CASE FINDING, SCREENING AND ASSESSMENT
In most jurisdictions individuals presenting with a first episode of psychosis are usually assessed through hospital emergency departments. If they are assessed by an emergency physician who recognizes the nature of their presenting problem, they may receive a psychiatric assessment either in the emergency department or following admission to hospital. Such decisions are likely to depend on the physician’s perception of risk to the person or others, the patient’s acuity of presentation and willingness to be admitted to hospital. Not uncommonly they may go untreated on the first few occasions following presentation to a clinician or they may discharge themselves from the hospital or the emergency department. If they are treated, this treatment is often provided on an inpatient unit where patients with a variety of chronic illnesses are being treated without consideration of the young person’s special needs.
It is now well recognized that there are significant systemic delays in engaging a person with a first episode of psychosis in treatment. In order to reduce these delays and create a climate of quick access to assessment and treatment a stepwise approach has been taken in our program. This has involved a number of systemic changes, some of which are listed as follows:
- We have set up an adequate assessment procedure (to be described in detail later).
- The referral system has been opened to all possible sources including prospective patients, their families and educational institutions.
- We have made assertive connection with family physicians, guidance counsellors and teachers in schools, counselling and health services at all post-secondary educational institutions and all community agencies likely to come into contact with the youth.
- Information has been provided to all potential sources of referral regarding the availability of the our service and basic information about the nature of psychosis and its treatment. This information is provided with a sense of optimism concerning treatment outcome.
- A screening procedure has been instituted for all incoming referrals in order to provide an immediate response.
- Finally, an active early case detection program has now been started in the community, using posters and pamphlets available in all public places, television and radio, advertising on public transit, etc. Details can be obtained from the program.
A formal screening procedure is conducted by an experienced clinician (a nurse case manager) when a young adult is identified with early signs of psychosis. An early intervention approach means responding within 24-48 hours with no waiting list.
A referral can be initiated by anyone. Common sources of referral include: self-referral, parents, teachers, secondary and post-secondary educational counselling centres, family doctors, traditional mental health services (including psychiatrists and psychologists in private practice), emergency departments, etc. The clinician receiving the referral asks questions relevant to basic criteria regarding eligibility for PEPP (see below). If there is any indication that the person may have psychotic symptoms or be at high or imminent risk for psychosis, a screening interview is offered. If the clinician is in doubt, the person is offered a screening assessment.
The assessment clinician will initiate contact with the client or referral source and arrange an immediate appointment. The initial contact with the client and family is of utmost significance and must be responded to with sensitivity as successful engagement of the young adult is often dependent upon a good first impression being made by the clinician. It is important to avoid alarming the client and family with labels and other medical jargon. It is better to concentrate on initiating and forming a therapeutic relationship with the client and family. A friendly and helpful attitude combined with a general interest in the family is often an effective means to successful engagement. Every effort is made to involve family in the screening procedure. This may be the most crucial time to connect with the family while also obtaining valuable information regarding the client and his/her presenting problems.
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