Early intervention for psychosis: Is it worth the investment?

Professor Keshavan described “early intervention” as a paradigm shift in psychiatry, particularly within the field of psychotic disorders. He said that the idea has been so captivating that there has been a tremendous push around the world for early intervention. However, questions have also been raised regarding both the effectiveness and cost-effectiveness of this approach.

Both speakers had the same three key questions to address:

1. What is ‘early intervention’, and is it a good idea?
2. Does it work?
3. Is it cost-effective?

There’s a moral imperative to provide the best possible treatment as early as possible to people with a serious mental illness

Professor Malla started by saying ‘yes’, early intervention is worth the investment, because it saves lives; improves lives through improving outcomes in all dimensions; reduces suffering for the patient and caregiver/family; is cost-effective in the long run; and finally, it is the only humane way to address the problem, i.e. there’s a moral imperative to provide the best possible treatment as early as possible to people with a serious mental illness.

Early intervention has two distinct components¹ said Professor Malla:

1. A comprehensive package of phase specific evidence-informed interventions e.g. assertive case management (ACM), second-generation antipsychotics (SGAs), cognitive behavioral therapy (CBT), family intervention (FI) etc., based on the need to influence outcome in the critical period of 2 to 5 years for establishment of long-term trajectories of outcome.
2. Reduction of delay in treatment, thereby providing treatment early, based on well-documented impact of duration of untreated psychosis on short- and long-term outcomes.

According to Professor Malla, there is plenty of evidence for the effectiveness of early intervention, with data from patients with first-episode psychosis (FEP) showing e.g. lower rates of treatment discontinuation, higher rates of remission, lower rates of relapse and better overall functioning (for review see²).

Early intervention lowers mortality

Furthermore, early intervention lowers mortality. The rate of all-cause death among people who used early psychosis intervention was four times lower than people with FEP who did not use these services³, translating into a number needed to treat (NNT) of 40, which according to Professor Malla is very low, if e.g. comparing with the use of statins in heart disease, with NNTs of more than 200.

Professor Malla went on to show data on early intervention for FEP from the United Kingdom, with £18 net savings for every £1 spent.⁴ He stated that early intervention services (EIS) are cost-effective, even when extended beyond two years – something which may not be necessary for more than half of the patients. Furthermore, by reducing the duration of untreated psychosis, the benefits of early intervention are enhanced, e.g. by improving negative symptom remission.⁵

Professor Malla concluded his part of the debate by saying that we owe it to young people and their families to give them a genuine chance of recovery by providing the state-of-the-art treatment in the best possible way.

His opponent, Professor Castle, started off by listing several shortcomings with the early interventions approach, with some focus on the situation in his home country Australia. First on the list was the question of focusing on young patients. He quoted a study where more than half of the patients had onset of FEP after the age of 25, and Professor Castle argued that by concentrating on young patients, we miss a lot of patients who would potentially benefit from treatment.⁶

Professor Castle went on to say that unfortunately, many people with psychosis have a poor outcome, despite early intervention, while others do really well, without early intervention⁷; providing a potential explanation as to why early intervention can produce good outcomes.

Next on the list was criticism regarding what is a long duration of untreated psychosis, to which there does not seem to exist one unequivocal definition. This was exemplified by published durations ranging from 22 to 67 weeks. Further, Professor Castle argued that despite various community interventions and training programs, no effects on the duration of untreated psychosis has been detected.⁸

Professor Castle then referred to the components of early intervention mentioned by Professor Malla, as “magic ingredients”, while at the same time explaining that there’s nothing magic or special about them, they simply constitute the components of good care. “Good care is good care”.

In a paper from 2010, entitled “Early intervention in psychotic disorders: Faith before facts?”⁹, which Professor Castle jokingly referred to as “the “Bosanac heresy”, Bosanac and colleagues already then discussed many of the points addressed during the debate.

In that paper, which turned out to be very controversial at the time, the authors concluded that “Clinicians and researchers might be better to concentrate their attention on advocating for the provision of better, fully integrated services for all people with psychotic disorders, irrespective of the stage of their illness”.

This was echoed by Professor Castle in his talk, emphasizing that the partition of treatment into “silo services” is damaging, with un-useful transition problems from adolescent to adult services with resultant loss and grief, and that “good care is good for you at any stage of the illness”.