Risk factors for psychosis in an ultra high-risk group: psychopathology and clinical features
Introduction
Biological and subthreshold clinical features of physical and mental disorders are often thought to be precursors to the development of full-blown disorder Helmchen and Linden, 2000, Magruder and Calderone, 2000. For example, individuals with ‘subclinical’ or ‘minor depression’ are at risk of developing major depression Pincus et al., 1999, Clarke et al., 2001. Indicated prevention refers to clinical intervention in individuals who display these putative markers in the hope that further progression of the illness process can be averted (Mrazek and Haggerty, 1994). We have previously described how individuals with subthreshold psychotic symptoms or other risk factors are at risk of developing a full-blown psychotic disorder (Yung et al., 2003) and have discussed the development and evaluation of possible preventive interventions aimed at this group of patients.
It is acknowledged that not all people with operationally defined subthreshold forms of psychosis will go on to develop a diagnosable psychotic disorder such as schizophrenia. Until individuals at risk of psychosis can be identified with nearly 100% certainty this will be the case with any predictive research. The challenge is to identify those individuals most likely to make this transition. These are the people in whom intervention at an early stage, in this case, before onset of frank psychosis, could be justified in order to prevent further deterioration and suffering.
Previous papers have described a method of identifying and recruiting individuals at high risk of developing a psychotic disorder to produce such an enriched sample Yung et al., 1995, Yung et al., 1996, Yung et al., 1998a, Yung et al., 1998b, Phillips et al., 1999, Yung and Jackson, 1999. We have deliberately avoided using the term ‘prodromal’ to refer to this group as that is a retrospective concept and therefore at odds with our prospective strategy of identification (Yung et al., 1996). That is, it is not clear at the time of their presentation whether psychosis will follow or not, a situation which is implied by the term ‘prodromal’. Instead, we have used the term “at risk mental state” (ARMS) (McGorry and Singh, 1995) to refer to these individuals who appear to be at risk of psychosis but in whom psychosis is not inevitable.
In a previous study (Yung et al., 2003), the “natural history” of the ARMS criteria was examined. A transition rate of 41% was demonstrated. Some factors that predicted an increased likelihood of the development of psychosis over the course of a year within this high-risk group were found, including long duration of subthreshold (‘prodromal’) symptoms, poor functioning and high levels of depressive and attenuated psychotic symptoms. A limitation of that study was a small sample size (n=49). The current paper continues that research by expanding the sample size to 104.
Section snippets
Subjects
Subjects were recruited into this study from the Personal Assessment and Crisis Evaluation (PACE) Clinic, Melbourne, Australia Yung et al., 1995, Yung et al., 1996. All referrals to the Clinic between March 1995 and January 1999 were screened for inclusion. Referral sources included general practitioners, psychiatric services, school and university counseling services, and other support agencies working with young people, such as drug and alcohol services. Subjects were included in the research
Intake characteristics
Mean age at first assessment of the 104 subjects included in this study was 19.4 years (median 19, S.D.=3.5, range 14–28). Fifty-one of the subjects were male (49%) and 53 were female (51%). The 95 who met criteria but were excluded from the study (see Table 2) did not differ significantly from the research sample in terms of age (mean 19.8 years, median 19, S.D.=3.8, range 14–28, p value=0.41) or gender (62% male, p value=0.087).
Table 3 shows some further variables at intake. A mean GAF score
Discussion
A method of combining trait risk factors (such as family history) and state risk factors (such as current mental state and deterioration in functioning) to identify those possibly at ‘ultra’ high risk of psychosis has been described. This strategy was used in a sample of 104 subjects. Thirty-six (34.6%) developed psychosis within 12 months and five more over an extended period, a total of 41 cases to date (39.4% of the sample). This ‘close-in’ strategy (Bell, 1992) delivers a much higher
Acknowledgements
This research was supported in part by a grant from the Victor Hurley Medical Research Fund and by a Research Program Grant from the Victorian Health Promotion Foundation. The authors gratefully acknowledge the contributions of Dr. Steven Adlard, Dr. Alison Blair, Shona Francey, Elizabeth Cosgrave, Jenny Bravin, Dominic Germano, Colleen McFarlane, Mats Hallgren, and Anthony MacDonald who assessed subjects and/or collected data for the study.
This paper was presented as a poster at the
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