Asian Journal of Psychiatry 5 (2012) 1–2
Contents lists available at SciVerse ScienceDirect
Asian Journal of Psychiatry journal homepage: www.elsevier.com/locate/ajp
Editorial
Early intervention in psychosis: Perspectives on Asian studies
The Kraepelinian view of schizophrenia as a chronic debilitating disorder with uniformly poor outcome has been challenged by the observations in various prospective studies; these studies report that the clinical outcome in schizophrenia is heterogeneous with about 30–50% of patients having good outcome (van Os and Kapur, 2009). The heterogeneity in outcome is shared by heterogeneity in factors that influence outcome; duration of untreated psychosis is considered one of the more important factors. A seminal work highlighted the proposition that schizophrenia patients who received antipsychotic treatment earlier had better outcome than those who did not (Wyatt, 1991). This view was supported by two comprehensive meta-analytic reviews which concluded that shorter duration of untreated psychosis was associated with modest positive effect on outcome (Marshall et al., 2005; Perkins et al., 2005). These findings are significant especially because duration of untreated psychosis is a modifiable factor. Indeed, this ‘modifiability’ dimension provided the much-needed impetus towards research on methods to identify and intervene in psychotic disorders at an early stage. Early intervention in psychosis encompasses therapeutic measures ‘before’ as well as ‘after’ the onset of psychoses. The ‘prodromal’ features before onset of frank psychosis symptoms was noticed many decades before (Meares, 1959); this was ascertained by later retrospective studies that reported schizophrenia to frequently show early, less severe manifestations of the disorder prior to onset of full psychosis (Hafner and an der Heiden, 1999). These observations underpinned the initiation of early intervention programmes with the pioneering works by McGorry and colleagues in Australia in 1994 and then moving to the United States and Europe shortly thereafter (Correll et al., 2010). A review of these first generation of intervention trials indicated that both pharmacologic and psychological intervention strategies may be of value in terms of symptom reduction and delay or prevention of onset of threshold psychotic disorder (McGorry et al., 2009). The Asian component of early intervention programmes in psychoses is the focus of the special section of this issue of the Asian Journal of Psychiatry. Kwon et al. describe the multi-faceted early intervention programmes in Taiwan (Kwon et al., 2012). In this article, the authors have summarized the clinical, cognitive and neurobiological abnormalities in clinical high risk as well as genetic high risk groups for psychosis. The authors propose that these individuals at risk for psychoses share common features when compared with earlier studies from Australia/western countries. The Changsha study by Stone et al. provide factor analytic validation for a subgroup with features of the Paul Meehl’s concept of schizotaxia
1876-2018/$ – see front matter ß 2012 Elsevier B.V. All rights reserved. doi:10.1016/j.ajp.2012.02.008
among those identified to be at familial risk for schizophrenia. They also report interesting observations pertinent to the use of risperidone in schizotaxia (Stone et al., 2012a,b). In this study, the authors have examined the possibility whether negative symptoms, neurocognitive deficits as well as other measures of clinical and social function in schizotaxia subjects (as defined by research criteria) were amenable to pharmacological treatment with risperidone. The findings of this double-blind, 6-week treatment trial, consistent with earlier open-label reports of risperidone administration in subjects with schizotaxia, suggest that some neurocognitive and clinical problems may be amenable to remediation in non-psychotic relatives of people with schizophrenia. Studies from Hong Kong (Wong et al., 2012), Japan (Mizuno et al., 2012) and Singapore (Verma et al., 2012) give a comprehensive description of various early intervention services in their respective countries. The study from India (Rangaswamy et al., 2012) adds further evidence to the effectiveness of early intervention programme. Together, these studies emphasize the need for further development and implementation of early intervention services to improve the outcome in schizophrenia. While these studies support the utility of early intervention ‘before’ as well as ‘after’ the onset of psychosis, one need to be aware of the controversies associated with these approaches. For example, a recent review that examined the ultra-high risk states and non-transition to frank psychosis concluded that ‘‘the longterm outcome of ultra-high risk subjects that do not develop psychosis is to date under-investigated’’ (Simon et al., 2011). A recent Cochrane review on early intervention in psychosis concluded that ‘‘there is emerging, but as yet inconclusive evidence, to suggest that people in the prodrome of psychosis can be helped by some interventions’’ and suggested that ‘‘larger and longer trials are needed in this area’’ (Marshall and Rathbone, 2011). In this context, the studies from various Asian countries reported in this issue are a valuable addition that supports the potential benefits of early intervention in psychosis. However, it is important to note that the stigma associated with the diagnostic label, the potential side-effects to antipsychotic medications and the cost intensiveness of various psychological/family interventions for ‘ultra-high risk’ subjects seriously emphasize the need for identifying (i) biomarkers that robustly predict transition to psychosis, (ii) cost-effective non-pharmacological interventions for subjects at early stages of prodrome and (iii) safer pharmacological treatment options.
