Occupational therapy in early intervention in psychosis (EIP): a scoping review of practice in Ireland and the United Kingdom (UK)

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.

The early intervention in psychosis literature has recently appropriated clinical terms with etiologic implications such as staging and pluripotent from the oncology literature without adopting the methodological rigor of oncology research. Oncology research maintains this rigor, among other methods, by examining the literature for evidence of bias and spin, which obscures negative trials. This study was designed to detect possible use of reporting bias and spin in the early intervention in psychosis literature. Articles were selected from PubMed searches for early intervention in psychosis, duration of untreated psychosis, first-episode psychosis, ultra-high risk, and at risk mental state between January 1, 2000, and May 31, 2013. 38 RCT and quasi-experimental articles reporting results from early intervention in psychosis paradigms were selected for inclusion. Articles were examined for evidence of inappropriate reporting of primary and secondary end points in the abstract (reporting bias) and presentation as positive despite negative primary end points (spin). While only 13% of early intervention articles reported positive primary end points, abstracts implied that 76% of articles were positive. There was evidence of bias in 58% of articles and spin in 66% of articles. There was a high prevalence of spin and bias in the early intervention in psychosis literature compared to previous findings in the oncological literature. The most common techniques were changing the primary end point or focusing on secondary end points when the primary end point was negative and reporting analyses using only a subset of the data. There appears to be a need for greater scrutiny of the early intervention in psychosis literature by editors, peer reviewers, and critical readers of the literature.

Young adults experiencing psychosis are at high risk for disengagement from their daily lives. Occupational therapy (OT) services play an important role in fostering participation, yet their intervention efficacy in Early Intervention in Psychosis (EIP) remains poorly understood. To determine the commonly utilized OT interventions and measurement tools that require further research to determine their efficacy and effectiveness. Cross-sectional, mixed-methods survey study. Quantitative descriptive statistics were completed on Microsoft Excel and qualitative thematic analysis was completed by two researchers using Dedoose. Online survey. Occupational therapy practitioners (OTPs) working on EIP programs in the United States were recruited through purposive and snowball sampling. The survey consisted of 24 closed and open-ended questions assessing use of interventions, outcomes tracked, and measurement tools. Study had 21 respondents. The most frequent interventions were self-regulation and activities of daily living (ADL). Self-regulation interventions were overwhelmingly sensory-based. Most commonly reported outcome measure was observation of participation in occupations. This study confirms the use of sensory and ADL-based interventions by OTPs in EIP programs. Findings suggest a strong sense of the role of OT within EIP as intervention use is relatively consistent across programs and focuses on client-centered, occupation-based interventions. Outcome tracking and quality improvement were gaps as most OTPs are not using standardized methods or not performing this. Additional study is required to determine the efficacy of commonly used interventions and to improve outcome measurement methods in EIP programs. Occupational therapy is an undervalued profession on teams that provide services to young adults dealing with the onset of a psychotic illness. This study is the first of many needed to demonstrate the impact OT services can have on the outcomes of the young adults who receive care for their psychotic illness. This study identifies what OT interventions are common, and what outcomes OT professionals track to determine their services' impact on these mental health care teams. These results will help to build the needed research on how helpful these common interventions are for young adults facing psychotic illnesses.

The case for early, medium and late intervention in psychosis

Besides intervention in prepsychotic period, early intervention in psychosis includes interventions done after the onset of the first-episode psychosis, namely psychopharmacological and psychosocial phase-specific intervention. The main aim is to reduce the duration of untreated psychosis (DUP) and to ensure that besides remission of the symptoms there is also a psychosocial recovery. Many centers set up an assertive and integrated early intervention program, involving an active search of patients with a treatment that includes antipsychotic medication, cognitive behavioral therapy, psychoeducation, family and vocational interventions. The authors of this review explain the concepts and main studies that support this kind of treatment in early psychosis. The results of published data show that is possible to reduce the DUP and improve the clinical and functional outcomes with this intervention. Critical period hypothesis proposes that deterioration occurs aggressively in the first 2 to 5 years of early psychosis, so it is crucial to intervene in this period to ensure a functional recovery. Cost-benefit ratio seems to be favorable to early intervention model, with reduction of in-stay period, which is an important component of the direct costs of psychotic illness. Early intervention service model organization is also reviewed by the authors of this research. The results of many studies show favorable outcomes for the integrative early intervention and so many countries included it in their political mental health directives and attributed funds for early intervention in psychosis.

