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Early intervention in psychosis

  • Swaran P. Singh (a1)

Early intervention in psychosis services produce better clinical outcomes than generic teams and are also cost-effective. Clinical gains made within such services are robust as long as the interventions are actively provided. Longer-term data show that some of these gains are lost when care is transferred back to generic teams. This paper argues that sustaining these early gains requires both a reappraisal of generic services and an understanding of the active ingredients of early intervention, which can be tailored for longer input in cases with poorer outcome trajectories.

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Early intervention in psychosis

  • Swaran P. Singh (a1)
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A Staging Model of Psychosis is Neccessary

Swaran P Singh
06 October 2010

I am grateful for Dr Agius’ comments and entirely agree that a staging approach allows the development of a comprehensive care pathway for psychotic disorders. With such an approach, the most efficacious and potentially less harmful interventions can be appropriately targeted at an earlier clinical stage of an emerging illness. Such a staging model is widely used in medicine and has recently been described as a heuristic framework for intervening early in all youth mental health problems (1, 2)

Half of all adult mental disorders begin in late adolescence, usually with an initial presentation of non-diagnostic symptoms. Mental health services, especially community mental health teams, offer interventions only when an illness is severe enough to reach a diagnostic threshold. This is partly due to the reactive nature of CMHT care and partly because of concerns about treating ‘false positives’, benign and transient states that will not make a transition into a major mental disorder. An unfortunate consequence of this well-meaning caution is that young people are denied earlier and safer interventions which are not only clinically appropriate at an early stage, but have the potential for altering the prognosis and preventing the emergence of more serious illness.

A staging approach also offers exciting possibilities for developing specific clinical and biological markers of mental illnesses and understanding the relationship between clinical states and neuropathological and neurophysiological changes that accompany illness progression (3)

I also share Dr Agius’ concern about the short-term financial pressures that may encourage managers to amalgamate EI services into CMHTs. This will simply dilute the well-established effectiveness of EI services in caring for vulnerable young people while offering no improvement in CMHT functioning.

Reference1.McGorry, P., Purcell, R., Hickie, I. B., Young, A. R., Pantelis, C., & Jackson, H. J. (2007). Clinical Staging: a jeuristic model for psychiatry and youth mental health. The Medical Journal of Australia , 187 (7), 40-42.2.Francey, S. M., Nelson, B., Thompson, A., Parker, A. G., Kerr, M., Macneil, C., et al. (2010). Who needs antipsychotic medication in the earliest stages of psychosis? A reconsideration of benefits, risks, neurobiology and ehics in the era of early intervention. Schizophrenia Research , 119, 1-10.3.Fusar-Poli, P., Howes, O. D., Allen, P., Broome, M., Valli, I., Asselin, M.-C., et al. (2010). Abnormal Frontostriatal Interactions in People With Prodromal Signs of Psychosis. A Multimodal Imaging Study. Archives of General Psychiatry , 67 (7), 683-691.
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Conflict of interest: None Declared

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A Care Pathway for Schizophrenia

Mark Agius, Associate Specialist South Essex University Partnership Foundation Trust
25 August 2010

Swaran Singh has recently argued for a Care Pathway for Psychosis orSchizophrenia.1. We have recently argued for a staging approach to Schizophrenia 2. Such an approach argues that there are different stages in the development of Schizophrenia, and that therefore different stages of the illness will require different interventions to optimise treatment,be it pharmaceutical, social or psychological. Furthermore, logically, thedifferent stages will require different goals of treatment , and differentexpected outcome measures. Thus, for example, the aim of treatment in thefirst or ‘at risk mental state’ stage of psychosis is to prevent psychosisdeveloping, while the aim of the second stage , or the first episode stage, is to end the psychotic episode and return the patient to work and education.Staging in schizophrenia also extends to the phase of chronic illness, andhere the goal will be, depending on the severity of the illness, to limit the positive and negative symptoms of the illness, to prevent relapse , and to optimise social inclusion, promoting a return to work if possible. Such a staging approach to schizophrenia is underpinned by the neuroimaging evidence, since the loss of gray matter linked with schizophrenia does start in the prodromal ‘at risk’ phase, becomes more prominent in the first episode, and then becomes incrementally more severe in the later stages of the disease . 3,4,5. Furthermore, different stages of the illness appear to be mirrored in different patterns of change in such structures as the hippocampus and the amygdala. 6., as wellas changes in pituitary volume. 7, 8. Thus, a ‘staging approach’ to schizophrenia does provide a logical framework for the development of a Care Pathway for Schizophrenia , with different stages, or phases requiring the development of specialised teamswith different expected outcomes , but who will always , in each phase of the illness , strive to optimise treatment in order to achieve the best results.Hence, such a pathway may include an ‘at risk mental health’ team, which will attempt to reduce the rate of transition to full psychosis in patients who are developing ‘prodromal’ symptoms . This would be followed in the pathway by a first episode service which will work assertively withpatients so as to deal with the first episode and return patients to work and education, and at the other end of the spectrum, Assertive outreach teams will work with those difficult to treat patients who have demonstrated the most serious deterioration in functioning.What, however , is missing in this care pathway , is the treatment of those patients who are returned to Community Mental Health Teams after three years in an Early Intervention service, and who are not deemed ill enough to require referral to the Assertive Outreach Teams. These constitute the majority of patients with long term Schizophrenia. Unfortunately, since Community Mental Health Teams have other priorities ,and indeed are oriented to dealing with patients with relatively less severe forms of mental illness, many of these patients may receive suboptimal care, sometimes consisting of the simple delivery of medicationwithin a Depot or Clozapine Clinic , and without the systematic delivery of psychosocial interventions . As a result, in many cases, social inclusion is not optimised as a direct result of the loss of the AssertiveApproach to care. It is therefore small wonder that both the LEO 9 and theOPUS 10 services report a loss of improvement in outcomes within five years of first treatment, after patients have been transferred from Early Intervention Teams to the care of Community Mental Health Teams. It is of interest that a study in Russia 11, where patients were followed up assertively for five years , has shown no such loss of improvement in outcomes. It is urgent that the development of ongoing assertive, specialised teams for psychosis , as suggested by Singh, should be developed in order to complete the Shizophrenia Care Pathway. The CMHT cannot provide such an assertive service, since it is focussed on other things. Seen in this perspective, recent suggestions that Early Intervention and Assertive Outreach Teams should be amalgamated into CMHTs and provide elements of specialised care within the CMHTs must further confuse the focus of the CMHTs and constitute a serious misreading of the evidence.

