Family-Focused Treatment for Adolescents and Young Adults at High Risk for Psychosis: Results of a Randomized Trial

Abstract

Objective Longitudinal studies have begun to clarify the phenotypic characteristics of adolescents and young adults at clinical high risk for psychosis. This 8-site randomized trial examined whether a 6-month program of family psychoeducation was effective in reducing the severity of attenuated positive and negative psychotic symptoms and enhancing functioning among individuals at high risk. Method Adolescents and young adults (mean 17.4±4.1 years) with attenuated positive psychotic symptoms, brief and intermittent psychosis, or genetic risk with functional deterioration were randomly assigned to 18 sessions of family-focused therapy for individuals at clinical high risk (FFT-CHR) in 6 months or 3 sessions of family psychoeducation (enhanced care, or EC). FFT-CHR included psychoeducation about early signs of psychosis, stress management, communication training, and problem-solving skills training, whereas EC focused on symptom prevention. Independent evaluators assessed participants at baseline and 6 months on positive and negative symptoms and social-role functioning. Results Of 129 participants, 102 (79.1%) were followed at 6 months. Participants in FFT-CHR showed greater improvements in attenuated positive symptoms over 6 months than participants in EC (F[1,97]=5.49, P=.02). Negative symptoms improved independently of psychosocial treatments. Changes in psychosocial functioning depended on age: participants over 19 years showed more role improvement in FFT-CHR, whereas participants between 16 and 19 years showed more role improvement in EC. The results were independent of concurrent pharmacotherapy. Conclusion Interventions that focus on improving family relationships may have prophylactic efficacy in individuals at high risk for psychosis. Future studies should examine the specificity of effects of family intervention compared to individual therapy of the same duration and frequency.

Limitations of Research on Psychosis in Childhood and Adolescence:Current Controversies and Future Directions

“…For example, Miklowitz et al [11] reported a reduction in positive symptoms of psychosis as a result of family interventions in conjunction with skills-based training for adolescents at risk for psychosis. They noted that the combination of teaching strategies for stress reduction and problem solving with increased family support and improved communication proved to be beneficial.…”

Intervention in the Context of Development: Pathways Toward New Treatments

“…This hope of early actionable concerns has led investigators to push prevention research toward earlier and earlier points of development. In schizophrenia research, children or adolescents are treated at the point when familial risk and early symptoms converge (Miklowitz et al, 2014). In ASD research, high-risk populations such as younger siblings are tracked during infancy to identify the first warning signs of atypical trajectory that may in turn be treated incrementally from low-to high-intensity approaches as the specific trajectory and response of the child becomes clearer (Green et al, 2013).…”

“…Although this group is at much heightened risk, the majority do not go on to receive a diagnosis within 2 years. Some promising data have emerged for the use of cognitivebehavioral therapy, family therapy, atypical antipsychotic medications, and omega 3 fatty acids to prevent progression to schizophrenia, but these initial findings are quite mixed and await replication (Marshall and Rathbone, 2011;Miklowitz et al, 2014). One concerning finding is that while some could potentially be protected from progressing to a psychotic disorder, all of those who are treated are exposed to side effects of medications, most notably weight gain because of atypical antipsychotic medications including risperidone and olanzapine (Marshall and Rathbone, 2011).…”

“…Unfortunately, outcomes measured 6-8 years after MTA study completion were not predicted by treatment in the randomized trial but were instead predicted by initial symptom trajectory, regardless of treatment (Molina et al, 2009). Longitudinal follow-up of promising short-term treatment studies, such as the recent Prevention Trial of Family-Focused Treatment in Youth at Risk for Psychosis (Miklowitz et al, 2014), is critical to understand the relationship between initial symptomatic response and meaningful long-term outcomes.…”

Overdiagnosis in the Era of Neuropsychiatric Imaging

“…Indeed, one of the primary motivations behind these changes was to encourage intervention in the prodromal phase of psychiatric disorders, with the aim of preventing progression (4). Support for this paradigm came partly from encouraging studies of early intervention in youth at risk of schizophrenia and other neuropsychiatric disorders (5)(6)(7)(8)(9). To identify patients who might benefit from intervention, the NIMH called for research into physiological biomarkers for psychiatric disease, particularly into neuroimaging biomarkers.…”