title: The Dark Side of the Moon: Meta-analytical Impact of Recruitment Strategies on Risk Enrichment in the Clinical High Risk State for Psychosis.
abstract: BACKGROUND
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: paolo.fusar-poli@kcl.ac.uk.
authors.forename: Paolo
authors.initials: P
authors.lastname: Fusar-Poli
authors.affiliation: University Hospital of Child and Adolescent Psychiatry and Psychotherapy, Department of Child and Adolescent Psychiatry, University of Bern, Bern, Switzerland;
authors.forename: Frauke
authors.initials: F
authors.lastname: Schultze-Lutter
authors.affiliation: 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;
authors.forename: Marco
authors.initials: M
authors.lastname: Cappucciati
authors.affiliation: Department of Psychosis Studies, King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK;
authors.forename: Grazia
authors.initials: G
authors.lastname: Rutigliano
authors.forename: Ilaria
authors.initials: I
authors.lastname: Bonoldi
authors.affiliation: Department of Biostatistics, Institute of Psychiatry Psychology and Neuroscience, King's College London, London UK;
authors.forename: Daniel
authors.initials: D
authors.lastname: Stahl
authors.affiliation: Department of Psychiatry (UPK), University of Basel Psychiatric Clinics, Basel, Switzerland;
authors.forename: Stephan
authors.initials: S
authors.lastname: Borgwardt
authors.affiliation: Department of Psychiatry (UPK), University of Basel Psychiatric Clinics, Basel, Switzerland;
authors.forename: Anita
authors.initials: A
authors.lastname: Riecher-Rössler
authors.affiliation: Department of Psychiatry, University of Calgary, Calgary, Alberta, Canada;
authors.forename: Jean
authors.initials: J
authors.lastname: Addington
authors.affiliation: Department of Psychiatry, University of North Carolina, Chapel Hill, NC;
authors.forename: Diana O
authors.initials: DO
authors.lastname: Perkins
authors.affiliation: Department of Psychiatry, Yale University, New Haven, CT;
authors.forename: Scott W
authors.initials: SW
authors.lastname: Woods
authors.affiliation: Department of Psychiatry, Yale University, New Haven, CT;
authors.forename: Thomas
authors.initials: T
authors.lastname: McGlashan
authors.affiliation: Department of General Psychiatry, Institute of Mental Health, Singapore, Singapore;
authors.forename: Jimmy
authors.initials: J
authors.lastname: Lee
authors.affiliation: Department of Psychiatry and Psychotherapy, University of Cologne, Cologne, Germany;
authors.forename: Joachim
authors.initials: J
authors.lastname: Klosterkötter
authors.affiliation: Institute of Brain, Behaviour and Mental Health, University of Manchester, Manchester, UK.
authors.forename: Alison R
authors.initials: AR
authors.lastname: Yung
authors.affiliation: 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;
authors.forename: Philip
authors.initials: P
authors.lastname: McGuire
mesh_terms: D006801:Humans; D018579:Patient Selection; D011618:Psychotic Disorders / Q000175:diagnosis / Q000453:epidemiology*; D018570:Risk Assessment
keywords: CAARMS; SIPS; meta-analysis/risk; prevention; psychosis; schiz-ophrenia