Treatment of the schizophrenia prodrome: is it presently ethical?

Neurobiology and systems biology of stress resilience

Stress resilience is the phenomenon that some people maintain their mental health despite exposure to adversity or show only temporary impairments followed by quick recovery. Resilience research attempts to unravel the factors and mechanisms that make resilience possible and to harness its insights for the development of preventative interventions in individuals at risk for acquiring stress-related dysfunctions. Biological resilience research has been lagging behind the psychological and social sciences but has seen a massive surge in recent years. At the same time, progress in this field has been hampered by methodological challenges related to finding suitable operationalizations and study designs, replicating findings, and modeling resilience in animals. We embed a review of behavioral, neuroimaging, neurobiological, and systems biological findings in adults in a critical methods discussion. We find preliminary evidence that hippocampus-based pattern separation and prefrontal-based cognitive control functions protect against the development of pathological fears in the aftermath of singular, event-type stressors [as found in fear-related disorders, including simpler forms of posttraumatic stress disorder (PTSD)] by facilitating the perception of safety. Reward system-based pursuit and savoring of positive reinforcers appear to protect against the development of more generalized dysfunctions of the anxious-depressive spectrum resulting from more severe or longer-lasting stressors (as in depression, generalized or comorbid anxiety, or severe PTSD). Links between preserved functioning of these neural systems under stress and neuroplasticity, immunoregulation, gut microbiome composition, and integrity of the gut barrier and the blood-brain barrier are beginning to emerge. On this basis, avenues for biological interventions are pointed out.

An open label pilot trial of low-dose lithium for young people at ultra-high risk for psychosis

AIM

Lithium, even at low doses, appears to offer neuroprotection against a wide variety of insults. In this controlled pilot, we examined the safety (i.e., side-effect profile) of lithium in a sample of young people identified at ultra-high risk (UHR) for psychosis. The secondary aim was to explore whether lithium provided a signal of clinical efficacy in reducing transition to psychosis compared with treatment as usual (TAU).

METHODS

Young people attending the PACE clinic at Orygen, Melbourne, were prescribed a fixed dose (450 mg) of lithium (n = 25) or received TAU (n = 78). The primary outcome examined side-effects, with transition to psychosis, functioning and measures of psychopathology assessed as secondary outcomes.

RESULTS

Participants in both groups were functionally compromised (lithium group GAF = 56.6; monitoring group GAF = 56.9). Side-effect assessment indicated that lithium was well-tolerated. 64% (n = 16) of participants in the lithium group were lithium-adherent to week 12. Few cases transitioned to psychosis across the study period; lithium group 4% (n = 1); monitoring group 7.7% (n = 6). There was no difference in time to transition to psychosis between the groups. No group differences were observed in other functioning and symptom domains, although all outcomes improved over time.

CONCLUSIONS

With a side-effect profile either comparable to, or better than UHR antipsychotic trials, lithium might be explored for further research with UHR young people. A definitive larger trial is needed to determine the efficacy of lithium in this cohort.

Is the psychopathology of acute and transient psychotic disorder different from schizophrenic and schizoaffective disorders?

Objective

This study explores psychopathological aspects of acute and transient psychotic disorders (ATPD), a diagnostic category introduced with ICD-10, to elucidate its relationship with schizophrenia and schizoaffective psychoses.

Methods

We recruited all consecutive inpatients fulfilling the ICD-10 criteria of ATPD (F23) during a 5-year period as well as control groups with “positive” schizophrenia (PS) and bipolar schizoaffective disorder (BSAD) matched for gender and age at index episode. For the evaluation of psychopathological parameters during index episode a standardized symptom list was used. Prepsychotic (prodromal) symptoms were also assessed.

Results

During the prepsychotic period few differences between the groups were detected. The most important difference between ATPD and the other two other psychotic disorders regarding phenomenology of the full-blown episodes was a higher frequency of “rapidly changing delusional topics”, “rapidly changing mood” and anxiety in ATPD.

Conclusion

ATPD show a characteristic psychopathological picture consistent with earlier concepts such as cycloid psychoses and bouffée délirante. Nevertheless, psychopathology alone is not enough to establish ATPD as an independent nosological entity.

Recent advances in the prevention of mental disorders

PURPOSE

Prevention of mental disorders is a rapidly growing area of research with substantial potential benefits for population health. This paper reviews the evidence base for prevention of depression, anxiety, and schizophrenia.

METHODS

We synthesized evidence from recent systematic reviews and meta-analyses published between 2013 and 2018 on prevention of depression, anxiety, and first-episode psychosis. We included reviews of randomized controlled trials testing psychological, psychosocial, and pharmacological preventive interventions.

RESULTS

There is good evidence that depression and anxiety can be prevented, although effect sizes are generally small. Indicated prevention of first-episode psychosis appears promising. Economic evaluations provide support for prevention of depression, anxiety, and first-episode psychosis, but more studies evaluating costs and benefits are needed to strengthen the knowledge base, particularly regarding long-term outcomes, which include chronicity of the prevented disorder, as well as later occurence of important comorbid mental and physical health problems. Promising areas for further development include internet- or computer-based prevention strategies, mindfulness-based interventions, and integration of prevention programs within occupational settings.

CONCLUSIONS

A number of interventions to prevent mental disorders are efficacious. While intervention effect sizes are generally small for prevention of depression and anxiety, they may nonetheless be of significant population benefit. Using the growing evidence base to inform policy and dissemination of evidence-based prevention programs is critical for moving prevention science into real-world settings.

What can triumphs and tribulations from drug research in Alzheimer's disease tell us about the development of psychotropic drugs in general?

Drug development for psychiatric disorders has almost ground to a halt. Some newer drugs are better tolerated or safer than older ones, but none is more effective. Years of failure in preventing or delaying the onset of illness, ameliorating symptoms, lowering suicide rates, or improving quality of life has put the commercial investments that had previously funded drug development at risk. To promote the development of psychiatric drugs with greater efficacy, we need to improve the way we bring potentially beneficial drugs to market. We need to acknowledge, as has been done in other specialties, that people differ in their response to drugs. Psychiatric drug research needs to be grounded in a better understanding of molecular brain mechanisms, neural circuits, and their relations to clinical disease. With this understanding, drugs need to be more precisely directed at specific brain targets. In psychiatric drug development, government, industry, regulatory bodies, and academia should realign to ensure medical science is used in the best interests of patients.

Interaction of social role functioning and coping in people with recent-onset attenuated psychotic symptoms: a case study of three Chinese women at clinical high risk for psychosis

Clinical high risk of psychosis is defined as the period in which the first signs of psychotic symptoms begin to appear. During this period, there is an increased probability of developing frank psychosis. It is crucial to investigate the interaction between psychotic symptoms and the individual's personality and life experiences in order to effectively prevent, or delay the development of psychosis. This paper presents case reports of three Chinese female subjects with attenuated positive symptoms, attending their initial outpatient assessment in a mental health service, and their longitudinal clinical outcomes. Information regarding each subject's symptoms and life stressors was collected at 2-month intervals over a 6-month period. The assessments indicated that these women were suffering from the recent onset of symptoms in different ways. However, all three hid their symptoms from others in their school or workplace, and experienced a decline in performance related to their social roles and in their daily functioning. They were often excluded from the social groups to which they had previously belonged. A decline in social activities may be a risk factor in the development of psychosis and a mediator of functional sequelae in psychosis. Effective treatment strategies may include those that teach individuals to gain insights related to their symptoms and a service that provides a context in which individuals can discuss their psychotic symptoms.

