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BACKGROUND: Identifying young people as at clinical high-risk (CHR) for psychosis affords opportunities for intervention to possibly prevent psychosis onset. Yet such CHR identification could plausibly increase stigma. We do not know whether these youth already perceive themselves to be at psychosis-risk (PR) or how their being told they are at PR might impact how they think about themselves. METHODS: 148 CHR youth were asked about labels they had been given by others (labeling by others) or with which they personally identified (self-labeling). They were then asked which had the greatest impact on how they thought about themselves. We evaluated whether being told vs. thinking they were at PR had stronger effects. FINDINGS: The majority identified nonpsychotic disorders rather than PR labels as having the greatest impact on sense of self (67.6% vs. 27.7%). However, participants who identified themselves as at PR had an 8.8 (95% CI=2.0-39.1) increase in the odds of the PR label having the greatest impact (p

Despite the appeal of early intervention in psychosis, there is concern that identifying youth as having high psychosis risk (PR) may trigger stigma. This study employed a pre-post design to measure change in PR participants' emotions about PR upon being told of their PR status and according to whether this was the first time receiving this information.Participants (n = 54) identified as at PR via structured interview rated their emotions about PR before and after being told they were at PR. Qualitative analyses explored the valence of participant reflections on being given this information.Participants reported significantly less negative emotion after being told of their PR status (p .001), regardless of whether they were hearing this for the first time (p = .72). There was no change in positive emotions or the predominant belief that they should keep their PR status private. Most participants commented positively about the process of feedback but negatively about its impact on their self-perceptions and/or expectations of others' perceptions of them.This is the first study to collect pre-post data related to being told one is at PR and to examine quantitative and qualitative responses across and within individuals. For a majority of participants, clinical feedback stimulated negative stereotypes even as it relieved some distress. To actively address internalized stigma, clinicians providing feedback to PR youth must attend to the positive and negative impacts on how youth think about themselves as well as how they feel.

Depressed mood appears to be highly prevalent in clinical high risk (CHR) samples. However, many prior CHR studies utilize modest size samples and do not report on the specific impact of depression on CHR symptoms. The aim of the current paper is to investigate the prevalence of depressive disorders and the impact of lifetime depression on baseline clinical presentation and longitudinal outcomes in a large cohort of individuals meeting CHR criteria in the second phase of the North American Prodrome Longitudinal Study (NAPLS-2). Depression was assessed both categorically (via DSM-IV-TR diagnoses) and symptomatically (using a clinician-rated scale of depressive symptoms) within a sample of 764 individuals at CHR and 279 controls. Current and lifetime depressive disorders were highly prevalent (60%) in this sample. Depression diagnoses were associated with more pronounced negative and general symptoms; individuals with remitted depression had significantly less severe negative, disorganized, and general symptoms and better social and role functioning relative to those with current depression. Current mood disturbance, as measured by scores on a clinician-rated symptom scale, contributed beyond the impact of positive and negative symptoms to impairments in social functioning. Both symptomatic and diagnostic baseline depression was significantly associated with decreased likelihood of remission from CHR status; however depression did not differentially distinguish persistent CHR status from transition to psychosis at follow-up. These findings suggest that depressed mood may function as a marker of poor prognosis in CHR, yet effective treatment of depression within this population can yield improvements in symptoms and functioning.

Learning objectives After participating in this activity, learners should be better able to: Abstract The psychosis prodrome, or period of clinical and functional decline leading up to acute psychosis, offers a unique opportunity for identifying mechanisms of psychosis onset and for testing early-intervention strategies. We summarize major findings and emerging directions in prodromal research and provide recommendations for clinicians working with individuals suspected to be at high risk for psychosis. The past two decades of research have led to three major advances. First, tools and criteria have been developed that can reliably identify imminent risk for a psychotic disorder. Second, longitudinal clinical and psychobiological data from large multisite studies are strengthening individual risk assessment and offering insights into potential mechanisms of illness onset. Third, psychosocial and pharmacological interventions are demonstrating promise for delaying or preventing the onset of psychosis in help-seeking, high-risk individuals. The dynamic psychobiological processes implicated in both risk and onset of psychosis, including altered gene expression, cognitive dysfunction, inflammation, gray and white matter brain changes, and vulnerability-stress interactions suggest a wide range of potential treatment targets and strategies. The expansion of resources devoted to early intervention and prodromal research worldwide raises hope for investigating them. Future directions include identifying psychosis-specific risk and resilience factors in children, adolescents, and non-help-seeking community samples, improving study designs to test hypothesized mechanisms of change, and intervening with strategies that, in order to improve functional outcomes, better engage youth, address their environmental contexts, and focus on evidence-based neurodevelopmental targets. Prospective research on putatively prodromal samples has the potential to substantially reshape our understanding of mental illness and our efforts to combat it.

