Max Birchwood worked for many years as clinical director of youth mental health services and director of research and innovation in Birmingham and Solihull Mental Health Foundation Trust. He pioneered the concept and practice of early intervention in psychosis in the UK and internationally, opening the UK’s first Early Intervention in Psychosis service in 1994. This was informed by his concept of the ‘critical period’ in psychosis, which he translated into the mental health policy framework for the UK government as part of the NHS ‘National Plan’
Max presented evidence from the UK National EDEN project, a prospective longitudinal study which followed over 1000 individuals with a first episode of psychosis who were receiving early intervention services.
- Many severe mental health problems seen in adult services start in adolescence or early adulthood (e.g. psychosis, bipolar disorder).
- Formal onset of psychosis is best described as the “end of the beginning” of psychosis – i.e. the prodromal period.
- However, not all psychological difficulties predating the first onset are part of psychosis. There are also identifiable psychosocial risk factors for psychosis, with adversity in early adulthood and the experience of other psychological dififculties being associated with increased risk.
Young males make up over 70% of people with first episode psychosis, have a pattern of earlier onset and poorer functioning in adolescence and are less likely to return to levels of community and role functioning than females with the disorder and their age peers. Males are doubly disadvantaged in the face of these disorders, even in the context of these high intensity, ‘gold standard’ services.
In the EDEN project, three groups were identified:
- A “high and decreasing” group start at a high level of functioning and drop over time.
- A “moderate and increasing” group benefit quite well from engagement with early intervention services.
- A “low and stable” group of consumers who make a limited recovery and don’t appear to be benefiting from early intervention.
The ‘low and stable’ pattern of social functioning was seen in 66% of individuals, with young males making up over ¾ of this group. These young males often have a poorer adolescent functioning which forms part of this trajectory. They are twice as likely to be ‘NEET’ (Not in Education, Employment or Training) within 12 months of onset of psychosis, which is a major risk factor for long term unemployment.
The study also identified a trajectory of antisocial behaviour, harm to others and incidents of aggression, from adolescence onwards. This was twice as prevalent in males as females and represented a high degree of continuity from adolescence, not directly linked to the severity of psychosis symptoms. However, acting on delusions such as command hallucinations to defend against supposed threat, was greater in males.
On the other hand, affective dysfunction including social anxiety disorder, depression and PTSD symptoms were less prevalent in young males, though still a significant problem for a large number.
Young men with first episode psychosis are at very high risk of social exclusion and NEET status, requiring a particular focus in early intervention services.