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IMPROVING DETECTION OF YOUNG PEOPLE AT RISK OF PSYCHOSES

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    Improving the detection of young people at risk for psychoses is the first and perhaps most important step in trying to prevent psychotic episodes. This topic was discussed during the ‘Prevention of Mental Disorders in Europe: Where are we?’ symposium held online as part of the 33rd European College of Neuropsychopharmacology (ECNP) Congress.

    Paolo Fusar-Poli of the Institute of Psychiatry, Psychology and Neuroscience at King’s College London, UK, and an Associate Professor of Psychiatry within the Brain and Behavioural Sciences Department at the University of Pavia in Italy, discussed some of the initiatives that are helping in improve the detection of ‘at risk’ youths.

    Improving the detection of young people at risk for psychoses is important for prevention.

    Preventing psychoses in ‘at-risk’ youth

    The prevention of psychosis is essentially based on three key components: detection of individuals at risk for psychosis, prognosis of their clinical outcomes, and then implementation of preventive treatments.

    With regards to detection, Prof. Fusar-Poli discussed the Outreach and Support In South-London (OASIS) service that he has been involved with for nearly 10 years. OASIS, was set up in 2001 and is one of the oldest Clinical High Risk for Psychosis (CHR-P) services in the UK.1,2
    The aim of the service is to identify young people with subtle but distressing symptoms who have health-seeking behaviour and provide them with non-stigmatising, non-judgemental advice.

    Outreach services are very important to detect young people who are at risk of psychotic episodes, Prof. Fusar-Poli noted. The OASIS team has recently launched the ‘Me and My Mind’ website to help young people access the serviced they need.

    Improving detection of ‘at risk’ youth needs a critical mass of cases in order to provide sufficient data for analyses. This is one of the reasons for the creation of the Pan-London Network for Psychosis Prevention (PNP).1
    This network joins up several health services with the UK’s capital city that serve more than 2.3 million Londoners and is able to recruit around 220 individuals at high risk for psychosis a year.

    Determining outcome of psychotic episodes

    Once detected, determining the likely outcome of at-risk individual is more challenging, Prof. Fusar-Poli said. This can currently only be done at a group level and say that someone is or is not at risk, he observed. There is, however, lot of work going on to try to improve prognostication at an individual level.

    One of the initiatives Prof. Fusar-Poli is involved in is the EU-funded PSYSCAN project. This is a consortium of experts from academia, clinical practice and industry who are aiming to develop a decision-making tool to help clinicians resolve key issues in the management of patients with psychotic disorders.

    Different measures are being acquired, such as clinical, neurobiological and electrophysiological predictors which will be analysed with advanced statistical methods including machine learning. The hope is to develop a tool that can be used on a smart device, such as an iPad, and will help predict, stratify and monitor individual patients.

    For example it is hoped the tool will be able to distinguish individual prognoses, such as if someone at risk is likely to experience a psychotic episode but recover or develop more full-blown psychotic disease and experience persistent disability and functional impairment. This will address an important limitation in current practice, Prof. Fusar-Poli observed, and is of strategic importance in guiding the personalisation of preventive treatments.

    There are similar projects ongoing elsewhere in Europe and North America. These include the Personalised Prognostic Tools for Early Psychosis Management (PRONIA) project, the North American Prodrome Longitudinal Study, and the Philadelphia Neurodevelopmental Cohort Study.

    Harmonising research efforts

    PSYSCAN, PRONIA, the North American and Philadelphia cohorts are also part of a wider consortium known as HARMONY – the Harmonization of At Risk Multisite Observational Networks for Youth. Their amalgamated findings should help to create a standardised global database of individual attributes for psychoses with information about clinical follow up. This will enable researchers to not only replicate, but also to validate clinical prediction tools, Prof. Fusar-Poli suggested. So far data on around 2,000 individuals at clinical high risk for psychoses has been collated and been analysed and the HARMONY consortium is in the process of testing cross-validated models across different databases. The results of these initiatives will be available over the coming few years.

    Another global initiative advancing the ability to predict outcomes in individuals and communities for psychosis is the ENIGMA Clinical High Risk for Psychosis Working Group. The ENIGMA Working Group has obtained brain magnetic resonance imaging scans of around 1,000 at-risk individuals and 600 controls and is looking to find biomarkers that might help predict individual clinical outcomes.

    ECNP Prevention of Mental Disorders and Mental Health Promotion network

    Ending his presentation, Prof. Fusar-Poli discussed the ECNP-funded network on the Prevention of Mental Disorders and Mental Health Promotion (ECNP PMD-MHP).3 This network includes centres of excellence in eight European countries and is backed by a grant from the European Brain Research Area (EBRA) project.

    The ECNP PMD-MHP network’s goals are fourfold:

    facilitate multidisciplinary collaboration;

    standardise core assessment, outcome measures and interventional research;

    promote clinical research partnerships;

    apply for European grant funding and in particular to advance experimental therapeutics

    Prof. Fusar-Poli noted that the latter goal in particular was an area that needed to be improved. There are currently no licenced pharmacological treatments to prevent psychosis, but several ongoing trials are about to be completed. The large-scale projects that are ongoing to improve the detection and prognostication of patients will also hopefully provide the statistical power to detect the potential effects of preventive treatments through their harmonised databases.

    References

    1. Fusar-Poli P, Estrade A, Spencer TJ, et al. Pan-London Network for Psychosis-Prevention (PNP). Front Psychiatry. 2019; 10: 707.
    2. Fusar-Poli P, Byrne M, Badger S, et al. Outreach and support in south London (OASIS), 2001-2011: ten years of early diagnosis and treatment for young individuals at high clinical risk for psychosis. Eur Psychiatry. 2013; 28 (5): 315–26.
    3. Fusar-Poli P, Bauer M, Borgwardt S, et al. European college of neuropsychopharmacology network on the prevention of mental disorders and mental health promotion (ECNP PMD-MHP). Eur Neuropsychopharmacol. 2019; 12 (29): 1301–11.

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