Schizophrenia is associated with substantial economic costs. According to the most recently published estimates, the total cost associated with schizophrenia in the US in 2013 was $155.7 billion.

 While this number is staggering in itself, even more striking is that the indirect costs such as those related to lost productivity, unemployment, premature mortality, and caregiving made up 75% ($117.3 billion) of this burden, dramatically overshadowing the direct costs of inpatient hospital stays, emergency room visits, outpatient visits, and prescription medications.

 These statistics speak to the enormity of the toll that schizophrenia and related psychotic disorders have on the whole spectrum of patients’ lives. Psychiatry, not unlike other areas of medicine, tends to take a reactive approach to treatment. Especially in the US, health insurance does not pay for treatment unless a condition is sufficiently severe or disabling, and we typically wait for a serious problem to arise before we take action. By the same token, psychiatric clinicians tend to focus somewhat narrowly on stabilization. 

We may think our jobs are done once a distressing symptom, behavior, or other crisis has been sufficiently reduced or stabilized. However, the disproportionately high burden of schizophrenia’s indirect costs suggests that our reactive approach is not working so well for our patients. These data serve as a call to action for psychiatry to shift from the traditionally reactive to a more proactive approach to patient care—one that does more to meet patients where they are. In the US, the biomedical framework has dominated how we view schizophrenia. In 2019, the National Institutes of Health spent $263 billion on schizophrenia research,

 with funding awarded primarily to studies investigating genetic, molecular, or circuit related mechanisms underlying the illness. Although such research is important for identifying new and better treatment targets, uncovering biomedical insights alone is insufficient to help our patients. Despite the vast research conducted in the past several decades to better understand biological mechanisms underlying psychosis, people with psychotic disorders continue to suffer, and so much about schizophrenia remains unknown.

Critically, we do not have a clear understanding of what causes schizophrenia or even what constitutes the main gestalt of the illness. Rather, we often resort to describing the illness in roundabout ways, such as by listing its assorted symptoms. How many scientific articles and book chapters on schizophrenia start with a sentence describing schizophrenia as a “devastating illness characterized by hallucinations, delusions, disorganized thinking, and bizarre behavior”? Sentences like these mirror the way schizophrenia is conceptualized in the DSM, but they do not provide a clear sense of what causes these myriad symptoms or how the symptoms relate to one another. Importantly, as anyone who has worked with patients knows, people are much more than a collection of their symptoms. Symptom remission is the primary outcome measure used in many clinical trials. Likewise, clinicians are trained to think operationally about what symptoms or behaviors they seek to target with a particular intervention—whether it is a specific medication, dose change, or hospitalization. However, the disproportionate impact of schizophrenia on indirect costs highlights the urgent need for psychiatry to go beyond the relatively narrow scope of symptom remission to focus more attention and effort on improving functional recovery and quality of life.

How can we accomplish this? The challenge is that there is no single algorithm for achieving this goal. Heterogeneity is inherent among people with psychotic disorders, and one size does not—and will not—fit all. We can, however, leverage one guiding principle—the importance of meeting people where they are. The 4 articles in this Special Report provide valuable perspectives on some of the ways we can meet people where they are.

on stage-specific treatment of psychotic disorders, Patrick D. McGorry, MD, PhD, highlights the differing needs of individuals across the various stages of illness. The philosophy is akin to treating patients with cancer; these patients are not uniformly treated with chemotherapy but rather are prescribed individually tailored treatment based on the specific stage of illness. In psychiatry, we need to consider psychotic disorders not as a single monolithic disorder, but rather a disorder that unfolds in stages. As such, we need to focus our efforts on preventing or delaying progression to subsequent stages, from which recovery may be more challenging. This stage-specific framework for understanding and treating psychotic disorders incorporates important public health principles, including aims for primary and secondary prevention.

 by Patricia E. Deegan, PhD, we hear the voice of someone who is not only an academic expert and pioneer in the topic of recovery, but also someone with lived experience. Dr Deegan is uniquely positioned to help clinicians understand how to effectively engage and empower individuals with psychosis to find hope and meaning by incorporating goals and preferences that matter to them. Everyone has dreams, hopes, values, preferences, and interests. Dr Deegan reminds us that symptom reduction might be helpful, but only in the service of personally meaningful goals.

The article on phenomenology and disordered selfhood by Josef Parnas, MD, and Maja Zandersen, MSc, PhD, highlights the importance of going beyond symptom checklists to understand the subjective experience of individuals with schizophrenia. They remind us that we must listen to what our patients tell us to appreciate the phenomenological essence and experience of schizophrenia spectrum disorders. This kind of careful listening and exploration, which involves joint collaboration as well as putting oneself in the mindset of the patient, can lead not only to improved understanding and prediction of schizophrenia, but may also be therapeutic in itself.

Last but not least, Antonio Waldo Zuardi MD, PhD, and José Alexandre Crippa, MD, inform us about the therapeutic potential of cannabidiol in individuals with psychotic disorders. Many patients look to and experiment with complementary and alternative products, whether for recreational use or perceived health benefits. Given the abundant evidence of the detrimental effects of cannabis on psychosis and psychosis risk, clinicians may be wary of any ingredients in cannabis. The authors differentiate the potentially anxiolytic and antipsychotic effects of cannabidiol from the psychotomimetic effects of THC. While cannabidiol is not approved for clinical use, Dr Zuardi and Dr Crippa summarize the research, which may be controversial and confusing for clinicians.

I am thrilled that the knowledge and perspectives of these experts could be brought together for clinicians. The hope is that the insights and recommendations in this Special Report can help psychiatry to go beyond what the biomedical model has traditionally prescribed for schizophrenia and proactively meet people where they are. We cannot afford not to, as underscored by $155.7 billion in economic costs associated with schizophrenia. Above all, meeting people where they are is a matter of public health—the health and quality of people’s lives depend on it.

