What demographic and clinical factors are associated with transition from early (subthreshold)
to full-threshold major persistent or recurrent psychiatric disorders? This longitudinal
cohort study of persons aged 12 to 25 years who presented to early intervention services
found significant and ongoing risk of transition to major anxiety, mood, psychotic,
or comorbid disorders. Poorer social function, psychotic-like experiences, manic-like
experiences, and circadian disturbance were associated with illness progression. A
clinical staging model for specific youth services may support the efficient allocation
of appropriate care to young people and support the evidence-based planning of relevant
early intervention and secondary prevention strategies. This Australian longitudinal
cohort study follows up 2254 individuals aged 12 to 25 years who obtained care from
early-intervention mental health services to compare progression of disorder based
on demographic features and clinical stage at presentation. 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. 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. 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). 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. 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). 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.