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ONE-WAY PASSAGE?
Voices from nowhere // Hallucinations // Full-blown paranoia // Doctors try to stop a terrifying disease before it even begins.

Halting Schizophrenia

By Charles Schmidt // Photographs by Peter Rad // Spring 2008
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Prodromal schizophrenia

A young man we’ll call John had been hospitalized multiple times for acute anxiety and depression when he began hearing voices and seeing violent images. The 19-year-old rarely left his parents’ home in a Portland, Me., suburb, and he had threatened suicide. Yet, desperate as his situation seemed, it was hardly unique. Each year thousands of adolescents and young adults are struck by similar symptoms that frequently, perhaps one time in three, prove to be the precursors to full-blown schizophrenia, a grim diagnosis of delusions and paranoia.

More often, though, schizophrenia doesn’t develop, so doctors have tended to proceed cautiously as they try to determine exactly what is troubling these young people. But William McFarlane, a psychiatrist at Maine Medical Center in Portland and director of a mental health program called Portland Identification and Early Referral (PIER), doesn’t wait. In John’s case, McFarlane and his staff moved to block John’s anticipated psychotic illness with a mix of medication and family counseling that helps patients cope with stressful situations at school and work. Two years later, John is living on his own for the first time, holding down a job at a Goodwill store and hoping someday to go to college. “They helped me control my emotions and deal with the images in my head,” he says. “I can go about my life now in a way that I couldn’t before.”

McFarlane thinks that, at least some of the time, schizophrenia can be headed off—and that measured against the undoubted perils of the disease, early action is justified. A condition that may account for as many as 25% of the suicides among young people in the United States, schizophrenia is notoriously difficult to treat. As patients begin to lose touch with reality, they tend to withdraw, putting themselves far beyond the reach of those who might help them. But studies show that one to two years typically pass between the onset of symptoms and the first psychotic breakdown, and McFarlane’s approach is to act decisively during this precursory, or prodromal, phase. Other scientists also advocate aggressive treatment during the prodrome, though McFarlane is more willing than most to take the controversial step of prescribing antipsychotic drugs to patients with severe symptoms who may or may not ultimately develop schizophrenia.

The potential benefit of keeping schizophrenia at bay, perhaps permanently, is huge, and McFarlane’s methods are now getting a much broader test. His research program has expanded from Portland to small cities in California, Michigan, New York and Oregon, and depending on the study’s conclusions, McFarlane’s methods could one day contribute to routine clinical practice. Meanwhile, other research is rushing ahead in the United States and elsewhere.

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An Ounce of Prevention

Five substances are being used or tested to keep prodromal symptoms from progressing into schizophrenia, but the risk-benefit ratios are still being worked out.

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hed-dossier

1.“Prediction of Psychosis in Youth at High Clinical Risk,” by Tyrone D. Cannon et al., Archives of General Psychiatry, January 2008. Involving 291 patients from research centers countrywide, this study was the largest to date to investigate the degree to which prodromal symptoms can predict schizophrenia—perhaps as often as 80% of the time.

2.“Prodromal Assessment With the Structured Interview for Prodromal Syndromes and the Scale of Prodromal Symptoms: Predictive Validity, Interrater Reliability, and Training to Reliability,” by Tandy J. Miller et al., Schizophrenia Bulletin, Vol. 29, No. 4, 2003. Describes the origins of the key diagnostic tool for prodromal symptoms.

3.“Family Expressed Emotion Prior to Onset of Psychosis,” by W.R. McFarlane and W.L. Cook, Family Processes, June 2007. This study concludes that the heightened “expressed emotion”—criticism and anger—that families experience during a member’s prodromal phase is a reaction to, not a cause of, the member’s symptoms.

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