Around 1% of the population will develop psychosis and schizophrenia (NICE, 2014).

Early Intervention in Psychosis (EIP) services are community-based multidisciplinary teams that seek to reduce the amount of time between the onset of symptoms and the start of treatment to improve outcomes. EIP has two objectives:

1. To prevent the onset of schizophrenia in people with prodromal (at risk of psychosis) symptoms (Marshall & Rathbone, 2011)
2. To provide effective treatment to people in the early stages of schizophrenia, with the goal of reducing long-term severity (Marshall & Rathbone, 2011).

UK guidelines state: “early intervention in psychosis services should be accessible to all people with a first episode or first presentation of psychosis” (NICE, 2014).

However, a 2011 Cochrane systematic review stated that whilst there was some evidence to support specialist EIP services, further trials were needed to strengthen the evidence base (Marshall & Rathbone, 2011).

A recent study by Tsiachristas and colleagues aimed to demonstrate the costs, outcomes and economic impact of EIP services, compared to other community mental health teams (CMHTs) (Tsiachristas et al, 2016).

Methods

The researchers conducted an analysis of a longitudinal retrospective observational study of service usage and outcome data from mental health and acute care services for people with a diagnosis of psychosis in contact with mental health services. Data was linked between the Mental Health Minimum Data Set from NHS Digital and acute care data from Hospital Episode Statistics.

• Participants: 3,674 people with psychosis, aged 16–35, in the Thames Valley and South Midlands regions.
• Intervention: EIP services
• Comparator: CMHTs
• Outcomes:
  • Housing status and changes in housing benefit paid
  • Employment and productivity gains created by change in employment status
  • Health of the Nation Outcome Scale (HoNOS)
  • Use of healthcare including inpatient length of stay (LOS) in mental health hospital wards, acute hospital emergency (A&E) visits, planned (elective) and emergency (non-elective) LOS in acute care hospital wards, outpatient visits in mental healthcare and acute care, and community mental healthcare contacts and associated NHS healthcare costs.
• Time: 3 years (April 2010-March 2013).

Results

The final sample consisted of 831 EIP patients and 2,843 patients who were under standard care.

Compared to patients receiving non-EIP services, patients receiving EIP services were:

• 116% more likely (95% CI, 1.263 to 3.708) to gain employment
• 52% more likely to become accommodated in a mainstream house (95% CI, 0.988 to 2.326)
• 17% more likely to have an improvement in the emotional well-being domain of the HONOS questionnaire (95% CI, 1.067 to 1.285)
• Using significantly less (costly) health services with a mean annual NHS cost saving associated with EIP of £4,031 (95% CI, £1,281 to £6,780)
• The key cost differences associated with EIP were:
  • Lower mental health inpatient costs (£4,075, 95% CI, £1,164 to £6,986)
  • Lower acute hospital outpatient costs (£59, 95% CI, £9 to £109)
  • Lower accident and emergency costs (£31, 95% CI, £12 to £51)
  • Higher mental health community costs (£648, 95% CI, £122 to £1,175).

The authors estimated that if all people with first-episode psychosis across England were treated by EIP services, the savings in societal costs would be £63.3 million per year, of which £33.5 million would be in NHS costs.

Conclusions

The authors concluded that the study demonstrates that being treated within an EIP service is associated with:

• Reduced inpatient length of stay in a mental health hospital
• Increased contact with a CMHT
• Increased chance of employment
• Improving accommodation status
• Improved emotional well-being.

Strengths and limitations

The study linked data from existing datasets for a range of outcomes. This type of study has many advantages; it adds to a limited evidence base by utilising existing data, it captured a large sample size over a 3-year time frame. Compared to an RCT, the data is relatively easy to access and longer-time frames are more feasible.

The study does have some key limitations; in particular:

• The diagnosis of first-episode psychosis was not directly recorded in the electronic patient records and had to be inferred from the data available (ICD-10 codes, HoNOS questionnaire and mental health clusters)
• Baseline characteristics between the groups were different (though the authors applied methods to limit the impact of this)
• Data did not include a measure of health state utility and mortality data was not obtained. These would have allowed for a cost-utility evaluation to be performed which could benefit decision makers comparing service types and other interventions
• Employment and housing outcomes are both important to the NHS in the context of mental health (Mental Health Taskforce, 2016). However, the type of employment (e.g. whether it is suitable/beneficial at the individual level) cannot be assessed, which may have important implications on quality of life. Similarly with housing, a move into mainstream housing may not necessarily mean that the housing is better quality or more suitable for individuals
• Access to mental health services and population characteristics differ across the UK. Hence, the results of this study may not be generalisable to other areas.

Summary

The evidence base of EIP services is limited and this study adds to the evidence base utilising existing national data and covering a large sample of patients and long timeframe.

The study was constrained by the data that is captured by the datasets used in the analysis. An RCT designed to address the same research questions would complement this study because it would be able to address the limitations recognised by the authors. In particular it could include a measurement of utility (e.g. the EQ-5D) so that QALYs can be calculated to inform cost-effectiveness analyses.

Links

Primary paper

Tsiachristas A, Thomas T, Leal J, Lennox BR. (2016) Economic impact of early intervention in psychosis services: results from a longitudinal retrospective controlled study in England. BMJ Open 2016;6:10 e012611 doi:10.1136/bmjopen-2016-012611

Other references

National Institute for Health and Care Excellence. Psychosis and schizophrenia in adults: prevention and management. Clinical guideline [CG178]. Published date: February 2014. Last updated: March 2014. Available at: https://www.nice.org.uk/guidance/CG178

Marshall M, Rathbone J. Early intervention for psychosis. Cochrane Database of Systematic Reviews 2011, Issue 6. Art. No.: CD004718. DOI: 10.1002/14651858.CD004718.pub3.

Mental Health Taskforce to the NHS. The five year forward view for mental health (PDF). February 2016.

Photo credits

• Alan Cleaver CC BY 2.0
• Anssi Koskinen CC BY 2.0
• Howard Lake CC BY 2.0
• Rolf Brecher CC BY 2.0