Early Psychosis Intervention: The International Context
Abstract: This article describes the research that informed the development of early intervention in psychosis and the spread of early intervention best practices in treatment programs throughout the world.
"Early Psychosis Intervention: The International Context" (2016)
By Pat McGorry & Heather Stavely
T he outlook for a young person in the early stages of a psychotic illness today can – and should – be very different from that of just three decades ago. During the 1980s, the first clinical studies highlighting the special needs of young people experiencing a first episode of psychosis caught the attention of clinicians and researchers, beginning with our research group here in Australia. Interest expanded rapidly around the world in understanding the biological and social factors that underpin psychotic illnesses, and in better ways to treat them. Since then, we have learned much about how these illnesses evolve and their neurobiology, which has allowed the development of better medical treatments. Clinical research has led to the development of services specifically designed around the unique needs of these vulnerable young people. We now know that experiencing a psychotic illness like schizophrenia does not inevitably lead to a lifetime of disability and dependence. Instead, timely and appropriate early intervention has the potential to eliminate, or at the very least reduce, the negative effects of these illnesses. This has led to a radical shift in our approach to the care of those living with psychosis: instead of simply managing symptoms, the focus of treatment is now intervening early with a strong emphasis on promoting recovery to enable the young person to live a meaningful and contributing life within the community.
The key aims of early intervention are to prevent illness, or when illness occurs, to minimize its impact. This is particularly important for psychosis, since one of the main reasons why these illnesses can be so devastating is that they typically appear during late adolescence and early adulthood. Disrupting life during this crucial transitional period can be devastating to young people's normal development process of finishing their education and beginning their working lives, developing intimate relationships, and establishing themselves as independent adults. If the illness is untreated, or poorly treated, this disruption can lead to long-term and even life-long disability.
Understanding How Illness Develops, and How Best to Treat it
Long-term studies have shown that schizophrenia almost always follows a long period of increasingly distressing symptoms, such as poor concentration, disturbed sleep, lack of energy, social withdrawal, depression, and anxiety. Over time, these symptoms slowly intensify; low-grade psychotic symptoms such as visual distortions, hallucinations, and early delusional thought processes appear; and the young person's ability to function in daily life is increasingly affected. Eventually, the psychotic symptoms increase to the point that a first psychotic episode occurs in which the person loses touch with reality. We now know that much of the disability associated with psychotic illness develops during this pre-onset period, well before the first episode,1 and that the most important risk factor for a poor outcome is a long duration of untreated illness. This is why early intervention is so important.
It is now possible to identify young people with early symptoms which are beginning to impact their functioning but which are not yet severe enough to prevent them from distinguishing reality. Appropriate care to reinforce functioning and prevent symptom deterioration for these "at clinical high risk" individuals may potentially prevent the onset of psychosis, or minimize the devastating consequences which come when individuals lose touch with reality in a first episode of psychosis. Moreover, for those who do experience a first episode of psychosis, treatment is no longer aimed at simply controlling their symptoms, but also at helping maintain or regain their developmental trajectory so they can make the best possible social and vocational recovery and enjoy a productive and meaningful life.
Early Intervention: Best Practices
Young people in the early stages of a serious mental illness most often present with a complex mix of relatively non-specific, but distressing, symptoms that wax and wane and develop further over time. This means that different treatment approaches are required than those used for people with well-established illness, who are usually older. Care for young people should reflect their different social, vocational, and developmental needs, be acceptable within the cultures of youth and the community, appropriate for their stage of illness, and have a strong focus on recovery. Care is best provided in a specialist youth mental health service that is able to offer multidisciplinary mental health care in a youth-friendly, stigma-free setting, with strong links to locally available services for young people, such as social services, schools, tertiary training institutions, and educational and vocational support organizations.
For young people experiencing the early stages of a psychotic illness, these services offer three core functions: (a) early detection; (b) acute care during and immediately following a crisis; and (c) recovery-focused continuing care, featuring multimodal interventions to enable young people to maintain or regain their social, academic, and career trajectory during the critical first 2–5 years following the onset of illness.
Using the Most Appropriate Treatment for the Stage of Illness
The type of interventions selected depend on each individual young person’s symptom profile, whether or not they are at risk of self-harm or suicide, or harming another person; any substance use or comorbid illness; and their family history, among other factors. However, this staged approach to care has three major benefits over traditional care. Firstly, the very early stages of a potentially serious mental illness are recognized as requiring treatment. Secondly, but no less importantly, treating early means that more benign treatments can be used first, which minimizes the risk of any side-effects associated with the treatments used for later stages of illness, and particularly the inappropriate use of medications. Thirdly, early treatment can prevent, or greatly reduce, the risk of ongoing disability if illness does develop or progress.
Interventions for Young People at Risk of Psychosis
A number of interventions for young people at clinical high risk for psychosis have been tested in clinical trials looking at the use of medication (low-dose antipsychotics and/or antidepressants), psychosocial treatments, or both, to prevent the onset of psychosis. An assessment of these studies has concluded that they are all effective; however, because even low doses of antipsychotic medications can cause serious side-effects, psychosocial interventions, including supportive therapy and Cognitive Behavioral Therapy (CBT), illness education, family work, group work and other benign interventions, such as dietary supplementation with fish oil, are currently recommended as first line therapy at this stage of illness.2 Drug therapies should only be considered if symptoms and impairment persist or worsen. This is particularly important because the majority of these young people will not go on to develop schizophrenia, although a significant number will continue to need professional mental health care, particularly for depression and anxiety.
