Department of Psychiatry, University of Melbourne and ORYGEN Research Centre, Locked Bag 10, Parkville, Victoria 3052, Australia. Tel: +61 3 9342 2850; fax: +61 3 9342 2921
Correspondence: e-mail: mcgorry{at}ariel.unimelb.edu.au
Declaration of interest The authors early intervention studies have received partial support in the form of investigator-initiated unrestricted research grants from Janssen-Cilag.
*Paper presented at the Third International Early Psychosis Conference, Copenhagen, Denmark, September 2002.
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ABSTRACT |
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INTRODUCTION |
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For many people, the distress associated with the diagnosis of psychotic disorders, such as schizophrenia, is made worse by the realisation that the disorder could have been caught sooner, if only the early manifestations had been recognised. As in other complex medical disorders, these early features are often overlooked because they resemble the manifestations of benign disorders and normal experience. Patients are unlikely to seek help, and even when they do, the possibility of emerging serious disorder is rarely considered. Such delays, occurring as they typically do during the crucial life stage of adolescence and early adulthood, have long-term effects. In psychiatry the situation is analogous to that in medicine generally but is even more challenging. The emergence of the clinical phenotypes of disorder must be detected within the flux of a developing personality; the person is still an unknown quantity. The young person and those close to him or her are not clear of the significance of changes in mood, experience and behaviour. The acquisition of new symptoms and their intensification are difficult to detect and interpret. Furthermore, the absence of diagnostic laboratory tests to validate clinical diagnosis and to predict future risk is another limitation. Nevertheless, the paradigm and the diagnostic challenge are identical. So, if we accept that serious mental illnesses such as schizophrenia and related psychoses are complex medical disorders affecting the central nervous system, why should we debate the value of early diagnosis?
Well, as David Sackett has clearly described (Sackett et al, 1991), early diagnosis in medicine is by no means always justified. Sackett has been highly critical of overenthusiastic preventive medicine advocates and makes many telling points (Sackett, 2002). His arguments apply principally to the presymptomatic stage of disease and the decision to undertake screening and proactive case-finding, and he sets out a number of criteria which need to be satisfied before this should be undertaken. These criteria have less relevance for early symptomatic diagnosis but are still instructive. Sackett also points out that the value of early diagnosis is dependent on the orderly progression of disease via a natural history from onset through diagnosis to outcome, and a second element, the notion of a critical point in the natural history of a disease, before which therapy is either more effective or easier to apply than afterward. The latter concept also underpins the concept of staging.
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FIRST-ORDER ISSUES |
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SECOND -ORDER ISSUES |
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Sacketts arguments, although directed at presymptomatic disease do, however, have some cautionary lessons for earlier diagnosis in psychotic disorders, even though the latter has necessarily confined itself to early symptomatic stages. Most do, however, dissolve when we focus on help-seeking cases with symptoms. Here the onus on the clinician is quite different. For symptom-free citizens who are sought out and offered therapy, we need to be very sure that their health will improve and we will do more good than harm. With help-seeking symptomatic patients we only have to try our best and are freer to offer less evidence-based treatments and to emphasise that even well-validated treatments do not work for everyone. This dichotomy is useful, yet when we attempt to improve levels of mental health literacy (Jorm et al, 1997) and encourage and direct help-seeking for symptomatic distress and unmet need, it becomes less clear-cut, with the onus shifting towards the need for a firmer evidence base and greater efficacy and safety for the treatments being offered. We are operating in a grey zone where Sacketts principles can indeed guide us.
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STAGING |
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The situation is nevertheless deceptively complex and evaluation studies need to be carefully designed. Cases detected earlier, especially by more proactive methods, may for some diseases have an intrinsically better prognosis, because (in cancer) the tumours are slow-growing (and benign) and have an increased chance of detection by screening. This is known as the length time bias. It may operate quite differently in other diseases. For example, in schizophrenia, insidious onset is associated with a worse, not better, prognosis, yet such cases would have an increased chance of detection in early diagnosis strategies. Staging has been applied in other serious medical disorders, such as diabetes and rheumatoid diseases. Patients may present for the first time at any of the stages from early to late, progression across stages may or may not occur, and such progression may be influenced by treatment. It has been assumed until recently, despite significant counter-evidence, that in the case of schizophrenia and related psychoses, a pernicious intrinsic progression was inevitable and was almost unmodifiable by treatment (Hegarty et al, 1994; Andrews et al, 2004). The early intervention paradigm has helped to challenge this view and the staging concept enables better clinical trials to be designed to study the content and timing of treatments. A further important bias to be factored into such trials is the lead time bias, which implies the need to correct in follow-up evaluations for the period by which the onset of effective treatment was brought forward.
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NEED FOR REFORM |
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Critics of the introduction of early diagnosis in psychiatry have highlighted many of these issues, often in an emotive and ingenuous manner, without reference to how these issues have been tackled in other branches of medicine. Proponents of early intervention have generally recognised the need to proceed carefully. They are mindful of the poor quality of psychiatric care even in the most advanced countries and the consequent potential for harm as well as benefit from drawing patients into such care, which may not meet their needs. This is why the early intervention field has placed so much emphasis on the need to reform the structure and modus operandi as well as to make the content of psychiatric treatment as stage-specific as possible. We are still at proof of concept stage but this a concept well worth the effort to prove. It is very likely, as in the rest of medicine, to represent a best buy and to reduce the burden of psychiatric disease. It does not imply a disinvestment in the later stages of disorder, another false dichotomy introduced by critics, rather, new investment is required for greater health gain, cost-effectiveness and quality of life for patients and families.
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