People meeting ultra high risk for psychosis criteria in the community
Authors: John G. Mills, Paolo Fusar‐Poli, Craig Morgan, Matilda Azis, Philip McGuire
Journal: World Psychiatry (2017)

The last two decades have seen an exponential growth in research on people at ultra high risk (UHR) for psychosis, generating valuable new information on the factors that contribute to the onset of the disorder1. However, most of these findings were obtained from individuals who presented to mental health services specialized for the UHR group. Because they have been selected through a clinical referral process, these subjects may differ from individuals who also meet UHR criteria but do not contact such services2. To date, research in this field has not included the latter group, which remains largely uncharacterized. We sought to address this issue by identifying young adults in the general population (aged 18-35 years) who met UHR criteria. We assessed their need for care and whether they had sought help, then compared their demographic and psychopathological features with those of UHR individuals who had presented to a clinical UHR service. Cross-sectional data from a general population sample (N=208) were collected via face-to-face clinical interviews between 2011 and 2013. Participants were recruited within the London boroughs of Southwark and Lambeth, using two sampling methods, which provided 100 and 108 individuals, respectively. One set of participants was enrolled from a random sample of local households identified using the Post Office's Small User Postal Address File3. The other set was contacted through local general practitioners, who sent out invitations to join the study. Inclusion required that individuals had never been diagnosed with a psychotic disorder or prescribed antipsychotic medication. Individuals from the community sample who met criteria for the UHR state were compared with UHR individuals (N=36) from the same geographical area who had presented to a clinical UHR service4 in the same time period. Psychopathology was assessed using the Comprehensive Assessment of At-Risk Mental States (CAARMS)5 and the Schizophrenia Proneness Instrument, Adult Version (SPI-A)6 by a researcher trained in their use. Participants were categorized as being in an UHR state if they met either the Personal Assessment and Crisis Evaluation (PACE)5 or the Cognitive Disturbances (COGDIS) criteria7. The level of functioning was assessed using the Social and Occupational Functioning Assessment Scale (SOFAS), while need for care was evaluated using the Camberwell Assessment of Need Short Appraisal Scale8. Information on help seeking was collected using questions from the US National Comorbidity Survey. Inverse sampling probability weights were calculated by comparing the age, gender and ethnicity of the study sample with census data (2011) for Southwark and Lambeth. Consequently, all percentages that follow are weighted. Binary logistic regression was used to quantify associations between age, gender, ethnicity, migrant status, childhood trauma, regular cannabis use and UHR status. Multinomial logistic regression was used to assess relationships with need for care and patterns of help seeking. Comparisons between clinical and community groups were made using χ2 and t tests. Analyses were adjusted for age, gender and ethnicity where appropriate. Finally, p values were adjusted for multiple testing using Hochberg's step-up procedure. Of the 208 participants, 100 were male. Mean age was 27.0 ± 4.9 years. Eighteen participants (8.7%) met the PACE criteria for the UHR state5, 16 (7.7%) met the basic symptom criteria7, and four met both, yielding a total of 30 (14.4%; estimated weighted prevalence: 12.6%, 95% CI: 8.8-17.7) who met criteria for the UHR state. Those who met UHR criteria were much more likely to have reported an unmet need for care than those who did not (OR=12.85, 95% CI: 3.94-41.96). They were also more likely to have sought help from any (professional or non-professional) source (OR=5.28, 95% CI: 1.71-16.33) and from professional agencies specifically (OR=4.99, 95% CI: 1.39-17.87). Approximately half of those meeting UHR criteria had sought help for a psychological or an emotional problem in the preceding 12 months, usually from a health professional (general practitioner, counsellor or psychologist). Only 35% of those who met UHR criteria had not felt they needed professional help. The community UHR individuals were similar to UHR individuals who had presented to a UHR service in age, gender, ethnicity, employment status, years in education, history of childhood trauma, and current cannabis use, but were more likely to be first generation migrants (40% vs. 11%, χ2=7.44, p=0.036). They had less severe positive symptoms (z=−4.21, p<0.001, r=0.515), negative symptoms (z=−2.63, p=0.017, r=0.321) and general psychopathology (an index of depression/anxiety) (z=−2.74, p=0.019, r=0.334), and higher levels of social and occupational functioning (mean SOFAS score: 70.47 ± 12.39 vs. 60.9 ± 11.11; t=−3.34, p=0.001, r=0.212). However, they had poorer functioning than non-UHR subjects (mean SOFAS score: 80.79 ± 9.71; t=4.45, p<0.001, r=0.277). These findings suggest that there may be a substantial number of young adults in the general population who meet UHR criteria but are not seen by specialized early detection services, even when these are relatively well developed4. These individuals appear to have less severe symptoms and functional impairment than those presenting to clinical services, consistent with the notion that the risk of psychosis in UHR samples depends on how they were recruited9. Nevertheless, the community UHR individuals were not, as has sometimes been suggested, “non-help-seeking”; half of them had already sought help, albeit from other non-specialized agencies. Clinical early detection teams may need to further extend their services into the community so that these individuals have better access to specialized mental health care. This might also increase the representation of this subgroup in research studies of the UHR state. John G. Mills, Paolo Fusar-Poli, Craig Morgan, Matilda Azis, Philip McGuire Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK