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Why Are Help-Seeking Subjects at Ultra-High Risk For Psychosis Help-Seeking?
Why Are Help-Seeking Subjects at Ultra-High Risk For Psychosis Help-Seeking?
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Psychiatry Research ∎ (∎∎∎∎) ∎∎∎–∎∎∎
Psychiatry Research
journal homepage: www.elsevier.com/locate/psychres
art ic l e i nf o a b s t r a c t
Article history: In addition to attenuated psychotic symptoms, individuals at high clinical risk of developing psychosis
Received 15 October 2014 display a wide range of psychopathological features. Some of these may be subjectively perceived as
Received in revised form more troubling than others and may therefore be more likely to trigger help-seeking behavior. We aimed
11 May 2015
at investigating the nature and prevalence of symptoms subjectively considered most distressing by
Accepted 20 May 2015
high-risk individuals at the time of their presentation to early recognition services and to determine
their impact on baseline and longitudinal functional and clinical outcomes. The clinical records of 221
Keywords: clients meeting ultra-high risk (UHR) criteria and receiving care at a specialized early intervention
Ultra-high risk (UHR) service (“Outreach and Support in South London”) between 2001 and 2011 were reviewed. Main
Psychosis
outcome measures were reason to seek help as subjectively reported by the clients, comorbid DSM-IV
Help-seeking
SCID diagnoses, transition to psychosis, psychosocial functioning at baseline and after a median follow-
Psychosocial functioning
Transition up period of 4.5 years. Affective symptoms, i.e., depression and/or anxiety, were the most commonly
reported subjective reasons to seek help (47.1%). Sub-threshold psychotic symptoms were reported by
39.8%. There was no significant association between subjective complaints at presentation and transition
to psychosis. However, the group reporting affective symptoms as their main subjective reason to seek
help at baseline had a significantly poorer longitudinal outcome in psychosocial functioning relative to
the group reporting sub-threshold psychotic symptoms. Assessment of subjective complaints in UHR
individuals at initial presentation may help to identify predictors of future functional outcome and tailor
treatments accordingly.
& 2015 Published by Elsevier Ireland Ltd.
http://dx.doi.org/10.1016/j.psychres.2015.05.018
0165-1781/& 2015 Published by Elsevier Ireland Ltd.
Please cite this article as: Falkenberg, I., et al., Why are help-seeking subjects at ultra-high risk for psychosis help-seeking? Psychiatry
Research (2015), http://dx.doi.org/10.1016/j.psychres.2015.05.018i
2 I. Falkenberg et al. / Psychiatry Research ∎ (∎∎∎∎) ∎∎∎–∎∎∎
syndrome (Fusar-Poli et al., 2013a,2013b). “Help-seeking” is clini- report what these main problems were. The second study found
cally close to impairments in functioning, subjective wellbeing and that the main reasons for the first consultation were onset or
quality of life and is ethically required to allow preventative distinct increase of peculiarities in behaviour, appearance or
interventions in this group. We have recently addressed these speech (53.3% of all cases), followed by 50.0% of all cases, who
aspects at meta-analytical level in a companion publication by our sought help because of self-perceived changes in well-being
group (Fusar-Poli et al., in press). We clearly found that UHR (Fridgen et al., 2013).
subjects are functionally impaired as compared to matched con- To our best knowledge, there are no studies available directly
trols and that the magnitude of their impairments is comparable investigating the subjective reasons for seeking help among UHR
to that of other psychiatric disorders (Fusar-Poli et al., in press). samples. The first aim of the present study was to determine the
Surprisingly, there are only a few studies exploring the impact of main subjective complaints prompting help-seeking behaviour in
this implicit inclusion criterion on baseline and longitudinal out- UHR individuals. We then aimed at describing the impact of
comes (e.g. Fridgen et al., 2013; Rüsch et al., 2013; Von Reventlow subjective presenting complaint on symptoms presentation at
et al., 2013). There have, however, been attempts to characterize baseline, comorbid DSM-IV diagnoses (identified on the SCID),
pathways to (Schultze-Lutter et al., 2009; Shin et al., 2010; Cocchi therapeutic interventions offered as well as longitudinal clinical
et al., 2013; Stowkowy et al., 2013; Von Reventlow et al., 2013; and functional outcomes.
