Early Psychosis Intervention: A Culturally Adaptive Clinical Guide

1. Development of Early Intervention Services: Introduction

The Idea of Early Intervention The concept of “early intervention” is not foreign to medical practice. The idea is rooted in the recognition that many illnesses evolve as a progression over time involving the accruement of irreversible adverse processes. Consequently, the timing of intervention becomes a prime factor affecting outcomes. The challenge confronting the field of early psychosis is that many of these pathological processes and their interactions are not yet clearly understood. In the meantime, clinicians and patients must nevertheless manage with the best possible judgements they choose. One uncontroversial fact in psychosis is that the condition nearly always has negative impacts on the quality of life of sufferers and carers (Chan et al., 2007; Law et al., 2005); the longer psychosis stays untreated, the longer the patients and their carers have to suffer. Thus, the devastating nature of the illness calls for the earliest healthcare intervention possible. In fact, the notion of early intervention is recognized by the East and the West alike. In English, the idiom “a stitch in time saves nine” spells out the wisdom that anything that needs doing is better to be done sooner rather than later. In Chinese, an equivalent concept is found in the saying bing xiang qian zhong yi (病向淺中醫), which literally means it is better to get treatment before an illness takes root. The undesirability of delay is taken for granted in many areas of medicine such as treatment of cancer, heart disease, and hypertension. The Concept of Schizophrenia and Early Detection In view of the obvious desirability of early intervention, it is intriguing that in the management of mental illnesses, particularly psychotic disorders such 1 Development of Early Intervention Services: Introduction Eric Yu-hai Chen 4 Eric Yu-hai Chen as schizophrenia, the concept of early intervention was never integrated from the beginning. This was perhaps partly due to heavy stigmatization associated with the condition, and partly to pessimism towards treatment outcomes. Such pessimistic attitudes towards the illness can be traced back to at least 1899 when Emil Kraepelin coined the term “dementia praecox” (where “praecox” refers to the adolescent onset and “dementia” denotes a downhill course of the disease) to describe the condition of progressive decline in patients with psychotic symptoms. At that time, Kraepelin and others viewed the condition as a brain disease comparable to dementia, with both conditions destined for progressive deterioration. Later, Bleuler in his 1908, Dementia Praecox or the Group of Schizophrenias, replaced the term “dementia praecox” by “schizophrenia ”, emphasizing the heterogeneity of the illness and suggesting variability in outcomes (Fusar-Poli & Politi, 2008). Nevertheless, Kraepelin’s concept of schizophrenia as brain deterioration prevailed. The perception of psychosis (particularly schizophrenia) as a serious condition has been commonly shared by patients and their families, doctors, social workers, and the general public, rendering it difficult to accept such a diagnosis. Such negative attitudes towards the condition was further reinforced by clinics and hospitals’ sample bias, namely, clinicians and patients alike had an inaccurate impression that psychosis was a more serious condition than it actually is. This view may have come about because the patients whom clinicians frequently review probably have a need to remain in more regular contact with the care system, possibly reflecting the presence of more complex and resistant symptoms. In fact, the subset of patients appearing more regularly in a hospital setting, and more likely over-represented in research studies, are those with the most severe form of the illness along the phenotypic continuum and do not represent the underlying population (Bak et al., 2005). Even though clinicians are aware of such bias, pessimism towards the illness is not easily dismissed. These perspectives foster a perception that the schizophrenia diagnosis involves irreversible damage to the brain or mind, leading to permanent changes that affect the core of a person’s individuality and personality. The treatment outcomes of schizophrenia have also been viewed as generally hopeless. In some Asian languages, the official translation of the term “schizophrenia” (精神分裂症) pose some language-specific problems. Rendering an explicit reference to a “broken mind” has led to further aggravation of the negative connotation (see Chapter 5, “Overview of the Development of Services for Early Psychosis in Korea”). Introduction of a novel term for “schizophrenia” Development of Early Intervention Services 5 and for “psychosis” has been the response for some locations (see Chapter 2, “Early Psychosis Services in an Asian Urban Setting: EASY and Other Services in Hong...