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Keywords:

  • early detection;
  • early intervention;
  • organizational aspects of early intervention services;
  • public mental health;
  • quality of training

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Acknowledgements
  7. References

Aim

To assess: (i) trainees' educational needs on early intervention in psychiatry; (ii) their satisfaction and competence in early detection and management of patients with severe mental disorders; (iii) characteristics of training on prevention and on early intervention in psychiatry; and (iv) organizational and clinical differences of early intervention programmes and services in different countries.

Methods

Sixty early career psychiatrists, recruited from the early career psychiatrists' network of the World Psychiatric Association, were invited to participate in the survey. Respondents were asked to provide the collective input of their trainees' association rather than that of any individual officer or member. An online survey was conducted using an ad hoc questionnaire consisting of 18 items.

Results

Thirty-five countries sent back the questionnaire (58.3%). University training in early intervention for mental disorders was provided in 13 countries (38%); 54% of respondents were not satisfied with received training and about half of them did not feel enough confident to provide specialistic interventions to patients at the onset of the disorder. Services for early intervention existed in 22 countries (63%). The most frequently available were those for schizophrenia (75%). Informative campaigns on mental disorders were usually carried out in almost all surveyed countries (85%).

Conclusions

Although prevention and early intervention represent one of the current paradigms of psychiatric practice and research, efforts are still needed in order to improve training programmes at university sites.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Acknowledgements
  7. References

Following the seminal works by McGorry[1] and others,[2] the practice of early intervention in psychiatry has became one of the most prevalent paradigms in modern psychiatry. With the growing evidence that early intervention is associated with a better outcome of patients with severe mental disorders and with a reduced admission rate,[3-7] programmes and services for prevention and early intervention have been developed in many countries.[8-11] Moreover, a recent survey carried out by the ROAMER consortium involving European stakeholders (i.e. national associations of psychiatrists, psychologists, users and carers, and trainees) had showed that early detection and management of mental disorders are among the top five priorities for all categories of European stakeholders.[12]

Services were initially focused on schizophrenia, but more recently a preventive approach has been adopted for other mental disorders as well, such as affective disorders, eating disorders, drug abuse and personality disorders.[13-16] A proliferation of services providing early intervention for severe mental disorders has been observed worldwide in the last 10–15 years,[17, 18] and several national governmental bodies launched guidelines on the development of these services, recommending substantial funding for this.[19-21]

Although the international movement on early intervention has profoundly modified psychiatric practice, the dissemination of such services and programmes remains frustratingly slow.[22] Barriers are related to care pathways,[23] professionals' characteristics and to collaboration with other specialized services (e.g. child and adolescent mental health services, adult mental health teams, schools),[24] which is not always very easy. Moreover, university training curricula rarely include the topic of prevention and early detection of mental disorders among the subjects of training. The consequence of this is that trainees and early career psychiatrists are probably not confident with prevention.

Under these premises, we decided to carry out an international survey to evaluate training and practice of early intervention for mental disorders in different countries of the world.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Acknowledgements
  7. References

An ad hoc questionnaire was developed using the same methodology adopted for other surveys recently carried out by the early career psychiatrists networks of the World Psychiatric Association (WPA) and the European Psychiatric Association (EPA).[25, 26] A first list of questions was drafted by the authors on the basis of their own experience and guidelines through focus groups. This list was sent to 10 early career psychiatrists coming from the network of the WPA, who were asked to send back their comments on the questionnaire before the survey implementation. Seven questions were deleted from the list because they were considered either not relevant (N = 5) or a repetition (N = 2). The final version of the questionnaire consists of 18 items, 12 being multiple-choice questions, 5 yes/no questions and 1 open question.

The 18 questions were subsequently grouped in the following four areas: (i) quality of training on early intervention (e.g. ‘Is there a dedicated teacher/supervisor for early intervention at university sites?’); (ii) satisfaction with received training (e.g. ‘Are you satisfied with received training?’); (iii) self-confidence in the early detection and management of patients with mental disorders (e.g. ‘Do you feel confident enough to provide early intervention to patients when you finish your specialist training?’); and (iv) organizational aspects of early intervention services (e.g. ‘Are services for early intervention of mental disorders available in your Country?’).