Omega-3 fatty acid supplementation changes intracellular phospholipase A2 activity and membrane fatty acid profiles in individuals at ultra-high risk for psychosis

The identification of an ultra-high risk (UHR) profile for psychosis and a greater understanding of its prodrome have led to increasing interest in early intervention to delay or prevent the onset of psychotic illness. In a randomized placebo-controlled trial, we have identified long-chain ω-3 (ω-3) polyunsaturated fatty acid (PUFA) supplementation as potentially useful, as it reduced the rate of transition to psychosis by 22.6% 1 year after baseline in a cohort of 81 young people at UHR of transition to psychosis. However, the mechanisms whereby the ω-3 PUFAs might be neuroprotective are incompletely understood. Here, we report on the effects of ω-3 PUFA supplementation on intracellular phospholipase A2 (inPLA(2)) activity, the main enzymes regulating phospholipid metabolism, as well as on peripheral membrane lipid profiles in the individuals who participated in this randomized placebo-controlled trial. Patients were studied cross-sectionally (n=80) and longitudinally (n=65) before and after a 12-week intervention with 1.2 g per day ω-3 PUFAs or placebo, followed by a 40-week observation period to establish the rates of transition to psychosis. We investigated inPLA(2) and erythrocyte membrane FAs in the treatment groups (ω-3 PUFAs vs placebo) and the outcome groups (psychotic vs non-psychotic). The levels of membrane ω-3 and ω-6 PUFAs and inPLA(2) were significantly related. Some of the significant associations (that is, long-chain ω-6 PUFAs, arachidonic acid) with inPLA(2) activity were in opposite directions in individuals who did (a positive correlation) and who did not (a negative correlation) transition to psychosis. Supplementation with ω-3 PUFA resulted in a significant decrease in inPLA(2) activity. We conclude that ω-3 PUFA supplementation may act by normalizing inPLA(2) activity and δ-6-desaturase-mediated metabolism of ω-3 and ω-6 PUFAs, suggesting their role in neuroprogression of psychosis.

Genealogy of instruments for prodrome evaluation of psychosis

OBJECTIVE

Over the last 15 years, researchers from around the world have developed instruments for assessing the risk of conversion to psychosis. The objective of this article is to review the literature on these instruments by focusing on genealogy links and on their performance in predicting conversion to psychosis.

METHOD

A systematic review of articles published since 1980 relating to risk assessment instruments for conversion to psychosis by manual search and consultation of electronic databases MEDLINE, EMBASE, and PsycINFO.

RESULTS

Three hundred ninety one (391) publications were selected and analyzed. Among these, 22 instruments were identified. These instruments are briefly described and placed on a timeline according to their year of publication. A code of positions, patterns, and forms is used to schematize the characteristics of each instrument. A table is presented to show changes in rates of conversion to psychosis within cohorts of subjects considered at risk according to the instruments. A second code of shades and outlines is used to schematize the characteristics of each cohort of patients. The two graphics set the stage for a discussion about the major strategies that were adopted to improve the performance of risk assessment instruments.

CONCLUSION

These graphics allow a better understanding of the origin, evolution, current status, strengths, shortcomings, and future prospects of research on risk assessment instruments. Clinical ImplicationsThe integration of theoretical approaches, the multicenter studies, and the pre-selection of patients with short questionnaires were the main strategies to improve the performance of instruments assessing the risk of conversion to psychosis.These instruments are better at predicting conversion to psychosis than conventional variables within a more limited time span and can therefore enable the evaluation of various risk factors and biomarkers that may be associated with psychosis. LimitationsThe studies selected for this review of literature were not classified according to their methodological quality.These studies are based on heterogeneous populations and this must be taken into account when comparing the rates of conversion to psychosis.This review of literature was based on published data only and they were no direct communication with the authors of these instruments.

Ethical implications for clinical practice and future research in "at risk" individuals

The last 15 years have witnessed a shift in schizophrenia research with increasing interest in earlier stages of illness with the hope of early intervention and ultimately prevention of psychotic illness. Large-scale longitudinal studies have identified clinical and biological risk factors associated with increased risk of psychotic conversion, which together with symptomatic and demographic risk factors may improve the power of prediction algorithms for psychotic transition. Despite these advances, 45-70% of at risk subjects in most samples do not convert to frank psychosis, but continue to function well below their age matched counterparts. The issue is of utmost importance in light of the upcoming DSM-V and the possible inclusion of the attenuated psychotic symptoms syndrome (APSS) diagnosis, with clinical and ethical implications. Clinical considerations include feasibility of reliably diagnosing the at risk state in non-academic medical centers, variable psychotic conversion rates, a non-uniform definition of conversion and extensive debate about treatment for individuals with an ill-defined outcome. On the ethical side, diagnosing APSS could lead to unnecessary prescribing of antipsychotics with long-term deleterious consequences, slow research by providing a false sense of comfort in the diagnosis, and have psychosocial implications for those who receive a diagnosis. Thus it may be prudent to engage at risk populations early and to use broad-spectrum treatments with low risk benefit ratios to relieve functional impairments, while simultaneously studying all subsets of the at risk population.

Cognitive behavioral therapy in prodromal psychosis

There is a strong impetus in the psychosis research field to develop interventions that aim to prevent the onset of psychotic disorders. Over the past 15 years there has been a tremendous development in the work aimed at understanding the pre-psychotic period. More recently there has been a focus on developing and testing treatments both pharmacological and psychological that could potentially prevent or delay the onset of psychosis. One of the psychological treatments that has received the most attention is cognitive behavioral therapy (CBT). Relatively few trials have been completed and this paper reviews the existing trials. Implications of these trials for the treatment of this early phase as well as for designing future studies are discussed.

The Singapore flagship programme in translational and clinical research in psychosis

AIM

This paper describes the rationale, aims and development of the Singapore Translational and Clinical Research in Psychosis, which is a 5-year programme.

METHODS

The authors provide a selective review of the pertinent findings from the clinical, neuropsychological, genetics and neuroimaging studies on high-risk population and how they were factored in the hypotheses and design of this translational clinical research programme.

RESULTS

This programme, which draws upon the previous work of various groups and the experience of the investigators of this consortium, comprises three interlinked studies. The first is a genome-wide association and copy number variation analysis using the diagnostic phenotype of schizophrenia and cognitive phenotypes, and a joint genome-wide analysis performed by combining our data with other datasets to increase the power to detect genetic risk factors. The second is a prospective study of a large group of individuals who are assessed to be at ultra-high risk of psychosis, and the third is a randomized controlled trial to improve neurocognition in patients with schizophrenia.

