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BMC Psychiatry volume 25, Article number: 187 (2025)
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Serious mental illnesses significantly contribute to the global health burden. The prodromal stage, marked by subclinical symptoms that impair daily functioning but do not meet full diagnostic criteria, often precedes the onset of serious mental illness. This stage can vary across regions, cultures, and demographics. High false-positive rates and low conversion rates to diagnosed mental disorders may increase stigmatization and delay timely care. This study aimed to explore the prodromal symptoms preceding serious mental illness in Taiwanese young adults.
A qualitative research design was employed, with semi-structured interviews conducted every three months until illness onset. Thirty-six individuals (aged 16–35) identified as ultra-high risk for psychosis were recruited from a psychiatric outpatient unit in central Taiwan over a two-year recruitment period. Among them, 24 participants who had developed a serious mental illness (9 with schizophrenia, 5 with bipolar disorders, and 10 with major depressive disorder) were included in the analysis. Data from these participants were analyzed using qualitative content analysis to explore their prodromal experiences and symptoms. The study adhered to the trustworthiness criteria, including credibility, transferability, dependability, and confirmability.
The 24 participants had an average age of 22.83 years, including 8 males and 16 females. Analysis of 52 interviews identified five primary themes and 16 sub-themes: sleep disturbances leading to fatigue, terror caused by confusion between reality and hallucinations, indecision due to cyclic fluctuations in control, gradual loss in sadness and despair, and experiences of self-denial and uncertainty. This study provides valuable insights for the early screening of prodromal symptoms of serious mental illness in Taiwan.
The findings may assist early detection, support interventions to prevent or delay the onset of serious mental illness, and reduce the individual, familial, and societal burdens associated with mental disorders.
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The 2022 World Mental Health Report highlighted the global burden of mental illnesses and the need for long-term care [54] . Before the full onset of serious mental illness, such as schizophrenia (S), bipolar disorders (BD), and major depressive disorder (MD), a prodromal stage often appears with symptoms that impair functioning but don’t meet diagnostic criteria. This stage, which can only be identified retrospectively, is closely linked to the concepts of ultra-high risk (UHR) for psychosis [33, 58] or at-risk mental state (ARMS) [15]. UHR and ARMS help identify those at high risk for psychosis, marked by symptoms like ideas of reference, paranoid ideation, perceptual disturbances, and the trait and state risk factor group [60]. However, these symptoms vary across regions and cultures [36, 43]. Strong societal stigma toward mental illness may cause individuals in the prodromal stage to hide symptoms or delay seeking help, worsening their condition [46]. Additionally, cultural norms favoring emotional restraint and social harmony may further obscure symptoms, making early detection more challenging [10]. Given these cultural and behavioral influences on symptom expression and help-seeking, this study aimed to explore the prodromal stage symptoms preceding serious mental illness in the Taiwanese population.
Attenuated Psychosis Syndrome, characterized by mild positive symptoms within the past year, brief limited intermittent psychotic symptoms, and idiosyncratic risk groups showing significant functional decline over the past year [44, 59], are widely accepted criteria for identifying UHR for psychosis. Commonly used assessment tools such as the Structured Interview of Prodromal Syndromes [55], Scale of Prodromal Symptoms (SOPS) [32], and Comprehensive Assessment of ARMS [61] help evaluate positive, negative, disorganized, and general symptoms in both clinical and research settings. However, these tools often suffer from high false-positive rates [15, 23], which can lead to stigmatization, disputes over medical insurance [62], and missed opportunities for appropriate care. Consequently, a more cautious approach is needed when assessing the prodromal stage [18, 39]. Moreover, the cultural stigma associated with mental illness screenings makes them less accessible, underscoring the necessity of integrating effective screening tools for high-risk individuals to improve early detection and reduce barriers to care.
The assessment of the prodromal state is closely tied to an individual’s sociocultural context [22]. It is influenced by a complex interplay of physiological factors (e.g., organ function, biological systems, age), psychological elements (e.g., mental state, illness response), and situational aspects (e.g., lifestyle, socioeconomic status, interpersonal relationships). Family roles, educational background, health knowledge, values, and past experiences further shape this assessment [4, 31]. Thus, presenting prodromal symptoms within a culturally relevant framework can significantly improve the accuracy of early detection efforts [30].
