versión impresa ISSN 0185-3325
Salud Ment vol.34 no.4 México jul./ago. 2011
Rationale and state of the art in early detection and intervention in psychosis
Justificación y estado de la cuestión en la detección e intervención temprana en psicosis
Tecelli Domínguez Martínez,1,2 Joan Manel Blanqué,3 Jordi Codina,3 Mónica Montoro,3 Lluis Mauri,3 Neus BarrantesVidal1,3,4,5
1 Universitat Autònoma de Barcelona, Departament de Psicologia Clínica i de la Salut, Facultat de Psicologia, Barcelona.
2 Ministerio de Asuntos Exteriores y de Cooperación y la Agencia Española de Cooperación Internacional para el Desarrollo (MAECAECID).
3 Sant Pere Claver Fundació Sanitària, Departament de Salut Mental, Barcelona.
4 University of North Carolina at Greensboro, Department of Psychology.
5 Instituto de Salud Carlos III, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Spain.
Departament de Psicologia Clínica i de la Salut,
Factultat de Psicologia, Universitat Autònoma de Barcelona (UAB) 08193 Bellaterra (Barcelona), España.
Tel. +34 93 581 38 64.
Fax. +34 93 581 21 25.
Recibido: 22 de diciembre de 2010.
Aceptado: 22 de marzo de 2011.
Schizophreniaspectrum disorders have a chronic and episodic course that results in impairment of all life domains. Pharmacological and psychosocial treatments provide symptom relief, but there is not a cure for schizophrenia and many patients suffer chronic impairment. In addition, it is expensive both in economical terms and also in terms of personal costs for both patients and their families.
International interest has grown over the past 15 years in the prognostic potential of early identification and intervention in the prodromal and firstepisode phases of psychotic illness. This focus is associated with increasing optimism about the benefits of implementing treatment as early as possible in the course of psychosis at least to help improve the course of illness, reducing its longterm impact.
The most recent epidemiological studies have shown that patients with longer duration of untreated psychosis (DUP) have worse shortterm outcomes in terms of treatment response, positive symptoms, negative symptoms, and global functioning. Neuroimaging studies have also indicated that prolonged untreated illness is associated with more pronounced structural brain abnormalities, while this is less prominent earlier in the course of the disorder. Therefore, early detection aims to reduce treatment delay in the hope of improving prognosis and reducing illness severity. Early intervention in psychotic disorders has gained momentum in the last decades, and there is now an estimated 200 centers worldwide offering specialized services for young people experiencing their first episode of psychosis. Each of these programs has unique characteristics and distinctive features in terms of treatment modalities and assessment tools, but most have a number of common elements and goals: a) early detection of new cases, b) reducing DUP, and c) providing better and continued treatment during the «critical period» of the early years of the disease.
Moreover, the role of family work in early psychosis can be crucial given that relatives are the main informal caretakers of persons with mental health problems. Family interventions in early psychosis usually offer psychoeducation and/or individual and group family therapy, communication and problem solving training, which can help to develop coping strategies and reduce distress and burden.
Intervention programs in early psychosis are usually composed by interdisciplinary teams, providing a wide range of integrated services that typically include psychoeducation, clinical case management, and group interventions. Specific interventions generally include pharmacotherapy, stress management, relapse prevention, social and employment rehabilitation support, and cognitive and family therapy.
Given the complex etiology and clinical manifestation of psychosis, treatment packages for people experiencing early psychosis need to be individually tailored to specific needs rather than applied homogenously across early psychosis patients.
The current challenge in the implementation of psychological interventions in the early stages of psychosis are: 1. to adapt treatment modalities that have been proven effective in stable and residual stages of the disease to its early stages; 2. to develop new forms of therapy tailored to the specific characteristics of these early stages of psychosis (prodromal and ultra highrisk phase, onset and first episode psychosis, and «critical period» or postcrisis psychosis); and 3. treatment packages need to be individually tailored to their specific needs rather than applied homogenously across a group of patients.
The aims of this paper are: 1. to present the basic concepts, rationale and state of the art of the early detection and intervention paradigm; 2. to review and present the main detection and intervention programs in early psychosis and 3. to provide an overview of the current psychotherapeutic approaches in early psychosis.
Key words: Early detection and intervention, early psychosis, psychotherapeutic approach, needadapted treatment.
