Early Intervention in PsychosisDr Charles MontgomeryConsultant PsychiatristSpecialist Team for Early Psychosis Devon Partnership NHS Trust
“I have seen how much progress early intervention teams have made, how innovative they have been, and the impact they are having. I now believe that early intervention will be the most important and far reaching reform of the NSF era. Crisis resolution has had the most immediate effect but I think early intervention will have the greatest effect on people’s lives.” Professor Louis Appleby, National Director for Mental Health Oct 10th 2008 Policies and Practice for Europe (DH / WHO Europe conference attended by 35 European Countries)
Early Intervention in Psychosis ‘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: • Early detection of psychosis • Reduce the long duration of untreated psychosis • Importance of the first 3-5 years following onset(critical period) for later biological, psychological and social outcomes
FEP typically commences in young people: as do many of the more serious mental disorders Victoria (Aus) Burden of Disease Study: Incident Years Lived with Disability rates per 1000 population by mental disorder
Youth Health Services weakest when they need to be strongest The issue • CAMHS / adult interface and transition issues – service centred rather than person centred We need • Partnerships with youth agencies to develop comprehensive youth focussed services • Young people’s inpatient care and crisis provision • Youth sensitive service provision • Extend the EI Paradigm to other mental health disorders that have their onset in youth
RAISE COMMUNITY AWARENESS IMPROVE ACCESS & ENGAGEMENT EARLY PSYCHOSIS DECLARATION INTEGRATED HEALTHCARE PROMOTE RECOVERY AND ORDINARY LIVES ENGAGE AND SUPPORT FAMILIES
Duration of Untreated Psychosis is less than 3 months on average 90% of affected individuals report satisfaction with their employment, educational and social attainments The use of involuntary treatment should be less than 25% “TRANSFORMATIONAL OUTCOMES” Suicide rates in the first two years after diagnosis are less than 1% All 15 year olds are educated to understand and deal with psychosis. 90% of families feel respected and valued as partnersin care All generalist and specialist health and social care practitioners know how to deal effectively with early psychosis
Early Intervention Services Nationally • NHS Plan 2000. MH-PIG 2001. NICE 2002. • NHS Operating Framework 2009 • 50 “discrete and specialist” UK services :120 UK teams • Young people 14-35 with 1st presentation and for 3 years • Reduce risk of developing psychosis • Improve detection • Reduce delays in accessing treatment/reduce stigma. • Maximise recovery • Prevent relapse after first episode • Plan for continuing needs & onwards care pathway
Early Intervention Provision (15,750 cases at end of March 08) 2 teams 24 teams 41teams 109 teams 127 teams160 teams 145services
What we do…. • 5% self referral • 55% from Primary care • 15% other agencies F.E.P. • 25% wards Age 14-35 • Contact within 48 hrs • Assessment within 7 days • 3- 6 month assessment • assertive engagement • Support for 3 years (low case loads)
Earlier AND better • Creative engagement process with assertive follow up • Low dose atypicals early • Family involvement from the start • Psycho-education • CBT • Practical help accessing training courses/work placements • Financial planning/support • Relapse prevention • Ensure good handover of care
After 3 years….. • Delayed Recovery : 20-25 % Long term support • Single episode, good recovery : 25%Primary care • Multiple episodes, partial recovery : 50%CMHT
The transition from pre-morbid phase through prodrome to first episode psychosis First episode psychosis Severity of Symptoms Prodromal phase At risk mental state Time The need for care preceeds capacity for definitive diagnosis
Three key clinical states The “at risk mental state”. The prodrome : non specific symptoms. anxiety, depressed mood , obsessions. The “critical period” (Birchwood, 1998) Disabilities in particular during first 3 years.
