Alison Yung: Treat before psychosis

SCHIZOPHRENIA carries a great personal and economic burden.

It begins with a non-psychotic prodromal phase before the onset of characteristic positive symptoms such as delusions and hallucinations. This prodromal phase is therefore a potential target for early intervention.

Criteria have been developed to identify the prodromal phase. Essentially, they include transient or subthreshold psychotic symptoms and/or a genetic risk for schizophrenia combined with a significant decrease in functioning.

Exact age criteria vary across different settings, but tend to be age between 14 and 30 years, the age at highest risk of psychosis onset.

These “ultra-high risk” (UHR) criteria are associated with high rates of onset of disorder, of 36% at 3 years after clinical presentation. About 73% of people “transitioning” have a schizophrenic psychosis, so individuals meeting UHR criteria are considered to be at high risk of schizophrenia.

Clinical services that treat individuals at ultra-high risk of psychosis who are symptomatic and help-seeking are now available almost worldwide. They receive referrals from GPs, counsellors, and other services that manage young people.

Presenting problems include a range of psychiatric symptoms and problems with living, and there are high rates of non-psychotic mental disorders. Treatment involves managing individuals’ current needs; monitoring for signs of deterioration and for evidence of the onset of psychosis; and attempting to prevent the onset of psychotic disorder.

Case management involves providing practical help with finances, accommodation, education and other issues.

Other treatment offered includes supportive therapy, stress management, cognitive therapy (CT), family-based treatment and pharmacological management of non-psychotic disorders.

Monitoring an individual’s mental state and detecting psychosis early allows prompt treatment and minimisation of the duration of untreated psychosis, which, if prolonged, is harmful to both patients and their families and is known to be associated with a poor outcome. Additionally, if a person becomes psychotic, treatment for the first episode of psychosis can begin with an existing treating team.

Trials of treatment with low-dose antipsychotics, CT and fish oil have been conducted and have shown reductions in transition rates.

A recent review of five trials found a significant effect of specific treatment (such as supportive counselling), compared with control treatment, in reducing the transition rate at 12, 24 and 36 months although antipsychotics were not proven in any trial to confer additional benefit. However, this review did not include two recently published articles (BMJ and Journal of Clinical Psychiatry) that found no difference between treatment and control groups.

All trials found that the interventions tested were effective at reducing symptoms and improving functioning among individuals at ultra-high risk of psychosis.

Importantly, since it seems that antipsychotics are no more effective than more benign treatments, the current recommendation is to use these safer options. This approach has the additional advantage that these interventions are likely to be effective across a range of different psychiatric symptoms and disorders.

Even if an individual meeting UHR criteria is not truly at risk of psychotic disorder, the therapy will still be of benefit. Antipsychotics are not recommended for individuals at ultra-high risk.

Evidence is also emerging that clinical services are at least likely to be cost-effective. They may even be associated with a reduction in health costs through a reduction in the proportion of people developing schizophrenia and a decrease in the duration of untreated psychosis. Savings are made through reductions in direct service contacts and in unemployment.

Telling individuals that they are at risk of psychotic disorder could lead to anxiety and self-stigmatisation. This may be offset by the help provided.

The knowledge that monitoring of mental state will detect signs of deterioration should they occur, and the realisation that others have similar experiences, can be reassuring.

Communication of risk can be seen as a relief.

It is important to note that treatment within a service for individuals at ultra-high risk and discussion of risk is different from giving a formal diagnostic label that implies a person has a valid and distinct diagnostic entity with an invariable outcome. Individuals at ultra-high risk of psychosis presenting to services are distressed and are seeking help.

Their management within specialised services enables the provision of practical help, treatment of current needs, assessment of mental state and early detection of onset of psychotic disorder. In some cases, psychosis may even be prevented. Currently recommended treatments such as supportive therapy, CT and fish oil are also likely to be of benefit for other psychiatric disorders.

Rather than waiting to see if schizophrenia develops, these benign interventions at this stage are justified.

Professor Alison Yung is professor of psychiatry at the Centre for Youth Mental Health, University of Melbourne.

This ‘Opposing Views’ article appears in the MJA. It is reproduced with permission of the MJA. Please click here to read the opposing view by Professor David Castle.

Posted 21 May 2012