| The use of such medication as a preventative therapy is controversial because there is no certainty that patients at risk of developing the psychosis will go on to develop the disease. Many patients fail to respond to these medications or only to a limited degree. None of these available medicines reliably produce a complete remission of symptoms. The diagnostic criteria used to identify individuals at risk for psychotic disorders is imprecise, particularly given that not all individuals assessed at high risk will transition to a psychotic disorder within one year. The transition rate for individuals may vary between 5%-40% depending on the population which the risk is assessed against. Therefore pharmacological interventions are not ideal since not all individuals may benefit in the long term and would also lead to unnecessary costs and waste of resources. |
| Whilst the potential benefit of preventing psychotic disorders is great, currently available strategies for prevention by treating attenuated symptoms with pharmacological psychiatric interventions[ e.g., antipsychotics, antidepressants, mood stabilizers] are not ideal. |
| Previous trials have investigated the preventive use of antipsychotic medications in ultra-high-risk groups. One study for example showed that a combination of risperidone and cognitive therapy for 6 months was significantly more effective than supportive counselling at end of intervention, but not at 12-month follow-up. A second study, compared 12 months intervention with olanzapine to placebo and found no significant intervention group differences. It was concluded that the benefits of pre-onset intervention with antipsychotics may outweigh the risks to a degree sufficient to endorse future trials. |
| However, the use of antipsychotic medication for indicated prevention remains controversial even in research settings because of the high number of false positives [about 70-80% of people who meet ultra-high-risk criteria do not progress to psychotic disorder within one year]. Stigmatization associated with the use antipsychotics, and unwanted side effects which include metabolic changes, sexual dysfunction and weight gain are often not acceptable. Other side effects may include dyslipidaemia, cardiac arrhythmia and osteoporosis. |
| Prevention of Psychotic Disorders and/or Treatment of Pychotic Symptoms |
This rather clear statement of the need for restraint on the use of antipsychotics in Dr. Patrick McGorry’s "ultra high risk" group of patients does, indeed, come from an authoritative source – Dr. Patrick McGorry himself. He wrote it as part of the application he filed with colleague Dr. Gunter Paul Amminger for a patent on the Omega-3 Fatty Acids in the treatment of this target population [the appearance of a conflict of interest…, Prevention of Psychotic Disorders and/or Treatment of Pychotic Symptoms].
It seems to me that the real question is not whether Dr. McGorry and his colleagues are on the right path. They seem to have successfully identified a pre-psychotic syndrome that is not nearly so precise as they had hoped, but certainly better than any we’ve had before. There’s some evidence from several fronts that giving these patients special attention may well have an impact on the subsequent course of disorder [shown in his first study and studies in the UK and Denmark]. He’s had difficulty reproducing his early success in a later trial. His experimental treatment with Omega 3 Fatty Acids was a success in an initial trial [successful enough for him to file a patent application]. So he’s making progress in fits and starts. Likewise there’s general agreement that an intensive early intervention program in patients who have already had their first psychotic break is warranted, though the exact details of how to intervene are still a work in progress.
| Deinstitutionalization was a wonderful reform idea which in many places resulted in perverse outcomes because it was not properly evaluated or resourced. Early intervention should not make the same mistake. |
| Early psychosis reform: too fast or too slow? |
This is another piece of sage advice, again from Dr. McGorry himself in an editorial he wrote in 2002 in the Acta Psychiatrica Scandinavica that speaks to the real question on the table [Early psychosis reform: too fast or too slow?].
Sorry, I’m missing something here. If there is no difference in 12 month outcome for those receiving risperidone and therapy vs therapy alone, or olanzapine vs placebo, what “benefits of pre-onset intervention with antipsychotics” are there to outweigh the risks? And would any therapy be justified if 70-80% of patients don’t progress in a 12 month period?