Study Deems Support, Not Drugs, Best for Youth at Risk of Psychosis

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Research by five U.K. universities across multiple sites for up to two years divided 288 young adults (14-35 years) deemed at risk for psychosis into two groups; 144 receiving cognitive therapy along with monitoring of mental state, and 144 receiving monitoring alone.  Transition to psychosis was equally low in both groups (23 out of 288, or 8%), but the frequency and intensity of  psychotic symptoms was significantly reduced in the group that received cognitive therapy. “The low rate of transition to psychosis in both groups and the recovery from psychosis and affective symptoms is clearly an important and optimistic message to convey” the study, which was published yesterday in the British Medical Journal, concludes. “…On the basis of low transition rates, high responsiveness to simple interventions such as monitoring, a specific effect of cognitive therapy on the severity of psychotic symptoms, and the toxicity associated with antipsychotic drugs, we would suggest that antipsychotics are not delivered as a first line treatment to people meeting the criteria for being in an at risk mental state.”

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Note from Kermit Cole, “In the News” Editor:
This is clearly a very important and interesting study, and interesting to note that the two U.S.-based news outlets within which I could find reference to it this afternoon (Medpage from the University of Pennsylvania and DoctorsLounge) both highlighted the seeming lack of efficacy of therapy, rather than the more profound implications of the low transition rates realized by simple monitoring of mental states, or the implications for medication that the study finds significant.

(To be fair, I am compelled to admit that when I saw this study early this morning, I hurriedly put it into the “later” bin for this same reason and did not recognize its significance until I looked more closely at it this afternoon.)

Here is the entire last paragraph of the study’s conclusions:

“This study has several clinical implications. Cognitive therapy reduces the severity of psychotic experiences without the use of antipsychotic drugs, which should provide the benefits of symptom based improvement without the associated risks of serious side effects. However, the low rate of transition to psychosis in both groups and the recovery from psychosis and affective symptoms is clearly an important and optimistic message to convey; both for young help seeking people meeting the criteria for being in an at risk mental state and for clinicians in contact with this population. It should encourage a normalising, non-catastrophic perspective on their psychotic experiences, and any treatment should largely be needs driven on the basis of what problems are presented and prioritised by service users; this is something that cognitive therapy is suited to, given its collaborative, problem oriented nature. However, active monitoring may also be beneficial and would be benign, easy to implement, and consistent with guidelines from the International Early Psychosis Association on treatment in the at risk phase48; a period of watchful waiting involving regular monitoring that lasts for at least 12 months could be safely recommended. The ethics of intervening before the onset of a disorder are always debatable, and this is especially so in relation to the use of antipsychotics for people in an at risk mental state, which often have significant adverse effects; for example, a recent systematic review concluded that some of the structural abnormalities in brain volume that have previously been attributed to the syndrome of schizophrenia may be the result of antipsychotic drugs,49 which has been recently supported by a high quality prospective study50 as well as experimental studies in healthy volunteers.51 There is also evidence that increased cardiovascular risk is detectable after first exposure to any antipsychotic drug52 and there is overwhelming evidence of weight gain induced by antipsychotics.53On the basis of low transition rates, high responsiveness to simple interventions such as monitoring, a specific effect of cognitive therapy on the severity of psychotic symptoms, and the toxicity associated with antipsychotic drugs, we would suggest that antipsychotics are not delivered as a first line treatment to people meeting the criteria for being in an at risk mental state.”

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Kermit Cole
Kermit Cole, MFT, founding editor of Mad in America, works in Santa Fe, New Mexico as a couples and family therapist. Inspired by Open Dialogue, he works as part of a team and consults with couples and families that have members identified as patients. His work in residential treatment — largely with severely traumatized and/or "psychotic" clients — led to an appreciation of the power and beauty of systemic philosophy and practice, as the alternative to the prevailing focus on individual pathology. A former film-maker, he has undergraduate and master's degrees in psychology from Harvard University, as well as an MFT degree from the Council for Relationships in Philadelphia. He is a doctoral candidate with the Taos Institute and the Free University of Brussels. You can reach him at [email protected]

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