Preface

A common theme in the recent literature on most mental disorders is that they often remain undetected and untreated for quite a long time, not rarely for several years, after the occurrence of their first manifestations. For some disorders - namely bipolar disorder, schizophrenia and some anxiety disorders - clinical research has directly documented the average interval between their onset and the time of their diagnosis and the start of appropriate treatment. For depressive disorders, a different way to document the same phenomenon has been the finding that a high proportion of cases are missed by general practitioners, although part of them are recognized in subsequent consultations. For other conditions -especially eating disorders and some anxiety disorders - the main focus has been on the multiple barriers to help seeking, which often delay recognition and treatment. In the case of Alzheimer's disease, neuropsychological and biological research has been decisive in documenting the latency between the first manifestations of the disease and the clinical diagnosis.

The argument underlying this vast and diverse body of literature has been that an early diagnosis and management of the various disorders may be essential in improving their course and outcome and in reducing or even preventing their social consequences. This hypothesis has received up to now only a partial empirical support for most of the above-mentioned disorders, but represents a major focus of research for virtually all of them. Moreover, it has been repeatedly pointed out that the reconstruction of the early phases of development of mental disorders may contribute significantly to the elucidation of their etiopathogenesis and, in the case of some of them, may allow devising prevention programmes.

Early detection and management of a mental disorder implies the availability of a thorough description of the prodromal manifestations of the disorder, the existence of assessment and screening instruments with a satisfactory sensitivity and specificity, the feasibility of screening programmes in the general population or in vulnerable groups, the successful engagement of a significant proportion of the subjects found to be at high risk, and the availability of validated programmes of intervention focused on the early phases of the disorder. All these elements are currently being developed for most of the above-mentioned mental disorders, and are already part of clinical practice in several contexts for some of them (notably schizophrenia).

This volume aims to provide an update on this complex and dynamic area of research and clinical practice, with a description of the precursors and prodromes of the various mental disorders (more or less extensive and detailed, depending on the current state of knowledge and on the complexity of the individual disorders); an outline of the available instruments for the assessment of the prodromal symptoms of the disorders and, when available, for their screening in the general population or in vulnerable groups; and a critical review of the screening, management and preventive interventions which have been tested up to now by empirical research. Emphasis is laid on the importance of sensitizing general practitioners to the early manifestations of the various disorders, and on the complexity of the ethical issues which arise in relation to the recognition and management of early psychosis.

Two chapters focus on research conducted in the offspring of patients with schizophrenia and bipolar disorder, because of the essential contribution that such research can provide to the elucidation of clinical, personological and biological precursors, of possible resilience factors, and of the prodromal symptoms and signs of these disorders. One chapter deals with the differential diagnosis of mental disorders in children, emphasizing the risk of overdiagnosis as well as of underdiagnosis of these disorders, the problems raised by psychiatric comorbidity and diagnostic instability in this age group, and the role of the environment in shaping the clinical picture of the disorders.

We hope that this volume will contribute to call the attention of psychiatrists and other mental health professionals to this rapidly growing and fascinating area of modern psychiatry, and to encourage some of them to approach it with the appropriate dose of optimism and pragmatism.

Mario Maj Juan Jose Lopez-Ibor Norman Sartorius Mitsumoto Sato Ahmed Okasha

This volume includes several chapters developed from presentations delivered at the 12th World Congress of Psychiatry (Yokohama, Japan, 24-29 August, 2002).

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