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.
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| 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.
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© Copyright Adrian Preda, M.D.
