APA 2010 Expert Video - Schizophrenia Prodrome: Consensus or Confusion?

Peter J. Weiden, MD


June 02, 2010

This feature requires the newest version of Flash. You can download it here.

Substance Abuse and Suicide at APA: Introduction

Dr. Peter Weiden: Hi. My name is Peter Weiden. I'm a Professor of Psychiatry at the University of Illinois Medical Center. It is my pleasure to speak with you for a few minutes from the American Psychiatric Association Annual Meeting in New Orleans.

What I'd like to speak with you about is a controversial area called prodrome in schizophrenia. A few years back, an Australian group led by Pat McGorry developed programs and clinics for first-episode schizophrenia patients.

They noticed that there were many patients who did not meet full criteria for schizophrenia in that they did not have full psychosis but seemed to be at risk of developing schizophrenia. The Australian group called these patients high-risk or ultra-high-risk patients.

In the United States, there was some interest in this. Here, those high-risk patients are called prodrome patients, meant to represent prodrome to getting schizophrenia.

Initial studies showed that of patients identified as high-risk, maybe 1 out of 3 converted to schizophrenia. More recent studies show that that's actually less frequent.

Here are some controversies. One is that the word prodrome is controversial, because prodrome implies that the person will get what you think they're going to get by definition. It winds up that most "prodrome patients" don't get schizophrenia. So prodrome is an incorrect word, even though it's used widely. It is much more appropriate to say high-risk or ultra-high-risk. This is not just semantics, because if you use the word prodrome it implies that that person is fated to have schizophrenia, and that will tend to trigger more likelihood of treatment, especially starting antipsychotics.

Prodrome is diagnosed by looking for attenuated symptoms of schizophrenia. Is the person odd, withdrawn? Does the person have quasi-psychotic symptoms? Remember, if they have full psychotic symptoms they're no longer high-risk; they now have schizophrenia or psychosis.

It winds up that in the North American research groups, [researchers] feel that they can predict in their high-risk population development of schizophrenia in about 80% using every statistical model that they can, over several years.

That leads to 2 other controversies. One is, should we treat high-risk patients? Does treatment mean starting antipsychotics before full-blown psychosis shows up, or does it mean just generally getting therapy and an evaluation, treating for substance abuse, providing support, and so on? [In terms of starting] antipsychotics, there are only a few studies on this, and they are not encouraging. Starting antipsychotics does not seem to delay conversion, or at best, delays conversion just a little bit. Yet if you start antipsychotics such as olanzapine or risperidone, [the agents for which studies exist], they have lots of side effects.

My personal opinion is that it would be a big mistake to routinely start antipsychotics for people who are screened as being high-risk or "prodrome," because you're going to be overtreating many people who don't convert to that illness. And, in the meantime, if you take that into the community, you're going to be way overtreating people who won't have schizophrenia.

If you define treatment as, "Do these patients need help, do they need assessment, do they need therapy? Of course!" then treatment makes sense. But unfortunately, in my opinion, in psychiatry treatment is often considered [a] knee-jerk [reaction in which we] prescribe antipsychotics.

The second controversy is, should high risk be in DSM-V? There's a big controversy surrounding this. Those proponents of including it in the DSM-V will say that we need to learn more about how to prevent conversion. They would say that in other disease areas, intervene early before a disease progresses to a late phase.

Those arguments, at the face of it, seem quite persuasive and even seductive, if you will. But I personally think it would be a big mistake to include this high-risk category in the DSM-V because of the problem of overdiagnosis, and we don't know as much about this yet as we would like to. So it is not yet a disease state in its own right, and for every 1 person who converts to schizophrenia, there will be 2 others who have depression, 2 others who have substance abuse problems.

My own personal view is that we're not ready yet to make it into a diagnosis, but it is a controversy, and I think you should know about it.

That's the news on high risk or prodrome from the APA 2010. Thank you for listening.