Skip to main content Accessibility help
×
×
Home

Information:

  • Access
  • Cited by 8
  • Cited by
    This article has been cited by the following publications. This list is generated based on data provided by CrossRef.

    Castle, David J 2012. The truth, and nothing but the truth, about early intervention in psychosis. Australian & New Zealand Journal of Psychiatry, Vol. 46, Issue. 1, p. 10.

    Yung, Alison R 2012. Selective bias in criticism of early intervention. Australian & New Zealand Journal of Psychiatry, Vol. 46, Issue. 9, p. 904.

    Iyer, Srividya N. and Malla, Ashok K. 2014. Intervention précoce pour la psychose : concepts, connaissances actuelles et orientations futures. Santé mentale au Québec, Vol. 39, Issue. 2, p. 201.

    Jones, Rose Major, Barnaby and Fear, Christopher 2015. Schizophrenia in a Primary Care Setting. Current Psychiatry Reports, Vol. 17, Issue. 10,

    Ruggeri, Mirella Bonetto, Chiara Lasalvia, Antonio Fioritti, Angelo de Girolamo, Giovanni Santonastaso, Paolo Pileggi, Francesca Neri, Giovanni Ghigi, Daniela Giubilini, Franco Miceli, Maurizio Scarone, Silvio Cocchi, Angelo Torresani, Stefano Faravelli, Carlo Cremonese, Carla Scocco, Paolo Leuci, Emanuela Mazzi, Fausto Pratelli, Michela Bellini, Francesca Tosato, Sarah De Santi, Katia Bissoli, Sarah Poli, Sara Ira, Elisa Zoppei, Silvia Rucci, Paola Bislenghi, Laura Patelli, Giovanni Cristofalo, Doriana and Meneghelli, Anna 2015. Feasibility and Effectiveness of a Multi-Element Psychosocial Intervention for First-Episode Psychosis: Results From the Cluster-Randomized Controlled GET UP PIANO Trial in a Catchment Area of 10 Million Inhabitants. Schizophrenia Bulletin, Vol. 41, Issue. 5, p. 1192.

    Lasalvia, Antonio Bonetto, Chiara Lenzi, Jacopo Rucci, Paola Iozzino, Laura Cellini, Massimo Comacchio, Carla Cristofalo, Doriana D'Agostino, Armando de Girolamo, Giovanni De Santi, Katia Ghigi, Daniela Leuci, Emanuela Miceli, Maurizio Meneghelli, Anna Pileggi, Francesca Scarone, Silvio Santonastaso, Paolo Torresani, Stefano Tosato, Sarah Veronese, Angela Fioritti, Angelo and Ruggeri, Mirella 2017. Predictors and moderators of treatment outcome in patients receiving multi-element psychosocial intervention for early psychosis: Results from the GET UP pragmatic cluster randomised controlled trial. British Journal of Psychiatry, Vol. 210, Issue. 05, p. 342.

    Behan, Caragh Masterson, Sarah and Clarke, Mary 2017. Systematic review of the evidence for service models delivering early intervention in psychosis outside the stand-alone centre. Early Intervention in Psychiatry, Vol. 11, Issue. 1, p. 3.

    Hansen, Hege Stige, Signe Hjelen Davidson, Larry Moltu, Christian and Veseth, Marius 2018. How Do People Experience Early Intervention Services for Psychosis? A Meta-Synthesis. Qualitative Health Research, Vol. 28, Issue. 2, p. 259.

    ×

Actions:

      • Send article to Kindle

        To send this article to your Kindle, first ensure no-reply@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

        Note you can select to send to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

        Find out more about the Kindle Personal Document Service.

        Should early psychosis intervention be the focus for mental health services?
        Available formats
        ×

        Send article to Dropbox

        To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

        Should early psychosis intervention be the focus for mental health services?
        Available formats
        ×

        Send article to Google Drive

        To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

        Should early psychosis intervention be the focus for mental health services?
        Available formats
        ×
Export citation

Summary

This issue of Advances carries two articles from Melbourne, Australia, outlining the rationale for, and implementation of, early psychosis services. Their publication provides an opportunity to address some of the more contentious issues relating to the early psychosis intervention movement.

Footnotes

See pp. 401–407 and 408–416, this issue.

Declaration of Interest

None.

Space limitations preclude a critique here of all of the issues regarding early intervention services. I will focus on the more contentious. Readers wishing for a broader review are referred to Bosanac et al (2010) and Pelosi & Birchwood (2003).

Are early intervention services associated with enhanced longer-term outcomes?

