Validation of “prodromal” criteria to detect individuals at ultra high risk of psychosis: 2 year follow-up

doi:10.1016/j.schres.2008.07.012

Schizophrenia Research

Volume 105, Issues 1–3, October 2008, Pages 10-17

https://doi.org/10.1016/j.schres.2008.07.012 Get rights and content

Abstract

Background

Identification of individuals “prodromal” for schizophrenia and other psychotic disorders relies on criteria that predict onset within a brief period. Previous trials and biological research have been predicated on the view that certain “ultra high risk” (UHR) criteria detect “the prodrome”, but there is a need to test the validity of these criteria.

Aim

To assess the predictive validity of the UHR criteria in a clinical population.

Method

The presence of UHR criteria was determined in 292 help-seeking individuals. At 2 year follow-up the number of new cases of psychotic disorder was assessed.

Results

The criteria significantly predicted onset of psychotic disorder within 2 years. The transition rate of 16% was much lower than in initial cohorts (over 40%).

Conclusions

The predictive validity of UHR criteria depends on the sample to which they are applied. Although young help-seekers meeting these criteria are at greater risk of psychotic disorder than those who do not meet them, caution is needed in their management, since a high transition rate can no longer be assumed.

Introduction

For the past 15 years our group has been working to identify people at high risk of imminent onset of psychotic disorder. We defined criteria for “ultra high risk” (UHR) status. These criteria are largely based on the presence of psychotic-like experiences. Initial testing of these criteria found that they were associated with a high likelihood of developing full-threshold psychosis (over 40% within 1 year (Yung et al., 2003)). Subsequently other research centres have used similar criteria and found transition rates of 9 to 54% (Olsen and Rosenbaum, 2006) with an average of 36.7% within 1 year (Ruhrmann et al., 2003). However, it may be the fact of seeking help from a UHR service, rather than the UHR criteria per se, which predict onset of psychosis. To investigate this we recruited a cohort who presented to a clinical service for young people with mental health problems, assessed their UHR status at baseline, and followed them up 2 years later to determine whether UHR status predicted subsequent psychotic disorder.

As we were recruiting participants through a clinical program, we also sought to determine the ability of clinicians to detect the UHR criteria. These clinicians were experienced in assessing and managing young people with mental health problems, but had not received any formal training in assessing UHR symptoms.

The primary aim was to determine the medium term (2 year) predictive validity of the ultra high risk (UHR) criteria in a sample of adolescents and young adults seeking help from a youth mental health service.

A secondary aim was to compare researchers “gold standard” assessment of UHR status, determined using a structured instrument, the Comprehensive Assessment of At Risk Mental States (CAARMS) (Yung et al., 2005), with clinicians' unstructured assessment of UHR status in the young people presenting.

That individuals who met the UHR criteria at baseline (the “UHR+ve” group) would have a higher risk of onset of psychotic disorder at 2 year follow-up, compared to those who did not meet UHR criteria at baseline (the “UHR−ve” group).

That clinicians without formal training in assessing the UHR criteria would only have moderate ability to accurately assess UHR status of young help-seekers compared to the “gold standard” research assessment.

Section snippets

Setting

The study was conducted at ORYGEN Youth Health (OYH), a publicly funded mental health service for people aged between 15 and 24 years living in Melbourne, Australia. There are about 900,000 people living in the catchment area, about 200,000 of whom are aged 15–24. The clinical service consists of three sub-programs, EPPIC (the Early Psychosis Prevention and Intervention Centre, for people with first episode psychotic disorder), PACE (Personal Assessment and Crisis Evaluation, for UHR

Baseline characteristics

Between April and October 2003 629 young people were referred to the OYH Triage service. Of these 629, 248 were excluded from the current study: 140 were already psychotic, 28 lived outside the catchment area, 17 were outside the age range of the study, 4 had inadequate English, 47 young people or their referrers were seeking telephone advice only and in 12 cases the case manager requested the research team not to approach the young person because of clinical considerations. The remaining 381

Discussion

Young people presenting to a youth mental health service were assessed for UHR status at baseline and the outcome, in terms of transition to psychosis within 2 years, was determined. We found that amongst this help-seeking group, those that were UHR+ve were at significantly greater risk than those who were UHR–ve (p < 0.0001). Thus help-seeking per se was not a risk factor for development of psychotic disorder, rather it was, as hypothesised, the UHR+ status at baseline that significantly

Role of the funding source

Funding for this was provided by a National Health and Medical Research (NHMRC) Program Grant (#350241) and by the Colonial Foundation. These sources had no further role in the study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication.

Contributors

Alison Yung designed the study and wrote the first draft of the manuscript. Barnaby Nelson, Magenta Simmons and Lisa Phillips collected and managed the PACE data and analyses. Carrie Stanford, Elisabeth Cosgrave, Eoin Killackey and Joe Buckby collected and managed the Youthscope data and analyses. Curie Stanford and Alison Yung undertook the statistical analysis. All authors contributed to and have approved the final manuscript.

Conflict of interest

Alison Yung, Lisa Phillips and Patrick McGorry have received investigator-initiated funding from Jansen Pharmaceuticals; Ptrick McGorry has received investigator-initiated funding from Astra-Zeneca; and Andreas Bechdolf has received investigator-initiated grant from Bristol-Meyers Squibb and has served as a lecturer and consultant for Janssen Pharmaceuticals, Eli Lilly, Astra and Sanofi-aventis. All the other authors report no conflict of interest.

Acknowledgements

All authors gratefully acknowledge the National Health and Medical Research (NHMRC) Program Grant (#350241) and the Colonial Foundation which provided funding for this study. We also thank the young people who participated.

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Validation of “prodromal” criteria to detect individuals at ultra high risk of psychosis: 2 year follow-up

Abstract

Background

Aim

Method

Results

Conclusions

Introduction

Section snippets

Setting

Baseline characteristics

Discussion

Role of the funding source

Contributors

Conflict of interest

Acknowledgements

Journal of the American Academy of Child & Adolescent Psychiatry

Schizophrenia Research

Schizophrenia Research

Schizophrenia Research

Diagnostic and Statistical Manual of Mental Disorders

Omega-3 fatty acids reduce the risk of early transition to psychosis in ultra-high risk individuals: a double-blind randomized, placebo-controlled treatment study

Schizophrenia Bulletin

Prediction of psychosis in ultra high risk youth: a multi-site longitudinal study in North America

Archives of General Psychiatry

Structured clinical interview for DSM-IV axis I disorders

Risk and protection in prodromal schizophrenia: ethical implications for clinical practice and future research

Schizophrenia Bulletin

Early Testing for Schizophrenia

Randomized, double-blind trial of olanzapine versus placebo in patients prodromally symptomatic for psychosis

American Journal of Psychiatry

Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of schizophrenia and related disorders

Australian and New Zealand Journal of Psychiatry