CLINICAL HANDBOOK OF SCHIZOPHRENIA - PART 7 pot

ing the onset of diagnosable psychotic disorder arises. Neurobiological changes that occur around the time of onset of full-blown psychotic disorder might also be prevented, mini - mized, or reversed. Thus, the prodromal phase presents two possible targets for interven - tion: (1) current symptoms, behavior, or disability, and (2) prevention of further decline into frank psychotic disorder. Aside from these two treatment aims, there are a number of other benefits of treat - ment of people during the prodrome. Individuals experiencing this early phase of the dis - order may engage more quickly with treatment than those who present late, when psy - chotic symptoms are entrenched, social networks are more disrupted, and functioning has further deteriorated. Additionally, the individual may be more likely to accept treat - ment if full-blown psychosis does emerge compared to the individual who has been un - well for a longer time before seeking assistance. This may be especially so given that the person is likely already to have developed a therapeutic relationship with a treating team. Effective treatment can be provided rapidly if the person does develop psychosis, possibly avoiding the need for hospitalization and minimizing the deleterious effect of extended untreated psychosis. Finally, prepsychotic intervention offers the chance to research the onset phase of psychotic illness, which may provide insight into the core features of the psychopathology and psychobiology of psychosis. However, intervention during the prodromal phase is an approach that carries risks as well as benefits. The most salient of these is the issue of false positives, which are indi- viduals who are identified as being at risk of developing a psychotic disorder, but who in fact are not destined to develop a psychotic disorder. These individuals may be harmed by being labeled as being at high risk of psychosis and may receive treatment unnecessarily. Clearly, it is difficult to distinguish these patients from those identified as being at risk of developing a psychotic disorder and who would indeed have developed a psychotic disor- der if some alteration in their circumstances (e.g., a treatment intervention, stress reduc- tion, cessation of illicit drug use) had not prevented this from occurring. This latter group has been termed the false false-positive group. These issues highlight the retrospective na- ture of the concept of the psychotic prodrome: Onset of frank psychosis cannot be pre- dicted with certainty from any particular symptom or combination of symptoms; the fact that an individual was “prodromal” can only be asserted once frank psychosis has emerged. Thus, the PACE Clinic introduced the term at-risk mental state (ARMS) to refer to the phase prospectively identified as the possible precursor to full-blown psychosis. Given the lack of specificity of many prodromal symptoms of schizophrenia and other psychotic disorders, strategies are needed to increase the accuracy of prediction of psychosis from the presence of an ARMS. The PACE Clinic adopted a “close-in” strategy to identify this population, using a combination of established trait and state risk factors for psychosis with common phenomenology from the prodromal phase of psychotic dis - orders, as well as narrowing identification to the age range of highest risk (late adoles - cence and early adulthood). According to PACE inclusions rules, UHR individuals must meet criteria for at least one of the following groups: (1) attenuated psychotic symptoms group, individuals who have experienced subthreshold, attenuated forms of positive psy - chotic symptoms during the past year; (2) brief limited intermittent psychotic symptoms group, individuals who have experienced episodes of frank psychotic symptoms that have lasted no longer than a week and have spontaneously abated; or (3) trait and state risk factor group, individuals who have a first-degree relative with a psychotic disorder, or who have a schizotypal personality disorder in addition to a significant decrease in func - tioning during the previous year. The person must be between ages 14 and 30 years, and cannot have experienced a psychotic episode for longer than 1 week or received neuroleptic medication prior to referral to the PACE Clinic. 