edited by Jean Addington, Shona M. Francey and Anthony Morrison; Somerset, New Jersey, John Wiley and Sons, 2007, 206 pages, $140
Dr. Munetz is professor and Margaret Clark Morgan Chair of Psychiatry, Northeastern Ohio, Universities College of Medicine, Rootstown, Ohio, and chief clinical officer, Summit County Alcohol, Drug Addiction and Mental Health Services Board, Akron.
Identifying individuals who are at high risk of developing schizophrenia and related psychotic disorders and intervening to either prevent or attenuate the course of the condition is far more complex than it sounds. Yet clearly such efforts, which can be thought of as secondary prevention programs, could have a significant public health impact if they are effective. Perhaps the most controversial aspect of intervening with people at high risk but who are not yet diagnosable are the potential risks of treatment, particularly the increasingly recognized risks of taking second-generation antipsychotic medication. This book is based on work demonstrating the effectiveness of cognitive-behavioral therapies in delaying the onset of psychosis among high-risk individuals. These treatment interventions, not commonly available in the United States, pose little risk and may offer many benefits, even to patients who would not have gone on to develop a psychotic disorder.
With editors from Canada, Australia, and the United Kingdom and contributors from these countries as well as from Germany and the United States, this book is international in its perspective. It is well constructed, starting with a short but instructive foreword from Patrick McGorry, the "father" of early identification and intervention strategies. The first several chapters focus on definitions and ways to identify target populations, and later chapters deal with assessment, engagement, and specific treatment interventions. There are a number of acronyms to master, including ARMS, or at-risk mental state, the preferred term for what were commonly referred to as prodromal states, which technically can be referred to only in retrospect, when a syndrome has clearly developed. Other acronyms include UHR mental state, for ultra-high risk, and BLIPS, for brief-limited-intermittent psychotic symptoms.
In addition to defining terms, Alison Yung, in the introductory chapter, strongly argues that cognitive-behavioral therapy should be a first-line treatment, with pharmacotherapy reserved for patients whose symptoms do not respond to the psychological intervention. She also suggests that prevention of conversion to psychosis should not be the only measured outcome but that delayed onset or attenuated severity of the disorder are also important outcomes.
Working With People at High Risk of Developing Psychosis has conceptual continuity among the 19 different contributors. For example, several contributors note that psychotic-like symptoms are surprisingly common in the general population. What may distinguish the high-risk group from others is the response to such experiences. Using the stress-diathesis model, psychotic disorders can be destigmatized, if not normalized, and a rationale for intervention can be developed. The target population for these programs is individuals with an at-risk mental state who experience distress and are therefore interested in help, whether the help is for depression, anxiety, substance abuse, or brief-limited-intermittent psychotic symptoms. Although the population is defined as help seekers, the authors argue—not quite persuasively—that such programs should be located outside traditional health care settings to minimize stigma.
This book arrived for review just as my community was beginning to plan to develop an early-identification and targeted-intervention program for psychotic disorders. I suspect that, like me, readers interested in developing programs to address individuals at high risk of developing psychosis will find this volume helpful and provocative.