Visualise Croke Park and Thomond Park full to capacity on match day. That is almost 120,000 people. More than 120,000 people are affected by schizophrenia and other psychoses in Ireland today. Now visualise others at home watching those matches on television. These people, not at the match but watching it and affected by it, are the families and carers of those with psychosis.  

Psychosis

Psychosis is characterised by lack of contact with reality, leading to changes in perception and a difficulty in organising thoughts and behaviour. This can lead to high levels of anxiety and distress. Schizophrenia is the most common of the psychoses, but mood disorders and substance misuse can also present with psychosis.

Psychosis usually begins in late adolescence/early adulthood when an individual is becoming independent, going to school or college, or working in their first job. Psychosis affects the person at a vulnerable stage of their life, robbing the person of their potential, and placing what can become a lifelong burden on the person and their family. Psychosis also places a huge economic cost on the State through direct costs of the illness itself, and indirectly through loss of resources from unemployment.¹ There is little that can be done to prevent psychosis.  

The outcome of psychosis is variable, with one-third of those with schizophrenia making a complete recovery. Many of the factors predicting recovery are fixed or non-modifiable; however, the duration of untreated psychosis (DUP) is one recovery factor that can be modified. Studies in Ireland and worldwide have shown that there is typically a delay of one to two years prior to receipt of effective treatment, a period characterised by suicidal thoughts and acts.^2-4

Early intervention

Medicine has long been aware of the value of the ‘golden hour’ and the importance of intervening early in physical illnesses. Similarly, research worldwide has shown that intervening early in mental illness improves outcomes and reduces disability. Central to the premise of early intervention is the belief that intervening early, reducing the DUP, can improve the outcome of the condition. Early intervention is part of National Health Service policy in the UK.

Ireland’s first early-intervention service for psychosis, DETECT (Dublin and East Treatment and Early Care Team), was the vision of Prof Eadbhard O’Callaghan. He held a strong belief in the premise that intervening early reduces the damaging effects of psychosis on the maturing brain. The DELTA (Detection, Education and Local Team Assessment) project was Ireland’s first early-intervention service and was funded by the Hospitaller Order of St John of God. With additional funding from the HSE, DELTA was expanded into the DETECT service in 2006. 

A Vision for Change recognised the need to roll out early intervention nationwide.⁵ The time for piloting such a service is over, and evidence internationally and at home shows that early intervention works. The National Clinical Programme Plan under development since late 2011 listed early intervention as one of three pillars of mental health to be rolled out nationally.⁶ Working groups are in place to deal with the logistics of implementing early intervention in psychosis nationally across all services.

Models of early intervention

Models of early intervention include specialised stand-alone services; enhanced generic services; and a hub-and-spoke model with a central specialist acting as a hub and early-intervention practitioners working alongside community mental health teams.⁷

DETECT is an adjunctive service to three community mental health services rather than a stand-alone service, serving a population of 375,000 in the south-east of Dublin and Wicklow areas. Following the international early-intervention for psychosis guidelines, DETECT aims to reduce the DUP and provide treatment for the early phase of a psychotic illness. This model improves and accelerates recovery in comparison to standard care.^3,8-10

The three tiers of intervention

There are three tiers of intervention. The first is early recognition, and includes a public education campaign. In addition to a public awareness campaign, DETECT also offers education in the form of workshops to GPs, other health professionals and any person who may come into contact with someone vulnerable to psychosis. These educate on the signs and symptoms of psychosis and the ‘risk state’ that may precede psychosis. Research internationally has shown that education and early recognition have reduced the delay to seeking treatment and the DUP from one to two years to six months.^2,11   

The second tier of intervention is a fast-track assessment within 72 hours for anyone referred by their GP with suspected psychosis. All referrals are assessed using a Structured Clinical Interview for DSM diagnosis. In the first five years of its existence, DETECT received 795 referrals, of whom 347 met the criteria for a psychotic condition. The majority of these met criteria for schizophrenia.¹²

The third tier of intervention is phase-specific intervention. Research shows that comprehensive specialised services for people with psychosis during the first three-year ‘critical period’ is superior to standard care.¹³ All who meet the criteria for psychosis are offered group-based cognitive behavioural therapy (CBT) and occupational therapy, and their families are offered the Carer Education Programme. 

CBT is an effective treatment for psychosis.¹⁴ CBT for psychosis helps the individual make sense of their experiences and reduces the associated anxiety and distress to minimise the negative effect of their symptoms on social and cognitive functioning. CBT runs once a week for 12 weeks.  

Eighty per cent of those with schizophrenia are unemployed.¹⁵ Work and occupation are essential for health and wellbeing. Individual occupational therapy sessions assist the person with psychosis in setting and achieving personally meaningful goals within the areas of productivity, social skills, self-care and community living skills. The average number of occupational therapy sessions attended is 12. The key outcome is to facilitate a return to a productive role. Sixty per cent of those who took up occupational therapy sessions in DETECT progressed onto formal education/training or paid employment.¹²

Family support has been shown to improve the outcomes of those with psychosis.¹⁶ The family education course provides a better understanding of the condition and the treatments available and is based on a collaborative philosophy. The programme is run over six sessions once a week. The course helps families to understand what their loved one is going through, and also facilitates the family member’s need for early contact and information and support. Families have a choice of attending an evening or weekend programme to facilitate attendance.  

