Academic journal article General Psychiatry

How Should We Intervene in Psychosis Risk Syndromes?

Academic journal article General Psychiatry

How Should We Intervene in Psychosis Risk Syndromes?

Article excerpt

1. What are psychosis risk syndromes (PRS)?

The occurrence of schizophrenia, affective psychotic disorders and other psychotic conditions are traumatic for both affected individuals and their families. With a peak age of onset of 18 to 30 years, psychotic illnesses often interrupt development during the transition from adolescence to adulthood. [1] Following the examples set with chronic physical illnesses such as diabetes and heart disease, the scientific focus on psychotic illnesses has increasingly shifted to early intervention. The goals of this new approach are to reduce illness progression and morbidity and, in time, to develop viable preventive interventions. [2] As part of this scientific reorientation, there is a growing body of work focused on populations at 'clinical high risk' for psychoses and on adolescents and young adults in the putative prodromal phase of a first psychotic episode--at which time there is illness-related deterioration in the functioning of the brain and in neurocognitive, social and role functioning. [3,4]

In the past decade, research diagnostic instruments such as the Comprehensive Assessment of At Risk Mental States (CAARMS) [5] and the Structured Interview for Prodromal Syndromes (SIPS) have been used to identify high-risk individuals and to distinguish different types of psychotic risk syndromes (PRS). [6,7] The SIPS classifies three types of psychotic risk syndromes: Brief Intermittent Psychotic Syndrome (BIPS); Attenuated Positive Symptom Syndrome (APSS); and Genetic Risk and Deterioration Syndrome (GRDS). The transition of PRS individuals to diagnosable psychosis has been of particular interest to researchers; [8] the largest meta-analysis available [9] reports an average transition rate of about 20% over the first year of follow-up and of about 35% over the first three years of follow-up. Therefore, populations with PRS provide an important opportunity to develop a systematic scientific strategy for the earlier intervention and possible prevention of psychosis.

2. Potential benefits and risks of intervening in PRS

Interventions for PRS, which target subjects with minimally detectable symptoms falling below the threshold of a psychotic disorder, can be considered a form of secondary or targeted prevention. The major aims of clinical intervention in PRS are: a) to reduce prodromal symptoms and related problems such as social withdrawal and academic difficulties; b) to reduce the risk of the subsequent onset of frank psychosis; and c) to minimize treatment delay for the subgroup of PRS subjects that do develop a first episode of psychosis.

However, the use of such preventive interventions has elicited ethical concerns. Identification as an individual with PRS can be associated with stigma and heightened anxiety, and the interventions themselves have potential short- and long-term side effects. [10] For instance, low-dose antipsychotic treatments--the cornerstone of the first wave of interventions for PRS--have been associated with neurotoxic effects in some animal studies. [11-13] Moreover, most persons with PRS do not subsequently develop frank psychosis (false positives), so there are important cost-benefit considerations in recommending that all persons with PRS be referred for treatment.

This raises the question of how to stage treatments to maximize prevention while minimizing harm. Some authors recommend phase-specific interventions that match the symptomatic presentation of PRS and that include more benign options before progressing to pharmacological treatments. [14,15] Psychosocial interventions should be a component of all interventions for individuals with PRS. They include crisis intervention, assistance in maintaining social functioning, psychoeducation for patients and their family members, and general social support. These basic psychosocial interventions can be augmented by other psychotherapeutic and psychopharmacological interventions depending on the specific needs of the patient. …

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