Psychiatry Interpersonal and Biological Processes

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Early Intervention for First Episodes of Schizophrenia: A Preliminary Exploration Ian R. H. Falloon To cite this article: Ian R. H. Falloon (1992) Early Intervention for First Episodes of Schizophrenia: A Preliminary Exploration, Psychiatry, 55:1, 4-15, DOI: 10.1080/00332747.1992.11024572 To link to this article: http://dx.doi.org/10.1080/00332747.1992.11024572

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Early Intervention for First Episodes of Schizophrenia: A Preliminary Exploration Ian R. H. Falloon THIS REPORT describes an uncontrolled study of intensive early intervention with adults who displayed signs and symptoms suggestive of schizophrenic disorders. Case detection rates that were lower than expected offer tentative support for the hypothesis that the initial florid episodes of schizophrenia may be modified when they are detected early and when effective therapeutic strategies are applied with minimal delays. The difficulty of drawing any substantive conclusions from this preliminary (3tudy is stressed, but further controlled replications of the approach may be warranted. INTRODUCTION

During the past two decades we have witnessed dramatic refinements in the long-term clinical management of schizophrenia. While the recovery rate has remained around 20% in the developed nations (Shepherd et al. 1989), florid episodes and exacerbations have been controlled effectively so that the locus of care for most sufferers of this disorder has changed from the· mental asylum to residence in the community. Low-dosage neuroleptic drugs have halved the rate of florid exacerbations, with an additional reduction where psychosocial stress management strate~es have been combined with optimal drug prophylaxis (Falloon and Shanahan 1990). Although these benefits appear to be most marked during the first year after a florid episode, they appear to have long-term benefits when the

programs are continued indefinitely, With careful monitoring by patients, caregivers and professional services so that intensive periods of integrated drug and psychosocial interventions can be targeted to those periods where the risk of exacerbations is high (Falloon 1985; Hogarty et al. 1987). The ability to target treatment resources to periods when a person's vulnerability to florid schizophrenia is high has been facilitated by several recent research· developments. These have included: a. Methods of systematically detecting the prodromal features of florid episodes of schizophrenia (Herz and Melville 1980; Docherty et al. 1978; Birchwood et al. 1989). b. The association between major life events and persisting major environmental stressors with the onset of

Ian R. H. Falloon, MD, is with the Buckingham Project, The Coach House, Finmere, Nr. Buckingham, England, MK18 4AR. The assistance of the family practitioners of Buckingham and Winslow, and of all members of the Buckingham Mental Health Service is gratefully acknowledged. This study was supported in part by grants from the Mental Health Foundation, Oxford Regional Research Fund, and Department of Health. Special thanks is given to Drs. Marc Laporta, Judith Burgess, Rebecca Mather, William Shanahan and Haroutyan Krekorian.

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florid episodes (Brown and Birley 1968; Leff et al. 1973). c. Findings that suggest that the pathogenic effects of stress are mediated through physiological arousal, high levels of which can be detected in clinical practice (Dawson and Nuechterlein 198-1). d. The development of low-dose and targeted pharmacotherapy that does not appear to impede the early recognition of psychological and physiological responses to stress (Kane et al. 1979; Carpenter et al. 1987; Marder et al. 1987). While these approaches have shown a high rate of exacerbations, most of these have been recognized at an early stage and immediate increases of medication have usually prevented major episodes (Herz et al. 1982). e. Strategies for educating patients and their informal caregivers in the community about the complex nature of schizophrenia, and its management with combined drug and psychosocial treatment, have facilitated sustained involvement in a long-term prophylaxis against florid episodes (Hogarty et al. 1987). f. Comprehensive strategies for long-term stress management that have enabled patients and their caregivers to further reduce long-term clinical, social and carer morbidity in a cost-efficient manner (Falloon 1985). g. The provision of continued social case management to ensure that major social stressors relating to changing needs for housing, finances and constructive activity are resolved in the most efficient manner (Stein and Test 1980). h. Cost-effective psychological treatment strategies that have facilitated resolution of, or coping with, the broad range of life event and ambient stresses associated with community living (Liberman and Mueser 1989).

