Future of Early intervention in Mental Health

Professors Alison Yung and Eóin Killackey share a summary of the key priorities for the early intervention field in the coming years.

Psychotic disorders such as schizophrenia affect about 1% of the population and can cause considerable disability and distress for the person and their family. Onset typically begins during a key period of human development, in early adolescence and young adulthood. Often disability in areas of social and occupational functioning persists, even when the symptoms are well managed. This means that an affected person may live with the condition for many years. It is therefore not surprising that schizophrenia is associated with a high burden of illness. Indeed, schizophrenia is the 5th leading worldwide cause of global disease burden among males and 6th among females(1).

Over 30 years ago early intervention for psychotic disorders began with the rationale of providing help before disability became established.  Use of a holistic range of interventions aimed to not only address symptoms of illness, but also the psychosocial consequences of illness. There are three main foci of such early intervention.

1. 1. Early identification to minimise the duration of untreated psychosis: A long duration of untreated psychosis (DUP) is associated with worse functional outcomes in both the short and long term (2). Strategies to reduce the DUP are effective (3) and can improve symptomatic and functional recovery in most people(4).
   2. Optimal care during the first episode of psychosis and the early years of illness: Optimal care consists of a multidisciplinary personalised approach that for most people includes use of antipsychotic medication at the lowest effective dose with timely change of medication in the case of non-response (5),(6); family interventions to support the family and assist family members to care for their relative; psychological intervention to manage symptoms and recognise early warning signs of relapse; and vocational and other psychosocial interventions to promote social and occupational recovery (7).  Comprehensive services that include such a recovery focus have been found to have superior outcomes compared to treatment as usual outcomes (8) and are cost-effective(9).
   3. Identification and further research of people at high risk for psychosis: It is also now possible to identify individuals at high risk of developing a psychotic disorder through the use of standardised “Ultra High Risk” (UHR) criteria(10). This opens up the possibility that psychosis could be prevented or at least delayed or its impact minimised in such individuals. While rates of psychosis onset in UHR individuals are several hundred fold above that of the general population, the majority of UHR individuals do not develop a psychotic disorder with a meta-analysis showing that the proportion is about 36% after 3 years(11). Research to better predict those most at risk would enable more targeted treatment strategies. UHR individuals are also at risk of a range of other poor outcomes(12-14) and research to improve prediction and interventions targeted these other outcomes is also needed.

In the early 2000s the lessons learned from early intervention in psychosis started to be applied more broadly to other areas of mental health including mood, personality and anxiety disorders. This led to the development of a number of services around the world such as Foundry, Access Open Minds, Jigsaw, headspace, @ease and Allcove. These services have in common an idea of intervening early and holistically to limit the progress of illness and promote symptomatic and functional recovery.

However, there is still much to be done in early intervention, both in psychosis and mental health more generally.

For example, while there is variation across different mental illnesses, the overall physical health of people with mental illness is worse than the general population. There can be high rates of cardiovascular disease, respiratory diseases and Type 2 diabetes (15-18). Despite this, compared to the general population, people with mental illness, particularly those with more severe mental illness are less likely to receive timely and appropriate treatment for their physical health needs. Poor physical health also decreases well-being, reduces adherence with medication and hinders recovery. Lifestyle interventions that increase physical activity, improve diet and decrease rates of smoking are effective in people with severe mental illness (19, 20). Research is needed into how to implement the effective components of lifestyle interventions across sectors and at scale.

Finally, while services that provide early intervention and optimal care for individuals with mental illness are now found in many countries, they are not yet widespread. Development and access to holistic early intervention services in low and middle incomes is a key priority. Establishment of such services will need to take into account local conditions, culture and traditions and resources. Research into the effective components of early intervention in mental health services and different ways of providing them is needed so these components can be prioritised in environments where there are several resource constraints.

Alison Yung is Professor of Psychiatry and NHMRC Principal Research Fellow at the Institute for Mental and Physical Health and Clinical Translation (IMPACT), Deakin University and the Centre for Young People’s Mental Health and Orygen, The University of Melbourne. She is President-elect of the International Early Psychosis Association. Alison has been researching the early stages of psychotic disorder since 1994. She created the UHR criteria and established a specialized research-clinical service, the PACE Clinic, that manages young people meeting these criteria. The instrument she created to assess risk for psychosis, the Comprehensive Assessment of At Risk Mental States (CAARMS) has been translated into 18 languages and is used throughout the world, both for clinical and research purposes. She is also interested in exercise as an intervention for mental illnesses and in improving the physical health of people with mental disorders.

Alison received the Lilly Oration Award for prominence in psychiatric research in 2009, and the Richard J Wyatt Award in 2010, for exceptional contributions to the area of early intervention in psychosis. In 2019 she was awarded the Society for Mental Health Founders Medal, in recognition of a significant contribution to psychiatric research and in 2020 received the Outstanding Translational Research Award from the Schizophrenia International Research Society. In 2014 and 2016 and she was named as one of the “world’s most influential scientific minds” by Thomson Reuters. She has over 400 publications and from 2016 to 2021 she was named as a “Highly Cited Researcher” by Clarivate Analytics.

Professor Eóin Killackey is Director of Research at Orygen and Head, Functional Recovery Research in Youth Mental Health at Orygen and the Centre for Youth Mental Health at The University of Melbourne. He completed his doctorate at Deakin University in 2000. Eóin has worked as a clinical psychologist in adolescent and adult public mental health settings and in private practice. His research is primarily in functional recovery for young people with mental illness. He is also interested in evidence-based interventions in mental health and barriers to their implementation. He is a founder of the International First Episode Vocational Recovery group. Eóin’s work has been recognised by the Australasian Society for Psychiatric Research’s Schering-Plough Organon Prize, Australian Rotary Health’s Knowledge Dissemination Award and the Society for Mental Health Research Oration Award. He has been named by Deakin University as an Alumnus of the Year.

