In the absence of conversion or remission, ie, while the patient is clinically prodromal, treatments of considerable variety are currently offered to patients and their families in prodromal clinics around the world. These include strategies of engagement; supportive psychosocial therapy; psychosocial case management; cognitive behavioral treatments; treatments of comorbid disorders, particularly substance abuse; family involvement, usually in the form of multifamily group psychoeducation; and finally pharmacotherapy with both antipsychotic and non-antipsychotic compounds.
Each treatment modality (to be described) was developed originally for dealing with established cases of schizophrenia, but our focus here will be the translation of these approaches to the prodromal patient. This literature is now quite substantial, will be quoted here frequently, and should be consulted for details. The major difference is that with the prodrome, all treatment modalities include ongoing psychoeducational discourse and active follow along. The prodrome may be the optimal period for psychoeducation because patients are worried about themselves and their cognitive resources for participating in a learning experience are not yet seriously compromised.
Phillips and Francey19
describe engagement as follows:
The engagement phase is obviously crucial. It provides the opportunity for the patient to get to know the therapist (and vice versa) and allows the therapist the opportunity to set ground rules for the rest of the therapy process and to assess expectations of the client. It also enables the therapist to emphasize the collaborative nature of the therapy. It is important that the language used by the therapist, as well as the “therapy tools”, are understood by the client and are appropriate for their developmental level. Cognitive development and other processes, which may be affected by the symptoms and experiences that contribute to the ultra high risk status of this specific client group, should also be carefully assessed. For instance, an individual who experiences brief and intermittent auditory hallucinations may have occasional concentration difficulties. Similarly, an individual who experiences persistent perplexity associated with intermittent paranoid thoughts may suffer marked social anxiety.
Key strategies for promoting engagement beyond basic counseling skills are:
Offering practical help
Working initially with the client's primary concerns and source of distress
Flexibility with time and location of therapy (office based, school, client's home)
Provision of information and education about symptoms
Working with family members, if appropriate, as well as the identified client
All in all, the primary aim of engagement is to make a human connection and to help the patient find enough comfort and advantage in the relationship such that he or she continues to show up for appointments. The slide into psychosis almost by definition involves withdrawal from real others into a shadowy world of imaginary encounters with stereotypic human caricatures. Engagement counters this decathexis and sets the stage for more structured interactions.
Yung et al6
describe supportive therapy as follows:
Although it does not specifically target psychotic symptoms, supportive therapy endeavors to provide the patient with emotional and social support and incorporates many of the constituents of Rogerian Person Centered Therapy including empathy, unconditional positive regard and patient-initiated process. The therapist aims to facilitate an environment where the young person is accepted and cared for and they can discuss concerns and problems as well as share experiences and feelings with the therapist.
In addition to promoting change through non-directive strategies, basic problem-solving approaches are also offered. This may include assisting the patient to develop skills, such as brainstorming responses to situations, role-playing possible solutions, goal setting, time management and so forth. The patient is encouraged to be pro-active and to monitor his or her own progress. Some degree of role-playing may occur within sessions as a springboard to changes in behavior outside the sessions.
Other elements of this “holding environment” include availability for crisis intervention and after-hours contact.6,20
Many prodromal clinics rotate beeper coverage for nights, weekends, and holidays, a concrete sign that the patient's risk for psychosis is taken seriously.
Supportive therapy often targets the social and instrumental domains of the patient's daily life rather than symptoms and psychopathology, the aim being to keep the patient “in the world” and to prevent attenuation of social ties secondary to intensified symptom formation. The therapies are usually highly structured, prescriptive, and time limited so as not to be perceived by the patient as too demanding or overwhelming.
