Abstract
The past two decades have witnessed major progress in the understanding and treatment of psychotic disorders. Exponential growth in neuroscience research has demonstrated that neurobiological dysfunction does indeed lie at the heart of these syndromes. There is consensus for the first time about the appropriate therapeutic model. A new generation of drug therapies have created the potential for more effective symptom control with better tolerability. An evidence-based renaissance in psychological interventions holds out the prospect of further and more comprehensive reduction of symptoms and comorbidity, and better adjustment to the psychosocial upheaval that flows from these illnesses. Substantial service reform has placed these illnesses within the mainstream of healthcare, community life and public consciousness. Expectations for quality treatment have never been higher. Greater optimism has developed and has allowed early intervention strategies to be seriously considered for the first time. This all sounds wonderful – but what are the real-world effects of these advances?
Looking at this reveals a number of paradoxes. Even in affluent developed countries such as Australia, there seems to have been little improvement in the everyday lives of most who experience persistent psychotic disorders. It costs on average $18 000 per annum in direct costs to treat someone for schizophrenia, a figure which at first glance seems high [1]. However, despite this expenditure, the quality of life and level of recovery of many patients remains extremely poor [1, 2]. Furthermore, despite the much vaunted advantages of mainstreaming, one key area that should have improved, the general medical care and physical morbidity and mortality of the patients remains seriously problematic [3]. Life expectancy is substantially reduced and access to treatment for serious medical conditions is worse than for the general population. There is clearly a huge efficacyeffectiveness gap in the health care of people with psychotic disorders. Despite the fact that we have a more efficacious range of treatments than ever before (which work extremely well under optimal conditions) the lives of a substantial proportion of patients in the real world remain relatively unaffected and in some cases are much worse as a result of perverse outcomes of reform. This has led some to question whether schizophrenia in particular (though bipolar disorder and severe depression can be subjected to the same argument) is really treatable, and to suggest that the treatment is very poor value for money [4]. Echoing Kraepelin, such pundits assert that the course of schizophrenia is immune to our efforts to improve it [5].
In fact the naturalistic outcome of schizophrenia is actually much better than realized for around 50% of cases [6], though as a result of the large gap between efficacy and effectiveness, those who achieve this may do so in spite of rather than because of treatment. For the substantial remainder, who dominate the service system and contribute to the gloomy picture painted by the recent studies cited, things are unacceptably poor. The average figure of $18 000 per annum quoted may be quite inadequate to produce quality outcomes for this group of patients and may also be purchasing the wrong inputs at the wrong time. Expenditure is skewed toward reactive damage control (acute phase treatment). Aftercare, that is the treatment of the recovery phase, is severely rationed and provided by a residual and poorly trained and supported workforce. What if the true mean direct cost to achieve good outcomes in this severe subgroup of cases is actually closer to say $30 000 per annum? What if there is a window of opportunity for such investment in better outcomes that closes over as the illness and its sequelae becomes more entrenched? Modal as well as mean expenditure should also be highlighted, since most patients would receive much smaller packages of healthcare per annum. The system is clearly reactive and minimalist. A number of vital questions emerge. How much
One obvious strategy that might narrow the efficacyeffectiveness gap and which is universally supported in the treatment of other medical disorders, notably cancer, heart disease and diabetes, is early intervention. In psychotic illness, this has also become much better accepted at a conceptual level, even becoming politically correct, in recent years, though as we shall see, the rhetoric dramatically outstrips the level of implementation, especially in Australia.
The case for early intervention in psychotic disorder
This has been articulated extensively elsewhere and has widespread support [7–10]. It can be conveniently summarized as follows.
1. Promotion of recovery from the first psychotic episode
Currently there are highly effective, if still imperfect, treatments to reduce symptoms and promote recovery. The probability of symptomatic recovery is very high (80–90%) following a first-episode of psychosis (e.g. Robinson
2. Secondary morbidity and mortality: staying alive and well
The onset of psychotic illness is associated with a range of comorbidity, which, if successfully addressed, should reduce mortality and improve recovery in a broader sense. These comorbidities include substance use disorders, smoking, social anxiety, depression and suicide. Suicide risk is at its peak in the early course. This risk can be reduced with the combination of optimism, quality care and retention in the service in the early years after onset [14]. Earlier use of clozapine may also contribute to this effort [15, 16].
