Early Intervention in Psychosis [61]

Who is the service for?

People aged between 14 and 35 with a first presentation of psychotic symptoms

People aged 14 to 35 during the first three years of psychotic illness

What is the service intended to achieve?

Psychosis is a debilitating illness with far-reaching implications for the individual and his/her family. It can affect all aspects of life - education and employment, relationships and social functioning, physical and mental wellbeing. Without support and adequate care, psychosis can place a heavy burden on carers, family and society at large.

The mean age of onset of psychotic symptoms is 22 with the vast majority of first episodes occurring between the ages of 14 and 35. The onset of this disease is therefore often during a critical period in a person's development. At present it can take up to two years after the first signs of illness for an individual and his/her family to begin to receive help and treatment. Lack of awareness, ambiguous early symptoms and stigma all contribute to the delay in appropriate help being offered and taken up.

Early treatment is crucial because the first few years of psychosis carry the highest risk of serious physical, social and legal harm. One in ten people with psychosis commits suicide - two thirds of these deaths occur within the first five years of illness.

Intervening early in the course of the disease can prevent initial problems and improve long term outcomes. If treatment is given early in the course of the illness and services are in place to ensure long-term concordance (co-operation with treatment), the prospect for recovery is improved.

An early intervention service should be able to :

• reduce the stigma associated with psychosis and improve professional and lay awareness of the symptoms of psychosis and the need for early assessment.
• reduce the length of time young people remain undiagnosed and untreated
• develop meaningful engagement, provide evidence-based interventions and promote recovery during the early phase of illness
• increase stability in the lives of service users, facilitate development and provide opportunities for personal fulfillment
• provide a user centered service i.e. a seamless service available for those from age 14 to 35 that effectively integrates child, adolescent and adult mental health services and works in partnership with primary care, education, social services, youth and other services
• at the end of the treatment period, ensure that the care is transferred thoughtfully and effectively

Evidence indicates that the following principles of care are important:

• Culture, age and gender sensitive
• Family orientated
• Meaningful and sustained engagement based on assertive outreach principles
• Treatment provided in the least restrictive and stigmatising setting
• Separate, age appropriate facilities for young people
• Emphasis on normal social roles and service user's development needs, particularly
• involvement in education and achieving employment
• Emphasis on managing symptoms rather than the diagnosis.
• A typical early intervention service will aim to meet the needs of a million total population. The service will comprise 3 or 4 teams and appropriate respite facilities. By April 2004 each early intervention service will have established its first team. The overall service will be established during the lifespan of the NSF through the initial investment and service restructuring /reinvestment. The exact configuration of the 50 services will be established on a regional basis.

Hours of Operation

• Core working hours should be 8am to 8pm, 7 days a week
• Out of hours (8pm to 8am) - advice should be available from staff at the community respite facility or alternative (either by telephone or by visiting the unit) or from an on-call member of the Early Intervention Team
• Note there is no provision for home visits out of hours. Service users should be referred to crisis resolution/home treatment team/out of hours CAMHS service if home visit is required (see below).

Links with Crisis Resolution/Home Treatment Team

For users aged 14 or over, the crisis resolution/home treatment team can provide crisis care out of hours - see crisis resolution/home treatment service specification for more details.

Local arrangements have to be made between the crisis resolution/home treatment team, the early intervention team and child and adolescent mental health services (CAMHS) to ensure service users who are under 16 years old have adequate and rapid access to an out of hours crisis service. As one of the principles of early intervention services is the maintenance and reestablishment of the integration of users with age appropriate mainstream community services, there need to be a wide range of close links fostered. This will include close ties with primary care, education, youth agencies, leisure providers and a variety of other services across the voluntary and statutory sectors.

Referrals

Early intervention is a specialist service. The service should take direct referrals from CMHTs, CAMHS, primary care, crisis resolution/home treatment team, forensic services, assertive outreach, other mental health services, acute medical services (including A+E).

Provision of Alternative Residential Care

Each service requires easy access to community respite care appropriate to each age group:

• Respite beds for adults over 22 years of age (separated from other mental health facilities)
• Young person's beds (adults aged 16 to 22)
• Regional unit adolescent beds

Risk Assessment and Policy on Violence

• Each team should have a written policy outlining the level of risk the team is able to manage
• Operational policy should explicitly address staff safety
• Description of the service, key elements and what to expect
• Name and contact details of care co-ordinator and other relevant members of the team
• Contact details for out of hours advice/intervention
• Information about assertive outreach approach and benefits of maintaining regular contact
• Ongoing care plan and information about medication
• Relapse prevention and crisis plan
• How to express views on the service

Staff Training Should Include:

• Principles of the service
• Training in all key components listed above
• Team building, colleague support and working within a team framework
• Medication - storage, administration, legal issues, concordance training and side effect management, prescribing to under 16 year olds
• Use of Mental Health Act and alternatives to hospital treatment
• Understanding of the Children Act
• Benefits to service user and family/carers of this service
• Suicide awareness and prevention techniques