November 27, 2005

Early Treatment for Schizophrenia - Expert Interview

Following is a short excerpt of a very good interview with a leading expert in early diagnosis and treatment of schizophrenia and psychosis, Dr. Jean Addington of the University of Toronto. For the full Interview - we recommend you log-on to Medscape, and register (its free) - you'll find it under the "Psychiatry & Mental Health" part of their web site.

Psychosocial Interventions in Early Psychosis: An Expert Interview With Jean M. Addington, PhD

In schizophrenia, as in many other medical conditions, the best outcomes are achieved through early and broad-based intervention. Not only the patient, but the entire family, should ideally be involved in the therapeutic process, and intervention should include not just medication, but case management, group therapy, and cognitive behavior therapy. One such model program is the Early Psychosis Treatment and Prevention Program, a joint initiative by the Calgary Health Region and the Canadian Mental Health Association of Calgary. On behalf of Medscape, Randall White, MD, FRCPC, interviewed one of the program's coordinators, Jean M. Addington, PhD, Associate Professor of Psychiatry, University of Toronto, Toronto, Ontario, Canada, and Director, Prime Clinic Centre for Addiction and Mental Health, Toronto.

Medscape: What is the time cutoff for early intervention in schizophrenia?

Dr. Addington: It's actually the first time people present for help, so different programs have different criteria. Usually, it's that the patients haven't received adequate treatment before. They might have gone to a general practitioner and got an antipsychotic and had that for a few weeks. They may have been sick for quite a long time, for several months, before seeking treatment. So when they first come in for treatment, they may have had the symptoms in varying degrees for quite a bit of time. Then there are other people who come to seek help as soon as they get sick.

In the Calgary [Alberta, Canada] program, from which I have most of my data, on average it was 53 weeks before people came looking for help.

Medscape: Can you briefly state what we know about the advantages of providing intervention as early as possible?

Dr. Addington: First of all, and this is something that's really unproven, there is a suggestion that the psychosis might at some level be toxic to the brain. Jeffrey Lieberman has written a lot about this. It makes sense that the longer an illness goes untreated, the poorer the recovery may be. There are some studies showing that the longer people are untreated, the longer it takes them to recover and the poorer that recovery is when it happens.

Second, the implications of a long duration of untreated psychosis can be devastating for people. It has a major impact on their relationships; their education and work opportunities; and especially, if young people are getting sick between 18 and 25 years
old, it can have a major impact on development. And it has devastating effects on families as well.

Medscape: The Calgary model for early psychosis intervention entails medication, case management, family intervention, group therapy, and cognitive behavioral therapy (CBT). What is the importance of the family interventions, and what do they entail?

Dr. Addington: These patients tend to be young and the majority are living at home; we really want to get them as well as possible as soon as possible. The family has a major role in helping them, and it's really important to engage the family in a no-fault atmosphere from day 1. Families are very keen to be involved, and they have been struggling with the young person through the development of the illness. They really need help with understanding this illness.

The second issue is that the family environment is important to recovery. The more stressful the environment, the more likely it is to exacerbate symptoms and impede recovery. You want people living in as stress-free a family environment as possible.

Medscape: By "stressful environment," are you referring to one with high expressed emotion, in which intrusive familial interactions tend to increase symptoms in people with schizophrenia?
Dr. Addington: Yes, but also stress in general can have an impact on symptoms. I don't think it has to meet the criterion of high expressed emotion. If the mother's really worried and doesn't know what's happening to her child, then she is unlikely to be dealing with crises with a calm attitude. We want to reduce the stress of family members and help them create a stress-free environment as much as possible for the patient to be living in, and also to understand the illness and how best to interact with and help the individual.

The studies that looked at expressed emotion tended to look at reducing the relapse rate. What we're trying to do in our family work is not just create a less stressful environment for the patient's well-being; we're also interested in helping the families feel better. These families are really distraught over what may be happening to their kids, who may not go on to meet the goals they once had in mind for them.

See the full interview at Medscape


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