Supportive Interpersonal Therapy, or SIT, is an example of such a therapy. It was developed for the prodromal clinics collaborating in the National Institute of Mental Health–sponsored PREDICT consortium that recruits and follows prodromal patients.21
The aim of SIT is to improve the ongoing functioning and social integration of persons in the study. It is divided into 5 phases over 23 weeks. Phase 1 (3 sessions) establishes a therapeutic alliance using supportive interactive techniques similar to those outlined by Yung et al6
above. Phase 2 (2 sessions) determines and articulates what social and functional areas in the patient's daily life are the most problematic. A list of potential goals is given to patients who have difficulty formulating specific targets (see Appendix 3
). Phase 3 (2 sessions) prioritizes the social and functional problems and develops a mutually agreed-upon treatment plan. Phase 4 (13 sessions) mobilizes the treatment plan with the goal being better integration of the patient into his or her social world. This includes modeling appropriate social skills, role-playing problematic social situations, identifying and monitoring the patient's positive attributes over the course of each week, reality testing experiences of stigmatization, and assigning tasks that will bring patients in contact with other people. Phase 5 (3 sessions) reviews the goals attained and the skills learned, develops a post-SIT treatment plan, and elicits feelings and issues regarding termination.
Case Management and Stress Management
Case management is a form of supportive therapy that deals with more immediate stressors and concrete administrative issues. As noted by Yung et al6
and by Phillips and Francey,19
with case management the therapist assists the patient with more practical issues (finding housing, handling money, applying for work or school, etc.). They feel such management must be provided in addition to other therapeutic efforts because neglect of basic daily living needs can generate stress and undermine the effect of even the best of therapies.
Stress management emerges from the stress-vulnerability model of schizophrenia and aims to reduce both the occurrence of stress in the patient's life as well as the patient's dysfunctional responses to stress. Phillips and Francey19
wrote about it as follows:
The components of this module are drawn from traditional stress-management approaches including relaxation training, education about stress and coping, and more specific cognitive strategies. As well as being primarily cognitive-behavioural in orientation, these strategies educate the clients to recognize and monitor their own stress levels, to develop an understanding of precipitants to distress, to recognize associated physiological and behavioural correlates of stress, and to develop appropriate strategies for coping with stressful events.
Psychoeducation about the nature of stress and anxiety. This entails a detailed discussion of the physical, behavioural and cognitive signs of stress. The physiological reactions concomitant with “flight and fight” responses are described to help in the process of distinguishing adaptive stress from unhealthy levels of stress. Personal signals of maladaptive levels of stress may also be identified.
Stress monitoring: Diary use is encouraged to record varying stress levels over specific time periods and to identify precipitating events or situations, and consequences of anxiety or stress.
Stress management techniques, such as relaxation, meditation, exercise, distraction are introduced.
Maladaptive coping techniques are identified—for example, excessive substance use and/or excessive social withdrawal. The psychoeducation provided is aimed at reducing health damaging behaviours and promoting more adaptive responses to stress.
Cognitions associated with subjective feelings of stress or heightened anxiety are identified through monitoring (which may include completion of an inventory of dysfunctional thoughts/irrational beliefs to identify maladaptive cognitions).
Cognitive restructuring is introduced, which counters dysfunctional thoughts (e.g., negative self-talk, irrational ideas), with more positive coping statements, positive reframing, and challenging.
Goal-setting and time management is introduced.
Assertiveness training is provided.
Problem-solving strategies are discussed.
Case management may target the patient's environment as well. Certainly this includes the family and is detailed below. For the youthful prodromal patient, this may also include the school. Counselors at the PRIME Clinic in New Haven, eg, reach out to educate school personnel about prodromal symptoms present in general and/or in a particular patient/student. In the latter instance, eg, it might be explained that a student is very sensitive to noise and may need assistance during the changing of classes or during lunch period in the noisy cafeteria. Or a patient experiencing disorganizing communication may need single-step directions. Schools have proven to be appreciative of such suggestions and their implementation has often diminished the patient's level of stress.
Prodromal symptom monitoring on a regular (eg, weekly) basis in clinics with a research agenda can prove to be a form of stress management. During weekly reviews of their prodromal symptoms, patients become educated about their “psychopathology” and how it is context dependent and often fluctuates with daily stress. Patients become reliable observers of their symptoms, often quantifying their variable severity based on the research rating scale (“I would score my idea that my friends are talking about me a 4 this week … I think it happened more because I didn't sleep too well over the weekend”). Objectifying and quantifying psychopathology with such monitoring can make it seem less foreign, mysterious, and overwhelming.
