September 18, 2017

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Is early intervention research stuck in its psychosis prediction paradigm?

By Peter B Jones, IEPA President

As President, my aim is to grow our organisation, IEPA Early Intervention in Mental Health, in four ways. These are reflected in our name and include:

  • Broadening our influence on mental health beyond psychosis
  • Making IEPA even more international
  • Strengthening the contribution of consumers to our evidence-based approach
  • Improving our communication and reach

In this post, I address how we might broaden the influence of early intervention, looking at how this is already happening and how we can keep this momentum going. This is something our cousin organisation, International Association for Youth Mental Health, is also focusing on at its forthcoming conference in Dublin this September.

Understanding early intervention in mental health

Our understanding of early intervention (EI) has steadily evolved from binary ‘categories’ of diagnosis that you either have or don’t have, towards a more holistic, multidimensional approach, taking into account the many different forces that contribute to mental illness over a person’s lifetime. IEPA’s role in advancing this reform across the world cannot be overestimated, and we each have a role to play as professionals and individuals. We’re next conferring and accelerating our thinking around this at the IEPA conference in Boston next year, under the theme “Broadening the Scope”.

Changing clinical psychiatry

The at-risk mental state, the ultra-high risk paradigm and other conceptual cousins are changing clinical psychiatry, mental health care and the way we think about psychiatric disorders, particularly in young people. Diagnostic categories in DSM-5 or ICD-10 are not inevitable and life-long destinations as someone becomes unwell; they can be bypassed through resilience, good fortune or wise counsel. The increasing strength of the consumer perspective has aligned with this new life-course paradigm for clinicians.

Early intervention and the ultra-high risk approach have taught psychiatry about careful clinical measurement over time.  The Comprehensive Assessment of At-Risk Mental States (CAARMS) exemplifies this.

For clinicians working with people who have a diagnosis of schizophrenia, this has been a remarkable change. It has given services a healthy dose of optimism, and given many young people their lives back. It has also shown us that there’s much more to first-episode psychosis than psychosis. When young people begin to become unwell with psychosis, depression and anxiety are almost always lurking close by. Their psychopathology can be kaleidoscopic.

But has EI research become stuck in its psychosis prediction paradigm?

We do more and more sophisticated reviews of classic data showing that someone who is at ultra-high risk of psychosis and who is already seeking help has a 30-50 per cent chance of developing a full psychosis syndrome, almost the toss of a coin.  But data from recent studies suggests an even more hopeful outlook.

We need to give careful attention to all those other problems that people with an at-risk mental state bring into the consultation. Many are battling with one or more of depression, anxiety, substance misuse, recent trauma, or childhood maltreatment. These are often as much part of the presentation as are the fragments of psychosis in the at-risk state.

We’ve got some great, evidence-based interventions for depression and anxiety, and increasingly confident approaches for helping people with trauma histories. Reducing distress from these sources may ease psychotic phenomena and help recovery.

Trials of preventative talking therapies, specific neuroprotective medications or observations of referrals from primary care suggest that the short- to medium-term transition rates are much lower: less than 10 per cent. This is great news for young people with the at-risk mental state, especially if those looking after them begin helping with their current, very real problems, rather than focusing on a condition (a full-syndrome psychotic disorder) they probably won’t develop.

The past two years have brought a succession of studies reminding us that dimensional models are a better description of reality than categories. Many pioneers in at-risk research have helped shift our thinking.

With colleagues in the UK, Jesus Perez and I are encouraging England’s large-scale, easy access services designed to improve access to psychological therapies (IAPT services) to recognise and respond to people with depression, anxiety and psychotic experiences. This is a combination that is common in these services but misunderstood and poorly treated. It probably indicates severe depression and anxiety, often with a trauma history, and needs prompt, effective treatment (EI). Very few people with this condition will ever develop a psychotic syndrome recognisable in DSM-5. We’re waiting on a funding decision for research to undertake a trial.

In a recent issue of World Psychiatry, van Os and Guloksuz reappraise and critique the at-risk field in a nice piece. This has been complemented by a thought-provoking review of therapeutic options by Alison Yung.

I think this is a really exciting time as models of mental states and diagnosis begin to be turned on their head by strong evidence, and as trans-diagnostic explanations of cause, mechanisms and therapies come to the fore.
Broadening the scope

These changes provide the logic and evidence for IEPA to be broadening the scope from psychosis to a wider range of mental ill health. IEPA has an important task in supporting low- and middle-income countries (LMICs) to reap the same benefits from EI that are sweeping across Australia, parts of Europe, Canada and some countries in Southeast Asia.

We have to make sure those starting out with the implementation of EI for psychosis don’t enter where our pioneers began. We must not give the impression that at-risk mental states are a chrysalis that will turn into a psychosis butterfly. Instead, today’s pioneers in countries yet to have EI as the mainstream need to embrace a transdiagnostic approach from the outset.

And there are high-income countries still to change. The United States has begun to accelerate rapidly through the Early Psychosis Intervention Network (EPINET) on the back of the encouraging results of NIMH’s RA1SE programme – the topic of Robert Heinssen’s plenary session at IEPA 10. Ambitious service developments here will surely help this goal.

IEPA’s name change from International Early Psychosis Association to IEPA Early Intervention in Mental Health reflected the importance of this shift in focus, and we have backed this up with further action. IEPA has extended its calendar from a biennial conference to one with events in between, growing our membership base and conference attendance as we go, and of course providing education, insight and forums for discussion. We have committed to increasing the quality and frequency of all communication via blogsLinkedIn and Twitter posts to offer existing and potential members access to a curated IEPA knowledge-bank that supports new learning. And we’d be happy for any suggestions on how to broaden our EI voice via communications and events; let us know your ideas.

In the meantime, please continue to read our posts and share, as well as attend and invite colleagues to our conferences to ensure that we all continue to advance our understanding and practice of EI in mental health.

Until next time.

For more, follow IEPA Network on Twitter or IEPA Early Intervention in Mental Health on LinkedIn.

Peter Jones iepa president