Making Early Intervention more equitable

A recent paper by Lappin et al. (2016) found that the majority of cases of first episode psychosis (FEP) presented after the age of 25 and a significant minority after the age of 35. Most older presentations were female. The authors concluded that the cut-off age for Early Intervention for Psychosis services of 25 in Australia and 35 in the United Kingdom are ‘gender- and age- inequitable’.

One solution is to extend the upper age range for services. This has recently been done in England, where since April 2016, the upper age limit for access to Early Intervention is 64. However, clinicians managing this new population of older individuals may need to develop new skills as there are variations in the presentations, diagnoses and clinical needs of the older versus younger FEP group (Lappin et al., 2016).

Rather than increase the upper age limit for Early Intervention services, McGorry (2016) proposes to retain the upper age limit of 25 but to expand the clinical focus to the emerging and early phases of a range of psychiatric illnesses. That is, to maintain the arbitrary age cut-off points but to dispense with a cut-off based on presence or absence of ‘psychosis’. The context is that the clinical picture in young people with mental health problems is often fluid, with symptoms evolving, new symptoms developing and high rates of comorbidity between anxiety, depression and sub-threshold psychotic symptoms. Removing the arbitrary requirement of a certain level of psychotic symptoms in order for a young person to access help would make services more patient-focussed and make discussions about the ‘true’ psychotic symptoms (e.g. compared to ‘traumatic’ psychotic experiences or substance induced experiences) redundant.

One issue with this approach is the potentially large number of patients that a service would need to manage and the range of skills that clinicians would need in order to treat a diverse range of problems. There is also the tension between managing early and emerging illness versus managing young people with established illnesses – Early Intervention is not the same as a youth mental health focus.

Finally, Jorm (2017) proposes ‘fuzzy’ age boundaries where there are no sharp age cut-off criteria. He suggests this could be applied to child, adult and older adult services. Jorm notes there are a number of advantages to this system. Furthermore, he claims that this model already works in practice, through the private health system. He suggests that public and private services could compete for managing patients, with the funding ‘following the patients’. However, it is not clear how this would work in the Australian healthcare system. Who would be in charge of allocating the funding? Would another layer of bureaucracy such as a Managed Health Care Organisation be required? And how would the amount of funding be determined? Using diagnosis would not work, as one person with FEP (or indeed any psychiatric illness) will have different needs, and therefore health costs, from another individual with the same diagnosis. A comprehensive assessment of needs including a projection into the future about prognosis would be required but would be difficult to implement in practice, and there is the danger that funding would be determined by an administrative rather than clinical approach. There are already concerns about the privatisation of National Health Service (NHS) in the United Kingdom, including lack of transparency about profits, costs, and level of care, due to ‘commercial confidentiality’, as well as evidence showing that directing public funds to private providers increases health inequality, with those from the most socially deprived areas particularly disadvantaged (Kirkwood and Pollock, 2016).

So how can Early Intervention services be made more gender- and age-equitable? Early Intervention is important for a range of mental health problems: to treat current issues, prevent secondary disorders from developing (such as depression or substance use disorders arising following untreated anxiety disorders) and reduce the risk of these illnesses persisting. Most mental disorders occur for the first time in adolescence and young adulthood. Transdiagnostic youth services are therefore justified. However, this model cannot replace Early Intervention for Psychosis services, as individuals will still present with early and emerging serious mental illness, such as schizophrenia (Fusar-Poli et al., 2013), for which comprehensive and long-term management is needed to minimise disability. Different clinical skills will be required in these different services. Communication between transdiagnostic youth services and Early Intervention for Psychosis is essential as staff in the youth services will need to be able to detect emerging psychotic disorders as these frequently begin with anxiety, depression and other non-specific features.

A ‘fuzzy’ boundary is impractical to apply as a public health policy. So where should the age cut off points be for youth services and early psychosis services? An evaluation of the implementation challenges, effectiveness and cost-effectiveness of expanded age range in England will be important to inform the planning of services in Australia and help to determine the optimal upper age range. Similar evaluation of youth services is needed. While no system is perfect, the aim should be to provide the optimal services at the right time.

See Commentary by Jorm (2017) 51: 532–533.