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Welcome to PsychEd, psychiatry podcast for medical learners by medical learners. This episode covers clinical high risk for psychosis. I'm Alex Raben.
I'm the host for this episode. I'm also a staff psychiatrist at CAMH. I'm joined by two co-hosts today, Rebecca Marsh.
Hi, everyone. I'm Rebecca. I recently finished medical school at U of T, and I'm an incoming psychiatry PGY-1 resident at McMaster.
Thanks, Rebecca. We also are joined today by our co-host, Luke Fraccaro. This is your first time on the podcast, Luke, but Luke really led this episode.
Thank you.
Thanks for having me, Alex. My name is Luke. I'm a PGY-1, soon to be PGY-2 psychiatry resident at the University of Toronto.
Thanks, Luke. And we're very thrilled today to have our expert all the way from Alberta, Dr. Thomas Raedler. He's a psychiatrist and associate professor at the University of Calgary.
He's also a member of the Matheson Center for Mental Health Research and Education of the Hotchkiss Brain Institute at that same university. Dr. Raedler is also one of the authors of the Canadian Treatment Guidelines for Individuals at Clinical High Risk of Psychosis. And that was actually how I personally gained some interest in this topic.
So we're really thrilled to have you, Dr. Raedler. Welcome to the show.
Thank you for having me. This should be interesting.
For sure we hope so. So why don't we jump right into the learning objectives for today's episode. We'll talk about what we hope to cover.
So by the end of this episode, we hope that you will be able to, number one, recognize a patient who is or may be clinically high risk for psychosis and have an approach to a differential diagnosis. Number two, understand the importance and utility and prognosis of the various risk groups within that clinical high risk population. And then finally, number three, that you have an approach to the initial management of this patient population and an understanding of the array of options of more specialized treatments that are available.
Okay, so that's what we're hoping to cover today. And we're actually going to start off with a case that we can bring with us through these various learning objectives to help bring it alive a little bit. And so I'm going to hand it over to Rebecca to take us through that case.
And then we'll launch into some questions.
Okay, so for our case, we have Eric, who is a 19 year old high school student who lives at home with his father and presents to the early psychosis intervention program today after referral from his family physician. So for the last four months, Eric has been absent from school several times a week, avoiding his peers due to a sense that they're out to get him and feeling as though someone is trying to speak to him directly through his assigned readings. Eric reports seeing markings on his parents' furniture move around on their own and has tried using self-talk on several occasions to remind himself that what he's seeing is not real.
He denies using any substances and is not currently taking any medications. His father expresses great concern that Eric has become increasingly withdrawn over the past year and Eric admits that he has not been feeling like himself at all. Both him and his father are hoping that you could provide some sort of answer.
Okay, so that's our case for today to keep in mind as we speak a little bit about this topic. So I guess just to get started in terms of a basic introduction to clinical high risk for psychosis, Dr. Raedler, would you be able to tell us what does it mean to be clinically high risk for psychosis?
The whole concept of clinical high risk for psychosis is a fairly new concept. Taking into consideration that we're trying to identify people with a severe mental illness or who are at risk of developing a severe mental illness at an early stage of illness because we believe that our ability to intervene is the best at the beginning of illness. So the whole concept of clinical high risk of psychosis is looking at a group of people who are considered to be seen at a higher risk than the general population of developing a psychotic illness.
Please keep in mind that it is not entirely uncommon for quote unquote healthy people to also experience some form of psychosis like symptoms. But this is a group of people who are considered to be at higher risk of developing a psychotic illness. However, at the same time, the symptoms have not crossed a threshold to a psychotic disorder like the ones that we all know.
And in order to get back to your vignette, obviously, one of the questions that I have just reading the vignette is, is this person still in the clinical high risk area of things? Or has this person already crossed the threshold to a true psychotic disorder? I would also like to mention that the group from Melbourne who has been implementing this concept has recently expanded on their concept of clinical high risk.
They're not just looking at clinical high risk for psychosis, but they're also including other psychiatric disorders, including bipolar disorder, depression, severe personality disorders, and psychosis as a way of identifying people who are at risk of developing a severe psychiatric illness and then try to help them at a very early stage and prevent a worsening of their condition.
And what kind of criteria or symptoms would you typically look for that would make someone clinically high risk?
