First Aid Recommendations for Psychosis: Using the Delphi Method to Gain Consensus Between Mental Health Consumers, Carers, and Clinicians

Abstract

Background: Members of the general public often lack the knowledge and skills to intervene effectively to help someone who may be developing a psychotic illness before appropriate professional help is received. Methods: We used the Delphi method to determine recommendations on first aid for psychosis. An international panel of 157 mental health consumers, carers, and clinicians completed a 146-item questionnaire about how a member of the public could help someone who may be experiencing psychosis. The panel members rated each questionnaire item according to whether they believed the statement should be included in the first aid recommendations. The results were analyzed by comparing consensus rates across the 3 groups. Three rounds of ratings were required to consolidate consensus levels. Results: Eighty-nine items were endorsed by ≥80% of panel members from all 3 groups as essential or important for psychosis first aid. These items were grouped under the following 9 headings: how to know if someone is experiencing psychosis; how to approach someone who may be experiencing psychosis; how to be supportive; how to deal with delusions and hallucinations; how to deal with communication difficulties; whether to encourage the person to seek professional help; what to do if the person does not want help; what to do in a crisis situation when the person has become acutely unwell; what to do if the person becomes aggressive. Conclusions: These recommendations will improve the provision of first aid to individuals who are developing a psychotic disorder by informing the content of training courses.

Introduction

A number of research studies have focused on the importance of reducing the duration of untreated psychosis (DUP) to ensure optimal recovery in psychotic disorders.^1,2 Two recent meta-analyses of the association between DUP and outcome in individuals experiencing first-episode psychosis found that length of DUP had a significant impact on a range of outcomes.^3,4 A longer DUP was associated with worse outcomes on depression/anxiety, positive and negative symptoms, and social functioning. Although these correlational studies cannot show that a longer DUP is the cause of the worse outcomes, they support efforts to explore the potential benefits of early intervention.

In response to such evidence, some researchers have turned their attention to the pathways to care experienced by these patients. Singh and Grange⁵ argue that understanding how individuals negotiate pathways to care is paramount, as factors that enhance or hinder help seeking ultimately help determine whether early intervention programs are successful or not. Family and friends can be important facilitators of pathways to professional care⁶ as they are in a unique position to observe changes in an individual's behavior and level of functioning. Because of this proximity, they may be the first to recognize the development of a psychotic episode in someone they care about. Despite the crucial role that family and friends may play in early intervention, many supporters lack the knowledge, skills, and resources to enable them to intervene effectively.

To empower family and friends with the confidence and knowledge to intervene when someone they care about may be developing a mental illness, Kitchener and Jorm developed the world's first Mental Health First Aid (MHFA) course based on the model applied to physical first aid. MHFA is defined as the help provided to a person developing a mental health problem or in a mental health crisis. The first aid is given until appropriate professional treatment is received or until the crisis resolves. The 12-h MHFA course trains members of the public to give early help to people developing a mental disorder (including psychotic disorders) and to give support in mental health crisis situations (such as assisting someone who is suicidal).⁷ There is an associated course manual⁸ that can be downloaded for free from http://www.mhfa.com.au.

Several trials have been conducted to evaluate the effects of the MHFA course. An initial uncontrolled evaluation with members of the public showed that the course improved recognition of mental disorders, changed beliefs about treatments to be more like those of health professionals, reduced stigmatizing attitudes, increased confidence in providing help, and increased the amount of help provided to others.⁹ Additionally, randomized control trials have been carried out with employees in a workplace setting and with members of the public in a large rural area.^10,11 In comparison to wait-list control groups, the trained groups showed greater confidence in providing help to others, improved helping behavior, greater concordance with health professionals about treatment and decreased social distance from people suffering from depression. The MHFA course has been widely disseminated in Australia and has been adapted by a number of other countries, including Scotland, England, Ireland, Hong Kong, Canada, Singapore, and Finland.

Although the MHFA course content is designed to be as evidence based as possible, there is very little empirical evidence on pre clinical interventions for developing mental disorders. Accordingly, there is limited knowledge about how a layperson can best help someone who may be developing a mental disorder. While randomized control trials provide the highest standard of evidence, it is not feasible or ethical to carry out such trials to evaluate MHFA strategies. In such situations, expert consensus provides an alternative. The aim of the present research was to develop recommendations for first aid for psychosis using the expertise of mental health consumers, carers, and clinicians. This research is part of a broader project to develop first aid recommendations for developing mental disorders and mental health crises. Results of a consensus study on depression first aid recommendations have already been published.¹²

METHODS

The Delphi Method

To survey expert opinion, we used the Delphi method which involves a group of experts making private, independent ratings of agreement with a series of statements.¹³ A summary of group ratings is fed back to the panel members who then complete a second round of rating. They can choose whether to change or maintain their original ratings. Several rounds may be required, depending on the desired level of consensus. The output from the process is statements about which there is substantial consensus in ratings.

