Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Early intervention
- Eugene G Breen (7 August 2008)
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Paging Dr. Freud
- Hugh Mann (26 August 2008)
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Start with getting the biochemistry right
- Edmond V O`Flaherty (10 September 2008)
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Re: Start with getting the biochemistry right
- Sharif Elleithy (12 September 2008)
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Late intervention for psychosis: no thanks.
- David E Shiers (9 April 2009)
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Neurobiological basis of Early intervention : Lost in argument ?
- Dumindu Witharana (11 April 2009)
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Eugene G Breen, Consultant Psychiatrist 62/63 Eccles St Dublin 7
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Early intervention in psychiatry is in theory laudable. The average multidisciplinary psychiatric team is stretched with 3-400 diagnosed patients not to mind looking for possible cases. Resources and prioritising their optimum use is the bottom line. Really the evidence base for the preventative effectiveness of early intervention is not convincing. There is no cure for psychosis, there is no cholesterol test for psychiatric illness, nor is there a vaccination or screening test available. What there is though, is a network of willing, committed and very well placed personnel, that are very sensitive to incipient psychiatric symptoms and these are parents, relatives, teachers, career guides, school/club mentors, among others. These unseen carers, when knoweledgable and educated and supported, can intervene in a very natural way, and support youngsters through tough patches, and refer firstly to the general practitioner if necessary. Hard wired illness that is genetically loaded, will manifest whither or which, and prevention or illness reduction translates into optimum management of chronic illness. Psychosocially induced and driven illness eg. substance abuse [in many], abuse, bullying, neglect, to mention a few, are not inexorable but comptetely preventable, and early intervention reaps great results in this area, and it is usually far removed from psychiatry services as such. Supporting these already existing services and personnel could be truly effective early intervention. Competing interests: None declared |
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Hugh Mann, Physician Eagle Rock, MO 65641 USA
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Psychiatric intervention is reflexively synonymous with pharmacotherapy. Modern psychiatry is dominated by reductionist, mechanistic psychopharmacology, which focuses almost exclusively on synapses, neurotransmitters, and SSRIs. Unfortunately, modern psychiatry has largely dismissed the seminal work of Sigmund and Anna Freud. The former described structural theory (id, ego, and superego); topographic theory (conscious, preconscious, and unconscious); oedipus and electra complexes; and transference and countertransference. The latter described ego defense mechanisms: repression, denial, rationalization, sublimation, identification, displacement, projection, and reaction formation. In my opinion, it is difficult, if not impossible, to truly understand someone’s motivation and behavior without an appreciation of these two great pioneers. Competing interests: None declared |
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Edmond V O`Flaherty, GP Gleneagle,Greygates,Mount Merrion,Co. Dublin
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I am a GP but about one third of my work is concerned with biochemical psychiatry.While patients continue on their antipsychotics or antidepressants I try to improve the situation by working on the biochemistry.This has given me enormous satisfaction and it is by far the most useful work that I do.I do not know if early intervention with antipsychotics would help a person who appears to be heading for a first psychotic episode but I am sceptical.However because psychiatric conditions are largely genetic it appears that the breakdown occurs when antioxidant protection has become inadequate because of the build-up over many years of oxidative stress.Before they reach that state there are many things that could be done. Paranoid schizophrenics for example have high copper and low histamine-they are overmethylated.Copper is involved in the conversion of dopamine to noradrenaline and in turn much of this finishes up as adrenaline.It is no wonder that they are so anxious and can hardly sit still.Niacinamide,zinc, B12 and folic acid together with other nutrients,especially antioxidants, will help a lot. Incidentally antipsychotics themselves are almost all poweful antioxidants. Competing interests: None declared |