In order to be eligible for diagnosis of clinical high risk of psychosis or attenuated psychosis syndrome, as it is now listed in the DSM-5, interestingly enough, it's listed in with a lot of details as a research diagnosis. As a condition that is subject to further studies, but at the same time, it's also listed with a lot of descriptors in the other schizophrenia spectrum disorders. So it has made it into DSM-5 and it also has a code now 298.8.
And the criteria that we're looking at are psychosis like symptoms, including delusions, hallucinations, disorganized speech. Again, that are not occurring at the same rate or intensity that we would expect for somebody with a psychotic disorder, but more than what you would consider to be quote, in quote, normal or explained by other factors.
That makes sense. And is there a typical age that someone who's clinically high risk presents at?
In most cases, people present in their late adolescence, early adulthood, which is, as you surely know, the age of onset for many other psychiatric disorders, especially schizophrenia, and with the whole concept of clinical high risk for psychosis, we're trying to identify people early on who are at risk of developing a psychotic disorder and then trying to implement treatments so that we can prevent worsening from occurring.
That makes sense. And with this presentation, are there other psychiatric illnesses that you should have on the differential or that can mimic some of these symptoms?
Yeah, there's always a lot of different diagnosis on the differential. And keep in mind that establishing a psychiatric disorder is frequently a process, not based on a one time assessment. Part of what we do in our clinic is we try to get to know people better.
Sometimes it takes a little bit of time for people to be willing to acknowledge the full extent of their psychotic symptoms. But obviously, first of all, you would want to make sure that you're not dealing with people who actually have a psychotic disorder, either unspecified schizophrenia spectrum disorder, bridge psychotic disorder, schizophrenia, schizoaffective disorder, or any of the other psychiatric disorders that can also show psychotic symptoms, including bipolar disorder and depression. There's also large overlap with personality disorders, especially with schizotypal personality disorder.
You always want to make sure that the symptoms are not caused by substance use or use of other substances or other medical problems that could be causing the symptoms that we're seeing.
Yeah, doing some reading, I was definitely considering a lot of those in terms of the schizotypal personality, the potential for substances. And I think now I'll hand it over to Luke to talk a little bit about the importance of having this clinical high risk for psychosis and the utility of it.
Yeah, so now that we have a bit of an understanding on what clinical high risk for psychosis is and who may be at risk for it, wondering now if we can talk about its importance and its utility. Kind of just like general question, why is it important to identify these individuals who are at risk of psychosis?
As I said earlier, the goal is to prevent a worsening of their clinical condition. And we're always hoping that we can prevent the manifestation of a true psychotic disorder or a serious mental illness to begin with. We're hoping that with implementing the right kind of treatment and also helping people to make lifestyle changes, that they will be able to stabilize their condition and not go on to develop a serious mental illness.
So this has seemed to be a prevention at a very early stage of illness.
And when reading through the research for this episode and thinking back to my experience observing in your clinic in Calgary, I was wondering how do these individuals get referred to clinical high risk clinics? Are they being referred by their family doctors or other concerned physicians who may see them maybe in an emergency scenario? How do the patients get referred to these clinics?
We try to make things as easy as possible. Essentially, we take referrals from whatever source. We take self-referrals.
We take referrals from family members. We have an organization, Access Mental Health in Calgary, that helps people find psychiatric treatment in the community. We take referrals from emergency rooms, psychiatrists, family physicians, or other community agencies.
We used to be part, well, we're still part of the NAEPL study, but as when the NAEPL study was at its height, NAEPL stands for North American Prodroma Longitudinal Study, which is a multi-center research study focusing on people who are considered to be at high risk of developing psychosis. They had a whole person dedicated to recruitment of possible subjects. We're very fortunate in Calgary that we have several clinics here that focus on people who are seen to be at high risk of developing psychosis.
The reality, however, is that these services are not as widely used as you would expect them to be. There should be a tremendous clinical need for these services, but we actually see far more need for early psychosis services as compared to the clinical high risk group of people.
So, for family physicians then who may be concerned about a patient of theirs who is showing possible signs of being at high risk for developing psychosis, are there like available screening methods that they can then use to maybe identify those who would be at higher risk to then make referrals to a psychiatrist who could assess them?
