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Appendix A (Utility of risk-status for predicting psychosis and related outcomes)

Glossary of Terms

Admission Rates Admission rates for each client were expressed as hospital admission days per year for the designated period (e.g., pre-PAS, post-PAS), pro-rated for variations in the relevant client data availability window. ‘MH admissions’ required identification of at least one ICD-10 MH diagnosis (i.e., first six categories in Table S2). Only MH admissions from 12+ years of age were considered.

Aggregate Diagnoses/Problem Categories

MH diagnoses (ICD-10) from hospital admissions data (HOSPAS/IPMS) and, where available, from community mental health assessments (CROOS/CHIME), were combined with coded presenting problems data from community mental health records into nine broad diagnostic categories: psychosis; depression, anxiety; substance misuse; personality disorders; other MH problems; psychosocial problems; physical diseases; and other non-mental health problems.

Assessment of At Risk Mental States (ARMS)/(CAARMS)

Assessment of psychosis risk-status at baseline (e.g., UHR) was based on standardised assessments, comprising the Comprehensive Assessment of At Risk Mental States (CAARMS) or its predecessor, the Assessment of At Risk Mental States (ARMS). These measures assessed several aspects of risk, including: family history-related vulnerability; recent deterioration in functioning; attenuated psychotic symptoms; and transient self-limited psychotic symptoms of less than one week’s duration (BLIPS).

Baseline Diagnostic Groups

Clients were allocated to one of six baseline diagnostic groups on a hierarchical basis (i.e., giving priority to evidence of psychosis, followed by psychosis risk), using all available community and inpatient health service data and assessments: Group-A, existing psychosis; Group-B, recent psychosis; Group-C, UHR; Group-D1, non-psychosis MH disorders with no MH admissions;Group-D2, non-psychosis MH disorders with prior MH admissions; and Group-E, undetermined, having received an incomplete assessment and/or with limited service contact information. Group-D1 was the reference group for the major analyses.

Community MH Contact Rates

Community MH contact rates referred to the estimated number of days per year on which a client had at least one contact with the designated community MH service, pro-rated for variations in the relevant client data availability window. Multiple contacts, or multiple clinicians from the same service recording a shared contact on the same day (e.g., group program), were counted as one contact day.

Conversion to Schizophrenia

Clients with a baseline history of psychosis or provisional/early psychosis diagnosis (i.e., Group-A/B) but no recorded schizophrenia diagnosis, and who were diagnosed with schizophrenia post-PAS, were regarded as having converted to schizophrenia.

Covariates (in Major Analyses)

Service-based data may be of variable quality, and in longitudinal data sets additional variation can arise from changes in service policies/practices and data recording systems. Consequently, a range of covariates were included in the major analyses controlling for demographic factors, treatment patterns, service changes (e.g., using year block as a proxy), and variations across individuals in pre- and post-PAS data availability (e.g., relating to when in the 10-year time frame they had their first and last service contacts).

CROOS/CHIME Data

Community-based MH service data (e.g., service contact and basic client information, diagnostic data, presenting problems) were extracted either from: CROOS (a standalone database) [1997 to 2002]; or CHIME (Clinical Health Information Management Exchange), an electronic community mental health clinical records system [2003 to 2009].

Glossary of Terms 1

HOSPAS/IPMS Data Inpatient-based MH service data (e.g., services used, admission/discharge dates, basic client information, diagnostic data) were extracted from regional electronic hospital records, either: HOSPAS [1993 to 2003]; or IMPS [2004 to 2009].

Number of Non-Psychosis Diagnosis/ Problem Categories

A simple count (out of 8) indicating the number of non-psychosis diagnosis/problem categories that were identified for the designated period.

PAS The Psychological Assistance Service (PAS) was established in Newcastle (Australia) in 1997. It is a community-based specialised MH Service for young people (aged 12-25 years) who may have recently experienced a psychotic episode or were potentially at increased risk based on current symptoms and impaired functioning. PAS did not restrict subsequent contacts only to UHR clients.

PAS Presentation Window

The PAS presentation/assessment window refers to a 2-month period from the initial PAS referral date, during which preliminary risk evaluations and, where appropriate, initial standardised assessments were conducted. Importantly, any evidence of psychosis (in service records) or based on clinical or standardised assessments conducted before the end of the 2-month PAS presentation window were regarded as existing or recent psychosis – but not as post-PAS (or subsequent) psychosis episodes. Consequently, clients with incipient psychosis at the PAS referral date were not viewed as transitioning, but as having recent psychosis (i.e., if they met relevant diagnostic/problem criteria by the end of the PAS presentation/assessment window).

Psychosis Outcomes Any service-based evidence of a subsequent psychosis episode (i.e., post the 2-month PAS presentation/assessment window), including formal assessments (e.g., by PAS) and from community/inpatient records identifying either an ICD-10 psychosis diagnosis or a presenting problem category listing psychosis.

Psychosis Risk Spectrum

We retained the whole service cohort (characterised as six baseline diagnostic groups) to ensure representation across the full spectrum of psychosis risk, including: transition risk (to psychosis); relapse risk (for repeated psychosis episodes); conversion risk (from early psychosis to a schizophrenia diagnosis); and risk for non-psychosis outcomes (and higher service utilisation).

Psychosocial Problems/Issues

A broad range of problems/issues were coded as ‘psychosocial’, including: ICD-10 factors influencing health and contact with health services (Codes Z00-Z13); relationship and parenting issues; housing and legal issues.

Service Cohort The current service cohort comprised all presentations to PAS between service commencement and December 2007 (+2 years for ongoing treatment profiles and other outcomes); N = 1997 index presentations (i.e., unique clients) during the 10-year service evaluation/audit period.

Service Contacts Counts were restricted to face-to-face contacts with MH staff, including information provision, assessments, and/or interventions.

Transition to Psychosis

Clients without a history of psychosis at baseline (i.e., Groups C to E) and who were subsequently identified as having a post-PAS psychosis episode were regarded as having transitioned to psychosis.

