Early psychological interventions for psychosis

Abstract

The manuscript correspond to an editorial in order to assess the most important and effective interventions for people with psychosis in the early stages.

Key Words: Schizophrenia; Psychological interventions; Psychosis; Early psychosis; Cognitive behavioral therapy

Core tip: The present manuscript is an editorial that tries to describe the most important results found regarding early psychological interventions in psychosis. A description of the main results found in this area is discussed.

INTRODUCTION

Schizophrenia and other psychotic disorders cause severe levels of disability, leading to a considerable burden for caregivers and health systems. At present, the most commonly used treatments rely on antipsychotic medication; however this approach is not sufficient for the improvement of functional outcomes, and approximately 50%-75% of the patients discontinue medication. In recent decades an interest in psychological therapies addressed to people with psychosis has emerged[1]. Psychological therapies for treating people with psychosis have been shown to be beneficial[2]; more than 40% of patients show clear improvement in symptoms, even in the absence of medication[3]. However, implementation in routine services is still poor despite the inclusion of these therapies in clinical guidelines. Haddock et al[4] reported that only 6.9% of services offer psychological interventions, although psychological treatments have been found to be cost-effective[5]. Treatment costs can be reduced to a limited extent not only by the prevention of psychotic symptoms and relapse but also by the improvement of role-functioning capacities. According to the Global Burden of Disease Study, schizophrenia causes a high degree of disability, which accounts for 1.1% of the total disability-adjusted life years (DALYs) and 2.8% of years lived with disability (YLDs). In the World Health Report, schizophrenia is listed as the 8^th leading cause of DALYs worldwide[6]. In this context the present editorial aims to revise the most effective psychological interventions for people with first-episode of psychosis and those developed for early interventions to prevent psychosis.

PSYCHOLOGICAL INTERVENTIONS FOR FIRST-EPISODE PSYCHOSIS

Early psychological interventions have been developed in recent decades in order to treat people with psychosis once the first symptoms appear.

Several clinical trials have tested the effectiveness of psychological interventions. Cognitive behavioral therapy (CBT) was one of the most used, and it has been adapted for specific areas of treatment. In the study of Lewis et al[7], CBT showed transient advantages over routine care alone or supportive counselling in speeding remission from acute symptoms in early schizophrenia. In contrast, Jackson et al[8] performed a clinical trial comparing CBT vs Befriending; the results showed that both groups improved in symptoms, but no specific effect of CBT was demonstrated. Specially addressed to cannabis consumption, Edwards et al[9] performed a clinical trial with a cannabis-focused intervention (based on CBT) which found significant changes regarding the consumption of cannabis. On the other hand, the cognitive orientated therapy for early psychosis based on cognitive therapy showed a greater average improvement in a measure of suicide ideation[10]. Other types of psychological treatment such as assertive community treatment in an intensive early-intervention program showed improved clinical outcome after 2 years (OPUS study)[11]. Moreover, psychological therapy based on Adherence Coping Education has been found to be useful in decreasing symptoms[12].

In a review by Barlati et al[13], the authors found several results that showed the efficacy of cognitive remediation therapy (CRT) in the early course of psychosis. Randomized controlled studies[14] demonstrated that a cognitive remediation program might have beneficial effects for some specific aspects of cognition. Wykes et al[15] carried out a single-blind randomized controlled trial with two groups, one receiving CRT and the other standard care, in patients with a recent diagnosis of early onset schizophrenia. Compared to standard care, CRT produced significant additional improvements in cognitive flexibility as measured by the Wisconsin Card Sort Test.

In summary, although the literature on psychological therapies in the early stages of the psychosis is still scarce, the results suggest that they could be beneficial in reducing several domains, such as symptoms, relapses, suicide, cannabis consumption and in improving cognitive functioning. These studies suggest that psychological treatment in these stages of the illness should be included in the clinical resources.

PSYCHOLOGICAL INTERVENTIONS AS EARLY STRATEGIES TO PREVENT PSYCHOSIS

Effective psychological interventions for early stages are needed due to the importance of early intervention in reducing chronicity. In this context, most studies have assessed the effectiveness of CBT in preventing transition to psychosis[16-21] as well as integrated therapies that combine individual cognitive-behavioural therapy, group skills training, cognitive remediation and multifamily psychoeducation[22]. Two meta-analyses have been performed regarding the effectiveness of early interventions in psychosis. The first one by Marshall et al[23] found that there was inconclusive evidence that interventions could help in the prodromal phase. In the second meta-analysis of Stafford et al[24] the authors explored the effectiveness of psychological interventions in preventing psychosis. The conclusions of the study point out that five of the clinical trials of CBT had a moderate effect on transition to psychosis at both 12 and 18 mo. Moreover, the authors suggested that integrated psychological therapies could reduce transition to psychosis.

LIMITATIONS AND CLINICAL IMPLICATIONS

Several studies have indicated the effectiveness of psychological therapies in the treatment of early psychosis, especially those centered on CBT and CRT treatment. However, the meta-analysis noted above[23,24] pointed up the difficulty of assessing the effectiveness of psychological interventions due to the small number of cases of patients that transit to psychosis. Moreover, Stafford et al[24] suggested that a limitation in the assessment of effectiveness of psychological therapies lies in the difficulty in blinding the intervention to patients. Nevertheless, all the clinical trials analyzed in the meta-analysis included a comparing group (supported counseling and monitoring). Several advantages arise in the use of psychological therapies for people with psychosis in several phases of the illness. First, the importance of addressing symptoms from the onset of the illness will improve the course of the illness. In recent years there has been interest in focusing attention on this population, creating specific programs for people with a first-episode psychosis. In this context, the implementation of psychological therapies should be necessary. Second, evidence of positive results regarding the implementation of CBT and CRT therapies has been demonstrated in early intervention in the care of people with psychosis. Considering these results, psychological therapies could be added to medication treatment for the improvement of symptoms, adherence, insight and information about the illness. Moreover no evidence was found regarding the potential disadvantages or risks of the implementation of psychotherapy. However, further studies are needed to better identify the specific domains in which psychological therapies will help people with psychosis.