Abstract
One might expect a book with such a provocative title to be either ‘ahead of its time’ or ‘premature’. In fact, it is neither. Rather, this is a sober, non-polemical account of the current state of play in detecting and treating young people putatively at very high risk for psychosis.
There are now at least nine centres around the world conducting work in this area, a tribute to the international influence of the Melbourne early psychosis group pioneered by Pat McGorry. The book provides an overview of Melbourne's PACE Clinic, a discussion of the concept of the ‘prodrome’ in the context of schizophrenia, practical details on establishing a clinical service for ‘ultra-high-risk’ patients, an account of treatment in this context and a discussion of some of the research findings in this field. Several useful clinical vignettes are provided, illustrating various aspects of assessment and treatment. The reader should not mistake this work for routine clinical practice; it is highly specialized clinical research and requires a service framework that is geared to measurement, research enquiry and rigorous evaluation.
In discussing the background to this clinical research, the authors take pains to point out that the prodrome is a retrospective concept and that, with current levels of knowledge, the prodrome cannot be reliably identified prospectively and it is preferable to refer instead to ‘at-risk mental states’. Although this approach is scientifically sound, it still carries certain risks. Unfortunately, it will not prevent less thoughtful clinicians from using material in this book to make ill-conceived judgments about whether a given patient is ‘prodromal for schizophrenia’ and intervene as if a diagnosis of schizophrenia had been made, with all the potential adverse consequences that may flow from this. Likewise, with the preliminary evidence found for efficacy of antipsychotic drugs in ultra-high-risk patients, some clinicians may feel moved to prescribe antipsychotic drugs for their own prodromal patients, with further potential for adverse outcomes.
The matter of false positives is the crux of the problem underlying the potential for such ill-advised interventions by clinicians outside the specialist clinical research setting, not to mention the ethics and cost-effectiveness of providing a form of treatment for those who do not require it. Although, as described in the book, some improvements in predictive power have been made, they require replication and further development before confident application to ordinary clinical practice can be justified. The authors address the false positive issue in some detail and later state that antipsychotic drugs are ‘used only in the context of a clinical trial’ (i.e. experimental research) and that it is currently ‘too early for codifying firm guidelines and recommendations regarding psychopharmacological treatment’. Gung-ho clinicians will ignore these caveats at their and their patients' peril, while cautious restraint in the face of pharmaceutical company influences will inevitably be a challenge for all clinicians.
False positives aside, the nature ofthe work described in this book raises a host of ethical issues, including informed consent, distinguishing clinical care from research, the risks of labelling, potential for stigmatization and problems of confidentiality. Many of these important issues are discussed by the authors, but those seeking a more detailed discussion may wish to turn to other sources as well, such as Corcoran et al.[1].
Prepsychosis intervention is thus controversial and raises a number of thorny problems, including inappropriate or premature application of the research findings by some clinicians. But many bold new clinical advances worth taking are bound to provoke questions or criticism, and carry some clinical risks. To the authors' credit, they do not shy away from these matters, but deal with them in a thoughtful manner. On the other side of the ledger, this area of work has injected a mood of greater optimism about schizophrenia generally and a sense of hopefulness that severe disability may be averted in this disorder.
There is a disappointing error (p.19) where the authors refer to their operationalized definition of psychosis ‘based on the presence of clear-cut threshold-level psychotic symptoms (delusions, hallucinations and formal thought disorder)’. However, in Box 3.2 to which they refer in this context, under the psychotic symptoms heading, they list only a number of schizotypal symptoms. This is unfortunate as the mistake has the potential to mislead the novice reader on a crucial matter.
This is a young area of clinical development and one that is very promising in terms of better outcomes for people with schizophrenia and the potential to prevent lifelong disability, if not prevent the onset of schizophrenia. It requires greater investment of resources to test its potential as the ‘proof of the pudding’ will be in long-term outcome studies of large patient samples.
Overall, the book provides an excellent overview of the current state of prodromal psychosis research and is, no doubt, the first of many such books to come in this burgeoning field.