As Murphy & Brewer point out (Murphy 2011a,b, this issue), a number of studies have shown that early intervention programmes for psychosis are liked by participants and their families and have beneficial effects while they are being delivered. But short-term effects are not of prime importance: it is well known that high-fidelity multidisciplinary teams can effect good outcomes for people with schizophrenia, whatever the stage of illness. What is critical to the early intervention field is whether they fulfil their ‘promise’ that early treatment can ameliorate longer-term outcomes.

Naturalistic studies

A number of investigators have attempted to measure whether there are such longer-term benefits. For example, the US study of Robinson et al (1995) reported cumulative relapse rates for 104 people with early psychosis to be 82% for a first episode and 78% for a second episode, over 5 years. Closer to home, the EPPIC group in Melbourne have performed a 7-year follow-up of 651 (of an original 723) consecutive early-psychosis patients (Henry 2010). Only 57.5% had schizophrenia, and outcomes for the schizophrenia group were conflated with those for patients with schizophreniform psychosis, a disorder with intrinsically better outcomes. In any event, outcomes were overall very poor, with only 14.9% showing full symptomatic and social/vocational remission. And from Sweden, Bodén et al (2010) reported on a naturalistic study of 144 first-episode patients. They found that those who had received a modified assertive community treatment (mACT) intervention had no better 5-year outcomes across multiple outcome domains than those who had not received it: indeed, the mACT group showed marginally worse positive symptom ratings (OR = 3.21; 95% CI 0.97–10.63). The reliance on historical control groups (i.e. a cohort from previous years) in the foregoing studies limits the conclusions that can be drawn, but the results do underscore the fact that the chances of relapse even with specialised early psychosis services are high, as is the risk of poor longitudinal outcomes.

Randomised controlled trials

The gold standard by which to assess the efficacy of interventions is the randomised controlled trial. Of course, these are very difficult and expensive undertakings, particularly in complex interventions such as early psychosis. Thus, three such studies deserve special mention. All essentially compared an early psychosis specialist programme with ‘usual care’; they included a broad range of psychotic illnesses and used multifaceted interventions. The Lambeth Early Onset (LEO) study in London (Craig 2004) found short-term (12–18 months) benefits from the specialist intervention in terms of hospital admission rates and vocational and social functioning (Garety 2006). However, at 5-year follow-up, benefits in terms of admissions had dissipated; indeed, there was a rapid ‘catch-up’ shortly after the specialist programme ended (Gafoor 2010). The OPUS study in Denmark similarly found that 2-year benefits, including improved psychotic symptoms and reduced substance use, were not sustained at 5 years (Bertlesen 2008). Finally, the Dutch study of Linszen et al (1998) also reported loss of early gains at longer-term follow-up.

Propping up the paradigm

Defenders of the early intervention paradigm (e.g. McGorry 2010; Singh 2010) assert that the lack of longer-term benefits from early intervention compels the field to deliver it for longer, a suggestion supported by Murphy & Brewer (2011a). But there is no evidence that this would generate the desired dividends, and also it skirts the main promise of early intervention, namely that it would ameliorate longer-term trajectories. All that these studies have shown is that good clinical care is good for patients while it is being delivered. We know this! Indeed, the intensive case management literature (e.g. Preston 2000) has shown that clinical and psychosocial benefits and reduced hospital admission rates can be achieved even in the most disabled, chronically ill patients. It is encouraging that Murphy & Brewer (2011a) acknowledge that there are patients in early psychosis services who require ongoing intense intervention, and are beginning specifically to target these individuals.

The DUP

Murphy & Brewer (2011a) also touch on another approach in the early intervention field, namely targeting the so-called ‘duration of untreated psychosis’ or DUP. This is the period of active psychotic symptoms antedating initial treatment and all too often it is associated with subsequent schizophrenia. Indeed, in many jurisdictions average DUP can be months to years. Longer DUP is associated with worse outcome in schizophrenia, but this finding is confounded by the fact that it may be a characteristic of a severe form of schizophrenia with an inherently poor outcome. Thus, there is a significant conceptual and therapeutic challenge in whether DUP can actually be reduced, and whether reducing it improves long-term outcomes.

