Early intervention for psychosis: current issues and emerging perspectives

Aim and paradigm

Over the past two decades, the early intervention approach to psychotic disorders has consolidated into a distinctive model. Data have been emerging to inform the effectiveness of various components of this paradigm (Marshall & Rathbone, 2011). The current issue reviews some of this data, as well as suggests some new perspectives for further development.

The ultimate objective of the early intervention initiative is to improve the long-term outcome of psychotic disorders. Psychotic disorders are complex in terms of aetiology and pathophysiology. Typically, multiple factors interact at different levels from genes, molecules, cells, brain circuits, cognition, to psychopathology (McCutcheon, Abi-Dargham, & Howes, 2019). The vast number of factors involved suggests that there will be multiple possibilities of ‘self-reinforcing’ interactions amongst different elements, forming stable loops. Some of these loops may become self-perpetuating or lead to escalations. Early intervention attempts to target the risk factors earlier rather than later, to reduce the entrapment of these loops.

Early intervention for psychosis has crystallized into three major components: (1) early detection (reducing the duration of untreated psychosis; DUP); (2) phase-specific intervention (providing effective intervention targeting the initial few years of the disorder); and (3) indicated prevention (preventative intervention for an at-risk group). With this overarching framework, early intervention programmes have been developed in different communities with different emphasis as well as cultural adaptations (Chen, Lee, Chan, & Wong, 2013).

In this issue, Albert reviews the effects of early detection initiatives on long-term outcome. Demonstration of a reduction in the DUP at the population level is a difficult endeavour. Only a handful of studies reported a reduction of DUP. Recent data suggest a potential interaction between phase-specific intervention and early detection. Intervention effectiveness may depend on the DUP (Browne et al., 2017). Further data will shed light on this point.

While the short-term effects of early intervention have been documented extensively, data on the sustainability of long-term effects have been scarce. Long-term efficacy of early intervention is critical for the idea that intervention in an early stage of the illness can lead to sustained outcome improvement beyond the duration of the intervention (often 2–3 years). Chan et al. review long-term data that shed light on this issue. Demonstrations of long-term effects are difficult as, over the years, there have often been concurrent improvements in services and outcomes for the standard care comparison group. However, sustained improvement in functioning and reduction in suicide have been reported. One of the key predictors of long-term outcome was patient’s adherence. Hui et al. review guidelines for maintenance treatment.

Apart from pharmacotherapy, psychological intervention has also been crucial for the treatment of psychotic disorders. Wong et al. review the efficacy of CBT treatment in group settings. Delivering psychological interventions in groups enhances cost-effectiveness as well as enables vicarious learning between participants. It is particularly relevant to locations where mental health resources are scarce. Besides the conventional use of cognitive behavioural therapy to address psychotic thoughts, a new perspective described in Chau et al. considers the role of loneliness in people struggling with psychotic symptoms. As well as offering insight into psychopathological mechanisms, this observation highlights the burden of social isolation and suggests a direction for future intervention.

Another essential component to early-psychosis work is the role of carers. Often following a first-episode illness, families and carers are positively engaged with the patient’s recovery process. Adequate support to carers will increase their capacity to provide the much-needed long-term support for patients. Mui et al. review the experience of caregiving for early psychosis and suggested themes (such as stigma) that are uniquely challenging for carers of psychotic patients. The experience of a psychotic condition can be seen in a broader cultural perspective. Good et al. provide a precious glimpse into psychosis, based on over 20 years of a unique ethnographic research programme in a less affluent population in Indonesia. The observations raise important questions about service prioritization, as well as the variations in illness presentations in different cultural settings (such as the relationship between acute-onset and outcome, challenging a conventional impression that acute-onset is associated with a better outcome; Castagnini, Munk-Jørgensen, & Bertelsen, 2016). Variations in illness expression with age are also explored in Suen et al.’s systematic comparison between late-onset psychosis and very-late-onset psychosis.

After decades of experience and data, it appears that the efficacy of early psychosis work is apparent (Nordentoft, Rasmussen, Melau, Hjorthøj, & Thorup, 2014). However, the effect on shortening the DUP is only evident in a few studies. Therefore, it seems that most of the observed efficacy may be attributed to the phase-specific intervention (rather than early detection). There are substantial variations in the contents of phase-specific interventions. Most interventions are based on psychosocial complements to pharmacotherapy in the form of case management (Chen et al., 2013). The exact intervention delivered depends on the training as well as the caseload of the case managers. Few studies have yet specified the detailed content of the case management. It may be possible to secure further improvements in outcome through the research of specific components of case management. Personalizing the case-management according to individual needs may enhance effectiveness.

Early intervention services are human services, and the outcome is dependent on the quality of human contact. Considerations of the quality of contact are necessary to appreciate the effect of scaling up of the services. Personal motivation of the intervention staff is likely to play a crucial role in the outcome. This motivation could reduce when the services become routine. The outcome data obtained in most of the pioneering studies emerge from initial teams with high motivation and commitment. They may not be sustained in a regular service context. Developing early intervention services with a self-learning culture may be essential for ensuring continuous quality improvement and staff motivation (Dar-El, 2013).

Self-learning teams should be able to monitor outcome on a regular basis, and identify sub-groups or conditions in whom the outcome is not optimal. Studies of novel factors determining outcomes could then lead to the design of innovative interventions to improve the outcome further. The new intervention could be tested in clinical trials and, if effective, could be implemented. Incremental improvement in the effectiveness of intervention could be achieved in this way and be incorporated into the service. Incorporation of this self-learning expectations may help to sustain the insistence of quality that is vital in early intervention work.