37. Treatment of the Schizophrenia Prodrome 381 Early work at PACE indicated that young people meeting these intake criteria had a 40% chance of developing a psychotic episode in the 12 months after recruitment, de - spite the provision of supportive counseling, case management, and antidepressant medi - cation, if required. This substantial “transition to psychosis” statistic provided good sup - port for the validity of the PACE criteria in identifying the UHR population. Since the mid-1990s, multiple centers internationally have adopted these criteria. Subsequent studies at PACE have included intervention trials that comprised both psychological and pharmacological treatments. These are reviewed briefly, along with the general treatment approach adopted by the PACE Clinic. GENERAL TREATMENT MEASURES Information Giving The rationale for use of the clinical service needs to be explained to the patient at initial assessment. This explanation should cover the dual focus of the clinical service—treatment of current symptoms and disability, and prevention of full-blown psychotic disorder. It is possible that being labeled as high risk for psychotic disorder may lead to stigmatization of the individual, both by others and by the person him- or herself. The PACE Clinic has addressed this issue in a number of ways: The choice of name avoids any direct reference to mental health; the location of the clinic is in a suburban shopping center, a nonstigmatizing and acceptable environment for young people; information is provided sensitively, emphasizing that psychosis is not the inevitable result of UHR status, that monitoring of mental state is available, and that timely intervention is provided if symp- toms worsen, and that the individual’s UHR status will remain confidential; ongoing op- portunities for discussion of risk and normal developmental challenges are provided; and referral to other mental health services that also emphasize early intervention and focus on recovery. Case Management Case management refers to helping the patient deal with practical issues, such as arrang - ing accommodation, arranging social security payments, enrolling in education, applying for employment, and liaising with other services. Case management is provided in addi - tion to specific psychological and pharmacological interventions. This is important, because neglecting difficulties in more fundamental aspects of daily living may have an impact on the efficacy of the therapy and increase the patient’s level of stress. Crisis Management Although the UHR population does not meet full DSM criteria for a psychotic disorder, it is not uncommon for these patients to experience crises. Therefore, risk issues need to be taken into account. It is necessary to have emergency and after-hours services available or to be able to tell young people how to access after-hours support should they need it. Family Interventions Family members are often distressed and anxious about the changes they have noticed in their UHR relative. Support for these family members is helpful. Psychoeducation about being at high risk for psychosis should be provided to family members to deal with their 382 VI. SPECIAL POPULATIONS AND PROBLEMS distress and to minimize the possible negative outcome of UHR status on family function - ing (e.g., pathologizing and stigmatizing the UHR individual). Parents should be provided information regarding their child’s progress and treatment, as appropriate. This process needs to be sensitive to the young person’s confidentiality and privacy. Additionally, it may become apparent that systemic family issues are a factor in the young person’s dis - tress and symptoms. These issues may be addressed in the clinic, or they may require re - ferral to a more specialized family service. PSYCHOLOGICAL TREATMENTS Psychological treatment has been a cornerstone of the treatment provided at PACE since its inception. Both supportive psychotherapy and cognitively oriented psychotherapy have received trials at PACE. These approaches share several characteristics: Both focus on engagement and the formation of a strong, collaborative, respectful relationship be - tween the therapist and the patient, and both aim toward the development of effective coping skills. Supportive Psychotherapy Although it does not specifically target psychotic symptoms, supportive therapy endeav- ors to provide the patient with emotional and social support, and it incorporates many of the constituents of Rogerian person-centered therapy, including empathy, unconditional positive regard, and patient-initiated process. The aim is to facilitate an environment in which the young person is accepted and cared for, and in which he or she can discuss con- cerns and share experiences with the therapist. Key strategies for promoting engagement beyond basic counseling skills include of- fering practical help, working initially with the client’s primary concerns and sources of distress, flexibility with time and location of therapy, provision of information and edu- cation about symptoms, working with family members, and collaborative goal setting. In addition to promoting change through nondirective strategies, basic problem-solving ap - proaches are also offered. This may include helping the patient to develop skills such as brainstorming responses to situations, role play of possible solutions, goal setting, time management, and so forth. The