Is early intervention for psychosis a waste of valuable resources?

Is early intervention for psychosis a waste of valuable resources?

INTRODUCTION

The concept of early intervention for psychosis has received much attention in recent years. The experience of pioneer services in the USA and Australia has convinced the UK Government to set aside millions of pounds to make dedicated early intervention teams an integral part of standard mental health services across the country. Other governments are set to follow suit. The rationale for early intervention is that there is a higher success rate if psychotic symptoms are treated early than if they are treated after they have been present for some time. It is also claimed that interventions early in the course of the illness can decrease the psychosocial impact of a psychotic illness that leads to secondary disability. But have these assertions been empirically demonstrated? Do such services simply take valuable resources, both in terms of funding and staff, from an already-overstretched mental health system, or do they change the trajectory of the disease process in a fundamental way? Dr. Max Birchwood, Director of the Birmingham Early Intervention Service, and Dr. Anthony Pelosi, consultant psychiatrist with a 'generic' community service in East Kilbride, Scotland, debate this issue.

FOR

A group of self-confessed evangelists has successfully encouraged the establishment of specialized teams for early treatment of psychotic disorders in several developed countries. Who could argue with their view that every troubled young person who may be developing a devastating chronic psychosis should be given immediate and specific treatment? Who could possibly be opposed to intensive input from highly staffed teams during the first few years of schizophrenia or manic depression? The answer to these questions is: everybody with a rudimentary knowledge of epidemiology and every experienced clinician.

Helene Verdoux and her colleagues have used the approach of the early intervention movement to illustrate the inconvenient fact that the positive predictive value of any test is dependent on the prevalence of the condition to which it applies. This means that for every individual who is appropriately treated during a prodromal phase of, for example, schizophrenia there are many more, with similar clinical features, who will never develop this uncommon illness. Vulnerable patients will unnecessarily receive powerful antipsychotic medication and equally powerful and potentially dangerous specific psychotherapy, making it inevitable that these identification and treatment programs for people at high risk of psychosis will do more harm than good. Warnings such as these have been dismissed as negative criticism by exponents of early intervention without any effective counterarguments.

Within the British health care system, uncertainties in the early management of severe mental disorders can be tackled by comprehensive locality-based psychiatric services that have good links with family doctors. All patients of all ages with non-specific features of mental illness should be given high-quality care appropriate to their current clinical and social needs. If a major psychosis declares itself, this will lead to prompt or, if the general practitioner considers it necessary, immediate re-assessment by the multi-disciplinary mental health team.

Amazingly, early intervention projects in the UK are excluding themselves from this difficult but vital part of community psychiatry. They only become involved when there is an obvious psychosis - so long as the patient is not middle-aged or old, and only for an arbitrary 'critical period' of a few years. These teams claim to have special skills and yet their papers and book chapters on intensive early intervention simply describe some basic aspects of good practice in the management of psychotic disorders. These publications read like extended essays by a candidate for the MRCPsych examination - and they would not even receive high marks since they gloss over the ethical and clinical quandaries that are faced when compulsory treatment has to be considered.

Early intervention practitioners not only claim special technical skills. They also have convinced themselves that ordinary mental health professionals are 'impatient and crude' in their use of medicine and 'neglect... psychotherapeutic and psychosocial aspects of treatment'. This, they maintain, arises partly from '... a lack of empathy with the predicament of the person experiencing the emerging illness'. It is undeniable that many patients in the early (and middle, and late) stages of a psychotic illness do not receive good care from routine services in the UK. Most failures of service delivery are due to inadequate numbers of appropriately trained clinicians. It is difficult not to feel angry when staff shortages are worsened by recruitment raids from early intervention projects. These teams should explain to the rest of us - and especially service users - how their greater empathy is compatible with giving up on patients and passing them back to hard-pressed local services after only three years of a chronic illness.

The enthusiasts of the early intervention movement are undoubtedly well-meaning in their desire to prevent chronic illness and minimize disability. However, their wishful thinking has misled health policymakers who are diverting resources to specialized teams, making it even more difficult to provide decent care to people with severe and enduring mental disorders. It takes more than leisurely work with highly selected patients for a few years to have any meaningful impact on the suffering caused by major mental illnesses. These least industrious of all evangelists should stop kidding themselves and bring their precious and much-needed skills back into the mainstream of mental health care.