Early Intervention in Psychosis services

Welcome to the ZSA Facts for Action series

This page provides key information to explain what Early Intervention in Psychosis (EIP) services are and will help build your understanding of the role this service has in suicide prevention.

Contents:

1. What are EIP services?
2. Who do EIP services support?
3. Why are EIP services important in the context of suicide prevention?
4. ZSA Suicide Prevention Resource Map Data – key takewaways
5. National guidelines for practice
6. Impact of COVID-19
7. Recommendations for action
8. ZSA Suicide Prevention Resource Map - related indicators
9. References

What are Early Intervention in Psychosis (EIP) services?

Early Intervention in Psychosis (EIP) services work with people aged between 14 and 65 experiencing an emerging psychosis, typically described as first episode of psychosis, and also those identified with an “at risk mental state”. The role of these services is to provide prompt assessment, treatment and support to people developing psychosis. These services offer a range of evidence based interventions shown to help people with psychosis and their families.

Psychosis is characterised as hallucinations, delusions and a disturbed relationship with reality (known as disordered thinking), which can cause considerable distress and impairment for the person and their family and carers.

Typically, before an episode of psychosis, many people will experience a relatively long period of emerging symptoms involving a change in their thoughts, feelings and behaviours, which is described as an “at risk mental state” (NHS England, the National Collaborating Centre for Mental Health and the National Institute for Health and Care Excellence, 2016).[1]    

Often people experiencing these symptoms will receive support and treatment based on clinical diagnoses of schizophrenia, bipolar disorder, psychotic depression or some less common psychotic disorders. It can take time to identify the correct diagnosis and support required, and this time can be critical in the long-term recovery of a person facing these symptoms, and so EIP services were developed to support the prompt access to specialist diagnosis and treatment.

People who experience psychosis can and do recover. The time from onset of psychosis to the provision of evidence-based treatment has a significant influence on long-term outcomes. The sooner treatment is started the better the outcome and the lower the overall cost of care (NHS England, the National Collaborating Centre for Mental Health and the National Institute for Health and Care Excellence, 2016).[1]

Research by Tsiachristas et al. in 2016[2] has shown that treatment within an EIP service is associated with better health and social outcomes and reduced costs. For example:

• 116% more likely to gain employment
• 52% more likely to have stable accommodation
• 17% more likely to have an improvement in emotional wellbeing (as measured by HoNOS, a clinician reported outcome measure)
• Annual average cost savings per person receiving EIP services of £4,031

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Who does EIP services support?

NHS Digital publishes an annual bulletin which reports on the use of mental health services based on the Mental Health Services Data Set submissions by providers. The latest publication (2020/21) shows:

• 14,883 referrals commenced an EIP pathway in 2019/20 with 74% commencing treatment within two weeks (in line with the national access standard)
• 39% of EIP pathways commenced were for people aged 14 to 24, 29% for those aged 25 to 34 and 32% for those aged 35+
• 58% of EIP pathways commenced were for males and 42% for females
• 56% of service users are of a white ethnic group. It should be noted that ethnicity was only recorded for 82% of those entering treatment, so we have also looked at ethnicity proportions based on the number of users with valid ethnicity recorded

The percentage of people entering EIP services from ethnic minority groups is 32% (where valid ethnicity is recorded). This is 11% higher than the percentage of the general population in these groups (21%) (based on ONS data). This suggests that people from ethnic minority groups are more likely to access EIP services than their white peers. Our Facts for Action for Severe Mental Illness highlights that psychoses are more common in ethnic minority groups and the higher rates of those entering the EIP services would appear to reflect this

People living in more deprived areas are more likely to enter EIP services than those from less deprived areas as illustrated by the fact that 67% of people entering treatment living in areas with higher than average deprivation (based on the Indicies of multiple deprivation). Our Facts for Action for Severe Mental Illness highlights that psychoses are more common in more deprived areas and the higher rates of those entering the EIP services from these areas would appear to reflect this.

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Why are EIP services important in the context of suicide prevention?