Panel Formation

We recruited mental health consumers, carers, and clinicians from Australia, New Zealand, the United Kingdom, Ireland, the United States, and Canada. To recruit consumers and carers, we approached mental health organizations (eg, Association of Relatives and Friends of the Emotionally and Mentally Ill in Australia, Rethink in the United Kingdom) to request that they distribute information about the study to any consumers (who had experienced psychosis) and carers (who had looked after someone with a psychotic illness) who may want to participate in the study. We specified that any consumers and carers who took part needed to feel comfortable reflecting on their experiences with psychosis, and as a result, the project was particularly appropriate for consumers and carers in publicly visible roles (eg, those who were working in advocacy positions or with support groups). We also approached consumers and carers in the public domain who had authored books, articles, or Web sites about their experiences with psychosis to invite them to participate. The clinical experts approached were international authorities on psychosis, as well as mental health clinicians working within clinical settings. Each potential participant was sent an information sheet about the study. Once they had agreed to participate, written informed consent was obtained from each panel member by e-mail or letter. In some cases where the participants did not have access to e-mail, consent was obtained via the telephone. Panel members were given the option of completing the questionnaires online using SurveyMaker (surveymaker.com.au), via e-mail or by paper mail. See figure 1 for the number of panel members who completed each round. This project received Ethics approval from the Human Research Ethics Committee at the University of Melbourne.

Fig. 1.

The Number of Consumers, Carers, and Clinicians Who Participated in each Round of the Study.

Questionnaire Development

A systematic literature review was conducted of Web sites, books, carer and consumer manuals, and journal articles for statements about how to help someone who may be developing a psychotic episode. This involved a comprehensive internet search using 4 different search engines (Google, AlltheWeb, MetaCrawler, and Yahoo). The following search terms were entered into each search engine: psychosis, first-episode psychosis, schizophrenia, help for psychosis, help for schizophrenia, psychosis family friends, schizophrenia family friends, psychosis carer, schizophrenia carer, help for hearing voices, help for hallucinations delusions, psychosis violence, what to do psychosis violence, family + psychosis + violence, psychosis + “doesn't want help.” The first 50 sites for each set of search terms were examined for statements about how to help someone who is or may be experiencing a psychotic episode. This technique yielded a total 300 sites per search engine. Any links that appeared on these Web pages that the authors thought may contain useful information were followed. To locate relevant journal articles, the following databases were searched: PsycINFO, PubMed, CINAHL, Medline, and Google Scholar. Key texts were identified through library searches, recommendations from relevant mental health Web sites, and http://Amazon.com.

The information gathered from these sources was analyzed by one of the authors (R.L.L.) and divided into sections based on common themes. A working group discussed this document and created individual questionnaire items to best represent these themes. We attempted to remain as faithful as possible to the original wording of the information but had to modify some wording to ensure comprehensibility and consistency of format across items. After several draft questionnaires, the group reached consensus on 146 items that formed the first questionnaire sent to panel members. The questionnaire items were organized under the following 8 subheadings: recognizing and acknowledging that someone the first aider knows may be experiencing psychosis (6 items); how to encourage someone who may be experiencing psychosis to seek professional help (12 items); how to help someone who may be experiencing psychosis seek professional help (6 items); how to interact with someone who may be experiencing psychosis (21 items); how to interact with someone who is experiencing symptoms of psychosis (29 items); how the first aider should respond in a crisis if the person they are helping becomes acutely psychotic (28 items); how to respond if the person the first aider is helping becomes aggressive (19 items); how to interact with someone who may be psychotic, if that person denies that they are unwell and refuses to get help (25 items). After each set of questions, panel members were asked whether they had any comments to add about that section.

The panel members were asked to rate each questionnaire item on a 5-point scale (1 = essential, 2 = important, 3 = do not know/depends, 4 = unimportant, 5 = should not be included) according to how important they believed it was as a potential MHFA standard for psychosis. They were asked to keep in mind that the standards will be used by the general public, and as such, the statements needed to be rated according to how important each one was as a way for someone, who does not necessarily have a medical or clinical background, to help a person who may have psychosis.

Analysis of Results

The survey responses were analyzed by obtaining group percentages for the consumers, carers, and clinicians for each item. The following cut-off points were used:

1. If at least 80% of the panel members in each of the 3 groups rated an item as essential or important as a potential first aid standard for psychosis, it was included as a standard for first aid for psychosis.

