Early initiation of treatment in schizophrenia may not slow down disease progression

STONY BROOK -- Overall mental health begins to decline in Individuals with schizophrenia once symptoms onset. This gradual decline often continues for many decades, regardless of when treatment begins. There is a common view that early intervention in schizophrenia slows or stops mental decline.

Researchers at Stony Brook University have found that those who receive early intervention in schizophrenia eventually experience the same declines as those whose treatment started later. This study published in the American Journal of Psychiatry suggests that typical interventions do not improve long-term outcomes, even if administered early. Studies of treatments for schizophrenia need to take into account how long study participants have been symptomatic, otherwise, the effects of treatment may appear greater than they are.

"Our finding is somewhat counterintuitive. There has been a good amount of evidence suggesting that if you get people who are having their first psychotic episode into treatment as soon as possible, you can avert irreversible declines," said Lead Author Katherine Jonas, PhD, Postdoctoral Fellow in the Department of Psychiatry in the Renaissance School of Medicine at Stony Brook University. "We found that if you compare people who got into treatment early with those who did not, the early treatment group only appears to have better outcomes because they are often younger, and haven't been sick as long."

Jonas and colleagues point out that comprehensive pharmacological and psychosocial treatment has shown to be effective in reducing symptoms and improving quality of life in schizophrenia. However, many patients in the US do not get these treatments. Most receive only antipsychotic medications, which help with hallucinations and delusions but not with other symptoms. Therefore, they caution that "while starting 'treatment as usual' earlier may not halt the disease process, comprehensive and sustained care has been shown to improve overall mental health for those with schizophrenia."

The study evaluated the duration of untreated psychosis (DUP) - defined as the amount of time that elapses between psychosis onset and treatment initiation. Data came from the Suffolk County Mental Health Project and included 287 individuals with schizophrenia or schizoaffective disorder. More than 2,000 patient observations spanning from childhood to 20 years after first hospital admission are included in the dataset. Overall mental health was evaluated at multiple points and related to DUP.

The association between long DUP and poor outcomes is well known in the treatment of patients with schizophrenia. Yet Jonas and colleagues found that in this study the association can be explained by lead-time bias.

"Lead-time bias is a phenomenon in which early detection - such as early screening for breast cancer or another disease - appears to improve outcomes because it enlarges the observation window of the disease," she explained.

The authors conclude in their study that the association between DUP and psychosocial function in schizophrenia may be an artifact of early detection, creating the illusion that early detection is associated with improved outcomes. Given this finding, they emphasize that shortening DUP does not necessarily change long-term illness course. DUP may be more of an indicator of illness stage than a predictor of course.