Adolescent Psychiatry (v.2, #2)

Objective: To describe the rationale, design, intervention, and sample characteristics of the Early Detection, Intervention, and Prevention of Psychosis Program (EDIPPP), a multi-site study of the effectiveness of Family-Aided Assertive Community Treatment (FACT) in preventing the onset of psychosis in a nationally representative sample of atrisk young people. Methods: Young people (age 12 - 25) and their families are assigned to a clinical high risk (CHR) group or a low risk group based on severity of positive symptoms of psychosis. Treatment families (CHR group) receive minimally 1 year of FACT and comparison families (low risk group) receive community care and monthly assessments. Initial betweengroups differences on key variables are statistically controlled according to procedures of the regression discontinuity design (RDD), so any emerging between-group differences in outcomes can be attributed to treatments. Results: 337 young people (mean age 16.6) were assigned to the treatment group (n = 250) or comparison group (n = 87). 86% of the CHR sample met DSM-IV criteria for an Axis I disorder. The RDD procedure successfully removed between groups differences in baseline scores on all but one of the key outcome variables. Conclusion: Six sites located in 4 distinct regions of the U. S. have successfully collaborated in the initial phase of a largesample test of FACT in preventing the onset of psychosis. Treatment outcome findings and other research initiated at individual sites will significantly increase our knowledge of the early phases of psychotic illness and the factors that may prevent it.

This article reviews the theoretical, conceptual and empirical background for the current and growing research on early identification and early intervention to obtain improved outcomes in psychotic disorders. The goal is to prevent episodes of psychosis and the functional disability that accompanies them. Described are the studies linking duration of untreated psychosis and later outcomes, the precedents for psychosis, current methods for assessing the likelihood of onset, and the treatment trials conducted to date. We conclude that the evidence is increasing that justifies early identification and prevention being routine clinical practice. We also conclude that further research needs to refine assessment methods to achieve higher predictive power and that treatments need to be better adapted to the specific conditions usually present during the prodromal period. Finally, larger-scale clinical trials and effectiveness studies need to be carried out to achieve better assessment accuracy and treatment efficacy. Such studies are currently underway in North America and Europe, with results expected in 2012.

Objective: The Portland [Maine] Identification and Early Referral (PIER) program was established in 2000 as a prevention system for identifying and treating adolescents and young adults at high risk of an initial psychotic episode. Community outreach and education to targeted groups was the primary method for identification. Methods: Community outreach and education is defined as any activity designed to inform key audiences about the importance of and methods for early detection and intervention of psychosis in adolescents and young adults. PIER program staff presented information on the early warning signs of psychosis and how to make a referral to target audiences within a young person’s social network. Results: Community outreach resulted in the referral of 780 youths who met demographic criteria, yielding 404 cases that were deemed sufficiently at risk to be eligible for formal assessment. After screening and assessment by PIER staff, 37% of community referrals were found to be at high risk for psychosis, and another 20% had untreated psychosis, yielding a correct-referral efficiency ratio of 57%. In addition, community educational presentations were significantly associated with referrals six months later. Conclusions: In its efforts to create a system of early identifiers for young people at the beginning stages of mental illness, the PIER program has developed a new model for community health education that has shown that it is possible to engage community members in the identification of adolescents and young adults who are experiencing the early symptoms of a psychotic disorder.

This article contains first person accounts in narrative and visual form created by clients and family members who have participated in the Early Detection and Intervention for the Prevention of Psychosis Program (EDIPPP). By the time most individuals join EDIPPP they have been experiencing a confusing constellation of thought and behavior changes. For most, EDIPPP signifies the next step in a journey of trying to reclaim a sense of agency in their lives and promise for the future. Understanding the process youth and families go through to make meaning of a “high risk” indication is critical for the clinicians who work with these families. By highlighting these first person accounts and the story they tell, we strive to contribute to this understanding and thereby enrich our discussion of the early detection and intervention for psychosis with the perspectives of individuals participating in our study. These narratives point to the potential value of further research focused specifically on how youth and families come to understand being at risk for psychosis.

