[No Title]

The International Early Psychosis Association would like to contribute to the debate on early intervention (Pelosi/Birchwood, 2003).

First, the international network promoting reform in early psychosis is led by clinicians and academics who have a record of commitment to evidence-based medicine and leadership in scientific research. The attempt to discredit this network as mere evangelism does not bear scrutiny. However, successful reform in health care is always a blend of logic, evidence and advocacy. The latter is not only a legitimate but an essential element.

‘We should be active and loud advocates of the mentally ill and be in the forefront of their battle to realise their rights. This might require that we relinquish some of our professional role and add some political activism to our daily chores - a sometimes difficult but now ever more necessary reorientation for doctors in general and psychiatrists in particular’ (Sartorius, 1998).

Second, Dr Pelosi seriously underestimates the weakness of existing generic models of care for early psychosis patients and their families (Garety & Rigg, 2001). Access to and quality of initial care for first-episode psychosis is poor in the UK setting, as it is in most affluent, developed countries. This indicates a structural as well as a funding problem. Services targeting ‘serious and enduring mental illness’ inevitably focus on the needs of ‘prevalent’ rather than ‘incident’ cases. The early intervention paradigm asserts that there is a need to subspecialise in relation to the needs of young early psychosis patients, both in terms of structure of the service and the content of interventions, according to a ‘staging’ model. This assertion has tapped into resistance to subspecialisation in general within psychiatry, which Dr Pelosi passionately expresses. However, excessive reliance on purely generic service models is not defensible and is bound to limit the quality of response in many areas of psychiatry. A balance should be sought.

Third, implementing overdue reforms inevitably creates secondary problems and ‘perverse effects’, which seem to lie at the heart of Dr Pelosi's concerns. Workforce supply, quality and morale are crucial issues. Without careful planning, there could indeed be adverse effects on pre-existing elements of the system. These second-order issues need to be tackled but do not seriously challenge the logic and urgent need for reform in early psychosis, and should not be allowed to delay or derail it. In the longer term, greater specialisation within an umbrella of integrated services is a pathway to better morale and quality. The successful emergence of other sub-specialty areas (e.g. old age psychiatry) illustrates this point. Looking further ahead, early intervention could ultimately represent a way station en route to a sub-specialty of youth psychiatry (McGorry & Yung, 2003).

Fourth, the emerging early intervention services are targeted from first-episode psychosis onwards and do not specifically include the prodromal phase, which remains a research issue. There are genuine issues involved in sub-threshold detection of a low-incidence disorder and these remain to be solved. However, the caution required in extending intervention to potentially prodromal patients cannot be used as an argument for delaying intervention to people with clearly diagnosable first-episode psychosis.

Far from being wishful thinking, this reform process is already leading to improved short-term outcomes for young people with psychotic illness in many centres around the world (Edwards & McGorry, 2002). The reform is delicately poised in the UK and there may well be secondary effects on mainstream systems, but these should not be seen as fatal flaws, rather as problems to be solved. In the UK setting, it is to be hoped that psychiatrists will play a leadership role in this vital endeavour, which should ultimately lead to a strengthening of the specialist mental health system. In other parts of the world we are looking to you to make a success of this important task and hope your pioneering reforms will help to guide our own efforts.