Adverse Short-Term Cardiometabolic Outcomes in PsychosisEarly Intervention Services: Which Risk Prediction Algorithm?

Introduction: Psychosis is a common and severe mental illness, with a large health and economic impact on societies worldwide. The earlier the illness is treated the better the long term outcomes. In England, Early Intervention in Psychosis (EIP) services have been introduced over the last 15 years to address this problem and they are included in the new Access and Waiting time standard in England published in April 2015. This standard mandates that all those with first episode psychosis should be treated within an EIP service within 2 weeks. They differ from standard community care in that they provide continuity across child and adult services, cognitive behavioural therapy, family interventions, assertive community treatment and vocational and educational support for early recovery. However, evidence about the effectiveness and cost-effectiveness of EIP services in England is inconclusive and their implementation is variable. We therefore undertook a health economic evaluation of EIP services to demonstrate the costs and outcomes associated with these services.Methods: We used routinely collected data (pseudonymised physical and mental health data licensed from the HSCIC – HES and MHMDS) of 4,104 patients with psychosis to compare the costs and effects of EIP services with other community mental health teams over a 3-year period (Apr 2010 – Mar 2013) in Thames Valley. Psychosis patients were identified using a combination of ICD-10 diagnosis codes, Mental Health Payment by Results Clusters and Health of the Nation Outcome Scales. The sample consisted of 923 patients were treated under EIP service and 3,181 patients were under standard community care. The analysis included the costs of acute hospital emergency (A&E) visits, length of stay in mental health hospital ward and acute care hospital wards, and community care services. Outcomes were measured in terms of getting employed and moving to mainstream housing during the follow-up period. Generalised Estimating Equations and Generalised Linear Models were used in the analysis and Propensity Score Matching was used to correct for confounding between the compared services.Results: EIP services resulted in on average saving of £1,761 (13%) in healthcare costs (p=0.059) compared to standard community care. This annual saving is translated into £32 (32%) less A&E costs (p<0.001), £378 (11%) higher community care costs (p=0.139), £1,295 (18%) less hospitalization costs in mental health wards (p=0.038), and £811 (28%) less hospitalization costs in physical health wards (p=0.010). In the outcomes side, patients in EIP services had about twice (109%) as much probability (p<0.001) to get employed over the 3-year period than patients in other community mental health teams. Among employed patients, EIP services increased the probability for patient to move to mainstream housing during the 3-year period by 63% (p=0.002).Discussion: The findings of this study show that EIP services save costs for the NHS. Considering that there are approximately 17,000 first episodes of psychosis each year in England, EIP services could save NHS about £30 million per year. The savings are higher when reduced social care costs due to higher mainstream housing and productivity gains due to higher employment are added. Considering the ability of patients with psychosis to live independently (i.e. to have a paid job and live in mainstream housing) as an indicator of health status, EIP services are also cost-effective.The results are in line with the findings from an RCT undertaken in 110 participants (LEO study), which identified cost savings associated with EIP services although the primary outcome measure of reduced admission did not reach significance. The strengths of this current study include the large dataset and the statistical techniques to analyse panel data and to control for confounding. Future cost-effectiveness studies of EIP services should include patient health outcome measurements and detail of the interventions provided within services, to try and identify the necessary components for a successful outcome.Integrating adolescent and adult mental health services and introducing complex interventions such as EIP services into routine clinical practice can improve patient health and reduce health and social care costs to the same extent as shown in RCT. This is an important finding for health services researchers, commissioners of healthcare and healthcare professionals.Conclusion: Our study suggests that EIP services, as implemented in the NHS in England, are cost saving and likely to be cost-effective. They could save the NHS about £30 million per year.

Early Intervention in Psychosis (EIP) services offer treatment to people experiencing a first episode of psychosis. Service users may be referred from primary care and discharged directly back at the end of their time in an EIP service. To explore the role of primary care in supporting EIP service users (SUs) and to understand how to improve collaboration between primary and specialist care. Qualitative study comprising semi-structured interviews with SUs, carers, healthcare professionals (HCPs), managers, and commissioners. Interviews were conducted either online or by telephone. Thematic analysis was carried out using principles of constant comparison. Patient and public involvement were key to all stages, including data analysis. In total, 55 interviews were conducted with SUs (n = 13), carers (n = 10), and GPs, EIP HCPs, managers, and commissioners (n = 33). GPs reported difficulties in referring people into EIP services and little contact with SUs while in EIP services, even about physical health. GPs suggested they were not included in planning discharge from EIP to primary care. SUs and carers reported that transition from EIP can lead to uncertainty, distress, and exacerbation of symptoms. GPs reported only being made aware of patients on or after discharge, with no contact for 3 years. GPs described difficulty managing complex medication regimes, and barriers to re-referral to mental health services. GPs have a key role in supporting people within EIP services, specifically monitoring and managing physical health. Inclusion of GPs in planning discharge from EIP services is vital.

