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The two most used semi‐structured psychometric instruments that define criteria for being at clinical high risk (CHR) for psychosis are the Comprehensive Assessment of At‐Risk Mental States (CAARMS) and the Structured Interview for Psychosis‐Risk Syndromes (SIPS). Although very similar there are important differences between these two measures. Developing harmonized psychometric criteria for defining CHR and associated outcomes would be beneficial for future research. This article describes the first step in this process by reporting on a NIMH workshop held in Washington DC, in February 2019 that was attended by experts in the field. The aim of this workshop was to examine the similarities and differences between the two measures and consider how the harmonization process could proceed. [ABSTRACT FROM AUTHOR]

Background: In the 1990s criteria were developed to detect individuals at high and imminent risk of developing a psychotic disorder. These are known as the at risk mental state, ultra high risk or clinical high risk criteria. Individuals meeting these criteria are symptomatic and help-seeking. Services for such individuals are now found worldwide. Recently Psychological Medicine published two articles that criticise these services and suggest that they should be dismantled or restructured. One paper also provides recommendations on how ARMS services should be operate. Methods: In this paper we draw on the existing literature in the field and present the perspective of some ARMS clinicians and researchers. Results: Many of the critics' arguments are refuted. Most of the recommendations included in the Moritz et al. paper are already occurring. Conclusions: ARMS services provide management of current problems, treatment to reduce risk of onset of psychotic disorder and monitoring of mental state, including attenuated psychotic symptoms. These symptoms are associated with a range of poor outcomes. It is important to assess them and track their trajectory over time. A new approach to detection of ARMS individuals can be considered that harnesses broad youth mental health services, such as headspace in Australia, Jigsaw in Ireland and ACCESS Open Minds in Canada. Attention should also be paid to the physical health of ARMS individuals. Far from needing to be dismantled we feel that the ARMS approach has much to offer to improve the health of young people. [ABSTRACT FROM AUTHOR]

It remains unclear whether the onset of psychosis is associated with deterioration in cognitive performance. The aim of this study was to examine the course of cognitive performance in an ultrahigh risk (UHR) cohort, and whether change in cognition is associated with transition to psychosis and change in functioning. Consecutive admissions to Personal Assessment and Crisis Evaluation (PACE) Clinic between May 1994 and July 2000 who had completed a comprehensive cognitive assessment at baseline and follow-up were eligible (N = 80). Follow-up ranged from 7.3 to 13.4 years (M = 10.4 years; SD = 1.5). In the whole sample, significant improvements were observed on the Similarities (P =.03), Information (P <.01), Digit Symbol Coding (P <.01), and Trail Making Test-B (P =.01) tasks, whereas performance on the Rey Auditory Verbal Learning Test (Trials 1–3) declined significantly (P <.01) over the follow-up period. Change in performance on cognitive measures was not significantly associated with transition status. Taking time to transition into account, those who transitioned after 1 year showed significant decline on Digit Symbol Coding, whereas those who did not transition improved on this measure (P =.01; effect size [ES] = 0.85). Small positive correlations were observed between improvements in functioning and improvements in performance on Digit Symbol Coding and Arithmetic (0.24, P =.03 and 0.28, P =.01, respectively). In summary, the onset of psychosis was not associated with deterioration in cognitive ability. However, specific findings suggest that immediate verbal learning and memory, and processing speed may be relevant domains for future risk models and early intervention research in UHR individuals. [ABSTRACT FROM AUTHOR]

Persistent negative symptoms (PNS) defined as negative symptoms that persist for at least six months in the absence of high levels of positive, depressive and extrapyramidal symptoms, are evident early in the course of schizophrenia from the first episode of psychosis. However, their presence even earlier in the illness, in those at Ultra High Risk of psychosis, has not been investigated. In this study, we examined the prevalence, baseline correlates and outcome of PNS in 363 Ultra High Risk individuals. Assessments were conducted at baseline and 2-14 years later (mean follow up time 7.4 years). Baseline assessments included demographic, clinical and neurocognitive measures, which were repeated at follow up. The prevalence of PNS in the UHR group was 6.1%. Poor premorbid social adjustment, deficits in verbal fluency and childhood maltreatment, specifically emotional neglect, were evident at baseline in the PNS group compared to the group without PNS. PNS were associated with poor psychosocial functioning and deficits in processing speed at follow up. Our findings suggest that PNS can be detected early, allowing for the identification of a subset of Ultra High Risk patients who are likely to have poor outcome. These individuals could be the target for specific intervention. Further research is needed into the pathophysiology of these PNS to develop specific interventions. [ABSTRACT FROM AUTHOR]

