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Early intervention is crucial when helping young people who have developed psychosis, write Kate MacDonald and Richard A Powell. And one project in Hull is ensuring early treatment is more likely by harnessing several young people’s agencies.

A "psychosis" is a disturbance in a person’s thinking that divorces them from reality. It often manifests in hallucinations, delusional ideas, disorganised speech patterns, and intense mood fluctuations. It first tends to emerge during the mid to late teenage years and early twenties, during an important developmental stage for young people, and can lead to the development of mental health problems such as schizophrenia.

The disruption which psychosis causes can result in educational, vocational, and social problems that impair confidence and young people’s ability to perform their daily roles. People with severe mental illnesses face huge disadvantages in the job market: one half of all people signed off for six months or more with a mental health problem will never work again.

Traditionally, child and adolescent mental health services (Camhs) have been responsible for addressing the needs of young people with psychoses. However, Camhs have weaknesses that hamper this role. Many have long waiting times, and young people may already have been experiencing psychosis for a long time before the referral was even made. Psychoses among this age group are relatively rare, so staff may lack the necessary expertise to prioritise cases and address individuals’ needs. Children with suspected psychosis often receive narrow, medically dominated care and the transition to adult mental health services at the age of 16 or 18 is often problematic, with some young people falling through the net or receiving inappropriate care in adult acute units.

The government has accepted the need for early assessment and care at the first sign of a psychotic illness, and sees early intervention in psychosis (EIP) services as a means of filling existing gaps for young people. There are plans to develop 50 EIP services across England so that by the end of next year all young people either experiencing their first episode of psychosis or the first three years of their psychotic illness will receive early and intensive support for up to three years.

A prerequisite to early and effective treatment is early detection. A long time lag between the first onset of psychotic symptoms and the point at which treatment is provided, known as the duration of untreated psychosis (DUP), increases the risk of individuals experiencing more long-term problems, including unemployment, impoverished social networks, loss of self-esteem and serious physical injury (including suicide).

Government guidance says the DUP should be reduced to no longer than six months. For most people, however, DUP is now estimated to be between one to two years. This delay is important. The damage caused by psychosis occurs mainly during the early stages of the illness, for a duration of up to five years.

This formative period of vulnerability and deterioration has been labelled the "critical period", the outcome of which predicts the long-term course of the illness. Offering effective treatment during this critical period can decrease the likelihood of relapse and social disability, limit adverse psychological problems, reduce longer term health care costs, limit the development of "treatment-resistant" symptoms, improve service engagement and avoid the revolving door syndrome of repeated relapses.

Early intervention services are sensitive not only to the developmental needs of young people but also to the different ways in which they seek help. Young people are more likely to seek non-stigmatising, friendly and age-appropriate services. EIP services attempt to reflect that fact.

In order to achieve these goals, however, EIP services must establish close and effective working partnerships with a range of statutory and non-statutory services. It is particularly important to develop closer working relationships between adult services (through which EIP teams are being developed) and Camhs to enable access to, and transition between, services.

In Hull and East Riding, the partnership between young people’s services and adult mental health services was central to the development of EIP.

The project was developed as a collaboration between the Early Intervention Service and Camhs inter-agency link team, the University of Hull, and Hull and East Yorkshire Mind, in a project funded by the youth employment and education advisory service, Connexions.

Hull’s goal was to improve access to mental health services and to create strong links between organisations within the city. Connexions needed access to specialist mental health services, while both the Camhs and adult services wanted access to education and the wider community.

The project has demonstrated how mental health and educational services can work together to develop models that enable early detection and referral, and the training of a range of front-line staff.

The project aims to do three things:

• Create a model for dealing with mental health issues within Connexions and secondary schools. The model needed to provide more efficient pathways into appropriate care.
• Enable rapid assessment, early intervention or referral to an appropriate agency.
• Develop appropriate skills to enable staff (Connexions personal advisers and teachers/support staff) to assess and support people with mental health problems in school and college.

The referral system was also designed with the specific objectives of reducing rather than increasing referrals of milder disorders, and selectively encouraging referrals of more serious mental health problems. It was also designed to enhance the skills of the primary care team to manage more common and less severe mental health problems more effectively.

The referrer meets with the young person, offering therapeutic input and training, as well as generally being available as a signposting resource to other services. At the heart of the project is cross-agency communication and feedback. Connexions’ personal advisers play an important role both by being a "communication centre" and supporting young people to enable them to return to school, attend college or take up training.

As well as supporting individuals with a first episode of psychosis, the service has an important health promotion role. The project team is currently working with the Community NHS Trust’s Mental Health Promotion Department (tapping into the National Healthy Schools Standard and Mind Out Campaign) and Hull and East Yorkshire Mind to develop a programme for students in schools and colleges with the objective of normalising mental health and encouraging students to seek help for themselves or their friends earlier.

This project is one example of how an EIP service can work in partnership with other agencies to reduce the DUP, provide young people with appropriate treatment, and work with education and Connexions to enable a young person to return to education or training.

Kate Macdonald is project manager, Early Intervention Service Development, Hull and East Riding Community NHS Trust. She is also a research psychologist at the department of psychiatry, University of Hull. Richard A Powell is acting senior researcher, policy and research directorate, Sainsbury Centre for Mental Health, London.