Imagine you are sitting in a meeting. You look up to the faces of other attendees, many of them glance over as you find your seat, and a few people stare. Someone catches your eye and you’re convinced he is part of a governmental conspiracy that you have been suspicious of for some time. These paranoid thoughts dart in and out of your head, making you increasingly uncomfortable, scared, and confused about how you became a target. You quickly scan the rest of the seats and notice more and more people staring at you. Beads of sweat start to collect on your forehead. You hear a voice saying “We will get you, we will get you.” You’re not sure where it is coming from but assume it must be one of the attendees behind you. At the first meeting break, you leave, constantly looking over your shoulder to make sure no one is following you.
Sound scary? Imagine navigating a world where everyone tries to convince you that there is no conspiracy and asks “Have you slept enough?,” “Are you on drugs?” or offers their opinion that “you sound crazy.”
Living with schizophrenia can be confusing. Individuals often receive terrifying and contradictory messages from their sensory world coupled with invalidating feedback from others’ responses to their stories and beliefs. It’s easy to feel isolated and misunderstood when you are told that what you experience isn’t “real,” and is “an illness.” It’s no wonder so many who suffer from the condition do not seek help and often end up in long-term hospitals, on disability, unhoused or incarcerated.
The outlook for a young person in the early stages of schizophrenia today can –and should – be different from that of the outcomes above. During the 1980s, the first clinical studies highlighting the special needs of young people experiencing a first episode of schizophrenia caught the attention of clinicians and researchers. Interest expanded rapidly around the world in understanding the biological and social factors that underpin schizophrenia, and in better ways to treat them. Since then, we have learned much about how these conditions evolve, which has allowed the development of improved treatments. Clinical research has led to the development of services specifically designed around the unique needs of these at-risk young people. We now know that experiencing it does not inevitably lead to a lifetime of disability and poor outcome. Instead, timely and appropriate early intervention has the potential to eliminate, or at the very least reduce, the condition. This has led to a radical shift in the approach to the care where the focus is intervening early with a strong emphasis on promoting recovery.
Minimizing or preventing the condition is particularly important for schizophrenia, considering one of the primary reasons why it can be so devastating is that it typically appears during late adolescence and early adulthood. Disrupting a young person’s life during this crucial transitional and identity period can be devastating to the process of finishing education and beginning work, developing intimate relationships, and establishing adulthood. If schizophrenia is untreated, or undertreated, this disruption can lead to long-term or life-long disability.
‘Understanding why and how to treat it’
Long-term studies have shown that schizophrenia often follows a period of increasingly distressing symptoms, such as poor concentration, disturbed sleep, lack of energy, social withdrawal, depression, and anxiety. Over time, these symptoms slowly intensify, low-grade psychotic symptoms such as visual distortions, hallucinations (e.g. hearing a voice that is not present), and early delusional thought processes appear (believing something that is not real and distressing), and the person’s ability to function in daily life is increasingly affected. Eventually, the symptoms increase to the point that a first episode occurs in which the person loses touch with what is real and what is not. We now know that much of the disability associated with psychotic illnesses develops during this early, high-risk stage, well before the first episode, and that the most important risk factor for a poor outcome is a long duration of untreated symptoms.
‘Stressing the early intervention’
It is possible to identify young people with early symptoms that are beginning to impact their lives but which are not yet severe enough to prevent them from distinguishing what is real and what is not. Appropriate care to reinforce functioning and prevent symptom worsening for these individuals may prevent the onset of schizophrenia, or minimize the devastating consequences which come when individuals lose touch with reality. Moreover, for those who do experience a first episode, treatment is no longer aimed at simply controlling their symptoms, but also at helping maintain or regain their developmental trajectory so they can make the best possible social and functional recovery.
‘Appropriate treatment for the stage’
The type of interventions depend on each person’s symptom experience and personal goals. This approach to care has three major benefits over traditional care: 1) The early stages of schizophrenia are recognized as requiring treatment; 2) Treating early means that less-intensive treatments can be used first, which minimizes the risk of any side-effects; and 3) Prevent, or greatly reduce, the risk of ongoing disability if it does develop or progress.
‘Interventions for Clinical High Risk’
A number of interventions for people at clinical high risk for schizophrenia have been tested in clinical trials looking at the use of medication, counseling treatments, or both, to prevent the onset of psychosis. A review of these studies has found that even low doses of some medications can cause serious side-effects, psychosocial interventions, including supportive therapies such as cognitive behavioural therapy (CBT), psychoeducation, family counseling, group counseling and other health-related interventions, are recommended as first-line therapy at this stage.
‘Young people having a first episode’
Treating a first episode of schizophrenia requires great sensitivity and clinical skill, and, ideally, managed in specialized services separately from individuals at later stages of schizophrenia. At this stage, low-dose antipsychotic medications and a range of counseling interventions may be helpful to maximize recovery.
Finally, early intervention is not a new approach in health care. In oncology, for example, the improvements in recovery and outcomes for many different cancer treatments have come not from dramatic breakthroughs or novel treatments, but from intervening much earlier with existing treatments, and delivering them in a more sustained and comprehensive fashion for as long as they are needed. The approach is similar for schizophrenia.
Early intervention for schizophrenia has clearly proven its value. Intervening early with a culture of hope and optimism, providing evidence-based care featuring collaboration with those receiving care and their families or primary support systems in an environment that is stigma-free and youth-friendly.
All of these elements are crucial to the success of this service model.
Over 20 years ago, the Early Assessment and Support Alliance (EASA) in Oregon, was established to develop a systematized effort to prevent early trauma and disability caused by schizophrenia and related conditions. If you or if you know someone who may be experiencing new or risk symptoms of schizophrenia please go to asacommunity.org for referral information.
The services are of no cost to those who qualify.
Birchwood, M., Todd, P., & Jackson, C. (1998). Early intervention in psychosis. The critical period hypothesis. The British Journal of Psychiatry Supplement, 172, 53-59.
McGorry, P., Alvarez-Jimenez, M., & Killackey, E. (2013). Antipsychotic medication during the critical period following remission from first-episode psychosis: Less is more. Journal of the American Medical Association: Psychiatry, 70, 898-900.
Ryan Melton is the Dean of Psychology and Counseling at Bushnell University and one of the founders of the Early Assessment and Support Alliance Model in Oregon.