Early detection and intervention in psychosis: State of the art and future perspectives

This book provides a concise understanding of the current status in early detection and intervention on the Psychosis front. The title is self explanatory and appropriate for this volume. The book consists of 15 chapters elaborated under six subsections, which proceed sequentially opening with the present scenario, the middle sections elaborating on the use of technology to understand psychosis at a molecular level and final discussions comprise innovations in the intervention strategies. The prelude to the book is a precise introduction by the editors.

Chapters one and two provide an overview to this book and our current understanding of the concept of early intervention in psychosis. The stress is on application of primary prevention strategies to psychiatry. The importance of molecular genetics, biological risk factors, power of predictability, time frame of breakout along with definitions and criteria relevant to this topic have been stated. This section also provides an understanding of why intervention at precursor stage is essential to limit damage in psychosis in young and its potential to hamper social life along with cognitive skills. The highlight of the book is pre-emptive and predictive psychiatry and the relevance of physical health to achieve mental well being.

The next four chapters are grouped under the subheading, ‘Early Detection of Psychosis: Clinical Assessments’. The history of origin of the concept of ‘Basic Symptoms’, the distinction between the first uncharacteristic phenomenon and first characteristic sign, the differentiation between prepsychotic and premorbid and the characteristics of basic symptoms have been explained. A separate chapter has been dedicated to the problem of psychosis high-risk states in adolescents. Adulthood itself is seen as a high risk state to develop any type of mental illness due to stressful life events, familial transitions and type II traumas such as parental divorce. The challenging aspect in adolescent onset psychosis is recognition of repeated somatic complaints and other unexplained bodily phenomenon, sudden episodes of anxiety, neurotic phenomenon, and unreasonable sustained beliefs as potential psychosis continuum. Also discussed here is the dilemma of overlapping spectra of autism and schizophrenia. The ‘concluding remarks’ direct the clinicians to take into account the gestalt of these particular symptoms and the comprehension of the gestalt while reaching a particular diagnosis.

The ‘Psychosis High–Risk State’ chapter stresses on the validity of the ‘attenuated psychotic syndrome’ and focussed intervention to decrease the duration of untreated psychosis. The critical viewpoint here is about the scarcity of the treatment catered to the negative symptoms and early deficits with a favourable bias towards the treatment of attenuated positive symptoms. The readers are provided with future directions into efficacious treatments such as combined psychotherapy and pharmacotherapy, preventive cognitive therapies and also therapies aimed at negative symptoms and cognitive symptoms, ameliorating emotional recognition; for an overall better prognosis.

This section also throws light on the stigma attached to a mental illness with special reference to ‘self stigma’ experienced by people with ‘at risk mental states’. Internalized stigma is a rarely discussed topic and this book brings to the forefront a newer dimension of stigma, where most similar works address this issue as being objective only. The suggestions to cater to ARMS (At-Risk Mental State) patients is to focus on ‘helpful aspects’ such as refrain from catastrophic revelations, psycho educate optimistically, offer interventions with non-judgmental social environment, aim to normalize everyday life, early detection services to be accessible and placed in a non-stigmatizing environment. Psychosocial interventions are favoured for ARMS, to avoid side effects of medications.

The subsequent sections of the book cover various diagnostic modalities aiding early detection. The focus is on neurocognition, neurophysiological assessments and neuroimaging techniques. The use of structural and functional MRI techniques have been discussed as important tools for reaching a definitive answer to elucidate brain changes and network interactions implicated in psychosis to predict outcomes and personalize interventions in the first chapter under section 3. Only relying on clinical features in the future will be insufficient and evidence from biomarkers and neuroimaging will benefit early detection to a large extent - current limitations include small sample size and paucity of replicated evidence.

The chapter on pattern recognition deals with using databases in recognition of multivariate pattern analysis (MVPA) for predictive medicine and predictive modelling in psychosis prodrome. MVPA may provide tools for identification of neurobiological signatures and delineating subtypes which share distinct disease pathologies. Ultimate aim is to generate reliable data with high generalizability. The next chapter focuses on the disconnectivity hypothesis of schizophrenia and gives an overview of neuroimaging findings of abnormal structural and functional connections.