Wiltink et al., 2013) and engagement with services in those who
seek help (Green et al., 2011). However, only a minority of studies
with relatively small sample sizes assessed symptoms or beha- 2. Methods
viours that initiated the contact (Addington et al., 2002; Stowkowy
et al., 2013). In these, depression and anxiety were the most 2.1. Participants
Please cite this article as: Falkenberg, I., et al., Why are help-seeking subjects at ultra-high risk for psychosis help-seeking? Psychiatry
Research (2015), http://dx.doi.org/10.1016/j.psychres.2015.05.018i
I. Falkenberg et al. / Psychiatry Research ∎ (∎∎∎∎) ∎∎∎–∎∎∎ 3
All analyses were performed in IBM SPSS Statistics 21. 3.2.1. Main reasons to seek help as subjectively reported by the
clients
2.4.1. Variables Affective symptoms, i.e. depression and/or anxiety were the
The predictor variable was the subjective presenting complaint at initial most commonly reported reasons to seek help (N ¼104, 47.1%).
contact with the high risk service. This was clinically defined according to the
Sub-threshold psychotic symptoms were reported by 39.8%
following categories: (1) APS, (2) psychosocial dysfunction, (3) affective symptoms,
(4) other complaints and (5) a combination of APS and affective symptoms. (N ¼88) Percentages of the main subjective complaints as reported
Outcome variables included: sociodemographic and clinical characteristics, psy- by the clients at presentation are given in Table 1.
chopathology, DSM-IV diagnoses, treatment recommendations, transition to psy-
chosis, functional outcome. Moderator variables included: gender, CAARMS
avolition score. 3.2.2. Association between main complaints and baseline
demographic and clinical characteristics
There was a significant between group difference in gender at
2.4.2. Cross-sectional analysis
Cross-sectional data were analysed descriptively using mean and S.D. or baseline, with male clients most frequently reporting APS (47.9% of
median and interquartile range (if applicable) for continuous variable and absolute males) and females most frequently reporting affective symptoms
and relative frequencies for categorical variables. The association between reasons (57,7% of females; χ2 ¼12.83, p ¼0.012), but no significant group
for help-seeking and sociodemographic, clinical and functional characteristics at difference in UHR type (χ2 ¼14.733, p ¼0.065). There were no
baseline were assessed with the Kruskal–Wallis test, correcting for multiple
comparisons with Bonferroni. Chi-square test and Fisher's Exact Test were
significant associations between subjective reasons for help-
employed for categorical variables. To follow significant Chi-square associations, seeking and age, ethnicity, employment status, living situation,
standardized residuals were used. marital status, or GAF scores (Table 2).
Table 1
Main complaints as subjectively reported by the clients and comorbid SCID diagnoses subsequently made by the clinicians. Numbers in grey cells (2nd row and 2nd column)
give absolute number and percentage of clients reporting any given main complaint/receiving any given comorbid diagnosis (χ2 ¼ 59.06, d.f. ¼16, p o0.001). The percentage
of clients reporting any given main complaint and subsequently receiving any given comorbid diagnosis is displayed in white cells.
Comorbid SCID diagnoses (in % of Depression and/or anxiety 9 (10.2%)a 3 (30%)a 61 (58.7%)a 3 (20%)a 2 (40%)a
reasons for help-seeking) n¼78 (35.3%)
Substance abuse n¼ 26 19 (21.6%)a 2 (20%)a 4 (3.8%)a 2 (13.3%)a 0
(11.8%)
a a a a
Other n¼35 (15.8%) 15 (17%) 2 (20%) 13 (12.5%) 3 (26.7%) 1 (20%)a
None n ¼73 (33%) 40 (45.5%)a 3 (30%)a 23 (22.1%)a 5 (33.3%)a 2 (40%)a
Unknown or not assessed 5 (5.7%)a 0 3 (2.9%)a 1 (6.7%)a 0
n¼9 (4.1%)
Total 88 (100%) 10 (100%) 104 (100%) 14 (100%) 5 (100%)
a
Percent of column total.
Please cite this article as: Falkenberg, I., et al., Why are help-seeking subjects at ultra-high risk for psychosis help-seeking? Psychiatry
Research (2015), http://dx.doi.org/10.1016/j.psychres.2015.05.018i
4 I. Falkenberg et al. / Psychiatry Research ∎ (∎∎∎∎) ∎∎∎–∎∎∎
Table 2
Association between main complaints and baseline demographic and clinical characteristics (median, range or %).