2
Editorial / Asian Journal of Psychiatry 5 (2012) 1–2
While the march 2012 issue features the first special theme section on early intervention, other special theme issues will follow in the subsequent issues, covering of key importance to Asian psychiatry, such as global mental health and spirituality. We will also expand our Medical Education Forum to under the two separate sections of Research Education and Clinical education. The goal is to foster psychiatrists and other mental health professionals early in their career for building their capacity towards developing into clinicians and researchers of excellence. References Correll, C.U., Hauser, M., Auther, A.M., Cornblatt, B.A., 2010. Research in people with psychosis risk syndrome: a review of the current evidence and future directions. Journal of Child Psychology and Psychiatry 51, 390–431. Hafner, H., an der Heiden, W., 1999. The course of schizophrenia in the light of modern follow-up studies: the ABC and WHO studies. European Archives of Psychiatry and Clinical Neuroscience 249 (Suppl. 4), 14–26. Kwon, J.S., Byun, M.S., Lee, T.Y., 2012. Early intervention in psychosis: insights from Korea. Asian Journal of Psychiatry 5 (1). Marshall, M., Lewis, S., Lockwood, A., Drake, R., Jones, P., Croudace, T., 2005. Association between duration of untreated psychosis and outcome in cohorts of first-episode patients: a systematic review. Archives of General Psychiatry 62, 975–983. Marshall, M., Rathbone, J., 2011. Early intervention for psychosis. Cochrane Database of Systematic Reviews CD004718. McGorry, P.D., Nelson, B., Amminger, G.P., Bechdolf, A., Francey, S.M., Berger, G., Riecher-Rossler, A., Klosterkotter, J., Ruhrmann, S., Schultze-Lutter, F., Nordentoft, M., Hickie, I., McGuire, P., Berk, M., Chen, E.Y., Keshavan, M.S., Yung, A.R., 2009. Intervention in individuals at ultra-high risk for psychosis: a review and future directions. The Journal of Clinical Psychiatry 70, 1206–1212. Meares, A., 1959. The diagnosis of prepsychotic schizophrenia. Lancet 1, 55–58. Mizuno, M., Nemoto, T., Tsujino, N., Funatogawa, T., Takeshi, K., 2012. Early psychosis in Asia: insights from Japan. Asian Journal of Psychiatry 5 (1). Perkins, D.O., Gu, H., Boteva, K., Lieberman, J.A., 2005. Relationship between duration of untreated psychosis and outcome in first-episode schizophrenia: a critical review and meta-analysis. The American Journal of Psychiatry 162, 1785–1804.