UHR Ultra-high risk (UHR) status was defined using the relevant CAARMS/ARMS criteria.

Glossary of Terms 2

Supplementary Tables (S1 to S14)

Contents Page

Data processing and categorizationTable S1. Clinical records data: Sources and changes during the audit period 2Table S2. Data coding – Diagnostic categories extracted from hospital and community data 4Table S3. Problem profiles for post-PAS period by baseline diagnostic group (N=1997) 5Table S4. Post-PAS psychosis diagnostic profiles for selected baseline groups 6

Survival analysesTable S5. Survival analyses: time to first post-PAS psychosis episode (N=1997) 7

Non-psychosis outcomes (>2 months post-PAS presentation) – major analysesTable S6. Prediction of subsequent episodes of depression (N=1997) 9Table S7. Prediction of subsequent episodes of anxiety (N=1997) 10Table S8. Prediction of subsequent episodes of substance misuse (N=1997) 11Table S9. Prediction of hospital admissions for MH problems in the post-PAS period (N=1997) 12Table S10. Prediction of high community contact rates for MH problems in the post-PAS period (N=1997) 13

Overall incidence rates and changes by post-PAS psychosis status [Excluding Group-E]Table S11. Aggregate (any episode) and new episode (post-PAS only) profiles by baseline diagnostic group (N=1747) [Excluding Group-E] 14Table S12. Number of non-psychosis diagnosis/problem categories by time period and post-PAS psychosis status (N=1747) 15Table S13. Number of MH admission days per year by time period and post-PAS psychosis status (N=1747) 16Table S14. Number of community MH contact days per year by time period and post-PAS psychosis status (N=1747) 17

Appendix A - Supplementary Tables S1 to S14 1

Table S1. Clinical records data: Sources and changes during the audit period

Year Block 1 (1997-2003) Year Block 2 (2004-2007) Data processing

Community records

Psychological Assistance Service (PAS)“Red books” Referral/contacts books

Used by PAS staff to record presentations, reviews and referral/discharge status. These were kept until 2007.

Assessment of At Risk Mental State (ARMS) Booklets, including: rating scales and cut-offs for measures such as the BPRS, the CASH, and the SCID-I structured interview; a quality of life assessment; 2 symptom interviews assessing affective, anxiety, psychotic and substance use disorders; 2 neuropsychological assessments sessions; an informant interview; a neurological assessment; and 2 self-report questionnaires.

Comprehensive Assessment of At Risk Mental States (CAARMS)

On the basis of the two assessments, PAS initially classified all assessed clients in terms of their probable psychosis status and, where appropriate, their UHR status was assigned (taking into account attenuated psychotic symptoms, BLIPS, and/or trait-state risk factor criteria). The sole source of UHR status information was the PAS assessments.

Overall, formal standardised ARMS or CAARMS based assessments were completed for one-third (34.2%) of PAS clients (year block 1: 511/1369, 37.3%; year block 2: 172/628, 27.4%). These assessments and the other, more informal, evaluations of likely psychosis risk (e.g., at PAS presentation) were all undertaken by the same team of experienced clinicians.

PAS database – internal MS – Access database used by the service to record outcomes of assessments, risk-status and diagnostic information.

There were 2206 presentations to PAS during the audit period, 32 of which were excluded because of insufficient key identifying data (e.g., name or medical record number, referral or presentation dates). Among the remaining 2174 presentations, there were 1997 index presentations (by 1178 male and 819 female clients), with 177 repeat presentations (for separate clinical episodes involving the same clients).

CROOS – standalone MS - Access database used by community services, including PAS, to record information about client referrals, registrations, service contacts and discharge diagnoses.

CHIME - Clinical Information Management Exchange System- introduced in 2003 as a community based clinical record system linking all community mental health and community health records.

Service contacts, diagnostic data, and presenting problems were initially processed separately; however, duplicate records and all admissions for persons younger than 12 years were deleted prior to the data being combined. As individuals varied in the length of time pre- and post-PAS for which service level data might be available (depending on their age at PAS presentation, the year they first presented, and the completeness of the relevant data systems), a common metric was adopted for calculating community contact rates, namely the number of service contact days per year (pro-rated for each individual based on the length of the available data window). Similarly, to facilitate data aggregation, mental health diagnoses and problems were re-classified into nine common categories (psychosis, depression, anxiety, substance misuse, personality disorders, other mental health (MH) problems, psychosocial problems, physical diseases, and other non-MH problems); for any hierarchical assignments (e.g., psychosis sub-categories) priority was given to diagnostic


information (i.e., DSM-IV or ICD-10 diagnoses) over ‘problems’ based CHIME listings.Hospital records

HOSPAS – Hospital Patient Administration System - hospital based clinical records which provided information on admissions, discharges and diagnoses. Records from HOSPAS system were migrated to the new IPMS system in 2003 and HOPSAS was archived at the end of that year.

IPMS – new Patient Administration System was introduced at the beginning of 2004.

Only admissions from 12 years of age onwards were considered. Both systems collected comparable clinical data in terms of demographic information, length of stay, service use and diagnoses; any duplicate records were removed after data aggregation. Diagnoses were also re-classified into the nine common categories as per the community dataset.

