Developing and Validating an Individualized Clinical Prediction Model to Forecast Psychotic Recurrence in Acute and Transient Psychotic Disorders: Electronic Health Record Cohort Study

Abstract

Acute and transient psychotic disorders (ATPDs) include short-lived psychotic episodes with a high probability of developing psychotic recurrences. Clinical care for ATPD is currently limited by the inability to predict outcomes. Real-world electronic health record (EHR)-based retrospective cohort study STROBE/RECORD compliant included all individuals accessing the South London and Maudsley NHS Trust between 2006 and 2017 and receiving a first diagnosis of ATPD (F23, ICD-10). After imputing missing data, stepwise and LASSO Cox regression methods employing a priori predictors (n = 23) were compared to develop and internally validate an individualized risk prediction model to forecast the risk of psychotic recurrences following TRIPOD guidelines. The primary outcome was prognostic accuracy (area under the curve [AUC]). 3018 ATPD individuals were included (average age = 33.75 years, 52.7% females). Over follow-up (average 1042 ± 1011 days, up to 8 years) there were 1160 psychotic recurrences (events). Stepwise (n = 12 predictors) and LASSO (n = 17 predictors) regression methods yielded comparable prognostic accuracy, with an events per variable ratio >100 for both models. Both models showed an internally validated adequate prognostic accuracy from 4 years follow-up (AUC 0.70 for both models) and good calibration. A refined model was adapted in view of the new ICD-11 criteria on 307 subjects with polymorphic ATPD, showing fair prognostic accuracy at 4 years (AUC: stepwise 0.68; LASSO 0.70). This study presents the first clinically based prediction model internally validated to adequately predict long-term psychotic recurrence in individuals with ATPD. The model can be automatable in EHRs, supporting further external validations and refinements to improve its prognostic accuracy.

Keywords: brief psychotic disorder; clinical prediction modeling; individualized prediction acute and transient psychotic disorder; psychosis; schizophrenia; validation.

Fig. 1.

PRISMA flow chart of the study population.

Fig. 2.

Internally validated (A) discrimination (AUC) and (B) calibration of the electronic health record-based, individualized prognostic model of psychotic recurrence for ATPD (n = 3018). Note: ATPD, acute and transient psychotic disorder; AUC, area under the curve.

Fig. 3.

Internally validated (A) discrimination (AUC) and (B) calibration of the electronic health record-based, individualized prognostic model of psychotic recurrence for ATPD F23.0 and F23.1 (n = 307). Note: ATPD, acute and transient psychotic disorder; AUC, area under the curve.