Early intervention models suggest psychological interventions given to an individual exposed to a traumatic event may prevent the onset of trauma-related symptoms.

Cognitive therapies are based on the theory that an individual’s perception of a situation influences his or her emotional response to it. They aim to help people identify distorted thinking and to modify existing beliefs. Cognitive processing therapy is a type of cognitive therapy that involves psychoeducation, written accounts about the traumatic event, and cognitive restructuring to address beliefs about the event’s meaning and its implications.

Cognitive behavioural therapy (CBT) is one of the most common psychological treatments that are effective for the treatment of PTSD. CBT challenges distorted, negative thinking patterns associated with the trauma. It aims to help people develop more adaptive cognitions and behaviours, and to rethink assumptions and reactions to the event.

Exposure therapies to desensitise people to trauma-related memories by exposing them to specific and non-specific cues related to the trauma.

Eye movement desensitisation and reprocessing (EMDR) involves the patient focussing on a disturbing image, memory, emotion, or cognition associated with the trauma while the therapist initiates rapid voluntary eye movements. This is based on the observation that the intensity of traumatic memories can be reduced through eye movements, although the underlying mechanisms remain unclear.

Other therapies include narrative therapy, which can be used to help people reconstruct a consistent narrative about the trauma. Psychoeducation may help normalise stress reactions. Psychodynamic therapy can help people process the trauma emotionally and gain a better understanding of their responses to it. Supportive therapy involves counsellors giving support, listening, and helping people talk over their problems. Family therapy focusses on improving family communication and functioning.

What is the evidence on effectiveness of psychotherapy for prevention of PTSD?

Moderate quality evidence found a medium-sized reduction in rates of PTSD diagnosis, and more improvement in PTSD symptoms for up to one month following psychological therapy (mostly CBT) in children and adolescents exposed to trauma. However, these effects were not significant over the longer term. Direct comparisons between interventions showed no differences in rates of PTSD diagnosis in children receiving CBT, EMDR, or supportive therapy. However, CBT was better than EMDR, play therapy, and supportive therapy for PTSD symptom improvement.

There was a small reduction in PTSD diagnoses in adults exposed to trauma by 3-6 months following multiple-session, early psychological interventions. However, there were no differences immediately post-treatment or at 7-12 months after treatment. There were also no differences in PTSD symptom severity, depression, anxiety, or quality of life. Authors report a high risk of bias in the included trials.

August 2021

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Scientific understanding of the neurobiological changes occurring during PTSD onset shows memory consolidation appears particularly vulnerable to disruption in the first six hours after trauma, making this a crucial period for intervention for prevention of PTSD. This technical commentary presents the evidence on pharmaceutical interventions administered during this period. Please also see the psychotherapy for prevention of PTSD topic.

What is the evidence on medications for the prevention of PTSD?

Hydrocortisone is a glucocorticoid, which attenuates heightened fear response through increased removal of fear-inducing memories. Moderate to low quality evidence found a medium to large, reduced risk of PTSD within 3-6 months post-trauma in people with severe physical illness or injury receiving hydrocortisone post-trauma. Risks were not assessed in these samples, so contraindications need checking.

There was no benefit of hydrocortisone over placebo after 6 months post-trauma. There were also no benefits of propranolol, oxytocin, gabapentin, fish oil, dexamethasone, escitalopram, imipramine, or chloral hydrate for preventing PTSD at any time frame. Studies are few and small.

August 2021

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The onset of bipolar disorder can be hard to identify, as early symptoms may be difficult to distinguish from normal mood fluctuations. Correct diagnosis and treatment is important because untreated illness may have an inherently ‘toxic’ effect, contributing to psychological deterioration and poor prognosis. An initial diagnosis of bipolar disorder usually follows the first distinct episode of mania, but may come after a long period of inappropriate treatments for other mood disorders.

What is the evidence for the course and outcome after a first-episode of bipolar disorder?

Moderate to high quality evidence suggests the mean interval between onset of symptoms of bipolar disorder and management of the disorder is around 6 years. Early age of onset of symptoms and bipolar II vs. bipolar I disorder were associated with longer treatment delays.

Moderate to low quality evidence finds the rates of symptom and functioning improvement and rates of relapse following a first hospitalisation for bipolar disorder vary widely between studies. For symptom improvement, sample rates varied between 26% and 98%, for functioning improvement, sample rates varied between 35% and 87%, and for relapse, sample rates varied between 21% and 74%.

