Disease-modifying interventions in psychiatry

Disease-modifying interventions do not just treat the symptoms of the disease but target the underlying disease process and natural course. The construct of disease-modifying treatments has transformed the care of disorders, like rheumatoid arthritis and multiple sclerosis, by shifting the focus to preventing end-organ damage rather than offering symptomatic treatment. As mental illness may have a chronic and progressive course, there is a need to consider whether any of our interventions may be disease-modifying. We, therefore, conducted a search using databases, including MEDLINE, EMBASE and PsycINFO, to identify peer-reviewed papers and grey literature related to the research question: ‘Which psychiatric treatments are disease-modifying?’ Disease-modifying properties were largely operationalised around end-organ changes, including structural brain changes evident on neuroimaging and cognition, and were reported for conventional psychotropics, as well as for novel pharmaceuticals and non-pharmacological interventions. Lithium and electroconvulsive therapy showed the greatest evidence as disease-modifying interventions. However, to establish this and identify potential other disease-modifying treatments, there needs to be a shift in the focus of psychiatric clinical trials to include primary outcomes that reflect disease progression and not just acute symptom burden. The potential disease-modifying properties of lithium and electroconvulsive therapy should spur the prioritisation of treatment higher up the algorithm, as well as the commencement of disease-modifying therapy as early as possible in the illness course to prevent adverse outcomes.