Given the potential severity of developing chronic mental health problems, particular attention has been paid to the first emergence of psychosis. Earlier detection is expected to lead to quicker access to the effective treatment that is necessary during the 'critical period' and is one of the main incentives for setting up early intervention in psychosis (EIP) services. EIP services have demonstrated good clinical outcomes since inception, but little is understood yet as to which specific element of EIP leads to these good outcomes. The aim of this research was to conduct an exploratory investigation of the elements that people experiencing a first episode of psychosis find most valuable about EIP treatment. The study employed a single group design and utilized Q-methodology. 20 people with first-episode psychosis aged between 18 and 35 were recruited and asked what they valued most about EIP. Four separate factors were identified, which were interpreted and named as 'therapeutic relationship', 'medical care', 'psychological interventions', and 'support, coping and recovery'. Three of the factors were consistent with a biopsychosocial approach of EIP that is recommended by expert professionals working in EIP services and Government guidance on service delivery. The factor that accounted for the most variance is 'therapeutic relationship', highlighting the importance of non-specific factors in mental health care and recovery from a first episode of psychosis. Service users reported that four main components of Early Intervention in Psychosis Services were helpful to them. These included a strong and effective therapeutic relationship, as well as medication, psychological therapies, and practical help and support. Services are valued both for the quality of the therapeutic relationship but also for their ability to deliver meaningful and valued treatments in this context.

People with new psychotic symptoms may be managed in an Early Intervention in Psychosis (EIP) service. They may be discharged back to primary care at the end of their time in an EIP service. To explore the role of primary care in supporting people with psychosis in an EIP service. Qualitative study, within a programme of work to explore the optimum duration of management in an EIP service in England. Semi-structured interviews were carried out with people in EIP services, carers, GPs, and EIP practitioners between September 2022 and September 2023. Data collection continued until information power was achieved. Data were thematically analysed using principles of constant comparison. While most service users and carers described their experiences of EIP services as positive, there are issues around access to and discharge from the services. GPs reported difficulties in referring people into EIP services, having little contact with people who are supported by EIP services, and not being included in planning discharge from EIP services to primary care. Service users and carers described challenges at the point of discharge from EIP services to primary care, associated with feelings of abandonment. This study suggests that GPs should have a role in the support of people in EIP services (in particular, monitoring and managing physical health) and their carers. Inclusion of GPs in managing discharge from EIP services is vital. We suggest that a joint consultation with the service user, their carer (if they wish), along with the EIP care coordinator and GP would make this transition smoother.

The effectiveness of Early Intervention in Psychosis (EIP) services for individuals with a first episode of psychosis (FEP) could be thwarted by high rates of early disengagement.AimsTo investigate which factors predict disengagement with EIP services. Using data from a naturalistic cohort of 786 EIP clients in East Anglia (UK), we investigated the association between sociodemographic and clinical predictors and disengagement using univariable and multivariable Cox proportional hazards models. Over half (54.3%) of our sample were discharged before receiving 3 years of EIP care, with 92 (11.7%) participants discharged due to disengagement. Milder negative symptoms, more severe hallucinations, not receiving an FEP diagnosis, polysubstance use and being employed were associated with greater disengagement. Our findings highlight heterogeneous reasons for disengagement with EIP services. For some patients, early disengagement may hinder efforts to sustain positive long-term EIP outcomes. Efforts to identify true FEP cases and target patients with substance use problems and more severe positive symptoms may increase engagement.Declaration of interestNone.

