Difficulties in the homogenization of the territorial implementation of early intervention programs in psychosis: A personal view of the Catalan model

The implementation of first-episode psychosis (FEP) programs in Spain has been uneven, and only three Autonomous Communities have prioritized and allocated a budget from the administration for these initiatives (Catalonia, the Basque Country, and the Foral Community of Navarra).¹ As stated in the white paper on early intervention in psychosis in Spain,¹ in our country no national program has been developed to guide actions that the Autonomous Communities can carry out by virtue of their powers in this area.

The implementation of FEP programs began in Catalonia in 2007 following the recommendations of the Mental Health and Addictions Master Plan from Catalonia with 12 pilot programs called Specific Care Programs for Incipient Psychotic Disorder (PAE-TPI), which initially provided partial coverage to the Catalan territory. A Pedagogical and Monitoring Commission of the PAE-TPI was created to promote a homogeneous implementation, and finally in 2018, thanks to a budget increase, it was generalized to the entire Catalan territory. These PAE-TPI programs attend young people between 14 and 35 years of age with an at-risk mental state (ARMS), an FEP or in the critical period (psychotic disorder with < 5 years of evolution).

Despite the intention to homogenize the implementation of the PAE-TPI Programs in the Catalan territory, there are some doubts as to whether this has been achieved, especially in the homogeneity of therapeutic approaches, including antipsychotic treatment or psychotherapeutic interventions.

Regarding antipsychotic treatment, in a recently published survey,² when asking psychiatrists who work in Catalonia about the first approach option for a patient with an FEP (observation, psychological treatment, pharmacological treatment with benzodiazepines, pharmacological treatment with antipsychotics), PAE-TPI professionals reported fewer antipsychotics as a first option compared to those who did not work on a PAE-TPI (70% vs 92%, p = 0.054). Although expectant management could be considered in teams that allow more intensive care, it is also worth asking whether there may not be a certain degree of under-treatment or “ARMS-like treatment” in the care of patients with an FEP by blurring the diagnostic-therapeutic boundaries between an ARMS or an FEP. The monitoring indicators of the Pedagogical Commission for the Evaluation of PAE-TPI in Catalonia focus on the incidence of new cases in the program, accessibility, psychotherapeutic follow-up, connection to the program, functional recovery, and administration of scales for screening side effects. Surprisingly, there is a lack of indicators related to pharmacological treatment (e.g., adherence to antipsychotic treatment, use of long-acting injectables [LAIs], or clozapine) or relapse/rehospitalization, especially considering the benefit of LAIs in linking to the PAE-TPI Programs, with lower disengagement rates from services in patients receiving LAIs compared to oral antipsychotics,³ or in the reduction of relapses and hospital admissions in FEP.⁴ It is also surprising that there is an indicator that delimits the proportion of screening for side effects with psychometric scales, without including an indicator that specifies the proportion of FEP patients receiving antipsychotic treatment. This aspect is somewhat worrying if we take into account that only 70% of the professionals who work in Catalonia in a PAE-TPI Program propose initial antipsychotic treatment for an FEP, or that only 38% of psychiatrists when treating an FEP refer to selecting the treatment taking into account clinical guidelines.¹

Regarding psychotherapeutic interventions, there also seems to be heterogeneity of approaches in different PAE-TPI Programs in Catalonia. In line with the aforementioned, some international experiences in the care of incipient psychosis, such as open dialogue,^5,6 have recently been applied in the Catalan territory including patients with FEP.⁷ As Seikkula and Olson⁶ conclude, the open dialogue approach is a way of resisting the experience of “pathology”, which builds a “transformative dialogue” within a social network. Previous publications suggest that this intervention corresponds to a lower incidence of hospitalization, relapse and use of pharmacological treatment.⁸ It is surprising, however, when reviewing the literature regarding open dialogue, that there are no randomized clinical trials, and that controlled longitudinal evidence uses a historical cohort as a comparator.⁵ It is worrying that open dialogue, whose quality of studies is problematic,⁹ can be adopted for the therapeutic approach for FEP patients. These approaches can lead to the administration of antipsychotic treatment for a few weeks or months.⁷ Although some authors ⁷comment that placing controlled clinical trials as a reference for effectiveness studies is particularly problematic for the development of dialogic practices, it would be convenient to use the scientific method before adopting a new paradigm in the care of psychotic disorders, especially in the use of public resources for the care of patients suffering from FEP. This is especially necessary because there is a great deal of scientific evidence with randomized clinical trials that demonstrate the efficacy of antipsychotic treatment both in the control of acute crises and in the prevention of relapses, while the evidence for other interventions such as open dialogue is very scarce and of low quality.¹⁰ On a personal level, as coordinator of one of the PAE-TPI programs in Catalonia, I find it worrying that different therapeutic approaches of interventions with little scientific evidence are being introduced and that the Catalan PAE-TPI model tends to be more heterogeneous than initially proposed. To give an example, in the last training conference (XIII edition) organized by the Pedagogical and Monitoring Commission of the PAE-TPI (https://www.clustersalutmental.com/js_events/xiii-jornada-de-los-programas-care-for-incipient-psychotic-disorders/) a presentation on the open dialogue model as a proposal for intervention in patients with FEP was included in the program. The impression is that over the years, and with the globalization of the PAE-TPI Programs, homogeneity of the care model is not being achieved. Furthermore, in some cases it seems that intervention proposals are far from the scientific evidence and the clinical guidelines. We should take as an example other countries such as England, a country with a culture of evaluating and making recommendations on health services and interventions with evidence-based clinical guidelines (e.g. NICE guidelines). For instance, in England they have proposed a randomized clinical trial in six Mental Health services to evaluate the efficacy of the open dialogue model with respect to the usual treatment to evaluate relapses, recovery and rates of use of services.¹¹ As these authors suggest, the results of this clinical trial financed by the National Institute for Health Research will make it possible to assess whether open dialogue can be an effective therapeutic alternative to the usual treatment, something that cannot be concluded today taking into account the scientific evidence available.

It would be advisable that the approach to FEP patients is carried out in accordance with scientific evidence and to seek greater homogeneity in the implementation of interventions in the PAE-TPI Programs, as well as to facilitate the continuous training of Mental Health professionals in this field. Public institutions should promote the continuous updating of clinical guidelines for approaching the treatment of people with an FEP based on scientific evidence. These aspects are essential at a time when there is a need to improve the early care of patients with a psychotic episode with a more homogeneous implementation of PEP programs in Spain, ensuring a minimum quality of care.¹

Conflict of interest

Javier Labad has received fees for giving presentations and/or participating in advisory boards from Janssen-Cilag, Otsuka, Lundbeck, Casen Recordati and Angelini.