Los trastornos del espectro psicótico presentan un curso crónico y episódico que provoca alteraciones en todas las áreas de la vida, generando importantes grados de discapacidad, pérdida de funciones psicosociales, grandes costos económicos, una comorbilidad considerable y sufrimiento tanto para los pacientes como para sus familias. A pesar de que los tratamientos farmacológicos y psicosociales han ayudado a aliviar los síntomas y mejorar la calidad de vida, en muy pocas ocasiones se logra una recuperación satisfactoria a nivel psicológico y funcional.
Durante los últimos 15 años, el optimismo creciente sobre la posibilidad de mejorar el pronóstico de la psicosis y alterar con ello el tradicional curso negativo de la enfermedad ha producido una reforma sustancial en la práctica clínica y en el desarrollo de estrategias de intervención temprana en muchos países. De esta manera, el desplazamiento del foco de atención desde las fases estables o residuales de la psicosis hacia los inicios de la misma está suponiendo una serie de innovaciones y avances, tanto en la evaluación y diagnóstico como en las modalidades terapéuticas y en la consiguiente reordenación de los servicios asistenciales.
Los estudios epidemiológicos más recientes han mostrado que los pacientes con mayor duración de la psicosis no tratada tienen peor respuesta al tratamiento farmacológico, mayor gravedad de síntomas positivos, síntomas negativos y peor funcionamiento global. Por otra parte, los estudios de neuroimagen también indican que un periodo prolongado de enfermedad no tratada produce anormalidades estructurales cerebrales más pronunciadas. Es por esto que la detección temprana en psicosis tiene como objetivo reducir la demora del tratamiento para mejorar el pronóstico y reducir la gravedad del trastorno.
La detección temprana y la aplicación del tratamiento específico más eficaz para cada fase inicial del trastorno son dos elementos que diferencian la intervención temprana de las formas habituales de asistencia actuales.
Cada vez existen más grupos en todo el mundo dedicados a establecer programas clínicos e iniciativas de investigación centradas en la psicosis temprana. Cada uno de estos programas tiene características particulares y rasgos propios en cuanto a las modalidades de tratamiento o los instrumentos de evaluación, pero la mayoría tiene una serie de elementos y objetivos en común: a) detectar de forma precoz nuevos casos; b) reducir el periodo de tiempo desde que el paciente presenta una sintomatología claramente psicótica hasta que recibe un tratamiento adecuado y c) proporcionar un mejor y continuo tratamiento en el «periodo crítico» de los primeros años de la enfermedad.
En el contexto de la prevención e intervención temprana, el trabajo con la familia puede ser crucial, ya que los familiares son los principales cuidadores informales y son una parte fundamental para la recuperación del paciente. La mayoría de las intervenciones familiares ofrecen psicoeducación y/o terapia familiar que ayudan a desarrollar estrategias de adaptación y afrontamiento, disminuir el estrés y la carga a largo plazo, así como mejorar la comunicación y la resolución de problemas.
Los programas de intervención en la psicosis temprana están habitualmente formados por equipos interdisciplinarios que proporcionan una amplia serie de servicios integrados que suelen incluir psicoeducación, manejo clínico de casos e intervenciones grupales. Las intervenciones específicas incluyen generalmente farmacoterapia, manejo de estrés, prevención de recaídas, apoyo y rehabilitación social y laboral, así como terapia cognitiva y familiar.
Dada la compleja etiología y manifestación clínica de la psicosis, los tratamientos para personas con psicosis incipiente deben ser adaptados individualmente a las necesidades específicas en lugar de aplicarlos homogéneamente a todos los pacientes por igual.
El desafío actual en la aplicación de intervenciones en la psicosis temprana consiste en: 1. conseguir adaptar aquellas modalidades de tratamiento que ya han demostrado su eficacia en las fases estables y residuales de la enfermedad a los inicios de la misma; 2. integrar y desarrollar nuevas formas de terapia que se adapten a las características específicas de cada una de las fases iniciales de la psicosis (fase prodrómica o de alto riesgo, inicio de la psicosis o primer episodio de psicosis y «fase crítica» o poscrisis) y 3. adecuar los tratamientos de manera individual en vez de aplicarlos de forma homogénea.
Los objetivos del presente artículo son: 1. presentar los conceptos básicos, la justificación y el estado de la cuestión del paradigma de detección e intervención temprana en psicosis; 2. hacer una revisión y presentar los principales programas de detección e intervención temprana en psicosis y 3. proporcionar una visión general de los enfoques psicoterapéuticos actuales en psicosis incipiente.