There are estimated to be 31.7 new cases of psychosis in England per year per 100,000 population (Kirkbride et. al 2012)[3] and approximately 0.7% of the adult population in England are experiencing a psychotic disorder at any point in time (Adult Psychiatric Morbidity Survey, 2014).[4] Both new cases and total cases in a population can vary significantly from one area to another according to age, sex, ethnicity, population density and social deprivation

Suicide is a major cause of death among people who develop psychotic illness (Nielssen and Large, 2009).[5] Early intervention reduces the risk of a young person taking their own life from up to 15% to 1% (Rethink Mental Illness and The Iris Network, 2014).[6]

The period between the onset of symptoms and adequate treatment is known to be a period with a greatly increased incidence of self-harm (Nielssen et al., 2012).[7] 18.4% of people experiencing their first-episode patients have self-harmed or attempted suicide prior to initial treatment, while the proportion of patients who completed acts of self-harm in the period after initial treatment was 11.4% (Challis et al., 2013).[8]

It is therefore vital, that people experiencing psychosis are able to access services quickly.

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ZSA Suicide Prevention Resource Map Data – key takewaways

Our Suicide Prevention Resource map developed with the NHS Benchmarking Network* includes a number of metrics from the network’s mental health projects which provide a picture of the overall situation for EIP services across England. This data shows wide variation in the number of people referred to and accessing these services and the amount of clinical contacts received by individuals:

• The number of referrals to early intervention in psychosis teams per 100,000 registered population (16-24) varies from 5 to 294, with an average of 76 referrals, up from 75 in 2019/20
• Number of referrals to Early intervention in psychosis teams per 100,000 weighted population (16-64) varies from 3 to 190, with a median average of 70, down from 72 in 2019/20
• The median waiting times for 1st routine appointment with Early Intervention in Psychosis (EIP) teams varies from 0.6 weeks to 11.5 weeks, with a median average waiting time being 1 week and for the second appointment it was 2 weeks
• Number of people on an Early intervention in psychosis teams caseload per 100,000 registered population (16-64) varies from 11 to 236, with a median average of 69, up from 62 in 2019/20
• Number of people on an Early intervention in psychosis teams caseload per 100,000 weighted population (16-64) varies from 7 to 214, with a median average of 58, up from 56 in 2019/20
• Number of contacts with Early intervention in psychosis teams per 100,000 registered population (16-64) varies from 107 to 6,651, with an average of 2,444 clinical contacts, up from 1,946 in 2019/20
• Number of contacts with Early intervention in psychosis teams per 100,000 weighted population (16-64) varies from 97 to 4,758, with an average of 2,176 clinical contacts, up from 1,868 in 2019/20
• Average annual number of contacts per person on the caseload of the Early Intervention in Psychosis team varies from 2 contacts to 68, with a median average of 37 contacts, up from 34 in 2019/20​

EIP services need to be able to rapidly and consistently meet the needs of the population that they serve so should be:

• Routinely looking at how many people are being referred and accepted onto the caseload and how this compares with expected number of new cases of psychosis within that population e.g. through use of predicted incidence data such as that published on the Psymaptic site.[9]
• Routinely checking that service users being are being assessed and accepted onto the caseload within two weeks of referral and that NICE clinical guidelines,[10][11] and the associated quality standards are being achieved.[12][13]
• Working with commissioners to see how they compare to similar services and identifying any other opportunities for improvement.

* All data from NHS Benchmarking Network projects is subject to change dependent upon permissions being receiving from provider organisations to have their data included in the map. The information reported reflects the data available as at 1/09/22.

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National guidelines for practice

NHS Long Term Plan

In 2021/22, the NHS Long Term plan target is that 60% of people referred to EIP services will begin a NICE-approved package of care within two weeks (NHS Mental Health Implementation Plan 2019/20 – 2023/24).[14]

The latest NHS Digital EIP waiting times data shows that 70.7% of those referred for EIP services in England waited two weeks or less for assessment and acceptance onto the caseload (October to December 2021), exceeding the Long Term Plan ambition for 2020/21.[15]

NICE guidelines

NICE approved care includes:

• Family Intervention
• Cognitive Behavioural Therapy for psychosis (CBTp)
• Physical health assessments
• Wellbeing support
• Carer focused education and support
• Education and employment support
• Medication

There is limited routine publicly available information to show how services are complying with these NICE standards, however data from the annual National Clinical Audit of Psychosis for England and Wales gives an indication.[16][17] There appears to be significant variation in the degree to which these standards are met across trusts and further information on this can be seen within the ZSA Suicide Prevention Resource Map (Early Intervention in Psychosis – Effective Section).