Abstract: Aim: People with schizophrenia have poor physical health and high rates of premature mortality. Risk factors for later cardiovascular disease are present from an early stage, and recording of these factors is recommended in first‐episode services. However, it is unclear whether cardiometabolic risk factors are monitored prior to first‐episode psychosis. Methods: A retrospective analysis was conducted on case notes of individuals accepted into a specialized early detection service for young people at ultra‐high risk for psychosis. Notes were assessed to determine whether the following physical health measures were recorded: height, weight, body mass index, blood pressure, blood glucose and lipids, physical activity levels, smoking status, substance use and alcohol intake. Results: Forty individuals were deemed at ultra‐high risk for psychosis and accepted into the service. The two measures reported most frequently were whether a person used substances (82.5%) or alcohol (72.5%), but more specific details were not commonly reported. A minority of case files contained information on height (2.5%), weight (7.5%), body mass index (5%), blood glucose (2.5%), smoking status (15%) and physical activity (7.5%). Six case files had no measure of physical health. Conclusions: Physical health and unhealthy lifestyle factors were not assessed routinely in the specialized service. Clear monitoring guidelines should be developed to establish routine assessment of common metabolic risk factors present in this population. [ABSTRACT FROM AUTHOR]

Attempts to identify people at imminent risk of psychotic disorder have been made during the past 20 years. High-risk criteria have been developed, and despite findings of a recent decline in the rate of onset of psychosis associated with these criteria, people identified still have a significantly greater risk, compared with the general population. Intervention studies in this group indicate that psychological treatments and fish oil appear to be just as effective as antipsychotics. Future research should refine risk factors for psychosis and examine outcomes other than psychosis. Research is also needed into what harms and benefits are associated with making the high-risk criteria into a formal diagnosis. [ABSTRACT FROM AUTHOR]

Abstract: “Transition to psychosis” has been the outcome of interest in Ultra High Risk (UHR) and “prodromal” studies. However, the point at which an individual crosses the line from high risk or prodromal state to psychosis threshold is arbitrary. There have been few attempts to examine whether this threshold has any validity in terms of biological markers or course and outcome. More research is needed to determine if the current point at which a person is declared “psychotic” is valid. Indeed some persons labeled as having developed psychosis may quickly recover. In such a situation their transition could be seen as “trivial”. Others who do not make “transition” may have worse outcomes. Validation of the transition point is an important issue as “risk syndrome for psychosis” (psychosis prodrome) is being considered for inclusion in the DSMV. Further, much research attempts to distinguish markers for psychotic disorders by examining the differences between UHR individuals who do and do not develop psychosis. Thus it behooves us not just to have this risk syndrome validated, but to have the hypothetical endpoint of psychosis validated as well. [Copyright &y& Elsevier]

Abstract: The proposed Risk Syndrome for Psychosis (RS) criteria are derived from the Ultra High Risk criteria (UHR) and prodromal or Clinical High Risk criteria (CHR), and consist of subthreshold or attenuated positive psychotic symptoms with operationalized recency and frequency criteria. The rationale behind the proposed inclusion of the RS in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSMV) is that several studies have found that the UHR/prodromal/CHR criteria predict onset of psychotic disorder, mainly schizophrenia, within a brief time period of a few years. Identifying individuals meeting these criteria thus affords the possibility of early intervention to prevent or delay onset of full blown psychotic disorder. However, the RS is yet to be properly validated. Additionally, there are potential dangerous unintended consequences of the reification of this syndrome as a formal diagnosis. Thus we feel it is premature to justify inclusion of the RS in the DSM. [Copyright &y& Elsevier]

