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. 2019 Nov 1;76(11):1167-1175.
doi: 10.1001/jamapsychiatry.2019.2360.

Clinical Stage Transitions in Persons Aged 12 to 25 Years Presenting to Early Intervention Mental Health Services With Anxiety, Mood, and Psychotic Disorders

Frank Iorfino  1 , Elizabeth M Scott  1   2 , Joanne S Carpenter  1 , Shane P Cross  1 , Daniel F Hermens  1   3 , Madhura Killedar  4 , Alissa Nichles  1 , Natalia Zmicerevska  1 , Django White  1 , Adam J Guastella  1 , Jan Scott  5 , Patrick D McGorry  6   7 , Ian B Hickie  1
Affiliations

Clinical Stage Transitions in Persons Aged 12 to 25 Years Presenting to Early Intervention Mental Health Services With Anxiety, Mood, and Psychotic Disorders

Frank Iorfino et al. JAMA Psychiatry. .

Abstract

Importance: The large contribution of psychiatric disorders to premature death and persistent disability among young people means that earlier identification and enhanced long-term care for those who are most at risk of developing life-threatening or chronic disorders is critical. Clinical staging as an adjunct to diagnosis to address emerging psychiatric disorders has been proposed for young people presenting for care; however, the longer-term utility of this system has not been established.

Objectives: To determine the rates of transition from earlier to later stages of anxiety, mood, psychotic, or comorbid disorders and to identify the demographic and clinical characteristics that are associated with the time course of these transitions.

Design, setting, and participants: A longitudinal, observational study of 2254 persons aged 12 to 25 years who obtained mental health care at 2 early intervention mental health services in Sydney, Australia, and were recruited to a research register between June 18, 2008, and July 24, 2018 (the Brain and Mind Centre Optymise Cohort).

Main outcomes and measures: The primary outcome of this study was transition from earlier to later clinical stages. A multistate Markov model was used to examine demographic (ie, age, sex, engagement in education, employment, or both) and clinical (ie, social and occupational function, clinical presentation, personal history of mental illness, physical health comorbidities, treatment use, self-harm, suicidal thoughts and behaviors) factors associated with these transitions.

Results: Of the 2254 individuals included in the study, mean (SD) age at baseline was 18.18 (3.33) years and 1330 (59.0%) were female. Data on race/ethnicity were not available. Median (interquartile range) follow-up was 14 (5-33) months. Of 685 participants at stage 1a (nonspecific symptoms), 253 (36.9%) transitioned to stage 1b (attenuated syndromes). Transition was associated with lower social functioning (hazard ratio [HR], 0.77; 95% CI, 0.66-0.90), engagement with education, employment, or both (HR, 0.47; 95% CI, 0.25-0.91), manic-like experiences (HR, 2.12; 95% CI, 1.19-3.78), psychotic-like experiences (HR, 2.13; 95% CI, 1.38-3.28), self-harm (HR, 1.42; 95% CI, 1.01-1.99), and older age (HR, 1.27; 95% CI, 1.11-1.45). Of 1370 stage 1b participants, 176 (12.8%) transitioned to stage 2 (full-threshold) disorders. Transition was associated with psychotic-like experiences (HR, 2.31; 95% CI, 1.65-3.23), circadian disturbance (HR, 1.66; 95% CI, 1.17-2.35), psychiatric medication (HR, 1.43; 95% CI, 1.03-1.99), childhood psychiatric disorder (HR, 1.62; 95% CI, 1.03-2.54), and older age (HR, 1.24; 95% CI, 1.05-1.45).

Conclusions and relevance: Differential rates of progression from earlier to later stages of anxiety, mood, psychotic, or comorbid disorders were observed in young persons who presented for care at various stages. Understanding the rate and factors associated with transition assists planning of stage-specific clinical interventions and secondary prevention trials.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr E. M. Scott is medical director, Young Adult Mental Health Unit, St Vincent’s Hospital Darlinghurst; discipline leader of Adult Mental Health, School of Medicine, University of Notre Dame; Research Affiliate, The University of Sydney; and Consultant Psychiatrist. She has received honoraria from Laboratoires Servier and Eli Lilly and Company for presenting educational seminars related to the clinical management of depressive disorders and has participated in a national advisory board for the antidepressant compound Pristiq, manufactured by Pfizer. She was the national coordinator of an antidepressant trial sponsored by Laboratoires Servier. Dr J. Scott is a visiting professor at Diderot University, the Norwegian University of Science and Technology, Swinburne University of Technology, and The University of Sydney and a Science Without Borders fellow (Brazil). She has received grant funding from the UK Medical Research Council and from the UK Research for Patient Benefit program. Dr Hickie was an inaugural Commissioner on Australia’s National Mental Health Commission (2012-18). He is the co-director, Health and Policy at the Brain and Mind Centre (BMC), University of Sydney. The BMC operates an early-intervention youth service at Camperdown under contract to headspace, National Youth Mental Health Foundation Ltd. Dr Hickie has previously led community-based and pharmaceutical industry–supported (Wyeth, Eli Lily, Servier, Pfizer, AstraZeneca) projects focused on the identification and better management of anxiety and depression. He was a member of the Medical Advisory Panel for Medibank Private until October 2017, a board member of Psychosis Australia Trust, and a member of Veterans Mental Health Clinical Reference group. He is the Chief Scientific Advisor to, and a 5% equity shareholder in, InnoWell Pty Ltd. InnoWell was formed by the University of Sydney (45% equity) and PricewaterhouseCoopers ([PwC] Australia; 45% equity) to deliver the $30 million Australian Government-funded Project Synergy (2017-2020; a 3-year program for the transformation of mental health services) and to lead transformation of mental health services internationally through the use of innovative technologies. No other conflicts were reported.

Figures

Figure 1.
Figure 1.. Two-Step Decision-Making Process Used to Assign Those Presenting to Care to the Appropriate Stage
A, Process used to assign clinical stage. B, Guidelines used to make these decisions.
Figure 2.
Figure 2.. Kaplan-Meier Curves of Time to Transition
A, Survival probability plots of the empirical and fitted time to transition for stage 1a to stage 1b. B, Survival probability plots of the empirical and fitted time to transition for stage 1b to stage 2. C, Survival probability plots of the empirical and fitted time to transition for stage 1a to stage 2.
See this image and copyright information in PMC

Comment in

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