Community-oriented family-based intervention superior to standard treatment in improving depression, hopelessness and functioning among adolescents with any psychosis-risk symptoms
Introduction
Early detection and intervention have been shown to be beneficial to young people in the at-risk state for psychosis, and during the last decade many early intervention services have been implemented around the world (McGorry et al., 2002, Marshall and Rathbone, 2011, Bechdolf et al., 2012, Morrison et al., 2012, Stafford et al., 2013). These early intervention services are intended for young people who are seeking help for their first psychosis episode or for psychosis-risk symptoms. Young people seem to benefit from early intervention in the sense of psychosis symptom reduction, even though currently it is not clear if special treatment models can lead to lower conversion rates from the at-risk state to psychosis (Bechdolf et al., 2012, Morrison et al., 2012, Stafford et al., 2013). Psychosis-risk symptoms are more prevalent in the general population of young people than in the part of the population which develops psychosis (Kaymaz et al., 2012), and a valid distinction between young people who are at risk and those who are not is difficult to make (Schimmelmann and Schulze-Lutter, 2012). Nevertheless, given that many adolescents seeking help with or without at-risk symptoms are in need of care, Schimmelmann and Schulze-Lutter (2012) have suggested that treatment is justified independent of conversion risk to psychosis as at-risk adolescents and their caregivers experience distress and impairment. At the moment, there is insufficient evidence to delineate appropriate strategies for early intervention (Schimmelmann and Schulze-Lutter, 2012). However, specific psychological treatment methods, such as cognitive behavioural therapy, seem to have a stronger effect on symptom reduction than standard treatment or supportive counselling (Stafford et al., 2013).
Psychological stress has been shown to have an impact on developing psychotic disorder according to the vulnerability–stress model of psychosis, which postulates that psychosis results from the combined effects of stress and trait-like vulnerability to psychosis (Zubin and Spring, 1977, Phillips et al., 2007). It has also been found that stress may generate other psychiatric symptoms, for example, depressive and anxiety disorders (Uliaszek et al., 2012). Loch et al. (2011) suggest that depression is present on a continuum of psychotic experiences; in their study, depression was present in a group of treatment-seeking subjects who had clinically relevant hallucinations and delusions, as well as in subjects who had no clinically relevant psychotic experiences.
Indeed, there is empirical evidence to suggest that emotional symptoms such as depression and anxiety may be intrinsic to the development of psychosis or may arise as a psychological reaction to psychotic symptoms (Nordström et al., 1995, Birchwood, 2003, Miller et al., 2003, Svirskis et al., 2005, Yung et al., 2008, Rietdijk et al., 2011; Marshall and Rathbone, 2011; Addington et al., 2011; Klonsky et al., 2012; Fusar-Poli et al., 2014). Perhaps even more clinically relevant is that an at-risk state is associated with a compromised level of functioning, as reflected by global assessment, and lowered general levels of functioning have been associated with increased risk for conversion to psychosis (Fusar-Poli et al., 2015).
Previous evidence suggests change in functioning – which is as important as symptom levels – among adolescents who are seeking help for psychiatric symptoms and who are treated in an early intervention service. However, the evidence is inconsistent as regards benefits resulting either from specific psychosocial or pharmacological treatment relative to standard or needs-based care. A pioneering Australian study (McGorry et al., 2002) of an early intervention treatment for subjects at clinical risk for psychosis reported an improvement in functioning in both a special treatment group (risperidone+cognitive behavioural therapy) and in a specific treatment group. Furthermore, no differences in the functioning ability of at-risk subjects who had received either cognitive therapy or monitoring were found after treatment in the multicentre study by Morrison et al. (2012). However, there was greater improvement in psychotic symptoms in the special treatment group (Morrison et al., 2012). Further, in a meta-analysis (Stafford et al., 2013) in which all available intervention studies (including antipsychotic medication, cognitive behavioural therapy, and omega-3 fatty acid supplement treatments) for psychosis risk were included, evidence of moderate quality indicated that cognitive therapy reduces transition to psychosis in at-risk subjects compared to standard treatment, and low- to very low-quality evidence for both omega-3 fatty acids and integrated therapy (individual cognitive behavioural therapy, cognitive remediation, group skills training and family treatment) showed reduced transition to psychosis at 12 months.
Family plays an important role in supporting adolescents (McFarlane et al., 2010), and thus family members' support to those who are undergoing adolescent psychiatric care is important. Family members need to know how to help and how to react in challenging situations (Wilson et al., 2010), but they also need the opportunity to express their own concerns about the family or the adolescent.
The emotional atmosphere in the family environment, parental attitudes, behaviour, and coping strategies are associated with functional outcomes and symptom expression in at-risk adolescents (O’Brien et al., 2008). In addition, a positive family environment predicts improvement in symptoms and social functioning among adolescents at imminent risk for onset of psychosis (O’Brien et al., 2006). Therefore, the family environment should be a specific target of treatment for individuals at risk for psychosis (Schlosser et al., 2010). Finally, previous studies have reported that adolescents with heightened risk of psychosis who seek help show significant improvement in psychotic experiences, quality of life, depression, anxiety, and hopelessness in a Family- and Community-orientated, need-adapted integrative treatment model (Granö et al., 2009, Granö et al., 2013, Granö et al., 2014).
A substantial group of studies shows that psychiatric symptoms are present in a continuum of psychotic symptoms (van Os et al., 2009). Furthermore, subsyndromal psychotic and emotional symptoms may be responsive to psychiatric treatment that focuses on stress reduction (Phillips et al., 2007). Our hypothesis was that stress-reducing care carried out in co-operation with family members in the community (schools, home) and with multidisciplinary workers from the community may have a stronger positive effect on the level of psychiatric symptoms and effectively supports functioning in help-seeking adolescents.