APS Psycho-social dysfunction Affective symptoms Other APSþ affective Test statistic
Continuous H (d.f.) p
Age 22 (16–35) 19.5 (17–29) 21 (15–34) 21 (17–27) 20 (14–34) 7.29 (4) 0.12
GAF 60 (35–80) 60 (45–70) 55 (35–85) 60 (45–78) 55 (40–70) 3.91 (4) 0.42
CAARMS subscales severity
Disorders of thought content 4 (0–6) 3 (2–5) 4 (0–6) 4 (0–6) 4 (0–5) 4.12 (4) 0.39
Perceptual abnormalities 3 (0–6) 4 (0–4) 3 (0–6) 3 (0–4) 3 (0–6) 1 (4) 0.91
Disorganized speech 2 (0–6) 2 (0–3) 2 (0–4) 0 (0–6) 2 (0–3) 1.6 (4) 0.81
Subjective experience 3 (0–5) 3 (2–3) 3 (1–6) 3 (2–4) 3 (2–4) 0.48 (4) 0.98
Cognitive change 1 (0–4) 2 (0–2) 1 (0–5) 0 (0–3) 2 (2–3) 1.99 (4) 0.74
Subjective emotional disturbance 2 (0–5) 2 (2–4) 2 (0–5) 2 (0–5) 2 (0–3) 4.23 (4) 0.38
Observed blunted affect 0 (0–5) 2 (0–4) 1 (0–6) 0 (0–2) 2 (0–3) 8.72 (4) 0.07
Observed inappropriate affect 0 (0–5) 0 (0–2) 0 (0–2) 0 (0–2) 0 (0–1) 0.95 (4) 0.92
Alogia 2 (0–5) 2 (0–3) 2 (0–6) 0 (0–3) 0 (0–3) 9.69 (4) 0.04a
Avolition 3 (0–6) 3 (0–4) 4 (0–6) 2 (0–5) 3 (3–5) 12.91 (4) 0.01a
Anhedonia 3 (0–6) 3 (0–5) 3 (0–6) 1 (0–3) 2 (0–4) 5.99 (4) 0.2
Social isolation 3 (0–6) 3 (3–5) 3 (0–6) 2 (0–4) 3 (0–4) 6.89 (4) 0.14
Impaired role function 3 (0–6) 3 (0–5) 3 (0–6) 2 (0–5) 2 (0–4) 4.07 (4) 0.39
Disorganized behaviour 1 (0–5) 0 (0–4) 0 (0–5) 0 (0–3) 2 (0–3) 2.24 (4) 0.69
Aggressive behaviour 2 (0–5) 2 (0–4) 3 (0–5) 3 (0–5) 3 (0–5) 2.25 (4) 0.69
Impaired motor function 1 (0–4) 1 (0–3) 0 (0–3) 0 (0–3) 1 (0–3) 1.49 (4) 0.83
Change in motor function 0 (0–2) 0 (0–3) 0 (0–3) 0 (0) 0 (0–1) 2.39 (4) 0.66
Impaired bodily sensations 0.5 (0–5) 1 (0–3) 0 (0–5) 0 (0–2) 2 (1–4) 6.05 (4) 0.19
Impaired autonomic function 2 (0–5) 3 (0–4) 3 (0–5) 3 (0–5) 2 (0–3) 2.66 (4) 0.62
Mania 0 (0–4) 0 (0–2) 0 (0–6) 0 (0–3) 0 (0–3) 2.83 (4) 0.59
Depression 3 (0–5) 4 (2–4) 3 (0–6) 3 (0–3) 3 (2–5) 9.29 (4) 0.05a
Suicidality & self-harm 2 (0–6) 2 (0–5) 2 (0–5) 2 (0–3) 3 (0–4) 1.79 (4) 0.77
Mood swings 2 (0–4) 2 (0–2) 2 (0–5) 0 (0–4) 3 (0–4) 4.11 (4) 0.39
Anxiety 3 (0–6) 4 (0–4) 4 (0–5) 3 (0–6) 4 (0–4) 5.66 (4) 0.23
OCD symptoms 0.5 (0–5) 0 (0–2) 1 (0–5) 1 (0–5) 2 (0–3) 1.72 (4) 0.79
Dissociative symptoms 0 (0–5) 2 (0–3) 0 (0–4) 0.5 (0–4) 0 (0–2) 2.44 (4) 0.66
Impaired tolerance to normal stress 3 (0–5) 3 (0–4) 3 (0–6) 3 (0–5) 3 (0–4) 4.45 (4) 0.35
Categorical χ2 (d.f.) p
Gender 12.83 (4) 0.012a
Male 47.9% 6% 37.6% 7.7% 0.9%
Female 30.8% 2.9% 57.7% 4.8% 3.87%
Ethnicity 8.314 0.742
Black 34.7% 14.3% 37.5% 41.7% 27.3%
