The European First-Episode Schizophrenia Network

The European First Episode Schizophrenia Network (EFESN) started in 1995. The first meeting was hosted in Robin Murray's department in London and was attended by 20 people from four European countries. Its most recent meeting in Switzerland in February 2002 was attended by over 100 delegates from 16 European countries; that, and the previous two meetings, were supported generously by an educational grant from AstraZeneca. This report is from a meeting of the EFESN held in Whistler BC, Canada in April 2001.

The EFESN is in principle an informal network of clinical scientists who are active researchers in the area of first-episode psychosis and schizophrenia. Its aims are to exchange information and encourage European collaborations. Such collaborations are potentially important for epidemiological studies as well as for the identification of comparatively uncommon cases within the first-episode framework, such as multiplex families and very early-onset cases. The network also exists to try to standardise some of the assessment procedures used in first-episode schizophrenia, including clinical assessments and imaging protocols.

It has long been realised that the collection of first-episode cases in a comprehensive way is important not only for incidence studies but also for outcome studies and studies of biological variables, such as imaging parameters, which are open to bias from the study of selected patient groups. By and large, European mental health care systems lend themselves to this epidemiological approach. The study of risk factors for schizophrenia depends largely on epidemiological pre-psychotic or incident cohorts, and the existence of national databases in Europe have facilitated this approach. Through such experiments it has become clear that a simplistic approach to the understanding of risk factors in schizophrenia is no longer tenable. Models of single major genes have given way once again to multi-factorial models of vulnerability and stress. Early neuro-developmental risk factors exist but are unlikely to be sufficient for expression of the disorder. Psychosocial risk factors as well as psychological factors appear to be in the ascendant again in the first years of the 21st century. The importance of neuro-cognitive deficits in chronic schizophrenia as predictors of clinical outcome has become clear and the delineation of how these deficits develop and at what stage is another key focus of first-episode psychosis research. It is clear once again that some of these deficits are progressive, whereas more subtle frontal executive deficits either precede the illness or are established very early after the psychosis develops. Hand in hand with this, structural imaging research has moved away from the position in the 1990s of relatively marked abnormalities pre-dating the onset of the disorder towards a more mixed neurodevelopmental and neurodegenerative model where some of the abnormalities are now seen as progressive, as a result both of the active disorder itself and of treatment. Importantly, too, the first episode as a legitimate focus for assertive treatment has replaced the focus of the past 30 years on chronic disabilities being addressed in community settings. The notion that early detection and intervention can improve clinical outcomes has strong face validity, although this remains to be tested formally in a randomised trial. The emerging role of new atypical drug treatments and non-drug treatments is a further dimension.

The 15 papers here represent a very partial cross-section of the research effort in first-episode schizophrenia now underway in Europe. In the first paper, John Waddington's group in Dublin re-examines the issue of gender differences in incidence of first-episode schizophrenia in a stable Irish community (Scully et al, 2002, this supplement). Esher, Romme, van Os and colleagues (Maastricht) examine long-term clinical outcomes in a unique sample of children hearing voices, which might be viewed as a variation in normal experience (Esher et al, 2002, this supplement). Per Mortensen's group in Copenhagen are currently the world leaders in identifying risk factors from national data sets. Here, Majella Byrne et al (2002, this supplement) look at the impact of family history on age at onset. Eve Johnstone's team in Edinburgh reports on neurocognitive deficits in a large cohort at genetic high risk (Johnstone et al, 2002, this supplement). From the Cologne group, Martin Hambrecht and colleagues report on subjective cognitive deficits in a sample from Europe's first clinical service for those with possible prodromal symptoms (Hambrecht et al, 2002, this supplement). The extent and profile of neurocognitive deficits in first-episode psychosis and how these might relate to the duration of untreated psychosis is explored by Eileen Joyce et al (2002, this supplement). Recent EFESN meetings have had an honorary non-European presentation and here, Lili Kopala's group from Canada reports on an open study of quetiapine in first-episode psychosis with apparent sparing of neurocognitive impairments (Good et al, 2002, this supplement). Paola Dazzan and Robin Murray (2002, this supplement) report the evidence for neurological soft signs in the first episode as predictors of outcome. Raimo Salokangas and his group (Turku, Finland; Salokangas et al, 2002, this supplement) and Rene Kahn and colleagues (Utrecht; Cahn et al, 2002, this supplement) each look at issues of the extent and specificity of brain structural abnormalities in first-episode samples. Amanda Skeate and colleagues from Max Birchwood's group address the factors that determine length of untreated psychosis, in terms of variations in normal healthy behaviour (Skeate et al, 2002, this supplement). Morrison, Bentall and colleagues examine initial results from a psychological treatment trial of operationally defined high-risk cases (Morrison et al, 2002, this supplement). Svein Friis et al (2002, this supplement) report on interim results from the important TIPS project, which is likely to be the first formal trial directly addressing the question of whether early detection and intervention really does improve clinical outcomes. The University of Manchester group reports on acute phase outcomes of the first full-scale trial of cognitive therapy in first-episode schizophrenia (Lewis et al, 2002, this supplement). Finally, Merete Nordentoft and colleagues (Copenhagen) present data addressing suicidal ideation in OPUS, a first-episode psychosis service (Nordentoft et al, 2002, this supplement).

First-episode schizophrenia is seen increasingly as a legitimate focus for research and treatment and the EFESN seems to have brought together researchers in a fruitful way. The aim of this supplement is to confirm the strength and depth of European research in this area.