Research

About the Study

A Framework for Research in Emerging Adults: The Stepped Care Project for Youth at Risk of Psychosis

Emerging adulthood is a critical developmental stage from age 16 to 24, an age group that has been overlooked with a significant impact on global health and social policy. Research indicates that 75% of mental illnesses begin before age 24; however, only 25% of youth with mental health concerns receive services. Emerging adulthood is a period of significant and dynamic neurodevelopmental changes that determine the later structure and function of the adult brain, and it has been hypothesized that the onset of most major mental illnesses is a consequence of aberrant neurodevelopmental processes during this period. Emerging adulthood is therefore a critical time for treatment, engagement with mental health services, and research. The goal of the Framework is to develop a world-leading clinical research platform to address knowledge gaps in the mental health of Emerging Adults (age 16-24 years), and to build capacity to conduct research and deliver evidence-based care for this population.

One of the projects of this Framework is "The Stepped Care Project for Youth at Risk of Psychosis". Schizophrenia and other psychotic disorders are amongst the most debilitating of illnesses. Focusing on youth at clinical high-risk (CHR) for psychosis allows better understanding of predictors and mechanisms of transition to psychosis. Over two years approximately 15-20% of CHR youth will develop a full-blown psychotic illness; however, the remainder continue to have poor functioning and intermittent symptoms relative to healthy controls. Evidence for treatments is limited since current treatments do not address the heterogenous course and outcomes of CHR youth. The difficulties of the emerging adult age-range (attrition from care, discontinuity, lack of alignment with diagnosis-specific adult services) are particularly relevant for CHR youth especially since there are no other specifically designed resources for them that address the need for care in the context of their transition from adolescence to adulthood.

First, the heterogeneity of the CHR population needs to be considered and thus specific treatments for specific subgroups should be studied. Second, the treatment modality needs to be specifically designed to address the presenting problem. Third, Treatment can be individualized and, knowing that these CHR individuals are a heterogenous group, interventions can be designed to address the changing clinical profile and/or the treatment response of these young people. These are known as adaptive interventions or sequential multiple assignment randomized trials (SMART trials) in which the type and/or dose of the intervention is individualized based on clinical presentation, individual differences, or treatment response. Thus, a potential treatment study for CHR might be to first offer education and support, then for non-responders offer more specific psychological interventions such as cognitive-behavioral therapy (CBT) or Cognitive Behavioral Social Skills Training (CBSST) or family interventions, and then if these therapies are ineffective, to offer medications. To design such a trial, we firstly need to understand what proportion of CHR individuals respond or do not respond at each of the different steps and secondly, to address what treatment to offer first and when to offer more intense and, ultimately, more costly treatments. The goals of achieving Precision Health objectives require that these questions be addressed through research.

The overall aim of the Stepped Care Project is to determine the most effective and efficient way to offer active and maintenance treatment resources for CHR youth. In this study participants will be 12-25 years old and will meet criteria for being at clinical high risk for psychosis. Clinical assessments will be conducted at baseline , 2-, 6-, 12- and 18 months. The first step would be to offer a range of treatments starting with the most benign. At the first step, participants can be involved in individual or group-based education and support and/or family education. Following this first step, depending on improvement in attenuated psychotic symptoms and/or social functioning, participants can move to the second step which includes longer term family involvement, individual CBT or the CBSST group.

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