Interventions for First-Episode of Psychosis
Treating a first episode of psychosis requires great sensitivity and clinical skill, and ideally care for these young people should be managed in specialized services separately from older people at later stages of illness. At this stage, low-dose antipsychotic medications and a range of intensive psychological and social interventions are essential to maximize recovery and minimize ongoing symptoms and disability. Most young people who experience their first episode of psychosis do recover. However, they remain at high risk for relapse, with around 50% relapsing within three years, and if they discontinue their treatment, as many do, at least 80% will relapse within five years.3
Intensive psychosocial interventions to promote, support, and maintain a meaningful recovery are crucial for young people with early psychosis. Ideally, these interventions should be offered to all these young people for the critical period of the first five years after diagnosis, when the risk of ongoing and entrenched functional disability is highest. Strategies targeted at maximizing functional recovery, such as those aimed at relapse prevention and vocational interventions, are key here, and complement and enhance each other. When combined with an appropriate approach to medication, including guided dose reduction or discontinuation for some young people, these approaches can significantly improve the outcome for many young people.
Physical Health in Those with a Psychotic Illness
Young people who are taking antipsychotic medication are at increased risk of weight gain and metabolic abnormalities, which may appear in the first few weeks of treatment. Causes include genetic predisposition, poor nutrition, lack of exercise, smoking, and substance abuse, as well as the side effects of antipsychotic medication. Moreover, there is strong evidence to suggest that people with psychotic illnesses receive inferior quality physical health care compared to those with chronic physical illnesses.4 Apart from these effects on physical health, the weight gain associated with antipsychotic treatment can affect a young person's self-esteem, increase self-stigma, and increase the chances of discontinuing medication, which increases the risk of relapse. Together, these factors mean that it is crucial to take measures to prevent and treat weight gain, preferably prior to it becoming an issue.
From its small-scale, experimental beginnings in just a few clinics around the world, it is pleasing to see that the early intervention approach, with its pre-emptive, recovery-oriented focus, has now spread to hundreds of clinics world-wide. It has proven its value in a range of long-term follow-up studies from around the world, which show significantly better clinical and functional outcomes for young people in the early stages of a psychotic illness treated within specialized early intervention services, compared to those treated in standard mental health services.5 An added benefit is that early intervention services have been shown to be more cost-effective than traditional services. Finally, and more importantly, they are highly valued by young people and their families.
Over 20 years ago now, the Early Psychosis Prevention and Intervention Clinic (EPPIC) was established in Melbourne, Australia. Similar approaches were quickly adopted in centers in the United Kingdom (UK) and in Denmark, and rapidly spread throughout the UK, Scandinavia, and to the Asia-Pacific region in the years that followed. Although a number of researchers in the United States (US) have been key leaders in early psychosis research, the healthcare funding structure in the US has limited the extent of service reform. The first early intervention service in the US, the Early Assessment and Support Alliance (EASA) in Oregon, was established 15 years ago to develop a systematized effort to prevent early trauma and disability caused by schizophrenia and related conditions, and a number of US academic centers also operate early intervention services. Recent results from the Recovery After an Initial Episode of Psychosis (RAISE) studies in the US have clearly demonstrated the effectiveness of early intervention, and the US is now investing in system reform.
Finally, early intervention is not a new approach in medicine. In oncology, for example, the enormous improvements in recovery and outcomes for many different cancer treatments have come not from dramatic breakthroughs or novel treatments, but from intervening much earlier with existing treatments, and delivering them in a more sustained and comprehensive fashion for as long as they are needed. Mental health professionals still have much to learn from the lessons gained from early intervention approaches in physical medicine. Early intervention for psychosis has clearly proven its value; to reap the full social and economic benefits of this approach we now need to expand early intervention to cover the full spectrum of mental ill-health in young people. For this approach to be effective, it must be offered in services that operate with a culture of hope and optimism, and provide intensive evidence-based biopsychosocial care featuring collaboration with young people and their families, in an environment that is stigma-free and youth-friendly. All of these elements are crucial to the success of this service model.
- Birchwood, M., Todd, P., & Jackson, C. (1998). Early intervention in psychosis. The critical period hypothesis. The British Journal of Psychiatry Supplement, 172, 53–59.
- McGorry, P., Alvarez-Jimenez, M., & Killackey, E. (2013). Antipsychotic medication during the critical period following remission from first-episode psychosis: Less is more. Journal of the American Medical Association: Psychiatry, 70, 898–900.
- McGorry, P. D., Goldstone, S. D., Parker A. G., Rickwood, D. J., & Hickie, I. B. (2014). Cultures for mental health care of young people: An Australian blueprint for reform. The Lancet Psychiatry, 1, 559–568.
- Shiers, D., Bradshaw, T., & Campion, J. (2015). Health inequalities and psychosis: Time for action. The British Journal of Psychiatry, 207, 471–473.
- Van Der Gaag, M., Smit, F., Bechdolf, A., French, P., Linszen, D. H., Yung, A. R., McGorry, P., & Cuijpers, P. (2013). Preventing a first episode of psychosis: Meta-analysis of randomized controlled prevention trials of 12 month and medium-term follow-ups. Schizophrenia Research, 149(1-3), 56–62.
McGorry, P. & Stavely, H. (2016). Early Psychosis Intervention: The International Context. Focal Point: Youth, Young Adults, and Mental Health, 30, 5-8. Portland, OR: Research and Training Center for Pathways to Positive Futures, Portland State University.