At Issue

Cochrane, Early Intervention, and Mental Health Reform

Analysis, Paralysis, or Evidence-informed Progress?

Patrick McGorry

Disclosures

Schizophr Bull. 2012;38(2):221-224. 

In This Article

Early Intervention in Psychosis

Over the past 15 years, early diagnosis and stage-specific treatment, a vital component of health care for potentially serious medical disease, have gained strong support in psychiatry. Ironically, this has been largely limited to what had originally been the seriously unpromising field of schizophrenia and psychosis. For 100 years pessimism had reigned supreme, but from the early 1990s, an international collaboration between researchers and clinicians began to challenge this self-fulfilling prophecy. From the beginning, this challenge has been evidence-based and led by clinical researchers, and it has produced a burgeoning and substantial literature to guide reform. The essence of the EIP paradigm is the contention that late intervention, especially for young people in a highly sensitive developmental period, is inherently damaging, at least psychosocially and possibly neurobiologically. Providing holistic and evidence-based intervention as soon as there is an undeniable need for care, and certainly as soon as frank psychotic symptoms have become sustained and disabling, is held to be not only a clinical and human imperative but also a strategy that should modify the impact of the illness, even if continuing care is needed in many or even most cases to maintain the initial benefits.

There have been 3 principle foci or stages around which research and reform have been conducted. The first is the stage from the onset of persistent symptoms and impairment, which indicates that a line has been crossed from the normal and transient stresses and strains of life and justifies a need for clinical care. In retrospect, after a psychotic or major mental disorder has supervened, this can be termed the prodromal stage. Looking prospectively, it has variously been termed the at-risk mental state, the subthreshold stage, or the ultrahigh risk (UHR) or clinical high-risk mental state, connoting the potential for resolution as well as progression. Since research has unequivocally shown that people in this stage are distressed, impaired, and have a need for care, as well as a markedly elevated risk (though not by any means inevitable) of sustained psychotic illness as well as other serious diagnostic and functional outcomes, there has been a (controversial) proposal to include operational criteria for this clinical phenotype in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.[7] The second stage is the period between the sustained onset of full-threshold positive psychotic symptoms and the provision of effective evidence-based care for first-episode psychosis, which has given rise to the measurable indicator of "duration of untreated psychosis" and corresponds to a second intervention target. Thirdly, the onset of a first episode of psychosis and the subsequent "critical period" of the next 2–5 years represents another opportunity to test disease-modifying strategies, both individual treatments and models of delivery. In summary, there has been widespread acceptance of the value of this approach, intense research activity for over 15 years, substantial innovation and upscaling of new service models in many countries, all supported by a cohesive international effort, an active scientific organization, the International Early Psychosis Association that has held 7 large international conferences, and, since 2007, a peer-reviewed journal, Early Intervention in Psychiatry.[8] There have been inevitable controversies and debates, and this is expected and welcomed as a sign that genuine change is being attempted. What is particularly striking is that young people, families, and local organizations have been strongly supportive of these reforms wherever they have been progressed. Moreover, while scientific skepticism is always justified, much of the doubt and resistance has arisen within clinical professional groups and is openly based on other than scientific grounds.

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