Psychiatr News July 4, 2008
Volume 43, Number 13, page 13
© 2008 American Psychiatric Association
Worsening of Symptoms Prevented by Early Detection
Mark Moran
Negative symptoms such as cognitive deficits and lack of affect and
volition have long been considered unmodifiable and appear to represent core
neurobiological deficits of schizophrenia.
Reducing the duration of untreated acute psychosis in first-episode
patients appears to prevent the worsening of negative symptoms—such as
cognitive deficits and lack of volition, among others—at two-year
follow-up.
That finding, from analysis of a public health intervention in Norway,
suggests that early identification and treatment of acute psychotic symptoms
may affect the core neurobiological deficit process of schizophrenia, and
through this alter the course and prognosis for the better.
The study, which appeared in the June Archives of General
Psychiatry, compared two distinct geographical areas of Norway. In one of
those areas researchers implemented a comprehensive early detection (ED)
system based on public-information campaigns and training of teams in the
community to detect low-threshold psychosis.
The other geographical location received no such intervention. However,
treatment protocols for people who were identified were identical in each
location.
Earlier analysis had already determined that patients in the area who
received the ED intervention entered treatment with less severe clinical
symptoms, less serious suicidality, and shorter total duration of their first
episode. That analysis appeared in the May 2006 American Journal of
Psychiatry.
Thomas McGlashan, M.D., senior author of the current study, explained that
the follow-up study shows that the differences seen at baseline between
patients in the two geographical areas continued two years later.
"The intervention is not treating the negative symptoms, but
preventing them from getting worse," he told Psychiatric News.
"The ED group was younger, so clearly we got them into treatment when
their negative symptoms weren't as well developed. Now, it looks like getting
them into treatment prevents those symptoms from getting worse."
The study was carried out between January 1, 1997, and December 31, 2001,
in four Scandinavian health care sectors. The ED area consisted of the North
Rogaland and South Rogaland health care sectors in Rogaland County, Norway,
with a combined total population of 370,000. The no-ED area consisted of the
Ullevaal health care sector of Oslo County, Norway, and Roskilde County,
Denmark, with a combined total population of 295,000.
There were no differences in age and sex distribution between the two
areas, and no differences in mean income levels and unemployment rates.
Because of Norway's national health insurance system, all sectors were
publicly funded, with no differences in utilization of inpatient psychiatric
services. All first-episode patients in all sectors of both areas were
assessed by trained personnel at first contact and assigned to the
first-episode treatment programs without delay. The programs adopted a
standard treatment algorithm for antipsychotic medication, individual
psychosocial treatment, and psychoeducational multifamily groups.
The ED program consisted of educational campaigns about psychotic symptoms
and their treatment directed at the general population through newspaper
advertisements and information campaigns directed at schools and general
practitioners. Specialized low-threshold early detection teams were
established that could be reached by a phone call from potential patients,
families, or friends from their social networks.
A total of 281 patients with a DSM-IV diagnosis of nonorganic,
nonaffective psychosis coming to their first treatment during the four
consecutive years were recruited, of whom 231 participated in the two-year
follow-up.
Results from the follow-up showed a statistically significant improvement
in the Positive and Negative Syndrome Scale negative component, cognitive
component, and depressive component in favor of the ED group. Statistical
analysis gave no indication that these differences were due to
confounders.
McGlashan said that preventing negative symptoms from getting worse is
important because it is those symptoms that appear to reflect the core
neurobiological deficits resulting from acute psychosis and that affect
long-term outcome, functioning, and quality of life.
"The negative symptoms have clearly come to be seen as where the
disability resides," he said. "One hundred years ago,
schizophrenia was regarded as a deteriorating illness. Now, that deterioration
is better described in terms of negative symptoms."
Moreover, he said, effective treatment of the symptoms has been elusive.
Some drug company trials of antipsychotic medications have claimed to treat
social isolation, for instance, by diminishing paranoia associated with
psychosis, but it is the lack of affect and volition—the "loss of
the joie de vivre" as McGlashan put it—that is characteristic of
the socially withdrawn patient with schizophrenia and more representative of
the core neuobiological deficits.
Traditionally those symptoms have been regarded as unmodifiable, with an
inevitably deteriorating course. In the Norwegian study, he said, "We
haven't treated them, but we have modified them."
He emphasized that clinicians who are seeing someone that they suspect may
be psychotic should try to get them evaluated and into treatment as soon as
possible.
"Delaying an evaluation and treatment can have serious
consequences," he said. "Earlier detection really makes a
difference."
An abstract of "Prevention of Negative Symptom
Psychopathologies in First-Episode Schizophrenia: Two-Year Effects of Reducing
the Duration of Untreated Psychosis" is posted at
<http://archpsyc.ama-assn.org/cgi/content/abstract/65/6/634>.
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