“Very early schizophrenia still constitutes a relatively unexplored territory. Entry into this territory calls for new ideas on the social problems involved in bringing the early schizophrenic promptly under treatment, or where the treatment should be carried out and in what it should consist.” D. Ewen Cameron (1938)

Background The primary rationale for early detection and intervention in schizophrenia is the disorder's severity, chronicity and treatment resistance. This suggests that researchers pay closer attention to schizophrenia's premorbid and onset phases, when the vulnerability to psychosis becomes expressed and the neurobiological deficit processes driving symptom formation appear to be the most active.

Method We review the evidence that brain plasticity may be retained or reversed despite deficit processes.

Results The data are preliminary but suggestive enough to warrant further research.

Conclusions Overall, we need to focus on the early course of schizophrenia, detecting cases early at onset or in the prodrome, testing whether this enhances treatment response and prognosis, and predicting at-risk cases early in the prodromal phase. Designs to address these questions are presented, and relevant issues are discussed.

Background The current study examines teacher ratings as a tool for identifying students at risk of developing psychosis. Follow-up and follow-back studies have shown that teachers are capable of identifying individuals who later develop serious mental illness.

Method We examine the long-term outcomes for individuals at genetic risk who were identified as showing markedly deviant behaviour and those identified who did not show markedly deviant behaviour.

Results Teachers were able to correctly anticipate 35% of students who developed schizophrenia. Furthermore, those identified as showing markedly deviant behaviour had poorer clinical and psychiatric outcomes 10 and 25 years later than those identified as not behaving with marked deviance. Their ratings also differentiated, within the group of people with schizophrenia, which individuals would show evidence of poorer functioning 25 years later. These results were replicated in a group of students not at genetic risk of schizophrenia. Within this low-risk group, teachers were able to predict which students would develop psychotic disorders.

Conclusions Teacher ratings were particularly useful in predicting clinical and psychiatric outcomes 10 and 25 years later. The applicability of these findings in early intervention and treatment research is discussed.

Background The identification of people at high risk of becoming psychotic within the near future creates opportunities for early intervention prior to the onset of psychosis to prevent or minimise later ill-health. The present study combines current knowledge about risk factors for schizophrenia with our knowledge of psychotic prodromes in an attempt to identify a group particularly vulnerable to impending psychosis. We wanted to identify people with high likelihood of transition to psychosis within a follow-up period of 12 months, and to determine the rate of transition to psychosis in this group.

Method Various state and trait risk factors for psychosis were used alone and in combination to operationally define a putatively high-risk group. Operationalised criteria for onset of psychosis were established. The individuals were assessed monthly on measures of psychopathology for six months.

Results Eight out of 20 people made the transition to frank psychosis within a six-month follow-up period. Follow-up of this group is still in progress, and the 12 month transition rate might prove to be higher still.

Conclusions We have demonstrated that it is possible to identify individuals with a high likelihood of onset of psychosis within a brief follow-up period. This lays the foundation for early treatment in an attempt to prevent, delay or minimise the severity of first onset of schizophrenia.

Background This study aims to gain an understanding of treatment delays and their nature in initial psychotic episodes. We investigated to whom people turn for help, how long that approach takes and subsequent delays in commencing treatment.

Method Qualitative and quantitative methods were combined with interviews of 62 people suffering from first-episode psychoses, aged 16–30 years, who had recently accessed a specialist mental health service in Melbourne, Australia. A modified version of the World Health Organization Encounter Form was analysed in conjunction with other data.

ResultsPathways to care and the ways in which they were experienced were highly variable, with 50% of people experiencing psychotic symptoms before approaching any service. The general practitioner played a key role with 50% of people having had GP contact at some point prior to commencing effective treatment. Where an individual's own efforts to seek early help failed, the role of relatives and others was subsequently vital.

Conclusions Opportunities exist for shortening delays through targeted health promotion activities and professional training. The need is indicated for a multi-layered or topographical strategy to identify and minimise critical barriers on the route to early intervention. Refinement of interview techniques and instruments of measurement are needed to enhance the explanatory power of data collected.

Background The Hillside Study of Risk and Early Detection in Schizophrenia is a prospective study of young probands (ages 14–28) and their at-risk siblings (ages 14–24). A major goal is the identification of early predictors of illness that will facilitate intervention. The project design and pilot study are discussed.

