Conclusion: Towards Standards for Early Prevention and Intervention of Nearly Everything for Better Mental Health Services

CHAPTER 27
Conclusion: Towards Standards for Early Prevention and Intervention of Nearly Everything for Better Mental Health Services

Alan Rosen^1,2,3 and Peter Byrne^4,5

¹ School of Public Health, University of Wollongong

² Brain and Mind Research Institute, University of Sydney

³Mental Health Commission of New South Wales, Australia

⁴ Homerton University Hospital, London

⁵ Royal College of Psychiatrists, UK

Introduction

In recent years, there has been an explosion of interest in the possibility of early intervention (EI) in mental health care, with the ultimate aim of preventing the onset of severe mental illness, or at the very least, preventing or reducing the secondary morbidity and impaired functioning associated with these illnesses. This has been largely driven by advances in our understanding of the early stages of the psychotic disorders, which have led to the identification of modifiable risk/protective factors that can be targeted by appropriate therapeutic interventions, leading to much better outcomes for affected individuals and their families. EI represents a key shift in theoretical perspective, providing a coherent focus for the timely prevention, detection and intervention in mental illnesses, and opens the way for a more congenial, pre-emptive or timely and ultimately, more personalised and preventive psychiatry. This shift in focus and perspective must be reflected in the timing, pattern and tenure of service delivery, as well as in service structures themselves. In this chapter, we review the EI paradigm as a rationale and framework for improving the systematising of evidence-based primary to tertiary preventive efforts and the responsiveness of mental health services for individuals with many types of significant psychiatric disorders and their families, in most age-groups and settings. We address some key questions: Is EI anything really new? Should it only be for young people with psychosis? Should the work of EI teams be time-limited? Can there be an EI approach to long-term or persistent disorders? Can EI be applied to enhancing wellness and wellbeing? We also address the need for and uses of tools of EI service quality, from values and principles to standards, accreditation, best practice and implementation guidelines and similar applications of fidelity criteria. We finally summarise the overall benefits of taking an EI approach, as potentially one of the most important advances in mental health care made in recent years.

The definition of and rationale for early intervention across the disorder, stage of life and phases of care spectra

Early interventions seek to reduce the impact of a clinical or behavioural condition or disability for individuals and the wider community, for example, by mitigating or alleviating the impact of a developing, a newly established or an existing disability, and/or preventing a further deterioration in an existing disability. They may be invoked as soon as the condition or disability is first identified or appears, where there is a discrete change in the condition or disability, or at particular lifetime transition points (widening and paraphrasing the definition of Productivity Commission of Australia [1]).

Early intervention is defined in multifaceted ways: ‘In relation to EI, ‘early’ can broadly be understood in two ways – namely, early in the life of a person (for example, newborns, children and youth – sometimes also described as early childhood intervention or support for children) or early relative to the identification or appearance of the disability’ [1]. EI should be timely, (as perceived by service-users rather than providers) in the sense of being as soon as the person presenting wants it, and as soon as all key resource people for example, close family, can be gathered, but not an emergency “here and now” response if it can be avoided. This is opposed to late intervention, and not subject to delays, rationing or waiting lists for urgent or pressing care, which would not be tolerated in the care of many other emerging, severe and acute clinical conditions, for example, in cardiac or cancer care.

Early intervention is closely linked to and intertwined with frameworks of prevention [2, 3]. Primary prevention is performed before a clinical condition has emerged. It involves anticipating the onset of a condition which can be completely avoided, or is amenable to reversal, substantive remission or considerable amelioration if picked up early. It includes genetic counselling, replacement of a missing nutrient or hormone and careful monitoring and counselling through potentially prodromal states. Secondary prevention includes EI once a clinical condition clearly exists. In early secondary prevention, early detection of a clinical condition is a prelude to effective EI to improve immediate clinical outcomes and prevent any continuing disability setting in, if possible. Tertiary prevention involves the restoring of a purposeful existence and restoration of functional competencies from disability, or the prevention or minimisation of permanent disability, even once chronicity has been established.

