Early detection and intervention in psychosis requires the maximum involvement of clients and their natural social networks, including primary care. Here, we outline the core principles that we believe must be embraced if this radical approach to the treatment of severe mental illness is to be realised:
1. A youth and client centred focus: Psychosis is mainly a problem affecting young people.
It con damage key aspirations such as work, self-determination and
relationships. These aspirations of youth must be reflected in the services
they receive, including the approach to engagement, and in the interventions
and opportunities presented by services. Young people with psychosis should be
encouraged to remain in contact with other young people. This can help to
increase a sense of hope for the future, and to regain or further develop their
former skills, interests and life goals.
2. Failure to engage should not lead to case closure: Achieving full and ongoing support and treatment in the early phase of psychosis can be compromised by a failure to engage with services (not attending out patient appointments, non-compliance with medication). The temptation to ‘wait and see’ by professionals until a further crisis emerges is strong. Valuable opportunities for intervention and prevention ore not grasped, and may jeopardise constructive engagement. A proactive approach to engagement both to the client and his/her immediate social network is crucial and must be sustained.
3. An emphasis on
social roles: Maintaining social roles and goals, particularly work,
is highly prized by young people and improving self esteem con positively
impact on the psychosis itself (Warner, 1994). Conversely, depression and
suicidal thinking in psychosis have been linked to loss of valued social roles
and prevent the individual from asserting on identity (Rooke & Birchwood,
4. Psychiatric treatment should be provided in the least restrictive and stigmatised setting and emphasise choice and low dose neuroleptics: 45% of clients hospitalised for an acute psychotic episode hove been found to hove symptoms of post traumatic stress disorder related to their psychosis and its treatment (McGorry et al., 1991). The treatment of clients in low stigma settings with medication regimes causing the minimum possible side.
5. The embracing of diagnostic uncertainty: “Schizophrenia does not present in neat parcels” (Thara et al., 1994, p54.) The diagnostic systems of DSM-4 and lCD- 10 are working models of mental disorder. This is particularly relevant to the early phase of psychosis where the reliability of diagnosis is modest at best, and the longitudinal stability of symptom presentation is low (McGorry 1991, 1992). Such uncertainty in diagnosis should not delay treatment, rather treatment should focus on the presenting symptoms. The avoidance of a syndromal diagnosis until symptoms stabilise (usually within the first 2 years of treatment) does not represent clinical or intellectual sloppiness, but a genuine response to the reality of the clinical situation. The embracing of diagnostic ambiguity is crucial when attempting to identify clients in the prodromal phases of psychosis, since non-specific symptoms often found in prodromal psychosis ore frequently found in normal teenagers (McGorry et al., 1995), and even with expert assessment, false positive rates are high. Those professionals and agencies working at the point of first contact must feel free to refer clients for expert assessment of symptoms based on a suspicion rather than a certainty of psychosis.
6. A family-orientated approach: Working closely with the family is a key ingredient to the success of the engagement process. Thinking of the family as part of a natural support network sets the stage for clinicians sensitively reconciling the apparent dilemma of client confidentiality with the family’s need to know. Coping with psychosis is not easy and we should also acknowledge the impact of psychosis on families and their legitimate needs for help and support. There is overwhelming evidence for the positive contribution families can make to the welfare of people with psychosis, particularly when those families are actively supported by psychoeducative interventions. We should recognise the valuable information families can offer clinicians about their relative’s problems in helping to formulate more effective treatment and rehabilitation plans and in helping to formulate more effective relapse and recovery plans and alerting services when things go wrong. There is a need for a clear ethical framework for supporting interventions to the family derived from a shored shared value base, and which balances the interests of its members with informed consent and confidentiality issues.