National Clinical Audit of Psychosis

To improve accessibility of the findings from the National Clinical Audit of Psychosis, Rethink has produced a version of the England report for use by members of the general public (2020).[18] The National Clinical Audit of Psychosis uses two ways of capturing information: an audit of case records for a sample of people receiving services and a service user survey. The key findings from the audit of case records are summarised below:

• 74% of people started treatment within two weeks of being referred (a 2% decrease on the previous year)
• 49% of people had received CBTp (an increase of 3% on the previous year)
• 21% of people had received family interventions
• People should be offered clozapine (an antipsychotic medication) if they haven’t responded well to other antipsychotics, the audit found that only 52% of people were offered clozapine who should have been
• 31% of people not in employment, education or training were receiving employment and education support
• 63% of people had received a comprehensive physical health check and received appropriate support
• 58% of carers for people receiving early intervention in psychosis services had been referred to or joined a carer-focussed education or support programme
• EIP services use patient and clinician reported outcome measures to look at whether services are effective and meeting the needs of the people using them. The audit found that only 41% of people had their outcomes recorded twice in line with the standards, however this was a big increase on 2018/19 when only 22% had.

The results from the audit are used to provide an annual performance assessment of EIP services with Level 4 being Top Performing and Level 1 being in Greatest Need of Improvement. 

NHS Mental Health Implementation Plan

The NHS Mental Health Implementation Plan 2019/20-2023/24[19] states that by 2020/21 60% of services will achieve Level 3 (Performing Well) and by 2023/24 this will rise to at least 95% of services at Level 3.  The latest data publicly available is for 2021/22[20] and showed that 44.2% of services achieved Level 3 against the Five Year Forward View for Mental Health Implementation Plan target of 50%.

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Impact of COVID-19

O’Donoghue et al. (2020)[21] state that “The Covid-19 pandemic poses significant challenges to the delivery of these [EIP] services, such as undetected cases or long delays to treatment.”

The article also suggests that the COVID-19 pandemic will likely increase the incidence of psychotic disorders and suggests how EIP services can adapt within this environment such as:

• Monitoring referral rates in real time
• Removal of barriers to service such as requiring referral from professionals
• Be flexible in how they conduct assessments and provide treatment e.g. through use of telehealth technology

In response to the pandemic, a number of bodies have undertaken work to predict the potential increase in demand for mental health services. 

One example of this is the work undertaken by The Strategy Unit[22] which predicts that there may be 1.8 million new presentations, recurrences or exacerbations of mental ill health across England in the next three years as a direct or indirect result of the pandemic with the next 18 months being particularly challenging for services. 

The Strategy Unit’s work suggests that there could be a 33% increase in overall demand in the next three years (to 2022/23) and their modelling app[23] estimates that Early Intervention in Psychosis services in England could receive an additional 7,272 referrals in the next three years equating to a 16.6% surge in demand:

• 6.9% in 2020/21
• 6.1% in 2021/22
• 3.5% in 2022/23

Local systems can use the app to model the potential surge in demand for their area and impact on specific services and use this to support planning.

The Centre for Mental Health, in collaboration with NHS Trusts and NHS England, has also worked on developing a modelling toolkit for forecasting additional demand for mental health services resulting from the pandemic.[24] This takes the results of various studies and enables the user to input the information they have about their local population into the model to generate an estimate of the amount of additional demand for mental health services in that area.   

