CHICAGO – Schizophrenia, bipolar disorder, and major depressive disorder all benefit from early diagnosis and aggressive therapy, and the new First Contact program at Northwestern Memorial Hospital is an attempt to provide it to all three disorders in an orderly way.
"A seamless integration of patient care from the very beginning" is how it was described by Dr. Will Cronenwett, medical director of outpatient psychiatry at Northwestern Memorial Hospital’s Stone Institute of Psychiatry in Chicago. Dr. Cronenwett outlined First Contact in a hospital seminar titled "Reinventing Inpatient Psychiatry."
Dr. Will Cronenwett
In the conventional model of care, the prodromes of schizophrenia, bipolar disorder, or depression were each seen as a precursor to that particular illness. Patients were recruited based on the risk of the illness, and treatment and disease progression were studied in that light, according to Dr. Cronenwett’s presentation.
The First Contact model, by contrast, is a clinical staging model dependent on time, and not on predicted illness, said Dr. Cronenwett.
"It’s dependent on somebody’s index presentation. ... Either they’ve identified themselves ... or somebody else has talked to them about getting help," he said. Prospective patients may appear healthy because the program intends to get them as early as possible in the course of the illness, ideally within a year of disease onset.
"Our point is to look at this as a staging model, as opposed to a model where we understand specifically where people are headed," said Dr. Cronenwett.
The First Contact program has three dimensions: clinical, research, and outreach. The treatment goals are symptom relief; education and empowerment; and support for role functioning. A specialized early intervention program is core to First Contact, as are coordinated inpatient and outpatient services. The treatment team will be multidisciplinary and will include community outreach. Cognitive behavioral therapy will be incorporated because it is considered effective for mood symptoms and psychosis in early phases of illness (J. Clin. Psychiatry 2009;70:1206-12). The program’s goals include improving the patient’s adaptation to the illness and increasing their subjective quality of life. Self-management will therefore be stressed, as will cognitive enhancement therapy.
The patient, family, and caregiver will all be educated in the program’s goals.
Research will also be integrated into the First Contact program, seeking disease markers via imaging, genetics, and cognitive changes. Outreach will be used to increase public awareness, promote early self-detection, and encourage early referrals. Dr. Cronenwett said there is evidence, although inconclusive, that early therapy reduces the duration of untreated illness (Acta Psychiatr. Scand. 2008;117:440-8).
Ultimately, Northwestern hopes to create and share guidelines for treatment of these illnesses.
None of this will be easy. In the initial phases, all of these illnesses are difficult to identify with accuracy. The first diagnoses, before the disease prodrome, are often unstable, especially for psychosis, but also for bipolar disease.
"Most people identified as prodromal don’t end up converting to psychosis," said Dr. Cronenwett (Am. J. Psychiatry 2011;168:800-5).
In this particular study, only 35% converted to psychosis, whereas 24% remitted completely. Other diagnoses – including anxiety disorder, depression, mania, and substance use disorder – also remitted over time.
He went on to say that the schizophrenia prodrome is a complicated clinical picture, and that the initial presentation does not predict the outcome. "Schizophrenia prodrome has been the most studied phenomenon to date," he said. "Oftentimes the first symptomatic presentation for what later gets diagnosed as schizophrenia is depression."
The bipolar prodrome, with its age of onset at 0-6 years, can present with any number of characteristics, including "stubborn" and "overly sensitive."
"The bipolar prodrome is probably more confusing than schizophrenia," said Dr. Cronenwett. The most common clinical elements are depressed or elevated mood, anger, perceptual changes, energy changes, functional impairment (Bipolar Disord. 2008;10:555-65). He said it may be 10 years between presenting symptoms and final diagnosis . Major depressive disorder is the least-studied prodrome, and overlaps with other prodromal phenomena, he said.
Dr. Cronenwett disclosed research support from Novartis and from Sunovion Pharmaceuticals.