May 24, 2021
By Christoph U Correll, MD
Why should we work closely with people experiencing a first episode of psychosis or first episode of schizophrenia to aim for recovery? Because they are the people closest to recovery.‘Recovery’ in this case involves two components:
- symptomatic stability or remission, and
- improvement in functionality in terms of self-care, social interactions, leisure activities and education or employment status.
Recovery also means to be connected: connected to oneself, to others, to meaning through purposeful activities, and to life and hope.
To give people the best chance of recovery possible, we need to provide early access to care, since a shorter duration of untreated psychosis has been associated with better symptomatic and functional outcomes (Howes et al. 2021). We also need to consider pharmacological treatment to prevent relapse (Leucht et al. 2012), as people who experience fewer episodes of psychosis and symptoms after they begin treatment have been shown to achieve better outcomes (Carbon and Correll 2014). Someone who stays relapse-free has a high chance of maintaining treatment response, improving functioning and reducing illness burden (Correll et al. 2018a).
Importantly, we need to find each person a treatment or treaments that have only minimal or, at least, subjectively tolerable, side effects, so that their quality of life and functioning are not adversely affected. (Tandon et al. 2020).
Adding psychosocial interventions to pharmacological treatment is likely to yield the best results (WHO, 2009). Psychosocial interventions include individual and family psychoeducation, individual and group psychotherapy, case management, skills training, and supported employment and education.
Early intervention services that combined 3–4 of these psychosocial interventions with medication, in an integrated, multi-team member approach, have been shown to improve 15 outcomes significantly better than usual care interventions (Correll et al. 2018b), which usually are not well integrated and mostly focus on phamacological treatment. In that meta-analysis, people receiving care at early intervention services had a 24% greater chance of achieving recovery.
Moreover, data suggest that the use of long-acting antipsychotics is associated with a reduced risk of treatment discontinuation, relapse, hospitalisation and even mortality (Taipale et al. 2018, Taipale et al. 2020; Kishimoto et al. 2021). Furthermore, treatment with a long-acting antipsychotic during the first episode of schizophrenia seems to markedly improve combined symptomatic and functional recovery, which was found to be as high as 44% in a 2-year follow-up study of 98 patients with a first episode of schizophrenia-spectrum disorders who received long-acting antipsychotics early on (Phahladira et al. 2020).
We still do not know the exact pathophysiology of the different forms of psychoses or schizophrenia, and pharmacological treatments currently treat symptoms rather than the illness itself. However, what we do know is that the use of medication and recovery-focused psychosocial care can yield results that go beyond symptomatic improvement and stability.
The key is finding a medication that works for each individual, that is not associated with relevant adverse effects, and which they are willing to take long-term – as well as taking advantage of psychosocial interventions. When treatment is managed in this way, people who are experiencing early psychosis should be hopeful that good symptomatic and functional outcomes are possible – meaning they can get back to the life they had before, and look forward to the future.
Christoph Correll is Professor of Psychiatry at The Zucker School of Medicine at Hofstra/Northwell, New York, USA, and also Professor and Chair of the Department of Child and Adolescent Psychiatry, Charité University Medicine, Berlin, Germany. Prof. Correll’s research and clinical work focus on the identification, characterization and treatment of youth and adults with severe mental illness, including psychotic and mood disorders. He further focuses on psychopharmacology, epidemiology, clinical trials, comparative effectiveness, meta-analyses, and the interface between physical health and mental health.
He has authored over 650 journal articles, served on several expert consensus panels, and received over 40 research awards for his work. Since 2014, the year of inception of this metric, he has been listed every year by Clarivate/Web of Science as one of the “most influential scientific minds” and “top 1% cited scientists in the area of psychiatry” (https://hcr.clarivate.com).
Carbon M, Correll CU. Clinical predictors of therapeutic response to antipsychotics in schizophrenia. Dialogues Clin Neurosci. 2014 Dec;16(4):505-24. doi: 10.31887/DCNS.2014.16.4/mcarbon. PMID: 25733955; PMCID: PMC4336920.
Correll CU, Rubio JM, Kane JM. What is the risk-benefit ratio of long-term antipsychotic treatment in people with schizophrenia? World Psychiatry. 2018a Jun;17(2):149-160. doi: 10.1002/wps.20516. PMID: 29856543; PMCID: PMC5980517.
