Individuals who are referred to prodromal programs and meet the criteria for a prodromal syndrome are generally help seeking and clinically heterogeneous, with a history of mood, anxiety and attenuated psychotic symptoms(
Addington, Cadenhead et al. 2007). The majority of the clinical high risk subjects in the NAPLS sample had subsyndromal psychotic symptoms that had either begun or worsened in the last year while a small subgroup also had a family history of psychosis plus a recent deterioration in functioning (
Miller, McGlashan et al. 2003). Impaired social and role functioning at the time of entry into the study (
Ballon, Kaur et al. 2007;
Cornblatt, Auther et al. 2007) was also evident in this group of individuals. The majority of the sample had at one time been treated with a variety of psychosocial treatments and/or psychotropic medications in the community, suggesting that as a group they were in distress prior to entry into the various programs and that these community-based treatments had not been fully effective or entirely uniform. The most common treatment received was psychotherapy followed by medication treatment with antidepressant or antipsychotic agents. Although this is a cross sectional description of treatment received by this sample and it is unclear what effect the various treatments had on the clinical presentation, it is representative of what treatment might look like in the community in a group of individuals at high risk for psychosis.
The baseline characteristics of the NAPLS sample and the corresponding treatment they had already received were also related to the level of severity and specificity of symptoms. Psychosocial interventions history was more common in individuals in the APS prodromal group who also had high ratings on negative, disorganized or general symptoms or impairment in premorbid, global, role or social functioning. Given that many individuals who meet the prodromal criteria are also experiencing nonspecific symptoms that could be due to an array of factors related to adolescent development, drug abuse, affective or anxiety disorders, the community standard appears to be to offer psychosocial treatments more frequently than pharmacologic intervention.
Psychotropic medication was more likely to have been prescribed to those individuals with a history of an affective, anxiety, or alcohol/substance use disorders, or who appeared most symptomatic on a scale of psychological functioning. It is clear that the standard of care in the community is to initiate pharmacologic treatment when there is a diagnosable condition that requires a specific treatment modality. Additionally, it was Caucasian individuals and those from families with higher education who were more likely to have received pharmacologic treatment suggesting that cultural and sociodemographic factors may have played a role in access to such care.
Early identification and treatment in the early phase of psychosis has been an area of increased interest and ethical debate over the last decade(
Falloon, Coverdale et al. 1998;
Cornblatt, Lencz et al. 2001;
McGlashan 2001;
McGorry, Yung et al. 2003;
Perkins 2004;
Corcoran, Malaspina et al. 2005;
Haroun, Dunn et al. 2006). Given the range of possible presentations of the psychotic prodrome and potential treatments, the prospect of developing clinical staging criteria and treatment algorithms is daunting. Although the clinical high risk population is help seeking, they do not necessarily require a “one size fits all” treatment approach but are better suited to needs based treatment(
Haroun, Dunn et al. 2006). Clinical, demographic, and vulnerability marker assessment tools are needed to better identify those who are at greatest risk for psychosis. Translational studies are essential to understand the mechanism by which psychosis evolves and inform preventive treatment.
The concept of clinical staging for psychotic disorders, similar to that which has been developed in the treatment of illnesses such as cancer or diabetes, has been suggested by McGorry et al (
McGorry, Hickie et al. 2006). Those individuals with milder symptoms and/or fewer risk factors would be treated with psychosocial treatments while those who have more severe symptoms and risk factors would be treated with pharmacotherapy in addition to psychosocial treatment.
Preliminary treatment algorithms (
Haroun, Dunn et al. 2006;
McGorry, Hickie et al. 2006;
Yung, Yuen et al. 2007) have been proposed that describe a graded treatment approach in the prodrome that begins with a thorough clinical assessment, differential diagnosis, psychoeducation and observation. Psychosocial treatments such as CBT, crisis intervention or supportive psychotherapy, substance abuse reduction and family psychoeducation are recommended for all stages. Neuroprotective strategies such as Omega 3 Fatty Acids, atypical antipsychotics and/or antidepressants and mood stabilizers would be initiated when the individual has more severe prodromal symptoms or Axis I pathology. However, the development of definitive treatment algorithms for those who may be at clinical high risk for psychosis is clearly hindered by the lack of published treatment studies that are rigorously controlled.
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