Early Detection and Intervention for Initial Episodes ...

VOL. 22, NO. 2, 1996

Early Detection and Intervention for Initial Episodes of Schizophrenia

by Ian R.H. FaIloon, Robert R. Kydd, John H. Coverdale, and Tannls M. Laldlaw

Abstract

Advances in the long-term clinical management of schizophrenia have shown that the skilled application of current therapeutic strategies may provide substantial benefits (Lehman et al. 1995; Falloon et al., in press). While full clinical recovery is rare, at least in the developed nations there are signs that social recovery is possible for most cases (Shepherd et al. 1989). Because florid episodes and exacerbations of schizophrenia can now be controlled effectively, the locus of care for most sufferers has changed from the mental asylum to residential settings in the community. Optimal doses of neuroleptic drugs have halved the rate of florid exacerbations, and psy-

chosocial stress management strategies combined with optimal drug prophylaxis have resulted in additional reductions of similar proportions. These benefits appear to be most marked during the first year after a florid episode (Hogarty et al. 1987). The gains can be sustained longer, however, when the programs are continued indefinitely— with careful monitoring by patients, caregivers, and professional services—so that intensive, integrated drug and psychosocial interventions can be targeted to those periods when the risk of exacerbation is high (Falloon 1985). These advances are derived from a series of studies that have associated stress factors with florid schizophrenic episodes in people biologically vulnerable to die disorder. Two major sources of stress have been delineated. The first, the ambient stress of daily living, includes a wide range of stressors, including housing, finances, nutrition, social support networks (family, friends, workmates, etc.), work and leisure pursuits, child rearing, and the everyday hassles and disappointments that confront almost all adults. Measuring such disparate conditions is difficult but possible using the Index of Expressed Emotion, which encompasses several major aspects of ambient stress (Leff and Vaughn 1985). The second major stress factor that has been associated with a higher risk of florid episodes is the occurrence of stressful life Reprint requests should be sent to Dr. I.R.H. Falloon, Dept. of Psychiatry and Behavioral Science, University of Auckland, Private Bag 92019, Auckland, New Zealand.

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Comprehensive programs of drug and psychosodal Interventions with adults who show early signs and symptoms of schizophrenic disorders may contribute to a lower Incidence and prevalence of florid episodes of schizophrenia. These programs combine (1) early detection of psychotic features by family practitioners and other primary care providers and (2) close liaison with mental health professionals well trained in psychiatric assessment and treatment strategies effective in reducing the prevalence of established cases of schizophrenia. Long-term monitoring for signs of recurrence of these subthreshold psychotic episodes, with further intervention as needed, appears essential to maintain these benefits. Schizophrenia Bulletin, 22(2): 271-282, 1996.

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Nuechterlein 1984). Attempts to specify biochemical changes using brain scan technology are exciting but remain well within the realm of basic research rather than clinical practice. Clinicians currently are able to predict the onset of major episodes of schizophrenia in established cases based on stress levels that are not readily resolved by individuals' coping strategies, the degree of physiological arousal, and idiosyncratic stress responses, termed "early warning signs." Detecting periods of high risk for major episodes can be facilitated by the ability to discriminate specific patterns of clinical responses considered the prodromal phases of florid psychotic episodes of schizophrenia (Docherty et al. 1978; Herz and Melville 1980; Birchwood et al. 1989; Tamer et al. 1991; Falloon 1992; Jackson et al. 1994). The phenomenology of prodromes of schizophrenia is as diverse now as it was when the disorder was first being studied (Kraepelin 1913). Attempts to develop checklists of the most commonly reported features have provided a focus for clinical discussions with individual cases, but defining the idiosyncratic prodromal signs of each individual provides greater specificity (Birchwood 1992). These prodromes or, perhaps more accurately, "at-risk mental states" (McGorry et al. 1996, this issue), appear to combine generic stress responses, such as dysphoric mood states, sleep disturbance, and social withdrawal, with the early features of the psychotic episode, such as perceptual and information processing defects. Only very detailed prospective observations will reveal the precise sequence of such clinical features.