Dr Shinn is Director of Clinical Research of the Schizophrenia and Bipolar Disorder Research Program at McLean Hospital and Assistant Professor of Psychiatry at Harvard Medical School. Dr Shinn has nothing to disclose regarding the subject matter of this Special Report.

Cloutier M, Aigbogun MS, Guerin A, et al. The economic burden of schizophrenia in the United States in 2013. 

 National Institutes of Health (NIH). Estimates of Research Funding for Various Research, Condition, and Disease Categories (RCDC). Feb. 24, 2020; 

https://report.nih.gov/categorical_spending.aspx

Articles

Despite the vast research conducted to better understand biological mechanisms underlying psychosis, people with psychotic disorders continue to suffer.

Meeting Patients Where They Are: A Public Health Imperative

When I was a teenager, I received a diagnosis of schizophrenia. My psychiatrist told me schizophrenia was a disease from which no one can get well. He told me to take high-dose antipsychotics for the rest of my life. At discharge, he told me to take my meds religiously and to avoid stress: no college, no romance, and no work.

After discharge I returned to my parents’ house and for many months sat in a chair in the living room, staring blankly into a cloud of cigarette smoke. My despair was palpable, but it was misunderstood as negative signs of schizophrenia. As the months passed by in a meaningless succession of minutes and hours punctuated only by the next med check visit and the next, it seemed to me the treatment was worse than the disorder. And so I stopped taking the antipsychotic.

Abruptly rejecting antipsychotic medicine was a resilient act of self-affirmation. I am a person, not an illness. I am a person, not a schizophrenic. I do not lack insight into the fact that I am unwell. My psychiatrist lacks insight into ME. I want to live my life, not my diagnosis.

Like so many who abruptly discontinue antipsychotics, I was rehospitalized within a few months. Looking back, I know progress in my recovery did not begin until my psychiatrist and I learned a new way of working together. Distilled from my personal experience, as well as from 3 decades of work articulating the journey of recovery and building pragmatic tools to support it, I offer the following thoughts.

A prescription for noncompliance arises when a message of hopeless chronicity is paired with a psychiatric medication. You have schizophrenia. You will be sick for the rest of your life. You must use medication for the rest of your life. This common message is a prognosis of doom. Many people will reject this hopeless forecast by rejecting the medicine. In rejecting the medication, they reject the prognosis of doom as well.

A prescription is more than what is written on a pad of paper. It is an interpersonal process. It includes the one who prescribes and the one who will try out and explore the prescription and its fit with the self. From day one, prescribe hope for recovery. Let people know that with effort and support it is possible to live a full and meaningful life beyond the diagnosis. Never mistake the person for the illness. Never tell people they will have to use medications for the rest of their life. Instead, take a pragmatic approach. Focus on how and if medication is helpful in supporting goal achievement in the present and the near future. Remember that using medication is not the goal. Medication is a means to get and to keep the life we want for ourselves.

Those of us who have a diagnosis of a psychotic disorder are, above all, human beings. We are more than the disorder. We are not passive objects to be fixed or cured. Even when experiencing psychosis, we are actively problem solving and trying to do something about it (eg, listening to music to distract ourselves from distressing voices). This active subject, the person, is our recovery partner. This is the person with whom we must develop the therapeutic alliance. Engagement and activation strategies should be used even during initial encounters, such as admissions or emergency department visits.

A simple question can be used to discover our recovery partner: “What do you already know how to do that helps?” A person may not have all the answers, but everyone tries something in an effort to manage psychosis. For instance, during my early psychosis, I told myself I had taken LSD (even though I had not). This was not a delusion. It was a strategy that helped me manage acute episodes of psychosis because an LSD trip is time limited. Knowing the experience would end helped me endure it.

Another powerful engagement and activation strategy is introducing 

 as part of recovery. Do this very early on in treatment. Personal Medicine

 is what we do to get well and stay well. It is self-initiated, nonpharmaceutical self-care activities that serve to decrease symptoms and improve thinking, mood behavior, and well-being, while also helping to avoid unwanted outcomes such as hospitalization. Examples include: reading Scripture at night helps me feel safe; working on car engines helps me ignore my voices; singing in my choir helps me forget my troubles; walking my dog gives me a reason to get up in the morning. All these strategies are Personal Medicine. “Smoking cigarettes helps me relax” is not, however. Tobacco is something we take, it is not what we do. Also, notice that Personal Medicine is different from generic coping strategies. Personal Medicine is personal.

Encouraging its use in psychiatric care underscores the importance of actively engaging in self-care during recovery. It elevates self-care to the status of medicine, which can be just as important as pharmaceutical medicine for recovery. Passively waiting for psychiatric medicine to make us well is usually futile. Personal Medicine does not compete with psychiatric medicine. The key is finding a synergy between the two. For many, the pathway into recovery involves finding the right balance between the things we do to be well and the pills we may take. Over time, Personal Medicine can grow into an entire toolkit of self-care strategies.

 Psychiatric medicine then becomes one tool among the many we use to support our recovery.

Use a simple, 2-part template to help people discover their Personal Medicine: “What do you do that helps you feel better and how does it help?” In some settings, certified peer supporters, therapists, and rehabilitation specialists help people discover their Personal Medicine prior to med visits. At each clinic visit ask, “Have you been using your Personal Medicine?”

Be sure to adjust psychopharmacology if it is interfering with Personal Medicine and the things that give life its meaning, purpose, and joy. If medications are causing a woman’s hands to tremble so much that she cannot do her job stitching flags (her Personal Medicine), then who would be surprised if she stopped taking those drugs? In a recovery-oriented approach, pharmacology must support—not disable—the things that matter, such as work. Finding the right balance between psychiatric medicine and personal medicine is the pathway to recovery for many patents.

