A randomized trial of family focused therapy with populations at clinical high risk for psychosis: effects on interactional behavior

Social network size in adolescents at clinical high risk for psychosis

AIMS

Adolescents and young adults at clinical high risk (CHR) for psychosis report few close friends. Social support has been linked to conversion to psychosis and psychosis relapse in CHR individuals. Expanding earlier research on loneliness and friendships at a single timepoint, this study described composition and changes in social network and its association with clinical and cognitive symptoms among CHR adolescents.

METHODS

Ninety five individuals (46 CHR individuals, 49 healthy volunteers) completed baseline and 1-year follow-up Social Network Index (SNI) evaluations and clinical interviews. Analyses first examined SNI size and composition across 10 categories (e.g., family, close friends, coworkers, classmates) between groups. Then, the relationship between SNI size and baseline social symptoms (i.e., paranoia, social anhedonia, social anxiety, social cognition), social function, and changes in symptoms and social networks over 1-year were examined within the CHR group.

RESULTS

CHR individuals showed smaller social networks overall, driven by fewer friendships and family relationships. Social cognition and social anxiety significantly related to SNI size at baseline, but social anhedonia and paranoia did not. SNI size related to social function, but with a modest effect size (r's = .45 and .56). Surprisingly, an increase in positive symptom severity related to an increase in familial but a decrease in coworker social network size.

CONCLUSIONS

The social support deficits in the CHR group were specific to relatives and friendships, with social anxiety and social cognition as implicated symptoms. Social relationships may serve as a promising early intervention target in individuals at CHR for psychosis.

Family communication and the efficacy of family focused therapy in individuals at clinical high risk for psychosis with comorbid anxiety

AIM

Comorbid anxiety disorder is related to greater illness severity among individuals at clinical high risk (CHR) for psychosis, but its potential role in moderating response to Family Focused Therapy (FFT) for CHR is unexamined. We investigated whether comorbid anxiety disorder in CHR individuals is associated with less constructive communication during family problem-solving interactions, whether their communication skills differentially improve after FFT, and whether FFT is effective in reducing anxiety in this population.

METHODS

Individuals recruited into the second phase of the 8-site North American Prodrome Longitudinal Study (NAPLS2) participated (N = 129). They were randomly assigned to 18-sessions of FFT-CHR or three-sessions of Enhanced Care (EC). Participants completed a diagnostic interview at pre-treatment, a family interaction task at pre-treatment and 6-months, and a self-report anxiety measure at pretreatment, 6 and 12-months.

RESULTS

Individuals at CHR with comorbid anxiety engaged in more negative and fewer positive behaviours during family problem-solving interactions at pre-treatment than did those without comorbid anxiety. There was a significant interaction between anxiety diagnosis and time on interactional behaviour scores, such that individuals at CHR with an anxiety diagnosis showed a greater decrease in negative behaviours and increase in positive behaviours from baseline to 6-months than those without anxiety disorder(s) regardless of treatment condition. However, individuals' self-reported anxiety symptoms decreased more in FFT-CHR than in EC from pre-treatment to 12-month follow-up, regardless of anxiety diagnoses.

CONCLUSIONS

Individuals at CHR with symptoms of anxiety benefit from family interventions in showing reductions in anxiety and improvements in family communication.

Psychosocial factors associated with the risk of developing psychosis in a Mexican general population sample

Epidemiological evidence has linked an array of sociodemographic and psychosocial factors with an increased risk of developing psychosis. However, research in samples from low- and middle-income countries is still scarce. This study used a Mexican sample to explore (i) sociodemographic and psychosocial differences between individuals with and without a positive screen for Clinical High-Risk for psychosis (CHR), and (ii) sociodemographic and psychosocial factors associated with screening positive for CHR. The sample consisted of 822 individuals from the general population who completed an online survey. Of the participants, 17.3% (n = 142) met the CHR screening criteria. Comparisons between those who screened positive (CHR-positive group) and those who did not (Non-CHR group) showed that participants in the CHR-positive group were younger, had a lower educational level, and reported more mental health problems than the Non-CHR group. Furthermore, relative to the Non-CHR group, the CHR-positive group had a greater prevalence of medium/high risk associated with cannabis use, a higher prevalence of adverse experiences (bullying, intimate partner violence, and experiencing a violent or unexpected death of a relative or friend), as well as higher levels of childhood maltreatment, poorer family functioning, and more distress associated with the COVID-19 pandemic. Groups did not differ in sex, marital/relationship status, occupation, and socio-economic status. Finally, when examined in multivariate analyses, the variables associated with screening positive for CHR were: having an unhealthy family functioning (OR = 2.75, 95%CI 1.69-4.46), a higher risk associated with cannabis use (OR = 2.75, 95%CI 1.63-4.64), a lower level of education (OR = 1.55, 95%CI 1.003-2.54), having experienced a major natural disaster (OR = 1.94, 95%CI 1.18-3.16), having experienced a violent or unexpected death of a relative or friend (OR = 1.85, 95%CI 1.22-2.81), higher levels of childhood emotional abuse (OR = 1.88, 95%CI 1.09-3.25), physical neglect (OR = 1.68, 95%CI 1.08-2.61), and physical abuse (OR = 1.66, 95%CI 1.05-2.61), and higher COVID-related distress (OR = 1.10, 95%CI 1.01-1.20). An older age was a protective factor for screening positive for CHR (OR = 0.96, 95%CI 0.92-0.99). Overall, the findings highlight the importance of examining potential psychosocial contributors to psychosis vulnerability across different sociocultural contexts to delineate risk and protective processes relevant to specific populations and better target preventive intervention efforts.

Psychoeducation for individuals at clinical high risk for psychosis: A scoping review

Psychoeducation is recommended in the treatment of patients with schizophrenia and has been shown to improve satisfaction with mental health service and treatment adherence, reduce relapse and hospital readmission rates, and enhance functioning and quality of life. Youth at clinical high risk for psychosis (CHR) may also benefit from receiving psychoeducation as part of their treatment. The goal of this study was to conduct a scoping review to map out the existing literature on psychoeducation for CHR individuals, including content, utilization, and benefits, in order to identify areas for future research and clinical care. Following PRISMA guidelines, we conducted a systematic search of electronic databases (MEDLINE, Embase, PsycINFO, Scopus, and Web of Science Core Collection) to identify literature through 02/25/2022 that provided data or significant commentary about the provision of psychoeducation to CHR individuals. After screening titles and abstracts, four co-authors assessed full-text articles for eligibility. Thirty-three studies were included in the review. Psychoeducation is recommended in the treatment of CHR individuals, is a preferred treatment option among CHR individuals, and many CHR programs report offering psychoeducation. However, details about the psychoeducational content and method of delivery are notably absent from recommendations and reports on the provision of CHR psychoeducation in real-world settings. We identified two brief and structured CHR psychoeducation interventions and one longer-term psychoeducational multifamily group model for CHR that show feasibility and promise, though they have not yet undergone randomized trials to evaluate effectiveness of the psychoeducation. We also identified several comprehensive CHR interventions that included an explicit psychoeducation module, though the unique role of the psychoeducational component is unknown. Despite being recommended as a critical component of treatment for CHR individuals and preferred by CHR individuals, the ways in which psychoeducation are being delivered to CHR individuals in real-world practice is still largely ambiguous. Rigorous evaluations of psychoeducation treatment models are needed, as well as investment from clinical programs to facilitate the implementation and dissemination of standardized psychoeducation for CHR individuals.

