I recently had the pleasure of visiting the beautiful city of San Francisco. While marvelling at such wonders as Alcatraz and the Golden Gate Bridge, I was struck by something more sinister about the city.  Homeless people were everywhere, many displaying clear evidence of mental illness. It was therefore fitting that the International Early Psychosis Association (IEPA) chose San Francisco as the host of its eighth biennial conference on early intervention. 

The keynote address was delivered by Dr Robert Heinssen of the US National Institute of Mental Health. He spoke about strategies to improve communication between scientists and policy makers, asserting that it takes an average of 17 years for a scientific finding to make its way through the academic system and eventually influence public policy. He concluded that it behoves scientists to include policy makers in designing research studies. This, he observed, was the only way to ensure implementation in a cost-effective manner and maximise positive outcomes.

Dr Heinssen also made reference to the Recovery After an Initial Schizophrenia Episode (RAISE) project, which Prof John Kane spoke about in the first plenary session. Prof Kane – chairman of psychiatry at Zucker Hillside Hospital in New York – described studies showing that 82% of first-episode psychosis patients relapse within five years. Prof Kane cited medication side-effects and adherence as key influencing factors of this figure. He went on to describe RAISE as a comprehensive and integrated intervention aimed at symptomatic recovery, minimising disability, and enabling social, academic and vocational rehabilitation. Prof Kane also discussed the NAVIGATE intervention for the early treatment of psychosis, consisting of a pharmacological computerised decision support system, individual resilience training (IRT), psycho-education for families, and supportive employment.

In the second plenary session, Dr Sophia Vindragov from the University of California spoke about neuroscience-informed cognitive training via laptop computer in recent-onset schizophrenia. In her opening lines, she remarked that “if you can’t bring the subject to cognitive training, at least you bring cognitive training to the subject”. 

A different pace was adopted in the final plenary session of day one. Tony Morrison, professor of psychology at the University of Manchester, spoke about the efficacy of cognitive behavioural therapy for psychosis in the absence of antipsychotic medication. He described several clinical trials, and used his evidence to caution against an “exclusive reliance” on antipsychotics. The thrust of his argument was that patients do not really gain anything by adding antipsychotics to CBT in early psychosis. The prevailing sentiment among attendees did not appear especially sympathetic to this view, although admittedly this was a conference dominated by biological psychiatry.

To further illustrate this, the fourth plenary session was delivered on day two by Dr David Lewis of the University of Pittsburgh. In speaking about schizophrenia as a disorder of complex neurodevelopmental deficit, he made a difficult field very accessible. He described the Feinberg theory (whereby schizophrenia is a disturbance of late developmental events in the prefrontal cortex) and the Weinberger Murray view (whereby schizophrenia is due to earlier neurodevelopmental deficits). Dr Lewis went on to propose a third (Keshavan-integrated) theory, which notes that different GABA-related brain structures develop at complex, protracted and distinctive rates. While all three theories refer to a critically sensitive period in which exposure to an adverse experience can have a profound impact on rapidly-changing brain circuitry, the Keshavan-integrated theory involves a far longer period of vulnerability to schizophrenia. 

Further plenary sessions were delivered by Prof Tyrone Cannon of Yale University (on biomarkers for conversion to psychosis), Dr Elaine Walker of Emory University (on stress and the HPA axis in emerging psychosis) and Prof Howard Goldman of the University of Maryland School of Medicine (on implementation of first-episode psychosis services). Not to be outdone, the Irish were well represented. The DETECT early intervention service for psychosis delivered five oral presentations (including my own), while Prof Mary Cannon of the RCSI delivered the penultimate plenary session on psychotic symptoms in childhood.   

Finally, Prof Patrick McGorry of the University of Melbourne, founder of the IEPA itself, gave an interesting closing perspective on the current direction of early intervention. It was an enjoyable and informative conference overall, every bit as rewarding as my walk across the Golden Gate Bridge.