For clinical application, the ability to discriminate between a "normal" stress response and an "atrisk mental state" is probably of limited benefit, since the former will also serve as a warning sign for the patient that the latter may be imminent if the current stress level cannot be ameliorated. High stress that induces physiological changes in the body—and thus, schizophrenic symptoms—is a sign that psychosocial strategies may be applied. When these strategies fail to resolve the stressor and early psychotic symptoms emerge, biomedical measures, including neuroleptic drug intervention, may be indicated to supplement and support the psychosocial management. It should be noted that early detection of an impending major episode is of value only when effective intervention strategies are available. Moreover, because such strategies will often be applied during benign states, their efficiency and safety are important. Several drug and psychosocial strategies devised recently offer promise in modifying the severity of psychotic schizophrenic episodes. In addition to drug interventions, education for patients and caregivers about schizophrenia and its management, including strategies for long-term stress management, have facilitated prophylaxis against florid episodes (Lam 1991). Drug therapy, combined with strategies that enable patients to cope with the whole range of ambient stressors and life events, has minimized long-term clinical, social, and caregiver morbidity in established cases (Falloon 1985). In addition, case management has ensured that major social stressors related to housing, finances, and


events (Brown and Birley 1968; Ventura et al. 1989). These are discrete stresses, such as the loss of a job, death of a close associate, or breakup of an intimate relationship. These events and their onset points can be more readily specified, but the severity of the associated stress is probably related to the difficulties that are provoked in the person's everyday life and raise ambient stress levels. These relationships have been more clearly delineated in the pathogenesis of depressive disorders than in schizophrenia (Brown and Harris 1978). An individual's coping behavior is likely to modify the level of ambient stress experienced as a result of any stressor. Coping behaviors include efforts to resolve the problems associated with the stressor and encompass the problem-solving capacity of the individual's intimate social network, particularly the family unit (Pearlin and Schooler 1978). Where a person is able to communicate readily with other people in his or her social habitat and receive assistance in solving the key problems, the risk of a detrimental outcome is likely to be minimized (Hardesty et al. 1985). The mechanisms through which stress factors trigger the pathophysiology of schizophrenia have not been identified. High levels of physiological arousal associated with neurotransmitter changes have been implicated. Attempts to specify the physiological changes specific to schizophrenic episodes, however, have proved relatively unrewarding. It is apparent that individuals show patterns specific to their stress responses, rather than patterns specific to schizophrenic episodes (Dawson and

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Methods Early Detection of Major Mental Disorders. The Buckingham Project began in 1984 as a model of community-based mental health care. The project served a semirural area of England with 35,000 inhabitants and a well-established primary health care service staffed continuously by family practitioners working in small practice groups and assisted by specialized community nursing practitioners. Delays in building mental health inpatient, outpatient, and daypatient units provided a natural situation for establishing a service that was fully integrated with primary care and included sharing of workspaces and medical records. This collaboration soon revealed that one of the major dilemmas faced by primary care services was discriminating the early signs of serious mental disorder from responses to stress so dramatic that patients urgently sought help from their family doctors. Recognizing and treating established cases presented little difficulty to experienced doctors and nurses, but detecting and treating early signs and symptoms presented a much greater challenge. A number of strategies were developed to facilitate early detection and have since been refined for application in other locations, including those described in this issue of the Schizophrenia Bulletin,

Initial consumer-oriented contact. It was considered important to ensure that initial mental health consultations were consumeroriented. Traditional expectations that patients would attend specialized clinics with established appointment procedures were abandoned. Instead, we adopted many

of the procedures that family practitioners found effective, including arranging to see patients with key friends or family members at the times and locations patients preferred, usually in their own homes or at the family practice offices. Though these straightforward arrangements often created some minor inconveniences for the mental health professionals, they tended to facilitate early, effective consultation. Enhancing the screening skills of the family practice team. One advantage of accessible family practitioner services is that consultations with almost every patient occur annually. Despite the brevity of many of these consultations and the fact that they are often made expressly for treatment of physical disorders, family practitioners are able to detect about two-thirds of all mental disorders and a higher proportion of psychotic disorders (Goldberg and Huxley 1980). In other words, most family practitioners provide reasonably good screening for mental disorders, even without training in formal screening procedures (Prince and Phelan 1994). Their longstanding relationships with patients and their families and their knowledge of patients' medical and social backgrounds provide a foundation for assessment seldom available to the specialist service, and certainly not at initial presentation. The key feature of our early intervention approach was very close liaison with family practitioners and general health nurses, with an emphasis on developing practical strategies for identifying early signs of major mental disorders. A 10-question screening interview (10-QS) developed for clinical


