Psychosis: Early Intervention

Lisa Cameron Excerpts

Wednesday 7th September 2016 Westminster Hall

[Norman Lamb]

We should always be guided by clinical judgment. That is critical. The standard that was introduced was for people between the ages of 14 and 65, which gives a clue about the appropriate level. This condition could emerge during teenage years, but we know that 50% of adult mental health problems start by the age of 14, so getting in and addressing problems early is critical.

[Dr Lisa Cameron (East Kilbride, Strathaven and Lesmahagow) (SNP)]

I thank the right hon. Gentleman for securing this important debate. Does he agree that although not everyone will suffer mental health problems in childhood, it is important that mental wellbeing is focused on in schools—both primary and secondary—to ensure that good mental health is promoted?

[Norman Lamb]

I thank the hon. Lady for that intervention, because I totally agree. When I was Minister, we set up a taskforce to look at how we could modernise children’s mental health services. It published a report last March called “Future in mind,” the whole focus of which is on shifting fundamentally towards prevention: establishing wellbeing, particularly in schools, and intervening much earlier to stop deterioration ever happening. That approach is much more effective. It can help teenagers through difficult years as they grow up, but it also stops the enormous cost to the system later of neglecting those problems.

Psychosis costs the NHS £11.8 billion a year. That is a vast cost. Only 8% of people who suffer from psychosis are in work, so the cost of the illness to society is enormous. The evidence of the effectiveness of early intervention in psychosis is overwhelming. It is clear that if we intervene quickly, we can have an impact on that condition, stop it in its tracks and give sufferers the chance of a good life, which the rest of us take for granted. If we neglect the condition, those people will almost inevitably suffer lives on benefits and with difficult relationships, at—this is critical—enormous cost to the state. Analysis shows that if we invested £1 in services for early intervention in psychosis, the return on that investment over a 10-year period would be £15. We might ask, “What is the reason not to do that?” It is overwhelming common sense. It is both morally right and the economically sensible thing to do.

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[Dr Lisa Cameron (East Kilbride, Strathaven and Lesmahagow) (SNP)]

It is a pleasure to serve under your chairmanship, Sir Roger. I thank the right hon. Member for North Norfolk (Norman Lamb) for securing this extremely important debate. I declare an interest, having worked as a clinical psychologist for 20 years in the NHS, and as a continuing member of the British Psychological Society, our professional body.

I shall start by giving a little context. I am heartened by some of the progress that has been made and by initiatives on mental health taken by Governments in the UK and Scotland over the years. When I started out, it was quite commonplace for patients to wait up to or more than a year for treatment. There appeared not to be any urgency about dealing with the waiting list and waiting times. That has improved very much, and we have waiting list standards. The HEAT targets—health improvement, efficiency and governance, access and treatment targets—focus service providers, policy makers and resources. So things are improving, but we clearly still have much work to do. I concur that we need to work in a conjoined way across the UK and share best practice models in doing so.

The service when I started in practice clearly was not good enough. Patients had been waiting far too long by the time they came into treatment. Often they had been admitted to hospital in an acute situation—perhaps they were suicidal—or had had multiple episodes of psychosis, and we were not providing the best possible standard of care. Psychosis is a distressing illness, which tends to be long-term, although people can recover at an early stage if we pick up their symptoms and provide the appropriate care timeously.

In psychosis, people experience symptoms of paranoia and, often, delusional belief systems that take them outwith reality. They may experience visual and auditory hallucinations. It is distressing for the person and also very much affects their family and those around them, and we must take it very seriously. Although it affects quite a small proportion of the population, it has huge ramifications for family relationships.