From “What’s the matter?” to “What matters to you?”

It can be challenging to take an antipsychotic each day; over time, people need a sense of how the medication helps them. There is no sense in taking pills that do not seem to work. Clinical phrases are often obtuse and unhelpful (eg, “The meds will help organize your thinking”; “The meds will make you less paranoid”; “The meds will return you to baseline”). These abstractions may not speak to what matters to the person. Instead, I recommend 2 approaches.

The first approach is to directly ask, “How will we know this medicine is working for you?” Examples might be: I’ll know the meds are working for me when I: “can concentrate on my biology homework”; “am more patient with my toddler”; “can follow a football game”; or “win at online gaming again.”

When first asked, people may say, “I don’t know. You’re the doctor. You tell me how the meds are supposed to help.” Redirect the person by prompting, “I am happy to share my ideas, but I need to understand what matters to you. If this medicine works for you, what will change for the better?” The answers will provide a wealth of information. For instance, it is not unusual to hear that a person has unrealistic expectations for medications: “I’ll know the medicine is working for me if my marriage improves.” Of course, medication cannot improve a marriage. Having such an expectation can be a set-up for rejecting medications that are not working. Helping people shape expectations is important. For instance, “The meds can’t improve your marriage per se, but if they work, they can help you focus more on your partner and less on your fears. How does that sound?”

Even during acute episodes of psychosis, demonstrating concern and understanding for what matters to the person can be extremely reassuring and help build an alliance. We can use our intuition to infer what matters. For instance, a person who has been hearing distressing voices may be exhausted and would welcome some rest: “This medicine will help you rest and feel safe. How does that sound to you?”

A second approach to helping people establish their goals for medication treatment is the use of Power Statements.

 Power Statements help people express how they want medicine to help. A 2-part stem can be used to help people create their power statement: “I want medicine to help ____, so that I can ____.” Examples include: “I want medicine to help make the voices go away so that I can focus on my job at the pizza shop”; “I want medicine to help me relax, so I can get together with my boyfriend again”; and “I want medicine to help me concentrate again so I can graduate from high school.”

Power Statements act like a compass, keeping treatment focused on outcomes that matter to the person. Typically, we assess treatment outcomes by more generic measures such as the Positive and Negative Syndrome Scale (PANSS) score, lower recidivism, and longer community tenure. But at the level of the individual, those metrics can disguise treatment failure. For instance, people may have fewer hospitalizations and be stabilized and maintained on high-dose antipsychotics in the community, but they may also be living an isolated life in smoke-filled, single room-occupancy lodgings, staring at a television, and sleeping their lives away. This is not recovery and, at the level of the individual, it is a treatment failure.

Power Statements provide psychiatric care providers with an understanding of what successful treatment outcomes are, as defined by the individual. They are a study of N=1, focusing psychiatric care providers on symptom reduction in the service of personally meaningful goals. Complete symptom suppression is not a prerequisite for recovery. Many of us learn how to manage symptoms while living the life we want for ourselves.

Power Statements are easy to scale and can be created as a pen-and-paper task. In some settings, certified peer supporters, therapists, and rehabilitation staff help people prepare their statements before the med check visit.

 Psychiatric care providers begin the visit by reviewing the statement and asking, “Is this still your goal for our work together?” or “Are we making progress toward your goal?”

The journey to use medication optimally to support recovery involves many challenges.

 It is more than learning to swallow pills on schedule. Psychiatric care providers can support us on that journey through recovery-oriented strategies that convey hope and engage us as partners in the creation of a life beyond the diagnosis.

Dr Deegan is Principal and owns 50% of the company Pat Deegan, PhD & Associates, LLC in Byfield, Massachu- setts. The company created the CommonGround Program, which includes software, training, and an online Recovery Library. Personal Medicine and Power Statements, mentioned in the article, are two elements of the CommonGround Program.

 Deegan PE. The importance of personal medicine: a qualitative study of resilience in people with psychiatric disabilities. 

 MacDonald-Willson KL, Deegan PE, Hutchison SL, et al. Integrating personal medicine into service delivery: empowering people in recovery. 

 Deegan PE, Carpenter-Song E, Drake REet al. Enhancing clients’ communication regarding goals for using psychiatric medications. 

 Deegan PE. A web application to support recovery and shared decision making in psychiatric medication clinics. 

Deegan PE. The journey to use medication optimally to support recovery. 

Those of us who have a diagnosis of a psychotic disorder are, above all, human beings. We are more than the disorder. 

Prescribing Hope for Recovery

SPECIAL REPORT: SCHIZOPHRENIA & PSYCHOSIS

Psychotic disorders are potentially serious and enduring, frequently leading to substantial disability and premature death from suicide or comorbid medical illness. These disorders have been seriously 

in health systems worldwide, even in high-income countries, despite the availability of a range of effective therapeutic interventions and models of care.

 The good news is that better medium-term outcomes are now achievable through early diagnosis and comprehensive early-intervention models of care. Moreover, these outcomes can be sustained, if backed up with high-quality ongoing care to maintain and build on a platform of 

 The challenge is to make this evidence-based and cost-effective approach the new standard of care in the US and globally.

Psychosis is best considered as a range of experiences or symptoms that can develop through the intensification of normal beliefs and perceptions to form delusions or hallucinations, or the acquisition of new and abnormal perceptual experiences or delusional ideas. These constitute what are termed the 

 of psychosis; however, there are other dimensions or syndromes associated with psychotic disorders, notably negative symptoms and mood disturbance.

Psychosis may begin with “orphan” or isolated experiences, but more commonly emerges in the context of fluctuating anxiety and depression, subtle subjective and behavioral changes, and subthreshold warning signs. This pattern, which has been carefully operationalized, represents an earlier, less specific stage—even a pluripotential stage––of illness that already justifies a need for care and attracts additional comorbid syndromes and functional impairment (stage 1).

