Abstract
We can all rally behind the praiseworthy goal of primary prevention of psychosis [1]. But trying to realise it now is extremely premature and likely to cause considerable unintended harm - both on the clinical and on the policy levels [2–3]. Three foundations must be firmly in place before embarking on this risky experiment: 1) accurate diagnosis; 2) interventions with proven efficacy; and 3) these must also have proven safety. “Psychosis Risk Syndrome” badly flunks all three of these basic requirements.
The false positive rate even in experienced hands is an astounding 60–70%. In average hands, it likely will rocket to 90% or more. It is totally unacceptable to stigmatise and subject to possibly harmful treatment the nine out of ten teenagers misidentified as being at risk for psychosis. Add to this that there is no treatment with proven efficacy and that making the diagnosis official in DSM-5 would increase the already scandalous off-label use of dangerous antipsychotic drugs in children and teenagers.
Teenagers are notoriously difficult to diagnose accurately. They have only a short (and often a very atypical) past track record that provides little basis for establishing a definitive current diagnosis or a trustworthy prognosis about the future evolution (or disappearance) of their symptoms. Diagnostic, prognostic, and treatment humility are called for, especially given all the other complicating factors in assessing this protean age group e.g. frequent psychoactive drug use, developmental storms, family tensions, peer pressures, social isolation, and psychosocial stressors. While it is certainly possible to identify a high-risk group of teenagers, it is impossible to be very specific about precisely what they are at risk for.
It may or may not be good policy and an efficient use of resources to provide a general mental health support and prevention program for troubled youth. But it is a clearly a bad idea to tie such a program to any unrealisable pretension of predicting psychosis, especially given all the dangers of stigma, reduced expectations, needless worry, and harmful treatment that are imposed on anyone who inappropriately acquires the misleading and pejorative labels “psychosis risk” or “ultra high risk”.
And there is an additional fourth policy strike against “Psychosis Risk Syndrome.” Prematurely promoting the holy grail of prevention will necessarily divert desperately needed resources from already declared patients we can diagnose accurately and treat effectively. Providing continuity of care throughout the life cycle of illness is a proven need, while only possibly preventing the progression of an alleged prodrome is no more than an untested act of faith. Mental health resources are too scarce to waste chasing fanciful dreams that cannot currently be realised.
McGorry's [1] graduated staging combining stepped diagnosis and stepped treatment has always been the proper approach whenever clinicians have confronted the baffling presentations of teenagers. But this should not be tied to an end point of preventing a presumed psychosis. Nor should it be oversold and overpromised as a panacea that will prevent or reduce later psychopathology, psychotic or otherwise. We simply don't yet know if early interventions with high-risk youngsters confer any significant lasting benefits. Nor do we know if this is the best possible mental health investment when it is compared to other alternatives that are much more likely to be cost effective.
Primary prevention in psychiatry is still no more than a research endeavour in its very earliest stages of development, certainly not proven enough to be incorporated into a vast public policy initiative. It makes great sense to pursue an active research program on “Psychosis Risk Syndrome”, but equally it makes no sense to include it as an official diagnosis in DSM-5 or to allow it any role (even as a small sideshow) in the delivery of EPPIC programs. Primary prevention must prove itself in methodologically sound research before it will be worthy of any large public investment.