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An Introduction to Early Intervention

Manchester Mental Health & Social Care Trust

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Aims & Objectives

To provide an overview of early intervention for psychosis.To provide a background to concepts of early intervention and the phases of a severe mental illness.To enable recognition of the signs and symptoms that might develop in a young person.

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What is Early Psychosis Intervention?

Early psychosis intervention refers to the evidence based approaches used in the management and treatment of psychosis

The approaches emphasise the importance of timely interventions which are individualised, intensive and comprehensive.

Intervention should be appropriate to the phase of the illness to reduce the likelihood of further episodes of illness

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What is Early Psychosis Intervention?

The incidence of first episode psychosis is estimated to be 15 – 20 cases per 100,000. Early intervention aims to reduce the duration of untreated illness which has a positive outcome in terms of reduction of relapse.This has been the impetus for the development of early intervention services Early interventions have substantially decreased the need for in-patient care. (McGorry 1998)

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An Introduction to the Evidence Base

Schizophrenia and other psychotic illness can be treated effectively if timely interventions are delivered in ways that are acceptable to the people receiving them.

However, schizophrenia may become a life long disorder if not treated appropriately in the early stages.

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An Introduction to the Evidence Base

The cognitive and psychosocial damage caused by psychosis appears to occur in the first 5 years, then a ‘plateau of disability’ occurs (Lieberman 1997)Treating during the ‘critical period’ can decrease relapse and social disability, limit psychological problems and reduce healthcare costs (McGorry & Jackson 1999)The longer the DUP, the more risk of long-term problems such as serious physical injury, unemployment, impoverished social networks, loss of self esteem ( Jackson & Farmer 1998;Johannessen 2001)

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An Introduction to the Evidence Base

Morrison et al (2004), in a randomised controlled trial (RCT) known as the ‘EDIE’ study (Early Detection and Intervention Evaluation) found that the young people they studied displayed two distinct subsets of experiences on entry to their programme:

1. Transient Psychotic Symptoms - ‘Brief Limited Intermittent Psychotic Symptoms’ (BLIPS). These can be ‘full-blown’ psychotic symptoms that last for a few days and then spontaneously resolve2. ‘Attenuated’ (Subclinical) Psychotic Symptoms - not severe or disruptive enough to be described as actual symptoms of psychosis

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Early psychosis -The Phases of Illness

• The first episode of psychosis has been identified as having four ‘phases’:

1. Prodromal2. Acute3. Early Recovery4. Late Recovery

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Adolescent behaviour or onset of illness?

In small groups consider all emotions , thoughts or behaviours that an adolescent might experience.

Write these down and share them with the rest of the group.

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The ProdromeThis is the stage which occurs before the development of psychotic symptomsA prodrome is difficult to identify as it is similar to the stages of adolescence.This may take on a greater meaning for others if the person has been identified as being vulnerable already due to their family or developmental history.The person might be distressed at this stage or show signs of changes in their behaviour.

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The Prodrome

The ‘prodrome’ might be an extended period lasting for months but this is not always the case

People presenting with these symptoms should be monitored within a primary care setting

(National Collaborating Centre for Mental Health, 2003)

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The signs associated with a prodrome

A sense of being suspicious or worried

Getting irritable and angry or feeling more tense than normal especially over trivial things

Experiencing mood swings – feeling low then feeling very happy

Having problems getting organized and being unable to establish a routine.

Feeling low or depressed. They may feel a sense of hopelessness about themselves and the future

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The signs associated with a prodrome

Changes in sleep pattern – an inability to get to sleep or waking up earlyChanges in appetite or eating habits - perhaps feeling a bit suspicious about food No sense of ‘get up and go’ anymore, a loss of energy or motivation to do anythingExperiencing difficulty remembering things such as appointments or practical arrangements

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The signs associated with a prodrome

Perceptual changes such as experiencing an unusual sense of taste, smell or seeing or hearing things differently

Not going out and becoming social isolated from friends or family

Feeling anxious about things. This might be in social environments or going out alone

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Brief Limited Intermittent Psychotic Episodes ( BLIPS)

These might be brief episodes of a full psychotic illness which might involve all the symptoms of a psychosis but for a brief and limited period.

Otherwise these might be similar to psychotic symptoms but not as intense as a ‘full blown’ psychosis.

They often occur within the prodrome phase but they do not necessarily lead to a ‘full disorder’.

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The Acute PhaseInitially the person might develop ‘attenuated’ positive symptoms. This phase is characterised by more serious symptoms such as hearing voices, having strange or frightening beliefs or experiencing difficulties with thinking processes.Sometimes due to the distress involved the person will refuse help or support. The goal at this stage is to resolve symptoms and prevent the establishment of secondary symptoms

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The Acute Phase

If the person is very disturbed they might present with behaviour which might cause them to be at risk to themselves or others and will need a risk assessment

An in – patient admission or home treatment team might be necessary.

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The Signs Associated with the Acute Phase

Hearing voices when nobody is around

Hearing ones’ own thoughts aloud

Believing objects around the house have been specially arranged

Thinking that the TV is sending special messages to the person.

Believing that they are being followed or someone is attempting to harm them

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The Signs Associated with the Acute Phase

Believing that people are talking about them or laughing at them without any evidence to substantiate that beliefUnusual behaviour such as excessive checking or wearing unusual clothes, sunglassesStaying up all night, pacing around.

These are just a few of the common signs experienced by people who are in the acute phases of an illness

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Early Recovery Stage

Often considered to be in the first six months following treatmentIt is during this time that the person is at most risk of suicide, especially when discharged from hospital.It is during this stage that the social, economic , physical and environmental and occupational needs should be assessedEach person will should receive a care plan and a named care co-ordinator

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Late Recovery Phase

This phase follows the early recovery phase by a further 12 monthsThe medication regime to maintain health should be establishedThe goal is to promote recovery and avoid relapseDuring this phase the clients should develop an awareness of the illness and develop skills to achieve life goals

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Late Recovery Phase

The first five years following a acute episode is referred to as the ‘critical period’

The risk of relapse is high during the critical period and occurs in around 80% of those who have an untreated psychosis.

Maintenance therapy of medication significantly reduces relapse rates

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Residual symptoms during the

recovery stages Negative symptoms are often present following an acute phase.These are generally the cause of long term disability People who experience negative symptoms may talk less spontaneouslyThe person might be unable to express themselves and appear to lack emotionLess energy and loss of motivation is common The ability to plan ahead and concentrate may be compromised

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Residual symptoms during the recovery stages

The person might continue to maintain abnormal beliefs or experiences following an acute episode yet might be less distressed about them

Secondary symptoms such as depression or anxiety may develop

Some clients might develop drug or alcohol problems as they seek a way of coping with distressing symptoms

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The Stages of Psychosis

In pairs read through the vignettes of the phases of psychosisTry to identify the symptoms present within the case studies and insert them into the table provided in the handouts Consider which symptoms are most characteristic of the different stages of a psychotic illness

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ConclusionEarly interventions for psychosis aim to decrease the duration of untreated illness and to improve outcomes by promoting recovery and preventing relapseFour stages have been identified in the course of psychosisThe prodromal stage is difficult to identify due to the associated developmental changes of adolescenceThe critical period following an acute phase needs to be closely monitored as relapse is common