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Book Title: Treating and Preventing Adolescent Mental Health Disorders
> pp. [130]-[134]
UNDEFINED: AUTHORS
Treating and Preventing Adolescent Mental Health Disorders
Print ISBN 9780195173642, 2005
pp. [130]-[134]
end p.130
PRINTED FROM Treating and Preventing Adolescent Mental Health Disorders (www.oup.com/amhi-treatingpreventing)
© Copyright Oxford University Press, 2006. All Rights Reserved
end p.131
PRINTED FROM Treating and Preventing Adolescent Mental Health Disorders (www.oup.com/amhi-treatingpreventing)
© Copyright Oxford University Press, 2006. All Rights Reserved
phrenia is variable, and despite a large literature, we know relatively little about the predictors of outcome. Duration of untreated illness in various studies also varies widely, ranging between 22 and 166.4 weeks (Norman & Malla, 2001). Several studies have suggested that prolonged duration of untreated illness (DUI) may predict poor outcome as evidenced by longer time to and level of remission. Based on such findings, it has been suggested that decreasing DUI, perhaps by early identification and intervention, might lead to a more favorable outcome. It has also been argued that prolonged untreated illness might be causally related to poor outcomes, perhaps as a result of a neurotoxic process. However, controversy has shrouded this literature, as some studies have not found an association between DUI and outcome. Prevention of schizophrenia through presymptomatic treatment is an exciting possibility, but future research is needed to develop the methodology by which to reliably identify those at risk before this strategy can become part of
routine clinical practice. Once remission from the first episode is reached, maintenance with antipsychotic treatment is indicated for at least 1 year. The overwhelming majority of individuals who do not remain on antipsychotic therapy eventually experience a relapse. This raises the question of the optimal length of continuation and maintenance treatment for patients who have recovered from a first episode of schizophrenia or related psychoses. Clinically useful predictors of the small minority who maintain remission without pharmacotherapy have not yet been identified. Atypical antipsychotics represent an advance in the treatment of first-episode schizophrenia, with strong evidence for greater tolerability with equal or better therapeutic efficacy. While future research will help to characterize their efficacy relative to one another and define the effect of their use on the long-term outcomes of schizophrenia, available evidence and consensus expert opinion support their use as first-line treatment in first-episode schizophrenia.
end p.132
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© Copyright Oxford University Press, 2006. All Rights Reserved
CHAPTER 7 Prevention of Schizophrenia
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There are currently recognized precursors of schizophrenia that are apparent during adolescence. A wide variety of early-intervention techniques have been developed that draw on the knowledge of these precursors to identify individuals at risk for the illness and to prevent the predisposition toward schizophrenia from developing into the full disorder. Unfortunately, most of the research that has enabled the identification of these precursors and the development of these intervention techniques has been performed retrospectively in adults with schizophrenia, with little specific research attention directed toward forms of schizophrenia that manifest during adolescence. In addition, prevention efforts have necessarily lagged behind studies of the risk factors, detection, and early intervention of the disease. Yet, a great deal has already been learned about risk-profiling and early intervention in schizophrenia generally, and those aspects that may be useful in understanding the adolescent forms of the illness are discussed below.
What Guides the Development of Early Intervention and Prevention Efforts?
Traditionally, prevention efforts have been classified at three levels: (1) primary prevention, which is practiced prior to the onset of the disease; (2) secondary prevention, which is practiced after the disease is recognized, but before it has caused suffering and disability; and (3) tertiary prevention, which is practiced after suffering or disability has been experienced, to prevent further deterioration. The primary/secondary/tertiary classification scheme is attractive and simple, but it does not serve to distinguish between preventive interventions that have different epidemiological justifications and require different strategies for optimal utilization. For example, this classification into primary, secondary, and tertiary prevention focuses on intended outcomes rather than on target populations or prevention strategies. More recently, the terms universal, selective, and indicated have been adopted as a valuable way to distinguish preventive interventions. All three of these preventive intervention strategies
refer to the target population. Universal preventive interventions are applied to whole populations, and aim at reducing risk and promoting protective factors. Because obstetric complications have been linked to the subsequent onset of schizophrenia in several studies (Zorenberg, Buka, & Tsuang, 2000), one potentially effective universal prevention strategy would be to focus on lowering the incidence of such complications through improved pre-, peri-, and postnatal care. In contrast to universal prevention strategies, selective and indicated interventions target specific subgroups for intervention. Selective interventions target those who are at elevated risk based on group-level characteristics that are not directly related to etiology. Because schizophrenia is a familial and heritable disorder (Gottesman, 1991), a selective prevention program for schizophrenia might focus on asymptomatic children with first-degree affected relatives or, more specifically, on those with particular combinations of schizophrenia-risk–specific gene variants, as they become known. Finally, an indicated intervention involves targeting individuals who either have signs of the disorder but are currently asymptomatic, or are in an early stage of a progressive disorder. Because there are no universal signs of schizophrenia, indicated interventions for this disorder have a somewhat broad definition. Two lines of research that may lead to indicated interventions for schizophrenia include the study of individuals with prodromal signs of schizophrenia (Eaton, Badawi, & Melton, 1995) and the characterization of individuals with schizotaxia, which can be defined as the underlying predisposition to schizophrenia that may or may not be expressed as prodromal symptoms (Tsuang, Stone, Tarbox, & Faraone, 2002). In order to develop and refine selective and indicated prevention efforts for schizophrenia, the disorder itself (as well as its precursors) must be thoroughly understood. Some of the risk factors for schizophrenia, such as birth complications and a family history of the disorder, are widely recognized. Others are just becoming known or are still being validated. When a wide variety of schizophrenia-specific precursors are available, these features can be used to maximize the efficiency and effectiveness of preventive ef
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doi:10.1093/9780195173642.003.0008
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