The current assessment and screening tools for Taiwanese populations, such as the Brief Self-Report Questionnaire for Screening Putative Pre-psychotic States [26], have notable limitations, including a low sensitivity of 0.56. While the Chinese version of the Prodromal Questionnaire, translated by Chiu et al. [11] from Loewy et al. [27], demonstrates a high sensitivity of 97%, its specificity is only 30%, reducing its accuracy in detecting prodromal characteristics. Furthermore, the Chinese Schizotypal Personality Questionnaire-Brief, translated by Ma et al. [28] for self-assessment among undergraduate students, has a sensitivity of 80% and specificity of 85.9%. However, only 9.2% of those identified develop mental illness within 12 months [29]. These limitations underscore the difficulties in early detection of prodromal cases in Taiwan.
Over the past few decades, researchers have made considerable efforts toward the early detection and prevention of individuals with prodromal psychosis or UHR/ARMS. Despite these efforts, challenges remain due to high false positive rates [7, 17] and low conversion rates [50], which impede the timely and effective delivery of appropriate health care. Strengthening the understanding of prodromal symptoms in high risk individuals is vital for enhancing screening accuracy and successfully implementing preventive measures. This can lead to earlier interventions, reduce long-term damage, and alleviate the burden of serious mental illnesses on individuals, families, and society [38, 57].
This study employed a qualitative research approach with a recruitment period from September 2021 to August 2023. Individuals who met the UHR criteria for serious mental illness were initially invited to participate in in-depth interviews. For those participants who developed serious mental illness within two years, their interviews were specifically analyzed to explore the symptoms and experiences during the prodromal stage of their condition.
Participants were recruited from the psychiatric outpatient unit of a medical center in central Taiwan. The inclusion criteria were: (1) individuals meeting the UHR criteria for serious mental illness with no history of substance abuse; (2) aged between 13–35 years; and (3) written informed consent. A review of research data compiled by Woods et al. [55] indicates that the lowest SOPS total score was 19.4 [45]. Therefore, to facilitate participant recruitment from clinical outpatient settings, this study adopted Shi et al. [45] as a reference, using SOPS total = 20 as the baseline screening criterion, based on the 19.4-point threshold. A total of 36 participants were recruited, of which 24 developed serious mental illness, such as schizophrenia, within two years. These 24 participants were included in the final qualitative analysis.
Data were collected through semi-structured, in-depth interviews conducted over a two-year period. Participants were interviewed every three months, with interviews ending upon a diagnosis of mental illness, resulting in approximately 1–8 sessions per participant. The interviews were conducted in a private, quiet, and undisturbed setting, and each session was fully recorded. Each interview lasted about 60 to 90 min and focused on assessing overall mental risk, current mental status, and health needs. The interview process was adaptable, with flexibility to modify methods, questions, or sequencing depending on the interview flow. The interviewer, a research team member with a doctoral degree and extensive clinical experience in psychiatry, conducted all sessions. The interviewer’s expertise ensured the depth, accuracy, and reliability of the interviews and evaluations.
This study employed a semi-structured interview format to explore participants’ emotions, symptoms, feelings and overall experiences related to their health and mental state. The guide includes the following prompts:
Begin with an introduction and clearly explain the purpose of the interview to the participant.
How would you describe your overall health?
What motivated you to seek medical treatment at this time?
Have you experienced any significant health issues recently?
Can you provide examples of any unusual experiences you have had?
Can you describe any specific challenges or troubles you’ve faced recently?
Have you noticed any changes in your mood, thoughts, or behavior? Under what circumstances do these changes typically occur?
What is your current status regarding schooling or employment?
Have you had any difficulties in your interpersonal relationships in the past six months?
Do you have friends or family members who understand your challenges, discomforts, or health needs?
Is there anything you wish your healthcare providers would do differently to support you?
Thank you for participating in this interview. Is there anything else you would like to share about your experiences that we haven’t covered?
The SOPS is a semi-structured interview tool consisting of 19 items designed to evaluate four major symptom domains: positive symptoms, negative symptoms, disorganized symptoms, and general symptoms. A score of 3–5 on any item is indicative of symptoms within the prodromal range, which must be present for at least one hour per day and at least four days per week on average [23, 25]. This tool is commonly used in clinical and research settings to assess prodromal symptoms in individuals at high risk for psychosis.
This study employed qualitative content analysis based on the procedures outlined by Denzin and Lincoln [13]. The analysis process was conducted through the following steps:
Listening and Transcription: The interview recordings were carefully listened to, paying attention to the spoken words, emotional tone, speed, and volume. These elements were transcribed verbatim.
Repeated Review: The interview content was reviewed and read multiple times, and relevant phrases or words aligned with the research objectives were highlighted.
