Marjorie MalpiedeThe psychiatrist and scholar shines light on Schizophrenia in young people
Dr. Theo Manschreck has spent his entire career helping people with mental illness live well in a challenging world. The nationally renowned psychiatrist and researcher is a leading authority on schizophrenia, a progressive disease that afflicts 3.2 million Americans.
Like bipolar disorder and other mental illnesses, schizophrenia most often presents in young adulthood, making the identification and addressment of the disease an important issue for parents, caregivers, and colleges, as well as individuals.
The pursuit and application of emerging information about mental illness is the pinnacle of Manschreck’s long career in mental health, which began in college when he took a summer job as a hospital mental health worker. It was then that he first realized that people generally have a poor appreciation for the pain of mental illness.
Stigma and misinformation compound the problem, as he learned from his subsequent work in other institutions, with veterans, and as a social worker on the South Side of Chicago.
Decades later, after degrees from Cornell and Harvard, esteemed positions and fellowships, Manschreck remains a compassionate champion for people with mental illness and a strong believer in the research that will help improve the quality of their lives.
While he still sees patients, Manschreck works with the Massachusetts Department of Mental Health as Chief Medical Officer for southeastern Massachusetts, where he hopes to introduce a new, holistic model for treating early schizophrenia.
In our interview, he demonstrates his deep knowledge of the discoveries that have been made in the past and talks about the important work that lies ahead.
Mary Christie Quarterly: What information are you learning about schizophrenia that will help people struggling with this disease, as well as those who may eventually become schizophrenic?
Theo Manschreck: I think things are changing about our concept of schizophrenia; the work that is being done in early intervention is teaching us new ways of looking at the disorder.
In the last few decades, there were a number of international centers, most notably in Australia, that had delved into the differences between younger people with early schizophrenia and those that have been living with the established disease.
They found that the young people often had very different needs than those that were ten years older; those who were at early stages had different manifestations characterized more commonly as “behavior” problems, such as substance abuse problems, legal entanglements, and academic struggles.
Meanwhile, there has been a lot of great work done in linking early diagnosis to outcomes. Werner Mendel, a psychiatrist at UCLA, followed about 500 people who had the disease for many years.
In delving into the histories of the people who became ill, he discovered that many of them had experienced earlier episodes of illness three or four times before they were ever admitted to a hospital for treatment and first diagnosed with the disease.
The reason was that these episodes were characterized by things like social withdrawal, truancy from school, getting arrested – events that were associated with “troubled kids” whose parents and peers saw them as “having a tough time.”
What Mendel discovered was that for these individuals, the disease had actually started long before the first diagnosis.
The problem was we didn’t have good ways of identifying it. The earliest manifestations were not necessarily psychosis symptoms but anxiety, depressed mood, and other non-specific symptoms — experiences that most anyone could have as a problem.
There was something different about these people, but it wasn’t clear what that was, how to identify them, and ultimately, how to manage them.
MCQ: Why is early diagnosis so important?
TM: One of the key concepts in understanding how this illness develops is to understand that the duration of time a person is ill before treatment begins is a critical variable. This is called DUP, duration of untreated psychosis.
This is really the crux of it because the earlier you know, the earlier you can medicate, or manage, and the better the patient outcomes will be.
Some very important research was done in the early 90’s by Richard Wyatt and others that showed that the amount of time the person had been psychotic before he or she was treated was a better predictor of outcome than they had ever anticipated. It became pretty clear that something was going on in the psychosis experience that was important.
Wyatt suggested that it was a reflection of the fact that psychosis was a symptom, like a fever. Underlying that symptom was a subtle but continuing and significant form of brain damage.
Logic has it that the sooner you can intervene, the better the patient outcomes will be. In fact, there is some evidence — and I think this needs to be amplified — that some of the efforts at early intervention may be pretty successful at averting much of what we think of as the illness.
That makes schizophrenia more in line with other progressive diseases like cancer or Parkinson’s. If you make a positive intervention, you may be able to not only stop it; you might actually arrest it to some extent.
Unfortunately, this is very new and I’m not sure the evidence is there to say much more than, “It seems possible.”
MCQ: So how do you address this challenge?
TM: Certain criteria are being developed to objectify what we can diagnose.
A fundamental question is: If you have a group of people with non-specific symptoms and you really can’t reliably make a diagnosis of a schizophrenia illness, how do you segregate out from all the symptomatic phenomena the ones that are most predictive of “conversion to psychosis” and which may indicate more definitively that schizophrenia is present?
