Letter to the Editor: Author reply to Letter to the Editor regarding ‘Discharge destinations for young people with a first episode of psychosis after attending an early intervention for psychosis service’

We welcome the letter and issues raised by Prof Pelosi relating to our article on discharge destinations for young people from an early intervention for psychosis service (EIS) (O’Donoghue et al., 2023). Prof Pelosi argued against the practice of discharging people from EIS to a lower-intensity service, such as primary care or private practitioner. Without any supporting evidence, Prof Pelosi claimed that some of those discharged will be living in a state of torment and neglect, while at the same time acknowledged that there are no data on those who ‘have not been sent back to psychiatric services for proper care’.

In the article, we endeavoured to provide as much data as possible about the discharge destinations of these young people and the demographic and clinical factors associated with the discharge destination. We have a different interpretation of the study’s findings and consider the high proportion of people being discharged to lower-intensity services to be reflective of the high rates of symptomatic and functional recovery obtained in these young people. In this large cohort of more than a thousand young people with a first episode of psychosis, the median duration of untreated psychosis (DUP) was 8 weeks, nearly two-thirds (65.9%) achieved remission of symptoms within 12 weeks, and 61% did not experience any relapses. In other words, most young people experienced psychosis for a relatively short period, compared to DUPs of >1 year observed in other jurisdictions (Kane et al., 2016) and achieved remission quickly, which was then sustained. Prof Pelosi is right that it can be challenging to engage individuals with impaired insight. Still, it can also be challenging to continually engage young people who have fully recovered and are busy doing productive things with their lives, such as studying, working, and socialising. It is a core component of the model of care at the Early Psychosis Prevention and Intervention Centre (EPPIC) that young people and their caregivers receive psychoeducation on the early warnings of relapse and how to access the appropriate service if needed (Steavly et al., 2013). Therefore, we still maintain that the large proportion of young people, who fully recover and have good prognostic indicators, can be monitored within a lower-intensity service, with access back to a higher-intensity service if needed. This is also in keeping with a recovery-orientated model of care and the skill base of practitioners within primary care who can monitor individuals who have recovered from a disorder with a risk of relapse.

Unfortunately, some do not make this rapid or complete recovery, or they experience relapses or have indicators of a poor prognosis. We agree with Prof Pelosi that these individuals should remain within the high-intensity, multi-disciplinary services. This was the underlying rationale for the study, as we believe that these individuals would be better served by continuing with the EIS, thereby preventing a further transfer of care to the general adult mental health services. As mentioned in the discussion, such a model of care is currently being developed with the EPPIC service and we are also developing clinical registers to enable data-linkage to provide more information on those who are discharged from EIS.

Prof Pelosi calls for the Royal Australian and New Zealand College of Psychiatrists, in conjunction with the Royal Australian College of General Practitioners, to ‘put a stop to this unacceptable clinical practice’ (of discharging people with a diagnosis of schizophrenia to primary care). Yet, the Royal Australian and New Zealand College of Psychiatrists have provided clear guidance on this matter in their clinical guidelines for the management of schizophrenia and related disorders (Galletly et al., 2016). These guidelines state: ‘sometimes people with schizophrenia who have had a period of stability under specialist health services are considered suitable to have further mental health care transferred to general practice’. These guidelines then state that this could occur when the individual and their family or caregivers have participated in a relapse recovery plan, there is an understanding and plan regarding medication, and there is clear communication between the specialist mental health team and primary care. All of these factors are part of the model of care and discharge planning from the EPPIC service.

The appropriate timing and service for discharge after attending an early intervention for psychosis service has not received the attention that it warrants. We agree with Prof Pelosi that more data are required to inform clinical practice and service development. However, in a separate article on the same topic, entitled: ‘Neglecting the care of people with schizophrenia: here we go again’, Prof Pelosi calls for all individuals with a diagnosis of schizophrenia or related disorder to be transferred to the adult mental health services after their tenure of care with the EIS and for general practitioners to refuse to accept the transfer of care and discharge pathways (Pelosi and Arulnathan, 2023). Such a proposal neglects an individualised approach to each person affected by psychosis and ignores the recovery achieved by many people attending EIS.