The objective of the study was to examine clinical, functional, and cognitive outcomes of at-risk mental state among Czech non-help seeking adolescents drawn from general population. The results revealed lower social and occupational functioning, and higher prevalence of subthreshold mental disorders in the ARMS + adolescents compared to the controls. Our findings thus confirm the hypothesis that that even the non-help seeking ARMS + adolescents have more psychiatric diagnoses and lower level of functioning. Furthermore, a significant association was found between the presence of subthreshold psychotic syndrome and quality of life among non-help seeking adolescents; the severity of CAARMS symptoms was negatively associated with general functioning. However, the presumption of poorer cognitive performance in ARMS + subjects could not be confirmed.
The prevalence of ARMS + adolescents in our sample (26%) was higher than previously reported [6, 29]. It can be attributed to the sampling bias, 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. Nevertheless, there are no data to support this surmise.
Two other studies reported high rates of comorbidities among the ARMS + samples, mainly with mood and anxiety disorders [14, 30]. However, both studies included help-seeking individuals only. In a study with non-help-seeking adolescents, 63% of those who met criteria for a prodromal risk syndrome also met criteria for at least one lifetime Axis-1 diagnosis [31]. In our non-help-seeking sample, the prevalence of other psychiatric disorders was lower. Interestingly, even the difference in the prevalence rates of threshold mental disorders between ARMS+/ARMS- subjects did not reach statistical significance. On the other hand, we should not overlook the high prevalence of subthreshold diagnoses in our ARMS + sample, similar to the prevalence observed in larger samples [32]. The subthreshold mental disorders were more frequent in the ARMS + group than in the ARMS- group. Since subthreshold anxiety and affective disorders have been found to precede full blown non-psychotic illness, these data emphasize the importance of clinical follow-up of the ARMS + adolescents [33–34].
Overall level of functioning, as indexed by the SOFAS score, were similar to the functioning level of non-help-seeking adolescent samples from other countries [29, 35]. The SOFAS score in our sample was mostly affected by the severity of CAARMS symptoms; therefore, not surprisingly, the ARMS + group had poorer functioning than the ARMS- group.
All of the ARMS + subjects belonged to the Attenuated Psychotic Syndrome (APS) group. Presence of the APS symptoms can cause significant distress, with greatest contribution of non-bizarre ideas [36]. Clustering of ARMS + individuals according to specific psychopathology can improve our ability to predict which of them develop psychosis [37].
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 [38]. In addition, those with both comorbid anxiety and depressive diagnoses were more severely functionally impaired. Even though the presence of current threshold or subthreshold diagnosis in our sample was not associated with the social and occupational functioning, the comorbidity rate was lower than in previously published studies [14, 30–31].
Our results suggest that the subclinical psychotic syndrome in the population of adolescents, even non-help seeking, have negative impact on their quality of life. We observed negative association between the severity of CAARMS symptoms and five subscales of KIDSCREEN, namely: 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, relations with parents. The results further corroborate findings from previous study, in which the authors showed with the same QoL instrument (KIDSCREEN52) that the ARMS subjects had poorer results than controls in Physical Well-being, Psychological Well-being and School Environment [39].
Somewhat 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 [16]. The discrepancy can be partially explained by different recruitment methods used and dissimilar cognitive tests administered. Haining and collaborators used online-screening approach to enrol participants and assessed cognitive performance with Brief Assessment of Cognition in Schizophrenia and three tasks from the CNB battery (the Continuous Performance Test, the N-Back Task and the Emotion Recognition Task) [16]. Another possible explanation of our negative findings is a relatively small, thus possibly underpowered, sample size. Furthermore, 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.
People commonly do not seek help until their problems are severe enough to interfere with their occupational or psychosocial functioning [35]. Even then, the reasons for persons with the ARMS symptoms to ask for help are mainly driven by depressed mood or anxiety [40].
In our study, we observed that adolescents with at-risk mental state experience significant functional decline compared to their healthy peers. It has been previously stated that the risk of transition into psychosis grows along with increasing intensity of subthreshold psychotic symptoms and decrease in functioning [37]. 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 [41]. 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 [42, 43]. There are also reports indicating that cognitive remediation in the ARMS subjects can improve functional outcome and cognition in the domains of verbal memory, attention, and processing speed, but the data are rather scarce [44].
Study limitation is the absence of assessment of negative symptoms across our sample. Several studies suggested that cognitive, social, and functional impairments in help-seeking individuals are associated more strongly with negative symptoms (mostly affective flattening and avolition-apathy), than with positive or depressive symptoms [13, 45–46]. Since the tools for assessment of ARMS status are designed to evaluate the risk of transition to psychosis, they emphasize the importance of positive symptoms and thus the importance of early negative symptoms is often overlooked.