There are several tools available that we use to establish a diagnosis. There's the SIPs and there's the CARMS. Both are structured clinical interviews that focus on people who are considered to be at high risk of developing psychosis.
The problem is, however, that both interviews take a lot of time. They take about one and a half hours. And in order to be able to administer them properly, the RAIDAs have to be well trained to be able to use these tools.
So they're not very practical for family physicians or other health care professionals. I guess the reason to refer to one of those clinics is if they have concerns that there may be a in quotation marks, budding psychotic illness occurring in a given patient. There's also another screening tool which I just read about.
I don't have personal experience with it. It's called the EPSI Early Psychosis Screening Over the Internet, which is a shorter version. It's about 26 questions or so and it can be administered over the internet.
But as I said, I haven't seen a lot of studies using this tool. So I cannot say for sure if it is as helpful as it seems on paper. And in our clinic, whenever we get people referred, we start out with doing a detailed interview and then we do what we would always do, try to get as much information either from past records, try to obtain collateral information.
And sometimes it takes a little bit of time to get to know people, to have them build up trust, to get the full story of what has been going on. Some people hesitate to admit to all their symptoms when we see them for the first time.
So once these patients have been referred to a clinic such as yours by concerned physicians, whether it's a family doctor or like you said, even sometimes self-referrals, I'm wondering now like what does the prognosis look like for these individuals who are at clinical high risk for psychosis? How many go on to develop psychosis?
That's an excellent question. And there's actually fairly good news there because it seems as if over the last decade, the conversion rate to psychotic illness has decreased significantly. It used to be in the range of 30 to 40 percent over a two to three year period.
And now it's more in the range of 15 to 25 percent. The longer you wait, the more cases there seem to be. But in most larger centers now, the conversion rate has decreased significantly.
But it still seems to be in the range of 20 to 25 percent over three years. And it's important to keep in mind that with people whom we see in our program who are being assessed for having a clinical high risk state for psychosis, that only a maximum of a third go on to develop a psychotic illness. However, this is not the only thing that I'm concerned about when I treat people who I see a clinical high risk of developing psychosis.
Because we also know from further studies that a lot of people who don't convert to a psychotic illness still continue to struggle with their level of comfort and also their level of functioning. So it's not all about preventing the conversion to psychosis from occurring. It's also helping people be more comfortable and reach their full potential and their full level of functioning.
So then to follow up on that, like what are some of the other possible outcomes for individuals who are clinical high risk? Like you mentioned, only around like a third or less would go on to convert to like a psychosis in the non-conversion group. What other possible outcomes can happen for these individuals?
Well, first of all, there's a large comorbidity with other psychiatric disorders, including anxiety disorders, mood disorders, substance use disorders, personality disorders. And in our clinic, we've also seen a significant amount of people who present with a previously undiagnosed autism spectrum disorder. So we do see a very varied group of people.
If there's another comorbidity present, obviously, we try to help people address that comorbidity. We treat their mood disorder. We treat their anxiety disorders, if possible.
We encourage people to use, make good choices for themselves. We encourage people to ideally stop using substances altogether. Or if that is not possible, if that is not what people want to do, to reduce their substance use as much as possible.
We encourage people to lead a healthy life by focusing on healthy activities, good nutrition, sufficient level of physical activities, and thereby trying to help them improve their overall level of functioning and their overall level of comfort, while not losing the risk of conversion out of sight. Obviously, whenever I assess a patient with a clinical high-risk clinic that I run, it's always on my mind to make sure that I'm not seeing a worsening of their risk of developing psychosis.
And are there any protective factors that can reduce an individual who is at clinical high risk of psychosis from progressing and converting to a psychotic disorder?
Yeah, we know that being health-seeking is a protective factor. Those are individuals who are interested in receiving help and we're trying to give them as much support in a multidisciplinary setting as possible. We know that addressing substance use helps to limit the risk of conversion.
We know that treating psychiatric comorbidities helps to limit the risk of worsening of their overall condition. So by implementing all of these treatments, or I would say by offering all of these treatments, we're trying to help people. And for some people, we try to come up with a treatment plan, and for some people, we just tell them that we're going to be monitoring their condition, or we're going to be available for them just in case if things do change.