CONCLUSION

The convergence of various factors including the unique structured characteristics of the Singaporean society, the presence of political will with availability of funding and the established research infrastructure make it possible to accrue the sample size for adequate power to elucidate biomarkers of disease risk and resilience.

Antipsychotic medication for early episode schizophrenia

BACKGROUND

Long-term treatment with antipsychotic medications in early episode schizophrenia spectrum disorders is common, but both short and long-term effects on the illness are unclear. There have been numerous suggestions that people with early episodes of schizophrenia appear to respond differently than those with multiple prior episodes. The number of episodes may moderate response to drug treatment.

OBJECTIVES

To assess the effects of antipsychotic medication treatment on people with early episode schizophrenia spectrum disorders.

SEARCH STRATEGY

We searched the Cochrane Schizophrenia Group register (July 2007) as well as references of included studies. We contacted authors of studies for further data.

SELECTION CRITERIA

Studies with a majority of first and second episode schizophrenia spectrum disorders comparing initial antipsychotic medication treatment with placebo, milieu, or psychosocial treatment.

DATA COLLECTION AND ANALYSIS

Working independently, we critically appraised records from 681studies, of which five studies met inclusion criteria. John Rathbone from the Schizophrenia Group supported us with the data extraction. We calculated risk ratios (RR) and their 95% confidence intervals (CI) where possible. For continuous data, we calculated mean difference (MD). We calculated numbers needed to treat/harm (NNT/NNH) where appropriate.

MAIN RESULTS

Five studies with a combined N = 998 met inclusion criteria. Four studies (N = 724) provided leaving the study early data and results suggested that individuals treated with a typical antipsychotic medication are less likely to leave the study early than those treated with placebo (Chlorpromazine: 3 RCTs N = 353, RR 0.4 CI 0.3 to 0.5, NNT 3.2, Fluphenaxine: 1 RCT N = 240, RR 0.5 CI 0.3 to 0.8, NNT 5; Thioridazine: 1 RCT N = 236, RR 0.44 CI 0.3 to 0.7, NNT 4.3, Trifulperazine: 1 RCT N = 94, RR 0.96 CI 0.3 to 3.6). Two studies (Cole 1964; May 1976) contributed data to assessment of side effects and present a general pattern of more frequent side effects among individuals treated with typical antipsychotic medications compared to placebo. Rappaport 1978 suggested a higher rehospitalisation rate for those receiving chlorpromazine compared to placebo (N = 80, RR 2.29 CI 1.3 to 4.0, NNH 2.9). However, a higher attrition in the placebo group is likely to have introduced a survivor bias into this comparison, as this difference becomes non-significant in a sensitivity analysis on intent-to-treat participants (N = 127, RR 1.69 CI 0.9 to 3.0). One study (May 1976) contributes data to a comparison of trifluoperazine to psychotherapy on long-term health in favour of the trifluoperazine group (N = 92, MD 5.8 CI 1.6 to 0.0); however, data from this study are also likely to contain biases due to selection and attrition. One study (Mosher 1995) contributes data to a comparison of typical antipsychotic medication to psychosocial treatment on six-week outcome measures of global psychopathology (N = 89, MD 0.01 CI -0.6 to 0.6) and global improvement (N = 89, MD -0.03 CI -0.5 to 0.4), indicating no between-group differences. On the whole, there is very little useable data in the few studies meeting inclusion criteria.

AUTHORS' CONCLUSIONS

With only a few studies meeting inclusion criteria, and with limited useable data in these studies, it is not possible to arrive at definitive conclusions. The preliminary pattern of evidence suggests that people with early episode schizophrenia treated with typical antipsychotic medications are less likely to leave the study early, but more likely to experience medication-related side effects. Data are too sparse to assess the effects of antipsychotic medication on outcomes in early episode schizophrenia.

Cannabis and psychometrically-defined schizotypy: use, problems and treatment considerations

Cannabis use is associated with onset of psychosis in individuals vulnerable for developing schizophrenia-spectrum disorders. The present study addressed three knowledge gaps pertaining to this issue: 1) clarifying the incidence of cannabis use in schizotypal individuals, 2) examining how cannabis use is related to psychosocial and physiological problems in schizotypy and interest in treatment, and 3) examining how cannabis use is associated with positive, negative and disorganization features of schizotypy. Scores from a measure of schizotypal traits were used to trichotomize 1665 young adults into schizotypy (top 5% of scorers), non-schizotypy (bottom 50% of scorers) and "unconventional" (scorers within the 50th to 85th percentile) groups. Nearly a quarter of the schizotypy group endorsed cannabis use at least weekly, a rate nearly two to four times that of the other groups. The schizotypy group also reported a much greater frequency of cannabis-related problems compared to the other groups. Despite this, interest in treatment for cannabis use in the schizotypy group was not elevated. Interestingly, 85% of individuals in the schizotypy group reported interest in psychological/psychiatric treatment more generally. Cannabis use was not associated with abnormal patterns of positive or disorganized schizotypy traits in the schizotypy group relative to the other groups. However, cannabis use was associated with lower severity of negative traits. Implications of these results are discussed.

Early and broadly defined psychosis risk mental states

Current definitions of the prodromal (or at-risk mental state) phase of schizophrenia include attenuated and/or transient psychotic symptoms as well as a combination of different risk indicators and a recent significant deterioration in global functioning. Data accumulated to date suggest rates of conversion to frank psychosis within two years in 25 to 40% of cases supporting the validity of these criteria. However, at this late phase of illness, functional deterioration is often already pronounced, highlighting the need for earlier identification. Moreover, negative symptoms and social impairments, cognitive deficits, other non-psychotic psychopathology and/or functional decline and non-specific biological indicators, often can be detected well before the at-risk mental state as currently defined; indicating that a broad characterization of an earlier stage may be possible. Identifying specific criteria to define this group of individuals, starting from the framework of familial high-risk, can help define a broader group of people, including earlier at-risk mental states, for future research. The hope is that this research will help facilitate intervention at earlier stages that may in turn minimize functional deterioration, and delay, attenuate or even prevent transition to psychosis. The disadvantages as well as the potential benefits of this approach are discussed.

Early detection and intervention evaluation for people at high-risk of psychosis-2 (EDIE-2): trial rationale, design and baseline characteristics

AIMS

Much research has begun to focus on the identification of people who are at high risk of developing psychosis, and clinical services have been initiated for this population. However, only a small number of studies have reported on the efficacy of interventions for preventing or delaying the onset of psychosis. The results of prior work suggest that cognitive therapy (CT) may be an effective, well-tolerated treatment. We report on the rationale and design for a large-scale, multi-site randomized, controlled trial of CT for people who are assessed to be at high risk of psychosis because of either state or state-plus-trait risk factors.

METHODS

The study employs a single-blind design in which all participants receive frequent mental-state monitoring, which will efficiently detect transition to psychosis, and half are randomized to weekly sessions of CT for up to 6 months. Participants will be followed-up for a minimum of 12 months and to a maximum of 2 years.

RESULTS

We report the characteristics of the final sample at baseline (n=288).

