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| Journal of the New Zealand Medical Association,
06-August-2004, Vol 117 No 1199
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Early intervention for psychosis in New Zealand
Mark Turner, Susan Nightingale, Cecilia Smith-Hamel, Roger
Mulder
Psychosis is defined as a primary disturbance of thinking,
which is reflected in certain symptoms—particularly disturbances in
perception (hallucinations), disturbances in beliefs and interpretation of the
environment (delusions), and disorganised speech patterns (thought
disorder).1
There are multiple causes of psychosis—including
substance abuse, exposure to severe stress, inherited and acquired medical
conditions or diseases, and mood disorders. Historically, the outcomes for those
with psychosis have generally been thought to be poor.
Early intervention for psychosisIn recent years, there has been a
growing interest in the concept of early intervention for psychosis.
Wyatt’s influential paper2 reviewed 22
studies in patients with schizophrenia. This review suggested that poor outcome
(long associated with an insidious onset) had as much to do with delayed use of
antipsychotics as the illness process itself. Wyatt concluded that early
intervention with neuroleptics in first-episode schizophrenia patients may
increase the likelihood of improved long-term course.
Three types of early intervention for psychosis have been
described: primary prevention, secondary prevention, and tertiary
prevention.3
Primary preventionEarly
intervention before or during the prodromal phase involves
indicated primary prevention and should
lead to a decrease in the incidence of psychosis. Several groups are currently
researching the feasibility of designing screening procedures to identify those
with an ‘at risk mental state’.4
Authors widely acknowledge the existence of early specific and non-specific
signs preceding the first psychotic episode; however, they have yet to clearly
demonstrate their ability to predict and specify the transition to
psychosis3 leading to clinical and ethical
concerns about initiating (antipsychotic medication) treatment at this
stage.
Secondary preventionSecondary
prevention means intervention in the early stages of the development of a
psychotic disorder, during the prodromal phase or onset of the first episode.
While secondary prevention may be initiated before the development of frank
psychotic symptoms (ie, during the prodromal stage), the majority of services
concentrate on reducing the ‘duration of untreated psychosis’ (the
period from the onset of psychosis to the implementation of ‘adequate
treatment’). Several studies have reported that the longer people remain
psychotic before beginning treatment, the more likely they are to suffer
relapses.5 Patients gain less benefit from
receiving maintenance antipsychotic
medication,6 and from intense
treatment.7
Further, long delays (between the onset of psychosis and
treatment) are associated with greater cognitive impairment, more severe
negative symptomatology, and poorer personal and social
outcomes.8,9 Recognition and intervention at
the earliest possible stage of florid psychosis could contribute to earlier
symptom remission, delay in relapse and prevention of psychosocial
deterioration.2
Tertiary preventionTertiary
prevention is not an early intervention strategy and has more to do with
the timing, duration, and content of adequate treatment aimed at reducing the
morbidity of the disorder.3 Along with
considerations of the importance of the duration of untreated psychosis,
evidence is also emerging of a ‘critical period’ for vulnerability
to relapse and development of secondary handicaps during the first 3 years
following the onset of a first psychotic
illness.10
Birchwood et al11 have
suggested that when disabilities develop following a first episode of psychosis
they usually do so during the first 3 years. Unemployment, impoverished social
networks, and loss of self esteem can develop rapidly during this
‘critical period’. The longer these needs are not dealt with, the
more entrenched they become. It has therefore been proposed that timely and
effective intervention at this stage might alter the subsequent course of the
illness and reduce the social toxicity of psychosis.
Early intervention for psychosis in the New Zealand context
generally involves recognition and intensive phase-specific intervention from
the time the individual becomes psychotic (although many services will accept
those with a suspected prodromal presentation). This involves a combination of
secondary and tertiary prevention strategies. In this case ‘early’
refers to treatment ‘earlier than usual’ in order to reduce the
duration of untreated psychosis (secondary prevention). The
‘intervention’ is comprehensive, intensive, phase-specific and
individualised treatment for these
individuals12 aimed at reducing the morbidity
associated with first episode psychosis (tertiary prevention).
