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Dr. Dixon Says Going Upstream Is Right but Not Without Risk

Moving Upstream is Not Without Risk

Researchers, over decades, have found a robust association between the duration of untreated psychosis (DUP) and outcomes. When measuring the period between the onset of psychosis and treatment, they consistently find that the longer the duration, the worse the outcome overall. Peeling back the layers of first and new episode psychosis often leaves researchers with more questions, including whether antipsychotics are neuro-protective or -toxic, or both depending on the person, and what constitutes treatment. Lisa Dixon, M.D., M.P.H., a Professor of Psychiatry at the Columbia University Medical Center, says it becomes messy. “Treatment marks the end of the DUP, but what defines treatment? Would it include a person admitted to the emergency department who receives two-days worth of antipsychotics but no further treatment? It gets murky, making it essential to get into the details.” 

Dr. Dixon says while recent studies have used a broader definition of treatment, for the most part, the end of the DUP means the use of antipsychotic medication, and what remains a consistent finding is that the longer the period of untreated psychosis, the poorer the outcome over the short and long term. She’s careful to point out that correlation doesn’t mean causation but says there’s no need to invoke causation to justify intervening early and shortening a person’s length of psychosis. “Who wants people struggling with the pain, fear, anxiety, and terror of psychosis without support and treatment? In 99 out of 100 people, it’s safer, more ethical, and better for us to treat the person earlier.” Once psychosis has been around for a certain amount of time, researchers think it can’t be fully treated or undone. Dr. Dixon says that similar to a tumor that grows and grows: once metastasized, psychosis becomes harder to control. This indicates that there might be a critical period where, if intervention happens early enough, it could potentially alter the course of the disorder. She says people deserve early identification and effective treatment that is person-centered and recovery-oriented. 

Early detection is a general principle that’s being applied to many illnesses in medicine and psychiatry, and it stands to reason that for many, if not most, disorders that detecting early will provide some benefits. At the same time, there are many conditions where premature action can be harmful, and watchful waiting would have better. Dr. Dixon says psychosis and schizophrenia can have a traumatic impact on a person’s life, and the early and first episode programs have successfully helped to change the lens, giving hope that people can live with these disorders successfully and meaningfully. “It’s our duty to provide services that do so maximally, but we shouldn’t ignore the potential problems associated with it.” 

Dr. Dixon highlights that going upstream can have an adverse impact if not implemented thoughtfully. In the movement toward early intervention, there is great excitement in the mental health field around whether identification could happen early enough to prevent onset. The problem, says Dr. Dixon, is that the majority of people who exhibit attenuated psychotic symptoms that might precede the development of psychosis don’t go on to develop psychosis. “You can see how it gets complicated. Let’s say clinicians want to offer treatment that prevents psychosis to this group of people, and the treatment has toxicity or is problematic in some other way, and only 20-30% would have ever gone on to develop psychosis. It could interfere with outcomes, potentially causing problems for people who wouldn’t ever have developed psychosis.” 

Dr. Dixon says the objective is to precisely understand the young people who are at risk, not just depend on a phenotype, and offer treatment that could change the development of the disorder. All of which should happen in conjunction with communities, schools, professionals, and families. She says some people may be more vulnerable to developing psychosis, particularly if exposed to structural and psychosocial adversity. “There’s a lot of work to be done,” says Dr. Dixon, “but those in the field need to be careful not to do more harm than good because we don’t know, and don’t have great markers at this point, to predict psychosis.” One population-based approach she thinks is up to meeting this challenge is to focus on youth mental health, including young people who may be having a prodrome, a phase that precedes psychosis. She says perhaps they won’t go on to develop psychosis, but they may have other struggles that benefit from treatment. “As long as what the clinician is trying to provide maps what the person needs, as opposed to what they are at risk for, then you are contributing to the greater good.” She notes that many, if not most, of the mental health conditions that cause pain, suffering, and disability in the world start in the late teens and young adulthood, and not just psychosis, but also depression, post-traumatic stress disorder, and anxiety. “A population-based approach to help mental health and wellness that meets the needs of all of these young people could allow the needs of a larger group to be addressed.”

The challenge, says Dr. Dixon, is there is a fine line between identifying people who are vulnerable and stigmatizing. When talking about young people and early identification, there has to be an awareness that it can shape how they view themselves and what labels they carry as a result, both to themselves and others. What clinicians tell youths, says Dr. Dixon, must be delivered in a way that’s actionable along with adequate support to help them understand what it does and doesn’t mean. “When a clinician says to a 17-year-old, you’re at risk for having breast or ovarian cancer, that teen may begin to think of herself differently. We want to be sure that what we are telling young people about their potential risks is the correct message.” 

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