Youth Mental Health Team, Brain and Mind Centre, University of Sydney, New South Wales, Australia.
The University of Notre Dame, St Vincent's and Mater Clinical School, Sydney, New South Wales, Australia.
JAMA Psychiatry. 2019 Nov 1;76(11):1167-1175. doi: 10.1001/jamapsychiatry.2019.2360.
The large contribution of psychiatric disorders to premature death and persistent disability among young people means that earlier identification and enhanced long-term care for those who are most at risk of developing life-threatening or chronic disorders is critical. Clinical staging as an adjunct to diagnosis to address emerging psychiatric disorders has been proposed for young people presenting for care; however, the longer-term utility of this system has not been established.
To determine the rates of transition from earlier to later stages of anxiety, mood, psychotic, or comorbid disorders and to identify the demographic and clinical characteristics that are associated with the time course of these transitions.
DESIGN, SETTING, AND PARTICIPANTS: A longitudinal, observational study of 2254 persons aged 12 to 25 years who obtained mental health care at 2 early intervention mental health services in Sydney, Australia, and were recruited to a research register between June 18, 2008, and July 24, 2018 (the Brain and Mind Centre Optymise Cohort).
The primary outcome of this study was transition from earlier to later clinical stages. A multistate Markov model was used to examine demographic (ie, age, sex, engagement in education, employment, or both) and clinical (ie, social and occupational function, clinical presentation, personal history of mental illness, physical health comorbidities, treatment use, self-harm, suicidal thoughts and behaviors) factors associated with these transitions.
Of the 2254 individuals included in the study, mean (SD) age at baseline was 18.18 (3.33) years and 1330 (59.0%) were female. Data on race/ethnicity were not available. Median (interquartile range) follow-up was 14 (5-33) months. Of 685 participants at stage 1a (nonspecific symptoms), 253 (36.9%) transitioned to stage 1b (attenuated syndromes). Transition was associated with lower social functioning (hazard ratio [HR], 0.77; 95% CI, 0.66-0.90), engagement with education, employment, or both (HR, 0.47; 95% CI, 0.25-0.91), manic-like experiences (HR, 2.12; 95% CI, 1.19-3.78), psychotic-like experiences (HR, 2.13; 95% CI, 1.38-3.28), self-harm (HR, 1.42; 95% CI, 1.01-1.99), and older age (HR, 1.27; 95% CI, 1.11-1.45). Of 1370 stage 1b participants, 176 (12.8%) transitioned to stage 2 (full-threshold) disorders. Transition was associated with psychotic-like experiences (HR, 2.31; 95% CI, 1.65-3.23), circadian disturbance (HR, 1.66; 95% CI, 1.17-2.35), psychiatric medication (HR, 1.43; 95% CI, 1.03-1.99), childhood psychiatric disorder (HR, 1.62; 95% CI, 1.03-2.54), and older age (HR, 1.24; 95% CI, 1.05-1.45).
Differential rates of progression from earlier to later stages of anxiety, mood, psychotic, or comorbid disorders were observed in young persons who presented for care at various stages. Understanding the rate and factors associated with transition assists planning of stage-specific clinical interventions and secondary prevention trials.
精神障碍对年轻人过早死亡和持续残疾的巨大贡献意味着，对于那些最有可能发展为危及生命或慢性疾病的人，早期识别和加强长期护理至关重要。临床分期作为一种辅助诊断方法，已被提议用于出现精神障碍的年轻人，但该系统的长期应用尚未确定。
确定从焦虑、情绪、精神病或共病障碍的早期阶段向晚期阶段过渡的比率，并确定与这些过渡时间相关的人口统计学和临床特征。
设计、地点和参与者：一项对 2254 名年龄在 12 至 25 岁之间的人的纵向、观察性研究，他们在澳大利亚悉尼的 2 个早期干预心理健康服务机构获得心理健康护理，并于 2008 年 6 月 18 日至 2018 年 7 月 24 日（大脑和思维中心 Optymise 队列）被招募到一个研究登记处。
本研究的主要结果是从早期临床阶段向晚期临床阶段的转变。使用多状态马尔可夫模型来检查与这些转变相关的人口统计学（即年龄、性别、参与教育、就业或两者兼而有之）和临床（即社会和职业功能、临床表现、个人精神病史、身体健康共病、治疗使用、自残、自杀想法和行为）因素。
在纳入研究的 2254 人中，基线时的平均（SD）年龄为 18.18（3.33）岁，1330 人（59.0%）为女性。种族/民族的数据不可用。中位数（四分位距）随访时间为 14（5-33）个月。在 685 名处于 1a 期（非特异性症状）的参与者中，253 名（36.9%）进展到 1b 期（衰减综合征）。过渡与较低的社会功能（风险比[HR]，0.77；95%置信区间，0.66-0.90）、参与教育、就业或两者兼而有之（HR，0.47；95%置信区间，0.25-0.91）、躁狂样体验（HR，2.12；95%置信区间，1.19-3.78）、精神病样体验（HR，2.13；95%置信区间，1.38-3.28）、自残（HR，1.42；95%置信区间，1.01-1.99）和年龄较大（HR，1.27；95%置信区间，1.11-1.45）相关。在 1370 名 1b 期参与者中，176 名（12.8%）进展到 2 期（全阈值）障碍。过渡与精神病样体验（HR，2.31；95%置信区间，1.65-3.23）、昼夜节律紊乱（HR，1.66；95%置信区间，1.17-2.35）、精神科药物（HR，1.43；95%置信区间，1.03-1.99）、儿童期精神障碍（HR，1.62；95%置信区间，1.03-2.54）和年龄较大（HR，1.24；95%置信区间，1.05-1.45）相关。
在不同阶段接受护理的年轻人中，从焦虑、情绪、精神病或共病障碍的早期阶段向晚期阶段进展的差异率有所观察。了解过渡的速度和相关因素有助于规划特定阶段的临床干预和二级预防试验。
