Early Psychosis Intervention Program in Bolivia

A description of the Australian Early Psychosis Intervention Model and a proposal to establish a Pilot Early Psychosis Intervention Program in

Bolivia.

Dr. Guillermo Rivera, MD, MHPS, Dr. Guillermo Rivera, MD, MHPS,

PhD.PhD.

Victoria (Aus) Burden of Disease Study: Incident Years Lived with Disability rates per 1000 population by mental disorder

First Episode of Psychosis typically commences in young people: as do many of

the more serious mental disorders

Agenda

1. Early Intervention in psychosis: A paradigm of care for young people

2. The EPPIC Model

3. The Current State of Psychosis Treatment in Bolivia

4. Arguments for early intervention in Bolivia

5. Programme Overview

6. Sustainability

1. Early Intervention in Psychosis: A paradigm of care for young people

‘Early intervention in Psychosis’ is a paradigm of

care for young people with a first episode psychosis and their families based on research and comprises three concepts:

1. Early detection of psychosis

2. Reduce the long duration of untreated psychosis

3. Importance of the first 3-5 years following onset (critical period) for later biological, psychological and social outcomes

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 follow-up and psychoed. during critical period

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

Assessmen

t Team

Optimizing 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 Maximize Recovery & Prevent Relapse

Fun

ctio

ning

Age

Prodrome

2nd episode of psychosis

16 20 24

Assertive fo

llow-up

Community Team

First episode of psychosis

Implications of delayed treatment

Greater decrease in functioning

Loss of educational opportunities

Impaired psychosocial and vocational development

Personal suffering/family burdens

Potential poorer response once treatment is provided

Greater costs

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Jackson, H. J., & McGorry, P. D. (2009). The recognition and management of early psychosis: a preventive approach. Cambridge University Press.

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

Early Psychosis Declaration

“We need committed people, we need good-will people, we need grass-roots people.

…this is a task for us all, each one with their possibilities and capabilities, but all together “

A collaboration between NIMHE / Rethink, IRIS, the World Health Organisation and the International Early Psychosis Association

The Early Psychosis Prevention and Intervention Centre (EPPIC) in Melbourne has pioneered early intervention in Australia for young people with psychosis.

Courtesy Orygen Youth Research Centre

2. The EPPIC Model

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

Specified aims of EPPIC

The early identification and treatment of the primary

symptoms of psychotic illness. To improve access to, and reduce delays in, initial treatment To reduce the frequency and severity of relapses, and to increase

the time to a first relapse To reduce secondary morbidity in the post-psychotic phase of illness To reduce the disruption to social and vocational functioning and

psychosocial development in the critical period following the onset of

illness, when most disability tends to accrue To promote well-being among family members and reduce the

burden for carers

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EPPIC provides a clinical service for up to 2 years to young people aged 15- 24 years living in the catchment area who have been diagnosed with a first episode of psychosis. 

EPPIC clinical work is provided in phases, according to the phase of illness. In a first episode of psychosis full recovery is possible with the appropriate multidisciplinary multi-faceted treatment. As treatment continues it needs to be tailored according to both the needs of the individual and their particular experience of the illness.

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Clinical Staging of Psychosis

3. The Current State of Psychosis Treatment in Bolivia

Less than half of the more than 250 adolescents and young adults* who are estimated to experience a first episode of psychosis in the city of Santa Cruz each year are ever diagnosed and receive psychiatric treatment.

Patients who are eventually recognized as having a first episode of psychosis are estimated to have experienced, on average, 2 years of symptomatology prior to diagnosis. At this stage, psychiatric treatment occurs most often in an inpatient setting and most frequently follows an episode of aggression that places the patient or others at risk for harm.

Most psychiatric treatment occurs in inpatient psychiatric hospitals during lengthy stays, which in Santa Cruz are not publicly funded. Outpatient options are limited.

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* Incidence estimate is based on World Health Organization incidence rates for schizophrenia spectrum diagnoses in

15-24 year olds.

Barriers

There is an especially strong stigma of mental illness throughout Bolivia.

Bolivia earmarked only 0.2% of its health budget for mental health. There aren’t public psychiatric facilities in Santa Cruz and all patients must pay out of pocket for a significant portion of their treatment

Bolivia has a especially low presence of psychiatrists, with an average of only 1 per 100,000 inhabitants

Informe de la Evaluación de Salud Mental en Bolivia Usando el Instrumento de la Evaluación de los Sistemas de Salud Mental de la OMS 2008.

