First psychotic breaks (alternative care) — INTAR conference

Peter Stastny,* MD, writes about an upcoming conference (Nov 23): “Alternative responses to first psychotic breaks: Rethinking psychiatric crisis.”

After several years, there is a renewed focus on treatment for first psychotic episodes. An emphasis on early intervention and prevention of psychosis, with the goal of shortening the “duration of untreated psychosis” has obscured the view on the actual services that are being offered to individuals in the midst of a first episode. Recently, the National Institute of Mental Health challenged the psychiatric field to develop a new, state-of-the-art intervention for an “initial schizophrenic episode” (RAISE), realizing that the outcome of conventional treatment leaves a lot to be desired.

Counter to common belief, a first psychotic episode may actually not have disastrous consequences. It may not herald a course characterized by multiple relapses, re-hospitalizations and a decline in functioning, social and economic standing, relationships and general well-being. Instead, a first breakdown may constitute an opportunity for early recovery and result in a positive realignment of psychological and social constellations, provided that interventions are tailored to the actual needs of the individual, respond to a crisis that has frequently taken hold of the person’s entire social support system, and ensure that no additional harm is inflicted at a time when a person is already quite vulnerable.

Interventions that fit this bill have been around for many years. Even going back to the days of moral treatment in the 19th century, one can find many instances of early recovery when people responded to the kind guidance and structure available in the best asylums. Scandinavian psychiatrists have long been at work to optimize interventions for first psychotic episodes, integrating family treatment, individual psychotherapy, optimal and targeted use of medication into a flexible package they termed “need-adapted treatment.” Several studies using variations of this approach have shown dramatically positive results, with little use of inpatient services, and much lower medication dosages than usual.

In this country, the Soteria study conducted by Loren Mosher and Alma Menn showed short-term benefits equal to acute hospitalization with significantly less use of antipsychotic medication, benefits that were sustained for at least two years. Countries that have managed to significantly reduce their reliance on inpatient services, such as the UK, Scandinavia and Italy, have been more open to embrace community-based innovations that are flexible, continuous, and supportive of individual resilience and social ties. But mental health consumers in the United States have benefited the least from such promising programs, due to the persistence of hospital-based services, a lack of suitable funding mechanisms, and little awareness about the safety and successes of these interventions. (read the rest)

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