Morris B. Goldman, MD Associate Professor of Psychiatry and Behavioral Sciences
Marko Mihailovic, MA, LCPC Clinical Research Manager
Philip G. Janicak, MD Adjunct Professor of Psychiatry and Behavioral Sciences
Northwestern University Chicago, Illinois
Disclosures Dr. Goldman has served as a speaker for PsychU/Otsuka, received research grants from the National Institute of Mental Health, and received income from Sunovion. Mr. Mihailovic reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products. Dr. Janicak has served as a consultant to TMS Solutions and Neuronetics and as a speaker for PsychU/Otsuka.
Second-generation screening(Figure, Step 2). A second screening aims to retain those pre-screened individuals who will become psychotic (ie, minimizing false negatives) while further minimizing those who do not (ie, minimizing false positives). The addition of cognitive, neural (eg, structural MRI; neurophysiologic), and biochemical (eg, inflammatory immune and stress) markers to the risk calculators have produced a sensitivity close to 100%.8,9 Unfortunately, these studies downplayed specificity, which remained approximately 20%.8,9 Specificity is critical not just because of concerns about stigma (ie, labeling people as pre-psychotic when they are not) but also because of the adverse effects of antipsychotic medications and the effects on future program development (interventions are costly and labor-intensive). Also, diluting the pool with individuals not at risk makes it nearly impossible to identify effective interventions (ie, power).27,28
While some studies focused on increasing specificity (to approximately 75%), this leads to an unacceptable loss of sensitivity (from 90% to 60%),29 with 40% of pre-screened individuals who would become psychotic being eliminated from the study population. The addition of other biological markers (eg, salivary cortisol)30 and use of learning health systems may be able to enhance these numbers (initial reports of specificity = 87% and sensitivity = 85%).8,9 This is accomplished by integrating artificial and human intelligence measures of clinical (symptom and neurocognitive measures) and biological (eg, polygenetic risk scores; gray matter volume) variables.31 However, even if these results are replicated, more effective pre-screening measures will be required.
Identifying a suitable sample population for prevention program studies is clearly more complicated than for FEP studies, where one can usually identify many of those in the at-risk population by their first hospitalization for psychotic symptoms. The issues of false positives (eg, substance-induced psychosis) and negatives (eg, slow deterioration, prominent negative symptoms) are important concerns, but proportionately far less significant.
Prevention and FEP interventions
Once a study sample is constituted, 1 to 3 years of treatment interventions are initiated. Interventions for prevention programs typically include CBT directed at attenuated psychosis (eg, reframing or de-catastrophizing unusual thoughts and minimizing distress associated with unusual perceptions); case management to facilitate personal, educational, and vocational goals; and family therapy in single or multi-group formats to educate one’s support system about the risk state and to minimize adverse familial responses.14 Many programs also include supported education or employment services to promote reintegration in age-appropriate activities; group therapy focused on substance abuse and social skills training; cognitive remediation to ameliorate the cognitive dysfunction; and an array of pharmacologic interventions designed to delay or prevent transition to psychosis or to alleviate symptoms. While most interventions are similar, FEP programs have recently included peer support staff. This appears to instill hope in newly diagnosed patients, provide role models, and provide peer supporters an opportunity to use their experiences to help others and earn income.32
The breadth and depth of these services are critical because retention in the program is highly dependent on participant engagement, which in turn is highly dependent on whether the program can help individuals get what they want (eg, friends, employment, education, more autonomy, physical health). The setting and atmosphere of the treatment program and the willingness/ability of staff to meet participants in the community are also important elements.11,12 In this context, the Headspace community centers are having an impact far beyond Australia and may prove to be a particularly good model.13
Continue to: Assessing prevention and FEP interventions
