[MUSIC PLAYING] We are the Association for Child and Adolescent Mental Health, or ACAMH for short, and this is ACAMH Learn. Psychotic experiences refer to unusual perceptual experiences like hearing or seeing things that other people don't or overvalued unusual beliefs. They're called psychotic experiences because they share some characteristics with the positive symptoms of psychosis, hallucinations, and delusions. But they're probably better described as perceptual and ideational disturbances because that more accurately describes what they are and avoids conflating them with psychotic disorders. They're quite common experiences, much more common than many people realise. Up to 1 in 5 children report experiences of hearing or seeing things that other people don't. And that's not including common experiences, like thinking you heard your name, being called in a noisy room. That's something more concrete than that. But they become less common as young people grow older. So in adulthood, the number goes from having been about 1 in 5 children to about 1 in 20 adults who report these experiences. For some young people, none, there appears to be no clinical relevance, and these can be experiences that happen in the context of normal development. We found, for example, in a pre-teen sample that were reporting these experiences was associated with a diagnosable mental health disorder in about half of cases, but not in the other half. It appears to become more common, however, as you enter into adolescence, that having these experiences is more likely to be associated with diagnosable mental health conditions. They're not associated with any particular group of mental health disorders. They can occur in people with the full spectrum of mental health conditions, from depression to anxiety, OCD to ADHD. In clinical samples, so young people who come to mental health services, these experiences are associated with more severe psychopathology. They're associated with more mental health service use, greater multimorbidity, which means having a higher total number of mental health disorders and poorer functioning than young people who come to those services who don't have psychotic experience. And they've also consistently been shown to be associated with a higher risk of suicidal thoughts and behaviours. So in this annual research review, I've included a book of practical advice on this, and the principles I suggest are, one, to contextualise the experiences, explain that unusual perceptual experiences are more common than most people realise. As I said, up to 1 in 5 children report hearing voices or similar phenomena at some stage, and for the majority of children, these experiences are transient. Two, educate, explain a little about the rapid brain development and reorganisation that's occurring in mid-childhood through adolescence, which may help us to understand why unusual perceptual experiences like this are more likely to occur, more likely to occur at this age. So for example, I often discuss how the brain is wiring and rewiring, making new connections, snipping or pruning old connections that seem to be less important. And these processes affect how brain cells and brain regions communicate with each other. So while this intensive the reorganisation is happening, it's not surprising that there will be some miscommunication, mistaking something they thought for something they heard, crossed wires essentially. This is especially likely to happen when the young person's brain and mind are already being overwhelmed or overloaded. For example, when they're feeling very angry or sad or distressed. Three, a minority of parents will worry that this is a sign of emerging schizophrenia, and I take the time to reassure that this is not the outcome for the vast majority of these young people. Greater than 90% of children and adolescents who report these experiences will not go on to develop a psychotic disorder. Four, where indicated, I treat or address factors that may be contributing to the occurrence of these experiences. So if the young person has a specific mental health disorder, it can be the case that effectively treating that condition may be associated with the reduction or resolution of psychotic experiences. It could also be the case, for example, that there's something stressful going on for the young person. And if you identify and support them around this, that may also help to ameliorate psychotic experiences. More broadly, the general principles of good mental health are likely to apply here, including advice around good sleep, exercise structure, and avoiding substance use. It's also important to be clear that anti-psychotic medications are not indicated for these experiences. There have been two main approaches to identifying psychosis risk in the literature over the past quarter century, the clinical high risk, or CHR, approach, and the familial high risk, or FHR, approach. The clinical high risk approach was a really innovative approach that emerged from centres in Australia and North America and spread to many parts of the world. This approach involves using a structured clinical interview to assess for symptoms of psychosis. And depending on the frequency of severe or severity of these symptoms, a clinical high risk stage or syndrome could be diagnosed. Initial studies suggested about 40% of this group went on to develop a psychotic disorder. Subsequent studies found lower transmission rates probably closer to 20%, but the transmission rates vary a lot from one study to the next. Sometimes a bit higher, but also sometimes much lower. The familial high risk approach is based on having one or more relatives, typically a parent with a history of psychosis because we know that there is some heritability to psychosis, though, it's less than many people realise. A meta-analysis suggests that if you have a parent with psychosis, you have an 8% chance of going on to develop psychosis. So that's a substantially elevated risk compared to if you don't have a psychosis. But still, more than 90% of people who have a parent with psychosis do not themselves go on to develop psychosis. Overall, these approaches have been very innovative and challenged us in psychiatry to think about prediction and prevention, which is something that's happening across many other areas of