2. If 80% or more of the panel members from 1 or 2 of the groups rated an item as essential or important, we asked all panel members to rerate that item.

3. If 70%–79% of panel members from all 3 groups rated an item as essential or important, we asked all panel members to rerate that item.

4. Any statements that did not meet the above 3 conditions were excluded.

To analyze the comments that panel members had written following each section, one of the authors (R.L.L.) read through all the comments and divided them into sections based on common themes. The working group evaluated the comments to determine whether they were original ideas that had not been included in the first round of the survey. Any comment that was judged by the group to be an original statement was included as a new item to be rated in the second round of the survey.

Results

See figure 2 for an overview of the numbers of items that were included, excluded, and rerated in each round of the survey.

Fig. 2.

The Number of Items That Were Included, Excluded, and Rerated in the 3 Rounds of the Study.

Round 1

One hundred and fifty-seven panel members from Australia (12 consumers, 33 carers, 20 clinicians), New Zealand (4 consumers, 5 carers, 6 clinicians), the United Kingdom (15 consumers, 11 carers, 14 clinicians), Ireland (2 clinicians), the United States (5 consumers, 5 carers, 3 clinicians), and Canada (9 consumers, 6 carers, 7 clinicians) took part in the first round of the survey. Out of these 157 panel members, 110 (70.1%) were female (71.1% of the consumers, 78.7% of the carers, and 54.5% of the clinicians). Out of the 52 clinicians on the panel, there were 7 Psychiatrists, 20 Psychologists, 1 Counsellor, 14 Occupational Therapists, 2 General/Medical Practitioners, 7 Nurses, and 1 Mental Health Support Worker. The median age category was 40–49 years for both the consumers and the clinicians and 50–59 years for the carers. The response rate for the first round of the survey was 80.1% (consumers = 75%, carers = 90%, clinicians = 75.4%); thirty-nine people who agreed to participate in the study did not complete the questionnaire (15 consumers, 7 carers, 17 clinicians). Eight of the participants began filling in the questionnaire but did not finish it (2 consumers, 1 carer, 5 clinicians).

Out of the 146 items included in the first round of the survey, 66 were rated as either essential or important by ≥80% of the consumer, carer, and clinician panel members. Fifty-two items were excluded and 28 items met the criteria to be rerated in the second round. Sixty-five new items were created from the panel members’ comments. A 93-item questionnaire was developed for round 2, which was comprised of the 65 new items as well as the 28 items to be rerated. This second questionnaire did not include any space for comments.

Round 2

Before they were asked to complete the second round of the survey, each of the panel members was sent a copy of a report that described how the results had been analyzed. This report also contained a list of the items from the first round to be included and excluded from the first aid recommendations, as well as the group percentages of the ratings for each of these items to be rerated in the second round. Panel members were also sent a copy of their original questionnaire responses to enable them to compare their responses for the items to be rerated to the group responses. They were then able to choose whether to maintain or modify their ratings for those items in the second round of the survey.

In the second round of the survey, 16 of the 93 items met the criteria for inclusion in the first aid recommendations, 50 items were excluded, and 27 items reached the consensus level which required rerating in the third and final round. One hundred and seventeen panel members completed the second round (74.5% of those who took part in the first round). Of these 117 participants, there were 33 consumers (73.3%), 43 carers (71.7%), and 41 clinicians (78.8%).

Round 3

Each panel member was sent a report detailing the results from the previous round, along with a copy of their round 2 questionnaire results. One hundred of the original 157 panel members completed the final round giving a response rate of 63.7% (consumers = 68.9%, carers = 61.7%, clinicians = 61.5%).

Final Recommendations

A sum total of 89 items from the 3 rounds were rated as essential or important by ≥80% of the panel members in each of the 3 groups. The authors grouped items of similar content under specific headings to make the recommendations more comprehensible (see table 1).

Table 1.

