Early psychosis – to intervene or not to intervene?

This article looks at early intervention in psychosis and implementation of early intervention from a health services perspective. It further discusses health economic evaluation as a method for evaluating health services and as a tool for assisting translation of evidence-based medicine into practice. 

For the purposes of this article, early intervention in psychosis refers to intervening as early as possible in a person’s first episode of psychosis, rather than to intervening in the prodrome. The concept of early intervention, first developed in Australia in the 1990s as a potential solution to chronic nihilism in the treatment of schizophrenia, has caught the imaginations of mental health professionals worldwide and generated no small amount of controversy.^1,2,3,4

The rationale behind early intervention is that psychosis most commonly occurs at a time critical to the development of a person to their full potential.⁵ Psychosocial factors operating during this ‘critical period’ result in the deterioration seen in psychotic illness. These include “loss of the educational and vocational trajectory, family stress or breakdown, loss of friendships, stigma, disruption of personality development, depression, substance misuse/abuse, homelessness, post-traumatic stress”.⁶

Early intervention is concerned with recovery – improving social, vocational and occupational outcomes, in addition to improving symptoms and reducing suicidality. Intervening early during this period to reduce the duration of untreated psychosis is hypothesised to minimise the impact of psychosis on the person’s potential and minimises the toxic effect of psychosis on the brain.⁷ The Initiative to Reduce the Impact of Schizophrenia (IRIS) guidelines in the UK state that goals of early intervention should be to reduce relapse requiring readmission to under 25%, improve the numbers not in education, employment or further training (NEET) to no more than their peers within the same locale with appropriate interventions, and improve service engagement to over 90%.⁸

Early intervention

Early intervention consists of a three-pronged approach within a multidisciplinary context:

• Reducing the duration of untreated psychosis
• Rapid assessment to establish the presence of psychosis
• Phase-specific interventions. 

Care should be delivered in the least restrictive and most appropriate environment. Methods to reduce the duration of untreated psychosis include education of any group that may come into contact with the target population, such as health professionals, primary care, college advisors, Gardaí and youth workers. This is so that people with potential psychosis may be directed along an appropriate pathway as early as possible. Sustained efforts to reduce the duration of untreated psychosis are required. The TIPS group in Norway found that its duration of untreated psychosis rose again once educational and advertising campaigns stopped.⁹ Rapid clinical assessment to establish the presence of psychosis ensures that people in their first episode of psychosis can receive appropriate treatment as early as possible, and that people not in their first episode can be directed toward appropriate care. Phase-specific interventions for first episode of psychosis include: family therapy, cognitive behavioural therapy (CBT) for psychosis and vocational rehabilitation, in particular individual placement and support (IPS).  

Increasingly now physical health interventions are included. The updated NICE guidance recommends that primary care monitor the physical health of those with psychosis.¹⁰ The HeAL statement published by the iPhys group recognises the right for young people with psychosis to have the same length and quality of lives as their peers, rather than the increased morbidity and mortality associated with severe and enduring mental illness.¹¹

Outcomes

Long duration of untreated psychosis is associated with poor outcome.^12,13 Reducing the duration of untreated psychosis is a key goal of early intervention services. It is possibly the only modifiable outcome, and reducing the untreated duration results in improved outcomes in the longer-term.^6,14,15,16 Specialised early intervention services are shown to improve outcomes in comparison to generic services in the short to medium term at 12 months, 18 months and two years.^17,18 Evidence from longer follow-up studies show gains do not persist after the first three to five years. Two randomised controlled trials (RCTs) examining outcome at five years showed some gains were lost after discharge from specialist services.^17,19 The LEO service in the UK showed no difference in outcome at five years.²⁰ The OPUS trial found that while improvements in functioning (GAF scores) found at two years did not persist at five years, there were higher rates of independent living and lower hospital days in the early intervention cohort.¹⁹ At 10 years early intervention participants in the OPUS trial had less negative symptoms and bed days; however the only statistically significant outcomes were lower use of supported housing in the early intervention cohort.²¹ Evidence to date appears to show that some sustained specialist treatment, even at low intensity, needs to happen to continue to show improved outcomes in the longer term.²²

Future directions for research

Research is now focusing on the optimal duration and modes of delivery of early intervention. The majority of research comes from specialist stand-alone centres delivering early intervention for a defined period of time to a defined cohort of people with their first episode of psychosis. These are, for the most part, academic centres that produce research, and there is a need for outcome research from real world settings. 

There are also questions as to the optimal method for delivering early intervention. In real world settings, there can be difficulties implementing specialist stand-alone centre delivery. This method is less suitable for a rural or remote area. These questions are relevant for Ireland, as early intervention in psychosis has been identified as one of three national clinical programmes to be implemented in mental health.²³

There are three main models of delivering early intervention, and most early intervention teams work on a variant of one of three models:

• Specialist stand-alone teams
• The ‘hub and spoke’ model
• Integrated early intervention.²⁴

Specialist teams are recommended by the proponents of early intervention and in international guidelines. ‘Hub and spoke’ models arise where specialist stand-alone early intervention is not suitable for example rural and remote regions or regions where incidence figures are lower. Early intervention ‘spokes’ are embedded within the community or the community mental health team (CMHT) and receive support, guidance and supervision from a central early intervention ‘hub’. Fowler et al showed the ‘hub and spoke’ model to have improved outcomes in comparison to historical controls receiving care as usual from the same service in Norfolk. However, outcomes were improved further when full specialist early intervention was implemented.²⁵ Integrated early intervention involves dedicated time for early intervention from CMHTs. There is no evidence from the literature to show that this method delivers the outcomes seen in specialist early intervention centres.

