What is your ultimate goal when treating schizophrenia?
I consider myself lucky to work in a clinic for people with first episode psychosis (FEP). In working with these patients, we can be ambitious in our aims. When the disease is more chronic, this may be less possible.
Many FEP patients do well in life; and my goal is to look for more than expected in terms of return to work and rehabilitation. What we do early can change the course of disease.
In FEP, we move beyond the idea that schizophrenia is always a devastating disease with poor quality of life. What we do early in FEP can change the course – for patients and their families.
What we do early in FEP can change the course of disease – for patients and their families.
You speak in terms of functional recovery....
Yes. For decades, we have been studying risk factors relating to the outcome of psychosis; and we can explain a high proportion of the variation. Factors relating to genetic makeup are ones we can do little about. But we can do something about the adverse prognosis associated with long duration of untreated psychosis (DUP).
In the RAISE study of early intervention, by John Kane and colleagues in the United States, the DUP is around 27 weeks. In some countries it can be up to a year before patients receive proper treatment, either pharmacological or psychosocial. This does not have to be the case.
Let’s do the best with the risk factors we can modify: DUP is one
Early episode patients can be treated cost effectively, as is shown by the work of the early intervention units in the United Kingdom. Effective treatment leads to better vocational outcomes, fewer admissions to hospital, and fewer suicide attempts. So it pays off – and is a nice example of how improved quality of healthcare can align with savings in health costs.
It has been estimated in the UK that for every extra £1 spent on early intervention in psychosis, the return on investment is £18.
So what are the main barriers to wider implementation of early intervention programmes?
It is not always easy to translate the evidence into routine clinical practice. One barrier is politicians. They have to make difficult decisions on limited budgets. They look for large unmet needs and short-term outcomes – and they do so for good reason, since they have the next election to think of.
In mental health, the pay-offs may be longer-term than in cancer or cardiovascular disease. But it is our duty to convey to politicians that early intervention is a good investment.