The Promise of Early Intervention
Early intervention in the treatment and possible prevention of serious mental illnesses, including psychotic illness, is both an exciting possibility and imperative for our mental health system. Research has demonstrated that many, if not most, persistent mental illnesses start in childhood or adolescence. Knowing that illness comes so early in life underscores the need for, and opportunities of intervening as soon as possible with accessible and high quality services. The result can be reduced disability and improved quality of life over a lifetime.
Biological, psychological and social functioning research suggests that early identification and intervention can reduce illness severity and the disability that follows. One dramatic study found that omega-3 polyunsaturated fatty acids actually reduced the likelihood of developing a psychotic illness among high risk youth. Effective early interventions in youth with existing psychotic illness included cognitive enhancement therapy, which consists of appealing individual and group computer exercises, and education, employment and family support. Such programs, when delivered early enough, not only improved outcomes but also preserved brain gray matter. While many of these studies require replication, they offer hope and pathways for treatment leading to the meaningful improvement of lives.
The challenges for OMH, and our colleagues in community and academic settings, are far more than understanding disease mechanisms and the neurology and physiology of the brain. We will need to tackle three critically important and interrelated tasks:
The first is how to enable affected individuals and their families in the community to seek and engage in clinical services. Unfortunately, in our current system, it may take months or even years for individuals with serious mental illness to come to clinical attention. We must be able to reach out to schools, primary care and pediatric practices, clergy and other community leaders to direct people in need to clinical care. We need to improve upon efforts to reduce the stigma of mental illness and its treatment, which varies across culture and ethnic groups. We will need to educate the public as well teachers and other professionals who encounter youth about what can be done and how to access services. Public health approaches designed in Australia, Denmark and the United Kingdom offer us successful examples in countries that have national health care systems. We must adapt these approaches for use in our multicultural society and fragmented health care system.
The second challenge we face is determining WHEN to intervene and treat. What problems, behaviors or symptoms require intervention? Numerous research studies tell us that a minority of individuals who have early signs and risk factors for psychosis ever develop psychotic disorders though many go on to develop other types of psychiatric problems. Since antipsychotic medication, like all medications, has side effects, unnecessary treatment with antipsychotic medication must be avoided. Instead, we must provide the right treatment at the right time for these young people who are at risk.
The final challenge for our system is in knowing HOW to assist young people with psychotic symptoms. Surprisingly, this is the task about which we know the most. Numerous studies in Europe, Asia and Australia underscore the importance of minimal use of medication, use of illness management and relapse prevention techniques, as well as supported education/employment and family support. Peer support and youth friendly environments are also critical. The experience of other countries needs to inform and shape how services are provided in this country.
I have seen that the optimism that occurs in clinical services that focus on early identification and treatment is contagious. The road ahead in developing early intervention programs for serious mental illness stands to help those young people affected and their families – and to generate enthusiasm and pride in clinicians who dedicate themselves to this critical work.