Family-focused therapy for individuals at high clinical risk for psychosis: A confirmatory efficacy trial

AIMS

Young people with attenuated psychotic symptoms (APS), brief intermittent psychosis, and/or genetic risk and functional deterioration are at high risk for developing psychotic disorders. In a prior trial, family-focused therapy for clinical high risk youth (FFT-CHR) was more effective than brief psychoeducation in reducing APS severity over 6 months. This 7-site trial will compare the efficacy of FFT-CHR to a psychoeducational and supportive intervention (enhanced care) on APS and social functioning in CHR individuals over 18 months.

METHODS

Participants (N = 220, ages 13-25 years) with a CHR syndrome will be randomly assigned to FFT-CHR (18 1-h sessions of family psychoeducation and communication/problem-solving skills training) or enhanced care (3 1-h family psychoeducational sessions followed by 5 individual support sessions), both given over 6 months. Participants will rate their weekly progress during treatment using a mobile-enhanced online platform. Family communication will be assessed in a laboratory interactional task at baseline and post-treatment. Independent evaluators will assess APS (primary outcome) and psychosocial functioning (secondary outcome) every 6 months over 18 months.

RESULTS

We hypothesize that, compared to enhanced care, FFT-CHR will be associated with greater improvements in APS and psychosocial functioning over 18 months. Secondarily, improvements in family communication over 6 months will mediate the relationship between treatment condition and primary and secondary outcomes over 18 months. The effects of FFT-CHR are predicted to be greater in individuals with higher baseline risk for psychosis conversion.

CONCLUSIONS

Results of the trial will inform treatment guidelines for individuals at high risk for psychosis.

Treatment outcomes for young people at clinical high risk for psychosis: Data from a specialized clinic

AIM

Treatment for youth exhibiting signs of clinical high risk for psychosis (CHR-P) has been emphasized in recent years, but there is need for a greater understanding of the course of symptoms and functioning across treatment. The aim of this study is to describe 10 years of naturalistic treatment outcomes in a real-world, specialized CHR-P outpatient clinic, the Center for Early Detection, Assessment, and Response to Risk (CEDAR) Clinic.

METHODS

The CEDAR Clinic routinely collects client outcomes data for the purposes of program development, monitoring treatment effectiveness, and characterizing the clinic population. Clients are assessed at baseline, every 6 months (for up to 2 years depending on duration of treatment), and at the end of treatment. A series of mixed-effects models were performed to analyse change over time in outcomes (symptoms and functioning) between baseline and follow-up time points.

RESULTS

Over time, clients' (N = 123) positive (F = 11.8, p < .001) and negative (F = 4.91, p = .002) symptoms declined relative to their baseline. Social functioning improved over time (F = 2.50, p = .049), as did depression (F = 8.60, p < .001) and hopelessness (F = 4.21, p = .004). Clients' total CEDAR treatment hours ranged across type of treatment service, but the amount of treatment clients received was not associated with any clinical outcomes.

CONCLUSIONS

Over the course of treatment at this real-world, specialized CHR-P program, clients exhibited significant improvement in clinical outcomes and did not significantly decline in any measured outcomes. We discuss this study in the context of current understanding and guidelines for specialized coordinated specialty care treatment for CHR-P.

Changing parenting style between two generations and its impacts on the severity of behavioral and emotional symptoms

OBJECTIVE

The purpose of this study is to compare the perceived parenting dimensions in mothers and their daughters (differences between two generations), and study the relationship between these dimensions and the severity of daughters' behavioral and emotional symptoms.

MATERIALS AND METHODS

300 participants (150 daughters with their mothers) participated in this study. They responded to the perceived parenting styles questionnaire (PSQ), and mothers were additionally asked to answer the child symptoms inventory-4 (CSI-4). Data analysis was done by the SPSS using the paired sample t-test and multiple regressions.

RESULTS

The results indicated a significant difference between perceived parenting dimensions in mothers and their daughters; specifically, acceptance and control dimensions increased through generation. It was also found that daughters' acceptance-rejection dimension could predict the severity of the symptoms of attention-deficit/hyperactivity disorders, autism spectrum disorders, depression, dysthymia, conduct disorders, and opposite defiant disorders. The control-autonomy dimension could also predict the severity of schizophrenia symptoms.

CONCLUSION

The results indicate the different parenting styles between two generations and the critical role of parenting in developing the children's psychopathology symptoms.

Early Detection and Prevention of Schizophrenic Psychosis-A Review

Psychotic disorders often run a chronic course and are associated with a considerable emotional and social impact for patients and their relatives. Therefore, early recognition, combined with the possibility of preventive intervention, is urgently warranted since the duration of untreated psychosis (DUP) significantly determines the further course of the disease. In addition to established diagnostic tools, neurobiological factors in the development of schizophrenic psychoses are increasingly being investigated. It is shown that numerous molecular alterations already exist before the clinical onset of the disease. As schizophrenic psychoses are not elicited by a single mutation in the deoxyribonucleic acid (DNA) sequence, epigenetics likely constitute the missing link between environmental influences and disease development and could potentially serve as a biomarker. The results from transcriptomic and proteomic studies point to a dysregulated immune system, likely evoked by epigenetic alterations. Despite the increasing knowledge of the neurobiological mechanisms involved in the development of psychotic disorders, further research efforts with large population-based study designs are needed to identify suitable biomarkers. In conclusion, a combination of blood examinations, functional imaging techniques, electroencephalography (EEG) investigations and polygenic risk scores should be considered as the basis for predicting how subjects will transition into manifest psychosis.

Comorbid early psychosis and borderline personality disorder: Conceptualizing clinical overlap, etiology, and treatment

Despite substantial efforts aimed at the detection and intervention for early symptoms of mental illness, there is relatively limited research on the clinical overlap between borderline personality disorder (BPD) and early psychosis, for example, clinical high risk (CHR) for psychosis, in young people. We present a narrative review of the clinical overlap between BPD and psychosis spectrum symptoms. Both conditions have unstable temporal course, and both are marked by functional impairment, increased suicide risk, and higher rates of psychiatric inpatient services. We then review evidence-based treatments for psychosis and BPD, emphasizing treatments for early presentations of these symptoms and initial research considering treatments for the overlap. Psychotherapies with the strongest empirical support include cognitive behavioral models, with BPD showing limited response to adjunctive pharmacotherapy. We end by discussing specific recommendations for future research, including longitudinal studies to determine the predictors of the course of illness and the development of treatments to target comorbid BPD and CHR symptoms.

