Health literacy in clinical-high-risk individuals for psychosis: A systematic mixed-methods review.
Journal
Early intervention in psychiatry
ISSN: 1751-7893
Titre abrégé: Early Interv Psychiatry
Pays: Australia
ID NLM: 101320027
Informations de publication
Date de publication:
12 2019
12 2019
Historique:
received:
06
08
2018
revised:
30
11
2018
accepted:
26
12
2018
pubmed:
29
1
2019
medline:
18
2
2020
entrez:
29
1
2019
Statut:
ppublish
Résumé
Numerous studies suggest that health literacy (HL) plays a crucial role in maintaining and improving individual health. Empirical findings highlight the relation between levels of a person's HL and her/his clinical outcome. To date, the role of HL in persons at-risk for psychosis has not been systematically reviewed. We conducted a systematic review using a mixed-methods approach to analyse a variety of study types. Peer-reviewed publications were systematically searched in PUBMED, Cochrane Library, PsycINFO and Web of Science. The search string returned 10587 publications. After screening, 15 quantitative, four qualitative studies and two reviews were included. Only one study assessed HL as primary outcome, assessing knowledge and beliefs about psychosis among the general population. In the other studies, sub-dimensions of HL were investigated. None of the publications operationalized HL or it's sub-dimensions with a validated measure. A lack of understanding of their condition, and fear of stigmatization, were associated with a delay in help-seeking among people with clinical-high-risk state for psychosis. Family members, school personnel, general practitioners and the internet play a crucial role in the HL process. Considerable barriers in obtaining adequate specialist support emphasize the urgent need of a "HL environment" for persons at risk for psychosis.
Types de publication
Journal Article
Systematic Review
Langues
eng
Sous-ensembles de citation
IM
Pagination
1293-1309Informations de copyright
© 2019 John Wiley & Sons Australia, Ltd.
Références
Addington, D., Berzins, S., & Yeo, M. (2012). Psychosis literacy in a Canadian health region: Results from a general population sample. The Canadian Journal of Psychiatry, 57(6), 381-388.
Addington, J., Case, N., Saleem, M. M., Auther, A. M., Cornblatt, B. A., & Cadenhead, K. S. (2014). Substance use in clinical high risk for psychosis: A review of the literature. Early Intervention in Psychiatry, 8(2), 104-112.
Australian Commission On Safety And Quality In Health Care. (2014). National statement on health literacy: Taking action to improve safety and quality.
Berkman, N. D., Sheridan, S. L., Donahue, K. E., Halpern, D. J., Viera, A., Crotty, K., … Viswanathan, M. (2011). Health literacy interventions and outcomes: An updated systematic review. Evidence Report/Technology Assessment (Full Report), (199), 1-941.
Boydell, K. M., Gladstone, B. M., & Volpe, T. (2006). Understanding help seeking delay in the prodrome to first episode psychosis: A secondary analysis of the perspectives of young people. Psychiatric Rehabilitation Journal, 30(1), 54-60.
Boydell, K. M., Stasiulis, E., Volpe, T., & Gladstone, B. (2010). A descriptive review of qualitative studies in first episode psychosis. Early Intervention in Psychiatry, 4(1), 7-24.
Boydell, K. M., Volpe, T., Gladstone, B. M., Stasiulis, E., & Addington, J. (2013). Youth at ultra high risk for psychosis: Using the revised network episode model to examine pathways to mental health care. Early Intervention in Psychiatry, 7(2), 170-186.
Brimblecombe, N., Knapp, M., Murguia, S., Mbeah-Bankas, H., Crane, S., Harris, A., … King, D. (2017). The role of youth mental health services in the treatment of young people with serious mental illness: 2-year outcomes and economic implications. Early Intervention in Psychiatry, 11(5), 393-400.
Broome, M. R., Woolley, J. B., Johns, L. C., Valmaggia, L. R., Tabraham, P., Gafoor, R., … McGuire, P. K. (2005). Outreach and support in South London (OASIS): Implementation of a clinical service for prodromal psychosis and the at risk mental state. European Psychiatry, 20(5-6), 372-378.
Brummitt, K., & Addington, J. (2013). Treatment possibilities for individuals at clinical high risk of psychosis. Early Intervention in Psychiatry, 7(2), 155-161.