The pandemic has seen a shift in the delivery of mental health care with fewer patients being referred to hospital and more appointments being carried out via phone/telemedicine/e-mail (NHS Digital 2021).[25]

In response to the COVID-19 pandemic, the NHS Benchmarking Network has developed a monthly mental health and learning disability COVID-19 dashboard which supports provider organisations to check the impact that COVID-19 has had on core service provision and the impact and extent of the switch to virtual and digital service provision. Whilst data is not available for EIP services specifically the data for adult and older adult community mental health services shows that:

• Prior to the pandemic approximately 25% of clinical contacts were non face to face and this increased during the early stages of the pandemic to 68% (face to face work reducing to 32%). 
• The proportion of work undertaken non face to face has decreased over recent months but is unlikely to return to pre-pandemic levels as providers and systems consider how to embed different delivery approaches in their recovery plans.
• Approximately 5% of clinical contacts are now undertaken using digital technologies e.g. video consultations and the data suggests that these methods are becoming embedded within services and are likely to remain an important part of service delivery in the future.

A number of recent articles (Ferrando et al., 2020; Parra et al., 2020; Smith et al. 2020)[26][27][28] have suggested that people with COVID-19 may be at risk of developing neuropsychiatric symptoms including psychosis. The articles suggest that further study is warranted but there could be implications in respect of increased demand for EIP services.

Despite the forecast increases in demand highlighted above, there have been widely reported reductions in GP consultations since the start of the pandemic leading to concerns about the care of non-COVID patients (The Health Foundation, 2020).[29] This was particularly stark during the first wave of the pandemic with a 30 percent reduction compared with previous years observed in the first week of the March 2020 lockdown. Whilst numbers started to recover during the early summer, the data reported by the Health Foundation suggests that they remain below normal levels. This pattern appears to evident for people experiencing psychosis as many EIP services have reported getting less referrals from primary care during the initial lockdown and seeing more people coming through acute pathways such as hospital admissions.[30]

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Recommendations for action

Action for NHS Commissioners and NHS Providers (mental health):

• Undertake analysis of the benchmarking data presented within the ZSA Suicide Prevention Resource Map to understand your comparative position and utilise this intelligence to develop local quality improvement programmes.
• Undertake a study to review likely population-level need informed by the epidemiological approach described by Kirkbride et al. (2017)[31], drawing on predictive data published within the Psymaptic tool [15] and utilise to underpin future commissioning and service-developments for people experiencing first episode of psychosis.
• Review trust / service results from the National Clinical Audit of Psychosis [16][17] and implement relevant recommendations and implement a quality improvement programme
• Undertake a local assessment of potential increase in demand for mental health services as a result of the COVID-19 pandemic and routinely monitor referral trends against this.

Action for NHS England / Improvement, Care Quality Commission, Welsh Government, Health Boards (Wales), and Improvement Cymru:

• Review and implement relevant recommendations from the National Clinical Audit of Psychosis [16] [17].
• Make data publicly available to show progress against NHS Long Term Plan mental health ambitions in a timely and accessible way to enable transparency and accountability.

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ZSA Suicide Prevention Resource Map – related indicators

Direct indicators

Referrals

• Referrals received per 100,000 registered population
• Referrals received per 100,000 weighted population

Waiting times

• Median waiting time for 1st appointment
• Median waiting time for 2nd appointment

Caseload

• Caseload per 100,000 registered population
• Caseload per 100,000 weighted population

Contacts

• Contacts per 100,000 registered population
• Contacts per 100,000 weighted population
• Contacts per person on caseload

Effective

• Cognitive behavioural therapy for psychosis (CBTp)
• Family Intervention
• Employment and education programme
• Physical health screening and interventions
• Carer-focused education and support

Indirect indicators

• SMI prevalence
• Gap in employment rate (%) for people with mental health conditions
• Index of Multiple Deprivation - Local Authority Score
• Emergency hospital admissions for intentional self-harm per 100k population
• Annual prescribing of antipsychotic drugs per 100,000 population
• Annual prescribing of antipsychotic depot injections per 100,000 population
• Total CCG spend on mental health (all ages) per 100,000 registered population (£)
• CCG spend on mental health (all ages) as a percentage of CCG base allocations

* All data from NHS Benchmarking Network projects is subject to change dependent upon permissions being received from provider organisations to have their data included in the map. The information reported reflects the data available as at 24/08/22.