Family environmental factors in at-risk mental states for psychosis

The family environment represents an important psychosocial factor that impacts psychosis prognosis, but little is known about its effect on the at-risk stages of psychosis. This study presents a comprehensive review and summarizes the state of the art of study on the wide range of family factors related to family functioning in the At-Risk Mental State (ARMS) for psychosis, as well as family interventions in ARMS individuals. Publications were retrieved by an extensive search on MEDLINE, PsycINFO and SCOPUS (1990-2020). Expressed Emotion is the most studied variable in ARMS literature, but there is scarce evidence of the role of other significant family factors at the ARMS stage. Overall, high Expressed Emotion did not appear to be reactive to ARMS patients' poor clinical status. However, initial evidence has suggested that relatives' beliefs about the disorder may play a significant role, either as mediators of these relationships or as predictors of Expressed Emotion. Available literature yet to yield a consistent pattern of findings on the association between Expressed Emotion or other family functioning indicators and negative outcomes, but some longitudinal studies highlight the greater potential for the protective effects of positive family environments at the ARMS stage. Family-based interventions have demonstrated benefits for both ARMS individuals and family dynamics. An increased focus on the impact of the at-risk stage of illness on relatives' mental well-being is required to provide family support based on their needs and to clarify the mechanisms leading to dysfunctional family dynamics during the critical ARMS period.

Computer-aided learning for managing stress: A feasibility trial with clinical high risk adolescents and young adults

AIM

The peak onset of psychotic disorders occurs during adolescence and early adulthood, yet treatments for youth at clinical high risk (CHR) for psychosis are generally designed for adults. CHR youth, despite poor academic and social engagement, spend hours each day playing complicated videogames. The aim of this study was to test the feasibility of integrating biofeedback and cooperative videogame play within family therapy as a means of engaging and enhancing this population's resilience.

METHODS

We conducted a feasibility trial of an innovative 12-week family therapy for CHR ages 12-30 (clinicaltrials.gov NCT02531243). We report feasibility outcomes and preliminary effect sizes for pre-post changes and youth-parent differences.

RESULTS

Of 88 individuals referred to the centre who met age and CHR criteria, 11 (13%) youth-parent pairs met full criteria and engaged in treatment. Ten (91%) completed at least six sessions. Youth found CALMS initially credible, but parents tended to find it more credible and to be more satisfied over time. Surprisingly, parents reported a better game experience than youth. As a group, youth and parent participants reported experiencing reduced stress and perceiving each other as less critical by the end of treatment. Youth were rated as having significantly improved social, but not role or global functioning by the end of treatment.

CONCLUSIONS

Multiuser videogames may have a role to play in engaging youth at risk for psychosis in therapy and reducing stress and familial risk factors. A number of key developments are needed to enhance the appeal, effectiveness and practicality of this approach.

Depression, family interaction and family intervention in adolescents at clinical-high risk for psychosis

AIM

The relationship between family behaviour and depression in adolescents at clinical high risk (CHR) for psychosis remains understudied despite high rates of depression in this population. This study examines the relationship between family problem-solving behaviours and depression in CHR adolescents and the impact of family interventions targeting subthreshold symptoms of psychosis on reducing symptoms of depression over 2-years.

METHODS

Participants were a subset of the North American Prodrome Longitudinal Study who were randomized to 6-months of family focused therapy for individuals at CHR or family psychoeducational treatment. We evaluated the relationship between communication during family conflict discussion and adolescents' symptoms of depression before treatment. At follow-up assessments the family treatment groups were compared on depression. Finally, we compared those in family treatment with matched controls.

RESULTS

Adolescents' constructive communication was associated with less severe symptoms of depression before treatment. Symptoms of depression improved for adolescents in both family treatment groups. However, there were no significant group by treatment interactions. When adolescents who participated in either type of family intervention were compared to CHR adolescent controls, symptoms of depression improved for adolescents in treatment and control groups, but there were no significant time by treatment interactions.

CONCLUSIONS

The communication skills of CHR adolescents are related to both depression and their parents' communication skills pre-treatment. However, reductions in depression over the course of the treatment trial cannot be attributed to family treatment. It is imperative to incorporate interventions that directly target depression into future family treatment studies.

Effects of family-focused therapy on suicidal ideation and behavior in youth at high risk for bipolar disorder

BACKGROUND

Youth who are at clinical and familial risk for bipolar disorder (BD) often have significant suicidal ideation (SI). In a randomized trial, we examined whether family-focused therapy (FFT) is associated with reductions in SI and suicidal behaviors in high-risk youth.

METHODS

Participants (ages 9-17 years) met diagnostic criteria for unspecified BD or major depressive disorder with active mood symptoms and had at least one relative with BD type I or II. Participants were randomly allocated to 12 sessions in 4 months of FFT or 6 sessions in 4 months of psychoeducation (enhanced care, EC), with pharmacotherapy as needed. Clinician- and child-rated assessments of mood, suicidal thoughts and behaviors, and family conflict were obtained at baseline and 4-6 month intervals over 1-4 years.

RESULTS

Participants (N=127; mean 13.2±2.6 yrs., 82 female) were followed over an average of 105.9±64.0 weeks. Youth with high baseline levels of SI who received FFT had lower levels of (and fewer weeks with) SI at follow-up compared to youth with high baseline SI who received EC. Participants in FFT had longer intervals without suicidal behaviors than participants in EC. Youths' ratings of family conflict significantly mediated the effects of treatment on SI at follow-up.

LIMITATIONS

Family conflict was based on questionnaires rather than observer ratings of family interactions.

CONCLUSIONS

Family psychoeducation with skill training can be an effective deterrent to suicidal thoughts and behaviors in youth at high risk for BD. Reducing parent/offspring conflict should be a central objective of psychosocial interventions for high-risk youth with SI.

Achieving Mental Health Equity: Children and Adolescents

This article briefly reviews the influences of protective and risk factors of child and adolescent mental health, and explores promising practices and outcomes of evidence-based programs designed to improve the mental health of youth, and the barriers for accessing quality and evidence-based child and adolescent mental health service delivery systems. The authors provide recommendations for individual practice improvements and policy, funding, and organizational practice improvements that will support mental health equity in child and adolescent populations.

Predictors of criticism and emotional over-involvement in relatives of early psychosis patients

Mechanisms underlying the manifestation of relatives’ expressed emotion (EE) in the early stages of psychosis are still not properly understood. The present study aimed to examine whether relatives’ psychological distress and subjective appraisals of the illness predicted EE dimensions over-and-above patients’ poor clinical and functional status. Baseline patient-related variables and relatives attributes comprising criticism, emotional over-involvement (EOI), psychological distress, and illness attributions were assessed in 91 early psychosis patients and their respective relatives. Relatives were reassessed regarding EE dimensions at a 6-month follow-up. Relatives’ psychological distress and illness attributions predicted criticism and EOI over-and-above patients’ illness characteristics at both time points. Relatives’ increased levels of anxiety, attributions of blame toward the patients, an emotional negative representation about the disorder, and decreased levels of self-blame attributions predicted EE-criticism at baseline. Relatives’ anxiety and negative emotional representation of the disorder were the only significant predictors of EE-criticism at follow-up, whereas anxiety, attributions of control by the relative and an emotional negative representation about the disorder predicted EE-EOI both at baseline and follow-up assessments. Understanding the components that comprise and maintain EE attitudes should guide early psychosis caregivers in family interventions, enhancing proper management of psychological distress and reduction of negative appraisals about the illness. The prevention of high-EE attitudes over time in a sensitive period such as early psychosis might be critical in shaping the health of caregivers and the outcome of the affected relatives.