Correll CU, Galling B, Pawar A, Krivko A, Bonetto C, Ruggeri M, Craig TJ, Nordentoft M, Srihari VH, Guloksuz S, Hui CLM, Chen EYH, Valencia M, Juarez F, Robinson DG, Schooler NR, Brunette MF, Mueser KT, Rosenheck RA, Marcy P, Addington J, Estroff SE, Robinson J, Penn D, Severe JB, Kane JM. Comparison of Early Intervention Services vs Treatment as Usual for Early-Phase Psychosis: A Systematic Review, Meta-analysis, and Meta-regression. JAMA Psychiatry. 2018b Jun 1;75(6):555-565. doi: 10.1001/jamapsychiatry.2018.0623. PMID: 29800949; PMCID: PMC6137532.
Howes OD, Whitehurst T, Shatalina E, Townsend L, Onwordi EC, Mak TLA, Arumuham A, O’Brien O, Lobo M, Vano L, Zahid U, Butler E, Osugo M. The clinical significance of duration of untreated psychosis: an umbrella review and random-effects meta-analysis. World Psychiatry. 2021 Feb;20(1):75-95. doi:10.1002/wps.20822. PMID: 33432766; PMCID: PMC7801839.
Kishimoto T, Hagi K, Kurokawa S, Kane JM, Correll CU. Long-Acting Injectable vs. Oral Antipsychotics for the Maintenance Treatment of Schizophrenia: A Comparative Meta-Analysis of Randomized, Pre-Post, and Cohort Studies. Lancet Psychiatry. 2021 Apr 16. [Epub ahead of print]
Leucht S, Tardy M, Komossa K, Heres S, Kissling W, Salanti G, Davis JM. Antipsychotic drugs versus placebo for relapse prevention in schizophrenia: a systematic review and meta-analysis. Lancet. 2012 Jun 2;379(9831):2063-71. doi:10.1016/S0140-6736(12)60239-6. Epub 2012 May 3. PMID: 22560607.
Phahladira L, Luckhoff HK, Asmal L, Kilian S, Scheffler F, Plessis SD, Chiliza B, Emsley R. Early recovery in the first 24 months of treatment in first-episode schizophrenia-spectrum disorders. NPJ Schizophr. 2020 Jan 8;6(1):2. doi: 10.1038/s41537-019-0091-y. PMID: 31913311; PMCID: PMC6949247.
Taipale H, Mittendorfer-Rutz E, Alexanderson K, Majak M, Mehtälä J, Hoti F, Jedenius E, Enkusson D, Leval A, Sermon J, Tanskanen A, Tiihonen J. Antipsychotics and mortality in a nationwide cohort of 29,823 patients with schizophrenia. Schizophr Res. 2018 Jul;197:274-280. doi:10.1016/j.schres.2017.12.010. Epub 2017 Dec 21. PMID: 29274734.
Taipale H, Tanskanen A, Mehtälä J, Vattulainen P, Correll CU, Tiihonen J. 20-year follow-up study of physical morbidity and mortality in relationship to antipsychotic treatment in a nationwide cohort of 62,250 patients with schizophrenia (FIN20). World Psychiatry. 2020 Feb;19(1):61-68. doi:10.1002/wps.20699. PMID: 31922669; PMCID: PMC6953552.
Tandon R, Lenderking WR, Weiss C, Shalhoub H, Barbosa CD, Chen J, Greene M, Meehan SR, Duvold LB, Arango C, Agid O, Castle D. The impact on functioning of second-generation antipsychotic medication side effects for patients with schizophrenia: a worldwide, cross-sectional, web-based survey. Ann Gen Psychiatry. 2020 Jul 13;19:42. doi: 10.1186/s12991-020-00292-5.
World Health Organization. Pharmacological treatment of mental disorders in primary health care. Geneva: WHO; 2009.
Declaration of Interests (last 3 years):
Dr. Correll has been a consultant and/or advisor to or has received honoraria from: Acadia, Alkermes, Allergan, Angelini, Axsome, Gedeon Richter, IntraCellular Therapies, Janssen/J&J, Karuna, LB Pharma, Lundbeck, MedAvante-ProPhase, MedInCell, Medscape, Merck, Mitsubishi Tanabe Pharma, Mylan, Neurocrine, Noven, Otsuka, Pfizer, Recordati, Rovi, Servier, Sumitomo Dainippon, Sunovion, Supernus, Takeda, and Teva. He provided expert testimony for Janssen and Otsuka. He served on a Data Safety Monitoring Board for Lundbeck, Rovi, Supernus, and Teva. He has received grant support from Janssen and Takeda.He is also a stock option holder of LB Pharma.
This project was made possible thanks to a sponsorship from H/Lundbeck A/S. The opinions expressed in these materials do not necessarily reflect those of H.Lundbeck.