Published 4 August 2008, doi:10.1136/bmj.a695
Cite this as: BMJ 2008;337:a695

Head to Head

Is early intervention in the major psychiatric disorders justified? Yes

¹ ORYGEN Research Centre, University of Melbourne, Locked Bag 10, Parkville, Victoria, 3052, Australia

Psychiatric disease can take many years to emerge fully. Patrick McGorry argues that early specialist treatment is essential, but Anthony Pelosi (doi: 10.1136/bmj.a710) is unconvinced that current evidence of benefit is enough to balance the potential harm

Early diagnosis and treatment is intuitively appealing and widely accepted in medicine. Over the past 15 years, early intervention has become established in psychotic disorders and must now be extended to other mental disorders. Early intervention covers both early detection and the phase specific treatment of the earlier stages of illness with psychosocial and drug interventions. It should be as central in psychiatry as it is in cancer, diabetes, and cardiovascular disease.

Evidence for early intervention

Mental illnesses have been called the chronic diseases of the young.¹ The incidences of mood, anxiety, psychotic, personality, eating, and substance use disorders are highest in adolescence and early adult life.² Serious mental disorders increase mortality and may produce decades of disability and unfulfilled lives. Thus, the potential benefits and cost effectiveness of early intervention in mental disorders arguably exceed those for medical diseases, which typically emerge later in life.

Early clinical features can be difficult to distinguish from benign conditions and normal experience, leading to concerns about premature labelling. However, we now have operational criteria that not only indicate a need for immediate clinical care but strongly predict imminent transition to psychotic disorder. The criteria include subthreshold psychotic features, emerging functional impairment, and family history as risk factors (box).^{3 4} Although the false positive rate may exceed 50-60%, all those identified are by definition help seeking and need some form of care.

Criteria to identify patients at very high risk of psychosis or with full threshold psychosis4 Very high risk Group 1: Trait and state risk factors Schizotypal personality disorder in the individual or a first degree relative with a psychotic disorder Significant decrease in mental state or functioning Symptoms maintained for at least a month Decrease in functioning occurred within past year Group 2: Subthreshold psychotic symptoms Presence of at least one of the following several times a week: Ideas of reference Odd beliefs or magical thinking Perceptual disturbance Paranoid ideation Unusual thoughts or disorganised speech Symptoms present for at least one week and not longer than five years Symptoms last occurred within the past year Group 3: Brief limited intermittent psychotic symptoms Presence of one or more of the symptoms listed in group 2 at least once a day Symptoms last less than one week and resolve spontaneously Symptoms must have occurred within the past year Full threshold psychosis Presence of one or more of the symptoms listed in group 2 at least once a day Symptoms last for more than one week

In reality, people with emerging mental disorders face the opposite problem to inappropriate labelling. Even in developed countries, people with fully fledged and sustained initial psychotic episodes have difficulty accessing appropriate care,⁵ resulting in widespread unmet need, poor access, treatment delay, and undertreatment.⁶ Delayed and inconsistent care may lead to suicide, offending, vocational failure, family stress, and substance misuse.⁷ The real danger of lack of care overshadows the theoretical one of premature labelling and overtreatment.

Treatment delay is independently linked to poor outcome in psychosis.⁸ A prospective cohort study of 281 patients in Scandinavia showed that intensive community education and mobile specialist assessment⁹ substantially reduced treatment delay compared with usual treatment. This in turn improved clinical outcomes, such as suicidal risk, social recovery, and negative symptoms.¹⁰ However, the course of positive psychotic symptoms was unchanged.

A large Danish randomised controlled trial has provided the best evidence so far that improved engagement, reduced relapse rates, and better social relationships and vocational recovery, can be achieved with a more specialised early psychosis programme that provides assertive community care, including phase specific drug and psychosocial interventions.¹¹ Most patients who develop psychosis manifest an often prolonged period of morbidity, retrospectively characterised as the prodrome. Several randomised controlled trials have shown that it is possible to delay the onset of fully fledged psychotic illness in young people at very high risk of early transition with either low dose antipsychotic drugs or cognitive behavioural therapy.¹²

A recent Cochrane review of seven randomised controlled trials,¹³ which mainly cover the prodromal stage, was unwilling to draw definitive conclusions because of insufficient data from randomised trials. However, in keeping with the conservative approach of Cochrane reviews, data from the extensive service reforms underway in hundreds of locations worldwide were not included. Randomised trials measuring long term outcomes are notoriously difficult in health services research. Yet early intervention is now better supported by data from such trials than comparable recent reforms in mental health. The best way to obtain further data is to extend the reform process, since evidence for new models typically emerges hand in hand with sequential yet flexible reform, as we have seen in both home based treatment and early intervention for psychosis.¹⁴ Early intervention is likely to be of similar value in other potentially severe psychiatric disorders, notably mood, personality, and substance use disorders, where emerging data and public policy are increasingly supportive.¹⁵

The risk to benefit ratio certainly shifts as treatments are offered earlier in the course of any illness. Yet, as for other medical conditions, evidence indicates that a critical point exists in the natural course of mental disorders, after which therapy is less effective.¹⁶ Professionals genuinely wish to avoid mistakes with change. Yet many resist altering their clinical practice and oppose the kind of subspecialisation essential for early intervention because of a misplaced faith in generic models of care.^{14 17}

