Predicting and Preventing Psychosis: Dr. Tyrone Cannon

What if young people at risk for developing a psychotic disorder could know of the danger ahead of time, and choose to engage in preventive therapy? They would have a better chance at a healthy life. In the experimental research and care facilities of the North American Prodrome Longitudinal Study (NAPLS), directed by Dr. Ty Cannon of Yale University, ultra-high risk teens are offered this opportunity.

Here you can watch an interview with Dr. Cannon.

If you would like to contribute funding to Dr. Cannon’s and other IMHRO-funded programs, please make a tax-deductible donation.

To learn more about Dr. Cannon's NAPLS programs, please visit the NAPLS website.

 

Comments

Gayle A's picture

Dear Dr. Cannon, Thank you so much for this very helpful interview. I've done a lot of research as a parent, and your name comes up often, so we are so fortunate that you are sharing your time. Our daughter is seventeen years old. She has acute schizoaffective disorder/bipolar I. She came to us three years ago asking to see a therapist saying, "something is wrong with my mind". It took about two and a half years to tame the psychosis with medications/therapies (often at a screaming level berating her from the moment she woke up until she fell asleep at night). She was an honor student, athlete, and musician. She has never self-medicated but used self-harm as a coping technique. She lost the ability to read music and can now, with medications/therapies read music again. She used to be an avid reader but was unable to comprehend/retain information. She is now able to read again but still has some trouble retaining information. She still has a fairly high IQ (87th percentile) but her cognitive abilities dropped significantly (17th percentile now). With the help of her therapies, she has been able to maintain a few friendships and participates regularly with her homeschooling group. She is taking seven medications, sees a cognitive behavioral therapist weekly, finished 24 weeks of intensive psychosocial rehabilitiation (very helpful) and sees her psychiatrist regularly. All of her therapies have been extremely beneficial. We finally have a combination of medications that seem to keep her psychosis at bay for the most part. We give her up to 20 mg Olanzapine ODT a couple of times per week to prevent terrifying dissociation. So here are my questions: 1.I am wondering what the likelihood of regaining her cognitive abilities might be after three years of rapid cycling/psychotic breaks. She is very bright but is currently struggling in testing situations (sometimes starting to disocciate) in trying to earn her GED so she may take a course at the local junior college. 2. I am also wondering if the number of medications she is taking (which have improved her situation significantly) will do any damage or help to keep her illness stable and prevent the gray matter loss you were discussing. 3. And a third question if you have the time. She has struggled with existential depression throughout this illness and it was the first symptom and the symptom that persistently hangs on with all of her therapies. Is there any treatment that can help with this overwhelming symptom? I hope I haven't asked too much. I just feel so fortunate to have the opportunity to ask these question. Thank you so much.
tycannon's picture

Thank you for your comments here. I have to emphasize first that I cannot provide detailed personal advice in this kind of format. Your daughter displays many features that the research suggests are predictive of a relatively good outcome - not the least of which are her high IQ, responsiveness to medications, and involved and caring parents. To address your questions, in order: 1. The cognitive deficits are unfortunately among the most difficult components to treat. There is a currently a lot of interest in developing and testing "cognitive enhancing drugs" that may be used adjectively with antipsychotics and mood stabilizers - these are still in the testing (pre-FDA approval) phase but some have shown some promise in early trials. Cognitive remediation therapy (a behavioral approach that is becoming widely available) also shows promise in some studies. 2. Polypharmacy (being on multiple meds) is a controversial topic. It is often difficult to discern which medications are necessary for the clinical benefit to occur and which may not be necessary (or if the benefit is due to the synergy of two or more). It is sometimes the case that prior medications are continued when a new one is started, even if the first one did not seem to be very effective, due to concerns over changing too many things at once. Then if symptoms improve it is perceived as risky to withdraw the first one, in case the benefit results from the synergy of the two. These kinds of decisions are based primarily on clinical judgement; there is very little empirical data on polypharmacy. In general it is reasonable to ask treatment providers if each medication is needed and see if they have specific rationale for each medication. 3. Your phase "existential depression" is interesting - this could refer to a few different things, but if I understand you correctly, my answer is about staying engaged in life with interests, pursuits and friends (even if these are scaled back from how they were before the illness started). Easier said than done, I know, but gentle encouragement of these things is certainly worthwhile.
brandon.staglin@staglinfamily.com's picture

DaffodilMom,

 

For more on the cognitive remediation mode of therapy, please see this interview with Dr. Sophia Vinogradov.

 

From my own experience I agree with what Ty has said about gentle encouragement to stay engaged in life; that kind of support from my family made a difference in my recovery. Being involved and caring about people and things have made my life not just livable but fulfilling.