November 2021

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People deemed at high risk for bipolar disorder can be identified by having a family history of a mood disorder and/or having subclinical symptoms that are not severe enough for a diagnosis. Subclinical symptoms include depression, difficulty with concentration, episodic mood swings, anxiety, sleep disturbances, and sensitivity to stress. Familial risk accompanied by mood dysregulation or other mood symptomatology could help define the population at high risk of bipolar disorder. Early intervention involves identifying and treating these high-risk individuals as repeated mood episodes put people at risk of poor symptomatic and functional recovery.

What is the evidence for psychosocial treatments for people at high risk for bipolar disorder?

Moderate quality evidence finds benefits of early interventions, particularly family-orientated therapies, for improving mood and functioning in people aged between 9 and 30 years who are at risk of bipolar disorder.

November 2021

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The course of bipolar disorder and its treatment response tends to worsen over time, highlighting the importance of early intervention. As bipolar disorder cannot be diagnosed on the basis of depression alone, the onset of a manic episode may indicate an underlying bipolar disorder. Interventions for first-episode psychosis or depression have begun to be extended to those with bipolar disorder, however such interventions need to be tailored to suit people with first-episode bipolar disorder, and research is sparse for these patients.

What is the evidence for psychosocial treatments for first-episode bipolar disorder?

Low quality evidence is unable to determine the benefits of interventions for people with first-episode bipolar disorder. More research is needed.

November 2021

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People deemed at high risk for bipolar disorder can be identified by having a family history of a mood disorder and/or having subclinical symptoms that are not severe enough for a diagnosis. Subclinical symptoms include depression, difficulty with concentration, episodic mood swings, anxiety, sleep disturbances, and sensitivity to stress. Familial risk accompanied by mood dysregulation or other mood symptomatology could help define the population at high risk of bipolar disorder. Early intervention involves identifying and treating these high-risk individuals as repeated mood episodes put people at risk of poor symptomatic and functional recovery.

What is the evidence for medication in people at high risk for bipolar disorder?

Moderate to low quality evidence finds aripiprazole was significantly superior to placebo in improving mood, ADHD, and functioning scores in children and adolescents with a parent with bipolar disorder. There were no effects of valproate compared to placebo.

November 2021

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Pending enough primary studies, we invite reviews on this topic to be conducted. Alternatively, we will endeavour to conduct our own review to fill this gap in the Library.

November 2021

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Early detection of bipolar disorder can prevent or delay the onset of the disorder, and improve clinical outcomes in people who develop it.

What is the evidence regarding early detection of bipolar disorder?

Moderate to high quality evidence suggests large effects of having psychotic symptoms or a family history of bipolar disorder as risk factors for transition to bipolar disorder in people with major depression. There was a medium-sized effect of higher risk of transition to bipolar disorder with early age of onset of depression, and a small effect of having a family history of any mood disorder. The risk of transition to bipolar disorder was greatest in the early stages of having a major depressive disorder (up to 5 years).

Moderate quality evidence suggests subclinical symptoms preceding an initial mood episode last around 27 months, and subclinical symptoms preceding a recurrent mood episode last around 1 month. Common subclinical symptoms (in order of decreasing prevalence) are too much energy, diminished ability to think, indecisiveness, pressured speech, talkative, elated mood, academic or work difficulties, insomnia and depressed mood. Less common subclinical symptoms (in order of decreasing prevalence) are over-productive/goal-directed behaviour, agitation, rage attacks, racing thoughts, anxiety, decreased need for sleep, irritable mood, fatigue, distractibility, sleep disturbance, disinhibition, weight loss/loss of appetite, hyperactivity, suicidal thoughts, feeling of worthlessness, mood swings, delusions, unkempt or bizarre appearance, guilt, and auditory hallucinations. Rare subclinical symptoms (in order of decreasing prevalence) are loss of interest, somatic complaints, being over-sensitive, hypersexuality, flight of ideas, hypersomnia, weight gain, self-harm, suicide attempts, and visual hallucinations.

Low quality evidence is unable to determine the accuracy of instruments used for early detection. Review authors conclude that the Child Behavioral Checklist – Pediatric Bipolar Disorder Phenotype and the General Behavioral Inventory – Revised have the better validity and utility than the Hypomanic Personality Scale, the Behavioral Activation Scale or the Family History Scale, and that more studies assessing these scales are required.