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References

[1] NHS England, the National Collaborating Centre for Mental Health and the National Institute for Health and Care Excellence (2016). Implementing the Early Intervention in Psychosis Access and Waiting Time Standard: Guidance. Available at: https://www.england.nhs.uk/mentalhealth/wp-content/uploads/sites/29/2016/04/eip-guidance.pdf 

[2] Tsiachristas, A., Thomas, T., Leal, J., & Lennox, B. R. (2016). Economic impact of early intervention in psychosis services: results from a longitudinal retrospective controlled study in England. BMJ open, 6(10), e012611. https://doi.org/10.1136/bmjopen-2016-012611 

[3] Kirkbride, J. B., Errazuriz, A., Croudace, T. J., Morgan, C., Jackson, D., Boydell, J., Murray, R. M., & Jones, P. B. (2012). Incidence of schizophrenia and other psychoses in England, 1950-2009: a systematic review and meta-analyses. PloS one, 7(3), e31660. https://doi.org/10.1371/journal.pone.0031660 

[4] Public Health England (2016). Psychosis Data Report – Describing variation in numbers of people with psychosis and their access to care in England. Available at: https://www.gov.uk/government/publications/psychosis-data-report 

[5] Nielssen, O. B., & Large, M. M. (2009). Untreated psychotic illness in the survivors of violent suicide attempts. Early intervention in psychiatry, 3(2), 116–122. https://doi.org/10.1111/j.1751-7893.2009.00117.x 

[6] Rethink Mental Illness and The IRIS Network (2014). Lost generation, why young people with psychosis are being left behind, and what needs to change. Available at: https://www.rethink.org/media/2628/lost-generation-rethink-mental-illness-report.pdf 

[7] Nielssen, O. B., Malhi, G. S., McGorry, P. D., & Large, M. M. (2012). Overview of violence to self and others during the first episode of psychosis. The Journal of clinical psychiatry, 73(5), e580–e587. https://doi.org/10.4088/JCP.11r07036 

[8] Challis, S., Nielssen, O., Harris, A., & Large, M. (2013). Systematic meta-analysis of the risk factors for deliberate self-harm before and after treatment for first-episode psychosis. Acta psychiatrica Scandinavica, 127(6), 442–454. https://doi.org/10.1111/acps.12074

[9] PsyMaptic. Psychiatric Mapping Translated into Innovations for Care. Available at: https://www.psymaptic.org/ 

[10] National Institute for Health and Care Excellence (2013). Psychosis and schizophrenia in children and young people: recognition and management (CG155). Available at: https://www.nice.org.uk/guidance/cg155 

[11] National Institute for Health and Care Excellence (2014). Psychosis and schizophrenia in adults: prevention and management (CG178). Available at: https://www.nice.org.uk/guidance/cg178

[12] National Institute for Health and Care Excellence (2015). Bipolar disorder, psychosis and schizophrenia in children and young people (QS102). Available at: https://www.nice.org.uk/guidance/qs102 

[13] National Institute for Health and Care Excellence (2015). Psychosis and schizophrenia in adults (QS80). Available at: https://www.nice.org.uk/guidance/qs80 

[14] NHS (2019). NHS Mental Health Implementation Plan 2019/20 – 2023/14. Available at: https://www.longtermplan.nhs.uk/publication/nhs-mental-health-implementation-plan-2019-20-2023-24/ 

[15] MHSDS Monthly: Performance October 2021 to December 2021 Access and Waiting Times Reference Tables (Table 2a for England and Provider data, Table 2b for England and CCG data). Available at: https://files.digital.nhs.uk/A2/8A09AD/MHSDS%20AWT_DecPrf_2021.xlsx  

[16] Royal College of Psychiatrists (2020). National Clinical Audit of Psychosis – National Report for the Early Intervention in Psychosis Audit 2019/2020. London: Healthcare Quality Improvement Partnership. Available at: www.rcpsych.ac.uk/NCAP 

[17] Royal College of Psychiatrists (2020). National Clinical Audit of Psychosis – Wales National Report for the Early Intervention in Psychosis Audit 2019/2020. London: Healthcare Quality Improvement Partnership. Available at: www.rcpsych.ac.uk/NCAP 