Is early intervention really a new idea?

Is EI a relatively new idea or a trajectory that always made sense to reflective and practical clinicians, their clientele and their family carers?

Pioneers such as Pat McGorry in Australia, Max Birchwood in the United Kingdom and Tom McGlashan in the United States explicitly led the charge to systematically research, systematise and roll out EI services for young people struggling with their first episodes of psychosis on a national basis. However, as they would readily acknowledge, there were many forebears promoting this trajectory. McGorry and colleagues [4] credit Harry Stack Sullivan (1927), Ewen Cameron (1938) and Ainslie Meares (1959) as key ancestors in their views that ‘if prepsychotic states could be recognised and if the person could receive help at this early stage, then the psychosis, with all its psychologically and socially disruptive effects, could be prevented or at least minimised.’ Many of us would join them in still citing Ian Falloon and Grainne Fadden [5] as developing and piloting county-wide, early prevention and intervention teams in the United Kingdom, which were not yet termed ‘early intervention’ teams but which functioned approximately as such. They operated closely with general practitioners, regularly working from and engaging their clientele in primary health settings. They provided timely psychosocial, evidence-based interventions and medications relatively sparingly only when necessary, for all psychiatric disorders and all age-groups. They appeared to reduce the emergence and incidence of severe psychiatric disorders. Other pioneering clinicians and researchers and a selection of their key contributions have been listed and referenced in Rosen et al. [6] (see extract in Table 27.1).

Table 27.1 Some pioneering EI researchers and clinicians and selected key contributions

Country	Investigators	Key contributions
Australia	Mario Alvarez-Jimenez Jackie Curtis Jane Edwards John Gleeson Eoin Killackey Henry Jackson Patrick McGorry Alison Yung	Developed the EPPIC and PACE early psychosis and prodromal services; developed a national youth mental health service stream, ‘headspace’; recognised the importance of physical health care in early psychosis; the EPPIC and PACE long-term studies; ACT and family intervention for EI; developed a vocational rehabilitation model for young people with first-episode psychosis; developed an innovative social media platform specifically to support recovery in early psychosis
Canada	Don Addington Jean Addington Lili Kopala Ashok Malla Bob Zipursky	Developed family interventions for early psychosis; developed the PRIME early psychosis service in Canada; contributed to the NAPLS study
Denmark	Merete Nordentoft	Developed an early psychosis service in Denmark; the OPUS study; Suicide prevention and EI.
Germany	Joachim Klosterkotter Stephan Ruhrmann Frauke Schultze-Lutter	Developed the basic symptoms criteria; contributed to the EPOS study
Hong Kong	Eric Chen	Developed the EASY early intervention service
Norway	Jan Olav Johannessen Tor K. Larsen Tom McGlashan	TIPS early detection and intensive community-based treatment study and service
Singapore	Siow Ann Chong	Developed the EPIP early intervention service
The Netherlands	Llewe der Haan Don Linzen Jim van Os	Investigation of the development of prodromal psychopathology, contributed to the EPOS study
United Kingdom	Max Birchwood Tom Craig Grainne Fadden Ian Falloon Paul French Peter Jones Helen Lester Shon Lewis Tony Morrison Paddy Power David Shiers	Developed family interventions; the Buckinghamshire study; the concept of the ‘critical period’; developed early intervention services in London, Birmingham and Manchester; developed CBT for psychotic symptoms; the EDIE trial; the EPOS study; physical health monitoring in early psychosis; family intervention for EI; EI in primary care
United States	Ty Cannon Barbara Cornblatt MatcheriKeshavan Jeffrey Lieberman Tom McGlashan Larry Seidman Richard J Wyatt	Developed early psychosis programmes in the United States; contributed to the CATIE trial and the NAPLS trial; Neurobiology of early psychosis

Should access to early intervention teams be time-limited?