tion of a stress/vulnerability model of mental disorders (Zubin and Spring 1977). It is postulated that' at any pointlr----I in time the interaction between biological and' psychosocial factors determines an individual's risk of succumbing to a mental disorder., When pathogenic factors exceed an individual's threshold for vul· , nerability there is a high ~isk that physiological changes will be triggered that may result in an episode. This threshold may be raised by combinations of prophylactic drugs and psychosocial stress management, thereby making episodes less likely. As the biological (e.g., genetic, biochemical, physiological) and psychological (e.g., perceived stress and tension, cognitive and behavioral responses, prodromal phenomena) signs that are associated with exceeding this threshold are more readily recognized, individuals can learn self-help strategies that ensure that these risk periods are minimized, thereby facilitating recovery from their disorders and preventing chronic disability. Such an approach has been achieved in many medical conditions, such as coronary heart disease, diabetes and peptic ulceration. While its application in psychiatry is in its infancy the prospects appear quite promising (Falloon and Shanahan 1990). However, one major limitation of this model for prevention and screening those at high risk is the measurement of stress, which is highly idiosyncratic and can only be measured through extensive interviews conducted by extensively trained assessors. This paper reports a preliminary feasibility study of this approach to the early detection and intervention with major mental disorders, with particular focus on schizophrenic disorders. The project evolved over a period of four years in several developmental phases within the context of an attempt to devise a scientistpractitioner model of mental health care that focused upon providing comprehensive state-of-the-art mental health manThe integration of all these factors into agement for all persons suffering from a coherent clinical management approach DSM-III Axis I disorders in an epidemiohas been facilitated through the formula- logically defined population of adults.

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IAN R. H. FALLOON

The task of identifying schizophrenia is family practitioner provided a gatekeepfacilitated by the usual presentation of ing role for referral to all specialized mediclearly specified florid symptoms that cal services and maintained every perrepresent a qualitative departure from son's lifetime medical records. A staff of normal mental phenomena, unlike many 12 nurse therapists, 2 psychiatrists, 1 depressive or anxiety states where case- psychologist, 1 social worker, 1 occupaness is based upon quantitative devia- tional therapist, and 2 secretaries were tions from normative experience. Fur- deployed in 4 teams within each of the thermore, the description of prodromal four group practices in the area. They restates in schizophrenia has an extensive . ceived extensive training in clinical and heritage, culminating in their formal in- psychosocial assessment and intervenclusion in the DSM-III classification sys- tion of all major mental disorders, with tems (APA 1980; revision 1984). Those regular multidisciplinary case supervicases that present with a more gradual sion and monitoring throughout. Further deterioration of cognitive functions and details of the service are provided in other personality change present a more diffi- publications (Falloon and Shanahan 1990; cult challenge for early intervention ap- Laporta and Falloon 1990). proaches. METHODS

In 1984 the author returned to England to develop a model mental health service that had the specific aim of preventing clinical and social morbidity associated with mental disorders in an epidemiologically defined population of 35,000, of whom approximately 20,000 were between the ages of 17 and 65. This population lived in and around the two small towns of Buckingham and Winslow, situated in a semirural area north of the cities of Oxford and Aylesbury, 60 miles northwest of London. The absence of an established mental health service in the area, and its relative isolation from existing hospital-based services, provided the opportunity for designing the service from scratch. In order to facilitate early intervention with major mental disorders, the service was based entirely within the existing network of family practices in the area. Virtually every person residing in this area was registered with 1 of 16 family practitioners in the area, where they were provided with a range of primary medical care, including regular health screening and long-term management of most medical and psychiatric disorders, including 24-hour domiciliary consultation for emergencies. The

Table 1 PRODROMAL SYMPTOMS OF SCHIZOPHRENIA ONSET OF ONE OF FOLLOWING WITHOUT EXPLANATION

Marked peculiar behavior Inappropriate or loss of affect Vague, rambling speech Marked poverty of speech and thought Preoccupation with odd ideas Ideas of reference Depersonalisation or derealisation Perceptual disturbances

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Early Detection Procedures Early detection of potential episodes of schizophrenia was based upon the recognition of changes in a person's mental state that were considered prodromal for the disorder. A two-stage approach was developed that entailed (1) training family practitioners to recognize prodromal symptoms and, without delay, to refer such persons for (2) immediate specialized mental health assessment. Family practitioner assessment. All 16 family practitioners in the area were trained to recognize 8 features that might indicate the early stage of an episode of schizophrenia. These symptoms are listed in Table 1. They are derived from the prodromal signs outlined in DSM-III (APA 1980). A checklist that included brief

