Interventions to Prevent Psychosis

An impending psychotic break can be identified and prevented if it is recognized early and appropriate steps are taken to head it off.

Gracia Lam

Tiffany Martinez was a 17-year-old college freshman when she began hearing voices, seeing shadowy figures and experiencing troubling, intrusive thoughts. Her friends at the University of Southern Maine, where she was majoring in psychology, noticed that she was acting strangely and urged her to get help.

They most likely saved her from a crippling mental health crisis, prevented the derailment of her education and ultimately enabled her to become a psychiatric nurse practitioner who can help other young people avert a psychiatric crisis.

Tiffany’s friends convinced her to go to the university’s health center, where she met with a nurse who had just attended an educational seminar about identifying the early signs of mental illness in young adults. The nurse suspected that Tiffany was at risk of developing a psychotic episode and referred her to the Portland Identification and Early Referral, or PIER, program at the Maine Health Center.

The program was developed in 2001 by Dr. William R. McFarlane, a psychiatrist who suspected that if early intervention could reverse the course of diseases like cancer and heart disease, it should do likewise for psychosis. Despite conventional wisdom suggesting otherwise, he persevered in the belief that an impending psychotic break could be identified and prevented if it was recognized early and appropriate steps taken to head it off.

Tiffany, who said her father had schizophrenia, was an early beneficiary of his vision and has become a poster child for what can be done to prevent a devastating, costly illness that afflicts up to 3 percent of the population.

After the PIER program was extended to 25 school districts in and around Portland, there was a 35 percent decline in new hospital admissions for psychotic symptoms, Dr. McFarlane said.

With funding from the Robert Wood Johnson Foundation, the model program has since been replicated at about 18 centers around the country, and the Substance Abuse and Mental Health Services Administration (Samhsa), a division of the Department of Health and Human Services, recently authorized funds to establish 21 new sites.

But while these programs are gearing up, Dr. McFarlane’s mission is to educate families, friends, physicians and college personnel about how to recognize a young person with the early warning signs of psychosis and get the help they need to stave off a crisis.

Dr. McFarlane, the former director of the PIER Training Institute in Portland who tutors personnel at PIER sites around the country, has noted that about 20 percent of all hospital admissions and disability payments are for patients with severe mental illness, mostly schizophrenia and other psychotic disorders. These ailments also shorten life by an average of 25 years.

“When you develop severe mental illness, you are driving off a cliff,” the psychiatrist said. “Imagine if you could stop a process that’s already underway.”

Psychosis, which is not a disease but a symptom of a brain illness, usually begins in late adolescence and young adulthood. The causes are not known. The disorder, which is genetically complex, tends to run in families — more than 100 genes have been linked to schizophrenia, for example. Its onset is often precipitated by episodes of intense stress or severe chronic stress.

There are many possible signs that someone is at risk of developing a psychotic break, but too often they are often dismissed as symptoms of typical adolescent behavior, experts say. Psychosis rarely comes on suddenly. Rather, the person gradually experiences changes in thoughts and perception, making it difficult for the person to recognize what is real and what is not, the National Alliance on Mental Illness (NAMI) points out.

The alliance lists these early warning signs:

• A worrisome drop in grades or job performance

• Trouble thinking clearly or concentrating

• Suspiciousness or uneasiness with others

• A decline in self-care or personal hygiene

• Spending a lot more time alone than usual

• Strong, inappropriate emotions or having no feelings at all

The person may hear, see or believe things that others do not; experience distracting sensations; be confused about what is real and what is not; and become mistrustful or even panicky.

Ms. Martinez recalled that she began to hear voices, see shadowy figures and have troubling, intrusive thoughts. “I would walk out into the courtyard outside my dorm and for some reason I had this thought to be careful of the trees because they were going to collapse on me,” she reported.

A number of studies in recent decades have shown that first episodes of psychosis can be prevented through early detection and treatment, as shown by a Dutch team in a 2013 meta-analysis of randomized controlled trials.

But the PIER program, which is multidisciplinary and relies heavily on multifamily group sessions, is likely to be the most comprehensive and perhaps most successful. Each group has two professional leaders, some combination of the following: a nurse, a social worker, an occupational therapist, a psychologist and sometimes a young person who has been through the experience and is now well.

Dr. McFarlane, author of a professional book, “Multifamily Groups in the Treatment of Severe Psychiatric Disorders,” said in an interview, “Families come with their kids, who at first usually have to be dragged in by their ears, but quickly become enthusiastic participants. Families get a lot of support from others in their group with issues they don’t know how to handle. The group is there to treat the illness, not the patient, who learns how to treat himself.”

The intervention is adapted to each individual and focuses on practical issues like how to stay in school, make and keep friends or jobs, how to handle stresses and plan for the future.

“We also emphasize the value of healthy eating and exercise and spending more time outdoors,” he added. “Only when necessary do we use medication, like a mood stabilizer or anti-depressive. This isn’t about drug treatment.”

Getting young people into a preventive program while they are still in the prepsychotic stage is critical to success. “Seventy-five percent of these young people are still in school or at work after our program; if intervention is started late, it would be only 25 percent,” the psychiatrist said.

He admits, however, that in some parts of the country, it can be challenging to find a comprehensive treatment program. California, he said, probably leads the nation in the number of programs currently up and running. The Samhsa Treatment Locator, at 1-800-662-4357, or the NAMI HelpLine, at 1-800-950-6264, available weekdays from 10 a.m. to 6 p.m. Eastern Time, or at info@nami.org., may be helpful in locating treatment services.