patient is encouraged to be proactive and to monitor his or her own progress. Some degree of role playing may occur within sessions as a spring - board to changes in behavior outside the sessions. Cognitively Oriented Psychotherapy A substantial body of evidence has indicated the benefits of psychological intervention, particularly cognitive-behavioral therapy (CBT), in the treatment of established psychotic disorders. It is also a highly acceptable, relatively safe form of treatment for patients. Given the reported benefits and acceptability of psychological treatment for people with established psychosis, a good case may be made for this intervention’s value in treating individuals in the prepsychotic or prodromal phase of illness. The assessment/engagement phase of this therapy is crucial. Patients may be con - fused or distressed by their symptoms, and early sessions provide an opportunity for the therapist to develop a formulation that can provide patients with some understanding of their symptoms, as well as guide the course of therapy. This early phase of therapy also provides an opportunity for the therapist to emphasize the collaborative nature of the 37. Treatment of the Schizophrenia Prodrome 383 therapy and to select appropriate interventions for the therapeutic relationship based on the client’s developmental level and symptomatic presentation. The strategies for engage - ment are similar to those mentioned earlier for supportive therapy. The cognitively oriented therapy developed at PACE for the high-risk group uses strategies developed for acutely unwell and recovering populations. Cognitive models ap - proach the core symptoms of psychosis as deriving from basic disturbances in informa - tion processing that result in perceptual abnormalities and disturbed experience of the self. Cognitive biases, inaccurate appraisals, and core self-schemas further contribute to maladaptive beliefs. Cognitive therapy aims to help people to develop an understanding of the cognitive processes (including biases and maladaptive appraisals) that influence their thoughts and emotions, and to develop more realistic and positive views of them - selves and events around them. The stress–vulnerability model of psychosis informs the treatment approach. A central assumption of this model is that environmental stressors (e.g., relationship issues, substance use, lifestyle factors) are key factors in precipitating illness onset in vulnerable individuals. This implies that the implementation of appropriate coping strategies may ameliorate the influence of vulnerability. Therefore, strengthening the in - dividual’s coping resources forms a core component of the cognitive therapy offered at PACE. Although stress management forms the backbone of this therapy, it is important to address the wide array of presenting symptoms in this population. To this end, a range of treatment modules have been developed within the cognitive therapy: Stress Manage- ment, Depression/Negative Symptoms, Positive Symptoms, and Other Comorbidity. The assessment of the presenting problem(s), and the client’s own perception of his or her functioning, informs the selection of modules to be implemented during the course of therapy. Although the therapy comprises individual modules targeting specific symptom groups, it may not be appropriate to target one group of symptoms in isolation (i.e., any course of therapy, indeed, any individual therapy session may incorporate aspects of more than one module). The therapy was designed to be provided on an individual basis, but it could potentially be adapted to suit a group treatment situation. Young people can currently attend PACE for a maximum of 12 months, with session frequency varying from weekly to every 2 weeks, and even monthly in the final stages, depending on client need. The treatment modules are described below. Stress Management In keeping with the stress–vulnerability model of psychosis, elements of the Stress Man - agement module are provided to all patients. This module has the added advantage of providing an easily understood introduction to cognitive–behavioral principles, which sets the direction of future sessions. Strategies include the following: • Psychoeducation about the nature of the stress and anxiety. • Stress monitoring that encourages patients to record varying stress levels over spe - cific time periods and to identify triggers and consequences of anxiety or stress. • Stress management techniques, such as relaxation, meditation, exercise, and dis - traction. • Identification of maladaptive coping techniques (e.g., excessive substance use, social withdrawal). 