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EARLY INTERVENTION FOR SCHIZOPHRENIA

eiaboration of these features was proSubstance abuse and organic medical vided for the family practitioners to refer conditions that may have contributed to whenever they suspected a possible to the current state were excluded by history and examination, supervised case. Training was conducted on an indiby the family practitioner and psychiavidual consultation basis for half the family practitioners and in group seminars trist. for the remainder. Role playing of exam- d. The differential psychiatric diagnosis ples of the prodromal symptoms was used was considered in consultation with the to clarify their nature. Most family pracpsychiatrist. This included consideration that the prodromal features could titioners said that they readily recognized be the early stage of a manic episode, these features when they occurred but had usually hesitated to go to the trouble atypical depression or acute anxiety to refer such cases to a mental health disorder. A history of previous episodes of mental disorders and family clinic unless they became much worse. history provided additional informaThe close collaboration with the mental tion to assist in defining the probabilhealth service in this project facilitated ity that the current state represented informal consultation, and the family the initial phase of a first episode of a practitioners gave assurances that any person with any unusual features would schizophrenic psychosis. In all cases a be referred for further assessment withproject psychiatrist conducted an independent assessment to validate key asout delay. Mental health assessment. The availpects of the mental health assessment, ability of 24-hour assessment by a multiusually on the day the features predisciplinary team of mental health professented at the family practice. sionals, including a senior consultant (IF), ensured that assessment could be made within an hour of referral, usually within Early Intervention Procedures The intervention strategies for persons a few minutes of the request. The mental who were suspected of experiencing a prohealth assessment included: drome of schizophrenia included educaa. Patient and key caregiver (usually a rel- tion, comprehensive stress management ative or household member) completed and neuroleptic medication. Each compothe modified version of the Early Signs nent was targeted according to individual Questionnaire (ESQ - Herz and Mel- needs within a structured clinical manville 1980). This lists a range of fea- agement protocol. tures found in the prodromes of florid schizophrenic episodes and was used to a. Education about the nature of schizoprompt patients and their caregivers to phrenia. Within 24 hours of detection specify prodromal symptoms. the patient and his or her key caregivb. If features reported by the family pracers were provided with an educational titioner or noted on the ESQ suggested seminar that provided a rationale for the early intervention program. They a prodromal state, the mental health professional completed a Present State were told that the features displayed Examination (PSE - Wing et al. 1974). by the patient were possible early signs of an impending florid episode of schizoAll mental health professionals working on the project had been trained to phrenia, and that the application· of treatment strategies that had proven research reliability (K > .80) on detecthighly effective in prevention of major ing and rating symptoms according to exacerbations in persons with estabthe PSE manual. c. A psychiatric, medical, drug and family lished schizophrenic disorders might ameliorate the current condition. Alhistory was conducted using a systematic schedule developed for the project. though it was emphasized that the per-

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IAN R. H. FALLOON

son's current features might be found in a range of disorders, including benign stress responses, the characteristic symptoms of schizophrenia, theories of etiology, prognosis, and effective integrated drug and psychosocial treatment methods were outlined in an informal discussion in the home. They were invited to note discrepancies between their present features and those characteristic of schizophrenia, and to alert the therapist if any more definitive phenomena developed. The high rates of remission and recovery from long-term application of effective treatment methods was emphasized, as well as the benefits that could be derived from continued support from family! friends backed up around the clock by a well-trained, committed domiciliary mental health service. Questions and concerns were discussed in frank and open manner that endeavored to foster an optimal therapeutic alliance and minimized fears about schizophrenia. At the completion of this education, informed consent to pursue the early intervention program was sought from patient and key caregivers. In every case this was granted with alacrity. b. Home~based stress management. At the conclusion of the initial educational meeting the rationale for a stress management approach that included key caregivers was provided. A brief assessment of major stressors that may have triggered the patient's current condition was made. Where a major life event was identified as a clear precipitant of the prodromal features, immediate efforts were made to assist patient and caregivers to cope and begin to seek ways to resolve any continuing major stress. Further assessment of stresses associated with life events and persisting ambient stress, as well as the coping capacity of the patient and caregivers was conducted as soon as· convenient. Daily sessions, usually including key caregivers, were conducted to problem solve efficient management of significant stresses. Intensive domi-

