Ethics of psychosis prevention – Could we? Should we?

The SIRS Ethics Committee inaugurated the first of its annual symposia at SIRS 2019 to discuss the ethical challenges in attempting to prevent an illness when an individual’s true risk is unknown.  The schizophrenia prodromal phase has long been considered a ‘target’ for preventative intervention. However, not all those considered to be at ultra-high risk (UHR) for psychosis go on to develop schizophrenia.  The panel discussed the associated ethical dilemmas.

Alison Yung, Melbourne University, Australia and Manchester University, UK, provided a concise guide to the ethical concerns clinicians facing with patients presenting in the prodromal phase. Their symptoms are non-specific, attenuated psychosis is present and they are experiencing behavioral changes. Are these patients at UHR for developing psychosis?

Criteria have been devised which try to ascertain whether this might be the case – do patients exhibit sufficient signs to qualify as UHR? But the UHR threshold is itself an arbitrary assessment. Therefore, it seems pertinent to ask whether these criteria are valid.

The ethical issues faced by clinicians fall into five broad categories:

Detection

  • advertising for patients in the prodromal phase is likely to pick up fewer patients who will go on to transition to psychosis than if patients had actively sought help of their own volition; nevertheless, can it be categorically said that these patients are or are not at risk and should they be treated, especially if their symptoms are transient?
  • on-line risk calculators also engender the same issues and their validity needs to be questioned for different populations

Service issues

  • clinical services love cut-off points and use them to determine whether or not patients receive therapies. Is this ethical?
  • how long should UHR services last? Most are for 1-2 years, yet it’s known that the risk period for psychosis is longer
  • how long should UHR patients be treated – a question fraught with engagement and resource issues? In the UK, all people meeting UHR criteria are offered the same treatment regardless of who is more and who is less at risk. If there was some means of predicting who will transition to psychosis, care could be targeted specifically.

Communication

  • how is degree of risk actually discussed?
  • should a diagnosis be made, or should a label be given in the prodromal phase?
  • how much hope or optimism can be communicated? Can hope be offered if outcome is uncertain?In Manchester, risk is not directly addressed. Instead, symptoms are managed rather than considering whether or not the patient might go on to transition to psychosis.

Interventions

  • treating the presenting symptoms is not controversial. However, risk/benefit ratios support different benefits with different interventions. Thus, twice as many patients need to be treated with CBT than with an antipsychotic to prevent 1 episode of psychosis. What to choose – more benign CBT with less likelihood of side-effects or an agent with a higher chance of adverse events?
  • better stratification of risk of psychosis could permit clinicians to target underlying disease mechanisms and offer more personalized approaches to treatment.

Validity of UHR criteria

  • these are largely based on the presence of positive symptoms – is this valid?
  • prevention of psychosis has traditionally been the outcome targeted; but if schizophrenia prevention is the target, do we need to modify the UHR criteria to include negative symptoms? Controlled studies have shown that for a number of different measures patients with first episode psychosis (FEP) are different from those individuals categorized as UHR. So, the threshold for predicting FEP is broadly correct. However, FEP is not the same as schizophrenia - and it’s unknown whether preventing one will prevent the other.
  • should outcomes be expanded to include e.g. help-seeking and distress?
  • should UHR criteria be viewed as transdiagnostic, detecting a range of poor outcomes, e.g. bipolar disorder, major depressive disorder or poor functioning?

As Professor Yung concluded that; there is no conclusion, just a series of issues of the field to consider.

Psychosis or attenuated psychosis?

Diana Perkins, Department of Psychiatry, University of North Carolina at Chapel Hill, described the dilemma she faces in the clinic, because there are no formal guidelines for discriminating between psychosis and attenuated psychosis.

In her practice, when patients present with frequent delusions that are unusual, illogical, not culturally held or compelling, she uses the patient’s level of conviction to determine whether the psychosis is attenuated or not. When the patient is adamant of their own conviction, it’s psychosis.

However, many other psychiatrists do not make the same distinctions. Any signs of psychosis, either attenuated or otherwise, and psychosis is diagnosed automatically – and this has ramifications in the interventions patients receive.  Professor Perkins was concerned that patients might be harming patients through this practice. “Perhaps we should be educating physicians about what is not psychosis,” she concluded.

Perhaps we should be educating physicians about what is not psychosis

Lower transition rates changing perception?

Mark Weiser, Sheba Medical Centre at Tel Hashomer Division of Psychiatry, Israel, explained that since the inception of UHR criteria, transition rates to psychosis have fallen to <10% after 1 year. The underlying reasons are unknown. Additionally, attenuated psychotic symptoms are relatively frequent in the general population, with approximately 10% of people admitting to having attenuated, generally transient positive symptoms; but are not seeking treatment. Such individuals could mistakenly be thought to be in the prodromal phase.

In the general population, with approximately 10% of people admitting to having attenuated, generally transient positive symptoms

This lower transition rate means that persons meeting UHR criteria are being exposed to low dose anti-psychotic treatment when only one in ten of them will have the transition. Furthermore, there are no data supporting that anti-psychotic treatment reduces the onset of psychosis, while there are ample data showing that even low-dose treatments cause side-effects. Such preventative strategies unnecessarily stigmatize a person as a future schizophrenia patient, when the vast majority will never have the illness.

These findings currently mitigate against giving antipsychotic treatment to those in the ‘prodromal’ phase. As Professor Weiser concluded, we need to wait until we understand the biology better.

Preventative strategies unnecessarily stigmatize a person as a future schizophrenia patient, when the vast majority will never have the illness

Our correspondent’s highlights from the symposium are meant as a fair representation of the scientific content presented. The views and opinions expressed on this page do not necessarily reflect those of Lundbeck.

References
  1. Weiser M. Am J Psychiatry 2011;168:761-3
  2. Werbeloff N et al. Arch Gen Psychiatry 2012;69:467-75
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