Early treatment of schizophrenia may not slow disease progression

The News in Brief:

• Individuals with schizophrenia begin to experience a decline in overall mental health once symptoms onset. This gradual decline often continues for many decades, regardless of when treatment begins.
• Early intervention in schizophrenia has been thought to slow or stop further declines. This study, however, 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.

STONY BROOK, February 12, 2020 — A Stony Brook University-led study reveals that, despite the common view that early intervention in schizophrenia slows or stops mental decline, those who receive early intervention eventually experience the same declines as those whose treatment started later. The finding, published online in The American Journal of Psychiatry, suggests that studies of schizophrenia should take into account how long study participants have been symptomatic, otherwise treatments may appear more effective than they actually 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 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.

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Co-authors include faculty from the Department of Psychiatry at the Renaissance School of Medicine and in the Department of Applied Mathematics and Statistics at Stony Brook University, and from the Feinstein Institute for Medical Research.

The research was supported in part by the National Institutes of Health (grant numbers MH44801 and MH094398).

About Renaissance School of Medicine at Stony Brook University:

Established in 1971, Renaissance School of Medicine at Stony Brook University includes 25 academic departments. The three missions of the School are to advance the understanding of the origins of human health and disease; train the next generation of committed, curious and highly capable physicians; and deliver world-class compassionate healthcare. As a member of the Association of American Medical Colleges (AAMC) and a Liaison Committee on Medical Education (LCME) accredited medical school, Stony Brook is one of the foremost institutes of higher medical education in the country. Each year the School trains nearly 500 medical students and more than 600 medical residents and fellows. Faculty research includes National Institutes of Health-sponsored programs in neurological diseases, cancer, cardiovascular disorders, biomedical imaging, regenerative medicine, infectious diseases, and many other topics. Physicians on the School of Medicine faculty deliver world-class medical care through more than 31,000 inpatient, 108,000 emergency room, and 940,000 outpatient visits annually at Stony Brook University Hospital and affiliated clinical programs, making its clinical services one of the largest and highest quality medical schools on Long Island, New York. To learn more, visit http://www.medicine.stonybrookmedicine.edu.