Most doctors fail to spot impending psychosis even when seeing patients days before psychotic episode

If only one could predict who is likely to become mentally ill, a number of Ontario researchers noted, one might be able to intervene earlier or even prevent the development of mental illness. In fact, their study, published recently in JAMA Psychiatry, showed that severe emotional illness in the form of psychosis was more often than not preceded by contact with mental health services and yet few healthcare providers spotted the danger signs.

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7 in 10 people reached out for help, to no avail

The authors of the study set out to answer the question:

Do people who are diagnosed with a psychotic disorder have unique trajectories of preceding mental health service use and diagnoses compared with people diagnosed with a mood disorder?

Their answer, based on a study following over 10,000 people aged between 15 and 29, was that in the 3 years before being diagnosed with a psychotic disorder (such as schizophrenia or mania), most people were seen by medical professionals for some other mental-health-related reason, but this failed to prevent them from spiraling further down into greater disorder.

72.2 percent of people diagnosed with a psychotic disorder for the first time had visited a mental health professional at least once in the 3 years preceding the diagnosis.

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Doctors spotted other problems but things still got worse...

In addition, people who developed psychotic disorders were more likely to have previously been diagnosed with other disorders such as those involving substance abuse, or personality disorders. Many had previously been treated for self-harm, including eating disorders. Some had been diagnosed with attention-deficit/hyperactivity disorders (ADD or ADHD).

The study’s authors found that “anxiety disorder” was the most common diagnosis in the 3 years preceding a diagnosis of psychotic disorder.

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In the final week before a psychotic break, doctors still saw nothing seriously amiss

The study found that almost half (48.1 percent) of all people diagnosed with a psychotic disorder had been in contact with a mental health service provider within the preceding 3 months of their diagnosis and, apparently, this contact and the recommended treatment did not prevent them from deteriorating still further.

Contacts included outpatient physician visits (psychiatrist, primary care, and pediatrician), emergency department (ED) visits, and hospitalizations. Primary care physician (PCP) visits were counted if they were mental health–related.

Even more strikingly, when the researchers looked at the final week before a diagnosis of psychotic disorder, they found that just over 1 in 5 people had visited a mental health service provider. Around half of these people had been admitted to a hospital emergency department while most others had seen their primary care provider (PCP).

That is to say, half of these people were in a condition serious enough to be admitted to an ED and yet were discharged, only to be diagnosed with a psychotic disorder within a week; the other half had seen their own doctor who also failed to detect any sign of a descent into psychosis that would occur within days.

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For many people, psychosis has an entrance but no exit

The study’s authors concluded that signs of imminent psychosis are likely present in many people and that it would be quite a good idea if doctors were better able to spot them:

... our finding that individuals with psychotic disorders had higher rates of acute care service use before first diagnosis suggests that there may be opportunities to further identify specific phenotypes or patterns of early presentation of psychotic disorders.

They stressed the importance of being able to predict who is likely to become psychotic, given that these people are extremely vulnerable and once a person has developed a psychotic disorder, the future trajectory is most commonly downhill:

Characterizing mental health service use trajectories preceding diagnosis of a psychotic disorder may help identify individuals at highest risk and in which settings they are at highest risk.

Psychotic disorders, such as schizophrenia, are among the leading causes of disability worldwide and are associated with poor outcomes and increased health care utilization, mortality, and costs.

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Wrong strategies? Or...

Unfortunately, the researchers added, “identification of groups at high risk of development of psychotic disorder remains a challenge” despite the “great effort [that] has gone into establishing clinical high-risk criteria for psychosis.”

Therefore, additional strategies are required for early identification (and prevention) of psychotic disorders.

Could it be that the strategies are lacking rather than the opportunities to put them into practice? Most of the people who become psychotic were right there in the hospital or outpatient setting and yet the doctor — or even psychiatrist — treating them failed to realize what was really going on.

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The study’s authors also noted that previous researchers have drawn similar conclusions based on large studies:

[Our findings are] in line with recent findings from a large cohort study showing an elevated risk for individuals with a history of any mental health–related inpatient admission to be diagnosed with psychosis or a bipolar disorder by age 28 years.

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... the Pharma elephant in the room

The only factor the study’s authors failed to even consider was the actual treatment "psychotics-in-the-making" received from those who saw them in the 3 years, months, or days before they were diagnosed with psychosis.

These medical professionals presumably did something when a person in distress came to see them, other than give them a clean enough bill of health (together with a bill) to let them go home again. For those diagnosed with other mental disorders, it is virtually a certainty that they were given a prescription for some psychiatric drug, whether it be an antidepressant, a benzodiazepine, or a neuroleptic.

Could ingesting these drugs have played some role in accelerating or otherwise contributing to the development of a psychotic disorder?

In fact, there is no need to wonder. There are literally hundreds of studies documenting links between antidepressants and psychosis, ADHD drugs and psychosis, benzodiazepines and psychosis, and even anti-psychotics (neuroleptics) and psychosis.

Why these Ontario researchers omitted mentioning the role of psychiatric drug prescription in the development of psychotic disorder is perhaps a mystery.

The information contained in this article is for educational and information purposes only and is not intended as health, medical, financial or legal advice. Always consult a physician, lawyer or other qualified professional regarding any questions you may have about a medical condition, health objectives or legal or financial issues. ‍

If you are struggling with suicidal thoughts, call a qualified free mental health helpline or seek help from a qualified therapist.