Debra A Russo

Psychiatric morbidity, functioning and quality of life in young people at clinical high risk for psychosis

Objective Recent studies suggest that psychotic-like experiences may also act as markers for non-psychotic psychiatric disorders, which may indicate that the focus of research in individuals at high risk (HR) for psychosis needs updating. In this study we thoroughly examined the clinical and functional characteristics of a consecutive cohort of young people at HR for psychosis and compared them to a matched sample of healthy volunteers. Method Between February 2010 and September 2012 60 help-seeking HR individuals, aged 16–35, were recruited from CAMEO Early Intervention in Psychosis Service, Cambridgeshire, UK. Forty-five age- and gender-matched healthy volunteers were randomly recruited from the same geographical area. Sociodemographic, psychiatric morbidity, functioning and quality of life measures were compared between both groups. Results HR individuals suffered a wide range of DSM-IV psychiatric disorders, mainly within the affective and anxiety diagnostic spectra. In comparison to healthy volunteers, young people at HR reported more suicidal ideation/intention, depressive and anxiety symptoms and presented with remarkably poor functioning and quality of life. Conclusion The presence of co-morbid moderate or severe depressive and anxiety symptoms was common in our sample of young people at enhanced risk for psychosis. A HR mental state may be associated not only with an increased risk for psychosis, but also other psychiatric disorders. Our findings may have implications for the future implementation of therapeutic interventions that this population could benefit from.

Trauma history characteristics associated with mental states at clinical high risk for psychosis.

Traumatic experiences have been positively associated with both severity of attenuated psychotic symptoms in individuals at high risk (HR) for psychosis and transitions into psychotic disorders. Our aim was to determine what characteristics of the trauma history are more likely to be associated with individuals at HR. The Trauma History Screen (THS) was used to enable emphasis on number and perceived intensity of adverse life events and age at trauma exposure. Sixty help-seeking individuals who met HR criteria were compared to a random sample of 60 healthy volunteers. Both groups were aged 16–35 and resided in the same geographical location. HR participants experienced their first trauma at an earlier age, continued to experience trauma at younger developmental stages, especially during early/mid adolescence and were exposed to a high number of traumas. They were more depressed and anxious, but did not experience more distress in relation to trauma. Both incidences of trauma and age at which trauma occurred were the most likely predictors of becoming HR. This work emphasises the importance of assessing trauma characteristics in HR individuals to enable differentiation between psychotic-like experiences that may reflect dissociative responses to trauma and genuine prodromal psychotic presentations.

Clinical effectiveness and cost-effectiveness of tailored intensive liaison between primary and secondary care to identify individuals at risk of a first psychotic illness (the LEGs study): a cluster-randomised controlled trial

Summary Background General practitioners are usually the first health professionals to be contacted by people with early signs of psychosis. We aimed to assess whether increased liaison between primary and secondary care improves the clinical effectiveness and cost-effectiveness of detection of people with, or at high risk of developing, a first psychotic illness. Methods Our Liaison and Education in General Practices (LEGs) study was a cluster-randomised controlled trial of primary care practices (clusters) in Cambridgeshire and Peterborough, UK. Consenting practices were randomly allocated (1:1) to a 2 year low-intensity intervention (a postal campaign, consisting of biannual guidelines to help identify and refer individuals with early signs of psychosis) or a high-intensity intervention, which additionally included a specialist mental health professional who liaised with every practice and a theory-based educational package. Practices were not masked to group allocation. Practices that did not consent to be randomly assigned comprised a practice-as-usual (PAU) group. The primary outcome was number of referrals of patients at high risk of developing psychosis to the early intervention service per practice site. New referrals were assessed clinically and stratified into those who met criteria for high risk or first-episode psychotic illness (FEP; together: psychosis true positives), and those who did not fulfil such criteria for psychosis (false positives). Referrals from PAU practices were also analysed. We assessed cost-effectiveness with decision analytic modelling in terms of the incremental cost per additional true positive identified. The trial is registered at the ISRCTN registry, number ISRCTN70185866. Findings Between Dec 22, 2009, and Sept 7, 2010, 54 of 104 eligible practices provided consent and between Feb 16, 2010, and Feb 11, 2011, these practices were randomly allocated to interventions (28 to low intensity and 26 to high intensity); the remaining 50 practices comprised the PAU group. Two high-intensity practices were excluded from the analysis. In the 2 year intervention period, high-intensity practices referred more FEP cases than did low-intensity practices (mean 1·25 [SD 1·2] for high intensity vs 0·7 [0·9] for low intensity; incidence rate ratio [IRR] 1·9, 95% CI 1·05–3·4, p=0·04), although the difference was not statistically significant for individuals at high risk of psychosis (0·9 [1·0] vs 0·5 [1·0]; 2·2, 0·9–5·1, p=0·08). For high risk and FEP combined, high-intensity practices referred both more true-positive (2·2 [1·7] vs 1·1 [1·7]; 2·0, 1·1–3·6, p=0·02) and false-positive (2·3 [2·4] vs 0·9 [1·2]; 2·6, 1·3–5·0, p=0·005) cases. Referral patterns did not differ between low-intensity and PAU practices. Total cost per true-positive referral in the 2 year follow-up was £26 785 in high-intensity practices, £27 840 in low-intensity practices, and £30 007 in PAU practices. Interpretation This intensive intervention to improve liaison between primary and secondary care for people with early signs of psychosis was clinically and cost effective. Funding UK National Institute for Health Research.