BACKGROUND: In spite of advances in early intervention in major mental illness, concerns linger regarding the risks of identifying youth as at clinical high risk (CHR) for psychosis. In particular, stigma in this population has been associated with increased emotional distress, social withdrawal, non-engagement in treatment, and suicide risk. Being told one has a CHR syndrome may be one source of stigma, yet no prior studies have conducted assessments both before and after people are given this feedback. Within the context of a larger study of stigma, we compared emotional responses to the CHR concept assessed before and after feedback by study clinicians. Notably, some participants had been already told of their risk prior to study entry whereas others had not. We expected different reactions to study feedback in these two groups. An informed discussion of risk might reduce stigma in those already worried about psychosis whereas it might increase stigma for those considering their risk for the first time. Thus, we predicted a small decrease in negative emotions following feedback in the first group, a small increase in the second, and no significant change in negative emotions for the group as a whole. METHODS: Fifty-seven CHR participants ages 12–35 were interviewed both before and after receiving formal clinical feedback about their risk status and eligibility for the study. This feedback typically included elements of psychoeducation and information about treatment options. In each interview participants were asked 1) the degree to which they felt 12 emotions in relation to risk for psychosis or schizophrenia, 2) whether they thought it was better to not tell anyone about psychosis risk. We analyzed pre-post change using general linear modeling with group (those told before study entry and those first told in the study context) as a between-subjects variable and the time between pre and post interviews as a covariate. RESULTS: Stigma was a significant concern in this sample as the vast majority of participants endorsed “It is better that I not tell people that I am at-risk,” both before and after feedback (75% pre to 71% post, McNemar test, p = 0.75). However, contrary to our hypothesis, participants experienced a significant decline in negative emotions (embarrassed, different, angry, ashamed, sad, worried; F= 20.7, p

Background The clinical high-risk state for psychosis syndrome (CHR) offers substantial potential benefits in terms of early identification and treatment for at-risk youth. Early treatment might lead to decreased symptoms, thus leading to reduced symptom-related stigma. However, stigma of the clinical high-risk state for psychosis designation might also initiate further stigma through the label of risk for psychosis. Identifying the effects of these sources of stigma is critical in order to best minimize stigma associated with CHR identification and to facilitate recovery. Methods Baseline stigma assessments were conducted with 170 clinical high risk state for psychosis individuals in a major, NIH-funded longitudinal study at Columbia University Medical Center, Harvard University Medical Center, and Maine Medical Center from 2012 to 2017. Labeling-related measures of stigma (e.g., “shame of being identified as at psychosis-risk”) adapted to the CHR group, and a parallel measure of symptom-related stigma (e.g., “shame of the symptoms associated with CHR”) were administered. These measures were examined in relation to outcomes of: a) self-esteem, b) quality of life, and c) social functioning, adjusting for sociodemographics and core CHR symptoms (e.g. attenuated psychotic symptoms). Results Results indicated that stigma related to symptoms was more strongly associated with all outcomes when compared with shame related to the risk-label. Stigma related to symptoms remained a significant predictor of self-esteem and quality of life even after accounting for stigma related to the risk-label and the effects of sociodemographics and CHR symptoms. Conversely, stigma related to the risk-label was no longer a significant predictor for outcomes after accounting for stigma related to symptoms. Discussion Overall, symptom-related stigma was a more salient correlate and was independently linked with self-esteem and quality of life even after accounting for the effects of stigma related to the risk-label. These results indicate that treating of symptoms through early identification and treatment may provide major benefit for CHR youth by also alleviating symptom-related stigma. These findings also indicate that CHR services should address stigma associated with symptoms immediately at first identification, as these have substantial effects on psychological and functional outcomes. These findings have implications for guiding implementation of specialized CHR services both in the United States and worldwide.

Objective: Functional impairments are debilitating concomitants of psychotic disorders and are present early in the illness course and, commonly, prior to psychosis onset. The factors affecting social and role functioning in early psychosis (EP) following treatment are unclear. We evaluated whether six months of participation in the PREPR, Boston, EP treatment program, part of a public-academic community mental health center, was related to improvements in social and role functioning and whether premorbid adjustment in adolescence, baseline neurocognition, and depression symptoms predicted functional improvement. Method: The Global Functioning Social and Role scales, MATRICS neurocognitive battery, and Calgary Depression Scale were assessed at baseline and six months during naturalistic treatment, while premorbid adjustment was measured at baseline. All participants were psychotic disorder patients in PREPR ( n = 46 with social functioning and 47 with role functioning measures at both time points). Results: Large improvements were observed in role functioning ( d = 0.84) and medium to large improvements were observed in social functioning ( d = 0.70). Models consisting of adolescent premorbid adjustment and change in depression symptoms predicted social and role functioning change, whereas neuropsychological functioning did not. Conclusions: Substantial improvements in social and role functioning were observed among this sample participating in a recovery-based EP program. The impact of clinical factors on social and role functioning was highlighted. Further studies of premorbid adjustment in adolescence and the treatment of depression in EP programs in controlled treatment trials are needed to confirm these findings.