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ciliary nursing care was available where necessary, supported by a range of psychological, social work and occupational therapists. This crisis management was conducted according to the Training in Community Living model of Stein and Test (1980). At all times the level of support was targeted according to the expressed needs of the patient and caregivers, and efforts were made to train efficient problem solving within the household unit according to the behavioral family therapy model of Falloon et al. (1984). For cases where coping skills were excellent and stress levels not excessive, stress management training was brief, usually no more than 1 or 2 I-hour sessions. c. Neuroleptic medication. Where features of perceptual or cognitive impairment, agitation or sleep disturbances were prominent, the family practitioner was advised to prescribe a small dose of a law-potency neuroleptic drug (usually thioridazine or chlorpromazine 25-100 mg daily). This drug therapy was carefully targeted to a specific impairment, such as early insomnia, muddled thinking, or preoccupation with an odd idea. Medication was monitored daily by nurses and psychiatrists, who alerted the family practitioner to the onset of any unwanted effects and inereased the dosage when indicated. This drug therapy was time limited, seldom lasting more than two weeks. Where no specific symptoms that were likely to respond to neuroleptic medication were evident, no neuroleptic drug was prescribed. Continued Care Procedures Stress management and drug therapy. The combined crisis-oriented stress management and drug strategies were continued until all evidence of prodromal features remitted. Continued monitoring of stress in the environment enabled the therapist to define the specific coping capacities of the patient and the household

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unit, both th~ strengths and weaknesses in efficiently resolving the stresses that confronted them on a day-to-day basis. This ongoing analysis provided the basis for further training in problem-solving skills for all members of the household unit. This training was continued until the unit displayed proficiency in problem solving all forms of stress that currently existed, as well as those considered likely to occur in the near future. A· regular weekly household meeting was considered the optimal format to ensure sustained stress management; this meeting was convened at home, specifically addressed problem issues for the patient as well as other household members, and was attended regularly by all household members. This recommendation was based upon empirical observations obtained in the earlier family-based stress management of schizophrenia (Falloon, 1985). Monitoring recurrence of prodromal features. Patients and their caregivers were trained to recognize the specific signs displayed by the patient during the prodromal phase. A wallet-sized card was provided for each patient that listed the 1-3 signs that were most likely to discriminate a future prodromal episode. Detailed procedures for immediate contact of family practitioll:er and mental health therapist were included on the card. Additional prompt sheets detailing identical information were provided for display on personal and household noticeboards, so that future episodes could be detected at the earliest possible phase. Mental health monitoring. The mental health therapist conducted assessment of clinical, social, and caregiver status at 3, 6,12, and 24 months after complete resolution of the prodromal state. Early warning signs were reviewed with patients and carers. Stress levels and coping functions were assessed and booster sessions were provided where the efficiency of household problem-solving functions had not been well maintained. In cases where disability persisted, further psychosocial rehabilitation strategies were provided,

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such as social skills, parenting, vocational or leisure skills training. After 24 months free of psychiatric impairment and associated disability, patients were transferred back to routine family practitioner monitoring. RESULTS

Expected incidence of initial florid schizophrenic episodes. A study of the incidence of first episodes of florid schizophrenia had been conducted using similar case definitions in the region of the present pilot study a decade earlier. This provided a crude guide to the expected incidence of schizophrenia. An annual incidence of 7.4 persons per 100,000 population had been admitted to hospital with schizophrenic disorders as defined by PSE/CATEGO classes S and P in Buckinghamshire during the years 1974-1975 (Shepherd et al. 1989). All the cases in this study had been referred to the hospital service by their family practitioners. This study was considered to have included a highly representative sample of persons who experienced the onset of schizophrenia in this region, although cases who did not present with serious be. havioral disturbance sufficient to warrant hospital admission would not have been included. Thus, it probably represents a more conservative estimate that expected using the methodology of the current study. Observed incidence of initial schizophrenic episodes. During a 4-year period from July 1, 1984, 1 person registered with the family practitioners participating in the pilot study was defined as having the onset of an initial episode of florid schizophrenia according to PSEI CATEGO criteria for classes S and P. This represented an annual incidence rate of 0.75 per 100,000 total population. This person was not admitted to hospital and experienced a full remission after 4 weeks of low-dose neuroleptic and stress management intervention. She presented to her family practitioner complaining of