First-rank symptoms and premorbid adjustment in young individuals at increased risk of developing psychosis

Background: Individuals at clinical high risk (CHR) for psychosis represent a heterogeneous group with a high rate of comorbid psychiatric disorders. There is little information on whether certain qualitative aspects of psychotic symptoms among CHR individuals may be predictive of future psychosis. This study focused on describing the prevalence of first-rank symptoms (FRS) among a sample of CHR individuals and its association with future transition to psychosis and, from a neurodevelopmental perspective, the level of adjustment of individuals at CHR during their childhood was also analysed. Sampling and Methods: Participants comprised 60 individuals at CHR (according to the Comprehensive Assessment of At-Risk Mental States, CAARMS) at the time of their referral to an early intervention service and 60 healthy volunteers (HVs). All subjects were assessed by senior research clinicians using the Mini International Neuropsychiatric Interview (MINI), and the Positive and Negative Syndrome Scale (PANSS). FRS were defined according to Kurt Schneiders original classification, and information was collected from PANSS, CAARMS and clinical reports. Early premorbid functioning was measured using the Premorbid Adjustment Scale (PAS). We grouped individuals by number and type of FRS and analysed transitions to full-blown psychosis over a 2-year follow-up period. We also correlated the general social and functional adjustment of these individuals during their childhood (6-11 years of age) with the future development of mental states at CHR and FRS. Results: Over 69% of CHR individuals had more than one DSM-IV psychiatric diagnosis, mainly within the affective and anxiety diagnostic spectra. At least one FRS was present in 43.3% of CHR individuals, and 21.6% of these had more than one. Auditory hallucinations and passivity experiences were the most commonly reported. Only 10% of individuals at CHR made a transition to first-episode psychosis (FEP) over 2 years and, except for passivity experiences, the presence of one or more FRS was not significantly associated with the transition to FEP. CHR individuals, especially those with FRS, had poorer premorbid functioning and adjustment as children across educational, social and peer relationship domains than HVs. However, this was not associated with FEP 2 years later. Conclusions: FRS might not be indicators of psychosis alone but of different psychiatric disorders. In line with the neurodevelopmental model of psychosis, individuals at CHR might be exhibiting several vulnerability traits and manifestations of abnormal developmental processes that might predict a future psychiatric disorder and/or long-term impairment.

Comparison of high and low intensity contact between secondary and primary care to detect people at ultra-high risk for psychosis: study protocol for a theory-based, cluster randomized controlled trial

BackgroundThe early detection and referral to specialized services of young people at ultra-high risk (UHR) for psychosis may reduce the duration of untreated psychosis and, therefore, improve prognosis. General practitioners (GPs) are usually the healthcare professionals contacted first on the help-seeking pathway of these individuals.Methods/DesignThis is a cluster randomized controlled trial (cRCT) of primary care practices in Cambridgeshire and Peterborough, UK. Practices are randomly allocated into two groups in order to establish which is the most effective and cost-effective way to identify people at UHR for psychosis. One group will receive postal information about the local early intervention in psychosis service, including how to identify young people who may be in the early stages of a psychotic illness. The second group will receive the same information plus an additional, ongoing theory-based educational intervention with dedicated liaison practitioners to train clinical staff at each site. The primary outcome of this trial is count data over a 2-year period: the yield - number of UHR for psychosis referrals to a specialist early intervention in psychosis service - per primary care practice.DiscussionThere is little guidance on the essential components of effective and cost-effective educational interventions in primary mental health care. Furthermore, no study has demonstrated an effect of a theory-based intervention to help GPs identify young people at UHR for psychosis. This study protocol is underpinned by a robust scientific rationale that intends to address these limitations.Trial registrationCurrent Controlled Trials ISRCTN70185866

Substance use in people at clinical high-risk for psychosis.