3. Collateral damage in the critical period
Psychotic illnesses usually have their onsets in late adolescence and young adulthood [17]. The social impact of the onset of psychosis is typically substantial. The peer network is crucial but fragile during this phase of life. Similar arguments apply to the evolution of self and social identity, transitions of family life, and vocational trajectories. There may be an enhanced risk of forensic problems that tend to peak in this age group anyway. Early intervention in all these areas may increase the chances of a more complete functional recovery in the wake of symptom resolution. Clinical resources and skill are required to tackle these psychosocial challenges. Merely treating the psychotic symptoms during the acute phase leaves most of the therapeutic work undone, yet this is what often happens in generic adult services. Such band-aid treatment of the acute phase with minimal specialist aftercare misses this key preventive opportunity.
4. Staging and neuroprotection
It is becoming more likely that the onset phase of illness during which clinical features and functional impairment emerge for the first time is associated with active yet subtle neurobiological changes in the patient [18]. Rather than the mysterious activation of a dormant neurodevelopmental vulnerability, it seems that complex neuronal dysfunction may develop as a new process around the period of onset [19]. Earlier crude models of neurotransmitter imbalance, derived in reverse from the mechanism of action of psychotropic medications, may ultimately give way to models based on intracellular disturbances and influences via gene expression upon neuronal integrity and connectivity. The therapeutic paradigm linked to such models is neuroprotection. If neuroprotective agents could be shown to reduce the risk of progression from early to more severe forms of disorder, then early intervention would receive even stronger support as a strategy. The concept of staging of disorder has not penetrated well into psychiatry. This proposes that earlier stages of illness are more responsive to treatment and the range of treatments used early on are less harmful. Thus, the risk–benefit ration is enhanced for both reasons. We already have some evidence for this in psychosis, however, the staging idea has greater heuristic value and should be more extensively examined. Neuroprotection is a highly congruent notion.
5. Evidence
There is mounting evidence that progression from the prepsychotic phase to first-episode psychosis can be prevented, that treatment delays prior to first-episode psychosis can be reduced and that phase specific treatment in the critical early years is more effective. This is reviewed in Malla and Norman [12]. This evidence is rapidly growing and is likely to support the reform process, which is proceeding on the basis of other kinds of evidence and advocacy in many places, especially the UK, Western Europe and Canada [10].
The Australian scene
The Early Psychosis Prevention and Intervention Centre (EPPIC) programme and the National Early Psychosis Project created a strong foundation for systematic reform of the service system in Australia during the First National Mental Health Plan. There have been three National Early Psychosis Conferences and three International Early Psychosis Conferences conducted within or from Australia, and healthy national and international networks have made early psychosis a growth point in research and service reform around the world. Despite this and the enthusiastic efforts of many clinicians around Australia, progress in service reform has plateaued, remains piecemeal and is frustratingly slow in contrast to what has been achieved in other countries, many of which began by emulating Australia. Policy and funding support at state and federal levels has been disappointing. A number of obstacles can be identified.
1 The specialist mental health system is seriously under-funded in contrast to other equivalent developed countries that are making more rapid progress in early intervention reform. There are simply not enough resources to provide specialist mental health care to those who already have serious mental illnesses.
2 As a direct consequence, the specialist mental health system manages demand by limiting access to what are perceived to be the most severe cases. For initial entry and acute care, those who are most behaviourally disturbed or at highest risk of violence or suicide; and for continuing care, those who demonstrate a pattern of repeated relapse or severe disability. This means that the new service system is in essence an asylum system, focusing on demonstrated chronic schizophrenia, devolved to a community setting. Even people who can show they have a severe and persistent illness will not necessarily gain secure access to specialist public psychiatric care. A substantial proportion will be discharged to unsupported primary care settings and denied regular specialist review. The basis of this targeting can be seen to be totally antithetical to early intervention, and this is reflected in the ubiquitous plaintive protests of families of young people around the nation regarding access, quality and tenure of treatment.
3 The targeting on chronic schizophrenia means that a broad diagnostic range of patients cannot gain entry to specialist services. This prevents the diagnostic ambiguity of early psychosis from being tolerated, and it also means that the early intervention paradigm cannot be extended to the full range of emerging disorder in young people. This is despite this phase of life being the peak period for onset and prevalence of mental disorders [20, 21]. While tackling this challenge will require a much more integrated primary-specialist model of care, there will need to be a capacity for many more nonpsychotic disorders to be seen and treated within specialist mental health services. Simply restricting the role of the specialist mental system to an ‘asylum in the community’ for severe or refractory schizophrenia cripples the ability of this system to play its proper role. A corollary is obviously the need for better integration with primary care, something that is inhibited by underresourcing and diagnostic censoring of the specialist system. Bypassing the existing devolved specialist mental health frameworks and creating an alternative workforce would lead to a continuing schism. Expansion of both primary and specialist systems is the way forward.