Classification and Coding: The highlighted content was classified, named, and coded into categories. This process was repeated several times to ensure accuracy and identify any new emerging codes.
Review and Summarization: Each coded item was reviewed to differentiate between primary and secondary attributes and their relationships. Comparisons and connections were drawn, and the data were re-summarized as needed.
Reclassification: Data with similar attributes were reclassified to identify their conceptual characteristics, refining categories to maintain consistency.
Thematic Development: Relationships between conceptual attributes were compared and integrated to form themes. The results were thoroughly described, leading to the development of new themes that encapsulated the data.
This study adhered to the trustworthiness criteria proposed by Lincoln and Guba [24], including credibility, transferability, dependability, and confirmability. To ensure credibility, the same interviewer conducted all interviews, which were audio-recorded and transcribed verbatim. Attention was given to the tone and speed of participants’ speech to gain insights into their emotional state. Non-verbal cues and affective responses were also documented during the interviews, contributing to the authenticity of the collected data. Additionally, regular discussions among the research team ensured alignment in interpretation and increased the credibility of the findings.
To enhance dependability, the analysis of verbatim transcripts was regularly discussed within the research team, ensuring consistency in interpretation and increasing the reliability of the findings. Both the interviewer and analysts, experienced in qualitative research, approached the data from a neutral standpoint, further strengthening the confirmability of the results. Transferability was addressed by securely encrypting and storing the collected data, allowing for future verification and application in similar research contexts. The ongoing discussions within the research team regarding the analysis process provided a robust framework for applying the findings to other scenarios, ensuring the study’s relevance and broader applicability.
Of the 24 participants, 6 (25%) received a confirmed diagnosis after only one consultation. Only one participant, who developed the illness after the fourth consultation, was followed for more than one year. During the data analysis process, no new category items emerged after analyzing the 18th participant. Although an additional 6 participants were analyzed, no new categories were identified. According to Sandelowski [42], data saturation is reached when no new information emerges from the collected data within a specific time frame and among a defined group of participants. Thus, under the given recruitment conditions, this study has achieved data saturation.
This study was conducted in accordance with the principles outlined in the Declaration of Helsinki and received approval from the Institutional Review Board of China Medical University Hospital in Taiwan (CRREC-110–034; CMUH110-REC3-152). Participant rights were rigorously safeguarded, and research findings were used solely for academic purposes. The study protocol included comprehensive explanations of the research objectives, and informed consent was obtained from all eligible participants prior to their involvement to protect confidentiality and autonomy. All Participants were informed that their interviews would be transcribed verbatim and that their identities would be anonymized using digital code names. 36 participants provided their informed consent before they participated in the study. Any personally identifiable information, such as names, was replaced with coded identifiers to ensure anonymity. Throughout the data analysis process, all data were securely stored in encrypted files, ensuring the confidentiality of participants and the integrity of the research.
This study analyzed 24 prodromal participants who developed diagnosed mental illnesses within two years of data collection. A total of 52 in-depth interviews were conducted, involving 8 males (33.3%) and 16 females (66.7%). The average age of the participants was 22.83 years (± 5.83). Most participants had attained senior high school or university-level education (n = 22, 91.7%). Additionally, 8 participants (33.3%) reported a family history of mental illness. Prior to the initial interview, 14 participants had experienced hallucinations, with 12 cases reporting auditory hallucinations (50%), 6 reporting visual hallucinations (25%), and 2 reporting both types of hallucinations (8.3%). Detailed data are presented in Table 1.
The results indicated that symptom changes during the prodromal stage could be categorized into five primary themes and 16 sub-themes. The main themes A-E were: sleep disturbances, confusion-driven terror, instability-stagnation spiral, lost in despair and uncertain self-perception. Detailed findings are presented in Table 2.
Most participants identified sleep disturbances as a primary reason for seeking medical care. They reported that their sleep disturbances were worsened by unhealthy sleep habits and emerging mental symptoms, resulting in prolonged physical and mental exhaustion. This theme encompasses three sub-themes.
Participants often described irregular sleep patterns, including staying up late and struggling to wake up early, which eventually resulted in unhealthy sleeping habits. For instance:
“…I don’t always go to bed at the same time; sometimes I sleep in the morning, sometimes at night…sometimes I watch movies…it’s irregular” (Case 32, Female, 24 years, MD).