Sometimes we see young people who are not that interested in undergoing more intense treatment, but we tell them the door is always open if things do change. We tell them our program runs for three years. Within those three years, if they want to come back, if they want to receive further treatment, or if they want to have further assessments done, all they need to do is give us a phone call, and we'll try to schedule them as soon as possible.
Great. So maybe just kind of taking this back to our clinical vignette example here. So if we look at our case with Eric being a 19-year-old high school student, who seems that he's been experiencing some of these, like, attenuated positive symptoms of psychosis, the fact that he and his father together are going to see a physician about this, that they are help-seeking, and that in his case, he does not use any substances, and I believe doesn't have any other comorbidities, would be like protective factors in this clinical example.
Eric's situation sounds like a very scary situation. And for a lot of people, just to know that there's a program available where they can get help, where people understand them, makes them feel more comfortable in itself. So I would be happy to admit Eric to my clinic, and then we would try and come up with a treatment plan to help limit his level of distress and help him to resume his previous level of functioning.
And on that note, Dr. Raedler, you mentioned kind of early on that you even wondered if Eric might be at that tipping point of conversion. And I wanted to explore that a little bit further. It's kind of the opposite of what Luke was saying with protective factors.
Are there also different risk levels within the clinical high risk population? I know people throw out terms like blips and attenuated positive syndrome and genetic risk. What do those terms mean?
And do they convey different risk? And does that apply in Eric's case?
Well, whenever we look at people who are at clinical high risk of psychosis, we look at three different syndromes. There's attenuated psychosis syndrome. Those are people who are experiencing psychosis like symptoms.
They happen at an intensity that does not cross this artificial threshold where we start to call it a true psychotic disorder, either because they're not severe enough or because they're not happening frequently enough. But they're still happening frequently enough that people are concerned about them. And in our clinic and in most other clinics, they're the bulk of the population that is considered to be a clinical high risk of developing psychosis.
However, there are two other syndromes that are different from the attenuated psychosis syndrome. There's the BLIPS, the brief limited intermittent psychotic symptoms. Those are people who for a very short period of time experience an acute psychotic episode.
It can be a couple of minutes. It can be up to a couple of hours where they experience typically very intense symptoms of psychosis. Either they become very paranoid or they start to experience perceptual abnormalities.
But then these symptoms are of short duration, either a couple of minutes or a couple of hours and don't tend to occur very frequently. And the other syndrome that we're aware of is genetic risk and deterioration syndrome, which encompasses people who have a family history of a first degree relative with a psychotic disorder and who have experienced some kind of decline in their own level of functioning. Again, the blips and the genetic risk and deterioration syndrome tend to be much occur much less frequent than the attenuated psychosis syndrome.
We know from different studies that interestingly enough, it seems as if the outcome of the genetic risk and deterioration syndrome actually doesn't seem to be that different from health seeking individuals who are not seen to be at high risk of developing psychosis. That came as a bit of a surprise to me, but that's the outcome of some of the studies. At the same time, we also know that over time, the risk of conversion to psychosis seems to be the highest for people who suffer from blips, the brief limited intermittent psychotic symptoms.
And those are the ones who are at the highest risk of developing psychosis. However, please keep in mind that the attenuated psychosis syndrome group is by far the largest of all groups. We also know that there are a couple of risk factors that put people at higher risk of developing psychosis.
Nothing should come as a big surprise. Those individuals who have a fairly high symptom burden in terms of psychosis like symptoms seem to be at higher risk of developing psychosis. Also, those individuals who present with primary negative symptoms seem to be at higher risk of developing a psychotic illness.
Those individuals who struggle with a significant decrease in their level of functioning at the time of their initial assessment also seem to be at higher risk of developing psychosis over the next three years.
I see. That's really helpful to break it down. So to recap, the attenuated psychosis syndrome is the largest group, but it's kind of in the middle in terms of level of risk because blips is what seems to be the highest and then the genetic deterioration risk and deterioration is the lowest there.
And then there are even some nuances within that, so if there's a lot of functional impairment or negative symptoms, that can also be an independent risk factor. With Eric, I'm wondering what category we think he falls in here. I was just reading through the vignette to see if I could identify.