White British 40.3% 71.4% 36.3% 41.7% 45.5%
White other 16.7% - 11.3% - 18.2%
Other 8.3% 14.3% 15% 16.7% 9.1%
Employment status 13.353 0.077
Student 22.5% 57.1% 20% 41.7% 45.5%
Employed 32.4% 14.3% 22.5% 25% 36.4%
Unemployed 17.7% 28.6% 57.5% 33.3% 18.2%
Marital status 6.637 0.829
Single 78.9% 85.7% 73.8% 83.3% 90.9%
Married 1.4% - 7.5% - -
Living together 11.3% 14.3% 12.5% 16.7% -
Divorced/separated 8.5% - 6.3% - 9.1%
Living situation 8.431 0.734
Living alone 18.8% - 19% 25% 30%
Living with parents 47.8% 71.4% 39.2% 33.3% 40%
Cohabiting 24.6% 28.6% 30.4% 16.7% 30%
Other 8.7% - 11.4% 25% -
UHR subtype 14.733 0.065
APS 59% 80% 78.1% 80% 76.9%
BLIPS 16.9% - 4.2% - 15.4%
More than one 9.2% 20% 17.7% 20% 7.7%
a
Uncorrected.
3.2.3. Association between main subjective complaints and and the group reporting attenuated symptoms (lower scores on
psychopathological assessment avolition subscale, p¼ 0.04).
Reasons for help-seeking reported by the clients at baseline was
significantly associated with the “Avolition” subscale (F¼ 2.287,
p¼0.049) and “Depression” subscale (F¼2.687, p¼0.034) in the 3.2.4. Subjective reasons for help seeking and comorbid diagnoses
structured assessment of psychopathology (CAARMS; Table 2). A Table 1 provides the comorbid SCID diagnoses made by the
post-hoc test revealed a significant group difference surviving psychiatrists at OASIS in relation to the clients' subjective reasons
Bonferroni-correction between the group reporting affective symp- for help-seeking and to SCID assessment. The most prevalent
toms as their main complaint (higher scores on avolition subscale) comorbid diagnosis (35.2%) was depression and/or anxiety; 33%
Please cite this article as: Falkenberg, I., et al., Why are help-seeking subjects at ultra-high risk for psychosis help-seeking? Psychiatry
Research (2015), http://dx.doi.org/10.1016/j.psychres.2015.05.018i
I. Falkenberg et al. / Psychiatry Research ∎ (∎∎∎∎) ∎∎∎–∎∎∎ 5
of the clients did not fulfill the criteria for any comorbid diagnosis. group: 70.0 (S.D. ¼3.1), affective symptoms group: 60.0 (S.
The proportions of specific comorbid SCID diagnoses were: Anxi- D.¼3.6); F¼4.45, p¼ 0.04; Cohen's d ¼2.9). This result was cor-
ety or social anxiety: 8.1% (n ¼18), depression: 20.8% (n ¼46), rected for differences in the duration of follow-up periods
personality disorder: 4.5% (n ¼10), substance use: 11.8% (n ¼26), between subjects and survived Bonferroni-correction.
