Abstract
I read with interest the paper by Yung et al. [1] which concluded that generic services may not provide optimum treatment for early psychosis patients and that treatment in this setting may not be cost-effective. This conclusion was based on, as the authors acknowledge, a limited comparison with a specialized service, EPPIC. By necessity this comparison was unable to adequately control for a variety of clinical and demographic variables that are likely to influence outcomes. In addition, the mean age of patients in the generic service was 27 years. EPPIC specifically targets patients in the youth age range 15–25 years and would not provide a service to a considerable number, if not the majority, of patients receiving treatment in the generic service, substantially limiting the value of this comparison. Differences in the duration of untreated psychosis (DUP) between the groups would not explain the difference in age of presentation; in contrast it is possible that the inclusion of an older treatment group in the generic service could explain the difference in DUP and possibly some of the less favourable outcome in patients treated in the generic service. In other words, the generic service may have been treating a greater number of poor prognosis patients who due to the nature of their symptoms (for example greater negative and cognitive symptoms) may have presented at an older age, with a longer DUP and with less treatment-responsive symptoms requiring a longer duration of hospital treatment. Patients of this sort in the catchment area of the specialist service may not present until too old to access the service.
As importantly for the implications of this work for service development, was the clinical context in which these patients were managed. As described in the paper, at the time of the audit, there were no specialized programs within the service for the treatment of these patients. There are numerous models in which these important patients can be managed. The paper compared an ‘undeveloped’ generic service to a specialized streamed early psychosis service. Another alternative is the use of specialized programs within generic services. These can take a variety of forms including secondary consultation and education programs, selected clinicians within certain teams developing a specific treatment focus or the development of specific dedicated clinical programs. A comparison of specialized early psychosis programs with early psychosis programs within generic mental health services may provide interesting results. For example, a study of a community-based program for early psychosis patients conducted in the late 1990s found a low rate of hospital treatment and a comparably low DUP [unpublished data, 1998; 2]. This program was based in a generic mental health service and involved the development of special treatment skills within a generic community mental health team. Planned prospective comparisons of various models of treatment within generic services are urgently required before conclusions can be drawn as to the clinical and health economic appropriateness of the management of early psychosis patients within these services.