Items That Received ≥80% Consensus from the Consumer, Carer, and Clinician Panel Members

First aid recommendation for psychosis	Round accepted
The first aider recognizing and acknowledging that someone may be developing psychosis
The first aider should be able to recognize the early warning signs and/or symptoms of psychosis.	1
The first aider should realize that although warning signs and/or symptoms of psychosis are often not very dramatic on their own, taken together they may suggest that something is not quite right.	1
The first aider should not ignore or dismiss warning signs and/or symptoms if they appear gradually and are unclear.	1
The first aider should not assume that the person exhibiting warning signs and/or symptoms is just going through a phase or misusing substances.	1
The first aider should not assume that the warning signs and/or symptoms of psychosis will go away on their own.	1
The first aider should be aware that the warning signs and/or symptoms of psychosis may vary from person to person and can change over time.	1
The first aider should take into consideration the spiritual and/or cultural context of the person's behaviors.	3
How the first aider should approach someone who may be experiencing psychosis
People developing a psychotic disorder will often not reach out for help. If the first aider is concerned about someone, they should approach the person in a caring and nonjudgemental manner to discuss their concerns.	1
Someone who is experiencing profound and frightening changes such as psychotic symptoms will often try to keep them a secret. The first aider should be aware that the person they are trying to help might not trust them or might be afraid of being perceived as “different” and, therefore, may not be open with them.	1
The first aider should make sure that she/he approaches the person privately about their experiences, in a place that is free of distractions.	2
The first aider should try to tailor their approach and interaction to the way the person is behaving (eg if the person is suspicious and is avoiding eye contact, the first aider should be sensitive to this and give the person the space they need).	2
The first aider should not touch the person without their permission.	2
The first aider should state, in specific behavioral terms, why she/he is concerned about the person and should not speculate about their diagnosis.	1
The first aider should allow the person to talk about their experiences and beliefs if they want to.	2
As far as possible, the first aider should let the person set the pace and style of the interaction.	3
The first aider should recognize that the person may be frightened by their thoughts and feelings.	1
The first aider should ask the person about what will help them to feel safe and in control.	1
The first aider should reassure the person that she/he is there to help the person and wants to keep them safe.	1
The first aider should let the person know that she/he is there to support them.	2
The first aider should allow the person to stay in control by offering choices of how she/he can help them where possible.	1
The first aider should convey a message of hope to the person by assuring them that help is available and things can get better.	1
If the person is unwilling to talk with the first aider, the first aider should not try to force them to talk about their experiences.	1
If the person is unwilling to talk with the first aider, the first aider should let them know that she/he will be available if they would like to talk in the future.	1
How the first aider can be supportive
The first aider should always treat the person with respect.	1
The first aider should try to empathize with how the person feels about their beliefs and experiences, without stating any judgments about the content of those beliefs and experiences.	1
The first aider should understand that the person may be behaving and talking differently due to psychotic symptoms.	1
The first aider must recognize that the person who may be experiencing psychosis may find it difficult to tell what is real from what is not real.	1
The first aider should avoid confronting the person and should not criticize or blame them.	1
The first aider should understand the symptoms for what they are and should try not to take them personally.	1
The first aider should not use sarcasm when interacting with a person who may be experiencing psychosis.	1
The first aider should avoid using patronizing statements when interacting with a person who may be experiencing psychosis.	1
The first aider should be honest when interacting with the person and should not make them any promises that cannot be kept.	1
How the first aider should deal with delusions (false beliefs) and hallucinations (perceiving things that are not real)
The first aider should recognize that the delusions and/or hallucinations are very real to the person.	1
The first aider should not dismiss, minimize, or argue with the person about their delusions and/or hallucinations.	1
The first aider should not act alarmed, horrified, or embarrassed by the person's hallucinations or delusions.	1
The first aider should not laugh at the person's symptoms of psychosis.	1
If the person exhibits paranoid behavior, the first aider should not encourage or inflame the person's paranoia.	1
How the first aider should deal with communication difficulties
People experiencing symptoms of psychosis are often unable to think clearly. The first aider should respond to disorganized speech by communicating in an uncomplicated and succinct manner and should repeat things if necessary.	1
After the first aider speaks, they should be patient and allow plenty of time for the person to digest the information and respond.	1
If the person is showing a limited range of feelings, the first aider should be aware that it does not mean that the person is not feeling anything.	1
The first aider should not assume that the person cannot understand what they are saying, even if the person's response is limited.	1
Whether the first aider should encourage the person to seek professional help
The first aider should ask the person if they have felt this way before, and if so, what they have done in the past that has been helpful.	2
The first aider should try to find out what type of assistance the person believes will help them.	2
The first aider should try to determine whether the person has a supportive social network and if they do, the first aider should encourage them to utilize these supports.	2
If the person decides to seek professional help, the first aider should make sure that the person is supported both emotionally and practically in accessing services.	2