Participants experienced difficulty falling asleep due to their illness or symptoms, which contributed to ongoing sleep disturbances. For example:
“…I didn’t sleep well… When I heard the auditory hallucinations, I never slept well. I didn’t sleep for two or three days! I felt very tired… I collapsed from exhaustion.” (Case 18, Female, 18 years, MD).
Incomplete sleep cycles caused by sleep disturbances led to the long-term accumulation of fatigue, resulting in daytime exhaustion. For instance:
“Each sleep cycle is incomplete, and if this continues, the body and mind will be very, very tired… The body seems to accumulate fatigue on its own, and after reaching a certain level, it can… sleep longer at a time.” (Case 01, Female, 19 years, BD).
Participants frequently reported difficulty distinguishing between reality and hallucinations. Delusions often triggered intense fear, while hallucinations made them feel vulnerable to malicious harm and unjust grievances. They also experienced feelings of emptiness and confusion about what was real. Many expressed a deep fear of these symptoms reoccurring, feeling that their entire ability to function was threatened by these psychotic experiences. This theme encompasses four sub-themes.
Participants experienced hallucinations that impaired their ability to accurately perceive real-life situations, leading to confusion and disruption in their daily lives. For instance:
“…When I went to the Outlet and used the restroom, there were many people lining up. When someone came out of one of the stalls, a person suddenly cut in front of me and entered the stall (the hallucination). Someone beside me asked why I didn’t go in, and I said I had just seen someone there. The person behind me said there was no one, which left me confused. I knocked on the door but got no response, so I opened it and found it empty… I was really shock; I clearly saw someone going in.” (Case 21, Female, 30 years, S).
Participants described an inability to control their thoughts and emotions, leading to heightened feelings of danger and fear. They felt overwhelmed by hallucinations and experienced an intensified fear of their recurrence, which negatively affected their emotional state. Many participants also reported entering trances where they were unaware of their actions, while others around them perceived their behavior as strange. For instance:
“When I was in high school, there was a week that was really… After I returned to normal and thought about that week, I couldn’t remember anything at all. Everyone said I had no facial expression and didn’t respond to anything they said, just being myself. When I think about it now, I have absolutely no idea what happened at that time. Everyone said I really looked like I was possessed by an evil spirit.” (Case 04, Male, 23 years, S).
Participants described feeling targeted and framed by peers in social situations, which heightened their stress and emotional pain. For instance:
“…At first, there were four girls sitting next to me, and then a group of people started laughing a lot. I didn’t know what they were laughing about, and the pressure kept building… Sometimes I heard them say, ‘You smell so bad,’ and I thought they were making fun of me, which made me feel aggrieved and hurt.” (Case 20, Male, 17 years, S).
Participants described how hallucinations severely impacted their ability to work and maintain daily routines. They felt disturbed and threatened by these symptoms, which made it difficult for them to function effectively. For example:
“I had to go to work that night, but I didn’t go because I was feeling really bad. Later, I started hearing noises occasionally. I couldn’t work on the last day, so I went home. After I got home, I heard the neighbor yelling at me. Then they stopped for a while, and I couldn’t hear it anymore. But then I heard it again later.” (Case 03, Female, 20 years, S).
Participants described a gradual loss of motivation in decision-making, which made them feel trapped and unable to progress. Their self-control fluctuated in a cyclical manner, leading to ongoing disruptions in their daily functioning. This theme includes two sub-themes.
Participants expressed a persistent inability to find motivation for daily tasks, leading to a lack of progress and a profound sense of stagnation. For example:
“…No more schooling. …all at home. …unemployed. …I don’t have any plans and I can’t get excited about anything.” (Case 33, Female, 23 years, MD).
Participants reported a conscious loss of self-control, marked by an inability to regulate their emotions, which significantly hindered their ability to work and manage daily tasks. They also noted that their emotional distress followed a cyclical pattern without any identifiable triggers, further disrupting their functioning. For instance:
“…I don’t know, but I feel like it’s a cycle. I can’t go out and just don’t want to do anything. It often affects my attendance rate, and I feel like I really can’t do anything. Suddenly I want to read a book or do a lot of things, but then there are days when I don’t want to do them.” (Case 23, Female, 20 years, MD).
When faced with stressful conflicts, participants were often unable to respond effectively and chose avoidance as a coping mechanism. This avoidance contributed to feelings of depression, which, in turn, triggered thoughts of self-harm. Over time, these thoughts escalated into self-harm behaviors that participants found increasingly difficult to control. This theme encompasses four sub-themes.