CONCLUSIONS

Our study aimed to expand the currently limited evidence base for best practice in interventions for individuals at high risk of psychosis.

Understanding the genesis of psychotic disorder: Issues in the prediction and prophylaxis of those at ultra-high risk

PURPOSE

Recent research is starting to identify individuals at an increased risk of developing a psychotic disorder. This review seeks to identify the 'state of the art' with respect to the clinical identification and treatment of individuals at 'ultra-high risk'.

METHOD

The research and clinical literature are reviewed with respect to a wide range of predictors relevant across development.

RESULTS

The review draws on evidence from childhood and adolescence to suggest that a range of biological, cognitive, personality, and social features are predictive of, but often not specific to, psychosis within the context of the diathesis-stress model. Much evidence supports the view that environmental stressors act in combination with vulnerability factors to increase risk of transition, often during late adolescence and early adulthood.

CONCLUSIONS

Recent clinical research has used both retrospective and prospective means of identifying individuals at ultra-high risk and has made substantial gains in predicting transition. The clinical implications of their identification are discussed in the context of current pharmacological and psychosocial treatment studies. However, significant unresolved clinical and ethical issues remain with both types of study.

The application of multiplexed assay systems for molecular diagnostics

For decades, the diagnosis of schizophrenia and other psychiatric disorders has relied on subjective assessments such as Diagnostic and Statistical Manual criteria. There is now increasing interest in the identification of altered molecular patterns in blood and other accessible body fluids that can be used to help identify, stratify, and monitor psychiatric patients. Since shorter periods of psychosis are associated with a better prognosis, an accurate molecular test may lead to early intervention and thereby improve patient outcomes. In addition, such a test would open up the possibility to stratify more accurately the disease and could represent a novel translational medicine tool, which is crucial for the discovery and development of more efficacious therapies.

Early signs, diagnosis and therapeutics of the prodromal phase of schizophrenia and related psychotic disorders

During recent decades, interest in the prevention of mental illnesses has increased. Improved diagnostic tools, the advent of atypical antipsychotic medications and the development of phase-specific psychosocial treatments have made intervention research in people at ultra-high risk for developing schizophrenia or a related psychotic disorder possible. Preliminary data suggest that low doses of atypical antipsychotic medications augmented by psychosocial treatments may delay the onset of psychosis in some individuals. Findings support further research for the establishment of best-practice standards.

Creating a platform to bridge service and research for early psychosis

Early identification of subjects at risk of developing psychosis is the key to early intervention. A prospective study on the psychopathological progress from prodromal state to full-blown psychosis was initiated in Taiwan in 2006. However, the clinical entity of our interests is ill-defined; therefore, recruitment of at risk subjects to participate in studies requires innovation. In November 2006, the study team launched a special clinic for cognitive and perceptual disturbance. In the first year, 142 subjects, mostly aged 16-30 year olds, made an appointment for this special clinic. More than 20 tentative diagnoses were made. Seventy-six subjects with a gradient of clinical severity were eligible for enrollment, and 68 gave informed consent to participate in the research. It seems that setting up a special clinic to provide a service for at risk subjects, combined with certain campaigns, could facilitate their engagement in a longitudinal prospective study for early psychosis.

Treatment history in the psychosis prodrome: characteristics of the North American Prodrome Longitudinal Study Cohort

AIM

Early identification and better characterization of the prodromal phase of psychotic illness can lead to targeted treatment and, perhaps, prevention of many of the devastating effects of a first psychotic episode. The primary aim of this manuscript is to describe the treatment histories of a large cohort of individuals who entered into one of seven prodromal research programs in a North American Prodrome Longitudinal Study consortium.

METHODS

Treatment histories from 372 clinical high-risk subjects are described along with demographic, symptom, diagnostic and functional variables that may have contributed to treatment decisions for this group of individuals.

RESULTS

Of all subjects included, 82.1% had received psychosocial and/or pharmacologic treatment prior to entry. Psychosocial interventions were more common in the attenuated psychotic syndrome prodromal sample, especially those with more negative, disorganized or general symptoms and more impaired functioning. Psychotropic medication had been administered to individuals with a history of Axis I disorders.

CONCLUSIONS

Given the many potential clinical presentations, treatments and ethical issues connected with the psychosis-risk syndrome, it is not surprising that clinicians administered a broad range of interventions to study participants prior to their entry into the various research programs. Those individuals with milder and non-specific symptoms were more likely to have received psychosocial treatments, whereas those with more severe symptoms received pharmacologic intervention. Clinical treatment research is needed that addresses the complexities of these psychosis-risk states and helps to specify appropriate treatment at different stages of the psychosis prodrome.

Evaluating early preventive antipsychotic and antidepressant drug treatment in an infection-based neurodevelopmental mouse model of schizophrenia

Current pharmacotherapy of schizophrenia remains unsatisfactory with little hope for complete functional restoration in patients once the disease has developed. A preventive approach based on intervention in the prodromal stage of the disease aiming to preserve functional integrity by halting the progress of the disease is therefore extremely attractive. Here, we investigated the effects of preventive antipsychotic or antidepressant drug treatment in a well-established neurodevelopmental mouse model of multiple schizophrenia-related abnormalities. Pregnant mice on gestation day 9 were exposed to the viral mimic polyriboinosinic-polyribocytidylic acid (2 mg/kg, intravenously) or corresponding vehicle treatment, and the resulting offspring from both prenatal treatment conditions were subjected to chronic antipsychotic (haloperidol or clozapine), antidepressant (fluoxetine), or placebo treatment during the periadolescent stage of development. The effects of the preventive pharmacotherapy on behavioral and pharmacological functions were then investigated in adulthood using paradigms relevant to schizophrenia, namely prepulse inhibition, latent inhibition, and sensitivity to psychostimulant drugs. We show that periadolescent treatment with the reference antipsychotic and antidepressant drugs can successfully block the emergence of multiple psychosis-related behavioral and pharmacological abnormalities in subjects predisposed to adult brain pathology by exposure to prenatal immune challenge. At the same time, however, our study reveals numerous negative influences of the early pharmacological intervention on normal behavioral development in control subjects. Hence, even though preventive pharmacotherapy may be beneficial in individuals with predisposition to psychosis-related brain dysfunctions, chronic antipsychotic or antidepressant drug treatment in false-positive subjects is associated with substantial risk for long-term behavioral disturbances in adulthood.