BackgroundSome high-risk (HR) mental states for psychosis may lack diagnostic specificity and predictive value. Furthermore, psychotic-like experiences found in young populations may act not only as markers for psychosis but also for other non-psychotic psychiatric disorders. A neglected consideration in these populations is the effect of substance misuse and its role in the development of such mental states or its influence in the evolution toward full psychotic presentations. Therefore, the main aim of this study was to thoroughly describe past and current substance use profiles of HR individuals by comparing a consecutive cohort of young people at high risk referred to a population-based early intervention clinical service with a random sample of healthy volunteers (HV) recruited from the same geographical area.MethodsWe compared alcohol and substance use profiles of sixty help-seeking HR individuals and 60 healthy volunteers (HV). In addition to identification of abuse/dependence and influence on psychotic-like experiences, differences between HR individuals and HV were assessed for gender, ethnicity, occupational status, age of lifetime first substance use, prevalence and frequency of substance use.ResultsThere were no cases of substance use disorder or dependence in either groups. HR individuals were significantly younger than HV when they first started to use substances (p = 0.014). The prevalence of overall HR substance use was similar to that of HV. Although HR individuals reported less cannabinoid use than HV currently (15% vs. 27%), and more in the past (40% vs. 30%), the differences were not statistically significant (p = 0.177 & 0.339 respectively). Current frequency of use was significantly higher for HR individuals than HV for alcohol (p = 0.001) and cannabinoids (p = 0.03). In this sample, only 5% of HR individuals converted to psychosis over a two-year follow-up.ConclusionsCertain profiles of substance use could potentially play a significant part in the evolution of HR presentations. Therefore, substance use may well represent a clinical domain that requires further emphasis and more detailed consideration in future studies.

Use of the theory of planned behaviour to assess factors influencing the identification of individuals at ultra-high risk for psychosis in primary care.

Aim: To design and assess the psychometric properties of a questionnaire to identify and measure factors that influence the identification of individuals at ultra‐high risk for psychosis in primary care. It will inform the subsequent design of educational interventions to help general practitioners (GPs; primary care physicians) detect these individuals.

34.3 IMPROVING THE DETECTION OF INDIVIDUALS AT RISK OF DEVELOPING PSYCHOSIS IN PRIMARY MENTAL HEALTH CARE

Abstract Background General practitioners are usually the first health professionals contacted by people with early signs of psychosis. It is unclear whether increasing the intensity of liaison between primary care and secondary care improves the clinical effectiveness and cost-effectiveness of detecting people with, or at clinical high-risk (CHR-P) of developing, a first-episode psychosis (FEP). This is important given political commitments to facilitate early intervention and decrease waiting times in mental health. We developed and tested a theory-based intervention to improve detection and referral of these mental states. Methods The LEGS study was a cluster randomised controlled trial (cRCT) involving primary care practices (clusters) in the county of Cambridgeshire and Peterborough, UK. Consenting practices were randomly allocated into two groups: (1) low-intensity liaison between primary care and secondary care, a postal campaign consisting of biannual guidelines to help in the identification and referral of individuals with early signs of psychosis and (2) the high-intensity intervention described in the previous section, which, in addition to the postal campaign, included a specialist mental health professional to liaise with each practice and support the theory-based educational package. Concealed randomisation involved a randomly permuted sequence in blocks, with 12 strata and 96 blocks. Practices that did not consent to be randomised constituted a practice-as-usual (PAU) group. The high- and low-intensity interventions were implemented over a period of 2 years for each practice during the study period April 2010 to October 2013. The primary outcome was the number of CHR-P referrals to Early Intervention in Psychosis Services per practice site predicated on an assumption that the intensive intervention would double them. New referrals were assessed clinically and stratified into those who met criteria for CHR-P or FEP (together: psychosis true positives) and those who did not fulfil such criteria for psychosis (false positives). Referrals from PAU practices were also analysed. An economic evaluation quantified the cost-effectiveness of the interventions and PAU, using decision-analytic modelling. Cost-effectiveness was expressed as the incremental cost per additional true positive identified. Results Of the 104 eligible practices, 54 consented to be randomised. Twenty-eight practices were randomised to low-intensity liaison and 26 practices were randomised to the high-intensity liaison. Two high-intensity practices withdrew. High-intensity practices referred more CHR-P (incidence rate ratio (IRR) 2.2, 95% CI 0.9 to 5.1; p = 0.08)), FEP (IRR 1.9, 95% CI 1.05 to 3.4; p = 0.04) and true positive (IRR 2.0, 95% CI 1.1 to 3.6; p = 0.02) cases. High-intensity practices also referred more false positives (IRR 2.6, 95% CI 1.3 to 5.0; p = 0.005); most (68%) of these were referred on to appropriate services. The total costs per true positive referral in high-intensity practices were lower than those in low-intensity or PAU practices; the high-intensity intervention was the most cost-effective strategy. Discussion Increasing the resources aimed at managing the primary–secondary care interface provides clinical and economic value in this setting. Early detection of CHR-P in primary care is clinically and cost-effective This talk will also introduce the continuation of this work; a 5-year research programme that will focus on the treatment of individuals with psychotic experiences in primary care settings.

