Our results revealed in a sample of non-help seeking adolescents drawn from general population high prevalence of individuals with at-risk mental state to develop psychosis (26%), higher than reported previously [6, 31]. Furthermore, ARMS + adolescents had lower social and occupational functioning, and more subthreshold mental disorders compared to ARMS- adolescents. All of the ARMS + subjects belonged to the Attenuated Psychotic Syndrome (APS) group. The
Subclinical psychotic syndrome in the population of non-help seeking adolescents have negative impact on their quality of life. We observed negative association between the severity of CAARMS symptoms and five subscales of KIDSCREEN: Physical Well-being, Psychological Well-being, Moods and emotions, Self-Perception, Parent and Home life. These domains cover crucial aspects of daily life, provide information on general health, life satisfaction, mood, loneliness, and relations with parents. The results further corroborate findings from previous research, which showed with the same QoL instrument that the ARMS subjects had poorer results than controls in Physical Well-being, Psychological Well-being and School Environment [32]. Overall level of functioning, as indexed by the SOFAS score, was similar to the functioning level of non-help-seeking adolescent samples from other studies [31, 33]. The SOFAS score in our sample was mostly affected by the severity of CAARMS symptoms.
Surprisingly, we failed to detect any significant difference in cognitive performance between the ARMS + and ARMS- groups. The data contradict previously reported impairment in processing and motor speed among non-help seeking ARMS subjects [18]. The discrepancy can be partially explained by the different recruitment methods used and/or dissimilar cognitive tests administered. Another possible explanation of our negative findings is a relatively small sample size. Cognitive performance in our study was not associated with the CAARMS symptoms severity, neither with the presence of threshold or subthreshold mental disorder. The lack of associations can be attributed to the lower prevalence of comorbidities.
In our non-help-seeking sample, the prevalence of other psychiatric disorders was lower than reported previously [34]. Although the difference in the prevalence rates of threshold mental disorders between ARMS+/ARMS- subjects did not reach statistical significance, the subthreshold mental disorders were more frequent in the ARMS + group. Their prevalence was similar to that observed in larger samples [35]. Results of a longitudinal study with help-seeking ultra-high risk youth showed that individuals with comorbidities had more severe symptoms, higher distress and lower level of functioning [36]. In addition, those with both comorbid anxiety and depressive diagnoses were more severely functionally impaired.
Recent research suggested that the earliest stages of mental disorders can be described by waxing and waning subthreshold states of depression and anxiety, often accompanied by psychotic-like disturbances of salience or perception and emotional dysregulation [37]. Thus, psychotic experiences can be seen as a transdiagnostic phenomenon, transitory in 80% of individuals, majority of them are diagnosed with a non-psychotic disorder [38].
High prevalence of AMRS + subjects in our sample should be viewed in light of several limitations. First, the onset of psychosis may also occur via previously identified nonpsychotic clinical risk syndromes [39]. Second, most of the individuals who will later develop psychosis (up to 95%) remain undetected at the time of their ARMS stage [40]. Higher prevalence found in our study subjects can be attributed to the sampling bias, as the subjects with subtle symptoms are more prone to participate in testing. Since there were no adolescents with threshold psychosis detected in our sample, it is possible that some subjects developed psychosis after initial screening and subsequently refused to participate in the study phase two. Finally, false positivity could also play the role.
Study limitation is the absence of assessment of negative symptoms, not covered by the brief version of CAARMS. Negative symptoms are associated more strongly with cognitive, social, and functional impairments in help-seeking individuals than positive or depressive symptoms [15, 41, 42]. Cross-sectional design and a relatively small sample limit generalizability of our results to the entire ARMS population.
The psychosis-predictive ability of CHR criteria in general population is unknown. There is a meta-analytical evidence of overall risk enrichment (pretest risk for psychosis at 38 months = 15%) in help-seeking samples selected for CHR assessment, as compared to the general population (pretest risk of psychosis at 38 months = 0.1%) [43]. The authors emphasised that intensive outreach campaigns and a higher proportion of self-referrals dilute the pretest risk for psychosis. Accordingly, the EPA guidance recommends restricting the CHR assessment to individuals already distressed by mental problems and seeking help [44]. Novel research approaches stress out sequential screening of CHR-P subjects, with future use of prescreening e-health methods [40].
The challenge is what kind of help can we offer and deliver to the non-help seeking ARMS subjects. In general, treatment of the ARMS individuals has two aims: to manage current symptoms and problems, and to reduce the risk of developing a psychotic disorder [45]. Current international guidelines recommend the least restrictive approach, i.e. psychological interventions as the first-line treatment, while the administration of antipsychotics is reserved for patients who do not respond to psychological management or who suffer from severe and/or progressive high-risk symptoms [46, 47]. It is important that the initiation of pharmacotherapy is based on shared-decision making [48, 49]. Moreover, scarce data indicate that cognitive remediation in the ARMS subjects can also improve functional outcome and cognition [50]. Recent meta-analyses concluded that there is a lack of evidence to favour specific effective interventions to prevent psychosis in CHR-P individuals [51, 52].