Friday, May 24, 2013

Preventing Transition to Schizophrenia: What Doesn't Work, What Might

One of the reasons I decided to become a child psychiatrist was seeing the devastating effects of schizophrenia in adult patients during medical school, and knowing even then how inadequate the treatments were. I thought that by working with children and adolescents, that someday I might be a part of preventing someone from developing schizophrenia in the first place.

However, during residency, I became more jaded about early intervention in treating "prodromal" symptoms, in large part because the institution where I was training emphasized biological treatments above all else. One professor, who had close ties to multiple pharmaceutical companies, exhorted us to use antipsychotic medications not only for teenagers with odd thinking or behaviors, but also for those with paranoid or schizotypal personalities, despite there not being a damn bit of evidence this would help anything.

When the evidence did start coming in for the use of antipsychotics to prevent transition to schizophrenia, it was not encouraging. From the most recent meta-analysis I could find:
One study compared CBT and risperidone with CBT and placebo. Very low quality evidence within the first six months of treatment suggested no difference in transition to psychosis (risk ratio 1.02 (95% confidence interval 0.15 to 6.94)), which remained at 12 months (1.02 (0.39 to 2.67)). Differences in symptoms of psychosis (total, positive, or negative), depression, and quality of life were not significant. Dropout was similar between groups (1.09 (0.62 to 1.92)), although the evidence was also rated as very low quality.

There was very low quality evidence for the benefits and harms associated with olanzapine, from one study comparing olanzapine with placebo. We saw no difference in transition to psychosis after 12 months (risk ratio 0.44 (95% confidence interval 0.17 to 1.08)). Dropout was similar between groups at 12 months (1.59 (0.88 to 2.88)). For participants taking olanzapine, there was a large effect on weight during the first eight weeks (standardised mean difference 0.81 (0.28 to 1.34)), which remained large at 12 months (1.18 (0.62 to 1.73)). Effects on symptoms of psychosis (total, positive, or negative), depression, and mania were not significant. Data at 24 months were not analysed because fewer than 50% of participants remained.
Thus, I was somewhat skeptical when I saw this on the Twitter yesterday:
Looking at the article (link is to Google's cached version in case you don't have a Medscape login), it described a comprehensive treatment program, implemented community-wide in Portland, Maine, that has "significantly reduced hospitalization rates for initial psychosis by one third." More encouraging was the fact that this program has successfully been replicated at 5 other locations across the country, and according to lead investigator Dr. William McFarlane, rates of conversion to psychosis were "almost identical" between the prodromal group and a control group. What the program actually entails is interesting, and a very different approach to just using an antipsychotic or doing CBT:
As part of the program, at-risk youth, identified with the Structured Interview for the Prodromal Syndromes (SIPS), are offered a comprehensive package of treatment consisting of family education, assertive community treatment, supported education/employment, and low-dose psychotropic medication.
Looking elsewhere, I found more details about the 8 components of the family-aided community treatment (FACT) program in this dissertation. I've truncated each of the bullet points to save space:
  • Community education and outreach: Early Assessment and Support Team/Alliance representatives go into the community to increase awareness about psychosis and to encourage early referrals. These education efforts are offered to a wide range of audiences...
  • Targeted outreach to those in need: Psychosis is often frightening, and even the thought of being diagnosed with such a serious mental health condition may cause a young person to refuse to seek help. Team members meet the youth and family at their level of readiness to form a relationship built on trust. Services are strengths focused and oriented toward issues young people find relevant...
  • Consistent services in the transition from adolescence to adulthood: Services are provided to teens and young adults by the same team...there is no discontinuity of care or caregiver teams just because a person ages out of childhood services.
  • Supported employment/education specialist: This specialist works closely with each program participant...the majority of young people involved with [this program] do not pursue federal disability funding.
  • Psychopharmacology treatment options: When it comes to medications, [the program] emphasizes education and choice. Medications are used cautiously, and close attention is paid to the side effects experienced by the individual.
  • Occupational therapists: These specialists are available to help assess and provide treatment for underlying sensory, cognitive, and functional issues.
  • Family inclusion: Families are viewed as essential partners in the decision making process. Most families participate in evidence-based multifamily psychoeducation treatment focused on increasing knowledge, reducing conflict, and problem solving.
  • Commitment from systems leaders: State and regional leaders work together to develop and realign funding streams, regulations, and workplace policies to best serve individuals in a flexible way, without barriers such as insurance restrictions and gaps between child and adult systems.
Since I was not at the APA, I have no idea how many of the participants in this program were on antipsychotic medications, or whether they could estimate how much the medications actually contributed to the overall outcome. However, I would be willing to bet that the program would work quite well even without the medication component.

Notably, this research is supported not by the NIMH, but by the Robert Wood Johnson Foundation, "the nation's largest philanthropy devoted solely to the public's health." This public health approach is what we need more of in mental health: It takes a village, not just a pill.