Letters to the Editor
Evidence for Early Intervention in First-Episode Psychosis
Early intervention (EI) in first-episode psychotic illness is now a well- recognized practice, with good face validity for its effectiveness. In Australia, it is often performed by specialized teams of clinicians with smaller caseloads than those of general adult mental health workers. They focus on engaging the client, they consider medication (usually low-dosage atypical antipsychotics), and they attempt to restore vocational or educational functioning as symptoms improve. Families or other caregivers are closely involved in monitoring the patient’s mental state and are given education and support. Studies in this area encounter methodological difficulties, particularly in sample size, purity, and retrospective designs; however, emerging evidence supports this work.
Clinicians can now identify young people exhibiting prodromal symptoms of impending psychosis with increasing accuracy (1). However, clinical and ethical concerns exist with treatment at this stage (particularly with medication). Moreover, family reactions may possibly be unhelpful, and stigma accompanies the use of psychiatric services. Using psychosocial strategies targeted to the presenting complaint and monitoring without medication, except when positive symptoms develop, should allay many concerns (2). The attractiveness of this work from clinical, epidemiologic, and resource perspectives encourages further investigation.
Where positive symptoms develop, the duration of untreated psychosis (DUP) is emerging as a predictor of future disability and illness course, particularly when it exceeds 1 year. Specifically, Loebel found that, rather than premorbid adjustment, age of onset, mode of onset, or illness severity, DUP best predicted the time to treatment response (3). The Northwick Park Study showed that DUP of less than 1 year was a stronger predictor of avoiding relapse at 2 years than was maintenance-medication status (4). Loebel postulated that active psychosis may represent the expression of a toxic neurobiological process, with each subsequent relapse rendering the patient more susceptible to another (5). For these reasons, early detection and prevention, or early treatment of relapse, are crucial foci of services. The etiology of delayed initial treatment is complex; it includes factors related to the mode and rapidity of illness onset, patient factors related to help seeking and the social support network, and systems issues relevant to the ease of service access (6). Therefore, any attempts to reduce the DUP must come from a multilayered approach; a broad educational focus is needed to reduce treatment delay and to ensure prompt, effective treatment from EI teams once psychosis is detected.
Eaton and others showed that many measures of symptomatology and psychosocial outcome taken 2 years after treatment of the initial psychotic episode are little different from those taken many years later (7). This suggests that after a “critical period” (8) early in the illness course, the sustained level of general disability does not change. This implication is double-edged: it provides further evidence against the progressive deterioration described by Kraepelin, but it also suggests that for many patients the expectations of functional or symptomatic recovery are limited after a certain period of being unwell. We propose that assertive attempts to reduce symptoms and restore social and vocational status during this period may have disproportionately beneficial long-term effects, although clear evidence for this does not yet exist.
Current research increasingly supports such clinical targets as preventing movement from the prodromal phase to acute psychosis, reducing the length of unresolved psychosis, and implementing assertive psychosocial interventions in the recovery period. Further longer-term prospective studies with data regarding illness course in treatment, as well as cost, will add to current knowledge.
1. Yung AR, McGorry PD. The prodromal phase of first-episode psychosis: Past and current conceptualisations. Schizophr Bull 1996;22:353–70.
2. Yung AR, McGorry PD. Point of view: is prespsychotic intervention realistic in schizophrenia and related disorders. Aust NZ J Psychiatry 1997;31:799–805.
3. Loebel AD, Lieberman JA, Alvir JMJ, Mayerhoff DI, Geisler SH, Szymanski SR. Duration of psychosis and outcome in first-episode schizophrenia. Am J Psychiatry 1992;149:1183–8.
4. Crow TJ, MacMillan JF, Johnson AL, Johnstone EC. A randomised controlled trial of prophylactic neuroleptic treatment. Br J Psychiatry 1986;148:120–7.
5. Loebel AD, Lieberman JA, Alvir JMJ, Geisler SH, Szymanski SR, Mayerhoff DI. Consistency of treatment response across successive psychotic episodes in recent-onset schizophrenia. Presented at International Congress of Schizophrenia Research; April 1993; Colorado Springs (CO).
6. Lincoln C, Harrigan S, McGorry P. Understanding the topography of the early psychosis pathways: an opportunity to reduce delays in treatment. Br J Psychiatry 1998; 172(Suppl 33):21–5.
7. Eaton WW, Thara R, Federman B. Structure and course of positive and negative symptoms in schizophrenia. Arch Gen Psychiatry 1995;52:127–34.
8. Birchwood M, Todd P, Jackson C. Early intervention in psychosis: the critical period hypothesis. Br J Psychiatry 1998;172(Suppl 33):53–9.
Mark Sanbrook, MBBS, FRANZCP
Anthony Harris, MBBS, FRANZCP