Hierarchical classification of baseline diagnostic groups

In effect, at baseline, we regarded all PAS clients as having either current evidence for a psychosis history (i.e., Groups-A/B) or being at elevated or heightened risk for psychosis or related conditions (i.e., Groups C to E) by virtue of their presentation to a specialised community MH service for young people and recent experiences of odd, unusual or unexplained symptoms and deterioration in functioning. As reported in Conrad et al. (2014), with respect to baseline diagnostic group assignment, priority was given to any evidence of psychosis in the period up to and including the 2-month PAS presentation window. Five groups were initially identified: Group-A – ‘existing psychosis’ prior to the PAS referral date (based on all available evidence from community and admission records, PAS referral information and assessments); Group-B – ‘recent psychosis’, based on similar information and assessments but with no evidence of psychosis in service records prior to the referral date (i.e., only in assessments/interviews during the PAS presentation window); Group-C – ‘Ultra-High Risk (UHR)’ group, based on PAS’s clinical assessment (and non-membership of Groups A or B); Group-D – ‘non-psychosis MH disorders’ group (e.g., depression, anxiety, substance misuse, personality disorders, etc), based on all available service level data and assessments (and non-membership of Groups A to C) – this was also the largest group (N=872 clients or 43.7%); and Group-E – labelled as ‘undetermined’ (N=250 clients or 12.5%), about whom limited baseline information was available (but with no basis for allocation to Groups A to D), including individuals deemed not suitable for full assessment (13.9% of Group-E), who refused assessment (13.4%), who were referred elsewhere (42.9%), or who had minimal or no contact with PAS (29.8%).

Subsequent to the Conrad et al. (2014) paper, and to facilitate identification of a more homogeneous non-psychosis reference group (for the major prediction analyses), we subdivided Group-D into two groups: D1 ‘non-psychosis MH disorders – no MH admissions’ (81.0%; regarded as the primary, lowest risk non-UHR, reference group) and D2 ‘non-psychosis MH disorders – with prior MH admissions’ (19.0%). While Group-D2 were viewed as potentially having more severe or higher acuity conditions at baseline, more importantly, they were also viewed as potentially being further along their current illness trajectory (by virtue of their recent MH admissions) and as potentially having conditions that were yet to fully evolve or be fully identified (which could include, for example, undiagnosed psychosis elements or related forms of comorbidity).

As reported in Conrad et al. (2014, Table 3), there were high rates of baseline comorbidity across all groups. The overall baseline percentages (excluding Group-E) were (N=1,747): Depression (43.8); Anxiety (25.1); Substance misuse (26.5); Personality disorder (17.1); Other MH problems (67.3); Psychosocial problems (40.4); Physical disorders (14.0); and Other non-MH problems (15.1).The corresponding baseline percentages for the newly subdivided groups were: Group-D1 - No MH admissions (N=706): Depression (36.8); Anxiety (16.1); Substance misuse (7.8); Personality disorder (11.8); Other MH problems (70.3); Psychosocial problems (23.7); Physical disorders (1.1); and Other non-MH problems (5.7). Group-D2 - Prior MH admissions (N=166): Depression (50.6); Anxiety (27.7); Substance misuse (57.8); Personality disorder (38.0); Other MH problems (79.5); Psychosocial problems (60.8); Physical disorders (38.6); and Other non-MH problems (48.2).


Table S2. Data coding – Diagnostic categories extracted from hospital and community data

Broad diagnostic categories(used for this project)

Formal diagnoses: Examples of associated ICD 10 codes used within both the hospital and CHIME data

Presenting problems: Examples of associated problem codes used within CHIME data

1. Psychosis Bipolar Disorder (F31), Schizophrenia (F20-F29) Psychotic disorder, Bipolar disorder2. Depression Depression (F32, F33) Depression3. Anxiety Somatic Disorders (F45) (Sleep disorders G47), Eating Disorder

(F50), Phobias (F40-F42), Habit/Impulse Disorder (F63)Neurotic disorder, Anxiety disorder, Eating disorder, Phobias, Insomnia

4. Substance misuse Substance use (F10-F19) Drug induced mental illness, cannabis, amphetamines

5. Personality disorders Specific Personality Disorders (F60), Mixed and other personality disorders (F61)

Personality disorder

6. Other MH problems Sexual Disorder (F66), Sex/Gender Related (F64–F65), Neurological Disorders (F90-F98), Intellectual Disability (F70-F79), Childhood Disorders (F80-F89), Delirium (F05), Dementia (F00-F03)

Adjustment disorder, social functioning issue, Developmental issues

7. Psychosocial problems Factors influencing health and contact with health services (Z00-Z13)

Relationship issues, housing, legal issues

8. Physical diseases Infectious and Parasitic diseases (A00-B89), Neoplasms (C00-D48), Blood Disorders (D50-D89), Endocrine (E00-E07), Disease of Nervous system (G00-G99), Diseases of Eye and Ear (H00-H95), Circulatory system (I00-I99), Respiratory System (J00-J99), Digestive (K00-K14), Skin (L00-L99), Musculoskeletal (M00-M99), Genitourinary (N00-N99)

Physical health issues, Sleeping issue

9. Other non-mental health problems or conditions

Procedures, Pregnancy (000-099), Perinatal (P00-P96), Congenital (Q00-Q99), Poisoning (T36-T50), Intentional Self Harm, External causes of morbidity (U50-U73), accidents (V00-V99)

Public safety, nutrition and eating well, infant feeding issues

Note: CHIME, Clinical Information Management Exchange community based clinical record system.


Table S3. Problem profiles for post-PAS period by baseline diagnostic group (N=1997)

Diagnosis or problem during post-PAS period (%)

Baseline diagnostic group assignment

Overall A: Existingpsychosis

B: Recent psychosis

C: Ultra High Risk (UHR)

D: Non-psychosis MH disorders E: UndeterminedD1: No MH

admissionsD2: Prior MH

admissions(N=1997) (N=289) (N=395) (N=191) (N=706) (N=166) (N=250)

Psychosis 29.7 62.3 49.9 17.3 14.6 [14.5] 25.9 15.2Depression 23.8 28.4 24.3 19.9 21.1 [19.4] 38.6 18.4Anxiety 14.7 17.6 16.2 16.2 11.6 [8.9] 19.3 13.6Substance misuse 28.6 44.6 35.9 15.2 19.7 [20.2] 41.6 25.2Personality disorder 14.0 20.4 15.9 8.9 9.5 [6.5] 25.3 12.4Any of the above major MH problems