No: the concept and practice should not be restricted by diagnosis, symptomatic presentation, age-group or phase of care. The most urgent priority for early prevention and intervention has been and will continue to be young people on the brink or threshold of severe mental illness. However, while the bulk of the action in research and dissemination has occurred in younger people with psychosis, and has been more recently applied more widely to young people with all mental conditions (www.headspace.org.au) many of the concepts, frameworks, access strategies and practices have much relevance to many age-groups, psychiatric conditions and phases of care [7].

Shiers, Rosen and Shiers [7] argue against strictly applied or automatic discharge or transfer from early intervention in psychosis teams to another team within 1.5 to 3 years, which has become the norm for many mental health services which operate them. They advocate for the intensity and elements of this approach continuing for 10 years or more, but only if required, for those individuals who are still buffeted in their lives by persisting or intermittent episodes of severe mental illness.

We expect flexibility too. As in Hickam’s Dictum (http://en.wikipedia.org/wiki/Hickam%27s_dictum), we commonly see a second common mental disorder in a person treated for something else. In this setting, we expect secondary prevention of (say) psychosis to run alongside primary prevention (sometimes secondary too) of problems with anxiety, depression and/or substances.

Is early prevention and intervention just for young people with first episode psychosis?

Shiers, Rosen and Shiers [7] maintain that ‘from our national perspectives, we are aware that other parts of the service can sometimes perceive EI teams as being or behaving as elitist. EI teams must respond positively by being both good service neighbours, (contributing constructively to an integrated mental health service), whilst at the same time becoming ambassadors for continuing this intensive EI type of approach for however long it takes, creating ripples into the sometimes still waters of systems of care further down the care pathway.’

For instance, they might do this by promoting psychosocial interventions, family work, physical care of individuals with mental illness, lowest-possible-dose medication treatments and minimal use of hospitals and involuntary care, strictly only when necessary. Early interventionists should be engaging other providers working with other phases of care and other conditions with the idea and sentiment that: ‘we value and have learnt from your expertise, your commitment to your clientele and what you do. We also have something we can bring to this – which we are happy to share’.

‘Maybe we need a series of pools, each drawing on a renewed wellspring of hope for different phases, and each with their own sequential spring-board of therapeutic optimism and creative inspiration. Just as ‘engagement’ is not solely an intervention applied at the beginning of the therapeutic encounter, but must keep being renewed throughout the therapeutic enterprise for each individual and family, so it is with (operationalising) hope-instilling and therapeutic optimism. The principles and practices of EI, with interventions directed towards more individually focused and hopeful ways of working and towards as complete a recovery as possible over whatever time it takes, should set ripples flowing out to all phases of care, and for mental health teams for all age-groups and in all sub-specialties of psychiatry’ [7].

Recently the Schizophrenia Commission UK recommended: ‘We want the values and ethos of EIP to spread across the entire mental health system…’ (and) ‘that Clinical Commissioning Groups commission services to extend the successful principles of EI to support people experiencing second and subsequent episodes…’ ([8], pp. 15–16) ([9], Chapter 15 in Byrne, Rosen et al., 2014, in press).

What are the essential ingredients of an early intervention approach?….underlying principles of early intervention provision

Table 27.2 summarises some of the candidate principles of all early intervention provision. These are largely the principles of any high quality contemporary mental health service, but brought forward, made convenient and systematised, so that easy access to such services can be assured from the moment of serious concern by individuals or their families, their primary practitioners and other referring agents. They also emphasise age-appropriate and welcoming environments, located centrally in their local or regional communities, and providing a relevant multiplicity of services operated locally where possible under the one roof.