The 'at-risk mental state' (ARMS) for psychosis has been critiqued for its limited prognostic ability and identification of a limited proportion of those who will develop a first episode of psychosis (FEP). Broadening the search for high-risk groups is key to improving population-level ascertainment of psychosis risk. To explore risk enrichment in diagnostic, demographic and socio-functional domains among individuals referred to an early intervention in psychosis (EIP) service not meeting ARMS or FEP criteria. A retrospective file review of 16 years of referrals to a tertiary EIP service in Ireland was undertaken. Diagnostic outcomes from standardised assessments (Structured Clinical Interview for DSM), demographic (age, gender, family history, nationality) and socio-occupational (relationship status, living status, working status) variables were compiled for those not meeting criteria. These were compared with individuals diagnosed with an FEP in the same period. From 2005 to 2021 inclusive, of 2025 index assessments, 27.6% (n = 558) did not meet either FEP or ARMS criteria, which is notably higher than the 5.4% (n = 110) meeting ARMS criteria. This group had high psychiatric morbidity, with 65.4% meeting criteria for at least one DSM Axis I disorder. Depressive, anxiety and substance use disorders predominated. Their functional markers were poor, and comparable to the FEP cohort. This group is enriched for psychosis risk factors. They are a larger group than those meeting ARMS criteria, a finding that may reflect EIP service configuration. They may be an important focus for further study in the search for at-risk populations beyond the current ARMS model.

Background: Mental health services have been demonstrated to play a key role in shaping how people make sense of their experiences of psychosis. Past research has highlighted the dominance of the biomedical model within services, however, first-person accounts suggest this is not always meaningful or helpful for recovery. Early Intervention in Psychosis (EIP) services aim to provide a more holistic, non-stigmatising approach for young people experiencing a First Episode of Psychosis (FEP). However, there is very limited research exploring how these services might impact upon how young people construct their experiences. This study aimed to explore the culturally available narratives drawn upon by young people accessing EIP services and the consequences of these for service utilisation and subjectivity. Method: Semi-structured interviews were carried out with five young people (aged 18-35) who were accessing an EIP service for a FEP. A Narrative Analysis (NA) approach facilitated exploration of how young people constructed their experiences of a FEP and how they narrated this had changed since accessing the EIP service. Results: The participant’s narratives emphasised the idiosyncratic ways they constructed their FEP, drawing on a range of culturally available discourses. While accessing the EIP service appeared to facilitate the exploration of a range of casual theories, often drawing on a biopsychosocial model, their narratives also highlighted the implicit power of the biomedical approach in shaping their sense of self and the future. Conclusions: The findings support previous literature that highlights the importance of meaning-making for young people experiencing a FEP. The discourses available within EIP services appear to play a key role in shaping young people’s constructions and this study highlights the value of privileging multiple perspectives when supporting people to make sense of their experiences of psychosis.

AimsIdentification of a psychosis risk syndrome to aid reduction of transition to a FEP is an important focus of worldwide research. ARMS for psychosis was defined by Yung and McGorry in 1996. UK EIP services were mandated to identify and ‘treat’ ARMS in the ‘Implementing the Early Intervention in Psychosis Access and Waiting Time Standard: Guidance' 2016. Sussex EIP services developed such an ARMS service with a 1-year pathway of assessment, intervention as indicated, and monitoring from 2017. Sussex serves a population of approximately 1.4 million, including areas with both low and high social deprivation indices. Transition rates from ARMS to FEP in recent studies have suggested widely varying rates of 8–17% of transition in a two-year period, notably less than initially identified by Yung et al. We aimed to establish the rate of transition to FEP within 12 months from identification of ARMS in Sussex EIP services.MethodsA retrospective study was conducted on all patients on the ARMS pathway, across five EIP services in Sussex, between Jan 2017-Oct 2021. The primary outcome measure was operationally defined transition to FEP; secondary outcome measures included clinical features and use of clinical services.Results71 cases were identified as meeting ARMS criteria, with mean age 21.4yo; range 14–35, from a total new caseload of 447 over this period.ARMS subcategories identified 4 state/trait, 55 attenuated psychosis and 12 BLIPS. Comorbidity was more common than not; mood disorders were identified in 17 cases. 23 cases met not in education, employment or training (NEET) criteria.All cases received full care coordination by lead practitioners. 19 cases were prescribed atypical antipsychotics. 18 cases received formal CBT.4 of the 71 cases transitioned to FEP within 12 months at mean time 35 weeks; range 28–45 weeks. 2 had attenuated symptoms and 2 experienced BLIPS. 3 were initially NEET.ConclusionWe report a very low transition rate to FEP of 6% in this service, consistent with other such UK services. Whilst the ARMS sample is low in number, a clear impact on EIP service case management is identified. Risk saturation is arguably required to justify continuing this ARMS pathway, achievable by primary focus on the BLIPS subgroup. Wider review of UK ARMS services is required to reduce dilution of EIP service models and reduction of their well evidenced effectiveness.

