Expanding the Reach of Early Psychosis Intervention

Over the past 2 decades, early psychosis intervention (EPI) has been one of the bright spots in mental health care, and the EPI phase-specific approach has moved from being merely promising to being considered the gold standard of care for people experiencing early psychosis. Specialized EPI programs are proliferating across the globe, and the movement continues to grow. The article by Anderson et al. ¹ in the current issue of CJP, however, raises some important questions about how to sustain this momentum.

It focuses on London Ontario’s Prevention & Early Psychosis Intervention (PEPP) Program, one of the pioneers of early psychosis, not just in Canada, but worldwide. Since one of the cardinal precepts of EPI is accessibility, the authors sought to find out what was happening with people experiencing early psychosis who hadn’t accessed the program. Just how many people were out there? What kind of services, if any, were they receiving? And were they somehow different from EPI users when it came to clinical or sociodemographic characteristics?

Surprisingly, they found a considerable number of EPI “nonusers.” In fact, more than 50% of people experiencing early psychosis had no contact with PEPP but had found help with a psychiatrist, general practitioner, or other mental health professional. Perhaps less surprisingly, they tended to differ from the typical PEPP client, being more likely to be from socioeconomically deprived areas and have a co-occurring substance issue; they were also more likely to be female and older than the typical EPI client. Another difference, seemingly antithetical to the early psychosis intervention ideal, was that EPI users were twice as likely to receive their index diagnosis in hospital.

An immediate question that comes to mind is why this other group of people isn’t accessing specialized early psychosis services. EPI fidelity standards at the front end of the continuum call for gatekeeper education, referral network development, and flexible admission criteria to make help-seeking pathways more reliable and inclusive. ² As the authors note, though, the frequency and intensity of PEPP’s community outreach has decreased over time. Community outreach initiatives are resource-intensive endeavors, and like other EPI programs, PEPP faces the dilemma of how to maintain or increase accessibility without any guarantee of expanded resources.

It appears that similar issues do exist across the North American early psychosis service landscape. A survey by EPION, Ontario’s Early Psychosis Intervention Network, ³ studied program implementation in relation to the Ontario EPI standards and found 3 specific challenges. The first was at the front end of the continuum, where public education/referral network development was the least likely standard to be implemented. Key informants explained this in terms of staff capacity: that any resources directed toward the front end of the program diminished the program’s ability to support their existing clients and maintain reasonably low caseloads.

The second challenge related to the comprehensiveness of supports within the program itself; although psychoeducation, illness management, and relapse prevention were strengths, there was a significant gap in wellness/recovery-oriented planning and supports, especially related to the education or vocational domain, where despite what fidelity standards would recommend, less than 50% of people had access to supported education or employment. Key informants noted the need for new resources and support for implementation of specific evidence-based models, for instance, the Individualized Placement & Support (IPS) model.

The third challenge was at the latter part of the service continuum, with the standard related to duration of service before graduation, where more than 25% of clients stayed with the program beyond the recommended 3-year graduation point, either because there was no appropriate next step or the person wasn’t ready to move on. Of course, challenges at the back end make it harder to bring people in at the front end of the EPI support continuum.

How, then, can EPI programs realistically expand access while still maintaining quality care, given these challenges with helping people move on and the concomitant pressure to raise caseloads? In the short term, the answer may not actually be at the front end but with a targeted investment outside of the programs. Arguably, an increased focus on supported education and employment could eventually help some people become less reliant on the support offered within the programs and perhaps graduate more quickly from EPI services. This, in turn, would free EPI programs to pay more attention to how they can be more accessible to more people in the beginning stages of their pathways to care.

Indeed, a fair amount of evidence suggests that the IPS model works well, with a number of newer studies showing that when done within an EPI context, it works even better. ⁴ A recent survey of American EPI program implementation ⁵ came to similar conclusions, recommending the expansion of community outreach as well as an increased focus on supporting functional and social recovery, that is, dedicating more attention and resources to things such as housing and employment.

By providing a stronger focus on social and functional recovery, not only can we help current clients become less reliant on clinical supports, but we can also make specialized EPI services more relevant to a broader range of potential clients, including women. As the Anderson et al. (in this issue) study points out, women typically have later onset and are more likely to be trying to stay attached to the workforce when they first seek help.

At the same time, by becoming more proactive at the front end, EPI programs can minimize the disruptiveness of people’s first experience of care. For EPI access standards are not just about reliable referral pathways but about making the first experience conducive to continued engagement. The NICE guidelines, ⁶ for instance, encourage the initial contact to be made in a setting that’s friendly to youth and young adults, avoiding inpatient admission whenever possible. As the Anderson et al. (in this issue) paper suggests, and a survey by the Canadian Consortium for Early Intervention in Psychosis ⁷ affirms, this continues to be a continuing challenge with many programs. Both show that even the most well-resourced EPI clinics continue to experience a significant proportion of referrals from inpatient units and emergency wards.

When we consider how to make our EPI programs more inclusive, we also have to think about how people experience care, not only at the beginning of the pathway, but as they move along the continuum. We need to achieve a dynamic flow through, so people don’t get stuck in services, and by making a targeted investment in supported employment, we can make EPI services more recovery oriented, and help people move beyond specialized care and on with their lives. We can then shift our attention back upstream, to strengthening relationships more broadly within our communities and with the young people who may need our support in the future.