Psychotic prodrome: Are antipsychotics effective? Ethical?

• weight and waist circumference
  
• vital signs
  
• metabolic parameters such as fasting blood glucose and lipid profile
  
• abnormal involuntary movements
  
• prolactin elevations.
  

Lifestyle modification—including diet and exercise to counteract the risk of weight gain—must be part of the treatment plan. Because the exact risks of antipsychotics are unknown—particularly their weight-gain potential among children and adolescents—we recommend specialist consultation (see Related resources) and careful documentation of all treatment decisions and discussions.

OTHER THERAPIES

Antidepressants. Researchers are also exploring the efficacy of using antidepressants and anxiolytics in the prodromal phase. The only published naturalistic study of adolescents found antidepressants alone or in combination with mood stabilizers or anxiolytics to be as effective as atypical antipsychotics in treating prodromal symptoms.¹⁷ A more substantial study is ongoing.

Psychotherapy. For patients with a suspected psychotic prodrome, nondrug strategies may help minimize functional and cognitive impairments, ease distress, and improve coping skills.

CBT has been shown to reduce psychotic progression over 12 months.¹⁸ Use CBT to help patients cope with the illness while focusing on:

• symptom monitoring
  
• premorbid and present functioning
  
• establishing a therapeutic alliance
  
• assessing the patient’s experience of psychosis and any thought distortions.
  

Also assess and treat co-occurring conditions such as alcohol and drug abuse. Involving the family in early intervention has been shown to improve prognosis.¹⁹

‘REAL WORLD’ EARLY INTERVENTION

Patients with prodromal symptoms are often referred to psychiatrists by family members, primary care physicians, or other mental health professionals. They tend to be young adults, and a few may present in their teens. Most are experiencing behavioral changes such as social isolation, feeling suspicious, perceptual disturbances, depression, and/or anxiety symptoms that seem abnormal but fall short of DSM-IV criteria for schizophrenia diagnosis.

Many clinical questions about schizophrenia’s prodromal phase remain unanswered (Table 3). Our primary aim is to adequately assess these patients and provide treatment and follow-up, taking into account:

• the individual’s presentation
  
• risks and benefits of available interventions.
  

Begin by educating patients and their families and providing social and emotional support to alleviate their distress that a mental illness may be developing (Box 2). Psychosocial and pharmacologic treatment options are based on presenting symptoms and other patient-specific variables.

Box 2

Psychotherapy should emphasize coping strategies, education about warning signals of psychotic conversion, establishing a therapeutic alliance, assessing thought distortions, and monitoring premorbid and present functioning.

Consider atypical antipsychotics for patients with distressing psychotic symptoms, rapidly deteriorating function, increased agitation, and safety risks. Consider antidepressant and/or anxiolytic therapy for depression and anxiety, respectively.

Discuss at length with patients and families the risks and benefits of pharmacologic treatments. When clinically appropriate, cautiously discontinue or taper any medication with patients’ consent, while monitoring for side effects and symptoms.

Related resources

• Issue devoted to early prodrome research. SchizophrBull 2003;29(4):621-879.
  
• Diagnostic and therapeutic intervention during psychotic prodrome. CNS Spectrums 2004;9(8):578-606.
  
• PRIME (Prevention through Risk Identification, Management & Education) Research Clinic. Department of Psychiatry, Yale University. https://info.med.yale.edu/psych/prime/pintro.html.
  
• Youth Mental Health Update. Schizophrenia: New strategies for early detection and treatment. RAPP Clinic, Zucker Hillside Hospital, Glen Oaks, NY. https://schoolnet.lij.edu/eshare/files/rapp.html
  

Drug brand names

• Aripiprazole • Abilify
  
• Olanzapine • Zyprexa
  
• Quetiapine • Seroquel
  
• Risperidone • Risperdal
  
• Ziprasidone • Geodon
  

Disclosures

Dr. Narasimhan receives research support from Eli Lilly and Co. and Janssen Pharmaceutica and is a speaker or consultant for Eli Lilly and Co., Pfizer Inc., and Abbott Laboratories.

Dr. Buckley receives research support from AstraZeneca Pharmaceuticals, Bristol-Myers Squibb Co., Eli Lilly and Co., Janssen Pharmaceutica, Novartis Pharmaceuticals Corp., Pfizer Inc., and Solvay Pharmaceuticals. He is a consultant to and/or speaker for Abbott Laboratories, Alamo Pharmaceuticals, AstraZeneca Pharmaceuticals, Bristol-Myers Squibb Co., Eli Lilly and Co., Janssen Pharmaceutica, Novartis Pharmaceuticals Corp., Pfizer Inc., and Pharmstar.