Source: The Conversation (Au and NZ) – By Pat McGorry, Professor of Psychiatry, The University of Melbourne
Psychotic illnesses such as schizophrenia cause severe distress and suffering for people who experience them and for their families.
All too often, these illnesses prevent those affected from completing education, starting work or keeping a job, and participating in their communities.
This can lead to impoverished lives and premature death, from suicide or preventable physical health conditions. People with psychotic illnesses die up to two decades earlier than those unaffected by these conditions.
These poor outcomes aren’t just part and parcel of the illness. Applying the strategies used to treat other diseases – such as early diagnosis and intensive early-stage care – can prevent psychotic illnesses from progressing or becoming life-long conditions.
Such care may be more costly than standard, delayed mental health care. But when you consider the economic gains from lower levels of disability, early intervention for psychosis delivers a substantial return on investment.
Fixing an outdated system
Mental health care reforms for psychosis started in Melbourne more than 30 years ago.
At the time, standard care for those experiencing their first episode of a psychotic illness started late and often resulted in traumatic experiences for the young person, demoralisation and increased risk of suicide.
Standard mental health services were dominated by middle-aged patients with long-term illness. Treatments were crude and limited, focusing on managing symptoms.
What were the goals of early intervention?
Early intervention for young people with psychosis offered hope for recovery through early diagnosis, combined with comprehensive multi-disciplinary team-based care. This included psychiatrists, psychologists, social workers, occupational therapists and others.
These services would be sustained during the critical period of the early years after diagnosis.
Early intervention offered a number of potential advantages over standard care, including:
- early diagnosis before the illness produces entrenched harm and disability
- being treated with greater care and respect
- being exposed to a hopeful and optimistic culture
- having family included and supported
- prioritising finding and maintaining work
- experiencing less stigma and treatment-related trauma.
Meanwhile, early intervention research created a scientific process to identify those at risk of developing psychosis and intervening before the full onset of the illness.
The goal was to prevent the development of psychosis or, if it did emerge, delay or mitigate its impact.
That was the idea, how has it worked in practice?
Over the decades since, hundreds of early psychosis programs around the world and an array of clinical trials have scientifically evaluated the effectiveness of early intervention for psychosis.
The programs target the early stages of illness and produce marked benefits in most patients.
This approach has shown:
a proportion of psychotic illnesses can be delayed and some may even be prevented
some cases of psychosis can be managed with little or no medication.
Importantly, these programs are extremely popular with young people and families.
But interventions can’t just stop suddenly
The recovery achieved through early intervention must be sustained by continuing care throughout the critical early years of illness.
The first wave of research and reform in early intervention created programs that only offered this enhanced care for two years. When people were discharged and started receiving standard care, some of the gains were lost.
More recent research has shown if the high quality of care provided by early psychosis programs is extended by a further three years (so five years in total), the gains are maintained.
Some critics argue achieving these functional outcomes in early psychosis isn’t worthwhile if it requires effort to sustain it.
This is like arguing it’s not worthwhile to secure remission from cancer because if the treatment is withdrawn or downgraded too soon, relapse occurs.
The better way of interpreting the evidence is to recognise that for a substantial subset of patients, the illness is persistent or recurrent. Therefore, having achieved a positive early outcome through early intervention it is essential to make every effort to sustain it.
Most patients require more prolonged intervention than the original two-year window of early psychosis care.
Early intervention saves money as well as futures
More than 20 economic analyses of early intervention in psychosis have shown a substantial return on investment.
While early psychosis care naturally costs more than substandard delayed care in generic settings, the clinical outcomes are substantially better than standard care, as studies from Denmark, the United States and Australia show.
And when accounting for the cost-savings from reduced rates of functional and social disability – which impairs family and social relationships – the overall economic outcomes are better, too.
This is due to a reduction in welfare dependence, greater tax receipts through employment, and reduced costs from suicide, offending and incarceration.
A recent evaluation of the Australian Early Psychosis Youth Services (EPYS) concluded these health services were not cost-effective.
However, it did not actually conduct a cost-effectiveness study, merely listing costs alone. It also failed to take into account the economic benefits seen from employment, education and justice – and the authors acknowledged this shortcoming.
When considering the economics of early intervention, it’s important functional and social recovery is included – meaning a person can work or study and participate more fully in society – rather than just symptom recovery and direct health care costs.
Crucially, the evaluation found young people with psychosis and their families highly valued the early intervention approach, which helps them pursue their hopes and dreams of a meaningful and fulfilled life.
If this article has raised issues for you, or if you’re concerned about someone you know, call Lifeline on 13 11 14.
Pat McGorry works for Orygen which originally developed and jointly led with international colleagues the scaling up of early intervention for psychosis paradigm. Orygen now provides expert clinical support and supervision to the national EPYS system of early psychosis with support from the Australian Government.
I have received substantial funding from NHMRC, NIMH, Wellcome Trust and State and Federal governments to support my research and clinical work in early psychosis and youth mental health.
I am a Founding Director of headspace and of Australians for Mental Health.
I was the Founding President and now Treasurer of the IEPA: Early Intervention in Mental Health, which is the global organisation which has fostered early intervention in psychosis and other mental illnesses since 1997.
I am Editor in Chief of Early Intervention in Psychiatry.
Andrew Thompson is a Professor of Youth Mental Health at the Centre for Youth Mental Health at the University of Melbourne and Director of Specialist Services at Orygen clinical program and has conducted some of the studies in this article. He receives research funding in grants from NHMRC, NIHR, NIMH, the Wellcome Trust and the Victorian State Government. He has previously had support from the University of Melbourne, the MRC, the MQ foundation, Neuroscience Research Grants, the Telematics Trust and the Royal Melbourne Hospital.
Ellie Brown has received funding from the Department of Health, the Wellcome Trust (UK), Western Victoria PHN, and the University of Melbourne. She is a Research Fellow at Orygen and has conducted some of the studies referenced in this article.
Eóin Killackey receives funding from NHMRC, Norwegian Research Council and Wellcome Trust, and has in the past received funding from ARC and Australian Rotary Health. He is the Director of Research at Orygen and has conducted some of the studies referenced in the article. He is currently President of IEPA:Early Intervention in Mental Health
– ref. Early intervention for psychosis might cost more initially but delivers a greater return on investment – https://theconversation.com/early-intervention-for-psychosis-might-cost-more-initially-but-delivers-a-greater-return-on-investment-173729