Abstract
In the January 2012 edition of this journal, Professor Castle claimed that his editorial was ‘the truth and nothing but the truth about early intervention services’ (Castle, 2012). However, an astute prosecutor would recognise that he was not telling ‘the whole truth’ and would have quickly found two faults in his evidence.
Firstly, Castle’s dismissal of the huge body of research about the ‘so-called’ duration of untreated psychosis (DUP) could be seen as a disingenuous attempt to undermine the need to redesign services so that they actually do treat people earlier. While there are significant methodological issues in the measurement and reporting of DUP, in particular the continued use of the figure for mean DUP that is skewed by a small number of outliers, there are well over a 100 studies of DUP, all of which show that a significant proportion of patients remain untreated for months or even years after the onset of psychosis (Large et al., 2008a). While DUP may be longer in people with an insidious onset who also have a poor prognosis, there is no data showing that insidious onset is the sole or even the main cause of treatment delay. Factors that are known to be associated with delayed treatment include income (Large et al., 2008b) and the effect of mental health laws (Large et al., 2008c). Our prosecutor might challenge Castle’s claim that he is ‘not for late intervention’ because any argument for retaining the status quo of generic treatment is in effect a tacit endorsement of the existing unacceptable delays in initial treatment.
Secondly, Castle overlooked the emerging body of evidence that earlier treatment of first episode psychosis can reduce the incidence of violence committed by people with psychosis, an outcome that also has the potential to reduce some of the stigma experienced by the mentally ill. In the last few years several research groups have examined the incidence of violence in cohorts of patients in the first episode of psychosis (Dean et al., 2007; Harris et al., 2010). A meta-analysis of these studies found that as many as 15% of presentations occurred after a physical assault, and violence was significantly associated with longer duration of untreated psychosis (Large and Nielssen, 2011).
Fuller Torrey has argued that the stigma attached to the mentally ill is largely derived from the failure to treat and the catastrophic behaviour of a small proportion of people with mental illness who are untreated (Torrey, 2011), an opinion supported by the findings of a community survey showing that the belief that the mentally ill are dangerous is an important component of stigma (Reavley and Jorm, 2012). Hence, any reduction in episodes of violence through the earlier treatment of psychosis could in turn reduce the stigma experienced by all people with mental illness.
In Castle’s defence, we agree that early psychosis services that accept referrals through the same channels as generic services probably have little effect on DUP. However, we do not share his pessimism about the potential success of community programs designed to reduce DUP. For example, early psychosis services linked to community wide awareness programs have been shown in one study to reduce both the DUP and the number of suicide attempts prior to initial treatment (Melle et al., 2006). In light of the finding of a disproportionate number of first episode psychosis patients among the survivors of violent suicide attempts (Nielssen et al., 2010), this outcome suggests that reducing DUP could reduce the rate of violent suicide attempts, and might also reduce the rate of serious violence towards others by those in early psychosis.
We also agree with Professor Castle that the age limit set by some early intervention services is discriminatory, especially towards women, who have an older mean age of onset than men. Age limits also have the effect of excluding many of the violent patients in first episode psychosis, who have a higher average age than other first episode patients, in part because of long DUP in many cases (Nielssen et al., 2011). Hence, age limits in early psychosis services might deny some patients what could turn out to be life saving treatment.
Finally, we can all agree with Castle’s desire for a universal, seamless and integrated mental health care system supported by a bi-partisan whole of government approach and a fair and rational allocation of the resources that are available. However, until the day those planets align, reform is most likely to come from strong advocacy for the right sorts of services. As there is now clear evidence that earlier treatment of psychotic illness, and intensive psycho-social treatment of first episode psychosis, reduces the long term disability associated with the disorder, we can tell whichever side is in power that early intervention represents a good investment of mental health resources regardless of the names given to the services that provide this care.
See Debate by Castle, 2012, 46(1): 10–13