Rangaswamy, T., Mangala, R., Mohan, G., Joseph, J., John, S., 2012. The Singapore Early Psychosis Intervention Programme (EPIP): a programme evaluation. Asian Journal of Psychiatry 5 (1). Simon, A.E., Velthorst, E., Nieman, D.H., Linszen, D., Umbricht, D., de Haan, L., 2011. Ultra high-risk state for psychosis and non-transition: a systematic review. Schizophrenia Research 132, 8–17. Stone, W.S., Hsi, X., Giuliano, A.J., Tan, L., Zhu, S., Li, L., Seidman, L., Tsuang, M.T., 2012a. Are neurocognitive, clinical and social dysfunctions in schizotaxia reversible pharmacologically? Results from the Changsha study. Asian Journal of Psychiatry 5 (1). Stone, W.S., Hsi, H., Tan, L., Zhu, Z., Li, L., Giuliano, A.J., Seidman, L.J., Tsuang, M.T., 2012b. Neurocognitive and clinical dysfunction in adult Chinese, nonpsychotic relatives of patients with schizophrenia: findings from the Changsha study and evidence for schizotaxia. Asian Journal of Psychiatry 5 (1). van Os, J., Kapur, S., 2009. Schizophrenia. Lancet 374, 635–645. Verma, S., Poon, L.Y., Subramaniam, M., Abdin, E., Chong, S.A., 2012. The Singapore Early Psychosis Intervention Programme (EPIP): a programme evaluation. Asian Journal of Psychiatry 5 (1). Wong, G.H.Y., Hui, C.L.M., Tang, J.Y.M., Chang, W.H., Chan, S.K.W., Xu, J., Lin, J.J.X., Lai, D., Tam, W., Kok, J., Chung, C., Hung, S.F., Chen, E.Y., 2012. Early intervention for psychotic disorders: real-life implementation in Hong Kong. Asian Journal of Psychiatry 5 (1). Wyatt, R.J., 1991. Neuroleptics and the natural course of schizophrenia. Schizophrenia Bulletin 17, 325–351.
G. Venkatasubramanian* National Institute of Mental Health & Neurosciences, Department of Psychiatry, Hosur Road, Bangalore 560029, India Matcheri S. Keshavan Boston, MA, United States *Corresponding
author. Tel.: +91 80 26995256; fax: +91 80 26564830 E-mail addresses: [email protected], [email protected] (G. Venkatasubramanian)
Contents lists available at SciVerse ScienceDirect
Asian Journal of Psychiatry journal homepage: www.elsevier.com/locate/ajp
Editorial
Early intervention in psychosis: Perspectives on Asian studies
The Kraepelinian view of schizophrenia as a chronic debilitating disorder with uniformly poor outcome has been challenged by the observations in various prospective studies; these studies report that the clinical outcome in schizophrenia is heterogeneous with about 30–50% of patients having good outcome (van Os and Kapur, 2009). The heterogeneity in outcome is shared by heterogeneity in factors that influence outcome; duration of untreated psychosis is considered one of the more important factors. A seminal work highlighted the proposition that schizophrenia patients who received antipsychotic treatment earlier had better outcome than those who did not (Wyatt, 1991). This view was supported by two comprehensive meta-analytic reviews which concluded that shorter duration of untreated psychosis was associated with modest positive effect on outcome (Marshall et al., 2005; Perkins et al., 2005). These findings are significant especially because duration of untreated psychosis is a modifiable factor. Indeed, this ‘modifiability’ dimension provided the much-needed impetus towards research on methods to identify and intervene in psychotic disorders at an early stage. Early intervention in psychosis encompasses therapeutic measures ‘before’ as well as ‘after’ the onset of psychoses. The ‘prodromal’ features before onset of frank psychosis symptoms was noticed many decades before (Meares, 1959); this was ascertained by later retrospective studies that reported schizophrenia to frequently show early, less severe manifestations of the disorder prior to onset of full psychosis (Hafner and an der Heiden, 1999). These observations underpinned the initiation of early intervention programmes with the pioneering works by McGorry and colleagues in Australia in 