Early Intervention: The International Perspective Paddy Power
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Early Intervention:Early Intervention:The International PerspectiveThe International Perspective
Paddy Power
“A Stitch in Time Saves Nine”
Development of Early Psychosis Programs
Melbourne, mid-80’s Buckinghamshire, mid-80’sNorth Birmingham UK early 90’sGermany, 1990’s (research1970’s) USA & Canada, early 90’s Scandinavia, mid-90sSwitzerland mid - 90sAmsterdam, late 90’sAustralia late 90’sUK 1999/2000Far East & South East Asia, 2001
Networks: IEPA & European FE Schizophrenia Network
Types of Early Intervention Model
• Option 1: Basis? (CAMHS, Adult, 1° Care, Youth service)
• Option 2: Service model? (Specialist vs generic)
– Specialist EI services• Stand alone EI service• Hub and Spoke model• Piggy-back supplementary EI model• Tertiary consultation EI services/clinic
– Generic Based Services• Top up with embedded EI worker/s• Top up with EI training and clinical guidelines
– Research based interventions
• Option 3: Degree of community integration – Public health promotion campaigns– integration with social services, education, employment, housing, A&D services, service user
agencies
Gallery Image 34 of 191
Aims of an Early Intervention service
• Reduce delays (& DUP) by:– promoting early detection and
collaborative engagement in the community
• Optimise assessment & diagnosis by:– Comprehensive Bio/psycho/social assessment
• Maximise recovery by: – providing integrated bio/psycho/social community Rx – focus on functional as well as symptomatic factors– addressing co-morbidity and treatment resistance early
• Prevent relapse by:– ensuring assertive followup and psychoed. during critical period
Intervening to Maximise Recovery & Prevent Relapse
Fun
ctio
ning
Age
Prodrome
2nd episode of psychosis
16 20 24
Asserti
ve follo
w-up
Community Team
First episode of psychosis
Optimising Inpatient Care and Treatment in Early Psychosis?
Fun
ctio
ning
Age
Prodrome
2nd episode of psychosis
16 20 24
First episode of psychosis
FEP Inpatientservices
Intervening to reduce the Duration of Untreated Psychosis (DUP)
Fun
ctio
ning
Age
Prodrome
2nd episode of psychosis
16
First episode of psychosis
20 24
Early
detection &
Crisis
Assessment
Team
Intervening in the Prodrome Phase of Early Psychosis
Fun
ctio
ning
Age
Prodrome
First episode of psychosis 2nd episode
of psychosis
16 20 24
Prodrome
clinic
Configuration of LEO Service
Primary Care
Early detection & crisis assessment team
LEO Community
Team
LEO Inpatient
Unit
2 ye
ar f
ollo
w-u
p
Prodrome clinic
LEO-CAT OASIS
psychotic prodromal
Canada’s Early Intervention Services
Ontario:•PEPP, London •FEPP, Toronto •Psychotic Disorders U., Hamilton•Ottawa FEPP•KPP&TP, Kingston
Alberta:•EPT&PP, Calgary (930,000)
British Columbia:•EP Initiative of British Columbia•EPIVMHC,Victoria•Vancouver•EPIP, White Rock
Quebec:•Levis•Montreal•Quebec City
Nova Scotia:•NSEPP•Halifax -
Saskatchewan:•EIPP, Saskatoon
Key figures:•Jean Addington•Bob Zipursky•Ashok Malla•Lili Kopala
Newfoundland•N&L EPP
Early Psychosis Programs in the USA
Pittsburg:•EI program (Keshevan)
N. Carolina:•FEP & prodrome studies (Lieberman)
New York:•Prodrome (Cornblatt)
Yale, New Haven:•PRIMHE (T. McGlashan)
Portland, Maine•PIER service (McFarlane)
LA California:•UCLA (Ventura, Neuchterlien etc)
Bethseda, MD: •NIMH research:(Wyatt etc)
Salem, Oregon:•Early Assessment & Support Team (EAST) (pop 600,000) Managed care funded
New Zealand’s Early Intervention Services
• Auckland: EPI Centre, Kari Centre, Taylor Centre, Manaaki CMHT - FEP, St Lukes FEP, Hartford House EPI, Campbell team Lodge EI team
•Wellington: Wellington EI service (400,000)
•Christchurch: Tatara House EIP service (380,000)
•Dunedin: Aspiring House EI service (150,000)
..
...
