Question
Question: What are the baseline clinical predictors, and long-term transition rates to a psychotic disorder in an ultra-high risk population?
Population: A total of 416 people (aged 15–30 years) considered at ultra-high risk (UHR) of developing a psychotic disorder, being treated at the Personal Assessment and Crisis Evaluation Clinic (PACE). Exclusions: people with a current or past psychotic disorder, known organic cause, and use of neuroleptics. Participants were tracked using the National Death Index, mental health record system, electoral roll, telephone directory, previous contacts and internet searching.
Setting: PACE Clinic, Melbourne, Australia; recruitment 1993–2006.
Prognostic factors: UHR criteria, defined as attenuated positive psychotic symptoms (APPS), brief limited intermittent psychotic symptoms (BLIPS), and trait and state risk factors (Trait). APPS was one or more of the following symptoms within the past year, present for between 1 week and 5 years and occurring at least several times a week: ideas of reference, perceptual disturbance, odd thinking and speech, odd behaviour and appearance, odd beliefs or magical thinking. BLIPS was one or more of the following symptoms within the past year, present for less than 1 week and occurring at least several times a week but resolved spontaneously: paranoid ideation, ideas of reference, perceptual disturbance, odd thinking or speech or magical thinking. Trait was defined as, within the past year, schizotypal personality disorder in the individual or a first-degree relative with a psychotic disorder, and decline in mental state or functioning (30% drop in Global Assessment of Functioning (GAF) score) for between 1 month and 5 years.
Outcomes: Transition to psychotic disorder. This was defined as one fully positive psychotic symptom several times a week and lasting for more than a week (assessment made by Brief Psychiatric Rating Scale (BPRS); Comprehensive Assessment of Symptoms and History (CASH); Comprehensive Assessment of At-Risk Mental States (CAARMS); GAF; or public mental health records). Survival analysis was used to analyse transition to psychotic disorder using Kaplan-Meier to estimate transition rates and Cox regression for significance of predictors.
Methods
Design: Prospective cohort study.
Follow-up period: Mean follow-up 7.5 years (range 2.4–14.9 years).
Main results
A total of 311 participants (74.8%) were interviewed at follow-up. Transition to a psychotic disorder had occurred in 114 people (27%). Rates of transition were highest during the first 2 years (20%), but risks of transition remained for up to 10 years after first referral (see online table 1). Overall transition rate was 34.9% over a decade (95% CI 28.7% to 40.6%). Baseline clinical predictors significantly associated with transition include baseline year, BLIPS symptoms, low functioning, conceptual disorganisation, thought disorder, negative symptoms, positive symptoms, impaired motor functioning and longer duration of symptoms. Stepwise regression indicated that global functioning, duration of symptoms and baseline year were the most significant predictors.
Conclusions
People with UHR of transition to psychotic disorders are at greatest risk in the first 2 years after service entry but remain at long-term risk. Long duration of symptoms and poor global functioning were among significant predictors of psychosis.
Abstracted from
Nelson B, Yuen HP, Wood SJ, et al. Long-term follow-up of a group at ultra high risk (‘Prodromal’ for psychosis: the PACE 400 Study. JAMA Psychiatry 2013; 70: 793– 802.
Footnotes
Sources of funding: National Health and Medical Research Council; Colonial Foundation Grant.
