EARLY INTERVENTION IN PSYCHOSES: CLINICAL AND ETHICAL CHALLANGES, CONCEPTS, EVIDENCE AND FUTURE DEVELOPEMENTS - Interventia precoce in psihoze: provocari clinice si etice, concepte, dovezi si directii viitoare

Patrick D.McGorry1, Eoin Killackey1,2, Alison Yung1

Abstract           

The rise of the early intervention paradigm in psychotic disorders represents a maturing of the therapeutic approach in psychiatry, as it embraces practical preventive strategies which are firmly established in mainstream health care. Early intervention means better access and systematic early delivery of existing and incremental improvements in knowledge rather than necessarily requiring dramatic and elusive breakthroughs. A clinical staging model has proven useful and may have wider utility in psychiatry. The earliest clinical stages of psychotic disorder are non-specific and multidimensional and overlap phenotypically with the initial stages of other disorders. This implies that treatment should proceed in a stepwise fashion depending upon safety, response and progression. Withholding treatment until severe and less reversible symptomatic and functional impairment have become entrenched represents a failure of care. While early intervention in psychosis has developed strongly in recent years, many countries have made no progress at all, and others have achieved only sparse coverage. The reform process has been substantially evidence-based, arguably more so than other system reforms in mental health. However, while evidence is necessary, it is insufficient. It is also a by-product as well as a catalyst of reform. In early psychosis, we have also seen the evidence-based paradigm misused to frustrate overdue reform. Mental disorders are the chronic diseases of the young, with their onset and maximum impact in late adolescence and early adult life. A broader focus for early intervention would solve many of the second order issues raised by the early psychosis reform process, such as diagnostic uncertainty despite a clear-cut need for care, stigma and engagement, and should be more effective in mobilizing community support. Early intervention represents a vital and challenging project for early adopters in global psychiatry to consider.

Keywords: Early intervention, psychosis, staging, health care reform, youth mental health

 

Rezumat

Aparitia paradigmelor pentru interventia precoce in tulburarile psihotice reprezinta o maturizare a abordarii terapeutice in psihiatrie, cuprinzand strategii preventive practice care sunt stabilite ferm in fluxul sistemului sanitar. Interventia precoce inseamna un acces mai bun si oferirea sistematica precoce a unor imbunatatiri ale cunostiintelor existente si in curs de dezvoltare mai degraba decat necesitatea unor progrese dramatice si evazivei. Un model de stadializare clinica s-a dovedit folositor si poate avea o utilitate mai larga in psihiatrie. Cele mai precoce stadii clinice ale tulburarii psihotice sunt nespecifice si multidimensionale si se suprapun fenotipic peste stadiile initiale ale altor tulburari. Aceasta implica faptul ca tratamentul ar trebui sa continue treptat, depinzand de siguranta, raspuns si progresie. Amanarea tratamentului pana cand dezechilibrul simptomatic si functional sever si mai putin reversibil a devenit vizibil reprezinta un esec al ingrijirii. In timp ce interventia precoce in psihoza s-a dezvoltat puternic in ultimii ani, multe tari nu au facut nici un progres, iar altele au obtinut doar o acoperire partiala. Procesul reformei a fost substantial bazat pe dovezi, discutabil insa daca mai mult decat alte reforme de sistem in domeniul sanatatii mentale. Totusi, chiar daca dovezile sunt necesare, ele nu sunt suficiente. Este de asemenea un produs secundar ca si un catalizator al reformei. In psihoza precoce, am vazut de asemenea, paradigma bazata pe dovezi folosita gresit pentru a infrange reforma depasita.

 Tulburarile mentale sunt bolile cronice ale tinerilor, cu debutul lor si impactul maxim in adolescenta tarzie si perioada de adult tanar.

 O viziune mai larga pentru interventia precoce ar rezolva multe din problemele secundare ridicate de procesul reformei in domeniul psihozei precoce, cum ar fi nesiguranta diagnostica in ciuda necesitatii clare pentru ingrijire, stigma si implicare si ar trebui mai eficienta in mobilizarea suportului comunitatii. Interventia precoce reprezinta un proiect vital si provocator pentru a fi luat in considerare de primii suporeri ai psihiatriei globale.

Cuvinte cheie: interventia precoce, psihoza, stadializare, reforma sanatatii, sanatatea mentala a tinerilor.

 

(World Psychiatry 2008; 7:148-156)

 


1Centrul de Cercetare si Departamentul de Psihiatrie ORYGEN

2Departamentul de Psihologie, Universitatea din Melbourne,  35 Poplar Rd., Parville, Victoria, Australia.

Sponsori si parteneri