Early Intervention in Psychotic Disorders

The introduction of neuroleptics into the treatment of schizophrenia half a century ago generated great optimism about improving the lives of individuals afflicted with this debilitating illness; despite some benefits, however, functional outcomes improved only minimally (1). A similar surge of enthusiasm greeted the introduction of the second-generation “atypical” antipsychotic medications with their broader spectrum of efficacy and fewer motor side effects; however, functional outcomes in schizophrenia and other psychotic disorders still remain poor. This has reinforced the belief of many in the field that much of the damage is already done by the time we first begin to treat schizophrenia and that the possibilities for improvement at this stage are quite limited irrespective of what treatments we apply, which, in turn, has led to renewed interest in trying to intervene before the onset of psychotic symptoms and marked decline in function. This volume, comprising 12 chapters, addresses several facets of this topic. Based on a meeting organized in Prague in late 1998, these 12 contributions from prominent research groups systematically dissect issues relevant to early intervention in schizophrenia while reviewing premier treatment programs around the world focusing on this topic.

The first two chapters address the issue of what premorbid characteristics predict the future development of schizophrenia. Using two different longitudinal prospective approaches, the authors define a set of premorbid characteristics that might predict future schizophrenia. In the next two chapters, a prospective and a retrospective study attempting to characterize the clinical profile of prodromal schizophrenia are described. The next three chapters review the status of three ongoing model early intervention programs in the prodromal phase of schizophrenia; additionally, the evolution of a new scale for the assessment of prodromal symptoms is described. The next four chapters describe strategies for early diagnosis and treatment of schizophrenia after its onset; the early Treatment and Identification of Psychosis Program is described, pharmacological and psychosocial approaches to treatment in this phase are reviewed, and unique aspects of intervention at this stage of schizophrenia are considered. The final chapter considers developmental and degenerative mechanisms implicated in early schizophrenic pathophysiology with an emphasis on the importance of early intervention.

This is an extremely well-constructed volume that systematically addresses topics relevant to early diagnosis and treatment in schizophrenia, focusing on primary and secondary prevention. Although the chapters are somewhat uneven (something to be expected in a book with multiple authors), they are all well crafted. The book flows smoothly and reads easily. Although the book has much to recommend it, there is a somewhat sermonizing feel; all of the contributions passionately make the case for prodromal/early intervention in schizophrenia and collectively suggest that we now have the means to make this happen. The objective of early intervention is certainly laudable, but this goal is not a new one, and previous efforts at accomplishing it have not been successful. A more critical consideration of these obstacles and a contribution or two addressing problems with current approaches would have been useful. An overview or summary would have been valuable. Overall, I thoroughly enjoyed reading this collection of papers and learned much from it.