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Ultra high-risk patients at long-term risk for psychotic disorder

Ultra high-risk patients were at risk for transitioning to a psychotic disorder up to 10 years of entry to mental health services, with the highest rate of transition occurring within the first 2 years, according to the results from a new prospective study published in JAMA Psychiatry. Interventions to improve functioning in patients during the prodromal phase of schizophrenia and other psychotic disorders may help mitigate the risk of that transition, researchers said.

“It is important to consider predictors that take longer-term outcome into account; limiting analysis to predictors of short-term (1-2 years) outcome may present a distorted picture of true risk factors for psychosis,” researchers wrote. “The issue of longer-term outcome is salient given the decision to include an attenuated psychosis syndrome based on the [ultra high-risk] criteria in Section III (conditions requiring further research) of DSM-5.”

Ultra high-risk criteria were based on the presentation of attenuated psychotic symptoms, brief limited intermittent psychotic symptoms, and genetic vulnerability, in addition to chronic low or a significant decrease in functioning.

The study followed 416 ultra high-risk patients who presented at the Personal Assessment and Crisis Evaluation (PACE) clinic in Melbourne, Australia, for up to 15 years. Transition to a psychotic disorder was measured using the Comprehensive Assessment of At-Risk Mental States, the Brief Psychiatric Rating Scale/Comprehensive Assessment of Symptoms and History, or using state public mental health records.

During the time to follow-up, 114 patients transitioned to a psychotic disorder. While the greatest risk for transition was within 2 years of presentation, patients continued to be at risk for up to 10 years. The overall average rate of transition was 34.9% (95% CI, 28.7-40.6) during 10 years, according to researchers.

The greatest predictors of transition were duration of symptoms before entering the PACE clinic, baseline functioning, negative symptoms, and disorders of thought content.

The researchers said ultra high-risk patients should be followed up for at least 2 years, with the possibility to return for care on a case-by-case basis. “Individuals with a long duration of symptoms and poor functioning at the time of referral may need closer monitoring,” they wrote. “Interventions to improve functioning and detect help-seeking [ultra high-risk] patients earlier also may be indicated.”

Disclosure: The researchers report no relevant financial disclosures.