Due to high self-expectations, participants increasingly found it difficult to cope with stress and began avoiding challenging situations. This avoidance stemmed from their growing inability to accept themselves in the face of these pressures. For instance:
“It’s because I have very high self-expectations. I want to accomplish everything perfectly. Being a club leader, along with environmental pressures like those from school and interpersonal relationships, created an invisible pressure that made me not want to go to school.” (Case12, Male, 18 years, BD).
Suicidal thoughts often emerged when participants experienced emotional breakdowns, with intense feelings of hopelessness and despair. For instance:
“…I was in a state of breakdown, feeling very bad, and during that time, I had a complete emotional collapse and disorder. …When I am at my worst and most emotionally shattered, I want to commit suicide. …It was a common occurrence. …I just wanted to jump off a building to end it all.” (Case15, Female, 16 years, BD).
Participants found it difficult to handle conflicts, which led to overwhelming emotions and a loss of control, manifesting in self-harming behaviors. For instance:
“…My grandmother has been taking care of me since I was three. …When she passed away, I was self-harming every day. …Everyone blamed me, saying I was the one who killed her. …I had mentioned casually that there was no fruit upstairs, and then my grandma went out to buy it and never came back. …The pressure was immense during that time. …So, I turned to self-harm to cope. …The injuries on my hand would heal, but I kept replacing the knife with an old one and then a new one.” (Case26, Female, 20 years, BD).
Participants resorted to self-harm as a way to manage their depression and found it difficult to control these impulses, even when aware that their family was monitoring them. Despite family members regularly checking in, the participants continued to engage in self-harm privately. For instance:
“…I just start cutting myself with a knife when I feel very depressed. …All in my room. …My mother didn’t know at first, but now she checks in regularly, for hours and hours. …I could hear her footsteps, so I knew she was coming. …There are new wounds recently. …I’ve been biting my hands a lot lately, biting until they bleed, and then picking at them.” (Case24, Female, 16 years, BD).
Participants expressed deep disappointment in themselves when their performance failed to meet personal expectations. This resulted in a gradual erosion of self-identity, emotional instability, and a noticeable decline in work or academic performance. Many felt increasingly confused about their sense of self and faced uncertainty about their future. This theme encompasses three sub-themes.
Participants reported a decline in abilities, especially in areas where they had previously excelled, which led to feelings of disappointment in themselves and a belief that they were failing to meet their parents’ expectations. This was compounded by anticipatory anxiety about future challenges. These feelings of self-criticism often resulted in a deep sense of worthlessness and a loss of self-identity. For instance:
“…In high school, I was only particularly good at English, but now it has declined. …and now my grades are not good again, and I am failing. …My parents feel very embarrassed and disappointed with such a result. … I disappointed in myself too. …Worrying about the next internship. …next semester. …Two months of internship. …I’m worried…I’m worried that I won’t know how to do anything there. …It’s a worry. I’m lazy. …I still feel like I’m worthless. I can’t change this, so it’s still the same. …I’ve always cared about what others think. …I have very little confidence in myself. …I feel like I’m not worthy. …is useless. …I will start to think that it would have been better if I had never been born.” (Case22, Female, 21 years, S).
Participants reported that despite receiving psychiatric counseling, their condition continued to deteriorate, leading to worsening emotional struggles and a decline in work performance. This resulted in frequent job changes and difficulties maintaining employment. For instance:
“…My homeroom teacher referred me to the counseling room, and I received psychiatric counseling for a while. However, I still couldn’t maintain the role I once held. …I’ve been constantly searching for new jobs and changing jobs. …But in the end, it was probably because of my emotions! It wasn’t good. …I worked at a beverage store last month, but by the end of the month, the boss said I often rolled my eyes at customers, and my expression was unpleasant. So I was forced to leave. …I’ve been changing jobs a lot lately. …I don’t have a job now.” (Case36, Male, 28 years, S).
Participants expressed confusion and uncertainty about their future, particularly regarding their education or career plans. Many felt unsure about their own direction and were hesitant to take the next steps. For instance:
“Currently, I want to take a break from school. …I have been on leave for two weeks now. …I must take a break from school. …I haven’t searched where to study painting yet. …I want to take a break from school, but I haven’t done so yet. …I must take a leave of absence. …I made up my mind to take a break from school. …I didn’t have any conflicts with my classmates. …I want to improve my abilities. …I feel like I will be studying all the time and won’t be able to do the things I like. …I haven’t decided what to do yet, I’m just going to take a leave of absence and stay home.” (Case28, Male, 27 years, S).
