VOL: 102, ISSUE: 05, PAGE NO: 28
Christina Rogers, MRCPsych, MB, BSc, BS, is staff grade psychiatrist, Covenant Churchill Clinic, London
Nurses are all too aware of the shortcomings of treatments for people with schizophrenia. The drugs available not only produce unpleasant or dangerous side-effects but in most cases also have no effect on the more debilitating negative symptoms. The manufacturers of the newer antipsychotic drugs claim better efficacy on the symptoms of schizophrenia compared with older alternatives but the statistically significant differences are small and their clinical significance is questionable (Taylor et al, 2003).
Attempts at social and psychological treatment have until recently aimed to improve the functioning of the individual despite their symptoms, having little or no effect on the development of new symptoms. The relationship between nurse and client often includes discussions about drug side-effects and intramuscular injections, which can only interfere with the standard of warm, understanding, professional support.
Over the past five years the NHS has aimed to move towards ‘a health service designed around the patient’, patient choice, improved access to services, care of the mental health needs of the community and improved availability of psychological treatments (Department of Health, 1999). When this plan was reviewed in 2004, the executive summary stated: ‘Complementing that drive for a high-quality personal service for individual patients when they are ill will be a much stronger emphasis on prevention’ (DoH, 2004).
Once someone has an illness, treatment is in many cases only able to reduce the impact of symptoms, rather than cure the disease. Preventive strategies are therefore the ideal.
Providing help early is particularly important in schizophrenia. The long-term outcome is socially and physically poor, even with modern treatments. One in ten people with severe mental illness commits suicide, and two-thirds of these deaths occur in the first five years of illness (Wiersma et al, 1998).
How early is early?
The earlier a psychotic illness is effectively treated, the less likely it is that negative symptoms will develop (Waddington et al, 1995).
It used to be thought that the negative social consequences of having schizophrenia developed gradually over the years, perhaps as a result of repeated assaults on the brain in the form of acute episodes.
Now a huge World Health Organization study has shown that these consequences primarily develop in the first three to five years of the illness (Jablensky, 1992). It follows from this that intervention to prevent these consequences must be in these years, or even earlier, to be effective.
One difficulty with this is that, of course, young people can spend up to two years with early symptoms of psychosis before they find their way into contact with psychiatric services (DoH, 2000). The reasons for this include a lack of awareness of the signs of early mental illness and the stigma associated with it.
Another problem is that it is likely to be difficult to convince the individual of their need to receive help so early in the disease process. The services have been developed with this specific problem in mind and various strategies are used to reduce problems of engagement.
Only 10 per cent of people have psychotic symptoms in the early stages. Other symptoms to look out for include:
- Somatic changes, perhaps similar to those found in depression;
- Continued tiredness;
- Mood changes;
- A dramatic fall in grades at school or college;
- A family history of psychosis (though it is important not to leap to conclusions).
These young people will not be presenting to the community mental health team in most cases, so the early intervention team must develop referral and educational links with schools, colleges and agencies that have contact with young people aged 13-19 years in particular, but also look to engage with people aged up to 45. Links should also be forged with child psychiatry and paediatric teams, college nurses and tutors as well as primary care.
The aim of intervention is to give the individuals and their families the skills to deal with difficulties in their lives so that they do not have to express their difficulties psychologically. Symptoms often appear in the context of normal stresses in people’s lives when they are struggling with relationships, work or home life. Strategies include:
- Clarify what is happening as much as you can, as quickly as you can. The history at this stage is often confused, but should include a rapid and thorough examination of the symptoms, resources and risks, including suicide. The client’s aspirations and understanding of the illness are crucial at this first assessment, and the aim of the meeting should be engagement rather than treatment;
- Support the family and the person in the family context. This is especially important in such early intervention. The emphasis is on the client’s views of their situation and problems. They are likely to be young and still dependent on their family so a good rapport with the family may be the most helpful therapeutic input you can give;
- Provide psychological education to the young person and their family, including drug education. The evidence is that merely teaching the family alternative strategies for dealing with emotional difficulties or conflicts can ameliorate difficulties to the extent that specialist treatment is no longer necessary. Those individuals with treatment-resistant positive symptoms should be provided with cognitive behavioural therapy in order to learn how to control and live with them;
- Identify and treat depression and suicide risk;
- Agree a relapse prevention plan with the client and their family. This should include clear contact points with the service;
- Avoid stigmatisation and development of a mental health persona. A risk of intervention at such an early age is that contact with mental health services might have a lifelong influence on the person’s self-image and self-expectations. This is clearly to be avoided and every effort should be made to encourage management of the difficulties within the family and the normal social networks of the person. Early intervention services are often located away from traditional psychiatric settings to achieve this;
- Support them back into ordinary life. An appropriate task for the early intervention services is the support and encouragement of the person in returning to ordinary activities and social functioning. In Michelbaston in Birmingham, for example, this support has been so effective that clients of the early intervention services are more likely than their well peers to be employed;
- Accessing appropriate inpatient care. If this is needed, inpatient facilities should be age appropriate, and should if possible be prevented by having intensive community support on a 24-hour basis. The early intervention team should be actively involved with inpatient reviews and discharge planning;
- Accessing appropriate long-term care. The person’s care needs to be integrated with the general acute mental health services or rehabilitation services. Discussions are ongoing as to what is the most sensitive way to achieve the transfer. One service model includes a consultant psychiatrist who works half time in the early intervention service and half time in the recovery service (rehabilitation);
- Assertive approach to engaging the client and their family. This illustrates telling differences between the interventions by early intervention services and those of general community mental health services. Early intervention workers will engage the family if they cannot engage the person and attempt to influence his or her perceptions of their condition indirectly. Workers might offer practical support to the person that they would find easier to accept than psychological or educational interventions;
- Boosters of treatment and support may be required through the individual’s life to maintain the preventive effect. In an analogy with immunisation, it is thought that early intervention may have a preventive effect for a certain length of time but occasional boosters are needed to prolong the effect.