BackgroundThere is a dearth of information on people with first-episode psychosis who do not access specialized early psychosis intervention (EPI) services. With this notable gap in knowledge comes the implicit assumption that nearly all cases of first-episode psychosis are detected and treated by EPI services. We sought to estimate the proportion of incident cases of non-affective psychosis who do not access these services, and to examine factors associated with EPI admission.MethodsUsing health administrative data, we constructed a retrospective cohort of incident cases of non-affective psychosis in the catchment area of the Prevention and Early Intervention Program for Psychoses (PEPP) in London, Ontario between 1997 and 2013. This cohort was linked to primary data from PEPP to identify EPI-users. We used multivariate logistic regression to model socio-demographic and service factors associated with EPI admission.ResultsOver 50% of suspected cases of non-affective psychosis did not have contact with the EPI program for screening or admission. Our findings suggest a clear gradient by age, with a decreasing likelihood of being treated in the EPI program with increasing age strata (age 46–50 years vs. age 16–20 years: OR=0.03, 95%CI=0.01–0.05). EPI-users are more likely to be male (OR=1.58, 95%CI=1.24–2.01), and less likely to live in areas of socioeconomic deprivation (OR=0.51, 95%CI=0.36–0.73). EPI-users also had a higher odds of psychiatrist involvement at the index diagnosis (OR=7.35, 95%CI=5.43–10.00), had a lower odds of receiving the index diagnosis in an outpatient setting (OR=0.50, 95%CI=0.38–0.65), and had a lower odds of prior alcohol-related (OR=0.42, 95%CI=0.28–0.63) and substance-related (OR=0.68, 95%CI=0.50–0.93) disorders.DiscussionMuch of the prior research on EPI services is predicated on the belief that nearly all patients with first-episode psychosis are represented in these services, with little discussion or consideration of people who may be receiving care elsewhere in the health system. We need greater consideration of patients with first-episode psychosis who are not accessing EPI services – our findings suggest this group is sizable, and there may be socio-demographic and clinical disparities in access. Non-psychiatric health professionals could be targeted with interventions aimed at increasing detection and referral rates.

Early intervention in psychosis (EIP) services are the dominant service model in the treatment of first-episode psychosis. They are a time-limited intervention and little is known about discharge destinations and outcomes once EIP treatment has concluded. To understand discharge pathways and predictors of relapse in an EIP service. We collected data on all patients with an electronic health record treated by EIP services in Oxford Health NHS Foundation Trust in the UK between 12 January 2006 and 7 March 2017 (n=701). Our primary outcomes were discharge destination at end of treatment and relapse. Most patients (83.5%) were discharged to primary care. Transfer to secondary care was associated with previous in-patient admissions (odds ratio (OR)=1.92, 95% CI 1.54-2.39) and longer EIP treatment (OR=1.04, 95% CI 1.03-1.06). Relapse rate was highest shortly after leaving EIP services. Relapse was associated with transfer to secondary care (hazard ratio (HR)=2.75, 95% CI 1.75-4.31), higher deprivation (HR=1.03, 95% CI, 1.01-1.05), a substance misuse disorder (HR=1.81, 95% CI 1.01-3.26) and a comorbid diagnosis of a personality disorder (HR=2.96, 95% CI 1.39-6.29). Most patients treated by the EIP service in Oxfordshire did not receive ongoing mental healthcare from secondary mental health services. We identified high deprivation and those with substance misuse problems or personality disorders as EIP populations with a high risk of relapse. None.