I don't think he has a family history, from what I can see here, but he is seeing markings on his parents' furniture moving around. So that sounds like a visual hallucination. So I'm guessing he's blips, but I don't know what you guys think.
I guess that's the most likely assumption.
He may be blips or possibly also attenuated psychosis syndrome, because I think it said somewhere that the symptoms were going on for a couple of weeks. I don't have the vignettes right in front of me. I think there was a statement on the time course.
For the last four months.
Four months. Yes. So that would be too long for what you would expect in blips.
It would be either a couple of hours or maybe a day or two at the very most. And then again, you're getting into threshold territory. At some point, you need to distinguish blips from a brief psychotic disorder.
Keep in mind, there's no clear cutoff for those things. In many cases, it's clinical judgment and it is up to the treatment team to make the ultimate decision. If they're still considered to be in the clinical high risk area of things, or if people feel that they have crossed the threshold to primary psychotic disorder, which then would put them out of the range of clinical high risk.
Right. So yeah, thanks for clarifying. And it sounds like the timing is quite important there.
As you say, blips, you would expect it to be briefer than the four months, but it sounds like we would need a bit more information. We'd have a few more questions for Eric and his family to sort that one through completely. I just had a quick follow up with the attenuated psychosis.
Can you give us a concrete example of that? Would that be like an overvalued idea versus a delusion? Like, is it just like fixed?
Would that be one attenuated symptom?
The criteria that is frequently used is that people still continue to have insights into these symptoms, that they're not convinced that they're happening. They still have some doubts into the reality of.
Part of the beauty of our field is that things are not black and white, that we have a lot of gray and sometimes it's light gray and sometimes it's dark gray, but gray remains gray and ultimately in many cases there is not an easy solution. And as I always tell my students that clear situations are clear, it's easy to identify somebody who's in the midst of a clear psychotic episode because the symptoms are so clear, it's this gray zone that can be very difficult. And also you would want to watch the time course of symptoms.
We also know that those people who are experiencing a clear worsening in the severity of symptoms are also at higher risk of eventually transitioning, converting to a psychotic illness. So that's something that we will be monitoring very closely.
Right. So that's a very good point that we're talking at idealistic terms here to help learn a lot of these points. But in clinical reality, it can often be pretty gray, but you could take advantage of longitudinal assessments and monitoring over time and certainly thinking through these principles in those clinical decisions.
I wonder if we, I think maybe now we can turn to treatment. We've alluded to some of that already. Dr. Raedler, you alluded to it, like treating comorbidity.
Helping with function. But yeah, I thought we could go through the some of the points you raise in the guidelines, the Canadian guidelines and how that applies to our case or people who fall into this category. So as you mentioned, and as the guidelines mentioned, ideally, these patients would receive specialized care at a specialized clinic, although you were mentioning that's not always possible.
How, I guess my question surrounding that point is how do these clinics run? Like how often would people be followed? Who's part of those teams?
Well, I can only speak for our clinic here at the University of Calgary. We're part of the Early Psychosis Intervention Program. All individuals who join our program are teamed up with a psychiatrist and a case manager.
And we tend, in the beginning, we try to see them more frequently, maybe every three, four weeks. But we always tell people clearly that we're always available for crisis situations. And I always tell people that we're just a phone call away.
If things change, they should just give us a call and we'll try to see them the very same day. We're in a fortunate situation that we have a lot of other services available in our program. We have a social worker who can help with some of the social aspects of life.
In Eric's situation, that doesn't seem to be that much of an issue because I think he was still living at home. So presumably, he didn't have to worry, have immediate worries about his livelihood, his safety. But it's important to have the support of a social worker if the social situation seems very difficult.
Then we also have occupational therapists working on a program helping people to look into options for their return, either back to school or back to work or planning what the next steps should be. We also have psychologists and individual therapy specialists in our program. We offer group therapy.
We offer individual therapy. We also have a family worker working in our program, which means that we can provide a lot of the treatments that are recommended for people who seem to be at a clinical high risk of developing psychosis. First of all, it's important to keep in mind that unfortunately we don't have a lot of clear information available.
There was a meta-analysis done recently and the summary is always the same, that we need more studies, we need more information to come up with clear recommendations. But with regards to treatment, we do have some general recommendations. We know that individual therapy can be very helpful, mainly CBT.
