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9. Prevention and Clinical Staging
Keywords
PreventionPsychosocial toxicityPrimary preventionSecondary preventionEarly intervention and detectionTertiary preventionRelapse preventionClinical stagingSymptomatic remission criteriaFunctional remission and recoveryEssential Points
The prevention of psychosocial toxicities due to untreated illness (job loss, interrupted education, criminal record) is an overarching goal of psychiatric treatment.
Eliminating cannabis use during the vulnerable period is an example of primary prevention in schizophrenia.
Early intervention (detection) and first-episode services are trying to bend the trajectory of schizophrenia toward a more benign illness course, with fewer chronic symptoms and better function.
Reducing the duration of untreated psychosis (DUP) below 3 months is needed for optimal negative symptoms remission. In the United States, the typical DUP is between 1 and 2 years.
Secondary prevention during the prodromal period in order to prevent the development of the full syndrome of schizophrenia is an area of great interest. Universal screening in the prepsychotic phase based on clinical ultra high-risk criteria is not sensitive or specific enough to predict transition to schizophrenia.
Indicated prevention (signs of illness already apparent) for high-risk persons is already a form of treatment and consists of individual therapy and family support.
Preventing psychotic relapse as an example of tertiary prevention may be one of the most important psychiatric treatment goals for patients with schizophrenia (treatment as prevention), including first-episode patients. Frequent relapse disrupts rehabilitation efforts and hinders sustained remission and eventual recovery.
Approach the prevention of the next episode in “last-episode psychosis” patients with the same urgency as you would in preventing the second episode in first-episode psychosis patients.
A natural outgrowth of a prevention framework is clinical staging to guide clinical care decisions with stage-specific interventions (one size does not fit all). Clinical staging emphasizes early detection, early treatment, and sustained treatment in order to avoid a progression toward higher (chronic) illness stages.
Treatment during later illness stages (i.e., acute phase, stabilization phase, and stable maintenance phase) tries to achieve symptoms response, symptom resolution, and (sustained) symptom remission plus functional recovery, respectively. A first episode of schizophrenia is already a later illness stage as cognitive and negative symptoms develop prior to the onset of psychosis.
Symptomatic remission in schizophrenia is defined as a relative absence of positive and negative symptoms, not a complete freedom from symptoms, for at least 6 months. Many patients are not truly asymptomatic.
Functional recovery is only possible for a minority of patients (less than 20%).
Always focus on rehabilitation and optimal functioning, even in the presence of symptoms (freedom from symptoms might not be possible).
“Nach dem Spiel ist vor dem Spiel.” [1]
(After the game is before the game.)
– Josef “Sepp” Herberger (1897–1977); fabled coach of 1954 West German soccer team
A prevention mind-set and clinical staging are two frames of reference that inform our care for patients with schizophrenia. Clinical staging which is a translation of prevention principles into clinical care defines stage-specific treatment goals and helps select stage-specific interventions in order to achieve the best possible treatment outcome, within the limitations of biology. Principles from this chapter are taken up in more detail in several other chapters. Optimal treatment for likely prodromal schizophrenia and a first episode of psychosis is covered in Chap. 11; treatment for severe and unremitting (treatment-resistant) illness in Chap. 12; treatment with clozapine in Chap. 17; and treatment with long-acting injectable antipsychotics in Chap. 18. The prevention of medical morbidity and mortality is such an important goal of schizophrenia treatment that I dedicate a separate chapter to it as well (Chap. 25).
Psychosocial Toxicities
Let us start with the end in mind: what constitutes a “bad outcome” of schizophrenia and what are factors leading to it? You probably would list, in addition to experiencing unpleasant symptoms, downstream social consequences of having a psychiatric illness such as unemployment, interrupted schooling, homelessness, being victimized, a criminal history, or loss of your reputation. These outcomes could be subsumed under the term “psychosocial toxicities.” Many factors can lead to them: arriving to treatment late or not at all, not receiving optimal treatment once in treatment, substance use, or poor engagement in or persistence with treatment [2]. Substance use and medical comorbidities are additional contributors. Psychotic relapses are responsible for much of the social damage that patients with schizophrenia accrue over time.
Key Point
Schizophrenia is a progressive social disease with accrued disability over time if no treatment is provided. For most, it is not a progressive brain disease with inevitable clinical outcomes.
Except for the small group of truly treatment-resistant patients who have nonresponsive biology, many of these “psychosocial toxicities” could be prevented with optimal psychiatric treatment. While we are currently not able to prevent schizophrenia, we can do a lot to mitigate the ramifications of having schizophrenia (its psychosocial toxicities) by providing care that is timely and optimal for the patient (one size does not fit all). In the language of HIV medicine: treatment as prevention.
Key Point
Preventing premature death and psychosocial toxicities from having schizophrenia (joblessness, loneliness, homelessness, victimization, and criminalization) is within the realm of possibilities for many patients who have schizophrenia. While a societal commitment is needed to achieve some goals, optimal clinical care is the foundation for living well despite schizophrenia.
