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Invited Commentary
November 30, 2018

Identifying Risk of Psychosis in a Primary Care Setting

Author Affiliations
  • 1Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
JAMA Netw Open. 2018;1(7):e185165. doi:10.1001/jamanetworkopen.2018.5165

Intervening early in the course of schizophrenia and minimizing the duration of untreated psychosis affords better symptomatic and functional outcomes.1,2 Thus, identifying individuals who are in a state of clinical high risk (CHR) for psychosis is key for delaying transition to psychosis and optimizing the longitudinal course of the disease. The CHR state consists of variable subgroups of symptoms, including broad and nonspecific symptoms (unspecified prodromal symptoms) that are often not recognized in a community setting.3 Furthermore, most individuals designated as CHR do not progress to psychosis.4 There remains a need to correctly identify individuals at high risk for psychosis and implement treatment early.

In the article “Association of Primary Care Consultation Patterns With Early Signs and Symptoms of Psychosis,”5 Sullivan and colleagues examined whether a predetermined set of CHR symptoms could identify patients who are eventually diagnosed with some type of psychotic illness. The authors used a nested case-control study design to examine data from the UK Clinical Practice Research Datalink. This collection is a repository for longitudinal patient data from general practitioner practices across the United Kingdom; it includes data from more than 35 million patients. The investigators examined a sample of 93 483 individuals over 9 years, 11 690 of whom had an incident diagnosis of psychosis. Both individuals with psychosis and the individually matched controls had been followed up for at least 5 years prior to the diagnosis of psychosis (referred to as the index date of diagnosis). Prespecified CHR symptoms were chosen based on existing literature, and included symptoms such as attention-deficit/hyperactivity disorder–like symptoms, social isolation, bizarre behavior, and blunted affect. Twelve of these 13 preselected symptoms were associated with an eventual diagnosis of psychosis, with the strongest association for young men with suicidal behavior. Importantly, those individuals who eventually developed psychosis increased their monthly number of primary care visits as they approached their date of diagnosis.

While the authors included all diagnoses potentially associated with psychosis, the results have important implications in the context of early intervention in schizophrenia. The authors accessed data from patients presenting in a primary care setting rather than a specialized mental health setting. As the authors note, most high-risk studies focus on the CHR state among treatment-seeking individuals in a psychiatric setting; only a few studies have examined the CHR state in a more general population. Primary care clinicians may be the initial and ongoing point of contact for individuals with a primary psychotic disorder. Ideally, primary care clinicians would recognize CHR symptoms and have direct means of referral to a specialized, early-intervention team; this path is both clinically effective and cost-effective.6 Thus, the primary care provider can play a crucial role in minimizing the duration of untreated psychosis.

This study’s main strengths include both the timely topic of early detection and intervention and the study design itself (nested case-control) within a large database. Important limitations include the lack of specificity of the symptoms the authors preselected and the lack of information regarding comorbid diagnoses. For instance, symptoms such as problems associated with cannabis, symptoms of mania, or depressive symptoms are not specific to psychotic illnesses and may in fact be part of emerging psychopathology for other psychiatric disorders. This lack of symptom specificity has clinical implications; discerning appropriate patients to refer to specialty early intervention becomes more difficult and imprecise, which may slow timely care. Another important limitation is the wide range of psychotic diagnoses included in this study (ie, not only primary psychotic illnesses). Incorporating these broad categories of psychosis (eg, organic psychosis and drug-induced psychosis) may impede referral to appropriate care, including early intervention teams. Future work may concentrate on validating these CHR symptoms and focusing on more limited diagnoses, such as primary psychotic illnesses like schizophrenia. Overall, this work by Sullivan and colleagues demonstrates the important role primary care clinicians must play in identifying individuals at high risk and opportunities for early intervention.

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Article Information

Published: November 30, 2018. doi:10.1001/jamanetworkopen.2018.5165

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2018 Brown HE. JAMA Network Open.

Corresponding Author: Hannah E. Brown, MD, Department of Psychiatry, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114 (hebrown@mgh.harvard.edu).

Conflict of Interest Disclosures: None reported.

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Kane  JM, Robinson  DG, Schooler  NR,  et al.  Comprehensive versus usual community care for first-episode psychosis: 2-year outcomes from the NIMH RAISE early treatment program.  Am J Psychiatry. 2016;173(4):362-372. doi:10.1176/appi.ajp.2015.15050632PubMedGoogle ScholarCrossref
Mills  JG, Fusar-Poli  P, Morgan  C, Azis  M, McGuire  P.  People meeting ultra high risk for psychosis criteria in the community.  World Psychiatry. 2017;16(3):322-323. doi:10.1002/wps.20463PubMedGoogle ScholarCrossref
Fusar-Poli  P, Bonoldi  I, Yung  AR,  et al.  Predicting psychosis: meta-analysis of transition outcomes in individuals at high clinical risk.  Arch Gen Psychiatry. 2012;69(3):220-229. doi:10.1001/archgenpsychiatry.2011.1472PubMedGoogle ScholarCrossref
Sullivan  SA, Hamilton  W, Tilling  K, Redaniel  T, Moran  P, Lewis  G.  Association of primary care consultation patterns with early signs and symptoms of psychosis.  JAMA Netw Open. 2018;1(7):e185174. doi:10.1001/jamanetworkopen.2018.5174Google ScholarCrossref
Perez  J, Jin  H, Russo  DA,  et al.  Clinical effectiveness and cost-effectiveness of tailored intensive liaison between primary and secondary care to identify individuals at risk of a first psychotic illness (the LEGs study): a cluster-randomised controlled trial.  Lancet Psychiatry. 2015;2(11):984-993. doi:10.1016/S2215-0366(15)00157-1PubMedGoogle ScholarCrossref
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