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IAN R. H. FALWON

sleep disturbance. Rather than immediately prescribing a brief course of sedative medication, as had been her previous management choice for such a presentation, the family practitioner asked the client wha~ was contributing to the sleep problem and was told that when she went to bed, she heard voices talking about her. She was under considerable stress preparing for university exams. The family practitioner immediately contacted the mental health therapist in her practice, a PSE was completed, a diagnosis of schizophrenia was confirmed, and after consultation with the psychiatrist integrated psychosocial and drug management was started. Observed incidence of "prodromal" symptoms. During the 4-year period 15 further cases (out of more than 1000 adults for whom family practitioners requested mental health consultations) were observed with symptom patterns suggestive of prodromal states, who had not experienced previous episodes of functional psychoses. All but one of these cases were referred by the family practitioners; the other presented after social services had contacted her family doctor. Not all cases were recognized as having specific early signs of schizophrenia by the family practitioners, who were screening for all DSM-III Axis I disorders. All but two of these cases experienced full and usually rapid recovery after brief integrated intervention that was provided by the multidisciplinary service, usually in the person's home setting. One developed a bipolar disorder, with recurrent depres~ive and hypomanic episodes that were readily treated in their early stages, using a similar integrated drug and stress management approach, with monitoring of early warning signs. Another, a 21year-old man, experienced 3 episodes of prodromal symptoms and has remained under continuous mental health supervision throughout the 5 years. These episodes are characterized by a feeling that something odd is going on, and by ideas of reference that suggest that a catastrophic event may be about to occur. At

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no stage have these disturbed thoughts met the criteria"for delusions that PSEI CATEGO employs. These episodes have resolved within several days of neuroleptic medication combined with psychosocial strategies to manage any precipitating stresses. The latter have usually involved an inability to cope with an interpersonal conflict, usually in the workplace. A combination of family-based stress management and social and vocational skills training has enabled this client to enhance his interpersonal skills, -to assert himself in the workplace, and to progress steadily toward his life goals without major setbacks. He currently takes prophylactic pharmacotherapy, 25 mg thioridazine daily, which is rapidly increased to between 100 and 200 mg daily when any signs of his thought disturbance recur. He remains one of the outstanding young sportsmen in the area, with excellent motor coordination. DISCUSSION

This paper describes an innovative clinical service that integrates primary care and mental health specialists. Screening for early signs of florid episodes of major mental disorders by family practitioners, coupled with immediate access to systematic psychiatric assessment and state-ofthe-art biomedical and psychosocial management, may enable some people to receive effective clinical management at an earlier phase of their disorder than is usually possible. Whether such an approach achieves any worthwhile benefits cannot be concluded from the methods employed in this very preliminary feasibility project. Nevertheless, the project director had the good fortune to have conducted a prospective study of schizophrenic disorders in the same region a decade earlier and was able to make a crude comparison with the incidence of new cases of that disorder with observed_ in this pilot study. A tenfold reduction in the observed incidence of florid episodes of schizophrenia was noted, when the

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same diagnostic criteria were applied. While such an observation appears dramatic, extreme caution should be applied to its interpretation. The lack of a randomly allocated control procedure and blind ratings of caseness precludes the drawing of any firm conclusions from the data presented. However, a number of additional methodological difficulties must be overcome in the scientific evaluation of this early intervention approach. These include: a. The efficiency of the case-finding tech,niques employed, particularly in cases where the onset is insidious. b. Establishing that the "prodromes" detected are specific to schizophrenic disorders. c. How much do changing incidence rates of schizophrenia depend on changes of diagnostic criteria? d. Accounting for drift of persons most vulnerable to schizophrenic disorders out of the area studied. e. The costs and benefits of this approach when applied in everyday clinical practice. Case-Finding Efficiency Persons experiencing acute onset of a change in their mental states appear to be readily detected in a rural community where most persons live with one or more family members or in close social groups. All the prodromal cases had experienced a recent onset of symptoms that had led them or their relatives to seek advice. Disturbed sleep, tension and irritability, incomprehensible conversations, magical thinking, poor concentration and emotional withdrawal were among the features noted most frequently. Remarkably similar features were reported by Kraepelin (1913) in his early descriptions of the onset of dementia praecox. More recent observations of prodromes in established cases have found similar patterns (Dochertyet al. 1978; Herz and Melville 1980; Birchwood et al. 1989). Further systematic study is needed to determine whether