This study analyzed interview data from 24 prodromal participants, categorizing the symptoms into five main themes (A-E) and 26 sub-themes. By examining UHR assessments conducted before the onset of illness, this research addressed the challenge of retrospectively identifying the prodromal stage, which is often difficult to capture in advance [6]. This approach provides valuable insights for the early detection and identification of prodromal young adults in Taiwan, where such studies are limited. The findings contribute significantly to both clinical practice and academic research by enhancing screening criteria for identifying prodromal phase of mental illness in Taiwan, improving early detection accuracy, and ultimately reducing the burden of mental illness on individuals, families, and society.
The results indicated that prodromal symptoms in individuals in Taiwan were interconnected, with initial signs typically manifesting as significant changes in sleep patterns. These disturbances frequently affected daytime mental states and gradually escalated into hallucinations involving familiar people, objects, and situations, inducing fear and confusion. As the symptoms progressed, individuals reported a lack of motivation to perform daily tasks, feeling trapped, and unable to move forward. They also experienced a gradual loss of focus and a weakened sense of self-identity. This confusion and uncertainty about the future further impaired their daily functioning, leading to a buildup of emotional and psychological stress. Over time, these symptoms became intolerable, culminating in self-harm behaviors that were difficult to control, ultimately affecting both academic and overall life performance.
Sleep disturbances are frequently reported in studies on prodromal psychosis [12, 34], commonly manifesting as irregular sleep patterns, difficulty falling asleep, and daytime fatigue [51]. Research by Zaks et al. [63] has demonstrated a strong association between sleep disturbances and symptom severity in UHR individuals, with evidence suggesting that disrupted sleep may exacerbate hallucinations and delusions in individuals with mental illness [53]. Consistent with these findings, the present study identified sleep disturbances (Theme A), highlighting their significant impact on daily functioning. Participants frequently reported experiencing daytime fatigue and severe mental exhaustion, which impaired their ability to engage in routine activities. These findings align with previous research indicating that sleep disturbances are prevalent among prodromal young adults.
Addressing sleep disturbances is essential, as improving sleep quality has been shown to alleviate psychiatric symptoms and reduce negative emotions in individuals with UHR or ARMS [5, 52]. Early detection and intervention targeting sleep-related issues may significantly improve the quality of life for individuals with ASMS, regardless of whether they transition to a clinical diagnosis. Thus, integrating sleep management into early intervention strategies is crucial for optimizing mental health outcomes and overall well-being.
In line with these findings, Theme E: Uncertain Self-Perception emerged in this study, highlighting the role of self-concept in shaping psychological experiences. This self-perception was influenced by academic performance (sub-theme E1) as well as difficulties in maintaining stable employment and social interactions (sub-themes E2–E3), reflecting broader lifestyle challenges that contribute to psychological distress and functional impairment. Similarly, Tsai, et al. [47] identified interpersonal deficits, poor nutrition, and low physical activity as key lifestyle factors among UHR individuals in Taiwan. The gradual onset of symptoms, as observed in Hong Kong, often delays recognition and help-seeking, leading to intervention only at more severe stages [20]. Additionally, cultural norms emphasizing emotional restraint and social harmony may obscure symptoms, complicating early detection and timely intervention.
Cultural influences also shape symptom presentation and mental health outcomes. Research from China has identified psychological and behavioral difficulties as early indicators of psychotic-like experiences, underscoring the importance of prompt assessment and intervention [21, 56]. Furthermore, a systematic review of risk factors for serious mental illness in Asia highlighted unique contributors, including low social engagement, shift work, and harmful alcohol use, which may influence both the onset and progression of mental illness [40]. These findings emphasize the complex interplay of sociocultural and lifestyle factors in mental health, reinforcing the need for early identification and culturally tailored interventions.
The findings of this study (Theme B) indicated that prodromal individuals experienced hallucinations and delusions, albeit often in a mild form [60]. The confusion between reality and distorted perceptions, coupled with the fear of losing control, similar to change in sense of self, including others and world [58], further exacerbates daily stress [35, 49]. Notably, these psychotic symptoms are not the primary reasons for seeking help; instead, emotional distress -particularly self-harming thoughts and behaviors- serves as the main motivator [14]. The present findings (Themes C & D) also align with Pelizza et al. [37], who reported that up to 66% of ultra-high risk individuals experience suicidal ideation, and 49% engage in lifelong self-harm behavior [48].
