Early Intervention Services in Wales?

Early Intervention Services in Wales?

Dr. Euan HailsClinical Lead Psychosis and Recovery

& National FEP Lead, Wales

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Aims and acknowledgements:

• To look at evidence for EI Services• To touch on service provision and developments in Wales• To acknowledge work of Rethink England and to thank

them for some slides!• To acknowledge work of Prof Shôn Lewis

Manchester Uni and to thank him for some slides!• To acknowledge work of Prof Jo Smith

Worcester and to thank her for some data!• To acknowledge work of all involved in FEP/EIP

developments across Wales.• To acknowledge work of 1000Lives Plus Wales.

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The Schizophrenia Commission

www.rethink.org

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Sir Robin Murray, Chair

www.rethink.org

The message that comes through loud and clear is that people are being badly let down by the system in almost every area of their lives.

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Early Intervention Services

www.rethink.org

“the great innovation of the last 10 years”

“the most positive development in mental health services since the beginning of community care.”

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Findings from the Schizophrenia Commission

www.rethink.org

...nowhere else have we seen the constant high standards, recovery ethos, co-production and multi-disciplinary team working.

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Findings from the Schizophrenia Commission

www.rethink.org

Those giving evidence emphasised the value base of early intervention services – their kindness, hopefulness, care, compassion and focus on recovery.

They provide treatment in non stigmatising settings, seek to maintain social support networks while an individual is unwell, take account of the wider needs of the individual and deliver education as a core part of the service to families, staff and service users.

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Evidence

www.rethink.org

A recent systematic review and meta-analysis suggested that specialised First Episode Psychosis programmes can significantly reduce the risk of relapse when compared to usual treatment

(Alvarez-Jiménez et al. 2011).

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Evidence

www.rethink.org

Early Intervention Services have a positiveimpact on the retention and gain of competitive employment.

McCrone et al. (2010)

10www.rethink.org

12%of people in standard care are in employment

35% of people in EI services are in employment

Evidence

McCrone et al. (2010)

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Evidence

www.rethink.org

Service model is based on evidence that suggests an association between the duration of untreated psychosis and overall prognosis.

(Marshall et al. 2005).

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Standard care outcomes in early psychosis

National Audit Data

Duration of untreated psychosis (DUP) 12-18 months

% admitted with FEP (entry point to EI)

80%

% admitted using MHA 50%

Readmission 50% (in 2 years)

% engaged @ 12 months 50%

Family involved (satisfied) 49% (56%)

Employment (including education and training) 8-18%

Suicide attemptedSuicide completed

48% 10% (in first 5 years)

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Specialist care outcomes in early psychosis Worcestershire EIS Outcome Data (Smith 2006: Smith 2009)

Duration of untreated psychosis (DUP)

National audit data

12-18 months

Worcs EIS 2006 n=78

5-6 months

Worcs EIS 2008 n=106 TBC

% admitted with FEP (entry point to EI)

80% 41% 17.5%

% admitted using MHA

50% 27% 10%

Readmission 50% (in 2 years) 28% (9.5% using MHA) 17% (56% using MHA)

% engaged @ 12 months

50% 100% (79% well engaged)

99% (70% well engaged)

Family involved (satisfied)

49% (56%) 91% (71%) 84% (TBC)

Employment (including education and training)

8-18% 55% 56%

Suicide attemptedSuicide completed

48% 10% (in first 5 years)

21% 0%

7% 0%

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Why is Early detection important?

• A delay in spotting that a young person might be developing a psychosis also leads to delay in getting help and treatment

• Such problems include less chance of complete remission of symptoms, an increased resistance to treatments (including medication), increased incidence of compulsory admissions, lack of insight, family problems, poverty, physical health problems, trauma, increased depression and suicide

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Why is Early detection important?

• The cognitive and psychosocial damage caused by psychosis appears to occur in the first 5 years. This is often referred to as the ‘critical period’.

• If help is not offered in this critical period, a range of long-term problems may develop - the ‘plateau of disability’ (Lieberman 1997)

• Treating during the ‘critical period’ can decrease relapse and social disability, limit psychological problems and reduce healthcare costs (McGorry & Jackson 1999)

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Duration of Untreated Psychosis(DUP) and National Guidelines

• Reducing DUP is a specific target in national mental health performance measures (WG, 2009)

• MH services are required to reduce DUP to 3 months and not exceed 6 months (WG, 2009)

• HOWEVER, these figures relate to ‘genuine’ psychosis, not to ‘pre-psychotic’ presentations

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FULL FEP TARGET - DRIVER DIAGRAM Content Driver Interventions

To improve clinical and social/functional outcomes for people with a first episode psychosis (FEP). To reduce duration of untreated psychosis (DUP) to 3 months.

Short term (2009) PSI service development target for all people with schizophrenia

Timely & appropriate management of FEP

Increase functioning / social recovery.