the need for constructive activity have also been resolved efficiently (Stein and Test 1980). To date, combined drug and psychosocial treatment has been limited to the long-term management of established cases. Treatment has usually been provided in specialized tertiary care settings and initiated long after patients presented. The association between early intervention and good clinical and social outcomes, however, suggests that treatment should begin as soon as schizophrenia is suspected (Crow et al. 1986; Munk-Jorgensen 1986; Wyatt 1991; Loebel et al. 1992; McGlashan 1996, this issue; McGlashan and Johannessen 1996, this issue; McGorry et al. 1996, this issue). As with almost all medical conditions, treatment delays are associated with poor—often with catastrophic—outcomes. All too often, when the accessibility and acceptability of services have been inadequate, mental health professionals have blamed the illness, the patients, or informal or primary caregivers. Factors that can lead to treatment delays include fears about the consequences of having a mental disorder, difficulties in gaining access to mental health services, poor screening by primary health professionals, inexact diagnosis by mental health professionals, and inefficient case management, particularly of suspected cases where symptoms matching diagnostic criteria are not yet evident. One way to solve these problems is to integrate specialized mental health care and primary health care services. The remainder of this article will outline one such venture and the preliminary results.


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Table 1. A 10-questlon screening (10-QS) 1. How have you been sleeping In the past week? Any difficulties getting to sleep? Waking early? 2. Have you lost your appetite recently? Weight loss of 2 or more kilograms? 3. Have you experienced loss of energy or interests recently? 4. Have you been worrying a lot about everyday problems? 5. Have you had difficulty concentrating on reading or watching television? Have you been more forgetful than usual? 6. How do you see the future? Do you ever feel that life is not worth living? Have you ever felt you would like to end it all? 7. Have you any odd habits, like checking or cleaning more than other people? 8. Do you ever have attacks of palpitations, sweating, shaking, or dizziness accompanied by feelings of intense fear? 9. Has anybody commented that your speech has become odd or difficult to understand? 10. Have you ever had the experience of hearing people's voices speaking when nobody seems to be around?

Table 2.

Prodromal signs checklist

Onset of one of the following without explanation: • Marked peculiar behavior • Inappropriate, or loss, of expression of feelings • Speech that is difficult to follow • Marked lack of speech and thoughts • Marked preoccupation with odd ideas • Ideas of reference—things have special meanings • Persistent feelings of unreality • Changes in the way things appear, sound, or smell

the request of the family practitioners. Formality was minimal. Referral letters were replaced with a card entitled "The Community Health Record" that enabled family practitioners to make brief, pertinent remarks about the nature of the problem, the reason for consultation, and current clinical management. Whenever possible, the initial specialist consultation was made jointly with the family practitioner

(or community nurse) most involved with the patient's health care. This consultation was usually preceded by a brief discussion about background and general health issues. Mental health screening of possible schizophrenic disorders. This discussion aimed to define six things. First, the specialist sought to identify the nature and duration of the disturbed behavior and the patient's mood and


use formed the basis for this training (table 1). Initial training seminars for each family practice, similar to those reported by Goldberg and Huxley (1980) in Manchester, were not well attended. Subsequently, family practitioners and nurses were trained by mental health therapists individually in case-related discussions and weekly tutorials. Despite this training's informality, family practice teams considerably enhanced their skills at detecting possibly serious mental disorders. In addition to screening for established symptoms with the 10-QS, the family practitioners were trained to recognize eight early warning signs of schizophrenia, derived from the prodromal signs outlined in DSM-1I1 (American Psychiatric Association 1980) (table 2). A checklist briefly elaborating on these features was provided to the practitioners. Most of the practitioners reported that they recognized these features readily but tended not to go to the trouble to refer patients to a mental health clinic unless they became much worse. In describing the frustration he felt when he referred early cases to mental health services, one family practitioner said, "when you send them to the psychiatrist you are told there is nothing wrong, or nothing you can do about it." Integrating physical and mental health services facilitated informal consultation and assured family practitioners that any person with unusual features would receive specialized assessment without delay. Accessible mental health specialist consultation. Mental health service staff were available to conduct routine assessments at any time throughout the week at