OCD: 3.6% (n ¼8), combined depression and substance use: 0.9%
(n ¼2), combined depression and personality disorder: 0.9% (n ¼2),
personality disorder and substance use: 0.9% (n ¼2), depression
4. Discussion
and anxiety: 6.3% (n¼ 14), other: 5% (n ¼11), none: 33% (n ¼73),
unknown/not assessed: 4.1% (n ¼9). There was a significant asso-
The main finding of this study was that the majority of
ciation between subjective reasons for help-seeking and subse-
individuals presenting for the first time in a specialized service
quent assignment of SCID diagnoses (χ2 (16) ¼59.06, p o0.001).
for people at high clinical risk of developing psychosis report
This association was mainly driven by the group reporting APS as
affective symptoms such as depression and/or anxiety as their
their main complaint, who in 45.5% of cases did not receive any
central subjective complaint and their main reason to seek help.
comorbid diagnosis (z¼2.1 p o0.05) as well as by the group
These individuals were more likely to be females, with high levels
reporting affective symptoms, who in 58.7% of cases received a
of comorbid depressive or anxiety diagnoses and affective symp-
comorbid diagnosis of depression and/or anxiety (z ¼4.0, p o
toms scored on the CAARMS. Although there were no differences
0.001). A logistic regression analysis revealed that the baseline
in treatments received from the service, these subjects had lower
group differences in gender (χ2 (4) ¼1.17, p ¼0.883) and CAARMS
functional outcomes than subjects complaining of attenuated
avolition subscores (B ¼ 0.972, p ¼0.692) did not have a statisti-
psychosis symptoms.
cally significant impact on comorbid diagnoses whereas assign-
Our first objective was to determine the most common sub-
ment of a comorbid affective diagnosis was related to high scores
jective reason for seeking help in UHR subjects. The UHR phase has
on the depression subscale of the CAARMS (B ¼ 0.832, p ¼0.001)
been found to be associated with considerable subjective distress
(Møller and Husby, 2000). The creation of specialized clinical
3.2.5. Subjective reasons for help seeking and treatment services for high-risk individuals and the increasing efforts which
recommendations have been put into early-detection research over the last decade
The intervention most frequently recommended to the clients ultimately aim at providing targeted interventions to prevent
after initial assessment was a combination of medication and CBT psychosis onset or attenuate the symptoms presented by help-
(44.3%). CBT was recommended as the only intervention in 37.6%, seeking individuals. To date, their reasons to seek help and the
monitoring in 13.4% and medication only (i.e. antipsychotic and/or nature of distressing experiences that are part of the UHR
antidepressant) in 4.6% of cases. However, there was no significant syndrome have, however, not received much research attention.
association between the clients' main subjective complaint and Our results indicate that despite being a defining feature of the
the type of intervention recommended by the clinicians (Table 3). UHR syndrome, attenuated psychotic symptoms alone may not be
the only distressing factor triggering help-seeking behaviour. A
3.3. Longitudinal analysis recent study in the general population of psychotic patients
confirmed that subclinical psychosis symptoms, in particular
During the follow-up period, 34 clients (15.4%) made a transi- experiences of thought control, paranoia and bizarre experiences,
tion to psychosis. Of these, 31 individuals developed a are significantly associated with various forms of help-seeking
schizophrenia-spectrum disorder (ICD-10: F20-F29) and 3 devel- behavior (Murphy et al., 2012).
oped bipolar disorder (ICD-10: F31). At follow-up, the majority of However, we showed that although quite common, they were
clients (63%) were medication free. less frequent than affective symptoms and may therefore be less
likely to prompt help-seeking behaviour in high-risk individuals.
3.3.1. Association between main complaints, transition to psychosis Conversely, our findings indicate that co-occuring affective symp-
and functional outcome toms may increase the burden of attenuated psychotic symptoms
Logistic regression analysis revealed no significant association to the extent that high-risk individuals feel the need to request
between main complaints at presentation and transition to psy- help for their condition. This notion is consistent with high
chosis over the course of the follow-up period (p¼ 0.696). The prevalence rates of psychotic-like experiences in the general
comparison of mean GAF scores at baseline and follow-up in the population which are not associated with subjective distress and
group seeking help because of APS versus the group seeking help therefore do not trigger help-seeking behaviour (Van Os et al.,
because of affective symptoms revealed no significant group 2009), and also with previous research showing that lower levels
differences (baseline GAF APS group: 56.2 (S.D. ¼1.8), affective of distress related to APS is associated with delayed help seeking
symptoms group: 56.3 (S.D. ¼2.1); F¼ 1.46, p ¼0.23), however, GAF behaviour in UHR individuals (Chung et al., 2010). The level of
scores at follow-up were significantly higher in the APS group distress in relation to affective and, as a consequence, also to
relative to the affective symptoms group (follow-up GAF APS attenuated psychotic symptoms, may be related to the severity of
Table 3
Reasons for seeking help and interventions recommended by clinicians (χ2 ¼13.075, d.f. ¼ 20, p ¼0.364).