Offer CBT for all people diagnosed – can be started in acute phase incl inpatients

Offer family intervention where person lives with or is in close contact with their family

(NICE Schizophrenia CG 82 2009)

Timely/regular provision of medical & PSI interventions (to be specified in a PIG) including:-

General health screening review and monitoring of

antipsychotic prescribing Outreach to primary care, social

services, children’s services, colleges, jobcentre+,CAMHS

Use of social functioning questionnaire

Use of Global Assessment of Functioning

60% with FEP in meaningful education/employment after 3 years in MH service

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Increased user/carer engagement & satisfaction

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Use of service engagement scale

Use of standardised Patient/Family Satisfaction scale

Use of quality of life measure MANSA V 2

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Duration of Untreated Psychosis (DUP)

• The longer the ‘DUP’ the more risk of long-term problems (Johannessen et al 2001)

• Early intervention has been shown to reduce DUP (Perkins et al 2005)

• Earlier detection is a core principle of Early Intervention teams

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Aims of HDUHB IAPT Project (depression, anxiety and psychosis)

• For patients entering our service to receive evidence based psychological therapies delivered by mental health professionals who are competent in their use.

• For our service to be NICE compliant.• NICE guidelines; Depression, Anxiety,

Schizophrenia and Bipolar Disorder.

Psychosis Pathway Hywel Dda UHB

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Based on an understanding of the typical course of psychosis, what should a care pathway for people with psychosis be aiming to achieve?

1. To delay or prevent psychosis emerging 2. To reduce the duration of untreated psychosis

(DUP)3. To provide optimal interventions to promote

social and clinical recovery4. To prevent or minimise relapse5. To offer services that promote individual

recovery and wellbeing

20Psychosis Pathway Hywel Dda UHB

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A revised care pathway for psychosis should achieve:

1. Better detection and monitoring of people with at risk mental states for psychosis (ARMS)

2. Lower rates of transition to psychosis for people with ARMS

3. Reductions in DUP for people with first episode psychosis 4. Higher rates of social and clinical recovery in early and

established psychosis5. Prevention or minimisation of relapse in early and

established psychosis 6. Improvement in long term physical health7. HB to offer services that promote individual recovery and

wellbeing

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Typical Course of Psychosis (Larsen et al 2001)

Early Intervention in Psychosis Pathway

Premorbid phase Very early symptoms Psychotic symptoms

Primary CareEarly detection of psychosis and relapse/EI for bodies and minds

Adolescence to Adulthood Transition

Psychosis

Treatment & Recovery Relapse?

“DUP”

2. Early Detection & Intervention in the ‘at-risk mental state’ (ARMS) phase (Early Detection) 3. Early Intervention after

onset of psychosis (EI) 4. Maintaining outcomes beyond EI service involvement: in primary care/GP Service

22Psychosis Pathway Hywel Dda UHB

1. Pre ARMS Phase - Education about Psychosis

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Ongoing secondary careinvolvement

Ongoing psychotic symptoms

Primary Care or Secondary Care Delivery of CBTp, BFI, Art Therapy, A-typicals, care-coordination, interface working to promote recovery and wellbeing

Early Psychosis to Established Psychosis Transition

Treatment & Recovery Relapse?

5. Maintaining outcomes beyond EI service involvement: in secondary care, AOT, CMHT, In-patients, R&R, CRHT, CIST, psychological services

6. Specialist intervention continue in established psychosis services promoting recovery and wellbeing

7. Maintaining outcomes in Established Psychosis service: AOT, CMHT, In-patients, R&R, CRHT, CIST services – return primary care/GP Service – recovery and wellbeing.

Secondary Care Established Psychosis Services Pathway - Enhancement of patient’s recovery and wellbeing by offering NICE Guidelines nominated care.

Established Psychosis

Ongoing Secondary/PrimaryCare involvement

Treatment& Recovery

8. Future support + future directions:•3rd Sector•Vocational Rehab•Housing•Education

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3 2 3 3 1 1 1 3 2-5

5

15

25

35

45

55

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PANSS SCORES (initial assessment + outcome scores)

PANSS initial

PANSS outcome

years in EIP service

Positive, Negative and General combined

PANSS scores

251 2 3 4 5 6 7 8 90

5

10

15

20

25

30

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DUP (months)

DUP (months)

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PANSS initialPANSS outcome

YEARS IN SERVICE QUALTS initial

QUALTS discharge outcome

43 20 3 0 0 completed degree got job v good outcome

47 33 2 11 8 working full time

44 30 3 11 2 vol working

40 33 3 9 6 stable vol work and looking at college courses

44 30 1 9 3 completed all her academic uni work back to home town EIP team

49 49 1 39 8 stable but referred to address drink probs

65 61 1 31 25 midway

47 33 3 0 0 good outcome for client doing vol work for Hywel Dda

42 39 2 0 0 midway

With thanks to:

