East Asian Arch Psychiatry 2013;23:169-70

Book Review

Early Psychosis Intervention: A Culturally Adaptive Clinical Guide

Editors: Eric Yu-Hai Chen, Helen Lee, Gloria Hoi-Kei Chan, Gloria Hoi-Yan Wong
Hong Kong University Press
USD 45.00; pp416; ISBN: 978-9888139927

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With the advances in medical technology, different modalities of state-of-the-art investigations and treatments are now available. All these will facilitate early detection of disease and improve survival. Yet, without any ‘audible’ or ‘palpable’ signs, what can a psychiatrist do to anticipate one of the major enemies, namely psychosis? What will be the potential hurdles?

Early Psychosis Intervention: A Culturally Adaptive Clinical Guide edited by Eric Yu-Hai Chen, Helen Lee, Gloria Hoi-Kei Chan, and Gloria Hoi-Yan Wong is a book that aimed to give readers an overview of the ways to deliver effective and efficient treatment during the early stages of psychosis by appreciating cultural differences between Asian and western patients. With the wisdom of experienced frontline psychiatrists and recent research findings, a comprehensive but practical approach to the management of psychosis, ranging from early detection as well as reintegration into the community, is covered.

This book starts with the analysis of early psychosis interventional developments in Asia. In Hong Kong, the first specialised early psychosis service was the Early Assessment Service for Young People with Early Psychosis (EASY). Before its introduction, only one-third of the psychotic patients received treatment within a month of illness onset, the mean delay being about 1.5 years. Possible underlying reasons included lack of public awareness and knowledge of mental illness, stigmatisation, and limited accessibility to psychiatric services. To overcome these obstacles, EASY was dedicated to raise public awareness through community education programmes and offer easily accessible assessment system via both telephone-based and face-to-face screening. Apart from that, the approach of rebranding ‘zhongxing jingshenbing’(重性精神病) as ‘sijue shitiao’(思覺失調)was adopted to reduce stigmatisation, in which the name itself only implies the biological nature and reversible component of the functional impairment. In conclusion, EASY was cost-neutral with improved clinical outcomes, in terms of negative symptoms and suicide rates.

Further in-depth discussion of early detection then follows. The authors suggest workplaces as an alternative setting of early detection, since most patients are adolescents or in early adulthood when they first develop psychosis. Early detection can also be improved by enhancing the collaboration among frontline gatekeepers (social workers and counsellors). The EASY service adopted a 2-stage assessment and referral system. Every referral was first assessed by a case manager in the first stage. Then potential cases were seen by a psychiatrist to pick up subtle and non-specific symptoms that fail to fit into clear diagnostic categories. Cautious interviews should be carried out before proscribing a definitive diagnosis. For high-risk cases, regular monitoring was offered by the EASY team.

Early intervention follows an established diagnosis. Compelling evidence supports the prompt use of antipsychotics once psychotic symptoms are identified. The shorter the duration of untreated psychosis, the better the outcome. Yet there is no consensus on the exact duration of antipsychotic use and what generation of agents to use. According to World Health Organization and the International Early Psychosis Association, recommendations on the use of second- versus first-generation antipsychotics depend on available resources.

Culturally relevant psychosocial case interventions are also illustrated. Psychological interventions targeting psychotic symptoms and functional deteriorations are increasingly recognised. Psychological Intervention Programmes with three main conceptual modules in early psychosis were developed. They included enhancing psychological adjustment to early psychosis, interventions for secondary morbidity, and cognitive behavioural therapy for drug-resistant psychotic symptoms.

Non-adherence increases the risk of relapse 5 fold. Engagement, which closely relates to drug compliance and clinical outcome, is therefore another cornerstone of psychosis intervention. A multidisciplinary approach has been adopted with community-based elements. Outreach service teams play a significant role in offering psychiatric assessment, restoring treatment continuity, and fostering engagement. The ‘low-threshold principle’ is emphasised. Support programmes in the EASY service work hand in hand with non-governmental organisations. They not only detect early or untreated psychosis, but also assist in reintegrating patients into the community through normalisation and vocational training.

Social stigma attached to mental illness is one of the major hindrances for patients and caregivers seeking help and reintegrating into society after recovery. In general, the public holds a misconception that mental patients are dangerous and that such illness is chronic, difficult to treat, and has a grave prognosis. Destigmatisation should be a long-term goal and needs to focus on both the general public and the affected family.

Remission is defined as absence of symptoms, or presence of only minimal symptoms. But there is no clear definition for ‘recover’. Yet challenges are inevitable; post- treatment deficit states with predominant negative symptoms and high mortality rates from suicide are commonly quoted issues. The authors touch on these potential hurdles and general approaches to relapse prevention.

In short, this book provides a comprehensive overview of early psychosis interventions, ranging from early detection to reintegration into the community. Apart from providing detailed and factual information on this subject, it is also culturally adapted to allow readers, particularly psychiatrists, who practise in Hong Kong to gain better insight.

Wayne Wing-Ki Tang, MBChB
(email: waynetwk@gmail.com)
Department of Psychiatry
Tai Po Hospital
Hong Kong SAR, China


The Editorial Board of East Asian Archives of Psychiatry wishes to thank the reviewers for volunteering their expertise and insight, and for their hard work and diligence in reviewing articles for the year 2013. 

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