This is a very difficult area to study, with the best experimental data coming from the Norwegian TIPS study (Friis 2005), which added a concerted early detection programme in two of four health sectors. In the regions in which the programme was put in place, DUP was indeed reduced (median 4 weeks v. 16 weeks in the control sectors). It has been reported that the 5-year outcomes were better for cohorts in the areas in which reduced DUP was effected (Larsen 2011), but gains were marginal and arguably not of clinical relevance: for example, there was a 0.4 point between-group difference on the Positive and Negative Syndrome Scale (PANSS) positive symptoms subscale at 5 years (not significant) and a 1.2 point difference on the negative symptoms subscale (also not significant). There was a highly significant difference on the cognitive sub-scale of the PANSS (1.2 points; P < 0.0001), but this subscale is not the gold standard for assessment of cognition and the clinical importance of this finding is unclear. It should also be stressed that TIPS was not a test of early intervention programmes as such (as all patients ostensibly had the same intervention), but specifically of whether reduction in DUP is achievable and beneficial. Actually, the results might well be attributable simply to the cohort in the reduced DUP group having been recruited at a stage of illness in which they showed fewer symptoms and this difference between the groups being sustained at 5-year follow-up. Also, there was significant bias in terms of ascertainment and attrition, leaving the generalisability and robustness of the results tenuous and requiring replication. Furthermore, other intervention studies have not consistently shown effects of DUP on outcomes (see Norman 2001).

Why have stand-alone services?

Murphy & Brewer (2011a) seem wedded to the idea of youth-specific services, although I am aware of no studies that support these as of themselves more effective than services that accept patients of any age. The fact is that many patients have an onset of psychosis after their mid-20s (Castle 1998) and these people also have needs related to their phase of development, such as relationships, children, jobs and so forth. How would services look if every subgroup (young, not so young, middle aged, elderly; male, female; married, unmarried; higher socioeconomic, lower socioeconomic; higher education, lower education; and so on) had its own service?

Many practitioners in early psychosis claim that stand-alone services are critical to maintain the integrity of what they do, and that joining with or being embedded in mainstream services would perturb their fidelity. Indeed, a leading group of experts in the field (McGorry 2010) have labelled generic services ‘pessimistic’ and implied that they are responsible for the fact that patients do not do as well once the intensive intervention ceases.

But no formal comparison of stand-alone and integrated early psychosis services has, to my knowledge, been performed. Furthermore, it has been convincingly shown that a high-fidelity early psychosis service can be delivered within mainstream mental health services (Petrakis 2010). There are also significant problems associated with stand-alone services, including silo effects (lack of communication and common goals between services), the potential de-skilling of the generalised workforce in the area of early psychosis and the difficulty of transitions between services for patients, their families and clinicians. Friis (2010) has raised another important point, notably the ‘loss’ experienced by the patient on transition from first-episode psychosis services: surely the response to that is to create services that look after people for as long as such care is required, which is what happens in generic services.

Who is, and who should be, ‘treated’?

Issues that I do not address in detail here include interventions for so-called ‘ultra-high-risk’ (UHR) patients. Murphy & Brewer (2011a) fail to distinguish between individuals in the prodrome and individuals at ultra-high risk of psychosis: this is a key conceptual problem for the field. They also fail to report that the rate of conversion to psychosis in recent studies of high-risk populations is very low and that work from EPPIC itself (Yung 2011) showed 6-month conversion rates of between 5.1% and 7.0%. The EPPIC study also failed to show any difference in primary or secondary outcomes between cognitive therapy plus risperidone, cognitive therapy plus placebo, supportive therapy and simply monitoring. Thus, the UHR approach, with its inherent dangers of labelling, medicalisation and exposure to what might be harmful treatments, is certainly not, to my mind, something that should be considered part of services: it is still very experimental and the outcomes are increasingly sobering rather than compelling. Readers are referred to the blog of the esteemed US researcher Allen Frances for more about this (Frances 2011).

Finally, Murphy & Brewer (2011a) skirt the issue of precisely who is being treated in the early psychosis services. While the large World Health Organization schizophrenia surveys showed fairly consistent rates of schizophrenia across the globe (around 7–14 per 100 000 population per year) (Jablensky 1992), reports from the UK at least show rates of early psychosis around 50 per 100 000 per year, and my estimates of the EPPIC rates are around 100 per 100 000 per year. This raises two immediate questions. First, who exactly is being treated, and do they all need treatment? And second, how much of the health budget will be needed to deliver care to this ever-expanding group? This second issue opens a can of worms regarding funding: although EPPIC claims to save money (Mihalopoulos 2009), we have seen no dividends returned to mainstream mental health services from such savings, and the fact that so much money is going into such services results in other parts of the health system being depleted: certainly this is occurring in Australia, with restrictions on new psychiatric medications and on access to psychologist services. We need a much better informed and equitable response to the mental health problems of our communities, not one built on faith rather than facts (Bosanac 2010), nor one that is simply a political response to intense lobbying by a few ‘true believers’.

