1. An Introduction to Early Intervention
Manchester Mental Health & Social Care Trust

2. Aims & Objectives
To provide an overview of early intervention for psychosis.
To provide a background to concepts of early intervention and the phases of a severe mental illness.
To enable recognition of the signs and symptoms that might develop in a young person.
Ask the group if they have any additional needs from the session

3. What is Early Psychosis Intervention?
Early psychosis intervention refers to the evidence based approaches used in the management and treatment of psychosis
The approaches emphasise the importance of timely interventions which are individualised, intensive and comprehensive.
Intervention should be appropriate to the phase of the illness to reduce the likelihood of further episodes of illness
It is important that the trainer emphasises the fact that this is early onset rather then the early signs of a relapse which is often referred to as ‘relapse prevention’ or ‘early warning signs’.

4. What is Early Psychosis Intervention?
The incidence of first episode psychosis is estimated to be 15 – 20 cases per 100,000.
Early intervention aims to reduce the duration of untreated illness which has a positive outcome in terms of reduction of relapse.
This has been the impetus for the development of early intervention services
Early interventions have substantially decreased the need for in-patient care. (McGorry 1998)
The incidence in 2001 was 15 per 10,000 (DOH 2001) but this varies according to areas of deprivation and ethnic groups especially amongst African-Caribbeans.

5. An Introduction to the Evidence Base
Schizophrenia and other psychotic illness can be treated effectively if timely interventions are delivered in ways that are acceptable to the people receiving them.
However, schizophrenia may become a life long disorder if not treated appropriately in the early stages.
Generally the onset of psychosis is uncommon in under 13yrs olds however the incidence increases in later adolescence.

6. An Introduction to the Evidence Base
The cognitive and psychosocial damage caused by psychosis appears to occur in the first 5 years, then a ‘plateau of disability’ occurs (Lieberman 1997)
Treating during the ‘critical period’ can decrease relapse and social disability, limit psychological problems and reduce healthcare costs (McGorry & Jackson 1999)
The longer the DUP, the more risk of long-term problems such as serious physical injury, unemployment, impoverished social networks, loss of self esteem ( Jackson & Farmer 1998;Johannessen 2001)
The DUP refers to duration of untreated illness (Duration Untreated Psychosis). Encourage the group to consider why young people might experience long periods of illness before they come to the attention of services. Reasons might include young people spending long periods outside the family home with friends who might not notice any signs and symptoms. Changes might be attributed to drug or alcohol use or teenage behaviour. There might also be a sense of denial that the family do not want to approach service for fear of stigma.

7. An Introduction to the Evidence Base
Morrison et al (2004), in a randomised controlled trial (RCT) known as the ‘EDIE’ study (Early Detection and Intervention Evaluation) found that the young people they studied displayed two distinct subsets of experiences on entry to their programme:
1. Transient Psychotic Symptoms - ‘Brief Limited Intermittent Psychotic Symptoms’ (BLIPS). These can be ‘full-blown’ psychotic symptoms that last for a few days and then spontaneously resolve
2. ‘Attenuated’ (Subclinical) Psychotic Symptoms - not severe or disruptive enough to be described as actual symptoms of psychosis
The EDIE study identified groups of young people with a potential vulnerability to the development of psychosis then randomly assigned them to one of two groups . The treatment group received cognitive behavioural therapy focusing upon problem solving and reality testing. The control group were assessed and closely monitored without any specific intervention . The results of the study were that the intervention group were less likely to develop psychosis than the control

8. Early psychosis -The Phases of Illness
The first episode of psychosis has been identified as having four ‘phases’:
Prodromal
Acute
Early Recovery
Late Recovery

9. Adolescent behaviour or onset of illness?
In small groups consider all emotions , thoughts or behaviours that an adolescent might experience.
Write these down and share them with the rest of the group.
Some of adjectives that you might encounter from the smaller groups include : fear, anxiety, apprehension, excitement , bad moods, lethargy, tiredness, tearfulness, anger, resentment.
Encourage the group to consider the difference between this and some of the signs and symptoms we are likely to talk about when we consider psychosis.
Also, if the group have not considered any positive aspects of adolescent behaviour, bring this to their attention.

10. The Prodrome
This is the stage which occurs before the development of psychotic symptoms
A prodrome is difficult to identify as it is similar to the stages of adolescence.
This may take on a greater meaning for others if the person has been identified as being vulnerable already due to their family or developmental history.
The person might be distressed at this stage or show signs of changes in their behaviour.
The concept of prodrome in illness is very common in physical ill health. The example often given is that of the prodromal period in measles. The person has actually developed measles yet, but there are certain characteristics that indicate a developmental stage of the measles virus.This is often only identified after full measles has developed.Is this similar in psychosis?

11. The Prodrome
The ‘prodrome’ might be an extended period lasting for months but this is not always the case
People presenting with these symptoms should be monitored within a primary care setting
(National Collaborating Centre for Mental Health, 2003)
Although young people at this stage should be monitored in primary care – this does not always happen!

12. The signs associated with a prodrome
A sense of being suspicious or worried
Getting irritable and angry or feeling more tense than normal especially over trivial things
Experiencing mood swings – feeling low then feeling very happy
Having problems getting organized and being unable to establish a routine.
Feeling low or depressed. They may feel a sense of hopelessness about themselves and the future
Can the group identify any other behavioural patterns or changes in thinking or feeling that might indicate the development of a psychosis?
It is often difficult to distinguish between depression and anxiety states and a prodrome of a psychotic illness

13. The signs associated with a prodrome
Changes in sleep pattern – an inability to get to sleep or waking up early
Changes in appetite or eating habits - perhaps feeling a bit suspicious about food
No sense of ‘get up and go’ anymore, a loss of energy or motivation to do anything
Experiencing difficulty remembering things such as appointments or practical arrangements
Encourage the group to consider the difference between these signs and normal adolescent behaviour.