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entire assessment and treatment. In these cases, mental health specialists can provide supervision and consultation when needed. Daily contact between mental health professionals and family practitioners fosters such collaboration. Patients and their caregivers may seek initial assistance for problems associated with schizophrenia onset from other medical, counseling, educational, and social agencies—even the police and judicial system (e.g., when persecutory ideation is prominent). As the gatekeepers for mental health service consultation, family practitioners screen cases before requesting second opinions and keep lifetime records of each person's physical and mental health. Requests by community nurses, social workers, teachers, counselors, police officers, lawyers, and other community agents for consultation for suspected mental health problems were made initially to the family practitioners, who decided whether to ask for a second opinion from the mental health specialists. Regular contact was maintained with these agencies, as well as with schools, church groups, volunteer groups, and others, so that consultation could be facilitated and cases detected as early as possible. Clinical management was also shared with these people when appropriate. Assessment of Early Psychotic States by Mental Health Professionals. Standardized interview procedures for assessing mental disorders are not generally taught in current training programs for the family practice or mental health professions. Most modern training programs focus on generic interviewing skills that emphasize

empathy and rapport building and the asking of open-ended questions that might eventually uncover psychiatric problems. Such interviews are seldom effective in screening for major mental disorders, particularly those characterized by bizarre experiences and phenomena, such as delusions, hallucinations, and thought interference. To overcome this problem, a standardized, semistructured mental health assessment schedule was developed. The schedule, which included interviews with patients and key caregivers, aimed to clarify biomedical vulnerability and psychosocial stress factors associated with major mental disorders (Falloon and Fadden 1993). This was followed by a standardized mental status assessment using the Present State Examination (PSE-9; Wing et al. 1974). All clinicians entering the service were trained in these interview procedures before they were permitted to assess patients. They also completed the self-paced learning program "Detecting the Characteristic Symptoms of Schizophrenia" (Falloon and Lukoff 1984) before receiving workshop training and personal tutoring. Clinicians rated 10 audiotaped interviews of people displaying a wide range of phenomenology, and their assessments were then scored item for item. A mean score of 80 percent exact item agreement was considered to demonstrate competence in this skill. In addition, clinicians conducted two PSE interviews, which were audiotaped, co-rated by an expert, and assessed for the quality of the interviewing skills. Further training was provided when needed. This rigorous training ensured that all people assessing patients


cognitive functioning, and to determine if the features suggested a schizophrenic disorder, distress caused by recent major stress, or delusions or hallucinations (10-QS) or merely behavior consistent with the patients' usual patterns, however strange. The specialist also looked for features suggesting a high risk for a schizophrenic disorder, for example, first-degree relatives diagnosed with a psychotic disorder, a birth injury and resulting developmental or learning problems, stimulant or drug use, and neurological irregularities such as motor incoordination or signs of temporal or frontal lobe dysfunction, including unpredictable aggressive outbursts or lack of social problem-solving skills. The other possible contributing factors the specialist would assess included current major life events and ambient stressors and the adequacy of coping efforts and community supports, current management of any physical disorders (e.g., drugs taken, neuroendocrine problems), current management of any mental disturbance by the primary care team or others, and the capacity of the primary care team to continue management with specialist backup when necessary. Often well informed about patients' social and medical histories, family practitioners, using medical records, can substantially reduce the time needed to secure reliable background information. Detailed medical assessment including laboratory testing may be a vital part of the initial mental health assessment, and the family practitioner is usually the best person to supervise such assessments. Indeed, in some cases the practitioner may be the best person to manage the


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and was unable to express his frustration in an appropriate manner. The family practitioner received this preliminary feedback, and no drugs were prescribed. A followup assessment by the project psychiatrist a few days later validated the therapist's assessment, which formed the basis for a report to the court. A program of social skills training and alcohol abstinence was initiated. No further phone calls were made, and the man began to make friends outside the bar environment. The court placed him on probation with the condition that he continue to receive mental health care and to abstain from using alcohol. The continuous availability of a multidisciplinary team of mental health professionals trained to make reliable assessments of mental disorders ensured that assessment was made without delay. Mental health assessments of patients considered to have early signs of schizophrenia followed the following course. First, the patient and the key caregiver (usually a relative or household member) completed the modified version of the Early Signs Questionnaire (ESQ; Herz and Melville 1980). This questionnaire, which lists features found in the prodromes of florid schizophrenic episodes, was used to prompt patients and their caregivers to identify prodromal symptoms, particularly those of a subtle nature, such as interpersonal withdrawal. If features reported by the family practitioner or noted on the ESQ suggested a prodromal state, a comprehensive psychiatric assessment was then completed. A psychiatric, medical, drug, and family history was also obtained, using the systematic schedule, to

