How much of the burden of schizophrenia is alleviated by treatment?

Introduction to ‘Early psychosis: abridge to the future’

Early intervention in psychiatry has taken a long time to emerge as a key strategy to reduce morbidity and mortality. In other fields of medicine it has received consistent support and great efforts are expended to educate the public about the value of early diagnosis and the benefits of timely intervention. There is finally substantial momentum behind similar endeavours in psychotic disorders, which, now they have reached ‘proof of concept’ stage, could begin to be extended across the spectrum of serious mental disorders. There is also ambivalence and resistance to this evidence-based reform which warrants careful analysis. The Third International Early Psychosis Conference proved to be a watershed and was the largest and most vibrant meeting to that point. This preface aims to set the scene for a selection of contributions, derived from the array of new evidence reported in Copenhagen, and recently fully updated.

Supportive psychodynamic psychotherapy for psychosis

The UK National Institute for Health and Care Excellence guidance suggests that psychodynamic principles may be used to understand the experiences of people with psychosis. In this article we consider the application of psychodynamic principles in psychotherapy for psychosis, focusing on one particular model: supportive psychodynamic psychotherapy (SPP). We describe this approach with a detailed fictitious case example and discuss how SPP has developed through significant modifications of classical psychoanalytic therapy and the evidence base for it. We consider its overlap with cognitive–behavioural therapy, its advantages and disadvantages, and the arguments for making SPP available as a treatment option in services for psychosis.

Psychiatry beyond the current paradigm

A series of editorials in this Journal have argued that psychiatry is in the midst of a crisis. The various solutions proposed would all involve a strengthening of psychiatry's identity as essentially 'applied neuroscience'. Although not discounting the importance of the brain sciences and psychopharmacology, we argue that psychiatry needs to move beyond the dominance of the current, technological paradigm. This would be more in keeping with the evidence about how positive outcomes are achieved and could also serve to foster more meaningful collaboration with the growing service user movement.

The role of "evidence" in recovery from mental illness

Evidence-based practice (EBP), a derivative of evidence-based medicine (EBM), is ascendant in the United States' mental health system; the findings of randomized controlled trials and other experimental research are widely considered authoritative in mental health practice and policy. The concept of recovery from mental illness is similarly pervasive in mental health programming and advocacy, and it emphasizes consumer expertise and self-determination. What is the relationship between these two powerful and potentially incompatible forces for mental health reform? This paper identifies four attempts, in the mental health literature, to delineate the role of "evidence" in recovery. One is the strong version of evidence-based practice-an applied science model-and three others address weaknesses in the first by limiting the authority of probabilistic findings. The paper also offers a fifth version, based on the concept of communicative accountability, which is derived from Habermas' work on communicative action. The fifth version responds to the other four and emphasizes learning, disclosure and respect in clinical and other helping relationships.

'Every me and every you': responding to the hidden challenge of mental illness in Australia

OBJECTIVE

To show that mental illness affects everyone in society, describe some of the main obstacles to better outcomes, and build confidence that they can be overcome.

METHODS

A review and analysis of relevant evidence and experience combined with personal advocacy.

RESULTS

Mental illnesses are common and seriously under-treated, reform of the system of care has completely stalled, and insidious reinstitutionalization of the modernized system is occurring. A number of contributing factors and possible solutions are identified, including mental health literacy and advocacy campaigns, a focus on young people and early intervention, and functional reintegration of the treatment of mental and substance use disorders.

CONCLUSIONS

A new wave of reform and major financial investment in the treatment of mental and substance use disorders is overdue. This can be best achieved by combining the evidence-based health care (EBHC) paradigm with a direct appeal to the self-interest of members of the general community. A National Institute of Mental Health and Addiction should be a key element of such reform, which must be a continuing process with substantially increased federal and State funding.

Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of schizophrenia and related disorders

BACKGROUND

The Royal Australian and New Zealand College of Psychiatrists is co-ordinating the development of clinical practice guidelines (CPGs) in psychiatry, funded under the National Mental Health Strategy (Australia) and the New Zealand Health Funding Authority. This paper presents CPGs for schizophrenia and related disorders. Over the past decade schizophrenia has become more treatable than ever before. A new generation of drug therapies, a renaissance of psychological and psychosocial interventions and a first generation of reform within the specialist mental health system have combined to create an evidence-based climate of realistic optimism. Progressive neuroscientific advances hold out the strong possibility of more definitive biological treatments in the near future. However, this improved potential for better outcomes and quality of life for people with schizophrenia has not been translated into reality in Australia. The efficacy-effectiveness gap is wider for schizophrenia than any other serious medical disorder. Therapeutic nihilism, under-resourcing of services and a stalling of the service reform process, poor morale within specialist mental health services, a lack of broad-based recovery and life support programs, and a climate of tenacious stigma and consequent lack of concern for people with schizophrenia are the contributory causes for this failure to effectively treat. These guidelines therefore tackle only one element in the endeavour to reduce the impact of schizophrenia. They distil the current evidence-base and make recommendations based on the best available knowledge.

METHOD

A comprehensive literature review (1990-2003) was conducted, including all Cochrane schizophrenia reviews and all relevant meta-analyses, and a number of recent international clinical practice guidelines were consulted. A series of drafts were refined by the expert committee and enhanced through a bi-national consultation process.