Cognitive Behavioral Therapy
Unlike supportive therapy and stress management, which generally targets functioning and anxiety but avoids psychopathology, the primary focus of cognitive behavioral treatment is on the patient's anomalous positive symptomatic experiences (aberrant auditory or visual percepts, suspiciousness about strangers, etc.) and his or her culturally unacceptable attempts to explain these experiences (eg, transmitter in my ear or being followed by the FBI). These explanations, in turn, usually arise in the context of relative isolation and are usually kept secret, at least at first. The patient does not try to “make sense” out of these experiences with another person or persons, thereby “normalizing” the experience.22
Cognitive behavioral therapy (CBT) attempts to provide the missing or avoided “normalization” with a variety of strategies.19,22
These include the following:
- Developing a relationship with the patient.
- Education about symptoms, their biopsychosocial germination, their frequency in the population, and their manageability.
- Avoiding the term schizophrenia and psychosis.
- Verbally challenging and reality testing delusional thoughts and hallucinations while generating and testing alternate explanations.
- Teaching coping strategies such as stress management, distracting attention, and strategic withdrawal.
- Normalizing psychotic-like experiences by suggesting that symptoms experienced are relatively common and manageable.
- Reality testing perceptual aberrations and suspiciousness by devising experiments to test the beliefs held by the patient.
- Self-monitoring of symptoms to enhance the connection between external events and emotional states.
- Modeling insight, judgment, and metacognitive functions for the patient.
- Reducing the distress and fear of catastrophe attending psychotic-like experiences.
Active efforts at engaging patients and normalizing their experiences may be especially effective in the prodromal clinical state given that substantial elements of insight are still present. Psychosis flourishes in isolation, but CBT can keep the patient connected with others by avoiding cognitive and interpersonal closure in the form of delusional certainty.
Combined Psychosocial Treatments
Most prodromal centers around the world currently offer psychosocial treatment packages that are mixtures or hybrids of engagement, supportive therapy, case management, stress management, and cognitive behavioral approaches.23,24
The German Research Network on Schizophrenia divides the prodrome into early and late phases, the early phase characterized primarily by basic symptoms and the late phase by prodromal symptoms and disability. This group recommends CBT for the earlier phase and pharmacotherapy for the later phase.25,26
Family-based treatment of prodromal patients has been modeled upon multifamily group psychoeducation approaches with first-episode schizophrenic patients.27
This approach is also formulated around the stress-vulnerability model of psychosis and the assumption that this model applies to cases that are prodromal as well as to cases that are already psychotic.
The treatment addresses several domains of risk factors. These were originally identified as mediators of relapse in established schizophrenia, but they may also be mediators of onset in prodromal patients, especially if onset is viewed as the “original” relapse. Among the risk factors identified and targeted by family treatment are high levels of expressed emotion (criticism, overinvolvement) in families toward patients, high levels of stigma aimed at patients and families resulting in unhealthy social isolation, and high levels of communication deviance resulting in poor family focus and uncoordinated familial collaboration.
Family intervention usually is initiated when the patient is admitted to the study. It tries to involve family and patient together and consists of 4 treatment stages: (1) engagement, (2) education, (3) re-entry, and (4) social/vocational rehabilitation.
The engagement phase aims to establish rapport and gains consent of the family and patient to enter ongoing treatment. The education phase is conducted via workshop sessions that provide classroom-like information about the biological, psychological, and social nature of psychotic disorders and their management. Following the workshop, meetings begin twice monthly with the family and the patient in the multigroup format. Content of sessions includes treatment compliance, stress reduction, modifying and mollifying life events, avoiding drugs and alcohol, and modifying expectations while patient and family are dealing with symptoms and their functional consequences. With time and better symptom control, the themes change to encompassing social and vocational rehabilitation. As noted by McFarlane,27
much of the effectiveness of this treatment results from increasing the size of the patient's and family's social networks by reducing the experience of being stigmatized and by providing a forum for sharing similar problems and finding collaborative solutions.
