Q: Does an early diagnosis of schizophrenia really make a clinical difference?
A: Remarkably, it has been shown that it takes an average of a year before a person who is experiencing active symptoms actually comes into contact with a mental health professional.
If you ascribe to the notion that active psychosis is biologically toxic to your brain (this is a contentious issue, although some provocative imaging findings support the notion), then the earlier the diagnosis is made and treatment instituted, the better. That is, the shorter we can make the duration of untreated psychosis, the better.
All of this seems intuitive, and it forms the basis for public awareness campaigns and service reconfigurations to enhance early access to care with the hope of better long-term outcomes. However, as in many areas, proving this has been problematic.
Most notably, a Norwegian study1 found surprisingly little benefit of early detection and treatment over conventional treatment in overall outcomes some 5 years into the illness. One explanation may have been that the services are already very good in northern Europe. Another—more provocative—explanation is that a first episode of psychosis is too late for diagnosis and intervention.
Across the globe, “prodromal clinics” now exist in which young people with seemingly prepsychotic symptoms are evaluated and, if appropriate, treated. However, there is robust and contentious debate regarding the validity and the reliability of “diagnosing” prodromal psychosis because in the following 2 years, approximately 50% of those affected experience an overt psychotic episode.2 This, of course, means that in half the cases, you have the opportunity to intervene earlier than you might otherwise have . . . and by intervening (with medication, talk therapies, etc), one hopes to avert this trajectory to psychosis. On the other hand, this approach will yield erroneous diagnoses and inappropriate treatments in the other half of cases—and this is always a serious concern.
While research and public policy sectors collide here on whether “earliest is best,” a point of agreement is that we should do everything we can to maximize the care of persons who already have a diagnosis of schizophrenia and who are early in their course of illness. The federal government has funded the RAISE schizophrenia initiative3 in an effort to optimize early-illness care for schizophrenia.
Dr Buckley is Dean at the Medical College of Georgia, Georgia Health Sciences University, Augusta. He is an Editorial Board Member of Psychiatric Times.
1. Johannessen JO, McGlashan TH, Larsen TK, et al. Early detection strategies for untreated first-episode psychosis. Schizophr Res. 2001;51:39-46.
2. Carpenter WT, van Os J. Should attenuated psychosis syndrome be a DSM-5 diagnosis? Am J Psychiatry. 2011;168:460-463.
3. National Institute of Mental Health (NIMH). Recovery After Initial Schizophrenia Episode (RAISE): a research project of the NIMH. http://www.nimh.nih.gov/health/topics/schizophrenia/raise/index.shtml. Accessed February 1, 2012.