Inger Kari Nerheim
Managing Director,Division of Psychiatry
Email: [email protected]
- ‘Are you feeling sad?’ – ‘Do you know anybody who has these symptoms: withdraws from friends and family, is turning careless about personal appearance, lies awake at night, or stays in bed all day.’ - ‘Are you worried about a friend?’ -‘Is anyone you know hearing voices?’
Stavanger University hospital runs ads like this in the regional newspaper of Stavanger in the Rogaland region of Norway several times a week, amid announcements, car sales, movies and shows, grocery and clothes bargains. The message is loud and clear: seek help early at signs of mental distress or illness. The TIPS (early detection and intervention) team is there to help you. Mental illnesses are like any other illnesses: they get better if you get help at the first symptom – and they are harder to treat if you wait until you are really sick.
Intervention in Mental Health
The aim in 1996 was to set up a study on the effectiveness of early intervention in the most severe psychiatric illness, schizophrenia. Was it possible to use modern mass media to create greater awareness about mental illnesses, to change help-seeking behaviour, and to actually get young people with psychosis to get treatment earlier? The average time gap, the duration of untreated psychosis, between the first symptoms – retrospectively – and first treatment for the disease, was in 1996, 118 weeks, i.e. more than two years. Two years with increasing bewilderment, alienation from family and friends, gradually losing touch with reality for many young people. Possibly, the resarchers setting up the study thought, one could even show that starting treatment early would make the course of the illness less severe? It was worth an effort.
Three sites were set up, in Oslo and Rogaland county, Norway, and in Roskilde, Denmark. Rogaland was the experimental site, trying to establish early detection, while Oslo and Roskilde provided detection as usual. All three sites gave a ‘state of the art’ treatment programme with individual talking therapies, medication and family group therapy, over a period of a minimum of two years. The inclusion to the study was rigorous, and the highest scientific standards set up. The research programme around the project involved three universities: Oslo; Roskilde; and Yale.
In Rogaland, two detection teams were established, with a ‘within 24 hours’ response time. Patients, parents, friends, teachers; anybody with a concern for a young person with symptoms of mental distress could call in and ask for an assessment.
The team would come to the home or the school and speak with the young person, using a systematic approach. A comprehensive information campaign rolled over the county’s towns and countryside.
All secondary schools – teachers and student advisors – were educated in early symptoms and told about the new early treatment service. The movie theatres ran ads before the main picture, showing ordinary girls and boys with problems, and where to get help. Every household in the county got a booklet informing them about the project, the symptoms, and where to get help.
Teachers, community and school nurses, and doctors were given courses and lectures, and were later targeted in ads in the local newspapers. They were sent pens, mugs and brochures with the detection teams’ telephone numbers on them, to ensure that the message was not forgotten.
The full-page ads started in 1996 were used in several series, and a marketing survey was carried out on a yearly basis. During the project, the knowledge of psychiatric symptoms rose to the same level as the knowledge about cardiac arrest and infarctia. In 2006, the newspapers remind the locals every week - along with “remember the birds in the winter” - to be alert to symptoms of severe mental distress; it is just as necessary to seek help early for mental problems, as for heart symptoms or diabetes.
Ten years later, the TIPS project is no longer a project, but a part of Stavanger University Hospital’s everyday programme for reducing stigma and educating the public about treating mental illness. The main results are scientifically weighed and found sound:
• Suicidal ideas, attempts and plans among young people with newly diagnosed psychosis are significantly lower in the site with early detection programmes, up to 50% compared with the two other sites.
• Use of modern mass communications methods significantly alters a population’s help-seeking practice around severe mental illness, and also “catches” a lot of less severe mental distress among the young; the 118 weeks of untreated schizophrenia is now reduced to an average of 16 weeks, with a median time lapse of two weeks (half of the help seekers get help before two weeks have passed from their first symptom).
• The health services are not flooded by help seekers, even with a low threshold for contact.
• The patients detected early are less ill at their first appointment, and at the one- and two-years’ follow-up.
The general consensus among usergroups is that the programme has reduced the stigma of mental illness in Rogaland county.
The Cost of Health Promotion
Stavanger University Hospital has annually for the last six years had a budget of approximately 120,000 euros for information-work and ads like these.
The results for the young, at-risk population is that they all know that there is help for mental illness, where to find the information should they need it, and that there is hope for a good life and even a cure for severe mental problems. The one year that we did not keep up the massive focus on information, and saved money, the negative results came fast. The length of time between the early symptoms and when help was given again rose. The hospital found this impossible to ignore, and redistributed means back to the information budget in the mental health clinic.
One of the buses driving along the freeway between Stavanger and Sandnes, two, medium-sized Norwegian towns, will for the next four years look like this. “Rapid help for young people with serious mental illness: 51515959”. The cost: a mere 3,500 euros, for four years, all day, all week. Worth it? Without a doubt!
Do doctors need pens and coffee mugs to remember the early intervention team? The pharmaceutical firms evidently think it works. Do young people react to the soft drinks ads or to clothes ads with cigarette names? The programme does not only rely on the baser marketing schemes, but has a wide array of films, brochures, courses for teachers, health personnel and families, that together build up a steadily renewed knowledge basis about mental illness and mental health in the local area.
The need for a comprehensive outreach system: Information cannot be given without early detection teams and a treatment program The TIPS programme rests on the experience of others, and collaborates with many other groups. The EPPIC programme in Melbourne has inspired many of these initiatives. PEPP in Canada, “Detect” in Ireland, the UK early intervention teams, and other projects in Europe and elsewhere are giving important results, and not to be forgotten, the ongoing joint European prediction of psychosis study, EPOS.
The TIPS programme has shown that information work and early detection both are important. There are no reasons that this should not be an integrated part of every community’s health service. There must be firm, yearly funding, and a standard treatment protocol must be agreed on and financed, building on international research results, and incorporating on a yearly basis changes in the international consensus on effective treatment for this unnecessarily debilitating disease. And, in the course of the detection work, we also can find the young people with depressions and anxiety, behavioural disorders etc, and give them as scientifically-based comprehensive treatment programmes as the ones for the psychoses.
The EU Green Paper, which is now being turned into a new framework for mental health in Europe, gives hope for the future. The ethics of this are unquestionable, and so are the economics; the saving of numerous life-years for Europe’s young people is a good investment from any angle.