C.    Ten-point Service Specification based on Regional IRIS Strategy guidelines:

Strategy 1: Early detection and assessment or psychosis as an essential component of early intervention.

Multi-disciplinary audit of pathways to care can reveal the variation in duration of untreated illness, the variety of pathways to care (GP,  Police, neighbour, church etc.) and their relationships to the pathways:

• identifies training needs and potential service developments in community, primary and secondary services
  
  
• improves collaboration between primary and secondary care to promote early detection and treatment
  
  
• enables client and carer experiences to influence development

Clinical guidelines for screening and referral. Inherent in this is a tolerance of diagnostic ambiguity and a focus on dominant psychotic symptoms rather than diagnostic frameworks.

Setting for initial assessment: non stigmatising e.g. assessment at home or GP surgery.

For some potential cases, presence of psychosis will be initially unclear: keep a three month ‘watching brief’, support as appropriate; those with an underlying psychosis. are likely to progress within this time frame.

Strategy 2: A key worker allocated on referral of the case to ‘stay with’ the service user and family/friends through the first 3 years (the critical period’) preferably within the assertive outreach model.

Strategy 3: A comprehensive assessment plan and collaborative assessment of needs should be drawn up, and driven by the needs and preferences of the client and his/her relative and friends.

Incorporates assessment of mental state, vulnerability, psycho-social and social factors (see Tool Kit), involving the client and his/her family: reviewed at:

• 6 weeks
  
  
• 3 months
  
  
• 2 years
  
  
  
  

Strategy 4: The management of acute psychosis to include low dose, preferably atypical neuroleptics and the structured implementation of cognitive therapy.

Clinical guidelines for use of neuroleptics should be agreed with explicit reference to regular review, dosages, side effect monitoring, treatment resistance and use of newer  atypical neuroleptics (Refer to Medication protocol for detailed consideration of pharmacological approaches)

Guidelines should include various treatment strategies including psychosocial inter­ventions; managing positive and negative symptoms; relapse strategies; cessation of medication.

Strategy 5: Family and friends actively involved in the engagement, assessment, treatment and recovery process:

Engagement of the client should always embrace the family, within one week of presentation so that crisis support, debriefing and the family’s perspective can be gained.

This initial contact should be at their home and include a ‘debriefing’ session, giving the family opportunity to ‘tell their story ‘ about the build up to psychosis and to give vent to their feelings.

Straightforward psychoeducation and support individually and in groups should be provided.

Psychoeducation and Family Intervention should be available focusing on:

• Ongoing relationship problems in the family
  
  
• Unresolved loss and despair in key relatives
  
  
• Problems of coping with psychosis-related behaviour, at home

Family and friends should, with the agreement of the client, be part of the ongoing review process.

Strategy 6: Strategies of relapse prevention/minimisation and for treatment resistance should be implemented to embrace vulnerability factors, prophylaxis, and early detection /intervention.

Relapse Prevention

Clients and families should be informed about the risk for relapse and what factors are within their control.

Relapse risk assessment should form part of the ongoing assessment progress and embrace:

• Vulnerability: (untreated psychosis, previous exacerbations)
  
  
• Prophylaxis: Utility of and adherence to medication regimes
  
  
• Stressors: both acute (life changes, cannabis abuse) and long term (interfamilial stress, unstable life patterns).

An individualised, shared and documented relapse prevention plan should be developed and rehearsed with the user and social network. This should include:

• lndividualised signs of relapse (‘relapse signature’)
  
  
• Development and rehearsal of a linked ‘relapse drill’, involving, where appropriate, a targeted and time limited neurolpetic medication
  
  
• An active relapse monitoring procedure

The experience of relapse/exacerbation should be viewed as an opportunity to learn about the relapse signature and operation of the relapse prevention procedure.

Treatment Resistance

The continued experience of psychotic symptoms within 6 months of first treatment suggests that such symptoms are likely to continue. The review at this point should declare the presence of drug resistant symptoms and determine an appropriate strategy.

• Trial with atypical neuroleptics such as Clozopine should be considered.
  
  
• Cognitive therapy can reduce drug resistant symptoms and should be considered.
  
  
• Teaching clients to deal with and cope with such symptoms to minimise distress may be required
  
  
  
  

Strategy 7: Facilitate clients’ pathways to work and valued occupation during the critical period, to include:

Assessment of clients best ever educational/vocational functioning work experiences and employment aspirations as part of the assessment plan and reviewed regularly.

User led vocational/educational-training program; where possible implemented in conjunction with e.g. Training and Enterprise Council and other relevant agencies.

Job training opportunities within mental health services where appropriate; tapping client’s invaluable experience of psychosis and of mental health services, and using their employment in services to provide an important stepping stone.

Strategy 8: Ensuring that basic needs of everyday living are met and reviewed regularly, which:

Makes available appropriate accommodation of the client’s choice.

Assesses the individual’s eligibility for benefits, grants etc.

Facilitates access to specialised help as needed: legal aid, social work, CAB etc.

Strategy 9: Assessment and treatment of ‘comorbidity’ in conjunction with psychosis addressing:

Problematic substance misuse, depression / suicidal thinking, social avoidance and intrusive memories linked to the psychosis, and assessed regularly.

Opportunities for personal counselling on matters concerning the development of and adaptation to psychosis. This might take the form of a structured recovery programme (see Tool Kit), including an opportunity to form alliance with others facing similar difficulties.

Specialised help for substance misuse including information about the risks for relapse

Strategy 10: Locally promoting positive images of young people with psychosis

A community education programme to emphasise the treatability of psychosis and counteract negative social attitudes regarding psychosis. This should be targeted at the professional and voluntary sectors likely to encounter young people with psychosis; for example student health services, schools, police, homeless agencies, and religious / cultural organisations.

Local media — form positive relationships with journalists on local newspapers, radio and television, in order to correct mistaken beliefs about psychosis.