Psychosis is a serious and potentially disabling disorder. The lifetime risk of experiencing a psychotic episode is around 3 in 100, with 80% of cases starting between the ages of 16 and 30 and 5% in patients under 16.

Although some young people make a full recovery from a psychotic episode, many go on to develop long-term illness, with the potential for huge personal suffering and social cost. The lifetime suicide risk for patients with psychosis is 10%, with the greatest risk occurring within the first five years of the illness.¹ Even after suicide is excluded, the risk of mortality is similar to chronic physical diseases such as diabetes.²

Only 12% of patients with psychosis living in the community are in employment, and patients face greatly increased rates of social isolation, eviction and divorce. The burden on patients' families and carers can be huge³ and the financial costs for society enormous.⁴

Studies suggest that the longer a psychotic episode is left untreated, the worse the outcome.⁵ Early intervention in psychosis services have been developed in a number of countries, including the UK. In March 2006, about half the population of England had access to an early intervention service.⁶

Increasing emphasis has also been placed on the detection of young people at risk before they reach the stage of full-blown illness. This has been based on the concept of an 'at risk mental state', characterised by varying combinations of attenuated symptoms (milder versions of psychotic symptoms), brief, limited, intermittent psychotic symptoms (full symptoms that only last a short time and remit spontaneously) or trait factors, such as a family history of psychosis.⁷ There is a 30-40% chance of people with at risk features progressing to full psychotic illness.

In recognition of the vital role that GPs have in detecting and helping young people who may be at risk of developing psychosis, new guidance on emerging psychosis has now been published by the RCGP and RCPsych.8 The guidance and a series of facts sheets are available online at www.earlydetection.csip.org.uk

GPs are often the first healthcare professional contacted for help and provide a vital conduit to specialist early intervention services. Particular strengths of GP involvement in the care of a patient with psychosis include their knowledge of the individual before the onset of symptoms, a strong relationship with the family and a commitment to long-term involvement.

The guidance gives helpful information about the early symptoms to look out for. Many early symptoms can appear to be non-specific and may evolve gradually. These include poor sleep, panic, mood changes, social withdrawal, problems at work or school and breakdown of relationships.

Early psychotic thinking, such as suspicion, mistrust or perceptual changes, can be difficult to uncover. However, the following useful examples of screening questions are included in the guidance:

• Have you felt that something odd might be going on that you cannot explain?
• Have you been feeling that people are talking about you, watching you or giving you a hard time for no reason?

• Have you been feeling, seeing or hearing things that others cannot?

• Have you felt especially important in some way, or that you have powers that let you do things which others cannot?

If uncertain, GPs are advised not to dismiss problems but to maintain a watching brief, pay careful attention to any concerns expressed by the patient's family and follow up on any missed appointments.

Psychosis is often heralded by a gradual deterioration in social and intellectual functioning. A GP's willingness to act on clinical intuition and respond to family concerns can be key to early detection. If emerging psychosis is suspected, GPs are advised to check for any physical illness and to assess the patient for risk, especially of suicide. Patients should be referred promptly, ideally to an early intervention in psychosis service.