Spsc_a_735253.indd

Adolescents at risk of psychosis have higher level of hopelessness than adolescents not at risk of psychosis NIKLAS GRAN Ö , MARJAANA KARJALAINEN , VIRVE EDLUND , ERKKI SAARI , ARJA ITKONEN, JUKKA ANTO , MIKKO ROINE Gran ö N , Karjalainen M , Edlund V , Saari E , Itkonen A, Anto J , Roine M. Adolescents at risk of psychosis have higher level of hopelessness than adolescents not at risk of psychosis. Nord J Psychiatry 2012;Early Online:1–7 Background : Hopelessness has been a widely studied phenomenon in psychotic disorders. However, previous evidence of hopelessness in at-risk state of psychosis is lacking. The primary aim of the present study was to investigate associations between at-risk state of psychosis and the level of hopelessness, the secondary aim being to investigate, at item-level, hopelessness differences in hopelessness profi le of adolescents at risk of psychosis. Methods : Hopelessness was assessed with the Beck Hopelessness Scale (BHS) and risk of psychosis with the PROD screen by an early detection team at the Helsinki University Central Hospital in a sample of 200 help-seeking adolescents between 11 and 22 years of age. Of them, 66 were classifi ed as belonging to the at-risk of psychosis group and 134 to the not-at-risk of psychosis group. Results : The at-risk group scored higher in total sum scores of hopelessness than the not-at-risk group (9.15 vs. 6.63, P ϭ 0.002). In an additional analysis of the BHS, the sub-item “ I have great faith in the future ” ( P Ͻ 0.001) differed by risk status of psychosis after correction for multiple analysis. In a logistic regression analysis, BHS subfactor III (sum scores of items “ I can ’ t imagine what my life would be like in 10 years ” and “ I don ’ t expect to get what I really want ” ) explained ( P ϭ 0.047) the at-risk status of psychosis after age, gender and other BHS subfactors had been adjusted for. Conclusions : Adolescents at risk of psychosis have higher hopelessness than other help-seekers. In light of a heightened possibility of suicidal behaviour, psychiatric care should pay attention to these fi ndings. • Adolescents , Hopelessness , Risk of psychosis. Niklas Gran ö , Helsinki University Central Hospital, Jorvi Hospital, Department of Psychiatry, Turuntie 150, 02740 Espoo, Finland, E-mail: niklas.grano@hus.fi ; Accepted 26 September 2012. Hopelessness has been a widely studied phenomenon diagnosed in persons in their early 20s (20), and as the at-risk state before the onset of psychosis may last 5 Nord J Psychiatry Downloaded from informahealthcare.com by HYKS Lastenlinnan Kirjasto on 11/21/12 lessness has been under investigation especially for its years (21 23), the psychosis risk period is mainly association to suicidal behaviour (5 – 7). Recent literature relevant to adolescence. Psychosis risk status is usually has provided a lot of information of at-risk state of psy- assessed by specifi c interview instruments. The SIPS/ chosis: for example, there are different assessment SOPS (Structured Interview of Prodromal Symptoms/methods and instruments to assess the statistical risk of Scale Of Prodromal Symptoms) interview has been developing psychosis (8 10) and how the at-risk state reported to have a predictive validity of between 27% of psychosis is associated with several symptoms such and 54%. SIPS/SOPS defi 15), poor quality of life (16) and develop psychosis within 1 month (24 19). However, little is studies show a tendency towards lower transition rates known of hopelessness in an at-risk state of psychosis. because of earlier referral, effective treatment strategies The at-risk state of psychosis or ultra high risk (UHR) and inclusion of larger number of false-positive subjects is a stage before fi rst-episode psychosis. It is based on (27). The transition rates in recent studies vary between statistical risk of transition to psychosis with specifi c risk 19% and 6.6%, depending on the assessment instruments symptoms. As the fi rst-episode psychosis is typically used and the length of the follow-up period. For example, Yung et al. (27) found a 16% transition rate in lacking. The main aim of the present study is to a 2-year follow-up with CAARMS (Comprehensive investigate associations between the at-risk state of psy-Assessment of At Risk of Mental State) method, and chosis and the level of hopelessness and additionally Ruhrmann et al. (28) found a 19% transition rate within investigate hopelessness differences at item-by-item an 18-month follow-up by the UHR criteria that used a level to get a more detailed analysis of the hopelessness combination of SIPS/SOPS and BSABS (basic symp- profi le in adolescents at risk of developing psychosis. of 15.6% based on the SIPS/SOPS criteria and basic Methods
