Toward the end of the 1970s, psychotherapists led by Carol Anderson at the University of Pittsburgh Medical Center launched a movement to rethink that approach. They began by stressing the long-standing evidence for schizophrenia’s biological roots, believing that the more the disease was understood by families, the less fearful it would seem. With a new talk therapy that they called psychoeducation, Anderson and her colleagues urged family members to temper their expectations of improvement, which had been found to stress patients and slow their progress. The best results, families were told, would come from low-key, convalescing interactions, which would allow patients to recover naturally from the shock of a psychotic episode. Even sudden noises and unanticipated changes in routine were to be avoided. Helping families learn how to direct their responses to the illness, rather than to the person suffering from it, is difficult, McFarlane says. But once they understood the process, they were relieved they could participate in the patient’s recovery.
McFarlane added his own twist by bringing families together in small groups. To his delight, he found that they bonded quickly in helpful ways. Patients treated in multifamily groups were more likely to stick with medication, he found, and within a few months, even the sickest among them were no longer psychotic.
Research during the late 1980s began showing that the sooner after a psychotic break patients were treated, the better they did. Symptoms were fewer and less intense. Often the symptoms could be controlled with a lower dose of medication than that used to treat full-blown psychosis. Patients also had less evidence of the loss of brain tissue, a key characteristic of the disease.
“This really captured the field’s imagination,” says Jeffrey Lieberman, who chairs the department of psychiatry at Columbia University College of Physicians and Surgeons and directs the New York State Psychiatric Institute. “Until then, we figured there wasn’t any real rush to treat. As long as patients weren’t hurting themselves or others, it wouldn’t matter if we treated them now or later. But when we recognized that treatments had to be fast, this created an urgency to find people with psychotic illness and to get them on medication quickly.”
With psychiatry turning to “first-episode” patients, those who had only recently suffered a psychotic break, McFarlane wondered if treating patients before psychosis even occurred might prevent schizophrenia altogether. He wasn’t alone in asking. In 1984 the late Ian Falloon (PDF), professor of psychiatry at the Auckland Medical Center in New Zealand, created a model mental health service in Buckingham and Winslow, two small towns northwest of London, to identify and treat high-risk patients in the community. Caregivers offered a range of supports, including family psychoeducation, home-based stress-management resources, and low doses of antipsychotic drugs. When the study wrapped up four years later, Falloon found that the incidence of schizophrenia in the treatment zones was one-tenth of what it had been a decade earlier. The program was not a controlled study, however, so there may have been other factors contributing to the decline.
By this time, McFarlane had perfected his own psychosocial technique at Columbia’s College of Physicians and Surgeons. There he came to find that multifamily therapy in schizophrenia worked best when combined with support from social workers, nurses, and psychiatrists to help patients find employment and housing so they could live independently. Using this approach, McFarlane claims he was able to halve rates of psychotic relapse and double employment, even among the sickest patients.
In 1992 McFarlane moved to the Maine Medical Center to become chief of the department of psychiatry. He also began consulting on a large first-episode treatment program in four cities in Norway and Denmark, applying insights from earlier studies that had convinced him that combining multifamily psychoeducation, social services, and low-dose antipsychotics could prevent relapse among young, first-episode patients.
The chance to apply that method with at-risk patients finally came in 1997. Aiming to replicate his success in Scandinavia, McFarlane set up a small first-episode pilot program in Portland. Within a few months he started getting referrals for patients who seemed on the verge of psychosis—he calls them “prodromal,” showing early symptoms and signs of a disease—so he decided to add them to the first-episode group. Over the following months, almost none of the handful of at-risk patients converted to psychosis. “It all went incredibly well,” he says. “So we thought, ‘Well, this is worth doing,’ and at that point, we started looking for funding to develop a formal team dedicated to prodromal patients.”
Just as McFarlane’s preventive program was getting under way, Thomas McGlashan, a psychiatrist from Yale School of Medicine, was facing fierce opposition to his plan to try out the antipsychotic olanzapine as a preventive treatment. Attacked by critics who insisted it wasn’t ethical to use the drug on young patients who weren’t yet psychotic, McGlashan says he supplied “about 200 pounds” of supporting documentation to the federal Office for Human Research Protections before he got a green light to continue.
McFarlane says that his program, too, faced strict ethical review from both the Maine Medical Center and the National Institute of Mental Health (NIMH). The difference, he believes, is that PIER fostered local support by engaging consumer advocacy organizations and safeguarding patient privacy. Because of the stigma surrounding mental illness, McFarlane says, confidentiality is crucial. “It’s a big issue that’s important to the success of the program, and we bend over backward to protect the privacy and confidentiality of these young people.”