Early detection of those at risk for developing psychotic disorders is a growing field that creates an opportunity for intervention early in the course of illness, with potential for improved prognosis. In the last two decades, a number of instruments aimed at assessing clinical risk for psychosis were developed, using various approaches. These instruments are reviewed in this paper, as well as diagnostic and clinical challenges that mental health professionals often face during the assessment of attenuated psychotic symptoms, a core syndrome indicating psychosis risk. A case example illustrates assessment and feedback techniques.

Environmental risk and protective factors in schizophrenia play a significant role in the development and course of the disorder. The following article reviews the current state of evidence linking a variety of environmental factors and their impact on the emergence of psychotic disorders. The environmental factors include pre- and perinatal insults, stress and trauma, family environment, and cannabis use. The review of evidence is followed by case examples and clinical applications to facilitate the integration of the evidence into clinical practice.

Cognitive Behavioral Therapy (CBT) is an established adjunctive treatment for schizophrenia with a growing evidence base. More recently, CBT has been applied to individuals identified as being at risk for developing psychosis in an attempt to delay or prevent a transition to psychosis, to reduce symptoms and improve functioning. CBT has also been employed effectively with adolescents in the treatment of depression, post traumatic stress disorder (PTSD), anxiety disorders and eating disorders. This paper reviews the evidence for the use of CBT with the clinical high risk for psychosis population and addresses adaptations to the approach for use specifically with adolescents.

Seventy percent of those who will have an episode of psychosis will have done so by age 25 (Kirkbride et al., 2006). Data from clinical trials of intervention during the clinical high risk period of psychosis have determined that the mean age is in mid-adolescence, 16-18 years of age (Amminger et al., 2010; McFarlane et al., 2010; McGlashan et al., 2006). For those reasons, early intervention inherently involves adolescents, and by extension their parents and other family members and supports. Regarding the type of intervention, it is relevant that the current empirically-derived standard of treatment for schizophrenia, as concluded by the Agency for Health Care Policy and Research survey of the treatment outcome literature, includes family psychoeducation, supported employment, assertive community treatment and antipsychotic medication,; i.e., a combination of psychosocial and pharmacologic interventions (Lehman et al., 2004; 1998). Combinations of all four of these treatments, as in Family-aided Assertive Community Treatment (FACT), achieve very low rates of relapse, substantial reductions of symptoms and remarkable functional outcomes, particularly in the domain of competitive employment (Cook et al., 2005; McFarlane et al., 2000; McFarlane, Dushay, Stastny, Deakins, & et al., 1996; McFarlane, Stastny, & Deakins, 2002; McFarlane, Stastny, Deakins, Dushay, & Link, 1995). Furthermore, a large comparative study of outcomes in community settings found that psychoeducational multifamily groups were more effective than single-family psychoeducation specifically in the first episode and in high-risk-for relapse cases, suggesting that particular psychosocial treatments may be especially effective in early phases of illness (Fjell et al., 2007; McFarlane et al., 1995; Petersen et al., 2005).

Adolescence and young adulthood mark the developmental period of highest risk for the onset of psychosis. The largely adolescent “psychosis-risk” population has therefore become the subject of much research interest, aimed at better defining who is at highest risk of worsening symptoms and function, as well as who may benefit from interventions during this important period. While it is clear that the current working definition of “ultra-high risk” (UHR) identifies a population for whom close monitoring is indicated, the actual treatment data are still evolving (and sometimes controversial). In this review, we begin with the premise that psychiatrists who work with adolescents and young adults may already be providing clinical services to these young people, possibly without the recognition of or focus on their UHR symptoms. Given this clinical reality, we then use the concept of “psychosis-proneness” to describe the historical evolution of how the field has conceptualized the transition from attenuated or brief states to full and persistent states. We describe how the robust literature investigating the impact of duration of untreated psychosis (DUP) on outcome has found that many cognitive and social deficits probably predate the onset of full psychotic syndromes such as schizophrenia, suggesting that a psychosis continuum or staging approach be applied to assessment and treatment planning in help-seeking adolescents and young adults exhibiting concerning changes in perception, belief structure or social communication. We then review the pharmacologic treatment studies that have been conducted in this population to date and propose a stepwise decision tree, using two vignettes to illustrate common clinical issues.