CLINICAL HANDBOOK OF SCHIZOPHRENIA

36. First-Episode Psychosis 369TABLE 36.1. Components of Early-Psychosis Treatment ServicesEarly interventionPublic educationGatekeeper educationEasy accessOptimal care3-year focus and continuous carePharmacotherapyCase managementFamily therapyIntegrated addictionsPatient educationment services (see Table 36.1). The strategies that promote early intervention and reducethe DUP require skills and knowledge that go beyond those traditionally taught to clinicians.They can, however, be learned by clinicians who are interested in broadening theirskills and their outlook on the health system.Early InterventionThere are two clinical justifications for early intervention in a first episode of psychosis.First it has been demonstrated that early treatment can reduce harm caused by socialdisruption and critical incidents, such as suicide attempts, that can occur during anepisode of untreated psychosis. Second, there is evidence that earlier intervention canimprove outcome over the first few years of the disorder. This evidence is based on anumber of studies and some recent reviews. Numerous strategies aimed at reducing theduration of untreated psychosis have been reported. These strategies have been assessed,but usually in combination, which makes it difficult to know which strategiesare critical.Gatekeeper education involves the education of those professionals who have firstcontact with individuals who are developing a first episode psychosis. These groups mostoften include family physicians, as well as school and college counselors. Education usuallyincludes making these clinicians aware of the frequency of the disorders and theirclinical manifestations, and suggested methods for accessing care. This education can easilybe provided by the first-episode treatment teams.Public education, although not studied to date as a stand-alone strategy, has been offeredin a number of ways. It has been part of high school education about mental health.Education about early intervention has played a major role in campaigns with a primaryfocus on reducing stigma or DUP. Public education programs may include television, radio,and/or cinema advertisements, and print campaigns and websites either as a first-lineinformation sources or as a backup to other forms of public education.Ensuring easy access to services is a third strategy for reducing the DUP. Specificstrategies include central access services with a single point of access for all mental healthservices, including psychosis treatment services. Improving access requires removing certainbarriers to care. For example, referrals do not have to come through a family physician.There is no need to exclude patients with comorbid substance abuse or mild developmentaldelay, or even those with past criminal convictions. In addition, providingservices and information in a variety of languages further serve to improve access. Outreachteams that conduct an initial assessment of patients in their own homes have alsobeen used, sometimes as part of crisis services, other times as a preferred service deliverymodel, and still other times only for those patients who are hard to reach.