McFarlane's Psychoeducational Multi-Family Group (PMFG) approach has been adapted by O'Brien and Cannon at University of California Los Angeles, with slight modification, for adolescents in the prodrome. M. O'Brien and T. Cannon (Personal Communication, 2006) report as follows:
… we have implemented PMFG procedures patterned after those described by McFarlane (2002) and modified so as to be appropriate for a prodromal population (O'Brien et al., in preparation), along with a parallel set of procedures for group therapy with individual patients who do not have a family member available to participate. Each PMFG consists of approximately 7 families and is co-led by two specially trained therapists. There are separate groups for young adolescents (ages 12-14-middle school age), and older adolescents (ages 15-17 or 18). Before each group begins, a series of “joining sessions” allow the therapists to address individual family concerns and to forge a working alliance with each family. All participants are invited to a half-day long psycho-educational workshop, led by the co-therapists and other relevant project staff, during which they are presented with information about the prodromal state, reasons for early intervention, biological basis for mental disorders, stress-vulnerability theories, psychopharmacological treatment, psychological treatment, school interventions, and recommendations for creating a protective environment. Following the workshop, groups begin meeting bi-weekly for 90-minute sessions over nine months (i.e., a total of 18 sessions). Meetings are structured to allow for the development of social, communication, and problem-solving skills and to support families' efforts to manage symptoms.
The first two group meetings focus on building comfort and a sense of a common mission among group members. In the first session, participants are asked to talk about themselves outside of the context of mental illness. The focus in on getting to know each member as a person and to understand each person's interests and strengths. The goal is to build some common ground among members, and to encourage them to maintain their involvement in these important pursuits. During the second session, each member is asked to discuss some of the symptoms that brought him or her to the treatment group. Typically, during this meeting, people report feeling relief as they hear they are not alone in their struggles with symptoms and they report feeling some hope that together with the other group members they will be able to solve some of the problems they are currently confronting. All remaining sessions are structured similarly. The first 15 minutes are spent socializing so that symptomatic young people and isolated families have the opportunity to practice talking about everyday matters with others. These skills are essential to building relationships in the community. Next, there is a “go-around” where each group member talks about what is going well that week, and what could be going better. After hearing about current challenges the group members are experiencing, the co-leaders identify a problem for the group to focus on during the remaining time. The problem is clarified and some contextual information is provided by the group member who is the focus of the problem solving. Then the group brainstorms possible solutions to the problem. Once a range of solutions has been listed, the group evaluates the pros and cons of each suggestion. Then, the individual member who has reported the problem is asked to select some solutions that he/she is willing to try. A detailed action plan is developed and a description of the problem solving session is later e-mailed to all group members for their reference. Each group meeting concludes with some socializing. This group format is supplemented by individual and/or individual family sessions as needed (i.e., to handle crises, etc.)
The greatest diversity of treatment practices in the prodrome exists around the use of antipsychotic medication. One double-blind clinical trial of medication vs placebo has been conducted to date,4
hardly a sufficient database to be informative or directive. Nevertheless, antipsychotic medication treatment recommendations still exist because these medications are powerful and because they constitute the mainstay of therapy for established psychosis. Without data, however, the recommendations are heavy on opinion and light on informed direction.
Indeed, no common direction emerges from the practices that exist and have been outlined. Some prodromal centers recommend against long-term antipsychotics unless and until an established DSM-IV
diagnosis of psychosis can be made20
or until frank positive symptoms have emerged for at least 1 week.17
Another center endorses psychosocial interventions and symptom-focused drug treatment for depression or anxiety in the early prodromal phase and additional antipsychotics in the late prodromal phase for psychotic symptoms and provides detailed recommendations concerning drugs and doses, eg, perphenazine 4–6 (12) mg, risperidone 0.5–1 (2) mg, olanzapine 2.5–5 (10) mg, or quetiapine 25–200 mg (R. Salokangas and M. Heinimaa, Personal Communication, 2006). Still others recommend against antipsychotics in principle but not in situations where there is risk of self-harm or aggression.17
Finally, the German Research Network on schizophrenia recommends against drug treatment of the early prodromal (basic symptoms) but is conducting a clinical trial of amisulpride for the late prodrome,15,26
the criteria for which are similar to the attenuated symptom groups of other centers.
