Early intervention in psychosis

Multidisciplinary 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. In addition, researchers in Spain showed that family intervention for psychosis (FIp) reduced relapse rates, hospitalization duration, and psychotic symptoms along with increasing functionality in first-episode psychosis (FEP) up to 24 months, according to a recent review published in Schizophrenia Bulletin.[11]. 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.

Interventions aimed at avoiding late detection and engagement of those in the course of their psychotic conditions.[12] Key tasks include being aware of early signs of psychosis and improving pathways into treatment.[13] Teams provide information and education to the general public and assist GPs with recognition and response to those with suspected signs, for example: EPPIC's[14] Youth Access Team (YAT)[15] (Melbourne); OPUS[16] (Denmark); TIPS[17] (Norway); REDIRECT[18] (Birmingham); LEO CAT (London)[19] "; STEP's Population Health approach to early detection.[20][21]

Prodrome or at risk mental state clinics are specialist services for those with subclinical symptoms of psychosis or other indicators of risk of transition to psychosis. The Pace Clinic[22] in Melbourne, Australia, is considered one of the origins of this strategy,[23] but a number of other services and research centers have since developed.[24] [25] These services are able to reliably identify those at high risk of developing psychosis[26] and are beginning to publish encouraging outcomes from randomised controlled trials that reduce the chances of becoming psychotic,[27] including evidence that psychological therapy[28] and high doses of fish oil[29] have a role in the prevention of psychosis. However, a meta-analysis of five trials found that while these interventions reduced risk of psychosis after 1 year (11% conversion to psychosis in intervention groups compared to 32% in control groups), these gains were not maintained over 2–3 years of follow-up.[30] These findings indicate that interventions delay psychosis, but do not reduce the long-term risk. There has also been debate about the ethics of using antipsychotic medication to reduce the risk of developing psychosis, because of the potential harms involved with these medications.[31]

In 2015, the European Psychiatric Association issued guidance recommending the use of the Cognitive Disturbances scale (COGDIS), a subscale of the basic symptoms scale, to assess psychosis risk; a meta-analysis conducted for the guidance found that while rates of conversion to psychosis were similar to those who meet Ultra High Risk (UHR) criteria up to 2 years after assessment, they were significantly higher after 2 years for those patients who met the COGDIS criteria.[32] The COGDIS criteria measure subjective symptoms, and include such symptoms as thought interference, where irrelevant and emotionally unimportant thought contents interfere with the main line of thinking; thought block, where the current train of thought halts; thought pressure, where thoughts unrelated to a common topic appear uncontrollably; referential ideation that is immediately corrected; and other characteristic disturbances of attention and the use or understanding of language.

The United Kingdom has made 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 outlines service specifications and forms the basis of a newly developed fidelity tool.[38][47] 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 outcomes. 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

In Australia the EPPIC initiative provides early intervention services.[48] In the Australian government's 2011 budget, $222.4 million was provided to fund 12 new EPPIC centres in collaboration with the states and territories.[49] However, there have been criticisms of the evidence base for this expansion and of the claimed cost savings.[50][51][52]

On August 19, 2011, Patrick McGorry, South Australian Social Inclusion Commissioner David Cappo AO and Frank Quinlan, CEO of the Mental Health Council of Australia, addressed a meeting of the Council of Australian Governments (COAG), chaired by Prime Minister Julia Gillard, on the future direction of mental health policy and the need for priority funding for early intervention.[53] The invitation, an initiative of South Australian Premier Mike Rann, followed the release of Cappo's "Stepping Up" report, supported by the Rann Government, which recommended a major overhaul of mental health in South Australia, including stepped levels of care and early intervention.[54]

New Zealand has operated significant early psychosis teams for more than 20 years, following the inclusion of early psychosis in a mental health policy document in 1997.[55] There is a national early psychosis professional group, New Zealand Early Intervention for Psychosis Society (NZEIPS),[56] organising a biannual training event, advocating for evidenced based service reform and supporting production of local resources.

Early psychosis programmes have continued to develop from the original TIPS services in Norway[17] and the OPUS randomised trial in Denmark.[16]

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

In the United States, the Early Assessment Support Alliance (EASA) is implementing early psychosis intervention throughout the state of Oregon.[57]

In the United States, the implementation of Coordinated Specialty Care (CSC), as a recovery-oriented treatment program for people with first episode psychosis (FEP), has become a US health policy priority.[58] CSC promotes shared decision making and uses a team of specialists who work with the client to create a personal treatment plan. The specialists offer psychotherapy, medication management geared to individuals with FEP, family education and support, case management, and work or education support, depending on the individual’s needs and preferences. The client and the team work together to make treatment decisions, involving family members as much as possible. The goal is to link the individual with a CSC team as soon as possible after psychotic symptoms begin[59] because a longer period of unchecked and untreated illness might be associated with poorer outcomes.[60][61][62][63]

The first meeting of the Asian Network of Early Psychosis (ANEP) was held in 2004. There are now established services in Singapore,[64] Hong Kong[65] and South Korea[66]