Continuity of care is an important therapeutic factor in psychiatric services. This study aimed to look at the continuity of care for patients following discharge from an early intervention in psychosis service. Continuity of care was assessed by looking at whether a patient was still with the same service after 3 years or more following discharge from an early intervention in psychosis service. If not, records were checked to see where their care had moved. Discharges from 2006 to 2009 were included in the study. Descriptive statistics were worked out to calculate the proportion of service users who remained with the same service and those who had moved to other services. About 8% of patients had moved to another service during the identified study period. Only 4% of patients had moved from a less intensive to a more intensive service within this time. The findings from this study showed that only a very small proportion of patients discharged from an early intervention in psychosis service move to another service in the 3 years following their discharge. Movement of patients to a more intensive service after discharge from the early intervention in psychosis team was even lower. Most patients thereby have a stable continuity of care following discharge from an early intervention team.

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.

An Early Intervention in Psychosis (EIP) programme aims to engage patients in early assessment and phase-specific interventions which are the key elements of the Irish National Clinical Programme for psychosis. This study aims to describe and review the EIP programme offered by Cork's North Lee Mental Health Services over a 5-year period. A retrospective descriptive study design was adopted to describe and review the EIP programme, patient demographics and treatments offered in the service over a 5-year period. A total of 139 patients were accepted into the programme over the 5-year period. The mean age of onset was 30 years (median = 28, SD = 9.9), and the mean duration of untreated psychosis was 8 months (median = 2.5, SD = 15.3). Two-thirds of patients were single on initial assessment, had a history of substance misuse and were unemployed. The majority of the cohort engaged with the keyworkers and occupational therapy but did not complete the full psychological or family programmes offered. Hospital admission was required for 12% of the cohort. Patients experiencing their first episode of psychosis can successfully be treated in the community with appropriate professional and family support. However, deficiencies were noted in physical health monitoring, as well as in the availability and engagement with family and psychological therapies. Properly resourced early interventions in psychosis teams are necessary to deliver services at internationally recognised standards.

Programs for early intervention in psychosis have shown clinical efficacy. The authors aimed to evaluate the cost-effectiveness of early intervention programs compared with standard care for the treatment of first-episode psychosis in the United States. A decision-analytic model integrating published data on clinical efficacy, costs, and health utilities was developed to evaluate early intervention versus standard care over the lifetime of patients after their first psychotic episode. Model input data were derived from meta-analyses, clinical trials, and U.S. national data. The main outcomes included hospitalizations, employment rate, quality-adjusted life years (QALYs), lifetime health care costs, and incremental cost-effectiveness ratios (ICERs). Compared with patients receiving standard care, patients in the early intervention strategy had 3.2 fewer hospitalizations and 2.7 more years of employment over the course of their remaining life expectancy. From a health care perspective, early intervention had an ICER of approximately $51,600 per QALY. From a societal perspective, early intervention saved costs (i.e., yielded greater health benefits and had lower costs compared with standard care). Results were sensitive to the effect of early intervention on suicide, cost of standard care, cost of early intervention, and the effect (relative risk) of early intervention on employment. A scenario analysis that excluded the effect (i.e., hazard ratio) of early intervention on suicide yielded an ICER of approximately $197,000 per QALY. These results suggest that it is economically beneficial to fund early intervention in psychosis programs in the United States. The findings indicate that early intervention in psychosis saves costs (from the societal perspective) and is cost-effective (health care sector perspective).

Gaming disorder (GD) is increasingly recognized as a clinically significant condition, yet its implications in first-episode psychosis (FEP) remain largely unexplored. This perspective article focuses on the intersection of GD and FEP, highlighting key diagnostic and treatment challenges, including symptom overlap that complicates differential diagnosis, the absence of validated screening tools, and difficulties in sustained patient engagement. Drawing insights from substance use disorder management in FEP, we propose a preliminary clinical framework for integrating GD assessment and intervention into early intervention in psychosis programs. This approach prioritizes comprehensive evaluation, patient-centered care, and a harm-reduction model that supports digital well-being. Addressing GD inFEP populations is crucial for optimizing functional recovery and promoting a holistic, recovery-oriented approach to psychiatric care. Further research is needed to refine screening tools and validate tailored interventions in this population.