1994 and then moving to the United States and Europe shortly thereafter (Correll et al., 2010). A review of these first generation of intervention trials indicated that both pharmacologic and psychological intervention strategies may be of value in terms of symptom reduction and delay or prevention of onset of threshold psychotic disorder (McGorry et al., 2009). The Asian component of early intervention programmes in psychoses is the focus of the special section of this issue of the Asian Journal of Psychiatry. Kwon et al. describe the multi-faceted early intervention programmes in Taiwan (Kwon et al., 2012). In this article, the authors have summarized the clinical, cognitive and neurobiological abnormalities in clinical high risk as well as genetic high risk groups for psychosis. The authors propose that these individuals at risk for psychoses share common features when compared with earlier studies from Australia/western countries. The Changsha study by Stone et al. provide factor analytic validation for a subgroup with features of the Paul Meehl’s concept of schizotaxia
1876-2018/$ – see front matter ß 2012 Elsevier B.V. All rights reserved. doi:10.1016/j.ajp.2012.02.008
among those identified to be at familial risk for schizophrenia. They also report interesting observations pertinent to the use of risperidone in schizotaxia (Stone et al., 2012a,b). In this study, the authors have examined the possibility whether negative symptoms, neurocognitive deficits as well as other measures of clinical and social function in schizotaxia subjects (as defined by research criteria) were amenable to pharmacological treatment with risperidone. The findings of this double-blind, 6-week treatment trial, consistent with earlier open-label reports of risperidone administration in subjects with schizotaxia, suggest that some neurocognitive and clinical problems may be amenable to remediation in non-psychotic relatives of people with schizophrenia. Studies from Hong Kong (Wong et al., 2012), Japan (Mizuno et al., 2012) and Singapore (Verma et al., 2012) give a comprehensive description of various early intervention services in their respective countries. The study from India (Rangaswamy et al., 2012) adds further evidence to the effectiveness of early intervention programme. Together, these studies emphasize the need for further development and implementation of early intervention services to improve the outcome in schizophrenia. While these studies support the utility of early intervention ‘before’ as well as ‘after’ the onset of psychosis, one need to be aware of the controversies associated with these approaches. For example, a recent review that examined the ultra-high risk states and non-transition to frank psychosis concluded that ‘‘the longterm outcome of ultra-high risk subjects that do not develop psychosis is to date under-investigated’’ (Simon et al., 2011). A recent Cochrane review on early intervention in psychosis concluded that ‘‘there is emerging, but as yet inconclusive evidence, to suggest that people in the prodrome of psychosis can be helped by some interventions’’ and suggested that ‘‘larger and longer trials are needed in this area’’ (Marshall and Rathbone, 2011). In this context, the studies from various Asian countries reported in this issue are a valuable addition that supports the potential benefits of early intervention in psychosis. However, it is important to note that the stigma associated with the diagnostic label, the potential side-effects to antipsychotic medications and the cost intensiveness of various psychological/family interventions for ‘ultra-high risk’ subjects seriously emphasize the need for identifying (i) biomarkers that robustly predict transition to psychosis, (ii) cost-effective non-pharmacological interventions for subjects at early stages of prodrome and (iii) safer pharmacological treatment options.