References1. Singh S Early intervention in psychosis. Br J Psychiatry 2010; 196: 343-345

2. Agius M, Goh C, Ulhaq S, McGorry P.The staging model in schizophrenia, and its clinical implications.Psychiatr Danub. 2010 ;22: 211-20.

3. Meisenzahl EM, Koutsouleris N, Gaser C, Bottlender R,Schmitt GJ, McGuire P, Decker P, Burgermeister B, Born C, Reiser M, Möller HJ. Structural brain alterations insubjects at high-risk of psychosis: a voxel-based morphometric study. Schizophrenia Research. 2008;102:150-62.

4. Meisenzahl EM, Koutsouleris N, Bottlender R, Scheuerecker J, JägerM, Teipel SJ, Holzinger S, Frodl T,Preuss U, Schmitt G, Burgermeister B, Reiser M, Born C, Möller HJ. Structural brain alterations at different stages of schizophrenia: a voxel-based morphometric study. Schizophrenia Research. 2008 ;104:44-60.

5. Pantelis C, Yücel M ,Wood, SJ, Velakoulis, D, Sun D, Berger G, Stuart GW, Yung A, Phillips L, McGorry P: Structural brain imaging evidence for multiple pathological processes at different stages of brain development in schizophrenia. Schizophrenia Bulletin. 2005; 31:672-696.

6. Velakoulis D, Wood SJ, Wong MT, McGorry PD, Yung A, Phillips L, Smith D, Brewer W, Proffitt T, Desmond P , Pantelis C: Hippocampal and amygdala volumesaccording to psychosis stage and diagnosis: a magnetic resonance imaging study of chronic schizophrenia, first episode psychosis, and ultra-high-risk individuals.Archives of General Psychiatry. 2006; 63:139-49.

7. Pariante CM, Vassilopoulou K, Velakoulis D, Phillips L, Soulsby B,Wood SJ, Brewer W, Smith DJ, Dazzan P, Yung AR, Zervas IM, Christodoulou GN, Murray R, McGorry PD, Pantelis C. Pituitary volume in psychosis. Br J Psychiatry.2004 ;185:5-10.

8. Pituitary volume predicts future transition to psychosis in individuals at ultra-high risk of developing psychosis. Garner B, ParianteCM, Wood SJ, Velakoulis D, Phillips L, Soulsby B, Brewer WJ, Smith DJ, Dazzan P, Berger GE, Yung AR, van den Buuse M, Murray R, McGorry PD, Pantelis C. Biol Psychiatry. 2005 ;58:417-23

9. Gafoor R, Nitsch D, McCrone P, Craig TKJ, Garety PA, Power P, McGuire P Effect of early intervention on 5-year outcome in non-affective psychosis Br J Psychiatry 2010 ; 196: 372-376.

10. Bertelsen M, Jeppesen P, Petersen L, Thorup A, Øhlenschlæger J,le Quach P, Christensen T Ø, Krarup G, Jørgensen P, Nordentoft M. Five-Year Follow-up of a Randomized Multicenter Trial of Intensive Early Intervention vs Standard Treatment for Patients With a First Episode of Psychotic Illness Arch Gen Psychiatry. 2008;65:762-771

11. Zaytseva Y. Efficacy of integrated program treatment of first episodepatients versus standard care. Psychiatric Health.2008 10;51 –57
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