Joseph P. McEvoy, MD
With the onset of schizophrenia, patients need reliable, consistent control of their symptoms to begin to rebuild their lives. The early and effective treatment of schizophrenia can make a significant difference in the long-term recovery of most patients.
The improved understanding of schizophrenia as a neurobiologic disorder and the recognition that intervention is needed as early as possible following the onset of illness offer the potential to optimize long-term treatment outcomes.1 Persons experiencing symptoms of schizophrenia may have limited insight into the nature of the illness, thus limiting their ability to seek and adhere to treatment. Therefore, it is important for those who play key roles in the development of young adults, such as teachers, counselors, and physicians, to recognize the symptoms of schizophrenia and help patients seek treatment.2
Family members and friends may believe that the individual is going through a growing phase or trying out a new philosophy of life rather than experiencing the early stages of a mental illness. For family members, the diagnosis of schizophrenia is further complicated because the onset of illness is usually in the late teens or early 20s, when young people may harbor ideas that may be perceived as unconventional. When these seemingly odd ideas are accompanied by a reversal in normal sleep cycles, withdrawal from social activities to spend more time alone, neglect of normal hygiene and self-care, or loss of jobs with ill-defined attribution of persecution or maltreatment, family members and other adults should consider seeking medical attention for the individual.
Unfortunately, there are often delays between the appearance of initial psychotic episodes and the correct diagnosis and treatment, which can result in decreased responsiveness to treatment and diminished social and occupational functioning. By identifying and treating psychotic episodes soon after onset, it may be possible to limit the damage, reduce recovery time, and help patients resume daily activities and social functioning.3
Early Negative Outcomes
A longer duration of untreated psychosis prior to starting therapy with antipsychotic medications is correlated with more significant, persistent psychopathology and poorer functional outcomes, according to recent studies.4 Therefore, to prevent deterioration in the quality of patients' lives, it is extremely important to identify individuals experiencing the onset of schizophrenia as early as possible in workplaces, schools, or physician offices.
Brain imaging studies suggest that many individuals experience a loss of brain volume following their initial psychotic episode. Even if persons with schizophrenia receive treatment immediately after onset, they still may lose brain volume, according to the latest studies.5
Figure 1is from a longitudinal follow-up study of patients experiencing a first psychotic episode and matched control subjects, conducted by Lieberman et al.5 The x-axis reflects the time in days between the baseline and follow-up brain scans. The y-axis reflects change in ventricular volume from baseline to follow-up. The greater the number, the greater the increase in ventricular volume and, consequently, the greater the loss of brain tissue volume. Control subjects, depicted by the diamonds, show no change in ventricular volume irrespective of the time between scans. The patients who had good therapeutic outcomes, depicted by the squares, similarly show no changes in ventricular volume. However, those patients who had poor therapeutic outcomes (triangles) show consistent increases in ventricular volume, and the longer the duration of follow-up, the greater the loss of brain tissue volume.
Reprinted from Biological Psychiatry; Volume 49; Lieberman J, Chakos M, Wu H, et al; Longitudinal study of brain morphology in first episode schizophrenia; pages 487-99.
Finally, recent studies show that patients who do lose brain volume clearly have a worse prognosis for recovery than those who do not. The longer antipsychotic medication is delayed, the more persistent and treatment-resistant the psychopathology may become, meaning that patients are more likely to suffer long-term functional impairments such as inability to sustain employment.4
Unfortunately, even after the early stages of the illness are treated, there is a high risk for psychotic exacerbations, especially if patients do not believe they need treatment or the treatment is incompletely effective. These individuals often do not want to view themselves as ill or needing treatment.6