DSM5 in Distress

The DSM's impact on mental health practice and research

Definitive Study Rejects the Diagnosis of "Psychosis Risk"

And finds no treatment benefit

The sad truth is that most clinical research has absolutely no effect on clinical practice—rarely does a study impact how we diagnose and treat patients. A paper by Morrison and colleagues in the British Medical Journal is that rare exception. For the pleasure of reading it, see: "Early detection and intervention evaluation for people at risk of psychosis: multisite randomized controlled trial."

The authors, from four British universities, investigated the effectiveness of cognitive therapy in preventing psychosis in young help-seeking people. The study compared a group of patients who received cognitive therapy plus monitoring of mental state with a group who received monitoring only.

This one beautiful study has succeeded in definitively answering two of the most timely and consequential questions facing psychiatry today: 1) Is it a good idea to include a "psychosis risk syndrome" in DSM 5? and 2) Can early treatment programs prevent psychosis? The answers to both questions—a conclusive and emphatic No.

First off, the study proves that we don't yet have the basic diagnostic tools needed to build a preventive psychiatry. Fundamental to any meaningful prevention program is the accurate identification of those who are really at risk. This study clearly demonstrates the impossibility of predicting who is (and who is not) likely to become psychotic. It is striking that only 8% of misnamed "ultra high risk" patients actually go on to have a psychotic episode. The unacceptably high false positive rate means that nine of 10 people entered into a psychosis prevention program will be misidentified and told they are at risk (or even worse at "ultra high risk") for eventually becoming psychotic—when quite clearly they are not. There can be no justification for burdening young people with such unnecessary stigma and worries, reduced ambitions, and the risk of receiving potentially dangerous antipsychotic drugs. If they have problems that need addressing, these should be addressed, but not under the misleading and pejorative auspice of their being at "ultra high risk."

 The authors follow their findings to the by now obvious conclusion that "psychosis risk syndrome" is still in its early research phase of development and makes no sense as an official category for DSM 5. Their powerful data support the almost unanimous opposition to "psychosis risk" as a DSM 5 diagnosis that has already been expressed by the leading researchers in the field—including most notably its pioneers, Patrick McGorry and Alison Yung. It is puzzling that DSM 5 persists in offering a suggestion so far out of touch with current clinical reality.

The treatment results are even more important and should discourage all unrealistic expectations that early and intense intervention can prevent psychosis. Those who received the preventive intervention were just as likely to become psychotic as those who did not. The conclusion is inescapable—prevention of psychosis is a wonderful but elusive goal, one that we cannot now achieve. Spending resources chasing an unattainable prevention will not help individuals to avoid psychosis and may instead distract from the more pressing mission of providing first rate care once they have become psychotic.

We are still in the early stages of prevention research and the findings so far are not encouraging. With such low rates of conversion to psychosis, it seems unlikely that a treatment effect will ever be demonstrated.

This one excellent study has killed two birds with one stone. It is a clear caution against the DSM 5 proposal for a psychosis risk syndrome and it should temper enthusiasm for rushing ahead with "ultra high risk" prevention programs. It does the cause of prevention no good to prematurely set impossible tasks that it cannot yet accomplish. Psychosis prevention is not yet ready for the real world. 

Allen Frances, M.D., was chair of the DSM-IV Task Force and is currently professor emeritus at Duke.

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