Once positive psychotic symptoms reach full threshold and are sustained, we can say that the stage of first-episode psychosis (FEP) is now present (stage 2), even if this typically occurs more gradually and dimensionally than is implied by the term, which is to a large extent an artefact of treatment systems. People are allowed to deteriorate to such an extent that a crisis is needed before entry to treatment can be achieved. 

is a heterogeneous umbrella term comprising a range of DSM/International Classification of Diseases diagnoses, including schizophrenia, schizoaffective disorder, brief psychotic disorder, and psychotic mood disorders. It can be seen as a gateway to more traditional diagnostic pathways as well as to remission and recovery.

Staging developed in clinical medicine as a strategy to add precision to diagnosis and treatment selection, and also to prognosis and prediction of outcome.

 Initially a purely clinical approach, it evolved––augmented by biopsy, imaging, and biomarkers––to a more sophisticated clinicopathological approach. Staging is a potentially useful strategy in conditions that have a propensity to persist or recur and lead to worsening impairment and/or premature death. Additionally, it is intimately linked to benefit-risk considerations, embedding the principle “first do no harm.”

Staging is valid when treatments offered in early stages of an illness can be shown to result in better outcomes, but they must be safer than treatments offered in late stages, as the benefit-to-risk ratio changes with illness progression. Remission or stabilization as well as progression are possible at each stage, but remission is usually less likely with each advancing stage, reflecting the interplay with prognosis.

Staging provides the optimal framework for early intervention and a preemptive approach to treatment; the goal is to reduce the risks of progression to later stages. This contrasts with the currently popular notion of stepped care, which is reactive, and only escalates treatment after rather than before a deterioration in clinical status. As such, stepped care represents more of a demand-management strategy than a preventive or preemptive clinical approach.

Biomarkers have the potential to sharpen the precision of staging in psychiatry; however, they are likely to span the traditional syndromal boundaries, which conversely contain heterogeneous biological subgroups. This means a transdiagnostic approach is essential for research and future refinement in staging because current categories are flawed. Transdiagnostic approaches acknowledge the fluid and dynamic nature of the onset and early stages of mental ill health, during which micro phenotypes ebb and flow; they either fade or evolve into a more stable syndrome or macro phenotype or, more commonly, syndromes, because comorbidity is very common (

). Staging has to accommodate this comorbidity and, as such, a transdiagnostic approach that transcends current diagnostic silos is required.

The idea of staging had been proposed earlier in common mental disorders.

 With the early intervention paradigm in psychosis, the ideal conditions existed for clinical staging to be formulated. Psychotic and severe mood disorders were utilized as prototypical disorders for which staging might have the greatest utility.

FEP was the fulcrum around which this began, and an evidence-based case was steadily made that the content of treatment for such cases was very different from what was appropriate for later stages of illness. An earlier clinical stage, the at-risk mental state or ultra/clinical high-risk state, was defined as covering the period prior to the threshold for a first episode of psychosis being reached. This period has become an intense focus for research and intervention.

The validity of these stages was supported by their manifestly different treatment needs and ultimately overwhelming 

that at least progression could be delayed, and early trajectories of illness significantly improved.

 Although some critics remained unconvinced, the mindset of the psychosis field moved from deterministic “doomed from the womb” thinking to a more preventive, recovery-oriented approach, strongly endorsed by patients and families.

A key strength of clinical staging is its ability to guide clinical practice, which is informed by several key principles (

of psychosis there is an earlier stage of illness during which positive psychotic symptoms (eg, distress, mood disturbance, functional impairment), are not dominant.

 During this prodromal stage, treatment consists of needs-based psychosocial interventions, influenced by cognitive behavior therapy (CBT), and a focus on treatable comorbid syndromes such as anxiety and depression, alleviating stress, strengthening coping, and minimizing illicit drug use. Because safer options are effective at this stage, antipsychotic medications are not indicated as first- or second-line treatment, and the benefit-to-risk ratio does not support their use.

Patients with FEP respond much better to all treatments if the duration of untreated psychosis (DUP) is reduced to a minimum. There is varying evidence on the exact window of time for optimal response, but delays of even a few weeks may make a significant difference to treatment response.

 This suggests that FEP might be better considered as a stage with substages within it. In fact, with a much shorter DUP now possible with early intervention, it may be possible for a small subgroup of patients to remit without antipsychotic medication if they are provided with intensive psychosocial interventions alone.

 This might be termed stage 2a. The RAISE (Recovery After Initial Schizophrenia Episode) study shows that specialized early psychosis care may only be more effective than standard care if DUP is not prolonged beyond a certain duration.

 This responsive substage could be designated stage 2b.

Within the first episode of psychosis, the staging approach and research evidence indicate that low doses of antipsychotic medications are effective but must be rigorously adhered to if adverse experiences are to be minimized and engagement maximized.

 Shared decision making has a crucial place here. The imperative to prevent weight gain and metabolic consequences means that medications least likely to produce these effects must be first line.

A subgroup of patients who do not respond to treatment with dopamine antagonists and reveal early treatment failure can be reclassified as a further substage of stage 2, or stage 2c. Alternatively, they can be regarded as having rapidly progressed to stage 4, even within the first 6 months post diagnosis. In this case, the benefit-to-harm ratio changes dramatically, and although clozapine has a number of risks, which means that it should not be used as first-line treatment, the evidence mandates its use early in the course of illness with treatment resistance or as illness rapidly progresses to stage 

Psychosocial treatments, notably vocational interventions such as Individual Placement and Support (IPS) and family interventions, must also be adapted to the stage of illness. Used early and throughout treatment, psychosocial interventions are especially effective at stage 2 in line with what is expected in a staging model and early intervention.

