Early psychosis feasibility study report

3.2 The stages of early psychosis

Page last updated: March 2011

Early intervention for psychosis can be defined as comprising three foci or stages for intervention:

  1. the ultra-high risk for psychosis stage
  2. the first episode of psychosis stage and
  3. the early recovery stage.
Early intervention at the onset of disorder or for those 'at-risk' of developing a disorder aims to prevent the progression of the illness and to minimise collateral damage to social, educational, and vocational functioning (McGorry and Yung, 2003). Reducing the delays into treatment is also considered pivotal to achieving the benefits associated with early intervention (Harrigan et al., 2003).

The principal reason for making such distinctions about 'stages' of illness (McGorry, 2007, McGorry et al., 2006, McGorry et al., 2007a) relates to the underlying risk of chronicity and specifically to the timing and duration of antipsychotic medication, since psychosocial interventions are needed at all stages (e.g. psychoeducation, family support, supportive counselling, and psychological therapies).

3.2.1 The ultra-high risk stage

The psychotic disorders characteristically begin with a prodromal phase before the onset of frank psychotic symptoms, during which much psychosocial damage occurs (Yung and McGorry, 1996b). Clearly, intervention during this phase (indicated prevention) may reduce this damage and even prevent onset of psychosis. One of the key challenges in attempting indicated prevention in psychosis is to determine which signs and symptoms are the precursors to the full-threshold disorder. Until recently, knowledge about this was gained from detailed history-taking and retrospective studies of patients with schizophrenia (Yung and McGorry, 1996b, Yung and McGorry, 2007, Moller and Husby, 2000). Frequently described prodromal symptoms were depressed mood, anxiety, irritability and aggressive behaviour, suicidal ideation and attempts, and substance use, as well as subtle subjective deficits including cognitive, affective and social disturbances (Yung and McGorry, 1996a). More proximal to the onset of frank psychotic symptoms (i.e. delusions and hallucinations), attenuated or sub-threshold psychotic symptoms may develop, such as overvalued ideas, perceptual disturbances and deterioration in functioning and behavioural symptoms (Bowers, 1965, Chapman and Chapman, 1987, Heinrichs and Carpenter, 1985, Herz and Melville, 1980). Identifying this prodromal phase, in order for intervention to be provided, is the essence of indicated prevention, as it provides the possibilities of
  1. minimising disability and adverse health and social impacts associated with this prodromal phase
  2. enabling recovery before symptoms and poor functioning become entrenched and
  3. preventing, delaying or ameliorating the onset of full-threshold psychotic disorders.
While this earliest stage has been termed the 'psychosis prodrome', this term can only be applied with certainty if a diagnosable psychotic disorder actually does develop. There is compelling evidence however that attenuated psychotic symptoms occur in the general population (Tien and Anthony, 1990, van Os, 2003, Verdoux and Cougnard, 2006) and are not invariably followed by frank psychosis (Poulton et al., 2000). Furthermore, the label 'prodrome' implies its status as a disorder or disease with inevitable progression. It is more accurate to describe the presence of the signs and symptoms described above as indicative of a 'risk state' for progression to psychotic disorder. Subsequently terms such as 'ultra high risk' (McGorry et al., 2003) or 'clinical high risk' (Cornblatt et al., 2002) have been used to indicate that psychosis is not inevitable and that false positive cases can occur. This symptomatic yet pre-psychotic stage is the earliest point at which indicated prevention for psychosis can currently be conceived (Mrazek and Haggerty, 1994).

