From the PresidentPsychiatry Newsby Jeffrey Lieberman, M.D.August 15, 2013
Medical research often takes a slow and unpredictable pace. The hours spent defining the question, setting up the experiment, and acquiring and then analyzing the data before getting to see the results makes for a long and arduous process. When you then add the time that it takes for new research findings to be translated into clinical practice, the rate of change in health care can be glacial. Psychiatry is certainly no exception to the seemingly snail’s pace of progress in health care. But despite this pervasive pattern, research does periodically gain sufficient momentum to make inroads into clinical practice and move the field forward, as was the case with the introduction of antipsychotic and antidepressant drugs, lithium, community mental health, the development of time-limited forms of psychotherapy [for example, cognitive-behavioral therapy, interpersonal therapy, and dialectical behavior treatment] and cognitive remediation.
I believe that we are at another game-changing moment in psychiatry with the rise of the early detection and intervention strategy [EDIS]. This new therapeutic strategy and model of care could have a significant effect on our ability to treat and limit the morbidity of mental illness beginning with schizophrenia and related psychotic disorders. While schizophrenia has been historically associated with a therapeutic nihilism due to its devastating and often irreversible consequences, research over the last two decades has changed attitudes and inspired optimism. Studies show that the earlier patients are diagnosed and treated, the better their responses to treatment. This leads to improved outcomes and higher chances of full recovery. The corollary to this is continued engagement of patients in treatment following their recovery and relapse prevention.
Among the reasons for this are findings from neuroimaging studies showing that the hallmark clinical deterioration of schizophrenia is associated with cortical gray matter atrophy, reflecting the loss of cell processes and synaptic connections. Unlike Alzheimer’s disease though, for which there currently is no “disease-modifying” treatment, early intervention and relapse prevention methods for schizophrenia coupled with antipsychotic medication may prevent illness progression. Moreover, additional research and first-person reports indicate that resilience, coping skills, and peer and family support can substantially contribute to favorable outcomes and recovery. Collectively, these findings have suggested the value of early detection, intervention, and sustained engagement with treatment to enhance recovery and prevent disability… Many individuals in the earliest stages of psychosis do not have health insurance, and even if they do, their plans do not cover comprehensive psychosocial and rehabilitative services. And while the public mental health system is designed to serve individuals without health insurance and to provide services not covered by insurance, the system favors individuals who have already become disabled by mental illness, limiting the availability of services for patients in the early stages of psychotic disorders. However, there are signs that state governments are beginning to grasp the implications of this new care model and implement it…This model of care requires financing schemes that will support sustained patient engagement and community functioning and that extend across adolescence to adulthood. More than a century after Kraepelin initially defined schizophrenia as a progressive illness leading to clinical deterioration and 60 years since the introduction of antipsychotic drugs, psychiatry has within its grasp the potential to limit the morbidity and disability associated with this disorder. EDIS could be the next great advance in psychiatric medicine and mental health care.
Reading this is nothing but conflict for me. Having seen a career’s worth of young adults who had psychotic illnesses, I’ve always felt that if the resources were really around, we could have a lot better outcomes just knowing what we already know. While some recover and are able to move on, way too many get lost in the illness and deteriorate in ways not dissimilar to the time of Kraepelin and Bleuler a century ago. I worry that any such program devised by Dr. Lieberman et al would ignore the wisdom of Robert Whitaker and his colleagues that medications are for episodes, not for life. I worry that the buzz-word "evidence-based" therapies [CBT, DBT] will over-ride common sense in helping these patients find their way; that eagerness to get a piece of the Affordable Healthcare Act will interfere with the kind of careful thought needed for such an undertaking. In ancient times [my early days in psychiatry], I don’t really think funding was the only reason for failure. Some of it was the hidden agendas ["empty those expensive hospitals"]["get these people on meds"]. Some was naïveté – assuming the patients wanted to "get well" in the way the programs wanted them to; not really understanding the dilemmas and paradoxes of the illness itself; and using rehab models from other situations that don’t really fit.
I think my view of this illness must be idiosyncratic. As disruptive and dramatic as ouvert psychosis can be, I don’t really see psychosis as the essential feature. In fact, one can make a pretty good case that psychosis is a solution rather than the problem itself. I tried to talk about this before [1. from n equals one…, 2. from n equals one…, 3. from n equals one…] and won’t repeat it all here except to say it’s what biological psychiatrists call "negative symptoms" and others call Anhedonia. It’s a relative deficit in using emotions as a compass and a cognitive problem with abstract thought – intuition. My thought is that the task is to help the patient find an individual adaptation to these more basic problems that fits them. In medicine, we talk about "following the patients." With these patients, "following" is essential, "following" until they find a life that works for them, then helping them get it. I hate to be so vague, but it at least lets me say what I want to say about Dr. Liebermans’ articles and plan. It sounds like he wants to lead them out of the wilderness. Leading patients with this illness is like "herding cats." And I’ve never known where a given patient is headed without "following." They don’t know either. But if you stick with them and help them stay out of trouble, using medications when you have to, stopping the meds when you can, many can find a way with help to live with the more basic problems the illness presents – rather than becoming a "chronic patient."