East Asian Arch Psychiatry 2012;22:88-9

EDITORIAL

It is inspiring that so many pioneering Asian psychiatrists have recognised that prevention and early intervention are key potential strategies in the struggle to reduce the burden of mental illness in our rapidly changing societies. Quite apart from the human cost, the economic impact of untreated or poorly treated mental disorders is a major threat to happiness and prosperity worldwide. In its 2011 report on the impact of non-communicable diseases, the World Economic Forum has shown that mental illness will equal cardiovascular disease as the major threat to gross domestic product both in developed and developing economies over the next 2 decades.² This is because mental disorders are chronic diseases of young people, with 75% of onsets occurring before the age of 25 years, and most occur between puberty and the mid-twenties.³ Obviously, this hits hardest in developing countries with their predominantly young populations.

In the western world, despite compelling logic and a substantial emerging evidence base which almost uniformly indicates that the early intervention paradigm is as valid in mental health as it is in physical health, timely and appropriate early intervention remains aspirational for the average patient experiencing the onset of a mental illness. This is in part a reflection of the inequity that people living with mental ill health around the world still experience, but also a reflection of a certain degree of lack of confidence and maturity within the mental health community. Despite 2 decades of indicative evidence, and the early intervention field having been led by an international array of academic clinicians deeply committed to evidence-based medicine, there  has  been  not  only  excessive  conservatism,  but also an attempt by a small group of academics to use the evidence-based  paradigm  selectively  to  introduce  doubt and undermine reform.⁴ Scepticism is central to science and is necessary, but a double standard is at work here, since similar doubts have not been fuelled in relation to any aspect of the status quo of traditional mental health care.

Fortunately, the dichotomy between early intervention and decent long-term care is demonstrably false, since investment  in  early  intervention  has  been  shown  to  be cost-effective, especially in relation to psychosis, where 5 studies all point to substantial savings that can be channelled into enhancing care programmes for the substantial and cumulative minority whose recovery is prolonged or elusive.^5-9  Many, although admittedly not all, of those who come to need such programmes do so precisely because they have received late, desultory, or poor-quality intervention from pessimistic and poorly resourced cultures of care, despite the best efforts of dedicated clinicians desperately propping up the latter.

We need to redouble our efforts to reconceptualise mental ill health in a more holistic way that accommodates both the reality of human distress and the need for psychosocial care, as well as the role for new therapies flowing from progress in neuroscience. An urgent priority is the reform, refinancing, and re-engineering of our systems of care so that people receive holistic care. Otherwise people with mental illness and their families will continue to suffer what Dr Thomas Insel, Director of the National Institute of Mental Health, calls “the soft bigotry of low expectations” (personal communication). Here in Australia, things are becoming more optimistic, with the Australian government recently announcing the funding of an additional 50 new youth mental health platforms, known as ‘headspace’ centres, and 16 early psychosis or Early Psychosis Prevention and Intervention Centre services over the next 5 years, among other significant investments in more holistic mental health care.

In this context the leadership shown by the authors of the papers in this issue is extremely timely and impressive, and they deserve our admiration and support. It is only a few years ago that Time Magazine highlighted the fact that the care of mentally ill people in Asia was lagging way behind the region’s economic growth and development.¹⁰

The papers in this issue report pioneering endeavours in early intervention for psychosis in India,¹¹   Hong Kong,^12, Korea,¹³  Japan,¹⁴  and Singapore¹⁵  that are not only laying the foundations for new knowledge in this burgeoning field, but also creating impetus for a transformation of the system of mental health care in these countries.

India is in the process of developing a national mental health reform policy and, while the importance of early intervention has been recognised, there are many challenges yet to be faced in the context of this developing economy. There is enormous potential for early intervention and a focus on youth mental health to become a key pillar of a modernised mental health system in India, and Rangaswamy et  al¹¹    are providing  much  of  the  data  and  experience to guide this process, with their groundbreaking early psychosis programme in Chennai, India. The Hong Kong group,¹²  led by Professor Eric Chen, has just celebrated the 10th anniversary of its establishment and has developed an impressive early psychosis service, encompassing several key platforms, for the 7 million population of Hong Kong. These authors have shown on an unprecedented scale that outcomes can be improved, suicide rates reduced, and cost- effectiveness demonstrated. Similarly, under the leadership of  Professor  Siow-Ann  Chong  and  Dr  Swapna  Verma in Singapore,¹⁵   a large-scale early psychosis programme is producing much better symptomatic and vocational outcomes for people with previously disabling and stigmatising illnesses. Things are a little more challenging in Korea and Japan,^13,14  where the mental health systems face broader challenges, yet here too we have gifted and determined leaders who are focusing on early intervention as a key solution.

