Early Intervention Teams services for early psychosis

Early Intervention Teams services for early psychosis Early intervention services work with people who are usually between 14 and 35, and are either at risk of or are currently experiencing a first episode of psychosis. This kind of service has been set up as the longer an episode of psychosis goes untreated, the poorer the outlook for someone. It is likely that if someone experiences symptoms of psychosis, the first time will usually be between the ages of 16 and 30. An early intervention team will be made up of staff such as a psychiatrist, psychologist, community psychiatric nurses, social workers and support workers. Research has shown that early intervention services (compared to standard services) may reduce hospital stays, reduce relapses and suicide rates. More recent research has found that this benefits of early intervention services may not continue in the long-term. More research on this is needed. This factsheet covers 1. Why early intervention? 2. Who is early intervention for? 3. What are the aims of early intervention? 4. Who makes up an early intervention service 5. How does early intervention work? 6. How to get access to an early intervention service 7. When can early intervention fail? 8. Useful Contacts 1

1. Why early intervention? Of those that experience symptoms of psychosis, most will experience them for the first time between the ages of 16 and 30. 1 Generally, traditional community mental health services have not been successful in engaging with young people who are at risk of, or are experiencing psychosis. 2 One of the reasons that early intervention has been focused on is because research has found that there is a link between a long period of untreated psychosis and a poorer outcome. 3 It is thought that the first 3 years of psychosis is a critical period, where long-term symptoms may emerge and repeated relapses can occur. Also psychosis can impact on someone s social and personal life, and have occupational consequences (e.g. on work or study) which could build up. 4 Therefore, it has been argued that services are needed to allow earlier treatment for psychosis and reduce the time that it goes untreated. When early intervention services are compared to standard mental health services, early intervention has shown - shorter periods of untreated psychosis 5 lower use hospital bed use 6 decreased relapse rates 7 better recovery, better engagement with services, increased service user/carer satisfaction and lower suicide rates 8 2. Who is early intervention for? Early intervention is generally for people who are - 9 aged 14-35 (the qualifying age range may vary between individual services) and experiencing their first episode of psychosis; or aged 14-35 during the first three years of a psychotic illness The NICE guidelines for schizophrenia recommend that early intervention services are offered to everyone experiencing a first episode or presentation of psychosis. 10 Early intervention services offer help to people for a limited amount of time, usually about three years. 3. What are the aims of early intervention? Mental health services setting up early intervention services was part of the NHS Plan. 11 Further guidance from the Department of Health 12 has set out a range of tasks for early intervention services including - reducing stigma and raising awareness of the symptoms of psychosis 2

developing engagement providing evidence-based treatments and promoting recovery for young people who have experienced an episode of psychosis working across the divide between child and adolescent services and adult services working in partnership with primary care, education, social services and youth services The overall aim of early intervention is to allow early identification and treatment for psychosis. This includes those who are experiencing their first experience of psychosis and can also include people who may be at risk of psychosis. 4. Who makes up an early intervention service? There will be a variety of staff who make up an early intervention service. The exact make-up may vary from area to area. However, it is likely to include psychiatrists, psychologists, social workers, community psychiatric nurses, occupational therapists and support workers. 5. How does early intervention work? The Sainsbury Centre for Mental Health (now known as the Centre for Mental Health) produced a list of core features of early intervention services. 13 In addition the National Institute for Mental Health in England identified elements that it sees as essential to the effectiveness of an early intervention service. 14 (The National Institute for Mental Health in England has since been replaced by the National Mental Health Development Unit). These two lists are combined below to give a picture of what you should expect from an early intervention service. A. Early detection and assessment Early intervention services should have a strategy for reaching people as early as possible. This includes effective pathways for referral A rapid initial assessment should be offered Young people should be referred and assessed if they are suspected of experiencing psychosis, not just where there is certainty. Assessment should be comprehensive, involving all professional groups, the person with the illness, family and friends A key part of assessment should be engagement. Cases should not be closed because the young person does not engage In addition to a mental and social assessment, the young person should have a risk assessment (including suicide) There should be access to translation services Areas of distress should be identified Professionals should realise that a diagnosis is not always possible 3

and treat the symptoms of illness Families and friends should be involved from an early stage B. Medication Young people should be involved in decisions about medication Young people should be given detailed information about medication There should be routine monitoring of side effects and prompt action taken to alleviate the unwanted effects of treatment Strategies for treatment resistance should be available C. Care co-ordination Key-workers should be allocated promptly and use assertive engagement processes where necessary Care plans should focus on recovery and empowering the young person All relevant parties (including carers and significant others) should be involved in care planning The key worker should be involved for three years Caseloads of key workers should not exceed 15 D. Co-existing disorders There should be specific and ongoing assessment and planning for - anxiety disorders, depression, suicide thoughts and feelings, alcohol/substance use and misuse, post-traumatic features. Carers should be assessed for similar problems. E. Basics Proper attention must be given to housing, income/finance, physical healthcare, practical support F. Psychosocial interventions The personal and social developmental needs of the young person must be recognised and addressed Psycho-education should be available to young people, families and carers Families should receive support and training around issues such as loss, adjustment, relapse prevention, expressed emotions etc. The young person should receive education about psychosis Cognitive behavioural therapy (CBT) should be available G. Education and occupation The young person should have a vocational assessment The young person should be supported in employment, education or other valued occupations within normal environments The achievement of normal social roles should be given the highest priority 4