The role of neurocognitive and motor variables likely to be implicated in multidomain prediction models has been discussed in the subsequent chapter. The discussion borders on cognitive deficit from aberrant neurodevelopment having emerged as the core feature of schizophrenia and also as end phenotype markers. The last chapter in this section shifts its focus to electroencephalographic predictors of psychosis. Psychopathological and neurocognitive studies have shown disturbances in information processing in Clinical High Risk (CHR) people. These act as markers to indicate sufficient risk for preventive intervention. Predicting psychosis with focus on quantitative data on EEG (electroencephalography) studies has a major advantage of being cost-effective as compared to the currently widely used neuroimaging techniques such as MRI.

The penultimate section directs its attention to various intervention modalities and innovations in the early intervention. Psychological methods aim at delaying the transition of CHR group to full blown psychosis, while also addressing other concerns faced by this group such as anxiety, depression, substance abuse, poor functioning, cognitive deficits to state a few. The chapter concludes with highlighting the less stigmatizing potential of psychotherapy while allaying transition, as not all CHR group transition to psychosis and hence exposing them to pharmacotherapy and its ill effects is debatable.

The non-pharmacological interventions other than psychotherapy as an alternative to antipsychotics focus on neuroprotection. The use of PUFA (polyunsaturated fatty acids) has emerged as a novel strategy for normal brain development, enhanced synaptic plasticity and functioning, cell membrane phospholipids such as eicosapentanoic acid have been known to have the potential to diminish adverse effects of antipsychotics and also improve their efficacy. The non-pharmacological intervention strategies help delay the transition to psychosis, enhance global functioning, achieve complete remission, improve problem solving and communication skills. Well formulated psychoeducation programmes, integrated psychological interventions, family focussed therapy are all essential interventions, but further studies are required to conclude on an optimum range of therapy sessions. This chapter summarizes with overall, pharmacotherapy being considered more specific but non-pharmacological interventions have the advantage of no side effects, being cost-effective and thus having higher acceptability.

The last chapter in this section discusses pharmacotherapy as an intervention. This chapter highlights the key features to be remembered while using antipsychotics. The relevant points mentioned are guidelines for drug use in early psychosis period, when the patients are drug naïve, more prone to adverse effects and more likely to be non adherent thus increasing the risk of relapse. The emphasis is on minimum effective use of medications, caution while switching drugs and watchful eye on potential adverse effects such as metabolic syndrome, sexual dysfunction, galactorrhoea which predict hostility and influence attitude towards adherence. Lastly the chapter discusses the lack of data and knowledge on how to improve adherence. It also mentions the problem of uncertainty in the duration of continuation of treatment and the underutilization of Long Acting Injectables (LAI) in early psychosis. The closing comments for the clinicians are ‘to start low and go slow’ with the medications.

The final chapter of this book is an overview of the highlights of the current understanding of this topic, the issues raised in the book and also novel strategies and interventions that can be put to use optimally while targeting this critical period of intervention in early psychosis. It raises important questions such as intervention dilemmas and need for future research for gender specificities in psychosis.

Overall, the book incorporates newer dimensions, scales, terminologies and guidelines along with reader friendly tabulations and illustrations. The suggestions are to intervene with education about pathogenic risk factors, research on service delivery, focus on health economics and reduction of stigma and discrimination, to successfully touch most domains of the concept of early detection and intervention in psychosis. It gives a brief history of the emergence of this concept, our current standing with regards to intervention strategies and awareness of both clinicians and the general population. The culture- and region-specific aspects of presentation in the early phase of psychosis could benefit this book considerably. The conclusions drawn at the end of each chapter could be more precise. The future directions mentioned after conclusions are especially relevant to the context of the book as aptly highlighted on the cover.