Introduction

CHAPTER 1 Introduction

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

¹ Homerton University Hospital, London

² Royal College of Psychiatrists, UK

³ School of Public Health, University of Wollongong

⁴ Brain and Mind Research Institute, University of Sydney

⁵ Mental Health Commission of New South Wales, Australia

Early intervention (EI) is arguably the single most important advance in mental health care of the past decade. In terms of all-time advances in mental health care delivery, EI is up there with the consumer, family, recovery, and human rights for psychiatric disability movements, person-centred and holistic integrated services, effective psychotropic medications and psychotherapeutic interventions, evidence-based psychosocial interventions and mobile assertive community-centred service delivery systems. EI represents a key shift in both theoretical standpoint and service delivery, and marks an end to the first era of community psychiatry – where we set up ‘accessible’ clinical structures by locality, and patients were expected to adapt to these. With EI, practitioners reconfigure how they work to engage, negotiate and agree interventions support and care with their service users. From a general practitioner (GP) perspective, some modern community mental health teams (CMHTs) have ‘raised the bar’ to focus only on those with severe mental illness (SMI), now implicitly or formally defined as established psychotic disorders. Many CMHTs decline people in crisis or in the early stages of illness: by the time their referral is accepted later on, engagement is harder and many interventions have a reduced efficacy. Like all useful ideas, EI is a simple one and has instant appeal to people in early stages of illness (crucially often before insight is lost) and to their families. Key clinicians, notably GPs and mental health professionals also have a strong self-interest in designing and supporting efficient EI services. It is both self-evident to them, and increasingly evident from emerging studies, that such timely approaches could save much harder and longer clinical endeavour further down the track. We list the key pioneers later (Chapter 27), many of whom have contributed to this book. Their work, along with impressive citations at the end of each chapter, should persuade readers new to EI that this will be a key component of the twenty-first century mental health care. This book’s main aim is to affirm for every clinician, every purchaser of services and other interested parties the high value of EI in most care settings from cradle to grave.

Prevention

Caplan’s three levels of prevention are well described [1, 2]. Primary prevention prevents the disorder from occurring in the first place, secondary restores health from an existing disorder, while tertiary attempts to claw back better function from persistent or long-term disorders. In mental health service delivery, most effort and money are devoted to tertiary prevention/maintenance treatment, where the quality of rehabilitation may be so variable that the term ‘rehabilitation’ may sometimes be a euphemism for habitual low-grade custodial care. Secondary prevention is the early recognition and treatment of psychiatric disorders: to date, the best evidence and best practice has been implemented in EI for psychosis in young people (see Chapters 7, 9, 15 and 21). This book will inform interventions in people from all age groups, building on the core components of excellent services: engaging, low (negative) impact practices that are culture- and age-sensitive with robust crisis interventions, assertive case management, flexible home visiting, family consultations and in and out of hours, active response services. EI teams should have a low threshold to identify individuals warranting assessment, monitoring and sometimes treatment, reduce stigma in patients and their local community, engage individuals with emerging symptoms and their family carers in low-key pre-emptive services even if formal treatment is not indicated, not wanted or not available, locally or anywhere. Their primary aim is to treat vigorously the first signs of the disorder in the first 3 years (‘the critical period’). In managing a complex mix of possible noncases and cases, medication is only one option and part of phase-specific organic and psychosocial interventions: comprehensive therapeutic assessment, crisis intervention, education, family work, cognitive behavioural therapy, assertive community treatment, substance misuse and vocational interventions, to name but eight.

Overview: structure of this book

EI principles also support service users and carers in their individual recovery models, and dare to aim for full remission or generate hope that their symptoms do not develop into lifelong disability. A large part of primary care, child psychiatry and consultation–liaison (general hospital) psychiatry works as secondary prevention, but within large caseloads across secondary services including CMHTs, there are many opportunities for EI. This book’s approach will be:

Across the age spans, identifying the best EI practices in specific groups.

Comprehensive: most common psychiatric disorders will be addressed – that is the ‘nearly everything’ of our subtitle. Because most psychiatric subspecialities have developed in isolation, they may be unaware of hard-won lessons from other colleagues in engaging and managing people from different demographic groups and cultures. Whether your patient is 8 or 80, there is much to be gained from an EI ethos.