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Sharif Elleithy, Clinical Psychologist St George's Hospital, London
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In response to Dr O' Flattery's comment that "psychiatric conditions are largely genetic" - I am sorry but I just could not let this one go. Despite four decades of research, this statement does not hold up. The often quoted twin-studies data on schizophrenia has a number of serious flaws (1) and indeed the most recent research on large populations concluded that there is unlikely to be a significant association between any of the candidate genes with schizophrenia.(2) At the same time perhaps the most reliable predictor of schizophrenia is stress. Stress from traumatic or neglectful childhoods (3, 4). Stress from social and economic deprivations.(5) I wonder if the reason why Dr O'Flattery's patients are anxious and cannot sit still is because they are very stressed. I also wonder if the reason Dr Flattery finds his biochemical work is useful, is more to do with his patients feeling that he is taking an real interest in them aside from their diagnosis. (1)Joseph, J. (2003) The Gene Illusion: Genetic Research in Psychiatry and Psychology Under the Microscope. PCCS Books, Ross-on-Wye. (2)Sanders, R. et. al (2008) No Significant Association of 14 Candidate Genes With Schizophrenia in a Large European Ancestry Sample: Implications for Psychiatric Genetics. Am J Psychiatry 2008; 165:497-506 (3)Janssen, I., Krabbendam, L., Bak, M., et al (2004) Childhood abuse as a risk factor for psychotic experiences. Acta Psychiatrica Scandinavica, 109, 38-45 (4)Read, J., Goodman, L., Morrison, A., et al (2004) Childhood trauma, loss and stress. In Models of Madness: Psychological, Social and Biological Approaches to Schizophrenia (eds J. Read, L. Mosher & R. Bentall), pp. 223 -252. Hove: Brunner-Routledge. (5)Hudson, C.G.(2005) Socioeconomic status and mental illness. Am. J. of Orthopsychiatry, Vol. 75, No. 1, 3–18 Competing interests: None declared |
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David E Shiers, Joint Lead to National Early Intervention in Psychosis Programme NMHDU C/o Uffculme Centre Queensbridge Rd. Moseley Birmingham B13 8QY
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As a GP I well recall the frustration of trying to negotiate the CAMHS / Adult Mental Health Service divide for adolescent patients and their families. However nothing prepared me for when my own daughter developed schizophrenia in her late teens [1]. Our local CAMHS consultant psychiatrist advised us to “hang on ‘til the Adult service as they were more into psychosis”. 12 months of chaos at home predated our discovery that although the adult service may have been 'into psychosis' they certainly weren’t 'into young people'. The subsequent three years of hospital based care seemed an expensive way of disabling someone for the rest of her life. Perhaps my daughter was unique in being so young? Well, more than three quarters of males and two thirds of females will have their first episode by age 35; most are in their late teens and twenties.[2] 20% will have done so under the age of 20 (5% under the age of 16) when they can expect a relatively poorer outlook than those older at onset, with recurrent illness and markedly impaired social functioning. [3] Does Dr Pelosi really believe in late intervention for these young people? Let me quote some findings from a study he co-authored in 2007 [4] which examined service provision for adolescent-onset psychosis in areas of central Scotland with a total population of 1.75 million: - 80% of first admissions were to adult acute psychiatric wards. - Those interviewed had high levels of morbidity. 55% had serious to pervasive impairment of functioning; there were relatively high levels of side-effects, negative symptoms, anxiety, occupational, friendship and family difficulties. - Care provision was better for ‘clinical’ than for ‘social’ domains; 20% had five or more unmet needs; 17% had at least one intractable problem. What Dr Pelosi and colleagues found in Scotland is matched by similar studies whenever generic community mental health services (CMHTs) are put under the microscope: excessive treatment delays, reliance on hospitalisation, huge rates of coercion eg 40% of first episodes (50% for young Black men) are legally detained [5]; the majority have disengaged services within 6m. Only EI teams can guarantee high levels of engagement and treatment which CMHTs simply cannot.[6, 7] So I make no apology now, as joint national lead on England’s Early Intervention Programme, for having encouraged a very different service response and indeed expectation for young people and families like mine. Nor is this just about fast access to specialist services; in England we expect by 2010 to have achieved full service coverage with a three year package of evidence-based interventions, in particular psycho-social and family interventions, far removed from pessimistic regimens of crisis, coercion and over reliance on antipsychotic medicines. And what was the conclusion of Dr Pelosi and his colleagues in their Scottish study? THIS DISORDER REQUIRES AN ASSERTIVE MULTI-AGENCY APPROACH IN THE CONTEXT OF A NATIONAL PLANNING FRAMEWORK. At least Dr Pelosi and I are agreed on something. Dr David Shiers
