Prevention and Early Interventions
By Matcheri S. Keshavan, MD |
February 1, 2006
Dr. Keshavan is professor and associate chair in the department of psychiatry and behavioral neurosciences at Wayne State University. Dr. Keshavan is a consultant to Eli Lilly and Company, Pfizer Inc., Bristol-Meyers Squibb and AstraZeneca.
Tertiary prevention seeks to prevent disability and relapse in patients who have already developed psychosis. First-episode patients show higher response rates to treatment (46% to 96%) compared to multi-episode patients but also show high rates of relapse due to noncompliance (Robinson et al., 2005). There is increasing evidence that relapse rates are reduced by early introduction of family intervention to reduce levels of expressed emotion, CBT to address cognitive distortions and individual psychotherapy aimed at restoring a sense of self and achieving mastery over the illness (for a review, see Haddock and Lewis, 2005).
Comprehensive early psychosis treatment packages involving pharmacologic and psychosocial treatments as outlined above are more cost-effective than treatment as usual in improving long term recovery, as shown by recent controlled trials. Petersen et al. (2005) randomized 547 patients to either integrated treatment over two years, consisting of assertive community treatment with family involvement and social skills training or standard treatment offering contact with a community mental health center. Patients in the integrated treatment limb had significantly better recovery of positive and negative symptoms, less comorbid substance misuse, better adherence to treatment, and more satisfaction with treatment. Investing in early and comprehensive intervention can therefore improve our patients' lives in the longer term as well as reduce overall costs of treatment.
First-episode patients with schizophrenia also have high rates of comorbid substance abuse, depression, noncompliance, and impairments in cognition and social skills. Dual diagnosis patients with psychosis and substance abuse are more likely to relapse. A recent controlled trial has shown that, compared to standard care, such patients are likely to benefit from combined psychosocial treatment packages including motivational enhancement (Barrowclough et al., 2001).
Patients with the first episode of psychosis are also likely to experience a high likelihood of depression and suicidal behavior during the early course of their illness. Controlled trials are underway showing initial promising results (Power et al., 2003). Noncompliance rates are high in the first episode of psychosis, perhaps related to high rates of poor insight. Motivational enhancement therapies may help improve compliance as shown in controlled trials in patients with psychotic disorders (Kemp et al., 1998). An uncontrolled study showed a lack of efficacy of this treatment in patients with schizophrenia or schizoaffective disorder (Byerly et al., 2005). Results from controlled studies in early schizophrenia are awaited. Finally, cognitive remediation studies have also begun to provide encouraging results in regard to improvements in functional outcome when introduced early in the course of schizophrenia (Hogarty et al., 2004).
In summary, the evidence base of early interventions in schizophrenia is rapidly gaining acceptance in the field. However, as the field matures, it will be necessary to more extensively replicate the findings of the handful of early prevention studies, more conclusively validate the criteria currently defining the prodrome, further extend the range of potential interventions to include treatments other than antipsychotics, and to target specific prodromal and possibly premorbid phases of illness. Evidence-based demonstrations of cost-effectiveness of such interventions are critically needed if this field of research is to sustain and solidify this paradigm shift.
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