Early Intervention for Psychosis (EIP) services aim to
provide intensive multidisciplinary treatment during the early phase of
psychosis (typically in New Zealand for the first 2 years, although
international research indicates that 5 years may be more
appropriate.25)
Briefly, EIP services should
provide1,13,25:
A key document outlining the style of
service provision for New Zealand services is the
Early intervention in psychosis: guidance
note1
While early
intervention is considered advantageous to optimal recovery, a consistent
finding from the literature is that the duration of untreated psychosis is long,
with a median of approximately 26 weeks.3,7,9
Examination of the help-seeking behaviour of individuals with first-episode
psychosis suggests that the individual and their family members may try a number
of times to obtain help before adequate treatment is
obtained.5,14
One of the important aspects of EIP services is an early
detection programme and in this regard, General Practitioners and other social
agencies have the potential to play a crucial
role.15
Relationship to general practice and other agenciesA large part of the delay in
referring people with first episode psychosis is associated with the
non-specific and insidious nature of the early signs of psychosis.
Key features that may indicate the presence of psychosis or
its prodromal stage include1:
Lester18
provides a useful checklist on what to look for in a GP consultation for first
episode psychosis. She concludes that it is important to not just ‘wait
and see’ what happens, or to dismiss symptoms (such as social withdrawal
as part of adolescence; or as secondary to drug
misuse).18 People with suspected first episode
psychosis should be referred to early intervention services for further
clarification of symptoms, and appropriateness for early treatment. Further
guidelines for GPs are available online from http://www.eppic.org.au/resources/earlydiagnosisbooklet.html
In Australia, the average GP will
have 3-4 patients with schizophrenia at any one time, and might be involved in
the diagnosis of 4-5 patients with schizophrenia in their
career.16 International estimates suggest there
are approximately 11 new cases of psychosis per 100,000 population per
year.17
The main problem is that prodromal-like symptoms are
extremely common in adolescence and early adulthood, and health professionals
must decide whether symptoms are just normal adolescent behaviour—or
something more serious. The non-specific nature of symptoms combined with a low
incidence rate means that primary healthcare professionals may overlook this
diagnosis. However, it is estimated that half of the people with first episode
psychosis have had contact with a GP prior to commencing effective
treatment.14 Preliminary data from Totara House
Early Intervention Service (in Christchurch) indicates that in the 6 months
prior to referral, 60 out of 122 people with first episode psychosis had contact
with a GP. Eleven (18.3%) of these people were referred to treatment at Totara
House (Turner; unpublished data; 2004).
This high rate of contact with GPs makes them an important
group to target with regard to any effort to reduce the duration of untreated
psychosis. In New Zealand, and in many other countries, most people with
first-episode psychosis appear to present to EIP services through acute
inpatient services.
Totara House figures show that 54% of clients are referred
following admission, and a further 19% from the Psychiatric Emergency Service at
Christchurch Hospital. This suggests that the early signs of psychosis are
unrecognised, and that people are only being seen once inpatient treatment is
required. Of particular concern is the fact that the early signs of psychosis in
Maori (and Pacific Peoples) may be missed by health practitioners, and that
Maori (and health professionals) may reframe psychosis in a cultural context
(Mason Durie; personal communication; April 2002).
To examine issues associated with the early identification
and treatment of psychosis, New Zealand is currently involved in an
international study examining GPs knowledge of first-episode psychosis. The
results of this study will help service development for primary healthcare
professionals involved in the management of early psychosis. This research is
timely given the move to a primary mental health care strategy.
While General Practitioners, in particular, have an
important role to play as ‘gatekeepers’ for early identification of
first episode psychosis, there are many other agencies who may be able to detect
the first signs of a developing psychotic illness (or at least notice that
‘something is not quite right’ and make appropriate referrals). For
example, follow-up and follow-back studies have shown that teachers are capable
of identifying individuals who later develop serious mental illness including
psychosis.19 Others include school guidance
counsellors, personnel managers with major employers, and a range of counselling
and support agencies. Identification of pathways to care and education aimed at
these agencies should be seen as a priority in New Zealand early intervention
services.
Early intervention for psychosis services in New ZealandA further potential barrier to early
referral to specialist EIP services is the lack of knowledge of the existence of
such services. There has been a steady growth of specialist services that work
with people with first episode psychosis. In 2000, there were 18 statutory
mental health services that work, wholly or partly, as early intervention
services for young people. Twelve of these were established in or after 1998,
through funding following the Mason
Report.20
A systematic survey was conducted by the authors on the
availability of EIP services in New Zealand.13
A detailed description of each service is available on the Internet from the
Mental Health Research and Development Strategy website: http://www.mhrds.govt.nz/files/4_29_71_98_EIP.pdf
Overall, New Zealand’s main
city centres are able to deliver quality care utilising the principles of EIP
services.1 Services appear to be well-informed
and familiar with the literature—and they are adapting it well to their
local conditions. However, there are many other areas with enthusiastic early
intervention staff frustrated by the lack of resourcing and
support/understanding from those unfamiliar with the principles of early
intervention.
