Intensive community outreach for those at ultra high risk of psychosis: dilution, not solution – Authors' reply

Abstract

Paolo Fusar-Poli colleagues have made an interesting interpretation of our findings from the Liaison and Education of General Practices (LEGs) study1Perez J Jin H Russo DA et al.Clinical effectiveness and cost-effectiveness of tailored intensive liaison between primary and secondary care to identify individuals at risk of a first psychotic illness (the LEGs study): a cluster-randomised controlled trial.Lancet Psychiatry. 2015; 2: 984-993Summary Full Text Full Text PDF PubMed Scopus (40) Google Scholar. They note that our high intensity intervention in primary care increased the referral not only of people at high-risk for or with a first-episode psychosis, but also of individuals suffering from neither of these states. As we acknowledged, our intervention was not specific for psychotic outcomes, but most of these “false-positive psychosis cases” required treatment by mental health services. From the point of view of the patients and primary care clinicians, the intervention worked; from our point of view, we confirmed our hypothesised doubling of psychosis referrals. Furthermore, this did not affect the effectiveness and cost-effectiveness of the high intensity intervention. Second, they present a hypothesis based on a probabilistic model. They argue that interventions to improve detection of psychotic symptoms in primary care would dilute transition rates. In other words, those referred by general practitioners intensively trained to detect these symptoms would probably be at a lower risk of making a transition to a DSM or ICD psychotic disorder; as with any test, the predictive value depends on the prevalence of the disorder. This scientific interest does not reflect the aim of our study. Our trial did not intend to detect only those individuals with psychotic symptoms who were more likely to make a transition to a psychotic disorder, but to establish new ways of working with primary care to encourage referral of people who experience psychotic symptoms so as to provide prompt and rehabilitating care. These people are highly affected by their symptoms and usually present with severe disability and poor quality of life, irrespective of whether or not they develop a psychotic illness.2Hui C Morcillo C Russo DA et al.Psychiatric morbidity, functioning and quality of life in young people at clinical high risk for psychosis.Schizophr Res. 2013; 148: 175-180Summary Full Text Full Text PDF PubMed Scopus (71) Google Scholar Although Fusar-Poli and colleagues understand “psychosis true-positive cases” as those that will certainly develop the illness, we employed this terminology to describe people presenting with psychotic symptoms in primary care that would benefit from attention by mental health services. We feel that the proportion of this group with psychotic experiences are served badly by the aim to perfect a predictive test for syndromal psychosis (ie, increases in these experiences that pass an arbitrary diagnostic threshold), by the term “at-risk for psychosis”, and by current diagnostic categories. They have psychotic experiences as part of what is often a kaleidoscopic and disabling mental state and usually require expert care. Our high intensity intervention improved access to this and saved money. We declare no competing interests. We acknowledge funding support from a NIHR Programme Grant for Applied Research programme (RP-PG-0606-1335) awarded to PBJ. The work forms part of the NIHR Collaboration for Leadership in Applied Health Research & Care East of England (CLAHRC-EoE). Clinical effectiveness and cost-effectiveness of tailored intensive liaison between primary and secondary care to identify individuals at risk of a first psychotic illness (the LEGs study): a cluster-randomised controlled trialThis intensive intervention to improve liaison between primary and secondary care for people with early signs of psychosis was clinically and cost effective. Full-Text PDF Open AccessIntensive community outreach for those at ultra high risk of psychosis: dilution, not solutionIn The Lancet Psychiatry, Jesus Perez and colleagues report findings from the Liaison and Education in General Practices (LEGs) cluster-randomised controlled trial,1 in which they investigated whether increased liaison between primary and secondary care improved the detection of primary care patients at ultra-high risk (UHR) of developing psychosis or first-episode psychosis (FEP), and concluded that it was both clinically and cost effective. However, the ratio of true-positive (UHR or FEP) to false-positive (neither UHR nor FEP) referrals from general practices was similar (approximately 1:1) across all the three treatment conditions (high intensity: 2·2:2·3, low intensity: 1·1:0·9, practice as usual: 0·6:0·8). Full-Text PDF