determine if the patient was at greater risk of having a schizophrenic disorder than others in the community, was exhibiting nonspecific stress responses, or merited further monitoring even though the initial presentation was uncharacteristic of a schizophrenic prodrome. People who had first-degree relatives who suffered from schizophrenia, who had a history of obstetric complications, who had had prodromal episodes in the past, or who made unexplained suicide attempts were all considered to have a higher risk of schizophrenia than the average person living in the community. Stimulant abuse and organic medical conditions that may have contributed to the current state, including convulsive disorders, received further specialized consultation when indicated. Next, the mental health professional would conduct a PSE. If the patient was highly disturbed or uncooperative, only the module dealing with schizophrenic symptoms would be completed. A nonmedical assessor was encouraged to consult with a team psychiatrist in such cases. The differential psychiatric diagnosis was then considered in consultation with the psychiatrist to determine if the prodromal features signified the early stage of a manic episode, atypical depression, or acute anxiety disorder. The mental health and family history provided additional information to assist in determining the probability that the current state represented the initial phase of a first episode of schizophrenic psychosis. In all such cases a project psychiatrist conducted an independent assessment to validate key aspects of


met the minimum standards for validity and reliability required for most psychiatric research projects. (Most of the nonmedical staff who completed this training exceeded the levels of reliability obtained by qualified project psychiatrists.) Family practitioners were thus assured that nonmedical staff were capable of deputizing for trained psychiatrists, at least for assessing routine cases. All assessments were reviewed by a psychiatrist, who provided a second assessment when any doubts or discrepancies arose. In one case example, a family practitioner sought consultation on a young man who had been arrested for making threatening phone calls to a local factory. The doctor was impressed by the bizarre nature of these calls and suspected that the man might be suffering from schizophrenia. A nurse therapist immediately conducted a detailed history, supplemented by information from the patient's mother, and followed up with a PSE. The therapist then consulted with the project psychiatrist and discussed the findings. Apparently the threatening phone calls always occurred at night after the man had been drinking heavily with friends. He was mildly mentally retarded and was coaxed to make the calls by his drinking companions, who found the behavior highly amusing. The man had no history of mental disorders or evidence of delusions or hallucinations. Nor was there a family history of mental disorders. The patient and his elder brother had both been laid off by the factory several years earlier, and the patient continued to be bitter about this. It was evident that he had limited interpersonal competence

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Early Intervention Strategies. When a person was suspected of experiencing an early phase of schizophrenia, an integrated crisis management program was initiated without delay. Each component of this program, which included education, stress management, and neuroleptic medication, was tailored to individual needs within a clinical management protocol. Increasing understanding of the nature of schizophrenia. Within 24 hours of detection, the

patient and key caregivers attended an informal educational seminar explaining the reason for early intervention. They were told that the features displayed by the patient were possibly early signs of an impending episode of schizophrenia and that treatment might ameliorate the condition. The characteristic symptoms of schizophrenia, theories of etiology, prognosis, and effective integrated drug and psychosocial treatment methods were outlined in an informal discussion in the home. The high rates of remission and recovery from effective long-term treatment were emphasized, as well as the benefits of support from family and friends and of 24-hour inhome care. Questions and concerns were discussed frankly to foster an optimal therapeutic alliance. The aim of this education was primarily to enhance the collaboration between patients and their informal and professional caregivers. We hypothesized that enhancing understanding of mental disorders in a specific way helped people take part in their own mental health care. This shared understanding between patient and professional appears to be a major factor in the successful monitoring of prodromes in established cases (Heinrichs et al. 1985). It has been argued that such education may have detrimental effects and lead to escape and avoidance responses by patients and their caregivers. We have not yet encountered such responses. On the contrary, education provided in this interactive, personalized, home-based manner appears to be highly reassuring to everyone involved. When this education was completed, informed consent to pursue the early intervention program was

