The most important development in patient care for schizophrenia this decade has been early detection and intervention at the 'prodromal' stage, when only early symptoms have appeared and before a diagnosis can be made with certainty.
Research has shown that early intervention can offer the possibility of delaying or preventing the emergence of a full-blown psychosis.
While there are concerns about the feasibility and the ethics of intervention at this stage, treatment offers a number of benefits for this symptomatic and help-seeking group, whether or not transition to psychosis occurs.
The early phase of psychotic illness determines its course and there is growing evidence that the longer the duration of untreated psychosis, the poorer the long-term outcome.
This had led to the development of new services for first-episode psychosis across the UK as part of the NSF for mental health. Even with these services, patients may already have severe symptoms, limited insight, impaired cognitive function, social and occupational decline, by the time they present.
Young people at risk
Prior to the first episode of psychosis, patients usually experience prodromal signs for one to five years. The prodrome can be difficult to identify because many of the symptoms are subtle and non-specific.
There are now well-validated criteria for identifying young people at high risk of psychosis. These are: attenuated psychotic symptoms, a very brief self-resolving psychotic episode, or a decline in overall function coupled with either schizotypal personality disorder or a first-degree relative with a psychotic illness.
Individuals who meet one or more of these criteria are said to have an 'at-risk mental state' (ARMS). Without treatment, about a third of patients with an ARMS will develop a first episode of a schizophrenic-like or affective psychosis within 12 months.
In a further third the prodromal symptoms persist but there is no transition to psychosis and in another third the symptoms improve. Follow-up studies have shown that those who become psychotic are more likely to have experienced prodromal symptoms for longer, to have poor general functioning initially and to be depressed.
Initial randomised controlled trials suggest intervention in the prodromal phase is indeed beneficial. The active treatments offered are low-dosage antipsychotic medication and/or cognitive behavioural therapy, which have been shown to ameliorate psychotic symptoms and reduce transition to psychosis. Additionally, all patients receive close monitoring and case management. There are only a handful of clinical services in the UK for people with an ARMS.
Pros and cons
In addition to the prognostic benefits, intervention at the prodromal phase has the potential to reduce overall costs of care and the patients are easier to engage with than patients who are already psychotic.
Patients and families are generally grateful to have the symptoms taken seriously and be given realistic means to deal with them themselves.
Nevertheless, this approach raises several ethical issues. Services are offering treatment to patients who may not develop a psychotic disorder, thereby stigmatising patients or possibly harming them with inappropriate treatment. In particular, pharmacological intervention, if not given skilfully, may cause unpleasant side-effects such as obesity and diabetes. Some argue that antipsychotic medication should not be prescribed for the 'at-risk' group, just psychological treatments.
Professor Hirsch is clinic director and consultant and Dr Johns is clinical psychologist at the pre-emptive rapid assessment and intervention service for early psychosis (PRAISE-P) at the Priory Group
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