Early Intervention in Schizophrenia

There has been much research in the Early Intervention (EI) in schizophrenia (which is now established as a standard therapeutic approach in North America, Europe and Australasia) for the past 15 years. Proponents of early intervention argue that if patients can be identified at an early stage in their illness and treated, then outcomes for schizophrenia should improve.

Let us first us examine the conceptualised development of schizophrenia from someone who is asymptomatic and functioning well to someone who presents with a first psychotic episode. Schizophrenia is now seen as a neurodevelopmental illness which means that the illness begins in prenatal life. Before the onset of the illness, premorbidly, the person is well, and only at risk from development of schizophrenia. These risks include genetic, intra-uterine, social and environmental influences. See cause of schizophrenia for further discussion of this point. In retrospect, parents sometimes identify problems in childhood such as delayed milestones, poor socialising, poor learning and clumsiness, which are all markers of the neurodevelopmental illness.

The next phase is marked by a functional decline with respect to schooling, work and socialising. This period is termed the schizophrenia prodromal stage (or schizophrenia prodrome), and is a well defined pre-psychotic phase of the illness. It is sometimes also referred to as the ultra-high risk period for psychosis. It is recognised by a negative functional shift and the presence of bizarre and strange thoughts and experiences which fall short of being classifed as psychotic - so called attenuated psychotic symptoms. This period may also be associated with social withdrawal, depressed and changeable moods, irritability and anxiety. The problem with this is, that a lot of parents of teenage children experince this with their kids and put the behaviour down to teenage difficulties. The thought that this behaviour might be due to a developing schizophrenia illness is not at the forefront of anyone's thoughts. Some adolescents adopt negative coping strategies such as drugs which complicates the diagnosis even further. At this point the patient often get diagnosed with other disorders such as depression, anxiety, conduct disorder or adjustment disorder.

The next stage is reached when these symptoms become prominent enough when an acute psychotic episode can be diagnosed. The reality is that the majority of individuals will be undiagnosed at this point for various reasons. These may include refusal to be seen by a doctor, lack of insight that they have an illness, misdiagnosis as another psychiatric disorder or comorbid drug abuse which confuses the clinical picture. This period during which the individual is not treated is termed the duration of untreated psychosis (DUP). It ends when the individual is diagnosed and treatment begins.

Many studies have demonstrated that outcomes are poorer, the longer the psychosis is left untreated. Thus shortening the DUP has been the focus of many early intervention programmes. Another theoretical option is to treat even before the DUP begins, ie to treat the at-high risk groups.

Evidence from earlier studies in Early Intervention have shown that outcomes can be improved. These studies however only measured outcomes up to 2 years. What was needed was evidence that these bebefits were maintained over longer periods.

Now, evidence is emerging which seems to support the view that early intervention in schizophrenia is beneficial to outcomes. The Norwegian Early Treatment and Intervention in Psychosis Study (TIPS) examined whether the DUP could be shortened and whether this would have any affect on outcomes. Patients were selected from 2 different geographical areas. One area had a program for the early detection of psychosis which consisted of educational campaigns directed to the general public, GPs and schools, and a clinical team specialised in the early detection of psychosis. Contact points and telephone numbers were also provided in the campaign. The other area did not have this program.

Norway has one of the most advanced medical systems and both patient groups received identical and excellent treatment which comprised 2 years of antispychotic medication, supportive individual psychotherapy once weekly and group family psycho-education twice monthly. Outcomes were measured at various points.

The main findings from the TIPS study was that 5 year outcomes were improved in certain domains for the early detection group. They entered the study with a shorter DUP, less symptoms and lower suicidality. The outcomes included better scores for negative, cognitive and depressive components. They also had more contact with their friends. These outcomes were present at 2 years and persisted to the 5 year outcome. Outcomes for positive psychotic symptoms and work were the same in both groups. There was no difference in the use of medication or therapy to account for these differences. Only the duration of untreated psychosis could account for the differences bewteen the 2 groups.

The other major study which looked at outcomes of early intervention in schizophrenia was the Danish OPUS study. This study looked at the difference between intensive vs standard treatment - it did not attempt to change the DUP. Both DUPs were similar in the 2 groups, ie intensive and standard treatment groups. The results showed better outcomes in the intensive treatmetn group after 2 years. These better outcomes were however lost at 5 years and the groups were indistinguishable. What these results suggest is that it is not only the intensity of the treatment which is important, but that the timing of intervention is crucial for better outcomes.

The TIPS study is the first study to show favourable outcomes at 5 years after early intervention in schizophrenia, and maintains optimism that reducing the DUP will improve functional outcomes.

The next logical step would be look further back for early intervention in schizophrenia and interevening in the schizophrenia prodrome before overt psychotic symptoms develop. I've discussed this under the schizophrenia prodrome.

There are now established early interevention teams in Australia, New Zealand, North America, Asia and the United Kingdom. In the UK, community mental health services now provide an early psychosis team with reduced case loads and reduced age-at-entry level with the aim to reduce duration of untreated psychosis to less than 3 months. However, as can be seen from the Norwegian study we need extensive community awareness campaigns to educate the public, we need to reduce stigma of mental illness and we need to increase access to the mental health services.


References
Psychol Med 2010,Oct,14:1-9
Psychol Med 2008,38:11411146.
Nature 2010 1 Nov,468:187
Curr Opin Psych 20:121125.
Arch Gen Psych 2008,65(7):762-771
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