Improving the responsiveness of mental health services is
one of the five service delivery areas on which the Government wishes the health
sector to concentrate in the short-to-medium
term.21 In addition, the targeting in this
strategy of public health and primary healthcare provide the platform for the
emergence of early intervention for psychosis as a central consideration for
mental health services under the New Zealand
Health Strategy.21
Public health initiatives aimed at mental health promotion
and increased co-ordination between primary healthcare providers and secondary
service providers (such as early intervention services) are core requirements of
the Government’s strategy.
EIP services are an important response to the increased
awareness and acceptance of mental illness promoted by public health campaigns
such as the ‘Like Minds Like Mine’ (http://www.likeminds.govt.nz/) project.
‘...the inclusion of prevention
activities highlights the growing importance and contribution of early detection
towards the effective management of mental health problems and of improved
community mental health
outcomes...’.22
Projects aimed at reducing the stigma associated with mental
illness may mean that people are more likely to seek help when (or even before)
a crisis develops. This may be particularly beneficial for professionals who
identify symptoms but then face resistance from clients regarding referral for
appropriate assessment.
Similarly, with the development of public education, the
various support agencies are likely to become better informed about the signs of
first-episode psychosis, and about the availability of EIP services. Should this
prove to be the case, appropriate services ought to be available to meet this
increased demand.23
The dual developments of early intervention for psychosis
and public education may have an increasing impact over the next generation as
the New Zealand Health
Strategy21 is implemented. However,
evaluation of the efficacy of these programmes is necessary to ensure the money
is well spent.
ConclusionA review of the
literature3 suggests that early intervention
for psychosis is successful in reducing the initial morbidity and distress
associated with the first psychotic episode; however, it is unclear whether it
leads to better long-term outcome. There is evidence that the earlier treatment
is given following the onset of psychosis, the more favourable the
outcomes9—at least in the short term.
This implies that attention should be paid to reducing the duration of untreated
psychosis by providing education to those professionals who may come in contact
with people who are experiencing first-episode psychosis.
EIP services can be justified clinically; it is sensible to
treat people with first-episode psychosis (as soon as possible after symptoms
develop) with intensive, comprehensive treatments. Whether it is superior to
existing treatments remains unclear. A feature in the
British Journal of
Psychiatry24 debated whether
‘early intervention for psychosis is a
waste of valuable resources’. The article concluded that they
remain, at least, an example of ‘basic
aspects of good practice in the management of psychotic disorders’
(page 196).
In summary, EIP services have a significant positive effect
for clients while in treatment. Although there is still insufficient evidence
regarding the long-term benefits of early intervention services, we recommend
referring clients to these services where they are available.
Furthermore, early referral to specialist services may lead
to better outcomes for those with first-episode psychoses—particularly
earlier psychotic and negative symptom remission, less psychosocial
deterioration, and increased treatment adherence.
Author information:
Mark Turner, Researcher, Totara House Early Intervention for Psychosis Service,
Canterbury District Health Board, Christchurch; Susan Nightingale, Clinical
Director, Adult General Mental Health Services, Canterbury District Health
Board, Christchurch Cecilia Smith-Hamel, Consultant Psychiatrist, Totara House
Early Intervention for Psychosis Service, Canterbury District Health Board,
Christchurch; Roger Mulder, Professor of Psychological Medicine, Department of
Psychological Medicine, Christchurch School of Medicine and Health Sciences,
University of Otago, Christchurch
Acknowledgements:
This article would not have been possible without continued financial support
for the research position at Totara House from the Mental Health Division of the
Canterbury District Health Board. We also thank the Totara House team for their
hard work in completing the research.
Correspondence: Mark
Turner, Totara House Early Intervention for Psychosis Service, Canterbury
District Health Board, 194 Bealey Avenue, Christchurch. Fax: (03) 377 9713,
email: mark.turner@cdhb.govt.nz
References:
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