This study observed that Themes A and C were predominantly associated with participants with MD, whereas Themes B and E were more frequently linked to participants with schizophrenia, and Theme D was primarily related to BD. However, analysis across Themes A–E revealed that experiences from all three diagnostic groups were present, though some conditions may have been less extensively represented. However, fewer studies report to screen them following these behaviors. As these individuals face fluctuating self-control, they increasingly fall into sorrow and despair, making it difficult to resist self-harm impulses. Therefore, providing effective stress-coping strategies [41] can mitigate the risk of suicide and self-harm, while also decreasing the likelihood of developing a more serious mental illness in the future [16].
Impairment of role functions is a key indicator of the prodromal stage of psychosis, particularly in adolescents and young adults who may struggle with academic or occupational performance [8, 9]. In Taiwan, where academic success is highly valued, students who fail to meet their own or their parents’ expectations often experience disappointment and stress [3]. Among UHR cases, academic performance typically declines within six months, which is a significant behavioral symptom observed in this study. However, nearly 50% of Taiwanese students report high levels of academic pressure [1], and academic anxiety is prevalent regardless of actual performance [2, 19]. Therefore, academic performance alone cannot serve as the sole indicator of behavioral deterioration. A comprehensive evaluation that includes academic performance, concentration, interpersonal interactions, and other related factors is essential when assessing young adults with UHR/ARMS for early signs of psychosis.
This study also highlights that significant academic decline, coupled with feelings of uncertainty, confusion, and self-denial, contributes to cognitive symptoms of reality distortion in prodromal symptoms of mental illness. This finding is particularly notable, as it differs from symptoms commonly identified in studies of participants with UHR or ARMS in other studies.
This study employed a qualitative research method, and due to the limited number of participants, along with the fact that they were recruited from a single medical institution, it remains difficult to generalize the symptom characteristics to all individuals with prodromal symptoms of serious mental illness. Due to the immediate onset of illness following recruitment, some participants had only one interview session, during which symptom interference may have resulted in less detailed narratives and limited data. Conversely, participants who completed 3–4 interview sessions were able to articulate their experiences more comprehensively, yielding richer data. These variations in interview frequency and symptom presentation inevitably influenced the depth and representation of the collected data.
Additionally, while the inductive analysis focused on pre-morbid interview assessments, it was constrained by the lack of objectively validated tools for symptom evaluation. As a result, comparing the symptom manifestations in this study with findings from other research may introduce some ambiguities. Furthermore, although the age range for inclusion was 13–35 years, the average participant age was 22.83 years, with a range of 16–35 years, indicating a lack of younger adolescent samples, a key developmental period for the onset of serious mental illness. This absence of younger participants could create a knowledge gap in understanding the prodromal symptoms of serious mental illness during this critical age range.
Moreover, as this study only completed a two-year follow-up and analyzed data exclusively from participants who had developed a diagnosed mental illness, it was unable to assess those who remained clinically at-risk but had not yet progressed to illness. Given that the prodromal stage may last 1 to 5 years [33, 58] before the onset of illness, it is uncertain whether the remaining 22 clinical participants will remain unaffected in the future. As a result, this study lacks comparative data from non-transitioning individuals, making it impossible to determine whether the prodromal symptoms of those who eventually developed a severe mental illness differ from those who did not. This limitation underscores the need for extended follow-up to further track these individuals and analyze the data of those who do not progress to illness. Such an approach would provide deeper insights into these differences and enhance the cultural relevance of prodromal symptom screening.
This study addresses the challenge of identifying the prodromal stage of serious mental illness, which is difficult to capture in advance. Findings show that in Taiwan, prodromal symptoms are interconnected, often beginning with significant sleep disturbances. Additionally, academic decline, combined with feelings of uncertainty, confusion, and self-denial, contributes to cognitive distortions, a unique finding compared to UHR/ARMS studies in other regions. These insights are crucial for enhancing screening criteria for early detection of mental illness in young adults in Taiwan, providing a valuable foundation for improving clinical practices aimed at early intervention.
Future research could integrate qualitative findings into structured clinical assessments, using the themes identified in this study to develop culturally adapted clinical symptom checklists. These insights may refine assessment tools, bridging experiential narratives with standardized screening measures and enhancing early identification and intervention strategies.
