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.
Unfortunately, these encouraging research findings have been slow to translate into clinical practice in the United States. It will not come as a surprise that an important reason for the slow implementation of the EDIS model of care is a lack of adequate financing. 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. New York, for example, has funded four demonstration programs providing EDIS services with plans to expand. In addition, based on the experience and anticipated results of the NIMH’s ambitious Recovery After an Initial Schizophrenia Episode study, the Centers for Medicare and Medicaid Services and the Substance Abuse and Mental Health Services Administration are considering funding and supporting EDIS services and models of care.
This new therapeutic model involves a multi-element team-based approach focused on recovery and composed of four components of care: (1) reducing the duration of active symptoms through rapid diagnosis and treatment of patients with first-episode psychosis; (2) sustaining treatment engagement and preventing psychotic relapse; (3) integrating pharmacologic management with psychosocial therapies and recovery-oriented approaches including shared decision making; and (4) offering social and vocational services, substance abuse treatment, and family education and support. 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. ■