14. The signs associated with a prodrome
Perceptual changes such as experiencing an unusual sense of taste, smell or seeing or hearing things differently
Not going out and becoming social isolated from friends or family
Feeling anxious about things. This might be in social environments or going out alone

15. Brief Limited Intermittent Psychotic Episodes ( BLIPS)
These might be brief episodes of a full psychotic illness which might involve all the symptoms of a psychosis but for a brief and limited period.
Otherwise these might be similar to psychotic symptoms but not as intense as a ‘full blown’ psychosis.
They often occur within the prodrome phase but they do not necessarily lead to a ‘full disorder’.
These brief episodes tend to last no longer than a week and spontaneously resolve.

16. The Acute Phase
Initially the person might develop ‘attenuated’ positive symptoms.
This phase is characterised by more serious symptoms such as hearing voices, having strange or frightening beliefs or experiencing difficulties with thinking processes.
Sometimes due to the distress involved the person will refuse help or support.
The goal at this stage is to resolve symptoms and prevent the establishment of secondary symptoms

17. The Acute Phase
If the person is very disturbed they might present with behaviour which might cause them to be at risk to themselves or others and will need a risk assessment
An in – patient admission or home treatment team might be necessary.
Issues of acute risk can sometimes overrule the wishes of the young person to avoid contact with services.
Risk MUST be our highest priority at all times.

18. The Signs Associated with the Acute Phase
Hearing voices when nobody is around
Hearing ones’ own thoughts aloud
Believing objects around the house have been specially arranged
Thinking that the TV is sending special messages to the person.
Believing that they are being followed or someone is attempting to harm them

19. The Signs Associated with the Acute Phase
Believing that people are talking about them or laughing at them without any evidence to substantiate that belief
Unusual behaviour such as excessive checking or wearing unusual clothes, sunglasses
Staying up all night, pacing around.
These are just a few of the common signs experienced by people who are in the acute phases of an illness
The trainer might wish to provide examples of their own clinical experiences.

20. Early Recovery Stage
Often considered to be in the first six months following treatment
It is during this time that the person is at most risk of suicide, especially when discharged from hospital.
It is during this stage that the social, economic , physical and environmental and occupational needs should be assessed
Each person will should receive a care plan and a named care co-ordinator
Encourage the group to consider why it is that the period immediately following discharge is a high risk time for young people. This is due to the stigma of being in hospital, a realisation of their future and though the illness is supposedly now treated they still feel upset and they might also have a residual depression.
The young person might fear relapse.
Often they will be returning home to face peers, family and friends who have no understanding of their experiences or returning to traumatic situations which initially triggered the symptoms of their illness and as a consequence they may feel alone and afraid.
The young person might have met people during their admission who have told them about distressing experiences of their involvement with mental health services and feel unable to cope with such a possible future.
The person might return to using alcohol or drugs to cope with problems .

21. Late Recovery Phase
This phase follows the early recovery phase by a further 12 months
The medication regime to maintain health should be established
The goal is to promote recovery and avoid relapse
During this phase the clients should develop an awareness of the illness and develop skills to achieve life goals
At this stage it is essential for the young person to develop trusting relationships not only with mental health professionals but also others involved in their life such as teachers and youth workers. Unit 3.4 discusses isses concerning social inclusion in more detail.

22. Late Recovery Phase
The first five years following a acute episode is referred to as the ‘critical period’
The risk of relapse is high during the critical period and occurs in around 80% of those who have an untreated psychosis.
Maintenance therapy of medication significantly reduces relapse rates
The trainers may want to discuss with the group issues around maintenance of medication and concordance Unit 3.2 (Medication) discusses these issues in more detail.

23. Residual symptoms during the recovery stages
Negative symptoms are often present following an acute phase.These are generally the cause of long term disability
People who experience negative symptoms may talk less spontaneously
The person might be unable to express themselves and appear to lack emotion
Less energy and loss of motivation is common
The ability to plan ahead and concentrate may be compromised
It essential to involve the family at this stage. Such interventions might include problem solving , goal setting and communication skills training alongside a psycho-educational package.

24. Residual symptoms during the recovery stages
The person might continue to maintain abnormal beliefs or experiences following an acute episode yet might be less distressed about them
Secondary symptoms such as depression or anxiety may develop
Some clients might develop drug or alcohol problems as they seek a way of coping with distressing symptoms
The young person might benefit from a wide range of interventions at this stage such as an Occupational therapy programme , dual diagnosis interventions and cognitive behavioural therapy alongside medication.

25. The Stages of Psychosis
In pairs read through the vignettes of the phases of psychosis
Try to identify the symptoms present within the case studies and insert them into the table provided in the handouts
Consider which symptoms are most characteristic of the different stages of a psychotic illness
This exercise might take some time and will need the support of the trainer

26. Conclusion
Early interventions for psychosis aim to decrease the duration of untreated illness and to improve outcomes by promoting recovery and preventing relapse
Four stages have been identified in the course of psychosis
The prodromal stage is difficult to identify due to the associated developmental changes of adolescence
The critical period following an acute phase needs to be closely monitored as relapse is common
The trainer may wish to revisit the aims and objectives to ensure the groups needs for the session have been met.