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Welcome to my blog, a place to explore and learn about the experience of running a psychiatric practice. I post about things that I find useful to know or think about. So, enjoy, and let me know what you think.


Sunday, September 1, 2013

No Present Like the Time

This post is a spinoff of two posts from two different blogs:

1. Conflicted on 1 Boring Old Man

2. Preventing Transition to Schizophrenia on Psycritic

Here's the deal. 1BOM writes about Jeffrey Lieberman's article in Psychiatric News, Early Detection of Schizophrenia: The Time is Now. 1BOM is all for early intervention in the treatment of schizophrenia, but he's conflicted because he thinks the fuss may be all cheerleading and no content.

In the comments, Psycritic references a model used in Portland, Maine, which involved training people in the community to recognize prodromal symptoms early, and then making treatment accessible. Then he/she (Psycritic, that is), links to his/her post.

Both posts are excellent, and I'm certainly all for early remediation, but I guess I'm just innately skeptical.

These are some of my thoughts on the topic:

-Jeffery Lieberman recently suggested we make nice with Big Pharma. I don't trust what's going on there. So what is this really about?

-How does the Portland model work?

-Does the model work?

-What are the implications of early detection/diagnosis?

This is what I learned:

In the Portland Program, "37% of the community referrals were found to be at high risk of psychosis, and another 20% had untreated psychosis, yielding an efficiency ratio of 57%. Prodromal cases identified were 46% of the expected incidence of psychosis in the catchment area. Community educational presentations were significantly associated with referrals six months later; half of referrals were from outside the mental health system."

They worked with people in the community, such as teachers, and general medical providers, and trained them to identify potential cases. A lot of work was done to de-stigmatize mental health issues, so people would be more willing to accept the help that was being offered.

The program is great once cases are identified. But what happens with the 43% of potential cases that turn out not to be prodromal or psychotic? Do they wonder why their teachers and doctors thought they might be "crazy"?

Another article, entitled, Is there any point in detecting high risk factors prior to a first psychosis? The link is to the abstract, which has a link to the full article, which is in Dutch. This review article concluded:

conclusion Screening all genetically vulnerable persons in the general population has no consequences for treatment. Early diagnosis by psychiatrists is certainly advisable. However, larger groups and longer studies are needed in order to demonstrate conclusively the preventive effect of interventions prior to a first psychosis.

Recall one diagnosis that didn't make it into DSM-5: Psychosis Risk Syndrome. The reasons this diagnosis was rejected included the difficulty in using its criteria to distinguish normal from abnormal:



There are plenty of eccentric teenagers out there-most don't go on to develop a full-blown psychotic disorder.


Here are some other problems:

-False positive rates in research settings range from 50%-84%. And note that these are research settings, where all raters have been extensively trained.

In pioneering studies in both Australia and the United States, young people with “subthreshold” psychotic symptoms and/or functional decline in the context of genetic risk for schizophrenia were ascertained and followed longitudinally for development of psychosis (Miller et al., 2003; Yung et al., 2003). In these earliest studies, prodromal status was associated with a 40 to 50 percent rate of “conversion” to psychosis within 1 to 2 years (Miller et al., 2003; Yung et al., 2003). A consortium of research groups in North America reported a more modest rate of transition to psychosis; for example 35 to 40 percent within 2.5 years (Cannon et al., 2008; Woods et al., 2009). In Australia, one-year transition rates for patients ascertained in successive years have steadily decreased over time: 50% in 1995 → 32% in 1997 → 21% in 1999 → 12% in 2000 (Yung et al., 2007). 
(Corcoran, 2010)


-Stigma associated with this "pre" diagnosis, as well as effects on the patient's future. Does a 17 year old with this diagnosis plan to go to college?

-The potential for inappropriate use of antipsychotics, with little evidence that this would be an effective strategy.

-Who is being assessed? In a research setting, the subjects are people who have been referred because something is off. In a more general population, the false positive rate will be even higher.

In the process of looking all this up, I came across an Editorial entitled, The Impossible Dream: Can Psychiatry Prevent Psychosis? This was from Early Intervention in Psychiatry, and written in 2007.  The authors were Jeffrey Lieberman and Cheryl Corcoran. Their conclusion:

We have demonstrated the political will and proven
capacity to address mental illness as a public health
issue, but are still limited in our identiļ¬cation of risk
states and effective prevention strategies. The
powerful tools of neuroscience – neuropsychology,
neuroimaging, neurophysiology and genetics – hold
great promise for the development of diagnostic
methods and novel interventions for the prevention
of serious mental illnesses in adulthood. A more
complete understanding of the pathological 
mechanisms that underlie schizophrenia and 
other disorders will facilitate diagnosis and inform the design
of innovative, safe and effective interventions. Then
we will truly be able to realize the promise of this
revolutionary new approach to prevent serious
mental illness.



My concern is about DSM-5. I read somewhere that the reason DSM-5 uses an Arabic five rather than a Roman five, like the previous DSM's, is that it's really DSM-5.0. Soon there will be 5.1, and  5.2. Like iOS.

Clearly, this topic has been on Jeffrey Lieberman's agenda for a while. But right now, the ability to effectively prevent mental illness is merely a wish. And I wouldn't put it past psychiatrists who want to be able to predict and intervene right now, and the pharmaceutical industry, which has a vested interest in encouraging the use of more medications, to jump the gun and push for Psychosis Risk Syndrome to make it into an upcoming edition of DSM-5.

Patience is what's called for. Now is not the time.




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