Barriers 2

There is a lack of mental health training for primary care health personnel. Limited ability to appropriately screen for, identify, and treat mental illnesses in the general population.

Bolivia has a highly fragmented medical system.

There are no electronic medical records. There is limited coordination of care between individual providers as well as between group providers, such as clinics and hospitals.

Informe de la Evaluación de Salud Mental en Bolivia Usando el Instrumento de la Evaluación de los Sistemas de Salud Mental de la OMS 2008.

4. Arguments for early intervention in Bolivia

It does not require significant investment in medical or physical infrastructure, technology or high-cost, hard-to-obtain medications.

It does not rely heavily on psychiatrists, of whom the supply is limited in Bolivia, or on a large workforce of highly trained personnel.

On a per patient basis, early intervention is far less costly than inpatient crisis treatment, which is the current de facto standard of psychiatric care for psychosis in this country.

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4. Arguments for early intervention in Bolivia

Our proposed early psychosis intervention program represents a low-tech, appropriate and potentially very transferable technology.

Bolivia does simply not need more mental health care – it needs a shift towards smarter, more strategically organized, more economical care – and this programme would represent an important step in this direction.

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5. Programme Overview

A pilot early psychosis intervention program called

Programa de Apoyo y Rehabilitación de la Sicosis

(PARES) will provide age appropriate bio-psycho

social treatment and support for 15-25 years old

with first episode psychosis and their families,

who reside in the neighborhood of Plan 3000 in the

city of Santa Cruz de la Sierra, representing a

catchment area of 350,000.

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Incidence data

Population of Plan 3000 350000% between 15-25 yo 25%Population growth rate 5%Incidence of new cases of affective and nonaffective psychoses 0,001Number of new cases per year 88% detected and referred year 1 25%% detected and referred year 2 33%# of new clients year 1 22# of new clients year 2 30Total clients at end of year 2 52

PARES Aims

This program’s specific objectives are to: Improve short and long-term outcomes for those

with psychosis Increase speed of recovery Decrease the need for hospitalization Reduce family disruption Decrease rates of relapse

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Four Principal Components

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Attention and Treatment

Service Model

Our programme will be implemented under a

"radial" model basis, where primary care,

responsibility and focus care program is in the

hands of current and leading providers of mental

health services (the "spokes"), but the contribution

of specialists is provided by a treatment team of

experts dedicated to first episode (the "hub").

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The team

manager

Full-time position The centralized ‘Hub’

provides support for the

spoke workers through

the delivery of clinical

supervision, training,

administration and

management.

Administrator Full-time position

Consultant

Psychiatrist

Part-time position

Consultant

Psychologist

Part-time position

The Hub

Social Worker Full-time position The community location

of the ‘Spokes’, provides

excellent opportunity to

encourage referrals from

local primary, voluntary

and generic youth

services, thus reducing

the DUP.

Mental Health

Nurse

Part-time position

Assistant

Psychologist

Part-time position

Assistant

Psychologist

Part-time position

The Spokes

6. Sustainability

We do believe that public funding for mental illness will increase over time, but it will take a significant, concerted, well organized, and consistent lobbying effort in order to make this change happen.

We have already begun working with and providing support to the organization of family members of people with psychosis in the city of Santa Cruz. We will continue to work with this organization, training and providing support in order to optimize their lobbying efforts.

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What is currently most lacking in order to support any lobbying effort for improved mental health treatment in Santa Cruz is a programme such as we are proposing that would provide a model of what mental health treatment should actually look like.

Anyone with psychosis, should have a right to expect the kind of comprehensive bio-psycho-social treatment that our program proposes. This is the argument that we believe we will be able to effectively make and communicate towards the public and lawmakers over time.

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Using terms often applied to sustainable development, early psychosis intervention programs represent an appropriate and potentially very transferable technology.

Therefore, one of the principal goals of our programme will be to create a model or blueprint that might be replicated in similar communities across Bolivia beyond Santa Cruz and possibly in other developing countries.

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Summary

This program includes an innovative outreach program that combines sound business principals with social goals in order to specifically target the largest barrier to early psychosis treatment in Bolivia: the stigma of mental illness.

By utilizing a mobile, multidisciplinary treatment team that emphasizes the roles of trained case managers focused on providing intensive individual and family support in the home, this program will provide culturally appropriate care that will leverage contributions from a limited supply of psychiatrists and shift dependence away from a fragmented medical system.

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