Further development of early intervention in psychosis

Abstract

Dear Editor, Much can be learnt from Singh et al.'s article1 on a 1-year naturalistic study of an early intervention service and by comparing it with other such studies. We have recently published our 3 year study of an early intervention service compared with treatment as usual. 2-4. In our study, patients managed by Early Intervention Team (EIT) based in Luton, South Bedfordshire were compared with those managed by standard Community Mental Heath Teams in the rest of Bedfordshire. We too have found important statistically significant differences between the two groups of patients, with the EIT having the better results. For example, in a comparison of 62 patients in either group, evenly matched by age and sex, the Early Team had better results in terms of employment and education (P = 0.09), patients continuing to live with their families (P = 0.007), having fewer readmissions to hospital (P < 0.0001) and less necessity to use the mental health act (P = 0.004). We feel that contributing factors to these results were the fact that by 3 years, the patients in the early intervention group were more likely to have been prescribed atypical antipsychotics, rather than typicals, including depot injections (P < 0.001), more likely to comply with taking medication (P = 0.015) and were more likely than the treatment as usual group to have received systematic psycho-education or other psychosocial interventions, including knowing how to identify early warning signs of relapse, acting upon these signs and occasional family interventions. Unlike Singh et al., we were able to demonstrate success in persuading patients in the Early Intervention Service (EIS) to stop using illicit drugs, particularly cannabis (P = 0.003), and we attribute this success to our systematic use of psycho-education. Unlike Singh et al., we did not have an employment specialist within the EI team, and therefore, we attribute our success in returning patients to work or education, sometimes despite some ongoing positive symptoms, to the quality of the assertive case management provided by the team. We wholeheartedly support one important observation of Singh et al. that of the need for a ward specifically designed for patients with a first or early episode of psychosis. The provision of such a ward is the most likely way to enable patients with a first episode of psychosis to receive inpatient treatment which is appropriate to their age group and their condition in the most appropriate way possible, so that these patients are more likely to engage with mental health services, and it is clear that such a ward is a presupposition of the IRIS guidelines,5 which were the starting point of the early intervention movement in the UK. Unfortunately, the policy implementation guide for EITs in England does not mention inpatient units, so that new commissioning money for Early Intervention is usually focused on Community Teams, but many first episodes of psychosis are initially treated in hospital. Despite the lack of specific funding, it should be possible in most cases to reconfigure inpatient services so that one ward is made available for the use of first episode patients, who could then receive age and illness specific interventions. Equally, we agree with Singh et al. that it is also our experience that an EIS which is based on a team which assertively follows up patients who have had a first psychotic episode for 3 years will not be able to reduce the duration of untreated psychosis, but that in order to achieve this result, a specific early detection team needs to be set up running parallel to the main EI team. Therefore, in agreement with Singh et al., we suggest that a complete EIS, as is the case with the archetypal service EPPIC,6 needs to be ‘multimodular’, containing at least the following interrelated modules; an Assertive Community Treatment Team, an Early Detection and Home treatment team and an Early Intervention inpatient ward. Not all of this need be funded by new money, but rather by an imaginative re-deployment of resources. A final point needs to be raised; Singh et al. report that substantial numbers of first episode patients were not referred to their service. It is essential that EISs must be funded adequately so that all patients in their catchment area who are experiencing a first psychotic episode can be accommodated in this service. Unfortunately in the case of ETHOS and our own service, this is often not the case. It is essential that adequate funding is made available to ensure that all patients receive the benefits of this treatment model. If this is not the case, our success will be overshadowed with intolerable issues of equity and fair and adequate treatment, which will make further development of Early Intervention in Psychosis in the UK fraught with insoluble difficulties.