Prevention in Schizophrenia
Public health traditionally differentiates between primary, secondary, and tertiary prevention activities [3]. Primary prevention aims to prevent a disease from ever occurring in a population (e.g., vaccinations, limiting environmental exposures by creating a clean environment); secondary prevention uses screening to detect a disease early (before the onset of symptoms) when treatments are more effective and potentially curative (e.g., cancer screening); tertiary prevention are treatment efforts that try to limit the impact of a disease (e.g., surgery and rehabilitation). Using a prevention framework increases our repertoire of interventions beyond providing treatment [4].
Primary Prevention
The holy grail of prevention is primary prevention by removing risk factors for an illness so that the illness never develops in the first place. Preventing prenatal nutrient deficiencies [5] and improving obstetric care to avoid birth complications [6] are examples in schizophrenia care. Preventing all cannabis use during early adolescence and adulthood, if it were possible, would constitute primary prevention as cannabis is considered a component cause of schizophrenia (see Chap. 4 on drug-induced psychosis). Increasing resilience (at the individual and at the community level) is another promising primary prevention intervention as it can neutralize risk factors like social stress and protects normal brain development [7].
Early Intervention
The past decades have seen a renewed interest in identifying people in at high-risk for developing schizophrenia and intervening in order to prevent the full syndrome of schizophrenia. The term “early intervention” is often used to capture screening (early detection) and treatment activities around the onset of full-blown psychosis [8]. In recognition of the important first few years around and after the onset of psychosis, a “critical illness period” has been postulated during which the provision of optimal treatment would have a positive effect on the long-term outcome. Many countries started specialized first-episode programs to provide stage-appropriate care.
Prevention in early psychosis and first-episode psychosis
Target group | Examples | |
|---|---|---|
Universal prevention | Whole population | Folic acid supplementation |
Improving obstetric care | ||
Selective prevention | Symptom-free but high-risk | Support to reduce stress |
Indicated prevention | Already showing signs of illness | Specialty “early intervention” care |
Early Detection
Unfortunately, a quite lengthy period of untreated psychosis precedes the initiation of psychiatric treatment. In the first-episode RAISE cohort, the median time from onset of psychotic symptoms to treatment was 74 weeks [9]. Shortening this so-called duration of untreated psychosis (DUP) is an example of early intervention as it may improve a patient’s prognosis [10, 11]. As opposed to the signs of a heart attack, most people would be hard-pressed to identify the signs of an acute psychotic episode, resulting in lengthy treatment delays on the patient side. Community efforts like education about psychosis combined with easy access and outreach can shorten the DUP. In one region in Scandinavia that implemented such a community-wide and multipronged early detection effort, the DUP was shortened from 4 months (which is already quite short) to about 1 month [12], which resulted in improved negative symptoms [13]. Unfortunately, the gains were lost once the educational campaign came to an end [14]. Treatment delays happen on the patient and family side (not seeking treatment) but also on the treatment system side when patients are not given easy access to seeing a psychiatrist, ideally somebody with expertise in early psychosis [15]. Any delay within the treatment system itself should be unacceptable; we do not accept it in oncology. Reducing DUP below 3 months appears to be critical for negative symptoms remission [16]. A particular challenge is identifying patients with a very insidious illness onset as treatment is greatly delayed.
I want to emphasize that early detection of a first episode of psychosis is a very late disease stage if viewed from the point of schizophrenia as a neurodevelopmental disorder. Treatment at this stage is already tertiary prevention – you are merely trying to blunt the effect of illness! Similarly, identifying people at high-risk during a putatively prodromal period is probably too late since neurocognitive problems develop many years before schizophrenia declares itself by the onset of psychosis (see Chap. 7 on natural history) [17]. The time for truly early intervention with the goal of changing a young person’s trajectory away from schizophrenia must therefore come much earlier than our current efforts. Children at high genetic risk because of a parent with schizophrenia, for example, may benefit from identification in pediatric care and close follow-up, including the avoidance of additional risk factors like cannabis use [7].
While the early intervention movement has clearly reinvigorated psychiatry, we cannot forget that chronic patients also benefit from optimal treatment. Moreover, long-term studies that have followed optimally treated first-episode patients (e.g., the OPUS cohort) have found that long-term support is needed to maintain gains made [18].
Tertiary Prevention
Tertiary prevention is the key concern for clinicians treating patients with established schizophrenia. Optimal disease management with the tools of our profession (pharmacotherapy, rehabilitation) can make the difference between a good life despite a serious illness and a life of homelessness or early death.
Key Point
Like multiple sclerosis, schizophrenia can be viewed as a relapsing-remitting disease, with accrued psychosocial toxicity over time due to relapse. Preventing psychotic relapse as an example of tertiary prevention may be one of the most important psychiatric treatment goals for patients with schizophrenia outside managing an acute psychotic episode.
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