Huijun Li - Handbook of Attenuated Psychosis Syndrome Across Cultures: International Perspectives on Early Identification and Intervention

Prevention and early intervention in psychotic disorders was regarded for many decades as a pipe dream. Those who held that dream were accused by their senior colleagues of the cardinal sin of offering false hope and indulging in rescue fantasies. How much the world has changed over the past three decades! Schizophrenia and psychotic disorders, imbued with pessimism and the soft bigotry of low expectations, seemed to be the least promising arena for the development of a preventively oriented psychiatry, but a global wave of dynamic translational research has transformed our field. We have finally realized that every other branch of medicine values the power of hope, and to strip hope away from patients and families at the onset of any treatable illness, however potentially disabling, deprives clinicians of one of their most powerful therapeutic tools. However, hope is not enough. We have also learned from cancer and other major noncommunicable diseases that if we diagnose early, treat intensively, and guarantee a secure tenure of expert care for as long as needed, especially in the early years post diagnosis, then outcomes can be dramatically improved, even with existing treatments. The evidence base for psychosis confirms the same is true for these disorders, provided that once we have got people well, we endeavor to keep them well. This approach however is still in mental health care, more honored in the breach than the observance. Despite the progress we have made, only a minority of patients worldwide benefit from implementation of this knowledge. We can do so much more for our patients, and the early intervention paradigm powered by implementation science and advocacy is the key.

The origins of what in North America is now increasingly referred to as the Attenuated Psychosis Syndrome goes back a long way. Kraepelin and Bleuler both described how dementia praecox and schizophrenia all too often developed imperceptibly and gradually with subtle changes and precursor signs and symptoms which eventually evolved into more florid and acute phases of frank psychosis. Harry Stack Sullivan in the 1920s described carefully the onset of schizophrenia and imagined the day when interventions might forestall the full expression of the illness. More recently, Ainsley Meares and Heinz Hafner described the prodromal stage of illness, and an operational definition of this prodromal stage was even included in the DSM III-R . Ironically, it was dropped from DSM IV because it was regarded as non-specific and unreliable. Yet, non-specificity is an essential feature of the concept of prodrome as adapted from infectious disease. Inspired by the knowledge that over 70% of first episode cases manifested a prodromal stage, our early psychosis research group, from 1991, initially Henry Jackson and I, and, then from 1993, Alison Yung, decided to study this stage of illness, initially retrospectively and then prospectively, using an operational definition that combined known risk factors, such as family history, functional decline, and attenuated or subthreshold symptoms as warning signs of fully fledged and sustained psychotic disorder. This later became known as indicated prevention. We established a satellite (PACE) clinic of the recently established EPPIC program in Melbourne and studied a prospective cohort of patients who manifested what we termed an at-risk mental state. We observed a 40% rate of progression to first episode psychosis within 1 year, despite providing needs-based clinical care to these patients. This led us to coin the term ultrahigh risk state to underline the huge elevation of risk that was present. In the USA, Barbara Cornblatt amended this term to clinical high-risk state to contrast the approach with the genetic high-risk paradigm that had been pursued to that point. The at-risk or ultrahigh risk approach was an example of the close-in research strategy that studied risk factors, including subthreshold symptoms, close to onset of disorder. It was able to enrich the sample for risk and collapse follow-up periods, offering huge advantages.