384 VI. SPECIAL POPULATIONS AND PROBLEMS • Identification of cognitions associated with subjective feelings of stress or height - ened anxiety, which may include the completion of relevant inventories. • Cognitive restructuring of dysfunctional thoughts that may be maintaining anxiety/ stress are countered with a more functional cognitive style (e.g., more positive coping statements, positive reframing, and challenging). Other strategies include goal-setting and time management, assertiveness training, and problem solving. Positive Symptoms The strategies incorporated within this module are primarily drawn from cognitive approaches to managing full-blown positive symptoms. The goal of this module is to enhance strategies for coping with positive symptoms when they occur, to recognize early warning signs of these symptoms, and to prevent their exacerbation through the implementation of preventive strategies. The fact that the experience of positive symp - toms by UHR individuals is less intense and/or less frequent than that of individuals with frank psychosis can assist in guiding UHR individuals to recognize and manage these symptoms. For example, unusual perceptual experiences may be more easily rec - ognized as anomalous, and attenuated delusional thoughts may be more easily dis- missed or challenged than more entrenched delusional thoughts. Strategies include the following: • Psychoeducation about symptoms, including a biopsychosocial account of the ori- gins of unusual experiences tailored to the individual patient. This can serve both to “normalize” these experiences and enhance motivation for treatment. It is important that the therapist’s language be modified appropriately for this population. For instance, be- cause these individuals have not been diagnosed with a psychotic disorder, it may not be helpful to use the term psychosis. Use of this term may depend on the individual’s level of anxiety about the possibility of developing a psychotic disorder and his or her general cognitive level. Generally, it is most useful to adopt the language that patients use to refer to their unusual experiences. Focusing discussion on dealing with current symptoms is of - ten more productive than concentrating on the potential negative outcomes. • Verbal challenge and reality testing of delusional thoughts and hallucinations. An individualized, multidimensional model of beliefs relating to delusional thinking or per - ceptual abnormalities is developed. This model is based on issues such as the meaning that the individual attributes to the experiences, the conclusions that he or she draws from the experiences and how he or she explains them. This model is then challenged by examining its supporting evidence and generating and empirically testing alternative in - terpretations of experiences. • Coping enhancement techniques, such as distraction, withdrawal, elimination of maladaptive coping strategies, and stress reduction techniques. • Normalizing psychotic experiences. Suggesting to patients that their attenuated psychotic symptoms are not discontinuous from normality or unique to them can serve to decrease some of the associated anxiety and self-stigma. • Self-monitoring of symptoms to enhance the client’s understanding of the relation - ship of his or her symptoms to other factors, such as environmental events and emotional states. An important component of self-monitoring is for the patient to be alert to any worsening of symptoms, which might indicate the onset of acute psychosis. 37. Treatment of the Schizophrenia Prodrome 385 Depression/Negative Symptoms Negative symptoms include low motivation, emotional apathy, cognitive and motoric slowness, underactivity, lack of drive, poverty of speech, and social withdrawal. These symptoms may often be difficult to distinguish from depressive symptoms, although emo - tional flatness as opposed to depressed mood is often used as a key distinguishing feature. Treatment of these symptoms is incorporated into the therapy, because evidence suggests that they have a significant impact on the future course of the disorder. Additionally, neg - ative symptoms may be easier to treat in the UHR population than in individuals with es - tablished psychosis, because the symptoms are less firmly entrenched. Cognitive-behavioral strategies used to target negative symptoms closely resemble those developed for treatment of depression. Strategies include goal setting, activity man - agement (both mastery and pleasure activities), problem solving, social skills training, and cognitive restructuring of self-defeating cognitions. Negative symptoms can serve a protective function in the sense of ensuring that the individual avoids potentially stressful situations that may precipitate or exacerbate positive symptoms. If there are indications that negative symptoms may be serving this protective function, then the patient is en - couraged to take a slow, graded approach to increasing activity levels and challenging tasks. Other Comorbidity This module includes cognitive-behavioral strategies for more severe anxiety and sub- stance use symptoms