Origins of Early Intervention in First-Episode Psychosis

EARLY PESSIMISM

Emil Kraepelin's concept of dementia praecox (premature dementia) ² was a crucial contribution to the understanding of schizophrenia. However, the concept was also responsible for portraying an overly pessimistic view regarding the prognosis of psychotic illnesses, and thus probably contributed to the delay in establishing more active and earlier intervention strategies. Kraepelin originally believed that the cause of dementia praecox was ‘psychopathic predisposition’ (perhaps the equivalent of ‘neurodevelopmental’ in modern terminology). Shorter observed that most patients with what Bleuler 10 years later called schizophrenia, would deteriorate into ‘dementia’, ³ and this belief has shaped our own views of psychotic illness well into this century.

ROLE OF ASYLUMS

In 1800 only a small number of individuals were confined in asylums but by 1904 there were 150 000 patients in USA mental hospitals alone. ³ It is likely that abuses of patients occurred including excessive use of restraint, overcrowding and neglect. By the late 1800s the asylums were becoming overcrowded and neglected. A study by MacKenzie of the asylum in Ticehurst, UK, showed that the median length of stay was approximately 25 years. ⁴ Sixty to 80 per cent of patients were likely to die in hospital and only between 2 and 11% recovered and were discharged. Since then, despite many changes in the theory and practice of the treatment of schizophrenia, including the reduction in bed numbers in psychiatric hospitals to a fraction of their former capacity, the physical and operational legacy that had been left continues to influence the current management and expectations we have for the outcome of our psychotic patients.

PSYCHOSIS: ORGANIC OR FUNCTIONAL?

Throughout the 19th century many believed that mental disorders were organic in nature. In Germany, Wilhelm Griesinger stated that ‘psychological diseases are diseases of the brain, insanity itself … is only a symptom’. ¹ In the absence of a means of studying psychosis scientifically (due to a lack of technology and an appropriate model to drive research), Kraepelin abandoned any attempt to classify mental illness by aetiology, preferring to focus on clinical course and outcome, with the pessimistic bias described previously. Perhaps also as a reaction to the emerging hopelessness of asylum psychiatry, a dynamic psychiatry dominated by Freud emerged. It took some decades and breakthroughs in neurochemistry and neuroimaging before a strong focus returned to the biological basis of psychotic illnesses. This focus helped drive the need for treatments that might be more effective if applied early in the course of illness.

COMMUNITY-BASED CARE

Although these historical ways of thinking were barriers to the development of EI strategies, positive forces began to emerge, starting with deinstitutionalization. Influences behind deinstitutionalization were sociological, medico-political, and financial. The antipsychiatry movement included proponents such as RD Laing ⁵ and Thomas Szasz, ⁶ who highlighted and challenged the power and control held in the institutions. Movies such as One Flew Over the Cuckoo's Nest, depicting the unwarranted use of electroconvulsive therapy (ECT) and psychosurgery, enjoyed great popularity. In NSW, the Richmond Report recommended that the health system ‘provide services which maintained clients in their normal community environment and reduce the size and number of fifth schedule hospitals by decentralizing the services they provide’. ⁷ As governments responded to this and later reports, and sought to reduce the cost of health care, patients were transferred out of expensive hospitals into community settings. The burden of care was thus transferred onto local medical officers, community mental health teams, and particularly patients’ families, initially without a corresponding increase in resources. There has been widespread criticism of the planning and mode of execution of the policy of deinstitutionalization and the move to community care. Despite the difficulties, consumer surveys frequently indicated a preference for community care. Early intervention principles emphasize the need to engage with the client, educate families and enlist their help in monitoring their relatives, and the minimization of the trauma involved in the treatment process, particularly that associated with hospital admission. Early intervention aims to have the main locus of care in the person's home, and thus deinstitutionalization and the acceptance of community-based care was necessary before any broad acceptance of EI strategies could occur.