52.2 72.3 67.3 43.5 38.5 [37.1] 64.5 42.4

Other MH problems^ 52.9 60.2 58.2 53.9 48.9 [49.2] 60.2 42.0Psychosocial problems 38.1 54.7 46.6 24.6 28.9 [31.5] 51.8 32.8Physical disorders 28.2 43.3 33.4 18.3 20.0 [21.0] 42.8 24.0Other non-MH problems 27.6 39.8 30.4 17.3 23.4 [25.0] 34.9 24.4

Any of the above problems 65.8 80.3 75.4 66.0 57.1 [58.1] 75.3 52.0None of the above 34.2 19.7 24.6 34.0 42.9 [41.9] 24.7 48.0

Number of non-psychosis diagnosis/problem categories identified (0-8) – Mean (SD)

2.28(2.39)

3.09(2.52)

2.61(2.37)

1.74(2.08)

1.83 [1.81](2.21) [(2.11)]

3.14(2.54)

1.93(2.41)

Note: ^ This category includes: emotional or behavioural problems, service related problems, adjustment disorders, childhood disorders, intellectual disability, and other problems (other behavioural and MH disorders, cognitive related problems, neurological disorders). Values in square brackets for Group-D1 are for the subset of clients with a formal standardised ARMS or CAARMS assessment at baseline (N=124) (i.e., confirmed as non-UHR); suggesting that the outcome profile for Group-D1 (the reference group for the major prediction analyses) was not unduly influenced by variations in baseline psychosis risk assessment methods (i.e., structured vs. informal clinician assessment), at least with respect to identifying clients at low risk. See Table S4 for post-PAS psychosis diagnostic profiles.


Table S4. Post-PAS psychosis diagnostic profiles for selected baseline groups

Subsequent psychosis: diagnostic or presenting problem category (%)

Baseline diagnostic group assignmentA: Existingpsychosis(N=289)

B: Recentpsychosis(N=395)

C to E: Other(N=1313)

Any evidence of psychosis post-PAS: NoYes

37.762.3

50.149.9

83.516.5

Source of evidence:Formal ICD-10 diagnoses [59.2] [46.1] [14.7] 1. Schizophrenia 39.4 (27.3) 34.2 (23.7) 8.9 (5.6) 2. Persistent delusional disorder 6.2 (0.3) 3.8 (0.2) 2.0 (0.8) 3. Acute or transient psychotic disorder 12.1 (5.2) 10.6 (3.7) 3.7 (2.0) 4. Schizoaffective disorder 13.8 (3.4) 8.6 (3.3) 1.9 (0.5) 5. Other nonorganic psychotic disorder 2.1 (0.3) 1.3 (0.5) 0.5 (0.3) 6. Unspecified nonorganic psychotic disorder 15.9 (4.4) 10.1 (3.7) 3.0 (0.9) 7. Bipolar disorder 19.4 (12.1) 10.9 (6.5) 5.4 (3.3)

Presenting or other problems from clinical records [26.3] [21.3] [7.4] 8. Schizophrenia (problem) 7.6 (0) 5.3 (0.5) 2.2 (0.4) 9. Bipolar (problem) 2.8 (0.7) 2.5 (0.7) 1.1 (0.4) 10. Other psychosis (problem) 20.4 (7.6) 15.4 (6.1) 5.0 (2.1)

Among clients with a post-PAS psychosis: Mean (SD) number of psychosis assessments Mean (SD) number of categories (1-10)

5.73 (6.70)2.24 (1.36)

4.87 (5.78)2.06 (1.26)

4.11 (4.87)2.04 (1.25)

Note: Tabled values are the percentage of each group with any evidence of that diagnosis/problem during the post-PAS period, based on all available psychosis assessments (A: 1031; B: 960, C to E: 891), with assignments not mutually exclusive; bracketed values () are for the first post-PAS psychosis episode. The majority of these psychosis assessments (1770, 61.4%) were sourced from hospital records (A: 683, 66.2%; B: 537, 55.9%; and C to E: 550, 61.7%). Overall ICD-10 diagnosis-based rates [third line] were approx. 90-95% of the aggregate post-PAS psychosis rates [second line].


Table S5. Survival analyses: time to first post-PAS psychosis episode (N=1997)

Baseline group assignment

A: Existing psychosis (N=289)B: Recent psychosis (N=395)C: Ultra High Risk (N=191)

D: Non-psychosis MH disordersD1: No MH admissions (N=706)D2: Prior MH admissions (N=166)E: Undetermined (N=250)Note: From a Cox proportional-hazards regression, with time to psychosis episode as the outcome, controlling for gender, age group, service year block, PAS treatment status, length of potential data availability windows, and 8 baseline comorbidity variables.Short-term: 431 events, 1,566 censored (78.4%).Medium-term: 594 events, 1,403 censored (70.3%); median post-PAS time (till end of audit period) = 87.0 months (range: 22–153); half of these psychosis episodes (296, 49.8%) were sourced from hospital records - A: 150 (83.3%); B: 80 (40.6%); C: 10 (30.3%); D1: 50 (48.5%); D2: 30 (69.8%); and E: 21 (55.3%).


Table S5 Continued Survival analyses: time to first post-PAS psychosis episode (N=1997)

Baseline group assignment

Time period for evaluating first post-PAS psychosis episode:Short-term: Within two years post-PAS Medium-term: Within whole post-PAS audit period

N (%) N (%) Median months(range)

Hazard ratio(99% CI;p-value)

A: Existing psychosis(N=289)

151(52.2)

5.76(3.71, 8.95; p<0.001)

180(62.3)

7.1(0–114)

4.61(3.18, 6.67; p<0.001)

B: Recent psychosis(N=395)

151(38.2)

4.11(2.71, 6.25; p<0.001)

197(49.9)

10.3(0–112)

3.49(2.48, 4.91; p<0.001)

C: Ultra High Risk(N=191)

17(8.9)

0.76(0.37, 1.55; p=0.317)

33(17.3)

24.0(7–110)

0.96(0.57, 1.64; p=0.849)

D: Non-psychosis MH disorders D1: No MH admissions (N=706)

64(9.1)

Reference group 103(14.6)

14.4(0–130)

Reference group

D2: Prior MH admissions (N=166)

