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Spring 2008 | Vol 11 No 3

Letter to the Editor

Early psychosis: Acting before the horse has left the barn

By Irvin Epstein

There continues to be controversy about the merits of early detection and treatment for youth psychosis, as seen in the Last Word column of the winter issue of CrossCurrents. The onset of psychosis can result in lifelong psychological changes. However, the diagnosis is often delayed because of uncertainty and no distinct biological markers or a “litmus test” for identifying early psychosis.
One obvious criticism is that of predictive validity in current studies and problems with the diagnosis of “false positives.” The goal of early intervention studies is to develop a database of predictive factors, markers and pre-psychotic symptoms that define early phases of illness. Research in the field is guided by principles of “do no harm” and by recognition of the high cost of a later diagnosis to the individual.

International collaboration has led to a shift from attempting to calibrate the prodrome – a period of disquiet, depression and subtle personality/behavioural changes – towards identifyng individuals “at risk” for psychosis.

Individuals with pre-psychotic features are already in distress and are help-seeking. First episode individuals often have substantial impairments in their mood, cognition and social functioning. Most are caught late and have been ill for months or years before presenting to the ER. This period of symptomatic distress or duration of untreated psychosis (DUP) has been correlated with evidence of irreversible gray matter changes on MRI, residual features, treatment resistance and a poorer overall prognosis.

Robinson demonstrated that 118 first episode patients who received appropriate treatment had only a 14 per cent chance of achieving an adequate level of recovery of psychological and social functioning after five years. The reality is that complete recovery from a first episode is very limited and the relapse rate was over 80 per cent after five years. This suggests that relapse is the rule not the exception. Other personal costs of late diagnosis can include vulnerability to depression, suicide attempts and substance abuse problems.

Recent research with the “at risk” population has provided further evidence about the link between DUP, brain changes and transition to a first episode. Both Simon in Switzerland and Eastvold in Utah have studied cognitive functioning in healthy controls, “at risk” subjects and first episode individuals. Both found that healthy individuals performed best, followed by “at risk” individuals who had modest intermediate cognitive impairments when compared to first episode subjects. This may lead to selective neurocognitive tests to assess vulnerability for psychosis.

Imaging studies have demonstrated brain changes over the first five years of active psychosis resulting in a 10–20 per cent decrease in grey matter in areas associated with cognition, organization and positive and negative features. Pantelis found that high-risk individuals who developed psychosis had greater gray matter loss than those who did not progress. Similarly, Davazikos showed that “at risk” individuals had subtle but less marked grey matter changes in the same areas of the brain than is typically affected in first episode patients.

In 2007, Lappin found a correlation between a longer DUP (over 26 weeks) and greater loss of grey matter in the areas responsible for organization, memory, learning and positive features. The ability to correlate early identifiable brain changes with evolving signs of psychosis may allow us to identify early those at risk. These studies would not be possible without having an early intervention focus.

New psychosocial/talk treatments are being studied to potentially prevent the emergence of psychosis. (Even though most medication studies show an advantage in reduction of early symptoms, the focus is now on neuroprotective agents to stabilize the brain at a critical period.) Clearly one size does not fit all and a combination of therapeutic approaches could offer the best opportunity to delay, modify or prevent onset of psychosis. The goal is to have an array of evidence-based approaches available for those already at risk and in distress.

We have had over 100 years of a “watch and wait” approach; it is time to change the game plan.  By offering help at an earlier stage and through effective public health campaigns to inform the community about risk factors and availability of services, we hope to change the view of schizophrenia.

Early intervention provides an opportunity to treat people before the chronic deficits and demoralization set in. Our current status quo of “too little too late” – “after the horse has left the barn” would not be acceptable in any other branch of medicine.

Dr. Irvin Epstein
Psychiatrist, Centre for Addiction and Mental Health