sought from patient and key caregivers. In every case, this intervention was welcomed. Home-based stress management. At the conclusion of the initial educational meeting, the rationale for a stress management approach that included key caregivers was provided, and the vulnerability and stress factors that may have triggered the patient's condition were outlined. When a precipitating life event or persistent ambient stressor was clearly identified, immediate efforts were made to help patient and caregivers cope with and resolve the problem. Further assessments of stressors and of the patient's and caregivers' coping capacity were made as soon as convenient. Stress management sessions, usually including key caregivers, were conducted daily. Intensive in-home nursing care was available when necessary, supported by a team of psychologists, social workers, and occupational therapists. This crisis management was conducted according to the home-based model of Stein and Test (1980). At all times, the level of support was targeted to the expressed needs of patient and caregivers. Efforts were made to teach efficient problem solving within the household according to the behavioral family therapy model of Falloon and colleagues (1984). For cases where coping skills were good and stress levels not excessive, stress management training was usually Limited to one or two 1-hour sessions. In cases where persisting social or interpersonal stresses such as unemployment, housing, marital conflicts, or interpersonal inadequacy were implicated, however, stress management


the mental health assessment, usually on the day the patient presented at the family practice. Patients were invited to discuss any stresses in their social environment preceding the onset of the early features. All changes in the social network that might have necessitated adjustment by the patient were considered whether they were positive or negative or whether they involved the patient directly or indirectly. The assessment routinely included an interview with key people in the patient's social environment, usually family members or friends. The aims of this interview were (1) to validate important aspects of the assessment and initial formulation and to provide further information when necessary, (2) to assess the strengths of home-based support for clinical management, including the individuals' understanding of mental disorders and their treatment (so that education could be tailored to their levels of comprehension), and (3) to assess the mental health of other household members and their own vulnerability to disorders as a result of the stress associated with caring for the disturbed person.

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Continued Care Procedures. Stress management and drug therapy. The combined crisisoriented stress management and drug strategies were continued until the prodromal features had remitted. Continued monitoring of stress in the environment enabled the therapist to define the coping capacities of the patient and the household and to provide for further training in problem-solving skills as needed. Training continued until the household displayed proficiency in coping with all major existing stresses as well as those considered likely to occur in the near future. A regular weekly household meeting, convened in the home, specifically ad-

dressed problem issues for the patient and household. This meeting, considered to be the optimal means of ensuring that stress management would be sustained, was based on empirical observations in earlier studies of family-based stress management for schizophrenia (Falloon 1985). Monitoring recurrence of prodromal features. Patients and their caregivers were trained to recognize the specific signs displayed by the patient during the prodromal phase. A wallet-sized card was provided for each patient listing the one to three signs that were most likely to discriminate a future prodromal episode. Detailed procedures for contacting the family practitioner and the mental health therapist were included on the card. Additional prompt sheets with identical information were provided for personal and household display so that future episodes could be detected as early as possible. Mental health monitoring. The mental health therapist conducted assessments of clinical, social, and caregiver status at 3, 6, 12, and 24 months after complete resolution of the prodromal state. Early warning signs were reviewed with patients and caregivers, and stress levels and coping functions were assessed and booster sessions provided if household problemsolving functions had lapsed. In cases where disability persisted, further psychosocial rehabilitation strategies, including social, parenting, vocational, and leisure skills training were provided. After 24 months free of psychiatric impairment and associated disability, patients were transferred back to routine family practitioner monitoring.

Evidence for Effectiveness: A Pilot Study. A clinical epidemiological study was conducted in one mental health service that was fully integrated with 18 family practitioners to provide care for a population of 35,000 in a semirural area of England (Falloon and Fadden 1993). All general practitioners and mental health professionals were trained to apply the early detection and intervention strategies. A previous study had revealed an annual incidence of 7.4 new cases of schizophrenia per 100,000 population as defined by PSE/CATEGO (Wing et al. 1974) classes S and P in Buckinghamshire during 1974 and 1975 (Shepherd et al. 1989). The sample included in this study was considered to be highly representative of people who experienced the onset of schizophrenia in this region. Individuals who did not present with behavioral disturbances sufficiently serious to warrant hospital admission were not included; thus, the sample represents a more conservative estimate than that expected using the methodology of the current study and is similar to the average hospitalized incidence found across the United Kingdom (Der et al. 1990). Observed incidence of new cases of schizophrenic disorders. In 4 years (1984 to 1988), one person was defined as having an initial episode of schizophrenia according to PSE/CATEGO criteria for classes S and P. This represented an annual incidence rate of 0.75 per 100,000 (Falloon 1992). This person was not admitted to a hospital and experienced a full remission after 4 weeks of low-dose neuroleptic and stress management intervention. She presented to her family practitioner complaining of