medicine perhaps most notably in cardiology and oncology. It's only quite recently been the case, however, that researchers have begun to investigate the sensitivity of these approaches. That means of all cases of psychotic disorders diagnosed in the population, what proportion are captured by or identified with clinical high-risk services or using the familial high-risk approach. And that's important because it tells us the upper limit of psychosis cases that we can hope to prevent using these approaches if we had a perfect preventive intervention. In both the clinical high risk and familial high risk approaches, however, the sensitivity is very low. Our recent meta-analysis suggests that in both cases, only between 6% and 7% of all psychosis cases in the population are captured with these approaches. Now that we are aware of the limited sensitivity of clinical high risk and familial high risk approaches, researchers are looking at additional ways that we might be able to identify or capture risk for psychosis earlier in life. One approach has been to look away from symptoms per se, and instead look at systems, look at systems that capture risk. One such system is the emergency department. So we have done research to show that young people who present to the emergency department with self-harm and have a high risk of going on to develop psychosis. And so it's quite obvious in that group that their mental health struggles, often depression or emerging personality problems, and less of a focus on recognising that also may be an early sign of risk for psychosis. At the same time, those approaches also capture a very small proportion of people who of all people who will go on to develop psychosis. Extending out from the familial risk approach, where you have a parent who has a diagnosis of psychosis, we have looked at parents who have made contact or been admitted to psychiatric hospitals for any reason, so a transdiagnostic familial risk approach. What we found in that case was that as opposed to the small number, 6% to 7% of psychosis cases that are identified, when you just look at parents with a history of psychosis, when we looked at parents with a history of inpatient admission for any reason, that identified 30% of future psychosis cases. So a substantially higher proportion that could be identified with that approach. We have also looked at child and adolescent psychiatry services or child and adolescent mental health services, CAMHS. We've used total national register data in Finland and the UK to explore what proportion of all psychosis cases diagnosed in the population emerge in people who had been to child and adolescent mental health services. Again, as opposed to the small proportion of cases that emerge from clinical high risk services or familial risk approaches, 6% to 7%, we found that up to 50% of psychosis cases that are diagnosed in the population by age 30 are in people who had been in child and adolescent mental health services. And so that's exciting in terms of prediction and prevention because it's pointing to existing services for children and adolescents who, by definition, are in a stage of brain development that might be more amenable to preventive intervention. And it's saying that we can identify groups in potentially far higher numbers in these services. So a lot of research remains to be done to look at child and adolescent mental health services and the detection of risk within those services. When a psychotic disorder has onset before age 18, that's what we call early onset-psychosis. And that applies to about 12% of psychosis cases. They have onset before age 18. In terms of treatment options, as a psychiatrist, I think biopsychosocial from a biological perspective, there's good evidence for most but not all antipsychotic medications during the acute phase of psychosis in adolescence. That includes aripiprazole, asenapine, lurasidone, olanzapine, paliperidone, quetiapine and risperidone. Meta-analytic research does not support the use of ziprasidone in adolescents. Some of the key principles to consider in terms of quality prescribing in psychosis, which were proposed by James Scott and colleagues in Australia, are, one, medication choice being informed by adverse effects because while all of the listed medications may be effective, they have different side effect profiles, and that's important to consider, including what matters most to the young person sitting in front of you. Two, close monitoring of metabolic side effects from the outside-- from the outset because, of course, that is one of the major challenges with some of them more than others. Three, regular medication risk benefit assessment. Four, assessment and intervention for co-occurring mood disorders. And Five, early consideration of clozapine. There is good evidence to support the efficacy of clozapine being in early-onset psychosis. Research shows a large effect size benefit over other antipsychotics, but it's very underused in adolescent with schizophrenia. At the same time, of course, these medications require expert management. It's less clear how long someone should remain on antipsychotic after the acute illness has resolved. Studies have followed young people for one or two years or more and have shown continued improvement in psychotic symptoms. But some of the evidence is based on open-label studies without a placebo comparison. And so it's unclear how much of the additional benefit comes from medication treatment versus what might have happened if the person was not on medication. So more research is needed to investigate maintenance antipsychotic treatment for people with early-onset psychosis. From a psychosocial intervention perspective, I wish there were far more that I could recommend, but the truth is that the evidence for early-onset psychosis is lacking. A systematic review of psychological interventions in early onset psychosis, published in schizophrenia bulletin in 2021, concluded scientific support for efficacy and effectiveness of psychological treatments for adolescents with schizophrenia is virtually missing. There have been a couple of studies since that time, but there remains very little evidence to support any specific psychosocial intervention in early-onset psychosis. So this is an area that clearly needs further research. [MUSIC PLAYING]