A small clinical trial led by an Australian researcher suggests that young people at very high risk for psychotic illness should engage in talk therapy as an initial treatment rather than take antipsychotic drugs.
Only about 36 percent of high-risk individuals will likely develop psychosis within three years, and many physicians are concerned about the prospect of treating everyone at risk with drugs, which come with side effects. Another concern is that individuals will carry the label of mental illness unnecessarily.
“This shows it’s quite safe and reasonably effective to offer supportive psychosocial care to these patients,” said study author Dr. Patrick McGorry. There is “no evidence to suggest that antipsychotic medications are needed in first-line” treatment, he said.
The trial included 115 patients of a clinic in Melbourne, Australia, for young people believed to be at “ultra-high risk” for a psychotic disorder such as schizophrenia.
The study was open to people between the ages of 14 and 30 who met at least one of three criteria: having low-level psychotic symptoms, having had previous brief episodes of psychotic symptoms that went away on their own or having a close relative with a psychotic disorder along with low mental functioning during the past year.
The study compared three types of treatment: talk therapy focused on reducing depression symptoms and stress while building coping skills plus a low dose of the antipsychotic risperidone, or talk therapy plus a placebo pill or therapy emphasizing social and emotional support plus a placebo.
The goal was to see how many patients in each group progressed to full-blown psychosis.
After a year, there was no notable difference between the groups, but about 37 percent of the patients dropped out of the study. McGorry, a professor at the Centre for Youth Mental Health at The University of Melbourne, said if the trial had included more people, significant differences between the groups might have come forth.
“The importance of detecting early signs and symptoms of a serious mental illness is not controversial,” said Matcheri Keshavan, M.D., a professor of psychiatry at Harvard Medical School. “But the best way of treating or preventing it remains controversial.”
The rates of going on to full-blown psychosis—which ranged from about 10 percent to about 22 percent—were lower in all three groups than in previous studies.
The reasons for this aren’t clear, but McGorry said it’s possible that more participants will develop psychosis after the 12-month study period ends. Many of the study participants were also taking antidepressants, which may have eased psychotic symptoms.
Also, as with many trials, most patients showed poor adherence to the medications used, which may have influenced the results, the authors note.
In a 2010 study, McGorry found that fish oil supplements might prevent psychosis in the same type of at-risk individuals. Going forward, “what is needed is some way of finding predictive biomarkers that can tell who might be at the highest risk,” said Keshavan. “We need to understand their brains.”
Source: Journal of Clinical Psychiatry