Development of a stage-dependent prognostic model to predict psychosis in ultra-high-risk patients seeking treatment for co-morbid psychiatric disorders.

BACKGROUND: Current ultra-high-risk (UHR) criteria appear insufficient to predict imminent onset of first-episode psychosis, as a meta-analysis showed that about 20% of patients have a psychotic outcome after 2 years. Therefore, we aimed to develop a stage-dependent predictive model in UHR individuals who were seeking help for co-morbid disorders. METHOD: Baseline data on symptomatology, and environmental and psychological factors of 185 UHR patients (aged 14-35 years) participating in the Dutch Early Detection and Intervention Evaluation study were analysed with Cox proportional hazard analyses. RESULTS: At 18 months, the overall transition rate was 17.3%. The final predictor model included five variables: observed blunted affect [hazard ratio (HR) 3.39, 95% confidence interval (CI) 1.56-7.35, p < 0.001], subjective complaints of impaired motor function (HR 5.88, 95% CI 1.21-6.10, p = 0.02), beliefs about social marginalization (HR 2.76, 95% CI 1.14-6.72, p = 0.03), decline in social functioning (HR 1.10, 95% CI 1.01-1.17, p = 0.03), and distress associated with suspiciousness (HR 1.02, 95% CI 1.00-1.03, p = 0.01). The positive predictive value of the model was 80.0%. The resulting prognostic index stratified the general risk into three risk classes with significantly different survival curves. In the highest risk class, transition to psychosis emerged on average ⩾8 months earlier than in the lowest risk class. CONCLUSIONS: Predicting a first-episode psychosis in help-seeking UHR patients was improved using a stage-dependent prognostic model including negative psychotic symptoms (observed flattened affect, subjective impaired motor functioning), impaired social functioning and distress associated with suspiciousness. Treatment intensity may be stratified and personalized using the risk stratification.

Cost-effectiveness of preventing first-episode psychosis in ultra-high-risk subjects: multi-centre randomized controlled trial.

BACKGROUND: Although there is evidence for the effectiveness of interventions for psychosis among ultra-high-risk (UHR) groups, health economic evaluations are lacking. This study aimed to determine the cost effectiveness and cost-utility of cognitive-behavioural therapy (CBT) to prevent first-episode psychosis. METHOD: The Dutch Early Detection and Intervention Evaluation study was a randomized controlled trial of 196 UHR patients with an 18-month follow-up. All participants were treated with routine care (RC) for non-psychotic disorders. The experimental group (n = 95) received add-on CBT to prevent first-episode psychosis. We report the intervention, medical and travel costs, as well as costs arising from loss of productivity. Treatment response was defined as psychosis-free survival and quality-adjusted life years (QALYs) gained. RESULTS: In the cost-effectiveness analysis, the proportion of averted psychoses was significantly higher in the CBT condition (89.5% v. 76.2%). CBT showed a 63.7% probability of being more cost effective, because it was less costly than RC by US$844 (£551) per prevented psychosis. In the cost-utility analysis, QALY health gains were slightly higher for CBT than for RC (0.60 v. 0.57) and the CBT intervention had a 52.3% probability of being the superior treatment because, for equal or better QALY gains, the costs of CBT were lower than those of RC. CONCLUSIONS: Add-on preventive CBT for UHR resulted in a significant reduction in the incidence of first psychosis. QALY gains show little difference between the two conditions. The CBT intervention proved to be cost saving.

[The detection of people with an ultra-high risk of developing psychosis: detection methods and baseline characteristics of the population]. / De detectie van mensen met een verhoogd risico op een psychose: detectiemethoden en basiskenmerken van de populatie.

