Improving outcome in schizophrenia: the case for early intervention

• Published in: Canadian Medical Association journal (CMAJ) 1999-03, Vol.160 (6), p.843-846
• Main Authors: Malla, A K, Norman, R M, Voruganti, L P
• Format: Article
• Language: English
• Subjects: Antipsychotic Agents - therapeutic use; Disease Progression; Humans; Mental disorders; Nursing; Predictive Value of Tests; Prognosis; Review; Risk Factors; Schizophrenia; Schizophrenia - diagnosis; Schizophrenia - drug therapy; Therapy; Time Factors; Treatment Outcome
• ISSN: 0820-3946; 1488-2329

The evidence implies that intervention early in the development of psychosis may lead to complete, or almost complete, recovery in a much larger proportion of patients than is currently the case. The beneficial effects of early intervention are supported by the suggestions that untreated psychosis may have a noxious effect on brain functioning,13 that patients experiencing their first episode of schizophrenic psychosis are much more responsive to antipsychotic medication than during subsequent episodes58 and that relatively low doses of antipsychotic drugs are needed at this stage.59 In addition, patients' social supports and insight, 2 important determinants of outcome,60,61 are likely to still exist during the early stages. Outcome studies in schizophrenia show that the greatest decline in functioning occurs in the first few years of the illness.' A longer period of illness is associated with increasing negative symptoms and cognitive and behavioural deficits.62 Medical and psychosocial interventions may be more effective when newer antipsychotics are used at a relatively early stage. The combination of better tolerance and greater brain plasticity associated with the new drugs could render the patient more amenable to psychosocial interventions. Therefore, evaluating the potential benefits of early intervention for psychosis must be a high priority. Systemic factors may also delay the initiation of treatment. These largely reflect the availability of appropriate professional services. Patients in whom a psychotic disorder is eventually diagnosed have frequently visited a physician for related problems, but the underlying illness remains undiagnosed.70 As a result, most patients with schizophrenia are subject to the deleterious effects of delay in the initiation of treatment. Strategies for reducing the duration of untreated psychosis that could be evaluated include teaching better methods of case detection at the primary care level, increasing awareness of psychosis among the public and targeting high-risk populations for early case detection and intervention. It has been proposed that "indicated prevention" efforts71 be directed toward people who are at high risk and who show minimal, yet detectable, signs and symptoms, but who do not meet the criteria for schizophrenia.72 The definition of "caseness" - the point at which a patient can be regarded as suffering from psychosis and in need of treatment--would have to be adjusted, so that treatment for psy