New Zealand National Early Intervention Group
Early Psychosis Programs in Australia
Victoria:•EPPIC•Dandenong•EP Program, Alfred Hosp.•Central East EP Project
Western Australia:•First Psychosis Liaison Unit, Bentley•EPOES, Fremantle •EEPP, Rockingham/Kwinana
New South Wales:•YPPI service, Gosford•EP program, Marouba•EP program, North Sydney•EPIP-SWAHS, Liverpool•EPIC, Penrith•Western Sydney FEPP
South Australia:•Noarlunga EP Program
Queensland:•Uni of Brisbane studies
ACT:•Canberra EI service .. . ..
.
..
National Early Psychosis Project (based at EPPIC)
South west Area
4 sectors•Inner West: (145,000)•North West: (266,700)•Mid west: (208,000)•South West: (237,600)
(Each sector has 20 CCU beds for long-stay patients)
EPPIC16 21
21
24
24
= Acute adult
= EPPIC beds
EPPIC serviceWestern Region of Melbourne (pop = 850,000)
Overview of Mental Health Services For Kids & Youth
Older Adolescent Service(follow-up to age 19)
EPPIC(18 month follow-up)
Youth Assessment Team
AcuteInpatient
Care
DayGroup
Program
Familywork
IntensiveOutreachSupport
Outpatient Case
Management
Western Region of Melbourne (800,000)
Non-psychotic Ages 15 -19
PsychoticAges 15-30
CognitiveTherapies
PACEClinic
Prodrome
PACE Treatment Trial(Phillips et al 2000, McGorry et al, 2002)
(n= 59)
0%
5%
10%
15%
20%
25%
30%
35%
40%
after 6 monthstreatment
NSI
Risp. +CBT
• RCT of CBT + low dose Risperidone X 6/12 versus supportive psychosocial therapy (NSI)
• Both groups ~ 50% received SSRIs
• Those fully compliant with Risperidone afforded greatest protection at 6 months (5.6%) and follow-up after meds ceased
• 2 suicides in refusal group (n=33)
Transition Rate to Psychosis
35.7%
9.7%
P = 0.026 Fisher Exact test
(N=28)
(N=31)
South East Asian Early Psychosis Network
Singapore:EPIP
1 team covers 4 M(S. Chong et al)
Tokyo, Osaka
(South Africa)Palau, Miconesia
Hong Kong: EASY - 4 teams cover 7M
(Eric Chen et al)
South Korea
Swiss Early Psychosis Programs
Geneva & Zurich:Swiss Early Psychosis Project SWEPP (Simon, Umbricht & Merlo)
Bern:•Uni Hosp. of Social & Comm. Psych.(Gekle) (Merlo - moved to Geneva)
Basil:•Uni Hosp. Basil: Basil FEPSY screening study (Gschwandtner et al)
German Early Psychosis Programs
Mannheim:•Central Insitute of Mental Health (Hafner, Maurer et al)
Dusseldorf:•RCT of psychological Rx in FEP (Klinberg)
Bonn:•Prodrome Rx (Hambrecht et al)
Cologne:•Cologne early Recognition study (Klosterkotter, Schultze-lutter et al)
Heidelberg: •Heidelberg Early Adolescent & Adult Recognition & Therapy Centre for Psychosis (HEART) EI service since since 1994 (Franz Resch et al)
Vienna, Austria:•Adolescent EI program at University Hosp. of Vienna (Amminger, Edwards)
......