References 

1.         Millier A, Schmidt U, Angermeyer MC, Chauhan D, Murthy V, Toumi M, et al. (2014): Humanistic burden in schizophrenia: A literature review. Journal of Psychiatric Research. 54:85–93.
2.         Crumlish N, Whitty P, Clarke M, Browne S, Kamali M, Gervin M, et al. (2009): Beyond the critical period: longitudinal study of 8-year outcome in first-episode non-affective psychosis. The British Journal of Psychiatry. 194:18-24.
3.         Hegelstad WV, Larsen TK, Auestad B, Evensen J, Haahr U, Joa I, et al. (2012): Long-Term Follow-Up of the TIPS Early Detection in Psychosis Study: Effects on 10-Year Outcome American Journal of Psychiatry. 169:374-380.
4.         Santesteban-Echarri O, et al (2017): Predictors of functional recovery in first-episode psychosis: A systematic review and meta-analysis of longitudinal studies. Clinical Psychology Review. 58:59-75.
5.         Barnes T, Drake R, Paton C, Cooper S, Deakin B, ., Ferrier N, et al. (2019): Evidence-based guidelines for the pharmacological treatment of schizophrenia: Updated recommendations from the British Association for Psychopharmacology. Journal of Psychopharmacology.1–76.  DOI: 10.1177/0269881119889296 journals.sagepub.com/home/jop.
6.         Kinon BJ, Chen L, Ascher-Svanum H, Stauffer V, Kollack-Walker S, Sniadecki L, et al. (2008): Predicting response to atypical antipsychotics based on early response in the treatment of schizophrenia. Schizophrenia Research. 102:230-240.
7.         Killackey E, Jackson HJ, McGorry PD (2008): Vocational Intervention in First-Episode Psychosis: A Randomised Controlled Trial of Individual Placement and Support versus Treatment as Usual. . British Journal of Psychiatry. 193:114-120.
8.         Correll CU, Galling B, Pawar A, Krivko A, Bonetto C, Ruggeri M, et al. (2018): Comparison of Early Intervention Services vs Treatment as Usual for Early-Phase Psychosis A Systematic Review, Meta-analysis, and Meta-regression JAMA Psychiatry. 75:555-565.
9.         Aceituno D, Vera N, Prina M, McCrone P (2019): Cost-effectiveness of early intervention in psychosis: systematic review. British Journal of Psychiatry. 215:388-394.
10.       Yung AR, Phillips LJ, Yuen HP, McGorry PD (2004): Risk factors for psychosis in an ultra high-risk group: Psychopathology and clinical features. Schizophrenia Research. 67:131-142.
11.       Fusar-Poli P, Bonoldi I, Yung AR, Borgwardt S, Kempton MJ, Valmaggia L, et al. (2012): Predicting psychosis: Meta-analysis of transition outcomes in individuals at high clinical risk. Archives of General Psychiatry. 69:220-229.
12.       Lin A, Yung AR, Nelson B, Brewer W, Bruxner A, Wood SJ (2013): Neurocognitive predictors of transition to psychosis: Medium-to long-term findings from a sample at ultra-high risk for psychosis. Psychological Medicine. 43:2349-2360.
13.       Lin A, Wood SJ, Nelson B, Beavan A, McGorry P, Yung AR (2015): Outcomes of non-transitioned cases in a sample at ultra-high risk for psychosis. American Journal of Psychiatry. 172:249-258.
14.       Yung  AR, Nelson B, Thompson A, Wood SJ (2010): The psychosis threshold in Ultra High Risk (“prodromal”) research: is it valid? Schizophr Res. 120:1-6.
15.       Correll CU, Solmi M, Veronese N, Bortolato B, Rosson S, Santonastaso P, et al. (2017): Prevalence, incidence and mortality from cardiovascular disease in patients with pooled and specific severe mental illness: a large-scale meta-analysis of 3,211,768 patients and 113,383,368 controls. World Psychiatry. 16:163-180.
16.       De Hert M, Correll C, Bobes J, Cetkovich‐Bakmas M, Cohen D, Asai I, et al. (2011): J, et al. Physical illness in patients with severe mental disorders. I. Prevalence, impact of medications and disparities in health care. World Psychiatry. 10:52-77.
17.       Stubbs B, Vancampfort D, De Hert M, Mitchell AJ (2015): The prevalence and predictors of type two diabetes mellitus in people with schizophrenia: a systematic review and comparative meta-analysis. Acta Psychiatrica Scandinavica. 132: 144–157.
18.       Schoepf D, Uppal H, Potluri R, Heun R (2014): Physical comorbidity and its relevance on mortality in schizophrenia: a naturalistic 12-year follow-up in general hospital admissions. European Archives of Psychiatry and Clinical Neuroscience. 264: 3–28.
19.       Schuch FB, Vancampfort D, Rosenbaum S, Richards J, Ward PB, Stubbs B (2016): Exercise improves physical and psychological quality of life in people with depression: A meta-analysis including the evaluation of control group response. Psychiatry Res. 241:47-54.
20.       Sánchez PH, Ruano C, De Irala J, Ruiz-Canela M, Martínez-González M, Sánchez-Villegas A (2012): Adherence to the Mediterranean diet and quality of life in the SUN Project. Eur J Clin Nutr. 66:360.

Declaration of Interests: None

Acknowledgements:

This project was made possible thanks to a sponsorship from H/Lundbeck A/S. The opinions expressed in these materials do not necessarily reflect those of H.Lundbeck.