Many of the people evaluated and followed may not experience these conversions and may actually get better and not have the same pattern of a typical case of schizophrenia.
Some of what we know is that there are cases associated with genetic (familial) background, but many, if not most, cases do not have such a family history.
There’s another category of greater risk we call “schizotypal disorder.” These are people with odd beliefs or peculiar behaviors, some believing they experience peculiar sensations, have telekinetic abilities, or fortune telling capacities. They may be seen clinically and a subgroup of them will go on to have a schizophrenia illness.
Then there is the traditional psychotic diagnostic presentation that usually is clearly easier to diagnose – being delusional and disorganized in your behavior, and so on.
MCQ: What are some of the implications of this for colleges?
TM: If you consider that schizophrenia is typically diagnosed before your mid-twenties, and that the onset of the disease could occur several years earlier, there are college-age students who could have this happen to them.
There are a lot of others who get through college and only experience such illness later. This is important because patient outcomes are largely determined by where you are on the train of life when you get the illness.
Years back, I did some consultations with young people who were recently recruited into the military to observe those who were hospitalized for psychotic breaks and to determine who needed to be discharged from military duty. It was a very sad experience in many ways.
A lot of what I saw was a collision between young people and various stressful factors: Most were 18 or 19, and this was the first time they had been away from home.
They were in the military going through rigorous and psychologically daunting training. Their efforts were demanding, the separation from familiar circumstances such as home and family was abrupt and challenging, and the disconnection from prior social ties fostered a sense of loss and anxiety.
The ingredients were assembled for possible clinical troubles. Those troubles had a clear base rate with each incoming group of recruits.
Not unlike the military, college can bring various forms of stress. There is a big difference between the cohort that is experiencing typical stress-related disorders and those that will develop schizophrenia, but there are definitely a number of people in college who will be at risk.
As much as possible, universities need to be able to identify the people who are at risk early on.
Hence, it is useful to provide opportunities for counseling and support in various aspects of student life, especially at the beginning of college life. The stresses begin at the outset of a college career, so early recognition is useful to plan for when it comes to student health, campus life, and academic settings.
It’s not altogether clear to me that effective interventions can be guaranteed without the contributions of professionals, but peer support and other sources of assistance are likely to be valuable on campus as well.
Screenings through health services of general and psychological health, as well as information about health prior to college, can be useful, of course.
Interviews or well-supported, clinically-reliable questionnaires may be important to identify those who are at some risk.
By estimating stress and psychological distress factors acknowledged by individuals as important and registering an impact on them, these tactics can help college personnel identify people who are at greater risk.
Also, in a campus setting, there is much opportunity to observe and monitor how students are doing.
Consider what may be learned through academic performance, for example. Careful research, designed to answer the questions required to find the keys to early identification, has promise in achieving relevant useful ends.
There is so much information of course to be learned in this area — we are at an early stage in this set of endeavors.
MCQ: What are some of the strategies that are working in this area?
TM: One of the innovations that started overseas and is coming here now is programming that is referred to as “first-episode psychosis.”
It is getting people in early through a network of associations like teachers, pastors, and parents.
We’re going to start something similar here in Massachusetts. The challenge is: How do you get people in, and once you do, what do you do to help them by getting them into the proper diagnostic categories?
These are young people who may or may not have schizophrenia. They may have other disorders. This is a model that works for bipolar disorder, which is by far more prevalent.
The first episode programming assumes there are multi-components — that you will need a variety of evidence-based supports to make it work — from medication and psychiatric assistance, vocational and educational assistance, and other supports that keep people on the train. One of the most useful components to this, especially for kids who are pretty young, is what’s called “family psycho education.”
This brings family members together to learn how to problem solve, educate themselves about illness, and learn how to be most helpful. For many families, useful teaching may be about insurance and navigating the systems of care provided to those with mental illness.
It may also be a critical factor in shoring up confidence.
MCQ: What are the ongoing challenges?
TM: The biggest problem, which is related to everything we talked about today, is removing stigma from the equation. If the master quest is to understand what’s going on with people as early as you can and to get them the help that they need as quickly as you can, we must confront the fact that stigma continues to be a barrier.
Stigma affects the individual with mental symptoms in many ways.
Fear of stigma in young people at risk may dishearten those who are seeking help, make them withdraw socially, and ultimately not get help. And it may make them feel ashamed, isolated, and discouraged. Parents and other relatives may also become affected by stigma.
Stigma is a disgrace and reflects on us all.
