Earlier intervention in psychosis - everybody’s business

Earlier intervention in psychosis - everybody’s business

A primary care view

Dr David ShiersDr Jo Smith

Joint leads NIMHENational EI Programme

Haugesund. Workshop on primary care. Sept 2nd 2008

Learning objectives

Explore the interface between psychiatry and primary care

Develop a marketing strategy to ‘sell’ early intervention to primary care colleagues

At any one time is responsible for:– 10-20 registered on his/her list with psychosis

– 30-50% without any support from specialist care (Kendrick,2000)

Average GP (list 1800) sees each yr:

– 250 new mental health cases

– 5 with severe mental health problems

– 1 with a first episode of psychosis

Continuity– Alertness to changes in behaviour and functioning which may

precede first episode and relapse– Potential for better physical health care

Care setting– More accessible and less stigmatising

Context: – Knowledge of individual before onset of

psychosis

– Family practice

Some GP views:

“I know that I cannot look after people with severe and enduring mental health problems. I do not have the skills or the knowledge. I couldn't do it well"

“Sometimes they have to be standing on a bridge before we can get people help and we have to exaggerate symptoms to get the psychiatrist’s attention at an earlier stage”

Helen Lester BMJ 2005

Contrasting with patients’ views typified by:

"I mean, the GP has to have some understanding of mental health but I don't expect my GP to know all of the issues to do with my illness...

...I would though expect him or her to refer me to a specialist person. The important thing is that somebody is looking after you so it's not just you on your own.”

Helen Lester BMJ 2005

Victoria (Aus) Burden of Disease Study: Incident Years Lived with

Disability rates per 1000 population by mental disorder

GPs see a FEP at an age when other serious mental disorders tend to develop

Pathways to Care Audit Data and GP Survey

North Staffs Pathways to Care prospective audit n = 45

(Macmillan, Ryles, Shiers & Lee 1998/9)

Sandwell GP interview n = 3 (Alderton 2000 )

Worcester Pathways to Care retrospective audit n = 30 and GP workshop n = 26 (Smith 2000)

Walsall Pathways to Care review from case notes n = 18 (Rayne 2002)

Gloucester GP Postal questionnaire n = 15 (Davis 2002)

Who are they?

50% < 24; youngest aged 13

Average age at onset = 21 75% live with parent(s) or

spouse

41% are employed or in full-

time education

Pathway players (n = 45)

General psychiatrists 45 Health visitor 3Family members 37 Work colleagues 3

GP 36 Private landlord 2

Police 22 Church 2

CPN 18 Occupational health 2

A&E 13 Friends 2

SW 11 O T 2

Psychologist 5 General physician 1

Teacher / Tutor 4 Learning diff psychiat 1

Neighbour 4 Forensic psychiatrist 1

Police surgeon 4 Substance misuse 1

Hostel staff 4 Homeless services 1

Probation officer 3 Solicitor 1

Prison staff 3 Ambulance services 1

Resource centre 3 Public Health 1

Symptoms presented to GPs?

7% - clear evidence of psychosis

37% - physical / somatic symptoms

50% report emotional and psychological changes

25% report changes in work and social functioning

Nature of their help-seeking to GP?

Prodrome: typically 2 – 6 m

~ 50% seek help <2 wks of psychotic symptoms

~ 20% of individuals have courage to seek help themselves

~75% relied on family members to seek help on their behalf

5 contacts on average to achieve pathway to care

GPs are first point of professional contact ~ 65%

DANGER AHEAD!!!DANGER AHEAD!!!Pressure wave- trapped

7-15m treatment delays Families’ concerns ignored

Crisis response is the rule– 73–80% hospitalised– 36–59% Mental Health Act– 45% police involved

Lifetime suicide risk 10% – 2/3 within first 5yrs

– around the FEP

50% disengage: likely crisis reengagement

Some get marooned…

Stagnation in a ghetto of disability

Relapse and remission

Path to social exclusion and health inequality?

