Aditi Sridhar
Introduction
A chronic problem within psychiatry relates to the diagnosis and treatment of First Episode Psychosis (FEP). At present, detecting FEP in individuals typically occurs at two extremes: it is either identified too late or is misdiagnosed. Both these situations can result in an individual’s disorder becoming refractory. This piece elaborates on the reasons for their existence and proposes a framework with which mental health professionals can put an end to this issue.
What is Psychosis?
Psychosis is a symptom that generally presents itself in psychotic disorders. They are marked by symptoms, both positive (delusions and hallucinations) and negative (anhedonia, motor retardation and depression) (Schwartz et al., 2014).
FEP is the stage at which an individual shows initial signs of disconnection from reality. This onset does not occur overnight; rather, those who experience FEP might have been displaying changes in their thought and perception of themselves and their surroundings for a while. However, due to the non-specificity and isolation of such symptoms, FEP can be initially hard to detect (Duckworth). As time goes on, these symptoms accumulate and may become noticeable to the individual themselves, their social support system, or other external but impersonal bodies, such as the police or the general public (Norman, 2014).
The Issue of Over-Diagnosis
Research reveals that the disproportionately high and unevenly distributed misdiagnosis of psychotic disorders is majorly due to clinicians’ biases (Schwartz et al., 2014). Racial and ethnic biases have led to individuals from minority communities being misdiagnosed with psychotic disorders (Schwartz et al., 2014). Incompetent in recognising cultural differences, clinicians identify behaviours and symptoms as psychotic when they deviate from the majority community’s norm. For example, the African-American population is overdiagnosed with schizophrenia, even when the diagnosis cannot be sufficiently justified. Parallelly, this group is underdiagnosed with Major Depressive Disorder and Bipolar Disorder (Schwartz et al., 2014). This implies a gross misdiagnosis, wherein their symptoms of bipolar disorder and major depressive disorder are mistaken for the symptoms of a psychotic disorder. Targeting the wrong disorder when treating symptoms leads to ineffective outcomes that are demotivating, distressing, and costly for both the patient and the clinician.
The issue of racial biasing does not stop here. Minority communities in the UK and the USA are more likely to be referred to mental health services via the police system, and face behavioural hospitalisations, rather than receive voluntary treatment (Halvorsrud, 2018). These communities in the USA account for 56% of those diagnosed through the criminal justice wing, whereas European Americans only make up 21% of this demographic (Schwartz et al., 2014). Even if one genuinely has a psychotic disorder, the compulsoriness of this process is traumatic and counterproductive (Halvorsrud, 2018).
A tangential, yet equally crucial issue arises with accurate referrals via the justice system. When an individual is admitted on the grounds of behavioural deviancies, it is likely that they are now at a stage in their psychosis that is more difficult to treat. Episodes of psychosis do not appear overnight. Therefore, it can be said that when an individual’s disorder is identified post-crisis, they must have had milder symptoms that were previously undetected. These crescendoed to some form of extreme behaviour that was noticed by organisations like the police. Leaving psychosis untreated for a prolonged duration negatively impacts the treatment trajectory of the disorder, as well as the quality of life (Marshall et al., 2005, Law et al., 2005).
The Issue of Under-Diagnosis
For decades, mental health professionals have aimed to reduce the duration of untreated psychosis in individuals. While many are mis- and over-diagnosed with psychosis, an almost equal number of people’s psychotic disorder is left undetected and those who are diagnosed find it difficult to access treatment. Thus, their duration of untreated psychosis is prolonged, and if at all they are able to access treatment, it is not as effective as if delivered earlier.
Duration of untreated psychosis (DUP) is the period from the first appearance of psychotic symptoms, to the beginning of sufficient treatment (Marshall et al., 2005). The extent of its relationship with the progression of psychosis is a controversial and highly debated one.
According to the neurotoxicity hypothesis, the brain undergoes an increasing and irreversible amount of neurodegeneration due to psychosis, which is a function of the duration for which it is untreated (Anderson et al., 2014). However, research has found contradictory evidence regarding this. Post-mortem analyses of brains diseased by schizophrenia show no signs of neuronal death. Additionally, there is no evidence that relapses are associated with progressive deterioration (McGlashan, 2006, Anderson et al., 2014).
However, McGlashan’s argument does not imply that untreated psychosis does not cause negative biological alterations and damage (2006). A study by Drake et al. revealed the curvilinear relationship between DUP and the improvement of psychotic symptoms (2020). A longer DUP results in a worsening of the foundational disease process, such that there is a decreased responsiveness to treatment as time goes on (Palaniyappan & Krishnadas, 2020).
The outcome of an individual’s psychosis is determined by social factors as well. Social support significantly impacts recovery (Norman, 2014). As a corollary of this, a longer DUP is correlated with a decrease in the strength of social support available to an individual (Norman, 2014). Thus, a logical conclusion can be drawn: as DUP increases, the outcome of an individual’s treatment is negatively impacted.
Recovery is also influenced by the individual’s self-esteem and perceived value in relation to others (Bjornestad et al., 2016). Therefore, social isolation reinforces the negative symptoms of psychosis. Many such individuals are also comorbid with social anxiety (Aikawa et al., 2018). A longer DUP may worsen their situation due to increased avoidance of social settings. It can also be a predictor of DUP since they may not take the initiative to seek help, or regularly interact with others for their symptoms to be noticed (Aikawa et al., 2018).
It is evident that DUP is a variable that can and should be manipulated, and thus clinicians are justified in seeking ways to shorten it. This involves building systems of early intervention to ensure that FEP is caught before it is too late. However, this is where the challenge lies. Many groups attach a great stigma to psychosis: there is a persistent belief that psychosis has paranormal origins, thus deterring help-seeking (Odoula, 2021). However, the accumulation of psychotic symptoms is a function of increased DUP and can put such individuals in positions of crisis, wherein they might be forcefully admitted. As discussed before, this derails the treatment trajectory. Therefore, there is a dire need for making early treatment more accessible.
Conclusion
Enhancing cultural competency amongst clinicians is vital to the diagnostic process. This prevents misdiagnosis and ensures early detection of FEP. The treatment of psychotic disorders is a multi-dynamic venture that must focus on rehabilitation not only in biological aspects but in the social and psychological ones too. They play a large role in preventing the relapse of psychotic episodes. Many high-income countries are well on their way to developing efficient early intervention centres. However, transferring this system to low- and middle-income countries is a challenge since there are financial as well as cultural barriers (Vaitheswaran et al., 2021). India, with over seven million individuals suffering from psychotic disorders, must actively improve early FEP interventions (Rangaswamy et al., 2012). They must seek to enhance the human resources available to counter the broken delivery of mental health services; breaking stigma and encouraging help-seeking are key points that will reduce the delay in detecting FEP. Thus, India can counter the pervading issues of a lengthy DUP as well as build cultural competencies surrounding the diagnosis of minority communities.
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