33(19.9)

2.11(1.16, 3.84; p<0.001)

43(25.9)

12.0(0–130)

1.62(0.97, 2.69; p=0.015)

E: Undetermined(N=250)

15(6.0)

0.69(0.32, 1.48; p=0.208)

38(15.2)

34.8(1–132)

0.87(0.52, 1.45; p=0.481)

Whole sample(N=1997)

431(21.6)

594(29.7)

11.6(0–132)

PAS treatment:Ongoing (N=407)

146(35.9)

2.06(1.53, 2.79; p<0.001)

173(42.5)

8.1(0-110)

1.92(1.46, 2.51; p<0.001)

Assessment only(N=1590)

285(17.9)

421(27.9)

13.4(0-132)

Note: From a Cox proportional-hazards regression, with time to psychosis episode as the outcome, controlling for gender, age group, service year block, PAS treatment status, length of potential data availability windows, and 8 baseline comorbidity variables.Short-term: 431 events, 1,566 censored (78.4%).Medium-term: 594 events, 1,403 censored (70.3%); median post-PAS time (till end of audit period) = 87.0 months (range: 22–153); half of these psychosis episodes (296, 49.8%) were sourced from hospital records - A: 150 (83.3%); B: 80 (40.6%); C: 10 (30.3%); D1: 50 (48.5%); D2: 30 (69.8%); and E: 21 (55.3%).


Table S6. Prediction of subsequent episodes of depression (>2 months post-PAS presentation) (N=1997)

Baseline characteristics % with a subsequentdepression episode

UnadjustedOdds Ratio 99% CI Adjusted Odds

Ratio (AOR) 99% CI

Gender: Male 19.9 (vs. 29.3) 0.60** (0.46, 0.79) 0.61** (0.45, 0.81)Age: Less than 18 years 23.7 (vs. 23.9) 0.99 (0.75, 1.30) 0.79 (0.50, 1.25)Treated by PAS 26.0 (vs. 23.2) 1.17 (0.84, 1.62) 1.26 (0.85, 1.87)Focal disorder: Depression 32.5 (vs. 18.3) 2.18** (1.63, 2.93) 1.94** (1.42, 2.67)Diagnostic group A: Existing psychosis 28.4 1.48# (0.98, 2.24) 1.37 (0.82, 2.27) B: Recent psychosis 24.3 1.20 (0.82, 1.76) 0.90 (0.58, 1.40) C: Ultra High Risk 19.9 0.93 (0.55, 1.57) 0.62# (0.35, 1.09) D: Non-psychosis MH disorders – D1: No MH admissions (Ref) 21.1 (1.00) - (1.00) - D2: Prior MH admissions 38.6 2.35** (1.46, 3.77) 1.81* (1.04, 3.21) E: Undetermined@ 18.4 0.84 (0.52, 1.37) 0.59* (0.34, 1.00)Comorbid conditions (pre-PAS) Anxiety 29.2 (vs. 23.0) 1.39* (1.00, 1.91) 0.98 (0.69, 1.40) Substance misuse 26.8 (vs. 23.8) 1.18 (0.85, 1.63) 0.92 (0.62, 1.37) Personality disorder 34.2 (vs. 22.6) 1.80** (1.26, 2.57) 1.40# (0.95, 2.06) Other MH problems 24.3 (vs. 25.0) 0.96 (0.71, 1.31) 1.20 (0.83, 1.75) Psychosocial problems 28.9 (vs. 21.6) 1.49** (1.11, 1.99) 1.19 (0.85, 1.67) Physical disorder 32.7 (vs. 23.2) 1.62** (1.10, 2.38) 1.16 (0.72, 1.86) Other non-MH problems 33.3 (vs. 23.0) 1.69** (1.16, 2.46) 1.20 (0.77, 1.87)

Note: Significance levels were based on Wald statistics: *p<0.01, **p<0.001, # trend (p<0.05); adjusted analyses controlled for all tabled variables plus service year block and length of available data windows (pre- and post-PAS). @ Missing comorbidity data were dummy-coded to mean values for this group.


Table S7. Prediction of subsequent episodes of anxiety (>2 months post-PAS presentation) (N=1997)

Baseline characteristics % with a subsequentanxiety episode


Ratio (AOR) 99% CI

Gender: Male 11.8 (vs. 18.9) 0.57** (0.41, 0.80) 0.58** (0.41, 0.81)Age: Less than 18 years 15.7 (vs. 13.5) 1.19 (0.85, 1.65) 0.95 (0.56, 1.61)Treated by PAS 16.0 (vs. 14.4) 1.13 (0.76, 1.68) 1.16 (0.73, 1.85)Focal disorder: Anxiety 22.1 (vs. 12.5) 2.00** (1.39, 2.89) 1.90** (1.26, 2.85)Diagnostic group A: Existing psychosis 17.6 1.63# (0.99, 2.69) 1.58 (0.86, 2.89) B: Recent psychosis 16.2 1.47 (0.93, 2.34) 1.19 (0.70, 2.01) C: Ultra High Risk 16.2 1.47 (0.82, 2.66) 1.14 (0.60, 2.14) D: Non-psychosis MH disorders – D1: No MH admissions (Ref) 11.6 (1.00) - (1.00) - D2: Prior MH admissions 19.3 1.82* (1.01, 3.28) 1.56 (0.78, 3.14) E: Undetermined@ 13.6 1.20 (0.68, 2.10) 0.88 (0.47, 1.63)Comorbid conditions (pre-PAS) Depression 15.2 (vs. 14.7) 1.04 (0.73, 1.48) 0.77 (0.52, 1.13) Substance misuse 16.2 (vs. 14.4) 1.15 (0.78, 1.69) 1.09 (0.68, 1.73) Personality disorder 18.5 (vs. 14.1) 1.38 (0.89, 2.12) 1.14 (0.72, 1.81) Other MH problems 14.1 (vs. 16.5) 0.83 (0.58, 1.20) 1.01 (0.65, 1.57) Psychosocial problems 17.1(vs. 13.4) 1.35# (0.95, 1.91) 1.10 (0.74, 1.63) Physical disorder 18.4 (vs. 14.3) 1.35 (0.85, 2.15) 1.11 (0.63, 1.94) Other non-MH problems 18.6 (vs. 14.2) 1.38 (0.88, 2.16) 1.06 (0.63, 1.80)



