Should add that in the US early intervention services have focused on “coordinated specialty care.” RAISE-ETP showed some benefits for this in FEP, but I think we can agree that team based care with psychotherapy, vocational rehab and family psychoed would likely be helpful at all stages of illness.
A fascinating topic, well explained. As a layperson & parent, one anxiety I have about early intervention in psychosis is its potential to justify an over-use of antipsychotic drugs, especially in young people. You do a good job describing the profile of a preventative drug, like statin -- it must be well tolerated and have few negative side effects. My purely anecdotal experience of the world is that antipsychotic drugs impair intellectual development, creativity, and sense of self. Your position in the UK, working within the context of the NHS, might be different from my perspective here from America, where I see many institutional incentives for at-risk youth programs, rehab and halfway houses, to over-rely on antipsychotic drugs to make their jobs easier, frankly. The worst-case scenario, which should be avoided at all costs, is that these drugs become a mechanism of control rather than a treatment. The potential is there, especially in a private and privatized system.
Thanks for sharing this perspective. The psychiatrists I have worked with are generally judicious about the use of antipsychotics - these are powerful medications after all! The one exception might be the use of very low dose antipsychotics in people at risk for psychosis, without much evidence of benefit.
That's good, but the overall trends are not good, both in UK and US. In the US, we experienced a troubling growth in pediatric prescription of antipsychotics before 2010, with stabilization in rates since then, but in UK it's still going up. "Antipsychotic medication use is substantially higher for youth in the United States than in most other developed countries."
It looks like a lot of concern is around prescribing ‘off label’ for other disorders. I don’t think early intervention would be responsible for rates of antipsychotic use in children under 14, for example, as most services have this as their lower age limit.
The topic of antipsychotic use in children probably warrants a post of its own!
You explain it well but the whole thing feels like a long drive that missed the turnoff miles ago. It seems like taking a bunch of heterogeneous groups who all have one symptom in common and creating the mother of all heterogeneous groups and then throwing out course criterion and sort of throwing treatment at them to see what sticks. I mean maybe focusing on psychosis is the way to go, I don't know but it seems like awfully large stew.
Any idea how the early intervention groups split along the lines of concepts like unsystematised schizophrenia and systematised schizophrenia?
I agree, the heterogeneity of this patient group (in terms of symptomatology, treatment response and prognosis) is a massive challenge.
I've seen figures of roughly 50% of first episode psychosis being diagnosed with schizophrenia, though obviously diagnosis in psychiatry isn't an exact science!
I get the spirit of it, but it just seems like a bit of a mess. I live in Australia, and I was assessed for prodromal psychosis at the Westmead Children's Hospital as a teen. I guess I got lucky, and nothing ever came of it. The clinician was quite perceptive, and the process wasn’t guided by any one-size-fits-all policy approach.
That was over a decade ago, though, and I do worry that these kinds of efforts lend themselves to bureaucratic policy approaches. When I was assessed, early intervention just seemed like a pathway to fairly standard care, but I worry about people getting "hoovered up" as hospitals move more and more towards standardizing care.
I assume you're familiar with Frank Fish's work on systematised and unsystematised schizophrenia?
Fantastic review! Thanks.
Should add that in the US early intervention services have focused on “coordinated specialty care.” RAISE-ETP showed some benefits for this in FEP, but I think we can agree that team based care with psychotherapy, vocational rehab and family psychoed would likely be helpful at all stages of illness.
Yes, I do recall positive results from this trial, with some benefits maintained at five year follow-up.
The US and UK healthcare system seem so different that I’d be reluctant to draw any conclusions
A fascinating topic, well explained. As a layperson & parent, one anxiety I have about early intervention in psychosis is its potential to justify an over-use of antipsychotic drugs, especially in young people. You do a good job describing the profile of a preventative drug, like statin -- it must be well tolerated and have few negative side effects. My purely anecdotal experience of the world is that antipsychotic drugs impair intellectual development, creativity, and sense of self. Your position in the UK, working within the context of the NHS, might be different from my perspective here from America, where I see many institutional incentives for at-risk youth programs, rehab and halfway houses, to over-rely on antipsychotic drugs to make their jobs easier, frankly. The worst-case scenario, which should be avoided at all costs, is that these drugs become a mechanism of control rather than a treatment. The potential is there, especially in a private and privatized system.
Thanks for sharing this perspective. The psychiatrists I have worked with are generally judicious about the use of antipsychotics - these are powerful medications after all! The one exception might be the use of very low dose antipsychotics in people at risk for psychosis, without much evidence of benefit.
That's good, but the overall trends are not good, both in UK and US. In the US, we experienced a troubling growth in pediatric prescription of antipsychotics before 2010, with stabilization in rates since then, but in UK it's still going up. "Antipsychotic medication use is substantially higher for youth in the United States than in most other developed countries."
https://www.manchester.ac.uk/discover/news/researchers-reveal-worrying-rise-in-antipsychotic-prescriptions-for-children-and-young-people/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3778027/
https://www.sciencedaily.com/releases/2020/11/201110112532.htm
It looks like a lot of concern is around prescribing ‘off label’ for other disorders. I don’t think early intervention would be responsible for rates of antipsychotic use in children under 14, for example, as most services have this as their lower age limit.
The topic of antipsychotic use in children probably warrants a post of its own!
You explain it well but the whole thing feels like a long drive that missed the turnoff miles ago. It seems like taking a bunch of heterogeneous groups who all have one symptom in common and creating the mother of all heterogeneous groups and then throwing out course criterion and sort of throwing treatment at them to see what sticks. I mean maybe focusing on psychosis is the way to go, I don't know but it seems like awfully large stew.
Any idea how the early intervention groups split along the lines of concepts like unsystematised schizophrenia and systematised schizophrenia?
I agree, the heterogeneity of this patient group (in terms of symptomatology, treatment response and prognosis) is a massive challenge.
I've seen figures of roughly 50% of first episode psychosis being diagnosed with schizophrenia, though obviously diagnosis in psychiatry isn't an exact science!
I get the spirit of it, but it just seems like a bit of a mess. I live in Australia, and I was assessed for prodromal psychosis at the Westmead Children's Hospital as a teen. I guess I got lucky, and nothing ever came of it. The clinician was quite perceptive, and the process wasn’t guided by any one-size-fits-all policy approach.
That was over a decade ago, though, and I do worry that these kinds of efforts lend themselves to bureaucratic policy approaches. When I was assessed, early intervention just seemed like a pathway to fairly standard care, but I worry about people getting "hoovered up" as hospitals move more and more towards standardizing care.
I assume you're familiar with Frank Fish's work on systematised and unsystematised schizophrenia?