experienced by UHR patients. The most frequent comorbid prob- lems experienced by UHR patients are social anxiety, generalized anxiety, panic disorder, obsessive–compulsive symptoms, posttraumatic symptoms, and substance use. Compo- nents of this module include psychoeducation about the comorbid symptoms and, in line with the stress–vulnerability model, the possibility of comorbid symptoms exacerbating attenuated psychotic symptoms; development of an appropriate model to explain the pa- tient’s symptoms, including consideration of his or her life experiences, coping strategies, developmental level, ongoing stressors, and available supports; and presentation of a cog - nitive-behavioral model of anxiety, including discussion of the relationship between cognitions, affect, and behavior. More specific strategies that may be employed, depend - ing on the presenting problems, include management of physiological symptoms of anxi - ety; exposure techniques; behavioral strategies, such as thought stopping, distraction, and activity scheduling; motivational interviewing in relation to substance use; and cognitive strategies. The first PACE intervention study demonstrated a reduction in transition rate to psy - chosis in the treatment group, which received a combination of low-dose antipsychotic medication and cognitively oriented psychotherapy over a 6-month treatment period, compared to the control group, which received supportive psychotherapy alone. At the end of the 6-month treatment period, nearly 36% of the control group had developed psychosis compared to 9.7% of the treatment group (p = .026). However, the difference between the groups was no longer significant 6 months after the cessation of treatment. Both groups demonstrated improvement on a range of measures of psychopathology and functioning after the initial 6 months. Because the treatment group received a combina - tion of antipsychotic medication and cognitive therapy, it was not possible to determine which intervention was the most helpful. A second trial, currently underway, aims to compare low-dose antipsychotic, cognitive therapy, and a combination of the two in a placebo-controlled design. Support for the efficacy of CBT in the UHR group comes from 386 VI. SPECIAL POPULATIONS AND PROBLEMS a recent British trial, which found that cognitive therapy significantly reduced the risk of transition to psychosis in a UHR group. PHARMACOLOGICAL TREATMENT Antipsychotic Medication The use of antipsychotic medication is based on its demonstrated efficacy with psychotic populations. It is thought that this might translate to the prepsychotic phase—that is, that antipsychotic medication may be useful in treatment of existing attenuated psychotic symptoms and in prevention of the emergence of frank psychosis. The first PACE intervention trial (described previously) used low-dose risperidone (1–2 mg per day) in combination with CBT. There were few side effects reported. How - ever, many patients were nonadherent (42%) or only partially adherent (13%) with medi - cation. The conclusion from this trial was that it may be possible to delay the onset of psychosis, although the “active ingredient” in the treatment provided (antipsychotic med - ication or cognitively oriented therapy) still needs to be distilled. However, the fact that the rate of transition to psychosis remained significantly lower in the risperidone-adherent subgroup at the end of the posttreatment 6-month follow-up period compared to the con - trol group provides some evidence for the potential efficacy of antipsychotic medication in this population. The Prevention through Risk Identification, Management, and Educa- tion (PRIME) team have recently reported a similar pattern of results with olanzapine. This study also had problems with adherence, with 32% of patients dropping out of treatment. Opponents of this treatment approach have argued that psychosis is not necessarily harmful, and that side effects of pharmacological treatment may in fact increase an indi- vidual’s morbidity without providing benefit, particularly in the false-positive subset of patients. In recognition of the need for further evaluation of the appropriateness and efficacy of antipsychotics in the UHR population, these medications should not be considered a first treatment option for this group at present. Exceptions may include situationsinwhichthere is a rapid deterioration of mental state, in which severe suicidal risk is present and treatment of depression has proved ineffective, or when the individual is judged to be a threat to oth - ers. If antipsychoticmedicationis considered, thenlow-dose atypicals should beused. How - ever, firm recommendations forpharmacologicaltreatment, including optimal dose and du - ration of treatment, will be only be forthcoming after more research. Other Pharmacological Agents Although the reported studies