Early intervention in psychosis: Evidence,evidence gaps,criticism and confusion

Professor Yung (2012) is correct to conclude that debate is required in the field of early psychosis. Unfortunately, selective citation forewent the opportunity for genuine debate. Denigration of the empirically robust and stringent Cochrane methodology seems curious and unfounded in a paper arguing for greater evidence for early intervention (EI) in psychosis.

Professor Yung doubts the capacity of generic services to implement and effectively run early psychosis services and purports to use data from our own study to support this argument. These data (Petrakis et al., 2011a) were derived from a comprehensive audit, conducted on all patients identified as having early psychosis who were within their first 2 years of treatment in a program that serviced patients aged 16 to 64 years. Professor Yung (2012) misquotes the paper, stating that in only two-thirds of cases had contact been made with family or carers. Family or carer involvement was not included in the case file audit as it was monitored via the care pathway records. Of the patients’ files with a care pathway (37/40), 92.5% had family or carer involvement. This compares to 69% in our historic (pre-early intervention) cohort. The assertion that the biopsychosocial assessment of patients was completed in only 65.5% of cases, and that in a substantial minority (29.1%) this process took a mean of over 2½ months, is misrepresented by Professor Yung (2012). It is data that were present in 65.5% (36/55) of cases and, of these, 33 had the item completed, with a compliance of 91.7%.

The suggestion by Professor Yung (2012) that our missing data are an ‘illustration that unless resources are specifically directed at management of first episode psychosis (FEP) patients it is difficult for clinicians to prioritise these tasks as they also juggle the needs of other patients’ is misleading. Moreover, it is insulting to suggest that working with ‘chronic illnesses’ is the barrier to guideline concordant care. When our data were placed in context through interstate and international benchmarking against the ‘specialist services’ of standalone teams unhampered by working with ‘chronic illnesses’, we were able to demonstrate equivalent or superior fidelity.

Finally, Professor Yung (2012) uses our mean duration of untreated psychosis (DUP) of 24 months to further argue that competition from other patients with complex problems impedes prompt treatment delivery. The more relevant average to comment on would have been the median DUP, as outliers have the potential to skew the mean. In our study, the median was 3 months (Petrakis et al., 2011b), comparing favourably to the 92 days in the historic cohort (Yung et al., 2003). When a service expands intake criteria to include patients up to 64 years of age, many patients would be expected to have a longer DUP. Put simply, the older a patient, the greater potential they have for a longer duration of illness – by virtue of age alone. This effect in turn can increase the mean DUP (Fitzgerald, 2003). Furthermore, at the recent World Psychiatric Association Congress, Malla (2011) described what he termed the ‘vacuum cleaning effect’; any time a new, comparatively better-resourced EI service is set up it is able to pick up cases where people have been unwell for some time.

The notion that early detection may save individuals many decades of suffering is of course important. Unfortunately, there will always be individuals who will not receive much needed treatment for various reasons. Those at greatest risk of falling through the gaps may reasonably be expected to be disadvantaged by socioeconomic, educational, cultural/linguistic and location factors. These may impede and delay access to service. Stand-alone services based on age may inadvertently exclude this group from treatment, exacerbating the disadvantage. Services available to patients irrespective of age of onset enable those who do fall through the gaps to at some point engage in a FEP treatment program, including intensive psychoeducation and support, collaborative practice inclusive of family/carers, and a focus on functional recovery, emphasising employment and community engagement.

In the psychology literature, Professors Rosen and Davison (2003) criticise ‘branded’ psychological therapies for obscuring empirically supported principles of change to the detriment of other approaches (even where they shared such principles) stifling debate and detailed scientific inquiry. Best treatment extended to patients with early psychosis shows similarities to best treatment interventions for severe mental illness at other stages; in particular, the integrative biopsychosocial approaches to treatment typified by intensive case management and assertive community treatment. The patterns now evident of reversion to mean with withdrawal of intensive support are no different from those observed in these models, and might similarly be at least partially modifiable where service provision is guided by patient need rather than arbitrary timelines. Integrating these observations from the two extremes of the treatment spectrum (an EI approach and an approach which grew out of attempting to support deinstitutionalisation) may serve to guide resources for treatment of all affected by severe mental illness, irrespective of age or service model. The virtue of ongoing care when needed is reinforced by the recent study of Norman and colleagues (2011), where extending care for up to 5 years resulted in gains being maintained in an early psychosis sample. This is consistent with Professor Castle’s (2012) view that individuals with psychotic illnesses should receive the very best of care as early and for as long as they need, in a continuum of care model.

See Debate by Yung, 2012 46(1): 7-9; See also Debate by Castle, 2012 46(1): 10–13