September 2021

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A key target of early intervention is “indicated prevention” for individuals at high risk of psychosis who have been identified with early signs of the disorder, but do not meet any diagnostic criteria. There are two key approaches for identifying people with early signs. The first approach is based on Huber’s Basic Symptoms, which focuses on a detailed way of describing phenomenological (subjective) disturbances in the domains of perception, cognition, language, motor function, will, initiative and level of energy, and stress tolerance. Because the basic symptoms refer only to subtle subjectively experienced abnormalities, they may reflect an earlier phase in the disease process than the second approach. The second approach identifies at-risk mental states as a combination of a family history of psychosis plus non-specific symptoms and recent decline in functioning, recent onset attenuated psychotic symptoms with a decline in functioning, and brief, limited, intermittent psychotic symptoms.

Early intervention treatments for people identified at a high risk of psychosis often comprise both pharmaceutical and psychosocial therapies, consequently this table presents the evidence for both.

What is the evidence for treatments for high-risk groups?

Moderate quality evidence suggests cognitive behavioural therapy (CBT) may reduce the risk of transition to psychosis for up to two years when compared to various control conditions, with no differences in symptoms, functioning, study retention or quality of life. There were some advantages of ziprasidone plus needs-based interventions for improving attenuated psychotic symptoms when compared to needs-based interventions alone, CBT plus needs-based interventions, or risperidone plus CBT and needs-based interventions.

There were no differences in rates of transitioning to psychosis between needs-based interventions with versus without additional components (aripiprazole, olanzapine, ziprasidone, risperidone, glycine or D-serine, omega-3, CBT, integrated therapies, or family therapies). There were no differences between CBT, omega-3, or cognitive remediation and various control conditions for social functioning, and no differences between NMDAR (glutamate) modulators, CBT, omega-3, risperidone, family therapies, or cognitive remediation and control conditions for negative symptoms.

May 2022

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People with a first episode of psychosis experience distressing symptoms such as unusual beliefs or abnormal behaviour (positive symptoms) and/or withdrawal or loss of interest in work or school (negative symptoms). Early intervention programs for schizophrenia and psychosis often combine many elements comprising both pharmaceutical and psychosocial therapies, and may involve enriched therapies that are tailored to an individual’s needs. The conclusions presented here are based on group data, and as such individual treatment programs need to be tailored by trained clinicians. Individual response to treatment can vary in terms of both symptoms and adverse effects.

What is the evidence on medications for first-episode psychosis?

For targeted early intervention services that include both antipsychotics and psychosocial components, moderate to high quality evidence finds small effects of greater improvements in symptoms, functioning, quality of life, and more remission and recovery than with treatment as usual.

Overall, there is a reasonable response to antipsychotics after a first-episode of psychosis; moderate quality evidence finds antipsychotics are associated with an 81% response rate when measured as a 20% reduction in symptoms, and a 52% response rate when measured as a 50% reduction in symptoms. For specific antipsychotics, high quality evidence finds greater improvement in overall symptoms with olanzapine than with haloperidol, and moderate to high quality evidence finds greater improvement in negative symptoms with olanzapine than with haloperidol, with no differences in positive symptoms. Moderate to high quality evidence finds greater improvement in overall symptoms with amisulpride or risperidone than with haloperidol. Moderate quality evidence finds greater improvement in overall symptoms with amisulpride than with quetiapine, and with ziprasidone than with haloperidol. There was greater improvement in negative symptoms with olanzapine than with risperidone, and greater improvement in positive symptoms with olanzapine than with quetiapine. There was greater improvement in both positive and negative symptoms with quetiapine than with haloperidol, and greater improvement in positive symptoms with risperidone than with quetiapine.

For relapse prevention, moderate to high quality evidence finds small effects of fewer relapses and hospitalisations with targetted early intervention services. Second-generation antipsychotics in general were found to be more effective than first-generation antipsychotics. Moderate quality evidence finds relapse and rehospitalisation rates were higher after discontinuation rather than maintenance of antipsychotics in people in remission following a first-episode of psychosis.

For treatment adherence, moderate to high quality evidence finds less all-cause discontinuation with targeted early intervention services. There was less all-cause discontinuation with risperidone than with haloperidol and less all-cause discontinuation with quetiapine than with haloperidol. Moderate to low quality evidence finds less all-cause discontinuation with aripiprazole or olanzapine than with haloperidol.

For side effects, olanzapine was associated with at least one use of drugs to treat parkinsonian symptoms. Quetiapine was associated with less akathisia than haloperidol, aripiprazole, risperidone, and olanzapine. Molindone resulted in less weight gain than risperidone, haloperidol, and olanzapine and less increase in prolactin release than risperidone.

October 2020

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