Prison and Community Populations at Ultra-High Risk of Psychosis: Differences and Challenges for Service Provision.

OBJECTIVE: The aim of the study was to explore the feasibility of expanding a community service for early detection of psychosis into a local London prison for men in the United Kingdom. METHODS: All new receptions to a local prison for men in South London were approached for routine screening. Those who met criteria for being at ultra-high-risk of psychosis were compared with a help-seeking sample from the community who met the same criteria. Clinical and sociodemographic characteristics were compared to determine whether the prison and community populations had similar profiles and mental health needs. RESULTS: Of 891 prisoners screened, 44 (5%) met criteria for being at ultra-high risk of psychosis. The community sample consisted of 42 participants. Compared with the community group, prison participants had lower scores on almost all symptom measures, were less likely to have remained in school and completed exams, and were more likely to be in short-term accommodations and to be of black race-ethnicity. Lifetime use of illicit drugs was similar between the groups, but recent use was much higher in the prison group. CONCLUSIONS: Expanding community services into custodial settings should take into account the different environment and needs of the prisoner population. Specifically, early detection and intervention services should target a broad range of mental health problems rather than psychosis alone.

Duration of untreated psychosis and need for admission in patients who engage with mental health services in the prodromal phase.

BACKGROUND: It is unknown whether prodromal services improve outcomes in those who go on to develop psychosis, and whether these patients are demographically different from the overall first-episode population. AIMS: To compare sociodemographic features, duration of untreated psychosis, hospital admission and frequency of compulsory treatment in the first year after the onset of psychosis in patients who present to prodromal services with patients who did not present to services until the first episode of psychosis. METHOD: We compared two groups of patients with first-episode psychosis: one who made transition after presenting in the prodromal phase and the other who had presented with a first episode. RESULTS: The patients who had presented before the first episode were more likely to be employed and less likely to belong to an ethnic minority group. They had a shorter duration of untreated psychosis, and were less likely to have been admitted to hospital and to have required compulsory treatment. CONCLUSIONS: Patients who develop psychosis after being engaged in the prodromal phase have a better short-term clinical outcome than patients who do not present until the first episode. Patients who present during first episodes may be more likely to have sociodemographic features associated with relatively poor outcomes.

Why are help-seeking subjects at ultra-high risk for psychosis help-seeking?

In addition to attenuated psychotic symptoms, individuals at high clinical risk of developing psychosis display a wide range of psychopathological features. Some of these may be subjectively perceived as more troubling than others and may therefore be more likely to trigger help-seeking behavior. We aimed at investigating the nature and prevalence of symptoms subjectively considered most distressing by high-risk individuals at the time of their presentation to early recognition services and to determine their impact on baseline and longitudinal functional and clinical outcomes. The clinical records of 221 clients meeting ultra-high risk (UHR) criteria and receiving care at a specialized early intervention service ("Outreach and Support in South London") between 2001 and 2011 were reviewed. Main outcome measures were reason to seek help as subjectively reported by the clients, comorbid DSM-IV SCID diagnoses, transition to psychosis, psychosocial functioning at baseline and after a median follow-up period of 4.5 years. Affective symptoms, i.e., depression and/or anxiety, were the most commonly reported subjective reasons to seek help (47.1%). Sub-threshold psychotic symptoms were reported by 39.8%. There was no significant association between subjective complaints at presentation and transition to psychosis. However, the group reporting affective symptoms as their main subjective reason to seek help at baseline had a significantly poorer longitudinal outcome in psychosocial functioning relative to the group reporting sub-threshold psychotic symptoms. Assessment of subjective complaints in UHR individuals at initial presentation may help to identify predictors of future functional outcome and tailor treatments accordingly.

The impact of delivering GP training on the clinical high risk and first-episode psychosis on referrals and pathways to care.

AIM: This project explored the impact of a general practitioner (GP) training programme on referrals and pathways to care for people at high clinical risk of psychosis or with a first-episode psychosis. The resources needed to deliver the training were measured to help inform other teams considering this approach. Satisfaction with the training was also explored. METHODS: All of the GP (48) practices in the London Borough of Southwark were approached. Presentations were given on the symptoms of a clinical high-risk state and the first signs of psychosis alongside information on how to access the teams. Referrals to the prodromal and first-episode teams 6 months before and after the training were recorded. Resources needed to deliver the training in terms of staff time were recorded. A questionnaire on attendees' satisfaction with the training was given. RESULTS: Sixty percent of eligible practices received education. On average, it took 2 h for every two staff members each to deliver the training. Over the 12-month period, the teams received 148 referrals. The training led to a significant increase in referrals to the two specialized teams and a significant increase in direct referrals to the teams from GPs. Attendees were satisfied with the training. CONCLUSIONS: This study indicates that GP education programmes are a viable and acceptable way of increasing the identification of young people at high clinical risk for psychosis or with a first-episode psychosis and increasing direct referrals to specialist teams.