Evidence summary: Identification of young people at risk of developing psychosis (headspace)

MythBuster: Suicidal Ideation headspace National Youth Mental Health Foundation is funded by the Australian Government Department of Health under the Youth Mental Health Initiative Evidence Summary: Identifi cation of young people at risk of developing psychosis

A woman in a green sleeveless top and black pants is sitting on the chair smiling at her man. The man has curly hair, short sleeve shirt with polka dots and dark slacks. He is holding an iPad in his lap while he sits next to a desk that has computer monitors and other items on it. There are several posters hanging up on the wall behind them.

Evidence Summary: Identifi cation of young people at risk of developing psychosis Section A: Heading 2 Evidence Summary: Identifi cation of young people at risk of developing psychosis Overview Over the past 20 years, in conjunction with the development of new models of care for treating psychotic disorders in young people, a series of studies have focussed on the prevention of psychotic disorders. This body of work has involved the identifi cation of specifi c risk factors for the onset of psychosis, the development of criteria to identify those most at risk of developing a psychotic disorder, and the testing of interventions designed to ameliorate, delay or prevent the onset of psychosis. This summary focuses on identifi cation and assessment, describing the criteria most commonly used to identify young people who are at increased risk of developing a psychotic disorder. Identifying those most at risk of developing a psychotic disorder In order to prevent, delay or ameliorate the onset of a psychotic disorder, efforts have been made to identify young people at high clinical risk of developing a psychotic disorder. Although a number of approaches have been taken, all published studies to date can be categorised as using basic symptoms criteria (see 'Key terms'), UHR criteria (see below) or a combination of both. Three measures have been used to assess UHR features: the Comprehensive Assessment of At-Risk Mental States (CAARMS; 2), the Structured Interview for Prodromal Syndromes (SIPS; 3), and the Basel Screening Instrument for Psychosis (4). However, the CAARMS has been validated with young Australians and is the most commonly used instrument locally, and thus is summarised here (see right). A full, operationalised version of the UHR Criteria and CAARMS are described elsewhere (5). It is recommended that clinicians are trained in administering the CAARMS before assessing psychosis risk, either through their headspace centre or through a training organisation. The Ultra-High Risk (UHR) Criteria To meet UHR Criteria, clients must meet one of two impaired functioning criteria, experiencing either: • A 30% or greater drop in functioning from a premorbid level, sustained for one month, occurring within past 12 months or, • Chronically low functioning for the past 12 months or longer, and meet criteria for at least one of the following groups: Group 1: Vulnerability Group Family history of psychosis in fi rst degree relative or Schizotypal Personality Disorder is identifi ed in the young person. Group 2: Attenuated Psychosis Group Individuals with sub-threshold (intensity or frequency) positive psychotic symptoms (as assessed with the CAARMS). The symptoms, along with a decline in functioning, must have been present in the past year. Group 3: Brief Limited Intermittent Psychosis Syndrome (BLIPS) Group Those who have experienced episodes of frank psychotic symptoms within the past year that have not lasted longer than a week and have spontaneously remitted (ie. without treatment). NB: It is possible for the same person to meet criteria for more than one group. Key terms Prodrome: The period directly before the onset of full-threshold or frank psychosis where noticeable changes occur (e.g. attenuated psychotic symptoms, decline in functioning). Most psychotic episodes will be preceded by a prodromal period, however the nature and length may vary for each individual and episode. A prodromal period can only be identifi ed retrospectively once the onset of psychosis has occurred. Transition: The point at which an individual is considered to have 'transitioned' or 'converted' to full-threshold psychosis from a prodromal state. Also termed 'conversion'. Ultra-High Risk (UHR): A term used in reference to those meeting the criteria to identify individuals considered to be at 'ultra- high risk' of developing psychosis. While the majority of people who meet the UHR criteria will not go on to develop a psychotic disorder (see 'transition rates' below), their risk is considerably higher than that of the general population. At-risk mental state (ARMS): A term describing the clinical features/symptoms (beyond genetics and symptoms alone) associated with a possible psychotic prodrome, indicating that they are at an increased chance of developing a psychotic disorder. This term describes an increased risk while acknowledging that the person may or may not transition to psychosis. The Comprehensive Assessment of At Risk Mental States (CAARMS, described below) is the dominant method of assessing ARMS. Basic symptoms approach: This approach focuses on anomalies of subjective experience as markers of psychosis risk (1). These 'basic symptoms' refer to subjective experiences of abnormalities in cognition, attention, perception, and movement and can be assessed with the Schizophrenia Proneness Instrument, Adult Version (SPIA) or the Bonn Scale for the Assessment of Basic Symptoms (BSABS).

Evidence Summary: Identifi cation of young people at risk of developing psychosis The Comprehensive Assessment of At-Risk Mental States (CAARMS) The CAARMS is the most commonly used instrument to assess the UHR criteria locally. The full version of the CAARMS includes seven domains with corresponding subscales: 1: Positive symptoms Unusual thought content; Non-bizarre ideas; Perceptual abnormalities; Disorganised speech 2: Cognitive change (attention/concentration) Subjective experience; Observed cognitive change 3: Emotional disturbance Subjective emotional disturbance; Observed blunted affect; Observed inappropriate affect 4: Negative symptoms Alogia; Avolition/apathy; Anhedonia 5: Behavioural change Social isolation; Impaired role functioning; Disorganising/odd/ stigmatising behaviour; Aggression/ dangerous behaviour 6: Motor/physical changes Subjective complaints of impaired motor functioning; Informant reported or observed changes in motor functioning; Subjective complaints of impaired bodily sensation; Subjective complaints of impaired autonomic functioning 7: General psychopathology Mania; Depression; Suicidality and self harm; Mood swings/ lability; Anxiety; Obsessive-compulsive disorder symptoms; Dissociative symptoms; Impaired tolerance to normal stress 3 Tips for assessment of psychosis risk • During the assessment, state the purpose of each section. For example, when asking questions about the client's mood, state I am going to ask some questions about your mood now or in assessing attenuated psychotic symptoms, Now I am going to ask you about some unusual thinking or strange experiences you may or may not have had . Indicate that it is part of a standard assessment to ask about experiences that may seem unusual. • Normalise and demystify psychotic-like symptoms. Clients may become concerned during the assessment that their experiences are abnormal, especially during the assessment of attenuated psychoti