To the authors’ knowledge, no previous studies have sought the expert opinions of mental health consumers, carers, and clinicians in regards to how to help someone who may be developing psychosis. Considering the diverse roles occupied by the panel members in this study, they were able to agree on a surprising number of statements covering a broad range of areas.
One of the strengths of this study was that panel members were able to submit comments after each section in the initial questionnaire. This enabled us not only to draw on the panel's experiences through their consensus ratings but also to utilize their expertise by developing new items from their comments. This process ensured that we did not overlook any pertinent issues and yielded 65 new items to be rated in the second round of the survey. For example, the items in the first section on recognizing and acknowledging that someone may be experiencing psychosis were all highly endorsed by the panel members; all 6 items achieved sufficient consensus in the first round to be included as first aid recommendations. However, many of the panel members had concerns with the concept of early warning signs because they are often very difficult to interpret. As such, they may signal a variety of conditions or conversely may not indicate a disorder at all. Several panel members stressed the importance of first aiders getting the balance right by being able to recognize what might be early signs or symptoms of psychosis but also being careful not to become hypervigilant. One of the consumers who had experienced this hypervigilance commented on how oppressive it can be. To incorporate these concerns into the questionnaire, we developed the following item: “The first aider should exercise caution in how they react to or interpret potential warning signs as the person they are helping may not develop psychosis.” Interestingly enough, this item did not achieve sufficient consensus to be included in the final first aid recommendations.
The comments also provided us with insight into how panel members’ roles influenced their ratings. This was apparent in the section on how the first aider should interact with someone who either denies that they are unwell or refuses to seek help. In this section, several of the items explored whether the first aider should seek appropriate professional help or advice on behalf of the person they trying to help. These items were more strongly supported by the carers than by the consumers or clinicians. For example, 61% of carers, 41.9% of consumers, and 29.8% of clinicians rated the following item as essential or important: “If the person cannot understand they are unwell and refuses to see a doctor, the first aider should make an appointment with a doctor to discuss their specific concerns and what can be done.” Although this item was not endorsed by all the carers, it can be hypothesized that it was more strongly supported by carers because of their frustration with dealing with loved ones who lack insight into their illness. One of the carers commented that, “The right to sanity should exceed the right to choose no treatment.” In contrast, the predominant theme running through the clinicians’ comments on this section related to maintaining the person's privacy and confidentiality, while many of the consumers were concerned about the person's right to decide not to seek help if they are not at risk of harming themselves or others.
The emphasis of these recommendations is on assisting a person who is beginning to show positive symptoms. However, it is known that positive symptoms are usually preceded by negative symptoms and functional impairment, which in turn are generally preceded by depressive mood.14
Early intervention may require that the affected person receive help at these earlier stages, not just when positive symptoms develop. While it is too much to expect that a member of the public could detect more subtle changes indicating a psychotic disorder, they are able to respond to depression. We have also developed depression first aid guidelines using a similar Delphi consensus methodology.12
These recommendations may be useful either where a depressive disorder is developing or where the person is in the very early stages of a psychotic disorder. Work is also underway to develop first aid recommendations for a number of other developing disorders and mental health crises, including how to help a suicidal person or someone who is deliberately injuring themselves.
A limitation of this study is that these recommendations may not be applicable to non-English speaking, non-Western countries. We decided not to include panel members from such countries because of the potential for culturally diverse interpretations of psychosis. We were also aware that individuals from many of these countries do not have access to the healthcare systems mentioned in some of the items. We are planning to conduct further studies into MHFA recommendations that are applicable in these countries.
As mentioned earlier, despite the different experiences of the panel members, we were able to obtain a high degree of consensus on a large number of items. As a result, these recommendations are distinct from much of the information currently available in the public domain about how to help someone who may be developing a psychotic disorder because they have been endorsed by a large number of mental health consumers, carers, and clinicians. These recommendations will be used to determine the content of MHFA training courses and could potentially lead toward first aid for psychosis being accredited in a comparable manner to that of physical first aid.15
They will also help friends and family to provide the best possible support to loved ones who may be experiencing psychosis.