indicate the possible benefit of antipsychotic medication in the high-risk population, it is possible that other interventions may be more appropriate for the early stages of illness. Indeed, frank psychotic symptoms may just be “noise” around an underlying disease process that might respond to something quite different from antipsychotic medication. If this is the case, then targeting attenuated psychotic symptoms in this population may result in symptomatic improvement, while the underly - ing disease process remains untreated and may continue to progress. Therefore, other pharmacological treatments, such as neuroprotective agents and antidepressants, have been suggested as being of potentially greater benefit in the UHR population. The rationale for neuroprotective agents is that dysfunctional regulation of genera - tion and degeneration in some brain areas might explain neurodevelopmental abnormalities 37. Treatment of the Schizophrenia Prodrome 387 seen in early psychosis. Neuroprotective strategies counteracting the loss or supporting the generation of progenitor cells may therefore be a therapeutic avenue to explore. Can - didate therapies include lithium, eicosapentanoic acid (EPA), and glycine. Studies using lithium, glycine, and EPA are currently underway at the PACE and PRIME Clinics. Other pharmacological interventions may also be indicated in the UHR group, de - pending on the young person’s presentation and current problems. For instance, specific treatment for syndromes such as depression and anxiety may include medication. RECOMMENDATIONS AND FUTURE DIRECTIONS This chapter has provided a brief overview of the identification of the high-risk popula - tion and the current approach to its psychological and pharmacological treatment, with an emphasis on the approach used at the PACE Clinic. This area, still in its infancy, there - fore requires constant evaluation. Although there is some evidence for the efficacy of the treatments we have reviewed, ongoing research will provide a clearer indication of the most effective types of psychological and pharmacological interventions, and suggest ave - nues for refining these interventions. Intervention research with this population should continue in the context of methodologically sound and ethical clinical trials. Larger sam - ple sizes, with a higher proportion of “true positive”cases are required to increase validity of the findings. Due to the early stage of research in this field, researchers need to keep an open mind about possible treatments and to be responsive to developments in related areas of research, including the treatment of established psychosis. In addition to intervention research, it is also necessary to continue attempts to determine the most potent psychopathological, neurocognitive, neurological, and biological vulnerability markers, and combinations thereof, for transition from an at-risk mental state to full psychosis. This will not only as- sist in increasing the accurate identification of truly prodromal individuals (i.e., minimize “false positives”) but also guide the refinement of treatment interventions. KEY POINTS • The prodromal phase of psychotic disorder presents two possible targets for intervention: (1) current symptoms, behavior, or disability, and (2) prevention of further decline into frank psychotic disorder. • The prodrome is a retrospective concept; the term at-risk mental state (ARMS) has been in - troduced to refer to the phase prospectively identified as the possible precursor to full-blown psychosis. • The PACE Clinic introduced a “close-in” strategy to identifying the ARMS population, using a combination of trait and state risk factors. • The treatment approach adopted by the PACE Clinic has comprised general treatment measures and both psychological (supportive psychotherapy and cognitively oriented psy - chotherapy) and pharmacological treatments. • General treatment measures include information giving, case management, crisis manage - ment, and family interventions. • Cognitively oriented psychotherapy is informed by the stress–vulnerability model of psycho - sis and comprises four treatment modules: Stress Management, Depression/Negative Symptoms, Positive Symptoms, and Other Comorbidity. • Intervention trials with antipsychotic medication indicate that rate of transition to psychosis may be reduced in medication-adherent individuals. 