Research in people with psychosis risk syndrome: a review of the current evidence and future directions

After decades of research, schizophrenia and related psychotic disorders are still among the most debilitating disorders in medicine. The chronic illness course in most individuals, greater treatment responsiveness during the first episode, progressive gray matter decline during early disease stages, and retrospective accounts of 'prodromal' or early illness signs and symptoms formed the basis for research on the psychosis risk syndrome (PRS), known variably as 'clinical high risk' (CHR), or 'ultra-high risk' (UHR), or 'prodromal'. The pioneering era of research on PRS focused on the development and validation of specific assessment tools and the delineation of high risk criteria. This was followed by the examination of conversion rates in psychosis risk cohorts followed naturalistically, identification of predictors of conversion to psychosis, and investigation of interventions able to abort or delay the development of full psychosis. Despite initially encouraging results concerning the predictive validity of PRS criteria, recent findings of declining conversion rates demonstrate the need for further investigations. Results from intervention studies, mostly involving second-generation antipsychotics and cognitive behavioral therapy, are encouraging, but are currently still insufficient to make treatment recommendations for this early, relatively non-specific illness phase. The next phase of research on PRS, just now beginning, has moved to larger, 'multisite' projects to increase generalizability and to ensure that sufficiently large samples at true risk for psychosis are included. Emphasis in these emerging studies is on: 1) identification of biomarkers for conversion to psychosis; 2) examination of non-antipsychotic, neuroprotective and low-risk pharmacologic and non-pharmacologic interventions; 3) testing of potentially phase-specific interventions; 4) examination of the relationship between treatment response during PRS and prognosis for the course of illness; 5) follow-up of patients who developed schizophrenia despite early interventions and comparison of illness trajectories with patients who did not receive early interventions; 6) characterization of individuals with outcomes other than schizophrenia-spectrum disorders, such as bipolar disorder and remission from PRS, including false positive cases; and 7) assessment of meaningful social and role functioning outcomes. While the research conducted to date has already yielded crucial information, the translation of the concept of a clinically identifiable PRS into clinical practice does not seem justified at this point.

Social dysfunction predicts two years clinical outcome in people at ultra high risk for psychosis

The experience of a first psychotic episode is associated with a marked impairment in psychosocial functioning. However, the decline may be already evident in the pre-psychotic phases and play a significant role in the etiopathology of the disease onset. A sample of subjects at ultra high clinical risk for psychosis ("At Risk Mental State", ARMS, n=152) was compared with a demographically-matched general population (n=98,072) on different measures of psychosocial functioning. The proportion of subjects with an ARMS living in communal establishments or living at home with their parents was significantly higher than that of the local population (p<0.001). Subjects with an ARMS showed also higher rates of unemployment as compared to the general population (p<0.001). GAF scores at baseline were significantly lower in unemployed ARMS as compared to students and employed ARMS (p=0.002). ARMS subjects living in communal establishments presented higher rates of co-morbid psychiatric conditions (p=0.007) and lower GAF scores at baseline (p=0.017). Finally, baseline unemployment and living in a communal establishment were associated with an increased risk of developing a psychotic episode within the following two years (p<0.05). We concluded that the "At Risk Mental State" is a clinical condition which is characterized by marked psychosocial impairment and by an increased vulnerability to psychosis. Unemployment at the first contact with the prodromal service may be a risk factor for the development of a psychotic episode.

Early intervention in psychotic disorders: Challenges and relevance in the Indian context

Over the last two decades, there has been an increasing interest in the concept of early intervention (EI) in psychotic disorders, notably schizophrenia. Several lines of research underlie this emerging paradigm shift: (a) an increasingly well-established association between the duration of prolonged untreated illness and poor outcome; (b) evidence of progressive neurobiological changes in the early course of schizophrenia both in the pre-psychotic and psychotic phases, as evidenced by brain imaging studies in schizophrenia; and (c) emerging data, albeit preliminary, suggesting the efficacy and effectiveness of EI programs in improving the outcome in these patients. Mental health service systems across the globe, including Asian countries, have been incorporating specialized early intervention programs. However, literature on EI in the Indian setting is relatively sparse. In this article, we will review the rationale and approaches to EI and the application of these approaches to the Indian context, in light of the available literature. We also examine the constraints in the implementation of EI. Controlled data are needed to evaluate EI and the roadblocks to them, in order to implement EI in the resource-strapped mental health service settings in India.

Treatment implications of the schizophrenia prodrome

Schizophrenia is a debilitating neurodevelopmental disorder that strikes at a critical period of a young person's life. Early identification of individuals in the prodromal phase of a psychotic illness can lead to earlier treatment and perhaps prevention of many of the devastating effects of a first psychotic episode. International research efforts have demonstrated the success of community outreach and education regarding the schizophrenia prodrome and it is now possible to use empirically defined clinical and demographic criteria to identify individuals at a substantially increased risk for a psychotic illness. The development of clinical staging criteria for psychosis that incorporates type and severity of clinical symptoms, level of global and social functioning, family history, substance use, neurocognitive functioning, and perhaps neurobiological information, could help to specify appropriate treatment for vulnerable individuals at different phases of the prodrome. Preliminary psychosocial and pharmacologic treatment studies report initial success in reducing severity of prodromal symptoms in "at-risk" samples, but further work is needed to refine the prodromal criteria and perform well controlled treatment studies in adequately powered samples. Treatment algorithms can then be tailored to presenting symptoms, number of risk factors present, and evidence of progression of the illness, to assure appropriate, safe and effective interventions in the early stages of psychosis.

Validity of the prodromal risk syndrome for first psychosis: findings from the North American Prodrome Longitudinal Study

Treatment and prevention studies over the past decade have enrolled patients believed to be at risk for future psychosis. These patients were considered at risk for psychosis by virtue of meeting research criteria derived from retrospective accounts of the psychosis prodrome. This study evaluated the diagnostic validity of the prospective "prodromal risk syndrome" construct. Patients assessed by the Structured Interview for Prodromal Syndromes as meeting criteria of prodromal syndromes (n = 377) from the North American Prodrome Longitudinal Study were compared with normal comparison (NC, n = 196), help-seeking comparison (HSC, n = 198), familial high-risk (FHR, n = 40), and schizotypal personality disorder (SPD, n = 49) groups. Comparisons were made on variables from cross-sectional demographic, symptom, functional, comorbid diagnostic, and family history domains of assessment as well as on follow-up outcome. Prodromal risk syndrome patients as a group were robustly distinguished from NC subjects across all domains and distinguished from HSC subjects and from FHR subjects on most measures in many of these domains. Adolescent and young adult SPD patients, while distinct from prodromal patients on definitional grounds, were similar to prodromals on multiple measures, consistent with SPD in young patients possibly being an independent risk syndrome for psychosis. The strong evidence of diagnostic validity for the prodromal risk syndrome for first psychosis raises the question of its evaluation for inclusion in Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition).

Psychoeducation with patients at-risk for schizophrenia--an exploratory pilot study

OBJECTIVE

To introduce a psychoeducational program for patients of at-risk mental state and its preliminary evaluation.

METHODS

The psychoeducational program was designed as a purely informative intervention and consisted of seven 1-h sessions. Sixteen at-risk mental state patients (mean age 26+/-4.9 years, 12 males/4 females, mean score on prodromal psychopathology (Bonn Scale for Assessment of predictive Basis Symptoms [BSABS-P] 18.6+/-13.3) were investigated.

RESULTS

Comparisons of means before and after psychoeducation showed a significant reduction in psychopathology and fatalistic LoC as well as an improvement in knowledge, global functioning and various areas of QoL. A qualitative evaluation of the psychoeducational program also showed advantages from patients' perspectives.

