The Recognition and Management of Early Psychosis: A Preventive Approach

This is the first text to focus on the potential of early detection of psychosis, and the practicalities of treatment. Based on the pioneering experience and research of a now well-established prevention and intervention center, and with contributions from international authorities, this book outlines a framework for intervention, reviews the evidence available to guide clinical practice, and describes models of treatment. Incorporating many personal narratives and case histories, this volume is strong on theory, sensitive on practical issues, and will challenge, inform, and guide clinicians in the mental health fields.

This book presents mainly the experiences of a group of Australian psychiatrists in the early recognition and treatment of psychosis. It addresses a major new issue in psychiatry: prevention of chronic psychiatric illness. At last, serious investigative studies are under way to attempt to prevent, rather than reverse, the effects of serious mental disorders. The difficulty with the book is that it is in part a how-to manual, in part a missionary tract, and in part a theoretical discussion of disease classification and orientation. The three threads are not well integrated.

The practical issues are well discussed in the book. How do you recognize early psychosis, or -- even more difficult -- psychotic prodromes: How does a health care system deal with the very real problem of getting patients with new-onset psychosis into treatment programs quickly? The evidence suggesting that immediate treatment is vital for a good outcome is clearly spelled out. These issues recur in a somewhat redundant fashion in the sections dealing with onset and assessment, which show how to proceed and the evidence for each step. The authors' concern for their patients and for the need to document a scientific basis for preventive treatment is evident. The how-to aspect of this book is well presented, and any group could use this book as a basis for developing a treatment program for early psychosis.

The authors' missionary zeal comes from the older social psychiatric tradition. Their implication, which troubles me, is that the old dichotomies between social and psychotherapeutic approaches, as opposed to medical and psychopharmacologic approaches, are still lurking. There is a sense that the current program of these Australian psychiatrists, which has grown out of the tradition of social psychiatry, has a somewhat defensive approach to the medical model. The theoretical discussion sets up the kraepelinian view of schizophrenia as a straw man. Kraepelin's definition of dementia praecox as a chronic deteriorating illness is repeatedly cited as a major justification for the lack of preventive measures. That such cases constitute only a small fraction of what is currently labeled schizophrenia is clear. It is also obvious that Kraepelin, who saw the illness as an untreatable disease of the brain, could only describe the downward course of his institutionalized patients.

What McGorry and Jackson want to combat is the pessimism surrounding the treatment of psychosis, and rightly so. I believe a better tactic is to look more to the biologic possibilities that have opened up new diagnostic approaches and medications. The chapter by Chatterjee and Lieberman on biologic variables is a straightforward review of this area, but it does not discuss future possibilities, which include data that second-generation antipsychotic medications may more fully reverse cognitive deficits than traditional medicines and the hope that new imaging techniques may be used to identify patients in a prepsychotic phase in whom overt psychosis will develop.

Optimism is not a matter of definition alone but of possibilities, and the possibilities in biologic psychiatry are not fully integrated in this work. An interesting example is the current approach to Alzheimer's disease. In this case, we have a syndrome with a downhill course, which was also initially defined in Kraepelin's department. It is, however, now viewed as a biologic disease that will ultimately be understood. As a result, diagnostic tests continue to sharpen the definition of the group at risk, and large-scale treatment trials are being undertaken with only minimal supportive evidence. McGorry and coworkers clearly sense the need to create an optimistic climate if preventive work in the area of schizophrenia is to move forward, but they have not fully used their best weapon: the dramatic advances in the understanding of the neurobiology of psychosis. They advocate the use of medication early on and also see that a treatment program must encompass pharmacotherapy, psychotherapy, and social programs. The message is on target, but the tone detracts.

An example of the bias in this book is evident in Birchwood's comment at the beginning of chapter 9, "the personal and social context of psychosis is a major influence." I would argue that it is as likely that the biologic basis of the onset of psychopathology is critical to the long-term trajectory of the disease. Efforts should be focused on identifying and inhibiting the biologic onset of psychosis.

The bias toward psychological and social factors in this book does not diminish its central message: early identification of psychotic illness is possible, and comprehensive early treatment can greatly diminish the severity of the illness. I am delighted to see concrete and innovative work under way in the area of prevention, and hope that biologic psychiatrists will add to these efforts and complement the excellent program detailed by McGorry and Jackson. If we work together, it may be possible to limit if not eliminate the chronicity of mental illness.

Reviewed by Fritz Henn, M.D., Ph.D.
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