San Francisco October 2012
You may have followed the debates and controversies surrounding the upcoming release of the DSM-V and in particular the proposal to include “attenuated psychosis syndrome” as a diagnostic category. The DSM-V committee originally proposed including attenuated psychosis syndrome as a full diagnosis, but recently backed off in response to pressure from clinicians, researchers and members of the public. This debate is one of the tips of an iceberg called “early intervention in psychosis” (EIP).
A disclaimer: I am carrying out an ethnography of the EIP movement and I also work as a clinician in this field, so one might say that I am in the not-so-comfortable position of an embedded reporter.
If, like me, you consider early intervention to be one of the key sites where concepts and practices of contemporary psychiatry are being transformed, you may find particularly interesting the EIP movement’s most recent biannual meeting, the 8th International Conference on Early Psychosis, which took place this October in San Francisco.
The EIP movement, which took off in the 90s, had a soaring success worldwide, and in particular in English-speaking countries. The research output is growing exponentially (as this graph of publications by year indicates) and new clinics are popping up everywhere.
The conference began with a plenary session delivered by John M. Kane: “The Early Treatment Of The NIMH Raise Initiative,” described an ongoing study testing the feasibility of delivering early intervention services in community-based, non-academic, “real-world settings utilizing current funding mechanisms” in the US. Until now, it has been recommended that EIP treatments be delivered in specialized clinics, but this has proved complicated in context of the US health care system as well as in sparsely populated areas. Training clinicians in regular psychiatric clinics to deliver EIP was proposed as a cost-effective, realistic and sustainable option. The Q/A session highlighted some major issues with this proposed approach: 1) many interventions (such as group therapy) were sacrificed in the transition to “real world” conditions; 2) community clinics are “bare bones” and this could be both a study confounder and a hindrance to delivering intensive-enough EIP interventions; 3) if the study fails to show positive results because of “under-dosed culture of care”, this “might prematurely close the field” of EIP.
Sophia Vinogradov presented a paper titled “Neuroscience-Informed Cognitive Training In Recent Onset Schizophrenia Using Laptop Computer.” This was an interesting glance into the potential future of psychiatric interventions: carefully crafted exercises, using neuropsychological knowledge from animal studies and contemporary technologies. I was relieved to learn that the cognitive training was superior to the control group (playing online games for 20 hours/week).
“Cognitive Behavior Therapy Without Antipsychotics: Is It Effective Across The Continuum Of Psychotic Disorders?” presented by Tony Morrison, was a major breech in the usual discourse about the inevitability of antipsychotic medication in psychosis. This presentation reviewed several studies showing robust and sustained improvements in patients refusing medication, but accepting Cognitive Behavioral Therapy. The presenter took the time to explain that he was not against medication, but against the overreliance on antipsychotics and a lack of choice or imposed choices.
Davis Shires received the Richard Wyatt Award in recognition of his work in reforming psychiatric services in the UK – the only country to require specialist EIP services for the whole country. We learned that Dr Shires was motivated by his personal experience with psychiatric services as his daughter developed psychosis in the 1990s. He mentioned a meeting with Pat McGorry (the former head of the most influencial EIP clinic) in Melbourne as a key element in his journey of improving psychiatric care. He urged the field to pay more attention to the “body” – especially to medication side effects.
Finally, Pat McGorry presented “Early Intervention In Psychiatry: Lessons From Psychosis,” reviewing the proposal to expand the principles of EIP—particularly the idea of early intervention—to all of psychiatry, using concepts borrowed from other medical fields (e.g. “staging” coming from cancerology – see video from another conference for details). This was proposed as the next development of the movement, and is already promoted by a dedicated journal (Early Intervention in Psychiatry) and a Youth Mental Health Program.
The initial motivations behind EIP were a discontent with the quality of care in traditional psychiatric settings and the hope that new, better treatments (not only medication, but also psychotherapy and social interventions) would improve the lives of persons suffering from psychosis if given sufficiently early (e.g. during a “critical period”). Social scientists might immediately notice EIP’s potential anti-psychiatric flavor and its daring claims of prevention. Indeed, psychiatry was not much into the prevention business, even less when dealing with schizophrenia or psychosis. After the initially focused claim of secondary prevention (i.e. halting or slowing the progression/relapse of psychosis), EIP began exploring primary prevention (i.e. protection from developing psychosis – the field of the “attenuated psychosis syndrome” or prodrome).
The movement is scaling up, leaving small, research-based university specialized clinics for “the real world” – hence the subtitle of this year’s conference: from neurobiology to public policy. Naturally, the critique of “typical” psychiatric care seems to recede as EIP advances.
Finally, the human basis of this movement is also expanding and changing: a new generation of clinicians, researchers and administrators arrived, happy to be part of this new, trendy, dynamic movement, but not necessarily sharing the motivations of the founders.
Given that the early intervention in psychosis movement is arguably on the forefront of the expanding borders of psychiatry, it is interesting to observe how it changes internally and how the rest of society responds to it. For the moment, the DSM-V committee backed-off and removed attenuated psychosis syndrome from the well established, but I bet EIP researchers are considering the fight only postponed until the next revision of DSM.
Constantin Tranulis is a psychiatrist doing clinical work in first episode psychosis and research on cultural and psychosocial dimensions of psychosis. He is currently a faculty member in the Division of Social and Transcultural Psychiatry at McGill University. His training in clinical psychiatry was completed with a fellowship in medical anthropology with an emphasis on illness narratives. Under a broad interest in subjectivity and psychosis, his current research explores what narratives are mobilized around persons suffering from a first episode of psychosis. He is also conducting a CIHR-supported ethnography of the First Episode Psychosis Movement.