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A critique of the “ultra‐high risk” and “transition” paradigm
Open accessAbstract
The transdiagnostic expression of psychotic experiences in common mental disorder (anxiety/depression/substance use disorder) is associated with a poorer prognosis, and a small minority of people may indeed develop a clinical picture that meets criteria for schizophrenia. However, it appears neither useful nor valid to observe early states of multidimensional psychopathology in young people through the “schizo”‐prism, and apply misleadingly simple, unnecessary and inefficient binary concepts of “risk” and “transition”. A review of the “ultra‐high risk” (UHR) or “clinical high risk” (CHR) literature indicates that UHR/CHR samples are highly heterogeneous and represent individuals diagnosed with common mental disorder (anxiety/depression/substance use disorder) and a degree of psychotic experiences. Epidemiological research has shown that psychotic experiences are a (possibly non‐causal) marker of the severity of multidimensional psychopathology, driving poor outcome, yet notions of “risk” and “transition” in UHR/CHR research are restrictively defined on the basis of positive psychotic phenomena alone, ignoring how baseline differences in multidimensional psychopathology may differentially impact course and outcome. The concepts of “risk” and “transition” in UHR/CHR research are measured on the same dimensional scale, yet are used to produce artificial diagnostic shifts. In fact, “transition” in UHR/CHR research occurs mainly as a function of variable sample enrichment strategies rather than the UHR/CHR “criteria” themselves. Furthermore, transition rates in UHR/CHR research are inflated as they do not exclude false positives associated with the natural fluctuation of dimensional expression of psychosis. Biological associations with “transition” thus likely represent false positive findings, as was the initial claim of strong effects of omega‐3 polyunsatured fatty acids in UHR samples. A large body of UHR/CHR intervention research has focused on the questionable outcome of “transition”, which shows lack of correlation with functional outcome. It may be more productive to consider the full range of person‐specific psychopathology in all young individuals who seek help for mental health problems, instead of “policing” youngsters for the transdiagnostic dimension of psychosis. Instead of the relatively inefficient medical high‐risk approach, a public health perspective, focusing on improved access to a low‐stigma, high‐hope, small scale and youth‐specific environment with acceptable language and interventions may represent a more useful and efficient strategy.
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“Conventional mental health services are not generally engineered to detect and prevent psychosis onset from anxiety or depressive disorders, as claimed by some authors 195,231”
From Preventive psychiatry: a blueprint for improving the mental health of young people (2021) · cites this paper as [231]
In the citing paper
“These findings, taken together, are particularly problematic given the conceptual concerns over the clinical validity and significance of the dichotomous concept of transition within the CHR-P paradigm 97,98 .”
From Lack of evidence to favor specific preventive interventions in psychosis: a network meta‐analysis (2018) · cites this paper as [98]
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Mapping the Onset of Psychosis: The Comprehensive Assessment of At-Risk Mental States
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Establishment of Diagnostic Validity in Psychiatric Illness: Its Application to Schizophrenia
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Colizzi, M., Lasalvia, A., & Ruggeri, M. (2020) · International Journal of Mental Health Systems · doi:10.1186/s13033-020-00356-9 · Cited by 727
Preventive psychiatry: a blueprint for improving the mental health of young people
Fusar‐Poli, P., Correll, C. U., Arango, C., Berk, M., Patel, V., & Ioannidis, J. P. A. (2021) · World Psychiatry · doi:10.1002/wps.20869 · Cited by 497
Beyond the “at risk mental state” concept: transitioning to transdiagnostic psychiatry
McGorry, P. D., Hartmann, J. A., Spooner, R., & Nelson, B. (2018) · World Psychiatry · doi:10.1002/wps.20514 · Cited by 488
Salazar de Pablo, G., Radua, J., Pereira, J., Bonoldi, I., Arienti, V., Besana, F., Soardo, L., Cabras, A., Fortea, L., Catalan, A., et al. (2021) · JAMA Psychiatry · doi:10.1001/jamapsychiatry.2021.0830 · Cited by 375
The slow death of the concept of schizophrenia and the painful birth of the psychosis spectrum
Gülöksüz, S., & van Os, J. (2017) · Psychological Medicine · doi:10.1017/s0033291717001775 · Cited by 369
Metadata
- Authors
- van Os, J., & Guloksuz, S.
- Affiliations
- Department of Psychiatry and Psychology Maastricht University Medical Centre Maastricht the Netherlands
- Venue
- World Psychiatry
- Publisher
- Wiley
- Published
- 2017-05-12
- Volume
- 16
- Issue
- 2
- Pages
- 200-206
- ISSN
- 1723-8617 (ISSN-L)
- 2051-5545
- PMC
- PMC5428198
- OpenAlex
- W2612786941
- Cited by
- 261
- References
- 61
- Citations by year
- 2026: 16 · 2025: 13 · 2024: 19 · 2023: 29 · 2022: 29 · 2021: 33 · 2020: 44 · 2019: 36 · 2018: 32 · 2017: 10
- FWCI
- 27.39
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- World Psychiatry (publishedVersion)
- Europe PMC (PubMed Central) (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Research Publications (Maastricht University) (submittedVersion, other-oa)
- Topics
- Health Sciences › Medicine › Psychiatry and Mental health › Schizophrenia research and treatment
- Social Sciences › Arts and Humanities › Philosophy › Mental Health and Psychiatry
- Health Sciences › Medicine › Psychiatry and Mental health › Bipolar Disorder and Treatment
- Keywords
- clinical high risk for psychosis, clinical high risk, psychotic experiences, transdiagnostic psychopathology, common mental disorders, schizophrenia risk, transition to psychosis, sample enrichment, omega-3 polyunsaturated fatty acids
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