Leading Research and Innovation in Early Psychosis Detection and Treatment

Dr. Ashok Malla

“Clinical research needs to be grounded in what is of direct and immediate benefit to patients—can we give people who have a serious disorder the best possible opportunity in the first two years to normalize their lives so they function in society without stigma?” As a pioneer in early detection and intervention of psychosis, Dr. Ashok Malla has pursued this ideal for over 20 years.

Although clinical research is the mainstay of his practice, Dr. Malla reflects that the most satisfying moments of his career are tied to patient care. He speaks of a young woman whom he followed for several years at the London Health Sciences Centre (LHSC) who keeps in touch. “It’s fantastic to see how she’s grown up to be a wonderful young woman, productive, finishing her university education—a trajectory that might not have been possible many years ago.”

This former patient received treatment in a unique early intervention program set up by Dr. Malla and his colleagues at the LHSC in the late 1990s. The impetus to create the program came from two sources. While running the LHSC’s community-oriented clinical research program for schizophrenia, Dr. Malla realized that patients typically came to the clinic after several admissions to hospital. New research at the time suggested that early treatment could lead to better outcomes. His experience also told him early intervention should be combined with intensive treatment.

A year after it was launched, the program gave rise to a research project that examined not only the impact of early intensive treatment but also the impact of early detection. The study included an assertive, community-wide, public-education campaign to teach people how to recognize psychosis early. It was for this work and his overall contributions to schizophrenia and psychosis research that Dr. Malla received the CPA’s JM Cleghorn Award for Excellence and Leadership in Clinical Research last November. The London program is recognized nationally and internationally as a leader in excellence for clinical psychiatric research on first-episode psychosis.

What were the results of the London, Ontario, research? They were not as expected, says Dr. Malla. “We didn’t reduce the duration of untreated illness because the program detected people who had been sitting at home for a long time and who had not been treated—in fact, in our second phase, patients were more severely ill than in the first phase.” The six-year study, which wrapped up this February, was conducted in two phases.

First, Dr. Malla and his team removed barriers to treatment and provided intensive case management including group interventions and medication. One of the biggest obstacles to setting up the program was the unwieldy administrative hospital structure, remembers Dr. Malla. He credits the commitment to patient care of the department chair at that time, Dr. Emmanuel Persad, for surmounting this problem and making it possible to connect the program to the community. An advisory committee that oversaw the running of the program included several community members and was chaired by a family member of a program participant. “That way they had a real say in what happened. They had an investment in it.” Dr. Malla adds, “Family involvement is the most essential part of these kinds of treatment approaches. You can’t do it without involving the family.”

Phase two of the study involved running an aggressive public education campaign and studying its impact. Although the London data have not been fully analyzed, Dr. Malla says it seems that, after two years, the education campaign may be beginning to reduce treatment delays once those patients with longer-duration psychosis have been treated. The study also confirmed Dr. Malla’s belief that intense biopsychosocial treatment, even without active case detection, results in excellent recovery rates and low reoccurrence. Despite leaving the LHSC two years ago to take a Canada Research Chair in Early Psychosis at McGill and become director of the Douglas Research Centre’s Clinical Research Division, Dr. Malla has continued to participate as a coinvestigator in an extended five-year follow-up study of FEP patients treated in the London program.

Why did he go to Montreal? The principal attraction was the research chair in early psychosis as well as increased collaboration opportunities, says Dr. Malla. His role as chair is to provide leadership and a framework to gather the existing elements of early psychosis treatment in Montreal. “People have been trying to build a common framework, but nobody had the experience we brought here. It’s beginning to emerge, hopefully, as a single program,” explains Dr. Malla.

Three months ago, he formed the McGill Network of Early Psychosis. It draws together under one program individuals conducting early psychosis research at the Douglas, the Montreal General, Allan Memorial, the Jewish General and Montreal Children’s hospitals. The McGill Network is putting forward a pre-psychosis research proposal, and Dr. Malla is confident it will launch its first project in the next six months. Along with colleagues from the Université de Montreal and Laval, Dr. Malla is also part of an effort to develop a Quebec-wide network of early psychosis programs—a venture partly funded by Valorisation de la recherche du Québec.

In addition to knitting together the elements of early psychosis research in Montreal, Dr. Malla is pursuing early intervention research in that city. Dr. Malla’s team will directly intervene with the sources of referral—primary care physicians and workers—and study whether this results in earlier treatment for patients. “Sixty per cent of people with psychosis first see their primary care physician, but most don’t get referred, either because patients don’t tell the whole story, the primary care workers or physicians are not thinking in those terms or they don’t know where to send the patient,” explains Malla. The team is setting up a baseline and creating video profiles aimed specifically at primary care physicians to convey the kind of cases typically missed. The study will follow the same basic protocol as the London study and should yield comparable data, he says. The Montreal study differs in that the patient cohort will be aged 14 to 30 years; in London, patients were aged 16 to 50 years.

Dr. Malla’s interest in schizophrenia bloomed early. Nearing the end of medical school in India, he did an internship in psychiatry where patients with obsessive– compulsive disorder and schizophrenia captured his interest. He then trained three years in England, obtained his diploma in psychological medicine and became a member of the Royal College of Psychiatrists in 1976. That year he moved to Canada, attended Memorial University of Newfoundland, trained in child psychiatry to obtain certification from Canada’s Royal College and worked briefly in St. John’s before going to the University of Western Ontario and the LHSC, where his interest in schizophrenia and early intervention solidified.

While Dr. Malla is enthusiastic about early intervention and believes that Canada’s provinces need to embrace it as part of mental health policy, as has been done in the UK, he offers two cautions. “Early detection and early intervention aren’t the same things. If you detect early you need to provide treatment— that’s what makes it an early intervention.” Dr. Malla warns that a bigger danger is confusing early psychosis intervention with early intervention in the prepsychotic phase. The latter is at the research stage—not everyone goes on to develop psychosis, and the science has yet to establish that pre-emptive treatment is safe and effective at this stage, he explains.

What does the future hold? Besides spending time with his five grown children and his wife, he is pursuing his love of downhill skiing, of music of every stripe, of Russian literature and of traveling—he once took a bus trip from England to Afghanistan. He and his wife’s immediate plans include a trip to Quebec City or France to supplement twice-weekly classes and to immerse themselves in French.

On the professional front, he also is pursing a cross-cultural study in Chenai, India. The early psychosis program in Chenai uses a protocol identical to the Montreal study. “It’s a cross-cultural comparison of outcomes in early psychosis.” Dr. Malla is also collaborating with imaging colleagues at the Douglas Hospital to examine the brains of individuals who don’t do well, despite early intervention.

When asked about the challenges and future of early intervention, Dr. Malla says longer term follow-up studies are needed to ascertain how long intensive early intervention treatment needs to be sustained. He also sees the training of researchers as a major challenge to the advancement of all research. Incentives are needed to reduce the financial burden of research training, says Dr. Malla, “Otherwise we’ll have a situation where we’re going to completely dry out of young clinical researchers.” He himself had one student quit halfway through a fellowship owing to financial pressures. Lastly, Dr. Malla feels governments need to understand that the savings from treatment approaches such as early intervention can’t always be measured in dollars, “How can you put a financial value to preventing suicide?” HC