a a a a
Reasons for help-seeking APS (n¼ 88) 6 (6.5%) 33 (37.7%) 31 (35.1%) 18 (20.8%) 88 (100%)
Psychosocial dysfunction (n¼ 10) 1 (10%)a 5 (50%)a 3 (30%)a 1 (10%)a 10 (100%)
Affective symptoms (n¼ 104) 2 (2.2%)a 38 (36.7%)a 56 (53.3%)a 8 (7.8%)a 104 (100%)
Other (n¼ 14) 7.7% 30.8% 46.2% 15.4%
APS þ affective (n¼ 5) – 2 (40%)a 3 (60%)a – 5 (100%)
a
Percentage of row total.
Please cite this article as: Falkenberg, I., et al., Why are help-seeking subjects at ultra-high risk for psychosis help-seeking? Psychiatry
Research (2015), http://dx.doi.org/10.1016/j.psychres.2015.05.018i
6 I. Falkenberg et al. / Psychiatry Research ∎ (∎∎∎∎) ∎∎∎–∎∎∎
depression and anxiety. Unfortunately, we are not able to make predictive value of either psychotic or affective symptoms for
any inferences about this potential relationship, as no severity future psychopathology or poorer clinical outcome is greatest
measures were acquired in our UHR sample, which has to be when they co-occur (Krabbendam et al., 2005; Kaymaz et al.,
considered a limitation of this study. However, we have specifically 2007; Wigman et al., 2012). Our results support this notion by
addressed in other papers the impact of affective symptoms on showing that UHR individuals perceiving affective symptoms as
psychopathology (Fusar-Poli et al., 2014a, 2014b, 2014c), function- the most burdening ones at the time of their approach and referral
ing (Fusar-Poli et al., in press; Fusar-Poli et al., 2014a, 2014b, to the early recognition clinic.
2014c), neurobiology (Modinos et al., 2014) and treatment (Fusar- The second aim of our study was to test the impact of the
Poli et al., 2014a, 2014b, 2014c) of UHR subjects. subjective reason for help seeking on longitudinal outcomes. We
Early recognition programs for young people at risk for psy- found that, despite not having a higher risk of developing
chosis aim to increase help-seeking rates to improve clinical psychosis, patients complaining of affective symptoms were more
outcomes. The correct labelling of difficulties experienced by these prone to have a poorer functional outcome in the future This has
people as signs of mental illness may thus on the one hand recently been confirmed in a longitudinal long-term study indi-
facilitate help-seeking. On the other hand, this label involves the cating that most URH people not converting to psychosis at follow-
danger of stigmatizing young people, in particular those who turn up would present with affective disorders including depression
out to be false positives. The stigma associated with schizophrenia and anxiety. This study also showed that the majority of these
is generally higher than that associated with depression disorders were present at baseline, with a lower number of cases
(Angermeyer and Matschinger, 2003). It is thus conceivable that of new onset of disorder and that baseline symptomatology was a
the clients in our sample may have considered it more socially poor predictor of these comorbidities (Lin et al., 2015).
acceptable to report affective rather than attenuated psychotic The transition rate of 15.4% over a median follow-up period of
symptoms as their main complaints (cf. Singh et al., 2012; Mittal et 4.5 years in our sample was relatively low, compared to meta-
al., 2015). analytical evidence indicating an increase of transition rates over
The pattern of main complaints reported by our clients is time, with rates being lowest at 6-months follow-up (18%) and
reflected by a relatively high prevalence of comorbid DSM-IV highest (36%) after three years (Fusar-Poli et al., 2012) and with
diagnoses of affective disorder (35.3%) in the same sample. This the speed of psychosis progression in UHR people being greatest
is well reflected by higher CAARMS scores at baseline in avolition during the first months after presentation (Kempton et al., 2015).
