The Dangers of Early Identification
By Dallas M. Ducar • It’s the end of a hard day of work and you arrive home to see your child alone, talking to herself. At first this may not seem odd, a child’s imagination can be quite active. Over time, however, she begins to seclude herself more, engage in occasional violent outbursts, and presents variable mood swings. Finally, after months of this, she begins to see things, but can still characterize them as hallucinations. She continues to maintain insight regarding the hallucinatory nature of such phenomena.
According to mental health clinicians the loss of psychological insight is widely considered to signal the beginning of a psychotic break. While this has the potential to lead to a multitude of diagnoses, it will signal the onset of the disease. This psychotic break isolates, debilitates, and exposes the patient while opening the door to the possibility of future medical expenses and psychotic episodes.
If it were possible to prevent a future psychotic break from occurring to your child, would you?
Researchers and clinicians have recently been examining this very question; whether early detection and intervention for the prevention of psychosis can be clinically effective.[i]
Psychotic episodes generally occur in the late teens or early twenties. The goal of this research is to understand whether the impulsive and angry behavior, along with first-person reports, can signal to clinicians that a patient needs help before it is too late. The investigators concluded, after a two-year study, that the at-risk groups showed better functional outcomes after treatment.
Yet to treat potential patients, one must also detect such patients.
Programs such as the Early Detection and Intervention for the Prevention of Psychosis Program (EDIPPP) contacts teachers, counselors, nurses, social workers, family members and other clinicians to increase the appropriate referrals of youth at risk.
However, programs like EDIPPP run the risk of both under-diagnosing and over-diagnosing. It may be possible that a worried parent can wrongly label and inadvertently stigmatize their child for what may simply be unruly behavior. This may result in inadvertent psychological damage of a vulnerable population, starkly contrasting the mantra “do no harm.”
Suppose one percent of the population is actually schizophrenic and half of them go to a mental health provider to report their symptoms while worried parents falsely refer 20 percent.
Out of a population of 100 people, one person will actually have schizophrenia and 99 will not. Moreover there will be .5 true patients and 19.8 false patients that undergo evaluation.
A Prodromal Questionnaire (PQ), which is based on Prodromal Syndromes (SIPS), has a measure of 71 percent sensitivity and 81 percent specificity.[ii] Giving the benefit of the doubt, suppose a mental health clinician is better at early identification than the PQ and has both a sensitivity and specificity of 85 percent.
Given the aforementioned sensitivity, specificity, and population of 100, the clinician will diagnose .425 true patients and 2.99 false patients, and possibly prescribe therapy and pharmaceuticals.
Therefore, the majority of people who are labeled and marked for treatment shouldn’t be and the majority of people who are not, should.
With the probability of false positives and false negatives being what they are, even amongst a clinician who is better than psychological scales and questionnaires, there is a huge risk of incurring positive feedback, which could lead to behavioral confirmation.
Furthermore, a review of prodromal intervention programs determined that the efficacy of the interventions themselves were inconclusive. [iii]
Early intervention, while different than early treatment, can still irreparably harm a patient. If a child is wrongly labeled it can affect the child’s identity for life. Moreover, research on the effects of antipsychotic drugs on children is sparse and it may be possible that treatment could do more harm than good.
The decision to handle mental conditions preventatively is a moral decision as any other. In an era where more healthcare models are moving to early-detection it is important to remain aware of the hurdles that exist in psychiatry. Parents may fear that the unorthodox behavior of their child, society may pressure disorderly youngsters to fall in line, and clinicians have the authority to diagnose and label. Clinicians must recognize these pressures, limits to identification, and remain prudent in their diagnosis. Perhaps in some cases, kids should just be kids.
[i] McFarlane, W. R., Levin, B., Travis, L., Lucas, F. L., Lynch, S., Verdi, M., ... & Spring, E. (2014). Clinical and functional outcomes after 2 years in the early detection and intervention for the prevention of psychosis multisite effectiveness trial. Schizophrenia Bulletin, sbu108. [ii] Olsen, K. A., & Rosenbaum, B. (2006). Prospective investigations of the prodromal state of schizophrenia: assessment instruments. Acta Psychiatrica Scandinavica, 113(4), 273-282. [iii] Marshall, M., & Rathbone, J. (2011). Early intervention for psychosis. Schizophrenia Bulletin, 37(6), 1111-1114.