Table S8. Prediction of subsequent episodes of substance misuse (>2 months post-PAS presentation) (N=1997)

Baseline characteristics% with a subsequent

substance misuse episode


Ratio (AOR) 99% CI

Gender: Male 32.5 (vs. 23.0) 1.62** (1.24, 2.11) 1.31# (0.98, 1.76)Age: Less than 18 years 24.7 (vs. 33.5) 0.65** (0.50, 0.83) 0.89 (0.57, 1.38)Treated by PAS 25.3 (vs. 29.4) 0.81 (0.59, 1.13) 1.06 (0.72, 1.58)Focal disorder: Substance misuse 56.2 (vs. 19.3) 5.38** (3.98, 7.28) 3.89** (2.71, 5.58)Diagnostic group A: Existing psychosis 44.6 3.29** (2.23, 4.86) 1.61# (0.99, 2.61) B: Recent psychosis 35.9 2.29** (1.59, 3.29) 1.39# (0.91, 2.13) C: Ultra High Risk 15.2 0.73 (0.41, 1.30) 0.69 (0.37, 1.28) D: Non-psychosis MH disorders – D1: No MH admissions (Ref) 19.7 (1.00) - (1.00) - D2: Prior MH admissions 41.6 2.90** (1.81, 4.66) 1.30 (0.73, 2.31) E: Undetermined@ 25.2 1.37 (0.88, 2.15) 0.85 (0.52, 1.39)Comorbid conditions (pre-PAS) Depression 26.7 (vs. 31.0) 0.81# (0.61, 1.07) 0.83 (0.60, 1.14) Anxiety 25.7 (vs. 30.2) 0.80 (0.58, 1.10) 0.83 (0.57, 1.20) Personality disorder 37.2 (vs. 27.4) 1.58** (1.12, 2.23) 1.35# (0.91, 2.01) Other MH problems 27.6 (vs. 32.2) 0.80# (0.60, 1.06) 1.18 (0.81, 1.72) Psychosocial problems 37.3 (vs. 23.5) 1.94** (1.47, 2.56) 1.21 (0.87, 1.69) Physical disorder 40.8 (vs. 27.2) 1.86** (1.29, 2.68) 0.96 (0.60, 1.52) Other non-MH problems 36.7 (vs. 27.7) 1.52* (1.06, 2.18) 1.03 (0.66, 1.61)



Table S9. Prediction of hospital admissions for MH problems in the post-PAS period (>2 months post-PAS presentation) (N=1997)

Baseline characteristics % with a subsequentMH admission^


Ratio (AOR) 99% CI

Gender: Male 38.1 (vs. 37.4) 1.03 (0.81, 1.32) 0.91 (0.70, 1.19)Age: Less than 18 years 36.4 (vs. 39.6) 0.87 (0.69, 1.11) 0.77 (0.51, 1.16)Treated by PAS 40.3 (vs. 37.3) 1.14 (0.85, 1.53) 1.27 (0.89, 1.80)Diagnostic group A: Existing psychosis 61.6 4.36** (2.98, 6.37) 2.82** (1.79, 4.45) B: Recent psychosis 46.1 2.32** (1.65, 3.26) 1.64** (1.11, 2.42) C: Ultra High Risk 24.1 0.86 (0.53, 1.40) 0.70 (0.41, 1.18) D: Non-psychosis MH disorders – D1: No MH admissions (Ref) 26.9 (1.00) - (1.00) - D2: Prior MH admissions 51.2 2.85** (1.80, 4.49) 1.53# (0.89, 2.62) E: Undetermined@ 29.6 1.14 (0.75, 1.74) 0.71 (0.45, 1.13)Comorbid conditions (pre-PAS) Depression 39.7 (vs. 38.4) 1.06 (0.82, 1.37) 1.02 (0.76, 1.37) Anxiety 38.3 (vs. 39.2 ) 0.96 (0.72, 1.29) 0.83 (0.59, 1.16) Substance misuse 58.3 (vs. 32.0) 2.99** (2.24, 3.99) 1.96** (1.39, 2.79) Personality disorder 50.3 (vs. 36.6) 1.76** (1.26, 2.45) 1.50* (1.04, 2.16) Other MH problems 37.7 (vs. 41.7) 0.84 (0.65, 1.11) 1.08 (0.76, 1.53) Psychosocial problems 47.6 (vs. 33.1) 1.84** (1.42, 2.39) 1.07 (0.78, 1.45) Physical disorder 62.0 (vs. 35.2) 3.01** (2.09, 4.34) 1.70* (1.09, 2.65) Other non-MH problems 52.7 (vs. 36.5) 1.94** (1.37, 2.74) 1.22 (0.80, 1.86)

Note: Significance levels were based on Wald statistics: *p<0.01, **p<0.001, # trend (p<0.05); adjusted analyses controlled for all tabled variables plus service year block and length of available data windows (pre- and post-PAS). @ Missing comorbidity data were dummy-coded to mean values for this group. ^ Overall, 37.8% experienced a subsequent MH admission.