Following the first episode (stage 2), patients may enter stages 3 or 4. Stage 3 interventions involve the prevention of relapse with efforts to prevent and treat comorbidity and persistent subthreshold or residual symptoms of psychosis and other associated syndromes. Long-acting injectables can be seen as a preventive strategy. However, a personalized approach with substages and subgroups reflects a heterogeneity within stage 3. Thus, dose reduction and possible discontinuation are possible for a subgroup of patients.

Long-term follow-up studies reveal that late remission occurs in about 16% of cases.

 Current guidelines for the use of medications are understandably conservative, but patient heterogeneity and response to medications need to be further explored. Later-stage patients who appear to have stabilized, but with continuing symptoms and functional impairment, can be offered a different suite of psychosocial interventions. Interventions specifically linked to this stage can greatly improve patients’ quality of life. These may involve meaningful activity including part-time work, strength-based strategies, social engagement within the community to combat loneliness, family support, financial support, and expert medical care to respond to the greatly increased risk of medical illnesses.

A contributing life is possible for most people and a holistic blend of expert psychiatric, medical, and social care is essential for this to occur. The “soft bigotry of low expectations” is a consequence of poorly resourced systems of care and antiquated diagnostic thinking that is blind to the opportunities that new models of care and high-fidelity implementation can deliver. Such approaches depend on congruent mindsets and conceptual frameworks, and a much more educated and supportive wider community.

Dr McGorry is a professor of youth mental health at The University of Melbourne and executive director of Orygen in Melbourne, Australia. He has received past unrestricted grant funding from Janssen-Cilag, AstraZeneca, Eli Lilly, Novartis, and Pfizer, and honoraria for consultancy and teaching from Janssen-Cilag, Eli Lilly, Pfizer, AstraZeneca, Roche, Bristol-Myers Squibb, and Lundbeck. He has received grant funding from the Colonial Foundation, the National Health and Medical Research Council of Australia, NARSAD, the Stanley Foundation, the National Institutes of Health, and the Australian and Victorian governments.

The Lancet Commission on global mental health and sustainable development

 Correll CU, Galling B, Pawar A, et al. Comparison of early intervention services vs treatment as usual for early-phase psychosis: a systematic review, meta-analysis, and meta-regression. 

Malla A, Joober R, Iyer S, et al. Comparing three-year extension of early intervention service to regular care following two years of early intervention service in first-episode psychosis: a randomized single blind clinical trial. 

Yung AR, McGorry PD. The initial prodrome in psychosis: descriptive and qualitative aspects. 

Clinical Staging in Psychiatry: Making Diagnosis Work for Research and Treatment.

Fava GA, Kellner R. Staging: a neglected dimension in psychiatric classification. 

McGorry PD, Hartmann JA, Spooner R, Nelson B. Beyond the “at risk mental state” concept: transitioning to transdiagnostic psychiatry. 

 McGorry PD, Ratheesh A, O’Donoghue B. Early intervention––an implementation challenge for 21st century mental health care. 

Ajnakina O, David AS, Murray RM. ‘At-risk mental state’ clinics for psychosis—an idea whose time has come—and gone! 

Fusar-Poli P, Salazar de Pablo G, Correll CU, et al. Prevention of psychosis: advances in detection, prognosis, and intervention. 

 McGorry PD, Nelson B. Clinical high risk for psychosis––not seeing the trees for the wood. JAMA Psychiatry. Published online March 11, 2020; Epub ahead of print.

Dama M, Shah J, Norman R, et al. Short duration of untreated psychosis enhances negative symptom remission in extended early intervention service for psychosis. 

Francey SM, O’Donoghue B, Nelson B, et al. Psychosocial intervention with or without antipsychotic medication for first-episode psychosis: a randomized noninferiority clinical trial. 

 Kane JM, Robinson DG, Schooler NR, et al. Comprehensive versus usual community care for first-episode psychosis: 2-year outcomes from the NIMH RAISE Early Treatment Program. 

Australian Clinical Guidelines for Early Psychosis––second edition updated. Orygen. 2016. 

www.orygen.org.au/Training/Resources/Psychosis/Clinical-practice-points/Australian-Clinical-Guidelines-for-Early-Psychosis

 Thien K, Bowtell M, Eaton S, et al. Clozapine use in early psychosis. 

Shah P, Iwata Y, Plitman E, et al. The impact of delay in clozapine initiation on treatment outcomes in patients with treatment-resistant schizophrenia: a systematic review. 

Killackey E, Allott K, Jackson HJ, et al. Individual placement and support for vocational recovery in first-episode psychosis: randomised controlled trial. 

Wunderink L, Nieboer RM, Wiersma D, et al. Recovery in remitted first-episode psychosis at 7 years of follow-up of an early dose reduction/discontinuation or maintenance treatment strategy: long-term follow-up of a 2-year randomized clinical trial. JAMA Psychiatry. 2013;70(9):913-920.

Harrison G, Hopper K, Craig T, et al. Recovery from psychotic illness: a 15- and 25-year international follow-up study. 

Psychotic disorders are potentially serious and enduring and have been seriously neglected in health systems worldwide. The good news is that better medium-term outcomes are now achievable.

Stage-Specific Treatment  of Psychotic Disorders

Fears about the overprescription of opioid analgesics and the opioid epidemic have resulted in initiatives for physicians to prescribe these medications more judiciously. However, new concerns about patients needlessly suffering untreated or undertreated pain have been raised.

Unfortunately, many lay people and even many health care providers still believe that opioids are the optimal treatment for all forms of pain and that there are no good alternatives. Studies, however, have shown that nonopioid pharmacologic therapies and nonpharmacologic therapies can be as effective and, in many cases, even more effective than opioids.

and meta-analysis of mind-body therapies (MBTs) for patients whose pain is being treated with opioids highlights how useful these modalities can be and the importance of considering them when caring for patients suffering with pain.