ON, onset of negative symptoms OP, onset of psychosis, positive symptoms OT, onset of treatment Early Course of Psychosis. (Modified from Larsen TK et al, Schzophr Bull 1996; 22:241-256.) Duration Untreated Psychosis OT OP ON Premorbid phase Prodromal phase Psychotic symptoms First treatment Residual symptoms End of Episode Episode onset Illness onset Illness duration Psychotic episode duration
First start treatment Transition to psychosis DUP & Pathways to Care First contact health service Predisposing factors? First contact any agency Triggers? BLIP DUP Symptoms Attenuated Sx. Psychosis ProdromeOnset Features: :positive symptom = hallucinations, delusional beliefs, thought disordeer. Negative symptoms = avolition, anhedonia, affective flattenoing, attentional impairment Features: poor concentration/motivation Depression, anxiety, odd behaviour Time
UK and International EI outcomes Research • EarIy Intervention: • London Mi-Data pan-London research network • First Episode Research Network (FERN) • EDEN and National EDEN • PSYGRID • LEO outcome data • Early detection: • EDIE and EDIE2 trial • EDIT • Burgeoning international evidence base: (eg. Addington, 2007, McGorry 2007, OPUS outcome data)
Association between DUP & outcome Early detection : suicide attempts, compliance, psychosocial outcomes Long DUP : readmission rates, initial remission Cochrane database : Marshall & Lockwood 2006
EI services reduce DUP TIPS project (Johannessen) in Stavanger Major public health educational programme Increase help seeking behaviour EPPIC service (McGorry) in Melbourne DUP reduced to 45 days Youth friendly environments
Compared to standard service • Lower DUP • More contact at f.u. 18 months • Fewer bed days & lower use of MHA • Significantly fewer relapses at five years • Reduction of suicide rate in young • Cost effective • Better at translating clinical recovery to social recovery
Paying the Price The cost of mental health care in England to 2026 McCrone P, Dhanasiri S, Patel A, Knapp M, Lawton-Smith S Kings Fund 2008 “Early intervention services for psychosis have also demonstrated their effectiveness in helping to reduce costs and demands on mental health services in the medium to long-term, and should be extended to provide care for people as soon as their illness emerges.”
Early Intervention with BME Communities: Base Case Costs (McCrone, Dhanasari, Knapp 2007)
EI Self Assessment Report 2007/08 • Red(not meeting EI PIG or min fidelity criteria providing for <50% target caseload) 5% • Amber (meets EI PIG and min fidelity criteria providing for 51-90% target caseload) 26% • Green (meets PIG and min fidelity criteria providing for between 91 and 100% caseload) 67%
EI Self Assessment Report 2007/08 SHA Averages East of England 2.8 North West 2.5 North East 2.7 East Midlands 3 London 1.9 South West 2.8 South East Coast 1.6 South Central 3 West Midlands 2.6 Yorkshire and Humber 2.5 Where 1 = RED, 2 = AMBER, 3 = GREEN
Future of EI and the EI Programme Threats: • Uncertainty over the future of NIMHE and regional/national EI Lead posts • Unlikely to be further EI specific national policy drivers • National EI Programme seen as very successful and a model for national programmes but unlikely to continue Strengths: • Strength and value of EI regional informal networks • EI in strong position: seen to be a’ solution’ to problems eg. DRE agenda, suicide, offender pathways and has demonstrated cost effectiveness • EI offers a successful paradigm for early detection/ intervention initiatives for other MH difficulties
Case Study • Melissa, 19 years old returned from University. • Youngest of three. • Became low in mood, couldn’t concentrate. • Had a trial of A-D’s & student counselling. What to do next ?
Take a history • Three months ago assaulted. • Pin prick marks on skin…? • Requesting second pregnancy test. • Began to fall behind in course work. • Thinks friends don’t like her. • Cannabis helps. • Denies voices “ I am not mad!” • Denies thoughts of DSH. • Mother phoned – bought a copy of the Koran. • “We should know about other religions” What to do next?
A month later….. • From mother = awake at night. • Not wanting contact with friends. • Mirrors turned around. Doing less and less. • From Melissa = feeling frightened. • Looks preoccupied. • Not sure but thinks thoughts are not hers. What to do next ?
A month later….. • Carrying Osama Bin Ladens child. • Special mission to reconcile East and West. • Mood becoming elated. • No auditory hallucinations. • Reluctantly accepts help & low dose atypical. • Aunt with schizophrenia & history of abuse. • Still using cannabis but less.
Learning points : • Adolescent angst depression psychosis. • A history needs time…. • Cannabis complicates life! • “Voices” not necessary. • Impaired concentration as 1st presentation. • Association with childhood abuse ? • Don’t forget the family history. • A good outcome with full recovery is the aim.
Useful web links for EI : hhtp://www.rethink.org hhtp://www.schizophreniaguidelines.co.uk hhtp://www.nimhe.csip.org.uk/home hhtp://www.iris-initiative.org.uk/ hhtp://www.iepa.org.au/ hhtp://www.eppic.org.au/ hhtp://www.mind.org.uk hhtp://www.thorn-cheltenham.org.uk/ hhtp://www.orygen.org.au/