Author's reply

The advocacy and political activism of the International Early Psychosis Association has clearly been successful in the UK since teams for their narrow sub-specialty have been introduced despite widespread shortages of trained mental health professionals. General psychiatrists also consider themselves to be advocates for people with mental illness. They may not have the public relations skills of the early intervention movement but they believe that clinical experience and knowledge of epidemiology and health economics should be more important in determining health policy.

The most ambitious aim of the early intervention specialists has been to identify and treat people during a pre-psychotic phase of illness. There now seems to be unanimous agreement that any such attempts to prevent the onset of, for example, schizophrenia could only lead to more harm than good. The International Early Psychosis Association should return to users, carers, policy makers and members of the public whom they have influenced (Goode, 1999) and explain the epidemiological and clinical errors behind their previous dreams of primary prevention.

There should also be unanimous agreement with your earlier correspondent that provision of care to young people who have recently developed a psychotic illness is not ‘rocket science’ (Owen, 2003). I have read and re-read accounts of the clinical methods of the early intervention practitioners. They describe straightforward psychosocial and pharmacological therapies that should be used by all multidisciplinary teams. The only distinguishing feature is the sub-specialists' touching faith in the effectiveness of antipsychotic medicines, which presumably arises from lack of prolonged experience with individual patients.

This inadequate experience of chronic illness is certain to lead to tragedies in the UK. The chosen remit of early intervention practitioners is to assist patients during the first 3 years of illness (Birchwood et al, 1998) - unless case-loads are high, when the ‘critical period’ can be reduced to 18 months (McGorry et al, 1999). When relapses occur, ordinary in-patient and community teams will, of course, have to pick up the pieces and I am in no doubt that they will be criticised for not being as attentive and caring as previous keyworkers.

Community mental health teams do not ‘inevitably focus on the needs of “prevalent” rather than “incident” cases’. Those who are definitely - or probably, or possibly - in the early stages of psychosis are high in their list of priorities. Unlike Manchanda et al, they do not require ‘controlled trials to assess the efficacy of early intervention’. These patients are unwell and they all require prompt and appropriate treatment. One of the most important tasks of consultant psychiatrists is to prioritise according to clinical need and it is frustrating when diversion of resources to highly protected teams makes difficult decisions even more painful. Your correspondents are shirking their responsibilities in depending on central planning to protect their case-loads (Milner, 2003; Owen, 2003). Valuable work has been done in this area (Kennedy & Griffiths, 2001) and training would be available for any sub-specialist who returns to mainstream practice.

The introduction of early intervention teams in the UK should now be halted. This will provide an opportunity for proper scientific evaluation by comparing the processes and outcomes of care in areas where these teams have and have not been established. It will also free up some financial and human resources for serious hospital and community psychiatry.