My next patient, Munira*, walks into the outpatients clinic with her mother. She’s shaking. Her opening statement is “no one can help me, no one believes me”. Her eyes dart around the room in a fearful manner. She tells me that the government are after her and that the police have a profile on her. She is desperate and distressed and wants help. Her mother cares for her full-time, but this is taking its toll.
I am a consultant psychiatrist working in an Early Intervention in Psychosis Team. I see patients just like Munira every day; sometimes they are so unwell that they have trouble eating and drinking enough; and occasionally they have thoughts of harming themselves or others.
Munira has psychosis, which is a mental health condition affecting three in 100 people. People with psychosis can experience hearing voices, paranoid thoughts, feeling frightened or distorting thinking. First episode psychosis is the emergence of these symptoms for the first time. Psychosis can affect all aspects of a person’s life. Munira has lost her friends, her relationship with her mother is strained and she is unable to attend sixth form.
The umbrella term psychosis is different to schizophrenia. Schizophrenia can be (but not always) a longer term condition which can include hearing voices and paranoid thoughts but also lack of motivation and social withdrawal. Nowadays many patients who experience psychosis only have one such episode in their lifetime and with treatment and support their lives resume as normal.
Nevertheless, it is important that first episode psychosis is picked up quickly and treated because of evidence that the quicker treatment leads to better outcomes. If left untreated, people with psychosis are more likely to suffer from poor physical health and poor quality of life.
In 2016 standards were introduced by NHS England to assess newly referred patients with first episode psychosis and start a comprehensive care package within 2 weeks. Standards of this care package include having access to antipsychotic medication, psychological therapy, physical health assessment and intervention, education and employment support and carers support. In this way, this fast-track approach is likened to that of cancer, which is welcomed, and is one step closer to achieving parity of esteem.
These standards have increased the speed at which people with first episode psychosis are being seen in the UK. According to the All Parliamentary Party Group (APPG) for Mental Health report, 74% of people with first episode psychosis were seen and commenced treatment within 2 weeks of referral in 2017/2018. Whilst this is to be celebrated, all is not as rosy as it seems. Being seen quickly is just one measure of a high quality EIP service. It is still the case that many EIP services are not able to deliver the full, evidence-based care package.
Munira was established on antipsychotic medication quickly, which helped dissipate her paranoid thoughts, but she has waited many months to start psychological therapy. Cognitive behavioural therapy and family therapy are two evidence-based talking therapies recommended for first episode psychosis, yet only a minority of patients receive these therapies. Munira has also waited a significant period to receive support with returning to college, despite this being an important part of her life and recovery. Physical health assessment and intervention remains an area that is neglected with only a fraction of people with first episode psychosis receiving a physical health assessment. We know that people with severe mental illness are more likely to develop heart disease and diabetes and are more likely to die up to 20 years earlier than healthy individuals. Only a minority of carers of people with first episode psychosis are being offered formal carers support. For Munira’s mother, her caring role for Munira is all-consuming and support for her is just as important as support for Munira herself. Further, there is evidence to suggest that some EIP services in the UK are being disbanded due to cuts.
This is by no means a criticism of frontline staff. Community mental health nurses care deeply about their patients but in some EIP teams they have extremely high caseloads which means that they are simply unable to provide the intensity of support these patients require. Ultimately people with first episode psychosis experience that not enough is being done to help them and mental health professionals feel frustrated about not being able to provide the service their patients deserve.
According to the Five Year Forward View, £70 million was promised to EIP services across the UK. For many mental health trusts, it has been extremely difficult to ring-fence this funding from their local Clinical Commissioning Groups (CCGs). The recent APPG for Mental Health report recommends that NHS England should hold CCGs to account on their spending in mental health; but there is much work to be done.
Let me be clear: first episode psychosis is the psychiatric equivalent of cancer. EIP services require the necessary funding not only to see people like Munira quickly but to deliver all the components of the EIP care package. As an EIP consultant psychiatrist myself I welcome these standards, however, an urgent response is required to fund all EIP services across the UK properly and give people like Munira the best chance of recovery.
*Munira’s name has been changed to protect her identity