In the period June–July 2012, sixty early career psychiatrists, representatives of early career psychiatrists of their national associations and recruited from the early career psychiatrists' council of the WPA,[27] were invited to participate in an online survey through email invitation. Each respondent was asked to provide the collective feedback of his/her association rather than that of any individual officer or member. Countries were grouped using the World Bank list of economies[28] in high-income (e.g. France, Portugal, Estonia) and middle-income countries (e.g. Latvia, Bolivia, Indonesia). All countries from the low income category (e.g. Ethiopia, Korea) did not return the questionnaire. Thirty-five associations returned the questionnaire (response rate of 58.3%); the respondents to the survey are listed in the acknowledgements.

Items were analysed by simple frequency counts; differences between countries' categories were explored using χ2 test or anova, as appropriate. The level of significance was set at P < 0.05. All analyses were performed using the Statistical Package for Social Science software (SPSS), version 18.0 (IBM, SPSS, Chicago, IL, USA).

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Acknowledgements
  7. References

Training programmes

Training programmes in early intervention for mental disorders were available in Australia, Brazil, Canada, Cyprus, Croatia, France, Germany, Nigeria, Norway, Serbia, Switzerland, Turkey, United Kingdom (38%). In 11 countries, the programmes included both practical (such as rotation in early intervention teams and provision of home visits to patients with a recent onset of the disorder) and theoretical activities, whereas in the remaining two countries (France and Nigeria) training was only theoretical. A university tutor in early intervention was available in eight countries (Canada, Cyprus, Croatia, Germany, Serbia, Switzerland, Turkey, United Kingdom). At the end of residency, 54% of respondents were not satisfied with received training and they did not feel confident enough to provide specialistic early intervention to these patients.

Real-world practice

Specialistic services for early intervention for mental disorders were present in 22 countries (63%), with a significant discrepancy between high- and middle-income countries, being available in 85% of the former and in 33% of the latter (P < .01). On the whole, early intervention services most frequently available were those for schizophrenia (available in 18 countries, 75%), substance abuse/dependence (available in 12 countries, 34%) and mood disorders (available in 6 countries, 24%). Services for eating disorders existed only in high-income countries (N = 4; 22%). Interestingly, early intervention services for substance abuse disorders were more frequently available in middle-income than in high-income countries (86% vs. 39%; P < .05). As regards early strategies and programmes offered, informative campaigns were usually conducted in 29 countries (83%). In particular, informative campaigns on substance abuse and on the risk of dependence for young people were available in 26 countries, anti-stigma campaigns in 21 countries, informative campaigns for general practitioners in 17 countries. Family supportive interventions, such as psychoeducation and/or treatments to assist young people with a parent affected by a mental disorder, were quite common, being available in 18 countries (53%). Specific programmes for high-risk populations, such as interventions to prevent suicide (12 countries, 34%) or to prevent post-partum depression or post-partum psychosis (7 countries, 20%), were becoming more widespread. Early intervention programmes and strategies provided in the surveyed countries are reported in Table 1.

Table 1. Early intervention programmes and strategies provided in the surveyed countries
CountryInformation on youth psychological distress for school teachersAnti-stigma campaignsInformation on substance abuse and risk of dependence for studentsInformative campaigns for GP on mental disordersSupportive family interventions for patients with recent onset of severe mental disordersEarly intervention for migrant populationProgrammes to prevent post-partum depression or psychosisSuicide prevention strategies
Albania xxxx   
Argentinax     x 
Australiaxxxxxxxx
Austria  x x   
Belgium    x   
Bolivia        
Bosnia xxxx   
Brazilxxx     
Canadaxxxxxxxx
Croatiax xx    
Cyprusxxx x   
Czech Republic xx  x  
Egypt  xxx   
Estonia  xxx   
France  xxx  x
Germanyxxxxxxxx
Greece    xx x
Hungary        
Indiaxxx x  x
Indonesiaxxxx   x
Italyxxx x   
Latvia xx     
Macedonia xxxx   
Nigeria        
Norwayxxxx  xx
Paraguay  x  x  
Poland xx  x  
Portugal xx     
Romaniax xxx  x
Serbiaxxxxxxxx
Spainx  x x  
Switzerland x     x
Turkey xxx    
United Kingdom x x    
USA xx x xx

As regards professionals working in early intervention settings, psychiatrists were engaged in all the 35 surveyed countries, psychologists in 25 countries (86%) and psychiatric nurses in 24 countries (83%). Other mental health professionals included social workers in 21 countries (72%) and occupational therapists in 12 countries (41%).

The main obstacles to access early intervention services were the lack of dedicated centres for early detection and management of patients (74%) and the high costs of these services – which were not reimbursed – for patients and their relatives (22%).

Summary of findings and conclusions

This is the first survey that explored the views of early career psychiatrists on early intervention training and programmes in several countries of the world.