A Randomized Comparison of Two Psychosocial Interventions on Family Functioning in Adolescents with Bipolar Disorder

Impairments in family functioning are associated with more severe depressive and manic symptoms, earlier recurrences, and more suicidal behaviors in early-onset bipolar disorder. This study examined whether family-focused treatment for adolescents (FFT-A) with BD I or II disorder led to greater increases in family cohesion and adaptability and decreases in conflict over 2 years compared to a briefer psychoeducational treatment (enhanced care, EC). Participants were 144 adolescents (mean age: 15.6 ± 1.4 years) with BD I or II with a mood episode in the previous 3 months. Adolescents and parents were randomized to either FFT-A (21 sessions) or EC (three sessions). Patients received guideline-based pharmacotherapy throughout the 2-year study. Trajectories of adolescent- and parent-rated family cohesion, adaptability, and conflict were analyzed over 2 years. FFT-A had greater effects on adolescent-rated family cohesion compared to EC over 2 years. Participants in FFT-A and EC reported similar improvements in family conflict across the 2 years. In the FFT-A group, low-conflict families had greater adolescent-rated family cohesion throughout the study compared to high-conflict families. High-conflict families in both treatment groups tended to show larger reductions in conflict over 2 years than low-conflict families. Family psychoeducation and skills training may improve family cohesion in the early stages of BD. Measuring levels of family conflict at the start of treatment may inform treatment responsiveness among those receiving FFT-A.

Effects of Family-Focused Therapy vs Enhanced Usual Care for Symptomatic Youths at High Risk for Bipolar Disorder: A Randomized Clinical Trial

IMPORTANCE

Behavioral high-risk phenotypes predict the onset of bipolar disorder among youths who have parents with bipolar disorder. Few studies have examined whether early intervention delays new mood episodes in high-risk youths.

OBJECTIVE

To determine whether family-focused therapy (FFT) for high-risk youths is more effective than standard psychoeducation in hastening recovery and delaying emergence of mood episodes during the 1 to 4 years after an active period of mood symptoms.

DESIGN, SETTINGS, AND PARTICIPANTS

This multisite randomized clinical trial included referred youths (aged 9-17 years) with major depressive disorder or unspecified (subthreshold) bipolar disorder, active mood symptoms, and at least 1 first- or second-degree relative with bipolar disorder I or II. Recruitment started from October 6, 2011, and ended on September 15, 2016. Independent evaluators interviewed participants every 4 to 6 months to measure symptoms for up to 4 years. Data analysis was performed from March 13 to November 3, 2019.

INTERVENTIONS

High-risk youths and parents were randomly allocated to FFT (12 sessions in 4 months of psychoeducation, communication training, and problem-solving skills training; n = 61) or enhanced care (6 sessions in 4 months of family and individual psychoeducation; n = 66). Youths could receive medication management in either condition.

MAIN OUTCOMES AND MEASURES

The coprimary outcomes, derived using weekly psychiatric status ratings, were time to recovery from prerandomization symptoms and time to a prospectively observed mood (depressive, manic, or hypomanic) episode after recovery. Secondary outcomes were time to conversion to bipolar disorder I or II and longitudinal symptom trajectories.

RESULTS

All 127 participants (82 [64.6%] female; mean [SD] age, 13.2 [2.6] years) were followed up for a median of 98 weeks (range, 0-255 weeks). No differences were detected between treatments in time to recovery from pretreatment symptoms. High-risk youths in the FFT group had longer intervals from recovery to the emergence of the next mood episode (χ2 = 5.44; P = .02; hazard ratio, 0.55; 95% CI, 0.48-0.92;), and from randomization to the next mood episode (χ2 = 4.44; P = .03; hazard ratio, 0.59; 95% CI, 0.35-0.97) than youths in enhanced care. Specifically, FFT was associated with longer intervals to depressive episodes (log-rank χ2 = 6.24; P = .01; hazard ratio, 0.53; 95% CI, 0.31-0.88) but did not differ from enhanced care in time to manic or hypomanic episodes, conversions to bipolar disorder, or symptom trajectories.

CONCLUSIONS AND RELEVANCE

Family skills-training for youths at high risk for bipolar disorder is associated with longer times between mood episodes. Clarifying the relationship between changes in family functioning and changes in the course of high-risk syndromes merits future investigation.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01483391.

EPA guidance on the early intervention in clinical high risk states of psychoses

This guidance paper from the European Psychiatric Association (EPA) aims to provide evidence-based recommendations on early intervention in clinical high risk (CHR) states of psychosis, assessed according to the EPA guidance on early detection. The recommendations were derived from a meta-analysis of current empirical evidence on the efficacy of psychological and pharmacological interventions in CHR samples. Eligible studies had to investigate conversion rate and/or functioning as a treatment outcome in CHR patients defined by the ultra-high risk and/or basic symptom criteria. Besides analyses on treatment effects on conversion rate and functional outcome, age and type of intervention were examined as potential moderators. Based on data from 15 studies (n = 1394), early intervention generally produced significantly reduced conversion rates at 6- to 48-month follow-up compared to control conditions. However, early intervention failed to achieve significantly greater functional improvements because both early intervention and control conditions produced similar positive effects. With regard to the type of intervention, both psychological and pharmacological interventions produced significant effects on conversion rates, but not on functional outcome relative to the control conditions. Early intervention in youth samples was generally less effective than in predominantly adult samples. Seven evidence-based recommendations for early intervention in CHR samples could have been formulated, although more studies are needed to investigate the specificity of treatment effects and potential age effects in order to tailor interventions to the individual treatment needs and risk status.

Interventions for prodromal stage of psychosis

BACKGROUND

Psychosis is a serious mental condition characterised by a loss of contact with reality. There may be a prodromal period or stage of psychosis, where early signs of symptoms indicating onset of first episode psychosis (FEP) occur. A number of services, incorporating multimodal treatment approaches (pharmacotherapy, psychotherapy and psychosocial interventions), developed worldwide, now focus on this prodromal period with the aim of preventing psychosis in people at risk of developing FEP.

OBJECTIVES

The primary objective is to assess the safety and efficacy of early interventions for people in the prodromal stage of psychosis. The secondary objective is, if possible, to compare the effectiveness of the various different interventions.

SEARCH METHODS

We searched Cochrane Schizophrenia's study-based Register of studies (including trials registers) on 8 June 2016 and 4 August 2017.

SELECTION CRITERIA

All randomised controlled trials (RCTs) evaluating interventions for participants older than 12 years, who had developed a prodromal stage of psychosis.

DATA COLLECTION AND ANALYSIS

Review authors independently inspected citations, selected studies, extracted data, and assessed study quality.

