As I said in my review of Jo Moncrieff's book The bitterest pills, Jo has provided one of the best summary critiques of early intervention in psychosis (chapter 10 of the book). Duration of untreated psychosis (DUP) is associated with poorer outcome but this was never a new finding as it has always been recognised that more acute onset of psychosis has a better outcome. Despite the attractiveness of early intervention services (EIS), the danger is that they may actually lead to over-treatment.
Whatever the advantages of intensive treatment for reducing readmission, there is little evidence that the underlying psychotic disease process is fundamentally modified by EIS. Two trials of EIS in Copenhagen and Aarhus County, Denmark and Lambeth, London did not specifically examine whether starting anti-psychotic medication early improves outcomes. Nonetheless, drug companies exploit the situation by encouraging early prescribing.
The early intervention approach becomes even more controversial when attempts may be made to bring people into treatment even before they have become psychotic, with the intended aim of reducing DUP even further. Thankfully, psychosis risk syndrome was specifically excluded from DSM-5 for lack of validity and insufficient evidence that early intervention in the so-called prodrome is effective (see previous post).
When I first trained, more people were probably admitted to hospital than now with a first episode of psychosis. However, there was no necessary rush to start anti-psychotic medication. Instead patients may have been assessed drug free for a week, to ensure that the primary diagnosis was psychosis. Overmedicating people with anti-psychotics may create unnecessary dependency and is not good practice.
3 comments:
Speaking as a person who has experienced "psychoses" on 3 occasions that resulted in psychiatric intervention or forced drugging, and also as a "carer" of many family members who have experienced altered mind states or "psychoses", I still believe that early SUPPORT is the way to go. But I don't like the word or action of "intervention" and didn't like being invaded by psychiatric drugs that took away my agency, made me vulnerable to takeovers and exploitation.
In 1967 my mother experienced another altered mind state or nervous breakdown as they called it back then. We lived in Perth, Scotland. She had given birth about 6 months before, to my youngest sister, I was 14 and a half. My father was distressed and asked me what we should do. We lived on the 4th floor of a 10 story block of flats. My mother's perceptions were altered. Eg she let the budgie out of the cage and out of the verandah window, thinking it would fly back. It didn't. We never saw the budgie again.
My father, a science fiction writer with the Daily Express in Fleet St, London, was distressed because he had been a psychiatric inpatient himself, about 3 years previously and knew the score. Forced ECT over many sessions. Forced drugs. Locked in. At the mercy of psychiatry, regarding freedom to leave, to get back on with your life. He didn't want to make the decision regarding my mother getting taken away in an ambulance to the local mental hospital in Perth.
So I made the decision. Someone had to. It wasn't safe for her to be in an altered mind state, 4 floors up, not sleeping, writing poetry, feeling the pain of the world, going outside into the darkness and wandering about the town. She resisted going into the psychiatric hospital because she'd been there before, knew the score. And berated us for sending her away to be forcibly shocked and drugged. We felt her pain.
But what else could we do? There were no alternatives available. Nearly 50 years later and there are still NO alternatives available for people in altered mind states, not caused by recreational drugs. Eight of us in my family have been subject to the forced drug treatment, stigma and ritual humiliation because we experience altered mind states naturally, whether due to the pain of living or extreme exhaustion. I have always resisted the regime when I could. It is a matter of principle. And because I don't like psychiatric drugs or being forced.
It is way beyond time that we stopped forcing drugs on people who experience altered mind states because they are sensitive and imaginative, experiencing the pain of living. Giving us labels because the treatment doesn't work. A failed paradigm is not the fault of the person. The system is to blame. Let's devise alternative ways of working with people in psychoses and stop making them/us the scapegoats for an unjust and unfair world. We deserve respect for being human.
C.M. puts his finger on how difficult it is for even critical psychiatrists to alter mind states regarding psychosis...the language of coercion survives in the terms used. 'intervention' rather than 'support'. How early is the 'intervention' to happen when it is unknown how the altered state will manifest - or would - or not if the person was left to explore in security and with support. People are aware of how they will be treated if they resist and often cave in when really they are prepared to experience the pain and attempt to get through it. The problem is not only in the medication itself but the stress endured by having to deal with mental health workers' attitudes - illness can be caused by fear and stress, it certainly exacerbates unwellness and it actually caused by the psychiatric intervention services themselves, but that is rarely if ever included in research.
I hadn't realised there was recent research published when I made this post - see NIMH director's blog. As Thomas Insel says, it should be no surprise that coordinated specialty care can be shown to improve outcomes. What I'm objecting to is that so much is made of DUP. For example, in the RAISE-ETP study, it is to be expected that clients with a shorter DUP have a better outcome. This is not a new finding. More acute presentations of psychosis have always had a better outcome than those with insidious onset. The trial has not specifically demonstrated that earlier intervention is of benefit, merely that more intensive input can be seen to be of benefit.
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