Abstract
Background
Research criteria for a clinical high-risk (CHR) syndrome identify persons with ~20% risk of converting to a psychotic disorder within 2 years. The CHR syndrome is based on the presence of attenuated positive symptoms, however as with schizophrenia neurocognitive, social cognitive, mood symptoms, behavioral disturbances, and functional impairments often are prominent features. Interventions in persons at CHR offer the potential to prevent the emergence of psychotic disorders such as schizophrenia and schizoaffective disorder, potentially avoiding the development of a chronic mental disorder that requires lifelong treatment.
Methods
The evidence base for pharmacological and psychotherapeutic interventions for early psychosis is summarized based on a literature review. The currently status of active pharmacological and psychotherapeutic interventions are ascertained by a search of government registries (e.g. clinicaltrial.gov).
Results
Clinical trials in CHR subjects generally find that psychotherapeutic and antipsychotics reduce risk of psychosis conversion. However, the results of meta-analyses conclude that there in insufficient evidence to support any specific intervention at present. At present there are several clinical trials underway to examine the effects of specific pharmacological treatments, psychotherapies, and a stepped-approach to care. The CHR syndrome is not yet fully recognized by the ICD or DSM diagnostic systems used by clinicians to document medical services.
Conclusions
Clinicians engaged in treatment of help-seeking persons with attenuated psychosis are challenged by the lack of an agreed-upon set of clinical diagnostic criteria and a relatively weak evidence base to guide treatment decision-making. Communicating this diagnostic and treatment uncertainties to patients and their families is a major issue. The risks of specific interventions, especially antipsychotic medications, is especially hampered by the lack of understanding of the risks for those clinical high-risk patients who do not progress to psychosis. Well-validated clinical and biological markers that enhance psychosis risk prediction, especially those that identify the underlying neuropathology driving psychosis risk together with specific interventions that address individual risk vulnerability are key to addressing heterogeneity.