Table S10. Prediction of high community contact rates in the post-PAS period (>2 months post-PAS presentation) (N=1997)

Baseline characteristics % with high community contacts^


Ratio (AOR) 99% CI

Gender: Male 25.9 (vs. 27.0) 0.95 (0.73, 1.23) 0.78# (0.58, 1.05)Age: Less than 18 years 24.0 (vs. 29.2) 0.77* (0.59, 1.00) 0.75 (0.46, 1.21)Treated by PAS 47.7 (vs. 20.9) 3.45** (2.55, 4.66) 2.82** (1.97, 4.05)Diagnostic group A: Existing psychosis 45.0 3.80** (2.56, 5.65) 2.80** (1.70, 4.60) B: Recent psychosis 37.0 2.73** (1.88, 3.94) 2.58** (1.66, 4.01) C: Ultra High Risk 23.6 1.43 (0.86, 2.38) 1.10 (0.61, 1.93) D: Non-psychosis MH disorders – D1: No MH admissions (Ref) 17.7 (1.00) - (1.00) - D2: Prior MH admissions 30.1 2.00** (1.21, 3.32) 1.72# (0.93, 3.15) E: Undetermined@ 12.0 0.63# (0.36, 1.11) 1.06 (0.57, 1.96)Comorbid conditions (pre-PAS) Depression 27.6 (vs. 29.0) 0.93 (0.70, 1.23) 0.79 (0.57, 1.10) Anxiety 31.7 (vs. 27.3) 1.25 (0.91, 1.71) 1.09 (0.75, 1.56) Substance misuse 39.1 (vs. 24.5) 2.03** (1.50, 2.74) 1.54* (1.05, 2.26) Personality disorder 27.9 (vs. 28.5) 0.97 (0.67, 1.41) 0.80 (0.53, 1.22) Other MH problems 32.1 (vs. 20.8) 1.85** (1.34, 2.55) 1.08 (0.72, 1.63) Psychosocial problems 34.1 (vs. 24.5) 1.63** (1.23, 2.16) 1.22 (0.86, 1.72) Physical disorder 44.9 (vs. 25.7) 2.42** (1.68, 3.49) 1.06 (0.68, 1.67) Other non-MH problems 39.4 (vs. 26.4) 1.85** (1.29, 2.66) 1.15 (0.75, 1.78)

Note: Significance levels were based on Wald statistics: *p<0.01, **p<0.001, # trend (p<0.05); adjusted analyses controlled for all tabled variables plus service year block and length of available data windows (pre- and post-PAS). @ Missing comorbidity data were dummy-coded to mean values for this group. ^ High community contacts= at least bimonthly contact with community MH services during the first two years post-PAS presentation window; overall, 26.3% experienced high community contacts.


Table S11. Aggregate (any episode) and new episode (post-PAS only) profiles by baseline diagnostic group (N=1747) [Excluding Group-E]

Diagnosis or problem (%)

Baseline diagnostic group assignmentOverall

(ExcludingGroup-E)

A: Existingpsychosis

B: Recent psychosis

C: Ultra High Risk (UHR)

D: Non-psychosis MH disordersD1: No MH admissions

D2: Prior MH admissions

(N=1747) (N=289) (N=395) (N=191) (N=706) (N=166)Any episode (pre- or post-PAS): Psychosis 49.4 (100)# (100)# 17.3 14.6 25.9 Depression 54.1# 50.9# 57.2# 67.5# 47.9 63.3# Anxiety 34.5 32.9 41.8 51.3# 25.4 39.2 Substance misuse 40.7 65.4# 52.7# 17.8 23.8 67.5# Personality disorder 26.2 29.4 27.3 25.7 19.3 47.6 Other MH problems^ 82.5# 83.4# 77.7# 85.3# 82.4# 89.2# Psychosocial problems 61.1# 84.4# 65.3# 55.0# 46.2 80.7# Physical disorders 35.8 63.0# 38.5 20.9 21.0 62.7# Other non-MH problems 37.1 52.6# 37.5 20.9 27.9 66.9#

New episodes (post-PAS only): Psychosis 10.2 - - 17.3 14.6 25.9@ Depression 10.3 14.2 7.6 5.2 11.0 12.7 Anxiety 9.3 11.4 7.6 8.4 9.2 11.4 Substance misuse 14.2 12.5 15.7 11.0 16.0 9.6 Personality disorder 9.1 12.8 11.1 4.7 7.5 9.6 Other MH problems^ 15.2 14.5 22.0@ 17.8 12.2 9.6 Psychosocial problems 20.7@ 14.2 26.1@ 13.1 22.5@ 19.9 Physical disorders 21.8@ 25.3@ 25.3@ 14.7 19.8 24.1@ Other non-MH problems 22.0@ 27.0@ 23.3@ 13.6 22.2@ 18.7Note: ^ This category includes: emotional or behavioural problems, service related problems, adjustment disorders, childhood disorders, intellectual disability, and other problems (other behavioural and MH disorders, cognitive related problems, neurological disorders). Group-E did not have adequate baseline comorbidity data and was excluded from these analyses. # Aggregate episodes (pre- or post-PAS) experienced by 50% or more of the group. @ New episodes (post-PAS only) experienced by 20% or more of the group.


Table S12. Number of non-psychosis diagnosis/problem categories by time period and post-PAS psychosis status (N=1747) [Excluding Group-E]

Number of non-psychosis diagnosis/problem categories(0-8) per time period forpost-PAS psychosis subgroups^


Overall(ExcludingGroup-E)

A: Existingpsychosis B: Recent psychosis C: Ultra High

Risk (UHR)



Clients WITHOUT a post-PAS psychosis episode (N=1191) (N=109) (N=198) (N=158) (N=603) (N=123)

Pre-PAS: Mean 2.37 3.48 2.52 2.53 1.74 4.07(SD) (1.58) (1.95) (1.72) (1.40) (1.02) (1.57)

Post-PAS: Mean 1.51 1.39 1.55 1.40 1.38 2.37(SD) (1.97) (2.09) (1.98) (1.76) (1.88) (2.30)

Difference (Post – Pre) -0.86 -2.08 -0.97 -1.13 -0.36 -1.70(SD) (2.24) (2.31) (2.21) (2.01) (2.06) (2.64)

Clients WITH a post-PAS psychosis episode (N=556) (N=180) (N=197) (N=33) (N=103) (N=43)

Pre-PAS: Mean 2.75 3.19 2.67 2.73 1.67 3.86(SD) (1.70) (1.68) (1.74) (1.57) (0.83) (1.82)

