VOL. 18, NO. 2, 1992
First-Episode Psychosis: Part I. Editors' Introduction
by Darrell G. Kirch, Jeffrey A. Ueberman, and Susan M. Matthews
Abstract
This is the first of two consecutive issues of the Schizophrenia Bulletin that will be devoted to the special theme of studies of first-episode psychosis. Given that until recently there was minimal research activity in this area, we were gratified as guest editors to have so many manuscripts contributed that we were able to fill two issues of the Bulletin. We see this heightened interest as significant in a number of ways. Most would agree that, until recently, studies of patients early in the course of schizophrenia and other psychotic illnesses had been seriously neglected. Although it traditionally has been viewed as vital to define
the course of any given disorder from the prodrome through the end stage, research on the major psychoses, especially schizophrenia, has been dominated by studies of patients who were in a relatively chronic state. Because of the nature of these disorders, patients frequently experience a recurrence of symptoms, often requiring repeated rehospitalizations. As a result, a majority of patients referred to clinical research facilities have been ill for years, thereby reducing the pool of eligible "first-admission patients" in these programs. In addition, many patients are referred to research centers because of their relatively treatmentrefractory clinical condition. One research strategy often employed to biologically study patients in this chronic state has been that of withdrawing patients from neuroleptic treatment in order to achieve a "drug-free" condition. In practice, however, this often involves a relatively brief wash-out period of 2 weeks or less from neuroleptic treatment. It is important to note that several promising strategies are under investigation to arrive at the most effective treatment plan for such chronic patients. These include reduced medication strategies, complete withdrawal of neuroleptic medication, and the combination of psychosocial treatments with medication, as well as the development of innovative treatment combinations (e.g., adjunctive medication and new drug development). Nevertheless, it remains distressingly clear to knowledgeable observers that we are lacking key information regarding the
Reprint requests should be tent to Dr. D.G. Kirch, Division of Clinical Research, National Institute of Mental Health, Parklawn Bldg., Rm. 10-105, 5600 Fishers Lane, Rockville, MD 20857.
Downloaded from http://schizophreniabulletin.oxfordjournals.org/ at New York University on May 16, 2015
Until recently, there has been a conspicuous lack of studies regarding the earliest phases of psychotic illness, with most research on schizophrenia and related disorders focusing on chronically ill patients. Currently, however, a number of investigators have turned their attention toward this topic, exploring the conceptual issues involved in defining the onset of psychosis, using case registers and population-based samples to do crucial epidemlologic studies on the course of schizophrenia, and developing mechanisms for identifying patients with first-episode psychosis and entering them into active research protocols. This issue of the Schizophrenia Bulletin is devoted to articles representing this full range of conceptual and empirical work on first-episode psychosis. The ultimate goal is for researchers working in this area to develop a network to enhance the sharing of concepts and data, with the eventual possibility of developing combined data bases and collaborative studies.
177
178
tative biological abnormalities appear, and how they may vary with the natural history of the disorder. The implications of this work for both understanding the pathophysiology of psychosis and developing prognostic markers are obvious. As described in an accompanying article in this issue of the Bulletin (Kirch et al. 1992, this issue), the idea of bringing these manuscripts together in two special issues of the journal is an outgrowth of a workshop on first-episode psychosis conducted by the National Institute of Mental Health in February 1991. The results of that workshop have been most gratifying insofar as they extend far beyond simply bringing together the body of work contained in these special issues. The investigators working in this area have opened new lines of communication and held subsequent meetings. There is every prospect that the result will be productive ongoing dialog on the data resulting from current studies, and new ways of resolving the complex conceptual and methodologic research issues inherent in these studies. Moreover, the possibility of establishing combined data bases and/ or conducting collaborative studies is now a real option for a growing group of dedicated investigators working in this area. As editors, we know that it is never possible to include all the relevant work being done in any given area within a special publication.
The groups reporting on their work regarding first-episode psychosis in these two issues of the Bulletin by no means include all the investigators interested in this topic. We encourage other groups currently working on (or planning to focus future studies on) first-episode psychotic patients to contact us so that we may broaden this informal network, hopefully enhancing our efforts to advance our understanding of these most disabling disorders.