POSITIVE LONG-TERM OUTCOME STUDIES

After many decades of accepting Kraepelin's views on the outcome of schizophrenia, the results of later outcome studies proved to be surprisingly positive. Manfred Bleuler conducted his naturalistic ‘followback’ study on 208 subjects, considered to be a representative sample of 653 patients admitted in 1942 or 1943 to Burgholzi Hospital in Zurich, Switzerland. ⁸ Bleuler based his diagnostic criteria on altered associations, autism, ambivalence and affect (the ‘four A's’), as well as positive symptoms such as delusions and hallucinations. Of first-episode patients followed for at least 5 years, he found that 66% were recovered or significantly improved and only 41% demonstrated impairment in social functioning. Luc Ciompi's ‘Lausanne investigation’ found similar results. ⁹ This high attrition study (only 18% of 1642 patients were reassessed) of admissions over 62 years (1900-1962) found that 49% of patients had a favourable long-term outcome. Results from these European studies broadly correlated with data from the USA. Encouraged by these results, there emerged the gradual acceptance of greater variability in the course and outcome of schizophrenia.

There were clear methodological problems with these naturalistic studies. These included contamination by multiple-admission patients, small sample sizes, a reliance on cross-sectional diagnoses that were not revised, and the exclusion of patients with substance abuse problems. ¹⁰ Despite these weaknesses, these studies were crucial in revealing the heterogenous and more optimistic course of schizophrenia and encouraged further research into psychotic illnesses and treatment variables linked with improved outcomes.

TREATMENT ADVANCES

Detecting an illness early is useful only if effective treatment is available. ¹¹ Thus the discovery and introduction of antipsychotic medications such as chlorpromazine in 1954 was crucial. These medications assisted in the discharge of patients from psychiatric hospitals and heralded the potential for the later development of community-based approaches to treatment. In acute psychosis these drugs were shown to be generally effective in controlling positive symptoms, and were essentially interchangeable in terms of efficacy. ¹² The prophylactic value of maintenance antipsychotic medication after a psychotic episode has been well established by Davis ¹³ among others. Overall, in an analysis of data from placebo-controlled trials, approximately 75% of patients relapsed in the year after a psychotic episode when taking a placebo medication, while only 15% relapsed while taking an antipsychotic. ¹⁴ Thus these medications provided an effective alternative to institutionalization as a treatment, providing a valid biological rationale for community treatment, and lessening the dependence of patients and clinicians on the institutions.

Well-known problems in the use of these medications included their range of side-effects, particularly extrapyramidal side-effects (EPSE), which contributed to poor treatment adherence. ¹⁵ They also had no effect on the negative symptoms of schizophrenia but rather ‘created’ or exacerbated these symptoms by producing EPSE or sedation. In many cases, patients became non-compliant and relapsed or were hampered in their psychosocial recovery. It has been found that patients experiencing their first psychotic episode will achieve good response rates with lowdose medication regimes. ¹⁶ Additionally, the locally available atypical medications risperidone, olanzapine, quetiapine and clozapine have offered advantages in these regards. They are generally accepted to have at least equal efficacy, as well as less extrapyramidal and prolactin-related side-effects, and a possible beneficial effect on negative symptoms. ^12,15,17 For treatment-resistant cases clozapine has been shown to improve cognition ¹⁸ and aggressive and hostile behaviour, ¹⁹ as well as sometimes reducing intractable positive symptoms. ²⁰ These same studies also suggest similar benefits from the other atypical medications.

Thus medications are now widely available that are efficacious at low doses, with an improved risk-benefit profile, which clinicians are more likely to prescribe and that patients are more likely to continue. These medications have resulted in a reduced risk of acute relapse and improved uptake and utilization of psychosocial interventions. It is suggested that the early introduction of these better-tolerated treatments might be advantageous by reducing the developmental disruption that comes with ineffectively treated psychosis.

CONCEPTUAL ADVANCES

Since 1940, new conceptualizations of the aetiology of relapse of psychotic illness have continued to challenge initial pessimism. Adolf Meyer proposed that psychological and biological processes be studied as dynamic interacting systems. ²¹ This approach was developed further by George Engel, who formulated the biopsychosocial model, which acknowledged the interaction of the three spheres of biological, psychological, and social functions in the presentation and course of mental illness. ²² Under these influences the conceptualization of the aetiology of schizophrenia became more holistic and the development of the illness was seen as a more complex interaction of factors involving underlying vulnerability and exogenous stressors.

Zubin and Spring's stress-vulnerability model integrated several of these different aetiological theories into an overall framework. ²³ They argued that vulnerability may be inherited or environmentally acquired, for example from birth complications, early experience, or negative peer interactions. Episodes of acute psychosis were triggered by the interaction with stressors, exceeding an individual's vulnerability threshold. This model proposed that individuals could learn techniques of improved coping and adaptation from previous episodes that might reduce the risk of psychotic relapse.

