American Academy Blog

Create a comprehensive system for early detection and intervention to reduce the odds of early onset psychosis

November 20, 2013 at 10:54 am 1 comment

I am not an expert in this field but I believe that there is growing evidence that we can identify youth who are vulnerable to a psychotic episode in young adulthood. Further, there are skill based interventions that can reduce those odds by teaching cognitive and social skills and, perhaps even, providing some medication to help youth better manage the stresses of adolescence and the predisposition toward psychosis that may be evinced by other neurological risks and predispositions (e.g., a history of seizures or other evidence of sensory overload). Given that social workers are placed in many elementary, middle, and high schools, the management of these risk management and amelioration protocols could become standard practice. This might require that social workers develop skills and opportunity to develop and lead these efforts or, at least, engage in the social and cognitive intervention and family work.

One thought on “Create a comprehensive system for early detection and intervention to reduce the odds of early onset psychosis

  • Jordan DeVylder - January 10, 2014 at 12:32 pm

    The feasibility of preventing schizophrenia and other psychotic disorders has become increasingly more realistic over the past decade, primarily due to the development of “clinical high-risk” programs. These tend to be small research-oriented programs serving help-seeking adolescents and young adults who are showing attenuated or sub-threshold psychotic symptoms, often accompanied by a recent decline in function, family history of severe mental illness, and the presence of other mental health conditions such as depressive or anxiety disorders. Clinical high-risk programs are focused on “early intervention” (prior to the first psychotic episode), but not necessarily specific to “early onset” psychosis, a term which generally refers to people who have onset of a full psychotic disorder in early childhood. The goal then is to prevent or intervene early regardless of the age at which psychosis onset occurs. Using these criteria, a high-risk group can be identified that goes on to develop schizophrenia at a rate of approximately 30% over 2 years (Fusar Poli et al., 2012), far surpassing the incidence rate among the general population and even that of other high risk groups, such as offspring of parents with schizophrenia.

    Clinical high-risk clinics typically exist within psychiatric settings, with limited input from the social work profession. However, given the age range of this population (where the probability of contact with school social workers is high) and the fact that most mental health practitioners in the United States are social workers, any widespread implementation of preventive approaches would require extensive social work involvement. It is therefore important for social work to take a lead role in developing evidence-based approaches to addressing the needs of this population. Initial results have supported the efficacy of psychosocial interventions, including cognitive-behavioral therapy as well as general supportive therapy (Addington et al., 2011; Morrison et al., 2004). This is consistent with descriptive studies showing that psychosocial factors, including low self-esteem and sensitivity to daily stressors, directly relate to the severity of sub-threshold psychotic symptoms (DeVylder et al., 2013; Pruessner et al., 2011). It therefore may be possible to delay or prevent schizophrenia onset by addressing these precursor factors, which are themselves causing distress, rather than attempting to address psychotic symptoms that may or may not progress.

    There are several concerns that must be taken into consideration as social work begins to explore this field. The term “psychosis-risk” may be met by some clinicians with an intuitive response to prescribe anti-psychotic medications. Given that only 30% of this population goes on to develop schizophrenia, there is the risk that the remaining 70% would receive a potentially harmful treatment with minimal benefit (Corcoran et al., 2005). This further supports the need to develop alternative psychosocial treatments, although this risk can be alleviated by the development of milder yet efficacious pharmacological interventions as well. For example, simple omega-3 fish oil tablets may be as effective as anti-psychotics in preventing schizophrenia onset (Amminger et al., 2010), do not have any known side effects, and can be recommended as an adjunctive over-the-counter supplement by social workers. Another risk is stigma related to the psychosis-risk label. It is feasible that any label that includes the word ‘psychosis’ may have harmful effects, yet also feasible that it may be seen as beneficial to someone living with very unusual and distressing experiences on an ongoing basis. This is currently an open question in need of research, but one that should be fully addressed before widespread implementation of any preventive approaches.

    Prevention of schizophrenia and psychotic disorders is a developing area with great promise as well as considerable risk. Social work involvement is essential as “clinical high-risk” progresses from being a research construct towards being a recognized clinical population through the steady global expansion of preventive and early intervention programs. The first step is research: to develop an evidence base for psychosocial interventions for this population, while minimizing risks associated with labeling and misguided pharmacological treatment. This is a help-seeking population with widespread clinical need. Given the close relationship between day-to-day stress factors and sub-threshold psychosis, it may be possible to prevent the progression of psychosis by addressing the stated needs of the population in a person-centered approach rather than focusing on the symptoms themselves. Executed appropriately, this can lead to a best-of-both-worlds approach where severe mental illness may be prevented without over-pathologizing those considered to be at-risk.

    Addington, J., Epstein, I., Liu, L., French, P., Boydell, K. M., & Zipursky, R. B. (2011). A randomized controlled trial of cognitive behavioral therapy for individuals at clinical high risk of psychosis. Schizophrenia research, 125(1), 54-61.

    Amminger, G. P., Schafer, M. R., Papageorgiou, K., Klier, C. M., Cotton, S. M., Harrigan, S. M., … & Berger, G. E. (2010). Long-chain {omega}-3 fatty acids for indicated prevention of psychotic disorders: a randomized, placebo-controlled trial. Archives of General Psychiatry, 67(2), 146.

    Corcoran, C., Malaspina, D., & Hercher, L. (2005). Prodromal interventions for schizophrenia vulnerability: the risks of being “at risk”. Schizophrenia research, 73(2), 173-184.

    DeVylder, J. E., Ben-David, S., Schobel, S. A., Kimhy, D., Malaspina, D., & Corcoran, C. M. (2013). Temporal association of stress sensitivity and symptoms in individuals at clinical high risk for psychosis. Psychological medicine, 43(02), 259-268.

    Fusar-Poli, P., Bonoldi, I., Yung, A. R., Borgwardt, S., Kempton, M. J., Valmaggia, L., … & McGuire, P. (2012). Predicting psychosis: meta-analysis of transition outcomes in individuals at high clinical risk. Archives of general psychiatry, 69(3), 220.

    Morrison, A. P., French, P., Walford, L., Lewis, S. W., Kilcommons, A., Green, J., … & Bentall, R. P. (2004). Cognitive therapy for the prevention of psychosis in people at ultra-high risk Randomised controlled trial. The British Journal of Psychiatry, 185(4), 291-297.

    Pruessner, M., Iyer, S. N., Faridi, K., Joober, R., & Malla, A. K. (2011). Stress and protective factors in individuals at ultra-high risk for psychosis, first episode psychosis and healthy controls. Schizophrenia research, 129(1), 29-35.

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