Palabras clave: Detección e intervención temprana, psicosis incipiente, tratamiento integrado y adaptado a las necesidades.
A conceptual change: From chronic schizophrenia to early psychosis
Schizophreniaspectrum disorders usually have a chronic and episodic course that results in impairment of all life domains. Patients frequently require hospitalization and many are unable to return to independent functioning in residual periods. Disorders typically start in late adolescence, disrupting patients' transition into adulthood.1,2
Pharmacological and psychosocial treatments provide symptom relief, but there is not a cure for schizophrenia and many patients suffer chronic impairment, which has huge social and economic costs.
In recent years there has been increasing confidence that preventive intervention in psychotic disorders might be a realistic proposition in clinical settings.3,4 International interest has grown over the past 15 years in the prognostic potential of early identification and intervention in the prodromal and firstepisode phases of psychosis, assuming that it could at least help to improve the course of illness, reducing its longterm impact.5 This is consistent with a recently adopted staging model in psychiatry, which emphasizes that less differentiated early phases of mental illnesses may benefit from a broader spectrum and simpler treatments, allowing young people to receive the help they need in a timely manner, with the potential for improved outcomes across several fronts.6 Thus, early intervention programs have been initiated worldwide, beginning with Yung, McGorry and colleagues7 in Australia and then moving to the United States and Europe shortly thereafter.
The early psychosis movement focused at first on the timely recognition and phasespecific treatment of firstepisode psychosis (FEP). However, it was also recognized that for most patients a prolonged period of attenuated symptoms and impaired functioning precedes FEP.1 Much of the disability associated with the psychotic disorders, particularly schizophrenia, develops long before the onset of frank psychosis and is difficult to reverse even if FEP is successfully treated.8 This preonset period of illness has been termed the «prodromal phase», characterized by various mental state features, including nonspecific symptoms such as depressed mood and anxiety, negative signs and symptoms as well as subthreshold or attenuated psychotic symptoms. Accordingly, the putative prodromal symptoms and signs can be divided into those that are more distal to the onset of psychosis (early prodrome) and those more proximal to the onset of psychosis (late prodrome).9 Nevertheless, the prodrome is a retrospective concept which cannot be deemed to have occurred until the onset of fullblown psychotic symptoms indicative of definitive psychotic disorder, when the opportunity for preventing onset has passed.1,10
The possibility to monitor prospectively those people at heightened risk for developing FEP lies in the new identification and followup of such population who demonstrate clinical high risk factors for subsequent psychosis, established as «atrisk mental state» (ARMS) and «ultrahigh risk» (UHR).11
The first study using UHR criteria found a transition rate of 40% to fullthreshold psychotic disorder within one year, despite the provision of needsbased psychosocial intervention and antidepressant treatment where indicated.12 This finding has subsequently been replicated by several groups internationally,13,14 including the recent multicentre North American Prodromal Longitudinal Study (NALPS),15 which reported an average 1year transition rate of 36.7% in UHR subjects who did not receive antipsychotic treatment. These results indicated that the UHR criteria are valid and reliable for predicting psychosis onset in this population.6
Unlike the predominant UHR approach, which only takes into account the severity of positive symptoms for meeting UHR criteria, the Hillside Recognition and Prevention Program (HRAP) in New York16 takes into account specific combinations of cognitive, academic and social impairments and disorganization/odd behavior.
EARLY DETECTION METHODS
Yung and McGorry17 were the first to develop operational criteria to detect UHR patients, resulting in the Comprehensive Assessment of at Risk Mental State (CAARMS). They distinguished three distinct highrisk groups to identify and follow prospectively the rate of conversion to psychosis: 1. attenuated positive symptoms (APS); 2. frankly psychotic positive symptoms that appear too brief and too intermittently to constitute a fully psychotic syndrome (brief limited intermittent psychotic symptoms, BLIPS) and 3. vulnerability group, characterized by functional decline in persons at risk for psychosis (because of meeting criteria for schizotypal personality disorder or having a firstdegree relative with a psychotic disorder). Moreover, Miller, McGlashan and colleagues developed the Structured Interview for Prodromal Syndromes (SIPS) and the companion Scale of Prodromal Symptoms (SOPS),18 which have become the prevailing prodromal instrument in North American studies, while the CAARMS has a predominating influence in Australia and many studies in Europe.