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the prodromes associated with initial episodes are identical to those that precede recurrences. In particular, it would be of interest to evaluate the effects of pharmacotherapy on prodromal states. In a substantial proportion of cases the onset of initial prodromal states is insidious, with a gradual onset over months and years. In such cases the onset is difficult to unravel from personality development, especially in maturing young people. Such cases are unlikely to be detected by the methods employed in this study. It is probable that several such persons who have experienced the earliest manifestations of a schizophrenic disorder remain undetected in the population and may be uncovered during the next few years when their conditions become more florid, or when progressive disability leads to contact with social agencies. Two such cases were detected in a survey of hidden morbidity that we conducted. The first was a former teacher, who had been dismissed from her job 6 years earlier, when her work had become progressively more disorganized in the year following the break up of a romantic relationship. She had become reclusive, caring adequately for herself and her cat in a small village, and refusing to accept any offers of help from family and neighbors. The second was a 32-year-old man who had been treated with benzodiazepines for anxiety symptoms for 15 years by his family practitioner. A psychiatric assessment in adolescence had concluded that he may have been developing schizophrenia at the time. The assertive outreach provided by the community-based mental health service may have led to improved case finding during the period of this study, but it is unlikely that all new cases have yet emerged. This remains a major problem for the design of early intervention programs and their evaluation. Specificity of Prodromes It is evident that the prodromal signs of schizophrenia include a broad range of symptoms, almost none of which are spe-

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IAN R. H. FALLOON

cific to that disorder. Emotional withdrawal, loss of interests, poor concentration, sleep disturbance, irritability and nervousness are common features of many mental disorders. Only the more bizarre psychotic features tend to be more likely to be associated specifically with schizophrenia and related disorders. Thus it is quite possible that some of the persons that we believed were showing the early si~s of schizophrenia were possibly developmg affective or anxiety disorders, or merely showing stress responses. In one case, described earlier,'a bipolar disorder emerged. It should be stressed that these data were collected as part of a comprehensive evaluation of a model service that aimed to provide cost-effective clinical management of all major mental disorders (Le., DSM-III-R Axis I). Family practitioners were encouraged to seek early consultations with all cases they suspected of developing a mental disorder with minimal formality. A similar low incidence of major depressive episodes has been found (Falloon et al. 1989). Depressive features are frequently the presenting features of schizophrenic episodes (Kraepelin, 1913; Docherty et ,al. 1978; Herz and Melville 1980; Herz et al. 1982). Thus, it is possible that some cases that we presumed were developing depressive episodes, were actually displaying prodromes for schizophrenia. The stress management approach was identical across all conditions, and drugs (including antidepressants) were used sparingly and targeted to clearly specified symptoms. Thus, it seems possible that this targeted ap" proach that integrates extensive stress management with low-dose drug therapy within an educational framework may enable many persons to avoid developing more severe presentations of mental disorders. Despite indications that it is possible to detect prodromes of schizophrenia at around the expected incidence rates, further research efforts would profit from an increase in the specificity of definitions of prodromal syndromes of the major men-

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tal disorders, as well as valid and reliable screening instruments that could be readily adopted in primary care settings. Several efforts to do this are underway (Molnar et al. 1988; Fava et al1990). Diagnostic Criteria Recent developments in the classification of' schizophrenia have led to a narrowing of the diagnostic spectrum, so that many cases formerly considered to have schizophrenic episodes are now excluded from that classification. While the PSE/CATEGO system employed in this project is much less restricted than the DSM-III systems, nonetheless several cases reported here would have met broader diagnostic criteria. Under such circumstances claims to have contributed ,~o the prevention of schizophrenia must be Interpreted conservatively. Certainly not one of the cases observed and monitored over 2 years displayed any of the deficit states or deterioration of social function a.ssociated with the more severe presentations of schizophrenia, including those where florid episodes are less prominent. Reports of the declining incidence of schizophr~nia in Europe, particularly the more malignant forms of the disorder (Munk-Jorgensen 1986; Der et al. 1990) must. be considered in the interpretation of this study. The average rates for first hospital admissions with schizophrenia in Britain during the period of this study were 8 cases per 100,000 per year, half the rate seen during the 1950s and '60s. This rate was almost identical to that obtained in the Buckinghamshire study of first admissions (7.4/100,000). However, a tenfold reduction was observed over the 5 years of this project. Moreover, case finding was undoubtedly more thorough than stu~es rely~g n patients presenting for hOSPItal admISSIOn or even hospital-based outpatient consultation. Migration of Potential Cases The low incidence of schizophrenia in this project could be associated with a differential migration of persons with high

