November 1st, 2010

Early detection equals improved outcomes even for psychosis

At Massachusetts General Hospital’s First-Episode and Early Psychosis Program (FEPP), they like to say, forget what you know about schizophrenia.

“People think about schizophrenia as this awful thing,” says Corinne Cather, Ph.D., a FEPP clinical psychologist. “It’s not a great thing, but we can improve the trajectory of schizophrenia where people can get better.”

FEPP helps patients and their families cope with a first episode of psychosis by providing comprehensive evaluation and diagnosis, psychological treatment and medication and psycho-education for families. The idea is that early diagnosis and intervention can keep an initial psychotic break from becoming full-blown schizophrenia.

“We are finding that identifying and treating psychiatric illnesses earlier can improve outcomes, as opposed to waiting until the disease is chronic,” says psychiatrist Oliver Freudenreich, M.D., director of the First-Episode program.

The program resides within the Schizophrenia Program at MGH. It began eight years ago to focus services on younger patients on the verge of a diagnosis and to help lessen feelings of stigma and hopelessness they could experience upon confronting a chronic patient population. The onset of schizophrenia is typically young adulthood, from age 15 to 25 for males and 25 to 35 for females.

“For young patients to have their first exposure to very ill patients was not a hopeful sight,” Freudenreich says.

Schizophrenia, like many mental health disorders, can start with vague symptoms such as anxiety, listlessness, difficulty functioning, sleeping problems and odd physical complaints. A family history of schizophrenia can alert parents or healthcare providers to be attentive to developing symptoms.

The next phase may include psychotic symptoms such as delusions, paranoia and disorganized speech, but they are “attenuated” in the sense that the person can mentally step back for a reality check. At that point, if he or she is willing to share these experiences, the FEPP program can step in and start to mitigate long-term effects.

Unfortunately, psychosis can be overlooked when the right questions aren’t asked, when the patient isn’t forthcoming or when a patient’s complaints are ignored. It’s an opportunity missed because longer durations of untreated psychosis predict poorer outcomes.

“How long do you think a person who ends up in the emergency room with psychosis has had clear-cut symptoms like hallucinations and delusions that weren’t recognized?” Freudenreich asks. “One to two years.”

About three out of 100 people will experience psychosis in their lifetimes. But not everybody with attenuated psychotic symptoms will develop schizophrenia. Only about one-third of patients seeking help for psychosis will convert, Freudenreich says. Schizophrenia affects about 1.1 percent of the U.S. population age 18 and older in a given year, according to the National Institute of Mental Health.

“We want to be very careful not to label people falsely as developing schizophrenia. So we specialize in the evaluation of people who are worried about schizophrenia but unsure,” Freudenreich says. “It requires expertise to know how to ask the questions.” Schizophrenia is diagnosed when symptoms last six months or longer. Until it’s declared, those who have experienced intermittent psychotic symptoms are considered high risk. There is preliminary data to suggest cognitive behavioral therapy could delay the transition to frank psychosis. CBT helps restructure maladaptive beliefs and the associated behaviors into ones that are more adaptive and constructive.

On the other hand, if individuals were treated with medication and the psychotic episodes went away, they may not need CBT. However, even if the psychosis responds to medication, adjunctive therapy can help normalize disrupted lives and deal with relapse prevention, social anxiety and goal setting.

“They come to an awareness they can hear voices and still have a rewarding life,” Cather says.

Another key is psycho-education for patients and families to demystify the illness and its treatment.

“The idea is that the more parents know, the better they can help their children,” Freudenreich says. “For most parents, it’s a shocking idea that a child who had been doing well is diagnosed with a potentially serious illness with implications down the road.”

While mental health screening has cast a wider net over the years, there are no reliable ways of detecting who is actually at risk for schizophrenia.

“It takes intensive screening and monitoring efforts, and probably a different system of healthcare,” Cather says. “In countries with socialized medicine, they have centralized ways of tracking patient progress that’s better than our system.”

By Nan Shnitzler

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