Preventive Strategies to Optimize Recovery in Psychosis
PATRICK MCGORRY AND SHERILYN GOLDSTONE
Over the past three decades, our historic view of schizophrenia as a catastrophic illness, with a progressive and inevitable decline as the usual outcome, has changed.1 A combination of better pharmaceutical treatments and a greater understanding of the epidemiology and neurobiology of psychosis have led to the development of more appropriate treatments and better services for those experiencing a psychotic illness and a shift in our approach to managing these potentially devastating illnesses.2 The focus of current treatment is no longer exclusively on managing symptoms but on promoting the best possible recovery, including social and vocational recovery, to enable those living with psychosis to live meaningful and contributing lives within their communities.
The timing of onset of the psychotic disorders is the major reason for their significant destructive potential. Epidemiological studies have shown that the vast majority of those with a psychotic illness experience its onset during their late teens to early 20s,3,4 a time in life when most young people are finishing their education and beginning their working lives, developing intimate relationships, and moving from their families of origin to establish themselves as independent in their own right. Disrupting a young person’s life during this crucial transition to independent adulthood inevitably affects his or her social, educational, and vocational development, a course of events that, if left unrecognized and unremedied, has the potential to cause significant and ongoing disability.5 Conversely, if the onset of illness is established in adulthood, the outcomes are substantially better.6
The idea that recovery from serious mental illness is possible was revived in the 1980s on the basis of long-term outcome studies that showed that up to two-thirds of those with schizophrenia achieved significant recovery, although, for many people, periods of good functioning were interspersed with periods of illness and poor functioning.7-11 Here, we understand recovery not simply in the medical sense of “the end of an episode of illness and return to the pre-illness state,” but in the broader sense of the individual’s journey to the restoration of hope and a sense of his or her identity; attaining positive coping skills, supportive relationships, meaningful activity; and living a contributing life within his or her community. This broader concept has evolved and been adopted by consumers around the world in combating stigma, pessimism, and social exclusion.12 However, in one sense, it could be argued that in belatedly affirming the value of the subjective nature of recovery, reasonable and achievable expectations for more complete “objective” or functional recovery have been undersold. This so-called soft bigotry of low expectations may have been reinforced not only by the underinvestment in and neglect of sustained quality care, but also through a tacit acceptance of this neglect and an understandable rejection of the poor-quality care that is typically on offer. However, it is more than reasonable for both clinicians and consumers to aspire to a personalized and optimized level of recovery and functionality.
An appreciation of the full spectrum of potential recovery must come from long-term studies of psychosis from its earliest stages. Early studies of young people experiencing a first episode of psychosis highlighted their special clinical needs, as well as the unique opportunity for early intervention to promote recovery and prevent the accumulation of ongoing secondary disability.13-15 Since then, a growing body of evidence from large international studies has shown that the course of the psychotic disorders is not fixed and that deterioration in social and occupational functioning and a poor prognosis are not inevitable, but rather that the course is fluid and malleable.16-24 Examination of the risk factors that can influence outcome has revealed that many of these may be reversible and that attention to these factors as part of treatment has the potential to limit or repair the damage. This has driven an explosion of interest in early intervention and phase-specific, recovery-focused treatment for early psychosis.