Early Intervention: a Rationale
Why is early intervention so important?
The loss of contact with reality characteristic of psychosis can be a very frightening and traumatic experience. A person’s first episode of psychosis can be particularly distressing and confusing for the individual, their family and peers, since the experience is so unfamiliar and difficult to understand. Given that this first episode commonly occurs in adolescence or early adult life, an important time for the development of identity, independence, relationships and long-term vocational plans, the onset of psychosis can therefore cause considerable disruption and numerous secondary problems can develop.
A psychotic episode commonly isolates the person from others and disturbs peer relationships. The person’s personal and social development will be put on hold, or may even slip backwards. Impairment of school and work performance is common with the potential for profound damage to future vocational prospects and consequent financial insecurity.
The impact on the family can cause strained or severed relationships and increased psychological morbidity amongst family members. In addition substance abuse may begin or intensify and the risk of suicide is increased. The longer the illness is left untreated the greater the risk of permanent derailment of the person’s psychosocial development.
There is also evidence to suggest that delayed treatment may cause the illness to become more biologically entrenched and less responsive to treatment. It appears that in some way psychosis may be biologically toxic. Indeed, longer periods of untreated psychosis have been related to slower recovery rates and reduced chances of full recovery, greater relapse rates and lower levels of social and occupational functioning. These effects appear to be independent of other prognostic factors. By contrast, early diagnosis and treatment leads to improved recovery and outcome.
Many individuals unfortunately experience prolonged periods of untreated psychosis during their first-episode. Numerous studies have demonstrated major delays between the onset of psychotic symptoms and the initiation of appropriate treatment. These delays, although variable, are often in the order of many months to a year or more.
Achieving Early Intervention
Clearly, this problem needs to be addressed. But how do we achieve early intervention? In practice, a number of strategies are required.
One important strategy is community education aimed at increasing the public’s awareness of these disorders and improving their knowledge of early signs.
In addition to increasing knowledge, we also need to lessen the fear and stigma associated with mental illness, which can cause some people to delay seeking help. In conjunction with this, we also have to promote awareness of these disorders amongst service providers working with young people, in particular general practitioners (GPs), teachers, and other professionals working with young people.
Although the presentation of first-episode psychosis is a relatively low frequency event in general practice, GPs have a crucial role to play. GPs are the first point of contact for the majority of people seeking assistance for their health concerns, whether they are physical or psychological. GPs are therefore quite likely to be the first person in a position to identify what is going wrong.
Theoretical concepts and principles of early psychosis
The underlying principles of intervention in early psychosis are threefold:
- Opportunities for clinical care should be made available in the shortest timeframe possible
- Assessment and prevention of secondary morbidity decreases the risk of mortality and morbidity in early psychosis
- Ongoing research is required to substantially test the efficacy of current treatments and to develop secondary prevention opportunities
Preventative intervention can occur in the three key phases of early psychosis:
- The "at-risk" phase, when symptoms are subtle and can be confused with adolescent development issues
- The period of frank symptoms of psychosis that remains untreated, which may compound the issues of risk and the development of prolonged disability
- The critical period after the onset of the first psychotic episode, which can be up to five years in duration, when treatment needs to be comprehensive and phase-specific
The International Early Psychosis Association Clinical Practice Guidelines were presented at the 3rd International Conference on Early Psychosis, Copenhagen, in 2002. Click here to view the full length guidelines.
The Second Edition of the Australian Clinical Guidelines for Early Psychosis were published in November 2010 and are available via the Orygen Youth Health website