H. Acute care Wherever possible, acute and crisis care should be provided at home by a crisis resolution service working together with the early intervention service The young person, family and friends should be told how to access care in a crisis If the young person needs to be cared for in hospital this should be in a suitable and safe environment which is appropriate to their age and not unnecessarily restrictive The use of the Mental Health Act should be avoided where possible If a young person is in hospital, the early intervention service should be actively involved in reviews and in discharge planning I. Style It is essential that the service must encourage optimism about recovery The service must be sensitive to the young persons needs relating to culture, gender, age etc. The service must be designed to be accessible, acceptable and engaging, being particularly sensitive to the needs of young people. Wherever possible, assessment and treatment should occur away from traditional psychiatric facilities J. Partnerships There should be collaboration between the early intervention service and - primary care, for example, your GP adult mental health services child and adolescent psychiatry social services non-statutory services education the young people and their carers youth organisations drug and alcohol services criminal justice services 6. How to get access to an early intervention service How to access an early intervention service may vary between geographical areas. GPs can usually refer directly to an early intervention team. Other specialist mental health teams (such as the Community Mental Health Team) can also make referrals. In some areas early intervention teams may accept self referrals or referrals from family members, carers or friends. 5

7. When can early intervention fail? Problems may arise with early intervention services if other health and social workers are slow to recognise possible symptoms of psychosis. This may lead to unnecessary delays before someone is referred to the local early intervention team. It is worth being aware that some early intervention teams in the country will also accept self referrals or referrals from friends or family members, as well as the more conventional access routes such as GP referrals. Early intervention services are a relatively new development in mental health services. Therefore, it is only recently that studies have started to look into whether or not their possible benefits carry on in the long-term (after someone s involvement with early intervention has ended). A recent study compared the number and length of hospital admissions of people treated for psychosis, who were either treated by the early intervention team or standard mental health care (Community Mental Health Teams). It looked at this 3.5 to five years after the first treatment for psychosis (so looking at the more long-term effects). It did not find any significant difference between hospital admissions for these two groups. 15 More research is needed in this area to clarify if the benefits of early intervention carry on in the long-term. If you or someone you know may benefit from an early intervention service but there are problems in accessing this, then you could discuss this with the Rethink Advice & Information Service. You could also contact our service if there are any problems with an early intervention service itself. Contact details for the Rethink Advice & Information Service are below in the Further Information section. The Centre for Mental Health has extensive information on early intervention in theory and in practice. For more information, go to their webpage, click on search and click on early intervention. Web - http://www.centreformentalhealth.org.uk/ At the forefront of research and practice, Australia has a number of sources of useful information. Among them, the Early Psychosis Prevention and Intervention Centre (EPPIC) has a helpful resources section - Web - http://www.eppic.org.au 6

1 Report on early detection and intervention for young people at risk of psychosis: CSIP North West & CSIP West Midlands 2 Singh, S.P. & Fisher, H.L. Early intervention in psychosis: obstacles and opportunities. Advances in Psychiatric Treatment 2005 (11): 71-78 3 Loebel, A.D. et al. Duration of psychosis and outcome in first-episode schizophrenia. American Journal of Psychiatry 1991 (149): 1183-1888 4 Birchwood, M. et al. Early intervention in psychosis. The critical period hypothesis. British Journal of Psychiatry 1998 (172) suppl.33: 53-59 5 Yung, A. et al. Management of early psychosis in a generic adult mental health service. Australian & New Zealand Journal of Psychiatry 2003 (37): 429-436 6 Craig, T. et al. The Lambeth Early Onset (LEO) team: randomised controlled trial of the effectiveness of specialised care for early psychosis. British Medical Journal 2004 (329): 1067-1070 7 Craig, T. et al. The Lambeth Early Onset (LEO) team: randomised controlled trial of the effectiveness of specialised care for early psychosis. British Medical Journal 2004 (329): 1067-1070 8 Power, P., (2004) Suicide Prevention in First Episode Psychosis: In Psychological Interventions in Early Psychosis. Editors: P. McGorry and John Gleeson. Wiley Press. 9 National Institute of Health and Clinical Excellence. Core interventions in the treatment and management of schizophrenia in primary and secondary care (update). Clinical Guidance 82, http://www.nice.org.uk. 2009. 10 National Institute of Health and Clinical Excellence. Core interventions in the treatment and management of schizophrenia in primary and secondary care (update). Clinical Guidance 82, http://www.nice.org.uk. 2009. 11 Department of Health (2000) The NHS Plan: A plan for investment, a plan for reform. London: Department of Health. 12 Department of Health (2001) The Mental Health Policy Implementation Guide. London: Department of Health. 13 Sainsbury Centre for Mental Health (2003) Briefing 23: A summary of A Window of Opportunity - A practical guide for developing early intervention in psychosis services. London: The Sainsbury Centre for Mental Health. 14 National Institute for Mental Health in England (NIMHE) (2003). Early intervention for people with psychosis: Expert Briefing. London: Stationery Office. 15 Gafoor, R. et al. Effect of early intervention on 5-year outcome in nonaffective psychosis. British Journal of Psychiatry 2010 (196): 372-376 7

The content of this product is available in Large Print (16 point). Please call 0300 5000 927. RET0104 Rethink Mental Illness 2011 Last updated January 2011 Next update January 2013 Last updated 01/10/2010 8