The review included 60 studies with 6404 participants. A variety of MBTs were employed, including meditation, hypnosis, relaxation, guide imagery, therapeutic suggestion, and cognitive-behavioral therapy (CBT) depending on the individual studies. The types of pain varied from procedural pain to burn pain to cancer-related pain to chronic pain. The impact of various MBTs on the pain and on the use of opioids were examined.

The findings indicated that meditation, hypnosis, therapeutic suggestion, and CBT were most likely among the MBTs to provide the greatest pain relief with moderate to large improvements. Meditation, hypnosis, and CBT appeared to have the greatest impact on opioid use. The researchers noted that the lack of evidence for the impact of the other MBTs may reflect that there were fewer studies rather than evidence that those MBTs are less likely to have an effect on either the pain or opioid use.

There were also indications that MBTs may provide some benefit for opioid craving and misuse, another reason why their use should be considered for patients on opioids for whom it is believed these medications should be discontinued.

There were differences between the types of pain for which the individual MBTs were studied. Studies that looked at meditation-based therapies primarily focused on chronic noncancer pain while most hypnosis, relaxation, and imagery studies focused on acute, procedural, or cancer-related pain. Whether this provides any guidance as to which type of therapy would be most beneficial for which type of pain is open to question and warrants further study.

It is worth noting that there is a great deal of overlap between many of the MBTs and what might be considered meditation by some could be considered relaxation or even hypnosis by others, so there is often a lack of clear demarcation between them. MBTs are not a magic bullet for the management of pain. They showed a moderate but statistically significant effect on the pain and resulted in a small but statistically significant reduction in opioid use.

In addition to these apparent benefits, MBTs also have one very significant advantage over many of the other treatments for pain: they are essentially free of adverse events. If they are tried and do not provide any benefit, the patient will be no worse off. As with all the other interventions to manage pain, no one can guarantee that MBTs will provide improvement but one can be as close as possible to certainty that they will not have any negative impact on those being treated with them. If the opioid epidemic has taught us anything it is that therapies initiated to help patients can end up having a destructive effect.

There is one very real limitation in the introduction of the MBTs as major treatments for pain. For the most part, in academic centers and hospitals, pain management is primarily considered to be a subspecialty of a single medical specialty—anesthesiology. The only significant exception to this is headache management, which is usually considered to be a part of neurology.

The reality is that few anesthesiologists and neurologists, even those who specialize in pain management, receive much, if any, training in the use of MBTs, nor do most primary care physicians upon whom the management of pain often falls. Thus, most patients with pain are unlikely to come into contact with caregivers who are knowledgeable about MBTs, much less know how to utilize them.

Obviously, the physicians most likely to be trained in the use of MBTs are psychiatrists, and this is one of many reasons why psychiatrists should be more involved in the care for patients with all forms of pain and not just those patients with diagnosable mental disorders.

There is a need for more and better studies on MBTs for pain. However, this can be said of all the other treatments for it. Let us recall that millions of patients have been prescribed opioids for the management of chronic pain although there are virtually no studies demonstrating their efficacy.

1. Garland EL, Brintz CEE, Hanley AW, et al. 

Mind-body therapies for opioid-treated pain: a systematic review and meta-analysis

This article was originally posted on February 20, 2020, and has since been updated. -Ed

For the millions of patients whose pain is being treated with opioids, mind-body interventions are proving to be important considerations to ease suffering.

Mind-Body Therapies for the Management of Pain: How Effective Are They?

Do you prescribe antidepressants for your patients with bipolar depression? If so, think again, and consider results from the Systematic Treatment Enhancement Program–Bipolar Disorder (

) studies. This was the largest federally funded group of studies of bipolar disorder treatment, and they included important randomized clinical trials involving subsamples of the 4360 patients enrolled.

Among the significant findings were the following:

1. Antidepressants (bupropion, paroxetine) are not more effective than placebo for bipolar depression (24% for the antidepressants versus 27% for the placebo in a 6-month trial).1 The antidepressants, when added to a mood stabilizer, did not induce more switches into mania (10% versus 11%), but the patients who participated in the study were probably at very low risk for switching. However, patients with bipolar depression with mixed features (defined as having 2 or more manic symptoms [eg, agitation and racing thoughts] with their depression) developed manias over the next several months that were more severe as compared with placebo-treated patients.

2. A group of 86 patients with bipolar disorder who responded to an antidepressant when depressed were identified. Some were rapid cyclers (4 or more episodes per year). All of the patients were also prescribed mood stabilizers such as lithium, valproate, or a second-generation antipsychotic. These patients were randomized to stay on the antidepressants or discontinue them. The patients with rapid cycling who were continued on their antidepressant had triple the number of depressions per year compared with those without rapid cycling. Yet, there was no difference in the rate of depressions between rapid and non-rapid cycling in the antidepressant discontinuation group. Thus, depressive morbidity and cycling were worsened by continuation of an antidepressant in patients with rapid cycling.

 were collected on the first 1500 patients looking for evidence of the antidepressant-associated chronic irritable dysphoria (ACID) syndrome described in previous case reports.

 It had been proposed that ACID was caused by treating patients who had bipolar depression with an antidepressant. The patient sample included 63% bipolar I patients with depression; most of the remaining patients had bipolar II. The researchers identified 83 patients in whom a depressive episode developed during the study period and for whom there was at least 1 year of follow-up information. Those who received an antidepressant for their depression had a 10-fold higher risk for ACID than the patients who were antidepressant free. ACID did not seem to occur in the natural course of bipolar disorder; it only occurred in those who received antidepressants.


