This session, chaired by Prof Charles Schulz from University of Minnesota, brought together a panel of experts in the important issue of first episode schizophrenia.
Dr Oliver Freudenreich from Massachusetts General Hospital, Boston opened the presentations, discussing strategies for evaluation of young patients presenting with an initial psychotic episode. He said he hoped to instil some optimism that high quality psychiatric care can have a profound effect on patients’ long-term outcomes. Key features of that care are that it is timely, safe and effective.
However beautiful the strategy, you should occasionally look at the results. Winston Churchill
It matters, he said, to investigate symptoms quickly, and to get the diagnosis right. An initial assessment that investigates typical presentations of first-episode schizophrenia, and screens for and excludes ‘organic’ causes of psychosis is important in guiding treatment. Dr Freudenreich also cautioned against delaying diagnosis by not taking account of the time a patient spent in prodrome or by placing too much emphasis on the presence of depression and/or prior drug use, which might result in exclusion of the diagnosis of schizophrenia. Both of these features commonly accompany the diagnosis of schizophrenia.
He also urged clinicians to consider the medical, as well as the psychiatric, side of the patient’s disease and its treatment. Thus, monitoring weight gain, metabolic problems etc, should help improve adherence to antipsychotic medication, and patients’ long-term health. Finally, Dr Freudenreich was clear that whatever approach to management was taken, the outcomes must be monitored over time to ensure that the treatment is effective.
Educating the Fair City
Timely access to diagnosis and treatment was a theme picked up by Dr Brian O’Donoghue from Melbourne, Australia. He described two services developed for early intervention and reduction of the duration of untreated psychosis (DUP), in Melbourne, Australia and Dublin, Ireland. Early detection focussed on public education on the symptoms of psychosis and how to access appropriate healthcare. Dr O’Donoghue commented on the creative ways in which continuous education could be approached in the current economic climate. For example, in Ireland a storyline about a young man developing schizophrenia was written into a popular soap opera. Such interventions can reduce delays in patients seeking appropriate help. Once within the healthcare system, the interventions in both countries focussed on rapid assessment, and engagement with the patient to ensure they access and maintain treatment. In addition to carefully monitored antipsychotic therapy, patients may access psychological therapies, group programmes, caregiver education, and therapies designed to support patients’ continued education or employment. Both of these programmes are now going to be rolled-out nationally.
Dr John Kane, from New York, discussed the Recovery After an Initial Schizophrenia Episode (RA1SE) programme. In this, a comprehensive and integrated intervention was developed to promote symptomatic recovery and maximise patient functioning. The intervention had four key components: medication, individual resiliency training, family psychoeducation, and supported education or employment. It was delivered at 34 clinics in the USA, and compared with usual community care at another 34 clinics. Patients who received the enhanced intervention showed significantly better quality of life than the controls – the primary outcome of the study. In addition, they showed other advantages, in terms of fewer school/work days lost and improvements in schizophrenia symptoms on the PANSS, but the two groups showed no difference in rates of hospitalisation during follow-up. Patients with a longer DUP were less likely to benefit from the enhanced intervention than those with a shorter DUP. It is important, Dr Kane, concluded, that we determine how to engage with patients with schizophrenia, so they can access effective treatment at an early stage.
Get well, stay well
What’s DUP got to do with recovery in schizophrenia? was the question posed by Prof Robert Zipursky of McMaster University, Hamilton, Ontario. He argued that DUP accounts for very little of the variance in the long-term outcomes in schizophrenia. Moreover, a longer DUP may well not be a causal determinant, but rather a marker for poor outcomes. He also reviewed evidence supporting the contention that schizophrenia is not a progressive disease, and stated that the course of treated schizophrenia appears to be one of stability rather than inevitable deterioration. There should therefore be an emphasis on helping patients achieve a high level of functioning early in the course of their illness, so that this can be preserved over time.
Prof Zipursky gave the important message that most patients with first-episode schizophrenia (70–90%) achieve symptomatic remission in the first year of treatment, and most are able to return to employment or education, and maintain social relationships having achieved remission. Using a comprehensive treatment programme, of effective pharmacological therapy, along with psychosocial treatments, patients can remain in remission for long periods of time. The deterioration that is often observed results from poor access or engagement with care, lack of adherence to treatment, co-morbid substance use or psychiatric disorders and social adversity. If these can be managed, clinicians should expect recovery not deterioration when their patients are provided optimal treatments and support. He concluded that ongoing clinical deterioration is not an inevitable part of the course of schizophrenia – when people get well they can stay well.