Cut the wait

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.