BACKGROUND: It has proved possible to detect persons who are in an at risk mental state (arms) and who run the risk of developing a psychosis. We need to find out whether the detection can be successfully carried out when these patients are being cared for by the secondary mental health care services. AIM: To summarise three studies forming part of a Ph.D. thesis about persons with a high risk of developing psychosis and to explore whether a two-stage screening programme can detect arms-patients among a general help-seeking population. METHOD: The case register of Parnassia (in The Hague) was used to pick out all persons who had developed a first-episode psychosis between 2005 and 2009 and who had sought help for non-psychotic psychological problems during this phase preceding a first-episode psychosis. Data from the Dutch edie-nl study were used to find out whether a two-stage screening method was able to detect arms-patients (aged 18-30) more accurately than the traditional screening method. The two-stage screening consisted of a Prodromal Questionnaire relating to all help-seeking subjects in the general population, followed by a gold-standard interview with patients who achieved a score higher than the cut-off level. RESULTS: 56.2% of the first-episode psychotic patients received help for non-psychotic psychiatric problems in the secondary mental health care services. Screening detected more arms-patients than did the referral method and the 'referred' patients developed three times as many psychotic symptoms over a period of 18 months. CONCLUSION: The secondary mental health care services care for 4% of the arms-patients and are in a position to detect arms-patients provided they use two-stage screening. Screening leads to fewer false-negative results than does the 'referral' method.

[Patients with an increased risk of developing a first psychotic episode: two cases]. / Twee patiënten met verhoogd risico op een eerste psychose.

Patients with an 'at risk mental state' (ARMS) run an increased risk of developing a psychosis within the near future. Patients with an arms can be divided into three groups: those with genetic predisposition to schizophrenia and displaying decreased social functioning, those with attenuated psychotic symptoms and those with brief limited and intermittent psychotic symptoms (BLIPS). Patients with an arms are often suffering from comorbid anxiety and depressive symptoms. Our study focuses on two patients with an ARMS.

Detection of people at risk of developing a first psychosis: comparison of two recruitment strategies.

OBJECTIVE: Better recruitment strategies are needed to improve the identification of people at ultra-high risk of developing psychosis. This study explores the effectiveness of two recruitment strategies: a screening method in a consecutive help-seeking population entering secondary mental health services for non-psychotic problems vs. a population referred to the diagnostic center of an early-psychosis clinic. METHOD: From February 2008 to February 2010, all general practitioner and self-referrals (aged 18-35 years) to the secondary mental healthcare service in The Hague and Zoetermeer were screened with the Prodromal Questionnaire; patients who scored above the cutoff of 18 and had a decline in social functioning were assessed using the Comprehensive Assessment of At-Risk Mental States (CAARMS). All referrals (aged 14-35 years) to the diagnostic center in Amsterdam were also assessed with the CAARMS. RESULTS: The screening detected a three-fold higher prevalence of at-risk mental states: these subjects were older and more often female. manova showed significantly higher scores for the screened population on depression, social anxiety, distress with positive symptoms, and a higher rate of transition to psychosis within 12 months. CONCLUSION: The screening method detects more patients with at-risk mental states than the referral method. The latter method is biased to young male patients in an earlier prodromal stage and a lower transition rate.

Ethnicity and baseline symptomatology in patients with an At Risk Mental State for psychosis.

BACKGROUND: Ethnicity has been associated with different incidence rates and different symptom profiles in young patients with psychotic-like disorders. No studies so far have examined the effect of ethnicity on symptoms in people with an At Risk Mental State (ARMS). METHOD: In this cross-sectional study, we analysed the relationship between ethnicity and baseline data on the severity of psychopathology scores in 201 help-seeking patients who met the ARMS criteria and agreed to participate in the Dutch Early Detection and Intervention (EDIE-NL) trial. Eighty-seven of these patients had a non-Dutch ethnicity. We explored the possible mediating role of ethnic identity. RESULTS: Higher rates of negative symptoms, and of anhedonia in particular, were found in the ethnic minority group. This result could be attributed mainly to the Moroccan-Dutch and Turkish-Dutch subgroups, who also presented with more depression symptoms when the groups were examined separately. The ethnic minority group displayed a lower level of ethnic group identity compared to the immigrants of the International Comparative Study of Ethnocultural Youth (ICSEY). Ethnic identity was inversely related to symptoms in the Moroccan-Dutch patient group. CONCLUSIONS: The prevalence of more severe negative symptoms and depression symptoms in ethnic minority groups deserves more attention, as the experience of attenuated positive symptoms when accompanied by negative symptoms or distress has proven to be predictive for transition to a first psychotic episode.