Treating Schizophrenia in the Prodromal Phase

Increasingly, we find ourselves interested in strategies for preventing or ameliorating in its earliest manifestations the horrible disease of schizophrenia. Thus research centers around the globe are working on learning what can be done in the earliest discernable stage of the illness. What we think we can discern we are labeling as "the prodromal phase," although it always remains to be seen whether a putative prodromal phase will become a psychotic illness. But we do know that in the ordinary course of events, treatment for psychotic illnesses often is begun a year or so too late, even after the psychosis has clearly begun. So any work that can help us intervene sooner in the course of illness will likely be very welcome.

In this remarkable and compact work, Treating Schizophrenia in the Prodromal Phase, the Australian authors describe their research in a specially created clinic for young people as well as similar work being done elsewhere. The book could be regarded as a primer on current thoughts about what constitutes a prodromal phase.

The work begins with a brief description of the prodromal phase as seen in the authors' clinic and arguments as to why this is an important area of effort: "a considerable amount of psychiatric symptoms, disability, and self-harming and other health-damaging behaviours occur during this prodromal phase …. If [it] can be recognized prospectively and treatment provided … , then disability could be minimized … neurobiological changes … could … be prevented, minimized, or reversed." The authors believe that people will engage more easily in treatment before the onset of full-blown psychosis. They discuss various conceptions of the prodromal phase; not all research groups define it equally. In their set-up, patients are referred by other clinics as they are identified as being at "ultra-high risk" of developing a psychotic illness. The patients are originally self-referred as a result of being in distress or wanting psychological support. The treatment is not involuntary.

The authors describe the treatment rationales, personnel, and outcomes and also include draft clinical guidelines for treatment. Almost all patients are given the opportunity to participate in research studies, and ethical and treatment-research interfaces are given careful consideration. The outcomes of their studies, as well as those of other studies around the world, are presented. Future directions are suggested at the end of the book.

The book is well written and could be easily understood by readers who do not have a medical background. The material is well organized, and, wherever possible, key points are repeated in a color-contrast box format, which makes it easy to go back over the material and pick out the highlights of the chapter. I found this very interesting reading and enjoyed learning about the prodromal phase and following the authors' thought processes as they reasoned through various issues, which makes me think this book would be an excellent educational and training resource for any mental health professional who is concerned with treatment for serious mental illnesses, including psychiatric residents and trainees in other professions that deal with psychotic mental illnesses, hospital and clinic administrators, and those who set policies on these issues.

I found myself rather envious in that Australia seems to have a system for treating mental illness without the drag effect of having to deal with finances and insurance. Could that be? If they can do this, why can't we?

Some very minor criticisms: it was very clear that the authors' clinic deals only with young people (ages 14 to 29 years) who are at a high risk of psychotic illness. However, there is a separate population that develops psychotic illness later in life, which was not part of the study and not even mentioned in the book. I would have liked to know the authors' thoughts on this population. Another problem—and here I am betraying my age—is the size of the font: the book is pleasantly compact, because the font is small, but I required a bright light to read it.

Dr. Galton is affiliated with the University of California, Los Angeles.