References

Bertelsen, M, Jeppesen, P, Petersen, L et al (2008) Five-year follow-up of a randomized multicentre trial of intensive early intervention vs standard treatment for patients with a first episode of psychotic illness: the OPUS trial. Archives of General Psychiatry 65: 762–71.
Bodén, R, Sundström, J, Lindström, E et al (2010) Five-year outcome of first-episode psychosis before and after the implementation of a modified assertive community treatment programme. Social Psychiatry and Psychiatric Epidemiology 45: 665–74.
Bosanac, P, Patton, G, Castle, DJ (2010) Early intervention in psychotic disorders: faith before facts? Psychological Medicine 40: 353–8.
Castle, DJ, Sham, P, Murray, RM (1998) Differences in distribution of ages of onset in males and females with schizophrenia. Schizophrenia Research 33: 179–83.
Craig, TK, Garety, P, Power, P et al (2004) The Lambeth Early Onset (LEO) Team: randomised controlled trial of the effectiveness of specialised care for early psychosis. BMJ 329: 1067.
Frances, A (2011) Seven questions for Professor Patrick McGorry. Psychiatric Times 15 Aug.
Friis, S, Vaglum, P, Haahr, U et al (2005) Effect of an early detection programme on duration of untreated psychosis: part of the Scandinavian TIPS study. British Journal of Psychiatry 187 (suppl 48): s2932.
Friis, S (2010) Early specialised treatment for first-episode psychosis: does it make a difference? British Journal of Psychiatry 196: 339–40.
Gafoor, R, Nitsch, D, McCrone, P et al (2010) Effect of early intervention on 5-year outcome in non-affective psychosis. British Journal of Psychiatry 196: 372–6.
Garety, PA, Craig, TKJ, Dunn, G et al (2006) Specialised care for early psychosis: symptoms, social functioning and patient satisfaction. Randomised controlled trial. British Journal of Psychiatry 188: 3745.
Henry, LP, Amminger, P, Harris, MG et al (2010) The EPPIC follow-up study of first-episode psychosis: longer-term clinical and functional outcome 7 years after index admission. Journal of Clinical Psychiatry 71: 716–28.
Jablensky, A, Sartorius, N, Ernberg, G et al (1992) Schizophrenia: manifestations, incidence and course in different cultures. Psychological Medicine Monograph Supplement 20: 197.
Larsen, TK, Melle, I, Auestad, B et al (2011) Early detection of psychosis: positive effects on 5-year outcome. Psychological Medicine 41: 1461–9.
Linszen, D, Lenior, M, De Haan, L et al (1998) Early intervention, untreated psychosis and the course of early schizophrenia. British Journal of Psychiatry 172 (suppl 33): 84–9.
McGorry, P, Johanssen, JO, Lewis, S et al (2010) Early intervention in psychosis: keeping faith with evidence-based health care. Psychological Medicine 40: 399404.
Mihalopoulos, C, Harris, M, Henry, L et al (2009) Is early intervention in psychosis cost-effective over the long term? Schizophrenia Bulletin 35: 909–18.
Murphy, B, Brewer, W (2011a) Early intervention in psychosis: strengths and limitations of services. Advances in Psychiatric Treatment 17: 401–7.
Murphy, B, Brewer, W (2011b) Early intervention in psychosis: clinical aspects of treatment. Advances in Psychiatric Treatment 17: 408–16.
Norman, RM, Malla, AK (2001) Duration of untreated psychosis: a critical examination of the concept and its importance. Psychological Medicine 31: 381400.
Pelosi, AJ, Birchwood, M (2003) Is early intervention for psychosis a waste of valuable resources? British Journal of Psychiatry 182: 196–8.
Petrakis, M, Hamilton, B, Penno, S et al (2010) Fidelity to guidelines in using a care pathway in the treatment of first episode psychosis. Journal of Evaluation in Clinical Practice 17: 722–8.
Preston, NJ, Fazio, S (2000) Establishing the efficacy and cost effectiveness of community intensive case management of long-term mentally ill: a matched control group study. Australian and New Zealand Journal of Psychiatry 34: 114–21.
Robinson, D, Woerner, MG, Alvir, JM et al (1995) Predictors of relapse following response from a first episode of schizophrenia or schizoaffective disorder. Archives of General Psychiatry 56: 241–7.
Singh, SP (2010) Early intervention in psychosis. British Journal of Psychiatry 196: 343–5.
Yung, AR, Phillips, LJ, Nelson, B et al (2011) Randomized controlled trial of interventions for young people at ultra high risk for psychosis: 6-month analysis. Journal of Clinical Psychiatry 72: 430–40.