Byrne, R., & Morrison, A. P. (2010). Young people at risk of psychosis: A user-led exploration of interpersonal relationships and communication of psychological difficulties. Early Intervention in Psychiatry, 4(2), 162-168.
Caplan, B., Zimmet, S. V., Meyer, E. C., Friedman-Yakoobian, M., Monteleone, T., … Seidman, L. J. (2013). Prevention and recovery in early psychosis (PREP([R])): Building a public-academic partnership program in Massachusetts, United States. Asian Journal of Psychiatry, 6(2), 171-177.
Carr, V., Halpin, S., Lau, N., O'Brien, S., Beckmann, J., & Lewin, T. (2000). A risk factor screening and assessment protocol for schizophrenia and related psychosis. The Australian and New Zealand Journal of Psychiatry, 34(Suppl), S170-S180.
Chung, Y. C., Jung, H. Y., Kim, S. W., Lee, S. H., Shin, S. E., Shin, Y. M., … Kim, Y. H. (2010). What factors are related to delayed treatment in individuals at high risk for psychosis? Early Intervention in Psychiatry, 4(2), 124-131.
Cocchi, A., Meneghelli, A., Erlicher, A., Pisano, A., Cascio, M. T., & Preti, A. (2013). Patterns of referral in first-episode schizophrenia and ultra high-risk individuals: Results from an early intervention program in Italy. Social Psychiatry and Psychiatric Epidemiology, 48(12), 1905-1916.
Cornblatt, B. A., Lencz, T., Smith, C. W., Correll, C. U., Auther, A. M., & Nakayama, E. (2003). The schizophrenia prodrome revisited: A neurodevelopmental perspective. Schizophrenia Bulletin, 29(4), 633-651.
Cotton, S. M., Filia, K. M., Ratheesh, A., Pennell, K., Goldstone, S., & McGorry, P. D. (2016). Early psychosis research at Orygen, the National Centre of excellence in youth mental health. Social Psychiatry and Psychiatric Epidemiology, 51(1), 1-13.
Domingues, I., Alderman, T., & Cadenhead, K. S. (2011). Strategies for effective recruitment of individuals at risk for developing psychosis. Early Intervention in Psychiatry, 5(3), 233-241.
Falkenberg, I., Valmaggia, L., Byrnes, M., Frascarelli, M., Jones, C., Rocchetti, M., … Fusar-Poli, P. (2015). Why are help-seeking subjects at ultra-high risk for psychosis help-seeking? Psychiatry Research, 228(3), 808-815.
Fridgen, G. J., Aston, J., Gschwandtner, U., Pflueger, M., Zimmermann, R., Studerus, E., … Riecher-Rossler, A. (2013). Help-seeking and pathways to care in the early stages of psychosis. Social Psychiatry and Psychiatric Epidemiology, 48(7), 1033-1043.
Fusar-Poli, P., Borgwardt, S., & Valmaggia, L. (2008). Heterogeneity in the assessment of the at-risk mental state for psychosis. Psychiatric Services, 59(7), 813.
Fusar-Poli, P., Tantardini, M., De Simone, S., Ramella-Cravaro, V., Oliver, D., Kingdon, J., … McGuire, P. (2017). Deconstructing vulnerability for psychosis: Meta-analysis of environmental risk factors for psychosis in subjects at ultra high-risk. European Psychiatry, 40, 65-75.
Gill, K. E., Poe, L., Azimov, N., Ben-David, S., Vadhan, N. P., Girgis, R., … Corcoran, C. M. (2015). Reasons for cannabis use among youths at ultra high risk for psychosis. Early Intervention in Psychiatry, 9(3), 207-210.
Green, C. E., McGuire, P. K., Ashworth, M., & Valmaggia, L. R. (2011). Outreach and support in South London (OASIS). Outcomes of non-attenders to a service for people at high risk of psychosis: The case for a more assertive approach to assessment. Psychological Medicine, 41(2), 243-250.
Harden, A. (2010). Mixed-methods systematic reviews: Integrating quantitative and qualitative findings. The Focus: Technical Brief, 25, 1-8.
Hauser, M., & Juckel, G. (2012). Psychoeducation in subjects at elevated risk for psychosis--a critical review. Current Pharmaceutical Design, 18(4), 566-569.
