Adolescence is a challenging period for everyone, but for those with mental illness, it’s particularly sensitive.
Between the ages of 14 and 25 – known as a “transition age” – is a time when symptoms of psychosis are known to appear. It's also when people switch from child mental health services into adult care – not always a seamless process.
Joanna Henderson, an assistant professor, and Dr. Aristotle Voineskos, an associate professor, both from U of T Faculty of Medicine's department of psychiatry and CAMH, are launching a new research project aimed at identifying early signs of psychosis. The ideas is that if we could spot the signs early, we could potentially ensure continuous care for the most vulnerable.
They spoke with U of T's Carolyn Morris about the new initiative, which is receiving key funding from the Miner’s Lamp Innovation Fund in the Prevention and Early Detection of Severe Mental Illness, a philanthropic initiative of IAMGOLD Corp. and its partners.
How are you setting out to identify the signs of psychosis early?
Aristotle Voineskos: Due largely to the way the brain develops, symptoms of psychosis only tend to emerge in mid to late adolescence. And while we’ve found certain associated biological or social factors, for the most part, researchers haven’t yet figured out what puts certain people at higher risk of developing psychosis symptoms later on.
These are much more common in youth than people realize – up to 20 per cent in the community if you include mild symptoms. We’re not talking about risk for schizophrenia. That’s not what this study is about. Instead, we’re focused on studying the number, severity and course of psychosis symptoms over time, and how those symptoms impact functioning.
One place we often forget to look at is young people who already have a mental health condition. Early psychosis has typically been the domain of adult psychiatrists, but we really need to partner with child and youth psychiatrists to understand trajectories of development and illness.
Recent research findings have found that kids who are diagnosed with conditions like autism spectrum disorder, oppositional defiant disorder or ADHD are at a higher risk of developing symptoms of psychosis later on. But that’s still a broad group of people, and only a fraction of them will actually go on to struggle with psychosis so we’re planning to follow a group over time and try to identify other possible signs that might serve as red flags.
What happens in our current system?
Joanna Henderson: There can be a number of challenges getting access to care, but if all goes well, a young person who is experiencing difficulties would be getting the care they need for ADHD or other diagnoses.
They might get referred to a psychiatrist, receive a diagnosis and be provided with medication or other treatment. Once they are adjusting and doing well, they would stop seeing the psychiatrist, and their care would be returned to their family doctor with care focused on maintaining treatment gains and monitoring for setbacks.
So they’d be getting the appropriate set of services for ADHD. What can be missing, however, is systematic screening over time for other kinds of difficulties. For example, even though a young person might be at a statistically higher risk for developing psychosis symptoms, they would not necessarily be monitored for these. And I wouldn’t want to alarm anyone – the risk of developing severe psychosis is still very low. With this study, we’re hoping to monitor a group of approximately 200 kids with diagnosed mental health problems like disruptive disorders, keep track of how they do over time and ideally identify specific red flags associated with psychosis.
How would the ability to spot the signs of psychosis early change the quality of care?
Aristotle Voineskos: Psychosis symptoms can have devastating repercussions for the individual, his or her family and others. School performance goes down. They can become socially isolated, and have increased suicidal thinking and more. We know that the longer psychosis goes on without being treated, the greater the adverse impact on that person’s life.
So early identification makes a big difference in how these people do. We thought it would be important to understand which young people already getting mental health care for issues that emerge earlier in life such as autism, ADHD, or depression have elevated risk for psychosis symptoms.
And we’re wondering if effective care for young people with those other conditions might in fact reduce the negative effects or eliminate the chance of experiencing symptoms of psychosis altogether.
What do you hope this research will ultimately achieve?
Joanna Henderson: Ultimately we hope that any new insight into early signs of psychosis will help us build a better model of care. Our approach is focused on partnering and collaborating with different health-care teams and building capacity in the system – and these closer ties are important as we try to fill in some of the gaps in care, especially with this transition age group.
We’ll be working closely with the clinical services within the Child, Youth and Emerging Adult Program, such as the Autism Clinic and our clinical research centres at CAMH – I’m the director of the Margaret and Wallace McCain Centre for Child, Youth and Family Mental Health, and Aristotle is director of the Slaight Family Centre for Youth in Transition.
The transition period is a time associated with greater mental health issues and substance use so there’s a major need for us to build bridges between services and provide ongoing support, especially for the most vulnerable youth.