Findings from STEP-BD studies indicate that antidepressants should be avoided in most cases when treating acute depression in patients with bipolar disorder. Rather, one should choose from among 5 medications with a reasonable evidence-base for effectiveness and safety in treating or at least preventing bipolar depressions, namely: lithium, quetiapine, lamotrigine, lurasidone, and cariprazine—or combinations of these.

 is Associate Professor of Psychiatry, Harvard Medical School, and Consulting Psychiatrist, US Department of Veterans Affairs, National Telemental Health Center, Bipolar Disorders Telehealth Program, Brockton, MA.

1. Sachs GS, Neirenberg AA, Calabrese JR, et al. 

Effectiveness of adjunctive antidepressant treatment for bipolar depression

2007;356:1711-1722.
2. El-Mallakh RH, VÃ¶hringer PA, Ostacher MM, et al. 

Antidepressants worsen rapid cycling course in bipolar depression: a STEP-BD randomized clinical trial

2015;184:318-321.
3 El-Mallakh RH, Ghaemi SN, Sagduyu K, et al.

 Antidepressant-associated chronic irritable dysphoria (ACID) in STEP-BD patients

This article was originally posted on April 24, 2020, and has since been updated. -Ed

Do you prescribe antidepressants for your patients with bipolar depression? If so, think again, and consider results from these studies.

The Case Against Antidepressants for Bipolar Depression: Findings from STEP-BD

Dr Moffic talks about the coronavirus pandemic and the burnout epidemic and what those elements mean psychologically for clinicians. 

The burnout journey goes back all the way to the 1970s, it only applied to the general public at the time. Around the year 2000, the burnout rate among physicians was virtually nil compared with the rest of the workplace and that is because we were more or less in control of what we were doing. But then for profit managed care came to be.

Burnout in the medical industry arose later on with the main symptoms being emotional exhaustion, cynicism, and feeling ineffective. Treatments were ineffective, mainly because it is a systems issue, with oppressive enterprises creating disengaged workers and clinicians and who experienced micro-trauma on a daily basis. Wellness is often discussed to help burnout, but it doesn't do the job because it insinuates the cause of the problem is on us.

During these challenging times, physicians have to be proactive in helping ourselves, especially now that the pandemic is upon us. And that starts now. There are support groups online for physicians if you just want to talk or get advice about how to maintain your mental health, and you can form your own support groups. That is hard principally because we are so busy with our work, but there are ways we can take care of our health. If you find ways to make your system work better, try to share it with other people. We have to do what we can make ourselves safe, make ourselves healthy. 

We also need administrators who actually love us. Love is a strange word in medicine. When I received an administrative psychiatry award in 2016, that is what my lecture was about. On top of everything else, administrators need to love your staff, and medical administrators, love us in our work. That is the only way we can work together in a compassionate and caring way. 

Dr Moffic is an editorial board member and regular contributor to 

 He was a tenured Professor at the Medical College of Wisconsin until he retired in 2012. Since then he has functioned as a private community psychiatrist providing pro bono services locally, nationally, and internationally. Currently, Dr Moffic is focused on four major advocacy initiatives: physician burnout, climate instability, Islamophobia, and Anti-Semitism. He is co-editor of 

Combating Physician Burnout: A Guide for Psychiatrists

 with Sheila LoboPrabhu and Richard F. Summers.

Videos

During these challenging times, physicians have to be proactive in helping ourselves. And that starts now. 

The Paradox of Self-Help

There are moments in history that require us to step back and refocus, to view the issues before us through a new lens and from a different vantage point. We are all now sitting squarely in such a moment.

Trevor Noah, comedian host of the Daily Show, who regularly offers commentary on current events, spoke recently and with a serious tone, setting aside his usual comic repartee. He constructed a narrative in which stories that seem separate—COVID and race, Amy Cooper, George Floyd, the protests, and the looting—are, in fact, connected, the resulting forces surging together to form 

We face multiple interconnected crises: the worldwide pandemic of COVID, the crashing economy and the overarching and crushing impact of systemic racism. And unrelentingly, the climate continues to change and the effects of climate dysregulation continue to roll out and roll on.

 has taken the greatest toll on communities of color; specifically African-Americans, Hispanic, and Indigenous communities. These communities have suffered the greatest number of deaths. These community members are losing their jobs at higher rates than white workers. Black workers able to keep their jobs are often likely to be categorized as “essential” workers in service sector jobs. In such positions, people are often forced to choose between risking their health and trying to maintain the often-tenuous economic security of their families.

We have known for some time that communities of color, often lower income, are exposed to environmental risks at a much higher level when compared to more affluent, white communities. These more vulnerable community members have a higher rate of exposure to environmental toxins and climate-related diseases and the least access to quality health care. These community members are often living in buildings and in locations that cannot withstand the increasing fury of extreme weather events resulting from the changing climate. And yet, because of structural racism, these same communities get the least amount of attention and support to redress these environmental injustices.

As mental health professionals, we have a responsibility to more fully appreciate the corrosive impact of structural racism on individual and societal psyches. Ruth Shim, MD, addressing the social determinants of health, offers a graphic representation of the multiple forces coalescing into adverse mental health outcomes. Of note, climate change is now recognized as one of the social determinants of health.

Perhaps some of us have enjoyed a kind of psychological comfort by keeping safe within our climate silo as we work on issues related to global warming. Is there a degree of protective privilege conferred by focusing so narrowly on climate change? Have we held a kind of hopeful expectation that in focusing just on the climate change part of the equation, it would naturally address the systemic injustices by a kind of ripple effect? That fantasy has been rattled. White, privileged people are positioned in a more “experience distant” manner from both the effects of climate change and racism than are communities of color. The events stemming from George Floyd’s murder have shown us a “here and now,” raw and bleak reality. The curtain has been pulled back, revealing the agony that has been present for centuries and is being expressed again on the streets of American cities. We must hold all things at this painful moment; the pernicious impact of systemic racism, the crisis of the COVID pandemic, and the immense threat of climate change.