symptoms within a 2-year follow-up. Haroun et al. (30) Subjects
reported a transition rate of 13% based on the SIPS/ The Jorvi Early psychosis Recognition and Intervention SOPS criteria within a 1-year follow-up, which is very similar to that which Skeate et al. (31) reported, namely, tral Hospital (HUCH) in Finland, was designed to be car- a transition rate of 6.6% based on the UHR criteria and ried out by an early detection, intervention and research basic symptoms within a 6-month follow-up. In sum, team for adolescents at risk of developing fi rst-episode despite of these lower transition rates, psychosis risk psychosis. The catchment area consisted of fi ve towns assessment tools provide a useful way to assess a possi- with a population of half a million. The JERI team was a bility of having a higher risk to develop fi rst-episode multiprofessional team of psychiatric nurses, occupational therapists, psychologists and a supervising psychiatrist. The Beck Hopelessness Scale (BHS) (5) has been The JERI team met adolescents at age between 11 and widely used for hopelessness assessment in schizophrenia 22 in their natural surroundings, e.g. at school or at home, together with their parents and a community phrenia patients found that in the BHS two-factor solu- co-worker, who originally contacted the JERI team by telephone because of undiagnosed and unclear mental more closely linked to suicide intent than the health problems of their clients. The team had three main tasks: fi rst, to identify among help-seeking adolescents schizophrenia patients, the mean BHS total score was the possible risk of developing psychosis; second, in such al. (2) reported that, for 100 schizophre- cases to meet frequently the client and the family, nia patients with a mean BHS score of 6.20, hopeless- together with the community co-worker, to fi nd a way to ness was correlated with depression. Moreover, Lysaker reduce stress and support the client ’ s overall functioning al. (4) reported a mean BHS score of 5.93 for 143 at school or at work; and third, if some other psychiatric schizophrenia patients. In other studies, hopelessness has disorders or untreated psychosis came up, to direct the been associated with suicidality. For example, heightened person affected into adequate psychiatric care. The detec- hopelessness in case of 32 suicide attempters was tion and intervention model was originally developed at reported by Nordstr ö m et al. (6), and Klonsky et al. (32) the Jorvi Hospital between 2006 and 2008 (36). reported that, with 414 psychotic patients measured with Subjects were assessed at baseline between 1 April the BHS, hopelessness predicted attempted suicide up to 2009 and 31 October 2011 with the PROD screen (8) to 6 years but not beyond and at baseline later suicide identify those at risk of developing psychosis. During the attempters had higher BHS scores. Finally, Hutton et al. project period, a total of 528 telephone contacts were (33) reported a high prevalence of at least mild suicidal made to the JERI team. Altogether 200 adolescents were ideation (58.8%) among 34 subjects at risk of psychosis. met, asked to fi ll questionnaires and interviewed. All Psychometric properties of the BHS vary depending on Nord J Psychiatry Downloaded from informahealthcare.com by HYKS Lastenlinnan Kirjasto on 11/21/12 subjects were interviewed using the screen, which exam- the population where the BHS has been examined. Kao ined their symptoms during the previous 12 months. al. (1) found a two-factor model for the BHS in a First, the PROD screen was completed as a questionnaire sample of schizophrenia patients, Beck et al. (5) found a by the respondent. After that, each of the answers was three-factor model with a suicidal population, Dyce (34) evaluated by a team worker through an interview as a found a three-factor model with an outpatient sample, true or as a false risk-item. The fi nal scores were based al. (35) found a two-factor solution with a sample of a community population. However, the sub- respondents, 66 were classifi ed as having the at-risk sta- items on the BHS are loaded differently on these factors, tus of psychosis, and 134 were classifi ed as not having depending on the population. To our knowledge, the BHS has not been analysed with a sample of help-seek-ing adolescents or in adolescents at risk of psychosis. Even though hopelessness is a well-studied phenom- Instruments