388 VI. SPECIAL POPULATIONS AND PROBLEMS • Although there is evidence for the effectiveness of a combination of low-dose antipsychotic medication and cognitively oriented psychotherapy in delaying rate of transition to psycho - sis compared to supportive psychotherapy alone, the active component in therapy still needs to be distilled. • In recognition of the need for further evaluation of the appropriateness and efficacy of antipsychotics in the UHR population, these medications should not be considered as a first treatment option for this group at present. • It is important to continue research into the most potent vulnerability markers for transition from ARMS to full psychosis, because this will assist in the accurate identification of truly prodromal individuals and guide the refinement of treatment interventions. REFERENCES AND RECOMMENDED READINGS Addington, J., Francey, S. M., & Morrison, A. P. (Eds.). (2006). Working with people at high risk of developing psychosis. Chichester, UK: Wiley. Corcoran, C., Walker, E., Huot, R., Mittal, V., Tessner, K., Kestler, L., et al. (2003). The stress cascade and schizophrenia: Etiology and onset. Schizophrenia Bulletin, 29(4), 671–692. McGorry, P. D., Yung, A. R., & Phillips, L. J. (2003). The “close-in” or ultra high-risk model: A safe and effective strategy for research and clinical intervention in prepsychotic mental disorder. Schizophrenia Bulletin, 29(4), 771–790. McGorry, P. D., Yung, A. R., Phillips, L. J., Yuen, H. P., Francey, S., Cosgrave, E. M., et al. (2002). A randomized controlledtrial of interventions designed toreduce the risk of progressionto first ep- isode psychosis in a clinical sample with subthreshold symptoms. Archives of General Psychia- try, 59, 921–928. Morrison, A. P., Bentall, R. P., French, P., Walford, L., Kilcommons, A., Knight, A., et al. (2002). Ran- domized controlledtrial ofearly detection and cognitive therapy for preventingtransition topsy- chosis in high-risk individuals: Study design and interim analysis of transition rate and psycho- logical risk factors. British Journal of Psychiatry Supplement, 43, s78–s84. Morrison, A. P., French, P., Walford, L., Lewis, S. W., Kilcommons, A., Green, J., et al. (2004). Cogni- tive therapy for the prevention of psychosis in people at ultra-high risk: Randomized controlled trial. British Journal of Psychiatry, 185(4), 291–297. Parnas, J. (2003). Self and schizophrenia: A phenomenological perspective. In T. K. A. David (Ed.), The self in neuroscience and psychiatry (pp. 127–141). Cambridge, UK: Cambridge University Press. Phillips, L. J., & Francey, S. M. (2004). Changing PACE: Psychological interventions in the prepsychotic phase. In J. F. M. Gleeson & P. D. McGorry (Eds.), Psychological interventions in early psychosis: A treatment handbook (pp. 23–39). Chichester, UK: Wiley. Yung, A. R., Phillips, L. J., & McGorry, P. D. (2004a). Treating schizophrenia inthe prodromal phase. London: Taylor & Francis. Yung, A. R., Phillips, L. J., Yuen, H. P., & McGorry, P. D. (2004b). Risk factors for psychosis in an ultra high-risk group: Psychopathology and clinical features. Schizophrenia Research, 67, 131– 142. 37. Treatment of the Schizophrenia Prodrome 389 CHAPTER 38 OLDER INDIVIDUALS THOMAS W. MEEKS DILIP V. JESTE OVERVIEW OF LATE-LIFE SCHIZOPHRENIA Popular images, as well as scientific discourses, regarding schizophrenia often focus on how the illness impacts young adults, but schizophrenia also affects a substantial portion of older adults. Among people over age 65, between 0.1 and 0.5% have schizophrenia compared to prevalence estimates near 1% in the general population. Despite the lower prevalence of schizophrenia compared to some other, late-life mental disorders such as dementia and depression, the health care costs for older adults with schizophrenia are quite significant, with one reported estimate of $40,000 per person per year. As the popu - lation structure of industrialized nations continues to shift toward ever-increasing num - bers of older adults, and as improved health care has extended life expectancy in schizo - phrenia, the importance of late-life schizophrenia can be expected to grow substantially in the upcoming decades. Before discussing the unique aspects of schizophrenia in older adults, it is helpful to consider the heterogeneity in this population. One characteristic of schizophrenia that creates important distinctions for illness course and treatment is the age of illness onset. Most older adults with schizophrenia (about 75–80%) developed the illness many years earlier, at a “typical” (i.e., early) age of onset—before age 40. This is notable, because al - though life expectancy is still somewhat abbreviated for persons with schizophrenia due to factors such as elevated smoking and suicide rates, many people are living with this ill - ness well into their later years. Most of the remaining 20–25% of older adults with schizophrenia have had what is considered a “middle-age onset” (between ages 40 and 65). Only about 3% of schizophrenia cases occur after age 65, which is often termed a very late schizophrenia-like psychosis. This terminology reflects that schizophrenia symp - toms beginning in late life may represent a distinct illness, often associated with medical or neurological abnormalities. Several distinguishing features of schizophrenia according to age of onset are outlined in Table 38.1. For instance, middle-age onset schizophrenia (compared to early, or typical, onset) generally demonstrates a higher preponderance of 390 [...]