Gayle A's picture

Thank you so much, Brandon. And thank you for your brainwaves program...it strengthens and informs caregivers. :)
Gayle A's picture

Thank you for your thoughtful answer to my questions. Your responses were very helpful. I will look into cognitive remedial therapy. Your responses re: polypharmacy are greatly appreciated. I will bring her list of medications to review with her psychiatrist during the next session and discuss the rationale for each (our psychiatrist is very easy to approach and works so well with parents/caregivers). We work diligently to keep her engaged and, while it can often be a two steps forward/one step back process (sometimes three steps back), I am glad to hear from you that it is worth the effort...especially if it helps with her overwhelming existential thoughts...something I had not considered. Thank you for doing so much good in the world...God bless you for your efforts and thank you again for your thoughtful response.

Being on fixed incomes and retired, we wonder how we can continue to afford the cognitive therapy that our son now receives once or twice a month. Will he need this therapy forever? He has started on Abilify and taken off his anti -phychosis meds, also off lithium which he was prescribed when released from the hospital. He also takes an anti depressant, but still seems woefully depressed. He will seldom go with either his father and I, to a movie, for a walk, to the store or out to a restaurant for a meal.. He does not seem motivated to help with outside chores with his Dad He has been home since August and although there is improvement, it seems that the progress is cyclical and he often goes steps backward with no warning. Is there any danger in urging him to try to return to some normal activities? We feel we may be allowing him to get by doing as little as possible. He no longer reads, sometimes plays his guitar, seldom takes our dog out for a run. He can't concentrate enough to play cards, but will play scrabble. He was an airplane mechanic and although at first he had plans for finding some sort of work, he never talks about that now. We talked with him about volunteering at the local airplane museum, & he seemed a bit interested, now he states that he can't do that yet. He watchs quite a lot of television, something that our family did not do much of. We wonder how to draw the line between nagging him to do more and letting him spend so much time alone, not intereacting with friends or family. The rainy days seem particularly hard for him. Is there much more we can do than to be friendly, loving, patient parents and allowing his cocooning without worry or trying to distract him with some activities? We are at a loss as to how to help him, besides the obvious doctor and medication route. Did I mention he sleeps alot, sometimes 12 or 14 hours a night and is upset when we try to wake him. Isn't to much sleep depressive in itself? We don't want to treat him like a child, on the other hand, we don't know how much structure to insist on. Can you advise us as to our role? Is there a reasonable amount of time for expecting to see real improvement or is this quiet, non communicative, sad and bewildered son of ours the new normal?
tycannon's picture

The kinds of symptoms you are describing - low energy, withdrawal from activities, withdrawal from social relationships - are, along with cognitive deficits, among the most difficult components to treat. Your intuitions about wanting to help your son reengage with his life are right on. Because during active phases of illness people can be overwhelmed by stimuli, withdrawal into low-stimuli, low-demand environments is very common, and over time a kind of inertia can develop. That your son is involved in cognitive therapy is a good sign. You might consider going together to some sessions of a family-based treatment. It might be easier, in that context, for you to share your concerns about your son's inactivity with him in a way that will not be over-stressing and can also lead to some problem-solving that you all work on together collaboratively. There is pretty good evidence that these family-based approaches are often beneficial for both patients and caregivers.

Hello Dr., thank you so much for taking questions. I have four children, two neurotypical and two with mental illnesses. My oldest son, 14, spent 42 consecutive days in a behavioral health hospital in September 2011 after a psychotic break and attempting to kill himself. We have struggled with his illness since just before age 7. He has now been diagnosed by the University of Illinois First Episode Psychosis Clinic with Early Onset Schizophrenia. He is currently taking 700mg of Clozaril, and has been for a year. This is the first real medication success we have seen since age 7. He has been on just about everything. We are fortunate that we have been able to have him placed in a therapeutic day school where he is doing better. He, as some of the other families have stated has seen a 30 point cognitive drop since 2005. We have not seen any regain in his cognitive ability as we all had hoped. My question is actually about my 8 year old son. I have seen him follow in nearly the identical footsteps of my oldest son. His psychiatrist is wonderful, works well with us and takes all of this seriously. Currently, he is on 400mg of Seroquel, 600mg of Trileptal and 25mg of Zoloft. He is in a diagnostic placement at a therapeutic day school, and the administration there is recommending he stay for at least a year. However, the therapist (his main one) at the therapeutic day school puts all of my son's problems down to being emotional. Even though we have reported hallucinations, auditory and visual, plus him running out of school, hour to two long meltdowns, threatening suicide, etc. His outpatient therapist has seen my eight year old (with two inpatient hospitalizations and three partial in the last year) throughout the whole year. She believes the course we are taking is the right one, but the therapeutic school is pretty interested in doing a med wash and starting from zero. I, however, agree with our psychiatrist that as our son has improved significantly on his medications and with the switch in school settings, it is to early to do anything except celebrate a little success. His psychiatrist believes he should be stable for a good period of time, and then eventually back off a little on the meds and see what happens, but is totally against a med wash. I agree fully with the psychiatrist. I believe the early intervention is beginning to help our 8 year old. The meds seem to have quelled the intense fear, non-sleep and meltdowns significantly. We still have issues, but nothing like we saw this past January. The change in placement also seems to be very reassuring. I am concerned about him because he is never a behavioral problem at school, which is why his mainstream school didn't want to agree to send him for a diagnostic, even though he ran out of school several times, threatened suicide, etc. This is the same issue I had with my older son, no one would believe anything was going on because they didn't see it. I am afraid that such a short placement will not be beneficial to my 8 year old, and perhaps keep the stress up and make things worse. Do you have any advice or thoughts? Thank you for what you are doing.
tycannon's picture

