Neither medication nor psychotherapy is effective in improving the prognosis for youngsters considered to be at high risk of developing psychosis, according to a major study just published.
The idea of identifying and treating young people at risk of becoming psychotic – because of a family history of schizophrenia, or because they’re showing some mild symptoms – has become very fashionable lately. But can we really do anything to pre-empt the disorder?
In this trial, 115 “ultra-high risk” Australian subjects were randomized to three different treatment conditions, or if they didn’t agree to treatment, they were just followed up to see what happened.
The treatments didn’t work. Here’s the smoking gun, showing the proportion who didn’t go psychotic over time:
This shows all four of the subject groups did pretty much the same in terms of their likelihood of becoming psychotic. Neither cognitive therapy, nor the antipsychotic drug risperidone (at a low dose) had any effect: those given ‘supportive therapy’ (basically: sympathetic chats) and a placebo pill did just as well.
There probably wasn’t even a placebo effect: none of the three treatment groups did better than people who got no treatment at all (monitoring group), although people weren’t randomly assigned to that group, so that’s a little less clear.
Is this a surprise? Yes, if you believed the early studies to examine this question which claimed great things for drugs and therapy. But the current findings are no shock if you’ve been following the (much larger) recent trials – for example the British one from earlier in the year, which found zero benefit of cognitive therapy.
Early small trials have a nasty habit of not working out in the long run.
The other lesson here is that even “ultra-high risk” folks usually don’t get psychotic: only about 10-20% of them, in fact, became ill in the first two years of this study; the British results I mentioned are very similar.
So is this really “ultra high”? Relatively, yes it is; even a 10% risk is far higher than the chance that a random person on the street would have. But in absolute terms, perhaps not.
A concern here is that rounding these folks up, labelling and ‘treating’ them might make their lives worse, or even increase the risk of psychosis. That’s not just my opinion: that’s what the very cognitive therapists who eagerly run these trials believe (or ought to, if they’re being consistent with their own theories).
One of the key ideas in cognitive accounts of psychosis is that the belief and fear that one is ‘going crazy’, or that you’re otherwise abnormal, is itself a major source of stress that actually leads to worsening of symptoms.
What could be scarier than being told you’re at “ultra high risk”?
Preventing psychosis is a great idea in theory. But most bad ideas are.
McGorry, P., Nelson, B., Phillips, L., Yuen, H., Francey, S., Thampi, A., Berger, G., Amminger, G., Simmons, M., Kelly, D., Thompson, A., and Yung, A. (2012). Randomized Controlled Trial of Interventions for Young People at Ultra-High Risk of Psychosis The Journal of Clinical Psychiatry DOI: 10.4088/JCP.12m07785