The Case for Early Intervention
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.
The dose required to treat first-episode patients with SZ is generally about half that prescribed when the illness becomes chronic. First and second generation antipsychotics were seen as nearly equally effective in studies, though drop-out rates were high in the CATIE Study as well as EUFEST [the European First Episode Schizophrenia Trial].
Indeed, "Continued medication adherence is far and away the strongest clinical predictor of sustained remission and stability, yet only 25 percent of first-episode patients will continue to take an antipsychotic consistently for one year after starting treatment." Almost all eventually stop their medication.
Anosognosia, the lack of insight, is in effect: More than 50 percent of first-episode patients will deny they have an illness once their initial psychosis subsides. A great number stop taking their medications.
It's clear to me I was on "the lucky end of the luck of the draw": After I was diagnosed, I took my medication as prescribed, every single day for four years. As I stated in the intro to this article, I will go to my grave championing early intervention. Along with the right meds, psychosocial treatments are instrumental. I attended a day program for two years, had weekly one-on-one sessions with a therapist, and OVR-the Office of Vocational Rehabilitation-sent me for training as a word processor so I could get my first job as an administrative assistant.
I'm not proud that I was one of the lucky ones. I offer my life, talents and experiences to others in the hopes that they will be encouraged to get help as soon as possible to avoid long-term disability. It's not my intention to be a prophet of doom and gloom by referring to the Harvard Mental Health Letter. Rather, it's the first step I'm compelled to take in reaching out to the general public: those not intimately affected yet [and hopefully not ever] by schizophrenia. Preaching to the choir isn't my intent [I sing off-key]. I feel it's imperative to come down from the choir loft and mingle with every day people living in the world, to show by our humanity and our humanness that we must carry each other across the threshold of hope that a person can recover.
The reality is, there are people for whom recovery is that much harder because of the delay in treatment-and it is my mission to halt that trend. The one barrier-stigma-I have overcome because I decided to be open and honest about what happened to me. I'm willing to risk rejection, I'm willing to stand alone in fighting for what I believe in: the right of every person diagnosed with SZ to recover to the best of their ability, and to be treated with dignity by those of us who will not ever be tormented by this medical condition.
Like any other disease, like cancer or stroke, early intervention is the best chance for recovery. If you had lung cancer, you wouldn't forgo chemo until it was too late. If you had a stroke, you'd call 911 immediately. I rest my case.