Science, Rhetoric, and the End of Psychosis

Recently, I have been told that incivility in the debate about early intervention in psychosis alienates the undecided. Exaggerated claims of cures and prevention on one side and caustic criticisms on the other side combine to reinforce the folk-wisdom of avoiding the company of fanatics, or at least of not discussing religion, politics, or psychosis at dinner parties.

The less partisan position appears to be a mildly skeptical suspension of judgment. Seductive hope that schizophrenia is a preventable neurodegenerative process is balanced against inconclusive evidence, leading to the thought, “I am open to the possibilities, but I am not yet convinced.”

As a critic of early intervention analysis, I have often heard, “Yes, evidence is lacking, but if rhetoric attracts greater funding, even for a small subset of patients, where’s the harm in pretending?”

My answer generally involves grabbing a lapel and offering a passionate defense of the scientific method. Early intense intervention for psychosis has not led to miraculous cures, although outcomes are better while the support continues.¹ Pretending that early intervention modifies the disease prevents the scientific accumulation of knowledge, where each step depends on the accuracy of previous steps. Funding driven by optimistic misrepresentations of early intervention means alternative treatments that may actually modify the disease attract less funding.

The problem is compounded by the distorting effects of politics. Early interventionists in Australia have attracted public funds to specialist units² based on optimistic misinterpretations of data. Once large sums have been sunk into bricks and mortar based on poor quality evidence, it becomes less politically possible to change course even if alternatives that do change the course of schizophrenia are empirically justified.

It is easy for skeptics to convince themselves of the prevalence of bias in the early intervention literature. My recent article provides many examples,³ and two are particularly illuminating. Consider the 10-year follow-up of the early detection of psychosis experiment by Hegelstad and colleagues.⁴ How convincing is a study that changed its primary outcome at 1 year, from relapse to symptoms, when the initial primary outcome showed no difference, and then changed its primary outcome again at 10 years, from symptoms to a novel measure of recovery, when symptom measures favored the control group? Next, compare McGorry’s statement that the OPUS study demonstrates the “disease-modifying” effect of early intense intervention⁵ with the conclusion by OPUS authors that “no basic changes in illness were seen after 5 years from the start of the program.”^1(p770)

These examples demonstrate the confirmatory bias that dominates early intervention research. Until this evidence is accurately interpreted, the early intervention crusade will serve only to obscure the true nature of psychotic illness and retard scientific progress toward a cure.

Financial disclosure:Dr Amos had no relevant personal financial relationships to report.

References

1. Bertelsen M, Jeppesen P, Petersen L, et al. Five-year follow-up of a randomized multicenter trial of intensive early intervention vs standard treatment for patients with a first episode of psychotic illness: the OPUS trial. Arch Gen Psychiatry. 2008;65(7):762–771. PubMed

2. Department of Health and Ageing. Major Expansion for headspace as EPPIC Moves Forward. May 23, 2013. Available at: http://www.agedcare.com.au/aged_care_news.php?title=major_expansion_for_andltemandgtheadspaceandlt_emandgt_as_eppic_moves_forward_463. Accessed March 24, 2014.

3. Amos AJ. A review of spin and bias use in the early intervention in psychosis literature. Prim Care Companion CNS Disord. 2014;16(1):e1–7. Abstract

4. Hegelstad WT, Larsen TK, Auestad B, et al. Long-term follow-up of the TIPS early detection in psychosis study: effects on 10-year outcome. Am J Psychiatry. 2012;169(4):374–380. PubMed.

5. McGorry PD. Truth and reality in early intervention. Aust N Z JPsychiatry. 2012;46(4):313–316. PubMed