Hauser, M., Lautenschlager, M., Gudlowski, Y., Ozgurdal, S., Witthaus, H., Bechdolf, A., … Juckel, G. (2009). Psychoeducation with patients at-risk for schizophrenia-An exploratory pilot study. Patient Education and Counseling, 76(1), 138-142.
Hawker, S., Payne, S., Kerr, C., Hardey, M., & Powell, J. (2002). Appraising the evidence: Reviewing disparate data systematically. Qualitative Health Research, 12(9), 1284-1299.
Heddaeus, D., Steinmann, M., Liebherz, S., Harter, M., & Watzke, B. (2015). Psychenet-The Hamburg network for mental health: Evaluation of the health network depression from the perspective of participating general practitioners. Psychiatrische Praxis, 42(Suppl 1), S54-S59.
Hood, L. (2004). A role in changing public attitudes. Nursing Times, 100(15), 42-43.
Hood, L., & Flores, M. (2012). A personal view on systems medicine and the emergence of proactive P4 medicine: Predictive, preventive, personalized and participatory. New Biotechnology, 29(6), 613-624.
Joa, I., Gisselgard, J., Bronnick, K., McGlashan, T., & Johannessen, J. O. (2015). Primary prevention of psychosis through interventions in the symptomatic prodromal phase, a pragmatic Norwegian ultra high risk study. BMC Psychiatry, 15, 89.
Kelleher, I., Murtagh, A., Molloy, C., Roddy, S., Clarke, M. C., Harley, M., & Cannon, M. (2012). Identification and characterization of prodromal risk syndromes in young adolescents in the community: A population-based clinical interview study. Schizophrenia Bulletin, 38(2), 239-246.
Keshavan, M. S., DeLisi, L. E., & Seidman, L. J. (2011). Early and broadly defined psychosis risk mental states. Schizophrenia Research, 126(1-3), 1-10.
Klosterkötter, J., Schultze-Lutter, F., Bechdolf, A., & Ruhrmann, S. (2011). Prediction and prevention of schizophrenia: What has been achieved and where to go next? World of Psychiatry, 10(3), 165-174.
Kohls, E., Coppens, E., Hug, J., Wittevrongel, E., Van Audenhove, C., Koburger, N., … Hegerl, U. (2017). Public attitudes toward depression and help-seeking: Impact of the OSPI-Europe depression awareness campaign in four European regions. Journal of Affective Disorders, 217, 252-259.
Kotlicka-Antczak, M., Pawelczyk, T., Rabe-Jablonska, J., & Pawelczyk, A. (2015). PORT (Programme of recognition and therapy): The first polish recognition and treatment programme for patients with an at-risk mental state. Early Intervention in Psychiatry, 9(4), 339-342.
Laba, T. L., Lehnbom, E., Brien, J. A., & Jan, S. (2015). Understanding if, how and why non-adherent decisions are made in an Australian community sample: a key to sustaining medication adherence in chronic disease? Research in Social and Administrative Pharmacy, 11(2), 154-162.
Langebeek, N., Gisolf, E. H., Reiss, P., Vervoort, S. C., Hafsteinsdottir, T. B., Richter, C., … Nieuwkerk, P. T. (2014). Predictors and correlates of adherence to combination antiretroviral therapy (ART) for chronic HIV infection: A meta-analysis. BMC Medicine, 12, 142.
Larsen, T. K., Melle, I., Auestad, B., Haahr, U., Joa, I., Johannessen, J. O., … McGlashan, T. (2011). Early detection of psychosis: Positive effects on 5-year outcome. Psychological Medicine, 41(7), 1461-1469.
Leopold, K., Pfeiffer, S., Correll, C. U., Bauer, M., & Pfennig, A. (2013). Early recognition centers for mental disorders-A complementary supply in the german health system. Psychiatrische Praxis, 40(5), 264-270.
Loewy, R. L., Bearden, C. E., Johnson, J. K., Raine, A., & Cannon, T. D. (2005). The prodromal questionnaire (PQ): Preliminary validation of a self-report screening measure for prodromal and psychotic syndromes. Schizophrenia Research, 79(1), 117-125.
Lohaus, A., & Schmitt, G.M. (1989). Fragebogen zur Erhebung von Kontrollüberzeugungen zu Krankheit und Gesundheit (KKG), Handanweisung. Göttingen, Toronto, Zürich: Hofgrefe.