Aims: The Early Intervention for Psychosis (EIP) service in Derby City and Derbyshire South County provides care for individuals aged 14–65 experiencing a first episode of psychosis. The service supports a diverse population across Derby City (Census 2021 population: 261,400) and Derbyshire South County (Census 2021 population: 349,000), reflecting varying demographic and clinical characteristics. This study examines diagnostic outcomes, referral sources, and discharge destinations of discharged patients.Aim was to ascertain the diagnostic outcomes, referral sources, and discharge destinations of patients discharged from the EIP service in Derby City and Derbyshire South County.Methods: All patients discharged from the EIP service between 1 April 2023 and 1 April 2024 were included. Included patients were under the service for at least 3 months. Some continued up to 3 years, while others were discharged earlier for reasons such as non-psychotic diagnoses. Data on diagnosis, referral source, and discharge destination were retrospectively collected from clinical records, recorded in an Excel spreadsheet, and analysed to identify key patterns and trends.Results: Nearly half of discharged patients (46.67%) had a psychosis spectrum diagnosis (F20–F29; ICD-10). Organic psychoses (4.4%), drug-induced psychosis (8.8%), bipolar disorder with psychotic symptoms (11.1%), other mood-related psychoses (6.6%), and non-psychotic conditions (22.2%) were also identified.Referrals came primarily from secondary mental health services (48.89%), inpatient units (34.4%), primary care (12.2%), and the Court Liaison and Diversion Service (4.4%).Discharge destinations showed that 42.7% of patients were transferred to Community Mental Health Teams, and 47.1% were discharged to primary care. Smaller proportions were discharged to learning disabilities services (1.1%), out-of-area early intervention for psychosis services (7.87%), or the perinatal team (1.1%).Conclusion: The Derby EIP caseload aligns with the service’s focus on first episode psychosis. Low referral rates from primary care indicate that many patients are first identified in crisis settings. However, the majority of patients being discharged to primary care highlights the effectiveness of an intensive, multidisciplinary approach. The small number of referrals to specialized services reinforces positive outcomes in EIP patients.

Early intervention in psychosis (EIP) services target the early manifestation of psychosis and provide multidisciplinary care. They demonstrate effectiveness and cost-effectiveness. Implementation of EIP services is inconsistent and piecemeal. This systematic review and narrative synthesis aims to identify barriers and facilitators to EIP service implementation. We conducted an electronic search of databases (EMBASE, Medline, Web of Science, and PsychINFO) to detect papers reporting EIP service implementation findings and associated barriers and facilitators. The search occurred between June to August 2020, and again in January 2021. Articles meeting inclusion criteria were extracted and narratively synthesized. A quality assessment was conducted using the Mixed Methods Appraisal Tool. Twenty-three studies were selected. The most common study design was descriptive accounts of implementation. Patient age ranged varied from 14 to 35years. We identified three barrier and facilitator domains: (a) system; (b) services; and (c) staff, and a range of subdomains. The most frequent subdomains were "funding" and "strength of collaboration and communication between EIP and outside groups and services". Associations between domains and subdomains were evident, particularly between systems and services. A range of barriers and facilitators to EIP implementation exist. Some of these are generic factors germane across health systems and services, while others are specific to EIP services. A thorough prior understanding of these challenges and enablers are necessary before implementation is attempted. Accounting for these issues within local and national contexts may help predict and increase the likelihood of services' success, stability, and longevity.

There is a dearth of information on people with first-episode psychosis who do not access specialized early psychosis intervention (EPI) services. We sought to estimate the proportion of incident cases of nonaffective psychosis that do not access these services and to examine factors associated with EPI admission. Using health administrative data, we constructed a retrospective cohort of incident cases of nonaffective psychosis in the catchment area of the Prevention and Early Intervention Program for Psychoses (PEPP) in London, Ontario, between 1997 and 2013. This cohort was linked to primary data from PEPP to identify EPI users. We used multivariate logistic regression to model sociodemographic and service factors associated with EPI admission. Over 50% of suspected cases of nonaffective psychosis did not have contact with EPI services for screening or admission. EPI users were significantly younger, more likely to be male (odds ratio [OR] 1.58; 95% confidence interval [CI] 1.24 to 2.01), and less likely to live in areas of socioeconomic deprivation (OR 0.51; 95% CI 0.36 to 0.73). EPI users also had higher odds of psychiatrist involvement at the index diagnosis (OR 7.35; 95% CI 5.43 to 10.00), had lower odds of receiving the index diagnosis in an outpatient setting (OR 0.50; 95% CI 0.38 to 0.65), and had lower odds of prior alcohol-related (OR 0.42; 95% CI 0.28 to 0.63) and substance-related (OR 0.68; 95% CI 0.50 to 0.93) disorders. We need a greater consideration of patients with first-episode psychosis who are not accessing EPI services. Our findings suggest that this group is sizable, and there may be sociodemographic and clinical disparities in access. Nonpsychiatric health professionals could be targeted with interventions aimed at increasing detection and referral rates.

