Early Psychosis: Interventions and Clinical-detection (EPIC) Lab, Institute of Psychiatry, Psychology & Neuroscience, Department of Psychosis Studies, King's College London, London, United Kingdom.
OASIS Service, South London and Maudsley National Health Service (NHS) Foundation Trust, London, United Kingdom.
JAMA Psychiatry. 2020 Jul 1;77(7):755-765. doi: 10.1001/jamapsychiatry.2019.4779.
Detection, prognosis, and indicated interventions in individuals at clinical high risk for psychosis (CHR-P) are key components of preventive psychiatry.
To provide a comprehensive, evidence-based systematic appraisal of the advancements and limitations of detection, prognosis, and interventions for CHR-P individuals and to formulate updated recommendations.
Web of Science, Cochrane Central Register of Reviews, and Ovid/PsychINFO were searched for articles published from January 1, 2013, to June 30, 2019, to identify meta-analyses conducted in CHR-P individuals. MEDLINE was used to search the reference lists of retrieved articles. Data obtained from each article included first author, year of publication, topic investigated, type of publication, study design and number, sample size of CHR-P population and comparison group, type of comparison group, age and sex of CHR-P individuals, type of prognostic assessment, interventions, quality assessment (using AMSTAR [Assessing the Methodological Quality of Systematic Reviews]), and key findings with their effect sizes.
In total, 42 meta-analyses published in the past 6 years and encompassing 81 outcomes were included. For the detection component, CHR-P individuals were young (mean [SD] age, 20.6 [3.2] years), were more frequently male (58%), and predominantly presented with attenuated psychotic symptoms lasting for more than 1 year before their presentation at specialized services. CHR-P individuals accumulated several sociodemographic risk factors compared with control participants. Substance use (33% tobacco use and 27% cannabis use), comorbid mental disorders (41% with depressive disorders and 15% with anxiety disorders), suicidal ideation (66%), and self-harm (49%) were also frequently seen in CHR-P individuals. CHR-P individuals showed impairments in work (Cohen d = 0.57) or educational functioning (Cohen d = 0.21), social functioning (Cohen d = 1.25), and quality of life (Cohen d = 1.75). Several neurobiological and neurocognitive alterations were confirmed in this study. For the prognosis component, the prognostic accuracy of CHR-P instruments was good, provided they were used in clinical samples. Overall, risk of psychosis was 22% at 3 years, and the risk was the highest in the brief and limited intermittent psychotic symptoms subgroup (38%). Baseline severity of attenuated psychotic (Cohen d = 0.35) and negative symptoms (Cohen d = 0.39) as well as low functioning (Cohen d = 0.29) were associated with an increased risk of psychosis. Controlling risk enrichment and implementing sequential risk assessments can optimize prognostic accuracy. For the intervention component, no robust evidence yet exists to favor any indicated intervention over another (including needs-based interventions and control conditions) for preventing psychosis or ameliorating any other outcome in CHR-P individuals. However, because the uncertainty of this evidence is high, needs-based and psychological interventions should still be offered.
This review confirmed recent substantial advancements in the detection and prognosis of CHR-P individuals while suggesting that effective indicated interventions need to be identified. This evidence suggests a need for specialized services to detect CHR-P individuals in primary and secondary care settings, to formulate a prognosis with validated psychometric instruments, and to offer needs-based and psychological interventions.
在有临床高风险精神病（CHR-P）的个体中进行检测、预后和干预是预防精神病学的关键组成部分。
提供对 CHR-P 个体的检测、预后和干预的进展和局限性的全面、基于证据的系统评估，并制定更新的建议。
从 2013 年 1 月 1 日至 2019 年 6 月 30 日，通过 Web of Science、Cochrane 中央评论数据库和 Ovid/PsychINFO 搜索了发表的元分析，以确定在 CHR-P 个体中进行的元分析。使用 MEDLINE 搜索检索文章的参考文献列表。从每篇文章中获得的数据包括第一作者、出版年份、研究主题、出版物类型、研究设计和数量、CHR-P 人群和对照组的样本大小、对照组类型、CHR-P 个体的年龄和性别、预后评估类型、干预措施、质量评估（使用 AMSTAR [评估系统评价的方法学质量]）以及关键发现及其效应大小。
在过去的 6 年中，共纳入了 42 项发表的元分析，涵盖了 81 项结果。在检测部分，CHR-P 个体较年轻（平均[标准差]年龄为 20.6[3.2]岁），更多为男性（58%），并且主要表现为持续 1 年以上的轻度精神病症状，然后才在专科服务机构就诊。与对照组参与者相比，CHR-P 个体积累了多种社会人口学危险因素。药物使用（33%的人吸烟和 27%的人使用大麻）、共病精神障碍（41%有抑郁障碍，15%有焦虑障碍）、自杀意念（66%）和自残（49%）在 CHR-P 个体中也很常见。CHR-P 个体在工作（Cohen d=0.57）或教育功能（Cohen d=0.21）、社会功能（Cohen d=1.25）和生活质量（Cohen d=1.75）方面均存在障碍。在这项研究中还证实了几项神经生物学和神经认知改变。在预后部分，CHR-P 工具的预后准确性良好，前提是它们在临床样本中使用。总体而言，3 年内精神病的风险为 22%，在短暂和有限的间歇性精神病症状亚组中风险最高（38%）。轻度精神病（Cohen d=0.35）和阴性症状（Cohen d=0.39）以及功能低下（Cohen d=0.29）的基线严重程度与精神病风险增加相关。控制风险富集并实施连续风险评估可以优化预后准确性。在干预部分，目前尚无确凿证据表明任何干预措施优于其他干预措施（包括基于需求的干预措施和对照组），以预防精神病或改善 CHR-P 个体的任何其他结局。然而，由于该证据的不确定性很高，仍应提供基于需求的和心理干预措施。
这篇综述证实了最近在 CHR-P 个体的检测和预后方面取得了重大进展，同时表明需要确定有效的针对性干预措施。这一证据表明，需要专门的服务机构在初级和二级保健环境中检测 CHR-P 个体，使用经过验证的心理计量学工具制定预后，并提供基于需求的和心理干预措施。
