Public-Health Effort Successfully Uncovers Prodromal Psychosis

The first six years of a public-health initiative in Portland, Maine, to identify young people at risk for psychosis shows that identification of at-risk individuals in the community by stakeholders inside and outside the mental health system is feasible and can result in early treatment.

From 2001 to 2007, the Portland Identification and Early Referral (PIER) program trained 7,270 professionals from the educational, medical, and mental health sectors about prodromal symptoms and means for rapid referral of at-risk youth. The program also undertook a broad-based public-education effort aimed at parents and young people (Psychiatric News, May 2, 2008).

This outreach effort resulted in 780 youth being referred by community participants to the PIER program for assessment, according to a report published in May in the APA journal Psychiatric Services.

Of the 780 community referrals to PIER, 148 individuals were found to meet criteria for prodromal psychosis, according to the report.

Community referrals to the program are screened by PIER clinical staff, usually by telephone, for basic demographic and clinical criteria—residence in the catchment area, age 12 to 35, no prior psychotic episode, and evidence of prodromal psychotic symptoms.

If PIER staff agree that an individual appears to be at high risk, he or she receives a formal assessment with the Structured Interview for Prodromal Syndromes.

Individuals found to be exhibiting symptoms of a prodromal syndrome receive a combination of family psychoeducation, supported employment and education, elements of assertive community treatment specifically tailored to prodromal symptoms, and psychiatric medication.

According to the Psychiatric Services article, PIER clinical staff spent much of the program's first year conducting on-site visits with groups of professionals likely to observe prodromal symptoms among youth early enough to avert onset of psychosis. In addition to presentations in these professionals' offices, educational sessions were held for groups of 50 to 200 of them—for example, grand-rounds presentations or meetings of public-school professionals.

The public-education campaign used commercial and public-service radio and television announcements and appearances on local radio and television talk shows, and created easy-to-read bookmarks, brochures, and flyers that were distributed directly to young people.

The report noted that the prodromal cases identified were 49 percent of the expected incidence of psychosis in the catchment area, indicating that the outreach and referral program was successfully identifying a substantial number of individuals who might have gone undetected until well after they had progressed to a full-blown psychosis.

In addition to the prodromal cases, outreach and referral to PIER also yielded another 79 individuals who were found to be already psychotic and “were quickly referred for treatment, usually without hospitalization,” the authors noted.

Psychiatrist William McFarlane, M.D., director of PIER and lead author of the Psychiatric Services article, also emphasized that many individuals who did not necessarily meet criteria for prodromal psychosis were nevertheless in need of psychiatric services for other conditions and were referred for treatment outside of the PIER program.

Typically, these referrals were for depression, anxiety, or posttraumatic stress disorder symptoms—“conditions that should be treated in adolescence early and preventively as well,” he said.

“So we think this system has an enormous potential for better psychiatric treatment generally,” McFarlane told Psychiatric News.

He said the goal of the program is to reduce the incidence of acute psychosis in the catchment area, and preliminary evidence indicates that the goal is likely to be achieved.

McFarlane emphasized that the heart of the program and any impact it may have on the incidence of schizophrenia is in the outreach and education effort. “It's all about the staging of an intervention,” he said. “It's just like heart disease—if you get someone with early angina into a catheter lab and treated with statins, the outcome is going to be qualitatively better than if you wait until the patient has a first MI.

“So it's all about at what stage of psychosis you get a person into treatment,” McFarlane said.

“Portland Early Identification and Referral: A Community-Based System for Identifying and Treating Youths at High Risk of Psychosis” is posted at <http://psychservices.psychiatryonline.org/cgi/content/full/61/5/512>.