Is Treating Patients with First-Episode Psychosis Cost-Effective?

Abstract

Ashok Malla, MBBS, FRCPC1; Anthony J Pelosi, FRCP, FRCPsych2 Can J Psychiatry. 2010;55(1):3-8. Ample Evidence Supports Specialized Early Intervention The last decade has seen a burgeoning interest not only in research in first-episode psychosis (FEP), its treatment, and early detection but also in the establishment of several early intervention (EI) services. While the enthusiasm for EI is inherently appealing, it has its detractors. Whether the benefits of a specialized EI approach to treatment of FEP are worth the costs it may incur has generated some heated debate. While we do not have all the answers yet, I will argue that this new development in service delivery is based on good evidence and likely to be cost-beneficial in the long run. To shed more light, rather than simply generate more heat, it is important to examine several key questions related to EI and its benefits. What is EI? Is it effective? Is it worth the cost and should EI be incorporated into mental health policy in Canada? Should EI include services for patients in the so-called prodromal stage of psychosis? There are several sources of ambiguity in the term EI that go beyond semantics. In the treatment of an FEP, 2 components of EI need to be clearly defined, one that relates to a phase-specific and specialized approach to treatment and the other that addresses issues of reducing delay through early case identification. An additional and more contentious issue relates to treatment of prodromal state. The 2-pronged question most often raised is: Why establish a new and specialized service for this patient population, and why not treat them in the same services as those with more established and chronic illness? The argument for a specialized approach to treatment in the early phase of psychosis goes something like this: in routine care, clinical response to treatment of FEP is generally very good, with relatively high rates of reduction in level of psychotic symptoms and more modest reduction of negative symptoms, often, however, followed by relatively high rates of relapse within the first 2 to 5 years.' Trajectories of long-term outcome are often defined relatively early in the course of illness.2 More intensive efforts at treatment during the early phase may improve outcome, at least for a substantial proportion of patients. In routine psychiatric services, highly specialized and intensive care is usually not introduced until considerably later in the course of illness, after considerable decline in functioning develops. Interventions at this late stage are unlikely to result in any substantial clinical or functional gains. The existent system is generally not equipped to deal with special needs of the young patients (and their family) with a new onset of psychosis. For example, such needs are associated with a significantly younger age, specific developmental stage, nature of psychopathology leading to ambiguity in diagnosis, naivete to the mental health system, and high rate of recreational substance use. Such special characteristics of FEP patients render them unlikely to engage or stay in and be adherent to treatment. In general, most EI services provide a modified version of an assertive case management program along with rational pharmacotherapy and specific psychological interventions such as cognitive-behavioural therapy (CBT) and family intervention. Two recent randomized controlled studies and numerous, mostly uncontrolled and quasi-experimental, studies have shown that specialized EI services provide superior effectiveness on measures of psychopathology, rates of remission and relapse, adherence to and retention in treatment, greater family involvement in treatment, and better community adjustment.3-4 A recent meta-analysis has confirmed that an enriched intervention provided to patients with FEP is likely to produce significantly better clinical and functional outcome, compared with routine care. …