Sam Grant, executive director of MN350.org in “

Black Environmentalists Talk About Climate and Anti-Racism

” suggests that we must “help people see the connection between that issue [racism] and the broader climate crisis. . . . So it’s not choosing this or that. Or this, then that. It’s this 

We must change our lens and see how these all weave together: the issues of the pandemic, the economic downturn, structural racism, as well as the degradation of our natural world caused by climate change. The classic figure-ground, vase and profile picture, familiar to us from psychology, is an apt model that allows us to toggle back and forth between a foreground focus upon the impacts of structural racism or upon the environmental crisis. Neither is more prominent or important but together reveal a fluctuating change in perspective. Both must be viewed to make the picture whole.

 captures the potential of this historic moment in a second way. We must focus on the foreground—the tattered and frayed aspects of our society now so harshly exposed. Yet, we must consider the background that is always present in a crisis, the possibility of transformational change. Both must be viewed to make the picture whole.

For climate advocates, we must make environmental justice core to our efforts, while simultaneously holding the awareness that climate change is progressing and threatens the habitability of this planet for us all. The real challenge is to bring new creativity to our efforts and forge multiracial coalitions to address the mental health and public health impacts of inequity, racism, and the climate crisis.

Read Up on the Links Between Racism and the Environment

 Race, Racism, and Mental Health Resources

The Link Between Climate Change, Health, and Poverty

 is in private practice and she is Assistant Professor, Department of Psychiatry, University of California, San Francisco; she is on the Steering Committee of the Climate Psychiatry Alliance. 

 is a staff psychiatrist at the Counseling and Psychological Services of the University of Pennsylvania, and a student in the Masters of Environmental Studies Program at the University of Pennsylvania; she is on the Steering Committee of the Climate Psychiatry Alliance. The authors have no conflicts of interest concerning the subject matter of this article.

1. Conrinthios A. Trevor Noah Relects on George Floyd Protests: “Police in America Are Looting Black Bodies. Yahoo Entertainment. June 1, 2020. 

The social determinants of mental health: psychiatrists’ roles in addressing discrimination and food insecurity

3. Sengupta S. Black Environmentalists Talk About Climate and Anti-Racism. 

On Climate, COVID, and Race

I have seen it all, or at least I thought I had.

But this current financial/health outlier-black swan event is one in which there are no easy answers as to the pandemic’s impact on our world or domestic economies, or the very survival of our health care system.

So amidst this world of unknowns, we share some tips and advice to weather the financial fallout of this storm.

Advice for young and mid-career physicians

If you are in the accumulation phase of your career, nothing has changed. Unless this is the end of our financial systems as we have known them, and that is highly unlikely, the companies in which you have invested and loved are now at fire-sale prices. This makes them good investments, provided you are going to hold them long-term. Just keep saving and investing as you have been.

is the last thing Wall Street wants to see. In fact, uncertainty is the last thing any of us wants to see, especially when it comes to our health or financial security. We have, as a team of financial advisors, witnessed more than 3 decades of ups and downs in the market, and just about every geo-political event imaginable.

But this downturn, as severe as it has been, is something that we have not seen before. It is disconcerting, to say the least, to watch your investment holdings lose up to 30% of their value in one week. However—and, yes, there is a however—even though we have not seen this particular rapid spiral into a bear market and possible recession, we know how things have turned out in the past: things always come back and advance further. This should be no different, since banks are strong and the government is giving its full accommodation to both the virus and the 

We have witnessed firsthand over the years that fear is the most dangerous emotion when it comes to investing. The feeling of watching your portfolio grow each year is pleasant, but it does not match the intensity and pain of watching your investments lose value. Presuming that you had a good financial plan and your exposure to stocks was not more than the absolute minimum risk you had to assume to achieve your financial goals, just stay the course.

You must remember that your stock portfolio represents a long-term strategy; so, do not sell because of fear. Selling after a large decline in the markets is turning a paper loss into a real loss.

Then comes the problem of getting back in before the markets turn upward, possibly as fast as they went down. This is the age of computer trading and things happen very fast, as we have experienced; this particular downturn may well be the fastest and most severe to date. It gave few investors a chance to trim their holdings, since the markets went down considerably in just 1 week.

For those retirement-ready or already retired

For those ready to retire or in retirement, reviewing your budget is essential. Specifically, it may be a good time to divide your expenses between essential and discretionary. Essentials such as food, mortgages, property taxes, utilities, car payments, and the like, must be paid. The discretionary side would be anything not essential, such as eating out, gifts, travel, and so forth. When you calculate the essential and discretionary costs, you can divide each number by your investment net worth, find what the percentage is, and stick to a budget that does not exceed this percentage.

As your portfolio goes down or up, and if the percentage is higher than planned, you may want to cut back on your discretionary spending until the portfolio has recovered. This will preserve principal and address the danger of creating a vicious cycle of depleting your savings when your withdrawal percentage keeps increasing as the portfolio value declines.

There are other strategies to consider. Some examples would be tax-harvesting losses by switching positions on the same day, thereby not missing a possible market upturn, but locking in future loss carry-forwards. Also, repositioning portfolios that previously had too much increase to consider a move because of capital gains. There are many positive moves to consider while we are experiencing these depressed markets.

Of course, it is imperative that you consult with a tax professional before making any changes.

Amidst this world of unknowns, the authors share some tips and advice to weather the financial fallout of this storm.

Meeting Patients Where They Are: A Public Health Imperative

Prescribing Hope for Recovery

Stage-Specific Treatment of Psychotic Disorders

Mind-Body Therapies for the Management of Pain: How Effective Are They?

The Case Against Antidepressants for Bipolar Depression: Findings from STEP-BD

The Paradox of Self-Help

On Climate, COVID, and Race

Investing Tips in a Time of Crisis

Masks, Machismo, and the American Man-Child

Open Letter to Quaranteens: Oh, the Places You’ll Go!