Zubin and Spring's model was extended by Nuechterlein et al., who focused on psychological processes that may underlie the stress-vulnerability interaction. ²⁴ These stressors might include stressful life events or social stress such as in high expressed emotion (EE) families, wherein there are high levels of hostility, criticism and negative comments. It was found that modifying the level of expressed emotion in the patient's therapeutic and home environment by a combination of education about schizophrenia and the teaching communication and conflict-resolution skills, led to a significant reduction in the rate of psychotic relapse. ^25–27 This finding led to the realization that psychosocial interventions were a crucial component of relapse prevention in schizophrenia.

These models could be easily understood by clients and their families, enhancing engagement, and promoting a working therapeutic relationship. They were radically different from previous models that tended to blame families for their relative's illness. The wider importanc of their gradual acceptance was to enhance the biologically mediated illness model, replacing it with new illness concepts that supported a significant role for timely, biopsychosocial interventions.

CONSUMER MOVEMENT AND THE RISE OF FAMILY ADVOCACY

Provision of health care in the western world has changed considerably in recent decades. The views of consumers and their families increasingly influence the type of interaction they have with mental health services, and in how those services are organized. ²⁸ It has frequently been shown that consumers prefer to be treated at home. ²⁹ It is likely that, using modern, more easily understandable concepts and explan, “tions of schizophrenia/psychosis and its treatment, patients may accept the rationale for the early commencement of treatment with a biopsychosocial framework. A close treatment alliance between the patient and the clinician based on mutual trust may assist them in deciding to accept home-based treatment when safety concerns allow it.

In parallel with consumer groups has been the development of family self-help/advocacy groups. Reasons include the reduction of inpatient beds, which has effectively shifted the burden of care onto many families. ²⁸ A reduction in the stigma associated with earlier theories of the parental causation of schizophrenia (for example, the ‘schizophrenogenic’ mother), ³⁰ have allowed parents to meet more freely together to help with each other's difficulties and interact more productively with professionals. Most family led advocacy groups preferred treatment at an early stage of illness exacerbation. ³¹ Many have already observed for themselves the progressive functional deterioration occurring in their relatives with unremitting psychosis and have been frustrated in attempts to seek treatment, particularly for an uncooperative relative.

Thus the requests of consumers and their families are often closely aligned with the principles of EI treatment. As the political influence of consumer and family advocacy groups grows, governments may well direct further resources to EI programmes.

POLICY INITIATIVES

In Australia the potential benefit of EI strategies has been recognized by the Federal Government in the First National Mental Health Plan ³² , which specifically focused on the importance of illness prevention and health promotion. These priorities have continued to be reflected in the Second National Mental Health Plan ³¹ and locally in NSW by the Centre for Mental Health's recent publications Caring for Mental Health ³³ and NSW Strategy: Making Mental Health Better for Children and Adolescents. ³⁴ These policy directions have been backed by specialized initiatives and funding to area mental health services aimed at improving care for people during their first episode of illness. The National Early Psychosis Project (NEPP) commenced in June 1996 and provided tertiary consultation, support and other services to clinicians treating early psychosis. One of the NEPP's major projects was The Australian Clinical Guidelines for Early Psychosis. ³⁵ These guidelines outlined the principles and practice of early treatment strategies. Since 1996/1997 an additional 2.38 million dollars in recurrent funding was allocated to area health services for depression and first-onset projects in NSW alone. ³⁶ )

Thus, the state government has strongly supported the rapid development of specialized EI services. Although this has been welcomed, the accompanying high expectations led to some haste in implementing services, and until recent years a relative lack of coordination existed at both the state and national levels. Possible reasons for this include a wide variety of existing services and practitioners treating early psychosis in different area health services and even within the same service. With few exceptions, there have not been comparable services to emulate, and in such a new and developing field there was a lack of coordinated training for staff. Nevertheless, funding and policy initiatives have provided a necessary platform on which to build services. The current phase of development is refining those services, with coordinated staff training and clear relationships with pre-existing services.

CONCLUSION

The relative pessimism regarding schizophrenia and its outcome and the paucity of effective treatments in the last century made attempts at early treatment seem futile. Today we have new outcome data, effective drugs and rationales for their use that are generally accepted and understood by patients and their families. Together with the support of policymakers, EI in first-episode psychosis is occurring. Future challenges include managing its growth, underpinned by a solid evidence base.