The aim of the present study was to assess change in functioning, level of psychosis-risk symptoms, as well as symptoms of anxiety, depression, and hopelessness in adolescents who participated in an early intervention and detection programme based on a Family- and Community-orientated treatment model. The idea was to compare the adolescents' improvement with a group of adolescents who were matched in age, follow-up time, and functioning and who received standard treatment (e.g. counselling and medication) in a secondary-care adolescent outpatient unit.
Section snippets
Procedure
The participants were selected from two separate studies that investigated two different treatment approaches carried out in Finland, by two separate research institutions: a Family- and Community-orientated, need-adapted integrative Treatment Model (FCTM) and Treatment As Usual (TAU). The FCTM studied early detection and intervention in adolescents who were treated at primary care. The TAU study followed adolescents in standard secondary care, to collect information about the development of
Results
The groups did not differ on clinical measures at baseline, as shown in Table 2b, but the FCTM group was, on average, 0.8 years younger. Combined-sample sum scores of the BAI (M=13.9, SD=7.8), BDI-II (M=17.9, SD=10.3), and BHS (M=8.2, SD=5.3) measures, as well as individual maximum values SOPS positive symptoms at baseline (M=2.7, SD=1.5; range 0–5) indicated moderate symptom severities. Change scores for the outcome variables are presented in Table 2c. FCTM was more effective than TAU in
Discussion
In the present study among subjects who had psychosis-risk symptoms, we found greater improvement in functioning and level of self-reported depression and hopelessness in adolescents who received need-adapted, Family- and Community-orientated integrative treatment instead of standard adolescent psychiatric treatment. Results were attained in a matched-pair study design with patients treated in two different treatment systems. In addition to the differences being statistically significant,
Disclosure of interests
The authors have no competing interests.
Acknowledgements
We are grateful to the adolescents and community co-workers who took part in the study and to the personnel at the HUCH Department of Psychiatry and Adolescent Psychiatry who helped in the data collection.
References (51)
- et al.
A randomized controlled trial of cognitive behavioral therapy for individuals at clinical high risk of psychosis
Schizophr. Res.
(2011) Global assessment of functioning: a modified scale
Psychosomatics
(1995)- et al.
The relationship between psychotic-like symptoms and neurocognitive performance in a general adolescent psychiatric sample
Schizophr. Res.
(2010) - et al.
The prodromal questionnaire (PQ): preliminary validation of a self-report screening measure for prodromal and psychotic syndromes
Schizophr. Res.
(2005) - 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) - et al.
The PRIME North America randomized double-blind clinical trial of olanzapine versus placebo in patients at risk of being prodromally symptomatic for psychosis. II. Baseline characteristics of the “prodromal” sample
Schizophr. Res.
(2003) - et al.
Positive family environment predicts improvement in symptoms and social functioning among adolescents at imminent risk for onset of psychosis
Schizophr. Res.
(2006) - et al.
Stress and psychosis: towards the development of new models of investigation
Clin. Psychol. Rev.
(2007) - et al.
Pathways to psychosis: help seeking behaviour in the prodromal phase
Schizophr. Res.
(2011) - et al.
Predicting the longitudinal effects of the family environment on prodromal symptoms and functioning in patients at-risk for psychosis
Schizophr. Res.
(2010)
Axis-I disorders and vulnerability to psychosis
Schizophr. Res.
Validation of ‘prodromal’ criteria to detect individuals at ultra-high risk of psychosis: 2-year follow-up
Schizophr. Res.
Need-adapted treatment of new schizophrenic patients: experiences and results of the Turku Project
Acta Psychiatr. Scand.
Preventing progression to first-episode psychosis in early initial prodromal states
Br. J. Psychiatry
Manual for Beck Depression Inventory-II
Beck Anxiety Inventory Manual
Beck Hopelessness Scale Manual
The measurement of pessimism: the hopelessness scale
J. Consult. Clin. Psychol.
Pathways to emotional dysfunction in first-episode of psychosis
Br. J. Psychiatry
Cultural and contextual influences in mental health help seeking: a focus on ethnic minority youth
J. Consult. Clin. Psychol.
Treatments of negative symptoms in schizophrenia: meta-analysis of 168 randomized placebo-controlled trials
Schizophr. Bull.
Br. J. Psychiatry
Intervention to improve level of overall functioning and mental condition of adolescents at high risk of developing first-episode psychosis in Finland
Early Interv. Psychiatry
Changes in depression, anxiety, and hopelessness symptoms during family-and community-oriented intervention for help-seeking adolescents at risk of psychosis
Nord. J. Psychiatry
Cited by (17)
Indicated prevention in psychosis risk—psychological approaches
2020, Risk Factors for Psychosis: Paradigms, Mechanisms, and PreventionThe family-oriented open dialogue approach in the treatment of first-episode psychosis: Nineteen–year outcomes
2018, Psychiatry ResearchCitation Excerpt :These include, for example, early-stage family interventions (Marshall and Rathbone, 2011), with a shortened duration of untreated psychosis (Farooq et al., 2009), and increased therapeutic alliance (Laska et al., 2014). Improved treatment outcomes have also been observed in other early and comprehensive intervention systems (Cullberg et al., 2006; Kane et al., 2015; Granö et al., 2016). Nevertheless, regarding the long-term outcomes of early intervention practices in the treatment of psychoses, research has been limited, and contradictory results obtained.
Links between mental health problems and future thinking from the perspective of adolescents with experience of depression and anxiety: a qualitative study
2023, Child and Adolescent Psychiatry and Mental Health