Wed Dec 15

Early intervention for psychosis might cost more initially but delivers a greater return on investment

Written by Pat McGorry, Professor of Psychiatry, The University of Melbourne

Psychotic illnesses ^[1] such as schizophrenia cause severe distress and suffering for people who experience them and for their families.

All too often, these illnesses prevent those affected from completing education, starting work or keeping a job, and participating in their communities.

This can lead to impoverished lives and premature death, from suicide or preventable physical health conditions. People with psychotic illnesses die up to two decades earlier ^[2] than those unaffected ^[3] by these conditions.

These poor outcomes aren’t just part and parcel of the illness. Applying the strategies used to treat other diseases – such as early diagnosis and intensive early-stage care – can prevent psychotic illnesses from progressing or becoming life-long conditions.

Such care may be more costly than standard, delayed mental health care. But when you consider the economic gains from lower levels of disability, early intervention for psychosis delivers a substantial return on investment.

Fixing an outdated system

Mental health care reforms for psychosis started in Melbourne more than 30 years ago ^[5].

At the time, standard care for those experiencing their first episode of a psychotic illness started late and often resulted in traumatic experiences for the young person, demoralisation and increased risk of suicide.

Standard mental health services were dominated by middle-aged patients with long-term illness. Treatments were crude and limited, focusing on managing symptoms.

What were the goals of early intervention?

Early intervention for young people with psychosis offered hope for recovery through early diagnosis, combined with comprehensive multi-disciplinary team-based care. This included psychiatrists, psychologists, social workers, occupational therapists and others.

These services would be sustained during the critical period of the early years after diagnosis.

Young person in pink shoes sits in a waiting room.

Early intervention aimed to provide sustained early care, rather than just treating symptoms after they emerged. Shutterstock ^[6]

Early intervention offered a number of potential advantages over standard care, including:

early diagnosis before the illness produces entrenched harm and disability
being treated with greater care and respect
being exposed to a hopeful and optimistic culture
having family included and supported
prioritising finding and maintaining work
experiencing less stigma and treatment-related trauma.

Meanwhile, early intervention research created a scientific process ^[8] to identify those at risk of developing psychosis and intervening before the full onset of the illness.

The goal was to prevent the development of psychosis or, if it did emerge, delay or mitigate its impact.

That was the idea, how has it worked in practice?

Over the decades since, hundreds of early psychosis programs around the world ^[9] and an array of clinical trials have scientifically evaluated the effectiveness of early intervention for psychosis.

One of the goals of early intervention is to help young people find and stay in work. Yasamine June/Unsplash ^[10]

The programs target the early stages of illness and produce marked benefits in most patients ^[11].

This approach has shown:

Importantly, these programs are extremely popular with young people and families.

But interventions can’t just stop suddenly

The recovery achieved through early intervention must be sustained by continuing care throughout the critical early years of illness.

The first wave of research and reform in early intervention created programs that only offered this enhanced care for two years. When people were discharged and started receiving standard care, some of the gains were lost ^[12].

More recent research has shown if the high quality of care provided by early psychosis programs is extended by a further three years (so five years in total), the gains are maintained ^[13].

Some critics argue achieving these functional outcomes in early psychosis isn’t worthwhile if it requires effort to sustain it.

This is like arguing it’s not worthwhile to secure remission from cancer because if the treatment is withdrawn or downgraded too soon, relapse occurs.

Young people in a boardroom put sticky notes on a white board.

Early psychosis care requires effort to sustain the outcomes. Jason Goodman/Unsplash ^[14]

The better way of interpreting the evidence is to recognise that for a substantial subset of patients, the illness is persistent or recurrent. Therefore, having achieved a positive early outcome through early intervention it is essential to make every effort to sustain it.

Most patients require more prolonged intervention than the original two-year window of early psychosis care.

Early intervention saves money as well as futures

More than 20 economic analyses of early intervention in psychosis have shown a substantial return on investment.

While early psychosis care naturally costs more than substandard delayed care in generic settings, the clinical outcomes are substantially better than standard care, as studies from Denmark ^[15], the United States ^[16] and Australia ^[17] show.

And when accounting for the cost-savings from reduced rates of functional and social disability – which impairs family and social relationships – the overall economic outcomes are better, too.

This is due to a reduction in welfare dependence, greater tax receipts through employment, and reduced costs from suicide, offending and incarceration.

A recent evaluation ^[19] of the Australian Early Psychosis Youth Services (EPYS) concluded these health services were not cost-effective.

However, it did not actually conduct a cost-effectiveness study, merely listing costs alone. It also failed to take into account the economic benefits seen from employment, education and justice – and the authors acknowledged this shortcoming.

When considering the economics of early intervention, it’s important functional and social recovery is included – meaning a person can work or study and participate more fully in society – rather than just symptom recovery and direct health care costs.

Crucially, the evaluation found young people with psychosis and their families highly valued the early intervention approach, which helps them pursue their hopes and dreams of a meaningful and fulfilled life.

If this article has raised issues for you, or if you’re concerned about someone you know, call Lifeline on 13 11 14.