We in Australia working in the mental health field are extremely proud to be part of the Asia-Pacific region. My colleagues and I have close relationships with nearly all of these Asian centres and are expecting to be able to work even more closely with our Asian colleagues as the 21st century progresses to ensure that young people, and particularly those with emerging psychotic illness, get the earliest and best possible care to ensure they have the best chance of leading happy and fulfilling lives despite the threat of serious mental illness.

Prof. Patrick McGorry, MBBS, MD, PhD, FRANZCP Email: pmcgorry@unimelb.edu.au

Executive Director, Orygen Youth Health Research Centre;

Professor, Centre for Youth Mental Health at the University of Melbourne;

Director of Clinical Services, Orygen Youth Health, Parkville, Australia

References

1. Asian Network of Early Psychosis Writing Group. Early Psychosis Declaration for Asia by the Asian Network of Early Psychosis. East Asian Arch Psychiatry 2012;22:90-3.
2. Bloom DE, Cafiero ET, Jané-Llopis E, Abrahams-Gessel S, Bloom LR, Fathima S, et al. The global economic burden of noncommunicable diseases. Geneva: World Economic Forum; 2011. Available at: www.weforum.org/EconomicsOfNCD. Accessed 1 April 2012.
3. Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2005;62:593-602.
4. McGorry P. At issue: Cochrane, early intervention, and mental health reform: analysis, paralysis, or evidence-informed progress? Schizophr Bull 2012;38:221-4.
5. Cullberg J, Mattsson M, Levander S, Holmqvist R, Tomsmark L, Elingfors C, et al. Treatment costs and clinical outcome for first episode schizophrenia patients: a 3-year follow-up of the Swedish “Parachute Project” and two comparison groups. Acta Psychiatr Scand 2006;114:274-81.
6. Goldberg K, Norman R, Hoch JS, Schmitz N, Windell D, Brown N, et al. Impact of a specialized early intervention service for psychotic disorders on patient characteristics, service use, and hospital costs in a defined catchment area. Can J Psychiatry 2006;51:895-903.
7. McCrone P, Craig TK, Power P, Garety PA. Cost-effectiveness of an early intervention service for people with psychosis. Br J Psychiatry 2010;196:377-82.
8. Mihalopoulos C, Harris M, Henry L, Harrigan S, McGorry P. Is early intervention in psychosis cost-effective over the long term? Schizophr Bull 2009;35:909-18.
9. Valmaggia LR, McCrone P, Knapp M, Woolley JB, Broome MR, Tabraham P, et al. Economic impact of early intervention in people at high risk of psychosis. Psychol Med 2009;39:1617-26.
10. Time Magazine 10 November 2003. “Hidden away.” Time website:http://www.time.com/time/world/article/0,8599,2047610,00.html. Accessed 1 April 2012.
11. 1 Rangaswamy T, Mangala R, Mohan G, Joseph J, John S. Early intervention for first-episode psychosis in India. East Asian Arch Psychiatry 2012;22:94-9.
12. Wong GH, Hui CL, Wong DY, Tang JY, Chang WC, Chan SK, et al. Developments in early intervention for psychosis in Hong Kong. East Asian Arch Psychiatry 2012;22:100-4.
13. Lee MS, Ahn SR, Park JI, Chung YC. Development of an early psychosis intervention system in Korea: focus on the continuing care system for first-episode psychosis treatment in Seoul. East Asian Arch Psychiatry 2012;22:105-9.
14. Nemoto T, Funatogawa T, Takeshi K, Tobe M, Yamaguchi T, Morita K, et al. Clinical practice at a multi-dimensional treatment centre for individuals with early psychosis in Japan. East Asian Arch Psychiatry 2012;22:110-3.
15. Verma S, Poon LY, Lee H, Rao S, Chong SA. Evolution of early psychosis intervention services in Singapore. East Asian Arch Psychiatry 2012;22:114-7.