Ultrahigh risk for developing psychosis and psychotic personality organization

Aims: Childhood adversities combined with unsafe parenting may disturb personality development. This study investigated whether psychotic personality organization as defined by Kernberg and assessed with de Dutch Short Form of the MMPI (DSFM) is more prevalent in ultrahigh risk (UHR) for psychosis compared with non-psychotic psychiatric control patients (NPPC). Methods: A total of 73 UHR and 119 NPPC patients were assessed with the DSFM and the Comprehensive Assessment of at Risk Mental States (CAARMS). Results: The results showed that the psychotic personality organization (PPO) was not associated to UHR status. The UHR group showed more severe symptoms, particularly higher scores on DSFM subscales negativism (negative affect) and somatization (vague somatic complaints) and severe psychopathology (psychotic symptoms and dissociation). Conclusion: The PPO profile is not associated to the risk of developing psychosis

Cost-Effectiveness of Virtual Reality Cognitive Behavioral Therapy for Psychosis:Health-Economic Evaluation Within a Randomized Controlled Trial

Background: Evidence was found for the effectiveness of virtual reality-based cognitive behavioral therapy (VR-CBT) for treating paranoia in psychosis, but health-economic evaluations are lacking. Objective: This study aimed to determine the short-term cost-effectiveness of VR-CBT. Methods: The health-economic evaluation was embedded in a randomized controlled trial evaluating VR-CBT in 116 patients with a psychotic disorder suffering from paranoid ideation. The control group (n=58) received treatment as usual (TAU) for psychotic disorders in accordance with the clinical guidelines. The experimental group (n=58) received TAU complemented with add-on VR-CBT to reduce paranoid ideation and social avoidance. Data were collected at baseline and at 3 and 6 months postbaseline. Treatment response was defined as a pre-post improvement of symptoms of at least 20% in social participation measures. Change in quality-adjusted life years (QALYs) was estimated by using Sanderson et al's conversion factor to map a change in the standardized mean difference of Green's Paranoid Thoughts Scale score on a corresponding change in utility. The incremental cost-effectiveness ratios were calculated using 5000 bootstraps of seemingly unrelated regression equations of costs and effects. The cost-effectiveness acceptability curves were graphed for the costs per treatment responder gained and per QALY gained. Results: The average mean incremental costs for a treatment responder on social participation ranged between €8079 and €19,525, with 90.74%-99.74% showing improvement. The average incremental cost per QALY was €48,868 over the 6 months of follow-up, with 99.98% showing improved QALYs. Sensitivity analyses show costs to be lower when relevant baseline differences were included in the analysis. Average costs per treatment responder now ranged between €6800 and €16,597, while the average cost per QALY gained was €42,030. Conclusions: This study demonstrates that offering VR-CBT to patients with paranoid delusions is an economically viable approach toward improving patients' health in a cost-effective manner. Long-term effects need further research. Trial Registration: International Standard Randomised Controlled Trial Number (ISRCTN) 12929657; http://www.isrctn.com/ISRCTN12929657

Individualized Prediction of Transition to Psychosis in 1,676 Individuals at Clinical High Risk: Development and Validation of a Multivariable Prediction Model Based on Individual Patient Data Meta-Analysis

Background: The Clinical High Risk state for Psychosis (CHR-P) has become the cornerstone of modern preventive psychiatry. The next stage of clinical advancements rests on the ability to formulate a more accurate prognostic estimate at the individual subject level. Individual Participant Data Meta-Analyses (IPD-MA) are robust evidence synthesis methods that can also offer powerful approaches to the development and validation of personalized prognostic models. The aim of the study was to develop and validate an individualized, clinically based prognostic model for forecasting transition to psychosis from a CHR-P stage.Methods: A literature search was performed between January 30, 2016, and February 6, 2016, consulting PubMed, Psychinfo, Picarta, Embase, and ISI Web of Science, using search terms (“ultra high risk” OR “clinical high risk” OR “at risk mental state”) AND [(conver* OR transition* OR onset OR emerg* OR develop*) AND psychosis] for both longitudinal and intervention CHR-P studies. Clinical knowledge was used to a priori select predictors: age, gender, CHR-P subgroup, the severity of attenuated positive psychotic symptoms, the severity of attenuated negative psychotic symptoms, and level of functioning at baseline. The model, thus, developed was validated with an extended form of internal validation.Results: Fifteen of the 43 studies identified agreed to share IPD, for a total sample size of 1,676. There was a high level of heterogeneity between the CHR-P studies with regard to inclusion criteria, type of assessment instruments, transition criteria, preventive treatment offered. The internally validated prognostic performance of the model was higher than chance but only moderate [Harrell’s C-statistic 0.655, 95% confidence interval (CIs), 0.627–0.682].Conclusion: This is the first IPD-MA conducted in the largest samples of CHR-P ever collected to date. An individualized prognostic model based on clinical predictors available in clinical routine was developed and internally validated, reaching only moderate prognostic performance. Although personalized risk prediction is of great value in the clinical practice, future developments are essential, including the refinement of the prognostic model and its external validation. However, because of the current high diagnostic, prognostic, and therapeutic heterogeneity of CHR-P studies, IPD-MAs in this population may have an limited intrinsic power to deliver robust prognostic models

