Detection and Intervention for Adolescents With Early Psychosis: Promising Approaches

May 16, 2016

The key to identification of prodromal psychosis may lie in community-based outreach.

RESEARCH UPDATE

In his APA 2016 presentation, “Early Detection and Intervention for Adolescents With Early Psychosis: Promising New Approaches,” Stephen Adelsheim, MD, Professor of Psychiatry at Stanford University, began with this quote from an adolescent with prodromal psychosis:

“I’d say I started having paranoid feelings about a year ago. If I really think, things started to happen little by little, but they gradually got worse. I didn’t notice because I thought the way I felt was right. And my parents didn’t notice because it was so gradual.”

Dr Adelsheim’s talk was a part of a symposium titled “Interventions for Early Psychosis in Children and Adolescents: New Advances in Community and Policy Approaches,” which captured the widespread problem in identifying youth and adolescents with emerging psychosis in many communities around the US. And, as many preventive and early intervention programs have been better integrated and finding success in Europe and Australia, Dr Adelsheim declares we have a lot of catching up to do.

[[{"type":"media","view_mode":"media_crop","fid":"42141","attributes":{"alt":"psychosis","class":"media-image media-image-right","height":"167","id":"media_crop_7499741800178","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"4538","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":"©Lightspring/Shutterstock","typeof":"foaf:Image","width":"189"}}]]Data indicate that the incidence of mental health issues is highest in the 10- to 30-year-old age group, and furthermore that fully half of all lifetime cases of mental illness start by age 14 and 75% by age 24. During this period, 79% don’t access care. However, as the quote above depicts, symptoms of prodromal psychosis present a notable challenge, as they can be quite subtle, emerge gradually, and are often overlooked by adolescents, their families, and many primary providers.

Dr Adelsheim presented data from the NIMH-funded RAISE (Recovery After an Initial Schizophrenia Episode) Early Treatment Program study-the first to examine duration in untreated psychosis (DUP) in community mental health centers in the US-which showed that the median DUP was a full 74 weeks and that 68% of the 404 15- to 40-year-olds with first-episode psychosis had greater than 6 months’ duration without treatment.1

Unfortunately, longer DUP and delay in initiating treatment have been shown to correlate with poorer outcomes in overall functioning, positive symptoms, and quality of life, in addition to diminished response to treatment and lower likelihood of remission.2 Early intervention is the key, as Dr Adelsheim notes, as a shorter DUP is associated with better response to antipsychotics, greater decrease in both positive and negative symptom severity, decreased frequency of relapse, more time at school or work, and overall improved treatment response over time (Table).

There is a greater need for training of professionals to recognize the early signs of psychosis, which can present as nonspecific cognitive problems-such as memory complaints, confusion, and odd or distracting thoughts-which have been shown to correlate with longer delays in treatment.3 However, while increased provider education is needed, the early signs may be more likely to be recognized by those who have more immediate contact with children and adolescents, including teachers, school counselors, and community members.4

Community outreach

Dr Adelsheim was involved in the Early Detection, Intervention and Prevention of Psychosis Program (EDIPPP), a 6-city multisite study that assessed the effectiveness of a community education and outreach program designed for prevention or intervention in young people at high risk for psychosis, or those at a very early point in their first episode of psychosis.5 It was modeled after a program developed by the Portland Identification and Early Referral (PIER) program in Portland, Maine, which educated more than 7000 professionals and found a 34% reduction in incidence of hospitalizations for first-episode psychosis.6

EDIPPP’s model was geared toward rapid referrals for preventive treatment by creating networks of community personnel to identify signs of early psychosis and to direct young people into Coordinated Specialty Care (CSC), a recovery-based treatment program. CSC uses a team of specialists who make personalized treatment plans, including psychotherapy, medication management, and family education, support, and case management.

Targets for educational presentations on the early warning signs of psychosis included school counselors and nurses, community school mental health and school-based health center teams, focused student and parent education efforts, and ongoing stigma management.

Symptoms of prodromal psychosis present a notable challenge. They can be quite subtle, emerge gradually, and are often overlooked by adolescents, their families, and many primary providers.

Many of the presentations were geared toward culturally diverse audiences and systems that were previously inaccessible. After nearly 1000 formal and informal presentations to 34,000 attendees completed in a 3-year period, 1652 referrals were received to the program. Of these, 520 (31%) were offered in-person orientation, 392 were assessed for treatment, and 337 met criteria for directing into support.

The study, and Dr Adelsheim himself, raised many important questions: eg, how to make educational interventions culturally appropriate for diverse audiences; how to build effective and integrated coordinated specialty care models in those areas that sought referrals; and what it means to truly integrate into primary and secondary schools, such as with respect to creating accommodations and focused special education. He states that “we have a long way to go” to frame these support systems for young people, and he advocates for continuing to move our interventions earlier with further research on models of integrating care at all levels.

As highlighted in the 2009 Institute of Medicine reportPreventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities, untreated mental health and substance use issues in this age group cause a significant burden on individuals, their families, and their communities, and can additionally carry over into adulthood without effective approaches at harm reduction. Increased interest has developed in finding evidence-based preventive practices. Dr Adelsheim’s and his colleagues’ work indicates momentum and success in community-based outreach approaches.

Disclosures:

Dr Kaylor is Chief Resident in the department of psychiatry and health behavior at the Medical College of Georgia, Augusta University, and a Staff Psychiatrist at The Bluff Plantation - Rivermend Health, in Augusta, Georgia.

References:

1. Addington J, Heinssen RK, Robinson DG, et al. Duration of untreated psychosis in community treatment settings in the United States.Psychiatr Serv. 2015;66:753-756.
2. Marshall M, Lewis S, Lockwood A, et al. Association between duration of untreated psychosis and outcome in cohorts of first-episode patients: a systematic review. Arch Gen Psychiatry. 2005;62:975-983.
3. Norman RM, Malla AK, Verdi MB, et al. Understanding delay in treatment for first-episode psychosis.Psychol Med. 2004;34:255-266.
4. Domingues I, Alderman T, Cadenhead KS. Strategies for effective recruitment of individuals at risk for developing psychosis. Early Interv Psychiatry. 2011;5:233-241.
5. Lynch S, McFarlane WR, Joly B, et al. Early Detection, Intervention and Prevention of Psychosis Program: community outreach and early identification at six U.S. sites. Psychiatr Serv. 2016;67:510-516.
6. McFarlane WR, Susser E, McCleary R, et al. Reduction in incidence of hospitalizations for psychotic episodes through early identification and intervention. Psychiatr Serv. 2014;65:1194-1200.