Evidence-Based Reviews

Schizophrenia prodrome: An optimal approach

Current Psychiatry. 2014 March;13(3):16-20, 29-30

References

1. Salokangas RK, McGlashan TH. Early detection and intervention of psychosis. A review. Nord J Psychiatry. 2008;62:92-105.
2. Perkins DO, Gu H, Boteva K, et al. Relationship between duration of untreated psychosis and outcome in first-episode schizophrenia: a critical review and meta-analysis. Am J Psychiatry. 2005;162(10): 1785-1804.
3. Stefanopoulou E, Lafuente AR, Fonseca AS, et al. Global assessment of psychosocial functioning and predictors of outcome in schizophrenia. Int J Psychiatry Clin Pract. 2011;15(1):62-68.
4. Yung AR, Nelson B, Thompson AD, et al. Should a “Risk Syndrome for Psychosis” be included in the DSMV? Schizophr Res. 2010;120(1-3):7-15.
5. Corcoran CM, First MB, Cornblatt B. The psychosis risk syndrome and its proposed inclusion in the DSM-V: a risk-benefit analysis. Schizophr Res. 2010;120(1-3):16-22.
6. Diagnostic and statistical manual of mental disorders, 5th ed, text rev. Washington, DC: American Psychiatric Association; 2013.
7. Schultze-Lutter F, Ruhrmann S, Berning J, et al. Basic symptoms and ultrahigh risk criteria: symptom development in the initial prodromal state. Schizophr Bull. 2010;36(1):182-191.
8. Correll CU, Hauser M, Auther AM, et al. Research in people with psychosis risk syndrome: a review of the current evidence and future directions. J Child Psychol
Psychiatry. 2010;51(4):390-431.
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Monitor or treat? An optimal approach

A key dilemma in the management of patients who exhibit signs and symptoms of schizophrenia prodrome is whether to simply monitor closely or to initiate treatment.

International clinical practice guidelines recommend several practical steps in the monitoring of patients in a prepsychotic state (Table 3),²³ but caution against the use of antipsychotic agents unless the patient meets diagnostic criteria for a psychotic disorder.

CBT. Some evidence supports the initiation of cognitive-behavioral therapy (CBT) during the initial prodromal phase and the addition of alow-dose atypical antipsychotic if the patient progresses to a later phase, characterized by BLIPS/APS.24,25 Evidence also suggests that a combination of CBT and antipsychotic medication might delay, but not prevent, the progression to a psychotic episode.9 Any risk of adverse metabolic complications precludes use ofan atypical antipsychotic.One potential alternative is the use of omega-3 polyunsaturated fatty acids (Box 2).^26,27

A clinically useful approach would be to view schizophrenia/psychosis prodrome not as a distinct diagnostic category but as a cluster of signs and symptoms associated with an increased risk of psychosis, with persons in this phase in need of close follow-up and, possibly, early initiation of an antipsychotic agent. It is important to engage the patient and his family at an early stage to educate them about the diagnostic uncertainty; to help them deal with the stigma; to manage risk factors; and, collaboratively, to decide on an intervention strategy.^23,28

Bottom Line

Despite several drawbacks, the concept of schizophrenia/psychosis prodrome may
be viewed as a cluster of signs and symptoms (rather than a distinct diagnostic category) associated with increased risk for psychosis that need close follow up. Follow up may involve psychoeducational and psychotherapeutic interventions and, need be, early initiation of antipsychotics. In addition, such symptoms may be associated with other psychiatric disorders such as bipolar disorder and obsessive- compulsive disorder. Timely attention and early intervention may alter the course
and improve overall prognosis.

Related Resources
• Early intervention in psychosis. WPA Education Committee’s recommended roles of the psychiatrist. www.wpanet.org/uploads/Education/Educational_Resources/earlyintervention-psychosis.pdf.
• Early Psychosis Prevention and Intervention Centre, Melbourne, Australia. http://eppic.org.au/psychosis.
• International Early Psychosis Association Writing Group. International clinical practice guidelines for early psychosis. Br J Psychiatry. 2005;187:s120-124. http://bjp.rcpsych.org/content/187/48/s120.full.

Disclosures
Dr. Madaan is an employee of University of Virginia Health System. As an employee with the University of Virginia, Dr. Madaan has received research support from Eli Lilly and Company, Forest, Merck, Otsuka, Pfizer, Shire, and Sunovion. He also has served as a consultant for the NOW Coalition for Bipolar Disorder, and on the American Psychiatric Association’s Focus Self-Assessment editorial board. Drs. Bestha and Kolli report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

Schizophrenia prodrome: An optimal approach

References

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