REFERENCES [1] Shiers D. (1998) Who cares? Personal View British Medical Journal 316: 785 [2] Kirkbride JB, Fearon P, Morgan C, et al. (2006) Heterogeneity in incidence rates of schizophrenia and other psychotic syndromes: findings from the 3-center AeSOP study. Arch Gen Psychiatry; 63(3): 250-8. [3] Hollis C (2003) Developmental precursors of child-and-adolescent- onset schizophrenia and affective psychoses: diagnostic specificity and continuity with symptom dimensions British Journal of Psychiatry 182: 37- 44 [4] Boeing L, Murray V, Pelosi A, et al (2007) Adolescent-onset psychosis: prevalence, needs and service provision British Journal of Psychiatry, 190, 18-26. [5] Morgan, C., Mallet, R., Hutchinson, G., et al (2005) Pathways to care and ethnicity. 1: Sample characteristics and compulsory admission British Journal of Psychiatry, 186, 281-289 [6] Craig T, Garety P, Power P, Rahaman N, Colbert S, Fornells- Ambrojo M, Dunn G (2004) The Lambeth Early Onset (LEO) team: randomised controlled trial of the effectiveness of specialised care for early psychosis, British Medical Journal, 329, 1067-1070. [7] Nordentoft M, Jeppesen P, Kassow P. et al (2002) OPUS project: a randomized controlled trial of integrated psychiatric treatment in first episode psychosis – clinical outcome improved, Schizophrenia Research, 53 (suppl.1), 51 Competing interests: None declared |
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Dumindu Witharana, Speciality Registrar Warneford Hospital , oxford, OX3 7JX, UK
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We read with interest opposing opinions expressed by Prof. McGorry and Prof. Pelosi regarding early intervention services in Psychiatry (McGorry,2008; Pelosi,2008). Intriguing the arguments are, both have failed to elaborate on neurobiological studies on which the early intervention in psychiatry is largely based on. Longitudinal follow up studies of people with first episode psychosis have shown an accelerated reduction in brain grey matter volumes, particularly in frontal and temporal lobes in early stages of psychosis, suggesting an active disease process (Pantelis et al, 2003). These findings are well supported by functional neuroimaging studies showing a hypofrontality during cognitive activation in people with schizophrenia (Davidson and Heinrichs, 2003). There is evidence to suggest that some of those neurobiological changes could progress rapidly during the early stages of the illness (Keshavan et al, 2005). A main aim of early intervention services has been to treat patients assertively during this early phase of vulnerability to prevent long term , irreversible neurological deficits. If treated early and vigorously , both neurobiological and social damage in early psychosis could be limited. We agree with Prof. Pelosi’s argument of this a possibility within a traditional Community mental health team setting. However , with lack of manpower and material resources, community mental health teams would struggle to meet the increased demand . Even with ample resources, a priority resource allocation for a limited group of people would not be feasible. Hence, the needs of this most vulnerable group could best be met by a specialised service. References McGorry, D.(2009) Is early intervention in the major psychiatric disorders justified? YES. BMJ 2008; 337;a695 Pelosi, A. (2009) Is early intervention in the major psychiatric disorders justified? NO. BMJ 2008; 337:a710 Keshavan, M., Berger, G., Zipursky, R., Wood,S. and Pantelis., C. (2005) Neurobiology of Early Psychosis. British Journal of Psychiatry,187 (suppl.48), s8-s18 Pantelis, C., Velakoulis, D., McGory, P.D et al (2003) Neuroanatomical abnormalities before and after onset of Psychosis: A cross-sectional and longitudinal MRI comparison. Lancet. 361. 281-288 Davidson, L. and Heinrichs, R. (2003) Quantification of frontal and temporal lobe brain-imaging findings in Schizophrenia : A meta analysis. Psychiatry Research, 122, 69-87. Competing interests: None declared |
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