We know that there are some studies showing that CBT was superior in terms of outcome when compared to supportive therapy. We also know that there's a tremendous role for family therapy as a first intervention. So we try to offer these interventions as well.
And then ultimately, there is also the risk of pharmacological treatment. And that is where I have two different thresholds. I have a fairly low threshold for treating subjects who seem to be a clinical high risk of developing psychosis for comorbidities like depression or anxiety.
I start treatment in a lot of my subjects with an antidepressant to try and help with those comorbidities. And it's frequently very helpful. But I do have a higher threshold for the use of antipsychotic medication.
But obviously, that's one of the issues that always comes up. First of all, it's important to keep in mind that we do not have good data on the use of antipsychotic medications. There were to date only two studies that I'm aware of, one using risperidone, one using olanzapine.
The study with risperidone showed initial superiority to people who were on placebo. But then after one year, the differences were no longer present. And the study with olanzapine showed some clinical advantages, but the side effect profile was fairly pronounced.
So the recommendation was to exert some caution about the use of these antipsychotics. But we have newer antipsychotics available. Unfortunately, there's not a lot of data supporting the use of these agents in people who are considered to be at clinical high risk.
The reality is, however, the closer people get to this artificial threshold for a psychotic illness, the more likely the treatments team will be to consider antipsychotic treatment. And it is something that I always bring up with people. I tell them, well, we typically try therapeutic interventions first, and if they're not getting the benefits they're hoping for, I tell them there's also the possibility to look into pharmacological treatment.
I tell them that is beyond the indications for these medications, but there is anecdotal evidence supporting their use. Ultimately, it is something that I leave up to each individual to decide for themselves. Please be, it's important to be aware that the NICE guidelines strongly recommend against the use of, using antipsychotics for preventative reasons.
However, as soon as people are seen to be psychotic, then obviously antipsychotics are being indicated. There was a fairly interesting recent development, and I also run our clinical trials program here at the University of Calgary. We were part of a clinical trial that was sponsored by Boehringer Ingelheim, that specifically focused on people who were diagnosed with attenuated psychosis syndrome.
It's an interesting story because the initial outcome measure for this clinical trial was a conversion to psychosis, and then apparently they did some more reading and saw that this doesn't seem to be that much of an issue anymore. With the cohort that they were hoping to recruit, they would not be able to see the effects that they were hoping for. They had some pretty convincing evidence from preclinical trials were using this compound, which was a phosphodiesterase 9 inhibitor, which works on the second messenger system and is also supposed to have some effects on synaptic pruning.
There were some interesting results from animal studies were using this compound in combination with doses of methamphetamine prevented some of the sensitization for psychosis that were seen in untreated animals from happening. However, this study was off to a very slow start because, as I said earlier, this condition is very difficult to recruit for and then COVID happened. And then I think it was about six months ago that the company eventually decided to discontinue this clinical trial after they had changed the outcome from conversion to psychosis to time to stabilization.
So the interesting thing is there's some interest from the pharmaceutical industry to pursuing treatments for this condition. And I do use pharmaceutical approaches frequently in my treatment. I think it would be great if we had a medication that even if the conversion rate is only 30 percent, if we could offer effective treatment to limit this risk of conversion.
But so far we have no agents with proven efficacy available.
But it's good to hear that there's interest in developing that because that's where you're going to have huge, I guess, public health ramifications down the line, fewer psychotic illnesses, which we don't have cures for at the moment and can be quite debilitating. And thank you for painting that picture of the clinic. It sounds very multidisciplinary.
It sounds like you take a sort of stepped approach with psychotherapies, primarily CBT sounds like has the most evidence. And then if needed, and the family therapy and family therapy.
That's a very important part of our program as well. And there's really good evidence for family therapy as well.
Of course. Yes. And I think that's also true for schizophrenia and the adult population.
So that makes sense to me intuitively. And then what I'm hearing, though, is you have a fairly high threshold for using antipsychotic medications, given the side effect profile of those medications, the sort of lack of research so far in that realm, but some degree of evidence. So it can be used, but more as a higher threshold before you go there.
I wonder, because I work in chronic care, so my mind is thinking longitudinally these days. How long do you follow patients in these clinics and what happens afterwards? Like if someone doesn't convert, but they still have these functional deficits, like, can you give us some idea of how that plays out?