MAIN RESULTS

We included 20 studies with 2151 participants. The studies analysed 13 different comparisons. Group A comparisons explored the absolute effects of the experimental intervention. Group B were comparisons within which we could not be clear whether differential interactive effects were also ongoing. Group C comparisons explored differential effects between clearly distinct treatments. A key outcome for this review was 'transition to psychosis'. For details of other main outcomes please see 'Summary of findings' tables. In Group A (comparisons of absolute effects) we found no clear difference between amino acids and placebo (risk ratio (RR) 0.48 95% confidence interval (CI) 0.08 to 2.98; 2 RCTs, 52 participants; very low-quality evidence). When omega-3 fatty acids were compared to placebo, fewer participants given the omega-3 (10%) transitioned to psychosis compared to the placebo group (33%) during long-term follow-up of seven years (RR 0.24 95% CI 0.09 to 0.67; 1 RCT, 81 participants; low-quality evidence). In Group B (comparisons where complex interactions are probable) and in the subgroup focusing on antipsychotic drugs added to specific care packages, the amisulpiride + needs-focused intervention (NFI) compared to NFI comparison (no reporting of transition to psychosis; 1 RCT, 102 participants; very low-quality evidence) and the olanzapine + supportive intervention compared to supportive intervention alone comparison (RR 0.58 95% CI 0.28 to 1.18; 1 RCT, 60 participants; very low-quality evidence) showed no clear differences between groups. In the second Group B subgroup (cognitive behavioural therapies (CBT)), when CBT + supportive therapy was compared with supportive therapy alone around 8% of participants allocated to the combination of CBT and supportive therapy group transitioned to psychosis during follow-up by 18 months, compared with double that percentage in the supportive therapy alone group (RR 0.45 95% CI 0.23 to 0.89; 2 RCTs, 252 participants; very low-quality evidence). The CBT + risperidone versus CBT + placebo comparison identified no clear difference between treatments (RR 1.02 95% CI 0.39 to 2.67; 1 RCT, 87 participants; very low-quality evidence) and this also applies to the CBT + needs-based intervention (NBI) + risperidone versus NBI comparison (RR 0.75 95% CI 0.39 to 1.46; 1 RCT, 59 participants; very low-quality evidence). Group C (differential effects) also involved six comparisons. The first compared CBT with supportive therapy. No clear difference was found for the 'transition to psychosis' outcome (RR 0.74 95% CI 0.28 to 1.98; 1 RCT, 72 participants; very low-quality evidence). The second subgroup compared CBT + supportive intervention was compared with a NBI + supportive intervention, again, data were equivocal, few and of very low quality (RR 6.32 95% CI 0.34 to 117.09; 1 RCT, 57 participants). In the CBT + risperidone versus supportive therapy comparison, again there was no clear difference between groups (RR 0.76 95% CI 0.28 to 2.03; 1 RCT, 71 participants; very low-quality evidence). The three other comparisons in Group C demonstrated no clear differences between treatment groups. When cognitive training was compared to active control (tablet games) (no reporting of transition to psychosis; 1 RCT, 62 participants; very low quality data), family treatment compared with enhanced care comparison (RR 0.54 95% CI 0.18 to 1.59; 2 RCTs, 229 participants; very low-quality evidence) and integrated treatment compared to standard treatment comparison (RR 0.57 95% CI 0.28 to 1.15; 1 RCT, 79 participants; very low-quality evidence) no effects of any of these approaches was evident.

AUTHORS' CONCLUSIONS

There has been considerable research effort in this area and several interventions have been trialled. The evidence available suggests that omega-3 fatty acids may prevent transition to psychosis but this evidence is low quality and more research is needed to confirm this finding. Other comparisons did not show any clear differences in effect for preventing transition to psychosis but again, the quality of this evidence is very low or low and not strong enough to make firm conclusions.

Early Detection and Preventive Intervention in Schizophrenia: From Fantasy to Reality

Scientific progress in understanding human disease can be measured by the effectiveness of its treatment. Antipsychotic drugs have been proven to alleviate acute psychotic symptoms and prevent their recurrence in schizophrenia, but the outcomes of most patients historically have been suboptimal. However, a series of findings in studies of first-episode schizophrenia patients transformed the psychiatric field's thinking about the pathophysiology, course, and potential for disease-modifying effects of treatment. These include the relationship between the duration of untreated psychotic symptoms and outcome; the superior responses of first-episode patients to antipsychotics compared with patients with chronic illness, and the reduction in brain gray matter volume over the course of the illness. Studies of the effectiveness of early detection and intervention models of care have provided encouraging but inconclusive results in limiting the morbidity and modifying the course of illness. Nevertheless, first-episode psychosis studies have established an evidentiary basis for considering a team-based, coordinated specialty approach as the standard of care for treating early psychosis, which has led to their global proliferation. In contrast, while clinical high-risk research has developed an evidence-based care model for decreasing the burden of attenuated symptoms, no treatment has been shown to reduce risk or prevent the transition to syndromal psychosis. Moreover, the current diagnostic criteria for clinical high risk lack adequate specificity for clinical application. What limits our ability to realize the potential of early detection and intervention models of care are the lack of sensitive and specific diagnostic criteria for pre-syndromal schizophrenia, validated biomarkers, and proven therapeutic strategies. Future research requires methodologically rigorous studies in large patient samples, across multiple sites, that ideally are guided by scientifically credible pathophysiological theories for which there is compelling evidence. These caveats notwithstanding, we can reasonably expect future studies to build on the research of the past four decades to advance our knowledge and enable this game-changing model of care to become a reality.

The last taboo: The experience of violence in first-episode psychosis caregiving relationships

OBJECTIVES

Informal caregiving relationships play an important role in facilitating recovery outcomes in psychosis. The relationship can serve as a source of positive experiences that co-exist alongside common challenges typically associated with mental health problems. People with psychosis, when compared to the general population, are more likely to perpetrate acts of violence, a relationship that is particularly evident during the first psychosis episode. Although victims of service user violence are typically people already known to them, such as informal carers, there remains a lack of understanding about their caring experiences and needs. This study sought to address gaps in the literature by exploring the subjective accounts of informal carers supporting a relative experiencing their first episode of psychosis who has also behaved violently towards them.

DESIGN

A cross-sectional design was employed.

METHODS

Individual semi-structured interviews, which were audio recorded and later transcribed for analyses, were undertaken with a convenience sample of eight carers drawn from a specialist early psychosis service. Interview questions focused on their experiences of patient violence, the subjective impact, and coping strategies. An interpretative phenomenological approach was used to analyse the data.

RESULTS

Participants were mostly living with their relative with psychosis and were typically female, parents, and from a black and minority ethnic background. Data analyses identified seven key themes from participant interviews including the lack of predictability over when the violence occurred, being scared and fearful, keeping quiet about what happens at home and in the caregiving relationship, and staying safe.

CONCLUSIONS

Reports by informal carers about experiencing violence and victimization from their relatives with psychosis are an important issue in some caregiving relationships during the first episode. Developing a more informed understanding of the specific needs of these carers and the caregiving relationship is indicated. The implications for service providers are discussed.

PRACTITIONER POINTS

Carers were exposed to a broad range of patient violence, which included being kicked and having weapons used against them. The violence typically occurred within carers' homes, when no other people were around. Patient violence impacted negatively on carer emotional and physical functioning, which included leaving carers living in fear of their own safety and what might become of their relative. The results highlight the importance of routinely asking first-episode carers about their experience of patient violence. The development of interventions (e.g., identification of early triggers, de-escalation) that are able to take account of the ongoing nature and complexity of the caregiving relationship but are purposefully aimed at supporting carers to remain safe in their relationship should be explored for their impact.