... TABLE 38.1 Clinical Comparisons of Schizophrenia According to Age of Illness Onset Early (typical) Middle-age onset onset Age of onset (years) Family history of schizophrenia Frequent prodromal childhood difficulties Female preponderance Negative symptoms Cognitive impairments Abnormal brain magnetic resonance imaging Require lower than usual dose of antipsychotics Very-late onset (schizophrenia- like psychosis)... appropriateness of medical care received This highlights an issue that becomes increasingly prominent as persons with schizophrenia age—medical comorbidity Because medical care for physical health in persons with schizophrenia has been notoriously inadequate for a variety of reasons (patient-, clinician-, and system-related), clinicians treating schizophrenia should be especially alert to the multitude of age-associated... American Journal of Geriatric Psychiatry, 7, 70 76 Marriott, R G., Neil, W., & Waddingham, S (2006) Antipsychotic medication for elderly people with schizophrenia Cochrane Database of Systematic Reviews, 25, CD005580 Palmer, B W., McClure, F., & Jeste, D V (2001) Schizophrenia in late-life: Findings challenge traditional concepts Harvard Review of Psychiatry, 9, 51–58 38 Older Individuals 3 97 Patterson,... subgroups, including the “old-old” (those over age 75 ) and persons with middle-age or very-late-onset schizophrenia, may respond to even lower doses (e.g., 25–33% of the usual adult dosage) The most evidence regarding effective daily doses from controlled trials exists for risperidone (ca.2 mg/day) and olanzapine (ca.10 mg/day) among relatively “young-old” adults (average age 65 70 ) Although antipsychotic... shown to be potent risk factors for homelessness in the general population and have also been found to be associated with homelessness in persons with SMI Perhaps the largest study of this question to date compared the prevalence of childhood adversities in severely mentally ill homeless persons and a comparison group of never-homeless psychiatric patients, and found that histories of out -of- home care... declined at a rate comparable to the downsizing of the state hospitals New York City, for example, lost approximately 90% of its single-room-occupancy hotel units, and the number of hospital beds declined by roughly the same 90% from its peak in the mid-1950s through the 1980s Lack of adequate funding and lack of appropriate services contributed to the failure of the community mental health system to provide... adults with schizophrenia are scarce) 4 Medications with the most data from controlled trials specifically for older adults with schizophrenia include risperidone, olanzapine, and haloperidol 5 Initial antipsychotic doses for older adults with schizophrenia should be 25–50% of those used in younger adults Whereas effective doses for older adults with early-onset schizophrenia are usually 50 75 % of those... need to be only 25–33% of younger adult doses for patients with late-onset schizophrenia or with “old-old” (over age 75 ) patients 6 Monitoring for medication-related side effects (irrespective of the specific medication used) should include regular evaluation for extrapyramidal symptoms and TD (e.g., using the Abnormal Involuntary Movement Scale), as well as routine monitoring of weight, blood pressure,... controlled trial of cognitive behavioral social skills training for middleaged and older outpatients with chronic schizophrenia American Journal of Psychiatry, 162, 520–529 Harris, M J., & Jeste, D V (1988) Late-onset schizophrenia: An overview Schizophrenia Bulletin, 14, 39–55 Jeste, D V., Barak, Y., Madhusoodanan, S., Grossman, F., & Gharabawi, G (2003) An international multisite double-blind trial of the... medications are pivotal in the treatment of late-life schizophrenia, clinicians, patients, and families often recognize their limitations Even when they are well-tolerated and effective, antipsychotic medications may not be sufficiently effective to return older adults with schizophrenia to “normal” functioning Also, medications have little effect on certain aspects of schizophrenia (e.g., social skills . subgroups, includ - ing the “old-old” (those over age 75 ) and persons with middle-age or very-late-onset schizophrenia, may respond to even lower doses (e.g., 25–33% of the usual adult dos - age). The. 38.1. Clinical Comparisons of Schizophrenia According to Age of Illness Onset Early (typical) onset Middle-age onset Very-late onset (schizophrenia- like psychosis) Age of onset (years) < 40. physical health in persons with schizophrenia has been notori - ously inadequate for a variety of reasons (patient-, clinician-, and system-related), clini - cians treating schizophrenia should be especially