Although there is widespread agreement that existing classification systems in psychiatry are insufficient for identifying illness and timely intervention, this is particularly problematic for mental ...health conditions experienced by young people. Existing categorical diagnoses tend to reflect and reify the well-established, chronic syndromes that receive treatment during adulthood, long after their onset--which typically occurs in youth. Among other things, this stands antithetical to the principles and objectives of early intervention paradigms.
Abstract Background Young relatives of individuals with schizophrenia (i.e. youth at familial high-risk, FHR) are at increased risk of developing psychotic disorders, and show higher rates of ...psychiatric symptoms, cognitive and neurobiological abnormalities than non-relatives. It is not known whether overall exposure to environmental risk factors increases risk of conversion to psychosis in FHR subjects. Methods Subjects consisted of a pilot longitudinal sample of 83 young FHR subjects. As a proof of principle, we examined whether an aggregate score of exposure to environmental risk factors, which we term a ‘polyenviromic risk score’ (PERS), could predict conversion to psychosis. The PERS combines known environmental risk factors including cannabis use, urbanicity, season of birth, paternal age, obstetric and perinatal complications, and various types of childhood adversity, each weighted by its odds ratio for association with psychosis in the literature. Results A higher PERS was significantly associated with conversion to psychosis in young, familial high-risk subjects (OR = 1.97, p = 0.009). A model combining the PERS and clinical predictors had a sensitivity of 27% and specificity of 96%. Conclusion An aggregate index of environmental risk may help predict conversion to psychosis in FHR subjects.
Background:
The first rate-limiting step for improving outcomes of psychosis through preventive interventions in people at clinical high risk for psychosis (CHR-P) is the ability to accurately detect ...individuals who are at risk for the development of this disorder. Currently, this detection power is sub-optimal.
Methods:
This is a conceptual and nonsystematic review of the literature, focusing on the work conducted by leading research teams in the field. The results will be structured in the following sections: understanding the CHR-P assessment, validity of the CHR-P as a universal risk state for psychosis, and improving the detection of at-risk individuals in secondary mental health care, in primary care, and in the community.
Results:
CHR-P instruments can provide adequate prognostic accuracy for the prediction of psychosis provided that they are employed in samples who have undergone risk enrichment during recruitment. This substantially limits their detection power in real-world settings. Furthermore, there is initial evidence that not all cases of psychosis onset are preceded by a CHR-P stage. A transdiagnostic individualized risk calculator could be used to automatically screen secondary mental health care medical notes to detect those at risk of psychosis and refer them to standard CHR-P assessment. Similar risk estimation tools for use in primary care are under development and promise to boost the detection of patients at risk in this setting. To improve the detection of young people who may be at risk of psychosis in the community, it is necessary to adopt digital and/or sequential screening approaches. These solutions are based on recent scientific evidence and have potential for implementation internationally.
Conclusions:
The best strategy to improve the detection of patients at risk for psychosis is to implement a clinical research program that integrates different but complementary detection approaches across community, primary, and secondary care. These solutions are based on recent scientific advancements in the development of risk estimation tools and e-health approaches and have the potential to be applied across different clinical settings.
McIlwaine et al discuss the study by Jones et al which offers a qualitative exploration of matters relating to transfers between early intervention service for psychosis (EIP) (also known as ...coordinated specialty care CSC in the US) and subsequent care, as well as their implementation. On the basis of 144 interviews with diverse stakeholders, the authors carefully identified and described the logistics behind transfers, service fidelity to recommended guidelines, and the subjective experience of transfers from both clinician and client perspectives. Their work highlights several additional points that warrant further reflection.
Adolescent media use is thought to influence mental health, but whether it is associated with psychotic experiences (PEs) is unclear.
To examine longitudinal trajectories of adolescent media use and ...their associations with PEs at 23 years of age.
This cohort study included participants from the Québec Longitudinal Study of Child Development (1998-2021): children who were born in Québec, Canada, and followed up annually or biennially from ages 5 months through 23 years. Data were analyzed between January 2023 and January 2024.
Participants reported their weekly amount of television viewing, video gaming, computer use, and reading at ages 12, 13, 15, and 17 years.
Lifetime occurrence of PEs was measured at 23 years of age. Covariables included sociodemographic, genetic, family, and childhood characteristics between ages 5 months and 12 years.