Family functioning moderates the impact of psychosis-risk symptoms on social and role functioning

BACKGROUND

Youth at clinical high-risk (CHR) for psychosis often experience difficulties in social and role functioning. Given evidence that family stress and support can impact psychosis-risk symptoms, as well as an individual's ability to fulfill social and role functions, family dynamics are hypothesized to moderate the effect of psychosis-risk symptoms on functioning.

METHODS

Participants at CHR (N = 52) completed the clinician-administered Structured Interview for Psychosis-risk Syndromes (SIPS) and the Family Assessment Device (FAD) General Functioning Scale, a self-report measure of family functioning including cohesion and support. Interviewers rated participants' current social and role functioning using the Global Functioning: Social and Role Scales.

RESULTS

Regression results indicated that positive symptoms, but not ratings of family functioning, statistically predicted social and role functioning. Perceived family functioning, however, moderated the effect of symptoms on social/role functioning. For individuals who perceived lower levels of family functioning, symptoms were moderately associated with social and role functioning (f² = 0.17 and f² = 0.23, respectively). In contrast, psychosis-risk symptoms were not significantly associated with social/role functioning for individuals with higher levels of perceived family functioning. Notably, positive symptoms and perceived family functioning were not associated with one another, suggesting that perceived family functioning did not directly impact symptom severity, or vice versa.

CONCLUSIONS

Findings support the notion that family functioning may be a clinically meaningful factor for individuals at CHR. Although this cross-sectional data limits our discussion of potential mechanisms underlying the pattern of findings, results suggest that familial support may be beneficial for individuals at risk for psychosis.

Family functioning in youth at-risk for serious mental illness

BACKGROUND

There is evidence that family functioning can be impaired in families of individuals with schizophrenia, first-episode psychosis, bipolar disorder, and recurrent depression, which are considered to be serious mental illnesses (SMI). Poor family functioning is one of the predictors of the course of SMI. However, it is unclear if poor family functioning is a result of illness, or conversely if poor family leads to higher risk of illness. Nonetheless, family functioning may be impaired even before the onset of illness, and little is known about earlier stages of risk and the importance of the family environment for youth at-risk for SMI.

OBJECTIVE

The present study aimed to examine differences in family functioning in a sample of youth at-risk of SMI across different clinical stages compared to healthy controls (HCs).

METHODS

Family functioning was evaluated with the Family Adaptability and Cohesion Evaluation Scales-IV (FACES-IV) for 41 non-help seeking youth with risk factors for SMI (Stage 0), 52 help-seeking youth with early mood and anxiety symptoms and distress (Stage 1a), 108 youth with an attenuated psychiatric syndrome (Stage 1b), and 42 HCs.

RESULTS

Results from multivariate linear regression analyses showed that participants in Stage 1a and Stage 1b significantly differ from participants in Stage 0 and HCs on most of the family functioning scales. However, these results were statistically but not clinically significant as the percentile values for each group fell within the same clinical ranges. The only clinical difference was that participants in stages 1a and 1b were somewhat less satisfied with their family compared to healthy controls and stage 0 participants.

CONCLUSIONS

An examination of group mean values demonstrated no difference in family functioning between the different groups with all groups in the healthy functioning range. However, family satisfaction is lower in youth at-risk for SMI who present with early signs of mood, anxiety or subthreshold psychotic symptoms than other participants. Early family psychoeducational interventions could be beneficial to improve family functioning.

Early Intervention in Mental Health for Adolescents and Young Adults: A Systematic Review

OBJECTIVE. The purpose of this systematic review was to describe the evidence for the effectiveness of early intervention to improve and maintain performance in occupations for youths with or at risk for serious mental illness (SMI).

METHOD. Titles and abstracts of 670 articles were reviewed, 234 were retrieved for full review, and 30 met inclusion criteria.

RESULTS. Moderate to strong evidence supports cognitive remediation (CR) and mixed evidence supports cognitive–behavioral therapy (CBT) as an adjunct modality to improve general functioning. Moderate to strong evidence supports use of supported employment and supported education (SE/E) to improve social and occupational outcomes in employment and academics. Strong evidence supports family psychoeducation (FPE) to prevent relapse and rehospitalization and improve problem-solving skills and general functioning.

CONCLUSION. Occupational therapy practitioners should integrate CR, SE/E, and FPE into early intervention with youth with or at risk for SMI. In addition, CBT is an effective modality for use with this population.

Family communication with teens at clinical high-risk for psychosis or bipolar disorder

Previous research has found that family problem-solving interactions are more constructive and less contentious when there is a family member with bipolar disorder compared with schizophrenia. The present study extended this research by examining whether family problem-solving interactions differ between clinical high-risk (CHR) stages of each illness. Trained coders applied a behavioral coding system (O'Brien et al., 2014) to problem-solving interactions of parents and their adolescent child, conducted just prior to beginning a randomized trial of family-focused therapy. The CHR for psychosis sample included 58 families with an adolescent with attenuated positive symptoms, brief intermittent psychosis, or genetic risk and functional deterioration; the CHR for bipolar disorder sample included 44 families with an adolescent with "unspecified" bipolar disorder or major depressive disorder and at least one first or second degree relative with bipolar I or II disorder. When controlling for adolescent gender, age, functioning, and parent education, mothers of youth at CHR for psychosis displayed significantly more conflictual and less constructive communication than did mothers of youth at CHR for bipolar disorder. Youth risk classification did not have a significant relationship with youths' or fathers' communication behavior. The family environment among help-seeking adolescents may be more challenging for families with an adolescent at CHR for psychosis compared with bipolar illness. Accordingly, families of adolescents at clinical high-risk for psychosis may benefit from more intensive or focused communication training than is required by families of adolescents at clinical high-risk for bipolar disorder or other mood disorders. (PsycINFO Database Record

The effects of psychoeducational family intervention on coping strategies of relatives of patients with bipolar I disorder: results from a controlled, real-world, multicentric study

Background

Psychoeducational family intervention (PFI) has been proven to be effective in improving the levels of family burden and patients' personal functioning in schizophrenia and bipolar disorders (BDs). Less is known about the impact of PFI on relatives' coping strategies in BD.

Methods

A multicenter, controlled, outpatient trial funded by the Italian Ministry of Health and coordinated by the Department of Psychiatry of the University of Campania "Luigi Vanvitelli" has been conducted in patients with bipolar I disorder (BD-I) and their key relatives consecutively recruited in 11 randomly selected Italian community mental health centers. We aim to test the hypothesis that PFI improves problem-oriented coping strategies in relatives of BD-I patients compared to the Treatment As Usual (TAU) group.

Results

The final sample was constituted of 123 patients and 139 relatives. At baseline assessment (T0), the vast majority of relatives already adopted problem-oriented coping strategies more frequently than the emotion-focused ones. At the end of the intervention, relatives receiving PFI reported a higher endorsement of adaptive coping strategies, such as "maintenance of social interests" (odds ratio [OR]=0.309, CI=0.04-0.57; p=0.023), "positive communication with the patient" (OR=0.295, CI=0.13-0.46; p=0.001), and "searching for information" (OR=0.443, CI=0.12-0.76; p=0.007), compared to TAU relatives, after controlling for several confounders. As regards the emotion-focused coping strategies, relatives receiving the experimental intervention less frequently reported to adopt "resignation" (OR=-0.380, CI=-0.68 to -0.08; p=0.014) and "coercion" (OR=-0.268, CI=-0.46 to -0.08; p=0.006) strategies, compared to TAU relatives.