We know from longitudinal studies that a significant proportion of people attending a clinic for high risk does convert to psychosis and will eventually end up in the psychosis stream, like for us, the early psychosis program or the adult psychosis program. We also know that there's a significant amount of people who do recover fully and then don't require further interventions, but we also know that there's also a significant amount of people in these clinics who, even though they do not convert to psychosis, continue to struggle with their level of functioning over time. Where even though the psychosis risk has been eliminated, their level of functioning is not what we would hope for.
And those people will then end up in the general psychiatric population. Our program runs for three years. And at the end, then we need to make decisions.
Obviously, if people have become symptomatic in terms of a psychotic illness, or also transitioned to, let's say, depression, or bipolar disorder, severe personality disorder, then we would refer them to for ongoing psychiatric care. A lot of the people, once they're done with the three years in our program, don't require ongoing psychiatric care, and then are discharged back to their family physicians. Well, knowing that if things change, they can always be referred again for psychiatric outpatient care.
Right. So it's quite a range of potential outcomes. But you tend to follow people for three years, and then make decisions based on where they're at at that point, it sounds like.
And also what kind of treatment people want to get.
Right. Makes sense. Thank you for covering that, Dr. Raedler.
I just want to see if my co-host had any last burning questions here, as we're almost out of time. But I want to make sure they have an opportunity.
Yeah, not so much of a question, but just kind of like an observation after reviewing for and prepping for this episode and our discussion today is that it seems that this group, like Clinical High Risk for Psychosis, even as you mentioned, Dr. Raedler, the proportion that are transitioning or converting to psychosis has decreased over the years, but there's still a significant amount that continue to have functional impairment or comorbidities. It kind of seems like this population is like a high risk for psychiatric disorders rather than just like a high risk for psychosis. And it's interesting to see how this, like studying this population continues in the future.
I'm wondering like, where do you see this field heading in the future? Or what more could be done?
Well, as I mentioned earlier, the group from Melbourne is now switching more to a general approach where they're looking at people who are considered to be at high risk of in quotation marks something and not so much of a focus on the high risk for developing psychosis, because we know that we can identify a group of people who are at high risk of severe psychiatric disorders. And I think it's a very good use of health care resources to try and offer as much treatment as possible to these people, because if we can prevent their situation from getting worse, if we can help them to get more comfortable, they will be able to have lifelong benefits from this treatment. In terms of where I see the field going is, first of all, it would be nice to have a better understanding of what is going on, having some kind of factors that help with risk stratification to identify people who are really low risk, people who are very high risk of developing psychosis or another psychiatric illness.
There's a lot of interest into biomarkers or other factors that help to identify the risk of an individual. It would also be great to have better treatment options available, more specific treatment options for this group of people, being able to find the right treatment for an individual patient. At this moment, we're using treatments that are well established in psychiatry, but we don't have a lot of very specific treatments for this group of people.
Hopefully, over the next couple of years, we will gain a better understanding of what we can do to help this fairly vulnerable group of people to become more comfortable and reach their goals in life.
Well, what a wonderfully hopeful message to end on. Thank you so much for that, Dr. Raedler. And as you say, this is an area where we can have an impact on people's lives that will potentially change their trajectory, for lack of a better word, for the better.
And so it's quite impactful and quite hopeful. I just want to make sure we have a nice wrap up here before our Zoom call closes on us. And I want to make sure, Dr. Raedler, that we thank you again for joining us.
And we really appreciate you taking the time out of your busy schedule to join us and to help our audience understand this really important topic. So thank you.
Thank you. It was my pleasure.
Well, until next time, everyone, thanks again for listening.
PsychEd is a resident-driven initiative led by residents at the University of Toronto. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views endorsed in this episode are not intended to represent the views of either organization.
This episode was produced and hosted by Alex Raben, Luke Fraccaro, and Rebecca Marsh. The audio editing was done by Rebecca Marsh. Our theme song is Working Solutions by Olive Musique.
A special thanks to our incredible guest Dr. Raedler for serving as our expert for this episode. You can contact us at psychedpodcast at gmail.com or visit us at psychedpodcast.org. Thank you so much for listening.