Introduction: An effective diagnostic and prognostic assessment of individuals at risk of psychosis is currently possible. The first rate-limiting step to successfully translate prevention of psychosis in clinical practice is to establish specialised Clinical High Risk for Psychosis services (CHR-P). This study systematises the knowledge regarding CHR-P services and provide guidelines for translational implementation. Methods: PRISMA/MOOSE-compliant (PROSPERO CRD42020163640) systematic review of Web of Science to identify studies until 4/05/2020 reporting on CHR-P service configuration, outreach strategy and referrals, service user characteristics, interventions, and outcomes. Psychosis risk in these services was meta-analysed. Results: 56 studies (1998-2020) were included, encompassing 51 distinct CHR-P services across 15 countries and a catchment area of 17,252,666 people. Most services (80.4%) consisted of integrated multidisciplinary teams taking care of both CHR-P and other patients. Outreach encompassed active (up to 97.6%) or passive (up to 63.4%) approaches: referrals came mostly (90%) from healthcare agencies. CHR-P individuals were more frequently males (57.2%). Most (70.6%) services accepted individuals aged 12-35 years, typically assessed with the CAARMS/SIPS (83.7%). Baseline comorbid mental conditions were reported in two-third (69.5%) of cases, past history of suicide attempts in one in ten (10.5%) and unemployment in one third (36.6%). Most services (87.1%) provided 2-years clinical monitoring (100%), psychoeducation (81.1%), psychosocial support (73%), family interventions (73%), individual (67.6%) and group psychotherapy (18.9%), physical health interventions (37.8%), antipsychotics (87.1%), antidepressants (74.2%), anxiolytics (51.6%) and mood stabilisers (38.7%). Outcomes were more frequently ascertained clinically (93.0%) and included: persistence of symptoms/comorbidities (67.4%), transition to psychosis (53.5%) and functional status (48.8%). A total of 22 independent services reported risk of psychosis onset at follow-up. 79.9% of the CHR-P individuals fulfilled Attenuated Psychosis Symptoms criteria, 10.6% fulfilled Brief Limited Intermittent Psychotic Symptoms criteria and 12.4% fulfilled Genetic Risk Deterioration criteria. The meta-analytical psychosis risk was 13.5% 95% CI= 11.2-16.0% (k=9, n=1876) at 12 months, 17.3% 95% CI= 14.4-20.5% (k=9, n=1985) at 24 months and 21.9% 95% CI= 17.8-26.6% (k=6, n=1587) at ≥36 months. Conclusion: Health service knowledge summarised by the current study will facilitate translational efforts for the implementation of CHR-P services worldwide.
Introduzione: una efficace valutazione diagnostica e prognostica degli individui a rischio di psicosi è ad oggi possibile. Il primo passo da compiere per trasferire con successo la prevenzione delle psicosi nella pratica clinica è l'istituzione di servizi clinici specializzati per individui ad alto rischio di psicosi (CHR-P). Questo studio sistematizza le conoscenze relative ai servizi CHR-P e fornisce linee guida per la loro implementazione. Metodi: revisione sistematica del Web of Science, conforme a PRISMA/MOOSE (PROSPERO CRD42020163640), includendo gli studi fino al 4/05/2020 che descrivono la configurazione del servizio CHR-P, le strategie di outreach e i referral, le caratteristiche degli utenti del servizio, gli interventi e i risultati. Il rischio di psicosi in questi servizi è stato inoltre meta-analizzato. Risultati: Sono stati inclusi 56 studi (1998-2020), che comprendono 51 distinti servizi CHR-P in 15 paesi e un bacino di utenza di 17.252.666 persone. La maggior parte dei servizi (80,4%) consiste in team multidisciplinari integrati che si occupano sia di pazienti CHR-P che di altri pazienti. Le strategie di outreach prevedono approcci attivi (fino al 97,6%) o passivi (fino al 63,4%): i referral provengono per lo più (90%) da enti sanitari. Gli individui CHR-P sono più frequentemente di sesso maschile (57,2%). La maggior parte (70,6%) dei servizi accetta individui di età compresa tra i 12 e i 35 anni, tipicamente valutati con CAARMS/SIPS (83,7%). Disturbi psichiatrici in comorbidità al baseline sono stati segnalati in due terzi (69,5%) dei casi, tentativi di suicidio in un caso su dieci (10,5%) e la disoccupazione in un terzo (36,6%). La maggior parte dei servizi (87,1%) fornisce un monitoraggio clinico di 2 anni (100%), psicoeducazione (81,1%), supporto psicosociale (73%), interventi familiari (73%), psicoterapia individuale (67,6%) e di gruppo (18,9%), interventi sulla salute fisica (37,8%), antipsicotici (87,1%), antidepressivi (74,2%), ansiolitici (51,6%) e stabilizzatori dell'umore (38,7%). Gli outcome sono più frequentemente valutati clinicamente (93,0%) e comprendono: persistenza dei sintomi/comorbidità (67,4%), transizione a psicosi (53,5%) e stato funzionale (48,8%). Un totale di 22 servizi hanno riportato il rischio di insorgenza di psicosi al follow-up. Il 79,9% degli individui CHR-P ha soddisfatto i criteri per Attenuated Psychosis Symptoms, il 10,6% ha soddisfatto i criteri per Brief Limited Intermittent Psychotic Symptoms e il 12,4% ha soddisfatto i criteri per Genetic Risk Deterioration. Il rischio di psicosi dopo meta-analisi è del 13,5% 95% CI= 11,2-16,0% (k=9, n=1876) a 12 mesi, 17,3% 95% CI= 14,4-20,5% (k=9, n=1985) a 24 mesi e 21,9% 95% CI= 17,8-26,6% (k=6, n=1587) a ≥36 mesi. Conclusione: Le conoscenze dei servizi sanitari riassunte dallo studio attuale faciliteranno gli sforzi translazionali per l'implementazione dei servizi CHR-P in tutto il mondo.
Implementing Clinical Services to Prevent Psychosis: a Systematic Review for Clinical Practice
CUTRONI, MARCELLO
2019/2020
Abstract
Introduction: An effective diagnostic and prognostic assessment of individuals at risk of psychosis is currently possible. The first rate-limiting step to successfully translate prevention of psychosis in clinical practice is to establish specialised Clinical High Risk for Psychosis services (CHR-P). This study systematises the knowledge regarding CHR-P services and provide guidelines for translational implementation. Methods: PRISMA/MOOSE-compliant (PROSPERO CRD42020163640) systematic review of Web of Science to identify studies until 4/05/2020 reporting on CHR-P service configuration, outreach strategy and referrals, service user characteristics, interventions, and outcomes. Psychosis risk in these services was meta-analysed. Results: 56 studies (1998-2020) were included, encompassing 51 distinct CHR-P services across 15 countries and a catchment area of 17,252,666 people. Most services (80.4%) consisted of integrated multidisciplinary teams taking care of both CHR-P and other patients. Outreach encompassed active (up to 97.6%) or passive (up to 63.4%) approaches: referrals came mostly (90%) from healthcare agencies. CHR-P individuals were more frequently males (57.2%). Most (70.6%) services accepted individuals aged 12-35 years, typically assessed with the CAARMS/SIPS (83.7%). Baseline comorbid mental conditions were reported in two-third (69.5%) of cases, past history of suicide attempts in one in ten (10.5%) and unemployment in one third (36.6%). Most services (87.1%) provided 2-years clinical monitoring (100%), psychoeducation (81.1%), psychosocial support (73%), family interventions (73%), individual (67.6%) and group psychotherapy (18.9%), physical health interventions (37.8%), antipsychotics (87.1%), antidepressants (74.2%), anxiolytics (51.6%) and mood stabilisers (38.7%). Outcomes were more frequently ascertained clinically (93.0%) and included: persistence of symptoms/comorbidities (67.4%), transition to psychosis (53.5%) and functional status (48.8%). A total of 22 independent services reported risk of psychosis onset at follow-up. 79.9% of the CHR-P individuals fulfilled Attenuated Psychosis Symptoms criteria, 10.6% fulfilled Brief Limited Intermittent Psychotic Symptoms criteria and 12.4% fulfilled Genetic Risk Deterioration criteria. The meta-analytical psychosis risk was 13.5% 95% CI= 11.2-16.0% (k=9, n=1876) at 12 months, 17.3% 95% CI= 14.4-20.5% (k=9, n=1985) at 24 months and 21.9% 95% CI= 17.8-26.6% (k=6, n=1587) at ≥36 months. Conclusion: Health service knowledge summarised by the current study will facilitate translational efforts for the implementation of CHR-P services worldwide.È consentito all'utente scaricare e condividere i documenti disponibili a testo pieno in UNITESI UNIPV nel rispetto della licenza Creative Commons del tipo CC BY NC ND.
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https://hdl.handle.net/20.500.14239/11885