CONCLUSIONS

This study provides empirical evidence for benefits of psychoeducation with patients of at-risk mental state for schizophrenia but is exploratory and has some limitations, e.g. the small sample size. Therefore the results have to be replicated in a randomized controlled trial in order to be able to demonstrate conclusively the effectiveness of psychoeducation in the pre-psychotic phase.

PRACTICE IMPLICATIONS

Results from this preliminary study suggest that psychoeducation is a promising intervention for patients of at-risk mental state for schizophrenia, and therefore worthy of more investigations.

Early intervention in patients at ultra high risk of psychosis: benefits and risks

OBJECTIVE

Prediction of transition to psychosis in the prodromal phase of schizophrenia has raised interest in intervention prior to the onset of frank psychosis. The aim of this review was to examine whether interventions in the prodromal phase have a favourable benefit/risk ratio.

METHOD

A literature search in PubMed, EMBASE and PsycINFO was performed.

RESULTS

Three randomized clinical trials with antipsychotic medication and/or cognitive behavioural therapy as clinical intervention suggested a positive effect at the end of treatment, but no significant differences were found at the end of follow-up periods from 1 to 4 years. Naturalistic studies present a hypothesis about a possible preventive effect of antidepressive medication. The results of eight other studies are more difficult to interpret. Side-effects of antipsychotic medication and non-adherence with medication are essential problems.

CONCLUSION

At the present time, the data concerning the benefits and risks do not justify prodromal intervention as standard clinical practice.

The proximal prodrome to first episode mania--a new target for early intervention

OBJECTIVE

Affective psychoses and bipolar disorders have been neglected in the development of early intervention strategies. This paper aims to gather current knowledge on the early phase of bipolar disorders in order to define new targets for early intervention.

METHODS

Literature review based on the main computerized databases (MEDLINE, PUBMED and PSYCHLIT) and hand search of relevant literature.

RESULTS

Based on current knowledge, it is likely that an approach aiming at the identification of impending first-episode mania is the most realistic and manageable strategy to promote earlier treatment. During the period preceding the onset of the first manic episode, patients go through a prodromal phase marked by the presence of mood fluctuation, sleep disturbance, and other symptoms such as irritability, anger, or functional impairment. Additionally, various risk factors and markers of vulnerability to bipolar disorders have been identified.

CONCLUSIONS

In the few months preceding first-episode mania, patients go through a prodrome phase (proximal prodrome) that could become an important target for early intervention. However, considering the low specificity of the symptoms observed during this phase, criteria defining high-risk profiles to first-episode mania should also include certain risk factors or markers of vulnerability. While more research is needed in high-risk groups (e.g., bipolar offspring), retrospective studies conducted in first-episode mania cohorts could provide valuable information about this critical phase of the illness.

A brief taxometrics primer

Taxometric procedures provide an empirical means of determining which psychiatric disorders are typologically distinct from normal behavioral functioning. Although most disorders reflect extremes along continuously distributed behavioral traits, identifying those that are discrete has important implications for accurate diagnosis, effective treatment, early identification of risk, and improved understanding of etiology. This article provides (a) brief descriptions of the conceptual bases of several taxometric procedures, (b) example analyses using simulated data, and (c) strategies for avoiding common pitfalls that are often observed in taxometrics research. To date, most taxometrics studies have appeared in the adult psychopathology literature. It is hoped that this primer will encourage interested readers to extend taxometrics research to child and adolescent populations.

The Ethics Committees of the American Academy of Child and Adolescent Psychiatry and the American Psychiatric Association: history, process, education, and advocacy

The American Psychiatric Association (APA) and the American Academy of Child and Adolescent Psychiatry (AACAP) are the primary organizational embodiments of the specialties of, respectively, general psychiatry and child and adolescent psychiatry in the United States. Professional organizations set guidelines and standards for the expected behaviors of their members. To those ends, ethics committees were established by both the APA and the AACAP. This article describes how each of these organizations, via their committees, produced codes of ethics, and continuously provide relevant educational materials and advocacy efforts. It also reviews the APA ethics committee's responsibility for the evaluation of ethical complaints lodged against members. In closing, the article examines ethical dilemmas lurking on the horizon, beginning to be faced by the specialties and thus likely to be addressed by the committees.

Ten good reasons to consider biological processes in prevention and intervention research

Most contemporary accounts of psychopathology acknowledge the importance of both biological and environmental influences on behavior. In developmental psychopathology, multiple etiological mechanisms for psychiatric disturbance are well recognized, including those operating at genetic, neurobiological, and environmental levels of analysis. However, neuroscientific principles are rarely considered in current approaches to prevention or intervention. In this article, we explain why a deeper understanding of the genetic and neural substrates of behavior is essential for the next generation of preventive interventions, and we outline 10 specific reasons why considering biological processes can improve treatment efficacy. Among these, we discuss (a) the role of biomarkers and endophenotypes in identifying those most in need of prevention; (b) implications for treatment of genetic and neural mechanisms of homotypic comorbidity, heterotypic comorbidity, and heterotypic continuity; (c) ways in which biological vulnerabilities moderate the effects of environmental experience; (d) situations in which Biology x Environment interactions account for more variance in key outcomes than main effects; and (e) sensitivity of neural systems, via epigenesis, programming, and neural plasticity, to environmental moderation across the life span. For each of the 10 reasons outlined we present an example from current literature and discuss critical implications for prevention.

PACE: a specialised service for young people at risk of psychotic disorders

Intervention in the prodromal phase of schizophrenia and related psychotic disorders may prevent or delay the onset of these disorders, or reduce the severity of the psychosis. Identifying the schizophrenia prodrome is difficult, however, because of its non-specific symptoms and the wide symptom variability between individuals. Over the past 15 years, we have investigated the schizophrenia prodrome and developed criteria for detecting people suspected of experiencing a prodromal phase (ie, they are thought to be at imminent risk of onset of a psychotic disorder). About 35% of those meeting our criteria have developed a psychotic disorder within 12 months. We have established a clinical service, the PACE (Personal Assessment and Crisis Evaluation) Clinic, for people with suspected incipient psychosis, and trialled interventions aimed at preventing or delaying the onset of psychotic disorders. Our results and studies in other countries seem to indicate that psychological and psychosocial interventions, either alone or in combination with pharmacotherapy, may be effective in at least delaying, if not preventing, the onset of a psychotic disorder.

Early intervention in schizophrenia: current and future perspectives

The last decade has witnessed an expanding interest in the concept of early intervention (EI) in psychotic disorders, notably schizophrenia. This is supported by the well-established association between prolonged untreated illness duration and poor outcome, as well as some evidence of progressive neurobiological changes in the early course of schizophrenia, both in the prepsychotic and psychotic phases as evidenced by brain imaging studies in schizophrenia. Increasingly, mental health service systems around the world have been incorporating specialized EI programs. Controlled effectiveness studies in recent years have yielded encouraging data. Several questions in regard to the timing, choice of interventions, and the populations most likely to benefit from EIs still remain. More evidence-based data are needed to place the EI models in schizophrenia on firm footing in order to effectively implement them in the resource-strapped community mental health service settings.

