Family-focused treatment improves attenuated psychotic symptoms, but does not differ from brief treatment in negative symptoms and social functioning in ultra high risk patients aged 12–35 years

Abstract

FROM: Miklowitz DJ, O'Brien MP, Schlosser DA, et al. Family-focused treatment for adolescents and young adults at high risk for psychosis: results of a randomized trial. J Am Acad Child Adolesc Psychiatry 2014;53:848-58.WHAT IS ALREADY KNOWN ON THIS TOPIC? Transition to psychotic episode can be reduced to about 50% by psychosocial interventions such as cognitive behavioural therapy (CBT), but there are no improvements in negative symptoms and social functioning. 1 2 Antipsychotic medications are not usually indicated unless the person meets criteria for a DSM-IV/ICD-10 psychotic disorder. 3 METHODS OF THE STUDYThe sample consisted of young ultra high risk (UHR) patients aged from 12 to 35 years as assessed with the Structured Interview for Prodromal Symptoms (SIPS) and the Scale of Prodromal Symptoms (SOPS). One hundred and twenty-nine participants were recruited at eight sites of the North American Prodrome Longitudinal Study and 102 were followed up at 6 months. The patients were randomised to 18 sessions of family-focused treatment (FFT) for clinical high-risk individuals or three sessions of family psychoeducation (enhanced care, EC). FFT consists of psychoeducation (eg, teaching families to create a prevention plan summarising early symptoms, stressors and preventative manoeuvers), communication training, and problem solving skills training. EC teaches a personalised prevention plan in three sessions. Measurement was blind and the primary outcome was attenuated psychotic symptoms on the SIPS/SOPS. The secondary outcome was social functioning (Global Assessment of Functioning, GAF). Completer analyses with analysis of covariance (n=102) and, if significant, intention-to-treat mixed-effect regression analyses (ITT; n=129) were conducted.WHAT DOES THIS PAPER ADD? ▸ FFT reduced attenuated psychotic symptoms compared to EC in completer analysis ( p=0.02) and ITT analysis ( p=0.04), but there were no effects on negative symptoms or social functioning. ▸ Changes in psychosocial functioning depended on age. The threeway interaction between treatment group, age group and time in completer analysis was significant ( p=0.005). Participants more than 19 years of age showed more role improvement in FFT, whereas participants between 16 and 19 years of age showed more role improvement in EC. LIMITATIONS▸ At baseline 27 patients were using antipsychotic medications. During the study six patients made a transition to psychosis (1 in FFT and 5 in EC), but at the same time 11 patients were prescribed antipsychotic medications (7 in FFT and 4 in EC: from 20.9% at baseline to 35.2%). The authors examined the competing effects of psychosocial treatment and antipsychotics in a single mixed model and found that they were independent, non-redundant predictors of outcome; however, one cannot rule out the possibility that FFT or antipsychotic medication or both were the active agents in reducing the (attenuated) psychotic symptoms. ▸ FFT is a mixture of four interventions. Improvement in communication was reported elsewhere, 4 but the...

Association between family functioning and psychotic transition in ultra-high risk adolescents and young adults

“…To the best of our knowledge, this is the first study showing with longitudinal data that better family functioning is a protective factor for PT. This finding supports the idea that improving family functioning may have a positive impact in terms of symptomatic evolution ( 50 ), and that early family intervention, in dysfunctional families, could prevent PT in UHR subjects ( 24 , 25 , 51 – 53 ).…”

“…Another study showed that the behavior of the family toward the UHR subject modified the outcome, with “positive remarks” and “signs of affection” (parental warmth), respectively, leading to a reduction in negative symptoms and improved social functioning ( 24 ). Conversely, one study found that family therapy improved positive symptoms, but not negative symptoms or social functioning ( 25 ). Criticisms from family members are linked to high levels of cortisol, a marker of stress, in patients and especially in UHR patients ( 26 ).…”