What's the big deal about treating "first-episode" schizophrenia with drugs? A lot, as it turns out. An Interview with Mary Ann Bruni linked my successful recovery to my mother's courageous action: within twenty-four hours of my breakdown, she drove me to the hospital and I was given Stelazine, which halted the positive symptoms within three weeks.
Now, the November 2008 Harvard Mental Health Letter corroborates my thinking that early intervention is vital in this critical phase: "Consensus is growing that this first psychotic episode represents a critical period for treating schizophrenia. It offers a unique opportunity to build a therapeutic alliance between patient and clinician, get treatment ‘right' the first time around, and do everything possible to improve long-term outcomes."
Recognizing the illness early and treating it, however, remains a significant challenge. One analysis of multiple studies found an average of nine months passed between the onset of psychosis and treatment, although delays could last as long as two years. A study conducted by the National Alliance on Mental Illness this spring indicated an average delay between onset and treatment of 8.5 years.
Barriers prompt delays in diagnosis and treatment: "Patients and family members may not recognize subtle symptoms or they may attribute abnormal thoughts and behavior to substance abuse, stress or other factors." Stigma, lack of health insurance, and other barriers that hinder access to medical care could also play a role.
The duration of untreated psychosis, "Not only predicts initial treatment response in patients with schizophrenia, but may also affect long-term outcomes." A meta-analysis of 43 studies concluded that, "The less time psychosis goes untreated, the more likely that antipsychotics would produce a response, including relief from positive symptoms like hallucinations and negative symptoms like social withdrawal."
This suggests the longer you wait, the less likely the meds will work, yet this hasn't been proven in all cases. Getting treatment later rather than never is a better option than not getting it at all. Neuroimaging studies suggest that loss of brain tissue progresses further in the first year-and-a-half after diagnosis. Such brain tissue loss is associated with worse outcomes in the long term. Second-generation drugs may protect brain tissue more than first-generation drugs.
Robin Cunningham, the other expert here at the Connection, heard voices for ten years before finding the right medication that stopped them, yet believes the fact that he was given medication within five days of the onset of his psychosis, protected him from further brain deterioration and loss of functionality. The only drug available to him at the time-in 1956-was Thorazine.
The ideal in treating first-episode SZ is not only to get psychotic symptoms under control, but to do so in a way that builds therapeutic alliance. The trick is prescribing medication at a dose sufficient to alleviate psychotic symptoms while minimizing side effects. In tandem, "adequate emotional support must be provided so that a patient is as motivated as possible to continue treatment after symptoms subside." Robin had an ally in his psychiatrist, Dr. Levy, who taught him coping skills-what can only be likened to cognitive therapy techniques years ahead of his time-and you can read about them in Robin's blog archives.