Early intervention in psychosis:
Dr David Shiers
GP advisor & National lead on
Early Intervention in
Psychosis Programme
RCGP Annual Conference. Nov 5th 2009
My GP ‘journey’
Kraepelin’s Dementia Care Model
‘Schizophrenia is like managing
the British empire: the orderly
management of decline’
Most serious mental disorders first appear
in teens / young adults
Victoria (Aus) Burden of Disease Study: Incident Years Lived with
Disability rates per 1000 population by mental disorder
Pressure wave- trapped
• 12-18m delay was typical
• Crisis response
– 73–80% hospitalised
– 36–59% Mental Health Act
– 45% police involved
• 50% disengage: likely
crisis reengagement
…on a path to inequality
 Excluded
 12% with a job
 In previous 2 weeks (Nithsdale survey)
o 39% either had no friends or had met none
o 50% no interest or hobby other than TV
 one in four have serious rent arrears
 Up to 25 years less life
 33% suicide and injury
o Lifetime suicide risk 10%;
2/ within first 5yrs, esp around the first
 66% are premature deaths from physical causes
o 2-3x rate of CVS, Respiratory or infective
o Lifestyle adverse factors: smoking; diet; activity
o Up to 5x rate of diabetes
o Poorer health care
A widening health inequality
Difference between general population and inpatients with schizophrenia in prevalence of:
 Rising prevalence of obesity
1988 +4.7%
2002 +14.7%
Reist et al (2007)
 Rising prevalence of diabetes
1979-1995 parallel trends
1996-2001 0.7% increase per year in people
with schizophrenia
Basu & Meltzer 2006
 76% in FEP smoke tobacco regularly
That’s the problem we
are trying to solve
Aims of EI services
1. Prevent psychosis in the ultra high risk individuals
– identify and intervene on cusp of psychosis
2. Reduce DUP (Duration of Untreated Psychosis):
– promote early detection & engagement by community agencies
– Comprehensive initial mental health assessments & diagnosis
3. Optimise initial experience of acute care & treatment:
– ‘Youth friendly’ Acute Home based/Hospital Treatment
4. Maximise recovery & prevent relapse during critical
Provide integrated bio/psycho/social interventions
focus on functional/vocational as well as symptomatic recovery
address co-morbidity and treatment resistance early
Support carers and network of community support agencies
The hazards can be reduced and
ultimately negotiated
• Timely support.
• Thorough preparation
• Effective use of well
developed evidencebased approaches
– for both the young person
– and their family.
Celebrate and prepare
• Have learnt something
• Have a guide/mentor
– Professional, family,
friend or peer
• Alert and ready for a
next time?
– Take remedial action
– Seek help
Supporting GPs’
to do a difficult
job better:
Early intervention is
everybody’s business
• EI psychosis services insufficient
by themselves
• GPs offer continuity, context and
family practice:
– Key role in care pathway of
emerging psychosis
– Listen and act on concerns of the
• Keep the body in mind.
– Alongside practice nurses, GPs can
be critical players in improving
physical health pathways
Equipped for the life
ahead both for the young
person and their family
Acknowledgements to:
Dr. Roy Morris Dunedin and Dr
Maryanne Freer, Newcastle for
contributing the white water
rafting metaphor
to for use of their video clips
and to Paddy Power for slides 18 & 19
You don’t need an engine when you have wind in your sails
Paul Bate 2004

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