There is an ongoing debate about how early one should intervene to prevent mental illness from unfolding. Prophylaxis or prevention is universally agreed as better than post diagnosis intervention in medicine. However when it comes to psychiatry prophylaxis is a bit of a Pandora box.
|Edvard Munch The Scream|
Specific prophylaxis has its own thorny issues. To this day, society still mistakes psychiatry definitions as judgment labels and then proceeds to stigmatize accordingly. This being the case for people who meet diagnostic criteria, how would anyone go about potentially labeling patients who, while being at risk for a disorder, do not in fact meet the required criteria? Choosing to prevent something that might occur is a very different proposition than slapping a prophylactic, yet stigmatizing label, on someone that might have never got it otherwise - and this the core the ethical dilemma that preventive psychiatry faces day in and day out.
Add the anti-psychiatry movement contention that the whole idea of mental illness is just a social construct. with the implication that treating mental illness with medications is literary a toxic and as such deeply unethical proposal and you will understand why studies of untreated patients are essential for our field.
The idea is simple. Here it is what one needs to do to understand the natural history of a mental illness: take people who have a psychiatric diagnosis follow them free of psychiatric intervention ("toxicity", medications, hospitalizations, etc.) for some time and then see who got worse, who got better, or who ended up somewhere in between.
If all got better you can throw away your prescription pad and join the anti-psychiatry convention. If all got worse and the doctor in you should remember your primun non nocere Hippocratic Oath, and acknowledge that if doing nothing actually harms your patients than you'd better do something about it. Which is, well, TREAT.
That is why I appreciate a study like Thirthalli et al. when one comes along. A rare study where patients who had a diagnosis of psychosis for quite some time where started on medications and then followed for up to a year. “The quite some time” part – with some patients with long duration of untreated psychosis (DUP) - in rare in modern day clinical psychiatric research, where most patients get rapidly diagnoses and treated.
Briefly, in this retrospective-prospective study, the newly treated patients showed that their symptoms severity and degree of dysfunction one year later correlated with the duration of untreated psychosis (DUP). In other words, the longer one was sick prior to treatment, the worse the shape they were going to be in one year later. Now, this is not a controlled, randomized study. There are missing details in describing the study population. We also don’t know if people treated with different medications improved differently, which would have been very helpful to put things in context. However as most of the patients took one of two newer antipsychotics the clinical changes do not seem to be due to medications. Yet, weaknesses considered, the double correlation of both functional and symptoms severity scores at follow up exclusively with the duration of untreated illness, strongly suggests that one should not wait but treat psychosis as early as possible.
While this does not answer general questions about early intervention for mental illness, when it comes to psychosis the message is clear.
Brain toxicity is a result of untreated psychosis.
Medications for psychosis make things better not worse.
Treating early is a good idea.
Remember primun non nocere? Not to treat is to harm. Therefore treat.
Thirthalli J, Channaveerachari NK, Subbakrishna DK, CottlerLB, Varghese M, Gangadhar BN.Prospective study of duration of untreatedpsychosis and outcome of never-treated patients with schizophrenia in India. Indian J Psychiatry. 2011 Oct;53(4):319-23
© Copyright Adrian Preda, M.D.