A different approach to early recognition was taken by German research groups, resulting in a set of criteria that are known as selfperceived cognitive and perceptual deficits, or «basic symptoms», characterized by subjective disturbances of selfperception, stress tolerance, thought organization, and social and nonverbal interactions that are generally not observed by others.19 The German concept of basic symptoms has been operationalized in the Schizophrenia Proneness Instrument Adult Version (SPIA)20 and recently adapted for child and adolescent population (the Schizophrenia Proneness Instrument, Child and Youth version SPICY).21
Rationale of early psychosis intervention
A key rationale for the early intervention paradigm has been the association between prolonged illness duration and poor outcome in the psychotic disorders. On the one hand, the duration of untreated psychosis (DUP) is negatively associated with the longterm symptomatic and functional outcomes in schizophrenia.22 Neuroimaging studies have also indicated that prolonged untreated illness is associated with more pronounced structural brain abnormalities, while this is less prominent earlier in the course of the disorder.23 On the other hand, research indicates that cognitive functioning deteriorates steeply before psychotic symptoms fully manifest.24 Thus, interventions delivered during the early phases of illness manifestation are believed to help preserve the individual's overall functional ability by reducing DUP and/or addressing the deterioration of functioning before FEP.25
Naturally, early detection raises important ethical issues26 as 60% or more ARMS will not, even without treatment, develop psychosis.27 However, it must be reminded that psychotherapy has been suggested as one approach for mitigating this problem by offering safe treatments,28 allowing delaying the onset of psychosis or ameliorating its severity once it begins, and thus it could also be unethical not to provide treatment to helpseeking or already disturbed individuals.
Moreover, the role of family work in early psychosis can be crucial given that relatives are the main informal caretakers of persons with mental health problems. In particular, relatives of schizophrenia patients report burden and distress, anxiety, depression and economic strain.29 High Expressed emotion (EE),30 which comprises overinvolvement, criticism and hostility, has been shown to be a robust predictor of relapse in both chronic and FEP patients.31,32 Even though it has been less studied in the early phase of psychosis, some studies have shown that high EE is already present in early psychosis.33,34 Given that the majority of ARMS and FEP individuals are adolescents or youngsters, investigation of family risk and protective factors would be essential for the design of developmentally appropriate early interventions.34
Main early detection and intervention programs
A clearer framework for guiding, designing, and evaluating preventive interventions in mental disorders has been developed. As a consequence, a series of research projects and realworld services systems are being created. Additionally, several influential international figures and research groups have developed and cooperated in disseminating a more optimistic set of ideas concerning early intervention in psychosis.3537
The focus on specific treatments aimed at preventing progression to psychosis or promoting recovery in those who have experienced a psychotic episode has tended to be classified into three main categories: 1. prodromal or «highrisk» phase; 2. onset or FEP; 3. postpsychosis phase, also known as «critical period», covering the period following recovery from FEP up to five years subsequently.38
Most groups working with the UHR population have attempted to engage patients in various psychological interventions using a recovery model of treatment. These interventions include case management, individual therapy, psychoeducation and CognitiveBehavioral Therapy (CBT), multifamily support groups and supported education and employment.39 However, specific family interventions, such as problem solving and communication skills training, have also been suggested as possible interventions that may improve the functional prognosis of young people at UHR for psychosis.40
The main early detection and intervention services and research programs are presented in table 1. Given that each program has numerous publications, table 1 shows only the references of those articles that describe the programs and those with the most recent findings. For more information, we also include some of the available websites of the programs.
FURTHER CONCEPTUAL DEVELOPMENTS AND THEIR POTENTIAL THERAPEUTIC APPLICATIONS
Psychotherapy takes place in diverse settings, with diverse groups, utilizing a bewildering array of techniques and styles informed by a vast array of theories and ideologies.
