Thursday, December 21, 2023

Patients at High Risk for Psychosis May Benefit From Step-Based Care

People who are at high risk of developing psychosis may benefit from a step-based care program that starts with low-intensity interventions before progressing to ones of greater intensity, according to a small study published in Psychiatric Services.

“Although comprehensive, cost-effective, and multicomponent treatment packages have been developed for individuals with psychotic disorders … treatment packages designed to address the complex needs of individuals at clinical high risk for psychosis are currently lacking,” wrote Sarah Hamilton, M.D., of Ohio State University and colleagues.

Hamilton and colleagues recruited people who were at clinical high risk for psychosis and enrolled in the Early Psychosis Intervention Center at Ohio State University for the study. Participants could participate in one or more of five intervention tracks, including psychotherapy, pharmacology, family support, peer or social support, and vocational and educational services. For most tracks, initial services were of low intensity and less specific to psychotic symptoms, such as psychoeducation that focused on anxiety or depression or the benefits of substance use reduction. Individuals who did not meet symptom response criteria after the initial intervention progressed to increasingly intense interventions more specific to symptoms of psychosis, such as metacognitive remediation therapy, which is designed to address the decline in cognitive functioning that accompanies psychotic disorders.

Participants were assessed weekly for positive symptoms and functional difficulties with the positive symptom items from the Structured Interview for Psychosis-Risk Syndrome (SIPS) and the Personal and Social Performance Scale (PSP), respectively. Participants were considered to have a symptomatic response if all positive symptom items on the SIPS were rated 2 or less (higher scores indicate greater symptom severity). A functional response was defined as a PSP score of 70 or more (with higher scores indicating better functioning), or a 5-point increase in the PSP from the baseline assessment score.

Thirty-eight participants attended step-based care clinical appointments for an average of 26 weeks and were regularly assessed for an average of 41 weeks total. Seven participants already met the criteria for symptomatic response at enrollment, and four individuals experienced onset of a psychotic disorder during the study period. Among the remaining 27 participants, two-thirds (67%) eventually met criteria for symptomatic response, with a median time to response of 11.1 weeks. These individuals continued to meet symptomatic response criteria for a median of 80% of the follow-up period.

Five participants already met the criteria for functional response at enrollment. Among the remaining 33 participants, 64% eventually met criteria for a functional response, with a median time to a response of 8.9 weeks. These individuals continued to meet functional response criteria for a median of 92% of the follow-up period.

“Although our results should be interpreted cautiously given that our study lacked a control group, our findings highlight the potential merits of step-based care for individuals at clinical high risk for psychosis,” the authors wrote. “[D]espite the additional challenges associated with delivering a personalized, multicomponent intervention package, our results suggest reasons for cautious optimism that such care may improve outcomes for individuals at clinical high risk for psychosis while minimizing exposure to interventions with greater risk or adverse effect profiles.”

For related information, see the Psychiatric News article “Predicting Psychosis: Field Moves From Assessment of Clinical Risk to Search for Biomarkers.”

(Image: Getty Images/iStock/StockRocket)

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