Table 27.2 Underlying candidate principles of all early intervention provision

(i)	Early prevention, detection and intervention is better than late prevention, detection and intervention Early prevention, detection and intervention in most mental health disorders usually provide much better recovery and outcomes much sooner for individuals and families suffering them [see below: Conclusion: The overall benefits of an EI approach: (a) the rational/logical benefit]. This implies encouraging prompt referral by community agencies, reducing treatment delays, providing low-key mobile crisis resolution services, individual and family education and minimising coercive emergency entry to mental health services.
(ii)	Taking a population/public health approach This entails not just resting on your laurels, your case-load or your waiting list, or just adopting a passive-response style of service, waiting for people in need to turn up. It requires an active-response anticipatory service, and being prepared to reach out, to engage people in need at home, if needed, or if invited in by the family, even by passing messages patiently beneath an isolated person’s locked bedroom door on multiple occasions, if necessary. This also means estimating the likely demand or projected number of people with new, as yet undetected, undiagnosed or untreated disorders, and planning and providing enough service providers both to meet this demand and to go out of your way to raise the awareness of potential referral sources, to look for potential clientele in need and to seek appropriate referrals.
(iii)	Requiring both evidence-based interventions and efficient service delivery systems Public health proactive approaches to prevention, early detection and intervention, and encouraging timely help-seeking is summarised in Section 2 of Table 27.2 Early intervention and in Australian Healthcare and Hospitals Association et al. 2008. It requires both specific sets of intervention methods or contents, involving specific skills training, supervision and fidelity measurement, as well as specific service delivery systems or service delivery vehicles (see Chapter 15). Sections on Crisis, as well as consideration of the Biomedical, Psychological, Social and Cultural components of care and recovery in Table 27.2 are also relevant to early intervention services. Low profile, low impact, least invasive, voluntary, community-based interventions and service delivery systems should be chosen for early intervention wherever possible.
(iv)	Integration and balance Thornicroft and Tansella [10], advocate for a better balance between community-based and hospital-based mental health care. Over the last 2 decades in Australia and New Zealand, the debate over whether mental health services should be provided ‘primarily or exclusively’ in community or hospital settings has been exposed as a contrived battle over a non-issue. For most of this period, clinical and other expert opinion leaders and policy-makers in this field have been advocating for integrated mental health services ([11-14]). This involves ensuring more than a balance in community and hospital service provision and resourcing, but integrating both, and a weighting of resources towards community care, with less emphasis on inpatient care, based on evidence—a necessary but insufficient precondition for effective design and delivery of mental health services. A wider integration should then be built with all-of-government and all-of-community partnerships (see Table 27.1).
(v)	Community focussed The World Psychiatric Association International Guidance [14] now proposes models ‘with most services… *provided in community settings close to the populations served, (and) with hospital stays being reduced as far as possible*, and usually located in acute wards in general hospitals.’ In middle to higher income countries, more viable community-based alternatives to long-term institutionalisation and many acute involuntary inpatient admissions can be provided by evidence-based modular mobile crisis and home treatment teams, early intervention teams, assertive community treatment teams and 24-hour staffed community-based residential respite centres [15]. The latter are voluntary and often staffed predominantly by NGOs and peer workers, with public clinical professionals visiting frequently. Specific assertive community teams and community respite houses for early intervention with young people have developed in some jurisdictions. Current and previous National Mental Health Strategies in several developed countries (e.g. Australia, New Zealand, United Kingdom, Ireland and Canada) have made a great deal of progress towards reforming mental health services, with a greater emphasis on community care. However, they have not gone far enough in terms of defining and making specific commitments to implement the required strategies on a continuing basis. An effective method of increasing the specificity, uniformity and fidelity of nationwide implementation is to define individual service components and staffing levels required to deliver a comprehensive, locality-based continuum of community care that addresses the needs of, say, an average population of 200,000. Earlier studies [16] specified the intervention costs fairly accurately, but vastly underestimated the costs of the service delivery systems (or transmission vehicles) and management and physical infrastructure (see Table 27.2 from Australian Healthcare and Hospitals Association et al. [17]). Service models need to be clearly defined; resourcing of services must be done on a rational and equitable basis, not simply on an historical basis; quality monitoring and outcome measures and standards must be meaningful and ensure good practice across multiple providers.
(vi)	Not only community-centred but also mobile 24-hour accessible home crisis engagement, assessment and care in both urban, suburban and regional settings, with telehealth-based proxies in rural/remote settings. They should be provided from one-stop-shop centres located at shopping and transport hubs, providing access to psychiatric, drug and alcohol and general medical clinical support and welfare services
(vii)	Managing clinical complexity Clinical complexity denotes the richness of our field and represents a pointed challenge to practitioners to widen our professional responsibilities. Most significant psychiatric disorders have multifaceted aetiologies, including genetic, developmental, psychological, social and cultural causes, precipitants and aggravating influences. This entails consideration in assessment and treatment as required, of multilayered formulations incorporating co-occurring disorders, combining psychiatric disorders with substance use disorders, physical illnesses and (e.g. cardiovascular or metabolic) sequelae of psychiatric treatment, other disabilities, transcultural or indigenous status and social determinants of disease such as poverty or homelessness. It follows that this will require a multifactorial holistic approach to intervention, encompassing biophysical, psychological, social and cultural approaches as well.
(viii)	Developing a person-centred approach Conventional health care paradigms focusing just on the disease state, primary diagnosis and immediate care are increasingly regarded as inadequate. *A person-centred approach* would also facilitate attention to the positive aspects of health, such as buoyancy or resilience, personal, family, social and cultural resources and quality of life. This is important for health promotion, prevention, clinical treatment, rehabilitation and recovery [18]. So services should be both service-user and family centred. Service-users are engaged in their own care and treatment. Families are engaged in the service-user’s care as much as possible. Services should be age-appropriate, stage of life friendly and sensitive to gender and culture. Services support service-users in recovering and maintaining age-appropriate social roles (e.g., going to school, maintaining a job). Services should be linked to other services and supports in the community, particularly primary care. Treatment should be provided in the least restrictive and stigmatising setting. Home-based treatment may be appropriate for adolescents and young adults [19].
(ix)	Clinical staging determines clinical care and support strategy Assessment, clinical treatments, care, support and follow-up are provided and titrated according to clinical staging, which is relevant and applicable to all psychiatric disorders (see McGorry P, Afterword).
(x)	Operating in accordance with and monitoring on the basis of evidence-based fidelity criteria.
(xi)	Fidelity monitoring ensures that teams or services are applying the core ingredients of evidence-based service delivery systems (e.g. Assertive Community Treatment (ACT), [20], [21]), or of an Intervention (e.g. cognitive behavioural treatment (CBT) [22, 23]), and hence for these and other essential components of an early intervention service (e.g. an early intervention in psychosis service, [23]).