[18] Rethink Mental Illness (2020). National Clinical Audit of Psychosis Lay Report for the Early Intervention in Psychosis Audit 2019/20. Available at: https://www.rcpsych.ac.uk/docs/default-source/improving-care/ccqi/national-clinical-audits/ncap-library/national-clinical-audit-of-psychosis-final-lay-report-2020.pdf?sfvrsn=e734404b_2 

[19] NHS England (2016). Implementing the Five Year Forward View For Mental Health.  Available at: https://www.england.nhs.uk/wp-content/uploads/2016/07/fyfv-mh.pdf

[20] NHS England and Improvement (December 2020). NHS Mental Health Dashboard Quarter 4 2021/22. Available at: https://www.england.nhs.uk/wp-content/uploads/2017/01/nhsmh-dashboard-q4-21-22.xlsm 

[21] O’Donoghue B, O’Connor K, Thompson A, McGorry P. The need for early intervention for psychosis to persist throughout the COVID-19 pandemic and beyond. Ir J Psychol Med. 2020 May 21: 1–6. Published online 2020 May 21. doi: 10.1017/ipm.2020.56 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7426603/ 

[22] The Strategy Unit (2020). Estimating the impacts of COVID-19 on mental health services in England. Available at: http://www.strategyunitwm.nhs.uk/sites/default/files/2020-11/Modelling%20covid-19%20%20MH%20services%20in%20England_20201109_v2.pdf

[23] The Strategy Unit (2020). Mental Health Surge Modelling app. Available at: https://strategyunit.shinyapps.io/MH_Surge_Modelling/ 

[24] Centre for Mental Health (2020). Forecast Modelling Toolkit. Available at: https://www.centreformentalhealth.org.uk/forecast-modelling-toolkit 

[25] NHS Digital (2021). Mental Health Services Monthly Statistics Performance October, Provisional November 2020. Available at:  https://digital.nhs.uk/data-and-information/publications/statistical/mental-health-services-monthly-statistics/performance-october-provisional-november-2020 

[26] Ferrando, S. J., Klepacz, L., Lynch, S., Tavakkoli, M., Dornbush, R., Baharani, R., Smolin, Y., & Bartell, A. (2020). COVID-19 Psychosis: A Potential New Neuropsychiatric Condition Triggered by Novel Coronavirus Infection and the Inflammatory Response? Psychosomatics, 61(5), 551–555. https://doi.org/10.1016/j.psym.2020.05.012 

[27] Parra, A., Juanes, A., Losada, C. P., Álvarez-Sesmero, S., Santana, V. D., Martí, I., Urricelqui, J., & Rentero, D. (2020). Psychotic symptoms in COVID-19 patients. A retrospective descriptive study. Psychiatry research, 291, 113254. https://doi.org/10.1016/j.psychres.2020.113254

[28] Smith, C. M., Komisar, J. R., Mourad, A., & Kincaid, B. R. (2020). COVID-19-associated brief psychotic disorder. BMJ case reports, 13(8), e236940. https://doi.org/10.1136/bcr-2020-236940 

[29] The Health Foundation (2020). Use of primary care during the COVID-19 pandemic. Available at: https://www.health.org.uk/news-and-comment/charts-and-infographics/use-of-primary-care-during-the-covid-19-pandemic 

[30] Iris (2020). Blog: Recovery, Restoration and the NCAP Audit. Available at:  http://iris-initiative.org.uk/ 

[31] Kirkbride, J. B., Hameed, Y., Ankireddypalli, G., Ioannidis, K., Crane, C. M., Nasir, M., Kabacs, N., Metastasio, A., Jenkins, O., Espandian, A., Spyridi, S., Ralevic, D., Siddabattuni, S., Walden, B., Adeoye, A., Perez, J., & Jones, P. B. (2017). The Epidemiology of First-Episode Psychosis in Early Intervention in Psychosis Services: Findings From the Social Epidemiology of Psychoses in East Anglia [SEPEA] Study. The American journal of psychiatry, 174(2), 143–153. https://doi.org/10.1176/appi.ajp.2016.16010103 

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Content reviewed and updated 1/09/22