decline in functioning

3. Symptoms must be brief, intermittent and limited

The other approach is based on Huber’s Basic Symptoms, which focuses on a detailed way of describing subjective disturbances, and may be an earlier indicator of risk than the first approach.

What is the evidence for early detection of psychosis?

Moderate to high quality evidence finds the mean rate of transition to psychosis in those assessed as being at clinical high risk for psychosis is around 16% by 2 years and 29% by 3 years. In people assessed as being at clinical high risk of obsessive-compulsive disorder are at higher risk of psychosis than people assessed as being at clinical high risk of bipolar disorder, which in turn has higher risk of psychosis than people assessed as being at high risk of depression. However, the rate of transition to psychosis are only one third the rate of transition to non-psychotic disorders in people at assessed as being at clinical high risk for non-psychotic disorders.

In children and adolescents assessed as being at clinical high risk of psychosis, transition rates were between 17% and 20% by 1 year follow-up and between 7% and 21% by 2 year follow-up. 36% of children and adolescents recovered from their clinical high risk status by 6-year follow-up, and 40% continued to meet clinical high risk criteria without transition to psychosis.

Studies with older samples reported higher transition rates than studies with younger samples, and more recent publications reported lower transition rates than older publications. Studies using the basic symptoms approach reported higher transition rates than studies using the ultra-high risk approach. Studies of people receiving psychosocial treatments (e.g. cognitive behavioral therapy) reported lower transition rates than studies of people receiving standard care (e.g. case management). Studies of people on antipsychotics also reported lower transition rates than studies of people not on antipsychotics.

Moderate to high quality evidence suggests instruments based on ultra-high risk criteria have good sensitivity and moderate specificity. Moderate to low quality evidence also suggests the BSABS scale, based on basic symptoms approach, has good sensitivity and moderate specificity. This indicates validated instuments are generally good at correctly identifying individuals who do develop psychosis, but not as good at identifying individuals who do not develop psychosis.

Moderate quality evidence suggests the model with the best predictive value (86%) for transition to psychosis was a clinical model including odd beliefs, marked impairment in role functioning, blunted affect, auditory hallucinations, and anhedonia/asociality. A biological model using grey matter volume, and a neurocognitive model using IQ, verbal memory, executive functioning, attention, processing speed, and speech perception, both had positive predictive values of 83%. An environmental model with a positive predictive value of 63% involved urbanicity, social-sexual aspects, and social-personal adjustment. The best combination model had a positive predictive value of 82% and involved disorganised communication, suspiciousness, verbal memory deficit, and decline in social functioning.

 

Also see the treatment topics for first-episode psychosis (pharmaceutical and psychosocial) and for individuals at high-risk of psychosis (pharmaceutical and psychosocial).

 

January 2019

First-episode psychosis outcomes

What are outcomes for people with first-episode psychosis or high-risk mental states?

After being identified as having high-risk mental states, or after an initial diagnosis of psychosis, relevant outcomes over the years following include transition to psychosis or schizophrenia, symptom severity, recovery and remission, relapse, employment, functioning, relationships, and quality of life. Investigating these outcomes and the factors influencing them provides insight into early treatment strategies.

What is the evidence for outcomes in people with first-episode psychosis or high-risk mental states?

Moderate quality evidence suggests up to 80% of people have good or intermediate outcomes following a first episode of psychosis (follow-up was for 3 years). Positive outcomes include lack of relapse or rehospitalisation, more employment, more insight and clarity, and improved relationships with family and friends. Predictors of good outcomes include being treated with a combination of pharmacotherapy and psychosocial therapy, and being from a developing rather than a developed country. Predictors of poor outcome include being treatment-naive, or being medicated with first generation rather than second generation antipsychotics.

For people with first-episode psychosis or schizophrenia and a current substance use disorder, moderate to high quality evidence suggests worse positive and depressive symptoms, and worse global functioning compared to people with first-episode psychosis or schizophrenia and a former, or no history of a substance use disorder. Moderate quality evidence also suggests an increased risk of relapse, re-hospitalisation, and treatment non-adherence, particularly if using cocaine, opiates, or ecstasy.

Moderate quality evidence indicates the average risk of transition to full psychotic episode in people at high clinical risk of psychosis is ~24-29%. Studies assessing psychosocial treatments or antipsychotics reported lower transition rates than studies assessing standard care or no antipsychotics. People with brief, limited or intermittent psychotic symptoms have higher transition rates to full psychosis than people with attenuated or milder psychotic symptoms, who in turn have higher transition rates than people with genetic vulnerability and a marked decline in functioning. Neurocognitive deficits, negative and disorganisation subclinical symptoms, but not positive subclinical symptoms, are associated with poor functioning in people with high-risk mental states.

 

Also see the treatment topics for first-episode psychosis (pharmaceutical and psychosocial) and for high-risk groups (pharmaceutical and psychosocial).

February 2019