Lynch, S., McFarlane, W. R., Joly, B., Adelsheim, S., Auther, A., & Cornblatt, D. D. (2016). Early detection, intervention and prevention of psychosis program: Community outreach and early identification at six U.S. sites. Psychiatric Services, 67(5), 510-516.
Makowski, A. C., Mnich, E. E., Ludwig, J., Daubmann, A., Bock, T., & Lambert, …v. d. K. O. (2016). Changes in beliefs and attitudes toward people with depression and schizophrenia-Results of a public campaign in Germany. Psychiatry Research, 237, 271-278.
Mantell, P., Baumeister, A., Jünger, S., & Woopen, C. (2019). Health literacy in people with mental disorders-A systematic review. Journal of Mental Health.
Matthes, J., & Albus, C. (2014). Improving adherence with medication: A selective literature review based on the example of hypertension treatment. Deutsches Ärzteblatt International, 111(4), 41-47.
McFarlane, W. R., Cook, W. L., Downing, D., Verdi, M. B., Woodberry, K. A., & Ruff, A. (2010). Portland identification and early referral: A community-based system for identifying and treating youths at high risk of psychosis. Psychiatric Services, 61(5), 512-515.
McGlashan, T. H., Addington, J., Cannon, T., Heinimaa, M., McGorry, P., & O'Brien, …. Y. A. (2007). Recruitment and treatment practices for help-seeking "prodromal" patients. Schizophrenia Bulletin, 33(3), 715-726.
McGlashan, T. H., Zipursky, R. B., Perkins, D., Addington, J., Miller, T., Woods, S. W., … Breier, A. (2006). Randomized, double-blind trial of olanzapine versus placebo in patients prodromally symptomatic for psychosis. The American Journal of Psychiatry, 163(5), 790-799.
McGorry, P. D., & Singh, B. S. (1995). Schizophrenia: Risk and possibility, handbook of preventive psychiatry (pp. 492-451). Amsterdam: Elsevier.
Miller, T. J., McGlashan, T. H., Rosen, J. L., Cadenhead, K., Cannon, T., Ventura, J., … Woods, S. W. (2003). Prodromal assessment with the structured interview for prodromal syndromes and the scale of prodromal symptoms: Predictive validity, interrater reliability, and training to reliability. Schizophrenia Bulletin, 29(4), 703-715.
Moher, D., Liberati, A., Tetzlaff, J., Altman, D. G., & PRISMA Group. (2009). Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. Journal of Clinical Epidemiology, 62(10), 1006-1012.
Mukhtar, O., Weinman, J., & Jackson, S. H. D. (2014). Intentional non-adherence to medications by older adults. Drugs Aging, 31(3), 149-157.
Nelson, B., Fusar-Poli, P., & Yung, A. R. (2012). Can we detect psychotic-like experiences in the general population? Current Pharmaceutical Design, 18(4), 376-385.
Nutbeam, D. (2008). The evolving concept of health literacy. Social Science & Medicine, 67, 2072-2078.
Perk, J. (2012). New European guidelines on cardiovascular disease prevention. Läkartidningen, 109(34-35), 1463.
Phillips, L. J., Yung, A. R., & McGorry, P. D. (2000). Identification of young people at risk of psychosis: Validation of personal assessment and crisis evaluation clinic intake criteria. The Australian and New Zealand Journal of Psychiatry, 34(2_suppl), S164-S169.
Platz, C., Umbricht, D. S., Cattapan-Ludewig, K., Dvorsky, D., Arbach, D., Brenner, H. D., & Simon, A. E. (2006). Help-seeking pathways in early psychosis. Social Psychiatry and Psychiatric Epidemiology, 41(12), 967-974.
Quijada, Y., Tizon, J. L., Artigue, J., & Parra, B. (2010). At-risk mental state (ARMS) detection in a community service center for early attention to psychosis in Barcelona. Early Intervention in Psychiatry, 4(3), 257-262.
Riecher-Rossler, A., Gschwandtner, U., Aston, J., Borgwardt, S., Drewe, M., Fuhr, P., … Stieglitz, R. D. (2007). The Basel early-detection-of-psychosis (FEPSY)-study-design and preliminary results. The Acta Psychiatrica Scandinavica, 115(2), 114-125.
