Psychosocial Interventions May Help Nip Psychosis in the Bud

Deborah Brauser

August 06, 2014

Psychosocial interventions may effectively head off psychosis or early-onset schizophrenia in at-risk teens and young adults, 2 new studies suggest.

Dr. David Miklowitz

The first study showed that young people with psychotic symptoms or a genetic risk for "functional deterioration" who underwent family-focused therapy (FFT) for 6 months had significantly greater improvements in positive symptoms of psychosis than those who received 3 sessions of family education.

"I was a little surprised to see that the effects of family-focused therapy showed up after 6 months because often it takes longer to see an effective therapy," lead author David J. Miklowitz, PhD, professor of psychiatry at the David Geffen School of Medicine at the University of California, Los Angeles (UCLA), and director of the UCLA Child and Adolescent Mood Disorders Program, told Medscape Medical News.

"The number 1 take-away is that early on in the onset of psychotic disorders, we may be able to do a lot with skills-oriented psychotherapy," added Dr. Miklowitz.

In the second study, patients with early-onset schizophrenia between the ages of 12 and 18 years showed significantly improved verbal memory and executive functioning after undergoing cognitive remediation therapy (CRT).

"Although further research is needed, the present study provides evidence of the potential of CRT as an intervention strategy for adolescents with this severe illness," write Olga Puig, from the Department of Child and Adolescent Psychiatry and Psychology of the Hospital Clínic in Barcelona, Spain, and colleagues.

Both studies were published in the August issue of the Journal of the American Academy of Child and Adolescent Psychiatry.

High-Risk Population

In the first study, Dr. Miklowitz and colleagues examined the effects of various interventions for individuals between the ages of 12 and 35 years who were classified as "clinical high risk" (CHR) for psychosis.

"We hypothesized that early psychosocial intervention would be strengthened by involving family members in treatment," write the investigators.

They add that this is because these CHR individuals are often living with their parents, and "the evolution of attenuated psychotic symptoms may be affected by family contextual variables."

A total of 129 CHR participants (57.4% male; mean age, 17.4 years) were enrolled at 1 of 8 sites across the United States between January 2010 and February 2012. Exclusion criteria included current diagnosis of schizophrenia or schizoaffective disorder.

All participants were randomly assigned to undergo 18 sessions during a 6-month period of intensive FFT (n = 66) or 3 sessions during a 1-month period of family education/enhanced care (EC, n = 63).

In FFT, the individuals were taught how to cope with stressors that may contribute to their psychotic symptoms, how to lessen negative symptoms and increase social engagement through behavioral activation, and how to improve problem solving and interpersonal communication skills. EC focused predominantly on symptom prevention.

At the end of 6 months, 102 of all participants were followed up (79.1%). Results showed that the family-focused group had significantly greater improvements in attenuated positive psychotic symptoms than did the EC group (P = .02).

Negative psychotic symptoms also improved ― but in both groups. In addition, there was no between-group difference in overall psychosocial functioning scores, with both groups showing improvements.

Age Matters

Interestingly, secondary analysis showed that social-role functioning improved more for the FFT group members who were older than 19 years vs their age-matched counterparts in the EC group (P = .04).

However, the EC group members between the ages of 16 and 19 years showed more improvement in psychosocial functioning than the FFT group members in the same age range (P < .05).

"We looked at better functioning, which means: did they go back to classes or back to work? Did they develop more friendships? Are they showing better functioning in their day-to-day lives?" said Dr. Miklowitz.

"We found that people 20 years and older did the best with the [FFT], whereas a little younger group did better with the control condition. This could be because some of the 16- to 19-year-olds just don't want that much contact with their families and with their parents in particular," he added. "We may have underestimated peer relationships in that age group."

Although adolescents between the ages of 12 and 15 years in the FFT group improved by 8.9 scale points vs 3.3 points in the EC group, this difference was not deemed statistically significant.

Only 1 of the FFT participants and 5 of the EC participants converted to psychosis. None of the 6 were taking antipsychotic medications at baseline. Finally, concurrent use of pharmacotherapy did not affect overall findings.

"Interventions that focus on improving family relationships may have prophylactic efficacy in individuals at high risk for psychosis," write the investigators.

They note that future studies should assess "the specificity of effects" for family-focused therapy vs individual therapy.

"We don't know if we can prevent people from developing psychotic disorders, but that's the goal. If you get some good structure and skill-oriented therapy early on, you're less likely to develop these disorders," added Dr. Miklowitz.

"I think the message for clinicians is to think through: how do I treat kids who fit this profile? Although they might be depressed or anxious, they might also show some subtle psychotic signs. So perhaps you should involve the family and educate them about things that might trigger those symptoms and about ways to better communicate with the patient."

In the second study, researchers examined whether CRT is effective in improving cognition and functioning in "symptomatically stable but cognitively disabled adolescents" with early-onset schizophrenia (EOS).

They enrolled 50 adolescents with EOS who were then randomly assigned to either CRT plus treatment as usual (n = 25; 52% males; mean age, 16.7 years) or treatment as usual only (TAU; n = 26; 52% males; mean age, 16.8 years).

TAU included psychoeducation about the illness, medical reviews, and case management in outpatient settings. CRT used "mainly paper-and-pencil tasks" as a strategy learning program.

Symptoms and performance were assessed at baseline and after treatment in both groups and also at 3 months' follow-up in the CRT group.

Primary outcome results showed that the CRT group had significantly greater improvements than the treatment-as-usual-only group in verbal memory (P = .003), working memory (P = .04), executive function (P = .02), and cognitive composite score (P = .009) at the end of treatment.

Compared with baseline, all of these improvements were maintained at the 3-month follow-up assessment (P = .003, P = .05, P = .02, and P < .001, respectively).

When examining secondary measures, the investigators found that the participants receiving CRT also showed improvements in daily living skills, global adaptive functioning, and self-perceived family burden at the end of treatment. All parameters were maintained at the 3-month follow-up except for functioning improvement.

Important Contributions

Randal G. Ross, MD, from the University of Colorado Denver School of Medicine, writes in an accompanying editorial that the American Academy of Child and Adolescent Psychiatry released an updated practice parameter in 2012 regarding the assessment and treatment of children and adolescents with schizophrenia.

"The recommendations included a clinical guideline that 'psychotherapeutic interventions should be provided in combination with medication therapies,' " he writes.

"The recommendation was issued as a clinical guideline rather than as a clinical standard because there have been only a few small studies suggesting benefit in this age population."

Dr. Ross adds that "much of the argument" supporting their use is based on the assumption that what works in adults is probably applicable to youth.

However, "two articles in this edition of the Journal attempt to narrow this critical gap in the literature," he writes. "These 2 approaches show benefit but also note important caveats."

He notes that combined take-home messages include that, consistent with the recent practice parameter, psychosocial interventions are important treatment components for this patient population and that it is important to realize that age-related differences occur.

In addition, "family interventions need to carefully consider the adolescent's interpretation of family involvement," and multivisit interventions may be problematic when translated to real- world settings.

"Future advances in psychosocial treatments need to consider not only efficacy but also whether the intervention is feasible and appealing to adolescents," he writes.

Still, Dr. Ross called the studies "critically important additions to the currently limited literature" on these types of interventions for young people with or vulnerable to schizophrenia.

"These studies are excellent examples of why additional work exploring outcomes in adolescent populations is critical for the field," he concludes.

Dr. Ross has reported no relevant financial relationships. The study authors have noted several disclosures, which are fully listed in the original articles.

J Am Acad Child Adolesc Psychiatry. 2014;53:833-834, 848-858, 859-868. Abstract 1, Abstract 2, Editorial

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