Are We Really Impacting Duration of Untreated Psychosis and Does It Matter?: Longitudinal Perspectives on Early Intervention from the Irish Public Health Services

EPA-1256 – Should early intervention in psychosis programs be autonomous or set up as a specialized units within psychiatric services? forethoughts about our approach

McGorry et al have persuasively and passionately advanced the case for early intervention in psychosis. The urgency to intervene early in life is underpinned by the fact that psychosis, like most other mental disorders, tends to have an onset in adolescence and early adulthood, which happen to be highly sensitive developmental periods in the life cycle. Though heuristic, early intervention in psychosis is handicapped by problems of clinical staging and acceptability. Clinical staging has a continuum, ranging from the earliest possible beginning of psychosis to first episode diagnosis of psychosis and the critical first 5 years after the diagnosis. The beginning pre-dates the “prodrome”, which term assumes certainty that the psychotic state will develop. We are talking of the very thin boundary when normal begins to transit to abnormal. The concept of ultra-high risk has been coined in the attempt to pre-date the “prodrome”. Efforts to increase the predictive value of ultra-high risk criteria have the potential to produce false negatives and in the process deny people who would otherwise benefit from early intervention the opportunity for treatment. On the other hand, less predictive ultra-high risk criteria would lead to false positives and in the process end up putting people on treatment when they do not need it, more so given the side effects and the negative impact at an early age. Despite the evidence, there are still skeptics who argue that there is not enough evidence for the concept of early psychosis and/or that early intervention works. Nevertheless, such skeptics have a role to play in keeping the inventors of the evidence on their toes while both appealing to a wider audience and eventually influencing policy and practice. This is indeed a healthy debate. Nearly all research on early intervention in psychosis comes from resource-rich countries, and little from developing countries and in particular from Africa. It is true there is a gross shortage of human and financial resources in this continent 1–3. This cannot, however, be an excuse for Africa to be left out of this endeavour. This continent has a young population, with more than 50% being less than 25 years of age, and a total population which is about 12% of the global one. Thus, Africa has a claim to this endeavour. The major players in this kind of research and their respective funders should collaborate with researchers operating in Africa in designing simple community-based identification of ultra-high risk individuals and initiating interventions. This does not require highly skilled psychiatrists. The social support is still intact in most societies in Africa and affordable drugs such as haloperidol, despite their limitations, are widely available. As happens with any new ideas, regardless of the overwhelming supportive evidence, the progression from evidence to policy and practice will be on a continuum. On this continuum will be on the one hand the few researchers producing the evidence and, on the other, the skeptics or laggards demanding for more evidence. In between will be a continually increasing number of acceptors, initially on the basis of the evidence, then on the basis of an increasing number of opinion leaders who practice the intervention, and finally on the basis of standard practice without even questioning the evidence for or against. The challenge to the inventors is whether or not they have the tenacity to generate both new and more evidence and navigate their inventions through this continuum while at the same time constructively engaging the skeptics. The way to achieve this is through research designs that will provide focused evidence of the earliest possible time intervention can be initiated, minimizing both false positives and false negatives. This should be a collective effort that takes on board globally representative participants with diverse sociocultural and economic backgrounds. This way, it will be much easier for the results to be co-owned and therefore easily accepted and implemented. Scientific evidence alone is not always enough.

BackgroundThe components of care delivered by Early Intervention in Psychosis (EIP) services vary, but the impact on patient experience is unknown.ObjectiveTo investigate associations between components of care provided by EIP...

Family intervention (FI) is recommended in national guidance to be offered to all service users accessing an early intervention in psychosis (EIP) team, due to the consistent evidence base in reducing relapse and rehospitalisation rates. However, FI implementation is poor nationally. Although barriers have been identified at the level of staff member and the organisation, there is a paucity of research identifying service user perspectives. A qualitative questionnaire design was used to explore service user perspectives of behavioural family therapy (BFT) within a specialist EIP service in northwest England. Most participants contacted reported they lacked knowledge and understanding of BFT, with 54% reporting that this intervention had not been offered to them. This finding was unexpected and is inconsistent with the offer of BFT documentation in their clinical notes. Reasons for accepting BFT included to increase understanding of family members and for them to also be supported. Reasons for declining BFT included a preference for one-to-one interventions and not wanting family involved in their care. National guidance on FI for psychosis is not reliably being translated to clinical practice, with many participants reporting that they were not offered this intervention. A key factor in accepting or declining an offer of BFT appeared to be whether participants wanted family members to be involved in their care. A lack of understanding of the BFT approach was evident, it is recommended that the offer of FI in psychosis is improved for service users to make an informed decision.