Adapted from Iris Guidelines 2012, Ministry of Health and Longterm Care: Early Psychosis Intervention Standards, Ontario, 2011 [19], Australian Clinical Guidelines for Early Psychosis, 2010 [24].

Service quality: defining a good service

Extrapolating from the AIMHS Standards [25, 26] and the National Standards for Mental Health Services [27], a comprehensive mental health service is defined as one which brings together a number of components into a unified system, ensuring continuity of care for consumers and families, with a focus on a partnership between public, NGO and fee-for-service mental health services.

These components may now often include:

– a single point (or process) of entry into a service
– specialist crisis intervention, assessment, acute care, ongoing care and rehabilitation care across the service user’s lifespan [15, 28].
– a specialist EI team
– a care coordination or case management system integrating inputs from inpatient and community public mental health, NGO and fee-for-service provider services.
– the active involvement of consumers and families
– interdisciplinary mental health teams, including
– Consumer and carer peer support workers, vocational, housing, dual disorder drug and alcohol and community forensic professionals, indigenous and/or transcultural/bilingual mental health workers where relevant and sessional community pharmacists.
– a coordinated management system between all partner services on a whole-of-government and whole-of-community basis.

Quality improvement and standards, accreditation

We propose the development of a set of standards of early prevention, detection and intervention to apply to all mental health disorders in all age-groups, including co-occurring disorders.

We have been taught informally over the years that …. laws are meant to be bent, rules are meant to be broken, and guidelines are meant to be interpreted …. but standards are meant to be aspired to and independently monitored.

Adherence to laws, rules and guidelines is variable, according partly to the strength of the evidence, to how compelling is the moral case put for adherence, and especially to the negative and positive sanctions (i.e. rewards and punishments) which may be applied.

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