was prolonged until high stress levels had been resolved. Targeted neuroleptic medication. When features of perceptual or cognitive impairment, agitation, or sleep disturbance were prominent, the family practitioner was advised to prescribe a small dose of a low-potency neuroleptic drug, usually thioridazine or chlorpromazine 25 to 100 mg daily. Drug therapy was carefully targeted to a clearly specified impairment (e.g., "sleeping 4 hours per night," "unable to concentrate on television for more than 2 minutes"), and the minimum effective dose was given (McEvoy et al. 1991). Nurses and psychiatrists monitored the effectiveness of this intervention strategy daily, alerting the family practitioner to the onset of any unwanted effects. Drug therapy was time limited and seldom lasted more than 1 week. If no specific symptoms likely to respond to neuroleptic medication were evident, no neuroleptic drugs were prescribed.


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without major setback. The remaining people who presented with subthreshold psychoses all remained free of significant psychiatric symptoms throughout a 2-year followup period. Detection of "hidden" cases. The low incidence of new cases of schizophrenia in this project prompted a specific effort to uncover any cases that may not have been detected. A review was conducted of all persons in the area who were regularly prescribed psychoactive drugs. Social services and general community nursing services were asked to review any cases that might be attributed to major mental disorder. Six additional cases of definite schizophrenia were detected. All the individuals had experienced onset of the disorder before the study period; in four, the onset was more than 5 years earlier. Appropriate clinical management was instigated with beneficial results. Four other cases with diagnoses of schizophrenia were reviewed and considered to have alternative conditions, and their clinical management was altered accordingly.

Discussion This article presents a methodology for the early detection of and intervention in initial episodes of schizophrenic disorders so that individuals can receive effective clinical management before psychotic features have reached the levels on which modern diagnostic systems are based. A small pilot study suggested that the incidence of florid episodes of schizophrenic disorders was noticeably reduced. While such an observation appears dramatic, extreme caution should

be applied to its interpretation. The efficiency of the case finding used in this study was limited by the inability to secure funding to conduct a comprehensive epidemiological survey. These limitations are discussed fully in other articles (Falloon 1992; McGlashan 1996, this issue; McGlashan and Johannessen 1996, this issue). Qaims of preventing major health problems always invite skepticism and create controversy in the medical profession. The difference between averting the florid episodes of a clinically defined disorder such as schizophrenia and actually preventing the disorder must be stressed. However, until the pathophysiology of a disorder is better understood, such an early detection approach may merit consideration. Any conclusions drawn from this work should focus merely on the possibility that intervention with schizophrenia and other major mental disorders should occur as soon as the first symptoms of the disorder present, not delayed until the full syndrome is evident and clear diagnostic criteria are met. All the cases we have treated at an early stage showed at least one symptom of a disorder within the schizophrenia spectrum, and all responded well to specific standard treatment approaches. The targeted approach to medical treatment focuses on specific symptoms with specific remedies, particularly symptoms linked to arbitrary diagnostic criteria. Psychiatric treatment remains symptomatic, and treatment of schizophrenia in particular is highly safe when it adheres to well-defined guidelines. This is especially true for lowdosage, short-term use of neuroleptic medication and for psycho-


sleep disturbance. Rather than immediately prescribing a brief course of sedative medication, the previous management choice for such a presentation, her family practitioner asked her what was contributing to the sleep problem. She told the practitioner that when she went to bed she heard voices talking about her. The family practitioner immediately contacted the mental health therapist in her practice, a PSE was completed, a diagnosis of schizophrenia was confirmed, and, after consultation with the psychiatrist, an integrated psychosocial and drug management program was started. Observed incidence of "prodromal" symptoms. During the 4-year period, 15 other cases with symptom patterns suggesting an early phase of a florid schizophrenic episode were observed; however, these cases failed to reach the diagnostic thresholds for functional psychotic disorders. All but two experienced full and rapid recovery after brief integrated intervention. One developed a bipolar disorder, with recurrent depressive and hypomanic episodes that were readily treated in their early stages using a similar integrated drug and stress management approach with monitoring of early warning signs. Another man experienced three episodes of prodromal symptoms and has remained under continuous mental health supervision since that time. After several years of intermittent medication targeted to prodromal periods, he was prescribed continuous low-dosage oral neuroleptics. A combination of family-based stress management and social and vocational skills training has enabled him to progress slowly but steadily toward his life goals

