Early Intervention May Help Keep Psychosis At Bay
Just as early detection of cancer increases the odds of a favorable outcome, diagnosis and intervention for patients in the early phases of schizophrenia or other primary psychotic disorders might help them to preserve a high level of mental and social function, investigators reported at the American Psychiatric Association’s Institute on Psychiatric Services.
Early results from a small study of adolescents and young adults considered to be at clinical high risk for developing psychosis suggest that a combination of individualized therapies plus group, family, educational, vocational, and social interventions can significantly reduce overall psychotic symptoms, decrease depression and anxiety, and lower patient perceptions of the disruptions that psychosis causes in their lives, said Dr. Michael Birnbaum, a psychiatry resident at Columbia University in New York.
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Dr. Michael Birnbaum
“Early intervention is based on the idea that mental illness is a progressive pathologic process, that there are very distinct stages, and that each stage requires very specific interventions for that stage,” he said.
Psychosis is a clinical manifestation of a progressive pathological process that begins prenatally and progresses until the second or third decade of life when a psychotic episode occurs and a threshold is reached, he said.
The course of schizophrenia moves from the premorbid phase of asymptomatic genetic and environmental vulnerability, to the prodromal phase that might range from generalized, nonspecific symptoms to subthreshold symptoms and mild functional decline, to the first full-threshold psychotic episode with significant functional decline, and finally to remission and relapse.
Early intervention in at-risk patients aims to delay or prevent progression to psychosis and its deleterious effects on social, educational, and occupational functioning. With early treatment, patients might be more engaged and trusting of their therapists, and have a “less risky and traumatic mode of entry into psychiatric care,” Dr. Birnbaum said.
Risks High During Critical Period
During the critical period – the first 2-5 years after an initial psychotic episode – an early intervention plan can set the parameters for long-term recovery and outcome. It is during this critical period, Dr. Birnbaum said, that there is the highest risk for disengagement, relapse, and suicide, and the most pronounced functional decline (Schizophr. Bull. 1996;22:201-22).
In this phase, the goals of treatment are management of symptoms through medication, psychosocial interventions aimed at minimizing disability and maximizing functional outcome, reducing stigma, allowing the patient and family to mourn and adapt, and for the clinician to provide the patient with hope.
“We know that reducing the duration of untreated psychosis has a huge impact,” he said.
Columbia University has established an early intervention program dubbed PEER, for Prevention, Education, Evaluation, and Rehabilitation. The program is a subspecialty service in which research is translated into clinical practice aimed at early detection and targeted interventions with a multidisciplinary team.
Treatment domains in the program include individualized interventions to help patients recover by exploring personal goals and providing education about the disease and treatments; medication aimed at improving mood and lessening anxiety and symptoms of psychosis, as well as preventing exacerbations; group interventions for improving social skills, decreasing isolation, and reducing stigma; family interventions to promote involvement, reduce stress, and teach crisis management skills; and educational and vocation interventions to help patients achieve their employment goals.
Short-Term Improvements Seen
Dr. Birnbaum and his colleagues conducted a small clinical study of 16 male and 4 female participants in the PEER program. The patients were 12-30 years old, had been diagnosed with a primary psychotic disorder within the last 5 years, and were considered to be at clinical high risk for developing psychosis as identified by the Structured Interview for Prodromal Symptoms and the Scale of Prodromal Symptoms.
Patients were assessed with a wide variety of validated scales for substance abuse, intelligence, disability, and depression and other symptoms.
At baseline, the patients presented with clinically significant anxiety and depression, 70% met criteria for suicide risk, and 23% were considered to be at high risk of suicide. Two-thirds of the sample said their symptoms were disrupting their lives, and more than half reported regular use of alcohol and marijuana.
At 3 months’ follow-up, however, investigators saw significant reductions on the Brief Psychiatric Rating Scale, from a baseline mean of 34.1 to 30.87 (P less than .01), and significant reductions in the rates of depression and anxiety as measured by the Beck Depression Inventory, revision 2, and Self-Report for Childhood Anxiety Related Emotional Disorders (SCARED) rating scales.
In addition, decreases were found in overall symptoms of psychosis, in perceived disruption of school or work (from 75% at baseline to 55% at 3 months), and in disruptions in social life or leisure activities (from 85% to 54.5%). The interventions did not, however, make a difference in use of either alcohol or marijuana.
“It’s hard to draw too many conclusions from this; it’s just preliminary data, but we like to think that joining the PEER program has been helpful, and contributes to decreasing the perceived distress and stabilizing the psychotic symptoms, depression, and anxiety. We’re happy to find out that there’s less disruption, or at least less perceived disruption, in their lives, and we clearly have to focus more on alcohol- and marijuana-focused treatments,” said Dr. Birnbaum.
The investigators hope to follow the patients longitudinally to determine what works and what does not, and, ideally, to be able to contribute to future guidelines on intervention in psychosis, he concluded.
Dr. Birnbaum disclosed no relevant conflicts of interest.