The impact of illicit drug use
Recreational cannabis use is very prevalent in the target group for early intervention. Between 55 and 60 per cent of children admit to using cannabis (Patton et al, 2002), so cannabis use on its own is not necessarily relevant to the development of psychosis (Van Os, 2002). What does appear to be relevant is abuse, typically on a daily basis, of cannabis or amphetamines, both of which have been linked most closely to relapse in psychotic illness (Patton et al, 2002).
Anyone who takes drugs has the potential to develop psychotic symptoms, but it is only those with a vulnerability to psychosis who will have symptoms that persist even when they are no longer taking the drugs. These are among the people who might benefit from early intervention.
Just under half of the early intervention group use one of these drugs daily, which would of course make it difficult for them to achieve mental stability. So drug education is particularly important for those with psychotic symptoms.
Outcome of early intervention
Early interventions have driven down suicide rates in the first five years of schizophrenia from about 10 per cent to almost zero (Miles, 1977).
The National Institute for Mental Health in England undertook a review of the available research on early intervention services. It found that people with prodromal symptoms who received a phase-specific intervention (low-dose risperidone and cognitive behavioural therapy) plus care from a specialised team were significantly less likely to develop psychosis by the six-month follow-up than those who only received care from a specialised team (McGorry et al, 2002). They also demonstrated that hospital admission rates were significantly lower for those who had family therapy and outpatient care for their first psychotic episode, as against those who had only outpatient care.
A recent randomised controlled trial of treatment of those presenting for the first time with psychosis showed that specialist interventions significantly reduced the number of admissions and dropouts from treatment (Craig and Garety 2004). Limitations to early intervention can be found in Box 1 (p29).
We can conceptualise the development of the disease in terms of a familial disposition and social or drug stresses, combined with a lack of compensatory psychological skills. This could allow us to approach people with this disease with attention to their active coping skills, which should instil hope in both clients and professionals - a hope that is considered a primary requirement of recovery (Torgalsboen and Rund, 2002).
Morrison and French (2004) showed that, using operational criteria developed by Yung et al (1996), young people who have prodromal schizophrenia can be prevented from developing both positive and negative symptoms of the disease with specially directed cognitive behavioural therapy (Morrison and French, 2004). Cognitive behavioural therapy of up to 26 sessions for these people also reduced the need for antipsychotic medication.
The potential change in the treatment for and attitude towards schizophrenia is dramatic. Not only could the worst effects of schizophrenia be preventable, but achieved with a psychological intervention rather than a pharmacological one.
In an article following the Third International Early Psychosis Conference, McGorry et al (2005) consider that: ‘There is finally substantial momentum behind preventative strategies in psychosis which, now they have reached ‘proof of concept’ stage, could begin to be extended across the spectrum of serious mental disorders.’
Each week Nursing Times publishes a guided learning article with reflection points to help you with your CPD. After reading the article you should be able to:
- Understand the difference between preventive treatment and classical treatments;
- Understand how this affects the way in which contacts are made between the symptomatic individual and health care professionals;
- Be aware of the factors that might limit the effectiveness of early intervention;
- Be aware of the most recent research and possible future developments in early intervention.
Use the following points to write a reflection for your PREP portfolio:
- Write about where you work and why this article is relevant to your practice;
- Reflect on the last time that you encountered a patient with early symptoms of schizophrenia;
- Identify any information from this article that you could have used in this situation;
- Write about how you will use this information in your future practice;
- Summarise what measures you will take to follow up what you have learned.
This article has been double-blind peer-reviewed.
For related articles on this subject and links to relevant websites see www.nursingtimes.net