It can be difficult to distinguish the early signs of mental illness from normal variations in behaviour in adolescence and early adulthood. This article explores, with reference to recent research, why it is important to try, and how to access appropriate and sensitive care.
Professionals are loath to suggest psychosis as a reason for unusual behaviour in young people, but studies show that this reluctance can result in valuable treatment time being lost, writes Christina Rogers
Severe mental illness can come on gradually, often in the teenage years and the early twenties. The initial signs include withdrawal, disruption of family relationships and poor selfcare.
Anyone who works with young people knows that any of these signs can be mistaken for normal variations in adolescent behaviour. Professionals are reluctant to label odd behaviour as mental illness before the signs become unmistakably abnormal.
According to Department of Health statistics, young people can spend up to two years with early symptoms of psychosis before they find their way into contact with psychiatric services.
The National Institute of Mental Health in England (Nimhe) studies found that the bigger the time gap between onset of symptoms and treatment, the more likely patients are to have poor outcomes across a range of measures. Delay increases the risk of lack of drive and initiative, poor self-care and embarrassingly abnormal social behaviour that continues into later life. One in 10 people with severe mental illness commits suicide, and two-thirds of these deaths occur in the first five years of illness.
Because of the time of life when these disorders begin, there can be severe consequences on the person’s ability to become independent, creative and self-motivated individuals in adult life.(1)
Reaching help early is important in any mental disturbance in adolescence, but particularly so in schizophrenia. It used to be thought that the longterm social consequences of having schizophrenia developed gradually over the years. Fifteen years ago a major World Health Organisation study showed that in fact these consequences develop primarily in the first three to five years of the illness. It follows from this that intervention to prevent these consequences must be in these years, or even earlier, to be effective.(2)
It is also important to bear in mind that, if a person’s first contact with a care service is delayed until the peak of an acute episode, they may experience it as intrusive or abusive. Nimhe reviewed the available research on early intervention services in 2003. It found that people with early symptoms who received a tailored intervention plus care from a specialised team were less likely to develop psychosis at six-month follow-up than those who received care from a specialised team only. They also found that hospital admission rates were significantly lower.
Early interventions have reduced suicide rates in the first five years of schizophrenia from about 10 per cent to almost zero.(3)
These services represent a significant change in the approach to mental illness, focusing on prevention of long-term effects rather than treatment of acute illness. So effective were they that from the end of 2004 the Department of Health funded early intervention services throughout England.
So who should be considered for referral? The classic early signs of psychotic illness include irritability, a significant change in energy level, a feeling of persecution, or odd behaviour, for example laughing to oneself for no apparent reason. One would not be in any doubt that this represented a serious problem – most likely of drug abuse, or severe mental illness.
However, this clear evidence of illness occurs in only 10 per cent of sufferers in the first months of illness. Before this, there may be changes in sleep, appetite and sociability, perhaps mimicking depression, feeling tired all the time, mood changes or a dramatic fall in grades at school or college.
The presence of drug abuse or recent triggering stresses is common, and should not prevent referral to specialist services. As adolescence is a time of experimentation and life change, both are common anyway, and both can start the process of psychotic breakdown in a previously healthy young person.
Early intervention services have a role in educating youth services in the routes to their service, and dispelling some of the concerns that such services may have about involving young people (usually aged 13-19, but up to the age of about 45) in specialist mental health services. There will therefore be several routes of referral, not only through the local community mental health team, but also school nurses and college tutors, youth clubs and paediatric services.
These early intervention services are special in the sense that they are fully aware of the stigmatising consequences of any mental health referral, and the risk that it may have a life-long influence on the person’s self-image and self-expectations.
Early intervention services are often located away from traditional psychiatric settings for this reason. Every effort will be made to encourage management of the difficulties within the family and the normal social networks of the person. The aim of intervention is to give the individuals and their families the skills to deal with difficulties in their lives so that they do not have to express their difficulties psychologically. The first meeting would focus on engaging the client in the process rather than starting treatment straight away. The client’s own aspirations and understanding of their problems are clearly crucial at this first assessment.
The team will be aware that good rapport with the family and other social support may be the most helpful therapeutic support they can give. This would include talking with the individual and their family about their alternative options for coping with stress, and drug education. The evidence is that merely teaching the family new strategies for dealing with emotional difficulties can be enough to make specialist treatment unnecessary. Those individuals with distressing mental symptoms are taught cognitive behaviour techniques to control and live with them and are screened for depressive illness and suicide risk.
Early intervention workers will engage the family if they cannot engage the client. They might offer practical support if the client finds this easier to accept than psychological or educational interventions. And they might drop in to the person’s home to make a brief mental state assessment on occasion. The client is encouraged to develop a range of fulfilling tasks and relationships to buffer them against future stresses. In Michelbaston in Birmingham, this support has been so effective that clients of the early intervention services are more likely than their well peers to be employed.
There may be reluctance to refer to psychiatric services because of the notoriously distressing adverse effects of antipsychotic drugs. Early intervention services will, it is true, use medication if necessary, but the efficacy of psychological treatments in the prevention of relapse and permanent effects of distressing psychotic symptoms has made us reassess our attitudes to them as illnesses.
We now see the development of psychological distress in terms of a family disposition and social or drug stresses, combined with a lack of more productive psychological skills. This allows us to approach people with hope. A hope which is, of course, a requirement of recovery.(4)
CHRISTINA ROGERS works as a staff grade psychiatrist in a community mental health team in Croydon, south London. She has a particular interest in preventive psychiatry.
TRAINING AND LEARNING
The author has provided questions about this article to guide discussion in teams. These can be viewed at
www.communitycare.co.uk/prtl and individuals’ learning from the discussion can be registered on a free, password-protected training log held on the site. This is a service from Community Care for all GSCC-registered professionals.
(1) Nimhe Expert Briefing, Early Intervention for People with Psychosis, summer 2003
(2) A Jablensky, N Sartorius, G Emberg and colleagues, “Schizophrenia: manifestations, incidence and course in different cultures: a World Health Organisation 10-country study”, Psychological Medicine, monograph supplement 20; 1-97, 1992
(3) M Marshall, A Lockwood, A Systematic Review of the Effectiveness of Early Intervention for Psychosis, 2003
(4) A K Torgalsboen, B R Rund, International Review of Psychiatry, 14(4), p312-317, 2002
● P French, A P Morrison, Early Detection and Cognitive Therapy for People at High Risk of Developing Psychosis: A Treatment Approach, John Wiley and Sons, 2004
● P D McGorry, M Nordentoft, E Simonsen, Introduction to “Early psychosis: a bridge to the future”, British Journal of Psychiatry, 2005; 187: 1-3
This article appeared in the 18 January issue under the headline “Give hope a chance”