Early intervention in psychosis

Early intervention in psychosis is a clinical approach to those experiencing symptoms of psychosis for the first time. It forms part of the new prevention paradigm for psychiatry and is leading to reform of mental health services, especially in the United Kingdom. There has been consider academic interest over the past decade This approach centers on the early detection and treatment of early symptoms of psychosis during the formative years of the psychotic condition. The first three to five years are believed to be a critical period. The aim is to reduce the usual delays to treatment for those in their first episode of psychosis. The provision of optimal treatments in these early years is thought to prevent relapses and reduce the long term impact of the condition. It is considered a secondary prevention strategy.

The duration of untreated psychosis (DUP) has been shown as an indicator of prognosis, with a longer DUP associated with more long term disability.

Components of the model
There are a number of functional components of the early psychosis model, and they can be structured as different sub-teams within early psychosis services. The emerging pattern of sub teams are currently:

Early psychosis treatment teams
Multiple discipline clinical teams providing an intensive case management approach for the first three to five years. The approach is similar to assertive community treatment, but with an increased focus on the engagement and treatment of this previously untreated population and the provision of evidence based, optimal interventions for clients in their first episode of psychosis. For example, the use of low-dose antipsychotic medication is promoted ("start low, go slow"), with a need for monitoring of side effects and an intensive and deliberate period of psycho-education for patients and families that are new to the mental health system. Interventions to prevent a further episodes of psychosis (a "relapse") and strategies that encourage a return to normal vocation and social activity are a priority. There is a concept of phase specific treatment for acute, early recovery and late recovery periods in the first episode of psychosis.

Early detection function
Interventions aimed at improving the detection and engagement of those early in the course of their psychotic conditions. Key tasks include being aware of early signs of psychosis and improving pathways into treatment. Teams provide information and education to the general public and assist GPs with recognition and response to those with suspected signs, e.g. EPPIC's Youth Access Team (YAT) (Melbourne), OPUS (Denmark) TIPS (Norway), REDIRECT (Birmingham), LEO CAT (London).

Prodrome or "at risk mental state" clinics
Specialist services for those with subclinical symptoms of psychosis or other strong indicators of risk of transition to psychosis. The PACE clinic in Melbourne, Australia, is considered one of the origins of this strategy, along with the IOP based service OASIS in South London , and Yale medical school based clinic, PRIME. These services are able to reliably identify those at high risk of developing psychosis and are beginning to publish encouraging outcomes from randomised controlled trials that reduce the chances of becoming psychotic, including evidence that psychological therapy and high doses of fish oil have a role in the prevention of psychosis.

History
Early intervention in psychosis is a preventative approach for psychosis that has evolved as contemporary recovery views of psychosis and schizophrenia have gained acceptance. It subscribes to a "post Kraepelin" concept of schizophrenia, challenging the current assumptions originally promoted by Emil Kraepelin in the 19th century, that schizophrenia (or dementia praecox) was a condition with a progressing and deteriorating course. Psychosis is now formulated within a diathesis–stress model, allowing a more hopeful view of prognosis, and expects full recovery for those with early emerging psychotic symptoms. It is more aligned with psychosis as continuum (e..g as with the concept of Schizotypy) with multiple contributing factors, rather than schizophrenia as simply a neurobiological disease.

Within this changing view of psychosis and schizophrenia, the model has developed from a divergence of several different ideas, and from a number of sites beginning with the closure of psychiatric institutions signaling move toward community based care (e.g. Falloon ). In 1986, the Northwick Park study discovered an associated between delays to treatment and disability, questioning the service provision for those with their first episode of schizophrenia. In the 1990s, cognitive behavioural therapy emerged as a treatment paradigm for delusions and hallucinations, predominately in the United Kingdom. The next step came with the development of the EPPIC early detection service in Melbourne, Australia in 1996 and the prodrome clinic led by Alison Yung. This service was an inspiration to other services, such as the West Midlands IRIS group, including the consumer non-governmental organisation Rethink; the TIPS early detection randomised control trial in Norway; and the Danish OPUS trial. In 2001, the United Kingdom Department of Health called the development of early psychosis teams a priority. The International Early Psychosis Association, founded in 1998, issued an international consensus declaration together with the World Health Organisation in 2004. Clinical practice guidelines have been written by consensus.

Clinical outcome evidence
An early psychosis approach has been shown in formal studies to reduce the severity of symptoms, improve relapse rates, and decreases the use of inpatient care, in comparison to standerd care, at 18 months follow up. These studies also clearly show greater levels of user satisfaction with the service. . Although the evidence for an ongoing positive impact has yet to be established, some have noted that the underlying assumptions and lack of evidence for the current late intervention standard service approaches make the rationale early intervention overwhelming (Max Birchwood).

The earlier 2006 Cochrane review continues to report a lack of strong research evidence for specific early detection and early intervention programmes, although does acknowledge the need to intervene earlier for those with psychosis. Since that time, the emerging evidence on treatment outcome for early psychosis is positive.

Current literature on cost
Evidence from the United Kingdom suggests that the costs of an early psychosis service are considerably less compared to standard care with one year costs for early psychosis teams (£9422) two thirds the cost of standard teams (£14394). This is maintained at year 3 and is thought to be due to the reduce inpatient costs with the more intensive community follow up provided by early psychosis services.

An Australia historical comparison of direct health costs found a clear econmoic advantage for an early psychosis approach compared to standard care, at 12 month follow up. Also see the October 2008 report by Access Economics Pty Limited commissioned by Orygen Research Centre in Melbourne which concludes "EI not only costs nearly $AUS2000 less per person annually than TAU (treatment as usual) in trial-related costs, it also saves nearly $AUS1500 in health system and other financial costs...total saving to society of nearly $AUD9000 per patient per year" (page 32). This does not take into account the potential benefits of EI in reducing suicides and positive impact on vocational outcomes.

United Kingdom
The United Kingdom has probably made the most significant service reform with their adoption of early psychosis teams, with early psychosis now considered as an integral part of comprehensive community mental health services. The Mental Health Policy Implementation Guide (2001) outlines service specifications and forms the basis of a newly developed fidelity tool (Birchwood, unpublished). There is a requirement for services to reduce the duration of untreated psychosis, as this has been shown to be associated with better long term outcome. The implementation guideline recommends:


 * 14 to 35 year age entry criteria
 * First three years of psychotic illness
 * Aim to reduce the duration of untreated psychosis to less than 3 months
 * Maximum caseload ratio of 1 care coordinator to 10-15 clients
 * For every 250,000, (depending on population characteristics) one team
 * total caseload 120 to 150
 * 1.5 doctors per team
 * Other specialist staff to provide specific evidence based interventions

Australia & New Zealand
Services have spread from the origin founding EPPIC initiative in Melbourne (Victoria, Australia) since the 1990s

New Zealand has operated significant early psychosis teams for more than ten years, following the inclusion of early psychosis in a mental health policy document in 1997 (blueprint for mental health service). There is a national early psychosis professional group New Zealand Early Intervention in Psychosis Steering Group, organising training events and producing local resources.

Scandinavia
Early psychosis programmes have continued to develop from the original TIPS services in Norway and the OPUS randomised trial in Denmark.

North America
Canada has extensive coverage across most provinces including established clinical services and comprehensive academic research in British Columbia (Vancouver), Alberta (EPT in Calgary), and Ontario (PEPP, FEPP).

Asia
The first meeting of the Asian Network of Early Psychosis (ANEP) was held in 2004. There are now established services in Singapore and Hong Kong.