Conclusion

PFI is effective in improving the adaptive coping strategies of relatives of BD-I patients, but further studies are needed for evaluating the long-term benefits of this intervention.

Development of a Boston Treatment Program for Youth at Clinical High Risk for Psychosis: Center for Early Detection, Assessment, and Response to Risk (CEDAR)

Over the past two decades, increasing attention has been given to the importance of early intervention for psychosis. This article describes the development of the Center for Early Detection, Assessment and Response to Risk (CEDAR), which focuses on early identification and treatment of youth at clinical high risk for psychosis. There are relatively few models in the United States for such programs, and we present our developmental story, focusing mainly on the CEDAR Clinic, as a case study of how such a program can develop. We describe the rationale, infrastructure, and services provided at the CEDAR Clinic, and present some descriptive data from the CEDAR Clinic through 2016. A case example is provided to illustrate treatment at CEDAR. We hope that the cultural history of our program's development is informative for clinicians and policy makers as one model of how to build an early intervention service. We believe that this article is timely in view of the growing momentum in the United States for developing programs for intervening as early as possible for youth at clinical high risk for psychosis.

Involving Parents/Family in Treatment during the Transition from Late Adolescence to Young Adulthood: Rationale, Strategies, Ethics, and Legal Issues

The progression from adolescence to adulthood is a time of tremendous change, characterized by issues of identity formation, autonomy, and shifting relationship dynamics. The family is embedded in all aspects of this transition and serves as both a protective support and a limiting factor, a complicated duality that raises psychological, ethical, and legal issues. This article discusses the influence of familial factors and provides assessment strategies for evaluating the family in relation to treatment of transitional age youth. It is increasingly evident that family engagement is a significant contributor to outcomes for transitional age youth seeking mental health treatment.

Do Family Interventions Improve Outcomes in Early Psychosis? A Systematic Review and Meta-Analysis

Family interventions for psychosis (FIp) are effective in reducing service user relapse and carer distress in people with schizophrenia-spectrum conditions. Several treatment and best practice guidelines recommend FIp for all people with schizophrenia. However, outcome findings in relation to early psychosis groups have been inconsistent. The current paper reports a systematic review and meta-analyses of articles that evaluated FIp in early psychosis with a clearly defined comparison group. A combination of electronic database searches (using PsychINFO, Medline, and CENTRAL), citation searches and hand searches of key journals and reviews was conducted. Peer-reviewed articles published in English from database inception to June 2016 were included. Methodological quality was assessed using the Effective Public Health Practice Project Quality Assessment Tool (EPHPP). Seventeen papers from 14 studies met inclusion criteria for review, the overall quality of which was moderate. Meta-analytic synthesis showed that FIp improved service user functioning and reduced the likelihood of relapse by the end of treatment. Psychotic symptoms were significantly reduced in the FIp group at follow up, but this was not evident at end of treatment. In terms of FIp target mechanisms, carers receiving FIp were more likely to shift from high to low expressed emotion and less likely to report patient focused criticism or engage in conflict communication than carers randomized to standard care. Carer burden and well-being were improved by the end of treatment but gains were not sustained at follow up. FIp had no impact on carer emotional over-involvement. The findings indicate that FIp is an effective intervention for early psychosis service users and their relatives. However, further research is required to establish which key therapeutic components of FIp are most effective for whom, in addition to understanding the mechanisms by which FIp might affect positive change.

Family-Focused Therapy for Bipolar Disorder: Reflections on 30 Years of Research

Family-focused therapy (FFT) is an evidence-based intervention for adults and children with bipolar disorder (BD) and their caregivers, usually given in conjunction with pharmacotherapy after an illness episode. The treatment consists of conjoint sessions of psychoeducation regarding bipolar illness, communication enhancement training, and problem-solving skills training. This paper summarizes over 30 years of research on FFT and family processes in BD. Across eight randomized controlled trials with adults and adolescents with BD, FFT and mood-stabilizing medications have been found to hasten recovery from mood episodes, reduce recurrences, and reduce levels of symptom severity compared to briefer forms of psychoeducation and medications over 1-2 years. Several studies indicate that the effects of FFT on symptom improvement are greater among patients with high-expressed emotion relatives. New research focuses on FFT as an early intervention for youth at risk for BD, neuroimaging as a means of evaluating treatment mechanisms, and progress in implementing FFT in community mental health settings.

High-risk diagnosis, social stress, and parent-child relationships: A moderation model

Stress is related to symptom severity among youth at clinical high-risk (CHR) for psychosis, although this relation may be influenced by protective factors. We explored whether the association of CHR diagnosis with social stress is moderated by the quality of parent-child relationships in a sample of 96 (36 CHR; 60 help-seeking controls) adolescents and young adults receiving mental health services. We examined self-reported social stress and parent-child relationships as measured by the Behavior Assessment System for Children, Second Edition (BASC-2), and determined CHR status from the clinician-administered Structured Interview for Psychosis-Risk Syndrome (SIPS). The social stress subscale, part of the clinical domain of the BASC-2, assesses feelings of stress and tension in personal relationships and the relations with parents subscale, part of the adaptive domain of the BASC-2, assesses perceptions of importance in family and quality of parent-child relationship. There was a modest direct relation between risk diagnosis and social stress. Among those at CHR, however, there was a significant relation between parent-child relationships and social stress (b=-0.73, t[92]=-3.77, p<0.001, f(2)=0.15) that was not observed among non-CHR individuals, suggesting that a positive parent-child relationship may be a protective factor against social stress for those at risk for psychosis. Findings provide additional evidence to suggest that interventions that simultaneously target both social stress and parent-child relationships might be relevant for adolescents and young adults at clinical high-risk for psychosis.

Psychometric Properties of Prodromal Questionnaire-Brief Version among Chinese Help-Seeking Individuals

Prodromal Questionnaire (PQ) and Structured Interview for Prodromal Syndromes (SIPS) have been used as a two-stage process for identifying subjects at clinical high risk (CHR) of psychosis. The Prodromal Questionnaire-Brief version (PQ-B) contains 21 items derived from the PQ. The present study aimed to examine the psychometric properties of PQ-B in a Chinese help-seeking outpatient sample and to explore which items can better predict CHR diagnosis by SIPS and future transition to psychosis. In our preliminary epidemiological study, 1461 patients from a pool of 2101 individuals (15–45 years of age) completed the two-stage process. In the present study, 239 (20%) people were randomly selected among the sample who met the initial PQ-B screening criteria but had no positive diagnosis on SIPS, as well as 72 individuals with negative results on both PQ-B and SIPS, 89 prodromal and 105 psychotic subjects, yielding a total of 505 participants. The internal consistency coefficient for the PQ-B was good, with a Cronbach’s alpha of 0.897. The concordant validity of PQ-B with SIPS dichotomized diagnosis of prodrome/psychosis versus no psychosis was 0.54. To ensure 80% or a higher sensitivity and a certain specificity, 7 and 24 were respectively set as the cutoff points for the PQ-B total score and distress score for Chinese help-seeking outpatients. A logistic regression model based on six PQ-B items could allow predicting the psychotic diagnosis on SIPS, with an accuracy of 65.8%. Prodromal individuals who scored higher on the 12^th item of PQ-B (Do you worry at times that something may be wrong with your mind?) were less likely to convert to psychosis. PQ-B is a useful instrument for screening CHR subjects, but the cutoff score may be higher than that recommended by the author scores for help-seeking individuals in outpatient clinics. Some specific PQ-B items may have significant predictive power on dichotomized SIPS diagnoses and deserve special attention from researchers in future studies.

