Of FEP’s, DUP’s and BS

No, they are not lyrics to an obscure doo-wop song.  First episode psychosis (FEP) and duration of untreated psychosis (DUP) remain the foci of great numbers of early intervention programs in Western countries.  When youth and young adults experiencing severe emotional distress come into contact with these programs, they will likely encounter an overzealous biomedical approach.  “Untreated” in DUP-anese is considered synonymous with unmedicated, which often creates a sense of urgency and a myopic fixation on getting these youth started on anti-psychotics and keeping them on.

What is the impact of this medical model and its accompanying chemical imbalance narrative on these emerging adults?  How often does it set them on a course of regained functioning and restored hope, or does it serve as a gateway into a lifetime of disability and discouragement?  The stakes are very high for youth, their families and communities.

In Anatomy of an Epidemic, Whitaker cited a 2008 GAO report that identified one in sixteen young adults as seriously mentally ill.  Once on SSI or SSDI, few young adults seem to come off of it.  These youth and young adults deserve our best, most up-to-date care and compassion, without succumbing to the “soft bigotry of low expectations.”

Yet, despite the mounting and compelling evidence (Harrow and Wunderink) for a very selective and judicious use of neuroleptics – many of these youth will continue to be subjected to the sledgehammer of polypharmacy.  On her MIA blog Dr. Sandra Steingard has provided an excellent analysis of the “optimal use of neuroleptic drugs.”  In her overview, Steingard argues that:

• “The impression of short term efficacy (of anti-psychotics) tends to be inflated.”
• “The impression of long term risk tends to be minimized.”
• “The impression about the risks of delaying treatment (Duration of Untreated Psychosis) with anti-psychotics is inflated.”
• Although anti-psychotics are sometimes remarkably effective in reducing psychotic symptoms, this does not mean they are always required.”

What will be the time lag between research and practice?  Now that Thomas Insel, Director of NIMH, has seen the light and called for a change, how many more youth will be treated inappropriately and potentially harmed before the current standards of practice and pharmacentric approaches are replaced?  Studies from the translational research field postulate that it currently averages seventeen years for scientific evidence to migrate into clinical practice.  Can we hurry it up?  These are not abstract questions. If I had a family member seeking help for “distressing anomalous experiences”, I would want the best treatment for them now.

I modestly propose the following incremental steps while awaiting the revolution.

• Consign the “get them on meds right away and maintain for life” standard to the dust-bin of mental health history, along with gay conversion therapy and pre-fontal lobotomies.
• Replace the almighty DUP with the concept of Delay of Intensive Psychosocial Treatment (DIPT) forwarded by Haan et al in a 2003 study.  The sooner youth in severe emotional distress can be engaged in additional caring relationships with peer mentors and providers trained in Open Dialogue style services, the better.
• Ensure that all early intervention programs are well versed in providing trauma informed care.  Evidence of the prominent role that trauma seems to play in the onset of psychosis is strong and growing.  Healing from trauma will not come from a prescription of Abilify.
• Provide robust vocational interventions for youth and young adults.  Youth experiencing severe distress frequently lose contact with the protective factors of school, work and training opportunities.  Many providers work hard at getting youth onto SSI disability rolls – we need to work much harder at helping youth not need it.