[Gavin Robinson (Belfast East) (DUP)]

The hon. Lady is building on an impressive speech by the right hon. Member for North Norfolk (Norman Lamb). Does she accept that while it is right to pay attention to how quickly people get treatment after diagnosis, the biggest barrier to early intervention and treatment is securing diagnosis? I have personal experience, as my wife struggled for two years to get a diagnosis. Once she got it treatment was put in place, but it was far too long to wait. Until we crack that nut and, rather than dismissing people’s symptoms and struggles, deal with them practically, sympathetically and professionally, early intervention is only a myth to be discussed. We need the diagnosis first.

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[Dr Cameron]

I thank the hon. Gentleman for that intervention about his personal and family experience. What he says is totally true; the issue is about shortening the gap between presentation and emergence of symptoms, and diagnosis. That is also true of other mental health problems and developmental disorders. Autistic spectrum disorders are the ones that stand out to me, particularly because parents often struggle for years to obtain a diagnosis, and therefore their children do not receive appropriate intervention early enough. They struggle with understanding their child and family relationships can deteriorate as a result, so I very much concur with the hon. Gentleman’s point.

That is why the mental health taskforce setting a standard for England is such a positive development. It is intended to achieve parity of esteem, but again, we cannot just have that in words—we must have the action to follow. The initiative and standard also establish that this is a national priority, which is important, because it has not been in the past. Mental health services have often been seen as an adjunct, which is not good enough, because we know that, for instance, one in four people experience depression in their lives, while many more experience other types of mental health problems, such as anxiety.

Although only a small proportion of the population will experience psychosis, mental health problems and difficulties are widespread. Most of us will at some point experience someone in our life having mental health difficulties, so it is important that we have the standard in place and that care is within two weeks from referral. It is also really important that the data are recorded, because services have to be standardised. That is the other issue to consider, because some trusts can often implement things more quickly than others. We need to ensure there is not a postcode lottery across services and that people can access good mental health provision wherever they may be in the country. I would welcome that.

Psychosis requires multi-professional services, so a specialist team is required. Providing such a team is often labour-intensive and costly, but we should focus on the cost-effectiveness over the long term. As the right hon. Member for North Norfolk said, if we do not intervene early, the cost to society, the health service and people’s lives far outweighs the cost of the NHS provision that we must make. Standards focus policy makers on resources and ultimately improve care. The Scottish Government are currently undertaking a consultation on their mental health strategy, and early intervention and prevention will be key pillars in that. We now have a Mental Health Minister, Maureen Watt, who will be focusing on the delivery of the strategy, which will be informed by carers, service users, professionals, research and best practice.

One project I am aware of is the Esteem project in Glasgow, run by my colleague Suzy Clark, which covers Argyle and Clyde and is an early intervention service for psychosis. I understand that there is no waiting list and patients are usually seen within five days of referral, which is a huge change from the days when I started out. If patients are admitted to hospital they are assessed at the service within 24 hours, so people can feel supported straight away. It is very much a holistic service, looking at psychiatry with a medical model but also looking at psychological interventions and family support.

In the National Institute for Health and Care Excellence guidelines, cognitive behavioural training for psychosis is important. It helps people who are suffering from the positive symptoms of psychosis to begin to reappraise those symptoms, so that they can once again make a connection with reality and begin to be rehabilitated back into day-to-day life. Behavioural family therapy is also extremely important. As I have mentioned, psychosis affects not just the person who suffers but their whole family and social circle.

People can suddenly find themselves in a caring role, and research indicates that spending 10 hours and above per week as a carer can be a challenge to someone’s wellbeing. Once again, we can see the ramifications of avoiding putting best practice in place and not giving early intervention the priority it deserves. Depression is common in carers. They describe a need for information, practical help and emotional support, often from other people in a similar situation. Crucially, the outcome for and individual who suffers psychosis also partially depends on their relationship with their carer and family. That is why services and treatment have to look at the individual in a holistic manner and make sure that the available interventions encompass the family.

