22.01.2013: (Please note that Archives of General Psychiatry has changed name to JAMA Psychiatry)
High risk state for psychosis (=at risk mental state/Ultra High Risk) (HR) indicate the presychotic phase when people present with potentially prodromal symptoms. ‘Prodromal’ was first introduced by Mayor-Gross. Huber and Gross first described the basic symptoms in 60s. Hafner et al (1989) showed that 73% of all first admitted psychosis patients had a prodromal phase that lasted up to 5 yrs in average. Establishment of clinical services for potentially prodromal individuals started in 90s. Soon , various diagnostic criteria emerged.
UHR criteria includes attenuated psychotic symptoms (APS), brief limited intermittent psychotic episode (BLIP), and genetic risk and deterioration syndrome [GRD]) and unspecified prodromal symptoms (UPS). Basic symptoms (BS) are subjectively experienced disturbances of different domains ( perception, thought processing, language, and attention) that are distinct from classic psychotic symptoms in that they are independent of abnormal thought content and reality testing and insight into the symptoms’ psychopathologic nature is intact.Various assessment tools have emerged to capture the UHR criteria and BS.
Huge interest in this area has been mainly driven by the hope that better understanding would lead to treatments that would prevent the transition to frank psychosis. There is also realisation that HR state may have various outcomes of which only one is psychosis.
Paolo Fusar-Poli et al review our current knowledge of HR state in this article.
Epidemiologic research: Prevalence of HR state in general population is not known. General population interview data suggest that 4-8% have psychotic symptoms or psychotic like experiences. In children this may be up to 10% and have no clinical significance and most disappear by itself.
Outcome: Meta-analysis by Fusar-Poli et al 2012 : of approximately 2500 HR individuals ( who sought help): mean transition risk,of 18% at 6 months of follow-up, 22% at 1 year, 29% at 2 years, 32% at 3 years, and 36% after 3 years. ie less than 40% will develop in to psychosis in 3 yrs. Most of this 36% will develop a DSM/ICD schizophrenia spectrum disorder. Those who do not develop psychosis, generally show lower level of functioning than normal controls. Some of them whose prodrome resolves only to develop full psychosis later on(“outpost syndrome”). Yung et al 2011 reported that HR individuals continue to develop psychotic disorder up to 10 years after initial presentation. In general,it may be that transition rate of HR state is up to 80% if followed sufficiently longer.
Please note that the transition criteria used in these studies are either 1. Yung’s criteria : the occurrence of at least 1 fully positive psychotic symptom several times a week for more than 1 week or 2. SIPS criteria require the presence of at least 1 fully positive psychotic symptom several times per week for at least 1 month or at least 1 fully psychotic symptom for at least 1 day if this symptom is seriously disorganizing or dangerous.
Conclusion: There is a high transition rate in criteria met HR states.Risk remain high up to and at least 10 yrs. Identification and sufficient follow-up of HR states are clinically necessary.
Comment: This is the first part of the summary of the review.
The Psychosis High-Risk State: A Comprehensive State-of-the-Art Review. Fusar-Poli P, Borgwardt S, Bechdolf A, Addington J, Riecher-Rössler A, Schultze-Lutter F, Keshavan M, Wood S, Ruhrmann S, Seidman LJ, Valmaggia L, Cannon T, Velthorst E, De Haan L, Cornblatt B, Bonoldi I, Birchwood M, McGlashan T, Carpenter W, McGorry P, Klosterkötter J, McGuire P, Yung A. JAMA psychiatry 2013; 70(1) :107-120.