Post-PAS: Mean 4.08 4.12 3.68 3.39 4.48 5.37(SD) (2.25) (2.17) (2.25) (2.67) (2.13) (1.80)

Difference (Post – Pre) 1.33 0.92 1.01 0.67 2.81 1.52(SD) (2.60) (2.43) (2.60) (3.15) (2.25) (2.49)

Note: ^ These data were included in a Baseline diagnostic group by Post-PAS psychosis status by Time (5 x 2 x 2) repeated measures analysis of covariance, controlling (using standardised scores) for gender, age group, service year block, PAS treatment status, and length of available data windows (pre- and post-PAS); see Figure 1 (main text) for a graphical presentation of the difference data. There were significant main effects for diagnostic group (F(4, 1731)= 40.32, p<0.001) and post-PAS psychosis status (F(1, 1731)= 226.86, p<0.001), as well as three interaction effects involving differential changes over time: by diagnostic group (F(4, 1731)= 25.79, p<0.001); by post-PAS psychosis status (F(1, 1731)= 313.68, p<0.001); and by diagnostic group by post-PAS psychosis status (F(4, 1731)= 5.60, p<0.001). The latter effect reflected a more marked concurrent increase in non-psychosis diagnosis/problem categories for members of Group-D1 experiencing a post-PAS psychosis episode (N=103, mean difference= 2.81), relative to the other four groups (N=453, mean difference= 1.00). Supplementary analyses revealed that the diagnosis/problem categories contributing most to this disparity were depression and other MH problems; for example, members of Group-D1 with a post-PAS psychosis episode experienced an increased rate of depression from 36.9% to 50.5% (compared with a reduction from 41.3% to 34.4% for the other four groups) and an increased rate of other MH problems from 67.0% to 89.3% (compared with a less marked increase from 61.2% to 77.0% for the other four groups).


Table S13. Number of MH admission days per year by time period and post-PAS psychosis status (N=1747) [Excluding Group-E]

Number of MH admission days per year by time period forpost-PAS psychosis subgroups^




Risk (UHR)




Pre-PAS: Mean 0.51 2.55 0.67 0.21 0.00 1.36(SD) (1.74) (3.34) (2.39) (1.00) (0.00) (1.76)

Post-PAS: Mean 0.38 0.65 0.46 0.19 0.28 0.78(SD) (2.01) (3.37) (1.83) (0.88) (1.49) (3.42)

Difference (Post – Pre) -0.13 -1.90 -0.21 -0.03 0.28 -0.58(SD) (2.49) (4.47) (2.76) (0.97) (1.49) (3.83)


Pre-PAS: Mean 2.15 3.90 1.80 0.24 0.00 3.12(SD) (4.14) (4.74) (4.00) (0.60) (0.00) (5.16)

Post-PAS: Mean 11.46 17.43 8.19 5.20 7.69 15.26(SD) (27.07) (33.89) (20.25) (13.72) (21.58) (36.32)


Note: ^ These data were included in a Baseline diagnostic group by Post-PAS psychosis status by Time (5 x 2 x 2) repeated measures analysis of covariance, controlling (using standardised scores) for gender, age group, service year block, PAS treatment status, and length of available data windows (pre- and post-PAS); see Figure 1 (main text) for a graphical presentation of the difference data. There were significant main effects for diagnostic group (F(4, 1731)= 15.35, p<0.001), post-PAS psychosis status (F(1, 1731)= 125.56, p<0.001) and time (F(1, 1731)= 76.44, p<0.001), a significant diagnostic group by post-PAS psychosis status interaction (F(4, 1731)= 6.82, p<0.001), as well as two interaction effects involving differential changes over time: by post-PAS psychosis status (F(1, 1731)= 94.57, p<0.001); and by diagnostic group by post-PAS psychosis status (F(4, 1731)= 4.93, p=0.001). Among clients experiencing a post-PAS psychosis, there was a mean difference (i.e., increase) of 13.26 MH admission days per year on average for the A and D2 groups (N=223), versus 6.66 for the other three groups (N=333).


Table S14. Number of community MH contact days per year by time period and post-PAS psychosis status (N=1747) [Excluding Group-E]

Number of community MH contact days per year by time period for post-PAS psychosis subgroups^




Risk (UHR)




Pre-PAS: Mean 1.04 1.39 0.86 1.38 1.02 0.70(SD) (1.85) (1.69) (1.03) (2.61) (1.97) (0.86)

Post-PAS: Mean 2.38 3.79 2.56 2.48 1.94 2.83(SD) (7.08) (9.55) (6.49) (4.26) (6.91) (8.87)



Pre-PAS: Mean 1.14 1.17 1.12 1.41 1.00 1.27(SD) (2.14) (1.82) (2.07) (4.10) (1.67) (2.62)

Post-PAS: Mean 12.22 14.14 11.98 4.21 11.76 12.58(SD) (17.86) (17.40) (14.84) (3.92) (26.30) (11.75)


Note: ^ These data were included in a Baseline diagnostic group by Post-PAS psychosis status by Time (5 x 2 x 2) repeated measures analysis of covariance, controlling (using standardised scores) for gender, age group, service year block, PAS treatment status, and length of available data windows (pre- and post-PAS); see Figure 1 (main text) for a graphical presentation of the difference data. There were significant main effects for diagnostic group (F(4, 1731)= 4.21, p=0.002), post-PAS psychosis status (F(1, 1731)= 135.69, p<0.001) and time (F(1, 1731)= 244.93, p<0.001), as well as significant or trend level interaction effects involving differential changes over time: by diagnostic group (F(4, 1731)= 3.28, p=0.011); by post-PAS psychosis status (F(1, 1731)= 131.11, p<0.001); and by diagnostic group by post-PAS psychosis status (F(4, 1731)= 3.15, p=0.014). Among clients experiencing a post-PAS psychosis, there was a mean difference (i.e., increase) of 2.80 community MH contact days per year for Group-C (N=33), versus 11.60 on average for the other four groups (N=523).


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