If either the person experiencing psychosis or the first aider lacks confidence in the medical advice they have received, they should seek a second opinion from another medical or mental health professional.	1
What the first aider should do if the person does not want help
The first aider should recognize that even if the person does realize that they are unwell, their confusion and fear about what is happening to them may lead them to deny that there is anything wrong.	1
If the person refuses to seek help, the first aider should encourage them to talk to someone they trust.	1
The first aider should be aware that the person who is experiencing psychotic symptoms may lack insight that they are unwell.	1
If the person does lack insight, the first aider should be aware that they might actively resist the first aider's attempts to encourage them to seek help.	1
When someone who is experiencing symptoms of psychosis denies that they are unwell, the first aider's course of action should depend on the type and severity of the person's symptoms.	1
The first aider needs to recognize that unless a person with psychosis meets the criteria for involuntary committal procedures, they cannot be forced into treatment.	1
The first aider should remain patient, as people experiencing psychosis often need time to develop insight regarding their illness.	1
The first aider should never threaten the person with the mental health act or hospitalization.	2
If the person refuses to get help, the first aider should remain friendly and open to the possibility that they may want the first aider's help in the future.	1
What the first aider should do in a crisis situation when the person has become acutely unwell
In the event of a crisis, when the person experiencing psychosis has become acutely unwell…
the first aider should try to remain as calm as possible.	1
the first aider should evaluate the situation by assessing the risks involved (eg whether there is any risk that the person will harm themselves or others).	1
the first aider should assess whether the person is at risk of suicide.	2
if the person has an advance directive/relapse prevention plan, the first aider should follow the guidelines set out in the plan.	2
the first aider should try to find out if the person has anyone s/he still trusts (eg close friends, family) and should try to enlist their help.	3
the first aider should assess whether it is safe for the person to be alone and if not, should ensure that someone stays with the person.	2
the first aider should communicate in a clear and concise manner and use short, simple sentences.	1
the first aider should use a moderate, nonthreatening tone of voice.	1
the first aider should speak quietly at a moderate pace and should answer all the person's questions calmly.	1
the first aider should comply with requests that are not endangering or unreasonable. This gives the person the opportunity to feel somewhat in control.	1
the first aider should be aware that the person might act upon a hallucination or delusion.	1
the first aider should remember that their primary task is to de-escalate the situation and therefore should not do anything to further agitate the person.	1
the first aider should try to maintain safety and protect the person, themselves, and others around them from harm.	1
the first aider should have access to an exit.	1
the first aider should remain aware that they may not be able to de-escalate the situation, and if this is the case, they should be prepared to call for assistance.	2
and the person is a danger to themselves or others, the first aider should make sure they are evaluated by a medical or mental health professional immediately.	1
if the first aider's concerns about the person are dismissed by the services they contact, they should persevere in trying to seek support for the person.	3
if crisis staff arrive, the first aider should convey specific, concise observations about the severity of the person's behavior and symptoms to the crisis staff.	1
if other people arrive, the first aider should explain to the person experiencing psychosis who the people are, that they are there to help, and how they are going to help.	1
What the first aider should do if the person becomes aggressive
The first aider should be aware that people with psychosis are not usually aggressive and are at a much higher risk of harming themselves than others.	2
The first aider needs to recognize that certain symptoms of psychosis (eg, visual or auditory hallucinations) can cause people to become aggressive.	1
The first aider should know how to de-escalate the situation if the person they are trying to help becomes aggressive.	1
The first aider should not respond in a hostile, disciplinary, or challenging manner to the person who is being aggressive.	1
The first aider should not threaten the person as this may increase fear or prompt aggressive behavior.	1
If the person is showing aggression, the first aider should avoid raising their voice and should not talk too fast.	1
If the person is showing aggression, the first aider should stay calm and avoid nervous behavior (eg, shuffling their feet, fidgeting, making abrupt movements).	1
The first aider should not try to restrict the person's movement (eg, if the person wants to pace up and down the room).	2
If the person becomes aggressive, the first aider should remain aware that the person's symptoms or fear causing the aggression may be exacerbated by the first aider taking certain steps (eg, involving the police).	3
The first aider should take any threats or warnings seriously, particularly if the person believes they are being persecuted.	1
If the first aider is frightened, they should seek outside help immediately as they should never put themselves at risk.	1
If the person's aggression escalates out of control at any time, the first aider should remove themselves from the situation and call the crisis team.	3
When contacting the appropriate service, the first aider should not assume the person is experiencing a psychotic episode but should outline any symptoms and immediate concerns.	3
If the police are called, the first aider should tell them that the person is experiencing a psychotic episode and that the first aider needs the help of the police to obtain medical treatment and to control the person's aggressive behavior.	1
The first aider should let the police know whether or not the person is armed.	1

Discussion

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.

Funding

National Health and Medical Research Council Program (grant 179805); an Australian Rotary Health Research Fund grant; Infrastructure support from the Colonial Foundation.