Solutions for cost effective and humane care

The first step in establishing successful early intervention is to ensure that the potential seriousness of unrecognised and poorly treated mental illness is understood. Secondly, developing youth friendly services for enhanced access to quality multidisciplinary care¹⁸ is probably the single most cost effective measure in mental health care reform.¹⁵ Thirdly, clinical staging should be strongly embraced¹⁹ as treatment needs differ according to stage of illness. Staging minimises stigma, creates exit strategies for people who have been wrongly diagnosed, and promotes the study of novel interventions, consumer choice, and sequential specialisation of care. Finally, a broad based social movement is crucial to sustainable evidence based reform, and we need to listen to the wider community, which is demanding genuine progress in mental health care.

Cite this as: BMJ 2008;337:a695

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I thank Rosemary Purcell for editorial help in preparing this manuscript.

Competing interests: PDMcG has received unrestricted research grant support from Janssen- Cilag, Eli Lilly, Bristol Myer Squibb, Astra-Zeneca, Pfizer, and Novartis. He has acted as a paid consultant for, and has received speaker’s fees and travel reimbursement from, all or most of these companies. He has also received extensive research support from the Australian government’s National Health and Medical Research Council and independent research foundations.

References

1. Insel TR, Fenton WS. Psychiatric epidemiology: it’s not just about counting anymore. Arch Gen Psychiatry 2005;62:590-2.[Free Full Text]
2. Patel V, Fisher A, Hetrick S, McGorry PD. Mental health of young people: a global public-health challenge. Lancet 2007;369:1302-13.[CrossRef][ISI][Medline]
3. Yung AR, Phillips LJ, Yuen HP, McGorry PD. Risk factors for psychosis in an ultra high risk group: psychopathology and clinical features. Schizophr Res 2004;67:131-42.[CrossRef][ISI][Medline]
4. Yung A, Phillips LJ, McGorry PD, eds. Treating schizophrenia in the prodromal phase. London: Taylor & Francis, 2004.
5. Saxena S, Thornicroft G, Knapp M, Whiteford H. Resources for mental health: scarcity, inequity, and inefficiency. Lancet 2007;370:878-89.[CrossRef][ISI][Medline]
6. Andrews G. Meeting the unmet need with disease management. In: Andrews G, Henderson S, eds. Unmet need in psychiatry; problems, resources, responses. Cambridge: Cambridge University Press, 2006:11-36.
7. Killackey E, Yung AR. Effectiveness of early intervention in psychosis. Curr Opin Psychiatry 2007;20:121-5.[ISI][Medline]
8. Marshall M, Lewis S, Lockwood A, Drake R, Jones P, Croudace T, et al. Association between duration of untreated psychosis and in cohorts of first-episode outcome patients: a systematic review. Arch Gen Psychiatry 2005;62:975-83.[Abstract/Free Full Text]
9. Melle I, Larsen TK, Haahr U, Friis S, Johannessen JO, Opjordsmoen S, et al. Reducing the duration of untreated first-episode psychosis: effects on clinical presentation. Arch Gen Psychiatry 2004;61:143-50.[Abstract/Free Full Text]
10. Larsen TK, Melle I, Auestad B, Friis S, Haahr U, Johannessen JO, et al. Early detection of first-episode psychosis: the effect on 1-year outcome. Schizophr Bull 2006;32:758-64.[Abstract/Free Full Text]
11. Petersen L, Jeppesen P, Thorup A, Abel M-B, Øhrenschlaeger J, Christensen TO, et al. A randomised multicentre trial of integrated versus standard treatment for patients with a first episode of psychotic illness. BMJ 2005;331:602.[Abstract/Free Full Text]
12. Cannon TD, Cornblatt B, McGorry P. Editor’s introduction: the empirical status of the ultra high-risk (prodromal) research paradigm. Schizophr Bull 2007;33:661-4.[Abstract/Free Full Text]
13. Marshall M, Rathbone J. Early intervention for psychosis. Cochrane Database Syst Rev 2006(4):CD004718.
14. McGorry PD. Evidence based reform of mental health care. BMJ 2005;331:586-7.[Free Full Text]
15. McGorry PD, Purcell R, Hickie IB, Jorm AF. Investing in youth mental health is a best buy. Med J Aust 2007;187:s5-7.[ISI]
16. Sackett DL, Haynes RB, Guyatt GH, Tugwell P. Clinical epidemiology: a basic science for clinical medicine. 2nd ed. Boston: Little Brown, 1991.
17. Pelosi AJ, Birchwood M. Is early intervention for psychosis a waste of valuable resources? Br J Psychiatry 2003;182:196-8.[Free Full Text]
18. McGorry PD. The specialist youth mental health model: strengthening the weakest link in the public mental health system. Med J Aust 2007;187:s53-6.[ISI][Medline]
19. McGorry PD, Hickie IB, Yung AR, Pantelis C, Jackson HJ. Clinical staging of psychiatric disorders: a heuristic framework for choosing earlier, safer and more effective interventions. Aust N Z J Psychiatry 2006;40:616-22.[CrossRef][ISI][Medline]

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