Early intervention in psychosis (EIP) efforts have not delivered on their promise of preventing more serious schizophrenia from developing, according to a review of the literature published in Progress in Neurology and Psychiatry. And the problem may be, the authors argued, that EIP efforts actually still come too late while attempting to address the wrong causes.
Writing with a medical student, University of Hull psychiatrist Ann Mortimer stated that EIP programs have essentially been founded on what may be a false assumption. Just because a lot of young people with serious, problematic schizophrenia symptoms often don’t get treatment early, they wrote, doesn’t necessarily mean that if they are treated early, their outcomes will be better.
“The finding that longer duration of untreated psychosis (DUP) was associated with poor premorbid functioning in the year before onset, insidious onset and more negative symptoms at onset, then led to the widely accepted, but rather sweeping assumption, that by reducing the duration of untreated psychosis, longterm outcome could be improved,” they wrote. “The obvious alternative, however, is that schizophrenia of the kind which leads to a poor outcome is naturally associated with insidious onset, worsening premorbid function and a lack of help seeking. Thus, lengthy duration of untreated psychosis is integral to poor outcome. Early treatment will not make a difference, because poor outcome is predetermined by intrinsic severity factors that command poor treatment responsiveness, whenever treatment starts.”
In their review of the scientific literature, they highlighted many studies that found no improvements among groups that received early intervention. They also described over-arching problems in those studies that seemed to find positive outcomes. For example, one study, they wrote, had a strong bias: When people dropped out of the early detection group, that was described as a positive outcome because it was assumed the people no longer needed treatment; however, when participants dropped out of the other group, it was considered to be a sign that their psychotic conditions were worsening. In another study, the majority of patients were engaged in “extensive substance abuse, usually cannabis, stimulants or both,” and hence their symptoms may have been substance-induced psychosis rather than schizophrenia per se, suggested the authors.
The authors also suggested that some apparent positive outcomes are actually being caused by the fact that EIP tends to “bycatch” many young people who aren’t and won’t ever become psychotic, anyway. The authors described it as an “inescapable” issue of concern that commonly assumed schizophrenia inception rates are about 7-14 per 100,000 population per year, while referral rates to EIP services are typically around 100 per 100,000 per year. “Just what is going on here?” they asked.
They also noted the high rates of childhood trauma and other types of adversity common among young people being drawn into EIP efforts, and argued that EIP may be a misplaced, belated misuse of resources and efforts. “Nevertheless, childhood adversity and its causes are social problems, which rationally require social solutions, not young people’s mental health services post hoc. Ensuring that every child is adequately parented, securely integrated within their family, and benefits from caring educational provision and supportive workplaces, is an ideal that perhaps should not be compromised by the enormous task of its realisation. Early intervention can only be expected to work if it addresses treatable disease, as in the rest of medicine.”
Mortimer, Ann, and Timothy Brown. “Early Intervention in Psychosis: Another Triumph of Hope over Experience?” Progress in Neurology and Psychiatry 19, no. 3 (May 1, 2015): 10–14. doi:10.1002/pnp.379. (Abstract) (Full text)