Worsening of Symptoms Prevented by Early Detection

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>.▪