Putative high risk for psychosis should not be considered a disorder

The paper by Fusar-Poli and colleagues on functioning and quality of life (QoL) in people meeting supposed ‘high-risk’ status for psychosis ¹ concludes, inter alia, that high-risk individuals do not differ statistically from individuals with established psychotic disorders in terms of QoL. This conclusion is used to help justify the views of the authors that ‘impairments in functioning and QoL are key features of the high-risk state’ (p. ) and that high risk is ‘not just a state of risk’ but a ‘disorder’ (in their title). However, reference to the original paper by Francey and colleagues ² shows that QoL was actually higher in high-risk individuals than a first-episode psychosis comparison group. Thus the meta-analytic results shown in Fig. 2(b) of the paper by Fusar-Poli et al ¹ are incorrect and, should the correct data be applied, would show that supposed high-risk individuals have overall better QoL than those with a ‘true’ psychotic illness.

Also of relevance in the study of Francey et al ² was that QoL did not distinguish those high-risk individuals who supposedly transitioned to psychosis from those who did not, again throwing doubt on the views of Fusar-Poli et al that these supposed deficits reinforce the case for ‘prevention of transition’ (p. ) and ‘treatment of the current condition’. These latter ‘clinical implications’ are not, to my mind, supported by the data presented and disavow the fact that the majority of people supposedly at high risk for psychosis do not develop a psychotic illness and also that no treatment has consistently and replicably been shown to alter the likelihood of such transition. ³ Hence, the assumption that the data presented should persuade us that the high-risk state is a ‘disorder’ or even a ‘condition’ is beyond me.

Finally, the authors attribute to me a view that high-risk individuals are ‘not at all dysfunctional’ (p. 200), but this is disingenuous: the point is that the supposed high-risk state is composed of a heterogeneous group of individuals and that many of them cannot be considered to have a ‘disorder’ in a heuristic, predictive or treatment sense.