Staging intervention and meeting needs in early psychosis

Kraepelin's idea to use outcome as a diagnostic criterion for dementia praecox, so that the outcome of this condition was by definition gloomy, was criticized from the very beginning. Bleuler 1defended the view that a schizophrenia diagnosis should be set at the beginning of the illness, so that a patient with schizophrenia had the possibility to recover without retrospective rediagnosing. The Bleulerian approach, fertilized by Freudian psychodynamic ingredients, led to the broadening of the schizophrenia concept, resulting, however, in unreliable schizophrenia diagnoses. In reaction to this untenable situation, the neo-Kraepelinian diagnostic classification (DSM-III) was produced, and outcome once again became a diagnostic criterion. This diagnostic reform meant a setback for early intervention, because a clinician had to wait for a long time before the correct diagnosis could be confirmed and evidence-based intervention could be introduced.

To overcome the disadvantage caused by the current clinical diagnostic practice, McGorry et al suggest to concentrate not on schizophrenia, but on all (functional) psychotic disorders, considering their development as stages from risk state, via first episode, to recovery or critical period. From the point of view of early intervention, this psychosis staging is justified. Only a small proportion of ultra-high risk patients who develop psychosis will progress to a schizophrenia diagnosis. Early and comprehensive intervention could reach patients at their pre-psychotic stage and possibly prevent or delay their sliding into psychosis. These patients may suffer from rather severe (subclinical or subsyndromal) symptoms and functional decline: they do not fulfil the criteria for clinical diagnoses, but can progress to various types of psychoses, thus requiring a broader range of clinical skills than treatment for patients with confirmed schizophrenia. Actually, the care of ultra-high risk patients follows the principles of the dimensional approach, and focuses on treating various symptoms and functional deficits, without waiting for a structural diagnosis; preventive thinking characterizes the whole disorder detection and intervention process.

The ultra-high risk or late initial prodromal state is now well defined, and there are reliable instruments for detecting ultra-high risk subjects, although the distinction between an ultra-high risk condition (brief intermittent psychotic symptoms) and brief psychoses is not clear-cut. The early initial prodromal state, defined by basic symptoms, may precede the late initial prodromal one, and offer an earlier stage for psycho-social intervention 2,3. Although there is no consensus as yet on how to treat patients with early prodromal states, a few intervention studies suggest that both psychosocial and pharmacological intervention are promising.

It is rather surprising how vigorously the authors defend atypical over conventional antipsychotic drugs. It is true that, in the EUFEST study 4, the discontinuation rate among patients receiving low dose haloperidol was higher than among patients with atypical drugs. However, this study was open and, as the authors state, “expectations of psychiatrists could have led to haloperidol being discontinued more often”. Both conventional and atypical antipsychotic drugs are heterogeneous groups, and we have no good comparative studies between different antipsy-chotics in the treatment of patients at risk of psychosis or with first-episode schizophrenia. A couple of studies using perphenazine (CATIE) 5or several conventionals (CUtLASS) 6as comparative drugs suggest that the differences in effectiveness between conventional and atypical drugs may be small. The poor reputation of conventional neuroleptics is mainly due to the high daily doses patients were prescribed. The clinical staging approach, when speaking about psychoses instead of schizophrenia, aims to reduce the stigma related to the concept of schizophrenia. This same strategy may also suit the names of antipsychotic drugs. As the authors state, it is paradoxical that antipsychotic drugs are widely used in the treatment of patients in the prodromal phase, while they are not allowed in clinical trials. By changing the names of drugs from antipsychotic back to neuroleptic drugs, a large amount of the fears related to the psychosis concept and use of drugs could be over-come.

Intervention studies have shown that, even in optimal conditions, only a part of psychoses, including schizophrenia, can be prevented. However, at the community level, the duration of untreated psychosis can be shortened 7. This is one of the most important achievements of the early detection and intervention approach. Still, the need for comprehensive care is considerable. On the basis of his studies and long experience, Alanen 8launched the concept of need-adapted treatment, which includes five main elements: a) flexible and individually planned and carried out therapeutic activities; b) examination and treatment dominated by a psychotherapeutic attitude; c) different therapeutic approaches should supplement, not replace each other; d) treatment should attain and maintain a continuous interactional process, and e) follow-up of the individual patient and the efficacy of the treatment. Moreover, need-adapted treatment emphasizes that the needs of an individual patient may change. The treatment system should be sensitive to these changes and try to meet the actual needs comprehensively. This also means that the need for care can extend over the so-called critical period.

The question of special early detection and intervention clinics is important. Most patients with prodromal states attend primary care and/or community mental health centres, depending on the local treatment system. This means that all teams meeting patients with mental problems should be aware of the possibility of psychosis and should try to screen and examine patients also from this point of view. Specialized clinics may meet only a (small) proportion of patients at risk of psychosis, but they have on important role to play in educating community and other teams.