Method Fifteen adolescents were compared to 14 typical age-of-onset adults, all undergoing their first hospitalisation for schizophrenia.

Results There were no differences between adolescents and adults on any of the measures administered (i.e. attention, eye tracking, neurocognitive or clinical). In addition, for the sample overall, no association was found between neurocognitive functions and clinical state, either at admission or after treatment.

Conclusions Individuals with adolescent onset of schizophrenia are considered to be representative of schizophrenia in general. Furthermore, neurocognitive deficits and clinical symptoms are concluded to be two independent classess of risk indicators.

Background Early detection and intervention in schizophrenic disorders is an important challenge for psychiatry.

Method Review of literature on effective biomedical and psychosocial intervention strategies.

Results Comprehensive programmes of drug and psychosocial interventions with adults who show early signs and symptoms of schizophrenic disorders may contribute to a lower incidence and prevalence of major episodes of schizophrenia. These programmes combine early detection of psychotic features by primary care services, with close liaison with mental health professionals. Long-term monitoring of signs of recurrence, with further intervention, appears essential to maintain these benefits.

Conclusions Field trials demonstrate that effective early treatment strategies can be routinely applied in clinical practice.

Background The HOMES (Home-Oriented Management of Early Psychosis) programme is a new home-based management programme for people presenting for the firsttime with psychotic illnesses. The present paper aims to present preliminary data as to the efficacy of this programme and factors identified as being associated with successful prevention of hospital admission.

Method The programme applied to all the people presenting to the Dandenong Hospital Department of Psychiatry with first-episode psychosis who are considered suitable at first assessment for home-based management. A programme description is included in the paper. Prospective evaluation data on the first 31 people managed within the programme is presented.

Results Twenty-two out of 31 people were managed without the necessity for hospital admission. Illness severity was not related to the ability to manage this group of people outside of hospital. The level of social support and duration of untreated psychosis prior to treatment, may be most closely related to home-based treatment success.

Conclusions Home-based management of people with first-episode psychosis is feasible and offers a viable alternative to admission for this group. Home-based treatment is dependent on the degree of social support but is independent of the degree of illness severity.

Background The early course of illness in first-episode schizophrenia was examined with special emphasis on the duration of untreated psychosis and pathways to care.

Method The consecutively admitted individuals (n=34) were assessed on premorbid functioning, duration of untreated psychosis, global functioning, symptoms and social network. To clarify the obstacles for receiving earlier treatment, 17 case histories with long duration of untreated psychosis were intensively studied.

Results The duration of untreated psychosis was on average very long (130 weeks), the median value was 54 weeks. The long duration of untreated psychosis group (> 54 weeks) had greater deterioration in the premorbid phase, a weaker social network and were more withdrawn than the short duration of untreated psychosis group (< 54 weeks). The main obstacles for receiving treatment were withdrawal and poor social network.

Conclusions In order to identify people earlier, a system of detection must be mobile, easily accessible and attentive to early symptoms of psychosis. It seems to be important to educate the social network related to the individual about the importance of early treatment.

Background We consider the evidence for the proposition that the early phase of psychosis (including the period of untreated psychosis) is a critical period' in which (a) long-term outcome is predictable, and (b) biological, psychological and psychosocial influences are developing and show maximum plasticity.

Method First-episode prospective studies, predictors of outcome and the genesis of patients' key appraisals of their psychosis are reviewed.

Results The data support the notion of the ‘plateau effect’, first coined by Tom McGlashan, which suggested that where deterioration occurs, it does so aggressively in the first 2-3 years; and that critical psychosocial influences, including family and psychological reactions to psychosis and psychiatric services, develop during this period.

Conclusions The early phase of psychosis presents important opportunities for secondary prevention. We outline a prototype of intervention appropriate to the critical period. The data challenge the widely held assumption that first-episode psychosis is a benign illness posing little risk.

Background Studies of first-episode patients allow investigation of the biological basis of psychotic disorders without the potential confounds of prior treatment and illness chronicity. Prospective studies of this population can clarify the impact of illness course and treatment on neurobiology.