Which perspectives can endophenotypes and biological markers offer in the early recognition of schizophrenia?

The early recognition of schizophrenia seems crucial; various studies relate a longer duration-of-untreated-psychosis to a worse prognosis. We give an overview over common psychopathological early recognition instruments (BSABS, CAARMS, SIPS, IRAOS, ERIraos). However, many clinical symptoms of prodromal schizophrenia stages are not sufficiently specific. Thus we review recent contributions of neuroimaging and electrophysiological as well as genetic studies: which new diagnostic perspectives offer endophenotypes (such as P300, P50 sensory gating, MMN, smooth pursuit eye movements; indicating a specific genetic vulnerability) together with a better understanding of schizophrenic pathophysiology (state-dependent biological markers, e.g. aggravated motor neurological soft signs during psychosis) in prodromal schizophrenia when still ambiguous clinical symptoms are present. Several examples (e.g. from COMT polymorphisms to working memory deficits) illustrate more specific underlying neuronal mechanisms behind behavioural symptoms. This way, a characteristic pattern of disturbed cerebral maturation might be distinguished in order to complement clinical instruments of early schizophrenia detection.

Prospective investigations of the prodromal state of schizophrenia: review of studies

OBJECTIVE

The paper presents a comprehensive overview of prospective studies monitoring or intervening in the pre-onset phase of first episode psychosis.

METHOD

A systematic literature search was conducted and supplemented by a manual search. All relevant studies were ordered and intensively reviewed according to specified criteria. Methodological and conceptual issues are discussed.

RESULTS

Reports of 23 prospective studies were found, some describing subsamples of larger samples. Major methodological and conceptual divergences exist.

CONCLUSION

Applied criteria detect individuals with a significantly increased risk of psychosis within the schizophrenia spectrum, but these criteria are only validated on clinical populations. The significance of differences in sample-characteristics is unclear. Most study samples are small. Results are preliminary and in need of further research before they constitute a realistic knowledge base. Methodological and conceptual issues should not be underestimated.

Risk and protection in prodromal schizophrenia: ethical implications for clinical practice and future research

Over the last decade schizophrenia researchers have turned their attention to earlier identification in the prodromal period of illness. A greater understanding of both risk and protective factors can lead to improved prevention and treatment strategies in this vulnerable population. This research, however, has far-reaching ethical implications. One year follow-up data from 50 individuals who met established criteria for a prodromal state is used to illustrate ethical issues that directly affect clinicians and future research strategies. At 1-year follow-up, the psychotic transition rate was 13%, but it increased in subsequent years with smaller sample sizes. One-half developed an affective psychosis. The converted sample was older (p > 0.05) than the nonconverted sample and more likely to have a premorbid history of substance abuse, as well as higher clinical ratings on "subsyndromal" psychotic items (delusional thinking, suspiciousness, and thought disorder). Despite a lack of conversion, the nonconverted sample remained symptomatic and had a high rate of affective and anxiety disorders with evidence of functional disability. This conversion rate is relatively low compared to similar studies at 1 year. Specific risk factors were identified, but these findings need to be replicated in a larger cohort. By examining the rate of conversion and nonconversion in this sample as an example, we hope to contribute to the discussion of implications for clinical practice and the direction of future research in the schizophrenia prodrome. Finally, our data strengthen the evidence base available to inform the discussion of ethical issues relevant to this important research area.

Factors associated with the prodromal progression of schizophrenia that influence the course of the illness

OBJECTIVE

This study examined factors influencing the prognosis of patients with different prodromal manifestations of schizophrenia and the association of diagnosis and antipsychotic treatment with the frequency of future acute inpatient care.

METHODS

Data was collected from the medical records of 24 patients initially diagnosed with schizophrenia.

RESULTS

Seventy-six percent of the patients (N=18) had at least one psychiatric assessment before the debut of schizophrenia. Patients who were assessed prior to the initial diagnosis of schizophrenia presented in two distinct time frames. Patients in the first wave received a different Axis I diagnosis, depending on the phase of prodrome upon time of initial evaluation. Receiving any Axis I diagnosis during the prodromal stage in wave one correlated with an increased need for acute inpatient treatment (P>.0001) in the following 3 years. Among the patients in wave two, those who received antipsychotic treatment required less acute inpatient care than those who did not (P=.004).

CONCLUSION

Obtaining a psychiatric history of assessments and interventions during the prodromal period of schizophrenia can be useful for prognosis.

What causes the onset of psychosis?

It has become increasingly clear that the simple neurodevelopmental model fails to explain many aspects of schizophrenia including the timing of the onset, and the nature of the abnormal perceptions. Furthermore, we do not know why some members of the general population have anomalous experiences but remain well, while others enter the prodrome of psychosis, and a minority progress to frank schizophrenia. We suggest that genes or developmental damage result in individuals vulnerable to dopamine deregulation. In contemporary society, this is often compounded by abuse of drugs such as amphetamines and cannabis, which then propel the individual into a state of dopamine-induced misinterpretation of the environment. Certain types of social adversity such as migration and social isolation, as well as affective change can also contribute to this. Thereafter, biased cognitive appraisal processes result in delusional interpretation of the abnormal perceptual experiences. Thus, a plausible model of the onset of psychosis needs to draw not only on neuroscience, but also on the insights of social psychiatry and cognitive psychology.

Treating early psychosis: who, what, and when?

Early intervention and prevention in schizophrenia is just over 10 years old. The assumption guiding this field is that intervention is likely to be most effective if it begins before psychosis sets in, ie, during the prodromal phase. Although a substantial number of prodromal treatment programs have been initiated around the world, three early programs have generated most of the intervention findings to date: Personal Assessment and Crisis Evaluation (PACE) in Australia, and the Prevention through Risk Identification, Management, and Education (PRIME) and Recognition and Prevention (RAP) programs in the USA. The data suggest that early intervention leads to a reduction in prodromal symptoms and clinical distress. However, prevention of psychosis remains an unresolved question. Other issues include defining who should be treated, with what, and when. In addition, treatment targets associated with functional disability, such as early prodromal negative symptoms and risk factors, continue to emerge. Newly identified targets, in turn, suggest the need for a variety of novel interventions and treatment strategies.

Prospective study of adolescents with subsyndromal psychosis: characteristics and outcome

OBJECTIVE

The aim of this study was to examine the characteristics and outcome of adolescents with psychotic disorder not otherwise specified (PsyNOS) and brief psychotic disorder (BrPsy), two neglected subsyndromal diagnostic entities.

METHODS

As part of an ongoing, naturalistic study investigating adolescents considered to be prodromal for schizophrenia, 29 youngsters (mean age, 16.2 +/- 2.7 years) with PsyNOS or BrPsy were identified as theoretically at highest risk for schizophrenia and followed for over 6 (mean, 22.8 +/- 19.4) months.

