Source: Lena Andery, Clinical Specialist, Eppic Statewide Services, Australia, Early Psychosis News, Number 6, May 1997

Schizophrenia and other psychotic disorders have taken some time to reach
the mainstream public health arena despite the prevalence, burden and cost
of these conditions. A key reason for this is the stubborn nature of
attitudes about psychosis.

The stereotype of a chronically psychotic institutionalized individual has
its origins early in this century with Kraeplin's (the first researcher of
what was later to become called schizophrenia - 1919) description and
diagnosis of dementia praecox. In spite of new knowledge within psychiatry this impression has largely remained. Pessimism has also been rife amongst
many mental health workers in the past, who have felt rather helpless in
their inability to affect positive outcomes.

However, an increase in the amount of research associated with first episode psychosis, and current knowledge suggests that intervening during the early years can have a
significant impact on outcome (2). The period of time following onset has
been called the 'critical period' (3), and is the crucial time to instigate optimal, integrated psycho-social interventions.

Research also suggests that a significant time period often separates the
onset of psychotic symptoms and the initiation of appropriate treatment.

Delays in treatment can have serious consequences for patients and their families.

A growing body of evidence suggests that delays in the treatment of a psychosis can have serious effects on medium to long-term outcome (4). The duration of untreated
psychosis has been associated with slower and less complete recovery,
increased risk of relapse, and substantial treatment resistance (5,6).
Given what is known about the 'critical period' and the risks of delayed
treatment, early intervention can be seen as crucial for positive outcomes.

Early deterioration can be understood by considering secondary effects of
the disease. The consequences of psychosis can have extremely serious
effects on the individual and their family. These consequences may be more
important in the so-called deteriorative process than the illness itself.

Given that a first psychotic episode is likely to occur in adolescence and
early adulthood, the disruptions caused by unrecognized and untreated
symptoms can alienate the young person from their family and friends and
disrupt their education and vocational functioning. This disruption to
social networks, educational and vocational development and to personality
formation can create major difficulties for the young person trying to
establish identity and direction in life.

For families who often do not understand exactly what is occurring, a great deal of distress results. Family conflict which exacerbates stress at home in turn impacts negatively on the individual experiencing psychosis. Delayed treatment is more likely
to be associated with police intervention and compulsory admission to
psychiatric hospitals established to deal with older chronically ill
individuals. These aspects of treatment are obviously traumatic for the
individual and their families and post traumatic stress disorder may be an
outcome of the experiences. Other types of secondary effects include,
social anxiety, depression, substance abuse and homelessness (7).

Despite the obvious need to intervene early, there are often lengthy delays
between the onset of psychosis and effective treatment. Studies have found
the mean length of untreated psychosis to be one year, with the mean length
of total illness (including the prodrome - ed. note - Prodrome is a medical
term for a symptom which indicates the impending outbreak of a disease) to
be 3 years (4). There are a number of reasons for these delays in effective
treatment.

Firstly, there are delays related to the inability of most individuals,
their family and friends to recognize the signs and symptoms of psychosis.
This is also the case, unfortunately, with many general practitioners and
other primary care professionals.

Secondly, even if the illness is recognized, there is often a reluctance to
seek help due as a result of the fear and stigma often associated with
mental illness, and a lack of knowledge about where to obtain useful
resources.

Thirdly, some services are inaccessible or non responsive.

Finally, the groups at risk of extended delays in treatment for a psychotic
episode include homeless people, those with drug and alcohol problems and
people with personality disorder and intellectual disability.

In summary, the consequences of psychosis cause much of the early
deterioration that is seen in these disorders. Given this, delays in case
identification, for the reasons discussed above, can be seen to represent a
major public health problem (2,8).

Secondary morbidity can be minimized by early and vigorous treatment in the
early phase of psychosis. Reducing treatment delay has is associated with
better outcome, less disability and reduced financial costs over the
long-term.

A preventative approach is needed to meet these goals. Secondary and
tertiary preventative strategies enable a focus in the intensive treatment
of first episode psychosis to promote recovery and repair disrupted
networks.

Recent research has produced a range of clinical data which suggests that
big-psycho-social treatments can make a difference to the long-term course
and outcome of psychosis by reducing morbidity and disability (2,9,10).

References

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