Over the past two decades we’ve seen growing efforts to prevent psychosis developing in people with subtle signs and symptoms of the disorder, termed ‘Clinical High-Risk State for Psychosis’ (CHR-P).1 These approaches have the potential to improve the lives of many people, particularly adolescents who are at the age that psychosis usually begins. However, most previous evidence on this topic has focused on adults.2 Now, Ana Catalan and colleagues from around the globe have performed a systematic review and meta-analysis of child and adolescent research to advance our understanding of the detection, prognosis and interventions for CHR-P in this age group. Catalan et al. identified 87 articles involving >4,500 young people (mean sample age <18 years) for inclusion in their analyses.
In terms of detection, 16-36% of participants in mental health settings met the CHR-P criteria. Screening questionnaires had good accuracy for discriminating those who did and did not meet criteria for CHR-P. Interestingly, accuracy improved when using information from both the young people themselves and their parents. Most CHR-P adolescents (83%) presented with attenuated positive psychotic symptoms, such as perceptual disturbances or paranoid ideas that are sub-threshold for a psychotic disorder diagnosis. Common co-morbidities included mood and anxiety disorders, while functioning and cognition were also often impaired.
For prognosis, the risk for psychosis onset ranged from 10% at 6 months to 22% at 36+ months follow-up. Finally, for intervention, the researchers found that that 30% of CHR-P adolescents were prescribed antipsychotics, while 60% received psychotherapy. They did not find sufficient evidence to recommend a particular treatment over others to prevent transition to psychosis. Findings from preliminary randomised controlled trials on family interventions, cognitive remediation and fish oil supplementation suggested these treatments might improve symptoms, impaired cognition and functioning.
Various limitations to this study should be noted when interpreting these data. For example, the age range of the study participants varied greatly and the number of participants in each study was modest. The studies were also heterogeneous in terms of their design and quality. Finally, most of the included studies involved patients engaging with psychiatric services, thus representing a help-seeking clinical sample. For now, it seems that the CHR-P paradigm may be useful in adolescents, representing a promising avenue for prevention. However, the limited evidence for effective interventions indicates the need for further research in this field.
Catalan, A. et al. (2020), . J. Child Psychol. Psychiatr. doi: 10.1111/jcpp.13322.
1Fusar-Poli, P. et al. (2013), The Psychosis High-Risk State: A Comprehensive State-of-the-Art Review. JAMA Psychiatry, 70, 107–120. doi: 10.1001/jamapsychiatry.2013.269.
2Fusar-Poli, P. et al. (2020), Prevention of psychosis: advances in detection, prognosis, and intervention. JAMA Psychiatry. 77, 755-765. doi: 10.1001/jamapsychiatry.2019.4779.
Clinical High-Risk State for Psychosis (CHR-P): describes features associated with developing a psychotic disorder, including attenuated or short-lived psychotic symptoms (potentially prodromal symptoms) and genetic risk.