CBT in the prevention of psychosis and other severe mental disorders in patients with an at risk mental state: A review and proposed next steps

Patients with an ‘At risk mental state’ (ARMS) for developing psychosis can be treated successfully with CBT to postpone and prevent the transition to a first psychotic episode. A characteristic of individuals that meet ARMS criteria is that they are still open for multiple explanations for extraordinary experiences. CBT aims to normalize extraordinary experiences with education and to prevent delusional explanations. The treatment is not only effective, but also cost-saving in averting psychosis as well as in reducing disability adjusted life years at 18- and 48-month follow-up. Profiling within the ARMS group results in a personalized treatment. The screening and early treatment for ARMS fulfills all the criteria of the World Health Organization and is ready to be routine screening and treatment in mental health care. At the same time, ARMS patients are complex patients with multi-morbid disorders. Especially childhood trauma is associated to ARMS status, together with co-morbid PTSD, depression, substance abuse and anxiety disorders. Psychotic symptoms appear to be severity markers in other non-psychotic disorders. Preventing psychosis in ARMS patients should be broadened to also address other disorders and aim to reduce chronicity of psychopathology and improve social functioning in general. Several mechanisms play a part in psychopathology in ARMS patients such as stress sensitivity as a result of adverse experiences, dopamine sensitivity that is associated with salience and aggravates several cognitive biases, dissociation mediating between trauma and hallucinations, and low self-esteem and self-stigma. New avenues to treat the complexity of ARMS patients will be proposed

Psychosis risk screening in routine mental health care

Background: Routine screening for psychosis risk in mental health care is not common practice. However, a systematic screening process might allow for the identification and treatment of UHR patients to prevent or delay psychosis. Furthermore, it may aid reducing DUP of undetected patients with a psychosis. But, is it possible to apply the criteria for ultra high risk for psychosis in populations with lower a priori probability of psychosis? Method: We used a two-stage screening procedure to screen all consecutive young adults, aged 18-35 years, who were help-seeking for nonpsychotic disorders (n = 3533) at the secondary mental health services in the Hague with a 16-item version of the Prodromal Questionnaire. Results: In the general help-seeking population, a cut-off score of 6 or more positively answered items on the 16-item version of the PQ has a high true positive rate (87%) and high specificity (87%) when differentiating UHR/psychosis from those with no Comprehensive Assessment of At-Risk Mental States (Yung et al., 2005) diagnosis. Conclusion: Young people with attenuated psychotic symptoms can be reliably identified in a general help-seeking population. The PQ-16 is recommended as routine screening tool in mental health care settings because it is feasible to screen large help-seeking populations

Psychosis risk screening in routine mental health care

Background: Routine screening for psychosis risk in mental health care is not common practice. However, a systematic screening process might allow for the identification and treatment of UHR patients to prevent or delay psychosis. Furthermore, it may aid reducing DUP of undetected patients with a psychosis. But, is it possible to apply the criteria for ultra high risk for psychosis in populations with lower a priori probability of psychosis? Method: We used a two-stage screening procedure to screen all consecutive young adults, aged 18-35 years, who were help-seeking for nonpsychotic disorders (n = 3533) at the secondary mental health services in the Hague with a 16-item version of the Prodromal Questionnaire. Results: In the general help-seeking population, a cut-off score of 6 or more positively answered items on the 16-item version of the PQ has a high true positive rate (87%) and high specificity (87%) when differentiating UHR/psychosis from those with no Comprehensive Assessment of At-Risk Mental States (Yung et al., 2005) diagnosis. Conclusion: Young people with attenuated psychotic symptoms can be reliably identified in a general help-seeking population. The PQ-16 is recommended as routine screening tool in mental health care settings because it is feasible to screen large help-seeking populations