Clinically significant personality traits in individuals at high risk of developing psychosis

It is still unclear to what extent personality may influence the development of psychosis. We aimed to explore significant personality traits in individuals at high-risk (HR) for psychosis. Personalities of forty HR individuals and a matched sample of 40 healthy volunteers (HVs) were evaluated with the Millon Multiaxial Inventory (MCMI-III). They were also assessed with the Positive and Negative Symptoms Scale (PANSS), Beck Depression and Anxiety Inventories (BDI-II and BAI), Global Assessment of Functioning (GAF) and Mini-International Neuropsychiatric Interview (MINI 6.0.0). Fishers exact test was employed to compare frequency of traits. Mann-Whitney U test and logistic regression were used to establish relationships between traits and symptoms, and the effect of age, sex and symptoms on such traits. Most HR individuals (97.5%) had at least one significant trait; 75% had personality disorders, mainly depressive, borderline or schizotypal. Only histrionic and narcissistic traits were more prevalent in HVs. Negative symptoms were related to schizoid and paranoid traits. Depression was more severe with borderline traits. Most HR individuals (67.6%) had more than one DSM-IV Axis I diagnosis, mainly depressive/anxiety disorders. Transition rate was low (5%). Certain personality profiles may not be markers for conversions to psychosis but contribute to high morbidity in HR individuals.

Common mental disorder including psychotic experiences: Trailblazing a new recovery pathway within the Improving Access to Psychological Therapies programme in England

Psychotic experiences, depressive and anxiety symptoms may be manifestations of a latent continuum of common mental distress. The Improving Access to Psychological Therapies (IAPT) programme has increased the reach of psychological treatments to people with common mental disorders in England. However, psychotic experiences are neither measured nor considered in therapy. We aimed to confirm the presence of psychotic experiences among IAPT service‐users and determine whether these experiences are associated with higher depression/anxiety levels and poorer recovery. All service‐users that attended the Fenland and Peterborough IAPT teams in Cambridgeshire between November 16, 2015 and January 29, 2016 participated in a service evaluation. In addition to routine mesures, such as the Generalized Anxiety Disorder‐7 questionnaire (GAD‐7) and the Patient Health Questionnaire‐9 (PHQ‐9), we introduced a shortened version of the Community Assessment of Psychic Experiences (CAPE‐P15) to measure psychotic experiences. Classes of individuals were identified with latent class analysis. Associations were reported using Pearson correlation coefficient. One hundred and seventy‐three services‐users were included, mostly females (N = 133; 76.9%). The mean age was 36.6 (SD = 13.3). Around 30% likely belonged to a class with psychotic experiences. CAPE‐P15 frequency was significantly correlated to PHQ‐9 (r = 0.44; P < .001) and GAD‐7 (r = 0.32; P < .001). Similarly, CAPE‐P15 distress and both PHQ‐9 (r = 0.43; P < .001) and GAD‐7 (r = 0.38; P < .001) were highly correlated. These associations were replicated after the initial period of the therapy, indicating poor recovery. Some IAPT service‐users suffer psychotic experiences. Tailoring available evidence‐based psychological therapies for these people in IAPT settings might trailblaze a new care pathway to improve recovery in this group.