Abstract
It is reassuring to be a member of a profession that questions dogma and encourages frank debate and the occasional ideological schism. The target articles by Castle (2012) and Yung (2012) are cogent, well argued and civil. These two papers are the latest addition to the ongoing debate related to the overlapping fields of early intervention for (a) psychosis and (b) individuals thought to be ‘prodromal’ or at ultra-high risk of psychosis (McGorry, 2011; Rosenman and Anderson, 2011). The salient points of these debates are well rehearsed in peer-reviewed journals. The topic has also excited some interest in the general media (Carr, 2010; Sweet, 2011).
As Jorm (2011) pointed out recently, when these debates are more closely scrutinized, there is much common ground. Clearly, all parties want to optimize clinical and social/functional outcomes for those with psychosis. Australian researchers have led the world in pioneering early intervention services for psychosis – we should be proud of these achievements. As with all health-care innovations, the evidence base needs to be constantly refreshed and adjusted [sometimes the ‘truth wears off’ (Lehrer, 2010)]. Often, the empirical evidence base and clinical practice leapfrog each other – it was ever thus.
In this commentary I would like to step aside from the fine-grained details of the early intervention debate to explore a related issue. But, firstly, we need to reflect on the behaviour of our profession in history. Psychiatrists (alienists) in the 19th century would often keep themselves busy by obsessively describing symptoms and signs – our profession engaged in vigorous debate about how best to classify phenomenology. These pursuits served a dual purpose. They provided an important empirical foundation for future diagnostic taxonomy. In addition, they served as a convenient distraction from the depressing reality that there were few, if any, effective treatments for psychosis in those times.
Inspired by the title of David Castle’s (2012) article, I would like to politely suggest that the early intervention debate masks a deeper ‘unspeakable truth’. (Members of our profession who are easily offended should look away now.) Regardless of the intensity or duration of early intervention, and regardless of whatever creative mix of biopsychosocial treatments we use, the clinical and functional outcomes for people with psychosis are suboptimal. Exactly how suboptimal is a matter for debate. Preliminary data from a systematic review of remission/recovery in schizophrenia found that, on average, the annual recovery rate was only 1.4% (Saha et al., 2008). Put simply, these data suggest that for every 100 individuals with schizophrenia, only one or two individuals per year meet recovery-related criteria. Could we be doing any worse than this?
In an ideal world, we would not need to treat psychosis because one day we might be able to prevent it (as we have done with general paralysis of the insane, which competed with dementia praecox for hospital beds in the last century). However, in the absence of primary prevention, we must aim for interventions that deliver immediate, complete, and sustained recovery for everyone with psychosis. Alas, we are a long way from being able to achieve these goals. This is the plain truth – the ‘unspeakable truth’. Rather than face this frustrating and sobering issue, we find other topics to distract ourselves.
Mental health professionals like to help. We are hungry for any new developments that may result in clinical improvements – even the slightest clinical gain is a laudable outcome. Psychiatry is not unique in this respect. A recent review (Leucht et al., 2012) pointed out that while the efficacy of most treatments in psychiatry is modest, the effect sizes for our interventions were comparable to many other fields of medicine. Thus, we should not feel that psychiatry is differentially ineffectual compared to many other fields of health care.
The case I wish to prosecute relates to the deeper issue of how we can address the unavoidable burden of disability associated with schizophrenia (Andrews et al., 2003). We need to build the capacity to undertake more clinically focused research. Mental health research remains relatively underfunded compared to other fields of health (Christensen et al., 2011). If we want to make inroads into better treatments and prevention for psychosis, we need to understand how brains work. We need to learn how brains are built and how they interact with the ecology of the family and wider society. We need to understand how they break and how to fix them. Psychiatry needs to take a more assertive stance in driving neuroscience research. Too often we have been passive recipients of ‘leftover’ neuroscience. Neuroscience needs us, just as much as we need neuroscience (McGrath and Richards, 2009).
I respectfully suggest that the time and energy invested in the early intervention debate might be better invested in pursuing more clinical research and more psychiatrically informed neuroscience. Curiously, in the recently released fourth draft of the Ten Year Road Map for Mental Health Reform (Department of Health and Ageing, 2012), there is a great deal of attention accorded to early intervention and youth-focused services. However, the word ‘research’ only occurs five times, while the words ‘brain’ and ‘neuroscience’ do not appear at all.
Last century, a visionary Australian health professional developed a form of early intervention for a crippling disorder that affected young people. This intervention was initially rejected by the mainstream services, but eventually became widely accepted and exported around the world. Sister Elizabeth Kenny found that physiotherapy delivered early after the onset of poliomyelitis resulted in persistent reductions in disability. Last century, other visionary Australian health professionals disturbed our complacency and developed services that offered prompt and intensive treatments for those with their first episode of psychosis. We should not allow debates about these services to distract us from the more substantive issue – the evidence shows that even with optimal and prolonged early intervention, the outcomes for psychosis remain suboptimal. Essentially, early psychosis services use the standard suite of therapeutic interventions at a critical time of the illness – it makes perfect sense. However, if we want to make serious inroads into improving outcomes for psychosis, we will require strategic and tenacious research (as was required to make inroads into infectious diseases such as polio and syphilis).
This commentary is not intended to be nihilistic about schizophrenia outcomes – hope is an important ingredient in the therapeutic alliance. Nor should these comments be misconstrued as reflecting badly on hard-working clinicians. Our profession should be optimistic about future treatments for schizophrenia – we need to set our goals higher and develop new treatments. Some of these might emerge from early intervention-based research. Modern neuroscience is an intensely fertile area of research – we need to harness these discoveries to learn more about the neurobiological correlates of psychotic disorders. We need better treatments for psychosis and we need them urgently. To do this, we need to accelerate neuroscience discovery.
See Debate by Yung, 46(1): 7–9; See also Debate by Castle, 2012, 46(1): 10–13