and depressive subscales. Of additional interest, these clients were Low transition rates may in part be due to the fact that the clients
more likely to be females, in line with consistent evidence were provided with different types of interventions (e.g. medica-
indicating higher prevalence of affective disorders in females as tion, psychotherapy) whenever necessary. This may in some cases
compared to males (Kessler, 2003). Affective symptoms, in parti- have delayed or prevented transition to psychosis and may thus in
cular depression, are the earliest and most common symptoms part explain the lack of association between reasons for help-
retrospectively reported by patients in their first episode of a seeking and future transition. There is consistent meta-analytical
psychotic illness (Häfner et al., 2005) and have been identified as evidence indicating that focused interventions in UHR can halve
common features of the UHR syndrome prior to the emergence of the risk of psychosis progression (risk ratio ¼ 0.54; Stafford et al.,
psychotic symptoms in prospective studies (Häfner et al., 1999). 2013). Indeed in a separate manuscript investigating the impact of
The emergence of specific affective symptoms may predate that of focused treatments in the same sample, we found that use of
positive symptoms and reflect core psychopathological alterations antidepressant treatments in UHR subjects with prominent affec-
underlying the onset of psychotic experiences (Mishara and Fusar- tive symptoms was associated with a reduced risk of developing
Poli, 2013). A retrospective study in first-episode patients con- psychosis over time (Fusar-Poli et al., 2014a).
firmed that the most common disorders triggering help-seeking The low transition rate in our sample as well as the lack of
behaviours were mood and anxiety disorders (N ¼385 (39.1%)) association between reasons for help-seeking and transition rates
(Rietdijk et al., 2011). may in part also be due to the fact that transition to psychosis as
High comorbidity rates with affective disorders in help-seeking defined by CAARMS criteria is only assumed if positive symptoms
individuals meeting UHR criteria have consistently been reported are present. However, the threshold defining the onset of a
in the literature (Velthorst et al., 2009; Addington et al., 2011; for a psychotic disorder in people at-risk is arbitrary (Lin et al., 2012).
meta-analysis see Fusar-Poli et al. (2014a, 2014b, 2014c)). In part, Nevertheless, a previous analysis in a large UHR sample (N ¼509)
this may be due to a selection bias which is enriching the risk of confirmed no evidence of comorbid affective diagnoses on transi-
psychosis, as UHR samples have in most cases been recruited in a tion rates (Fusar-Poli et al., 2014b). This study however did not
clinical context (Fusar-Poli et al., 2014b). However, cognitive analyse the effect of comorbid diagnoses on the functional out-
models of psychosis propose that affective dysregulation play a comes of UHR subject. While only a minority of UHR individuals
key role in the formation and maintenance of psychotic symptoms will go on to develop frank psychosis (Yung et al., 2007), many of
(Garety et al., 2001). Similarly, phenomenological models of those who do not meet criteria for a psychotic disorder will have
psychosis onset highlight mood disturbances as key distinctive very poor functional outcomes, and will continue to require social
features of this phase (Mishara and Fusar-Poli, 2013). This is and clinical support (cf. Addington et al., 2011). A recent meta-
consistent with data from the prospective study of subclinical analysis estimated that only one third of the initial UHR sample
psychotic experiences in the general population (Van Os et al., will eventually develop a clinical remission from the risk state
2009), which suggests that these are more likely to lead to (Simon et al., 2013). The factors that may predict functional
clinically significant psychotic symptoms if mood deterioration outcome in people at high-risk for psychoses have not been widely
(Hanssen et al., 2005) or trauma (Spauwen et al., 2006) are also studied and there is an increasing interest to investigate functional
present. On the other hand, psychotic symptoms are also a outcomes other than transition. The largest (N ¼ 101, follow-up
common feature of disorders of anxiety or depression both in from 3 to 5 years) and most recent study published to date,
clinical (Hanssen et al., 2003) and epidemiological general popula- however, has shown that reduced neurocognitive performance,
tion samples (Wigman et al., 2012), indicating that there may be a functional impairments, and symptoms other than positive atte-
shared vulnerability to both affective and psychotic phenomena. In nuated symptoms at baseline predicted an increased risk of poor
addition, previous evidence also suggests a reciprocal causal functional outcomes in our sample. Of interest the authors con-
influence between affective and psychotic phenomena, as the cluded that “poor functional outcomes were not entirely
Please cite this article as: Falkenberg, I., et al., Why are help-seeking subjects at ultra-high risk for psychosis help-seeking? Psychiatry
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