RESULTS

Contrary to our expectations, only 7 of the 26 individuals (27.0%) with follow-up data developed schizophrenia or schizoaffective disorder, and only 2 subjects (7.7%) retained their diagnosis of BrPsy/PsyNOS. The most frequent other diagnoses at follow-up were mood disorders (34.6%), personality disorders (11.5%), and obsessive-compulsive disorder (7.7%). Regarding severity of outcome, 38.5% of the patients progressed to a syndromal psychotic disorder, 23.1% continued to have attenuated positive symptoms, and 38.4% improved to having attenuated negative symptoms only, or no positive or negative symptoms. BrPsy was associated with lower maximum levels of negative symptoms (p = 0.02) and higher likelihood of symptom remission (p = 0.02).

CONCLUSIONS

This study indicates that psychotic symptoms not fulfilling criteria for schizophrenia or a psychotic mood disorder are unreliable predictors of a syndromal psychotic disorder outcome at 2 years. Long-term studies of PsyNOS and BrPsy are needed to clarify where these disorders fall in the developmental course of schizophrenia.

Pathogenesis of schizophrenia: a psychopathological perspective

BACKGROUND

Despite interest in early treatment of schizophrenia, premorbid and prodromal symptomatology remain poorly delineated.

AIMS

To compare pre-illness symptomatology in patients at high risk of schizophrenia who progress to illness with that of high-risk subjects who remain well and with normal controls.

METHOD

Using Present State Examination (PSE) data, symptomatic scales were devised from participants of the Northwick Park Study of first-episode schizophrenia and scores were compared on the first and last PSEs of participants of the Edinburgh High Risk Study.

RESULTS

At entry, when still well, high-risk individuals who subsequently became ill (mean time to diagnosis 929 days; s.e.=138 days) scored significantly higher on'situational anxiety', 'nervous tension', 'depression', 'changed perception'and 'hallucinations'than those remaining well and normal controls, who did not differ. With illness onset, affective symptomatology remained high but essentially stable.

CONCLUSIONS

In genetically predisposed individuals, affective and perceptual disorders are prominent before any behavioural or subjective change that usually characterises the shift to schizophrenic prodrome or active illness.

Prevention of schizophrenia: can it be achieved?

Schizophrenia is a serious mental disorder with a profound impact on patients, their caregivers and society. It is also an expensive disorder to treat, despite being relatively rare. In this paper, prevention of schizophrenia is described in terms of primary, secondary and tertiary prevention. Schizophrenia is regarded as a neurodevelopmental disorder with different phases. Primary prevention essentially involves education programmes about the association of obstetric complications and the increased risk of schizophrenia. Secondary prevention involves intervention at the prodromal phase. We review the literature and discuss the evidence relating to intervention in this phase of the illness. Early intervention could result in reduction in morbidity and better quality of life for the patients and their families. The prodromal phase can now be identified, based on current symptoms, with reliability and predictive validity for the risk of development of schizophrenia in the following year. We also discuss possible risks faced by prodromal patients, such as unnecessary stigmatisation, and the role of drug treatment during intervention at this stage. Any recommendation that anti-psychotic medications be routinely prescribed in this phase should be supported by more research work. Drug and psychosocial intervention is indicated as part of tertiary prevention to prevent further disability in the illness.

How does studying schizotypal personality disorder inform us about the prodrome of schizophrenia?

An increasing emphasis in the schizophrenia literature has been on the prodromal phase of the illness. The study of schizophrenia spectrum illness, including schizotypal personality disorder, has added important insight into the etiology, neuropathology, and treatment of schizophrenia, which can facilitate early identification, intervention, and perhaps prevention of the illness. The heterogeneity of the schizophrenia spectrum makes its definition elusive at best. The primary aim of the Cognitive Assessment and Risk Evaluation Program at the authors' institution is to combine the current knowledge of clinical and demographic risk factors for schizophrenia with the rapidly emerging data on vulnerability markers, or endophenotypes, that are associated with schizophrenia. The use of brain-based vulnerability markers may help to identify neurobiologically and clinically meaningful subgroups within this heterogeneous population of individuals in the early stages of schizophrenia. Another important aim of the Cognitive Assessment and Risk Evaluation program is to thoroughly assess those individuals who have not converted to psychosis to understand potential protective factors, reduce the rate of false positives, and decrease disability. The current review details a strategy for researching the schizophrenia prodrome by using information gained from research in schizotypal personality disorder.

Emerging findings in ethics of schizophrenia research

PURPOSE OF REVIEW

We review recent publications pertaining to six topics: investigators, professional integrity, and sources of potential bias; scientific designs; protocol safeguards; influences on research participation decisions and perceptions of risk; informed consent--decision-making capacity, appreciation and the therapeutic misconception, and voluntarism; and informed consent--intervention studies.

RECENT FINDINGS

Little empirical work has been conducted on investigator training and potential conflicts of interest. Numerous conceptual pieces have tackled controversial issues related to study designs, with the initial focal point being the ethics of placebo-controlled studies; only a handful of reports, however, have empirically addressed these topics. Emerging findings pertinent to protocol safeguards in schizophrenia research suggest general support by individuals with schizophrenia for a variety of safeguards. Recent work on influences on participation decisions suggests that people with schizophrenia use fundamentally similar considerations as medically ill people and healthy comparison participants--a combination of personal and altruistic motives. Much of the data-based literature has focused on informed consent. We highlight studies indicating that patients living with schizophrenia show heterogeneity in consent-related abilities but may possess key strengths in the research situation, not simply greater vulnerability as suggested in the historical literature. Furthermore, consent-related abilities appear to be enhanced with educational interventions.

SUMMARY

Empirical studies focusing on a variety of ethically relevant domains in schizophrenia research are needed. Future studies should incorporate quantitative and qualitative methods, integrate perspectives of stakeholders, and investigate the effects and appropriateness of current protocol safeguards.

The catechol-O-methyltransferase polymorphism: relations to the tonic-phasic dopamine hypothesis and neuropsychiatric phenotypes

Diverse phenotypic associations with the catechol-O-methyltransferase (COMT) Val158Met polymorphism have been reported. We suggest that some of the complex effects of this polymorphism be understood from the perspective of the tonic-phasic dopamine (DA) hypothesis. We hypothesize that the COMT Met allele (associated with low enzyme activity) results in increased levels of tonic DA and reciprocal reductions in phasic DA in subcortical regions and increased D1 transmission cortically. This pattern of effects is hypothesized to yield increased stability but decreased flexibility of neural network activation states that underlie important aspects of working memory and executive functions; these effects may be beneficial or detrimental depending on the phenotype, a range of endogenous factors, and environmental exigencies. The literature on phenotypic associations of the COMT Val158Met polymorphism is reviewed, highlighting areas where this hypothesis may have explanatory value, and pointing to possible directions for refinement of relevant phenotypes and experimental evaluation of this hypothesis.

The use of pharmacotherapy in the prodrome of schizophrenia

In treating schizophrenia there has been a shift in focus, with more attention being paid to early intervention based on the notion that effective treatment at this point can improve outcome. Most of this work has centred on pharmacotherapeutic interventions during the first psychotic break. More recently, attention has turned to the potential value of intervening even earlier, that is during the so-called "prodrome" that has been identified as predating the first psychotic break by as much as 4-5 years. We now have a limited number of published reports addressing this topic and these are reviewed here.