Value of early intervention in psychosis

The energy invested in debates about the benefits of early intervention sometimes generates more heat than light, especially when the issue is seen as related to the allocation of resources. The practice of medicine in Canada, while unique, has some parallels to the UK system and so the recent debate (Pelosi/Birchwood, 2003) is of considerable interest to us. Although we find ourselves in agreement with Dr Pelosi's concerns about intervention in putative prodromal phases of psychotic illness, the potential value of prompt intervention once psychotic illness has been established seems quite defensible on the grounds of both reducing ongoing suffering and possibly improving long-term outcome. Although the evidence for prompt treatment improving the long-term outcome for psychosis is not irrefutable, there is substantial evidence that such a relation may well exist (Norman & Malla, 2001; Malla et al, 2002).

Dr Pelosi implies that first-episode psychosis programmes are elitist and excluded from mainstream psychiatry. Enthusiasm for the early intervention approach need not be to the detriment of other aspects of the mental health system. Our experience is that such programmes increase the public recognition of the need for, and influence the political will to provide, a higher standard of care for people with psychotic disorders. However, we must continue to evaluate whether early intervention with phase-specific pharmacological and psychosocial chosocial interventions reduces the overall burden of chronicity or residual symptoms in these patients.

We have become concerned that the focus on prompt intervention will deflect attention from the need for delivering appropriate interventions - timing is certainly not everything! Early intervention programmes should, in time, also be able to provide information to better identify those likely to have a ‘prolonged recovery’ (Edwards et al, 1998) or be treatment refractory. This is not the time to turn back, but to move forward and support controlled trials to assess the efficacy of early intervention.

Hopefully, the development of early intervention programmes will result in better linkages between child and adult psychiatry services and also with those involved in long-term care to ensure treatment of psychosis throughout the life cycle and not just for the first 2-3 years. Early intervention programmes are the first steps towards achieving these goals.