The main findings of this survey were: (i) early career psychiatrists were not satisfied with the quality of training provided at university sites on early intervention skills; (ii) the level of dissemination of early intervention services in high-income countries was well established; and (iii) the most frequently available early intervention services were those for schizophrenia in high-income countries and for substance abuse in middle-income countries.

As regards the quality of training, early career psychiatrists felt to have not received enough practical skills during residency, as confirmed by the fact that about 50% of them did not feel confident to provide specialistic intervention at the end of their training. Interestingly, in a similar survey aimed at exploring early career psychiatrists' views about training in psychotherapy, trainees were satisfied with received training and felt able to treat patients in psychotherapy.[26]

Another important finding was the good level of dissemination of early intervention services worldwide. In medium-income countries there was a higher number of early intervention services for substance abuse as compared with the high-income ones. This reflected the different focus of mental health policies due to the high incidence of substance disorders in these countries.[29] On the contrary, services for early detection and management of eating disorders were not available in many countries, although these disorders became ‘one of the epidemic of the XXI century’.[30] National bodies should consider and include these services among the priorities for early detection policies.

This study had some limitations, which need to be acknowledged. First, it was not possible to reach all countries. In fact, respondents from low- or very-low-income countries were missing from the survey. In countries where basic patients' needs were often not satisfied, the provision of early intervention services still remained a chimera. Second, respondents were chosen from a list of selected early career psychiatrists who were probably not representative of all early career psychiatrists of their countries. However, this possible bias was overcome by inviting people to respond on behalf of their association and not on behalf of themselves (i.e. they had to consult the other members of the association before providing their inputs). A third limitation was due to the fact that this was a purposely designed survey. However, the response rate of 58.3% showed that not only those who were interested in the practice of early intervention had been invited to participate.

Although the practice of early intervention for mental disorders is now widespread, the training is still far to be satisfying for trainees and early career psychiatrists. Although prevention and early intervention represent one of the paradigms of modern psychiatry,[31] the new generation of professionals feel not confident to use preventive approaches or to treat patients in the early stages of their illness.

In order to improve training and practice of early intervention in the real world according to the early career psychiatrists' perspectives, the following suggestions could be taken into account:

  • Implementing rotations and exchange programmes for residents, in particular for those from low- and middle-income countries. One successful experience is the one recently carried out by the WPA in collaboration with the Centre for Youth Mental Health/Orygen Youth Health Research Centre, University of Melbourne, Australia.[32]
  • Organizing the teaching of practical skills during residency.
  • Encouraging the collaboration among different involved professionals, strengthening the fact that multidisciplinary teams are necessary in early intervention settings.
  • Promoting mental health-care policies for early detection and management of mental disorders also in countries where this practice is still not a priority.
  • Providing dedicated centres for patients with a recent onset of mental disorder, who have different needs from patients with established disorders.

If prevention in psychiatry has to become one of the new paradigms of a modern mental health care, much work still remains to be done. Early career psychiatrists should be ready to take on this task.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Acknowledgements
  7. References

We are grateful to the following early career psychiatrists who compiled the questionnaire and made this survey possible: Federico Rebok (Argentina), Prachi Brahmbhatt (Australia), Nursen Yalcin (Austria), Marinela Kulla (Albania), Nele De Vriendt (Belgium), Guillermo Rivera (Bolivia), Goran Račetović and Amra Delic (Bosnia-Herzegovina), Felipe Picon (Brazil), Emiko Moniwa (Canada), Neophytos Theodorides (Cyprus), Nikolina Jovanovic (Croatia), Alexander Nawka (Czech Republic), Hussien Elkholy (Egypt), Marina Cojocarn (Estonia), Olivier Andlauer (France), Iris Calliess (Germany), Rafail Psaras (Greece), Sandeep Grover (India), Hervita Diatri (Indonesia), Andrea Fiorillo (Italy), Laura Shtane (Latvia), Amra Delic (Macedonia), Oluyomi Esan (Nigeria), Anne Kamps (Norway), Rodrigo Ramalho (Paraguay), Agnieszka Butwicka (Poland), Marianna Pinto da Costa (Portugal), Adriana Mihai (Romania), Marija Mitkovic and Slavica Nikolic (Serbia), Guillermo Lahera Forteza (Spain), Florian Riese (Switzerland), Banu Aslantas and Sinan Guloksuz (Turkey), Gregory Lydall (United Kingdom) and Joshua Blum (USA).

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Acknowledgements
  7. References