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EARLY INTERVENTION FOR SCHIZOPHRENIA

vulnerability to schizophrenia out of this area. Drift of established cases from suburbs into inner-city areas has been documented (Faris and Dunham 1939). A higher rate of chronic mental disorders has been found in the lower social classes (Hollingshead and Redlich 1958). However, there is little evidence that the incidence of schizophrenia is higher in any specific location or social class, merely that persons suffering chronic mental disorders aggregate in .areas of high social deprivation. Furthermore, specific rural areas have been associated with high prevalence of schizophrenia (Torrey 1989). Of course, persons left the area during the course of the study. It is probable that a differential migration of young people most at risk of developing schizophrenia occurred as they left to seek training and further education in larger centers. However, the Buckingham region is an area of population growth and development, with excellent employment opportunities, and education facilities are readily available either locally or within commuting range. The high regard of the service led to families of mentally disordered persons immigrating so that they could avail themselves of our resources. However, drift away from social supports is often a feature of the prodromal phase of schizophrenia and may lead some people to move to settings of social isolation, both urban and rural, long before any florid symptoms emerge. A definitive study would need to devise strategies for minimizing this important source of error. Costs and Benefits Schizophrenia remains one of the major public health problems in industrialized countries, with substantial economic costs compounding human suffering. Any strategies that appear to reduce the morbidity associated with this disorder must be considered seriously, particularly if this reduction appears to be sustained. This uncontrolled epidemiological investigation offers promise that detection of

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the disorder at an early stage in its development may delay and even prevent the onset of disability. Clearly such strategies must be replicated under more rigorously controlled conditions. Such a replication necessitates a well-developed comprehensive primary health care network, with close collaboration between mental health and family practice. In the absence of well-defined prodromal syndromes, projects that focus exclusively on preventing schizophrenic episodes would appear to make inefficient use of resources. However, a generic program that integrates stress management with targeted drug therapy can be applied to all functional psychoses, with the selection of the specific drug determined by the predominant pattern of symptoms. Staff in the Buckingham Project divided their time equally between early detection, crisis management, and long-term rehabilitation. Although evidence of drug-related disability is a major concern for prescribers of neuroleptic drugs, brief use of low doses tends to minimize the risk of serious side effects. Close monitoring of the effects on specific symptoms ensures that ineffective strategies are readily adjusted and that the benefit/cost ratio remains positive. Educating persons about schizophrenia and other major mental disorders appears to have considerable benefits, with very rare deleterious effects. Inevitably some persons who would not develop any significant disorder will receive stress management and drugs that they do not need. They may also worry needlessly about the possibility of developing schizophrenia in the future. Promising research on information processing suggests that we may soon be able to differentiate those persons most vulnerable to this disorder, and thereby alleviate the concern of those we have considered vulnerable solely on phenomenological grounds (Nuechterlein 1990). This future research must estimate the relative costs and benefits of this approach, and must consider whether it is an advance over waiting till persons de-

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IAN R. H. FALLOON

velop florid episodes to make accurate diagnoses and begin effective treatment (cf. Crowet al. 1986). It is concluded that a comprehensive mental health service that is integrated within the ambit of an effective primary care program may be able to provide specific interventions for persons who present with features that are consistent with prodromes of schizophrenia. This very

limited preliminary survey suggests that this may prove feasible and may even contribute to a lower incidence of florid episodes of schizophrenia, or at least to a more benign presentation of the disorder. Although a random-controlled outcome study of such an approach presents a major undertaking, this is an essential step in validating the approach outlined in this report.

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Acta Psychiatrica Scandinavica (1986) 73:645-50. NUECHTERLEIN, K. H. Methodological considerations in the search for indicators of. vulnerability to severe psychopathology. In J. W. Rorbaugh, R. Johnson, and R. Parasuraman, eds., EventRelated Potentials of the Brain. Oxford University Press, 1990. SHEPHERD, M., WATT, D., FALLOON, I., and SMEETON, N. The Natural History of Schizophrenia. Psychological Medicine Monograph 16. Cambridge University Press, 1989. STEIN, L. I., and TEST, M. A. An alternative to men-

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