enon in schizophrenia (1 – 4), previous evidence of hope- The PROD screen (21-item dichotomy screen where 12 lessness in the at-risk state of psychosis is almost totally items are specifi c psychosis-risk items and responses are additionally processed through interviews after a positive (5) and high internal consistency (alpha answer) is based on the content of SIPS (9), Interview The BHS consists of the following 20 true – false items: for the Retrospective Assessment of the Onset of Schizo- 1) I look forward to the future with hope and enthusiasm; phrenia (IRAOS) (37) and BSABS (10) manuals, and is 2) I might as well give up because I can ’ t make things designed for a telephone interview or a self-report (8). Questions in the PROD screen are meant to cover the 3) When things are going badly, I am helped by knowing following: 1) the main symptom categories in SIPS; 2) ned by IRAOS, with 4) I can ’ t imagine what my life would be like in 10 years; prodromal prevalence higher than 50% in early stages of 5) I have enough time to accomplish the things I most broadly defi ned schizophrenic psychosis (38); and 3) eight basic symptoms with the highest discriminating 6) In the future, I expect to succeed in what concerns value in predicting future schizophrenic psychosis in the Aachen prospective early recognition study of 7) My future seems dark to me; schizophrenia (39). The PROD screen examines the 8) I expect to get more of the good things in life than the presence of symptoms during the previous 12 months. Specifi c risk items are: diffi culties in thinking clearly or 9) I just don ’ t get the breaks, and there ’ s no reason to concentrating, interfering thoughts or thoughts interrupted (SOPS A5, C3; IRAOS B.1. section 4; BSABS C.1.1. 10) My past experiences have prepared me well for my C.1.13); experience of thoughts running wild or diffi culty in controlling the speed of thoughts (SOPS A5b; BSABS 11) All I can see ahead of me is unpleasantness rather than C.1.3.); diffi culties in understanding written text or speech heard (SOPS C3; BSABS C.1.6.); diffi culty in controlling 12) I don ’ t expect to get what I really want; one ’ s speech, behaviour or facial expression while com- 13) When I look ahead to the future, I expect I will be municating (BSABS A.7.2.); feeling that events in the environment or other people ’ s behaviour specifi cally con- 14) Things just won ’ t work out the way I want them to; cern oneself (SOPS A.1.d; BSABS C.1.17); feeling 15) I have great faith in the future; euphoric (SOPS A3); disorders in connection with vision 16) I never get what I want, so it ’ s foolish to want (SOPS A.4.a; BSABS C.2.2, C.2.3. S2, C.2.8, C.2.9); disorders in connection with hearing (SOPS A.4.de; 17) It ’ s very unlikely that I will get any real satisfaction BSABS C.2.4.); diffi culties in carrying out ordinary rou- tine activities for the last 1 week (IRAOS 53; BSABS 18) The future seems vague and uncertain to me; C.3.3.); feeling that something strange or inexplicable is 19) I can look forward to more good times than bad A.1.d; IRAOS B.1. section 12); feelings, thoughts or 20) There ’ s no use in really trying to get something I want behaviours that could be considered weird or peculiar (SOPS A1, C1, C2); and feeling that one is being followed or being infl uenced in some special way (SOPS Items 2, 4, 7, 9, 11, 12, 14, 16, 17, 18 and 20 are keyed A2; IRAOS B.1. sections 13 and 15) (8). The PROD true and items 1, 3, 5, 6, 8, 10, 13, 15 and 19 are keyed screen has been standardized by evaluating the results false. Each response is scored as 0 or 1, and the total with SIPS (9). The PROD screen reached 75% specifi city hopelessness score is a sum score of all responses. and 80% sensitivity, and 77% overall predictive power Nord J Psychiatry Downloaded from informahealthcare.com by HYKS Lastenlinnan Kirjasto on 11/21/12 with a cut-off point of two or more in an epidemiologi- assessment, all team members were certifi ed in the use cally mixed sample carried out by telephone interview of the SIPS interview. The study was accepted by the (8). This was the threshold used in the present study. The ethics committee of HUCH, and voluntary participation adolescents who scored 0 or 1 points in the PROD screen in the study was emphasized. All subjects gave their were classifi ed into a “ not-at-risk ” group and those who informed consent prior to their inclusion in the study, scored 2 points or more were classifi ed into an “ at-risk ” and all details that might disclose the identity of those group. The SIPS interview has been reported to have a subjects are omitted. predictive validity as between 27% and 54% SIPS/SOPS defi ned prodromal state subjects developed psychosis Statistical methods