Scandinavian Early Psychosis Services
0
2
4
6
8
10
12
14
16
DUP (median in weeks)
Early detectionStandard
Norwegian Services:•TIPS - Roskilde/Stravanger (Larsen, Johannessen etc)•UNA-projektet, Oslo•EOP, Skien
Swedish Services:•Parachute Project (1.5 M), Stockholm•Sodertalja Psykiatriska Sektor, Sodetalje•TUPP Project, Stockholm (Cleland)
Finland:•Turku: Detection of early Psychosis project(Suomela et al)
Control
DU
P m
edia
n (
wee
ks)
OPUS study(Nordentoft et al )
RCT of Assertive Community Follow-up in First Episode Psychosis
0%
5%
10%
15%
20%
25%
30%
35%
Psychotic Sx 2years
-ve Sx 2 years
Standard teamsEarly Intervention team
% c
ases
with
mod
/sev
ere
sym
ptom
s
Merete Nordentoft, Bispebjerg Hospital, Department of Psychiatry, 2004
The cost saved for in-patient care/year = €600,000 for 100 patients = wages of 10 staff
0
10
20
30
40
50
60
70
80
90
Bed days in 1st year
Standard teams
Early Intervention team
582 patients (18 - 45 year olds) with non affective first episode psychosis
Mea
n B
ed d
ays/
patie
nt
(p <0.05)
Dutch & Belgian EI Programs
Belgian Projects:•PECC (Janssen-Cilag)
Netherlands:•Academic Medical Centre (Don Linszen)•University of Maastricht: NEMESIS (Van Os, J.) •University Med Centre, Utrecht (Dutch Prediction of Psychosis Study- DUPS)
Other European Projects:•European Prediction of Psychosis (EPOS) study (6 centres: Birmingham, Amsterdam, Cologne, Turku, Santander, Dannstadt)•Dublin: SJOG Hospital (E. O’Callaghan)•Bordeaux: (Helen Verdoux)•Barcelona, Madrid, Santander: 4 prodrome research programs•Lisbon: planning EI service•Eastern European, Russian & Middle East: research programs & plans for services
Early Intervention Services in England
EI teams include:•North Birmingham EI service•LEO & OASIS service•Plymouth service•Manchester •Tower Hamlets•ETHOS•COAST•Sheffield EI service•STEPS, Poole
•NHS plan: PIG
•IRIS: Newcastle declaration
•50 teams by 2005-23 EI teams to date
£1M
Glasgow: •EI service (A Blair)
Edinburgh•YPU @ Royal Edinburgh Hosp.•Edinburgh High Risk study(E. Johnstone)
RCT of LEO Community Team Engagement with Services at 18 months
(N=138)
In contactwith services
In hospital Lost tocontact
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
LEOControl
p<0.02
At 6 months:
African Caribbean engagement:
= 89% vs 27 %:
LEO vs Control
% C
lien
ts s
till
att
end
ing
at 1
8 m
onth
s
(Craig et al, 2004)
Adherence to prescribed antipsychotic medication over 6 months
1
0.5 0.61
0.28
1 2 3 4 5 6Months post randomisation
0
Pro
port
ion
taki
ng m
edic
atio
n
LEO
OTHER
(Craig et al, 2004)
LEO Trial ResultsRelapse at 18 months, from full or partial recovery
(N=122)
p<0.05
% o
f cl
ient
s w
ho r
elap
sed
(Craig, Garety et al, 2004)
Significant better improvements @ 18 months follow-up::
• Positive and Negative symptoms
• Insight & treatment adherence
• GAF score
• Satisfaction with services0%
10%
20%
30%
40%
50% LEOControl
Hospitalisation rates for LEO patients
0%10%20%30%40%50%60%70%80%90%
100%
% LEO patients admitted
Control Group
LEO Trial Rx. group
Inter trials group
1st LEO CAT group
LEOCAT trial
(n=71)
(n=63)
(n=156)
LE
O T
rial
Gro
up
1st
LE
OC
AT
% L
EO
pat
ien t
s ad
mit
ted
2000 - 2001 - 2003 - 2004-2005
LEO Ward opens
LE
OC
AT
Tri
al
Inte
r st
udy
LE
O g
roup
Con
trol
gro
up
(st
and
ard
car
e)(n=73)
(n=73)
Discharges Destinations after 2 years Follow-up with LEO
Lost10%
GP39%
CMHT32%
Died1%
OPD12%
Private 3%
Prison2%
Rehab1%
136 LEO clients discharged to date:
• 37 to Out of Area services
– 17 overseas
(n=269)
20 additional clients overdue discharge
–14 waiting CMHT transfer
Economic Benefits of Intervening Early:Comparison of LEO vs. Estimate of Standard Costs
in First Episode Psychosis(2003 figures)
£18,527
£8,951
£8,323
£7,033
£-
£5,000
£10,000
£15,000
£20,000
£25,000
Standard NHSservices
LEO service
CMHT's costs
Hospital costs
* Based on ratios from Agustench & Cabases (2000), estimates by Guest & Cookson (1999) and adjusting for 3% inflation for 2003
LEO costs (including LEOCAT):
Total of £15,985 over 2 years
NH
S C
ost p
er f
irst
epi
sode
pat
ient
/yea
r
Total standard NHS cost (estimate)
Total = £26,851 over 2 years
Savings with LEO = £10,866 (40.4% less than standard NHS costs)
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