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Cited by 489Schizophrenia research and treatmentMental Health Research TopicsMental Health and Psychiatry

Beyond the “at risk mental state” concept: transitioning to transdiagnostic psychiatry

Open access
McGorry, Patrick D., Hartmann, Jessica A., Spooner, Rachael, Nelson, Barnaby·2018·World Psychiatry
DOI 10.1002/wps.20514PMC PMC5980504
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Abstract

The “at risk mental state” for psychosis approach has been a catalytic, highly productive research paradigm over the last 25 years. In this paper we review that paradigm and summarize its key lessons, which include the valence of this phenotype for future psychosis outcomes, but also for comorbid, persistent or incident non‐psychotic disorders; and the evidence that onset of psychotic disorder can at least be delayed in ultra high risk (UHR) patients, and that some full‐threshold psychotic disorder may emerge from risk states not captured by UHR criteria. The paradigm has also illuminated risk factors and mechanisms involved in psychosis onset. However, findings from this and related paradigms indicate the need to develop new identification and diagnostic strategies. These findings include the high prevalence and impact of mental disorders in young people, the limitations of current diagnostic systems and risk identification approaches, the diffuse and unstable symptom patterns in early stages, and their pluripotent, transdiagnostic trajectories. The approach we have recently adopted has been guided by the clinical staging model and adapts the original “at risk mental state” approach to encompass a broader range of inputs and output target syndromes. This approach is supported by a number of novel modelling and prediction strategies that acknowledge and reflect the dynamic nature of psychopathology, such as dynamical systems theory, network theory, and joint modelling. Importantly, a broader transdiagnostic approach and enhancing specific prediction (profiling or increasing precision) can be achieved concurrently. A holistic strategy can be developed that applies these new prediction approaches, as well as machine learning and iterative probabilistic multimodal models, to a blend of subjective psychological data, physical disturbances (e.g., EEG measures) and biomarkers (e.g., neuroinflammation, neural network abnormalities) acquired through fine‐grained sequential or longitudinal assessments. This strategy could ultimately enhance our understanding and ability to predict the onset, early course and evolution of mental ill health, further opening pathways for preventive interventions.

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  • Transdiagnostic models recognise the fluid nature of mental illness in this age group and distinguish early clinical stages (assumed low progression) from later stages (high persistence, impairment, disease extension).

    “Transdiagnostic models 197,198 recognise the fluid nature of mental illness in this age group and make a distinction between early clinical stages (which are assumed to have low rates of progression to severe, persistent, or recurrent disorders) and later stages (which are characterised by high rates of persistence, impairment, and disease extension). 199”

    From The Lancet Psychiatry Commission on youth mental health (2024) · cites this paper as [198]

    The Conclusions describe diffuse, unstable symptoms in early stages and transdiagnostic trajectories. “The New Diagnosis” section distinguishes early, subthreshold stages from later full-threshold stages with varying recurrence and severity. The paper does not establish the claimed low progression rate for early stages generally or high rates of persistence, impairment, and disease extension for later stages; its CHARMS section reports a 30% transition rate for Stage 1b, compared with less than 5% for Stage 1a. (LLM, conf=0.84)

    Experimental — accuracy not yet measured

  • Indicated prevention is currently the most promising avenue for preventive efforts.

    “Although indicated prevention is currently the most promising avenue for preventive efforts, 198,275 universal and selective interventions also have value. 276,277”

    From The Lancet Psychiatry Commission on youth mental health (2024) · cites this paper as [198]

    The CHARMS approach section (page not available in our copy) proposes identifying at-risk people for preventive intervention trials, supporting the value of targeted prevention. The paper does not say that indicated prevention is currently the most promising avenue or compare it with universal and selective prevention. (LLM, conf=0.78)

    Experimental — accuracy not yet measured

  • Earliest expressions of psychopathology have high rates of co-occurrence, change from one clinical picture to another, and only gradually differentiate into more distinct mental disorders.

    “These earliest expressions of psychopathology have high rates of co-occurrence, change from one clinical picture to another, and only gradually differentiate into more distinct mental disorders [67, 69, 70].”

    From Efficacy of a transdiagnostic Internet prevention approach in adolescents (EMPATIA study): study protocol of a randomized controlled trial (2024) · cites this paper as [67]

  • The need to establish a 'threshold' for subsyndromal depression in order to distinguish it from 'ordinary feelings of sadness' has been widely acknowledged.

    “The need to establish a 'threshold' for subsyndromal depression in order to distinguish it from 'ordinary feelings of sadness' has been widely acknowledged, and different solutions have been proposed. 61”

    From Time for united action on depression: a Lancet–World Psychiatric Association Commission (2022) · cites this paper as [61]

  • Prevalence of subthreshold syndromes of depressive symptoms with shorter duration (typically two weeks) is as high as 17%.

    “But prevalence of subthreshold syndromes of depressive symptoms with shorter duration (typically two weeks) is as high as 17%. 61,169”

    From Time for united action on depression: a Lancet–World Psychiatric Association Commission (2022) · cites this paper as [61]

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Cites

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Research works printed but not linked: 3

  1. Kirmayer L, Lemelson R, Cummings C (eds). Revisioning psychiatry: inte- grating biological, clinical and cultural perspectives. Cambridge: Cam- bridge University Press, 2015.
  2. Purcell R, Jorm AF, Hickie IB et al. Demographic and clinical characteris- tics of young people seeking help at youth mental health services: baseline findings of the Transitions Study. Early Interv Psychiatry 2015;9:487-97.
  3. Scheffer M, Carpenter SR, Lenton TM et al. Anticipating critical transi- tions. Science 2012;338:344-8.

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Authors
McGorry, P. D., Hartmann, J. A., Spooner, R., & Nelson, B.
Affiliations
The University of Melbourne (AU)
ORCID
Venue
World Psychiatry
Publisher
Wiley
Published
2018-05-24
Volume
17
Issue
2
Pages
133-142
ISSN
  • 1723-8617 (ISSN-L)
  • 2051-5545
DOI
10.1002/wps.20514
PMC
PMC5980504
OpenAlex
W2806195288
Cited by
488
References
95
Citations by year
2026: 48 · 2025: 51 · 2024: 65 · 2023: 61 · 2022: 57 · 2021: 86 · 2020: 59 · 2019: 46 · 2018: 13
FWCI
40.13
Type
journal article
Language
en
Open access
Licence
onlinelibrary.wiley.com/termsAndConditions#vor (vor)
Locations
  • World Psychiatry (publishedVersion)
  • PubMed Central (publishedVersion)
  • PubMed (publishedVersion)
Topics
  • Health Sciences › Medicine › Psychiatry and Mental health › Schizophrenia research and treatment
  • Social Sciences › Psychology › Experimental and Cognitive Psychology › Mental Health Research Topics
  • Social Sciences › Arts and Humanities › Philosophy › Mental Health and Psychiatry
Keywords
clinical high risk for psychosis, transdiagnostic psychiatry, psychosis onset prediction, clinical staging model, psychosis risk syndromes, persistent psychosis, dynamical systems theory, network theory, joint modeling, machine learning, multimodal biomarkers, neuroinflammation, EEG biomarkers

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