Method We summarise preliminary findings from our ongoing magnetic resonance imaging and spectroscopy studies of first-episode schizophrenia patients being conducted prospectively from index evaluations through a period of two years; during this period, patients were treated with either a conventional antipsychotic such as haloperidol, or the atypical risperidone.

Results Baseline neurobiological evaluations in first-episode schizophrenia patients have revealed evidence for structural and functional brain abnormalities consistent with a neurodevelopmental model of this illness. Our preliminary data support the value of risperidone as an antipsychotic drug of first choice among patients with early schizophrenic illness.

Conclusions Focused studies of first-episode patients have the potential to unravel pathophysiology of schizophrenic illness. Such knowledge is critical for more effective early detection, intervention and even prevention of this enigmatic disorder.

Background A growing interest in first-episode schizophrenia reflects the belief that this line of investigation will lead to further developments regarding schizophrenia's aetiology, course and outcome.

Method Evidence from more recent clinical trials involving first-episode schizophrenia is integrated with neuroimaging data, specifically positron emission tomography, to provide direction regarding pharmacotherapy.

Results Individuals with a first episode of schizophrenia appear particularly responsive to pharmacotherapy, as well as quite sensitive to side-effects. At the same time, current clinical and receptor-binding data support the efficacy of low-dose neuroleptic treatment.

Conclusions Early and effective treatment of schizophrenia has been associated with better long-term outcome. Low-dose neuroleptic therapy is an effective treatment strategy and the diminished risk of side-effects with this approach may further enhance compliance and outcome.

Background The Early Psychosis Prevention and Intervention Centre (EPPIC) commenced operation in Melbourne, Australia, in 1992. It offers a model for management of first-episode psychosis, utilising principles of early detection, low-dose medication and comprehensive psychosocial interventions within the least restrictive setting.

Method Data were examined from the first three months of treatment for all consecutive people with first-episode psychosis (n=231) accepted in the programme in 1995–1996. A subsample of patients (n=120) was assessed comparing clinical ratings with variables of gender, diagnosis, hospitalisation, and medication.

Results Hospitalisations were brief, and avoided for a third of the people. Low-dose antipsychotic medication was maintained in both in-patient and community settings. Those people with manic psychosis were more likely to be hospitalised. Hospitalised people received higher antipsychotic dosages, and had a greater rate of reduction in Brief Psychiatric Rating Scale psychotic sub-scale scores at three months follow-up. Eighty per cent of a representative subsample had responded to treatment and 63% were in remission by the end of the three months.

Conclusion This naturalistic study suggests that the feasibility of implementing the EPPIC model in a range of clinical settings is promising and applicable in practice.

Background The concept that early intervention with antipsychotic medications improves the long-term course of schizophrenia is discussed.

Method This report reviews the literature concerning early intervention with antipsychotic medications for people with firstepisodes, and how it affects long-term morbidity. It also studies the effects of discontinuing antipsychotic medications on relapse for people with first episodes.

Results Early intervention with antipsychotic medications appears to decrease the long-term morbidity of schizophrenia.

Conclusions Early intervention with antipsychotic medications should be encouraged for people experiencing their first episode of schizophrenia. This report proposes that studying the various phases of subject response to treatment can be helpful in elucidating when antipsychotic medications should be tapered or withdrawn.

Background Studies have proved that early intervention can delay psychotic relapses, and prevent psychosocial deterioration in people with schizophrenia and related disorders.

Method Our study with young people with recent onset schizophrenia has shown that an intensive intervention programme had a beneficial effect on the occurrence of psychotic relapse and the course of psychotic syndromes. This effect lasted until the end of the 15-month intervention. No significant effect of the two different intervention conditions became apparent.

Results The results of a follow-up study showed that this beneficial effect did not last. Fifteen per cent of the people had a psychotic relapse during the intervention, whereas 64% relapsed during follow-up.

Conclusions These results show that referral to other mental health agencies after intervention is not sufficient and that more support is required to continue disease management, medication compliance and stress management.

Background Depression has been described in people presenting with first-episode schizophrenia, a group at high relative risk of suicide.

Method This was a longitudinal cohort study of 113 people during an acute relapse and 13 having a first episode. Follow-up occurred at three months and at one year. This report compares level of depression in the first episode and in the relapsing group. Levels of depression were assessed using the Calgary Depression Scale for Schizophrenia (CDSS).