Means, chi-squares and standard deviations for variables The BHS (5, 40) was used to assess hopelessness in were calculated. Group differences and item-by-item subjects. The BHS was originally designed to assess differences between those at risk of psychosis and those hopelessness in suicidal patients, and it is also sensitive not at risk were calculated by using the independent to depression (5). The BHS has high reliability (0.93) samples -test. As there is no previous literature of factor structure on BHS concerning help-seeking ado- status of psychosis after age, gender and other BHS lescents or adolescents at risk of psychosis, we analy- sed our BHS by the Principal Component Analysis with
Varimax rotation. Items 1, 3, 5, 6, 7, 10, 15, 18 and 19
were loaded on factor I, items 2, 9, 11, 14, 16, 17 and Discussion
20 on factor II, items 4 and 12 on factor III and items
The main result of the present study is that adolescents 8 and 13 on factor IV. Sum scores of the items were at risk of psychosis have signifi cantly higher sum scores used to build each factor. Bonferroni correction was in hopelessness than other help-seeking adolescents. In calculated for multiple analysis in the item-level analy- an additional item-by-item analysis, the at-risk group dif- sis of risk status of psychosis. A logistic regression fered in several items from the not-at-risk of psychosis analysis adjusted to age and gender was used to test group and had higher scores in hopelessness. However, associations between at-risk status of psychosis and after correction for multiple analysis, only the sub-item subfactors of BHS. All statistical analyses were per- “ I have great faith in the future ” differed by risk status. formed with the PASW 19.0 statistical package. Finally, in logistic regression analysis subfactor III (Items “ I can ’ t imagine what my life would be like in 10 years ” (item 4) and “ I don ’ t expect to get what I really want ” ) explained signifi cantly the at-risk status of psychosis. To Table 1 shows that hopelessness mean sum score is sig- our knowledge, this is the fi rst time these results are nifi cantly higher in the at-risk group (9.15 vs. 6.63, reported, with these instruments, in adolescents at risk of P ϭ 0.002). The at-risk group does not differ in age from psychosis. the not-at-risk group ( P ϭ 0.259), and gender distribution The main fi nding of the present study is that adoles- is in balance in the total sample ( P ϭ 0.157). BHS factors cents at risk of psychosis have higher level of hopeless-I ( ness than adolescents below the threshold of at-risk of signifi cantly by risk status. In Table 2, after Bonferroni psychosis. According to Beck et al. ’ s (5) original valida-correction for multiple analysis, item “ I have great faith tion study of BHS, the sub-item in the future ” ( P Ͻ 0.001) differs signifi cantly by risk sta- the future ” (scored as false) has a high correlation (0.74) tus of psychosis. In logistic regression analysis (Table 3), to the total BHS scores. Hence, our fi nding that this higher hopelessness in BHS factor III (Including items “ I sub-item is related to the at-risk status of psychosis is not can t imagine what my life would be like in 10 years surprising. In factor analysis, BHS was loaded on four factors. The third factor, including the items (item 12) explained signifi cantly ( P ϭ 0.047) the at-risk imagine what my life would be like in 10 years ” (item 4) Table 1. Independent samples t -test of hopelessness (Beck Hopelessness Scale, BHS) sum score in adolescents by risk status of developing psychosis (PROD) ( n ϭ 200). Nord J Psychiatry Downloaded from informahealthcare.com by HYKS Lastenlinnan Kirjasto on 11/21/12 s , standard deviation. * Total gender chi-square ϭ 2.000, df ϭ 1, sig. ϭ 0.157. Table 2. Description of sub-items of the Beck Hopelessness Scale and the analysis * of item-by-item differences by risk status of developing psychosis ( n ϭ 200). 1. I look forward to the future with hope and enthusiasm.
2. I might as well give up because I can ’ t make things better for 3. When things are going badly, I am helped by knowing they can ’ t 4. I can ’ t imagine what my life would be like in 10 years.
5. I have enough time to accomplish the things I most want to do.
6. In the future, I expect to succeed in what concerns me most.
8. I expect to get more of the good things in life than the average 9. I just don ’ t get the breaks, and there ’ s no reason to believe I will in 10. My past experiences have prepared me well for my future.