The challenge for any therapeutic intervention at this pre-psychotic stage has been to define the clinical frontier that indicates a need for care, representing the boundary between normal human experience and psychopathology. Obviously, this requires a defined set of clinical and other predictors that identify the subgroup of young people who are at imminent risk for psychotic disorder. The first operational definition of a pre-psychotic 'at risk' or 'Ultra High Risk' (UHR) mental state, which could be shown to confer a substantially high risk of fully-fledged psychosis was developed and tested in the early 1990s at the Melbourne PACE Clinic (Yung and McGorry, 1996a). Using these UHR criteria, it was possible to detect and engage a subset of young people presenting with demonstrable clinical needs who were at incipient risk for frank psychotic disorder (Yung and McGorry, 1996a, Yung and McGorry, 1996b, Yung et al., 1996, Yung et al., 1998, Yung et al., 2003, Yung et al., 2004). The rate of transition to full-threshold psychotic disorder within 12 months in this sample was approximately 35% (Yung et al., 2003, Yung et al., 2004), a rate 400 times greater than the expected incidence rate for first-episode psychosis in the general population. Notwithstanding the fact that false positives are still common, this capacity to define a group of people at such dramatically elevated risk for psychosis is a major advance, and has been recognised as such worldwide. These criteria have now been validated in a number of national and international studies (Amminger et al., 2010, McGlashan et al., 2003, McGorry et al., 2003, Cannon et al., 2008, Woods et al., 2009, Yung and McGorry, 1996a, Yung et al., 2003), and combining these and other studies, an average annual transition rate of 36.7% has been reported in young people not receiving antipsychotic medication (Ruhrmann et al., 2003). These UHR criteria, and closely related variant forms of them, currently underpin most of the early intervention programs world-wide focused on the pre-psychotic stage. They also connote risk for other potentially disabling syndromes, notably mood and anxiety disorders.

Therapeutic interventions during this phase aim to treat symptoms, minimise distress and disability, and actively prevent transition to full-threshold psychosis. A further benefit of intervention during the UHR phase is that should transition to full-threshold psychosis occur despite the interventions offered, effective antipsychotic treatment can be immediately initiated with minimal delay and without the trauma and disruption that is often associated with the onset of acute symptoms, since a therapeutic alliance has already been established between the young person, their carer(s) and the treatment team.

3.2.2 First-episode psychosis

Intervention during this second stage involves a therapeutic focus on the period after the onset of fully-fledged psychosis: first-episode psychosis (FEP). Since considerable evidence has shown that one of the few malleable risk factors that can influence the clinical and functional outcomes for young people with psychotic disorders is the duration of untreated psychosis, from a therapeutic point of view this stage can be divided into the period before psychosis is detected and the period after detection. Unfortunately, even in first-world countries, the duration of untreated psychosis can be prolonged, and when psychosis is detected, the initiation of effective treatment is often delayed (McGlashan, 2005), underlining the need for appropriate specialized early intervention services.

The aims of treatment during this phase are firstly, to minimize the duration of untreated psychosis; and secondly, when psychosis is detected, to engage the young person and initiate appropriate pharmacological and psychosocial treatments to ameliorate acute symptoms and to minimise the associated distress and disability, promote recovery and prevent secondary morbidity. Such intensive interventions aimed at maximal symptomatic and functional recovery and the prevention of relapse are ideally delivered during the early weeks and months of treatment (Birchwood et al., 1998, McGorry and Yung, 2003), and are discussed in more detail in section 3.4.

3.2.3 The critical recovery period: the first five years after diagnosis

This third stage involves the critical 2-5 years beyond the first treated episode of illness, which is crucial in setting the parameters for longer term recovery and outcome (Birchwood et al., 1998, Gleeson et al., 2005). This is the period of maximum risk for disengagement, relapse and suicide (Harris et al., 2005) as well as coinciding with the major developmental challenges of forming a stable identity, peer network, vocational training and intimate relationships (Arnett, 2004). Providing a stream of care specially focused on young people at this stage of illness is required to maximise the chances of continued engagement and continuity of care, adherence to treatment, appropriate lifestyle changes, family support and vocational recovery and progress (Fowler et al., 2009). If these programs are only provided for 1-2 years post-diagnosis, there is evidence that some of these gains are eroded (Bertelsen et al., 2008, Nordentoft et al., 2002). Like any other form of medical intervention, specialised early psychosis treatment is likely to be effective as long as the active treatment continues – it is not a cure (Friis, 2010). An emerging consensus suggests that for a substantial subset of clients at least, specialised early psychosis care needs to be provided for a longer period, ideally up to 5 years in many cases (Friis, 2010, Singh).

The treatment goals in this recovery phase are the maintenance of medication and/or increasing use of effective psychosocial interventions to minimise the development of disability and maximise functioning. Proof of concept is now established for these strategies (Craig et al., 2004, Jeppesen et al., 2005), and is discussed in more detail below.