Reference Kirch, D.G.; Keith, S.J.; and Matthews, S.M. Research on firstepisode psychosis: Report on a National Institute of Mental Health Workshop. Schizophrenia Bulletin, 18:179-184, 1992.
The Authors Darrell G. Kirch, M.D., is Deputy Director, and Associate Director for Clinical Neuroscience, Division of Clinical Research, National Institute of Mental Health, Rockville, MD. Jeffrey A. Lieberman, M.D., is Director, Psychiatric Research, Hillside Hospital-Long Island Jewish Medical Center, Glen Oaks, NY. Susan M. Matthews, B.A., is Research Analyst, Division of Clinical Research, National Institute of Mental Health, Rockville, MD.
Downloaded from http://schizophreniabulletin.oxfordjournals.org/ at New York University on May 16, 2015
clinical phenomenology, biological correlates, and treatment response of patients with schizophrenia and other psychoses in the earliest stage of their illness. The large number of different investigators and research groups contributing to these two special issues on first-episode psychosis reflects a real turning point in our scientific approach. Using both epidemiologic methods and innovative protocols for channeling patients into research studies at a very early point in their illness, the investigators contributing to this issue have turned the spotlight on the crucial early phases of psychosis. In addition, the reviews and conceptual papers that are included highlight the special methodological problems involved in studies of first-episode psychotic patients. A number of key issues are dealt with both theoretically and empirically by our contributing authors. These include the especially difficult problems of defining the actual age of onset of prodromal and active symptoms and of delineating the boundaries of what really constitutes the "first" episode, as well as subsequent "relapses," of schizophrenia or other psychotic illnesses. Another issue that cannot be ignored by investigators in the current medical and sodal climate is the chronology and interrelationship between substance abuse and psychotic illness. Several of the reports also examine the vital question of where in the course of psychotic illness pu-
SCHIZOPHRENIA BULLETIN
First-Episode Psychosis: Part I. Editors' Introduction
by Darrell G. Kirch, Jeffrey A. Ueberman, and Susan M. Matthews
Abstract
This is the first of two consecutive issues of the Schizophrenia Bulletin that will be devoted to the special theme of studies of first-episode psychosis. Given that until recently there was minimal research activity in this area, we were gratified as guest editors to have so many manuscripts contributed that we were able to fill two issues of the Bulletin. We see this heightened interest as significant in a number of ways. Most would agree that, until recently, studies of patients early in the course of schizophrenia and other psychotic illnesses had been seriously neglected. Although it traditionally has been viewed as vital to define
the course of any given disorder from the prodrome through the end stage, research on the major psychoses, especially schizophrenia, has been dominated by studies of patients who were in a relatively chronic state. Because of the nature of these disorders, patients frequently experience a recurrence of symptoms, often requiring repeated rehospitalizations. As a result, a majority of patients referred to clinical research facilities have been ill for years, thereby reducing the pool of eligible "first-admission patients" in these programs. In addition, many patients are referred to research centers because of their relatively treatmentrefractory clinical condition. One research strategy often employed to biologically study patients in this chronic state has been that of withdrawing patients from neuroleptic treatment in order to achieve a "drug-free" condition. In practice, however, this often involves a relatively brief wash-out period of 2 weeks or less from neuroleptic treatment. It is important to note that several promising strategies are under investigation to arrive at the most effective treatment plan for such chronic patients. These include reduced medication strategies, complete withdrawal of neuroleptic medication, and the combination of psychosocial treatments with medication, as well as the development of innovative treatment combinations (e.g., adjunctive medication and new drug development). Nevertheless, it remains distressingly clear to knowledgeable observers that we are lacking key information regarding the
Reprint requests should be tent to Dr. D.G. Kirch, Division of Clinical Research, National Institute of Mental Health, Parklawn Bldg., Rm. 10-105, 5600 Fishers Lane, Rockville, MD 20857.