Usually, the most widely used interventions in psychosis are psychoeducation and CBT. A multitude of studies have demonstrated a clear superiority of psychoeducational family interventions as compared with standard treatments,64 and may be considered both clinically beneficial and costeffective.65 However, it is well known that psychoeducation by itself may not be sufficient to reduce the consequences of the experience of caregiving for a family member of a psychotic patient and, therefore, it has to be seen as a precursor and catalyst for subsequent complementary psychotherapeutic and psychosocial treatment strategies.64
Moreover, in regard to CBT, there are controversial results and its effectiveness is still not entirely clear for the early phases of psychosis,66 because only a small number of controlled trials of CBT in early stages of psychosis have been published.67 In contrast to the substantial body of positive findings for individual CBT treatment of chronic psychosis, the majority of data on individual CBT for early psychosis is not favorable.68
On the other hand, the relative shortage of systematic research in modern dynamic models can give the impression of a lack of positive results, unlike CBT techniques.69 In fact, therapies based on psychodynamic traditions do not feature greatly in recent discussions, and more research is needed to provide relevant answers to the unsolved questions regarding their usefulness and efficacy in early psychosis intervention.70 However, this tradition probably has most extensive experience and elaborates conceptions for dealing therapeutically with cases in the borderline area of normality and psychosis.26
No single type of therapeutic activity is ideal for all patients. Different subgroups of patients require different approaches within a broad spectrum of psychotherapeutic models. There is a clear need for a broader theoretical foundation of a set of therapeutic techniques, and also for the ability of greater depth and duration of therapy.71 The stressvulnerability model, along with advances in research of CBT, has been an opportunity for the fusion of dynamic and cognitive approaches, such as in the cognitive analytic therapy72 or the psychodynamicinterpersonal psychotherapy73,74 which rely less on direct interpretations than in conventional psychodynamic therapy and make more emphasis upon the patienttherapist relationship than in interpersonal therapy or CBT. Although the experience of these integrative models is still limited and requires more extensive and systematic formalization and evaluation, it seems that their recent development could play a useful role in the expansion of psychotherapeutic theory and practice.72
The current challenges for psychological interventions in early psychosis are: 1. to adapt treatment modalities that have been proven effective in stable and residual stages of the disease to early psychosis and 2. to develop new forms of therapy tailored to the very specific characteristics of the early stages of psychosis.75
Given the complex etiology and clinical manifestation of psychosis, treatment packages for people experiencing early psychosis need to be individually tailored to specific needs rather than applied homogenously across early psychosis patients.76 One example is the work of the group leaded by Alanen et al.77 in Finland, which has created a needadapted treatment approach, considering in each case both individual and interactional factors. They combine different forms of treatment in a flexible, individually designed intervention in order to take into account the needs of both patients and families, using psychoeducational principles in combination with medication, family intervention techniques, and individual psychotherapy.
Following this example, the Sant Pere ClaverEarly Psychosis Program (SPCEPP), currently being developed in Barcelona, is an integrative model and needadapted treatment always planned individually and taking into account the therapeutic needs of both patients and the people closest to them, based directly on the work of Alanen et al.77 This clinical program is attached to an early psychosis research project conducted by the Universitat Autònoma de Barcelona (UAB), which is presented in Domínguez et al.
The shift in focus from the stable or residual phase of the illness towards its initial stages has led to a series of innovations and advances not only in assessment and diagnosis, but also in therapeutic approaches, with the consequent reorganization of care services and health policies.75
Increasing evidence suggests that it is possible both to identify individuals who may be at risk of developing psychosis, and subsequently reduce or delay the transition to psychosis, as well as to ameliorate the severity of nonpsychotic symptoms and distress. Nevertheless, and despite this encouraging work and findings, more research is needed to provide relevant answers to the unsolved questions regarding the usefulness and efficacy of early intervention in psychosis.70
Although recently published reviews on interventions in ARMS concluded that the effects of interventions are currently indecisive,71 and even though the costeffectiveness of early intervention is still scarce, recent evidence suggests that early intervention in psychosis may not only improve the clinical course of psychotic disorders, but also make such disorders less costly to treat compared with more traditional forms of care.78 However, more research on the efficacy of early intervention is needed to demonstrate the extent to which the benefits persist in the longer term.79
Bringing treatment more rapidly to a person who has become psychotic is in itself enough to justify early detection efforts.80 However, the highlighted ethical issues need to be considered seriously when working with young people thought to be at risk of developing psychosis, and further work is therefore needed to investigate and improve intervention options. Finally, despite the emphasis on prevention, it is also important not to forget those patients with a poorer prognosis in need of a long and continuous attention.
This work has been possible thanks to the support by the Fundació La Marató TV3 (091110). Neus BarrantesVidal is funded by the Spanish Ministry of Science and Innovation (Plan Nacional I+D+I PSI200804178), and the Generalitat de Catalunya, Suport als Grups de Recerca (SGR2009672). Tecelli Domínguez Martínez thanks the Spanish Foreing Ministry (MAECAECID) for PhD grant. We want to specially thank Elías Vainer, Mercè Jané, Iván Torices, Ma. Antonia Massanet, Ramón Berni, Cristina González and David Clusa for their comments and collaboration in the preparation of this manuscript. Finally we thank the support offered by Fundació Sanitària Sant Pere Claver.
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