The economic case

Economic evaluation provides a systematic framework for evaluating an intervention. The ratio of the difference in costs and the differences in outcomes provides one figure, the incremental cost-effectiveness ratio (ICER), to summarise those differences. As mental health problems affect people in more than one way, it is appropriate to evaluate the impact of all these effects. Direct effects of mental health problems lead to service responses from healthcare providers. Indirect effects include a reduced ability to work, study, engage in recreation or self-care. The economic evaluation can be from the health service perspective if it includes only direct costs, or from the wider societal perspective if it includes indirect costs such as lost productivity, morbidity or mortality. 

Health services and resource use are documented in a systematic way. Unit costs are applied to the units of health services. Internationally unit cost information is published in manuals, such as that published annually by the Personal Social Services Research Institute (PRSSU) in the UK. However, where published information is not available, local costs or costs from other published studies are applied. Outcome measurement is determined by both the perspective of the study and by the commissioner of the study. Where the outcomes are in natural units, usually a single condition-specific outcome, the economic evaluation is termed a cost-effectiveness study. Natural units include patient-reported outcome measures, such as satisfaction, quality of life or symptoms, and objective measures such as blood pressure or waist circumference etc. Cost-utility analysis is a form of cost-effectiveness study, where outcomes are measured in units that incorporate length and quality of life into one measure, eg. quality adjusted life years (QALY) or disability adjusted life years (DALYs). QALYs are preference based measures, as each score has an assigned weight. Where outcomes are translated into monetary terms the evaluation is termed a cost-benefit analysis. This type of evaluation is not commonly done in health settings as it is difficult to value mental health outcomes in monetary terms. An intervention is cost-effective if it costs less and is more effective. Occasionally interventions are more expensive but have better outcomes. In this case, there is a threshold of willingness to pay for an intervention. The ICER indicates the probability of the intervention being more cost-effective than an alternative. If the ICER, or cost per outcome, is below the willingness-to-pay of the budget holder, it is more likely to be acceptable. 

Economic evaluation in early intervention in psychosis

Psychosis results in higher rates of unemployment, higher levels of disability payments and increased dependence on caregivers. There are lower rates of educational attainment and reduced productivity.^26,27,28 There is an argument for including the societal perspective when making a case for the economic impact of early intervention services. Unit cost evaluation should be comprehensive and include not only the cost of the early intervention teams, but the costs of all agencies involved with the person, including social, educational, general and mental health services, and the cost of informal caregiving. By measuring all these direct and indirect costs it is feasible to see where the extra costs of early intervention teams are offset by reduced costs elsewhere in the system. 

Evaluations of early intervention show reduced direct costs in the short and medium term, primarily by reducing inpatient days. The first evaluation of early intervention was a historical case control, comparing direct costs of matched pre and post EPPIC patients in Melbourne. The cost savings held when the cohort was re-examined at 7.5 years.^29,30 Other pre-post evaluations in Canada³¹ showed reductions in lengths of stay, emergency room visits and involuntary admissions with a non-significant difference in mean costs. Further evaluations were conducted alongside the LEO and OPUS randomised controlled trails. There was no significant difference in mean costs between early intervention and standard care, however the overall ICER showed a probability that early intervention was cost-effective.^32,33 By using economic modelling, researchers can expand cost-effectiveness evaluations to include data on the societal impact of early intervention. Decision analytic models have shown that early intervention is cost-saving when employment, education and other indirect costs such as homicide and suicide are taken into account.³⁴

Translating research to practice

Economic evaluation provides a method for simultaneously evaluating the costs and outcomes of providing a service in a language that is common to managers, policy makers and practitioners. The health services budget is finite. How do we decide who should get their service funded? Traditionally mental health, with the exception of emotive issues such as suicide, has not been good at making itself heard. Conducting an economic evaluation provides information for policy makers in concrete terms. It can give information on the budget impact of an intervention, and also facilitate identification of areas where cost savings can be made. For example, the Health Information and Quality Authority (HIQA) prospectively evaluated public access automatic external defibrillators (AEDs) by a health technology assessment. The introduction of increased AEDs was not cost-effective under any proposed scenario; however the evaluation identified areas where the intervention could become cost effective, for example by training and having a register of AED locations that could be accessed by phone.³⁵

Translating research into practice is important. Initiatives such as the Assessing Cost Effectiveness of Prevention program in Australia (http://www.sph.uq.edu.au/bodce-ace-prevention) facilitate this. Evaluations are commissioned and presented in a simple traffic light coded manner. This enables utilisation of such evaluations by both clinicians and policymakers. The goal of economic evaluation is quality improvement. Initiatives like these assist in identifying practices that do not work or are inefficient. These can be decommissioned in order to make way for or fund effective interventions. Economic evaluation provides a method for systematically evaluating interventions in this manner. 

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