Rethinking Psychosis Treatment in Young People
Psychosis is a mental disorder that can effect up to 3% of the population, and usually starts in late adolescence or early adulthood. It can have devastating effects for the individual and their family. Common symptoms of psychosis are hallucinations (hearing or seeing things that others cannot) delusions (false beliefs) and difficulty with memory, concentration, motivation, and organisation of thoughts.
The NHS has invested in a national network of Early Intervention in Psychosis services, so all young people with first episode psychosis can access the best available treatments; these include medication, talking therapies, family therapy and employment support. Evidence suggests that medication has an important role to play in treating psychosis, and in preventing it coming back, but the medications we have to use right now are not ideal for everyone. As COVID-19 focuses attention on individual mental health, the need for early interventions and personalised treatments are more important than ever.
Current medication treatments for psychosis all work in the same way (by blocking receptors for a neurochemical called dopamine) and have significant side effects for a lot of people who take them. The current medication we have also do not work well enough in over 30% of people with psychosis, who have significant treatment resistant symptoms. While some young people recover fully a large percentage go onto have long-term difficulties.
We need to develop new treatments, identify existing treatments that could be repurposed for effective use in psychosis, and move towards better and more personalised medicine. Our previous work has identified that depression and anxiety experienced in and after first episode psychosis is very important in predicting poorer outcomes. Depression has not been traditionally seen as a core feature of psychosis, - it is under-recognised and may be poorly treated. Our work on depression in first episode psychosis has informed better guidance on its identification and treatment, and we are now completing a large, multicentre randomised trial of antidepressant medication in first episode psychosis that will give definitive answer as to whether it is possible to prevent depression in psychosis and the added benefits this may bring.
The growth in understanding of the causes and consequences of mental health disorders over the past years has been matched only by that in immunology, the bodily system that controls, monitors, and responds to environmental challenges. There is good evidence to suggest that how we differentially respond to environmental stressors (e.g. bullying, childhood adversity, deprivation) via stress pathways and immune dysfunction may be causally related to depression, psychosis and other mental health disorders. This gives the opportunity to accelerate the development of better treatments based on immune dysfunction. But there are a number of challenges first to be addressed. Not all young people with psychosis show immune dysfunction, and we need to better understand how to stratify groups into those who may and may not benefit from immune based treatments. We are completing the Psychosis Immune Mechanism Stratified Medicine study (PIMS) - a 5-year program that will be the start of a number of avenues of investigation into the immune system in psychosis.
In the context of this, the challenge that COVID-19 brings to our mental health is considerable but also highly relevant. We have seen clear evidence of the impact of COVID-19 on mental health with increases in depression, anxiety and distress related to social isolation, economic hardship and uncertainty. Young people may be differentially effected by this for a number of reasons, including the increased need for social contact in adolescence and the increased uncertainty of roles, jobs and security. However, COVID-19 also has a direct and profound impact on the immune system which may be relevant to brain function for those who have severe infection; and the short and longer term mental health sequelae to this immune challenge, and how to address is, rapidly evolving. We are working with the Post-hospitalisation COVID-19 study (PHOSP-COVID) to investigate and address the mental health and brain related impacts of COVID-19, and how these may be mitigated in the future.
Recent advances in the understanding of mental health disorders challenges the perpetuation of division between the mind and the body. COVID-19 and recent work at the Institute for Mental Health on immune dysfunction in depression and psychosis also highlights this. One of the final frontiers in medicine is the complex and intertwined nature of the brain response to the environment, and how this may lead to, or protect from, mental health difficulties. To improve health for future generations we need better integration of mental and physical healthcare, full parity in funding for interdisciplinary research that includes psychiatry, and a recognition of the need for this integration at all levels of policy and decision making.
Rachel Upthegrove, Professor of Psychiatry and Youth Mental Health