Ultra-high-risk paradigm: lessons learnt and new directions
Open accessAbstract
Within the embryonic early psychosis field in the early 1990s, the conceptualisation and definition of an at-risk or ultra-high-risk (UHR) mental state for psychosis was a breakthrough which transformed the clinical and research landscape in psychiatry. Twenty-five years later, we have a new evidence base that has illuminated the neurobiology of the onset phase of psychotic disorder, delivered Cochrane level 1 evidence showing that the onset of full-threshold sustained psychotic disorder can be at least delayed, and is paving the way to a new generation of transdiagnostic research. Here, we document the contribution of the UHR approach to understanding the underlying mechanisms of psychosis onset as well as the long-term outcomes. Particularly, we highlight that psychosis onset can be delayed in those meeting UHR criteria and that these criteria have a higher valence for subsequent psychotic disorders and some valence for persistent non-psychotic syndromes. Critiques have helped to identify some of the limitations of this paradigm, which are acknowledged. These include evidence that psychotic disorders can emerge more acutely and from other, as yet undefined, precursor states. Rather than defending, or alternatively questioning the value of, the UHR approach, we propose a broader, transdiagnostic staging model that is consistent with the pluripotent and variably comorbid trajectories for mental disorders. This approach moves beyond psychosis to capture a wider range of subthreshold symptoms and full-threshold disorders, thus enhancing prediction for the emergence and progression of a range of mental disorders, as well as providing new avenues for early intervention and prevention.
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A trans-diagnostic clinical high-risk mental state (CHARMS) paradigm may increase capacity to intercept a wider range of lower risk cases than those with attenuated psychotic symptoms only, including people with sub-threshold bipolar and borderline personality symptoms as well as mild-moderate depression.
“a trans-diagnostic clinical high-risk mental state (CHARMS) paradigm may increase capacity to intercept a wider range of lower risk cases than those with attenuated psychotic symptoms only, including people with sub-threshold bipolar and borderline personality symptoms as well as mild-moderate depression [22]”
From Prevention and early intervention in youth mental health: is it time for a multidisciplinary and trans-diagnostic model for care? (2020) · cites this paper as [22]
Progress has been made for psychotic disorders due to successful application of an at-risk mental state concept.
“While progress has been made for psychotic disorders, also due to the successful application of an at-risk mental state concept [22]”
From Prevention and early intervention in youth mental health: is it time for a multidisciplinary and trans-diagnostic model for care? (2020) · cites this paper as [22]
Pathways to mental disorders are pluripotent and trans-diagnostic.
“increasingly clear evidence that pathways to mental disorders are pluripotent and trans-diagnostic [22]”
From Prevention and early intervention in youth mental health: is it time for a multidisciplinary and trans-diagnostic model for care? (2020) · cites this paper as [22]
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- Authors
- McGorry, P. D., & Mei, C.
- Affiliations
- The University of Melbourne (AU)
- Corresponding author
- McGorry, Patrick D
- Venue
- Evidence Based Mental Health
- Publisher
- BMJ
- Published
- 2018-10-24
- Volume
- 21
- Issue
- 4
- Pages
- 131-133
- ISSN
- 1362-0347 (ISSN-L)
- 1468-960X
- PMC
- PMC10270365
- OpenAlex
- W2898193019
- Cited by
- 52
- References
- 36
- Citations by year
- 2026: 2 · 2025: 4 · 2024: 8 · 2023: 2 · 2022: 14 · 2021: 6 · 2020: 11 · 2019: 3 · 2018: 1
- FWCI
- 0.80
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Evidence-Based Mental Health (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- HighWire Press Open Archive (submittedVersion)
- Funders
- National Health and Medical Research Council
- Topics
- Health Sciences › Medicine › Psychiatry and Mental health › Schizophrenia research and treatment
- Health Sciences › Medicine › Psychiatry and Mental health › Bipolar Disorder and Treatment
- Social Sciences › Psychology › Clinical Psychology › Psychopathy, Forensic Psychiatry, Sexual Offending
- Keywords
- transition to psychosis, early psychosis, psychosis risk syndromes, subthreshold symptoms, long-term outcomes, early intervention, prevention, comorbidities
- MeSH terms
- Humans, Psychotic Disorders, Disease Progression, Risk Assessment, Prodromal Symptoms
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