4 Policy support at State and Federal level in general has been disappointing. The Second National Mental Health Strategy turned away from practical forms of prevention and early intervention to educational models and more diffuse forms of mental health promotion and universal prevention that have proven ineffectual because they are premature and not ‘best bets’ or ‘best buys’ at the present state of knowledge. There has been a belief at the bureaucratic level that for a number of reasons, the streamed EPPIC model cannot be replicated. This is despite the following facts. The EPPIC programme is no more expensive than standard specialist public sector care [1; Mihalopoulos C: unpublished report] costing approximately $16 000 per annum per patient. Indeed, in Victoria EPPIC is somewhat cheaper on a per capita basis than Area Mental Health Service care, and is becoming more cost-effective as time passes [21, 22]. What EPPIC does do, which sector services do not, is guarantee tenure within the specialist mental health system for at least the initial 18 months after diagnosis. In other words, the funding is available and deployed up-front for an 18-month episode of care, irrespective of acuity, disability or risk, provided firstepisode psychosis is diagnosed. Thus, important aftercare work in the recovery phase is ensured. Other services do not guarantee treatment to early psychosis patients. Treatment is often only provided in a reactive way, for example when admission is unavoidable, or when frequent relapses and disability make continuing care impossible to withhold. Thus, ultimately expenditure is similar to or even greater than that of EPPIC, to the detriment of both patients and funding bodies. For example, the study of Yung
5 A final obstacle to the successful implementation of early intervention in psychosis is the lack of integration of specialist mental health with primary care and relevant community agencies. Mainstreaming with tertiary general hospitals has some ideological attractions and some practical benefits, though there are serious weaknesses at the clinical level, notably the use of emergency departments for acute psychiatric presentations. Until recently, much less attention has been paid to mainstreaming with general practitioners (GPs) and, in the case of young people, youth agencies, educational institutions and other community organizations.
Practical steps forward: better survival, better quality, better value for money
Although Australia has slipped behind in early intervention reform, it is now emerging that the situation can improve and that Australia can again be at the forefront of early intervention work. Here are some proposals as to how this can best be achieved.
1 Guaranteed access to specialist mental health services for a minimum period of 3 years post-diagnosis for all young people aged 15–25 with a first-episode of psychosis. New funding is clearly required to support this though in due course there will be major offsets downstream as the St Vincent's audit [23] implies.
2 Such funding must be quarantined into new structures, programmes and teams. In view of the poorly funded and hence reactive state of public psychiatry, new resources will otherwise be rapidly diverted or leached out to support other gaps in the system. New structures, such as streamed young people's (15–25 years) inpatient beds and streamed community services, are needed anyway on clinical grounds. This could be done conservatively within the existing sector-based system by defining early psychosis as covering the first 3 years post onset. A service with a catchment area of 200 000 residents would have around 50 cases per annum and if these were retained in the early psychosis programme within the service for 3 years, the steady state would be around 150. Such a critical mass of cases would support around eight beds, ten case managers (based on overseas benchmarks), a small team of psychiatrists and registrars, group programmes and a detection and engagement team. Since much, but not all, of this care is already provided by existing structures, the model could be implemented through a combination of new funding and reallocation of existing resources. For example, most of the inpatient needs are already being covered in generic acute units. The main change here would be to designate a quantum of beds as ‘early psychosis’ beds. Creating a structural specialization within the service in this way could form the basis for wider diagnostic expansion in young people. A quantum of non-psychotic young people in the same age range and early phase of illness could be provided with direct services as well as in shared care models.
3 The child versus adult psychiatry service model split is a serious flaw for early intervention and for modern and appropriate developmental psychiatry models. It needs to be transcended by proactive youth-orientated models. Good linkages can be developed between such youth models and both child and adult psychiatry. However, youth mental health services primarily need to be mainstreamed with an array of youth-orientated services and environments as well as drug and alcohol services and primary care. A youth health model can be constructed through such integrations and partnerships and could provide a blueprint for continuing psychiatric reform more broadly. Early detection and engagement can be radically improved through such reforms and specialist mental health care can also be delivered in a less salient and stigmatized manner. Clinical pathways between the rest of the specialist mental health system can be managed procedurally. These new structures can be engineered as prototypes, phased in and evaluated progressively as a series of successive approximations, a process of service system ‘morphing’. A staged approach based on justifiable levels of reform is appropriate. For example, systematic early psychosis reform could be the initial building block.
4 Integration of key services under one management system is a specific related goal (e.g. drug and alcohol and mental health is the most urgent priority) and closer relationships with primary care are desirable.
There a number of key national processes that should result in a sound Third National Mental Health Plan that promotes further growth and reform in mental health care. We are hopeful that strong investment in early intervention and better services for young people with emerging psychiatric disorder will be among the highest priorities, since this is not only where the greatest public health burden lies, but also where cost-effectiveness of intervention is likely to be maximal.