Schizophrenia Research Forum - A Catalyst for Creative Thinking

Live Discussion: Clinical Care and Research in the Early Stages of Schizophrenia

S. Charles Schulz

Barbara Cornblatt

John Kane

Andrea Auther

Michael O’Sullivan

In the lead-up to next year’s 13th International Congress on Schizophrenia Research in Colorado Springs, Colorado, SRF and the ICOSR will host a series of live discussions on topics of high current interest. This summer we will focus on research that is especially relevant to the clinic with, first, a discussion on the period before or just after the diagnosis of schizophrenia. Later this summer we will take up the topic of comorbidities, specifically schizophrenia and addictive disorders.

ICOSR co-director S. Charles Schulz of the University of Minnesota led a panel that included Barbara Cornblatt of the Albert Einstein College of Medicine, John Kane of North Shore University Hospital and Long Island Jewish Medical Center, Andrea Auther of the Zucker Hillside Hospital, and Michael O’Sullivan of the University of Minnesota in the discussion of recent and current research on the early stages of schizophrenia. This discussion was held in conjunction with the Schizophrenia International Research Society and the International Prodromal Research Network, which will host the Psychosis Satellite Meeting at ICOSR 2011.

View Comments By:
L. Kola Oyewumi — Posted 28 July 2010
Don Linszen — Posted 28 July 2010

Background Text
S. Charles Schulz

Recent years have seen substantial attention focused on the early stages of schizophrenia with a major motivation of understanding the illness before long-term effects of medication treatments and chronicity of illness. As first-episode programs emerged, there came a greater recognition of the clinical utility of early intervention. Examination of the impact of duration of untreated psychosis (DUP) led to a substantial focus on the possibility of diminishing poor outcome in young people with the illness. As the movement in the early stages of schizophrenia through first-episode programs progressed, many clinicians began examining the prodrome—non-specific symptoms preceding the onset of the illness. Work around the world has examined the possibility of psychosocial, nutraceutical, or pharmacologic interventions to diminish prodromal symptoms and even to perhaps forestall the onset of serious psychiatric illness. The purpose of the Webinar presentation will be to examine prodromal programs—including family interventions, to describe a new NIMH-funded trial designed to examine the impact of specific multimodal interventions compared to treatment as usual, and to close with an exploration of recent first-episode brain imaging and neuropsychological testing in the first episode as well as a discussion of family interventions at this stage of disease.

Barbara Cornblatt is director of the RAP (Recognition and Prevention) Program at The Zucker Hillside Hospital, which is a combined treatment and research center. Research focuses on the identification of early biomarkers and risk factors in at-risk adolescents and young adults that predict future psychosis, especially schizophrenia. Prevention of psychosis is the long-range treatment goal of the program. Selection and evaluation of potential treatments are based on research findings, and both pharmacological and psychosocial treatment strategies are currently under study. The program is based on a neurodevelopmental framework, suggesting that there are several different prodromal stages and that treatment should be tailored to the specific needs of the patients, which may differ considerably, depending on whether they are in the early or late stages of the prodrome. In this context, family-focused therapy has several advantages that will be discussed by Andrea Auther, who is the co-director of the RAP Program’s clinical component.

John Kane, Chair of Psychiatry at The Zucker Hillside Hospital, has been involved in the treatment and research of first-episode patients for over two decades. He and his colleagues have reported on the psychobiological characteristics of the first episode and have also published extensively on both short and long-term pharmacologic treatment. Kane now heads a large NIMH-funded intervention study in first-episode schizophrenia and will describe the background and goals of this research.

Charles Schulz, Head of the Department of Psychiatry at the University of Minnesota Medical School, has a long-held interest in the early stages of schizophrenia, beginning with his work with imaging in adolescents with the illness. In this Webinar, Schulz will discuss a multimodal MRI sequence performed in a pilot study with the MIND Research Network to examine differences between first-episode patients and controls, as well as to patients who have had the illness for many years. His colleague, Michael O’Sullivan, will discuss the utility of family psychoeducation to help support parents whose son or daughter has come down with the illness. He will present information on the parents’ response to treatment.

At the conclusion of the Webinar, Schulz, Kane, and Cornblatt will briefly discuss organizations related to their work and the goals of their societies and meetings.

Comments on Online Discussion
Comment by:  L. Kola Oyewumi
Submitted 27 July 2010
Posted 28 July 2010

Thanks for this timely live discussion. Clinical care and research in the early phase of schizophrenia are interesting but challenging.

Many patients with a first episode of psychosis (FEP) present with an associated history of substance use/abuse, particularly marijuana, which has been linked with increased risk for schizophrenia. These patients and/or their caregivers are unable to date the onset of psychotic symptoms and the beginning of "excessive substance use" even after psychosis has cleared with treatment. This makes a clear diagnosis difficult at first presentation, despite the clinician's knowledge of the various criteria for drug-induced psychosis and schizophrenia.

The questions are:

1. After how long should you consider discontinuing antipsychotic treatment (APT), knowing that a diagnosis of schizophrenia may require longer-term or lifelong APT, whereas drug-induced psychosis, and brief reactive and schizophreniform psychoses may not.

Many patients with FEP ask the question: How long am I going to take this medication?

2. All patients with an FEP may not convert to schizophrenia, and a good number get better with initial APT. Most patients and caregivers request a trial discontinuation of APT when in remission, risking relapse and functional decline if the patient has schizophrenia.

If they insist on stopping APT, our current approach is to provide education for early detection of relapse and to encourage continued participation in our program. This helps us with prompt treatment of relapse. It also gives us the opportunity to study "time to relapse" (TTR), an area difficult to explore with formal research because of ethical implications.

Do you have other suggestions?

View all comments by L. Kola OyewumiComment by:  Don Linszen
Submitted 28 July 2010
Posted 28 July 2010

Is a first psychotic episode program a necessary condition to detect people at high risk of psychosis?

View all comments by Don Linszen