Introduction and Overview
Thank you for participating in this course. I'm excited to share this knowledge because it is a rare and exciting opportunity to be a part of the mental health field, specifically involved with adolescents, and the innovative work that is being done in this area.
Today, we're going to define the prodromal phase and how to recognize it. We're going to look at outreach early detection, and how to disseminate information and promote awareness in the community. We will review early detection and assessment of individuals with psychosis symptoms. Then we'll discuss how to develop the TAY program from this PIER-specific model, followed by ideas about future development in terms of how the program is doing and where it’s going.
This course will focus specifically on the progression and current innovative work of early detection for prodromal psychosis symptoms within the Transitional-Aged Youth (TAY) populations. We'll talk about aspects of using of the Portland Identification and Early Referral (PIER) Model’s outreach and assessment. Finally, we will discuss the strengths and challenges in implementing this program, depending on county and state specifications.
What is the Prodromal Phase?
The prodromal phase is the early stage that precedes the acute phase. This is where visible signs and symptoms appear before the psychotic break. When we talk about psychosis, most people envision a dirty, disheveled person standing out in the street, perhaps talking to themselves. Not as many people understand that there is a phase before that break, and that it comes at a younger age. This is the prodromal phase. These are the early symptoms, the early signs, that precede the acute break when they usually lose touch with reality.
If you look at the spectrum from left to right (Figure 1), the people who experience psychosis typically move through the following phases:
- Prior to symptoms
- Early symptoms
- Psychosis/Psychotic symptoms
- Treatment and Recovery
- Potential for Relapse
Ideally, we want to start treatment earlier, in the at-risk phase, where the person is younger, and symptoms are not as strong. Where the person still wants to get help and has insight to know that there's something wrong. The whole idea here is that we want to decrease the number of relapses, or “revolving door” cases.
Figure 1. Phases of psychosis.
Statistics
Approximately 25% of hospital admissions and disability payments in the U.S. are associated with patients with severe mental illness (mainly schizophrenia and other psychotic disorders). On top of that, schizophrenia causes a 25-year reduction in life expectancy, second to heart disease, cancer and suicide. The average time between onset and symptoms and initial treatment is one to two years. That's a long time between when they first notice symptoms and when they get help. Because of that, the longer duration that the psychosis is untreated, and the increasing number of episodes (i.e., the acute phase), the stronger the deterioration and the weaker response to treatment. Again, the earlier you diagnose it, the better the outcome is.
PIER Model Based Research
The PIER model (Portland Identification and Early Referral), was a combined effort from multiple agencies and programs across the world.
- The United Kingdom conducted an early intervention study. From that study, they concluded that early intervention helps to identify people at risk for serious mental illness.
- In Australia, the PACE Clinic (Personal Assessment and Crisis Evaluation), determined from their program that early identification intervention leads to better prognosis.
- In Norway, at the Rogaland Psychiatric Institute, they found out that it's possible to reduce the duration of untreated psychosis (DUP).
- In the United States, from the PACE information, the TIPS program, and PRIME (from Yale, in CT), they concluded that it is possible to identify people in a pre-psychotic state.
Using the studies from these four countries, it was determined that a program could be created from these findings, which resulted in the PIER Model. There are many other countries involved in mental illness research and programs (e.g., Denmark and Canada), however the four main countries involved in developing the PIER model are the United Kingdom, Australia, Norway and the United States.
Prodromal Research
In 1999, the PIER program conducted their own prodromal research. They selected sites to study in the following states: Maine, Oregon, Michigan, New York, California and New Mexico. Over a six-year period, they found that if they provided early intervention, there was a 34% decrease in hospitalizations. They also determined that less than 15% of clients decreased function toward a psychotic symptom level, as compared to 30-40% before receiving the prodromal services.
In 2006, the EDIPP Model (Early Detection and Intervention for the Prevention of Psychosis) decided to replicate the PIER model study in a larger nationwide setting. They conducted research and created programs to see what they could find. Their study reached three million community members. Of the 1,221 young people referred, 29% joined the program. Of the group that joined, there was only a 6.3% conversion rate (i.e., people who went into acute phase hospitalization). Additionally, 83% of the participants remained at the same functional baseline 24 months later. Clearly, it is critical to intervene at an early age.
Symptoms and Red Flags
There are four basic symptom categories in the SIPS assessment, as well as in our outreach when we educate the community. These symptom categories are: positive symptoms, negative symptoms, disorganized symptoms and general symptoms.
- Positive Symptoms
Typical positive symptoms in the psychotic phase include: unusual thought and delusional ideas; suspiciousness; persecutory ideas; grandiose ideas; hallucinations; perceptual distortions; and disorganized communication.
- Negative Symptoms
Common negative symptoms include social anhedonia, avolition, decreased emotional expression or ability to experience of self, and impaired occupational functioning.
- Disorganized Symptoms
Often, we see odd behaviors or appearance, bizarre thinking, difficulty with focus and attention, and personal hygiene impairments.
- General Symptoms