A total of 1226 participants were included in the analyses (713 58.2% female, 513 41.8% male). For each media type, latent class mixed modeling identified 3 group-based trajectories, with subgroups following trajectories of higher use: television viewing, 128 (10.4%); video gaming, 145 (11.8%); computer use, 353 (28.8%); and reading, 140 (11.4%). Relative to lower video gaming, higher video gaming was preceded by higher levels of mental health and interpersonal problems at age 12 years. Adjusting for these risk factors mitigated the association between higher video gaming and PEs at age 23 years. The curved trajectory of computer use (189 15.4% participants), characterized by increasing levels of use until age 15 years followed by a decrease, was associated with higher PEs (estimated difference, +5.3%; 95% CI, +1.5% to +9.3%) relative to lower use (684 55.8% participants). This association remained statistically significant after covariable adjustment.
This study found that longitudinal trajectories of media use during adolescence were modestly associated with PEs at age 23 years, likely reflecting the influence of shared risk factors. Understanding the environmental determinants and psychosocial functions of media use during adolescence may help better integrate digital technologies in the prevention and management of PEs.
Abstract Objectives In the context of a stress–vulnerability framework, hyperactivation of the hypothalamic–pituitary–adrenal (HPA) axis is thought contribute to the risk, onset and course of ...psychotic illness. However, recent reports regarding static and dynamic features of the HPA axis suggest a more complex set of phenomena at play in the early phases of psychosis. Methods We review literature regarding structural and functional aspects of the HPA axis in subjects at risk for or experiencing the first episode of psychosis, including evidence favoring as well as that which contradicts a model of HPA axis hyperactivation. Results Static measures of diurnal cortisol and hippocampal/pituitary volumes suggest that the HPA axis is in a hyperactivated state in early phases of psychosis. In contrast, the dynamic cortisol response to encountered or anticipated stress is blunted in the same populations. These incongruent findings need to be better understood. Conclusions We consider potential explanations for the seemingly contradictory elevation and blunting of HPA biomarkers in the early course of psychosis. Finally, we propose and explore implications of a conceptual model of tonic HPA hyperactivation and phasic HPA blunting that integrates and reconciles these data.
Recognizing that current frameworks for classification and treatment in psychiatry are inadequate, particularly for use in young people and early intervention services, transdiagnostic clinical ...staging models have gained prominence. These models aim to identify where individuals lie along a continuum of illness, to improve treatment selection and to better understand patterns of illness continuity, discontinuity and aetiopathogenesis. All of these factors are particularly relevant to help‐seeking and mental health needs experienced during the peak age range of onset, namely the adolescent and young adult developmental periods (i.e., ages 12‐25 years). To date, progressive stages in transdiagnostic models have typically been defined by traditional symptom sets that distinguish “sub‐threshold” from “threshold‐level” disorders, even though both require clinical assessment and potential interventions. Here, we argue that staging models must go beyond illness progression to capture additional dimensions of illness extension as evidenced by emergence of mental or physical comorbidity/complexity or a marked change in a linked biological construct. To develop further consensus in this nascent field, we articulate principles and assumptions underpinning transdiagnostic clinical staging in youth mental health, how these models can be operationalized, and the implications of these arguments for research and development of new service systems. We then propose an agenda for the coming decade, including knowledge gaps, the need for multi‐stakeholder input, and a collaborative international process for advancing both science and implementation.
Abstract Background and Hypothesis Symptoms that precede a first episode of psychosis (FEP) can ideally be targeted by early intervention services with the aim of preventing or delaying psychosis ...onset. However, these precursor symptoms emerge in combinations and sequences that do not rest fully within traditional diagnostic categories. To advance our understanding of illness trajectories preceding FEP, we aimed to investigate combinations and temporal associations among precursor symptoms. Study Design Participants were from PEPP-Montréal, a catchment-based early intervention program for FEP. Through semistructured interviews, collateral from relatives, and a review of health and social records, we retrospectively measured the presence or absence of 29 precursor symptoms, including 9 subthreshold psychotic and 20 nonpsychotic symptoms. Sequences of symptoms were derived from the timing of the first precursor symptom relative to the onset of FEP. Study Results The sample included 390 participants (68% men; age range: 14–35 years). Combinations of precursor symptoms most frequently featured depression, anxiety, and substance use. Of 256 possible pairs of initial and subsequent precursor symptoms, many had asymmetrical associations: eg, when the first symptom was suspiciousness, the incidence rate ratio (IRR) of subsequent anxiety was 3.40 (95% confidence interval CI: 1.79, 6.46), but when the first symptom was anxiety, the IRR of subsequent suspiciousness was 1.15 (95% CI: 0.77, 1.73). Conclusions A detailed examination of precursor symptoms reveals diverse clinical profiles that cut across diagnostic categories and evolve longitudinally prior to FEP. Their identification may contribute to risk assessments and provide insights into the mechanisms of illness progression.
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