Can we predict conversion to first-episode psychosis?

A better understanding of the pre-psychotic and prodromal symptoms of psychosis can aid correct diagnosis, and provides an opportunity for earlier and potentially more individualised intervention. Recent results from a study detailing common and important symptoms that precede conversion to first-episode psychosis (FEP) were presented at SIRS 2022.

Dr Vincent Paquin, McGill University, Montreal, Canada, presented his recently published work where the patients with FEP, 14 to 35 years of age, were enrolled over a 15-year period from a specialized, early intervention, out-patient programme from a catchment area of more than 300,000 people in Montreal.1

The most common precursors to first-episode psychosis are affective symptoms


Non-psychotic symptoms (NPS) are the most common precursors to psychosis

In the 390 patients with psychosis included in the study, 27 pre-defined precursor signs and symptoms were evaluated retrospectively using semi-structured interviews and questionnaires from patients and their families.1

The 10 most common precursor symptoms were depression (reported in about 75% of patients), followed in descending order by anxiety, substance use, impaired role functioning, social withdrawal, impaired concentration, sleep disturbance, decreased energy, suspiciousness, and irritability.2 Suspiciousness was the most common sub-threshold psychotic symptom (STPS) identified (seen in 48% of patients).3

Depression is the most common precursor to first-episode psychosis

Combinations of symptoms were also evaluated. Groups of pre-psychotic symptoms most commonly found together were depression and anxiety (reported in 56% of patients) and depression, anxiety, and social withdrawal (reported in 38% of patients).3


A first symptom of suspiciousness may be key to predicting time to FEP

Patients with a first symptom of suspiciousness had a significantly shorter time to FEP onset (hazard ratio [HR]=2.37) and had a significantly higher symptom incidence rate (incidence rate ratio [IRR]=3.20) compared to patients with other first symptoms.1 Patients with suspiciousness were significantly more likely to develop anxiety (IRR=3.69), but patients with anxiety were not at higher risk of developing suspiciousness.3

Early onset of suspiciousness is a marker of rapid symptom accumulation and conversion to first-episode psychosis

Non-psychotic symptoms significantly associated with a faster speed to FEP included elated mood (HR:1.95) and impaired role functioning (HR:1.72). A first symptom of self-harm was associated with a significantly lower incidence rate of additional symptoms (IRR=0.06).1


FEP : First-Episode Psychosis
SIRS: Schizophrenia International Research Society 
NPS: non-psychotic symptoms
STPS: sub-threshold psychotic symptom 
HR: hazard ratio
IRR: incidence rate ratio

BE-NOTPR-0171; approval date : 05.2022

Our correspondent’s highlights from the symposium are meant as a fair representation of the scientific content presented. The views and opinions expressed on this page do not necessarily reflect those of Lundbeck.

  1. Paquin V, et al. Dynamic association of the first identifiable symptom with rapidity of progression to first-episode psychosis. Psychol Med 2021:1-9. 
  2. Paquin V. Oral presentation at SIRS 2022.
  3. Paquin V. Following Breadcrumbs to Win the Race: Retrospective Examination of Precursor Symptoms in First-Episode Psychosis (Abstract). SIRS 2022.
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