Recovery From Schizophrenia: Psychiatry And Political Economy

292 DESEGREGATING SCHIZOPHRENIAadvocates suggest that delayed treatment has a direct effect in prolongingpsychosis. Some have even suggested that untreated psychosis may be toxic tobrain function. 65 But the association between prolonged psychosis and pooroutcome may not be causative at all. We know from data presented earlier in thisbook that about half of the first episodes of schizophrenia-like conditions in theDeveloped World progress to remission. 66 Samples of patients with a longduration of illness will exclude such good-prognosis cases, but patients whoprogress rapidly to remission will be included in samples with a short duration ofpsychosis. Early detection samples, therefore, are biased to include more goodprognosiscases.If the association between duration of untreated psychosis and poor outcome isprimarily due to the fact that psychoses of recent onset are more likely to result inremission of symptoms, then we should find that those studies that demonstrate anassociation between duration of illness and outcome are those that include casesof recent onset. In fact, this is the case. Virtually all the studies showing a positiveassociation use samples with a duration of illness of less than six months; 67 thosethat exclude such cases do not show an association between duration of untreatedpsychosis and outcome. 68No one, of course, is in favor of late intervention in schizophrenia and thereare many reasons to intervene early in psychotic disorders. Doing so is likely todecrease the social disruption for the patient and his or her family, reduce damageto self-respect, family ties and friendships, and help the patient maintain his or heremployment, studies and accommodation. On the other hand we have to becareful not to leap in too early and diagnose someone with a long-lastingcondition when, in fact, they may only have a psychotic disorder of briefduration. A number of studies have demonstrated that the outcome of earlypsychosis can be good for many people even if they are not treated withmedication. 69 To mistakenly label and treat the person with a brief psychosis ashaving a long-term disorder may lock him or her into a career as a psychiatricpatient unnecessarily.Comprehensive, or even adequate, treatment services for people with a firstepisode of psychosis are not universally available, and a focus on early interventionconcentrates attention on optimal treatment and increases prospects for improvingtreatment services more broadly. The positivistic approach of the earlyinterventionadvocates raises optimism in general for the treatment ofschizophrenia, increases community awareness and assists in stigma reduction.Even though the theoretical basis for early intervention is weak and it carries therisk of over-treatment of some cases, it has a positive side effect on communityattitudes to schizophrenia. There are other ways, however, with which we maytackle the enormous problem of the stigma of schizophrenia.