September 26, 2020
By Paul French
Early intervention in psychosis (EIP) services aim to identify and offer treatment at the earliest opportunity, thereby minimising treatment delay. This approach which has been adopted throughout the world has brought not only improved clinical outcomes but also renewed optimism for the potential of recovery for people with psychosis. Early psychosis services aim to detect changes at the earliest point, minimising the impact of emerging symptoms but also ensuring that their functioning is sustained and maximised in order to keep a person as close to their developmental trajectory as possible. Having a focus on harmful impacts of any illness on work, social or family is vital to this approach and for some, preventing the need for longer term care. However, despite the best efforts of these early approaches some people will require ongoing support.
- For people experiencing their first episode of psychosis, one in five will have no further psychotic episodes within the next five years. (1)
- Persisting psychotic symptoms unresponsive to treatment at two years, have been reported in 16%. (2)
- Rates of relapse under specialized early intervention services were 17% (95% CI: 13%‐21%) at 9 months, 38% (95% CI: 14%‐66%) at 24 months and 54% (95% CI: 36%‐70%) at more than 10 years. (3)
Deciding who will benefit from a more prolonged period of care and treatment through a specialist rehabilitation service has had little discussion and even less research interest. Rehabilitation will benefit those people who struggle to attain their previous levels of functioning either because the symptoms they experience have such a profound impact on them or because they just require more intensive support provided over a longer period of time.
The National Institute for Clinical Excellence in England (NICE) has recently published guidance on rehabilitation for adults with complex psychosis. It focuses the mind on the fact that regardless of the approach by EIP, a number of people attain only a limited recovery from psychotic related symptoms and functional impairments. As ever NICE is clear on who the guidance relates to, what are the important challenges they face and what intervention strategies have sufficient clinical and cost-effectiveness evidence to develop treatment recommendations. Furthermore, it also contains a large and long-awaited emphasis on the importance of physical health care central to the approach now widely adopted in EIP services.
At first glance, this guidance may appear to have little to do with early intervention approaches. But this is not so. The guidance presents not only a challenge but an opportunity for early psychosis services to support this vulnerable population. Indeed its opening recommendation states that rehabilitation should be offered to “people with complex psychosis .. as soon as it is identified that they have treatment resistant symptoms of psychosis and impairments affecting their social and everyday functioning”(NICE NG 181 Recommendation1.1.1). Furthermore, NICE also makes a research recommendation asking, “what is the efficacy and cost effectiveness of rehabilitation services compared with treatment as usual for people with complex psychosis with residual disability, who are leaving early intervention services?”
This raises a number of questions for the EIP community (i) How often do we think about rehabilitation services for people who are leaving EIP care? (ii) For those people who still require ongoing care due to their complex psychosis, should we instead extend the time they are able to access EIP? (iii) Should we stick with a three year intervention window for EIP and ensure transfer of care to rehabilitation as opposed to a frequent practice of referral to a community mental health team if ongoing care is required? (iv) Should we consider earlier referral to rehabilitation than perhaps current practice in EIP?
(i) The vast majority of people leaving EIP care tend to be transferred to Primary Care services, and those transferred to Secondary Care tend to have higher rates of relapse (Puntis et al., 2018). We also know from the same study that up to one third of people initially transferred to Primary Care are referred back to secondary care services within 2 years. This clearly indicates that we need to better understand who may require more long term care alongside considering the possibility of rehabilitation.
(ii) EIP pathways are typically 3 years enabling people to access a range of interventions that will help reduce symptoms and protect against future relapse. Some services offer a diluted pathway with shorter duration, often dictated by service constraints and limited capacity whilst, in rare cases, a more long term approach may be adopted. There is limited evidence for longer pathways in EIP which have found conflicting results with one study extending EIP only from 2 to3 years and not beyond. Additionally, these trials have focussed on offering everyone on the EIP caseload an extended period of intervention as opposed to focussing on those who are most likely to benefit, so perhaps testing out a 5 year intervention for those people with “treatment resistant symptoms and impairment” as supported by this latest guidance from NICE.
(iii) Perhaps the other way of thinking about this, is that we need to expand the offer of rehabilitation to enable more people access to specialist teams who could continue to focus on the work established by EIP but renew their efforts with some additional skills and resources which are dedicated towards rehabilitation.
(iv) It may be that the current practice of working with people for 2-3 years in EIP services does some people a misjustice and we need to consider diverting some people out of EIP sooner in order to make use of the specialist rehabilitation offer. Again, this requires accurate identification.
Whatever the solution, the new NICE guidelines help to remind us that a 2 -3 year window of interventions is not a panacea for everyone and some people may well benefit from an extended period of time in EIP to consolidate what has been achieved. In addition, these guidelines provide an ideal opportunity to open up a dialogue with your local rehabilitation service and collaborate to improve the care pathway of this vulnerable population. We need to devise strategies to identify those people likely to benefit from more long term rehabilitative care and support them to gain earlier access to a range of treatments that may be outside of the scope of EIP and work on how we identify who those people are who might most benefit from further intensive focused input from a specialist rehabilitation service. In addition, whilst these guidelines have been written specifically for people with complex psychosis, it reminds us that many mental health conditions would benefit from early intervention strategy but also the ability to be provided with more sustained care for those people who require it.
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1. Carbon M, Correll CU. Clinical predictors of therapeutic response to antipsychotics in schizophrenia. Dialogues Clin Neurosci 2014; 357: 505-24]
2. Simonsen E, Friis S, Opjordsmoen S, et al. Early identification of non-remission in first-episode psychosis in a two-year outcome study. Acta Psychiatr Scand 2010; 357: 375-83.
3. Fusar-Poli P, McGorry PD, Kane JM. Improving outcomes of first-episode psychosis: an overview. World Psychiatry. 2017;16(3):251-265. doi:1