Fusar-Poli Paolo, De Micheli Andrea, Signorini Lorenzo, Baldwin Helen, Salazar de Pablo Gonzalo, McGuire Philip
Early Psychosis: Interventions and Clinical-detection (EPIC) Lab, Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, 5th Floor, PO63, 16 De Crespigny Park, SE5 8AF London, UK.
OASIS service, South London and Maudsley NHS Foundation Trust, London, UK.
EClinicalMedicine. 2020 Oct 7;28:100578. doi: 10.1016/j.eclinm.2020.100578. eCollection 2020 Nov.
Most services for individuals at Clinical High Risk for Psychosis (CHR-P) provide short-term clinical care. This study determines the real-world and long-term clinical outcomes beyond transition to psychosis in a large cohort of CHR-P individuals.
Retrospective RECORD-compliant real-world Electronic Health Records (EHR) cohort study in secondary mental health care (the South London and the Maudsley -SLaM- NHS Foundation Trust). All CHR-P patients accessing the CHR-P service at SLaM in the period 2001-2018 were included. Main outcomes were long-term cumulative risk of first: (i) developing an ICD-10 psychotic disorder (primary outcome), receiving a treatment with (iia) antipsychotic medication, (iib) benzodiazepines, (iic) other psychotropic medications, (iid) psychotherapy, receiving an (iiia) informal or (iiib) compulsory admission into a mental health hospital, and the time to these events; (iiic) number of days spent in hospital and (iv) cumulative risk of death for any reason and age/gender Standardised Mortality Ratio (SMR). Data were extracted from the EHR and analysed with Kaplan Meier failure functions, Cox and zero-inflated negative binomial regressions.
600 CHR-P patients (80.43% Attenuated Psychotic Symptoms, APS; 18.06%, Brief and Limited Intermittent Psychotic Symptoms, BLIPS, 1.51% Genetic Risk and Deterioration Syndrome) were included (mean age 22.63 years, range 13-36; 55.33% males; 46.44% white, mean duration of untreated attenuated psychotic symptoms 676.32 days, 1105.40 SD). The cumulative risk to first psychosis was 0.365 (95%CI 0.302-0.437) at 11 years; first antipsychotic 0.777 (95%CI 0.702-0.844) at 9 years; first benzodiazepine 0.259 (95%CI 0.183-0.359) at 12 years; first other types of medications 0.630 (95%CI 0.538-0.772) at 9 years; first psychotherapy 0.814 (95%CI 0.764-0.859) at 9 years; first informal admission 0.378 (95%CI 0.249-0.546) at 12 years; first compulsory admission 0.251 (95%CI 0.175-0.352) at 12 years; those admitted spent on average 94.84 (SD=169.94) days in hospital; the cumulative risk of death for any reason was 0.036 (95%CI 0.012-0.103) at 9 years, with an SMR of 3.9 (95%CI 1.20-6.6). Compared to APS, BLIPS had a higher risk of developing psychosis, being admitted compulsorily into hospital, receiving antipsychotics and benzodiazepines and lower probability of receiving psychotherapy. Other prognostic factors of long-term outcomes included age, symptoms severity, duration of untreated attenuated psychotic symptoms, ethnicity and employment status.
Duration of care provided by CHR-P services should be expanded to address long-term real-world outcomes.
This study was supported by the King's College London Confidence in Concept award from the Medical Research Council (MRC) (MC_PC_16048) to PF-P. GSP is supported by the Alicia Koplowitz Foundation. HB is supported by a National Institute for Health Research Maudsley Biomedical Research Centre studentship.
大多数针对临床高危精神病个体（CHR-P）的服务提供短期临床护理。本研究确定了一大群CHR-P个体在转变为精神病之后的现实世界和长期临床结局。
在二级精神卫生保健机构（南伦敦和莫兹利国民保健服务基金会信托基金 - SLaM）进行的一项符合回顾性记录要求的现实世界电子健康记录（EHR）队列研究。纳入了2001年至2018年期间在SLaM接受CHR-P服务的所有CHR-P患者。主要结局为首次出现以下情况的长期累积风险：（i）发展为国际疾病分类第10版（ICD-10）精神病性障碍（主要结局），接受（iia）抗精神病药物治疗、（iib）苯二氮䓬类药物治疗、（iic）其他精神药物治疗、（iid）心理治疗，接受（iiia）非自愿或（iiib）强制住院治疗，以及这些事件发生的时间；（iiic）住院天数和（iv）任何原因导致的死亡累积风险以及年龄/性别标准化死亡率（SMR）。数据从电子健康记录中提取，并使用Kaplan Meier失败函数、Cox回归和零膨胀负二项回归进行分析。
纳入了600例CHR-P患者（80.43%为精神病性症状衰减型，APS；18.06%为短暂有限间歇性精神病性症状，BLIPS；1.51%为遗传风险和恶化综合征）（平均年龄22.63岁，范围13 - 36岁；55.33%为男性；46.44%为白人，未治疗的精神病性症状衰减的平均持续时间为676.32天，标准差1105.40）。11年时首次发生精神病的累积风险为0.365（95%置信区间0.302 - 0.437）；9年时首次使用抗精神病药物的累积风险为0.777（95%置信区间0.702 - 0.844）；12年时首次使用苯二氮䓬类药物的累积风险为0.259（95%置信区间0.183 - 0.359）；9年时首次使用其他类型药物的累积风险为0.630（95%置信区间0.538 - 0.772）；9年时首次接受心理治疗的累积风险为0.814（95%置信区间0.764 - 0.859）；12年时首次非自愿住院的累积风险为0.378（95%置信区间0.249 - 0.546）；12年时首次强制住院的累积风险为0.251（95%置信区间0.175 - 0.352）；住院患者平均住院94.84天（标准差 = 169.94）；9年时任何原因导致的死亡累积风险为0.036（95%置信区间0.012 - 0.103），标准化死亡率为3.9（95%置信区间1.20 - 6.6）。与APS相比，BLIPS发展为精神病、被强制住院、接受抗精神病药物和苯二氮䓬类药物治疗的风险更高，接受心理治疗的可能性更低。长期结局的其他预后因素包括年龄、症状严重程度、未治疗的精神病性症状衰减的持续时间、种族和就业状况。
CHR-P服务提供的护理时长应延长，以应对长期的现实世界结局。
本研究由伦敦国王学院获得医学研究理事会（MRC）的概念验证奖（MC_PC_16048）资助给PF-P。GSP由阿莉西亚·科普洛维茨基金会资助。HB由英国国家卫生研究院莫兹利生物医学研究中心奖学金资助。
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