“…“…can’t get a job, can’t get a can’t get a job, can’t get a girlfriend, can’t get a telly, can’t girlfriend, can’t get a telly, can’t get nothing… it’s just everything get nothing… it’s just everything falls down into a big pit and you falls down into a big pit and you can’t get out…” can’t get out…” Hirschfeld, 2002Hirschfeld, 2002

“…“…our overwhelming feeling was of an our overwhelming feeling was of an opportunity missed - to what degree she opportunity missed - to what degree she has been needlessly disabled by those has been needlessly disabled by those first four years of care we’ll never know” first four years of care we’ll never know” Mother 2002Mother 2002

... a path to inequality Excluded

12% with a job In previous 2 weeks (Nithsdale survey)

o 39% either had no friends or had met noneo 34% had not gone out sociallyo 50% no interest or hobby other than TV

one in four have serious rent arrears 3x divorce rate

Dis-ease up to 25 years less life 33% suicide and injury

66% premature deaths from physical disordersEg. Deaths due to coronary heart disease: kills more than two-thirds of people with

schizophrenia, compared with about a half in the general population,

Accounted for by excess smoking; obesity; hypertension; diabetes

Antipsychotics – link with obesity, diabetes (up to 5x rate)

Lifestyle issues – poverty, diet, exercise, smoking (2x rate)

Poorer health care – poor access to physical health services; discrimination; diagnostic overshadowing

That’s the problem we are trying to solve

What do young people and families need?What do young people and families need?

OptimismOptimism

Confidence in a whole systems response to their help-Confidence in a whole systems response to their help-seekingseeking

Earlier detectionEarlier detection– of psychosisof psychosis– of ‘at risk mental state’?of ‘at risk mental state’?

Specialist services that Specialist services that – ‘‘do psychosisdo psychosis’ as well as ’ as well as ‘do young people’‘do young people’– pre-empt crisis; offer less traumatic ‘first engagements’ pre-empt crisis; offer less traumatic ‘first engagements’ – offer age / phase specific care in ‘critical period’ of first 3-5 yrsoffer age / phase specific care in ‘critical period’ of first 3-5 yrs– provide recovery oriented services from the startprovide recovery oriented services from the start

Support for familiesSupport for families

What do specialist services need What do specialist services need from primary care?from primary care?

GPs as key pathway players to:GPs as key pathway players to:– Listen for and act on family concernsListen for and act on family concerns– Be aware of key indicatorsBe aware of key indicators– Be flexible and accessible to promote help-Be flexible and accessible to promote help-

seeking of these young peopleseeking of these young people– Involve EIS at the earliest opportunityInvolve EIS at the earliest opportunity– Organise care to meet physical health needOrganise care to meet physical health need

What does primary care need from What does primary care need from specialist services?specialist services?

Youth friendly approach – ban outpatient clinics!Youth friendly approach – ban outpatient clinics!

Low threshold of access to specialist adviceLow threshold of access to specialist advice– MH assessment of those with suspected FEPMH assessment of those with suspected FEP– Monitoring / review of those deemed at ‘high risk’ of FEPMonitoring / review of those deemed at ‘high risk’ of FEP– Individual support for FEP Individual support for FEP

Collaborative approach Collaborative approach – Clear pathways (e.g. for those aged 14-18; for those with Clear pathways (e.g. for those aged 14-18; for those with

co-morbid drug misuse) co-morbid drug misuse) – Relapse planning Relapse planning – Planned exit from EIS Planned exit from EIS

Marketing EI to primary care?

Colin’s journey

RapidsRapids

EddyEddy

FamilyFamily

PCPC

Family crisis

Drop out of Educ’n

Isolated from friends

Suicide attempt

Offending behaviour

Mental illness

Homeless

Drugs

RapidsRapids

RapidsRapids

No money

Distressed

No job

Youth Youth workerworker

Using Nature – EddiesEarly detection of danger ahead

Pull ashore, get out, take a look and regroup

Use understanding of the nature of the journey and knowledge to stop and even regain some ground

Safety raft

White water

Rapids

Eddy

Family

Guides

Lookout with life ring

Supporting GPs’ to do a difficult

job better:

Acknowledgements to:

Dr. Roy Morris Dunedin and Dr Maryanne Freer, Newcastle for contributing the white water rafting metaphor

and to Guzer.com for the images

Early intervention is everybody’s business

EI services insufficient by themselves

GPs offer continuity, context and family practice:– Key role in care pathway of those with

emerging psychosis

– Ability to listen and act on concerns of the family

– In it for the long term

– EI for bodies as well as minds

Equipped for the life Equipped for the life ahead both for the ahead both for the

young person and their young person and their familyfamily

[email protected]

[email protected]

www.earlydetection.csip.org.uk

Thank you