IEPA clinical practice guidelines for ARMS

Prof Shôn Lewis

University of Manchester UK

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At risk mental state: Yung et al 1998

• Attenuated positive symptoms– subthreshold for severity

• Brief limited intermittent psychotic symptoms– subthreshold for duration (<1 week)

• Schizotypal personality or first degree relative with psychosis plus recent functional deterioration

• Seeking help

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High risk of acronyms

• PACE• PRIME• EDIE• RAP• FETZ• TOPP• PIER• OASIS• EPOS• CARE• NAPLS• SPAM

– Society for Prevention of Acronyms in Mental health

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Rates of one year transition ARMS to psychosis (adapted from Lisa Phillips et al 2005)

Centre Transition rate

PACE 41%PRIME 38%TOPP 43%EDIE 26%PIER 23%

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IEPA clinical guidelines for early psychosis

• Formulated Copenhagen 2002• 29 authors A-Y• Published 2005• To be updated 2008• Covered

– ARMS– First episode– Recovery (6-18 months) and critical period phase

IEPA writing group Br J Psychiatry 2005 187 s48 s120-124

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Prevention in early psychosis

• Three targets for preventative interventions in early psychosis– Prepsychotic phase– Initially untreated psychosis– First episode

IEPA writing group Br J Psychiatry 2005 187 s48 s120-124

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General statements

• Early identification will reduce burden– May improve long term outcomes

• Public education important• Careful, low dose drug treatment in first

episode• Psychosocial treatments important in

promoting recovery• Users and families engaged in developing

better treatments

IEPA writing group Br J Psychiatry 2005 187 s48 s120-124

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The prepsychotic period: clinical guidelines

• At risk mental state needs to be considered in young people with deteriorating functioning or unexplained agitation

IEPA writing group Br J Psychiatry 2005 187 s48 s120-124

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The prepsychotic period: clinical guidelines

• Help seeking people with ARMS need to be engaged and assessed and offered– Regular monitoring and support– Specific treatment for depression or

substance use– Psychoeducation and help to develop coping

skills– Family education and support– Information about risks of psychosis

IEPA writing group Br J Psychiatry 2005 187 s48 s120-124

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The prepsychotic period: clinical guidelines

• Care offered in a low stigma environment– At home; primary care; youth-friendly office-based

setting

• Antipsychotic drugs not usually indicated– Exceptions might be risk of suicide or violence, or

rapid deterioration– If used, regard as therapeutic trial for up to 6 weeks

• If help declined, consider support from friends and family

IEPA writing group Br J Psychiatry 2005 187 s48 s120-124

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Issues for ARMS interventions

• Safety and acceptability• Efficacy and effectiveness• Availability and cost• What is the therapeutic target?

– Prevention versus treatment

• Ethics– Of treatment; Of non-treatment

• Population impact

IEPA writing group Br J Psychiatry 2005 187 s48 s120-124

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Issues for ARMS interventions

• Refinement of risk estimates• Modifying risk and protective factors• Developing a clinical algorithm

– Psychological intervention first?– Drug treatment second?– How long for?

IEPA writing group Br J Psychiatry 2005 187 s48 s120-124

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Which psychological intervention?

• Cognitive therapy (Morrison et al, 2006; Ruhrman et al, 2007)

• Also? (from psychosis literature)– Family intervention– CT for relapse– Motivational interventions– Cognitive remediation

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Which drug treatments?

• Antipsychotics?– Appear effective

• RCT data with risperidone; olanzapine; amisulpride

– BUT risks from side effects– Doubtful acceptability for many

• Antidepressants?– Anecdotal evidence

EDIE trial: ResultsTransitions to psychosis at 12 months

0

5

10

15

20

25

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PANSS Medication Diagnosis

control

CBT

Morrison et al, 200441

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Improving monitoring and interventions in physical health problems of people with early psychosis

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What happens when people with psychosis develop physical disorders?Five-year survival rates

28%

19%

22%

12%

9%8%

0

5

10

15

20

25

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CHD Diabetes Stroke

People with schizophrenia

People without schizophrenia

Hippisley-Cox J et al (2006) A comparison of survival rates for people with mental health problems and the remaining population with specific conditions.Disability Rights Commission. Equal treatment: closing the gap, July 2006

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What we specifically suggest… • For the local EIP spoke staff to make themselves available on a regular agreed

basis to discuss and screen potential cases/ARMS cases.

• For people with psychosis - the local EIP spoke will support and case manage these people in primary or secondary care as appropriate with GP’s (in primary care) and responsible clinicians (in secondary care).

• For people with ARMS - psychological therapists working as part of the local EIP

spoke will offer CBT, monitoring and psychotherapeutic support in PC to prevent or delay psychosis emerging.

• If ARMS patients become psychotic- they will be case managed in primary or secondary care by the local EIP service as appropriate.

A revised care pathway for psychosis is in development which will support this approach.

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Contact:

• Dr. Euan [email protected]