Downloaded from http://schizophreniabulletin.oxfordjournals.org/ at New York University on May 16, 2015
Until recently, there has been a conspicuous lack of studies regarding the earliest phases of psychotic illness, with most research on schizophrenia and related disorders focusing on chronically ill patients. Currently, however, a number of investigators have turned their attention toward this topic, exploring the conceptual issues involved in defining the onset of psychosis, using case registers and population-based samples to do crucial epidemlologic studies on the course of schizophrenia, and developing mechanisms for identifying patients with first-episode psychosis and entering them into active research protocols. This issue of the Schizophrenia Bulletin is devoted to articles representing this full range of conceptual and empirical work on first-episode psychosis. The ultimate goal is for researchers working in this area to develop a network to enhance the sharing of concepts and data, with the eventual possibility of developing combined data bases and collaborative studies.
177
178
tative biological abnormalities appear, and how they may vary with the natural history of the disorder. The implications of this work for both understanding the pathophysiology of psychosis and developing prognostic markers are obvious. As described in an accompanying article in this issue of the Bulletin (Kirch et al. 1992, this issue), the idea of bringing these manuscripts together in two special issues of the journal is an outgrowth of a workshop on first-episode psychosis conducted by the National Institute of Mental Health in February 1991. The results of that workshop have been most gratifying insofar as they extend far beyond simply bringing together the body of work contained in these special issues. The investigators working in this area have opened new lines of communication and held subsequent meetings. There is every prospect that the result will be productive ongoing dialog on the data resulting from current studies, and new ways of resolving the complex conceptual and methodologic research issues inherent in these studies. Moreover, the possibility of establishing combined data bases and/ or conducting collaborative studies is now a real option for a growing group of dedicated investigators working in this area. As editors, we know that it is never possible to include all the relevant work being done in any given area within a special publication.
The groups reporting on their work regarding first-episode psychosis in these two issues of the Bulletin by no means include all the investigators interested in this topic. We encourage other groups currently working on (or planning to focus future studies on) first-episode psychotic patients to contact us so that we may broaden this informal network, hopefully enhancing our efforts to advance our understanding of these most disabling disorders.
Reference Kirch, D.G.; Keith, S.J.; and Matthews, S.M. Research on firstepisode psychosis: Report on a National Institute of Mental Health Workshop. Schizophrenia Bulletin, 18:179-184, 1992.
The Authors Darrell G. Kirch, M.D., is Deputy Director, and Associate Director for Clinical Neuroscience, Division of Clinical Research, National Institute of Mental Health, Rockville, MD. Jeffrey A. Lieberman, M.D., is Director, Psychiatric Research, Hillside Hospital-Long Island Jewish Medical Center, Glen Oaks, NY. Susan M. Matthews, B.A., is Research Analyst, Division of Clinical Research, National Institute of Mental Health, Rockville, MD.
Downloaded from http://schizophreniabulletin.oxfordjournals.org/ at New York University on May 16, 2015
clinical phenomenology, biological correlates, and treatment response of patients with schizophrenia and other psychoses in the earliest stage of their illness. The large number of different investigators and research groups contributing to these two special issues on first-episode psychosis reflects a real turning point in our scientific approach. Using both epidemiologic methods and innovative protocols for channeling patients into research studies at a very early point in their illness, the investigators contributing to this issue have turned the spotlight on the crucial early phases of psychosis. In addition, the reviews and conceptual papers that are included highlight the special methodological problems involved in studies of first-episode psychotic patients. A number of key issues are dealt with both theoretically and empirically by our contributing authors. These include the especially difficult problems of defining the actual age of onset of prodromal and active symptoms and of delineating the boundaries of what really constitutes the "first" episode, as well as subsequent "relapses," of schizophrenia or other psychotic illnesses. Another issue that cannot be ignored by investigators in the current medical and sodal climate is the chronology and interrelationship between substance abuse and psychotic illness. Several of the reports also examine the vital question of where in the course of psychotic illness pu-
SCHIZOPHRENIA BULLETIN