The only clear conclusion that can be drawn from the existing practices is that much more clinical trial research needs to be done. Open-label trials of aripiprazole28
and of non-antipsychotic compounds such as glycine29
and omega-3 fatty acids30
are being conducted, and such efforts should be welcome. Ultimately, however, the risk-benefit ratio of antipsychotic medication treatment for this new clinical entity will not become clear until multiple clinical trials utilizing Cochrane-strict methodology are conducted.
In addition to meeting criteria for a prodromal syndrome, many patients struggle with additional problems and symptoms suggesting the presence of one or more concomitant symptom constellations and/or disorders. Common “adjunctive” psychopathologies include bipolar disorder, major depressive and/or dysthymic disorder, anxiety disorders (especially social phobia), personality disorders (especially avoidant), and substance use disorders (especially marijuana). Many patients come to the prodromal clinic already being treated for one or more of these, eg, antidepressants for low mood, mood stabilizers for cycling mood or irritability, benzodiazepines for anxiety, and 12-step dual diagnosis programs for substance abuse and dependence.20
Such adjunctive problems are treated rather uniformly across prodromal centers. If the patient is already being treated with medication for mood, anxiety, or substance use at intake, it is usually continued. Should such problems emerge while the patient is being followed in the center, non-antipsychotic pharmacotherapy is often begun, eg, mood stabilizers for bipolar mood swings, anti-depressants for depressed mood, and benzodiazepines for anxiety (for limited periods of times).20
Such an approach is often labeled “symptomatic treatment,” a term which suggests that the prescribed drug is specific to the symptom and does not affect the trajectory of the prodrome. This assumption that adjunctive medicine is orthogonal to the prodrome may be in error. Certainly no studies have been conducted to date demonstrating that symptomatic treatment is limited to the symptom and fails to impact the prodromal syndrome. Indeed, antidepressants and mood stabilizers such as lithium are felt by some31
to reduce the probability of conversion to psychosis. Such studies are clearly needed given the popularity of off-label symptom-focused prescriptions.
Important Issues for the Future
Many issues not addressed here are important foci for future studies of prodromal recruitment and treatment. One is the distinction between being at risk and being disordered, ie, what is meant by “conversion” or “onset” and how this point can be tested for validity. Another is how recruitment can maximize the ratio of true- to false-positive prodromal cases. The recruitment practices described in this article target “help-seeking” prodromal patients and, as noted by Van Os and Delespaul32
, the high ratio of true- to false-positive cases ascertained in the study centers described here means that current recruitment has been successful in drawing, encountering, or finding highly selected samples that are “enriched” with risk. How and why these recruitment strategies accomplish this enrichment is an important clinical epidemiologic question. While this communication samples descriptively the nature of existing recruitment practices among nascent prodromal clinics in research samples, careful comparative epidemiological studies of recruitment practices and resulting samples are needed to answer the question as to how enrichment happens and how it might be engineered.
Summary: Toward Treatment Guidelines
As noted above, the symptomatic prodromal state is a new clinical entity. As such, all treatments of this entity are experimental or “off-label.” Furthermore, much more research will be required before clear treatment guidelines can be articulated that maximize benefit and minimize risk. Nevertheless, certain clinical strategies appear close to achieving guideline status because they are common to most if not all prodromal centers worldwide. Those have been highlighted in this communication, and they are summarized by Yung et al6
in their book on prodromal treatment. Their core elements of the current treatment of the prodromal patient are reproduced below.
Young people who are distressed by signs and symptoms of an at risk mental state (ARMS) and are seeking treatment should be:
—engaged and assessed by a mental health service that is aware of the unique needs of this clinical group;
—offered regular monitoring of state;
—offered specific treatment for syndromes, such as depression, anxiety or substance misuse, and assistance with other problem areas as necessary (such as interpersonal, vocational and family-related);
—provided with psychoeducation and support to better understand the symptoms they have experienced;
—offered treatment to assist in developing skills to cope with subthreshold psychotic symptoms that might be experienced;
—offered family education and support;
—provided with information in a flexible, clear and careful way about risks for mental disorders, as well as existing syndromes
—provided with appropriate treatment with minimal delay if symptoms worsen and an acute psychotic episode develops.