2
Editorial / Asian Journal of Psychiatry 5 (2012) 1–2
While the march 2012 issue features the first special theme section on early intervention, other special theme issues will follow in the subsequent issues, covering of key importance to Asian psychiatry, such as global mental health and spirituality. We will also expand our Medical Education Forum to under the two separate sections of Research Education and Clinical education. The goal is to foster psychiatrists and other mental health professionals early in their career for building their capacity towards developing into clinicians and researchers of excellence. References Correll, C.U., Hauser, M., Auther, A.M., Cornblatt, B.A., 2010. Research in people with psychosis risk syndrome: a review of the current evidence and future directions. Journal of Child Psychology and Psychiatry 51, 390–431. Hafner, H., an der Heiden, W., 1999. The course of schizophrenia in the light of modern follow-up studies: the ABC and WHO studies. European Archives of Psychiatry and Clinical Neuroscience 249 (Suppl. 4), 14–26. Kwon, J.S., Byun, M.S., Lee, T.Y., 2012. Early intervention in psychosis: insights from Korea. Asian Journal of Psychiatry 5 (1). Marshall, M., Lewis, S., Lockwood, A., Drake, R., Jones, P., Croudace, T., 2005. Association between duration of untreated psychosis and outcome in cohorts of first-episode patients: a systematic review. Archives of General Psychiatry 62, 975–983. Marshall, M., Rathbone, J., 2011. Early intervention for psychosis. Cochrane Database of Systematic Reviews CD004718. McGorry, P.D., Nelson, B., Amminger, G.P., Bechdolf, A., Francey, S.M., Berger, G., Riecher-Rossler, A., Klosterkotter, J., Ruhrmann, S., Schultze-Lutter, F., Nordentoft, M., Hickie, I., McGuire, P., Berk, M., Chen, E.Y., Keshavan, M.S., Yung, A.R., 2009. Intervention in individuals at ultra-high risk for psychosis: a review and future directions. The Journal of Clinical Psychiatry 70, 1206–1212. Meares, A., 1959. The diagnosis of prepsychotic schizophrenia. Lancet 1, 55–58. Mizuno, M., Nemoto, T., Tsujino, N., Funatogawa, T., Takeshi, K., 2012. Early psychosis in Asia: insights from Japan. Asian Journal of Psychiatry 5 (1). Perkins, D.O., Gu, H., Boteva, K., Lieberman, J.A., 2005. Relationship between duration of untreated psychosis and outcome in first-episode schizophrenia: a critical review and meta-analysis. The American Journal of Psychiatry 162, 1785–1804.
Rangaswamy, T., Mangala, R., Mohan, G., Joseph, J., John, S., 2012. The Singapore Early Psychosis Intervention Programme (EPIP): a programme evaluation. Asian Journal of Psychiatry 5 (1). Simon, A.E., Velthorst, E., Nieman, D.H., Linszen, D., Umbricht, D., de Haan, L., 2011. Ultra high-risk state for psychosis and non-transition: a systematic review. Schizophrenia Research 132, 8–17. Stone, W.S., Hsi, X., Giuliano, A.J., Tan, L., Zhu, S., Li, L., Seidman, L., Tsuang, M.T., 2012a. Are neurocognitive, clinical and social dysfunctions in schizotaxia reversible pharmacologically? Results from the Changsha study. Asian Journal of Psychiatry 5 (1). Stone, W.S., Hsi, H., Tan, L., Zhu, Z., Li, L., Giuliano, A.J., Seidman, L.J., Tsuang, M.T., 2012b. Neurocognitive and clinical dysfunction in adult Chinese, nonpsychotic relatives of patients with schizophrenia: findings from the Changsha study and evidence for schizotaxia. Asian Journal of Psychiatry 5 (1). van Os, J., Kapur, S., 2009. Schizophrenia. Lancet 374, 635–645. Verma, S., Poon, L.Y., Subramaniam, M., Abdin, E., Chong, S.A., 2012. The Singapore Early Psychosis Intervention Programme (EPIP): a programme evaluation. Asian Journal of Psychiatry 5 (1). Wong, G.H.Y., Hui, C.L.M., Tang, J.Y.M., Chang, W.H., Chan, S.K.W., Xu, J., Lin, J.J.X., Lai, D., Tam, W., Kok, J., Chung, C., Hung, S.F., Chen, E.Y., 2012. Early intervention for psychotic disorders: real-life implementation in Hong Kong. Asian Journal of Psychiatry 5 (1). Wyatt, R.J., 1991. Neuroleptics and the natural course of schizophrenia. Schizophrenia Bulletin 17, 325–351.
G. Venkatasubramanian* National Institute of Mental Health & Neurosciences, Department of Psychiatry, Hosur Road, Bangalore 560029, India Matcheri S. Keshavan Boston, MA, United States *Corresponding
author. Tel.: +91 80 26995256; fax: +91 80 26564830 E-mail addresses: [email protected], [email protected] (G. Venkatasubramanian)