Decreases in perceived maternal criticism predict improvement in subthreshold psychotic symptoms in a randomized trial of family-focused therapy for individuals at clinical high risk for psychosis

Perceived criticism (PC) is a measure of how much criticism from 1 family member "gets through" to another. PC ratings have been found to predict the course of psychotic disorders, but questions remain regarding whether psychosocial treatment can effectively decrease PC, and whether reductions in PC predict symptom improvement. In a sample of individuals at high risk for psychosis, we examined a) whether Family Focused Therapy for Clinical High-Risk (FFT-CHR), an 18-session intervention that consists of psychoeducation and training in communication and problem solving, brought about greater reductions in perceived maternal criticism, compared to a 3-session family psychoeducational intervention; and b) whether reductions in PC from baseline to 6-month reassessment predicted decreases in subthreshold positive symptoms of psychosis at 12-month follow-up. This study was conducted within a randomized controlled trial across 8 sites. The perceived criticism scale was completed by 90 families prior to treatment and by 41 families at 6-month reassessment. Evaluators, blind to treatment condition, rated subthreshold symptoms of psychosis at baseline, 6- and 12-month assessments. Perceived maternal criticism decreased from pre- to posttreatment for both treatment groups, and this change in criticism predicted decreases in subthreshold positive symptoms at 12-month follow-up. This study offers evidence that participation in structured family treatment is associated with improvement in perceptions of the family environment. Further, a brief measure of perceived criticism may be useful in predicting the future course of attenuated symptoms of psychosis for CHR youth.

The Next Big Thing in Child and Adolescent Psychiatry: Interventions to Prevent and Intervene Early in Psychiatric Illnesses

The last two decades have marked tremendous progress in our ability to prevent and intervene early in psychiatric illnesses. The interventions described in this article range from established, empirically-supported treatments to creative interventions early in their development and deployment. Some of these interventions are low-technology programs delivered in social settings (such as schools), and some rely on sophisticated emerging technologies such as neuroimaging. This article reviews 4 preventative interventions: 1) The use of structural brain imaging to identify children at risk for familial depression who are most likely to benefit from preventative cognitive behavioral therapy 2) The Good Behavior Game, a school based program that, when implemented in 1st grade classrooms, cut the incidence of substance use disorders in students in half when those students were 19 years old, 3) The SPARX video game, which has the potential to be an accessible, appealing, and cost-effective treatment for the thousands of teens affected by mild to moderate depressive disorders, and 4) Intensive psychosocial treatments which can reduce the progression of from the ultra high risk state to the first episode psychosis by 50% over 12 months. All of these interventions have tremendous potential to reduce the suffering and disability caused by psychiatric illness to both children and adults.

Emotional and behavioral symptomatology reported by help-seeking youth at clinical high-risk for psychosis

Subthreshold psychosis-like experiences are typically the focus of psychosis-risk screening as they are associated with a greater propensity for future illness. Potentially prodromal individuals identified as being at clinical high-risk (CHR), however, report a variety of distressing and impairing mental health symptoms in addition to subthreshold psychosis symptoms, indicating that this population is of clinical interest regardless of whether or not they develop psychosis. In the current study, 90 young people (12-21) seeking mental health services completed the Behavior Assessment System for Children, Second Edition (BASC-2), a broad-range checklist of emotional and behavioral concerns and adaptive skills, followed by the Structured Interview for Psychosis-risk Syndromes to assess psychosis risk. Those who met criteria for CHR (n=35) reported elevated scores across several BASC-2 scales including depression, attention problems, locus of control, and sense of inadequacy compared to help-seeking youth without CHR (n=55). Most of these scales were also elevated compared to general population norms. Further, the CHR group had significantly lower scores on two adaptive scales, self-reliance and relations with parents, indicating more impairment in these domains. Results indicate that young people at CHR experience more pervasive and/or more severe symptomatology across several domains of clinical significance compared to a similar group of help-seeking youth not at CHR. Results from this study aid in the understanding of symptom correlates of CHR status beyond attenuated symptoms that can provide clinical information relevant for treatment.

Flexibility and structure may enhance implementation of family-focused therapy in community mental health settings

This study elicited provider and administrator preferences in implementing an evidence-based practice (EBP) for bipolar disorder or psychosis, family-focused therapy (FFT). Providers (n = 35) and administrators (n = 5) from three community mental health centers took part in FFT training and participated in pre- and post-training focus groups. Transcripts were examined using conventional content analysis. Providers and administrators discussed barriers to implementing EBPs. Successful EBPs were described as incorporating flexibility and close supervision to maximize provider adherence. Providers expressed preferences for structured EBPs like FFT that have both explicit implementation steps and built-in flexibility.

Family-focused treatment for adolescents and young adults at high risk for psychosis: results of a randomized trial

OBJECTIVE

Longitudinal studies have begun to clarify the phenotypic characteristics of adolescents and young adults at clinical high risk for psychosis. This 8-site randomized trial examined whether a 6-month program of family psychoeducation was effective in reducing the severity of attenuated positive and negative psychotic symptoms and enhancing functioning among individuals at high risk.

METHOD

Adolescents and young adults (mean age 17.4 ± 4.1 years) with attenuated positive psychotic symptoms, brief and intermittent psychosis, or genetic risk with functional deterioration were randomly assigned to 18 sessions of family-focused therapy for individuals at clinical high risk (FFT-CHR) in 6 months or 3 sessions of family psychoeducation (enhanced care [EC]). FFT-CHR included psychoeducation about early signs of psychosis, stress management, communication training, and problem-solving skills training, whereas EC focused on symptom prevention. Independent evaluators assessed participants at baseline and 6 months on positive and negative symptoms and social-role functioning.

RESULTS

Of 129 participants, 102 (79.1%) were followed up at 6 months. Participants in FFT-CHR showed greater improvements in attenuated positive symptoms over 6 months than participants in EC (F1,97 = 5.49, p = .02). Negative symptoms improved independently of psychosocial treatments. Changes in psychosocial functioning depended on age: participants more than 19 years of age showed more role improvement in FFT-CHR, whereas participants between 16 and 19 years of age showed more role improvement in EC. The results were independent of concurrent pharmacotherapy.

CONCLUSION

Interventions that focus on improving family relationships may have prophylactic efficacy in individuals at high risk for psychosis. Future studies should examine the specificity of effects of family intervention compared to individual therapy of the same duration and frequency. Clinical trial registration information-Prevention Trial of Family Focused Treatment in Youth at Risk for Psychosis; http://clinicaltrials.gov/; NCT01907282.