Violence risk is an important part of a comprehensive clinical assessment in first-episode psychosis. This study addresses limitations of previous violent outcome research in first-episode psychosis, which has typically investigated selected cohorts or been restricted to violence occurring prior to service contact, with limited use of police data. For individuals consecutively assessed by Early Intervention in Psychosis (EIP) services in two UK regions (n = 177), violent outcomes in the subsequent 12-months were collected using electronic patient records, supplemented by police data. Of individuals accepted by EIP services (n = 109), electronic medical records indicated around 1 in 4 (n = 28, 25.7%) perpetrated any physical violence, and 1 in 10 (n = 10, 9.2%) were arrested or charged for violent offences in the 12-months after first contact. Police data on all individuals assessed (n = 177) reported 1 in 7 (n = 26, 14.7%) were arrested or charged for violent offences in the 12-months after first contact. EIP services should consider integrating multi-agency sources of data to evaluate violent outcomes. The potential role of violence risk management should be further examined.

Early Intervention in Psychosis services improves outcomes for young people with psychosis, but 25% disengage in the first 12 months with costs to their mental health. To refine a toolkit and training and evaluate effectiveness, implementation, and cost-effectiveness of the Early Youth Engagement-2 intervention to reduce disengagement. Cluster randomised controlled trial with economic and process evaluation. Randomisation at team level stratified by site. Research assistants, outcome assessors and statisticians were masked to treatment allocation for the primary disengagement and cost-effectiveness outcomes. Participants and teams administering the interventions were unmasked. Twenty Early Intervention in Psychosis teams in five sites across England. A total of 1027 young people (14-35 years) with first-episode psychosis (F20-29, 31; ICD-10); 20-282 Early Intervention in Psychosis staff. Team-based motivational engagement (Early Youth Engagement-2) intervention, delivered by Early Intervention in Psychosis clinicians alongside standardised Early Intervention in Psychosis, supported by the implementation toolkit (training, website and booklet series). Standardised Early Intervention in Psychosis, including National Institute for Health and Care Excellence guidelines approved interventions. Primary outcome - time to disengagement over 26 months (days from date of allocation to care co-ordinator to date of last contact following refusal to engage with service, or lack of response to contact for consecutive 3-month period). Secondary outcomes - mental health, recovery, quality of life, service use, at 6 and 12 months. Economic outcomes - National Health Service mental healthcare costs, wider societal care costs, clinical and social outcomes over 12 months; cost-effectiveness. Process evaluation outcomes - fidelity to the Early Youth Engagement-2 model, implementation process scores, therapeutic alliance, qualitative outcomes. Disengagement was 16% across both arms. The multivariable Cox regression on 1005 participants estimated an adjusted hazard ratio for Early Youth Engagement-2 + standardised Early Intervention in Psychosis (n = 652) versus standardised Early Intervention in Psychosis service alone (n = 375) of 1.07 (95% confidence interval 0.76 to 1.49; p = 0.713). There were no observed differences between arms for any secondary outcomes. The health economic evaluation indicated lower mean mental healthcare costs of -£788 (95% CI -£3571 to £1994) and marginally improved mental health states for intervention participants. Early Youth Engagement-2 participants spent 30 more days per year in education and training (95% CI 1.52 to 53.68; probability positive outcome for the intervention: 99%), but these outcomes must be viewed very cautiously as only 22% of the sample provided data. The process evaluation revealed heterogeneous implementation fidelity and constant pressure to adapt to widespread disruption from COVID-19. There was no effect on therapeutic alliance: the most likely active change mechanism was through psychoeducation. Lower than expected disengagement, high loss to follow-up and impact of COVID-19 on fidelity, implementation and outcomes. In the primary clinical effectiveness analysis, 95% confidence limits ruled out a reduction of more than 24% in the risk of disengagement with the Early Youth Engagement-2 intervention. In a cost-effectiveness analysis, estimates fell in the direction of dominance of the Early Youth Engagement-2 intervention (reduced costs, marginally better mental health states). Dissemination of the booklet and website resources and an adapted version of the model as stand-alone tools for use in good-practice routine Early Intervention in Psychosis care. This study is registered as ISRCTN 51629746. This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 16/31/87) and is published in full in Health and Social Care Delivery Research; Vol. 13, No. 33. See the NIHR Funding and Awards website for further award information.