Rietdijk, J., Hogerzeil, S. J., van Hemert, A. M., Cuijpers, P., Linszen, D. H., & van der Gaag, M. (2011). Pathways to psychosis: Help-seeking behavior in the prodromal phase. Schizophrenia Research, 132(2-3), 213-219.
Ruhrmann, S., Klosterkötter, J., Bodatsch, M., Bechdolf, A., Schimmelmann, B. G., Nikolaides, A., … Schultze-Lutter, F. (2012). Pharmacological prevention and treatment in clinical at-risk states for psychosis. Current Pharmaceutical Design, 18(4), 550-557.
Ruhrmann, S., Schultze-Lutter, F., Salokangas, R. K., Heinimaa, M., Linszen, D., Dingemans, P., … Klosterkötter, J. (2010). Prediction of psychosis in adolescents and young adults at high risk: Results from the prospective European prediction of psychosis study. Archives of General Psychiatry, 67(3), 241-251.
Ruhrmann, S., Schultze-Lutter, F., Schmidt, S. J., Kaiser, N., & Klosterkötter, J. (2014). Prediction and prevention of psychosis: Current progress and future tasks. European Archives of Psychiatry and Clinical Neuroscience, 264(Suppl 1), S9-S16.
Schimmelmann, B. G., Michel, C., Schaffner, N., & Schultze-Lutter, F. (2011). What percentage of people in the general population satisfies the current clinical at-risk criteria of psychosis? Schizophrenia Research, 125(1), 99-100.
Schmidt, S. J., Schultze-Lutter, F., Schimmelmann, B. G., Maric, N. P., Salokangas, R. K., Riecher-Rossler, A., … Ruhrmann, S. (2015). EPA guidance on the early intervention in clinical high risk states of psychoses. European Psychiatry, 30(3), 388-404.
Schultze-Lutter, F. (2009). Subjective symptoms of schizophrenia in research and the clinic: The basic symptom concept. Schizophrenia Bulletin, 35(1), 5-8.
Schultze-Lutter, F., Marshall, M., & Koch, E. (2012). Schizophrenia proneness instrument, child and youth version (SPI-CY), extended English translation. Rome, Italy: Giovanni Fiorito Editore.
Schultze-Lutter, F., Michel, C., Schmidt, S. J., Schimmelmann, B. G., Maric, N. P., Salokangas, R. K. R., … Klosterkötter, J. (2015). EPA guidance on the early detection of clinical high risk states of psychoses. European Psychiatry, 30(3), 405-416.
Schultze-Lutter, F., Picker, H., Ruhrmann, S., & Klosterkötter, J. (2008). The Cologne early recognition and intervention center for mental crises (FETZ). Evaluation of Service Use. Medizinische Klinik, 103(2), 81-89.
Schultze-Lutter, F., Rahman, J., Ruhrmann, S., Michel, C., Schimmelmann, B. G., Maier, W., & Klosterkötter, J. (2015). Duration of unspecific prodromal and clinical high risk states, and early help-seeking in first-admission psychosis patients. Social Psychiatry and Psychiatric Epidemiology, 50(12), 1831-1841.
Schultze-Luttter, F., Addington, F., Ruhrmann, S., & Klosterkötter, J. (2007). Schizophrenia Proneness Instrument, Adult version (SPI-A). Giovanni Fioriti Editore. Rome: Giovanni Fioriti Editore.
Scott, T. L., Gazmararian, J. A., Williams, M. V., & Baker, D. W. (2002). Health literacy and preventive health care use among Medicare enrollees in a managed care organization. Medical Care, 40(5), 395-404.
Shin, Y.-M., Jung, H. Y., Kim, S.-W., Lee, S.-H., Shin, S.-E., Park, J.-I., … Chung, Y.-C. (2010). A descriptive study of pathways to care of high risk for psychosis adolescents in Korea. Early Intervention in Psychiatry, 4(2), 119-123.
Simon, A. E., Dvorsky, D. N., Boesch, J., Roth, B., Isler, E., Schueler, P., … Umbricht, D. (2006). Defining subjects at risk for psychosis: A comparison of two approaches. Schizophrenia Research, 81(1), 83-90.
Simon, A. E., Theodoridou, A., Schimmelmann, B., Schneider, R., & Conus, P. (2012). The Swiss early psychosis project SWEPP: A national network. Early Intervention in Psychiatry, 6(1), 106-111.