This study aimed to explore the symptoms and manifestations of the prodromal stage preceding the onset of serious mental illness in Taiwan. The findings revealed several common prodromal symptoms, including nighttime sleep disturbances, daytime fatigue, psychotic symptoms such as delusions and hallucinations, periodic depression and mood fluctuations, fear of losing self-control, and a heightened sense of uncertainty. These symptoms often left individuals unable to cope with stress and reality, leading to confusion, a sense of powerlessness about the future, and in some cases, the emergence of self-harm behaviors. Future research should build on these findings by developing objective indicators to enhance the sensitivity and accuracy of detecting prodromal cases of mental illness in Taiwan.
These study data are deidentified participant data. The data that support the findings of this study are available beginning 12 months and ending 36 months following the article publication from the corresponding author, WFM, upon reasonable request at lhdaisy@mail.cmu.edu.tw.
Schizophrenia
Bipolar Disorders
Major Depressive Disorder
Ultra-high risk
At-risk mental state
Scale of Prodromal Symptoms
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This study thanks 36 study participants for participating and supporting grants from China Medical University (CMU112-MF-106; CMU112-IP-04), National Science and Technology Council (MOST 110-2314-B-039-041-MY2; NSTC112-2314-B-039-015), and Taichung Veterans General Hospital (TCVGH-1127401E), Taiwan. China Medical University, Taichung Veterans General Hospital and National Science and Technology Council had no further role in study design, study collection and analysis, interpretation of data, writing of the report, and in the decision to submit the paper for publication.
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The study was supported by research grants from China Medical University (CMU112-MF-106; CMU112-IP-04), National Science and Technology Council (MOST 110–2314-B-039–041-MY2; NSTC112-2314-B-039–015), and Taichung Veterans General Hospital (TCVGH-1127401E), Taiwan. All funding had no role in study design, study collection and analysis, interpretation of data, writing of the report, paper submission and the publication.
Department of Public Health (in Nursing), China Medical University, Taichung, Taiwan
Yu-Fen Chen
Department of Nursing, Taichung Veterans General Hospital, Taichung, Taiwan
Yu-Fen Chen
School of Nursing, China Medical University, No. 100, Sec. 1, Jingmao Rd., Beitun Dist., Taichung City, 406040, Taiwan
Tzu-Pei Yeh, Hsing-Chi Hsu, Shu-Hua Lu & Wei-Fen Ma
Department of Nursing, China Medical University Hospital, No. 100, Sec. 1, Jingmao Rd., Beitun Dist., Taichung, 406040, Taiwan, Republic of China
Tzu-Pei Yeh, Shu-Hua Lu & Wei-Fen Ma
Graduate Institute of Biomedical Sciences, China Medical University, Taichung, Taiwan
Hsien-Yuan Lane
Department of Psychiatry, China Medical University Hospital, Taichung, Taiwan
Hsien-Yuan Lane
Department of Psychology, College of Medical and Health Sciences, Asia University, Taichung, Taiwan
Hsien-Yuan Lane
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Study conception and design: Y.-F.C., S.-H.L. & W.-F.M. Data collection: Y.-F.C., T.-P.Y., S.-H.L., H.-Y.L, & W.-F.M. Data analysis and interpretation: Y.-F.C., T.-P.Y., H.-C.H., S.-H.L. & W.-F.M. Drafting of the article: Y.-F.C., T.-P.Y., H.-C.H., H.-Y.L., S.-H.L., & W.-F.M. Critical revision of the article: Y.-F.C., T.-P.Y., H.-C.H., H.-Y.L, S.-H.L. & W.-F.M.
Correspondence to Shu-Hua Lu or Wei-Fen Ma.
This study was conducted in accordance with the principles outlined in the Declaration of Helsinki and received approval from the Institutional Review Board of China Medical University Hospital in Taiwan (CRREC-110–034; CMUH110-REC3-152). Participant rights were rigorously safeguarded, and research findings were used solely for academic purposes. The study protocol included comprehensive explanations of the research objectives, and informed consent was obtained from all eligible participants prior to their involvement to protect confidentiality and autonomy. Participants were informed that their interviews would be transcribed verbatim and that their identities would be anonymized using digital code names. All participants provided their informed consent before they participated in the study. Any personally identifiable information, such as names, was replaced with coded identifiers to ensure anonymity. Throughout the data analysis process, all data were securely stored in encrypted files, ensuring the confidentiality of participants and the integrity of the research.
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Chen, YF., Yeh, TP., Hsu, HC. et al. Clinical symptoms of the prodromal stage preceding serious mental illness in Taiwanese young adults: a qualitative study. BMC Psychiatry 25, 187 (2025). https://doi.org/10.1186/s12888-025-06643-4
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