11. All I can see ahead of me is unpleasantness rather than pleasantness.
12. I don ’ t expect to get what I really want.
13. When I look ahead to the future, I expect I will be happier 14. Things just won ’ t work out the way I want them to.
15. I have great faith in the future.
16. I never get what I want so it ’ s foolish to want anything.
17. It ’ s very unlikely that I will get any real satisfaction in the future.
18. The future seems vague and uncertain to me.
19. I can look forward to more good times than bad times.
20. There ’ s no use in really trying to get something I want because I and “ I don ’ t expect to get what I really want ” (item 12), Therefore, further studies are required to clarify the fac-was associated signifi cantly with the at-risk status of psy- torial structure in BHS separately for help-seeking ado- chosis, after controlling age and gender. According to lescents and for adolescents at risk of psychosis. Still, other factorial structures of BHS derived from various the present fi ndings suggest that higher scores on BHS clinical and non-clinical populations, the results suggest items that are measuring one that factorial constructs vary a lot in different populations. imagining what might happen in one associated with the at-risk status of psychosis. A high suicidality among schizophrenia patients is a well-known Table 3. Logistic regression analysis of subfactors of the Beck fact (42, 43), and hopelessness is associated with sui- Hopelessness Scale (BHS) by being at risk of developing psychosis — adjusted for age and gender ( n ϭ 200). 5). Thus, it is an interesting and important fi nding that hopelessness in at-risk state of psychosis Nord J Psychiatry Downloaded from informahealthcare.com by HYKS Lastenlinnan Kirjasto on 11/21/12 reaches a mean sum score of more than 9 points, which has been a common cut-off point for high hopelessness and associated with a heightened suicide risk (7, 40). al. (32) found with a sample of psychosis patients that a cut-off point of 3 or more on BHS yielded to sensitivity and specifi city values similar to those found in non-psychotic populations when using a cut-off point of 9 or more. This may refl ect a possibility that on a continuum of psychotic experiences subjects at risk of psychosis might on BHS have a lower cut-off point for suicidal behaviour than non-psychotic populations. More- over, previous literature on hopelessness in psychosis has * Factor III including BHS items “ I can ’ t imagine what my life would be focused on schizophrenia research with subjects older like in 10 years ” (item 4) and “ I don ’ t expect to get what I really want ” than in our study (1, 2). Hence, it is a notable fi nding that hopelessness is associated with the psychosis-risk between a single BHS item and psychosis-risk status status already in the adolescence, as the mean age of our after multiple testing might refl ect power problems of subjects was only a little over 15 years. the study. It is also possible that higher scores on one As the PROD screen was standardized by evaluating broad psychometric construct (PROD) co-vary with the results with the SIPS (Structural Interview for higher scores on another broad psychometric construct Prodromal Symptoms) screen (9) and the PROD screen (BHS), which additionally limits the generalizability of reaches a 75 % specifi city and 80% sensitivity with a the present results. The present sample consists of help-cut-off point of two or more in a epidemiologically seeking adolescents, who are selected without any speci-mixed sample (8) and our subjects were help-seeking fi cation of inclusion or exclusion criteria, suggesting that adolescents for mental health problems, it is possible that we cannot generalize these fi ndings to other clinical those who scored two or more in the present study samples. Finally, repeating the present study in the mainly belong to the true risk group of psychosis. How- future with some other psychosis-risk instrument, for ever, there is still a danger of being classifi ed as a false example with the Schizophrenia Proneness Instrument positive. At the moment, there is no golden standard for for Children and Adolescents (SPI-CY), would give an at-risk of psychosis defi nition. This means that it is valuable information. diffi cult to compare the present results with those of In sum, the present results describe hopelessness of at-risk literature, and this is mainly due to inadequate adolescents at-risk state of psychosis and give a new defi nition of risk status. Hence, the present results have and more detailed picture of it. These fi ndings should be to be interpreted in light of those risk symptoms that considered in the psychiatric care for adolescents at risk construct our screening instrument, the PROD screen, are of psychosis, especially in light of their heightened pro-mostly positive symptoms of psychosis and basic symp- toms, and do not include genetic risk of psychosis. Addi-
tionally, the predictive validity of the transition rate for Declaration of interest: The authors report no confl icts
a later psychosis by the PROD screen is unknown. Gen- of interest. The authors alone are responsible for the erally declining transition rates achieved with other content and writing of the paper.
screening instruments suggest that possible predictive
transition rate with the PROD screen cannot be espe-
cially high. Moreover, our previous study (15) reported References
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