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Schizophr Bull. 2016 May;42(3):732-43. doi: 10.1093/schbul/sbv162. Epub 2015 Nov 20.

The Dark Side of the Moon: Meta-analytical Impact of Recruitment Strategies on Risk Enrichment in the Clinical High Risk State for Psychosis.

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University Hospital of Child and Adolescent Psychiatry and Psychotherapy, Department of Child and Adolescent Psychiatry, University of Bern, Bern, Switzerland;
Department of Psychosis Studies, King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK; Department of Brain and Behavioural Sciences, University of Pavia, Pavia, Italy;
Department of Psychosis Studies, King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK;
Department of Biostatistics, Institute of Psychiatry Psychology and Neuroscience, King's College London, London UK;
Department of Psychiatry (UPK), University of Basel Psychiatric Clinics, Basel, Switzerland;
Department of Psychiatry, University of Calgary, Calgary, Alberta, Canada;
Department of Psychiatry, University of North Carolina, Chapel Hill, NC;
Department of Psychiatry, Yale University, New Haven, CT;
Department of General Psychiatry, Institute of Mental Health, Singapore, Singapore;
Department of Psychiatry and Psychotherapy, University of Cologne, Cologne, Germany;
Institute of Brain, Behaviour and Mental Health, University of Manchester, Manchester, UK.
Department of Psychosis Studies, King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK; OASIS Service, South London and the Maudsley NHS Foundation Trust, London, UK;



The individual risk of developing psychosis after being tested for clinical high-risk (CHR) criteria (posttest risk of psychosis) depends on the underlying risk of the disease of the population from which the person is selected (pretest risk of psychosis), and thus on recruitment strategies. Yet, the impact of recruitment strategies on pretest risk of psychosis is unknown.


Meta-analysis of the pretest risk of psychosis in help-seeking patients selected to undergo CHR assessment: total transitions to psychosis over the pool of patients assessed for potential risk and deemed at risk (CHR+) or not at risk (CHR-). Recruitment strategies (number of outreach activities per study, main target of outreach campaign, and proportion of self-referrals) were the moderators examined in meta-regressions.


11 independent studies met the inclusion criteria, for a total of 2519 (CHR+: n = 1359; CHR-: n = 1160) help-seeking patients undergoing CHR assessment (mean follow-up: 38 months). The overall meta-analytical pretest risk for psychosis in help-seeking patients was 15%, with high heterogeneity (95% CI: 9%-24%, I (2) = 96, P < .001). Recruitment strategies were heterogeneous and opportunistic. Heterogeneity was largely explained by intensive (n = 11, β = -.166, Q = 9.441, P = .002) outreach campaigns primarily targeting the general public (n = 11, β = -1.15, Q = 21.35, P < .001) along with higher proportions of self-referrals (n = 10, β = -.029, Q = 4.262, P = .039), which diluted pretest risk for psychosis in patients undergoing CHR assessment.


There is meta-analytical evidence for overall risk enrichment (pretest risk for psychosis at 38 monhts = 15%) in help-seeking samples selected for CHR assessment as compared to the general population (pretest risk of psychosis at 38 monhts=0.1%). Intensive outreach campaigns predominantly targeting the general population and a higher proportion of self-referrals diluted the pretest risk for psychosis.


CAARMS; SIPS; meta-analysis/risk; prevention; psychosis; schiz-ophrenia

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