Health promotion in psychosis services

Introduction

Psychosis affects 1-3% of the population. An estimated 7,500 young people aged 14-35 in the UK will have an emerging psychosis every year (Department of Health, 2011).

Typical signs include:

• Hearing, seeing, sensing or smelling things that other people do not;
• Thinking and believing that everything is about or related to you;
• Becoming preoccupied with suspicions that others are out to harm you;
• Thoughts being faster or slower;
• Feeling as though thoughts are being put in your head or disappearing.

These are just some signs people with an emerging psychosis might experience. Each person’s experience will be different so treatment needs to be tailored according to individual experiences and needs.

Mental illness has traditionally attracted a less favourable focus in terms of policy and innovation, leading some to describe mental health services as “Cinderella services” (DH, 2011). However, long-term mental illnesses such as schizophrenia and bipolar disorder can reduce life expectancy by 15-20 years and limit employment prospects by 84%. They cost society £6.7bn a year and lead to suicide in 10% of those affected (DH, 2011; McCrone et al, 2010). Carers and families have associated health and social risks including depression and loss of employment as a result of caring for their relative (Jackson and McGorry, 2009). This suggests they should receive more attention and effort. 

Recent research into UK early intervention in psychosis services (EIIP) has shown they improve prognosis and save up to £290m a year through detecting and treating symptoms early instead of waiting for the illness to take a permanent hold (Jones et al, 2010).

Aims of EIIP

EIIP services work for up to three years with young people aged 14-35 with a
first episode or at high risk of developing psychosis. The framework was founded by Patrick McGorry and colleagues in Australia in 1989. The first UK EIIP team was set up in Birmingham in 2001. Surrey and Borders Partnership Foundation Trust formed its first service in 2004, and now has three teams, including North East Hampshire and Surrey Heath, which undertook this project.

EIIP works to detect and treat psychosis early and focuses on broader outcomes rather than on simply reducing symptoms. Helping young people reintegrate into education, work and wider society is just as important. The fundamental aims are to:

• Reduce the duration of untreated psychosis (DUP) to achieve the best outcomes for clients and families and, where possible, to prevent long-term mental illness;
• Engage communities in promoting health and reducing stigma. This will make talking about mental health and psychosis easier and lead to more people being able to seek help early;
• Help young people to reclaim an ordinary life, which may include family life, friends, education, work and other aspirations.

Barriers and health promotion

The success of the above aims depends on clients and families being able to access EIIP and mental health services early. Identified barriers include lack of awareness, shame and stigma (Wong et al, 2009). Negative associations with mental illness can lead young people and their families to feel too ashamed to ask for help from a GP. Parents also report hesitation due to fear of being blamed and labelled as a “bad parent” or being marginalised alongside their child (Wong et al, 2009).

We undertook this comparative study to:

• Evaluate the impact of focused health promotion activities on EIIP outcomes;
• Standardise the way we track the progress of people who use EIIP during the three years;
• Be better able to predict risk factors for poor outcomes.

The World Health Organization (2009) defined health promotion as “the process of enabling people to increase control over, and to improve, their health”. We worked to raise awareness of psychosis and the help available. This included:

• Attending health fairs at secondary schools, colleges and the local university;
• Quarterly meetings with local GPs and other primary care practitioners to raise awareness;
• Involving service users to co-create a youth-oriented EIIP website, which was promoted with leaflets, posters and other materials. This microsite
• can be accessed via Surrey and Borders Partnership Trust’s main site or directly by visiting www.sabp.nhs.uk/eiip.

The audit

The EIIP team keeps a secure database and information was anonymised. The trust gave ethical approval. An audit was then conducted and its findings collated:

• Number of young people accessing the EIIP service and their gender;
• Sources of referral;
• Number of those admitted to hospital in 2009 and 2010;
• Number of young people discharged to primary or acute care after three years of EIIP.

Results

In 2010, the total caseload of North East Hampshire and Surrey Heath EIIP was 52. Of these, 69% were male and 31% female. This difference is not fully understood, but one hypothesis is that EIIP’s efforts have been focused on hard-to-reach groups, such as young men. While this might have succeeded, it may have made the service more male oriented so less likely to appeal to women. This needs investigation.

Efforts to promote awareness succeeded in increasing referrals to EIIP by 50%. Research carried out within EIIP showed that the average duration of untreated psychosis was 90 days (the general average is 98 days) but, since this project started, this has fallen to an average of 35 days. April 2010 figures were compared with figures from April 2009.

The majority of referrals (55%) were from community mental health teams (CMHTs). These usually originated from GPs who had referred clients to CMHTs, who referred to EIIP. Meetings with GPs revealed that some were unaware they could refer directly to EIIP. Some GPs (15%) did refer directly and these seemed to be the surgeries that had been visited by EIIP clinicians to raise awareness of the service.

The third highest source of referrals (10%) was from inpatient wards and self-referrals. Anecdotal accounts of events leading up to admission often pointed to several weeks of deterioration. Professionals and non-professionals alike sometimes mistakenly dismissed this deterioration as “behavioural problems” or “teenage angst”.

EIIP achieved a 75% reduction in admissions to acute inpatient units and a 50% reduction in admissions under the Mental Health Act (1983, amended 2007) sectioning (formal admissions). Reduced use of emergency and inpatient services results in more cost-effective illness management (McCrone et al, 2010).

After three years of EIIP, 65% of people were discharged back to their GPs. This followed a tailored and phase-specific approach to offering interventions to meet individual needs. Discharging to GPs is prepared well in advance (no less than six months) so clients and their families are prepared for less intensive input. The remaining 35% were discharged to CMHTs.

Conclusion

The data show promising preliminary results for young people experiencing psychosis who access EIIP.

Further investigation is needed to determine whether health promotion can lead to sustained improvements in health outcomes. Further work is necessary to ensure equal access to EIIP regardless of demographics, increase self-referrals by young people and their families, and GP referrals. This is likely to reduce DUP and improve the long-term prospects of those who have experienced first-episode psychosis.