Published 4 August 2008, doi:10.1136/bmj.a710
Cite this as: BMJ 2008;337:a710

Head to Head

Is early intervention in the major psychiatric disorders justified? No

¹ Department of Psychiatry, Hairmyres Hospital, East Kilbride G75 8RG

Psychiatric disease can take many years to emerge fully. Patrick McGorry (doi: 10.1136/bmj.a695) argues that early specialist treatment is essential, but Anthony Pelosi is unconvinced that current evidence of benefit is enough to balance the potential harm

General practitioners and psychiatrists must ensure that prompt diagnostic assessment and appropriate care are available for young people who seek help (or whose families seek help) because of worrying changes in emotions, thinking, and behaviour. In a small minority of such patients it will emerge over time that the initial symptoms were, in fact, the start of a severe—and sometimes devastating—psychotic illness.

Health professionals and families will inevitably ask themselves whether more could have been done in the earliest stages. But without the benefit of hindsight, when does it become justified to prescribe antipsychotic drugs that have serious side effects? When should patients be offered at least as powerful and potentially dangerous psychotherapy addressing the causes and consequences of psychosis? Important programmes of research are under way that will inform these difficult clinical judgments.¹ So far, evidence from randomised trials does not support the use of psychological therapies or drugs as preventive interventions. At best, they have led to only modest delays in the development of full blown psychosis in some of the participants with potentially prodromal symptoms.²

Unfortunately, researchers have somehow managed to convince themselves that general practitioners and ordinary psychiatric teams are not interested in these difficulties, leading to care that is "often delayed or inadequate, and sometimes crude or harmful."³ They have established an international movement that advocates highly specialised services for the specific identification and treatment of young people who may be developing psychotic illness.

Danger of overtreatment

Richard Warner and others have pointed out the clinical and epidemiological flaws in their approach.^{4 5} In particular, Warner has patiently explained how the positive predictive value of any test is dependent on the prevalence of the condition to which it is applied.⁴ Schizophrenia and related illnesses are rare, but symptoms that point to their imminent onset are quite common.⁶ Therefore most patients who enter these specialist programmes will unnecessarily receive potentially dangerous treatments. Data are emerging from the clinics of early intervention enthusiasts that illustrate nicely what they have been warned about for years.⁷ When psychiatrists referred selected patients to a schizophrenia prodrome clinic, about half went on to develop a psychosis. After teachers, college counsellors, and families were encouraged to refer young people with possibly prodromal symptoms directly to the same clinic for the same care plans, the proportion developing psychosis steadily declined, until almost 90% were receiving unnecessary "preventive" interventions.⁷

When the leaders of the early intervention movement are pinned down, they accept these criticisms and concede that preventive work should be confined to research projects.^{8 9} However, this has not stopped their skilful lobbying of politicians, journalists, patients, and carers with upbeat messages about the prevention and attenuation of schizophrenia.^{10 11 12} Service commissioners are being fed information that "a local at risk service demonstrated a lower rate of transition to psychosis (7%) when compared with local (22-30%) and international (36-50%) data in the absence of targeted preventative interventions."¹² Who can blame policy makers for diverting resources to such services when nobody explains to them that such differences in outcome can only be due to patterns of referral?

Naive clinical practice

As well as exaggerating the current scope for prevention, practitioners of early intervention claim special expertise in the initial treatment of young adults who have developed a psychotic illness. However, their care plans consist of standard interventions that should be provided by every multidisciplinary psychiatric team.¹³ The subspecialists may obtain better short term outcomes, but they do so mainly by turning down difficult referrals. Lists of exclusion criteria vary but can contain the following: any previous treatment with neuroleptic drugs, affective psychoses, brain injury, drug or alcohol induced psychosis, and personality disorder.¹⁴ Early intervention centres provide care for only three years because they have decided this is the critical period in major psychiatric disorders. If the workload becomes too much for them, the teams simply reduce their input to two years or even 18 months.^{14 15}

These services disrupt continuity of care. Patients are often transferred back to the psychiatrist who originally diagnosed the psychosis, and up to 40% are being discharged to their general practitioner.¹ Many of these patients will relapse, although we cannot accurately predict which ones. Hard pressed family doctors and inpatient and community mental health teams will, of course, have to pick up the pieces while the previous key workers will remain unaware and unable to learn from their wrong decisions.

I am sorry to be critical of well intentioned colleagues. However, their self imposed lack of clinical experience combined with relentless political lobbying have led to unacceptable distortions of healthcare priorities. It is time to divert resources to ordinary clinicians who are prepared to tackle the genuine challenges of treating and trying to prevent severe mental illnesses. Unfortunately, this requires a lot more than carefully regulated work for some arbitrary critical period of a few years.

Cite this as: BMJ 2008;337:a710

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Competing interests: None declared.

References

1. Power P, McGuire P, Iacoponi E, Garety P, Morris E, Valmaggia L, et al. Early intervention in the real world. Lambeth Early Onset (LEO) and Outreach and Support in South London (OASIS) service. Early Intervention in Psychiatry 2007;1:97-103.[CrossRef]
2. Marshall M, Rathbone J. Early intervention for psychosis. Cochrane Database Syst Rev 2006;(4):CD004718.
3. International Early Psychosis Writing Group. International clinical practice guidelines for early psychosis. Br J Psychiatry 2005;187:S120-4.[CrossRef][Web of Science]
4. Warner R. Fact versus fantasy: a reply to Bentall & Morrison. J Mental Health 2003;12:351-7.[CrossRef]
5. Cougnard A, Salmi LR, Salamon R, Verdoux H. A decision analysis model to assess the feasibility of the early detection of psychosis in the general population. Schizophr Research 2005;74:27-36.[CrossRef]
6. Van Os J, Hanssen M, Bijl RV, Vollebergh W. Prevalence of psychotic disorder and community level of psychotic symptoms. Arch Gen Psychiatry 2001;58:663-8.[Abstract/Free Full Text]
7. Yung AR, Yuen HP, Berger G, Francey S, Hung T, Nelson B, et al. Declining transition rate in ultra high risk (prodromal) services: dilution or reduction of risk? Schizophr Bull 2007;33:673-81.[Abstract/Free Full Text]
8. McGorry PD, Warner R. Consensus on early intervention in schizophrenia. Schizophr Bull 2002;28:543-4.[Free Full Text]
9. Manchanda R, Norman RM, Malla A. Value of early intervention in psychosis. Br J Psychiatry 2004;185:171.[Free Full Text]
10. Eaton L. How early intervention saves lives. Health Serv J 2006 Nov 23:22-5.
11. Schmidt C. Putting the brakes on psychosis. Science 2007;316:976-7.[Abstract/Free Full Text]
12. Care Services Improvement Partnership, National Institute for Mental Health England. Early detection factsheets. Commissioners factsheet. London: CSIP/NIMHE, 2007.
13. Marshall M, Lockwood A, Lewis S, Fiander M. Essential elements of an early intervention service for psychosis: the opinions of expert clinicians. BMC Psychiatry 2004;4:17.[CrossRef][Medline]
14. Sainsbury Centre for Mental Health. A window of opportunity. A practical guide for developing early intervention in psychosis services. London: Sainsbury Centre for Mental Health, 2003.
15. Edwards J, McGorry PD. Implementing early intervention in psychosis. A guide to establishing early intervention services. London: Martin Dunitz, 2001.

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