An Introduction to Early Intervention

1. An Introduction to Early Intervention Manchester Mental Health & Social Care Trust

2. 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.

3. 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

4. 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)

5. 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.

6. 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)

7. 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 resolve • 2. ‘Attenuated’ (Subclinical) Psychotic Symptoms - not severe or disruptive enough to be described as actual symptoms of psychosis

8. Early psychosis -The Phases of Illness • The first episode of psychosis has been identified as having four ‘phases’: • Prodromal • Acute • Early Recovery • Late Recovery

9. 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.

10. The Prodrome • This is the stage which occurs before the development of psychotic symptoms • A 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.

11. 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)

12. 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

13. The signs associated with a prodrome • Changes in sleep pattern – an inability to get to sleep or waking up early • Changes 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 anything • Experiencing difficulty remembering things such as appointments or practical arrangements

14. 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

15. 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’.

16. The Acute Phase • Initially 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

17. 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.

18. 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

19. The Signs Associated with the Acute Phase • Believing that people are talking about them or laughing at them without any evidence to substantiate that belief • Unusual behaviour such as excessive checking or wearing unusual clothes, sunglasses • Staying 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

20. Early Recovery Stage • Often considered to be in the first six months following treatment • It 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 assessed • Each person will should receive a care plan and a named care co-ordinator

21. Late Recovery Phase • This phase follows the early recovery phase by a further 12 months • The medication regime to maintain health should be established • The goal is to promote recovery and avoid relapse • During this phase the clients should develop an awareness of the illness and develop skills to achieve life goals

22. 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

23. 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 spontaneously • The person might be unable to express themselves and appear to lack emotion • Less energy and loss of motivation is common • The ability to plan ahead and concentrate may be compromised

24. 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

25. The Stages of Psychosis • In pairs read through the vignettes of the phases of psychosis • Try 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

26. Conclusion • Early interventions for psychosis aim to decrease the duration of untreated illness and to improve outcomes by promoting recovery and preventing relapse • Four stages have been identified in the course of psychosis • The prodromal stage is difficult to identify due to the associated developmental changes of adolescence • The critical period following an acute phase needs to be closely monitored as relapse is common