Results The median CDSS score was statistically significantly higher in the first-episode group both during the acute phase and at three month follow-up. At one year the first-episode group continued to have higher levels of depression than the multiple episode group.

Conclusions For people with a first episode of schizophrenia, depression is a major problem during the initial acute phase and during the first year of illness. In light of the high risk of suicide in this population, recognition and treatment of depression requires greater attention.

Background The present study describes the results of the pilottesting of a therapy we have developed for people with first-episode psychosis. Cognitively-oriented psychotherapy for early psychosis (COPE) is aimed at facilitating the adjustment of the person, and at preventing or alleviating secondary morbidity in the wake of the first psychotic episode.

Method Eighty people formed three groups: those who were offered and accepted COPE (COPE subjects); those who refused COPE (refusal subjects); and those who were offered neither COPE nor any other continuing treatment from our service (control subjects). The individuals were assessed prior to, and at the end of, COPE treatment (a 12-month period) on the Integration/Sealing Over, Explanatory Model, Scale for the Assessment of Negative Symptoms, Brief Psychiatric Rating Scale, Quality of Life, SCL–90–R, and Beck Depression Inventory measures.

Results People who received COPE obtained significantly superior scores (P < 0.05) to the control group on four of the seven measures but only significantly out-performed the refusal group on one of the seven measures (P<0.05). The COPE group performed significantly worse on the BDI than the refusal group (P < 0.05). Effect sizes are also provided for each measure.

Conclusions There seems to be a place for psychological therapy in this group of people butour results need to be replicated in a more definitive randomised controlled trial and such a study is now in progress.

Background Cognitive-behavioural treatments have previously been explored in the treatment of chronic psychotic problems, but recently, the effectiveness of these treatments has been investigated with regard to recent onset and acute psychosis.

Method The literature relating to cognitive-behavioural treatments in psychosis is explored and the application of the approach to recent onset psychosis is described in detail.

Results There appears to be a growing body of evidence that the advances made in the treatment of people with chronic treatment resistant psychosis can be similarly applied to people with recent onset and acute psychosis.

Conclusions Cognitive-behavioural treatments are feasible with recent onset psychotic patients although further evaluation of their effectiveness is necessary.

Background Early identification and specialised treatment of individuals with enduring positive symptoms may assist in alleviating symptoms and has the potential to change the course of illness.

Method Prevalence and descriptive data on enduring positive symptoms in two first-episode samples are outlined. Attempts to incorporate the focus of early intervention for persisting psychosis into routine clinical care of individuals with first-episode psychosis are described.

Results Of the 227 individuals with first-episode psychosis who were assessed using the Brief Psychiatric Rating Scale at 3/6 months and 12 months following initial stabilisation (from a total sample of 347), 6.6% experienced enduring positive symptoms at all three time points. When the analysis was restricted to schizophrenia, schizophreniform and schizoaffective disorders (n=158) the percentage increased to 8.9%. These patients had significantly longer mean duration of untreated psychosis prior to initiation of treatment and, at 12-month follow-up, significantly higher depression and poorer psychosocial functioning.

Conclusions The association of untreated psychosis with treatment resistance supports the argument for early intervention as soon as possible following the onset of psychotic symptoms.

Background We evaluate the impact of a group-based, transitional, psychosocial programme, within a comprehensive service (the Early Psychosis Prevention and Intervention Centre, EPPIC), on recovery from first-episode psychosis.

Method Individuals using the service (and meeting study criteria) were assessed on a range of symptom and functioning instruments at entry, after 6 weeks and 6 months. Participants received comprehensive case management and services according to their identified needs. Thirty-four people who had attended the group programme were compared at 6 month follow-up with 61 EPPIC patients who had not attended.

Results The people attending the group programme had a lower level of premorbid adjustment than the comparison group, and a trend towards exhibiting a higher level of negative symptoms, prior to commencing the group programme. However, at 6 month follow-up, no significant differences were found between the groups.

Conclusions Involvement in the group programme may have had a positive impact on a subgroup of EPPIC subjects with poor level of premorbid adjustment, by providing a ‘holding pattern’ in the critical period following the emergence of first-onset psychosis, and thus prevented deterioration and the development of disability.