Service evaluation

Since DETECT commenced, delays to effective treatment have reduced from 19 months at inception to three months in 2007/2008, a time of intense educational campaigns, including a storyline on RTÉ’s Fair City programme. The delay has since increased to nine months, highlighting the importance of the first tier of intervention, the necessity of an adequately funded sustained public education campaign.

Improved outcomes are also evident in a reduction in negative symptoms, reduction in inpatient hospitalisation and improved social and vocational outcomes. In addition, GPs and mental health professionals in the catchment areas surveyed about DETECT are satisfied with the service.¹⁷

The future

One of the most important findings, both internationally and by DETECT, is that once the intensity of the educational campaign is reduced, the DUP begins to creep up. Therefore, it is important that public education campaigns are adequately funded. In any national implementation of early intervention, tier one of early intervention (public education and reducing delays to effective treatment) should happen in conjunction with assessment and treatment.

A crucial question to answer, especially in the current economic climate, is whether early intervention is a wise use of scarce resources. International findings from Australia and the UK have shown that early intervention costs less than treatment, primarily due to a reduction in inpatient hospital costs. In addition, these reductions in cost have persisted in the long term.^18,19

DETECT is currently conducting a cost-effectiveness study with funding from the Health Research Board. In addition, an eight-year follow-up study has commenced, funded by a research grant from the Hospitaller Order of St John of God. 

With early intervention due to be implemented nationally as part of the National Clinical Programme Plan, outcome results and service evaluation by DETECT will be useful in planning services to help those with psychosis in the most effective and resource-wise manner. 

Declaration of interest: none.

References

1. Behan C, Kennelly B, O’Callaghan E. The economic cost of schizophrenia in Ireland: A cost-of-illness study. Ir J Psych Med 2008; 25 (3): 80-87
2. Melle I, Larsen Tk, Haahr U et al. Reducing the duration of untreated first-episode psychosis: effects on clinical presentation. Arch Gen Psychiatry 2004; 61(2): 143-50
3. Harris MG, Henry LP, Harrigan SM et al. The relationship between duration of untreated psychosis and outcome: an eight-year prospective study. Schizophr Res 2005; 79(1): 85-93
4. Clarke M, Whitty P, Browne S et al. Suicidality in first episode psychosis. Schiz Res 2006; 86(1-3): 221-225
5. Department of Health. A Vision for Change, Report of the Expert Group on Mental Health Policy. Government Publications, 2006 (http://www.dohc.ie/publications/vision_for_change.html)
6. Update on Vision for Change and Mental Health Service Developments
7. (www.dohc.ie/publications/vision_for_change_5th/hse_local/hse_office_assistant_nat_dir_mental_health)
8. Singh SP, Fisher HL. Early intervention in psychosis: obstacles and opportunities. Advances in Psychiatric Treatment 2005; 11: 71-78 (doi:10.1192/apt.11.1.71)
9. Garety Pa, Craig Tk, Dunn G et al. Specialised care for early psychosis: symptoms, social functioning and patient satisfaction: randomised controlled trial. Br J Psychiatry 2006; 188: 37-45
10. Bertelsen M, Jeppesen P, Petersen L et al. Five-year follow-up of a randomized multicenter trial of intensive early intervention vs standard treatment for patients with a first episode of psychotic illness: the OPUS trial. Arch Gen Psychiatry 2008; 65(7): 762-71
11. Melle I, Larsen Tk, Haahr U et al. Prevention of negative symptom psychopathologies in first-episode schizophrenia: two-year effects of reducing the duration of untreated psychosis. Arch Gen Psychiatry 2008; 65(6): 634-40
12. Marshall M, Lewis S, Lockwood A et al. Association between duration of untreated psychosis and outcome in cohorts of first-episode patients: a systematic review. Arch Gen Psychiatry 2005; 62(9): 975-83
13. Report on the DETECT Service: 5 year progress, Plans for the Future (http://www.detect.ie/documents/5YEARDETECTREPORT2011.pdf)
14. Petersen L, Nordentoft M, Jeppesen P et al. Improving 1-year outcome in first-episode psychosis: OPUS trial. Br J Psychiatry Suppl 2005; 48: s98-103
15. Alvarez-Jimenez M, Parker AG, Hetrick SE et al. Preventing the second episode: a systematic review and meta-analysis of psychosocial and pharmacological trials in first-episode psychosis. Schizophr Bull 2011; 37(3): 619-30
16. Crowther RE, Marshall M, Bond GR, Huxley P. Helping people with severe mental illness to obtain work: systematic review. British Medical Journal 2001; 27(322(7280)): 204-8
17. Pitschel-Walz G, Leucht S, Bauml J et al. The effect of family interventions on relapse and rehospitalisation in schizophrenia – a meta-analysis. Schizophr Bull 2001; 27(1): 73-92
18. Renwick L, Gavin B, McGlade N et al. Early intervention service for psychosis: Views from primary care. Early Intervention in Psychiatry 2008; 2(4): 285-90
19. Mihalopoulos C, Harris M, Henry L et al. Is early intervention for psychosis cost-effective over the long term? Schizophr Bull 2009; 35(5): 909-18
20. McCrone P, Craig TK, Power P, Garety PA. Cost-effectiveness of an early intervention service for people with psychosis. Br J Psychiatry 2010; 196(5): 377-82