Cognitive impairment is a well-documented predictor of transition to a full-threshold psychotic disorder amongst individuals at ultra-high risk (UHR) for psychosis. However, less is known about whether change in cognitive functioning differs between those who do and do not transition. Studies to date have not examined trajectories in intelligence constructs (e.g., acquired knowledge and fluid intelligence), which have demonstrated marked impairments in individuals with schizophrenia. This study aimed to examine intelligence trajectories using longitudinal data spanning an average of eight years, where some participants completed assessments over three time-points. Participants (N = 139) at UHR for psychosis completed the Wechsler Abbreviated Scale of Intelligence (WASI) at each follow-up. Linear mixed-effects models mapped changes in WASI Full-Scale IQ (FSIQ) and T-scores on Vocabulary, Similarities, Block Design, and Matrix Reasoning subtests. The sample showed stable and improving trajectories for FSIQ and all subtests. There were no significant differences in trajectories between those who did and did not transition to psychosis and between individuals with good and poor functional outcomes. However, although not significant, the trajectories of the acquired knowledge subtests diverged between transitioned and non-transitioned individuals (β = -0.12, 95 % CI [-0.29, 0.05] for Vocabulary and β = -0.14, 95 % CI [-0.33, 0.05] for Similarities). Overall, there was no evidence for long-term deterioration in intelligence trajectories in this UHR sample. Future studies with a larger sample of transitioned participants may be needed to explore potential differences in intelligence trajectories between UHR transition groups and other non-psychosis outcomes. [ABSTRACT FROM AUTHOR]

Over a quarter of a century ago, the formulation of the "at risk mental state" and operational criteria to prospectively identify individuals at "clinical" or "ultra-high risk" (UHR) for psychosis created a global wave of research momentum aimed at predicting and preventing first-episode psychosis. A substantial number of randomized controlled trials (RCTs) were conducted to determine if transition to psychosis could be delayed or even prevented. The efficacy of a range of interventions was examined, with standard meta-analyses clearly indicating that these could at least delay transition for 1-2 years and that outcomes improve. Recently, network meta-analyses have attempted to identify the most effective intervention. These highlighted the fact that no one form of intervention is superior to the rest, a finding interpreted in such a way as to create doubts concerning the value of intervening. These doubts have been reinforced by a subsequent Cochrane review which judged the quality of the evidence as low or very low. Here, we report a narrative review of findings from RCTs and meta-analyses on the efficacy of interventions in UHR. We also critique the network meta-analyses and the Cochrane review, and indicate that many of the trials were of the highest possible quality for such research, and were published in top ranked psychiatry journals, which demand such quality. Although outcomes vary, and the UHR group is clearly heterogeneous, we highlight the clinical benefits of psychosocial treatment. The next generation of clinical trials seek to elucidate the optimal type, duration and sequence of interventions. [ABSTRACT FROM AUTHOR]

Background Transition to psychotic disorder has been the traditional outcome of interest for research in the at-risk mental state (ARMS). However, there is growing recognition that individuals with ARMS may function poorly regardless of whether they develop psychosis. We aimed to review the literature to determine whether there are specific factors associated with, or predictive of, functional impairment in the ARMS population. Method An electronic database search of MEDLINE, PsycINFO and Embase from inception until May 2014 was conducted using keyword search terms synonymous with the at-risk mental state and functioning. Eligible studies were original peer-reviewed English language research articles with populations that met validated at-risk diagnostic criteria and examined the cross-sectional or longitudinal association between any variable and a measure of functioning. Results Seventy-two eligible studies were identified. Negative symptoms and neurocognitive impairment were associated with poor functioning in cross-sectional studies. Negative and disorganised symptoms, neurocognitive deficits and poor functioning at baseline were predictive of poor functional outcome in longitudinal studies. Positive symptoms were unrelated to functioning in both cross-sectional and longitudinal studies. Functional disability was persistent and resistant to current treatments. Conclusions Negative and disorganised symptoms and cognitive deficits pre-date frank psychotic symptoms and are risk factors for poor functioning. This is consistent with a subgroup of ARMS individuals potentially having neurodevelopmental schizophrenia. Treatments aimed at improving functioning must be considered a priority on par with preventing transition to psychosis in the development of future interventions in the ARMS group. [ABSTRACT FROM AUTHOR]