Smith, S. G., O'Conor, R., Curtis, L. M., Waite, K., Deary, I. J., … Wolf, M. S. (2015). Low health literacy predicts decline in physical function among older adults: Findings from the LitCog cohort study. Journal of Epidemiology and Community Health, 69(5), 474-480.
Sørensen, K., Van den Broucke, S., Fullam, J., Doyle, G., Pelikan, J., Slonska, Z., … (HLS-EU) Consortium Health Literacy Project European. (2012). Health literacy and public health: A systematic review and integration of definitions and models. BMC Public Health, 12, 80.
Stowkowy, J., Colijn, M. A., & Addington, J. (2013). Pathways to care for those at clinical high risk of developing psychosis. Early Intervention in Psychiatry, 7(1), 80-83.
Thomas, J., & Harden, A. (2008). Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Medical Research Methodology, 8, 45.
Thomas, J., Harden, A., Oakley, A., Oliver, S., Sutcliffe, K., Rees, R., … Kavanagh, J. (2004). Integrating qualitative research with trials in systematic reviews. The British Medical Journal, 328(7446), 1010-1012.
Tlach, L., Wusten, C., Daubmann, A., Liebherz, S., Harter, M., & Dirmaier, J. (2015). Information and decision-making needs among people with mental disorders: A systematic review of the literature. Health Expectations: An International Journal of Public Participation in Health Care and Health Policy, 18(6), 1856-1872.
Verbrugghe, M., Verhaeghe, S., Lauwaert, K., Beeckman, D., & Van Hecke, A. (2013). Determinants and associated factors influencing medication adherence and persistence to oral anticancer drugs: A systematic review. Cancer Treatment Reviews, 39(6), 610-621.
von Reventlow, H. G., Kruger-Ozgurdal, S., Ruhrmann, S., Schultze-Lutter, F., Heinz, A., … Juckel, G. (2014). Pathways to care in subjects at high risk for psychotic disorders-A European perspective. Schizophrenia Research, 152(2-3), 400-407.
Waldrop-Valverde, D., Jones, D. L., Gould, F., Kumar, M., & Ownby, R. L. (2010). Neurocognition, health-related reading literacy, and numeracy in medication management for HIV infection. AIDS Patient Care and STDs, 24(8), 477-484.
Welsh, P., & Tiffin, P. A. (2012). Observations of a small sample of adolescents experiencing an at-risk mental state (ARMS) for psychosis. Schizophrenia Bulletin, 38(2), 215-218.
Welsh, P., & Tiffin, P. A. (2013). Attitudes of patients and clinicians in relation to the at-risk state for psychosis. Early Intervention in Psychiatry, 7(4), 361-367.
White, S., Chen, J., & Atchison, R. (2008). Relationship of preventive health practices and health literacy: A national study. American Journal of Health Behavior, 32(3), 227-242.
Wiltink, S., Velthorst, E., Nelson, B., McGorry, P. M., & Yung, A. R. (2015). Declining transition rates to psychosis: The contribution of potential changes in referral pathways to an ultra-high-risk service. Early Intervention in Psychiatry, 9(3), 200-206.
Woopen, C. (2015). Gesundheitskompetenz. In D. Sturma & B. Heinrichs (Eds.), Handbuch Bioethik (pp. 280-286). Stuttgart: Metzler.
Yung, A. R., Stanford, C., Cosgrave, E., Killackey, E., Phillips, L., Nelson, B., & McGorry, P. D. (2006). Testing the ultra high risk (prodromal) criteria for the prediction of psychosis in a clinical sample of young people. Schizophrenia Research, 84(1), 57-66.
Yung, A. R., Yuen, H. P., Berger, G., Francey, S., Hung, T. C., Nelson, B., … McGorry, P. (2007). Declining transition rate in ultra high risk (prodromal) services: Dilution or reduction of risk? Schizophrenia Bulletin, 33(3), 673-681.
Yung, A. R., Yuen, H. P., McGorry, P. D., Phillips, L., Kelly, D., Dell'Olio, M., … Buckby, J. (2005). Mapping the onset of psychosis: The comprehensive assessment of at-risk mental states. The Australian and New Zealand Journal of Psychiatry, 39(11-12), 964-971.