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thereby alleviate the concerns of those we have considered vulnerable solely on phenomenological grounds (Nuechterlein 1990). Medicine is not an exact science, however. Therefore, it is likely that clinical phenomenology will always remain the cornerstone of clinical diagnosis and outcome assessment. Future research on early intervention must estimate all the relative clinical, social, and economic costs and benefits of this approach and ascertain whether early intervention is an advance over waiting until persons develop florid episodes before receiving accurate diagnoses and treatment (see Crow et al. 1986). At present, schizophrenia is one of the major public health problems in industrialized countries, with substantial economic costs compounding human suffering. Any strategies that appear to reduce the morbidity associated with this disorder must be considered seriously, particularly if such reductions appear to be sustained. The key element of the approach we have developed is dose collaboration between comprehensively trained mental health and family practice professionals. Such a service may be the most difficult component of this approach to replicate, especially if the service is restricted to providing early intervention solely for schizophrenic disorders. In the absence of welldefined prodromal syndromes, projects that focus exclusively on preventing schizophrenic episodes would appear to make inefficient use of resources. However, a generic program that integrates stress management and drug therapy can be applied to all functional psychoses, with drug selection determined by the predominant pattern

of symptoms. Staff in the Buckingham Project divided their time equally among early detection, crisis management, and long-term rehabilitation of all major mental disorders in a clearly defined catchment area, based on registration with family practitioners in the area rather than on geographical borders. Additional evidence suggests that similar benefits were achieved from early intervention with depressive symptoms (Falloon et al. 1992). We conclude that a comprehensive mental health service integrated with an effective primary care program may be able to provide specific interventions for persons who present with features consistent with prodromes of schizophrenia. This very limited preliminary project suggests that this approach may prove feasible and may even contribute to a lower incidence of florid episodes of schizophrenia, or at least to more benign presentations. Though it would be a major undertaking, a random-controlled outcome study is essential to validating the approach outlined here. We are currently seeking research funding to carry out such a trial in Auckland, New Zealand, comparing individuals with "at-risk mental states" who are randomly assigned to continued family practice care with those receiving an approach similar to the one described in this article.

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educational approaches to stress management. It is likely that some of the cases we treat in this way may have remitted without any specific treatment, and it could be argued that the risk in treating such cases is not justified. However, the risks of delaying treatment are well documented and could be seen as an indictment of the laissez-faire attitudes of many psychiatric services that, despite decades of protest from professional critics and from patients and their families, refuse to adopt consumer-oriented approaches to care or even to incorporate major clinical advances into their practices. Consistent with this lack of professional understanding of consumer needs, the major argument against this early intervention approach has not been the risk of serious drug side effects but concern that the patients may suffer as a result of being labeled with schizophrenia. Educating people about schizophrenia and other major mental disorders appears to have considerable benefits and very few deleterious effects. Early intervention is the very antithesis of the "labeling" concepts that have been so justifiably criticized. Inevitably some people who will not develop any significant disorder receive information and stress management that they do not need. They may also worry needlessly about the possibility of de- . veloping schizophrenia in the future. In the few cases we have treated, such problems have not arisen. Promising research on information processing, biochemistry, genetics, and brain scanning suggests that we may soon be able to differentiate those persons most vulnerable to this disorder and

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The Authors Ian R.H. Falloon, M.B., Ch.B., D.Sc., is Professor of Psychiatry, University of Auckland, New Zealand, and Director of the international Optimal Treatment Project for schizophrenic disorders. Robert R. Kydd, M.B., Ch.B., Ph.D., is Professor of Psychiatry and Head of the Department of Psychiatry and Behavioural Science, University of Auckland. John H. Coverdale, M.B., Ch.B., is Senior Lecturer in Psychiatry and Tannis M. Laidlaw, Ph.D., is Lecturer in Psychiatry, University of Auckland, Auckland, New Zealand.


McGorry, P.D.; Edwards, J.; Mihalopoulos, C; Harrigan, S.M.; and Jackson, H.J. EPPIC: An evolving system of early detection and optimal management. Schizophrenia Bulletin, 22(2):305-326, 1996.