The Esteem project provides CBT for psychosis and behavioural family therapy. It also helps individuals to look at early warning signs and identify their symptoms at an early stage when they start to become unwell, so that they can contact appropriate providers if they have a subsequent episode. Outcomes from the first episode study by Professor Gumley at Glasgow University show massively significant and favourable outcomes following early intervention and service involvement. I must mention that Tony Morrison is also leading on the issue at Manchester University, so we can see that areas of expertise are developing right across the UK, which is heartening. We need to focus on early intervention; it is key. It leads to better prognosis, has better outcomes and reduces the risk of further relapse. It helps a person reintegrate into society, assists their carers and family and is cost-effective.

I welcome the Minister to her role, and I urge that the direction that is given is the best practice that has been recommended. We need that for service delivery, patient care, clinical effectiveness and cost-effectiveness. We must ensure there is parity of esteem for mental health.

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[Kerry McCarthy]

I very much agree, and I would love to see more research into the reasons for that. We know that early intervention is crucial and that if there is intervention after the first episode of psychosis, it can be deflected further down the line. It may be that young men’s reluctance or the lack of access to those services means that they go on to develop full-blown psychosis, which then blights their adult lives. There could be all sorts of reason. I have heard my hon. Friend speak about this before. I know she thinks it is a really important issue, and I agree with her.

Young people are even more marginalised. I have the Riverside unit for young people in my constituency at Blackberry Hill hospital. It is part residential, part day placements. I visited it recently. If the spaces are full, a number of young people get sent a considerable distance from home and away from their friends and families for treatment, which is not ideal. If we are trying to deal with young people in very vulnerable circumstances, displacing them from their families and support networks is obviously wrong.

Dr Dominique Thompson, who is in charge of the GP services at the University of Bristol, has given me figures in the past about the proportion of the casework of GPs at universities that is now on mental health-based issues, and it has grown exponentially. That is everything ranging from anxiety, stress and depression right through to severe psychosis. I make a plea that the health services at universities are not the same as ordinary neighbourhood GPs; they need particular support. They deal with young people who are away from home and away from their support networks. We know that GPs are under pressure—particularly in terms of recruitment, which is a debate for another day—and it is important they have the resources to deal with that.

I want to mention briefly one source of help that is available to GPs. I met a group of researchers yesterday who are part of the Avon and Wiltshire Mental Health Partnership NHS Trust and are based at Blackberry Hill hospital in my constituency. They do something called BEST—best evidence summaries of topics—in mental health, which is a web-based service. Basically, these experts look through all the information available and distil it down to easy paragraphs for clinicians, so that rather than having to wade through all the material on the internet, clinicians are given some guidance as to what they are likely to be looking at and the likely best treatments. The funding for that service is under threat. A cross-party group of MPs from the Avon and Wiltshire area met those researchers yesterday. We think that the service should at the very least be piloted, with a view to rolling it out nationally, because it is a really valuable resource. We are going to write to the Minister about that, but I wanted to flag it up today.

Finally, I was looking this morning at the NICE guidance on early intervention in psychosis access. It pays passing reference to substance abuse, saying:

“Around 40% of people with first episode psychosis misuse substances at some point in their lifetime.”

I would like to see more research done into cannabis-induced psychosis. It is clear to me—partly from anecdotal evidence, but there is research out there—that partly because of the stronger strains of cannabis that are now available, more people are presenting with cannabis-induced psychosis. There may be a connection between that and people going on to develop full-blown psychosis, or people may have a cannabis-induced psychotic episode and then recover. Speaking partly from personal observation, I think that in some cases drug use makes it more difficult to diagnose when people are suffering first-time psychotic episodes. I would like to see more research into that.

[Dr Lisa Cameron]

The hon. Lady is making an extremely valid point in terms of comorbidity. Comorbid substance abuse often precludes people from treatment, and they can be turned away from treatment centres. As she said, it is very common and should not mean that people cannot access treatment.

[Kerry McCarthy]

There is also the issue of whether people feel they are self-medicating by smoking. They may feel that it helps their symptoms, whereas it quite often exacerbates their symptoms.