Therapeutic Considerations in Individuals at Clinical Risk for Developing Psychosis

Abstract

In the last two decades, increased focus has been placed on earlier identification and treatment of psychotic illness in an effort to prevent illness onset and/or long-term sequelae of schizophrenia. Typically, a 16- or 17-year-old young man or woman is referred to our clinic by a mental health provider who has noted thought disorder (referential thoughts, suspiciousness) in addition to depression and/or anxiety. The individual is usually someone who has stopped socializing with friends, has poor grades, has experimented with illicit substances (frequently cannabis), endorses unusual beliefs, but maintains insight. We begin by obtaining a thorough history, including collateral sources such as family and school counselors and a medical history to rule out any organic causes. Oftentimes there is a family history of schizophrenia or bipolar disorder, traumatic childhood, and at times a history of social discomfort and bullying. It is not uncommon for our clients to endorse depression and social anxiety in addition to prepsychotic perceptual abnormalities. In our clinic, we use a multimodal risk-reduction approach that matches the risks of illness with risks and benefits of prescribed treatment. For instance, in early-stage patients, we encourage low-risk treatments including cognitive behavior therapy, social skills training, cognitive training, family-focused psychotherapy, relaxation techniques, and neuroprotective agents such as omega-3 fatty acids. Antidepressants are used for prominent neurovegetative symptoms, although they are used with caution, as some individuals meeting criteria for prodromal psychosis, or clinical high-risk criteria, go on to develop bipolar spectrum disorders. Low-dose atypical antipsychotic treatments are reserved for patients closer to psychotic transition. All patients, regardless of stage of illness, are encouraged to optimize physical activity and to abstain from illicit substance use. Looking toward the future, we hope to obtain a biomarker profile (blood tests, neurocognitive, neuroimaging, and neurophysiological assessment) in each patient at the outset which, combined with clinical factors, will guide individualized treatment.