Sometimes different treatment providers see issues differently and advocate different treatment approaches. This is not uncommon in particular with children because the clinical picture can be murky and the best treatment approach thus ambiguous. As I said in response to another post, I cannot give detailed personal advice in this format. However, I think the approach you are taking - listening to each provider and developing your own opinion, based on all of the points of view and on your own observations and experiences with your son - is the right way to go. In general, we have to educate ourselves in order to be maximally effective as advocates for our loved ones with these kinds of symptoms.

I was reading the above story of the son who was an aircraft mechanic and it reminded me of the early days with my son, who is now 21. My son has been dealing with psychosis since he was 15. Fortunately, we found a wonderful child psychiatrist who has been our rock for the past 6 years. Everything that Dr Cannon has said is what we have done, including antipsychotic medication that my son cannot do without. I would like nothing more than to have him off all meds, but no one has the answer to that just yet. What I wanted to say to the parents of the aircraft mechanic, and anyone else that is struggling, is that our son behaved in the same way and it took me quite some time to work out things that he could do and would tolerate. It was not much, but he would go out for lunch, most often because it was later in the day. He would go to the gym with family members and close friends, and that was about it. The rest of the time he slept. He couldn't go to movies because he became agitated. He watched tv, lots of cartoons because they seemed to soothe him. It was very difficult to engage him in anything. Eventually, a combination of us lowering our expectations, him finding small things that engaged him, going to his psychiatrist, often with me, helped him gradually grow and be able to cope with going back to school, (night school)and finishing year 12. Our family supported him and my family and friends supported us. I want to let you know that broadening our circle of family and friends and asking for their help, support and encouragement was, in retrospect, the single thing that kept things going for all of us. I found I had an insatiable appetite to learn about the illness and connect with as many people as I could to find out their experiences and the experiences of those with the illness. So lots of listening, to others and especially to my son. I was his advocate and protector. My son is now 21, he has had a job at a museum as an attendant, that he enjoyed. The job suited him down to the ground. He could choose his shifts that were either 10am - 2pm or 1pm - 5pm and as many days per week as he wanted or could manage. He was part of a pool of workers that placed zero stress or pressure on his attendance. When he was feeling unwell, he could withdraw without penalty or having to explain about his illness. Shame and prejudice still takes a toll. Now, as I write, he is living in Europe with his girlfriend that he met at the museum. This reality seemed as far away as mars back in the early days. He is well, studying for a Community Development degree online from an Australian University, learning the local language in local classes and is supported by the most wonderful young woman, 20, and her loving and supportive family. The two of them live in a university town about an hour from her family in a flat. She studies at the university and they are leading a very functional and happy life. This may not last forever, but it is so much more than we ever expected could be possible from a young man who could barely leave his bedroom. Good luck and thank you IMHRO for your inspiration and access to information and individuals like Dr Cannon. As a parent I need to know of any developments and research that might help my son and family deal with mental illness. I'm waiting for a medication breakthrough. Something without side effects, and preferably a cure.
brandon.staglin@staglinfamily.com's picture

Borisholly,

Your family's story is wonderfully moving and inspiring. Thank you for sharing.

We will keep working to fund the best possible science on the path to better meds and cures.

Brandon

tycannon's picture

I agree - very inspiring and your example says it better than anyone else could.
brandon.staglin@staglinfamily.com's picture

To DaffodilMom, nativedhtr, jm2walsh and Borisholly, thank you for being a part of Brain Waves. I wish you and your families the best, and hope to see you here again. Ty, thank you for your compassion, passion, and insightful answers!

 

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