TREATMENT RECOMMENDATIONS

This guideline provides evidence-based recommendations for the management of schizophrenia by treatment type and by phase of illness. The essential features of the guidelines are: (i) Early detection and comprehensive treatment of first episode cases is a priority since the psychosocial and possibly the biological impact of illness can be minimized and outcome improved. An optimistic attitude on the part of health professionals is an essential ingredient from the outset and across all phases of illness. (ii) Comprehensive and sustained intervention should be assured during the initial 3-5 years following diagnosis since course of illness is strongly influenced by what occurs in this 'critical period'. Patients should not have to 'prove chronicity' before they gain consistent access and tenure to specialist mental health services. (iii) Antipsychotic medication is the cornerstone of treatment. These medicines have improved in quality and tolerability, yet should be used cautiously and in a more targeted manner than in the past. The treatment of choice for most patients is now the novel antipsychotic medications because of their superior tolerability and, in particular, the reduced risk of tardive dyskinesia. This is particularly so for the first episode patient where, due to superior tolerability, novel agents are the first, second and third line choice. These novel agents are nevertheless associated with potentially serious medium to long-term side-effects of their own for which patients must be carefully monitored. Conventional antipsychotic medications in low dosage may still have a role in a small proportion of patients, where there has been full remission and good tolerability; however, the indications are shrinking progressively. These principles are now accepted in most developed countries. (vi) Clozapine should be used early in the course, as soon as treatment resistance to at least two antipsychotics has been demonstrated. This usually means incomplete remission of positive symptomatology, but clozapine may also be considered where there are pervasive negative symptoms or significant or persistent suicidal risk is present. (v) Comprehensive psychosocial interventions should be routinely available to all patients and their families, and provided by appropriately trained mental health professionals with time to devote to the task. This includes family interventions, cognitive-behaviour therapy, vocational rehabilitation and other forms of therapy, especially for comorbid conditions, such as substance abuse, depression and anxiety. (vi) The social and cultural environment of people with schizophrenia is an essential arena for intervention. Adequate shelter, financial security, access to meaningful social roles and availability of social support are essential components of recovery and quality of life. (vii) Interventions should be carefully tailored to phase and stage of illness, and to gender and cultural background. (viii) Genuine involvement of consumers and relatives in service development and provision should be standard. (ix) Maintenance of good physical health and prevention and early treatment of serious medical illness has been seriously neglected in the management of schizophrenia, and results in premature death and widespread morbidity. Quality of medical care for people with schizophrenia should be equivalent to the general community standard. (x) General practitioners (GPs)s should always be closely involved in the care of people with schizophrenia. However, this should be truly shared care, and sole care by a GP with minimal or no specialist involvement, while very common, is not regarded as an acceptable standard of care. Optimal treatment of schizophrenia requires a multidisciplinary team approach with a consultant psychiatrist centrally involved.

Utilising survey data to inform public policy: comparison of the cost-effectiveness of treatment of ten mental disorders

BACKGROUND

Mental health survey data are now being used proactively to decide how the burden of disease might best be reduced.

AIMS

To study the cost-effectiveness of current and optimal treatments for mental disorders and the proportion of burden avertable by each.

METHOD

Data for three affective, four anxiety and two alcohol use disorders and for schizophrenia were compared interms of cost, burden averted and efficiency of current and optimal treatment. We then calculated the burden unavertable given current knowledge. The unit of health gain was a reduction in the years lived with disability (YLDs).

RESULTS

Summing across all disorders, current treatment averted 13% of the burden, at an average cost of 30,000 Australian dollars per YLD gained. Optimal treatment at current coverage could avert 20% of the burden, at an average cost of 18,000 Australian dollars per YLD gained. Optimal treatment at optimal coverage could avert 28% of the burden, at 16,000 Australian dollars per YLD gained. Sixty per cent of the burden of mental disorders was deemed to be unavertable.

CONCLUSIONS

The efficiency of treatment varied more than tenfold across disorders. Although coverage of some of the more efficient treatments should be extended, other factors justify continued use of less-efficient treatments for some disorders.

Premorbid, psychosocial and clinical predictors of the costs of schizophrenia and other psychoses

BACKGROUND

Predictors of the costs of psychosis have received insufficient research attention, particularly factors associated with indirect costs.

AIMS

To identify the predictors of direct mental health care costs and indirect or time-loss costs in psychotic disorders and to discuss their implications for future interventions.

METHOD

Structured interview data from the Low Prevalence Disorders Study (n=980) were used to examine predictors of the costs of psychosis in Australia. Estimates of annual costs per patient were derived from the perspectives of government and society. Hierarchical regressions were used to assess the contributions to costs of premorbid, psychosocial and clinical factors.

RESULTS

Schizophrenia involved greater costs than other psychotic disorders. Non-completion of high-school education and chronicity of illness course were predictive of higher costs across all categories, and some factors were linked primarily with mental health care costs (e.g. age at onset, current symptomatology) or indirect costs (e.g. male gender, overall disability).

CONCLUSIONS

Several concurrent strategies were recommended, including early intervention programmes and assertive evidence-based rehabilitation and supported employment programmes aimed at reducing disability. The cost-effectiveness of these approaches needs to be evaluated from the perspectives of both government and society.